CP Flashcards
Most common neuro disorder encountered by pediatric PTs
CP
Cerebral palsy
Non-progressive lesion of brain resulting in disorder of posture and voluntary movement.
Occur during fetal development of first year of life
Progressive musculoskeletal impairment
Etiology of CP
Hypoxic, ischemic, infection, congenital, or traumatic MRI studies CVA (1/3 Infant bilaterally) Maternal infection Prematurity
Discriminate infant neuromotor tests to assist in prediction and ID of CP
AIMS
TIMP and NSMDA before or after term
GM
Best combo of sensitivity and specificity for predicting CP in early months
Prechtl’s assessment of general movements
Best for predicting CP in older infants
AIMS
NSDMA
Characteristics of CP
Cog delays Behavioral issues Speech impairment Hearing impairment Vision impairment Seizure disorder Urinalysis incontinence Constipation Sensory impairments visual-spatial, visual perception, tactile
Tetraplegia
All four limbs involved (quad)
Diplegia
All four limbs involved. Both legs are more severely affected than the arms
Hemiplegia
One side of body affected. Arm is usually more involved than leg
Triplegia
Three limbs involved, usually both arms and a leg
Monoplegia
Only one limb affected, usually an arm
Motor differences CP: spastic
Motor cortex
Motor differences dyskinesia
Basal ganglia
Motor differences CP: ataxic
Cerebellar lesion
Motor differences CP: mixed
Spastic and dyskinesia
Gross motor function classification system
Five level
Self initiated movements - sitting, transfer, mobility
Age bands
<2, 2-4, 4-6, 6-12, 12-18
GMFCS general heading level 1
Walks w/out limitations
GMFCS general heading level 2
Walks w/ limitations
GMFCS general heading level 3
Walks using a hand held mobility device
GMFCS general heading level 4
Self mobility w/ limitations, may use powered mobility
GMFCS general heading level 5
Transported in a manual w/c
GMFCS before 2nd bday level 1
More in and out of sitting and floor sit w/ both hands free to manipulate objects
Creep, pull to stand and walk holding onto furniture
18m-2y walk without AD
GMFCS before 2nd bday level2
May require use of hand in sitting
Combat crawl or creep
May pull to stand and walk holding onto furniture
GMFCS before 2nd bday level 3
Sit with low back supported
Roll and combat crawl
GMFCS before 2nd bday level 4
Require trunk support for sitting, able to control head
Roll to supine and may roll to prone
GMFCS before 2nd bday level 5
Unable to maintain antigravity head and trunk postures in prone and sitting
Require assistance to roll
GMFCS before 2nd to 4th birthday level 1
Transition in and out of sitting and standing w/out assistance
Walk as 1 deg mobility
GMFCS before 2nd to 4th birthday level 2
Pull to stand at surface
Creep w/ reciprocal pattern and cruise
Walk w/ AD as preferred mobility
GMFCS before 2nd to 4th birthday level 3
Frequent “w” sit
Combat crawl or creep as 1deg mobility
Walk short distances indoor w/ walker and adult assistance for steering
GMFCS before 2nd to 4th birthday level 4
Adaptive equipment for sitting and standing
Self mobility limited to short distance
GMFCS before 2nd to 4th birthday level 5
No means of (I) movement
GMFCS before 4th to 6th birthday level 1
Walk indoors and outdoors
Climb stairs
Emerging fun and jump
GMFCS before 4th to 6th birthday level 2
Short indoor walking w/out mobility device, outdoor on level surface
Climb stairs w/ rail
Unable to jump or run
GMFCS before 4th to 6th birthday level 3
Walk w/ handheld mobility device on level surface
Require assistance to climb stairs
Frequently transported long distances
GMFCS before 4th to 6th birthday level 4
Self mobility possible w/ powered WC
Transported in community
GMFCS before 4th to 6th birthday level 5
No independent movement
GMFCS before 6th to 12th birthday level 1
Walk at home, school, outdoor and in community
Climb stairs w/out railing
Gross motor skills but speed, bal, coord limited
GMFCS before 6th to 12th birthday level 2
Walk in most settings,
Climb stairs holding rail
Difficulty walking long distance and balancing on uneven terrain, inclines, crowds, small spaces
May walk w/ physical assistance, hand held mobility device or wheeled mobility for long distance
Minimal ability to perform gross motor skills such as running and jumping
GMFCS before 6th to 12th birthday level 3
Children walk using hand held mobility device in most indoor setting
Climb stairs holding onto rail w/ supervision or assistance
W/C when traveling long distances, may self propel shorter distances
GMFCS before 6th to 12th birthday level 4
Children use methods of mobility that require physical assistance or powered mobility in most settings
May walk short distances at home w/ physical assistance or use powered mobility or body support walker
Manual or power w/c in other settings
GMFCS before 6th to 12th birthday level 5
Manual w/c in all settings
Limited in ability to maintain antigravity head and trunk postures and control leg and arm movement
GMFCS before 12th to 18th birthday level 1
Walk at home, school, outdoor, community
Climb curb and stairs w/out assistance or railing
Perform gross motor but speed, balance, coordination limited
GMFCS between 12th and 18th birthday level 2
Walk in most settings but enviro factor and personal choice influence mobility choices
At school/work, require hand held mobility device for safety, climb stairs holding onto a railing
Outdoors, use w/c when traveling long distance
GMFCS between 12th and 18th birthday level 3
Walking using hand held mobility device
Climb stairs w/ railing w/ sup or assist
Self propel manual or power w/c at school
Outdoors - transported in w/c
GMFCS between 12th and 18th birthday level 4
W/c in most settings
Physical assist 1-2 people required for transfers
Indoor- short distance w/ physical assist, w/c or walker
