Cerebral Palsy: effects of Atypical Development on motor control and posture Flashcards
1
Q
What is CP defined as
A
a group of permanent disorders
- often accompanied by disturbances of sensation, perception, cognition, communication, and behavior, by epilepsy, and by secondary musculoskeletal problems
2
Q
Cerebral Palsy- involvement
A
- involves one or more extremities
- trunk is usually involved
- clinical presentation varies greatly
- impairments in sensation, perception, cognition, communication, and behavior
- Seizure disorder
3
Q
Epidemiology in CP
A
- incidence 2/1000 live births
- higher incidence with males
- tends to be higher in African Americans than in whites
4
Q
Causes of CP occur…
A
- Prenatal 70%
- peri-natal 5-10% (neonates)
- post natal 6%
- most often it is due to low birth weight or maternal factors
5
Q
CP is associated with what causes
A
- mechanical trauma
- traumatic brain injury
- Atypical uterine growth
- genetic factors
- prematurity
- low birth weight
6
Q
How to best diagnosis CP
A
- MRI > CT
- MRI cannot always be done in the NICU
- MRI or CT also revels treatable conditions such as hydrocephalus, arterial venous malformation (AVM), subdural hematomas
- Diagnosis, classification, and treatment are often based on abnormalities tone (where it happened in the brain)
7
Q
Prenatal causes of CP
A
- Maternal infections eg rubella, herpes simplex
- inflammation of placenta (chorion)
- Rh incompatibility (mother is + and baby is -)
- Drugs taken by mother during pregnancy
- diabetes during pregnancy
- genetic causes
- exposure to radiations
- maternal jaundice
8
Q
Peri-natal causes of CP
A
- prematurity, immature respiratory and cardiac functions
- asphyxia: body is deprived of O2
- meconium aspiration: 1st bowel movement is in placenta and they end up ingesting it
- birth trauma
- disproportion
- breech delivery
- rapid delivery
- low birth weight
- coagulopathy
- prolonged labor
- multiple births
9
Q
Post natal causes of CP
A
- brain damage secondary to cerebral hemorrhage, trauma, infection, anoxia, ischemia
- low blood sugar
- MVA
- Shaken baby syndrome
- drowning
- lead exposure
- infections
- meningitis
- encephalitis
10
Q
Other causes of CP
A
- cerebrovascular event in first 28 days post birth
- HIE (hypoxic ischemia encephalopathy): lack of O2
- infections
- maternal/infant congenital brain malformation
- jaundice/kernicterus
11
Q
3 types of lesions with neurological damage and CP
A
- hemorrhage
- encephalopathy
- neuropathy due to malformations of the CNS
12
Q
Hemorrhage: neurological damage
A
- below the lining of the ventricles intraventricular hemorrhage
- grades 1-4 (not always predictive of how bad the CP is)
13
Q
Encephalopathy
A
- anoxia or hypoxia
- HIE: hypoxic ischemia encephalopathy
14
Q
what are the old categories of cerebral palsy
A
- congenital
- acquired
- genetic
15
Q
Traditional classifications of cerebral palsy
A
- monoplegia: 1extremity is affected (crouch gait)
- diplegia/paraplegia: 2 extremities are affected
- triplegia: 3 extremities are affects
- hemiplegia: 1/2 body is affected
- tetraplegia/double hemiplegia: 4 extremities are affects
16
Q
Diaplegia
A
- LE affected with little to no upper body spasticity
- most common form of spastic
- most people with spastic diplegia are fully ambulatory but are tight and have a scissor gait
- flexed knees and hips to vary degrees and moderate to sever abduction
- near sighted and intelligence is unaffected in most cases
- in 1/3 cases strabismus may be present
17
Q
CP classification based on muscle tone
A
- hypertonic/spastic (further classified by distribution of tone)
- athetoid: from basal ganglion, with diatonic, smooth motions
- ataxic: cerebellum not smooth movement patterns
- flaccid/hypotonic
- mixed types
18
Q
Current classification and definition: of cerebral Palsy
A
- origin of problem
- level of involvement
- predictive information
- tracts progress over time
- functional abilities
- GMFCS
19
Q
GMFCS
A
- Gross motor function classification system
- you can look and determine where they are and classify severity of mobility with CP
- based on child’s current gross motor abilities and need of assistive devices
- used from 2-18 years
20
Q
GMFCS Level 1
A
- walk at home, school, outdoors and in community
- they can climb stairs without use of railing
- children perform gross motor skills such as running and jumping
- but speed, balance, and coordination are limited
21
Q
GMFCS Level 2
A
- walk in most settings
- climb stairs holding onto railing
- may experience difficulty walking long distances and balancing on uneven terrain, inclines, in crowed areas of confined spaces
- may walk with physical assistance, handheld mobility device or wheeled mobility over long distances
- minimal ability to preform gross motor skills such as running/jumping
22
Q
GMFCS Level 3
A
- walk using hand-held mobility device in most indoor settings
- may climb stairs holding onto a railing with supervision or assistance
- children use wheeled mobility when traveling long distances and may self propel for shorter distances
23
Q
GMFCS Level 4
A
- use methods of mobility that require physical assistance or powered mobility in most settings
- may walk for short distances at home with physical assistance or use powered mobility or a body support walker when positioned
- at school, outdoors and in community that are transported in manual wheelchair or in powered mobility
24
Q
GMFCS Level 5
A
- children are transported in manual wheelchair in all settings
- limited in their ability to maintain antigravity head and trunk postures and control leg and arm movements
25
Gross motor function measure
- GMFM
- validated for 5 months to 16 years
- GMFG-66 and GMFM-88
26
GMFM-66
- provides much more information to assist with realistic goal setting for children with CP
- some predictive value
- original
