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Cerebral Palsy Flashcards

1
Q

CP Defenition

A
  • Cerebral palsy (CP) describes a group of permanent disorders of the development of movement and posture causing activity limitations that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain.
  • The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication, and behavior, by epilepsy, and by secondary musculoskeletal problems
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2
Q

Etiology - Birthweight

A
  • Birthweight:
    • 1000-1499 grams (2.2-3.3 lbs) highest prevalence of CP
    • Below 1000 grams had no more increased risk than 1000-1499 grams
    • Lowest risk if birthweight >2500 grams (5.5 lbs) live births
  • LBW: infants – periventricular leukomalacia (PVL,) periventricular hemorrhage, cerebral infarct
  • Normal weight term infants – hypoxic-ischemic encephalopathy (HIE) most common cause (resulting in dyskinetic or spastic quad CP
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3
Q

Etiology – Gestational Age

A
  • Gestational age:
    • Highest prevalence of CP at 23 weeks GA, lowest after 36 weeks GA
    • Biggest risk if born <28 week
    • Term infants: ~55-65% of kids with CP were term
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4
Q

Genetics

A
  • Genetics: some evidence there are phenotypes for increased risk for CP
  • Already identified 6 genes
  • Single-gene mutations found in some cases
  • Familial cases
  • 2-5 times more common in consanguinity
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5
Q

PVL

A
  • Often caused by HIE
  • Associated with cognitive impairments
  • PVL: >80% develop CP
  • Posterior lesions worse than anterior lesions
  • Focal cysts associated with spastic diplegia
  • Extensive cysts associated with spastic quadriplia
  • Non-cystic PVL also associated with CP
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6
Q

PVL/ IVH

A
  • Grades I-II PVL likely to walk by 2 yo
  • Grades III-IV, only 10% walk
  • Can also have intraventricular hemorrhage (IVH)
  • Grades I-II, minimal risk of neurological impairment
  • Grades III-IV, high risk of neurological impairment
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7
Q

Maternal risk factors

A
  • Seizure disorder
  • Thyroid disease
  • Cognitive impairment
  • Heart disease
  • Respiratory disease
  • Hypertension
  • >40 yo
  • Pre-eclampsia
  • Chorioamnionitis
  • Still birth or neonatal death
  • Abnormal amount of amniotic fluid
  • Bleeding in 2nd or 3rd trimester
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8
Q

CP: Early Diagnosis

A
  • Preemie with abnormal MRI and abnormal motor signs on General Movements or Test of Infant Motor Performance useful in identifying the presence and location of an injury in ∼89% of kids with CP
  • Doesn’t predict the severity of CP
    • (AIMS/TIMP in 4-10 month old for prediction of and ID of CP)
  • 25-50% of babies with CP will not show signs of CP as newborns
  • Prechtl’s qualitative assessment of general movements (GMs) is the most predictive assessment tool to detect infants, as young as 3 months who have the highest risk of CP…”
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9
Q

General Prognosis

A
  • “All children with cerebral palsy will have physical challenges. The bigger the child’s brain injury, the more likely the child is to have other co-occurring impairments, diseases, and functional limitations accompanying the physical disability, except for pain and behavior, which are common regardless of the level of physical disability.”
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10
Q

Predictors of Independent Walking in Young Children with CP

A
  • Sit-to-stand, and stand to sit
    • Based on the postural control
    • and functional strength needed
  • Closed chain exercises mimicking everyday activities has shown to increase strength and functional ability
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11
Q

Visual Deficits

A
  • Up to 71%
  • ROP
  • Nystagmus
  • Homonymous hemianopsia (25% of hemiplegia)
  • Strabismus
    • Esotropia: deviation of eye towards midline (more common)
      Exotropia: deviation of eye away from midline
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12
Q

Modified Ashworth: Body Structure/Function-Spasticity

(Quantifying Muscle Tone)

