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PassPMR - 09 Pediatrics > 2- Cerebral Palsy > Flashcards

2- Cerebral Palsy Flashcards

1
Q

What is the definition of Cerebral Palsy? 🔑🔑 MOCK Dr. Haitham

List 15 complications - challenges in CP child? 🔑🔑 OSCE Dr. Haitham

A

DEFINITION

  1. Permanent motor disorders affecting movement and posture, causing activity limitation.
  2. Caused by non-progressive disturbances that occurred in the developing fetal or infant brain <3yo.
  3. Also accompanied by disturbances of sensation, perception, cognition, communication, and behavior, by epilepsy, and by secondary musculoskeletal problems.

CHALLENGES

  1. Movement & Posture
    1. Movement → Weakness
    2. Posture → Scoliosis, DDH
    3. Activity limitation → WC, Osteoporosis, Contracture
  2. Sensory: Tactile, Proprioception
  3. Perception: Vision, Hearing
  4. Cognition: IQ, MR 50%
  5. Communication: Language, Dysarthria, Dysphagia & Sialorrhea
  6. Behavioral: ADHD
  7. Seizure 50%
  8. Secondary MSK: Spasticity
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2
Q

Name 5 affected systems w/ 1 example in CP

Mention 1 way to rehabilitate/manage it. 🔑🔑 MOCK Dr. Haitham

A

💡 Move Post Active, CP Coco Bee, Seizure & MSK

  1. Movement & Posture
    1. Hemiplegia/Hemiparesis → Assistive devices, orthosis
    2. Posture
      • Scoliosis → Brace and orthopedic referral
      • DDH → Casting, pavlic harness
    3. Activity limitation
      • WC
      • Osteoporosis
      • Contracture → Orthosis, surgery
  2. Sensory: Tactile, Proprioception
  3. Perception:
    • Vision impairment (Strabismus, refractory errors) → eye glass prescription
    • Hearing impairment → hearing aids
  4. Cognition: IQ, MR 50%
    • Special schooling with individualized program planning
  5. Communication
    • Language
    • Dysarthria → oromotor exercises
    • Dysphagia → PEG tube, NG tube, oromotor exercises
    • Sialorrhea → Atropin, scopolamine, oromotor exercises
    • Dental caries, gingival hyperplasia → Follow dentist
    • Aspiration → Vaccination , chest wall ex, improve cough/ventilation, mucolytics.
  6. Behavioral: ADHD
  7. Seizure 50%
    • Anti-epileptics
  8. Secondary MSK
    • Spasticity → ROM Ex, Orthosis, Modalities, Baclofen, ITB, BTX
  9. Autonomic Dysfunction
    • Neurogenic bladder: CIC, anti-cholenergic medications
    • Neurogenic bowel: stool softener, bulking agents, suppositories, enemas
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3
Q

What is the number 1 cause of death in children with CP?

What are 3 Risk factors for pneumonia in children with CP? 🔑🔑

A

💡 Pneumonia (90% of deaths of children with CP related to pneumonia).

Dysphagia

  1. Aspiration

Breathing

  1. Kyphoscoliosis
  2. Airway obstruction

Cough & Clear

  1. Decreased mucous clearance
  2. Suppuration

Ref: Braddom pg 1260.

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4
Q

How common is CP? How does this compare with spina Bifida? 🔑🔑 Dr. Haitham

What is the number one risk factor/cause of CP? 🔑🔑 Dr. Haitham

A

COMMON

1-2.3/1,000 live births for CP.

Ref: Braddom pg 1253.

1-2/1,000 live births for SB.

Ref: Delisa pg 1496.

TWO MAJOR FACTORS

  1. Low birth weight <2,500 grams (59.6 per 1000 live births)
  2. Birth at <32 weeks of gestation ****(111.8 per 1000 live births)

💡 “…immature vasculature and fluctuations in cerebral blood flow”

Braddom 6th Edition Chapter 47 Cerebral Palsy pg1006-1007

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5
Q

List 5 Etiologies or risk factors for developing cerebral palsy. 🔑🔑 Dr. Haitham

A

PRECONCEPTION

  1. Maternal seizures
  2. Intellectual disability
  3. Thyroid disease (hyper and hypo)
  4. History of stillbirth or neonatal death
  5. Maternal age older than 40 years
  6. Low socioeconomic status

