Cerebral Palsy Flashcards
Cerebral palsy is…
- Umbrella term
- Nonprogressive developmental disorder
- Caused by insult to the developing brain
- Motor and sensory impairments
What are some comorbidities of cerebral palsy?
Sensation and sensory processing involvement, perception, cognition, communication/speech issues, behavioral and emotional disorders, mental retardation
There has been a steady prevalence of CP in the last _____ years. Why?
40 years
increase in survival rate of preterm babies
Incidence of CP in single births?
2-3/1000
Incidence of CP in twin births?
15/1000
Incidence of CP in triplet births?
80/1000
Incidence of CP in quadruplets?
43/1000
What is the main etiology behind CP?
Changes in prenatal brain development (75% of all cases)
What are some other etiologies behind CP?
congenital brain anomalies, prenatal events, perinatal events, post/neonatal events (10-18%)
Why can a definitive diagnosis only be made after 12 months?
neuroplasticity
What studies are available to diagnose CP?
MRI, cranial ultrasound
What is the typical presentation of an infant/child with CP?
Abnormal muscle tone, atypical posture, movement with persistent reflexes, non-progressive
What other diagnoses can mimic CP?
metabolic and mitochondrial disorders (they are progressive however)
What is bleeding into the ventricles called?
Intraventricular hemorrhage (IVH)
What is bleeding into tissues around the ventricles?
Germinal matrix hemorrhage (GMH)
What is bleeding into the ventricles and around the venrticles called?
Periventricular intraventicular hemorrhage (PIVH)
What is a periventricular cyst (PVC)?
a cyst that may form in the area where the bleed occurred once the acuteness has resolved
What are some known risk factors for CP?
Mechanical ventilation (can cause IV bleeding) Injury during critical periods of brain development
When is periventricular white matter most sensitive to insult and injury?
between 24-34 weeks gestation
What are some antenatal risk factors for CP?
- prematurity and LBW
- intrauterine injections
- multiple gestation
- pregnancy complications
What are some perinatal risk factors for CP?
- birth asphyxia
- complicated labor and delivery
What are some postnatal risk factors for CP?
- non-accidental injury
- head trauma
- meningitis/enchephalitis
- cardio-pulmonary arrest
What are some strategies for preventing CP?
Obstetrical care (magnesium sulfate for preeclampsia, antibiotics for infection, corticosteroids for preterm labor)
What is the most common movement disorder associated with cerebral palsy?
spasticity
What is spasticity?
increased resistance to passive movement which increases with increased velocity
What are the movement disorders associated with CP?
Spastic, hypotonic, dyskinetic, athetoid, ataxic
What is dyskinesia?
uncontrolled movement
What is athetoid?
slow, writhing movement
What ataxia?
balance and control disorder
What is affected in diplegia?
legs
What is affected in hemiplegia?
one side of the body
What is affected in quadriplegia/tetraplegia?
all four limbs
Which type of plegia is most common in CP?
diplegia
What are the levels of the GMFM?
Level I- independent
Level II- walk w/o AD, limited community amb
Level III- walk with AD, limited community amb
Level IV- self mobility with limitation, transported in comm
Level V- difficulty controlling all movement, severely limited
What is the other name for the GMFM
Gross Motor Functional Classification
What changes in the muscle changes does the hyperactive stretch reflex cause?
decreased longitudinal growth of muscle fibers
decreased volume of muscle
change in muscle unit size and fiber type
How is the Modified Ashworth Scale for spasticity score?
00-4
What is involved in a comprehensive assessment of children with CP?
motor attainment, neurologic signs, primitive reflexes, postural reactions
What is diplegia often caused by?
infarct in white matter of periventricular area caused by hypoxia
What type of gait and AD do children with diplegic CP have?
crouched gait, Lofstrand crutches
How is the cognition in children with diplegic CP?
normal
What is hemiplegia often caused by?
periventricular white matter abnormalities, cervical subcortical lesions, brain malformations, nonprogressive postnatal injuries
How are the UE and LE often positioned in children with CP?
elbow flexed, shoulder adducted, wrist flexed, foot plantarflexed
How is the cognition in children with hemiplegic CP?
social and emotional deficits present (resemble adult stroke patients with impulsivity and forgetfulness)
What are the equipment requirements for children with hemiplegic CP?
AFOs and splinting, sometimes crutch or cane
What is quadriplegia often caused by?
periventricular white matter lesions (basal gangia, occipital area)
How is the cognition in children with quadriplegic CP?
variable (supergenius to below normal IQ)
What are the equipment requirements for children with quadriplegic CP?
significant requirement throughout lifespan
What is dykinesia often caused by?
deep gray matter lesions (sometimes periventricular white matter)
Where is one of the typical places of excess movement in patients with dyskinesia?