A
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13
Q

Classification

A
  • Anatomic distribution and location
    • Diplegia: both lower extremities
    • Hemiplegia: UE &LE on one side of body
    • Quadriplegia: all 4 extremities
    • Trunk can be involved in all
  • Movement Disorders
  • Gross Motor Function Classification System
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14
Q

Movement Disorders

A
  • Related to location of brain damage
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15
Q

Spastic CP

A
  • Spastic: motor cortex or white matter projections to/from cortical sensorimotor
    • Produces abnormal patterns of posture and movement
  • Increased muscle tone in antigravity muscles
  • Abnormal postures and movements with patterns of all flexion or all extension
  • Imbalance of tone across jointsà contractures and deformities (hip flexors, adductors, internal rotators; knee flexors; ankle plantarflexors; scapular retractors; glenohumeral extensors and adductors; elbow flexors; forearm pronators
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16
Q

Dyskinetic forms:

A
  • Dyskinetic forms (uncontrolled and involuntary movement); basal ganglia involvement
    • Results in general instability, abnormal postural patterns, lack of coordinated, rhythmical, and accurate movements
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17
Q

Dyskinetic movements can be:

A
  • Twisting and repetitive movements – known as dystonia
  • Slow, ‘stormy’ movements – known as athetosis
  • Dance-like irregular, unpredictable movements – known as chorea.
  • Dyskinetic movements often co-occur alongside spasticity.
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18
Q

Dystonia

A
  • “Dystonia is a movement disorder in which involuntary sustained or intermittent muscle contractions cause twisting and repetitive movements, abnormal postures, or both.” (Sanger et al, 2010, p. 1541)
    • More predictable movements than chorea
    • Triggered by voluntary attempt to move
    • Absent during sleep
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19
Q

Chorea

A
  • “Chorea is an ongoing random-appearing sequence of one or more discrete involuntary movements or movement fragments.”
  • Movements are brief, jerky, discrete motions appear to constantly move
  • “…multiple, repeated, but not rhythmic movements”
  • Motions more rapid than dystonia and worsen with movement
  • Doesn’t stop with relaxation
  • Caused by damage to the cerebral cortex, basal ganglia, cerebellum, or thalamus
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20
Q

Ballism

A
  • “…ballism as chorea that affects proximal joints such as shoulder or hip. This leads to large amplitude movements of the limbs, sometimes with a flinging or flailing quality.”
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21
Q

Athetosis

A
  • “Athetosis is a slow, continuous, involuntary writhing movement that prevents maintenance of a stable posture.”
  • Smooth, “sinuous, continuously…flowing, ongoing, random movement…”
  • Snake-like movements
  • Same regions of body vs. chorea
  • Present at rest as well as when attempting to move
  • No sustained movement as in dystonia
  • Distal more than proximal; trunk, face, neck
  • Use weights distally, weighted belt, weighted vest, weighted walker
  • Use approximation
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22
Q

Athetoid CP (Dyskinetic)

A
  • Decreased muscle tone; floppy baby
  • Poor proximal joint stabilityà poor functional stability
  • Decreased coordination when child assumes upright
  • Poor visual tracking
  • Speech delay and oral motor problems/drool
  • Tonic (primitive)reflexes persist interfering with functional posture and movement
    • (so use sidelying positions to decrease effect
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23
Q

Ataxia

A
  • Ataxia: Inability to make smooth, accurate, coordinated movements
  • Multiple causes including CP - results from damage to cerebellum
  • (also genetic disorders, CNS damage, fetal alcohol syndrome)
  • “…abnormal movements in ataxia increase near a target (intention tremor and dysmetria) and improve with stabilization of proximal joints…”
24
Q

Ataxic CP

A
  • Low postural tone à poor balance
  • WBOS; unsteady/staggered gait
  • Uncoordinated movement
  • Initial hypotonia followed by ataxia
  • Intention tremor of hands
  • Poor visual tracking, nystagmus
  • Speech articulation problems

Use deep pressure/approximation

Lycra suit to improve proximal stability

Weighted walker (Increase proprioception)

25
Q

Gross Motor Function Classification Scale (GMFCS)

