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Pediatrics > CP > Flashcards

CP Flashcards

1
Q

what is CP?

A

non-progressive brain injury that occurs before, during or after birth up to 3 years of age

UMNL resulting in motor abnormalities

wide range of involvement, mild to severe

cognitive skills also vary

difficult to diagnose in babies <4 months

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2
Q

what are major signs of CP?

A

slow motor development

retention of primitive reflexes

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3
Q

what are classifications of CP?

A

divided into several classifications each with typical patterns of movement

1- hypotonic 
2-rigid
3-ataxic
4- fluctuating tone/athetoid/dystonic
5-spastic/hypertonic
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4
Q

describe hypotonic CP:

A

pattern of motor expression: whole body involvement

area of brain involvement: generalized

varying severity

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5
Q

describe rigid CP:

A

pattern of motor expression: whole body involvement

area of brain involvement: generalized

varying severity

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6
Q

describe ataxic CP:

A

pattern of motor expression: whole body involvement

area of brain involvement: extrapyramidal cerebellar

varying severity

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7
Q

describe fluctuating tone/athetoid/dystonic CP:

A

pattern of motor expression: whole body involvement

area of brain involvement: extrapyramidal basal ganglia

varying severity

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8
Q

describe spastic/hypertonic CP:

A

pattern of motor expression:

  • monoplegia
  • diplegia/paraplegia

area of brain involvement: pyramidal motor tracts

varying severity

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9
Q

describe mild severity for CP:

A

gross motor: independent walker

fine motor: unlimited function

IQ: >70

speech: >2 words
overall: independent function

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10
Q

describe moderate severity for CP:

A

gross motor: crawl or supported walk

fine motor: limited function

IQ: 50-70

speech: single words
overall: needs assistance

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11
Q

describe severe CP:

A

gross motor: no locomotion

fine motor: no function

IQ: <50

speech: severely impaired
overall: total care

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12
Q

what is spasticity?

A

motor disorder

velocity dependent increase in tonic stretch reflexes

hyper-excitability of the stretch reflex

exaggerated tendon jerks

one component of the UMNS

altered activity patterns of motor units occurring in response to sensory and central command signals which lead to co-contractions, mass movements, and abnormal postural control

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13
Q

what is the pathophysiology of spasticity?

A

Proposed theory:

  • imbalance b/w excitatory and inhibitory impulses to the alpha motor neuron
  • due to lack of descending inhibitory input to the alpha motor neuron
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14
Q

what are signs of UMNS?

A

positive signs:

  • spasticity
  • rigidity
  • hyper-reflexia
  • primitive reflexes
  • clonus

negative signs:

  • lack of strength
  • lack of motor control
  • lack of coordination
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15
Q

what are types of involuntary movement disorders?

A

dystonia

chorea

athetosis

choreoathetosis

ataxia

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16
Q

what is dystonia?

A

abnormal posturing, twisting or repetitive movements

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17
Q

what is chorea?

A

irregular dance-like movements

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18
Q

what is athetosis?

A

writhing, distal movements

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19
Q

what is choreoathetosis?

A

combo of both chorea and athetosis

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20
Q

what is ataxia?

A

flailing movements, wide-based gait

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21
Q

how is the ash worth scale of muscle tone scored?

A

1 = no increase in tone

2 = slight increase in tone

3 = marked increase in tone, but affected part(s) easily flexed

4 = considerable increase in tone: passive movement difficult

5 = affected part(s) rigid in flexion or extension

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22
Q

how is the modified ash worth scale of muscle tone scored?

A

0 = no increase in muscle tone

1 = slight increase in muscle tone, manifested by a catch and release or by min resistance at the end of ROM when the affect part(s) is moved into flexion or extension

1+ = slight increase in muscle tone, manifested by a catch, followed by min resistance throughout the remainder (less than half) of the ROM

2 = more marked increase in muscle tone through most of the ROM, but affected part(s) easily moved

3 = considerable increase in muscle tone, passive movement difficult

4 = affect part(s) rigid in flexion or extension

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23
Q

what is the modified tardieu scale??

