Cerebral Palsy (Part 2) Flashcards
What are 5 ways to distinguish an infant with CP from an uninvolved infant at 4 months of age?
- neck hyperextension
- shoulder retraction
- ability to bear weight on the forearms while prone
- ability to maintain a stable head position in supported or independent sitting
- flex the hips actively against gravity
What are the 3 purposes of the assessment?
- discover the functional abilities and strengths of the child
- determine the primary and secondary impairments
- discover the desired functional and participation outcomes of the child and family
What are 9 positions you should assess a child’s functional antigravity control?
- supine
- prone
- side-lying
- sitting (shirt, long, side, ring)
- quadruped
- kneeling
- half-kneeling
- standing
- walking
What are 5 things to assess in a child who functions from a wheelchair?
- Alignment and mobility of body
- Shifting of weight
- Propulsion of the wheelchair
- Management of the wheelchair and its parts
- Transfers
What is the most important thing to assess in a wheelchair bound child?
ALIGNMENT
- check for contractures, scoliotic deformation, pressure ulcers, etc.
Historically, posture was defined through reflex terminology and facilitated through what?
controlled sensory feedback
What role does sensory feedback have on postural control?
The child received feedback from having completed the task previously and makes the necessary postural adjustments to complete the task in the most efficient way
Describe postural setting
Muscles become active around a joint or joints, without obvious movement, in anticipation of a task
How is postural control through feedforward learning learned?
through trial and error
What are 3 questions to ask yourself when assessing a child’s posture?
- Does the child have a variety of ways to transition between postures or only stereotypical choices?
- Does the child actively push into the supporting surface with the pelvis or extremities
- Can the child repeat movements or tasks and make small changes in motor performance?
What does the clinical term “tone” describe?
the impairments of spasticity and hypo/hyper extensibility of muscles
What are 4 signs of increased tone?
- distal fixing (toe-curling or fisting)
- difficulty moving a body segment through a range
- asymmetric posture
- retracted lips and tongue
What are 3 signs of decreased tone?
- excessive collapse of body segments
- loss of postural alignment
- inability to sustain a posture against gravity
What are 2 forms of CP that exhibit fluctuating levels of stiffness?
- athetosis
- ataxia
What 10 things should be included in the musculoskeletal assessment of children with CP?
- ROM
- spine evaluation
- thoracic movement
- eval of the shoulder girdle and UE
- exam of the hip and pelvis
- femoral anteversion
- knee exam
- tibial torsion
- foot examination
- leg length discrepancy
When performing ROM measurements you should perform the limb slowly through the range to avoid eliciting a stretch reflex.
The first “catch” is considered what?
What is the second “catch”?
functional range: the range that the child can access for function
absolute range: the actual length of the muscle
What is the goal of stretching?
To bring the functional and absolute range numbers as close to each other as possible
Describe the process of assessing spinal flexion
Place the child in supine and round the spine putting the child’s knees up to their chest
What is considered abnormal spinal flexion?
When there is a flattened area (without SP chowing or showing less) this is considered reduced spinal flexion
What position are spinal extension, lateral flexion, and rotation most easily assessed in?
sitting
What muscle groups in the spine do children with CP typically have limitations in?
spinal and capital extensors
Describe rib position in a typically developing baby under 6 months. What happens to this position as the child develops upright posture?
There is an approximate 90 degree angle between the ribs and spine.
There is a PA downward slant to the ribs
What 2 things does the PA downward slant of the ribs allow for?
1) an increased ability to expand the diameter of the thorax in both an AP (pump-handle) and lateral (bucket-handle) direction
2) the thoracic (external intercostals) and abdominal (obliques) muscles to fix the ribcage
Because the downward slant of the ribs nerve fully develops in children with CP what is the result?
1) The mechanical advantage of the pump-handle and bucket-handle motions of inspiration are minimized
CP children do not have the muscle tone to necessary to stabilize the rib cage which results in what?
