Cerebral Palsy Pt 1 Flashcards
definition of cerebral palsy
- Group of clinical symptoms or a syndrome characterized by a disorder of movement and posture due to a static lesion or defect in an immature brain
- Most common non-progressive movement disorder in children
risk factors associated with development of CP
History taking should include screening questions related to the mother’s health, pregnancy, birth and post-birth period. Risk factors for CP may be at the maternal or infant level.
maternal risk factors
- Thyroid condition
- Infection during pregnancy
- Pre-eclampsia
- Multiple pregnancy (i.e. twins or greater)
infant risk factors
- Prematurity
- Intrauterine growth restriction
- Low birth weight
- Acute intrapartum hypoxic event
- Moderate to severe encephalopathy
- Neonatal seizures
- Neonatal infection
- Hypoglycaemia
- Jaundice
additional risk factors identified in children born at term
- Placental abnormalities
- Birth defects
- Meconium aspiration
- Instrumental/emergency caesarean delivery
- Birth asphyxia
- Respiratory distress syndrome
postnatal risk factors
- Head injuries: TBI’s
- Infections: meningitis, encephalitis
- Brain hemorrhage: IVH
- Asphyxia: HIE, cardiac arrest, near drowning
small percentage of children acquiring CP after one month of age
generally a result of stroke, which may occur spontaneously or from complications associated with another condition or medical intervention
how CP is classified
According to muscle tone/movement patterns (MOTOR TYPE)
according to distribution in body (TOPOGRAPHY)
spastic
Spasticity is a velocity-dependent resistance to stretch by the muscles. It is characterized by an excessive stiffness in the muscles when the child attempts to move or maintain a posture against gravity.
dyskinetic
Dyskinesia/hyperkinesia refers to an increase in muscular activity that can result in excessive abnormal movements, excessive normal movements, or a combination of both. Dyskinetic/hyperkinetic CP is characterized by abnormalities of tone and various movement disorders including dystonia, athetosis and chorea.
ataxic
Ataxia is characterized by shaky movements and affects a person’s coordination and balance. It is the least common form of CP - less effect on muscle tone, but great impact on balance and coordination. Exhibit difficulty with balance, coordination, and maintenance of stable alignment of head, trunk, shoulders, and pelvis.
mixed
child shows components of high and low muscle tone; examples:
CP where more than one motor type is present, for example spasticity and dystonia.
Usually one motor type will be dominant.
monoplegia
involves single extremity; upper or lower
hemiplegia
involves one side of body
dipelgia
total body is affected with LE’s/trunk more affected than UE’s/face
quadriplegia
total body affected including face, neck, and trunk with equal involvement – typically seen in dyskinetic and ataxic types
triplegia
involves three extremities
dystonia
characterized by sustained or intermittent muscle contractions causing repetitive or twisting movements
athetosis
characterized by uncontrolled, slow and writhing movements that prevent maintenance of a stable posture. It involves continuous smooth movements that appear random and are not composed of recognizable sub-movements or movement fragments. Athetosis is made worse by attempts to move however it may also be present at rest. Athetosis is distinguished from dystonia by the lack of sustained postures, and from chorea by the lack of identifiable movement fragments
chorea
ongoing random-appearing sequence of one or more discrete involuntary movements or movement fragments.
Chorea is distinguished from dystonia due to the apparently random, unpredictable, and continuously ongoing nature of the movements, compared with the more predictable and stereotyped movements or postures of dystonia. The movements of chorea often appear more rapid than those associated with dystonia
primary impairments
- Primary impairments are those that are immediate and a direct result of the cortical lesion in the brain.
- The nervous system damage that causes cerebral palsy can occur before or during birth or before or during birth or before a child’s second year, the time when myelination of the child’s sensory and motor tracts and CNS structures rapidly occurs.
- As a “non-progressive condition”, the original defect or lesion occurring the in the CNS typically does not worsen or change over time.
- However, because the lesion occurs in immature brain structures, the progression of the child’s motor development may appear to change (secondary impairments)
- Growth can be severely impacted in children with CP. Separate growth tables are available to track overall growth for both boys and girls with CP
secondary impairments
- in systems or organs over time due to the effects of one or more of the primary impairments
• For example, a child with cerebral palsy may have a primary impairment of hypertonia and a muscle imbalance across a joint. This abnormal muscle tone may cause poor alignment across a joint, further muscle weakness, and eventually a contracture in the joint.
