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Of all children in the US born with Cerebral Palsy (CP), 30-40% of them will be diagnosed with Hemiplegic CP (HCP), presenting with one side of the body weaker than the other. The resulting asymmetries impede the ability of children with HCP to distribute weight evenly between their lower limbs. This often contributes to poor postural control and 'favoring' of their uninvolved side for stability during balance and gait. Much is still unknown about the biomechanical characteristics of asymmetry in the lower limbs. There are a few previous research studies completed in biomechanics labs that highlight some gaps in knowledge regarding our understanding of posture and balance in this population of children, but the availability of clinical assessments that help inform the implementation and impact of treatment targets for posture and balance are sparse. This dissertation showcases two independent studies aimed at some of the gaps in knowledge for posture and balance in children with HCP. The first study in this dissertation presents and tests the reliability when a clinical measure, the Posture and Postural Ability Scale (PPAS) was modified for use in children with HCP going through a therapeutic process. The PPAS was originally developed and tested with adults in controlled settings, often with individuals being placed in postures for examination. For the study presented here, modifications focused on scoring postures when children with HCP naturally assumed various sitting and standing postures during treatment. Researchers and an experienced therapist video-coded the modified PPAS. Intrarater and interrater reliability was calculated via Cohen's kappa, percent agreement and Intraclass Correlation Coefficients. Although reliability amongst and between researchers were weak (kappas < 0.7), videos were successfully scored, demonstrating the tool is feasible. In addition, some high levels of intrarater reliability was obtained by a more experienced clinician. Suggestive that this modified PPAS could serve as a potential tool for qualified clinicians to collect meaningful posture and postural control data. The second study addressed a specific gap in knowledge about the characteristics of gait anticipation (GA, i.e., expectation of initiating a step) in children with HCP on balance. Balance and limb symmetry metrics were compared during standing in three children with HCP and typically developing (TD) peers that were matched by age and sex, alongside a third (independent) sample of 12 unmatched TD children. Motion capture analysis and force plate technology were utilized to record and follow how center of pressure (COP) and center of mass (COM) move during quiet standing (without anticipating gait) and standing with GA. This study applied a Symmetry Index (SI) to COP displacement and COP velocity allowing for quantification of asymmetries between the lower limbs during standing with and without the anticipation of gait. Children completed multiple standing trials where they were ask to stand for 35 seconds (5 seconds to obtain balance and 30 seconds of data collection). Standing trials, involved sets where children were instructed that they would not walk forward and GA trials where they were asked to stand knowing that a light would indicate they should walk forward. The light also indicated which limb (i.e. right or left) the child should step forward with first. Limb designation for stepping forward was randomly generated. Data was examined across and within (15 second blocks) 30 seconds of standing. We had the following hypotheses: 1) GA would increase COP displacement and COP velocity for children with HCP greater than TD peers who would have no change; 2) children with HCP would have different levels of symmetry between the lower limbs when expecting to walk than TD peers; and 3) children with HCP would have different reaction times based on the limb (i.e., involved versus uninvolved) they were asked to start walking with. The HCP group showed the largest increase in COP displacement when comparing standing with no expectation of walking where they had an average of 22.0 ± 10.0 mm over 30 seconds of standing to an average of 24.5 ±9.90mm during GA. The matched group average was 11.3 ±8.87mm with no expectation of walking and 4.6 ±12.6mm with GA. The TD group's COP displacement remained relatively similar with an average of 8.04 ±6.40mm during when not expecting to walk and an average of 8.29 ±6.70mm with GA. Similar increases were seen for COP velocity. Comparisons for symmetry between limbs showed that COP was displaced more underneath the uninvolved side (first 15s was 79.52%) for children with HCP, and that COP displacement asymmetry switched to become larger underneath the involved side over time (the latter 15s was -82.81%) when there was no expectation for walking. This was inverted during GA, where children with HCP initially had more COP displacement on the involved side (-72.68%) and transitioned to higher levels on the uninvolved side (99.66%) as they prepared for gait initiation. Children with HCP took 0.2 seconds longer to initiate gait with their uninvolved (not preferred) side and also took twice as long to initiate gait overall in comparison to TD peers. Our data suggests that our listed hypotheses may be correct. However, this study has limitations to sample size, demographics and biomechanical metrics. Future studies should replicate these findings and include larger, more diverse samples with further metrics such as load. If findings are confirmed, this data suggests that therapies should consider that children with HCP might change postural strategies during standing when they are anticipating walking forward in comparison to simply standing in place. This dissertation seeks to set a foundation for