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
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
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
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
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
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
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
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…”
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.”
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
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
- Esotropia: deviation of eye towards midline (more common)
12
Q
Modified Ashworth: Body Structure/Function-Spasticity
(Quantifying Muscle Tone)
A
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
14
Q
Movement Disorders
A
- Related to location of brain damage
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
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
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.
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
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
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.”
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
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
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)
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Gross Motor Function Classification Scale (GMFCS)
* 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
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ICF: Body functions and structure
* 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
Best predictor of ambulation
* 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
PT intervention: Spasticity
* Characterized primarily by 2 patterns
* Croucher
* Extender
\**Cognitive, visual, auditory and oral motor deficits*
29
Spastic CP-*Croucher*
* 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?
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Crouched gait
* 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
Crouched gait muscle effects
* 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!
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Croucher
* 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
Interventions
* 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
Extender
* 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
Quads
* 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
## Footnote
*\*Quads used to compensate for weak glut max*
36
PT Intervention: Hypertonia
**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
PT Intervention- Infancy
* 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
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PT Intervention-Preschool
* 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
Upright Mobility
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
PT Intervention-School-Age/and up
* 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
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Strength (Muscle Force Production)
* 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
Bone Mineral Density
* *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
Locomotor training
* 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
Interventions: Evidence Present
* 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
.
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Mobility Opportunities via Education (MOVE)
* 4 components
* Sitting
* Standing
* Walking
* Transitioning
\*Based on the principle that Movement is the foundation of all learning
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Goal, Activity, Motor, Enrichment
| (GAME)
* 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
UE Training
* 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
Participation level
* Community fitness programs
* Powered child cars
49
Medical interventions
* Medications
* Orthopedic surgery
* Neurosurgery
50
Meds- Management of Spasticity
* 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)
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Baclofen pump
* 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
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Injectible Meds
* *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
Orthopedic Surgeries- Soft tissue related
* 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
Orthopedic surgeries- Bone related
* 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
Neurosurgery
* 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
Adeli Suit
* 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
