2- Cerebral Palsy Flashcards
What is the definition of Cerebral Palsy? 🔑🔑 MOCK Dr. Haitham
List 15 complications - challenges in CP child? 🔑🔑 OSCE Dr. Haitham
DEFINITION
- Permanent motor disorders affecting movement and posture, causing activity limitation.
- Caused by non-progressive disturbances that occurred in the developing fetal or infant brain <3yo.
- Also accompanied by disturbances of sensation, perception, cognition, communication, and behavior, by epilepsy, and by secondary musculoskeletal problems.
CHALLENGES
- Movement & Posture
- Movement → Weakness
- Posture → Scoliosis, DDH
- Activity limitation → WC, Osteoporosis, Contracture
- Sensory: Tactile, Proprioception
- Perception: Vision, Hearing
- Cognition: IQ, MR 50%
- Communication: Language, Dysarthria, Dysphagia & Sialorrhea
- Behavioral: ADHD
- Seizure 50%
- Secondary MSK: Spasticity
Name 5 affected systems w/ 1 example in CP
Mention 1 way to rehabilitate/manage it. 🔑🔑 MOCK Dr. Haitham
💡 Move Post Active, CP Coco Bee, Seizure & MSK
- Movement & Posture
- Hemiplegia/Hemiparesis → Assistive devices, orthosis
- Posture
- Scoliosis → Brace and orthopedic referral
- DDH → Casting, pavlic harness
- Activity limitation
- WC
- Osteoporosis
- Contracture → Orthosis, surgery
- Sensory: Tactile, Proprioception
- Perception:
- Vision impairment (Strabismus, refractory errors) → eye glass prescription
- Hearing impairment → hearing aids
- Cognition: IQ, MR 50%
- Special schooling with individualized program planning
- 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.
- Behavioral: ADHD
- Seizure 50%
- Anti-epileptics
- Secondary MSK
- Spasticity → ROM Ex, Orthosis, Modalities, Baclofen, ITB, BTX
- Autonomic Dysfunction
- Neurogenic bladder: CIC, anti-cholenergic medications
- Neurogenic bowel: stool softener, bulking agents, suppositories, enemas
What is the number 1 cause of death in children with CP?
What are 3 Risk factors for pneumonia in children with CP? 🔑🔑
💡 Pneumonia (90% of deaths of children with CP related to pneumonia).
Dysphagia
- Aspiration
Breathing
- Kyphoscoliosis
- Airway obstruction
Cough & Clear
- Decreased mucous clearance
- Suppuration
Ref: Braddom pg 1260.
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
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
- Low birth weight <2,500 grams (59.6 per 1000 live births)
- 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
List 5 Etiologies or risk factors for developing cerebral palsy. 🔑🔑 Dr. Haitham
PRECONCEPTION
- Maternal seizures
- Intellectual disability
- Thyroid disease (hyper and hypo)
- History of stillbirth or neonatal death
- Maternal age older than 40 years
- Low socioeconomic status
ANTENATAL
- Birth defects
- Small for gestational age
- Low birth weight
- Placental abnormalities
- Incompetent cervix
- Abnormalities in fluid volume
- Maternal bleeding in the second and third trimesters
- Hypertension, preeclampsia
- Chorioamnionitis
INTRAPARTUM:
- Birth hypoxia
- Meconium aspiration
- Abnormal duration of labor
- Fetal presentation
NEONATAL:
- Seizures
- Respiratory distress
- Hypoglycemia
- Infections
- Jaundice
POSTNATAL:
- Stroke
- Abusive head trauma
- Bacterial meningitis
- Motor vehicle crashes
Braddom 6th Edition Chapter 47 Cerebral Palsy pg1006-1007
What are the types of CP? 🔑🔑
Spastic CP features & Subtypes 🔑🔑
When do you consider abnormal Babinski?
💡 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
Baby prefers left hand at 9 months old.
Which type of CP? Examination? Will my child walk? 🔑🔑
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
Baby age 18 months not walking, he does crawling only.
