Cerebral Palsy
Exploration of an Occupational Therapy Home Educational Program using the Pilates Method to support occupational performance for an adolescent diagnosed with Cerebral Palsy
Study Presented at AOTA, 2018
PART I
Cerebral Palsy (CP) is a common non-progressive neurological disorder, a result of fetal or infant brain injury (Russchen et al., 2014; Silva, Pfeifer & Funayama, 2013; Novak, Cusik & Lanin, 2009). In the US, there are 3.6 infants per 1000 live births diagnosed with CP each year (Almasri, O’Neil & Palisano, 2014). The condition is characterized by motor and postural impairments. Symptoms range from mild unilateral spasticity, sensory and visual inattention to the affected side, focal epilepsy, to severe bilateral spasticity and dyskinesia, contractures, scoliosis, loss of ambulation, intellectual and visual impairments (Colver, Fairhurst & Pharoah, 2014; Marron et al., 2012; Tsoi et al., 2011).
Limited studies on cardiorespiratory fitness and persons with CP also revealed individuals with CP presented with decreased heart rates, oxygen uptake, ventilation, and blood lactate concentrations (Rimmer, 2001; Lundberg, 1978). A study by Rose et al., (1985) compared heart rates of 12 children with quadriplegic or diplegic CP using a wheeled walker or cane to 12 typically developing peers. Results indicated higher heart rates and slower walking associated with poor fitness levels for the CP group. Chest infections have also been associated with cerebral palsy (Colver, Fairhurst & Pharoah, 2014).
The disorder may lead to long-term postural, movement, and intellectual challenges (Almasri, O’Neil & Palisano, 2014; Lima, Cardoso & Silva, 2016). It is a physical disability with 35% of individuals diagnosed with the disorder classified as non-ambulatory and categorized as level IV or V on the Gross Motor Function Classification System (GMFCS) (Palisano et al., 2007). Thus, depending on the level of severity, individuals suffering from CP may require long-term specialized care (Taylor, Cotter & Stephan, 2013; Fatudimu, Hazmat & Akinyinka, 2012).
Current therapeutic interventions include occupational and physical therapy. Types of services include physical training such as strength, constraint induced movement therapy (CIMT) and exercise, medical intervention such as intrathecal baclofen, diazepam, botulinum toxin A, and behavioral intervention such as conductive education and adaptive technology (Myrhaug et al., 2014; Novak et al., 2013; Tsoi et al., 2011; Hoving et al., 2009; Verschuren et al., 2007; Engsberg, Ross, & Collins, 2006; Bar-Haim et al., 2006; Nolan et al., 2006; Stiller et al., 2003). Home programs are also a common type of intervention occupational therapists use with individuals diagnosed with CP. They are strategies formulated in a way that the content can be performed by the client or with the support of a caregiver or aide with little to no skilled assistance from the therapist (Novak & Berry, 2014; Novak, 2011; Novak, Cusick & Lowe, 2007; Taylor et al., 2004; Chen et al., 1998).
PART II - PILATES STUDIES
The spine is the pillar that supports the body’s weight and connects the head, chest, pelvis, shoulders, arms and legs. When there is presence of clinical instability of the spine, there is a “reduced capacity of response to physiological loading“ (Panjabi, 2003). Due to the nature of the disorder, youth with CP have displayed poor core stability essential for sitting balance and distal control of limbs (Ahmed et al., 2014; Prosser et al., 2010; Rosenbaum et al., 2007; van der Heide & Algra, 2005).
Pilates is an integrative approach that combines strength and control while facilitating breath and movement. Joseph Pilates, (1880–1967) the founder of the method, designed it so it could be tailored to each person’s needs, functional abilities, and skills. Originally entitled Contrology, it is bound by six fundamental principles: centering, concentration, control, precision, flow, and breath (Wells, Kolt & Bialocerkowski, 2012; Caldwell et al., 2007; Adamany & Loigerot, 2004; Pilates & Miller, 2001). These principles, applied throughout each exercise act as guidance in order to achieve motor control, or as Pilates stated in his book, Return to Life through Contrology, “mind control over the body” (Pilates & Miller, 2001).
A systematic review was performed by Wells, Kolt and Bialocerkowski (2012) on the definition of Pilates exercises. One hundred and nineteen articles were included in order to compare the use of Pilates exercises as a health-promotion tool for healthy individuals to the use of Pilates exercises as a rehabilitation tool. Results of the review identified Pilates as a mind-body type of exercise that combines strength, core stability, flexibility, muscle control, posture and breathing.
Results of the systematic review and other studies showed that posture was the most used term in conjunction with low back pain. Specifically, Pilates exercises may support posture and alleviate low back pain by stabilizing trunk muscles including the transverse abdominis and multifudus (Ferreira et al., 2010; Urquhart et al., 2005; Granata el al., 2001: Hides et al., 1994). A repeated-measures descriptive study by Endleman (2008) evaluated the activation of the transverses abdomens (TrA) and internus abdominis (OI). Participants (18 women and men, mean age 43 years old) were healthy adults with no history of back pain. Results showed that specific classical Pilates exercises, such as the Hundred, Roll-up, and Single Leg Circle on the mat and the Hundred on the reformer apparatus activate the TrA and OI as observed under ultrasound imaging.