A
  • Level I most functional to Level V most involved
  • Provides method of predicting child’s outcome
  • Maximal mobility generally between 9-12 yo
  • Overview of child’s current functional abilities
    • Based on performance in daily life
      • self initiated movement with emphasis on sitting and walking
      • functional limitations
      • Need for handheld AD
      • Need for wheeled mobility
      • quality of movement (somewhat)
  • NOT an outcome measure: Do not set goal of treatment to change someone’s classification
26
Q

ICF: Body functions and structure

A
  • Muscle Tone Abnormality
  • Muscle Strength: Insufficient force generation
  • Skeletal Structure Changes:
    • Torsion of long bones
    • Joint instability
    • Premature degenerative changes in WB jts
    • Boney malalignment (scoliosis)
    • Hip subluxation/Dislocation
    • fractures
27
Q

Best predictor of ambulation

A
  • Sitting independently by 24 months
    • (walk at least 15 meters w/ or w/o AD by 8yo)
  • If not sitting independently by 36 months, low chance of achieving a functional independent ambulation
28
Q

PT intervention: Spasticity

A
  • Characterized primarily by 2 patterns
    • Croucher
    • Extender

*Cognitive, visual, auditory and oral motor deficits

29
Q

Spastic CP-Croucher

A
  • Think about the posture of a child who has a crouched gait (eg excessive knee flexion).
  • Think about what muscles need to be strengthened for a child who has a crouched gait?
30
Q

Crouched gait

A
  • Posture
    • Hip flexion
    • Hip adduction
    • Hip IR
    • Knee flexion
    • Genu valgum
    • Foot pronation
    • Excessive ankle dorsiflexion
    • WBOS—-strong influence on hip (address it)
    • (also need a vertical tibia for line of gravity to go through joint to keep hip and knee straighter)
    • Use orthotic to control foot if needed to get above
31
Q

Crouched gait muscle effects

A
  • Tight fascia lata
  • Poor glut max
  • Tight hamstrings
  • Tight hip adductions

-can be consequence of tight TFL; if TFL tight then if you adduct hip, the leg will move into hip IR and flexion (supine and stand)

Doing adductor release will not help!

32
Q

Croucher

A
  • Glut max is key to hip and trunk control-must get active hip extension to get long term carry over to correct hip IR also
  • Stabilizaiton of pelvis by abdominals and elongation of hips flexors
    • Hip extensors and abdominal muscles act as force couple to posteriorly tilt pelvis
  • If cannot extend hip joint then extension comes in the low back leading to increased lumbar lordosis
  • So must elongate hip flexors while also trying to activate abdominals and glut max
    • Work in half kneel-straddle bolster and rotate to each side into half kneel (can then move body to stretch hamstrings or rectus femoris)
  • Tight hip flexors→ anterior pelvic tilt
  • Tight hip extensors→ posterior pelvic tilt
  • If hip joint is restricted into flexion because of a posterior pelvic tilt/tight hip extensors
    • lumbar extension becomes lumbar flexion
  • No mobility at hips in pull to sit
    • Rectus abdodminus used for stability (not mobility)
    • This further increases the posterior pelvic tilt and hip extension
33
Q

Interventions

A
  • Think about the posture of a child who has an “extender” gait.
  • Think about what muscles need to be strengthened for a child who has an extender gait?
  • Besides strengthening, how else do we treat the impairments?
34
Q

Extender

A
  • High tone and strong extension-cannot move out of sagittal plane
  • Look the same in standing as they do in horizontal
  • No lower extremity dissociation
  • Try to work with arms forward to decrease scapular adduction
  • Hip muscles not working-quads work overtime extending knee and stretching hamstrings and gastroc (hamstring stretch mechanically extends hip and gastroc stretch mechanically plantar flexes ankle
35
Q

Quads

A
  • Stretch of tight hamstrings at distal attachment (knee) causes proximal attachment to move posteriorly into posterior pelvic tile (hip extension)
  • Knee extension also stretches the gastrocnemius muscle and cause plantar flexion

