Cerebral Palsy Flashcards
Three criteria for diagnosis of CP?
1) static brain lesion
2) lesion occurred before birth or first few years of life
3) neuromotor control deficit with altered movement or posture
Greatest risk factor for development of CP?
Prematurity
Are most children with CP born premature?
NO
What are 5 preconception/maternal risk factors for CP?
maternal seizures, maternal thyroid disease, advanced age (>40), obesity, use of reproductive technology, coagulopathy
Most common topographic form of CP?
Hemiplegia (39%)
Does hemiparetic CP typically demonstrate greater impairment in the upper or lower extremity?
upper
What are the 5 different movement patterns seen in CP?
spastic, dyskinetic, hypotonic, ataxic, and mixed
What are the two most common movement patterns seen in CP?
Spastic followed by dyskinetic
At what age can a child be classified with the GMFCS? Why?
Age 2, before this assessments are often inaccurate due to evolving myelination.
GMFCS II
ambulatory but limitation with uneven surfaces and inclines
GMFCS III
use of hand-held mobility device (Lofstrand crutches or rolling walker), may propel a manual wheelchair independently
GMFCS IV
rely mostly on wheeled mobility at home and in community.
GMFCS V
No independent mobility
What ages is the Manual Ability Classification used?
4 to 18
MACS II
slower with manual function but independent with daily activities
MACS III
can complete some activities independently with set-up or assistance
MACS IV
continuous support needed to complete a portion of activity
MACS V
No handling of objects
CFCS II
effective communicator but slower
CFCS III
effective communicator with familiar partners but not effective with unfamiliar partners
CFCS IV
inconsistent communication, even with familiar partners
CFCS V
ineffective communication
What ages is the Eating and Drinking Ability Classification System designed for?
3 and older
EDACS II
needs additional time
EDACS III
some limitation to safety
EDACS IV
significant limitations to safety
EDACS V
unable to eat or drink safely
Most common finding on MRI in children with CP?
PVL
When is a repeat MRI recommended if initial MRI is normal in a child with motor abnormalities?
2 years old
What are 4 primitive reflexes that can be used to evaluate for early CP?
moro, palmar grasp, ATNR, tonic labyrinthine reflex
What are three ways that the 4 primitive reflexes can be highly suspicious for CP?
1) persistence beyond 6 months
2) asymmetric response
3) obligatory response (unable to break out)
At what age do the parachute and lateral protection reactions emerge?
6 months
What ages is the HINE appropriate for?
2 months to 2 years
Optimal HINE scores at 3, 6 and 9 months (not at risk for CP)?
67, 70, 73
What portion of the HINE exam is most predictive?
movement quality and quantity
HINE score at 3-6 months indicating likely GMFCS III or IV
less than 40
HINE score at 3-6 months indicating likely GMFCS I or II
40 - 60
What HINE score at 3 months is highly sensitive and specific for development of CP?
56
Up to what age can the General Movement Assessment be used?
5 months
When is the infant “writhing period”
from preterm to 6-9 weeks
When is the infant “fidgety period”
9 to 20 weeks
How are abnormal fidgety movements characterized?
larger amplitude with moderately exaggerated speed and jerkiness
What assessment is the reference standard for early detection for CP?
GMA
What are three indications for genetic testing in suspected cases of CP?
1) neuroimaging is non-revealing
2) family history of childhood neurologic disorder
3) developmental deterioration
What should be suspected in a previous healthy child with acute encephalopathy without explanation?
metabolic disorder
What imaging findings are more common in children with intellectual disabilities?
gray matter injuries and malformations
What are 5 risk factors for recurrent admission due to respiratory illness in children with CP?
GMFCS IV, dysphagia, seizures, snoring, recent respiratory admission
What are three strategies to address frequent aspiration?
saliva control, g-tube placement with fundoplication, and thickening of feeds
Three treatments for impaired mucociliary clearance?
saline, bronchodialators, chest PT
What is the most common foot deformity in CP?
Equinovalgus
What degree spinal curves are likely to progress?
