Cerebral Palsy Flashcards
What is the most common form of spastic CP?
Diplegia
Diplegia primarily affects?
Lower extremities
What causes diplegia?
infarct in the white matter of periventricular area caused by hypoxia
What is the cognitive state associated with diplegia?
Normal cognition
What is the definition for Cerebral Palsy?
“A group of permanent disorders of the development of movement and posture, causing activity limitations that are attributed to non-progressive (nerve lesion) disturbances that occurred in the developing fetal or infant brain”
Why is Cerebral Palsy termed non-progressive?
Because the lesion does not get worse/progress – but movement symptoms can progress with age
Types of movement disorders associated w/ CP (5):
Athetoid, Dyskinetic, Ataxic, Spastic, Hypotonic
Spastic movement disorder
Increased resistance to passive movement which increases with increased velocity of movement
Hypotonic movement disorder
Some infants present with hypotonia w/ transition to spasticity or ataxia
Dyskinetic movement disorder
Uncontrolled movement
Athetoid movement disorder
Slow, writhing movement
Ataxic movement disorder
Balance and control disorder
Classification of parts of the body affected by CP:
Diplegic (legs are more affected); Hemiplegic (one side of the body); Quadriplegic/tetraplegic (all four limbs)
Spastic CP results from what kind of damage to brain?
pyramidal
Dyskinetic and ataxic CP results from what kind of damage to brain?
Extrapyramidal
Type of CP resulting from lesion in cortex, basal ganglia, and cerebellum:
Cortex = Spasticity
Basal Ganglia = Athetosis
Cerebellum = Ataxic
What is the etiology of CP?
Changes in prenatal brain developent
Congenital brain anomalies
There are 3 events in time in which CP can develop. Name those. Which is most common?
- Prenatal Events (prior to birth)
- Perinatal events (during birth)
- Post/neonatal events (after with no upper age limit)
Prenatal and Perinatal events are most common
Is CP easy to diagnose?
Difficult due to plasticity of the developing brain
At what age can CP be diagnosed?
CP is not diagnosed until age 3 and up to age 5
What is the typical presentation for Infants with CP?
Abnormal muscle tone
Atypical posture
Movement with persistent reflexes
Non-progressive (lesion)
What are other diagnoses that can mimic CP
Metabolic disorders (protein breakdown) Mitochondrial disorders
What are the 4 Neuroimaging available for pts with CP?
- Intraventricular hemorrhages
- Germinal matrix hemorrhages
- Periventricular intraventricular hemorrhages
- Periventricular cyst
What can you see with Intraventricular hemorrhages?
bleeding into the ventricles
What happens in Germinal matrix hemorrhages
bleeding into the tissue AROUND the ventricles
Where are you bleeding in Periventricular intraventricular hemorrhages?
Bleeding into BOTH AREAS. (into and around the ventricles)
the name gives you a subtle hint
Can neuroimaging be the only predictive for the development of CP
NOPE! Not singly predictive predictive for the development of CP
Risk factors for development of CP
Injury during critical periods of brain development.
Periventricular wite matter is most sensitive to insult and injury between 24-34 wks of gestation
Risk factors for development of CP antenatal
Prematurity and LBW
Intruterine infections
Multiple gestation
Pregnancy complications
Risk factors for development of CP perinatal
Birth asphyxia
Complicated labour and delivery
Risk factors for development of CP postnatal
Non-accidental injury
Head trauma
Meningitis/encephalitis
Cardiopulmonary arrest
CP is caused by…..
An insult to the developing brain
CP is often accompanied by what other disturbances?
- Sensation and sensory processing involvement
- Perception
- Cognition
- Communication and speech issues
* ** CP may include all of these, just one, or a combination.
Over the last 40 years has the prevalence of CP gone up?
No, it has remained steady
Compared to the past increased survival of _________ &; _____ _______ has been seen.
Preterm; Very Preterm
What birth has the highest likelihood of producing a CP child? Why?
Triplets.
When multiple babies are in the womb, the placenta has to accommodate/deliver more nutrients and oxygen to the babies. In triplets, the placenta acts as if there are 2 babies, instead of 3, so there is an increased chance one child will not get enough oxygen and have CP.
What areas of the body are affected with hemiplegia?
UE and LE on the same side of the body
What areas of the brain area affected in hemiplegia?
Periventricular white matter abnormalities and cervical-subcortical lesions
Describe cognitive function in patients with hemiplegia
normal; social and emotional deficits are prevalent
Describe equipment requirements for patients with hemiplegia
minimal equipment needed
What areas of the body are affected with quadriplegia?
volitional muscle control of all four extremities are severely impaired
Where is the lesion located in patients with quadriplegia?
Periventricular white matter lesions
During a comprehensive assessment for an infant/child with CP, you are looking to identify abnormalities in what 4 areas?
