Cerebral Palsy Pt 2

Question 1

common compensations seen in children with CP

Answer 1

• Excessive trunk movements (extension and lateral flexion)
• Wrist flexion with finger extension (to release toys)
• Shoulder internal rotation and abduction, elbow flexion and forearm pronation during reach – affects grasping pattern in hand

Question 2

often, these compensations affect

Answer 2

fluidity of visual skills due to use of total body movement patterns

Question 3

characteristics of the arm

Answer 3

• Poor ability to reach and place the hand
• Little variation or ability to reach and use the hand without total body or arm movements
• Use of arm/hand requires more effort and lacks variability of movement patterns
• Use of compensatory strategies
• Use of hand requires more effort and lacks variability of movement patterns

Question 4

Characteristics of the hand

Answer 4

• Immature grasping patters: gross/raking grasp to lateral pinch
• Indwelling thumb (limited web space) and radial side of hand tightly fisted
• Excessive wrist flexion and ulnar deviation
• Hyper-extension of MCP joints(knuckles) and IP joints
• Immature grasping patterns, many times object must be placed in the hand

Question 5

Therapeutic ways to improve arm/hand function

Answer 5

1. Provide sensory experiences for the hand (tactile and weightbearing)
2. Proper positioning to decrease extension-dominated patterns and make reaching easier (ie. sidelying or 90/90 in chair)
3. Position/placement of toys – distance and field of movement will affect movement (good and bad!)
4. simulate the correct movements patterns during play activities (helps motor learning)
5. Facilitation of normal transitions and postures
6. Use Kinesiotape, splinting to help with joint alignment, prevent contractures of hand and wrist.

Question 6

International Classification of Functioning, Disability and Health (ICF)

Answer 6

• Provides a standard language and framework for the description of health and health-related states
• Help us to describe changes in body function and structure, what a person with a health condition can do in a standard environment (their level of capacity), as well as what they actually do in their usual environment (their level of performance)

Question 7

domains in ICF

Answer 7

1) body functions and structure

2) domains of activity and participation

Question 8

In ICF, the term functioning refers to

Answer 8

all body functions, activities and participation, while disability is similarly an umbrella term for impairments, activity limitations and participation restrictions

Question 9

examples of ICF body structure and function

Answer 9

abnormal movement patterns, strength, sensory, endurance, vision

Question 10

examples of ICF execution of activities that increase participation

Answer 10

skill and timeliness with self feeding to inc participation in meals with family
improve motor skill with hand to mouth feeding, improve visual motor and visual perceptual skills
improve oral sensory awareness and postural stability

Question 11

Systematic Review of Interventions for CP

Answer 11

166 articles met the inclusion criteria (74% systematic reviews) across 64 discrete interventions seeking 131 outcomes

• 16% (21 out of 131) were graded ‘do it’ (green=go)
• 58% (76 out of 131) ‘probably do it’ (yellow measure)
• 20% (26 out of 131) ‘probably do not do it’ (yellow measure)
• 6% (8 out of 131) ‘do not do it’ (red=stop)

Question 12

5 categories of interventions

Answer 12

• Spasticity Management
• Contracture Management
• Improved Muscle Strength
• Improved Motor Activity
• Improved Function and Self-Care

Question 13

what are the “active ingredients” of these interventions which may be leading to functional changes

Answer 13

High intensity of tx
Motivation 
Top down approach
Simulation of activities 
Repetition of motor activity to lay the map down to do the action

Question 14

dosing

Answer 14

represents a critical and pressing aspect of intervention that is central for treatment efficacy and is defined as the frequency, intensity, time, and type of an intervention

Question 15

frequency

Answer 15

refers to how often, such as the number of sessions for a given intervention per day, week, or month

Question 16

intensity

Answer 16

how hard the child works within the intervention session (# of repetitions per minute, day, or week or amount of work)

Question 17

time

Answer 17

duration of the intervention

Question 18

type

Answer 18

the kind of intervention and can be focused on (ICF): body functions and structures, activity, or participation. Within types, variation exists. For example, task practice can vary in the type of behavioural shaping (ie, structured versus unstructured training) and amount of feedback or reward

Question 19

To date, the minimum doses for changing structure and function, activity, and participation in children with CP are

Answer 19

unknown and determining the effective dose of specific interventions is a focus of future intervention studies

Question 20

Goal Directed Therapy / Task-Oriented Therapy

Answer 20

focuses on everyday skills in the child’s natural environment with the goal of improving performance and increasing independence with daily activities.
- collaborate to set goals with the therapist providing strategies for task specific practice to utilize a motor learning approach

Question 21

goal directed therapy is effective in

Answer 21

improving hand function and self care skills

Question 22

Constraint Induced Movement Therapy (CIMT)

Answer 22

rehabilitation strategy to increase functional use of the weaker or affect upper limb through repetitive and adaptive task practice while the strong or non-affected upper limb is restrained

Question 23

Bimanual Therapy

Answer 23

retains the intensive structure and task practice at CIMT, but the focus is improving the ability to perform bimanual activities.

Bimanual therapy uses carefully planned, repeated practice of two-handed, or bimanual, games and activities to improve a child’s ability to use their hands together in daily activities. It involves intensive, massed practice, similar to the dosage required for CIMT (> 30 hours) and can be provided during individual or group therapy formats.

Question 24

Home programs

Answer 24

Home programs are individualized multimodal interventions that target body structure, activities, and participation problems identified collaboratively by the child, parents and the occupational therapist.

