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Pediatrics > cerebral palsy > Flashcards

cerebral palsy Flashcards

1
Q

def of Cerebral Palsy

A
  • non-progressive lesion of the brain resulting in disorder of posture and voluntary movement
  • occur during fetal development of first year of life.
  • progressive musculoskeletal impairment seen in most children
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2
Q

CP etiology

A
  • Prenatal, pernatal, or postnatal
  • hypoxic, ischemic, infection, congenital or traumatic
  • MRI studies (Time of insult) - prenatal (75%), Perinatal 6-8%, postnatal 10-18%
  • CVA
  • Maternal infection
  • prematurity
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3
Q

Role of the PT in diagnosis of CP

A
  • assessing asymmetry, involuntary movement, abnormal reflexes and delayed postural reactions
  • may use predictive and discriminative infant neuromotor tests to assist in prediction and ID
  • -Alberta infant motor scales (AIMS)
  • -test of infant motor performace (TIMP)
    • Precht’l assessment of general movements (GM) has the best combination of sensitivity and specificity for predicting CP in early months

**AIMS and NSDMA are better in older infants

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4
Q

behavioral issues in CP

A
  • 25% of children with CP have behavioral issues

–5x> than typical children

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5
Q

Quadriplegia

A
  • all four limbs are involved
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6
Q

diplegia

A
  • all four limbs are involved. both legs are more severely affected than the arms
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7
Q

hemiplegia

A
  • one side of the body is affected. the arm is usually more involved than the leg
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8
Q

Triplegia

A
  • three limbs are involved, usually both arms and a leg
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9
Q

monoplegia

A
  • only one limb is affected, usually an arm
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10
Q

classification motor differences

A
  • spastic- motor cortex
  • dyskinesia- basal ganglia
  • ataxic- cerebellar lesion
  • mixed- spastic and dyskinesia
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11
Q

gross motor function classification system (GFMCS)

A
  • five level classification system
  • categorized in age bands (<2, 2-4, 4-6, 6-12,12-18)
  • based on self-initiated movements. emphasis on sitting, transfers and mobility. need for hand held mobility devices or wheeled mobility
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12
Q

GMFCS levels

-general heading

A

Level 1- walks w/o limitations
Level 2- walks with limitations
Level 3- walks using a hand-held mobility device
-Level 4- self mobility with limitations, may use powered mobility
-Level 5- transported in a manual wheel chair

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13
Q

Before 2nd birthday

GMFCS Level 1

A
  • move in and out of sitting and floor sit with both hands free to manipulate objects
  • creep, pull to stand and walk holding onto furniture
  • 18 mo -2 years walk w/o assistive device
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14
Q

Before 2nd birthday

GMFCS level 2

A
  • may require use of hands in sitting
  • combat crawl or creep
  • may pull to stand and walk holding onto furniture
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15
Q

Before 2nd birthday

GMFCS Level 3

A
  • sit with low back supported

- roll and combat crawl

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16
Q

Before 2nd birthday

GMFCS level 4

A
  • require trunk support for sitting, able to control head

- roll to supine and may roll to prone

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17
Q

Before 2nd birthday

GMFCS level 5

A
  • unable to maintain antigravity head and trunk postures in prone and sitting
  • require assistance to roll
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18
Q

2nd to 4th birthday

GMFCS Level 1

A
  • transition in and out of sitting and standing w/o assistance
  • walks as primary mobility
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19
Q

2nd to 4th birthday

GMFCS Level 2

A
  • pull to stand at surface
  • creep with reciprocal pattern and cruise
  • walk with assistive device. preferred mobility
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20
Q

2nd to 4th birthday

GMFCS Level 3

A
  • frequent “W” sit
  • combat crawl or creep as primary mobility
  • walk short distance indoors with walker and adult assistance for steering
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21
Q

2nd to 4th birthday

GMFCS Level 4

A
  • adaptive equipment for sitting and standing

- self mobility limited to short distance: creep, crawl, roll

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22
Q

2nd to 4th birthday

GMFCS level 5

A
  • no means of independent movement
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23
Q

4th to 6th birthday

GMFCS level 1

A
  • walk indoors and outdoors
  • climb stairs
  • emerging run and jump
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24
Q

4th to 6th birthday

GMFCS level 2

A
  • short indoor walking without mobility device: outdoor on level surface
  • climb stairs with rail
  • unable to jump or run
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25
Q