A

consistent velocity stretch of muscle

standard positions for specific muscles

note point of resistance to max velocity stretch (R1)

note amount of muscle contracture or muscle length (R2)

relationship between R2-R1

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24
Q

what are the levels of the gross motor function classification system- expanded and revised (GMFCS- E&R)

A

Level I: walks w/out limitations

Level II: Walks with limitations

Level III: walks using a hand held mobility device

Level IV: self-mobility w/ limitations; may use power mobility

Level V: transported in a manual w/c

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25
Q

what are the levels of the MACS: manual ability classification system for children w/ CP 4-18 y/o?

A

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

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26
Q

what is the purpose of the GMFM: gross motor function measure ?

A

describe a current level or motor function

evaluate change overtime in gross motor function in children with CP and DS

assist to determine functional tx goals

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27
Q

what is the age range for GMFM?

A

validated for sensitivity to change over a 6 month period in children from 5 months to 16 y/o

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28
Q

what are the 5 dimensions of the GMFM?

A 
1- lying and rolling
2- sitting
3- crawling
4- standing
5- walking, running, jumping
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29
Q

how is the GMFM administered?

A

each section can be administered individually

scored based upon a 4 point scale that measures how much of the item the child completes

dimension scores and total scores are achieved and then converted into the percentage of the max score for the dimension

time required: 45-60 min

GMFM-66- computer scoring available

  • interval scale
  • improves ability to quantify changes in motor function
  • relates changes in one child to another
  • from one period of time to another in the same child
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30
Q

what are pros of the GMFM?

A

developed for children with CP

concerned with quantity of functional movement, not quality

measures change over time

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31
Q

what are cons of the GMFM?

A

no normative data

many items are scored based on length of time in a position which may not correlate to functional movement

not concerned with quality of movement

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32
Q

what is spastic diplegia?

A

involvement in LEs

scissoring gait

lordosis

limited LE disassociation- moves in total movement patterns- flexion- extension

good head and upper body control

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33
Q

what is spastic quadriplegia?

A

affects all 4 extremities

poor balance b/w flexors and extensors

extensors overpowering

underlying low tone in trunk

poor head control

easily develop muscle tightness leading to hip dislocations

trunk deformities

34
Q

what is spastic hemiplegia?

A

one side involvement

tendency to ignore involved side

scoliosis

retracted pelvis, hip IR, ADD, ankle PF, forefoot inversion

35
Q

what is hypotonic?

A

total body

poor head and trunk depending on involvement

shoulder instability leading to limited fine motor control

hip instability- ER and ABD of hips

W-sitters

scoliosis, kyphosis

standing- knee hyperextension and pronated feet

36
Q

what is athetoid?

A

continuous movement

fluctuation in tone flexion and extension

poor control in mid ranges

don’t develop as many contractures

may develop hamstring tightness- use to stabilize

trunk- underlying low tone

37
Q

what does ataxic mean?

A

jerky, unsteady movements

increases with excitement

trunk- low muscle tone

shoulder and hip instability

need a lot of support in standing and sitting

38
Q

what are common spine impairments for the child with CP?

A

trunk deformities due to muscle imbalance

prone to scoliosis, increased kyphosis or lordosis

difficulty with rotation skills

shallow respirations

short vocalizations

39
Q

what are common LE impairments for the child with CP?

A

tight hip flexors, adductors and IRs, medial hamstrings

hip subluxation/dislocation

femoral anteversion

limited disassociation

high riding patella from spastic quad

tibial torsion

gastroc tightness

calcaneal plantarflexion

leg length discrepancy

40
Q

what are common gait impairments for the child with CP?

A

limited or excessive trunk mobility

limited active trunk rotation with increased lordosis

hips remain flexed

increased adduction and IR

knees remain flexed or may be hyperextended

valgus foot or decreased BOS in plantar flexion

hemiplegia- decreased WS onto affected side, posturing of involved UE

41
Q

what are characteristics of diplegia CP?

A

features: legs involved more than arms. 50% preterm

ambulation potential: 90% walk

associated sensory & developmental impairments: strabismus, learning, attention & communicative disorders are common

ADL function: independent in self-care and spinster control

42
Q

what are characteristics of triplegia CP?

A

features: combo of diplegia and hemiplegia

ambulation potential: 50% walk

associated impairments: strabismus, cognitive, communicative, learning and attentional disorders are common

ADL function: difficulty with manual dressing tasks, climbing stairs and perennial hygiene

43
Q

what are characteristics of hemiplegia CP?

A

features: one side of body, arm more involved than leg. At least 50% are prenatal in origin.

ambulation potential: 100% walk

Associated impairments: visual field cut, mild-mod cognitive and communicative disorders. High rate of partial seizures.

