CP Flashcards
1
Q
describe defining characteristics of CP
A
group of permanent disorders
disorders of movement and posture
non-progressive injury to the brain
can have progressive secondary MSK issues
2
Q
true or false: any child w/ a brain injury before 3 years can go on to develop CP
A
true
3
Q
Motor disorders of CP are often accompanied by what other things?
A
perception
sensation
congnition
communication
behavior
epilepsy
2ndary MSK problems
4
Q
what are the two main things CP is classified by?
A
neuropathic: type of muscle tone
anatomic: distribution of limb involvement
5
Q
How do CMFCS levels change as the child grows?
A
they normally do not! once a child is at a certain level you can prognosticate they’ll be at this level their entire life
6
Q
Describe GMFCS levels
A
I: walks w/o limitations
II: walk w/limitations
III: walks using hand held mobility device
IV: self mobility w/limitations, may use power mobility but control it themselves
V: completely dependent, transported in manual WC
7
Q
True or false: CP is a relatively uncommon diagnosis?
A
false!
8
Q
in diplegia what is more effected? Upper or LE?
A
LE»_space;»UE
9
Q
what is the most common kind of CP
A
spastic diplegia
10
Q
what is more common, isolated CP or CP and co-occuring developmental disabilities?
A
a combination of CP and Developmental disabilities
11
Q
true or false, many times we know the specific cause of CP
A
false! but we know a lot about what sets the stage/risk factors
12
Q
are genes a predisposing risk factor for CP?
A
YES! 14% found to have genetic mutation.
but more research needed to be done
13
Q
what are two major risk factors for developing CP in preterm babies?
A
structural and functional immaturity of blood vessels
physiologic immaturity of cerebral vasculature: no autoregulation!
14
Q
Explain preterm arterial system an the risk associated with it
A
arteries grow inward from cerebral cortex towards the germinal matrix (sparsely supplied so its at high risk of ischemia)
terminal branches of arteries are small, fragile and prone to hemorrhage
15
Q
Explain the preterm venous system and the risk associated with it
A
big terminal vein, if there is a hemorrhage from the end branches of the arteries this can clog up the veins and cause ischemia or a hemorrhage of the vein itself
16
Q
what do full term babies have that preterm infants do not have in terms of blood flow?
A
they have less auto regulation of cerebral blood flow leading to increased risk of underflow/overflow. if there is a change in systemic vitals, this is going to change blood flow in the brain
17
Q
other than blood flow, what is another system in preterm that makes them vulnerable to CP?
A
(if you said oligodendrocytes you’re also right)
CV system susceptibility: ineffective heart due to not being totally developed
fluctuations in BP and systemic oxygenation
18
Q
other than blood and CV system what is another system at risk in preterm infants?
A
oligodendrocyte development: responsible for myelination.
If there is ischemia injury to these cells then there is a risk for disruption of future myelination of white matter
19
Q
what is arterial ischemic injury to arterial end-zones?
A
PVL: perventricular keukomalacia
20
Q
what does PVL affect
A
immature white matter
necrosis to all celll types and axonal pathways (including oligodendrocytes)
21
Q
is PVL normally bilateral or unilateral?
A
bilateral
22
Q
what lobes does PVL normally affect
A
frontal and parietal bilaterally
23
Q
other than PVL what is the other main injury seen in preterm babies?
A
IVH: intraventricular hemorrhage
24
Q
Grade I-IV of IVH
A
I: bleed into germinal matrix
II: bleed into lateral ventricles w/no hydrocephalus
III: bleed into lateral ventricles w/hydrocephalus
IV: PVHI - periventricular hemorrhagic infarction
25
is PVHI normally unilateral or bilateral?
unilateral
26
obstructed drainage in the terminal vein causing large area's of ischemia is normally what?