collaborations between biomechanists and therapists alike, potentially highlighting novel opportunities to develop more innovative treatment options for children with HCP. / Doctor of Philosophy / Children with hemiplegic cerebral palsy (HCP) show limitations in coordination and activation of muscles on one side of their body; additionally, clinicians report an asymmetrical distribution of weight in their legs during standing and walking based on observation. This lower limb asymmetry is often paired with poor coordination and is believed to negatively impact posture and balance. Children with HCP often have difficulty starting and stopping walking, altered balance during sitting and standing, and challenges completing everyday activities such as navigating around or across obstacles and climbing up steps. I have worked together with my committee members to complete two independent projects measuring posture and postural control. The first project is a reliability study where researchers tested the utility of a modified measurement tool that could be used to score postures and postural control of children assuming natural postures during therapy sessions. The modified tool was based on a previously developed tool called the Posture and Postural Ability Scale (PPAS). The study had multiple researchers and a therapist score previously recorded treatment videos. Outcomes suggest that our modified PPAS could be used to score postures from video recordings of therapy session, but that increased modifications in the tool and scoring protocol are needed to improve the reliability of the tool. The second project funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development involved children with HCP and typically developing (TD) peers. The goal of the project was to understand if children with HCP change characteristics of standing when they know they will begin to walk. We also wanted to better understand issues surrounding how symmetrical (or not) children with HCP were with the use of both their involved and uninvolved legs. We found that children with HCP do alter characteristics of standing when they anticipate walking much more that TD peers. We also found asymmetries between the two limbs during standing that differed based on children with HCP's anticipation of walking.

Fundação de Amparo a Pesquisa no Estado do Rio Grande do Sul / People who have suffered stroke often have difficulty during walking. One of the reasons is hemiplegia, which is the main motor impairment caused by stroke. Hemiplegia generates asymmeries in limb control that often can result in compensation and overload in one of the hemisphere, leaving individuals susceptible to joint moments and/or exaggerated in both affected and unaffected limbs. The objective of this study was to analyze joint mechanics during hemiplegic gait, post-stroke. The sample was composed of 28 hemiplegic subjects and 22 subjects without hemiplegia. Kinetic and kinematic gait magnitudes were obtained for subsequent calculation of joint moments via inverse dynamics method. The hemiplegic individuals were divided into two groups: fast group and slow group, according to their self selected speed adopted during the data collection, and subjects without hemiplegia took part of the third group. Comparisons were conducted between groups and between the affected and unaffected members in the hemiplegic group. The results showed similar joint moments patterns between hemiplegic individuals and subjects without hemiplegia. Nevertheless, a higher number of differences were found in joint moments between groups and it became more evident at the beginning of the stance phase. Few differences were found on comparisons between the affected and unaffected limbs within the hemiplegic group. We concluded that people who have suffered strokes are susceptible to changes in joint moments, being more evident in hemiplegic individuals who adopted a faster walking speed. It occurs because the walking speed is an intervening factor for the calculation of joint moments. / Pessoas que sofreram Acidente Vascular Encefálico (AVE) frequentemente apresentam dificuldade durante a marcha. Um dos motivos para tal é a hemiplegia, que é o principal comprometimento motor ocasionado pelo AVE. A hemiplegia gera assimetrias corporais que muitas vezes podem resultar em compensações e sobrecargas em um dos hemicorpos, deixando os indivíduos suscetíveis a momentos articulares desproporcionais e/ou exagerados nos membros afetado e não afetado. O objetivo deste estudo foi analisar a mecânica articular durante a marcha de hemiplégicos, pós-AVE. A amostra foi composta por 28 sujeitos hemiplégicos e 22 sujeitos sem hemiplegia. Foram obtidas grandezas cinéticas e cinemáticas da marcha para posterior cálculo dos momentos articulares utilizando o método de dinâmica inversa. Os indivíduos hemiplégicos foram divididos em dois grupos: grupo rápido e grupo lento, de acordo com a velocidade autosselecionada adotada, e os sujeitos sem hemiplegia constituíram o terceiro grupo. As comparações foram realizadas entre os três grupos e entre os membros afetado e não afetado do grupo hemiplégico. Os resultados mostraram curvas de momentos articulares similares para indivíduos hemiplégicos e sujeitos sem hemiplegia. Ainda assim, um maior número de diferenças foi encontrado nos momentos articulares entre grupos e estas se fizeram mais presentes no início da fase de apoio. Nas comparações entre os membros hemiplégico e não hemiplégico poucas diferenças foram encontradas. Conclui-se que pessoas que sofreram AVE estão suscetíveis a alterações nos momentos articulares, sendo estas alterações mais evidentes no grupo hemiplégico que adotou uma velocidade de caminhada mais rápida. Isso ocorre porque a velocidade de caminhada é um fator interveniente para o cálculo dos momentos articulares.

