Cerebral Palsy Part 1

Question 1

What causes CP?*

Answer 1

Due to static lesion in CNS occurring

during pre/peri/neonatal periods!

Question 2

Actual manifestations, or presentation will

Answer 2

change over time

Question 3

Five essential elements:

Answer 3

– Group of disorders
– Permanent but not unchanging
– Disorder of movement and/or posture and motor function (SUPER IMPORTANT)
– Due to non-progressive etiology
– Etiology arises in developing/immature brain

Question 4

CP is the most common cause of

Answer 4

physical disability

in developed countries

Question 5

Prevalence over time?

Answer 5

Not declined because many more babies survive after born prematurely like 24 week gestation due to technology

Question 6

Prenatal Associated Factors

Answer 6

• Prenatal Malnutrition
• Poor Maternal Prenatal Condition

• Maternal Infection*

• Urinary tract infections
• Viral Infections (Rubella, Cytomegalovirus)
• Intrauterine infection – Causes fetal inflammation leading to CNS damage

• Multiple Gestation (placenta providing nutrition for multiple babies)
• Genetic/chromosomal anomalies• Thyroid disorder and treatment with
thyroid hormone
• Treatment with estrogen, progesterone
• Seizure disorder
• Bleeding in third trimester (prenatally born babies receive 02 support which put pressure on their vulnerable vessels, causing them to bleed)*

Question 7

Perinatal Risk Factors

Answer 7

– Preterm births

– High or Low birth weight

Question 8

Postnatal factors

Answer 8

– Trauma (dropping)
– Near Drowning
– Shaken Baby Syndrome
– Infections
– Infectious and toxic substances exposure
– Tumors

Question 9

Three types of lesions:

Answer 9

– Hemorrhage

– Encephalopathy from anoxia/hypoxia

– Brain malformations

Question 10

Prevention:

For encephalopathy

Answer 10

therapeutic hypothermia
reduces infant mortality and major
neurodevelopmental disability

Question 11

Prevention: during premature labor to decrease frequency mod-severe CP in preterm infants

Answer 11

Maternal administration of magnesium sulfate

Question 12

Prevention: in vitro fertilization

Answer 12

Avoidance of multiple embryo implantation

Question 13

Topographic Distribution (4)/ distribution of tone

Answer 13

– Monoplegia

– Diplegia (more tone in LE than UE)

– Hemiplegia

– Quadriplegia

Question 14

Spastic CP: where in brain and presentation

Answer 14

motor cortex, white matter projections
– spasticity and hyperreflexia resulting in atypical posture
and movement

Question 15

Dyskinetic CP: where in brain and presentation

Answer 15

basal ganglia
– Dystonia - involuntary sustained or intermittent m. contraction with repetitive movements and atypical posture
– Athetosis - involuntary distal writhing movement, poorly graded proximal voluntary movement, underlying hypotonia

Question 16

Ataxic CP: where in brain and presentation

Answer 16

cerebellum

– Lack of normal or expected voluntary movement (weak core, so strengthen their core)

Question 17

Mixed CP: presentation

Answer 17

– Spasticity and dyskinesia

Question 18

GMFCS level 1* : walks with, limitations in

Answer 18

– Walks without restrictions

– Limitations in more advanced gross motor skills (speed, balance, coordination)

Question 19

GMFCS level 2* : walks with, limitations in

Answer 19

– Walks without assistive devices

– Limitations walking outdoors and in the community (uneven terrain, jumping, need person support them on stairs)

Question 20

GMFCS level 3* : walks with, limitations in

Answer 20

– Walks with assistive mobility devices (crutches, canes, wheelchair)
– Limitations walking outdoors and in the community (walks stairs with supervision, creep on stomach without leg movements)

Question 21

GMFCS level 4* : walks with, limitations in

Answer 21

Self-mobility with limitations (creep and crawl on short distances. Physical assist one or two persons required. Powered wheelchair is best for them)
– Transported or used power mobility outdoors and in the community

Question 22

GMFCS level 5*: walking ability, limitations

Answer 22

– Self-mobility is severely limited even with use of assistive technology

Question 23

Prognosis: Growth Curves

Answer 23

90% potential reached at 3 years for Level V

and at 5 years for Level I

Question 24

Strongest predictor of walking ability for all types of CP

Answer 24

Cognitive functioning

Question 25

CP correlated with presence of (3)

Answer 25

Visual and hearing impairments and | epilepsy

Question 26

By Age 8: Plegias Diagnosis and prognosis for functional ambulation percentages

Answer 26

– Mono/Hemiplegia - 100% – Diplegia – 60-90% – Quadriplegia – 0-70%

Question 27

By Age 8: Prognosis for functional ambulation with motor function **Best predictor**

Answer 27

– Sit independently by 2 – GOOD **Best predictor** | • If not sitting by 3, POOR (important to sit due to postural control, indicates great chance for child to walk)