Operate powered chair or manual w/c
GMFCS between 12th and 18th birthday level 5
Manual w/c in all settings
Limited in ability to maintain antigravity head and trunk postures and control leg and arm movements
Self mobility is severely limited
Strongest predictor of walking ability in all types of CP
Cog function
Best predictor for amb of 15+ m by age 8
Independent sitting by 24 mo
If indep sitting not obtained by age 3,
Likelihood of functional walking is very low
Most children w/ CP reach 90% of motor pro entail before age
3 for most sever
5 for least involved
Most common contracture in children w/ CP
Shoulder add Elbow, wrist, finger flex Hip flex and add Knee flex Ankle PF
Primary impairment in CP
Diminished force production capability
CP muscle strength
Low EMG
Greater weakness
Distal> prox, con > Eccles, fast > slow
Contributes to bone deformity
CP skeletal impairments
Torsion of long bones, joint instability, premature degenerative changes
Scoliosis
Hip subluxation
CP selective control
Isolated muscle activation in selected pattern in response to voluntary posture
Poor selective control contributes to impaired motor function
CP motor learning
Difficulty anazlying their own movements and using feedback to improve performance
Motor memory often impaired
CP pain
61% of amb children
Modified ashworth and CP
Low reliability
Modified tardieu
Point of catch to rapid movement
Mechanical resistance to slow stretch indicates muscle length
Difference b/n catch and mechanical resistance
Modified tardieu large difference
Indicates large reflexive component to motion limitations
Modified tardieu small difference
Indicates a more fixed contracture
Selective control assessment of LE
SCALE
Rating specific isolated movement
CP other exam and eval
ROM, MMT, endurance and efficiency of movement
Observation of sway or repsonse to perturbation
SATCO
Pain (asses frequently)
Activity part, differentiate b/n capacity, performance, motivation
CP exam considerations - infancy
Consider infant’s temperment, state of regulation and handling tolerance
Provide baseline for monitoring
CP exam consider - pre school aged
Require more frequent reassessment
CP strengthening
Both concentric and eccentric
CP PRE
4-12x week
3x/wk
80-90% max load
Lower resistance for increased reps for endurance
CP CV endurance
EE walking can be up to 3x >
GMFCS levels 1 and 2 respond well to specific training
Swimming programs for all levels
CP modified constrain induced movement therapy
Useful w/ hemiplegia
Constraining unaffected UE
Mass practiced w/ affected UE
CP spasticity management
Intervetion if interfering w/ function or comfort
Passive stretching - short term ,minor effect
SDR
Botox
Baclofen
Muscle length best maintained
Through active movement in lengthen position
Casting
Orthoses
Positioning
Solid AFO
Max restriction of ankle movement
Hinged orthoses
Permit DF
Dynamic or posterior leaf spring orthoses
Reduce equinus in swing
Permit ankle DF in stance
Absorb more energy in midstance
Reduce desireable power generation at push off
SMO
For pronation
Orthotic and GMFCS level 1-3
Used to allow for more efficient gait and prevent deformity
GMFCS level 4, 5 orthotic
Prevent deformities
May allow child to be positioned in standing for physiological and psychosocial benefits
AFOs and gain in children w/ CP
Increased velocity, reduced cadence, increased step and stride length, increased duration of SL support
Improved EE and possibly decreased O2 consumption
Muscle lengthening AFO
Minimum of 6 hours/day
AFO and sit to stand
Solid AFO may impede transition unless it is positioned w/ a forward inclination
GMFCS levels 4 and 5 individualized postural management
Prevent positional contractures/deformities
Prevent skin breakdown
Facilitate function and participation
Promote safe, comfortable and biomechancially optimal sleep position
GMFCS levels 1-3 weight bearing program
Increase/maintain bone mineral density
Maintain LE extensibility
Promote acetabulum development
GMFCS levels 1-3 may indicate use of stander at age
1
Posterior walkers
Improve posture and gait pattern,
Less EE than anterior walker
Safe and effective mobility in power w/c can be achieved as early as
17 mo of age
CP tx focus infancy
Positioning, carrying, feeding, etc Symmetry, handling, posturing, functional motor Biannual activity Inhibition of hyperextension Trunk then lateral control
CP to pre school
Reduce primaryimpair, prevent secondary impair
Engage outside family
Hip joint integrity
Goal attainment scaling
Individualized, criterion referenced measured of change
-defined a set of unique goals for client, then specify range of outcomes
PEGS
Percieved efficacy and goal setting
Age 5-9
Picture of task
Allows child to self report percieved competence in every day activites and set goals for intervention
Parallel questionnaires for caregivers and educators
GAS 5 point rating scale
-2 much less expected outcome
-1 less than expected outcome
0 expected outcome after intervening
+1 greater than expected outcome
+2 much greater than expected outcome
Amb skill direct intervention
Ther ex Functional training in self care and home management Manual therapy Modalities AD, ortho, adaptive equipment
Amb skills levels 4 and 5
PWB on treadmill
Supported amb
Focus on CP fitness
Address/monitor ROM and strength
Amb skills 4 and 5
Explore all options for (I) mobility
Equipment may be required to compensate for postural and movement control limitations
Shock absorption concern
Energy conservation is not expected
Amb skills intervetion for level 3
Upright posture and stability
Developing forward progression
Shock absorption
Energy conservation
Amb skills level 1 and 2
Ongoing analysis of posture and stability in diff enviro and functional activities
Regular even of orthotic fit/function
Monitor gait efficiency
Fitness program w/in community