PVHI a complication of IVH
27
other than PVHI what is another complication of IVH
posthemorrhagic hydrocephalus
28
blood obstructs the CSF pathway, get ventricular distension, and compression/ischemia of white matter all describe what?
posthemorrhagic hydrocephalus
29
what symptom are you likely to see in a child who had IVH
hemiparesis: bc its normally unilateral in nature
30
what kind of injury in a preterm infant is likely to form a germinal matrix hemorrhage?
cerebellar injury
31
if there is an inflammatory injury in a preterm baby, what is at risk?
cytokines released which are toxic to oligodendrocytes
circulation and predispose to ischemia
32
characteristics of PVL
arterial endzone injury
bilateral
Frontal: cognition often spared, trunk and UE
Parietal: cognition, vision affected
Generally LE >>UE involvement
33
characteristics of PVHI
terminal vein hemorrhage
unilateral
massive
severe impairment
34
2 characteristics of cerebellar injry
hypotonia
ataxia
35
Does posthemorrhagic hydrocephalus tend to affect lower or upper extermities more?
LE>UE
36
name three common non-motor symptoms of preterm infant brain injury
cognitive and learning deficits (often seen with bilateral injury)
epilepsy
language/behavioral challenges with cerebellar lesions
37
Is spastic diplegia associated with IVH or PVL?
PVL: white matter disease
38
oligodendrocytes being more mature in full term infants can lead to what issue?
developing neurons in grey matter have incredibly high glucose and oxygen demand. This leads other areas of the brain susceptible to ischemia bc the blood is shunted to the areas that need the blood most
39
in a full term infant, the areas most vulnerable to ischemia are areas supplied by what three things?
MCA, PCA, ACA
40
Cerebrovascular injuries can come in three flavors for full term babies what are they?
global hypoxia
ischemic infarct/stroke
hemorrhage
41
Blood diverts from where to where in the event of global hypoxia/ischemia?
what areas are supplied?
from organs to the brain
areas supplied are those most in need: BG, thalamus, brainstem, sensorimotor cortex
42
match the following global hypoxia to their sx
prolonged/incomplete
brief/incomplete
brief/complete
no deficits
injury to area with the greatest demand, no organ damage
parasagittal watershed and white matter injury, end organ damage
prolonged/incomplete: parasagittal watershed and white matter injury; end organ failure (blood diverted to grey matter)
brief/complete: injury to grey matter areas with most demand; no organ damage
brief/incomplete: no deficits
43
Name the three kind of strokes in full term infants?
AIS: arterial ischemic stroke
CVST: cerebral venous sinovenous thrombosis
ICH: intracranial hemorrhage
44
small amount of clotting in the venous system gernally causing what kind of stroke?
CVST: cerebral venous sinovenous thrombosis
45
Aneurysm, AVM, damage or fragile blood vessels generally cause what kind of stroke in full term babies?
ICH: intracranial hemorrhage
46
Cardiac disease, arteriopathy, intravascular, blood abnormalities, trauma/clotting at birth are all what?
potential causes of stroke
47
Describe an artery dissection
fragment of the inner layer breaks off, can have pooling, clotting or aneurysm due to pressure build up
48
most common kind of AVM is found where?
what is it?
what is the most common presenting symtpom?
vein of Galen malformation
there is no capillary bed because the vein is just one giant ball, blood is flowing too fast
blood pressure regulation issues!
49
Vein of Galen malformation presenting symptom
inability to regulate blood pressure
they cannot coordinate suck, swallow, breath
surgical intervention needed
50
generally speaking you have a good idea how a child with CP will present based on imaging and diagnosis?
nope! You can line up different babies with the same initial injury and look totally different! We’re not sure why.
but its still good to think about what a typical presentation based on hx and MRI would be and figure out why the child you're looking at might look different from that.
51
CP is a non-progressive disorder of _____ and/or ______
movement and posture
52
Is CP diagnosis looking for UMN or LMN issue?
UMN; remember its the brain!