ADL function: difficulty with fasteners for dressing, independent in basic self-care and spinster control tasks

44
Q

what are common characteristics of quadriplegia CP?

A

features: significant involvement of all 4 limbs

ambulation potential: 25% walk, however 100% walk who have sitting balance by 2 years

associated impairments: epilepsy and significant mental retardation in 50% (IQ<50). Deafness and severe visual impairment in 50%.

ADL function: high rate of self-care, communicative, and contingency limitations

45
Q

what are general treatment principles for the child with CP??

A

important to know type of tone predominates

as well as underlying tone in trunk

based on normal movement

constantly adjust handling and movement

functional stretching and strengthening

challenge child during therapy

bracing and adaptive equipment important to enhance function

work closely with family and other professionals

46
Q

why use ball therapy?

A

use of moving surface such as a therapy ball

fun

challenging

used to momentarily alter tone and enhance movement control

increase strength

increase ROM

improve balance and equilibrium responses

improve protective reactions

47
Q

what are principles to decrease tone?

A

slow rhythmical movement of a child on moving surface

elongation

rotation in trunk

disassociation of extremities

weight bearing with weight shift (long ranges of movement)

fast rotational (passive) movement through the trunk works sometimes- need to be cautious

vibration- with exhalation

48
Q

what are principles to increase tone?

A

active movement by the child- straight or diagonal plane

weight bearing: body over limb (small range of movement)

compression: increased loading on joint- must have good normal alignment- should be intermittent or intermittent with movement (bouncing on a ball)

tapping- direct stimulation to the muscle belly

resistance- using gravity

49
Q

what are tx options for patients with spasticity?

A

rehab therapy

intrathecal baclofen (ITB therapy)

Oral meds

injection therapy

neurosurgery

orthopedic surgery

50
Q

who is on the “team” ?

A

child and family

physicians

  • physiatrist
  • neurologist
  • neurosurgeon
  • orthopedic surgeon
  • PCP

nurse/nurse practitioner

social worker

PT

OT

SP

dietician

psychologist

educator

51
Q

what are the most common oral meds?

A

Baclofen (Lioresal)

Diazepam (Valium)

Tizanidine (Zanaflex)

Dantrolene sodium (Dantrium)

52
Q

what are advantages to oral meds?

A

non-invasive, not permanent

effective management for some patients

53
Q

what are disadvantages to oral meds?

A

difficult to achieve a steady state

following a schedule may be difficult

side effects: drowsiness, hypotonia, weakness – may limit effectiveness

54
Q

what are neurosurgical treatments?

A

neurectomy

myelotomy

anterior rhizotomy

selective dorsal rhizotomy

cordectomy

thalamotomy

55
Q

what are advantages to intrathecal baclofen (ITB) therapy?

A

reversible

non-invasive dose adjustments

potential for fewer side effects than oral drugs

evidence to support efficacy in reducing spasticity

may improve function, comfort and care

56
Q

what are disadvantages to intrathecal baclofen (ITB) therapy?

A

complications: infection, catheter problems, OD, baclofen withdrawal

refills- approx every 3 months

cost

57
Q

ITB trial:

A

presently admitted for trial

also down on OP basis in pediatric imaging

pre-ashworth assessment by PT/OT

catheter trial or bolus injection

re-assessed using ash worth scale at 2 and 4 hours post injection

also, re-assess functional skills- sitting, transfers, and ambulation if applicable

successful trial is a decrease of average LW ash worth score of at least 1 point

58
Q

what are post ITB pump therapy considerations?

A

symptoms of OD

symptoms of withdrawal

59
Q

what are symptoms of OD for ITB?

A

somnolence (excessive drowsiness)

respiratory depression

seizures

rostral progression of hypotonia

loss of consciousness progressing to coma

60
Q

what are symptoms of withdrawal for ITB?

A

pruritus without rash

diaphoresis

hyperthermia

hypotension

neurological changes, including agitation or confusion

sudden generalized increase in muscle tone, spasticity and muscle rigidity

61
Q

what are the guidelines for handling and positioning post ITB pump implant for first 2-4 weeks?