Greater than 40
What are five risk factors for progression of a spinal curve?
spasticity, quadriparesis, younger age, poor sitting balance, pelvic obliquity
What is the most common upper extremity contracture in CP?
thumb-in-palm
What is the most important outcome to predict satisfaction after surgical correction of an upper extremity contracture?
cosmesis
Most common type of pain in GMFCS I, II?
headaches
Most common type of pain in GMFCS IV, V?
back pain
External rotation of the leg is associated with what type of ankle deformity?
valgus
What is the best type of therapy for patients with CP?
active, task-specific, and goal directed
What benefits are seen when using NMES in children with CP?
short-term increase in muscle volume and strength
What parameters improve with FES in CP?
strength, gait kinematics, and SMC
What parameter has not been shown to improve with FES in CP?
walking speed
What is a realistic speech therapy goal in CP?
Improved intelligibility in a child with dysarthria
Children older than what age typically do not have recurrence of tightness after surgery for contracture?
6
What causes neuromuscular scoliosis?
imbalance in control of trunk musculature
When should spinal surgery for scoliosis be considered in a child with CP? (degree for skeletally immature and mature)
- skeletally immature: over 40 degrees
- skeletally mature: over 50 degrees
What can we say about evidence in relation to using hyperbaric oxygen in children with CP?
There is inadequate evidence for benefits or risks
What marijuana-derived product has shown improvement in spasticity and comfort in children?
dronabinol
What percentage of patients with CP report a quality of life similar to typically developing children?
50%
What are two predictors of reduced quality of life in children with CP?
pain, psychological challenges
What are the three categories that best predict ambulation in the CP population?
- primitive reflexes
- gross motor development
- topography of CP
What topographic type of CP has best potential for ambulation?
hemiplegia
What can be said about timing of gross motor development and prognosis for ambulation in the CP population?
Children are likely to functionally ambulate if sitting by 2 years old an unlikely to functionally ambulate if not sitting by 4 years old
What can be said about primitive reflexes/postural responses and prognosis for ambulation?
persistence of primitive reflexes or absence of postural reactions at age 2 is associated with a poor prognosis for ambulation
What is the life expectancy of most children with CP?
near-normal
What are three reasons that a diagnosis of CP may be excluded?
Progressive nature, primary peripheral etiology, injury occurred after CNS fully developed (2 years)
What can we say about prevalence rates of CP in the past 20 years?
Rates have stayed the same at around 1 per every 500 births
What two factors are associated with increased prevalence of CP?
Very early gestation, very low birth weight
Why are premature children more prone to CP?
The germinal matrix around the ventricles has immature vasculature and it prone to ischemia or hemorrhage
What are the 5 categories of risk factors for CP?
Preconception, Antepartum (during pregnancy), Intrapartum (during labor), Neonatal (first 28 days), Postnatal
What are 5 antepartum (during pregnancy) risk factors for CP?
intracranial hemorrhage, placental abnormalities, toxins, infections, maternal disease (seizures, hyperthyroidism)
What are four intrapartum risk factors for CP?
Birth hypoxia, meconium aspiration/staining, hyperbilirubinemia, traumatic delivery
What are 5 neonatal risk factors for CP?
Seizures, infection, hypoglycemia, respiratory distress, jaundice
What are three postnatal risk factors for CP?
Head injury, stroke, infection
What is hypertonia?
Examiner induced abnormally increased resistance to movement about a joint
What is hyperkinesia?
Unwanted excess movement by the child
What are the three subdivisions of hypertonia?
Spasticity, dystonia, rigidity
Why are seizures more likely in spastic hemiplegia?
Cortical involvement of the lesion
What is a grade 3 intraventrcular hemorrhage?
With ventricular dialation
What is a grade one intraventricular hemorrhage?
Isolated to the germinal matrix
What is a grade 4 intraventricular hemorrhage?
With parenchyma hemorrhage
What are 4 negative motor signs in CP?
Ataxia, Apraxia, weakness, reduced selective motor control
What should one suspect if there is persistent hypotonia in a CP patient?
Genetic or metabolic syndrome
What GMFCS levels tend to require reclassification over time?