*Quads used to compensate for weak glut max

36
Q

PT Intervention: Hypertonia

A

Facilitate normal motor milestones:

◦Prone on elbows

◦Rolling

◦Sitting

◦Standing

◦Commando crawling on belly

◦Transitioning into/out of sitting and quadruped

◦Creeping on hands and knees

◦Pulling to standing

◦Lowering self to sitting

◦Cruising

◦Standing independently

◦Ambulating using push cart

◦Ambulating with 1-2 hands held

◦Taking steps independently

◦Ambulating independently

37
Q

PT Intervention- Infancy

A
  • Everyday handling and positioning of infants influences development
  • Don’t forget importance of mid-line activities and promotion of symmetry
  • Include all planes of motion in movement act
    • A/Pà lateral à rotational
  • Self exploration
  • Promote environmental and social interaction
  • Trial and error
  • Start standers if possible
38
Q

PT Intervention-Preschool

A
  • Development of locomotor, cognitive, communication, fine motor, self-care and social abilities
  • Control of posture/alignment and mvts
  • Look for limits in participation
  • Muscles need to be extended to their limits regularly
  • Bones need compressive forces
  • Cardiovascular system challenged
  • STANDERS
  • Main goal is for independent mobility
39
Q

Upright Mobility

A

Posterior walkers/posture walkers

  • Encourages upright posture during gait
  • Promotes improved gait characteristics
  • Decreases energy expenditure compared to anterior walker

GMFCS Level IV can use wheeled walking devices that support trunk and pelvis

  • allows for interaction with environment/participation
40
Q

PT Intervention-School-Age/and up

A
  • More of the same but focus of child may shift to school and community life
  • TM training with PBWS (GMFCS III-V)
  • Aquatics
  • Prevention of secondary impairments
  • Maintenance of achieved level of motor function as child enters adolescence
  • Prevention of overuse syndromes
  • Progressive resistance training recommended
    • Therabands
    • Free weights
    • Isokinetics
    • Functional movements
41
Q

Strength (Muscle Force Production)

A
  • Strength can be improved via free weights, isometric, isokinetic, open and closed-chain isotonic, body weight, weighted backpacks, pulley systems, and electrical stimulation but its impact on activities or participation unknown
  • Effect of strengthening on gait, gross motor function, self-esteem, or quality of life inconclusive and/or limited
  • At least 3/week for 6 weeks
42
Q

Bone Mineral Density

A
  • Skeletal loading interventions: effects on kids with CP inconclusive – more effect on kids who are ambulatory
  • Type of loading important: static activities, vibrating platforms, standers, combination of weight-bearing and strengthening activities
    • 30 minutes, 5/week x 2 mo or 2/day, 30 minutes x6 mo
    • Amount of force needed not documented
    • May need longer duration in kids with CP
  • Medications/vitamins: growth hormone, calcium, vitamin D, bisphosphonates
    • Unknown what type is better in child to prevent osteoporosis as adult with CP
    • Unknown impact on activity or participation
43
Q

Locomotor training

A
  • Affects gait speed, endurance, community ambulation
  • Studies have used variety of self-paced, pre-set pace, fasted pace, and variety of amount of body weight support
  • 30 minutes 2/day x2 weeks or 2/day x6+weeks
44
Q

Interventions: Evidence Present

A
  • Ankle serial casting (3-6 weeks)
  • Orthotics-AFOs improve gait kinematics
    • Static vs. dynamic AFOs
  • Fitness training
  • Hip monitoring
  • Prevention of pressure sores
  • CIMT
  • Context-focused therapy
  • Goal directed/functional training
  • HEP

.