53
Cp is a diagnosis of what?
exclusion! rule out other diagnoses
54
is prevalence of CP increasing or decreasing
increasing due to an increase in NICU survivors
55
true of false perinatal hypoxia is the majority of CP
false! its the minority of cases, its common we don't really know the cause many times.
56
TORCHS is what?
an acryonym for the list of infections that lead to prenatal risk factors for CP in fetus's
57
name a couple prenatal risk factors for CP
exposure to toxins
TORCHS: infections
genetics
drug or alcohol use
Rhesus incompatibility
58
true or false: there is a correlation between low birth weight and CP
true! <1,500 grams 9% have CP
59
two major risk factors of perinatal CP
PVL
| IVH
60
major risk factor for postnatal CP
stroke, hypoxia (cardiac arrest, near drowning, respiratory failure), infection
61
what does the diagnosis of CP tell you about what the child will look like?
it doesn't really tell you anything
62
What are the two ways CP is classified?
neuropathic: type of muscle tone
anatomic: distribution of limb involvement
63
what is athetoid movement
slow, involuntary, convoluted, writhing movements
64
what are the two caveats of GMFCS classification
useful for >6 years old
its all self initiated movement
65
what kind of involvement do most patients have with CP
mixed with one region predominating (cortica/pyramidal, BG, or cerebellum)
66
CST involvement normally leads to what kind of sx
spasticity
67
cerebellum involvement normally leads to what kind of sx
ataxia
68
BG involvement normally leads to what kind of symptoms
everything other than spasticity and ataxia; athetosis, chorea, chreoathetosis, ballismus, dystonia
69
loss of supraspinal inhibition creates what?
spasticity
70
talk about the cascade of spasticity
spasticity --> no stretch in the muscles during normal play --> contractures --> abnormal skeletal forces --> bony deformity
71
are there other concerns than MSK for kids with CP
DUH
CNS, gastrointestinal(speech, swallowing), genitourinary (bladder, reflux)
72
what is the principle of surgery for these kids
problem oriented! if the problem is the hip subluxing then we're going to do surgery to prevent subluxation.
set realistic goals!
Pt priorities!
73
compare and contrast dynamic and static contracture
dynamic: due to spasticity
static: actual contracture of the. muscle so no matter what you won't get full ROM
74
These are the four top priorities for CP patients, put them in order from most to least important
ADL's
Communication
Walking
Mobility
Communication
ADL's
Mobility
Walking
75
Loss of selective motor control, abnormal balance and spasticity are three common primary problems of CP (BRAIN RELATED). What are the three options for medical treatment for spasticity
drugs
botox
neurosurgery: dorsal rhizotomy, thrathecal baclofen
76
Diazepam, tizanidine and baclofen are all used for what purpose?
decrease tone/spasticity BUT can lead to sedation, hypotonia and parents don't like it necessarily
77
mechanism for botox?
irreversibly blocks ACH release by nerves at motor end points
BUT more motor end points grow so it is reversible chemical denervation!!!!
78
how long does botox last?
4-6 months
79
What are the two characteristics for a pt selected for botox?
dynamic muscle contracture
<4 muscles involved
80
these are all goals of what medical intervention?
delay surgical intervention
facilitate stretching
adjunct to PT and casting
stimulates surgery
botox
81
what does a phenol/alcohol nerve block do?
similar to botox, destorys motor end points
last longer
more painful
82
what medical intervention decreases stimulation from muscles spindles through getting rid of a section of afferent rootlets?
doral rhizotomy
83
what intervention prevents the need for orthopaedic surgery in about 50% of people.
dorsal rhizotomy
84
This is the selection criteria for what intervention
```
pure spasticity
no fixed contracture
good selective motor control
4-8 yrs old
good congition to coooperate with rehab
```
dorsal rhizotomy
85
This is the selection criteria for what intervention
3-8 yr old spastic diplegic
former preemie
Low body weight
pure spasticity
selective dorsal rhizotomy (SDR)
86
what are the results of dorsal rhizotomy
PERMANENT decrease in spasticity
supraspinal effects (UE function, bladder function, speec, swallowing)
87
Complications of dorsal rhizotomy include
sensory loss and dysethesias (abnormal sense), weakness, neurologic bladder
88
what intervention gives you local delivery of meds ot the SC?
