cerebral palsy Flashcards
def of Cerebral Palsy
- 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
CP etiology
- 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
Role of the PT in diagnosis of CP
- 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
behavioral issues in CP
- 25% of children with CP have behavioral issues
–5x> than typical children
Quadriplegia
- all four limbs are involved
diplegia
- all four limbs are involved. both legs are more severely affected than the arms
hemiplegia
- one side of the body is affected. the arm is usually more involved than the leg
Triplegia
- three limbs are involved, usually both arms and a leg
monoplegia
- only one limb is affected, usually an arm
classification motor differences
- spastic- motor cortex
- dyskinesia- basal ganglia
- ataxic- cerebellar lesion
- mixed- spastic and dyskinesia
gross motor function classification system (GFMCS)
- 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
GMFCS levels
-general heading
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
Before 2nd birthday
GMFCS Level 1
- 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
Before 2nd birthday
GMFCS level 2
- may require use of hands in sitting
- combat crawl or creep
- may pull to stand and walk holding onto furniture
Before 2nd birthday
GMFCS Level 3
- sit with low back supported
- roll and combat crawl
Before 2nd birthday
GMFCS level 4
- require trunk support for sitting, able to control head
- roll to supine and may roll to prone
Before 2nd birthday
GMFCS level 5
- unable to maintain antigravity head and trunk postures in prone and sitting
- require assistance to roll
2nd to 4th birthday
GMFCS Level 1
- transition in and out of sitting and standing w/o assistance
- walks as primary mobility
2nd to 4th birthday
GMFCS Level 2
- pull to stand at surface
- creep with reciprocal pattern and cruise
- walk with assistive device. preferred mobility
2nd to 4th birthday
GMFCS Level 3
- frequent “W” sit
- combat crawl or creep as primary mobility
- walk short distance indoors with walker and adult assistance for steering
2nd to 4th birthday
GMFCS Level 4
- adaptive equipment for sitting and standing
- self mobility limited to short distance: creep, crawl, roll
2nd to 4th birthday
GMFCS level 5
- no means of independent movement
4th to 6th birthday
GMFCS level 1
- walk indoors and outdoors
- climb stairs
- emerging run and jump
4th to 6th birthday
GMFCS level 2
- short indoor walking without mobility device: outdoor on level surface
- climb stairs with rail
- unable to jump or run
4th to 6th birthday
GMFCS level 3
- walk with handheld mobility device on level surface
- require assistance to climb stairs
- frequently transported long distances
4th to 6th birthday
GMFCS level 4
- self mobility possible with powered WC
- transported in community
4th to 6th birthday
GMFCS level 5
- no independent movement
6Prognosis and outcome based on cognitive function
- cognitive function is the strongest predictor of walking ability in all types of CP
Prognosis and outcome based on independent sitting
- 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
GMFM-66
- 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
Common impairments- Muscle tone and extensibility
- hypertonia and hypoextensibility
- contracture:
- most common: shoulder adductors, elbow, wrist and finger flexors, hip flexors and adductors, knee flexors, ankle plantar flexors
common imapirments- muscle strength
- diminished force production capability- primary impairment
- low EMG activity
- greater weakness: distal>proximal, conc> eccentric, fast>slow speeds of movement
- contributes to bone deformity
common impairments- skeletal structure
- 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
common impairments- selective control
- isolated muscle activation in selected pattern in response to voluntary posture
- poor selective control contributes to impaired motor function
common impairments - postural control
- difficulty responding to challenges and fine tuning postural activity
common impairments- motor learning
- difficulty analyzing their own movements and using feedback to improve performance
- motor memory often impaired
common impairments- pain
- 61% of ambulatory children
- -50% of parents felt it interfered with ADLs
common impairments - activity and participation
- 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
examination of muscle tone and extensibility
- 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
examination of strength
- MMT
- Functional
- endurance and efficiency of movement
examination of selective control, postural control and motor learning
- selective control assessment of the lower extremity (SCALE)
- observation of sway or response to perturbation
- segmental assessment of trunk control (SATCo)
examination of pain
- assess frequently regardless of cognitive level and communication ability
- pain assessment instrument for cerebral palsy. Range of potentially painful activities
examination of activity and participation
- therapist to differentiate between: capacity, performance, motivation
- several assessment tools
examination consideration of infancy
- consider infant’s temperament, state of regulation and handling tolerance
- provides baseline for monitoring
examination consideration pre school aged
- require more frequent reassessment
muscle strengthening in CP
- using both concentric and eccentric muscl eforce
- transitions against gravity, ball activities, treadmill, tricycle, and stair negotiation
progressive resistance training in CP
- 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
cardiovascular endurance in CP
- 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
therapeutic interventions sensory intergration
- arousal or calming
- proprioception, vestibular, tactile
therapeutic interventions- modified constraint induced movement therapy
- useful with hemiplegia
- constraining unaffected UE
- mass practiced with affected UE
therapeutic interventions- treadmill training
- partial weight bearing options
- task specific motor learning
therapeutic interventions- e-stim
- pain control
- muscle strengthening
- NDT
spasticity management
- interventions used if spasticity is interfering with function or comfort
- passive stretching- short term, minor effects
- selective dorsal rhizotomy
- botox
- baclofen- oral or intrathecal
intervention for muscle length
- 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
Goals of LE orthoses
- 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
Solid AFOs
- maximum restriction of ankle movement
hinged orthoses
- permits DF or whatever movement we want to be blocked
dynamic or posterior leaf spring orthoses
- reduce equinus in swing
- permit ankle DF in stance
- absorb more energy in midtance
- reduce desirable power generation at push off
SMOs orthoses
- for pronation
Orthotic management (Morris)- GMFCS level 1-3
- used to allow for more efficient gait and prevent deformity
Orthotic management GMFCS levels 4-5
- 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
effects of AFOs on gait in children with CP
- increased velocity, reduced cadence, increased step length and stride length, increased duration of single leg support
- improved energy efficiency and possible decreased O2 consumption
orthotic management for muscle lengthening
- minimum of 6 hours per day
- may decreased need for Achilles tendon surgery
orthotic management effects on sit to stand
- solid AFO may impede transition unless it is positioned with a forward inclination
positioning of GMFCS level 4 and 5
- 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
positioning of GMFCS level 1-3
- 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
CP mobility with posterior walker
- 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
establishing goals for CP kids
- individualized, criterion referenced measured of change
- defining a set of unique goals for a client, and then specifying a range of outcomes
perceived efficacy and goal setting (PEGS)
- 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
GAS 5-Point scale
-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
developing ambulation skills with direct intervention
- therapeutic exercise
- functional training in self-care and home management
- manual therapy
- modalities
- assistive devices, orthotics, adaptive equipment
intervention for Level 3 - upright posture and stability
- ABC’s of posture
- using assistive device and orthotics
- developing strategies to control weight shift of COM
- strengthening postural muslces
intevrnetion for level 3- developing forward progression
- 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
intervention for level 3 shock absorption
- diligent monitoring between and within LEs
-developing ambulation levels 1 and 2
- 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