A

avoid excessive trunk movement to avoid a catheter dislodgment

  • no hip flexion >90
  • no passive trunk rotation or twisting
  • log roll child
  • avoid forward trunk flexion beyond 45
  • no vigorous hamstring stretching

avoid heat producing modalities in area of pump

progress with activity level per child’s tolerance

62
Q

what positioning should be used after ITB?

A

sidelying- pillow under top leg for support and to avoid rotation of trunk

prone on stomach- as tolerated- good position for playing

sitting:
- avoid side and long sitting
- no hip flexion >90
- when sitting unsupervised use chest strap or tray to avoid forward flexion
- support feet

63
Q

lifting and transfers post ITB?

A

stand pivot transfers: may initially need increase support secondary to decreased muscle tone for support

1 person lift: support one arm along back and other under hips

2 person lift: 1 person supports back and other supports under hips

keep back straight as possible. Do not flex hips past 90

64
Q

what is selective dorsal rhizotomy (SDR)?

A

dorsal sensory roots are severed

each rootlet within root is stimulated

abnormally- responding rootlets are severed

often performed on children 7-10 y/o

usually involves 6-12 months of intensive therapy post-op if improved function is the goal

complications include possible sensory loss

65
Q

what are considerations for SDR?

A

decrease positive signs
-spasticity (multi-segmental)

improve negative signs
-lack of motor control (use rehab to address)

consider other negative signs
-lack of strength (consider whether decreasing hypertonia will be detrimental to posture and function)

66
Q

what are advantages to SDR?

A

permanent- one time procedure

evidence for efficacy in reducing spasticity and improving function in children with spastic diplegia

67
Q

what are disadvantages to SDR?

A

permanent- may need spasticity

potential adverse effects: spinal, sensory

not effective for dystonia

68
Q

what are 2 orthopedic surgery options?

A

soft tissue operations:

  • lengthenings
  • releases
  • tendon transfers

bony operations

  • osteotomies
  • fusions
69
Q

what are advantages to orthopedic surgery?

A

effects usually last a few years

70
Q

what are disadvantages to orthopedic surgery?

A

anesthesia risks

non- weight bearing after bony procedures

risk of weakness, decreased function

71
Q

what are injection therapies?

A

anesthetic/diagnostic nerve blocks

  • procaine
  • lidocaine

neurolytic nerve blocks

  • ethanol
  • phenol

botulinum toxin

72
Q

what is botulinum toxin?

A

Clostridium botulinum injected into the muscle

interferes with release of ACh at the NMJ

no systemic effect

may be administered without anesthesia

EMG guidance for small muscles

results typically last 3-6 months

73
Q

what are advantages to injections?

A

not permanent

evidence to support efficacy in reducing spasticity and improving function

effects are localized- not systemic

74
Q

what are disadvantages to injections?

A

not permanent- may need to repeat

ethanol and phenol- require greater skill to inject, increased risk of paresthesias, dysesthesas

botulinum toxin: more expensive than other injections, may develop antibodies

75
Q

what is a serial casting procedure?

A

non-invasive, non-surgical procedure

short leg cast applied using soft cast rolls

casted at present end range of ankle dorsiflexion with knee extension

re-casted weekly

series of casts for 3-4 weeks or until full ROM is achieved

able to be removed without cast saw

76
Q

what are goals for serial casting children with spasticity?

A

improve muscle length

improve ankle-foot alignment in ambulation

improve gait pattern in functional ambulation

improve comfort with use of orthotics

enhanced functional motor control

limit need for repeat orthopedic surgery

77
Q

what is the care and management post cast application?

A

no restrictions regarding activity level

however, limit outdoor and running activities for safety

child should wear cast shoes at all times while ambulating outdoors

no skid socks can be used indoors

take extra precautions on rainy/snowy days to prevent cast from getting wet

child should take sponge baths or apply effective plastic cover with tape to form complete seal

78
Q

what are concerns that would warrant prompt removal of serial cast?

A

evidence of painful muscle spasm

evidence of presence of a pressure or friction sore

evidence of an allergic reaction to casting materials

swelling or other signs of circulatory constriction

refusal to bear weight on casted foot

if cast becomes wet

79
Q

what are advantages of rehab?

A

noninvasive

active involvement of the patient and/or family

emphasis on functional gains

80
Q

what are disadvantages of rehab?

A

casting, orthoses, positioning: skin integrity at risk

cost of treatments, equipment

requires patient motivation and participation for functional gains, motor learning

Pediatrics (11 decks)

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