4th to 6th birthday

GMFCS level 3

A
  • walk with handheld mobility device on level surface
  • require assistance to climb stairs
  • frequently transported long distances
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26
Q

4th to 6th birthday

GMFCS level 4

A
  • self mobility possible with powered WC

- transported in community

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27
Q

4th to 6th birthday

GMFCS level 5

A
  • no independent movement
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28
Q

6Prognosis and outcome based on cognitive function

A
  • cognitive function is the strongest predictor of walking ability in all types of CP
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29
Q

Prognosis and outcome based on independent sitting

A
  • independent sitting by 24 months is best predictor for ambulation of 15+ meters by age 8 (with or w/o device)
  • if independent sitting is not obtained by age 3, likelihood of functional walking is very low
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30
Q

GMFM-66

A
  • based on data, most children with CP reach 90% of motor potential before age 3 for most severe and by age 5 for least involved
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31
Q

Common impairments- Muscle tone and extensibility

A
  • hypertonia and hypoextensibility
  • contracture:
  • most common: shoulder adductors, elbow, wrist and finger flexors, hip flexors and adductors, knee flexors, ankle plantar flexors
32
Q

common imapirments- muscle strength

A
  • diminished force production capability- primary impairment
  • low EMG activity
  • greater weakness: distal>proximal, conc> eccentric, fast>slow speeds of movement
  • contributes to bone deformity
33
Q

common impairments- skeletal structure

A
  • torsion of long bones, joint instability and premature degenerative changes in WB joints
  • scoliosis rate 15-61%. increases with age and GMFCS level
  • hip sublaxation and dislocation
    35. 3% have migration of greater than 30% of femoral head
34
Q

common impairments- selective control

A
  • isolated muscle activation in selected pattern in response to voluntary posture
  • poor selective control contributes to impaired motor function
35
Q

common impairments - postural control

A
  • difficulty responding to challenges and fine tuning postural activity
36
Q

common impairments- motor learning

A
  • difficulty analyzing their own movements and using feedback to improve performance
  • motor memory often impaired
37
Q

common impairments- pain

A
  • 61% of ambulatory children

- -50% of parents felt it interfered with ADLs

38
Q

common impairments - activity and participation

A
  • opportunities for participation in home, school and community are increasing. technology and social attitudes/policies
  • participation restriction in social and intimate relationships and paid employment continue in adulthood
39
Q

examination of muscle tone and extensibility

A
  • modified ashworth: low reliability with CP
  • modified tardieu: measures point of “catch” to a rapid movement. mechanical resistance to slow stretch indicates muscle length. difference between catch and mechanical resistance.
  • -large difference indicates large reflexive component to motion limitation. small difference indicates a more fixed contracture
40
Q

examination of strength

A
  • MMT
  • Functional
  • endurance and efficiency of movement
41
Q

examination of selective control, postural control and motor learning

A
  • selective control assessment of the lower extremity (SCALE)
  • observation of sway or response to perturbation
  • segmental assessment of trunk control (SATCo)
42
Q

examination of pain

A
  • assess frequently regardless of cognitive level and communication ability
  • pain assessment instrument for cerebral palsy. Range of potentially painful activities
43
Q

examination of activity and participation

A
  • therapist to differentiate between: capacity, performance, motivation
  • several assessment tools
44
Q

examination consideration of infancy

A
  • consider infant’s temperament, state of regulation and handling tolerance
  • provides baseline for monitoring
45
Q

examination consideration pre school aged

A
  • require more frequent reassessment
46
Q

muscle strengthening in CP

A
  • using both concentric and eccentric muscl eforce

- transitions against gravity, ball activities, treadmill, tricycle, and stair negotiation

47
Q

progressive resistance training in CP

A
  • 4-12 week duration
  • 3x/week
  • 80-90% max load
  • lower resistance and increased reps for endurance
  • use of free weight, elastic bands, isokinetic equipment and functional movements
48
Q

cardiovascular endurance in CP

A
  • energy expenditure in walking can be up to 3x greater for children with CP
  • promote physical activity. GMFCS level 1 and 2 respond well to specific training. swimming programs for all levels
49
Q

therapeutic interventions sensory intergration

A
  • arousal or calming

- proprioception, vestibular, tactile

50
Q

therapeutic interventions- modified constraint induced movement therapy

A
  • useful with hemiplegia
  • constraining unaffected UE
  • mass practiced with affected UE
51
Q

therapeutic interventions- treadmill training

A
  • partial weight bearing options

- task specific motor learning

52
Q

therapeutic interventions- e-stim

A
  • pain control
  • muscle strengthening
  • NDT
53
Q

spasticity management

A
  • interventions used if spasticity is interfering with function or comfort
  • passive stretching- short term, minor effects
  • selective dorsal rhizotomy
  • botox
  • baclofen- oral or intrathecal
54
Q

intervention for muscle length

A
  • best maintained through active movement in lengthened position
  • tardieu study showed prevention of plantar flexor contractures with stretch beyond threshold for at least 6 hours during daily activity
  • sustained passive stretching: casting- single or serial, orthoses, positioning
55
Q