Question 28

Spasticity definition

Answer 28

velocity-dependent resistance of muscle to stretch, excessive inappropriate involuntary muscle activity

Question 29

What leads to spasticity for people with CP

Answer 29

UMN injury leads to decreased cortical input to reticulospinal and corticospinal tracts. Loss of descending inhibitory input through reticulospinal tract increases excitability of alpha motor neurons (extrafusal) and gamma motor neurons (intrafusal) leading to spasticity

Question 30

Hypoextensibility of Muscle with CP patients

Answer 30

• Mechanical changes in muscle – Resistance to passive stretching at a shorter length than normal muscle ``` • Contractures – Accumulation of collagen in muscles – Decreased muscle performance – Muscle Imbalance – 2 joint muscles ```

Question 31

Nature of spastic muscles

Answer 31

• Reduced maximal neuromuscular activation • Type-1 fiber predominance (some disagreement) • Fatty replacement • Short and stiff muscle fibers • Grow at slower rate than bones (55% rate)

Question 32

Muscle strength with Children with CP

Answer 32

unable to generate normal voluntary force in a muscle or normal torque about a joint/ lever arm biocmechanics • Inappropriate co-activation of antagonistic muscles

Question 33

How muscle changes with CP affects the skeletal system and what deformities come up

Answer 33

• Delayed skeletal maturation (no weight bearing therefore lacking ossification)• ``` Skeletal Deformities – Leg length discrepancies – Lower limb deformities – Congenital talipes equinus varus (Club feet) – Other foot deformities ```

Question 34

Joint Deformities: causes and prevalance in GMFCS levels 1 and 5

Answer 34

Hip subluxation and dislocation (lack weight bearing prevents femoral head to dig into acetabulum) – Not seen in Level I – 90% in Level V

Question 35

What happens when you see child with LLD with hip subluxation?

Answer 35

Refer to orthopedic surgeon, re access every time you see the kid as the LL can change.

Question 36

Neuromotor System: Poor selective control

Answer 36

– Co-contraction of agonists and antagonists – Reduced speed, mirror movements ( child reaches with right arm but left arm also reaches to the right. Dangerous when baby needs left hand to grab a handle) , abnormal reciprocal activation