ANTENATAL

  1. Birth defects
  2. Small for gestational age
  3. Low birth weight
  4. Placental abnormalities
  5. Incompetent cervix
  6. Abnormalities in fluid volume
  7. Maternal bleeding in the second and third trimesters
  8. Hypertension, preeclampsia
  9. Chorioamnionitis

INTRAPARTUM:

  1. Birth hypoxia
  2. Meconium aspiration
  3. Abnormal duration of labor
  4. Fetal presentation

NEONATAL:

  1. Seizures
  2. Respiratory distress
  3. Hypoglycemia
  4. Infections
  5. Jaundice

POSTNATAL:

  1. Stroke
  2. Abusive head trauma
  3. Bacterial meningitis
  4. Motor vehicle crashes

Braddom 6th Edition Chapter 47 Cerebral Palsy pg1006-1007

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6
Q

What are the types of CP? 🔑🔑

A
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7
Q

Spastic CP features & Subtypes 🔑🔑

When do you consider abnormal Babinski?

A

💡 Extensor Babinski response (abnormal at >2 years)

1. Spastic monoplegia

Isolated upper extremity (UE) or LE involvement

2. Spastic diplegia (75% of premature infants)

Primarily LE >> UE involvement

Early hypotonia followed by development of spasticity (just like stroke)

History of intraventricular hemorrhage, PVL

Long term contracturs and spasticity

Classic scissoring gait with toe walking.

3. Spastic triplegia

Three extremities with the bilateral LEs and one UE classically affected → Spasticity

Scissoring and toe walking is observed

4. Spastic tetraplegia

Difficult delivery with evidence of perinatal asphyxia

Truncal hypotonia with appendicular hypertonia or total body hypertonia exists

5. Spastic hemiplegia

MCA infarction

Hemiparesis by 4 to 6 months of age with hypotonia being the first indicator

Cranial nerves may be involved (facial weakness).

Cuccurollo 4th Edition Chapter 10 Pediatrics pg776 & pg780

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8
Q

Baby prefers left hand at 9 months old.

Which type of CP? Examination? Will my child walk? 🔑🔑

A

HAND PREFRANCE = SPASTIC HEMIPLEGIA 39% of CP

  • Preferential hand used prior to 1 year of age

Cause

  • MCA infarction
  • 70% to 90% are congenital
  • 10% to 30% are acquired secondary to vascular, arteriovenous malformations, inflammatory, or traumatic

Clinical Examination

  • Refractory error; may have hemianopsia
  • Speech is preserved
  • Cognitive impairment in 28%
  • Seizures in 33%.
  • Visual deficits in 25%
  • Learning disabilities
  • Cranial nerves may be involved (facial weakness).
  • Hemiparesis by 4 to 6 months of age with hypotonia being the first indicator
  • Arm more involved than leg (MCA)
  • Asymmetric crawl seen (hemi-paresis)
  • Cortical sensory deficit (hemi-anasthesia)

Will my child walk?

  • Average age of walking is 24 months.
  • Circumduction gait “stroke-like”

Cuccurollo 4th Edition Chapter 10 Pediatrics pg777

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9
Q

Baby age 18 months not walking, he does crawling only.

Which type of CP? Examination? Will my child walk? 🔑🔑

A

COMMANDO CRAWLING = SPASTIC DIAPLEGIA 38% of CP

Cause

  • Periventricular leukomalacia (PVL), Ischemia due to intraventricular hemorrhage.
  • In the corona radiata, descending fibers from the motor cortex are arranged with those subserving the LE medially and UE laterally.
  • Larger lesions affect both the UE and LE and result in quadriplegic CP.

Features

  • Early hypotonia followed by development of spasticity (just like stroke)
  • Developmental delay in gross motor skills
  • Seizures 20% to 25%
  • Mild cognitive impairment in 30%.
  • Strabismus in 50% and visual deficits in 63%. (Risk of amblyopia)
  • Muscles affected : hip flexors, adductors, and gastrocnemius muscles
  • LL examination shows UMN sings
  • Gait
    • Classic scissoring gait with toe walking (talipes equinovarus deformities)
    • Couch Gait

Will my child walk?

  • Most diplegics ambulate with classic scissoring gait with toe walking.
  • Some require assistive devices

Cuccurollo 4th Edition Chapter 10 Pediatrics pg777

Braddom 6th Edition Chapter 47 Cerebral Palsy pg

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10
Q

Difficult delivery with evidence of perinatal asphyxia.