intrathecal baclofen
89
what are indications for intrathecal baclofen
spasticity interfering w/ function or ease of care
ambulatory pts where rhizotomy is contraindicated
90
what are the four main times that PT's are used for CP patients
early intervention: <3
post-op
targeted intervention: coming back after a couple months out for a tune up
Primary care: 3-4 times a week coordinating a lot of care
91
Serial casting how many weeks per cast for how many weeks
casts every 1-2 weeks for 6-8 weeks
92
true or false, for these patients orthotics commonly come above their knees?
false! they're very heavy and hard to donn and doff
93
Role of orthopedic surgery is to restore anatomy and maximize biomechanical function through changing _____ and ______
ROM and alignment
94
the focus is on what for sugical intervention in PG
FUNCTION!
95
true or false: for CP surgery they are trying to address one thing at ta time?
false! address all components at once (lever arm, soft tissue, bony deformity)
96
what is the deal with goal setting as far as surgery goes
make it realistic! for someone who is GCMS 5 you're not doing surgery so they can walk again, you're doing it so they can be comfortable in their WC
97
primary, secondary or tertiary problems are being addressed with orthopedic treatment
teritary for sure, maybe secondary
98
what is the primary, secondary problem here
contracture and spasticity
spasticity = primary (from the brain and decrease in descending inhibition)
secondary = contracture causing bony deformity and muscle shortening and LEVER ARM DYSFUNCTION
99
is lever arm dysfunction talking about greater or lesser moment arms?
smaller moment arms where in normal individuals there are larger ones AS WELL AS lever arms existing which shouldn't exist (such as a large transverse plane lever arm on the foot)
100
what happens in the pre-op evaluation?
```
functional level
strength
ROM
observational gait analysis
x-rays of involved body part
problems list
maybe even instrumented motion analysis
```
101
true or false: dynamic and static soft tissue contractures are treated with muscle tendon lengthening surgeries.
true!
102
what do you need to think about as far as PT for someone who has undergone a muscle tendon lengthening procedure?
weakens the muscle!
103
what intervention change the pull of overactive muscles in order to substitute for weaker muscles?
tendon transfer: done for "muscles out of phase?" or ones that are creating deformity
104
cutting and realigning bones to correct a deformity
common in the hip and knee is what kind of surgical intervention
osteotomy
105
what is a surgical stabilizing procedure commonly done in the spine and the foot
fusion
106
what is the montra for CP surgery?
address as much as you can at once
107
if someone has femoral torsion which way is it commonly rotated
commonly femoral ANTEVERSION
108
intramuscular psoas lengthening would be done for what deformity?
hip flexion deformity
109
where do you lengthen for a psoas procedure
"at the brim" not at the insertion which is the lesser trochanter
110
what procedure is described
- pt in prone
- tibia is straight up and down
- guidewire from head of femoral neck to to head
Derotational osteotomy: guidewire is defining torsion:
111
what is normal femoral anteversion in degrees?
20-25
once you get the person to this normal anteverison you put plates and screws in to hold it here
112
who are you doing the following procedures in
- psoas lengthening
- derotational osteotomy
- rec femoris transfer
- medial hamstring lengthening
- tibial derotational osteotomy
- recession technique (for equinus)
- lateral column lengthening
- triple arthrodesis
- intramuscular tib posteiror, gastroc lengthening or split tendon transfer
etc. etc.
ambulatory individuals!
113
hamstring contracture and torsional deformity cause cause what problem
excessive knee flexion in stance phase
114
spastic rec fem can cause what?
impaired clearance during swing: it should be relaxed but its straightening.
