Cerebral Palsy Flashcards
Cerebral Palsy
Definition
A group of permanent disorders of the development of movement & posture causing activity limitations that are attritbuted to non-progressive distrubances that occurred in the developing fetal or infant
The motor disorders of cerebral palsy are also accompanied by disturbances of sensation, perception, cognition, communication, and behaviour by epilepsy & by secondary MSK problems
- Can all occur b/c brain injury - depends on type & where in the brain
LESION = non-progressive BUT impairments progress & become more apparent
CP: Etiology & RF
(8)
Multifactorial d/t static lesion in the developing brain - also linked w/ PVL (Periventicular Leukomalacia) = form of white matter disorder
RF
1. Prematurity - INC risk d/t difficulty w/ ventilation - inadequate O2 & CO2 gas exchange
2. Atypical Intraurterine Growth (low/high birth weight)
3. Infection (in utero & post-natal)
4. Infarction - INC risk of stroke in utero (neonatal period) w/ mothers who are: obese, older, fmaily Hx of thembo/metabolic disease
5. Developmental defect (ie. lissencephaly - smooth brain - lacks folds & microcephaly (small brain))
6. Multiple Gestation - more babies in womb = INC risk for at least one or all
7. Placental Pathology - malfunction or inflammation fo placenta
8. Trauma (pernatal, perinatal - during birth, early post-natal - could be d/t shaken baby syndrome)
What is the most prevalent type of CP?
Spatic type CP
Types of Classifications
(2) + 2
Classification by Impairment
Anatomic Distribution - “where”
- Hemiplegia
- Diplegia
- Quadriplegia
Type of Impairment
- Spastic
- Dyskinetic
- Mixed
Classification by Function
- Gross Motor Function Classifciation System (GMFCS)
Classification by Impairment
(4)
Hemiplegia
- One side of the body is affected (similar to stroke)
Diplegia
- The legs are more affected than the arms
Quadriplegia
- Arms, legs, and trunk are affected
Asymmetrical diplegia
- The legs are more affected than the arms & one side of the body is more affected than the other
Type of Impairment: Spastic
Describe (5)
Spastic - specific type of HYPERtonia
- Velocity-dependent resistance to passive elongation
- Damage to cortex or white matter to & from sensorimotor cortex
- Most common type of CP
- DIPLEGIA most common distribution of spastic CP
** Scisooring gait - Adductor spasticity kicks in & they start crossing their legs over
** Toe walking - PF b/c of spasticity
POSTURAL INSTABILITY
Type of Impairment: Dyskinetic:
Ataxic
Describe (2) & Part Affected
Ataxic
- Movement disorder characterized by intention tremor, lack of mm control, and poor coordination of voluntary movements
- Most children with ataxis CP can walk without gait aid, but may have difficulty with balance
CEREBELLUM is affected
1 of 3 sub-categories of DYSKINETIC
Type of Impairment: Dyskinetic:
Athetosis
Describe (4) & Part Affected
Athetosis
- Movement disorder characterized by slow, continuous, involuntary writhing (contusion of body parts // continuous twisting & squirming mvmts) movments
- Commonly affects the distal extremities & mouth)
- Difficult to maintain a stable posture
Legs are also ER (valgus) & twisting which makes balancing difficult > torso rocks around in an attempt to compensate
- Significant limitations in gross motor function
2/3 sub-categories of DYSKINETIC
Type of Impairment: Dyskinetic:
Dystonic
Describe (2+3) & Part Affected
Dystonic
Dystonia (INVOLUNTARY mm contractions):
- A movement disorder that is characterized by involuntary sustained or intermittent mm contractions leading to repetitive mvmts, abnormal fixed postures, and disordered tone
Dystonic Posturing:
Co-contraction (involuntary) of muscles causing sustained abnormal posture
- Dystonic movements are typically patterned & may included twisting or tremulous movement (tremor)
- Often triggered by voluntary movement
- Significant limitations in gross motor function & fatigue due to high metabolic demand
*THALAMUS is damaged - relay center &/or BASAL GANGLIA (putament or caudate nucleus)
3/3 sub-cateogires of DYSKINETIC
Type of Impairment: Mixed
Describe
Mixed
- Combination of dyskinetic & spastic
- Diffuse brain injury to motor cortex & the basal ganglia
Classification by Function:
Gross Motor Function Classification System (GMFCS)
More objective measure - can be used to communicate the severtiy of the disease (clinically & for research)
Focused on what the child CAN do in regard to self-mobility
- 5-level (I-V) classification system that described gross motor functin (regardless of the type of CP - applied to all types)
- 5 Age Groups:
1. 0-2
2. 2-4
3. 4-6
4. 6-12-12-18 - Scale is considered stable after the age of 2
- Child is classified by the method of mobility
Gross Motor Function Classification System (GMFCS) - General Headings for each level
Level I - Walks without limitations
Level II - Walks with limitations
Level III - Walks Using a Hand-Held Mobility Device
Level IV - Self-mobility w/ Limitations; May Use Powered Mobility
Level V - Transported in a Manual W/C
Gross Motor Function Classification System (GMFCS):
Level I
(3)
- Walks w/o restrictions
- Limitations in more advanced gross motor skills (runing, jumping)
- DO NOT need a mobility aid
Gross Motor Function Classification System (GMFCS):
Level II
(2)
- Walks w/o devices
- Limitations in walking outdoors & in the community (inclines, crowds, uneven surfaces)
Gross Motor Function Classification System (GMFCS):
Level III
(2)
- Walks with mobility devices
- Limitations in walking outdoors and in the community
Gross Motor Function Classification System (GMFCS):
Level IV
(2+1)
- Self mobility with limitations
Walks very short distances w/ use of aid - Children are transported OR use power mobility outdoors & in the community
Gross Motor Function Classification System (GMFCS):
Level V
(3)
- Self-mobility is severely limited even with the use of supporting technology
- NO means of independent mobility
- Completely dependent
Associated Impairments
(6)
- Cognitive impairments
- Sensory impairments
- Behavioural problems
- Speech & language
- Perceptual dysfunction
- Problems with motor planning (apraxia)
All housed in the cerebral cortex
DEPENDs on where the brain damaged occurred
Most of these will be seen in SPASTIC CP - b/c insult occurred in the Sensiomotor cortex (cerebral cortex)
Cognition will not be seen w/ THALAMUS insult - not connected
What is the most common distribution of Spastic CP?