La restauration fonctionnelle du membre supérieur chez l'hémiplégique séquellaire reste toujours l'objectif primordial recherché durant le processus de réhabilitation. De nos jours, les techniques émergentes de rééducation montrent de plus en plus d'efficacité et de réalisme, si elles sont accompagnées par les techniques conventionnelles et classiques. De plus, quelques idées anciennes ont évoluées vers l'utilisation du renforcement musculaire du membre atteint afin d'améliorer sa fonction motrice. En effet, le renforcement musculaire isocinétique constitue une technique potentiellement intéressante de rééducation pour des hémiplégiques. Dans le cadre de notre travail doctoral, nous avons utilisé le concept isocinétique pour réhabiliter les déficits moteurs et diagnostiquer les déficits de coordination du membre supérieur hémiplégique. En premier lieu, nous avons essayé de montrer le rôle de l'isocinétisme pour optimiser la prise en charge du membre supérieur chez l'hémiplégique. Nous avons d'abord présenté une revue de littérature sur le renforcement musculaire isocinétique après hémiplégie suite à une lésion cérébrale. Ensuite, nous avons évalué la faisabilité d'un programme basé sur ce type de renforcement, pour le coude et le poignet chez des hémiparétiques. Ainsi, l'utilité et l'efficacité de ce type de réentraînement isocinétique ont pu être mises en évidence. En second lieu, nous avons utilisé l'isocinétisme pour comprendre l'implication du rôle des afférences dans le déficit de coordination bimanuelle après accident vasculaire cérébral causant une hémiplégie. Dans l'ensemble, ces différents résultats autorisent à recommander l'outil isocinétique pour quantifier les déficits moteur et de coordination du membre supérieur chez l'hémiplégique, en vue d'une meilleure élaboration et mise en place de protocoles de rééducation isocinétique. / Functional restoration of the upper limb in sequelae hemiplegic remains the primary objective during the rehabilitation process. Nowadays, emerging rehabilitation techniques show more efficiency and realism, if they are accompanied by conventional and standard techniques. In addition, some old ideas have evolved to use the affected limb muscle strengthening to improve motor function. Indeed, the isokinetic muscle strengthening is a potentially interesting technique for rehabilitation of hemiplegic patients. As part of our doctoral work, we used the isokinetic concept to rehabilitate motor deficits and diagnose coordination deficits for hemiplegic upper limb. First, we tried to show the role of isokinetic to optimize the management of upper limb in hemiplegic patients. We firstly presented a review of literature on isokinetic muscle strengthening after hemiplegia following a brain injury. Then, we evaluated the feasibility of a training program based on this type of reinforcement for the elbow and wrist in the hemiparetic patients. Thus, the usefulness and effectiveness of this type of isokinetic exercise training have been highlighted. Second, we used the isokinetic to understand the contribution of afference-based processes to the impairment of bimanual coordination after stroke causing hemiplegia. On the whole, these results allow recommending the isokinetic tool to quantify motor and coordination deficits of upper limb in hemiplegic patients, for better development and implementation of isokinetic rehabilitation protocols.