Sternal fibers cause depression of the xyphoid process and the sternum during inspiration
What does the combination of reduced thoracic expansion and sternal depression result in?
Shallow respiratory efforts which will result in vocalizations that will be of short duration and will be low in intensity
What trunk muscles are the most important to train and why?
the obliques because they aid in forceful expiration needed for coughing and sneezing
Why do children with CP demonstrates tightness and limitation of the shoulder girdle, most notably pec major?
they never attain adequate UE weight bearing in prone
What shoulder motions are the most restricted in a child with CP?
- flexion
- abduction
- ER
What are 4 other UE limitations observed in the child with CP?
- elbow extension
- forearm supination
- wrist extension
- finger extension
What position should hip adduction and abduction be measured in?
in supine with the hip and knee extended
What position should hip IR/ER be measured in?
in prone with hip extended and knee flexed
Because children with CP have very tight hip flexion, adduction, and internal rotation they are at risk for what?
hip dislocation/subluxation
In what direction do subluxations tend to occur? What does this lead to?
superior and posterior
A leg length discrepancy in which the involved side leg appears shorter than the uninvolved side
What is the most important measurement for a PT to consistently track?
hip abduction with knee and hip extension
If any child under the age of 8 has less than __ degrees of hip abduction they should be referred to an orthopedic surgeon
45
Femoral anteversion is a torsion or _____ rotation of the femoral shaft on the femoral neck
internal
At birth an infant has approximately how many degrees of femoral anteversion?
40
As a person ages they have how many degrees of femoral anteversion? Why?
15
Because active extension and ER of the hip tighten the anterior capsule of the hip joint
When can excessive femoral anteversion be suspected?
When ER at the hip is substantially less than IR
What will indicate the degree of hamstring tightness?
passive straight leg raising or measurement of the popliteal angle
What does tibial torsion describe?
a twist of the tibia along its axis so that the leg is rotated internally or externally
What are the 2 ways in which tibial torsion can be determined?
1) by the intersection of a line drawn vertically from the tubercle and a line drawn through the malleoli
2) the thigh-foot angle
What are the landmarks used when measuring the thigh-foot angle?
- transmalleolar axis
- femur
Describe the relationship between tibial torsion and hip anteversion and how a child with CP presents
The tibia typically “unwinds” from a position of IR to ER due to changes in force on the tibia arising from the decrease in femoral anteversion that occurs as a typical child grows. In children with CP excessive femoral anteversion often results in compensatory external tibial torsion to maintain the foot facing forward
What ankle motion is often limited in a child with CP?
dorsiflexion
Depression of the medial longitudinal arch is caused by what?
adduction and plantarflexion of the talus with relative eversion of the calcaneus
What percentage of children with CP demonstrate a LLD?
70%
How can LLD be managed?
shoe lifts
What tool is helpful in determining whether a child with CP will walk?
GMFCS
Describe the gait of a child with hemiplegic CP
- the majority of their weight is borne on the uninvolved LE
- there is brief and incomplete weight shift on the uninvolved LE
- involved shoulder held in hyperextension and elbow flexion
- commonly walk on toes
What are the 7 potential types of gait deviations in children with diplegic CP?
- Equinovarus
- Planovalgus
- Crouch
- Jump knee
- Stiff knee
- Recurvatum
- Idiopathic toe walking
Describe the gait of a child with equinovarus gait
- PF through stance phase
- hips and knees hyperextended
Describe the gait of a child with planovalgus gait
Equinas of the hindfoot and pronation of the forefoot which results in excessive loading of the plantar, medial portion of the foot and increased foot drop
Describe the gait of a child with crouched gait
Knees and hips are flexed throughout the gait pattern
In children who display crouched gait midstance knee flexion greater than __ degrees results in functional ambulation becoming imporsisble
30
Describe the gait of a child with jump knee gait
- anterior pelvic tilt
- hip flexion
- ankle equinus
Describe the gait of a child with stiff knee gait
persistent knee extension through swing phase
Describe the gait of a child with recurvatum gait
Knee extension in early stance phase progressing to hyperextension in mid to late stance
How can you tell the difference between idiopathic toe walkers and mild diplegic CP?