- Motor attainments
- Neurological signs
- Primitive reflexes
- Postural reactions
The purpose of the assessment is to:
- Discover functional abilities & strengths
- Determine primary and secondary impairments
- Discover the desired functional & participation outcomes of the child and/or family.
- Use an organized approach order to get an accurate baseline of the child’s functional abilities
Give an example of a primary impairment and secondary impairment.
Primary - A child cannot use their hand because of spasticity from a lesion.
Secondary - Child has cannot feed themself because they cannot use their hand.
What are postural preparations?
Strategies the child uses before a functional movement & increase stability by changing the BOS or increasing muscle activation around joints
What is the biggest key (for a therapist) during an assessment?
Observation
What is the etiology of CP
- Changes in prenatal brain development
- Congenital brain anomalies
- Prenatal, perinatal, and post/neonatal events
When is CP typically diagnosed?
Not until 3 YO and up to 5 YO
What imaging is used to diagnose CP? What is he preferred method?
MRI–>preferred, provides greatest detail**
Cranial ultrasound-less invasive
CT
What is a typical presentation of an infant with CP?
abnormal muscle tone
atypical posture
movement with persistent reflexes
non-progressive (lesion)
What are other diagnoses that can mimic CP?
Metabolic disorders (protein breakdown) Mitochondrial disorders
What are the 4 types of Neuroimaging? and what can each see?
- Intraventricular hemorrhages (IVH)–>bleeding into the ventricles
- Germinal matrix hemorrhages (GMH)–>bleeding into the tissue AROUND the ventricles
- Periventricular intraventricular hemorrhages (PIVH)–>bleeding into BOTH areas (into and around ventricles)
- Periventricular cyst (PVC)–>form in the area where bleed occurred once the acuteness has resolved
How is the Neuroimaging graded?
I through IV, with IV being the most severe
NOT SINGLY PREDICTIVE FOR THE DEVELOPMENT OF CP
What area of insult is the most sensitive to insult and injury? What weeks of gestation is that?
Periventricular white matter is most sensitive
Between 24-34 weeks of gestation
Risk factors for antenatal (Refer to the flow chart)
Prematurity and low birth weight
Intrauterine infections
Multiple gestation
Regnancy complications
Risk factors for Perinatal
birth asphyxi
Complicated labor and delivery
Risk factors for Postnatal
non-accidental injury
Head trauma
Miningitis/encephalitis
Cardiopulmonary arrest
Protective factors for Obstetrical care
Magnesium sulfate
Antibiotics
Corticosteroids
What is the purpose of PT in children with CP? ie what do we allow the child to do?
Allow infant to become the most independent possible in performing functional tasks throughout lifetime
What should therapeutic intervention focus on
Prevention of disability by minimizing effects of impairment
Prevent or limit secondary impairments
Static positioning and symmetry in postures
Dynamic patterns of movement opposite to habitual abnormal spastic patterns
Goals to change child’s impairments?
- Elongate: HS and heel cords
- Use WB activities and postural challenge to increase tone and strength
- Use adaptive equipment
- Respiratory exercise
- Seating: neutral head, hips/knees/ankles at 90d flexion, hips in abduction if spastic adductors
What are some special considerations for CP patients
- External Support: hand placement proximal
- Sensory Systems: provide sensory input to help facilitate appropriate motor output (weighted clothing)
- Avoid Prolonged static positions: facilitate weight shifts and transitions
What 2 systems must be addressed during treatment
Movement and Sensory Systems. They are linked
What is developed as the child practices skill or taks with PT guidance
Feedforward
Describe Gait of spastic diplegia
limited mobility in L-spine and pelvic girdle
Compensate with increased movement of trunk, head, neck, and UE
-Feet either in valgus outside the lateral dimensions of the trunk or narrow BOS with heels off of floor in PF
Describe the gait of hemiplegia
Asymmetry: most of BW borne on uninvolved LE
Brief and incomplete weight shift on uninvolved LE
UE swing on uninvolved side. Involved shoulder held in hyperextension and elbow flexion
Gait in Athetosis
high fleion of hip initially during stepping; LE plaed into extension with adduction, IR and PF
Thracic spine in excessively flexed with rotation of c-spine with jaw jutting forward and rotated to one side
What is common to see in Hemiplegic gait
Toe walking
tight gastroc
asymmetrical weight shift to involved side
What are the 7 characteristics of Diplegic gait
Equinovarus: ankle in PF throughout stance with hips and knees extended
Planovalgus: equinus of hindfoot, PF muscle weakness
Crouch: knees and hips flexed throughout gait
Jump knee: Jump due to strong quadriceps contraction during late stance phase
Stiff Knee: increased knee extension throuhout swing phase, forcing child into circumduction, vaulting, and upward pelvic tilt
Recurvatum: overactivity of gastroc
Idiopathic toe walking
Inhibitive casts are used for…
- to decreases spasticity by immobilization to prolong stretch of muscles
- progressively using them to improve ROM
Medical treatment for Spasticity
- Baclofen (oral or intrathecal)
- Diazepam (best at night)
- Botox
- Surgery: Selective Dorsal Rhizotomy (dorsal rootlets cut b/t L2-S2 or L2-S1)
Why is home management important?