Four limbs are involved, patient in WC.

Which type of CP & Will my child walk? 🔑🔑

A

COMPLICATED PREGNANCY = SPASTIC TETRAPLEGIA 23% of CP

Causes

  1. Major hypoxic event (perinatal asphyxia) usually a history of difficult delivery.
  2. Medial motor cortex, which affects UE more severely than LE (homunculus)
  3. Focal & Multifocal ischemic brain injury
  4. Injury to bilateral cortical zones

Highest incidence of significant disability:

  • Strabismus
  • Seizures in 50%
  • Significant mental retardation
  • Legs are usually more involved than arms
  • Initial period of hypotonia which eventually develops into extensor spasticity
  • Truncal dystonia, Opisthotonus and precocious head raising
  • Oromotor dysfunction, pseudobulbar involvement → risk of aspiration
  • Feeding difficulties—may need G-tube
  • Hip dislocation
  • Scoliosis (Any disease with weakness & immobility = scoliosis)
  • Persistent primitive reflexes

Will my child walk?

  • 50% require assisted ambulation, assisted ADL
  • 25% independent in ambulation, modified ADL
  • 25% completely disabled

Cuccurollo 4th Edition Chapter 10 Pediatrics pg778

Braddom 6th Edition Chapter 47 Cerebral Palsy pg1010

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11
Q

Dyskinetic CP features & subtypes

List 3 Important screening tool. Will my child walk?

A

EXTRAPYRAMIDAL = DYSKINETIC

Causes

  • Kernicterus (neonatal hyperbilirubinemia, hemolysis)
  • Hypoxia of the basal ganglia and thalamus

Subtypes

  1. Athetosis: Slow writhing, involuntary movements, especially in the distal extremities.
  2. Chorea: Abrupt, irregular jerky movements,
  3. Choreoathetoid: Combination of athetosis and choreiform movements.
  4. Dystonia: Slow rhythmic movements associated with abnormal posturing.
  5. Ataxia: Uncoordinated movements often associated with nystagmus, dysmetria, and a wide-based gait

Features

  • Involuntary movements first in the hands and fingers
  • Athetosis
  • Coordination deficits
  • Seizures in 25%
  • Defects in postural control
  • Movement patterns typically increase with stress or purposeful activity.

Screen

  • Sensorineural deafness (high incidence)
  • Pseudobulbar involvement (dysarthria, dysphasia, drooling, and oromotor dyskinesias.)
  • Nonambulatory patients are at risk for hip dysplasia and scoliosis

Charectristics

  • During sleep, muscle tone is normal, and involuntary movement stops.

Will my child walk?

  • 50% attain walking, most of them after 3 years of age, independent in ADLs
  • 50% are nonambulatory, dependent in ADLs

Cuccurollo 4th Edition Chapter 10 Pediatrics pg778-779

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12
Q

What is the GMFCS classification? What does it stand for? When is it used? 🔑🔑

A

Gross motor function classification system (GMFCS) is a functionally based system to standardize gross motor function in the CP child.

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13
Q

What is GMFCS 4? List 3 aids/mobility devices 🔑🔑

A

GMFCS 4

  • Mainly wheelchair dependent (preferred mobility)
  • May walk short distances indoors.

Mobility Devices

  1. Walker with body support (standing frame).
  2. Manual wheelchair.
  3. Power wheelchair.

Ref: GMFCS-ER document.

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14
Q

4 y/o male: spastic diplegic CP, sits independently, can rise from ground, needs wall or table to pull-to-stand, ambulates independently indoors without aid.

Outdoors can ambulate on level ground, stairs with railing, but cannot run or jump. 🔑🔑

(a) GMFCS level
(b) List 2 predictions about ambulation at 12 y/o

A

LEVEL

  • GMFCS 2 (ambulates with limitations)

AMBULATION

  1. Minimal ability to run or jump.
  2. Difficulty walking on uneven terrain.

Ref: GMFCS – ER document.