Idiopathic toe walkers only have mild gastroc tightness and no hamstring tightness. They can also walk normal when instructed to do so
What are the 6 most common gait deviations seen in kids with quadriplegia?
- stiff knee
- crouch
- excessive hip flexion
- intoeing
- equinus
- scissoring
True or False
Functional community amubulation throughout life is not a realistic goal for children with quadriplegic CP, however it is important to encourage ambulation through their adolescent years
True
Describe the gait of a child with athetotic CP
- high flexion of hip initially during stepping
- LE placed into extension with adduction, IR, and PF
- thoracic spine is excessively flexed with rotation of the cervical spine with the jaw jutting forward and rotated to one side
Although it is difficult to make improvements with PT in children with athetotic CP what intervention strategies may be helpful in improving balance?
Weighted vest/ankle weights
Describe the gait of a child with ataxic CP
- Widened BOS
- Increased double-limb support time
Ataxia typically follows initially ___ tone
low
What is the purpose of physical therapy in children with CP?
to allow the infant or child to become the most independent possible in performing functional tasks throughout his or her lifetime
What are the 2 focuses of the therapeutic intervention?
- Prevention of disability by minimizing effects of impairment
- Preventing or limiting secondary impairment such as contractures, scoliosis, etc.
What are 4 therapeutic interventions?
- stretching
- weight bearing activities
- alignment in sitting
- respiratory exercises
What 2 muscles are essential to elongate?
hamstrings and heel cords (gastroc)
Why are weight bearing activities important?
to increase muscle tone and strength
How should you position a child with CP in sitting?
- head in neutral
- hips, knees, ankles at 90 degrees’ flexion
hips in abduction
What are 2 ways in which the therapist can provide sensory input to help facilitate the appropriate motor output?
- Gentle muscle rubbing
- Joint approximation
If a CP patient is in a weight bearing position for too long they fatigue which causes them to do what?
rely on their ligaments for support
When used with invasive procedures, strength training may _____ the outcomes of these procedures
prolong
The original focus of NDT was to treat what type of patients?
Those with pathophysiology of the CNS, specifically children with CP and adults with hemiplegia
What is the ultimate goal of NDT?
for the child to have the most independent function as possible according to age and abilities
Describe in general how NDT is performed
‘Handling’ is used to establish or re-establish the postures and movements that the client needs to become functional in a meaningful way and feedforward is developed as the child practices the skill or task with the therapist’s guidance
What is the key to orthopedic intervention?
Prevent deformity through detection at an early stage
What is the most common pattern of spinal deformity is children with CP?
neuromuscular scoliosis
What is neuromuscular scoliosis primarily caused by?
an imbalance between agonist and antagonist muscles that leads to the development of S-shaped or C-shaped curves
In what type of children is scoliosis the most severe?
In nonambulatory children functioning at levels IV and V on the GMFCS
Scoliosis progresses quickly during puberty with curve progression up to - degrees per month
2-4
True or False
Neuromuscular scoliosis is responsive to orthotic treatment (stretching, strengthening, joint mobs, or ES)
False
What is the treatment of choice in children older than 10 years with curves greater than 50 degrees?
spinal fusion
What is the standard surgery for excessive femoral anteversion?
femoral derotation osteotomy with blade plate fixation and medial hamstring release
Describe windswept deformity
the pelvis is oblique and the legs may (typically do) or may go the opposite direction
What is the most common deformity at the knee?
knee flexion contracture
What does a knee flexion contracture lead to?
contracture of the knee joint capsule and shortening of the sciatic nerve
Describe pes valgus positioning of the foot
- Eversion, plantarflexion, and inclination of the calcaneus
- Abduction of the forefoot
What is the typical treatment choice for children with CP?
Combination of baclofen (systemic) and Botox (injection) works best