Miyake et al., (2012) performed a pre and post study to examine the influence of core strengthening exercises on upper extremity function in relation to skilled motor behavior and postural sway. Results of the study showed improved trunk stability and postural balance. A study by Akuthota and Nadler, (2004) hypothesized the core is a box that helps stabilize the trunk through co-contractions of the paraspinals, gluteus muscles, diaphragm, pelvic floor, and hip girdle (Miyake et al., 2012).
Rosenblum and Josman (2003) indicated that a stable trunk allowed for dynamic stability of the shoulder girdle while Fallang et al., (2000) stated that increased postural stability was associated with increased hand reaching performance. Caldwell et al., (2009) performed a comparative controlled study on the effectiveness of Pilates versus tai chi on perceived self-efficacy, quality of sleep, mood, balance, and strength in college-aged people. The two most significant results of the study were the improvement in self-efficacy and mood.
Pilates has been found to enhance static and dynamic balance, lower-extremity strength, and quality of life for individuals who have suffered a stroke (Lim et al., 2016; Shea & Moriello, 2014) and to improve balance in the elderly population (Sim, Kim & Go as cited in Lim et al., 2016; Rydeard, Leger & Smith, 2006; Hyun, Hwangbo & Lee, 2014).
A randomized controlled trial by Kucuk at al., (2016) on the effectiveness of Pilates as a therapeutic tool for multiple sclerosis (MS), a neurological disorder, found a statistical difference in the clinical Pilates group versus traditional exercises. Results showed an increase in cognitive functions, quality of life, and physical performance. Guclu-Gundz et al., (2014) also performed a study on the feasibility of Pilates as a therapeutic tool for persons with MS and found statistical difference between the Pilates group and the control group. Results of the study found improvement in balance, mobility, and upper and lower extremity muscle strength for the Pilates group.
Dos Santos, Serikawa and Rocha (2016) examined the effects of Pilates exercise on strength and postural control for a child with CP. The participant was an 8-year old girl diagnosed with hemiparetic CP and classified as level I on the GMFCS. Results of the study showed an increase in knee and ankle extensors/flexors of both unaffected and affected limbs and a decrease in kinetic variables. The authors concluded that Pilates is a feasible rehabilitative tool that can applied to increase lower-body strength and postural control during quiet standing for a child with CP.
Previous studies on the efficacy of Pilates as a component to therapeutic intervention used divergent applications of the original work including clinical Pilates and Pilates-like exercises ( Kocuk et al., 2016; Lim et al., 2016; Shea & Moriello, 2014; Miyake et al., 2013). For the purpose of this project, we adhered to the Classical Pilates approach including the principles and exercises. The aim of the case study was to explore the integration of classical Pilates as a key component to a home-program for a youth diagnosed with CP.
PART III - EXCERPT of PILATES HOME PROGRAM INTERVENTION
* Name of the Exercise and Execution Purpose
Modification and Gradation Cues
* HUNDRED
WITH/WITHOUT BREATH-A-CIZOR
10x
Inhale for 5 seconds, exhale for 5 seconds this constitutes 1 rep
breath and coordination
(increase lung capacity, engagement of accessory breathing muscles, endurance, strengthen abdominal muscles)
sit in the wheelchair, no arms pumping, feet on the foot rests
perform lying down
begin with 5x, gradually build to 10x
Challenge when strong:
a. perform the Hundred 2x (at the beginning of the sequence and at the end)
b. perform the Hundred 2x in a row.
c. combine cues used for the Hundred and T.V. exercise
tactile cue example: therapist/parent hand over the abdominals to guide proper engagement; also supports the client’s awareness of abdominal engagement
verbal cues example: “pull navel to spine on the inhale, draw it up the spine on the exhale”
visual cues: stop if ATNR reflex is present; watch for involuntary UB and/or LB contracture-decrease # of reps, rest between reps
* one to two cues at a time. add more only when both client and parent confidently and correctly apply the cues to the exercise independently
NECK STRENGTHENER
3x-5x
Sit upright, hand on front of forehead. Inhale, pull navel to spine. Resist hand on forehead and hold for 3-4 counts. Release and exhale. Repeat hand on each side of the head and back of the head. This constitutes as 1 rep.
Strengthening of neck, trunk and abdominal muscles, improve trunk symmetry and dual activation of both sides of the body
begin with 1x, gradually build to 5x in each direction, 2-3x a week
Challenge: perform 5x 3-4x a week, therapist/parent increases resistance
therapist/parent acts as the resistance because the client is unable to use his hands to perform the exercise in its entirety
tactile cue example: therapist/parent places one hand against the forehead/side of the head/back of the head. do not press into the client’s head, just resist their movement
verbal cue example: “resist my hand” “breathe”
visual cues: stop if ATNR reflex is present; watch for involuntary UB contractures, elevated shoulders or head deviation from the center