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15
Q

Positive & negative prognostic factors for walking 🔑🔑 OSCE Dr. Haitham

A

Positive

  1. Rolling by 18 months
  2. Sitting by age of 2 yo
  3. Crawling by age 1.5-2.5 yo

Negative

  1. Three primitive reflexes at 2 years
  2. Not sitting by age of 4
  3. Seizures
  4. Cognitive Deficit / Mental Retardation
  5. Tetraplegic CP

Braddom 6th Edition Chapter 45=7 CP pg1011

Cuccurollo 4th Edition Chapter 10 Peds pg782

Delisa 5th Edition Chapter 46 Children with Disability pg1484 5th Edition

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16
Q

List 4 causes of toe walking in 4 year old. 🔑🔑

A

💡 Remember the 3 common topics in peds (CP, SB, DMD) + CMT + LLD

  1. Cerebral palsy.
  2. Congenital muscular dystrophy (DMD, BMD).
  3. Tethered cord syndrome.
  4. Global developmental delay.
  5. Charcot-marie-tooth disease.
  6. Autism.
  7. Idiopathic
  8. Limb-length discrepancy.

Ref: 2012 J Am Acad Orthop Surg 2012;20:292-300.

Peds rehab textbook pg 191.

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17
Q

4 year old boy: toe-walking, scissoring, hypertonic legs > arms, 20 degrees passive hip ABD, equinovarus deformity in gait but passive ankle movement just past neutral

Most likely diagnosis & List 5 treatments to improve ambulation 🔑🔑

A

DIAGNOSIS

  • Cerebral palsy - spastic diaplegia

NON-PHARMACOLOGICAL

  1. Physiotherapy: Stretching, heat
  2. Orthosis: AFO (solid AFO covering MTP joint) or Serial casting
  3. Gait Aids: Forearm crutches, walker

PHARMACOLOGICAL

  1. Anti-spastic meds (baclofen, dantrolene, tizanidine etc)
  2. BoNT injections

SURGICAL

  1. Orthopedic: tendon lengthening (post tib), muscle release (adductors etc)
  2. Neurosurgery: Selective dorsal rhizotomy, ITB.

Ref: first principles.

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18
Q

Mention 4 Gait Findings in Spastic Hemiplegia 🔑🔑

A
  1. Upper limb posturing, no reciprocal arm movement
  2. Weak hip flexion
  3. Weak ankle dorsiflexion (foot drop)
  4. Supinated foot in stance phase (tibialis posterior spasticity)
  5. Hip hiking or hip circumduction due to long lower limb

Cuccurollo 4th Edition Chapter 10 Pediatrics pg781

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19
Q

Describe Spastic Diplegic Gait 🔑🔑

A
  1. Scissoring gait pattern
    1. Hip flexed and adducted
    2. Knees flexed with valgus
  2. Ankle equinus (toe walking)

Cuccurollo 4th Edition Chapter 10 Pediatrics pg781

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20
Q

Describe the gait and mention the possible causes 🔑

A
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21
Q

Describe (1) Equinus Knee Gait, list 1 cause & surgical treatment 🔑🔑

A

Description

  • Gastrocnemius contracture

Causes

  • Spasticity of the gastrocnemius muscles

Treatment

  • Hinge AFO
  • Tendo Achilles lengthening

Braddom 6th Edition Chapter 47 Cerebral Palsy pg1024 Table 47.10

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22
Q

Describe (2) Jumping Gait, list 2 causes & surgical treatment 🔑

A

Description

  • Excessive hip and knee flexion and ankle equinus (think all are contracted)

Causes

  1. Psoas, Hamstring, rectus femoris, and gastrocnemius contractures
  2. Weakness
  3. Bony rotational deformities

Treatment

  • Hinged AFO
  • Extension osteotomies of the femur

Braddom 6th Edition Chapter 47 Cerebral Palsy pg1024 Table 47.10

23
Q

Describe (4) Crouch Knee Gait, list 2 causes & surgical treatment 🔑

A

Description

  • Excessive hip and knee flexion, and ankle dorsiflexion

Causes

  • Psoas, Hamstring, rectus femoris, and gastrocnemius contractures or weakness

Treatment

  1. GRAFO
  2. Extension osteotomies of the femur

Braddom 6th Edition Chapter 47 Cerebral Palsy pg1024 Table 47.10

24
Q

Describe Scissoring Gait, list 2 causes & surgical treatment 🔑🔑

A

Description

  • Excessive lower extremity adduction

Causes

  1. Femoral anteversion
  2. Medial hamstring spasticity
  3. Hip adductor spasticity

Surgical Treatment

  1. Adductor tenotomy or myotomy
  2. Hamstring lengthenings

Braddom 6th Edition Chapter 47 Cerebral Palsy pg1024 Table 47.10

25
Q

Describe Stiff Knee Gait, list 2 causes & surgical treatment

A

Description

  • Decreased knee flexion range of motion through-out the gait cycle

Causes

  1. Overactive rectus femoris during swing phase

Surgical Treatment

  • Rectus femoris transfer

Braddom 6th Edition Chapter 47 Cerebral Palsy pg1024 Table 47.10

26
Q

Mention possible joint pathology and the potential effect on gait. 🔑🔑 Dr. Maitha

A

Michael A. Alexander Pediatric Rehabilitation - 5th Edition

27
Q

Child with cerebral palsy and achilles lengthening 2 years ago.