• The resulting muscle contractures, poor body alignment, and poor ability to initiate movement would be considered secondary impairments.
• This is important to understand since the diagnosis of cerebral palsy means a child has a static non-progressive lesion in the brain. Although the initial brain injury is unchanging, the results or the secondary impairments are not static and change over time with body growth and attempts to move against gravity.
• Children with cerebral palsy may continue to rely on automatic movement pattern because they are unable to direct their muscles to move successfully in more typical motor patterns.
• The atypical patterns used to play or complete functional activities may become repetitive and fixed. The repetition of the atypical movement patterns prevent children with cerebral palsy from gaining independent voluntary control of their own movements and can lead to diminished strength and musculoskeletal problems.
• The combination of impaired muscle co-activation and the use of reflexively controlled postures may lead to future contractures in the muscle, tendon, and ligamentous tissues, causing the tissues to become permanently shortened. Bone deformities and alterations of typical posture or spinal and joint alignment may also occur.
diagnosis/indicators highly predictive of CP
- No definitive diagnostic test; difficult to get medical diagnosis under 1 year of age
- Indicators highly predictive of CP
- Prematurity
- Low birth weight
- Hypertonus at birth or still present at 4 months
- Delayed motor milestones at 4 months
- Abnormal findings on MRI or HUS (head ultra sound)
key prognostic message - life long disability
CP is a life-long disability
• Disability increases with age
• Aging occurs earlier
• Rehabilitation planning must consider adulthood
key prognostic message - normal life expectancy
Almost all children with CP will have a normal life expectancy
• 5-10% of children with CP will die in childhood
• The risk of premature death increases with co-occurring epilepsy, intellectual disability and severe physical impairment
• Presence of severe dysphagia increases the risk of premature death
key prognostic message - presence of associated conditions affect outcomes
CP is almost always accompanied by associated conditions
• Screening for the presence of associated conditions should be routine and associated conditions managed if present
key prognostic message - severity predictions
Under 2 years of age, severity predictions are incorrect 42% of the time - voluntary movement is still developing and hypertonia may still be evolving with myelination
• MRI may provide some information for predicting function - unilateral injuries usually result in milder presentations; periventricular white-matter lesions generally result in milder motor impairments (ie, usually ambulatory) but not always, whereas brain malformations, cortical, subcortical, and basal ganglia lesions generally result in more severe motor impairments (ie, non-ambulatory)
using MRI to predict prognosis
Do not rely on MRI alone for predicting prognosis in children with CP
• Consider the likely cause of CP and the findings from MRI (if performed) when discussing prognosis with the child or young person and their parents or caregivers
• Combine information obtained about risk factors, neuroimaging and assessment of motor function **(especially the Hammersmith Infant Neurological Examination - HINE) to assist prediction of severity and therefore prognosis
characteristics of children with SPASTIC CP
Area of CNS damage: primary motor cortex, corticospinal tracts
Sub-classifications: monoplegia, hemiplegia, diplegia, or quadriplegia\
Muscle tone: hypertonic
UE’s- scapular retraction, shoulder add/ext/IR
LE’s- hip ext/add/IR, knee ext, ankle PF
Range and quality of movement: movement limited to midrange; labored and in synergistic patterns
Righting/Equilibrium/Protective extension: delayed or absent; pull into COG to increase postural stability
Respiratory Problems: decreased thoracic mobility, decreased respiration to support phonation
Speech problems: Dysarthria, decreased dissociation of tongue/lip/jaw with poor lip closure
Feeding Problems: abnormally strong gag reflex, tongue thrust, bite reflex, and rooting reflex
Deformities: ***at risk for contractures, hip dislocation
Other signs: associated reactions, exaggerated positive support reaction, clonus, increased DTR’s
Personality: postural insecure with fear of falling, may be afraid of loud noises,, most remain dependent, withdrawn and passive
characteristics of children with DYSKINETIC CP
Area of CNS damage: Basal Ganglia
Sub-classifications: usually quadriplegic
Muscle tone: usually hypotonia at birth; athetosis may develop 1-4 years of age; large sudden fluctuations; usually seen with spastic component