Which type of CP? Examination? Will my child walk? 🔑🔑
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
Difficult delivery with evidence of perinatal asphyxia.
Four limbs are involved, patient in WC.
Which type of CP & Will my child walk? 🔑🔑
COMPLICATED PREGNANCY = SPASTIC TETRAPLEGIA 23% of CP
Causes
- Major hypoxic event (perinatal asphyxia) usually a history of difficult delivery.
- Medial motor cortex, which affects UE more severely than LE (homunculus)
- Focal & Multifocal ischemic brain injury
- 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
Dyskinetic CP features & subtypes
List 3 Important screening tool. Will my child walk?
EXTRAPYRAMIDAL = DYSKINETIC
Causes
- Kernicterus (neonatal hyperbilirubinemia, hemolysis)
- Hypoxia of the basal ganglia and thalamus
Subtypes
- Athetosis: Slow writhing, involuntary movements, especially in the distal extremities.
- Chorea: Abrupt, irregular jerky movements,
- Choreoathetoid: Combination of athetosis and choreiform movements.
- Dystonia: Slow rhythmic movements associated with abnormal posturing.
- 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
What is the GMFCS classification? What does it stand for? When is it used? 🔑🔑
Gross motor function classification system (GMFCS) is a functionally based system to standardize gross motor function in the CP child.
What is GMFCS 4? List 3 aids/mobility devices 🔑🔑
GMFCS 4
- Mainly wheelchair dependent (preferred mobility)
- May walk short distances indoors.
Mobility Devices
- Walker with body support (standing frame).
- Manual wheelchair.
- Power wheelchair.
Ref: GMFCS-ER document.
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
LEVEL
- GMFCS 2 (ambulates with limitations)
AMBULATION
- Minimal ability to run or jump.
- Difficulty walking on uneven terrain.
Ref: GMFCS – ER document.
Positive & negative prognostic factors for walking 🔑🔑 OSCE Dr. Haitham
Positive
- Rolling by 18 months
- Sitting by age of 2 yo
- Crawling by age 1.5-2.5 yo
Negative
- Three primitive reflexes at 2 years
- Not sitting by age of 4
- Seizures
- Cognitive Deficit / Mental Retardation
- 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
List 4 causes of toe walking in 4 year old. 🔑🔑
💡 Remember the 3 common topics in peds (CP, SB, DMD) + CMT + LLD
- Cerebral palsy.
- Congenital muscular dystrophy (DMD, BMD).
- Tethered cord syndrome.
- Global developmental delay.
- Charcot-marie-tooth disease.
- Autism.
- Idiopathic
- Limb-length discrepancy.
Ref: 2012 J Am Acad Orthop Surg 2012;20:292-300.
Peds rehab textbook pg 191.
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 🔑🔑
DIAGNOSIS
- Cerebral palsy - spastic diaplegia
NON-PHARMACOLOGICAL
- Physiotherapy: Stretching, heat
- Orthosis: AFO (solid AFO covering MTP joint) or Serial casting
- Gait Aids: Forearm crutches, walker
PHARMACOLOGICAL
- Anti-spastic meds (baclofen, dantrolene, tizanidine etc)
- BoNT injections
SURGICAL
- Orthopedic: tendon lengthening (post tib), muscle release (adductors etc)
- Neurosurgery: Selective dorsal rhizotomy, ITB.
Ref: first principles.