Unfortunately, he developed crouched gait post operatively, List 3 possible MSK causes.

A
  1. Knee flexion contractures
  2. Achilles lengthening too long
  3. Weak gastroc-soleus

Ref: First principles.

28
Q

Which type of CP have the highest rate of mental retardation?

A

Spastic tetraplegic type has the highest rate of mental retardation

While spastic hemiplegic and diplegic types have the lowest

29
Q

Seizures in CP, overall chance of getting seizure?

Which has the most incidence?

Most common Type?

A

Incidence CP is 50%

Common in spastic tetraplegics (50%)

Grand mal with tonic–clonic convulsions is a common type.

30
Q

Hearing Impairment, causes and found in which type of CP?

A

Sensoryneural hearing loss

  • Increased prevalence in athetosis (dyskenetic)
  • Significantly impact the development of communication and cognition.

Caused by any insult to the developing brain:

  1. Kernicterus (most common)
  2. Intrauterine infections
  3. Perinatal hypoxia
  4. Meningitis
  5. Encephalitis
  6. Ototoxic Drugs

Cuccurollo 4th Edition Chapter 10 Pediatrics pg783

31
Q

What sensory deficit that might affect functional use of the extremity CP

A
  1. Two-point discrimination
  2. Proprioception
  3. Stereognosis
32
Q

List 3 most common vision abnormalities in CP other than strabismus 🔑🔑

A

💡 Strabismus (Esotropia) 60%, highest rate in spastic diplegics and tetraplegics.

EYES

  1. Retinopathy
  2. Refractive errors

OPTIC N.

  1. Homonymous hemianopsia
  2. Reduced visual acuity
  3. Amblyopia

EOM

  1. Strabismus
  2. Esotropia
  3. Oculomotor dysfunction (impaired accommodation)

Basal Ganglia

  1. Nystagmus

Cuccurollo 4th Edition Chapter 10 Pediatrics pg783

33
Q

Treatment for Dystonia in CP. 🔑🔑

34
Q

Child with CP. What are the non-surgical methods to manage his spasticity? 🔑🔑

A

ER-POLICE-MIS

  1. Education: avoid triggers, proper WC & position, bowel & bladder care
  2. Protection & Orthosis: Serial Casting or Splinting
  3. Loading: Stretching and weight bearing
  4. ICE & Modalities
  5. Oral Medication
  6. Injectable Medications
    • Nerve/motor point blocks
      • Temporary sensory dysesthesias
      • Permanent weakness leading to deformity (e.g., tibial block leading to calcaneovalgus foot)
    • Chemodenervation
      • Less technically demanding on clinicians
      • Does not cause dysesthesia
      • Decreased injection site pain and discomfort

Cuccurollo 4th Edition Chapter 10 Pediatrics pg785-789

Michael A. Alexander Pediatric Rehabilitation 5th Edition = Braddom 6th Edition (Colored)

35
Q

Child with CP. What are the surgical methods to manage his spasticity? 🔑🔑 OSCE

List 6 surgical modalities are useful in CP.

A

NEUROSURGICAL

  1. Selective rhizotomy
    • Indications
      • 3–8 years old
      • Lack of significant joint contractures
      • Good cognition and motivation
    • Contraindications
      • Children with poor head and trunk control
      • Use spasticity for functional purposes
    • Side Effects → Induced SCI
      • Hypotonia
      • Weakness
      • Bowel & bladder dysfunction
      • Hip dislocation (hip flexor spasticity)
  2. Intrathecal baclofen (ITB) pump

ORTHOPEDIC

  1. Soft tissue releases
  2. Tendon lengthening
  3. Tendon transfers
  4. Joint fusions
  5. Osteotomies (de-rotation or angulation osteotomies

