Cerebral Palsy (CP)

Question 1

What are the F-words in chldhood disability?

Answer 1

Function
Family
Fitness
Fun
Friends
Future
Challenge yourself to apply these factors in your work with children with disabilities and their families

Question 2

Define cerebral palsy

Answer 2

• group of permanent disorders of the development of movement and posture, causing activity limitation that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain

The motor disorders of cerebral palsy are also accompanied by disturbances of sensation, perception, cognition, communication, and behaviour, by epilepsy, and by secondary musculoskeletal problems.

Question 3

Describe the diagnostic process: how would one diagnose & when?

Answer 3

• No diagnostic test
• based on clinical presentation and medical history
• Diagnosis is usually made before the age of 2

Question 4

True or False: This is the most common motor disability in children, with girls being more impacted than boys

Answer 4

False: more common in boys (57%)

Question 5

What are the common causes of CP?

Answer 5

• Prematurity
• Low Birth Weight (LBW)
• Multiple Gestation
• Cerebrovascular Accident (CVA)
• Others

Question 6

Prematurity/LBW commonly leads to:
1. spastic quadriplegia
2. spastic hemiplegia
3. spastic diplegia
4. dystonia

Answer 6

3) spastic diplegia - Prematurity/LBW also commonly see white matter disorder

Question 7

True or False: Triplets are more likely to get CP compared to twins

Answer 7

True - risk of CP increases with multiple gestations

Question 8

define hypertonia and what it consists of

Answer 8

“Abnormally increased resistance to externally imposed
movement about a joint”

Consists of:
* Spasticity
* Dystonia
* Rigidity (uncommon in children with CP)

Question 9

Define spasticity

Answer 9

• Resistance to externally imposed movement increases with increasing speed of stretch and varies with the direction of joint movement, and/or resistance to externally imposed movement rises rapidly above a threshold speed or joint angle

Question 10

define dystonia

Answer 10

involuntary sustained or intermittent muscle contractions cause twisting and repetitive movements, abnormal postures, or both

Question 11

Name the types of CP

Answer 11

Spastic
* Spastic bilateral (spastic diplegia / spastic quadriplegia)
* Spastic unilateral (spastic hemiplegia)

Dyskinetic
* Dystonic
* Choreo-Athetotic

Ataxic
Mixed (presents with both spastic and dyskinetic features)

Question 12

Which type of CP is most common?
1. bilateral/diplegia
2. unilateral/hemiplegia
3. dystonia
4. bilateral/quadriplegia

Answer 12

2) unilateral/hemiplegia (40%)

Question 13

How would a spastic hemiplegic pt present?

Answer 13

• Spasticity noted on arm & leg of same side
• Since it affects grey matter, seizures may be present
• Most children walk independently but gross motor milestones are delayed and have difficulty with high level balance skills

Question 14

What is the leading cause of spastic unilateral CP?

Answer 14

perinatal stroke (MCA infarct) and congenital malformations

Question 15

Why are legs more often affected by damage to the periventricular leukomalacia than the
arms in spastic bilateral CP?

Answer 15

Because leg fibres of the corticospinal tract run closest to the ventricles

Question 16

What other medial issues is spastic quadriplegia typically asspciated with?

Answer 16

visual, auditory,
seizures, cognitive, digestive

Question 17

what is choreo-athetosis?

Answer 17

Slow, continuous, involuntary writhing movement that prevents maintenance of a stable posture

Question 18

Describe each level of the GMFCS classification system

Answer 18

GMFCS I: Walks without restrictions; limitations in more advanced gross motor skills

GMFCS II: Walks without assistive devices; limitations in walking outdoors and in the community

GMFCS III: Walks with assistive mobility devices; limitations in walking outdoors and in the community

GMFCS IV: Self-mobility with limitations; children are transported or use power mobility outdoors and in the community

GMFCS V: Self-mobility is severely limited even with the use of assistive technology

Question 19

What is the clinical presentation of CP?

Answer 19

Quite varied!
Gross motor function limitations are due to a combination of:
* musculoskeletal impairments (spasticity, strength, range of motion, skeletal alignment)
* sensory deficits (visual, proprioception, vestibular)
* motor coordination impairments

Question 20

What are classic muscles affected by spasticity in the UE and LE?

Answer 20

AKA ALL FLEXORS
- U/E: shoulder adductors/IR’s, elbow flexors, forearm pronators, wrist flexors, finger flexors, thumb adductors/flexors
- L/E: hip flexors/adductors, knee flexors, ankle PF’s

Commonly affects bi-articular muscles: biceps brachii, gracilis, hamstrings, gastrocnemius

Question 21

Spastic muscles are weak muscles. Is this a primary or a secondary impairment?

Answer 21

Primary impairment - longer sarcromeres

Question 22

How does bone/joint deformities impact a child with CP? What causes this?

Answer 22

• alterations to posture & alignment
  Caused by:
• abnormal skeletal development
• increased tone pulling on developing skeleton
• abnormal ground reaction force on developing skeleton

Question 23

Name 3 sensory deficits that could occur with CP

Answer 23

• Decreased proprioception
• Visual impairment
• Vestibular dysfunction (auditory impairment)

Question 24

What are 2 gait classifications used for individuals with CP?

Answer 24

1. Spastic diplegic classification - identifies the static position of each lower limb in mid stance in
   the sagittal plane (can be different for each leg)
2. spastic hemiplegic classification - identifies the static position of the hemiplegic limb in mid stance in the sagittal plane and also may describe the limb position at other phases of the gait cycle

Question 25

Name some PT goals of treatment with CP pts

Answer 25

• Maximize present and future gross motor function
• Prevent secondary impairments
• Optimize quality of life
  → Function (mobility, independence, ADL’s)
  → Pain
  → Ease of caregiving for the caregivers

Question 26

Is CP progressive?

Answer 26

Non-progressive

Question 27

What is the difference between the Hypertonia Assessment Tool (HAT) and the Modified
Ashworth Scale (MAS) or Modified Tardieu Scale?

Answer 27

HAT: used to classify the type(s) of tone present / MAS or MTS: assessment of severity and location (R2-R1 = degree of “dynamic component” with a large difference meaning they are likely to respond to BTX)

Question 28

What is the “dynamic window”?

Answer 28

The difference between R1 and R2, the range where tone is having most impact on function

Question 29

What is the most common orthopaedic condition in CP?

Answer 29

Equinus contracture

Question 30

What are potential side-effects of botulinum toxin A?

Answer 30

Most common is weakness in adjacent muscles caused by diffusion of BTX and less commonly can cause weakness in more distant muscle groups.

Question 31

What surgical procedure cuts a percentage of sensory (dorsal) nerve rootlets to decrease excitatory afferent inputs on the motor neuron, to then reduce spasticity?

Answer 31

Selective Dorsal Rhizotomy (SDR)

Question 32

What does an Intrathecal Baclofen Pump (ITB Pump) do at the spinal cord?

Answer 32

Works at the level of the spinal cord by inhibiting monosynaptic and polysynaptic reflexes possibly by decreasing excitatory neurotransmitter release.

Question 33

What treatment strategy for dystonia takes advantage of neuroplasticity and neuromodulation?

Answer 33

Deep Brain Stimulation (DBS)