Goals of LE orthoses

A
  • limit inappropriate joint movements and alignment
  • prevent contracture, hyperextensibility and deformity
  • enhance postural control and balance
  • reduce energy cost of walking
  • provide post-op protection to soft tissues
56
Q

Solid AFOs

A
  • maximum restriction of ankle movement
57
Q

hinged orthoses

A
  • permits DF or whatever movement we want to be blocked
58
Q

dynamic or posterior leaf spring orthoses

A
  • reduce equinus in swing
  • permit ankle DF in stance
  • absorb more energy in midtance
  • reduce desirable power generation at push off
59
Q

SMOs orthoses

A
  • for pronation
60
Q

Orthotic management (Morris)- GMFCS level 1-3

A
  • used to allow for more efficient gait and prevent deformity
61
Q

Orthotic management GMFCS levels 4-5

A
  • preventing deformities even if they at enot walking
  • may allow child to be positioned in standing for physiological and physcosocial benefits

-families should understand how to use and how lng each day, as well as the resoning for usage

62
Q

effects of AFOs on gait in children with CP

A
  • increased velocity, reduced cadence, increased step length and stride length, increased duration of single leg support
  • improved energy efficiency and possible decreased O2 consumption
63
Q

orthotic management for muscle lengthening

A
  • minimum of 6 hours per day

- may decreased need for Achilles tendon surgery

64
Q

orthotic management effects on sit to stand

A
  • solid AFO may impede transition unless it is positioned with a forward inclination
65
Q

positioning of GMFCS level 4 and 5

A
  • should have an individualized postural management program
  • prevention positional contrcatures and deformity
  • prevent skin breakdown
  • facilitate function and participation
  • promote safe, comfortable and biomechanically optimal sleep positions
66
Q

positioning of GMFCS level 1-3

A
  • emphasize activity
  • may require adaptive seating
  • WB programs. increase/maintain bone mineral density
  • maintain LE muscel extensibility, promote acetabular development

-may initiate use of stander at age 1

67
Q

CP mobility with posterior walker

A
  • posterior walkers improve posture and gait pattern
  • decrease energy expensiture versus anterior walker
    -safe and effective mobility in power wheelchairs can be achieved as early as 17 mo of age.
    treadmill training with body weight supported
68
Q

establishing goals for CP kids

A
  • individualized, criterion referenced measured of change

- defining a set of unique goals for a client, and then specifying a range of outcomes

69
Q

perceived efficacy and goal setting (PEGS)

A
  • 2nd ages 5-9
  • pictures of tasks
  • allows child to self report perceived competence in every day activities and set goals for intervention
  • parallel questionnaires for caregivers and educators
70
Q

GAS 5-Point scale

A

-2 - much less than expected outcome
-1- less than expected outcome
0 expected outcome after intervention
+1 - greater than expected outcome
+2 - much greater than expected outcome

71
Q

developing ambulation skills with direct intervention

A
  • therapeutic exercise
  • functional training in self-care and home management
  • manual therapy
  • modalities
  • assistive devices, orthotics, adaptive equipment
72
Q

intervention for Level 3 - upright posture and stability

A
  • ABC’s of posture
  • using assistive device and orthotics
  • developing strategies to control weight shift of COM
  • strengthening postural muslces
73
Q

intevrnetion for level 3- developing forward progression

A
  • forward progression of COM with less lateral
  • facilitating proximal co-contraction with axial rotation
  • work in and out of orthotics
  • isolated control between and within LEs
74
Q

intervention for level 3 shock absorption

A
  • diligent monitoring between and within LEs
75
Q

-developing ambulation levels 1 and 2

A
  • ongoing analysis of posture and stability as child ambulates in different environements and in varying functional activities
  • regular evaluation of orthotic fit and function.
  • monitor gait efficiency
  • fitness program within the community

Pediatrics (19 decks)

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