Syfte: Syftet med studien var att beskriva arbetsterapeuters erfarenheter av att använda sig av CI-terapi som intervention för barn med hemiplegisk cerebral pares. Metod: En kvalitativ ansats valdes för att beskriva arbetsterapeuternas subjektiva upplevelser. Åtta semistrukturerade intervjuer genomfördes med arbetsterapeuter som arbetade på barn- och ungdomshabiliteringar i landet och analyserades därefter utifrån kvalitativ innehållsanalys. Resultat: Den insamlade datan resulterade i fyra kategorier: Arbetsterapeutens stöd; Nätverkets betydelse; Anpassning av interventionen samt Organisatoriska strukturer. Resultatet visade att interventionen bör utgå från barnets motivation och lek i samverkan med barnets nätverk samt att interventionen mestadels bidrog till att barnet fick en utökad aktivitetsrepertoar. Vidare beskrevs att interventionen utfördes endast av några arbetsterapeuter runt om i landet då den är tidskrävande, kräver resurser och en tydlig struktur. Det framkom även att kollegialt stöd bland arbetsterapeuterna främjar genomförandet av CI-terapi. Slutsats: I studien framkommer att barnets aktivitetsrepertoar mestadels förbättrades med CI-terapi men kunde inte påvisas med nuvarande bedömningsinstrument. / Purpose: The aim of this study was to describe occupational therapists’ experience of using Constraint Induced Movement Therapy for children with hemiplegic cerebral palsy. Methods: A qualitative method was chosen to describe the subjective experiences of the occupational therapists. Eight semi structured interviews were conducted with occupational therapists that were working at different centres for child and adolescent rehabilitation in this country, thereafter the collected data was analysed using qualitative content analysis. Result: The results were divided into four categories: The occupational therapist’s support, The importance of the network, Adaptation of the intervention and The organisational structures. The result indicate that the intervention should be centred on the child’s motivation and play in collaboration with the child’s social network and the intervention usually leads to an extended activity repertoire for the child. Furthermore, the result indicates the intervention to be time consuming, demanding extensive structure and resources, which led to the intervention was performed by only a few occupational therapists. It also appeared that collegial support among occupational therapists promotes the implementation of Constraint Induced Movement Therapy. Conclusion: The study show that the child’s range of activities often were improved when using Constraint Induced Movement Therapy, but this could not be proven with today’s assessment instrument.

Made available in DSpace on 2016-04-28T20:40:05Z (GMT). No. of bitstreams: 1 Julia Schmidt Maso.pdf: 823462 bytes, checksum: c0425a5296506cda737f70dc32af1dc7 (MD5) Previous issue date: 2009-05-28 / Conselho Nacional de Desenvolvimento Científico e Tecnológico / The objective of this study is to understand and describe the difficulties of a person with hemiplegia as a consequence of a CVA (Cerebrovascular Accident), commonly known as stroke, and the process of symbolic grief of the body and the sequels. The emotional repercussion due to physical limitations acts significantly on the social, economical and emotional scope of the individual, causing disorganization to his/her life. To face these changes, the person has to count on his/her internal and external resources, which will or will not enable the elaboration of the process of the symbolic grief. A qualitative study was carried out based on the Theory of Attachment by John Bowlby with the participation of four hemiplegic adult patients. The data collection included a semi-oriented interview to describe and analyze the significance of the interrelation of himeplegia, between the body representation and the subjectivity of each person. The information arisen from qualitative analysis procedures was discussed and the conclusion was that it is difficult to measure, validate and recognize the existence of losses caused by the disease and the gradual appropriation of reality. The physical rehabilitation aiming at independence is evaluated according to the gain in life quality of the participants. However, mechanisms of defense, as denial or non acceptance, demonstrate the difficulty to adapt to a new reality. According to the results, we conclude that it is important to identify the expectations of the handicapped person, the significance he/she attributed to the disease and to his/her himeplegia. This survey supports the need to investigate the repercussion of the CVA in general to obtain a better result from the rehabilitation process / Este estudo teve como objetivo compreender e descrever a problemática da pessoa portadora de hemiplegia por Acidente Vascular Cerebral (AVC) e o processo de luto simbólico pelo corpo com sequelas. As