Range and Quality of Movement: DEPENDS ON TYPE: (Athetoid, choreoathetoid, dystonic). Extremities may move through extreme ranges, lack of grading of antagonistic muscles (jerky); little midrange control; limited stability; lack of coordinated movements; involuntary movements may be exaggerated by volitional movements
Righting/Equilibrium/Protective Extension: absent or delayed; unreliable if present
Respiratory problems: decreased thoracic mobility, shallow breathing
Speech problems: May have dysarthria, volume of speech may go up/down with breath
Feeding problems: Decreased due to instability, poor coordination of
tongue/jaw/swallow, strong gag, tongue thrust and poor coordination of oral muscles for chewing/swallowing
Deformities: low risk to develop but potential if has a spastic component
Other signs: normal DTR’s
Personality: Emotionally unstable and immature, sudden fluctuations from happy to extreme anger and tantrums, less fearful of movement, easily frustrated
characteristics of children with ATAXIC CP
Area of CNS damage: cerebellum
Sub-classifications: usually quadriplegic
Muscle tone: usually hypotonic but can fluctuate slightly, can have spastic or athetoid component
Range and Quality of Movement: poor coordination/balance, trouble with postural fixation an stabilizing proximal joints, clumsy, unable to direct or limit motion, intention tremors
Righting/Equilibrium /Protective Extension: usually developed but executed abnormally due to poor coordination, difficulty with balance
Oral Motor: speech is monotone and slow, decreased articulation, uses teeth to stabilize tongue or to hold cup to mouth when drinking
Deformities: low risk
Other signs: decreased DTR’s
Personality: no specific personality traits
OT assessment
- Early identification of atypical postures typically seen in children diagnosed with cerebral palsy can minimize the use of compensatory and dysfunctional movements which could lead to secondary impairments and decreased functional abilities later in life.
- During therapy sessions, more mature and typical movement patterns can be facilitated by the therapist in order to make progress in typical developmental milestones.
- Clinical assessment data creates a “picture” of the child’s functioning and indicates his or her strengths and weaknesses.
- Observation of a child completing simple tasks such as putting on a shirt, transitioning from a chair to the floor, opening containers, or playing with age appropriate toys will help a therapist identify atypical postures and movements that may be limiting functional abilities.
- Thorough assessment data are essential when working as part of a service delivery team and selection of assessment measures may be based on several factors including the child’s age, the setting (ie. home health, school system, community), and the caregiver’s and child’s specific concerns about functional limitations.
Gross Motor Function Classification System (GMFCS)
LEVEL I
Walks without Limitations. Performs gross motor skills like running and jumping but speed, balance, and coordination may be impaired.
LEVEL II
Walks with limitations. This includes on uneven surface, inclines, stairs, long distances or in crowds or confined spaces.
LEVEL III
Walks Using a Hand-Held Mobility Device. Walks on even surfaces, indoors and outdoors with assistive devices. Children may use manual wheelchair for long distances.
LEVEL IV
Self-Mobility with Limitations. Child may use powered mobility or require assistance from a caregiver. May walk short distances with a mobility device but relies primarily on wheeled mobility.
LEVEL V
Transported in a Manual Wheelchair. Child has no means of independent mobility and relies on caregiver for all transportation needs.
prognosis for walking
Most children will walk - 60% will walk independently (GMFCS I-II), 10% will walk with a walking aid (GMFCS III) and 30% are wheelchair users (GMFCS IV-V)
• The more severe the child’s physical, functional or cognitive impairment, the greater the possibility of difficulties with walking
• If a child can sit at 2 years of age it is probable (but not certain) that they will be able to walk unaided by age 6
• If a child cannot sit but can roll at 2 years of age, there is a possibility that they may be able to walk unaided by age 6
• If a child cannot sit or roll at 2 years of age, they are unlikely to be able to walk unaided
Manual Ability Classification System (MACS)
LEVEL I Handles objects easily and successfully.
LEVEL II Handles most objects but with somewhat reduced quality and/or speed of achievement.
LEVEL III Handles objects with difficulty; needs help to prepare and/or modify activities.
LEVEL IV Handles a limited selection of easily managed objects in adapted situations.
LEVEL V Does not handle objects and has severely limited ability to perform even simple actions. Requires total assistance.