Question 37

Neuromotor System: poor control in which areas

Answer 37

Postural, balance, coordination, motor control

Question 38

Gait issues

Answer 38

``` Toe walking, crouched gait, scissoring gait, windblown pelvis (pelvis swayed sideways), intoeing, out-toeing, leg length discrepancy, subluxation/dislocation, bony abnormalities, scoliosis, kyphosis, lordosis ```

Question 39

Atypical movement

Answer 39

* Delayed postural reactions * Persistence of primitive reflexes – is the best strategy they have! * Delayed movement onset, poor timing of force generation, poor force production, decreased speed of movement, increased co-contraction

Question 40

Medical Management of Spasticity: Oral Meds, when to use them

Answer 40

Night

Question 41

Medical Management of Spasticity: Botox, what does it do and rules of administering

Answer 41

Decreases ACH release to the muscle to paralyze it. Rule is giving botox injects to the child's individual muscles 3 months at a times. Only use 12 months to botox because over time, you cannot recruit a paralyzed muscle and deperipheralize the CNS.

Question 42

Medical Management of Spasticity: Alcohol (etyl/phenol), what does it do?

Answer 42

nerve block

Question 43

Medical Management of Spasticity: Baclofen, what does it do, two ways to administer, dosage

Answer 43

GABA agonist 1. Oral (bad for weak child as it affects child systemically) 2. ITB/ Intrathecal Low dose for who is really stiff and risk of bedsores and difficulty going on assistive device.

Question 44

Medical Management of Spasticity: SDR/ Selective dorsal rhizotomy

Answer 44

Cut some sensory nerve fibers that come from the muscle and enter the spinal cord. Using EMG to see which LE muscle rootlets cause spasticity, these are cut.

Question 45

Soft tissue surgeries

Answer 45

– tendon lengthening • May lead to effective weakening of MTU – tendon transfers

Question 46

Bony surgeries

Answer 46

– Arthrodesis ( fuse unstable joints) | – Derotational osteotomy

Question 47

Spinal Surgeries

Answer 47

Neuromuscular scoliosis – spinal stabilization

Question 48

Pros of orthopedic surgery for CP patients with different GMFCS levels

Answer 48

* Improve ambulation – GMFCS levels II and III * Pain Free sitting – GMFCS levels IV and V (preventing skin breakdown) * Hygiene

Question 49

Botox done when

Answer 49

Early spasticity management to prevent deformity/contractures – Botox 2-6 y.o.

Question 50

What surgeries done while growing

Answer 50

Soft tissue surgeries– Heel cord lengthenings most effective after 6 y.o. – Adductor tenotomy and iliopsoas recession to prevent hip dislocation

Question 51

What surgeries done after growth

Answer 51

Bony surgeries– Derotational osteotomy after 8 y.o.

Question 52

Orthopedic surgery is effective in

Answer 52

adolescents and | young adults!

Question 53

Gross Motor Function Measure (GMFM): Purpose

Answer 53

– Measure gross motor function in children with CP – Evaluate the magnitude of change over time or after intervention – Determine goals

Question 54

Gross Motor Function Measure (GMFM): Norm vs criterion referenced*

Answer 54

Criterion referenced

Question 55

Gross Motor Function Measure (GMFM): For who

Answer 55

– No specific age – Test validated on children 5 months to 16 years – A TD child of the age of 5 should be able to perform all skills in all dimensions

Question 56

* Can GMFM be adapted for use in infancy below | age of 2?

Answer 56

some issues – 66 doesn’t encapsulate and 88 doesn’t give credit for immature skills

Question 57

Manual Muscle testing be a reliable measure of muscle strength in children with CP? What is the best alternative?*

Answer 57

May not | • Muscle testing in functional activities and hand held dynanometry

Question 58

Modified Ashworth scale (MAS) used for grading of spasticity/ tone: 0,1, 1+, 2, 3, 4

Answer 58

0: No change in muscle response to flex/ext 1 : A slight catch and release or by minimal resistance at end of ROM when affected part is moved in flex/ext 1+ : Slight increase in muscle resistance into flex/ext followed by minimal resistance throughout remainder (less than 1⁄2) of ROM 2: Notable increase in muscle resistance throughout most of range but joint is easily moved 3: Marked increase in muscle resistance, passive movement is difficult into flexion or extension 4: Affected part is rigid into flex/ext when passively moved

Question 59

Tardieu Scale: Differentiates between... More reliable than...

Answer 59

• Differentiates between tone and contracture • More reliable than Ashworth Scale (it doesn't give info on when does the muscle fire, like hamstrings fires too early, person unable to swing their feet over as far as they should, resulting in decreased step length)

Question 60

Modified Tardieu Scale: R1 and R2

Answer 60

– R1: angle of resistance (fast stretch) | – R2: angle of PROM (slow stretch to see how much extensibility that patient has)

Question 61

Most considered sensory deficit for CP patients ***

Answer 61

• Pain*** • Precise assessment of light touch, proprioception, sharp/dull, 2-point discrimination difficult

Question 62

Pain is most prevalent in...

Answer 62

More prevalent in females, older, GMFCS level V

Question 63

Visual-Motor deficiencies and what to do when you observe them

Answer 63

– Strabismus – double image – Difficulty separating eye movement with head movement – inconsistent feedback, poor perceptual base – Behavioral vision therapy, prism lenses (observe if children are closing their eyes when taking steps!) - Refer them to neuro ophthalmology

Question 64

Most considered cognitive deficit for CP patients

Answer 64

learning!

Question 65

What are you trying to prevent with CP patients

Answer 65

Contractures

Question 66

What are you trying to facilitate

Answer 66

That treatment is working by reaccessing

Question 67

Nutrition considerations in PT eval

Answer 67

– Required for dendritic proliferation, myoneuronal junction efficiency – Hydration for healthy fascia – Increased risk of osteopenia – Often less nutritive caloric consumption than is required

Question 68

NMES/ Neuromuscular electrical stimulation: what does it do (3)

Answer 68

• Stimulation of muscle through its motor nerve • Improve ROM • Decrease in muscle tone (muscles that are tight and short are the ones we want to apply E-stim to)

Question 69

FES/Functional electrical stimulation

Answer 69

When NMES serves as orthosis or functional assist * Muscular Implantation of electrodes * Used simultaneously with exercise programs – activation of weak muscles during stance , unilateral loading, weight transfer, limb advancement

Question 70

Segmental Assessment of Trunk Control (SATCO): what is it measure, reliability

Answer 70

Static, active, reactive trunk control in different levels of support down the body, from shoulder girdle (level 1, head control SATCo level) to no support/ straps removed ( level 7, full trunk control SATCo level) Good reliability!

Question 71

Whole Body Vibration: Single Session

Answer 71

Reduced reflex excitability, hypertonicity, coordination deficits and mobility in children and adults with CP

Question 72

Whole Body Vibration: Multiple Sessions

Answer 72

improved muscle mass and bone mineral density (BMD)

Question 73

Whole Body Vibration: General benefits

Answer 73

Reduced spasticity, improved GMFM, | improved strength, improved gait and mobility

Question 74

Treadmill Training: Scientific Basis (4)

Answer 74

* Motor learning * Prolongation of stepping (more step on treadmill than being on ground) * Muscle strengthening * Velocity (changing treadmill speed imposes higher velocities)

Question 75

Treadmill Training: Why is Velocity important?

Answer 75

Hitting the threshold speed is what it takes to get from stepping to walking, the self selective speed is the speed which you go automatic. When kids walk slow, they never reach that threshold/automaticity place.