Cuccurollo 4th Edition Chapter 10 Pediatrics pg788-789

36
Q

What are the feeding challenges in CP? 🔑🔑

A

THINK LAYERS

  1. Lips: Difficulty sucking
  2. Tooth: Poor hygiene, detal carries
  3. Saliva: Sialorrhea
  4. Tongue: Dysarthria
  5. Chewing: Difficulty chewing
  6. Swallowing: Difficulty swallowing

CHALLENGES

  1. Oral hygiene
  2. Sialorrhea
    • Negatively affect social interactions.
  3. Dental Problems
    • Malocclusion, Enamel dysgenesis, Risk for cavities (carries/decay)
  4. Impaired oropharyngeal strength and coordination
    • Weak suck, poor coordination of the swallowing mechanism
    • Motor incoordination: difficulty swallowing, sucking, and chewing
  5. Psuedobulbar palsy
    • Dysarthria, drooling, and poor chewing
  6. Constipation
  7. Struggle to gain weight only to lose this weight quickly

COMPLICATIONS

  1. Malnutrition
  2. Aspiration
  3. Gastroesophageal reflux

Braddom 6th Edition Chapter 47 Cerebral Palsy pg1012

37
Q

Management of feeding in CP child? 🔑🔑

A

INVESTIGATIONS

  1. Dysphagia evaluation
  2. Modified barium swallow
  3. Fiber optic endoscopy evaluation

MANAGEMENT

Food

  1. Supplemental caloric and fluid intake
  2. Placement of gastrostomy tubes

Patient

  1. Low risk feeding strategies
  2. Postural techniques: Chin tuck, head tilt (strong), head rotation (weak)
  3. Swallowing techniques: Supraglottic swallow, double swallow, effortful swallow
  4. Cleaning techniques: Dry swallow, double swallow, wet or dry mouth cleaning
  5. Oromotor exercises
  6. Thermal stimulation

Dr. Matiham’s Notes

38
Q

List 4 Possible complications that could happen if dysphagia is left untreated. 🔑

A

MALNUTRITION

  1. Malnutrition & Anemia
  2. Growth disturbances
  3. Increased infection rates
  4. Skin breakdown
  5. Osteopenia

ASPIRATION

  1. Silent aspiration & Interstitial lung fibrosis
  2. Decreased life expectancy.

Braddom 6th Edition Chapter 47 Cerebral Palsy pg1012

39
Q

What are the possible complications of hypersalivation? What are the causes? 🔑

A

Anterior Drooling

  1. Social embarrassment
  2. Peri-oral skin breakdown & infection
  3. Dehydration
  4. Clothing and bibs become soiled and need frequent changing

Posterior Drooling

  1. Congested breathing
  2. Coughing
  3. Gagging
  4. Vomiting
  5. Aspiration +/- pneumonia.

Primary

  • Hypersecretion of the salivary glands

Secondary

  • Impaired neuromuscular control with dysfunctional voluntary oral motor activity that leads to an overflow of saliva from the mouth

Dr. Haitham Notes

40
Q

A child with CP with hypersalivation and drooling.

List 5 management options. 🔑🔑 Dr. Haitham

A

Education

  1. Rule out oral infection: Dental caries, Infection, Gingivitis

Non Pharma

  1. Behavioral therapy (cues, reward)
  2. Head positioning
  3. Colourful towels
  4. Decrease PO fluid intake NB dehydration
  5. Oral-motor therapy

Pharma

  1. Anti-cholinergic Scopolamine
  2. Botulinum toxin to salivary glands
  3. Atropin droplets

Intervention

  1. Low dose radiation
  2. Submandibular gland excision
  3. Submandibular duct relocation
  4. Submandibular Duct ligation

Dr. Haitham Notes

https://emedicine.medscape.com/article/879271-overview

41
Q

Normal function of Saliva?

A
  1. It protects the teeth and gingival tissues from infection
  2. Lubricates the oral mucosa to aid in swallowing and speech
  3. Deters foul breath by cleansing the oral cavity
  4. Promotes digestion by breaking down proteins and carbohydrates with amylase.

https://emedicine.medscape.com/article/879271-overview

42
Q

What are the four steps of pulmonary rehab for children with CP? 🔑🔑

A

💡 Those four steps are applied in any case of pulmonary rehabilitation.