115
rec fem transfer what do they make the rec fem?
they cut it and make it a knee flexor rather than an extender
116
for ambulatory pts which hamstrings are you lengthening?
medial ones (tendinosus, membranosus, gracilis)
117
after medial hamstring lengthening how long do they have a knee immobilizer on/
7-10 days and go to PT
118
if tibial torsion is > than what degree, will they do a fibular osteotomy for?
>25 degrees
119
ankle equinus is what?
stuck in PF
120
what do you want to avoid in procedures for equinus?
why?
Z/achilles lengthening
soleus is essential for stance support and power generation: you really really don't want to overstretch it its super hard to come back from!
121
what is the major thought behind all the surgical techniques done for equinus?
leave the muscle intact, just cut the fascia, its hard to overlengthen by accident this way
122
what is this the postop follow up for?
short leg ast 4-6 weeks
WBAT vs. NWB
MAFO
gastroc soleus recession
123
equinovalgus is most common in what kind of CP.
what is equinovalgus?
diplegia.
"bad flat foot"
Makes them wt. bear medially on their foot
equinovalgus = rear foot valgus/eversion.
forefoot ABD's
124
what is the major issue being equinovalgus?
tight achilles or gastroc soleus complex so they focus on lengthening it!
bracing --> surgery
125
other than gastroc lengthening what kind of surgery is done for equinovalgus?
calcaneal osteotomy, lengthens the lateral foot and pushes the forefoot back to midline (it drifts into ABD due to valgus of forefoot)
126
what are the two common deformities for equinovalgus?
rear foot valgus
forefoot varus
127
you would do a medial cuneiform osteotomy or talonavicular arthrodesis for what deformity?
equinovalgus where the forefoot goes ABD
128
when is a triple arthordesis indicated?
severe equinovalgus (forefoot is way over so they have to do a fusion)
pt is very limited or non ambulatory
129
flexible equinovarus is what
foot is supinated
130
intramuscular
| tib posterior lengthening would be indicated in what deformity?
flexible equinovarus
as well as gastroc lengthening
and split tendon tarnsfer
131
a split tendon transfer for flexible equinovarus changes
tib posterior to ______
tib anterior to ______
tib posterior to PERONEUS BREVIS
tib anterior to CUBOID
132
posterior tib tendon transfers to where
half the tendon stays at its insertion of the navicular, half goes to the lateral side to the peroneals!
Creating a Y out of the muscle: half still wants to invert and half wants to evert
133
what is this the post op for
WBAT 6 weeks
MAFO 6-12 months
posterior tib tendon transfer
134
Fixed equinovarus what are you thinking the surgical intervention is going to involve?
some kind of fusion/osteotomy
135
loss of what couple in crouched gait?
PF and knee extension
136
posterior capsule, knee flexion and hip flexion contracture are common in what gait?
crouched
137
quad insufficiency and patella alta are common issues in what deviation?
crouched gait
138
what are these the options for intervention for?
Serial casting
Hamstring lengthening
“Guided growth” with Plate or staples
Hamstring lengthening + posterior capsulotomy
Distal femoral extension osteotomy and patellar ligament advancement
crouched gait
139
crouched is what kind of gait
non sustainable!! they end up in WC
140
explain what guided growth is and what its used for
used for crouched gait "hamstring lengthening"
plates go in the anterior femur to stop growth, while posterior is left to grow so they straighten out
141
what is distal femoral extension osteotomy used for?
what is it?
crouched gait
cut the distal femur and tilt it up: allows for the same ROM just more of an arc of motion in the extension direction.
142
what do you need to do in conjunction to the distal femoral extension osteotomy?
patellar ligament advancement to make sure it has the correct length tension to allow for knee extension which is the overall goal anyway.