Communication Function Classification System (CFCS) - levels
LEVEL I Effective Sender and Receiver with unfamiliar and familiar partners.
LEVEL II Effective but slower paced Sender and/or Receiver with unfamiliar and/or
familiar partners.
LEVEL III Effective Sender and Receiver with familiar partners.
LEVEL IV Inconsistent Sender and/or Receiver with familiar partners.
LEVEL V Seldom Effective Sender and Receiver even with familiar partners.
prognosis for talking
1 in 4 children with CP will be non-verbal so it is important to assess and augment speech early
• Around 1 in 2 children with CP have some difficulty with elements of communication
• Around 1 in 3 children have specific difficulties with speech and language
• Communicative frustration can lead to behavioral disorders
• The more severe the child’s physical, functional or cognitive impairment, the greater the likelihood of difficulties with speech and language
• Uncontrolled epilepsy may be associated with difficulties with all forms of communication, including speech
• A child with bilateral spastic, dyskinetic or ataxic CP is more likely to have difficulties with speech and language than a child with unilateral spastic CP
Eating and Drinking Ability Classification System for Individuals with CP (EDACS) - levels
LEVEL I Eats and drinks safely and efficiently
LEVEL II Eats and drinks safely but with some limitations to efficiency
LEVEL III Eats and drinks with some limitations to safety; there may be limitations to efficiency
LEVEL IV Eats and drinks with significant limitations to safety
LEVEL V Unable to eat or drink safely, tube feeding may be considered to provide nutrition.
Vision Classification Systems (VFCS)
LEVEL I Uses visual function easily and successfully in vision related activities
LEVEL II Uses visual function successfully but needs self-initiated compensatory strategies
LEVEL III Uses visual function but needs some adaptations
LEVEL IV Uses visual function in very adapted environments but performs just part of vision-related activities
LEVEL V Does not use visual function even in very adapted
environments
VFCS limitation
raters might find it hard to identify the usual performance in daily activities, as opposed to the best or the worst one.
Modified Ashworth Scale (MAS)
- measurement of spasticity
• Completed in supine if possible (most accurate and the lowest score; any tension anywhere in the body will increase spasticity)
• Because spasticity is “velocity dependent” (the faster the limb is moved, the more spasticity is encountered), the MAS is done moving the limb at the “speed of gravity.” This is defined as the same speed a non-spastic limb would naturally drop. (fast)
• The test is done a maximum of three times for each joint. If it is done more than three times the short-term effect of a stretch impacts the score
• The MAS is done prior to goniometric testing. Goniometric testing provides a stretch and the short-term effect of a stretch impacts the score.
Positions used for MAS
Elbow. Start position: Elbow fully flexed, forearm neutral. Movement: Extend elbow from maximum possible flexion to maximum possible extension. (Triceps would be the same position, opposite direction.)
Wrist. Start position: Elbow as straight as possible, forearm pronated. Movement: Extend the patient’s wrist from maximum possible flexion to maximum possible extension.
Fingers. Start position: Elbow as straight as possible, forearm neutral. All fingers are done at once. Movement: Extend the patient’s fingers from maximum possible flexion to maximum possible extension.
Thumb. Start position: Elbow as straight as possible, forearm neutral, wrist in neutral. Movement: Extend the thumb from maximum possible flexion (thumb against index finger) to maximum possible extension (in anatomical position, “abducted”).
Hamstrings. Start position: Prone so that ankle falls beyond end of the plinth, hip in neutral rotation. Movement: Extend the patient’s knee from maximum possible flexion to maximum possible extension.
Quadriceps. Start position: Prone so that ankle falls beyond end of the plinth, hip in neutral rotation. Movement: Flex the patient’s knee from maximum possible extension to maximum possible flexion.
Gastrocnemius. Start position: Supine, ankle plantar flexed, hip in neutral rotation and flexion. Movement: Dorsiflex the patient’s ankle from maximum possible plantar flexion to maximum possible dorsiflexion not more than three consecutive times and rate the muscle tone.
Soleus. Start position: Supine, ankle plantar flexed, hip in neutral rotation and flexion and with the knee flexed to ~15°. Movement: Dorsiflex the patient’s ankle from maximum possible plantar flexion to maximum possible dorsiflexion.