45
Q

Mobility Opportunities via Education (MOVE)

A
  • 4 components
    • Sitting
    • Standing
    • Walking
    • Transitioning

*Based on the principle that Movement is the foundation of all learning

46
Q

Goal, Activity, Motor, Enrichment

(GAME)

A
  • 3 components:
    • 1.goal oriented activity-based motor training
    • 2.parent education
    • 3.ways to enrich the child’s learning environment

*The motor learning component of the intervention is based on the principles of motor learning and dynamic systems theory

47
Q

UE Training

A
  • CIMT: can affect body structure and function, activity, and participation levels
  • More practice is better (practice based/goal directed)
  • 90 hours, 15 days better than 60 hours, 10 days
48
Q

Participation level

A
  • Community fitness programs
  • Powered child cars
49
Q

Medical interventions

A
  • Medications
  • Orthopedic surgery
  • Neurosurgery
50
Q

Meds- Management of Spasticity

A
  • Oral meds-presynaptic inhibition of acetylcholine release
    • Baclofen —CNS
    • Diazepam (valium)—CNS
    • Tizanidine (zanaflex) —CNS
    • Dantrolene sodium (dantrium) —muscle
  • Baclofen pump-intrathecal programmable pump
  • GABA b-agonist (Inhibitory CNS neurotransimitter)

-Catheter delivers drug to subarachnoid space in SCà ms. relaxation (controls spasticity below SC level to which it is delivered)

51
Q

Baclofen pump

A
  • Pros
    • Longer lasting, more specific site of action, fewer side effects, can hold up to 4 month supply
  • Cons
    • Side effects of hypotonia, nausea, HA, 2° issues at surgical site or equipment failure/kinked catheter, overdose and withdrawal possible
  • Overdose
    • Very drowsy, dizzy, respiratory depression, seizure, hypotonia, loss of consciousness (call 911)
  • Withdrawal
    • Increase spasticity, tingling, HA, hyperthermia, hypotension, seizures, hallucinations, altered mental state, autonomic dysreflexia (call 911), itching without rash

MOST COMMON IN KIDS WITH SPASTIC QUADRIPLEGIA

52
Q

Injectible Meds

A
  • decrease local spasticity & Dystonia
  • decrease contractures
  • increase motor control
  • Non-systemic
  • Botox
    • Interferes with release of acetylcholine at NMJ
    • Directly into affected muscles-No systemic effect
    • Lasts 3-6 months (expensive)
    • Important to combine with casting/orthotics/night splinting, positioning, stretching and motor strengthening
  • Anesthetics/Diagnostic Nerve Blocks (Lidocaine)
  • Neurolyitc Nerve blocks (ethanol/phenol)
53
Q

Orthopedic Surgeries- Soft tissue related

A
  • Decrease contractures
  • Decrease abnormal bony alignment
  • Improve motor control and function
  • Soft tissue related
    • Tendon (tenotomy) or muscle lengthening
      • Most common: achilles tendon, hamstrings, iliopsoas, hip adductors, and hamstrings
    • Tendon/muscle transfers
      • Attachments moved to change direction of force
      • Most common: hip adductors transferred to hip abductor
54
Q

Orthopedic surgeries- Bone related

A
  • Bone-related
    • Cut, remove or reposition bone to facilitate normal alignment and prevent subluxation or dislocation
  • Osteotomies
    • Most common: femoral, tibial or pelvic
    • Femoral derotation osteotomy
  • Fusions
    • Spinal fusions

-Non-weight bearing after bony procedures and risk of weakness and decreased function

55
Q

Neurosurgery

A
  • Neurectomy, selective dorsal rhizotomy (SDR), deep brain stimulation
  • SDR
    • Typically between ages of 4-10yo (& GMFCS I-III)
    • Sever the dorsal sensory nerve roots with abnormal responses to stimulation
    • Decreases spasticity à improved motor control
    • Possible sensory loss and anesthesia/surgery risks
    • Not reversible
    • Ambulation is always the goal: intensive strengthening program required following surgery

-Most common in kids with spastic diplegia with selective muscle control and no deformity, good motivation

56
Q

Adeli Suit

A
  • Originally designed by the Russian space program for cosmonauts to maintain muscle tone in a weightless environment, the Adeli Suit has been modified to help people with cerebral palsy improve gross motor function and gait

Pediatrics (22 decks)

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