Question 25

Neurodevelopmental treatment (NDT)

Answer 25

NDT intervention is an individual approach to examining and improving movements during the performance of meaningful and functional daily activities
• A therapist evaluates the child’s movements by carefully analyzing how the child moves in and out of positions, maintains positions, and responds to changes in the environment
• A therapist examines muscle tone, joint integrity, ROM, and postural control during movements
• A therapist explores the child’s motivations for movements and his or her ability to initiate and terminate movements
• Quality of movement is considered (not IF a child can take sock off, but HOW the child takes sock off)

Question 26

Emerging Therapies – Robotics and Virtual Reality

Answer 26

Despite promising experiences and a large acceptance by the patients and parents, so far, few robotic, computer-assisted systems, and virtual reality programs have been rigorously evaluated in children with CP and well-designed randomized controlled studies in this field are lacking. It is unclear which systems are effective for specific types of CP and the best application for this technology (eg, duration, frequency, and intensity) to generate the best results

Question 27

5 essential elements for pediatric CIMT

Answer 27

• Constraint of the non-affected or stronger upper limb
• High dosage of therapy (30 hours or greater)
• Use of repetitive and adaptive task practice (massed practice)
• Sessions take place in the child’s natural environment if possible (e.g. home/school) although clinic/hospital models have been found to be effective also.
• Transition or discharge program to start when CIMT is completed

Question 28

task or activity analysis

Answer 28

is an important part of using a motor learning approach to training patients to learn new motor skills.
• Therapists will also evaluate functional cognition during the child’s completion of ADLs. Functional cognition refers to the thinking and processing skills that are used to accomplish everyday activities in clinical, home, and community environments.

Question 29

anti spasticity medication

Answer 29

•	Diazapam (Valium)
–	Interferes with impulses and connections between nerves
–	Oral, takes effect in 30 min., last 4 hours
–	Side effects
•	Baclofen (Lioresal)
–	Reduces contraction of muscles
–	Oral or by pump
–	Side effects
•	Dantrolene Sodium (Dantrium)
–	Interferes with impulses and connection between nerves
–	Oral, given 2-3 times daily
–	Side effects

Question 30

phenol injections

Answer 30

• Impairs conduction along the nerve through chemical neurolysis
• Last several months to a few years
• Can be used to produce a nerve block or motor point block

Question 31

nerve blocks

Answer 31

• Injection into motor nerves
• Affects all the muscles controlled by a nerve
• May cause sensory loss due to damaged sensory nerve fibers

Question 32

motor point blocks

Answer 32

• A specific motor nerve with a particular target muscle
• Does NOT affect sensation
• Duration – 4-6 months, then repeated
• Side effects – localized pain

Question 33

botox injections

Answer 33

• Direct injection into spastic muscle
• Small quantities used without spread to bloodstream
• Last 3-4 months
• Effect is dose dependent and reversible
• May use in conjunction with serial casting
• Disadvantages – cost of drug, unknown long term effects

Question 34

main purpose of orthoses or splints

Answer 34

maintain range of motion and assist with function. An orthosis is usually applied at the tolerable end of joint range. Often a variety of orthoses may be required for different activities and to achieve different goals.

Question 35

other uses for splints

Answer 35

support a weak or ineffective joint or muscle, prevent or correct joint, deformities, improve functional use of the upper limb, and improve position for hygiene and/or outward appearance

Question 36

serial casting

Answer 36

Casting is the application of individually molded casts made of either plaster or synthetic casting materials with the aim of increasing passive range of movement of tight or contracted muscles, by applying a prolonged low load stretch across a joint or joints to lengthen affected muscles.

Serial casting involves applying a number of casts in succession to gradually increase passive range of movement.

Casting is indicated when soft tissue contracture is interfering with function or causing potential biomechanical misalignment. Casting is not indicated when there are bony changes occurring at a joint. Casting only provides a short term stretch and is usually required to be repeated at regular intervals particularly as children undergo a growth spurt. Casting is unlikely to be an effective intervention for long term contractures where bony changes might be limiting ROM.

Question 37

common joints which respond to serial casting

Answer 37

• Wrist flexors
• Elbow flexors
• Heelcords
• Hamstrings

Question 38

orthopedic surgery

Answer 38

	Goals
•	Prevent deformity and pain
•	Correct deformity
•	Improve comfort
•	Improve function
	Types of surgeries
•	Hip flexor release
•	Hip adductor release
•	Hamstring release
•	Heelcord lengthening
•	Scoliosis
•	Wrist tendon transfer
•	Wrist tendon transfer
Typically, the flexor carpi ulnaris tendon is transferred to the extensor carpi radialis brevis muscle
Results in improved active wrist extension
•	Thumb-in-hand surgery
Release of thumb adductor
Flexor policis longus released

Question 39

complementary and alternative medicine (CAM) programs

Answer 39

• Hippotherapy: Therapeutic horseback riding
• Acupuncture/acupressure: Stimulation of specific points on the body with pressure or needles
• Massage therapy: Soft tissue mobilization
• Craniosacral therapy: Mobilization of cranium/sacral bone
• Myofascial release: Mobilization of interconnected facial system
• Tai Chi,Yoga and Pilates
• Biofeedback: Electronically utilizing information from the body to teach an individual to recognize what is going on inside of his or her own body
• Dietary Supplements
• Conductive Education: intensive, multi-disciplinary approach to education, training and development for individuals with cerebral palsy, spina bifida and other motor challenges.

Conductors: Specially trained teachers licensed after approximately five years of college level training. The conductor carries out the principles of CE. This method links speech, thought and movement together in a way that helps the child to focus on and internalize the movement.