II, III, IV
What medical comorbidity is more commonly seen in mild cases of CP?
Behavioral disorder
Is pain limited to more severe forms of CP?
No, it is seen at all levels of disability
What three things are malnourished patients with impairments at increased risk for?
Skin breakdown, osteopenia, infection
What is the treatment for upper airway obstruction in CP?
CPAP
What is the treatment for lower airway obstruction in CP?
Bronchodilators
What is the risk of seizure in the CP population?
30%
Injury to what part of the brain can present with severe dysarthria but preservation of intellectual abilities?
Basal ganglia
Why is strabismus important to recognize early?
To avoid amblyopia
When is CIC indicated in CP patients?
Chronic urinary retention
What is a 504 plan?
Accommodation for children who do not qualify for special education
What disability legislation has section 504?
The Vocational Rehabilitation act of 1973
What legislation mandated IEPs?
The Education of All Handicapped Children Act of 1975
What act provided funding for Early Intervention?
The Individuals with Disabilities Education Act (IDEA) of 1990
At what age is it reasonable to consider power mobility?
Around 18 months
What are some of the demonstrated benefits of AFOs in the CP population?
improved energy efficiency, stride length, and velcocity
What are three positive preoperative functional predictions of a good SDR outcome?
Ability to crawl, tall kneel, and squat.
Until what ages should orthopedic surgery in the CP population be delayed (unless hip subluxation) due to high risk of recurrence?
7 to 9 years old
What two muscle groups are most responsible for hip subluxation in the CP population?
Iliopsoas and adductors
What is guided growth?
A temporary medial hemiepiphysiodesis to increase femoral shaft angle
What are the two most effective parameters to monitor when determining timing of surgery to prevent hip dislocation in the CP population?
Acetabular index and migration percentage
When is surgical treatment indicated for a CP hip at risk of dislocation?
Acetabular index greater than 30 degrees or migration percentage greater than 33%
What are 5 comorbidities related to a dislocated hip in the CP population?
Pain, skin breakdown, impaired sitting balance, worsening scoliosis, hygiene difficulty
What type of muscles are most at risk for contracture in CP patients? Please give 4 examples
Biarticular (hamstrings, gastrocnemius, psoas, rectus femoris)
When can scoliosis in a CP patient be treated with observation?
When the curve is less than 40 degrees, flexible, and not impairing sitting balance
When does the insult responsible for a majority of CP cases occur?
during the prenatal period (in utero before delivery)
When is the extensor Babinski response abnormal?
greater the 2 years old
What is the most common type of CP seen in premature infants?
spastic diplegia
What type of CP is associated with sensorineural deafness?
dyskinetic
What is chorea?
abrupt, irregular jerky movements
What is athetosis?
slow writhing movements
What is the most frequent visual deficit in CP?
strabismus
What gaze deviation is seen in kernicterus?
paralysis of upward gaze
What is the characteristic hearing loss in CP?
sensory neural impairment
What milestone is a indication of good intellectual potential in CP patients?
speaking in three word sentences by age 3
What symptoms can be seen in pseudobulbar palsy in CP?
emotional lability, dysarthria, drooling
Typical age range for SDR?
3 to 8 years old
What are three predictors of successful employment in CP patients?
IQ level (> 80), hand function, and ambulation level
Three main NMSK causes for scissoring gait?
femoral anteversion, medial hamstring spasticity, hip adductor spasticity
How does jump gait present?
with excessive hip/knee flexion and ankle equinus
What is the most common diplegia gait pattern in young CP children?
jump gait
What is the goal in treating the CP hip?
Avoiding future hip pain due to OA
Chance of hip displacement in GMFCS V?
90%
Overall chance of hip displacement in CP population?
35%
Main factor associated with hip displacement?
GMFCS level
In which CP motor type is hip displacement NOT uniformly seen?
ataxic
4 factors that are greater determinants of ambulation potential than spasticity in the CP population?
weakness, poor selective motor control, poor balance, and sensory deficits
How may coxa valga contribute to hip dislocation in the CP population?
creating a longer lever arm for hip adductors