Mention 4 Gait Findings in Spastic Hemiplegia 🔑🔑
- Upper limb posturing, no reciprocal arm movement
- Weak hip flexion
- Weak ankle dorsiflexion (foot drop)
- Supinated foot in stance phase (tibialis posterior spasticity)
- Hip hiking or hip circumduction due to long lower limb
Cuccurollo 4th Edition Chapter 10 Pediatrics pg781
Describe Spastic Diplegic Gait 🔑🔑
- Scissoring gait pattern
- Hip flexed and adducted
- Knees flexed with valgus
- Ankle equinus (toe walking)
Cuccurollo 4th Edition Chapter 10 Pediatrics pg781
Describe the gait and mention the possible causes 🔑
Describe (1) Equinus Knee Gait, list 1 cause & surgical treatment 🔑🔑
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
Describe (2) Jumping Gait, list 2 causes & surgical treatment 🔑
Description
- Excessive hip and knee flexion and ankle equinus (think all are contracted)
Causes
- Psoas, Hamstring, rectus femoris, and gastrocnemius contractures
- Weakness
- Bony rotational deformities
Treatment
- Hinged AFO
- Extension osteotomies of the femur
Braddom 6th Edition Chapter 47 Cerebral Palsy pg1024 Table 47.10
Describe (4) Crouch Knee Gait, list 2 causes & surgical treatment 🔑
Description
- Excessive hip and knee flexion, and ankle dorsiflexion
Causes
- Psoas, Hamstring, rectus femoris, and gastrocnemius contractures or weakness
Treatment
- GRAFO
- Extension osteotomies of the femur
Braddom 6th Edition Chapter 47 Cerebral Palsy pg1024 Table 47.10
Mention possible joint pathology and the potential effect on gait. 🔑🔑 Dr. Maitha
Michael A. Alexander Pediatric Rehabilitation - 5th Edition
List 3 most common vision abnormalities in CP other than strabismus 🔑🔑
💡 Strabismus (Esotropia) 60%, highest rate in spastic diplegics and tetraplegics.
EYES
- Retinopathy
- Refractive errors
OPTIC N.
- Homonymous hemianopsia
- Reduced visual acuity
- Amblyopia
EOM
- Strabismus
- Esotropia
- Oculomotor dysfunction (impaired accommodation)
Basal Ganglia
- Nystagmus
Cuccurollo 4th Edition Chapter 10 Pediatrics pg783
Treatment for Dystonia in CP. 🔑🔑
Child with CP. What are the non-surgical methods to manage his spasticity? 🔑🔑
ER-POLICE-MIS
- Education: avoid triggers, proper WC & position, bowel & bladder care
- Protection & Orthosis: Serial Casting or Splinting
- Loading: Stretching and weight bearing
- ICE & Modalities
- Oral Medication
- 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
- Nerve/motor point blocks
Cuccurollo 4th Edition Chapter 10 Pediatrics pg785-789
Michael A. Alexander Pediatric Rehabilitation 5th Edition = Braddom 6th Edition (Colored)
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
- Scoliosis.
- Pelvic obliquity.
- Hip subluxation / dislocation.
- Contractures - hip flexion, knee flexion.
- Increased spasticity.
- Pain.
- Pressure ulcers.
Ref: First principles.
Describe potential musculoskeletal abnormalities at each joint of the lower extremity, in a child with spastic CP 🔑🔑
HIP
- Windswept deformity
- Adduction & internal rotation deformity of the elevated hip → risk for dislocation
- Abduction & external deformity deformity of the opposite
- Results in pelvic obliquity
- Hip dysplasia/sublaxation/dislocation
- Hip subluxation = Reimers’ migration index > 30%.
- Posterior dislocation ← Adducted, flexed, and internally rotated hip
- Early hip osteoarthritis
- Difficulty with positioning and hygiene
- Leg length abnormalities
- Femoral anteversion
- Flexion contractures.
KNEE
- Knee flexion contractures
- Spasticity in the hamstring muscles and static positioning in a seated position
- Genu valgus
- Femoral anteversion & hip adduction and flexion
ANKLE
- Equinus deformity (Equinovarus or Equinovalgus)
- Spasticity or contracture of gastrocsoleus complex
- Spasticity in tibialis posterior
- Resulting in planterflexion, inversion, supination
FEET
- Hallux valgus deformities
Ref: Alexander and Matthews p. 173-4
Mention 5 hip lines in plain xray 🔑🔑 MOCK Dr. Haitham
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)