- reinforces movements, positions and skills
- assists in preparing infant/child for next session
What do we as PT need to consider when developing activities for home?
consider the daily routine and family obligations
Why do we consult with the schools?
- essential for optimal outcome
- communication with teachers/professionals
- seating/mobility used to maximize educational experience
Other disciplines involved in the care of patients with CP
- team of professionals (doctors, OTs, Speech, etc)
- included child/family
Examples of toys for children with CP for 0-12 months
- basically anything that will catch their interest and keep them reaching and moving
- ball party light and sound ball
- Super Deluxe 3-D Lights and Activity Gym
- Symphony Tower
- Curiosity Cube
Examples of toys for children with CP for 1-3 years
- toys that keep them moving and interested
- Pound and Play (ball and mallet toy)
- beaded toy
- tube to crawl through
- box with shapes to put into them
GMFM Level I
Independent
GMFM Level II
Walks without assistive devices; limited in outdoor and community level ambulation.
GMFM Level III
IWalks with assistive devices; limited in outdoor and community level ambulation
GMFM Level IV
Self-mobility with limitations; children are transported or use power mobility outdoors and in community.
GMFM Level V
difficulty controlling all movements; self mobility is severely limited even with use of assistive technology.
Hyperactive Stretch Reflex
- Not a great test
- Decreased longitudinal growth of muscle fibers
- Decreased volume of muscle
- Change in muscle unit size and fiber type
Modified Ashworth Scale Modified Ashworth Scale
-not a great test
-Widely used for assessing spasticity
00 to 4
Comprehensive Assessment of child with CP includes:
- Motor attainments (usually slow)
- Neurological signs
- Primitive Reflexes
- Postural Reactions
How does spasticity develop?
Extrapyramidial tracts that originate in the motor cortex, BG, brainstem, & SC become damaged which results in loss of inhibition and disruption of stretch reflex arc. Uninhibited muscle stretch produces exaggerated, uncontrolled muscle arc activity accentuating the reflex arc and eventually resulting in spasticity
Goals of Orthopedic Interventions for infants & children with CP
- help each individual reach optimal functional ability.
- Prevent deformity through detection at an early stage
What should be evaluated in assessment of the spine?
- ROM
- Note scoliosis & excessive kyphosis or lordosis and whether curves are functional or structural
- Neuromuscular scoliosis
- Posterior spinal fusion
What should be assessed in evaluation of the hip?
-Femoral anteversion:
Degrees at birth? Degrees in the mature hip?Subluxation/dislocation.
Hips migrate because of muscle imbalance.
When holding a baby with CP, what 3 things do you need to be aware of?
- head
- posture
- support
When working with older children who have CP, what should you be aware of?
- Mobility abilities
- Alignment of major segments of the body
- Noticeable thrust with or without movement
- If in a w/c level of assist needed
When assessing a kid with CP walking, what should you look at?
- Gait pattern
(safety and stability, step length, stance time, swing time or BOS) - Symmetric or asymmetric gait
- Trunkal stability during gait
- Heel-toe gait or plantar flexion dominant
- Hip & knee position during stance phase
What does an ideal assessment include?
Assess functional antigravity control in multiple positions.
What would you assess in a higher level CP pt?
stairs, unilateral stance, running, jumping, etc
What would you assess in a wheelchair bound CP pt?
alignment and mobility of body, shifting of weight, propulsion of w/c, management of w/c and its parts, transfers
You should take goniometric measurement during an assessment of a pt with CP, but what are they normallyusually used for?
prescription of equipment
What are included in the assessment of movement?
- Observation of child at play
- Wheelchair skills
- Basic developmental skills
- Interaction with his/her environment
What are included in the assessment of postural control?
- Observation of child using feedback information
(proprioception, vestibular feedback) - How does the child transition into/out of positions?
- Can the child repeat movements and tasks?
(Feed forward learning)
With a CP pt, their body may be “fighting them” when trying to perform a task or sit up straight, what strategy can they use to combat this? And what will it do?
They may try to lay on the floor to try to achieve postural stability, so they can do the task, or play with the toy, etc.
What are included in the assessment of postural tone?
- The amount of “stiffness” in a muscle
- Look at primary vs. compensatory
- How does it interfere or assist with movement and function? (distal fixing)
When a CP kid collapses with postural alignment, what is that a sign of?
Decreased or fluctuating tone
What are some examples of distal fixing?