- ONLY CP
- tested barefoot and no assistive device
27
GMFM-88
- version valid for use with children with Down syndrome, SMA (spinal muscle atrophy) TBI, OI, hereditary spastic paresis, acute lymphoblastic leukemia
- tested with shoes on and assistive device
28
Spasticity
- velocity dependent hypertonicity
- characterized by resistance to passive stretch
- varies with directions of movement, eg flexion/extension
- related to loss of inhibition from brainstem to opposite muscle
- results in increase muscle tone
29
causes of spasticity
- abnormal reaction to sensation
- adaptive response to allow generation of movement when no alternatives exist
- adaptive response to instability caused by slow movements
30
non-surgical treatments for spasticity
- PT/OT
- speech therapy
- casting/bracing
- BOTOX
- oral medications
31
examples of oral medications for spasticity
- baclofen
- tizanidine
- dantrolene sodium
- diazepam
- clonazepam
- gabapentin
32
Surgical intervention for spasticity: selective dorsal rhizotomy
- test which nerve fibers in dorsal root cause the spasticity and cut it
- need PT for 5-6 days per week for months
- results in reduced afferent neuromotor signals from the LE with the aim of improving gait
- the dorsal spinal roots transmit sensation from muscle to the spinal cord
33
Surgical intervention for spasticity: SEMLS
- single event multilevel surgery
- helps correct bone and joint deformities
- allows for more balanced muscle and joint function
34
Spastic Diplegia/prognosis
- with treatment
- without treatment
- without treatment: progressively poor quality of life because these children cannot walk
- with intervention: 86% become at least household ambulatory
- often one side is more affected than other
- crouched gait
35
Spastic tetraplegia/quadriplegia
- 1st symptoms
- Motor control
- Typical Posture
1st symptoms may be difficulty with feeding and generalized hypotonia, escalates to muscle imbalance and spasticity within 1st year of life
motor control:
- extension tone usually dominant (lying in supine causes more extension)
- poor control of flexion
- poor ability to dissociated movement
Typical posture:
- hip adduction, IR
- knee extension
- ankle PF
- shoulder IR
- elbow flexed or extended
- forearm pronation
36
Hemiplegia
- most unsuspected
- most born full term with very low birth weight
- often related to maternal infant Rh incompatibility
- hemolytic disease of newborn
- prevented by mother taking rhogam
- UE is more significantly involved than LE
37
Athetosis characteristics
- not common
- fluctuating muscle tone/writhing movements
- very noticeable in speech, feeding, UE movement
- involuntary extraneous movement
- lack of graded muscle response - difficult to stop and start
- extremities function best at end ranges
- some sustain muscle activity too much while others have hard time sustaining it enough to complete a task
- often asymmetric involvement present
- incomplete of inadequate balance reactions
- reflexes may be abnormally retained
- often hearing loss is present usually intelligence is within typical ranges
38
Athetosis fluctuating tone movement
- involves abnormal involuntary movements
- movements disappear during sleep and increase with stress
- interferes with speaking, feeding, reaching, grabbing and any other skills
- about 20% of CP cases
39
Typical posture for CP with athetosis
- extension of cervical spine with scapular elevation and shoulder IR
- thoracic kyphosis with lumbar hyperextension
- lumbar extension often occurs exclusively at thoracolumbar junction
- Ribcage remains elevated, abdominal overlenghtened and cannot help with postural support - hard to breath
40
Gait with athetosis
- hips and knees are slightly flexed and ankle in DF
- may initiate weight shift from head or jaw, shuffle feet forward to walk
41
Hypermobility with athetosis
- repetitive exaggerated postures cause excessive mobility and or overlengthened muscles
- commonly affected joints:
1. TMJ
2. Cervical spine
3. shoulder
4. elbow
5. IP joints and thumb
6. anterior hip capsule
7. ankle
42
Ataxic CP
- deficits in cerebellum or thalamus
- generalized hypotonia, initial diagnosis may be floppy baby syndrome
- low postural tone, difficulty with sustained contraction against gravity
- Proximal intention tremor with purposeful movement – Jerky movements
43
Hypotonic CP
- associated with global impairments
- can be initially flaccid at birth
- can develop into athetosis or spastic type CP
- hypotonic, little to no movement
- excessive joint flexibility
- typical positions: supine "frog leg", ring sit on floor with posterior pelvic tilt and upper body supported on hands
- usually not cognitively motivated poor development of skills
44
Primary impairments with CP
- balance both static and dynamic
45
Secondary impairments with CP
- strenght
- ROM
- endurance
46
motor learning considerations with CP
- opportunities for movement
- environment: may need to reposition to move
- cognition and communication
- neuromuscular considerations: tone, ability, balance
- musculoskeletal considerations: kyphosis
- cardiovascular and pulmonary: most developmentally delayed
- integumentary: skin breakdown, infections
47
Cerebral palsy prognosis
- 90% of children survive into adulthood from developed countries
- functional outcomes: 90% of potential reached by age 3 for level 5; 90% of potential reached by age 5 for level 1
- often develop secondary disorders such as exacerbation of spasticity, metabolic disease, abnormalities of musculoskeletal, fatigue, chronic pain, and deformities
- decreased ambulation potential in those with rigid or hypotonic types, or persistent tonic neck reflexes
- if child is not independently sitting by 24 months they will most likely not walk
- employment: consider level of involvement, cognition, home support, education, vocational training
