CP Flashcards
Epidemiology & Pathophysiology of CP:
Defined as a persistent but changing movement and posture disorder that appears early in life due to non-progressing lesion in developing brain
Over-riding term for many afflictions
Usually classified as:
- Spastic or pyramidal: injury to cortex causing spasticity, hyperreflexia, hypertonia, contractures and clasp knife rigidity [exaggerated stretch reflex]
- Athetosis or extrapyramidal: injury to basal ganglia or cerebellum causing ataxia, chorea and lead pipe rigidity.
May also have an anatomical classification, often have scoliosis and GI tract symptoms [cause swelling, drooling, regurgitation/vomiting and abdominal pain]
Epidemiology & Pathophysiology of CP: Anatomical Classifications
- Hemiplegia [unilateral,often upper]
- Diplegia [bilateral, often lower]
- Tetraplegia [whole body, including cranial nerves]
- Monoplegia [single limb]
- Paraplegia [Legs only]
- Triplegia [3 limbs, 1 unaffected]
Epidemiology of CP:
1 in 400 babies in aus and world wide
Symptoms apparent by about 12-18months of age, may take until 6 years
Damage leading to CP can occur in foetal development, during birth, or soon after birth while NS is developing rapidly
No cure- some children’s symptoms improve with age but others decline.
Pharmacology of CP: Possible side effects ?
Focus on dyskinesia - dystopia, myoclonus, chorea/athetosis, and spasticity
Examples include botulinum [botox], baclofen, clonazepam, levedopa, lorazepam, valproate, phenobarbital, dantrolene
Possible side effects include:
- drowsiness and dizziness
- weakness and fatigue
- ataxia
- Dry mouth - NB
Conservative and Treatments of CP:
Strength & ROM training and motor learning
Use of specific measurable goals for skill acquisition better than physical therapy alone
Weight bearing exercise to improve bone mineral density in children, and foot orthoses may help gait
Strength training in spastic muscles leads to increased gait cadence and speed without increased energy
Swimming has also shown to increase baseline vital capacity
Surgical Treatments of CP:
Surgical treatments aim to relieve spasticity or correct deformity
Selective dorsal rhizotomy [cut sensory nerve fibres in lumbar regions] assists diplegic and tetraplegia spastic patients
- significant benefits to functional performance
In some cases may affect plantarflexor and hamstring strength
Long-term difficulties with back pain, sensory loss, decreased urologic function, spondylolisthesis need to refer to physician before exercise testing
Secondary Conditions and Consequences of CP:
Chronic pain, spasticity, obesity, urinary tract infections and pressure sores
Dependence on upper extremities predisposes overuse injuries, joint degeneration and tendon pathology
Severe spasticity reduces ROM, may affect breathing
Standard health issues with inactivity
Inability to perform large muscle group exercise exacerbates problems
GMFCS - The Gross Motor Function Classification System for CP - 5 level clinical classification system
Based on self initiated movement with emphasis on sitting and walking, not so much on quality of movement
Distinctions between levels of motor function based on functional limitations, the need for assistive technology, including mobility devices and wheeled mobility
Standard for mobility assessment and ambulatory ability prediction for CP
GMFCS Level 1 includes children whose functional limitations are less than typically associated with CP
Describe GMFCS Level 1:
Can walk indoors and outdoors and climb stairs without using hands for support
Can perform usual activities such as running and jumping
Has decreased speed, balance and coordination
Climb stairs with a railing
Has difficulty with uneven surfaces, inclines or in crowds
Has only minimal ability to run or jump
Describe GMFCS Level V:
Has physical impairments that restrict voluntary control of movement
Ability to maintain head and neck position against gravity restricted
Impaired in all areas of motor function
Can’t sit or stand independently, even with adaptive equipment
Can’t independently walk but may be able to use powered mobility
Important of Exercise for people with CP:
Help integrate into community and improve social inclusiveness - social environment very important with CP as they tend to be affectionate
Increases learning of visual and auditory tasks and memory tasks
Improves fatigue resistance to increased possibility of working
Minimise weight gain and accumulation of cardiac risk factors
Exercise Testing : Endurance
Make use of wheelchair testing, although spasticity and athetosis might ultimately limit performance
Arm ergometers useful; may need trunk stability when muscles lack function - own wheelchair
Ensure patient wont be injured if hands need to be strapped [spasticity may limit ROM on one side]
In walk, run and wheelchair tests on treadmills its often useful to increase grade more than velocity - increasing velocity may increase spasticity
Watch for balance coordination problems in walk/run tests
Spasticity of hip adductor might increase with fatigue increasing Genu Valgum [knock knees], may hit knees together and fall
Determination of aerobic capacity in wheelchair, arm crank and cycle tests has high reliability
Determination of anaerobic threshold in wheelchair athletes with discontinuous protocol has low reliability
Facial muscle and tongue problems may make collection of expired gas very difficult
Exercise Testing: Strength
ST/ testing OK in CP patients
Important to consider effect of antagonist spasticity - agonist may be strong when ‘strength’ is poor
Check ROM and stability before testing
Testing depends on level of disability - may range from traditional isoinertial strength tests [1RM, 8RM, etc] to isometric/isokinetic testing
Slower movements may optimise performance - consider using metronome
If increased spasticity after ex, allow period of recovery
Learning may be a problem if cognitive impairment
Exercise Testing : Balance, flexibility and movement testing
Flexibility testing can be done as per normal - need to test many joints/muscle groups using reliable test protocols
Functional balance/flexibility test may to bend over to touch toes - easy to measure and requires balance and flexibility
Given diversity of movement capacities, motion analysis/qualitative video analysis very useful to determine capacity and track progress
Exercise Prescription - Aerobic
10-15min at self selected pace on treadmill or cycle continuous or discontinuous as warm up, watch incline of treadmill if limited dorsiflexion due to spasticity
Subsequent stretching will improve function ROM, may need to be seated or supine if balance problems
Aerobic training principles same as for brain/SCI patients
Target large muscle masses, especially if some limbs are paretic
Think about specificity of long term therapeutic goals - centre of mass base for support, balance traning
Watch for foot drop in spastic patients- may increase fall risk, cycling and wheelchair programs an option.