Toe curling or fisting
What 2 types of CP that demonstrate fluctuating levels of stiffness?
Athetosis
Ataxia
What are signs of increased tone in a CP pt?
- distal fixing
- difficulty moving one body segment thru range
- retracted lips/tongue
What are signs of decreased tone in a CP pt?
- excessive collapse of body segments
- loss of postural alignement
- inability to sustain posture against gravity
What things are included in your musculoskeletal assessment?
- MMT (mainly on major joints)
- ROM
- Spine
(smoothness of movement, risk of developing scoliosis) - Thoracic movement (lung/pulmonary health)
- Shoulder girdle/UE
- Hip/Pelvis (femoral anteversion)
- TIbial Torsion
What should femoral anteversion be at birth? Adult?
Birth = 40 deg Adult = 15 deg
If dynamic scapular stability fails to develop, what position will the scapulae be fixed at?
downward rotation and anterior tipped (forward-tipped)
- cause the child to be limited in passive flexion, abduction and ER)
Describe cognitive function associated with hemiplegic CP
Cognition normal; social and emotional deficits prevalent
In reference to the hip/pelvis, what is the most important measurement for a physical therapist to consistently track?
Hip abduction with knee and hip extension
What are the 2 ways tibial torsion can be determined?
- By the intersection of a line drawn vertically from the tibial tubercle and a line drawn through the malleoli
- Thigh-foot angle = an angle formed by the transmalleolar axis and thigh in prone
From birth to adulthood what is the progression of tibial torsion
Relative internal tibial torsion –> external tibial torsion
What other areas of the brain may be affected with quadriplegic CP?
Basal ganglia and occipital areas
Describe cognition in patients with quadriplegic CP
variable cognitive effects
What type of equipment is required for pts with quadriplegic CP?
significant equipment throughout the lifespan
Define dyskinetic?
uncontrolled and involuntary movements
List different forms of dyskinetic movements?
Athetosis, rigidity, tremor, dystonia, ballismus, and choreoathetosis
What area of the brain is affected that causes dyskinetic movements?
deep gray matter lesions; sometimes periventricular white matter lesions
How does dyskinetic movements affect the C-spine?
often lead with head; jerking and frequent extension of C-spine causes orthopedic problems; most often begin to cause issues around age 21
Define ataxic CP?
disorder of balance and control in the timing of coordinated movements
Describe ataxic gait in CP
weakness, in-coordination, wide based gait, noted tremor
Where is the deficit located with ataxic CP?
cerebellum
What do pts with ataxic CP struggle with?
Difficulty with transference of skills
Hypotonic CP
often transient in evolution of athetosis or spasticity; can be part of mixed tone presentation
Long term means of mobility for quadriplegic pt
Usually not community ambulators; will often use powerchair for long term use
Purpose of encouraging gait and standing for pt w/ quadriplegic CP
May prolong ambulatory time before requiring powerchair / wheelchair. Assists w/ ability to participate in transfers through ability to bear weight.
What type of gait is difficult to improve upon through PT? What intervention may be helpful?
Athetotic gait; Use weighted vest/ankle weights
Name 2 features of ataxic gait:
Widened BOS, Increased double-limb support time
Name main PT goal for pts w/ ataxic gait.
Balance is primary goal in PT
What muscle groups have increased tone in those w/ spastic CP?
Increased muscle tone in antigravity muscles
Common contractures/deformities in those w/ spastic CP (10):
Hip flexors, adductors, internal rotators, knee flexors, ankle plantarflexors, scapular retractors, glenohumeral extensors and adductors, elbow flexors, forearm pronators.
What other deficits may be present in those w/ CP?
Possible visual, auditory, cognitive, and oral motor deficits
Common impairments w/ ataxic CP (7):
- Low postural tone
- Stance and gait are wide based
- Intention tremor of hands
- Uncoordinated movement
- Ataxia follows initial hypotonia
- Poor visual tracking; nystagmus
- Speech articulation problems
Common impairments w/ athetoid CP (8):
- Generalized decreased muscle tone; ‘floppy baby’
- Poor functional stability; esp. in proximal joints
- Ataxia and incoordination when child assumes upright position
- Muscle tone fluctuations
- Poor visual tracking
- Speech delay
- Oral motor problems
- Persistent reflexes
Persistent reflexes present w/ athetoid CP (3):
ATNR, STNR, TLR
NSCA Guidelines for Strength Training are relevant to what age or older?
7+ years
NSCA Guidelines for Strength Training
- Warm up: 5-10 minutes
- Type: single & multi-joint; concentric and eccentric
- Intensity/volume: 1-3 sets of 6-15 reps 50-80% of 1 RM
- Rest Intervals: 1-3 minutes
- Frequency: 2-4 x/week
- Duration: 8-20 weeks
- Progression: Inc resistance gradually (5-10%)
