CP Flashcards
what is CP?
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
what are major signs of CP?
slow motor development
retention of primitive reflexes
what are classifications of CP?
divided into several classifications each with typical patterns of movement
1- hypotonic 2-rigid 3-ataxic 4- fluctuating tone/athetoid/dystonic 5-spastic/hypertonic
describe hypotonic CP:
pattern of motor expression: whole body involvement
area of brain involvement: generalized
varying severity
describe rigid CP:
pattern of motor expression: whole body involvement
area of brain involvement: generalized
varying severity
describe ataxic CP:
pattern of motor expression: whole body involvement
area of brain involvement: extrapyramidal cerebellar
varying severity
describe fluctuating tone/athetoid/dystonic CP:
pattern of motor expression: whole body involvement
area of brain involvement: extrapyramidal basal ganglia
varying severity
describe spastic/hypertonic CP:
pattern of motor expression:
- monoplegia
- diplegia/paraplegia
area of brain involvement: pyramidal motor tracts
varying severity
describe mild severity for CP:
gross motor: independent walker
fine motor: unlimited function
IQ: >70
speech: >2 words
overall: independent function
describe moderate severity for CP:
gross motor: crawl or supported walk
fine motor: limited function
IQ: 50-70
speech: single words
overall: needs assistance
describe severe CP:
gross motor: no locomotion
fine motor: no function
IQ: <50
speech: severely impaired
overall: total care
what is spasticity?
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
what is the pathophysiology of spasticity?
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
what are signs of UMNS?
positive signs:
- spasticity
- rigidity
- hyper-reflexia
- primitive reflexes
- clonus
negative signs:
- lack of strength
- lack of motor control
- lack of coordination
what are types of involuntary movement disorders?
dystonia
chorea
athetosis
choreoathetosis
ataxia
what is dystonia?
abnormal posturing, twisting or repetitive movements
what is chorea?
irregular dance-like movements
what is athetosis?
writhing, distal movements
what is choreoathetosis?
combo of both chorea and athetosis
what is ataxia?
flailing movements, wide-based gait
how is the ash worth scale of muscle tone scored?
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
how is the modified ash worth scale of muscle tone scored?
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
what is the modified tardieu scale??
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
what are the levels of the gross motor function classification system- expanded and revised (GMFCS- E&R)
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
what are the levels of the MACS: manual ability classification system for children w/ CP 4-18 y/o?
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
what is the purpose of the GMFM: gross motor function measure ?
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
what is the age range for GMFM?
validated for sensitivity to change over a 6 month period in children from 5 months to 16 y/o
what are the 5 dimensions of the GMFM?
1- lying and rolling 2- sitting 3- crawling 4- standing 5- walking, running, jumping
how is the GMFM administered?
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
what are pros of the GMFM?
developed for children with CP
concerned with quantity of functional movement, not quality
measures change over time
what are cons of the GMFM?
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
what is spastic diplegia?
involvement in LEs
scissoring gait
lordosis
limited LE disassociation- moves in total movement patterns- flexion- extension
good head and upper body control
what is spastic quadriplegia?
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
what is spastic hemiplegia?
one side involvement
tendency to ignore involved side
scoliosis
retracted pelvis, hip IR, ADD, ankle PF, forefoot inversion
what is hypotonic?
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
what is athetoid?
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
what does ataxic mean?
jerky, unsteady movements
increases with excitement
trunk- low muscle tone
shoulder and hip instability
need a lot of support in standing and sitting
what are common spine impairments for the child with CP?
trunk deformities due to muscle imbalance
prone to scoliosis, increased kyphosis or lordosis
difficulty with rotation skills
shallow respirations
short vocalizations
what are common LE impairments for the child with CP?
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
what are common gait impairments for the child with CP?
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
what are characteristics of diplegia CP?
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
what are characteristics of triplegia CP?
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
what are characteristics of hemiplegia CP?
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
what are common characteristics of quadriplegia CP?
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
what are general treatment principles for the child with CP??
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
why use ball therapy?
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
what are principles to decrease tone?
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
what are principles to increase tone?
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
what are tx options for patients with spasticity?
rehab therapy
intrathecal baclofen (ITB therapy)
Oral meds
injection therapy
neurosurgery
orthopedic surgery
who is on the “team” ?
child and family
physicians
- physiatrist
- neurologist
- neurosurgeon
- orthopedic surgeon
- PCP
nurse/nurse practitioner
social worker
PT
OT
SP
dietician
psychologist
educator
what are the most common oral meds?
Baclofen (Lioresal)
Diazepam (Valium)
Tizanidine (Zanaflex)
Dantrolene sodium (Dantrium)
what are advantages to oral meds?
non-invasive, not permanent
effective management for some patients
what are disadvantages to oral meds?
difficult to achieve a steady state
following a schedule may be difficult
side effects: drowsiness, hypotonia, weakness – may limit effectiveness
what are neurosurgical treatments?
neurectomy
myelotomy
anterior rhizotomy
selective dorsal rhizotomy
cordectomy
thalamotomy
what are advantages to intrathecal baclofen (ITB) therapy?
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
what are disadvantages to intrathecal baclofen (ITB) therapy?
complications: infection, catheter problems, OD, baclofen withdrawal
refills- approx every 3 months
cost
ITB trial:
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
what are post ITB pump therapy considerations?
symptoms of OD
symptoms of withdrawal
what are symptoms of OD for ITB?
somnolence (excessive drowsiness)
respiratory depression
seizures
rostral progression of hypotonia
loss of consciousness progressing to coma
what are symptoms of withdrawal for ITB?
pruritus without rash
diaphoresis
hyperthermia
hypotension
neurological changes, including agitation or confusion
sudden generalized increase in muscle tone, spasticity and muscle rigidity
what are the guidelines for handling and positioning post ITB pump implant for first 2-4 weeks?
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
what positioning should be used after ITB?
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
lifting and transfers post ITB?
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
what is selective dorsal rhizotomy (SDR)?
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
what are considerations for SDR?
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)
what are advantages to SDR?
permanent- one time procedure
evidence for efficacy in reducing spasticity and improving function in children with spastic diplegia
what are disadvantages to SDR?
permanent- may need spasticity
potential adverse effects: spinal, sensory
not effective for dystonia
what are 2 orthopedic surgery options?
soft tissue operations:
- lengthenings
- releases
- tendon transfers
bony operations
- osteotomies
- fusions
what are advantages to orthopedic surgery?
effects usually last a few years
what are disadvantages to orthopedic surgery?
anesthesia risks
non- weight bearing after bony procedures
risk of weakness, decreased function
what are injection therapies?
anesthetic/diagnostic nerve blocks
- procaine
- lidocaine
neurolytic nerve blocks
- ethanol
- phenol
botulinum toxin
what is botulinum toxin?
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
what are advantages to injections?
not permanent
evidence to support efficacy in reducing spasticity and improving function
effects are localized- not systemic
what are disadvantages to injections?
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
what is a serial casting procedure?
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
what are goals for serial casting children with spasticity?
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
what is the care and management post cast application?
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
what are concerns that would warrant prompt removal of serial cast?
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
what are advantages of rehab?
noninvasive
active involvement of the patient and/or family
emphasis on functional gains
what are disadvantages of rehab?
casting, orthoses, positioning: skin integrity at risk
cost of treatments, equipment
requires patient motivation and participation for functional gains, motor learning