143
what are goals of surgeons for nonambulatory individuals
```
WC
Spine
hips
knees
feet
```
WC to maximize function
Spine
spine: straight enough to sit
hips: located, mobile, painless (Hip displacement can be super common - 2-75%)
knees: motion for sitting in good posture and transfers
feet: plantigrade
144
with spastic quadriplegia what is the biggest issue with the hips
what is strong
what is not
what does this do to alignment and to surrounding muscles
ADD overcome ABD and the person ends up flexed and ADD position, this lever arms the hip right out of the acetabulum.. The femoral head presses on the ADD muscle bellies and this misshapes the femoral head as well as disrupts the shape of the muscle
145
hips that are stable at ____ years remains table
18 years
146
_____% of hip dislocation have pain
50% and a lot can't communicate!
147
true or false: you can expect hips with severe subluxation to progress to dislocation?
true!
148
reasons to treat spastic hip
pain
ease of care
WC posture
pelvic obliquity and scoliosis
149
Reimer's migration index tells you the % of what?
femoral head outside of the acetabulum
150
what is a normal Reimers migration index (how much of the femoral head is outside of the acetabulum
CP normal: <30%
Subluxation >30%
Dislocation >90%
151
how many degrees of passive hip ABD is a red flag for spastic hip
< 45 degrees on either side
152
what is this the treatment options for
early: soft tissue lengthening
bony changes: reconstruction
end stage: salvage
spastic hip
153
if you are doing a STL (soft tissue lengthening) procedure for spastic hip, what would you be lengthening?
what assessment numbers would you look at?
ADD longus, gracilis, psoas
<8 years old
ABD <45
MI %: >30
THIS IS MODERATE
154
if a child is older and has MP% of >40-60% what is the surgeon likely to do?
bony surgery on either the femur or the acetabulum to fix the shape of it because we know with spastic hip both get deformed
155
femoral osteobomy for spastic hip are you tipping the femur into varus or valgus?
varus (remember its just the femur you're talking about, you want it back in the socket)
normal anteversion is ~125 degrees
156
explain acetabuloplasty simply
cut right above the cuff
cartilage inside is flexible
make a bone graft to put inside to shape the cuff
157
true of false, scoliosis progresses with skeletal maturity?
true!
158
True or false: 39-75% of individuals with spastic CP have scoliosis
true, idiot question
159
small or progressive scoliotic curves what is done
observe
160
true or false: bracing is the gold standard for scoliosis in CP
false! for idiopathic scoliosis it is! but kids with CP tend to not tolerate them well, and don't stop the progression
161
what are basically your two intervention options for scoliosis other than observing
surgery or brace (and bracing isn't great for CP scoliosis)
162
you want WC seat and back to be firm and squishy?
firm for support
163
soft or hard spinal orthoses tolerated best?
soft!
164
True or false: bracing in the CP population for scoliosis prevents progression
false! it slows the progression and may delay surgery
| can improve sitting balance, function and ease of care
165
if scoliotic curve is what degree do they consider surgery?
40-50 degrees
166
what are the two ways they tend to do spinal surgery?
segmental instrumentation
fuse it to the pelvis in nonambulators
167
true or false: complication rates for spine surgery are high?
true!
```
respiratory
gastrointestinal
skin wound
infection
implant related
pseudoarthrosis
```
168
what kind of CP is this describing
```
abnormal tone
increases with activity but is constant
squirming or writhing
disappears during sleep
kernicterus
non-ambulators
soft tissue surgery is unpredictable
```
athetoid CP
169
true or false: CP encompasses a specturm of pathology?
true!
170
just read it:
CP encompasses a spectrum of pathology
CNS lesion is static, musculoskeletal problems progress with growth
Priorities by adulthood are communication skills, ADL’s, and finally mobility
Treat each patient individually
Goal is to maximize function
Spasticity and it’s sequelae are amenable to treatment by neurosurgeons and orthopaedic surgeons but you’re not fixing the core problem (BRAIN)
```
just read it:
Orthopaedic treatment
Soft tissue and bony pathology
Hips, knees, ankles
Define problem list
Address all components at once
Have realistic goals
Adequate rehabilitation
Will still need orthotic support
Will still have problems with selectivity, balance, and spasticity!
```