Step 1) Prevention

  1. Immunizations
    • Influenza, Pneumococcal, COVID
  2. Management of dysphagia:
    • Repeated aspiration & Chest infections → Modified feeding & prophylactic antibiotics
    • Sialorrhea → Anticholinergic medications or botulinum injections

Step 2) Breathing

  1. Upper Airways
    • Sleep Apnea & Hypoventilation (pseudobulbar palsy, central or peripheral)
    • Treatment: CPAP
  2. Lower Airways / Ribcage
    • Scoliosis → Restrictive pulmonary disease
    • Treatment: Bracing or Surgery
  3. Muscles
    • Decreased vital and aerobic capacity (neuromuscular weakness)
    • Treatment: Noninvasive ventilator support

Step 3) Cough

  • Ineffective cough
  • Treatment:
    1. Non-Pharma: Cough assistance (manual or mechanical)
    2. Pharma: Bronchodilators

Step 4) Clearance

  • Decreased mucociliary clearance
  • Treatment
    1. Non-Pharma: Chest physiotherapy, vibration, percussion
    2. Pharma: Mucolytics, NAC

Cuccurollo 4th Edition Chapter 10 Peds pg783

Braddom 6th Edition Chapter 47 Cerebral Palsy pg1122

43
Q

List 4 Genitourinary Complications 🔑🔑

A

CP = STROKE

  • Detrusor over activity and a small bladder capacity
  • Loss of frontal lobe sacral inhibition centre, so detrusor is over active without inhibition.
  • Detrusor sphincter dyssynergia.
  • Anticholinergic treatments for dystonia or sialorrhea may trigger urinary retention.

COMPLICATIONS

  1. Urinary retention
  2. Urinary tract infections
  3. Vesicoureteral reflux
  4. Hydronephrosis

TREATMENT

  • Clean intermittent catheterization is required

Braddom 6th Edition Chapter 47 Cerebral Palsy pg1013

44
Q

List 4 Gastrointestinal Complications

A
  1. Gastroesophageal reflux disease (GERD)
  2. Esophagitis
  3. Dysmotility delayed gastric emptying
  4. Constipation

Braddom 6th Edition Chapter 47 Cerebral Palsy pg1013

45
Q

8 y/o male: spastic quad CP seen at the seating clinic. Patient has significant tone, resting position hips and knees >90, scissoring, requires lateral support. Current chair = sling seat + back.

List 4 possible MSK complications 🔑🔑 Dr. Mariam

A
  1. Scoliosis.
  2. Pelvic obliquity.
  3. Hip subluxation / dislocation.
  4. Contractures - hip flexion, knee flexion.
  5. Increased spasticity.
  6. Pain.
  7. Pressure ulcers.

Ref: First principles.

46
Q

Describe potential musculoskeletal abnormalities of the upper extremity in CP. 🔑

A

💡 CP is just like stroke in baby

  1. Shoulder adduction and internally rotated position.
  2. Elbow flexion contractures
    • Spasticity in the biceps, brachioradialis, and the brachialis
  3. Forearm pronation deformities
    • Affect functional use of the hand
  4. Wrist flexion, typically with ulnar deviation
  5. Finger flexion and swan neck deformities
    • Hand intrinsic muscle spasticity
  6. Thumb-in-palm deformity
    • Adduction at the carpometacarpal (CMC) joint
    • Hyperextension of the metacarpophalangeal and interphalangeal joints.

Ref: Alexander and Matthews p. 175

47
Q

Describe potential musculoskeletal abnormalities at each joint of the lower extremity, in a child with spastic CP 🔑🔑

A

HIP

  1. Windswept deformity
    • Adduction & internal rotation deformity of the elevated hip → risk for dislocation
    • Abduction & external deformity deformity of the opposite
    • Results in pelvic obliquity
  2. Hip dysplasia/sublaxation/dislocation
    • Hip subluxation = Reimers’ migration index > 30%.
    • Posterior dislocation ← Adducted, flexed, and internally rotated hip
  3. Early hip osteoarthritis
  4. Difficulty with positioning and hygiene
  5. Leg length abnormalities
  6. Femoral anteversion
  7. Flexion contractures.

KNEE

  1. Knee flexion contractures
    • Spasticity in the hamstring muscles and static positioning in a seated position
  2. Genu valgus
    • Femoral anteversion & hip adduction and flexion

ANKLE

  1. Equinus deformity (Equinovarus or Equinovalgus)
    • Spasticity or contracture of gastrocsoleus complex
    • Spasticity in tibialis posterior
    • Resulting in planterflexion, inversion, supination

FEET

  1. Hallux valgus deformities

Ref: Alexander and Matthews p. 173-4

48
Q

List 4 Risk factors for DDH in CP child 🔑

A

💡 XRAY HIP Reimers migration index > 30% = hip subluxation.

