Cerebral Palsy Part 1 Flashcards
What causes CP?*
Due to static lesion in CNS occurring
during pre/peri/neonatal periods!
Actual manifestations, or presentation will
change over time
Five essential elements:
– 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
CP is the most common cause of
physical disability
in developed countries
Prevalence over time?
Not declined because many more babies survive after born prematurely like 24 week gestation due to technology
Prenatal Associated Factors
- 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)*
Perinatal Risk Factors
– Preterm births
– High or Low birth weight
Postnatal factors
– Trauma (dropping) – Near Drowning – Shaken Baby Syndrome – Infections – Infectious and toxic substances exposure – Tumors
Three types of lesions:
– Hemorrhage
– Encephalopathy from anoxia/hypoxia
– Brain malformations
Prevention:
For encephalopathy
therapeutic hypothermia
reduces infant mortality and major
neurodevelopmental disability
Prevention: during premature labor to decrease frequency mod-severe CP in preterm infants
Maternal administration of magnesium sulfate
Prevention: in vitro fertilization
Avoidance of multiple embryo implantation
Topographic Distribution (4)/ distribution of tone
– Monoplegia
– Diplegia (more tone in LE than UE)
– Hemiplegia
– Quadriplegia
Spastic CP: where in brain and presentation
motor cortex, white matter projections
– spasticity and hyperreflexia resulting in atypical posture
and movement
Dyskinetic CP: where in brain and presentation
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
Ataxic CP: where in brain and presentation
cerebellum
– Lack of normal or expected voluntary movement (weak core, so strengthen their core)
Mixed CP: presentation
– Spasticity and dyskinesia
GMFCS level 1* : walks with, limitations in
– Walks without restrictions
– Limitations in more advanced gross motor skills (speed, balance, coordination)
GMFCS level 2* : walks with, limitations in
– Walks without assistive devices
– Limitations walking outdoors and in the community (uneven terrain, jumping, need person support them on stairs)
GMFCS level 3* : walks with, limitations in
– 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)
GMFCS level 4* : walks with, limitations in
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
GMFCS level 5*: walking ability, limitations
– Self-mobility is severely limited even with use of assistive technology
Prognosis: Growth Curves
90% potential reached at 3 years for Level V
and at 5 years for Level I
Strongest predictor of walking ability for all types of CP
Cognitive functioning
CP correlated with presence of (3)
Visual and hearing impairments and
epilepsy
By Age 8: Plegias Diagnosis and prognosis for functional ambulation percentages
– Mono/Hemiplegia - 100%
– Diplegia – 60-90%
– Quadriplegia – 0-70%
By Age 8: Prognosis for functional ambulation with motor function Best predictor
– 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)
Spasticity definition
velocity-dependent resistance of
muscle to stretch, excessive inappropriate
involuntary muscle activity
What leads to spasticity for people with CP
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
Hypoextensibility of Muscle with CP patients
• 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
Nature of spastic muscles
• 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)
Muscle strength with Children with CP
unable to generate normal
voluntary force in a muscle or normal torque
about a joint/ lever arm biocmechanics
• Inappropriate co-activation of antagonistic muscles
How muscle changes with CP affects the skeletal system and what deformities come up
• 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
Joint Deformities: causes and prevalance in GMFCS levels 1 and 5
Hip subluxation and dislocation (lack weight bearing prevents femoral head to dig into acetabulum)
– Not seen in Level I
– 90% in Level V
What happens when you see child with LLD with hip subluxation?
Refer to orthopedic surgeon, re access every time you see the kid as the LL can change.
Neuromotor System: Poor selective control
– 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
Neuromotor System: poor control in which areas
Postural, balance, coordination, motor control
Gait issues
Toe walking, crouched gait, scissoring gait, windblown pelvis (pelvis swayed sideways), intoeing, out-toeing, leg length discrepancy, subluxation/dislocation, bony abnormalities, scoliosis, kyphosis, lordosis
Atypical movement
- 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
Medical Management of Spasticity: Oral Meds, when to use them
Night
Medical Management of Spasticity: Botox, what does it do and rules of administering
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.