Diplegia
CP: Assessmet
2 Types
Motor Function
1. GMFM-88 > Gross Motor Function Measure
2. GMFM-66 - subset of 88 provides a more concise way of completing test
- Less time to complete & provides more detailed info of the lvl of difficulty of each item = more info to help create goals for the child
** GOLD STANDARD measure of motor function for children w/ CP
Spasticity:
- Modified Ashworth Scale
- Modified Tardieu Scale
GMFM-88 & GMFM-66
Decription & Details
Observational instrument to measure change in gross motor function of children w/ CP
- Valid from 5 months-16 years old
- Appropriate for children whose motor skills are below or equal to a 5-year old w/o any motor disability
5 Dimensions:
1. Lying & rolling
2. Crawling & kneeling
3. Sitting
4. Standing
5. Walking, running, jumping
Higher score is better
GMFM-88 is also validated for Down Syndrome
TUG is also reliable w/ CP children
AFOs commonly used with CP
(3)
Solid AFO
- Blocks all ankle mvmt at both talocrural & subtalar - locked in position (M-L instability)
- A rocker bottom shoe is often used in conjunction w/ a solid AFO to assist in gait
- Limits knee extension moment (DEC knee hyperextension)
Used:
- Post-Sx/ botox to protect mm
- Excessive DF
- Correctable equinus (foot can be passively moved)
Not Used:
- Crouch gait
- Fixed foot deformity
Hinged AFO
- Allows for a controlled amount of DF while still limiting PF
- Facilitates progression to foot-flat position in early stance
- Limits movement at subtalar
- Limits knee extension moment (DEC knee hyperextension)
Good for true equinus w/ a flexible foot b/c it takes them out of knee hyperextension
Used:
- Same as solid AFO: drop foot or subtalar joint OA
Not Used:
- Crouched gait
- Fixed equinus/ deformity
- Not appropriate if they just had a BOTOX injection or lengthening procedure
Ground-Reaction AFO (GRAFO)
- Blocks movement at talocrural joint & limits movement at subtalar joint
- Provides knee extension movement (INC knee extension)
ANTERIOR shell < blocks tibia from translating forward = prevents excessive knee flexion
Used:
- Good for gaits that have excess knee FLEX - want to take them out of knee flex. Ex. crouch gait, weak quads (poor eccentric control), overlengthened gastroc mm
Not used:
- FIXED hip or knee FLEX - will be painful
Medical Intervention
(8)
Bony Alignment (osteotomy & fusion)
- De-rotation osteotomy
- Fusion
Botox Injection
- Reduces spasticity (lasts ~3 months)
- Neuromuscular block of Ach / Trade-off = DEC mm strength
Intramuscular Baclofen
- Reduces spasticity
Selective Dorsal Rhizotomy
- Reduces spasticity
- Cutting dorsal root at SC
Serial Casting
- INC ROM
Soft Tissue Lengthening (mm & tendon) & Tendon Transfer
- INC ROM
Percutaneous mm/tendon release
- INC ROM
Reconstruction
- Hip reconstruction - if involved
Interventions - Address the Impairments
(9)
- Bone development/ deformity
Hip dysplagia (highly correlated w/ GMFCS Level V), scoliosis (structural or functional - looks like a LLD), & torsions (tibia) - Balance
- Coordination
- Motor Planning
- Range of Motion
Flexibility - prolonged positions in W/C
Contractures - can lead to functional limitations (stretching, serial casting, etc) - Strength
- Tone
- Spasticity
- Address participation limitations
- Transfers, gait, stairs
- Sports
- Play
Help become more independent
Teach them how to do these tasks - more involved in participation/ sports
Challenge them to perform functional activities & become better at them & also try to accomodate os they can be included