  1. High GMFCS (90% of grade 5, 0% grade 1).
  2. Passive hip abduction <35 degrees
  3. Hip flexion contracture >20 degrees
  4. Hip adduction spasticity

Ref: Alexander Matthews pg 174.

49
Q

Mention 5 hip lines in plain xray 🔑🔑 MOCK Dr. Haitham

A

1. Hilgenreiner line

Drawn horizontally through the inferior aspect of both triradiate cartilages.

Mainly used as a reference for the Perkin line and measurement of the acetabular angle.

2. Acetabular Index

Horizontal line connecting both Hilgenreiner line and a second line which extends along the acetabular roofs. (The normal range is 33º to 38º)

3. Perkin’s Line

Drawn vertically though the lateral most aspect of the acetabular roof, perpendicular to Hilgenreiner’s line.

The ossified femoral head should be located in the inferomedial quadrant created.

4. Shenton line

Imaginary curved line drawn along the inferior border of the superior pubic ramus and along the inferomedial border of the neck of femur. It should be continuous and smooth.

5. Reimer migration index

Radiographic measurement of femoral head bony coverage by the acetabulum

It is useful in assessing for developmental dysplasia of the hip as well as femoroacetabular impingement. (17-27%: normal)

50
Q

Describe potential spinal abnormalities of the spine in CP. 🔑

A
  1. Kyphosis - often seen in combo with significant weakness of spinal extensors and tightness of hamstrings, leading to posterior pelvic tilt
  2. Lordosis - frequently associated with hip flexion contractures
  3. Scoliosis - likelihood increases with severity of CP (overall incidence = 20%, as high as 68% in spastic quad); curves > 40 degrees tend to progress.

Ref: Alexander and Matthews p. 174-5.

51
Q

What is the Risser staging?

At what stages does menses start?

At what Tanner stage does peak progression of curve occur?

A

RISSER STAGING

  • Grading system to determine the skeletal maturity of an individual by measuring the ossification of the pelvis (iliac crest).

STAGES

0: no ossification.
1: < 26% (most rapid skeletal growth)
2: 26-50% - MENSES OCCUR
3: 51-75% (growth slows)
4: 76-99%
5: 100% (iliac apophysis fused to iliac crest; end of growth)

Ref: 2001 AAFP – adolescent idiopathic scoliosis, review and current concepts.

PEAK CURVE

Tanner stage 2-3.

52
Q

What are the risk factors for the progression of scoliosis? 🔑🔑

A

💡 Any conditions: young, high curve, immobility

  1. Quadriparesis.
  2. Increased spasticity.
  3. Larger curve – greater than 40 then to progress no matter the age.
  4. Younger age (earlier Risser and Tanner stages).
  5. Poor sitting balance.
  6. Pelvic obliquity.

Ref: Alexander and Matthews (which references Renshaw et al. Instr Course Lect 1996; 45: 475-490)

53
Q

Risk factors for osteoporosis & prophylaxis 🔑🔑

A

💡 Not just CP, any patient in wheelchair with poor oral intake.

Risk factors

  1. Decreased weight bearing
  2. Malnutrition (difficulty feeding)
  3. Decreased sunlight exposure.
  4. Use of anticonvulsants

Treatment

  • Weight-bearing
    1. Strengthening
    2. Aerobic Exercise
    3. Robotic and Partial Body Weight Support Treadmill Training (PBWSTT)
    4. Constraint-Induced Movement Therapy (CIMT)
    5. Functional Electrical Stimulation
  • Calcium and vitamin D
  • Bisphosphonates

Braddom 6th Edition Chapter 47 Cerebral Palsy pg1013

54
Q

List 4 Respiratory complications in a child with CP 🔑🔑

A
  1. Dysphagia
    • Repeated aspiration events
    • Interstitial fibrosis
  2. Breathing
    • Restrictive pulmonary disease (scoliosis)
    • Airway obstruction (high degree scoliosis)
    • Decreased vital capacity and aerobic working capacity
  3. Cough & Clearance
    • Decreased mucociliary clearance

Cuccurollo 4th Edition Chapter 10 Peds pg783

Braddom 6th Edition Chapter 47 Cerebral Palsy pg1122

PassPMR - 09 Pediatrics (5 decks)

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