Medical Management of Spasticity: Alcohol (etyl/phenol), what does it do?
nerve block
Medical Management of Spasticity: Baclofen, what does it do, two ways to administer, dosage
GABA agonist
- Oral (bad for weak child as it affects child systemically)
- ITB/ Intrathecal
Low dose for who is really stiff and risk of bedsores and difficulty going on assistive device.
Medical Management of Spasticity: SDR/ Selective dorsal rhizotomy
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.
Soft tissue surgeries
– tendon lengthening
• May lead to effective weakening of MTU
– tendon transfers
Bony surgeries
– Arthrodesis ( fuse unstable joints)
– Derotational osteotomy
Spinal Surgeries
Neuromuscular scoliosis – spinal stabilization
Pros of orthopedic surgery for CP patients with different GMFCS levels
- Improve ambulation – GMFCS levels II and III
- Pain Free sitting – GMFCS levels IV and V (preventing skin breakdown)
- Hygiene
Botox done when
Early spasticity management to prevent
deformity/contractures
– Botox 2-6 y.o.
What surgeries done while growing
Soft tissue surgeries– Heel cord lengthenings most effective after 6 y.o.
– Adductor tenotomy and iliopsoas recession to prevent hip dislocation
What surgeries done after growth
Bony surgeries– Derotational osteotomy after 8 y.o.
Orthopedic surgery is effective in
adolescents and
young adults!
Gross Motor Function Measure (GMFM): Purpose
– Measure gross motor function in children with CP
– Evaluate the magnitude of change over time or after intervention
– Determine goals
Gross Motor Function Measure (GMFM): Norm vs criterion referenced*
Criterion referenced
Gross Motor Function Measure (GMFM): For who
– 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
- Can GMFM be adapted for use in infancy below
age of 2?
some
issues – 66 doesn’t encapsulate and 88 doesn’t
give credit for immature skills
Manual Muscle testing be a reliable
measure of muscle strength in children with CP?
What is the best alternative?*
May not
• Muscle testing in functional activities and hand held dynanometry
Modified Ashworth scale (MAS) used for grading of spasticity/ tone: 0,1, 1+, 2, 3, 4
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
Tardieu Scale: Differentiates between… More reliable than…
• 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)
Modified Tardieu Scale: R1 and R2
– R1: angle of resistance (fast stretch)
– R2: angle of PROM (slow stretch to see how much extensibility that patient has)
Most considered sensory deficit for CP patients ***
• Pain***
• Precise assessment of light touch, proprioception,
sharp/dull, 2-point discrimination difficult
Pain is most prevalent in…
More prevalent in females, older, GMFCS level V
Visual-Motor deficiencies and what to do when you observe them
– 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
Most considered cognitive deficit for CP patients
learning!
What are you trying to prevent with CP patients
Contractures
What are you trying to facilitate
That treatment is working by reaccessing
Nutrition considerations in PT eval
– Required for dendritic proliferation, myoneuronal junction efficiency
– Hydration for healthy fascia
– Increased risk of osteopenia
– Often less nutritive caloric consumption than is
required
NMES/ Neuromuscular electrical stimulation: what does it do (3)
• 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)
FES/Functional electrical stimulation
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
Segmental Assessment of Trunk Control (SATCO): what is it measure, reliability
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!
Whole Body Vibration: Single Session
Reduced reflex excitability, hypertonicity, coordination deficits and mobility in children and adults with CP
Whole Body Vibration: Multiple Sessions
improved muscle mass and bone mineral density (BMD)
Whole Body Vibration: General benefits
Reduced spasticity, improved GMFM,
improved strength, improved gait and mobility
Treadmill Training: Scientific Basis (4)
- Motor learning
- Prolongation of stepping (more step on treadmill than being on ground)
- Muscle strengthening
- Velocity (changing treadmill speed imposes higher velocities)
Treadmill Training: Why is Velocity important?
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.