repercussões emocionais decorrentes das limitações físicas atuam de modo significativo no âmbito social, econômico e emocional do indivíduo, provocando uma desorganização em sua vida. Para o enfrentamento destas mudanças, a pessoa terá de contar com os seus recursos internos e externos, que possibilitarão ou não a elaboração do processo de luto simbólico. Foi realizado um estudo qualitativo embasado na Teoria do Apego de John Bowlby, do qual participaram quatro pacientes adultos portadores de hemiplegia. A coleta de dados incluiu a realização de uma entrevista semidirigida para descrever e analisar o significado da interrelação entre hemiplegia, representação do corpo e subjetividade para cada pessoa. A partir de procedimentos de análise qualitativa, as informações foram discutidas e revelou-se a dificuldade em validar e reconhecer a existência de perdas provocadas pela doença, e a gradual apropriação da realidade. A melhora física, como a conquista da independência, é avaliada pelo ganho na qualidade de vida dos participantes. Entretanto, mecanismos de defesa como a negação apontam para a dificuldade de adaptarem-se à nova realidade. Diante dos resultados encontrados, concluiu-se ser importante identificar as expectativas da pessoa portadora da deficiência e os significados atribuídos à experiência de adoecer e tornar-se hemiplégico. Esta pesquisa sustenta a necessidade de se investigar as repercussões do AVC de um modo global, para a obtenção de um melhor resultado no processo de reabilitação

Made available in DSpace on 2014-06-11T19:22:32Z (GMT). No. of bitstreams: 0 Previous issue date: 2010-08-31Bitstream added on 2014-06-13T20:09:44Z : No. of bitstreams: 1 estremote_mm_me_ilha.pdf: 1708238 bytes, checksum: b2b9251aec47823d0f93f23f57209dcb (MD5) / Neste trabalho descreve-se um sistema constituído por duas plataformas de forças e seus respectivos circuitos de condicionamento e interfaceamento de sinais, projetado para medir a distribuição de descarga de peso na região plantar de pacientes. Em cada plataforma de força foram acopladas 24 células de carga construídas com extensômetros. As características estáticas do sistema foram determinadas em laboratório utilizando pesos conhecidos. O sistema apresentou linearidade, com coeficiente de determinação de 0,9997, baixa histerese, precisão de 0,84% e resolução de 0,5 N. As medidas são apresentadas na tela de um computador facilitando a visualização para especialistas da área, principalmente médicos, fisioterapeutas e terapeutas ocupacionais. Utilizando o sistema foram medidas as distribuições de peso na região plantar de 87 indivíduos sem hemiplegia (sem histórico de queixas de dores ou problemas no sistema neuromusculoesquelético) e de 10 hemiplégicos crônicos, com mais de um ano de hemiplegia. Estes foram submetidos à avaliação utilizando a Escala de Equilíbrio de Berg. Entre os indivíduos se hemiplegia, estudou-se mais detalhadamente um grupo de 15 bailarinos e um de 12 ginastas rítmicas. Determinou-se a relação entre a distribuição de pesos nos antepés esquerdo e direito de indivíduos sem hemiplegia e hemiplégicos com o sistema implementado. Através do sistema constatou-se que a relação entre a distribuição de pesos no antepé esquerdo e direito dos indivíduos hemiplégicos é muito mais elevada que a dos indivíduos sem hemiplegia. Este resultado era de se esperar, uma vez que o hemiplégico descarrega seu peso predominantemente no lado não plégico / This work describes a system consisting of two force platforms and their conditioning circuits and interfacing signals, designed to measure the distribution of weight load on the plantar region of patients. Each force platform was constructed with 24 load cells with strain gages. The static characteristics of the system were determined in laboratory using known weights. The system showed linearity with determination coefficient of 0.9997, low hysteresis, accuracy of 0.84% and resolution of 0.5 N. The measurements are presented in a computer screen in a friend way for specialists in the health field, mainly doctors, physiotherapists and occupational therapists. Using the system we measured the weight distributions in the plantar region of 87 normal patients (no history of complaints of pain or problems in the neuromuscular system) and 10 hemiplegic, with more than a year of hemiplegia. The latter were evaluated using the Berg Balance Scale. Among normal subjects, we studied a further group of 15 dancers and one of 12 rhythmic gymnasts. The relationship between the distribution of weights in the left and right forefeet of patients with normal and hemiplegic was determined with the implemented system. Through the system we found that the relationship between weight distribution on the left and right forefoot of hemiplegic patients is much higher than that of normal patients. This result was expected, since the hemiplegic unloads his weight predominantly in non-paralyzed side