C5-C6
How is the cognition in patients with dyskinesia?
normal to above normal intelligence
Which type of movement disorder requires the most medication?
dykinesia
What does ataxia cause?
weakness, incoordination, wide based gait, noted tremor
What is ataxia often caused by?
deficit in cerebellum
What do patients with ataxia have particular difficult with?
transference of skills (therapy should be task specific)
What is important to assess in children with CP?
- motor attainments
- neurologic signs
- primitive reflexes
- postural reactions
_____ is a sign of increased tone.
distal fixing (toe curling or fisting)
_____ is a sign of decreased or fluctuating tone.
collapsing with postural alignment
What is normal femoral anteversion at birth? When fully developed as an adult?
40 degrees at birth
15 degrees once fully developed
How is tibial torsion measured?
thigh - foot angle (using transmalleolar axis and femur as landmarks)
What is one of the most important goals for PT for CP?
preventing surgery…. become as independent as possible
What kind of static positioning and dynamic patterns of movement do you want to facilitate?
Static positioning and symmetry in postures, facilitate postural control when able
Dynamic patterns of movement opposite to habitual abnormal spastic patterns
How do you want to provide external support?
proximally –> distally
What is the mature mechanism of the foot and knee?
knee extension before heel strike, knee flexion at mid-stance, knee extension at heel-off
What are some common gait deviations in patients with spastic hemiplegic CP?
toe walking (tight gastroc) Asymmetrical weight shift to involved side
What are some common gait deviations in patients with spastic diplegic CP?
equinovarus, planovalgus, crouch, jump knee, stiff knee, recurvatum, idiopathic toe walking
What are some common gait deviations in spastic quadriplegic CP patients?
not usually community ambulators, encourage gait/standing, long term means of mobility = power
What are some common gait deviations in patients with athetotic CP?
difficult to make improvements with CP, weighted vest and ankle weights can sometimes help
What are some common gait deviations in patients with ataxic CP?
widened BOS, increased double-limb support time, balance is primary goal of PT
What other kinds of deficits can patients with spastic CP have?
possible visual, auditory, cognitive, and oral motor
Where are contractures and deformities present in spastic CP patients?
hip flexors, adductors, internal rotators, knee flexors, ankle plantarflexors, scapular retractors, glenohumeral extensors and adductors, elbow flexors, forearm pronators
What do ataxic cerebral palsy patients present with?
low postural tone, wide-based stance and gait, intention tremor of hands, uncoordinated movement, poor visual tracking and nystagmus, speech articulation problems
How do patients with athetoid CP present?
decreased muscle tone, poor functional stability in proximal joints, poor visual tracking, speech delay, and oral motor problems, persistent reflexes
Which reflexes tend to persist in patients with athetoid CP?
ATNR, STNR, TLR
When can CP patients begin strength training?
7 yrs and older
What is the warm up dimenstions for strength training?
5-10 min
What is the type of strength training for CP patients?
single and multi-joint; concentric and eccentric
What is the intensity/volume of strength training for CP?
1-3 sets of 6-15 reps 50-80% of 1 RM
What is the rest interval for strength training for CP?
1-3 min
What is the frequency of strength training for CP?
2-4 x / wk
What is the duration of strength training for CP?
8-20 weeks
What is the progression for strength training for CP?
increase resistance gradually (5-10%)
What ROM measurements should be taken when evaluating a patient with CP?
Hip IR, hip abduction, popliteal angle
What type of spine deformities can accompany CP?
neuromuscular scoliosis, posterior spinal fusion
What types of hip deformities can accompany CP?
subluxation/dislocation…can also migrate because of muscle imbalance
Windswept deformity
Windswept deformity
What are some hip surgical procedures that can be done?
soft tissue transfer and/or release of adductors, iliopsoas, proximal hamstring
femoral osteotomy
pelvic osteotomy (iliac, Chiari, Salter, Steel, Pemberton)
combined femoral and pelvic osteotomy
resection of the femoral head and neck
arthrodesis and arthroplasty
What happens at the knee in patients with CP?
flexion deformity (spastic hamstrings)
stiff knee gait
tibial torsion
What happens at the ankle in patients with CP?
equinus deformity (shortened achilles) pes valgus (eversion, plantarflexion, inclination of calcaneus... abduction of forefoot) varus deformity
What is used conservatively to treat foot deformities in patients with CP?
AFOs
