CP - Assessment & Classification Flashcards
What is cerebral palsy?
- Group of disorders of the development of movement and posture, causing activity limitation
- Attributed to non-progressive disturbances that occurred in the developing foetal or infant brain
What are the motor disorders of CP often accompanied by?
Disturbances of sensation, cognition, communication, perception, and/or behaviour, and/or by a seizure disorder
What is the epidemiology of CP?
- Most common physical disability in childhood
- 600-700 children born with CP in Aus each year
- 2-2.5 per 1000 live births
What is the relationship between CP & premature delivery?
- % of children with CP born premi has remained constant
- But increased survival rates of very preterm babies
What are the different causes of CP?
- Prenatal (75%): Brain malformations, vascular insult, maternal infections
- Perinatal (6-9%): Hypoxia, neonatal encephalopathy, HIE
- Post natal (9-10%): ABI, vascular event, infections
What are the risk factors for CP?
- Prematurity
- Multiple birth
- Genetic background
What are the positive features of UMN syndrome?
- Increased proprioceptive reflexes producing spasticity
- Increased cutaneous reflexes producing flexor and extensor spasms & the Babinski response
What are the negative features of UMN syndrome?
- Paralysis
- Weakness
- Loss of dexterity
What are the characteristics of the functional deficits associated with damage to the immature brain?
- Reflect the neural lesion
- Impacted by the changing state of multiple systems due to growth and development
- Determined by what has been practised and achieved
What are the typical features of CP?
- Delay in achievement of motor milestones
- Atypical skill development not just a delay with abnormalities of posture and movement
- Secondary impact on musculoskeletal system due to change in forces acting on the growing child e.g. spasticity, weight bearing alignment which further impact movement and posture
What are the abnormalities of posture & movement in CP?
- Insufficient force generation
- Spasticity, increased reflexes
- Abnormal extensibility (usually hypo- but can have hyper-)
- Poor selective control with inability to activate specific muscle without moving the whole limb
- Poor regulation of activity in muscle groups in anticipation of postural changes & body movement leading to co-contraction of agonist and antagonist
- Decreased ability to learn unique movements
How was CP previously classified?
- Level of disability
- Area of body affected (hemiplegia, diplegia, quadriplegia, monoplegia, triplegia)
- Type of movement disorder (spastic, athetoid, dystonic, ataxic, hypotonic)
What are the current classification & assessment tools for CP?
- Gross Motor Function Classification Scale (GMFCS)
- Functional Mobility Scale (FMS)
- Gait Classifications: Hemiplegia and Diplegia
- Spasticity Measures: Tardieu, Australian Spasticity Assessment Scale (ASAS, Hypertonia Assessment Tool (HAT)
- Cerebral Palsy Check-Up (CPUP)
What are the features of the GMFCS?
- Summarises severity of disability in terms of function
- 5 components: Lying/rolling, sitting, crawling/kneeling, standing, walking/running/jumping
- Quantitative only
What are the features of the FMS?
- Measure of independent mobility
What are the 3 types of ataxic CP?
- Spasticity
- Dystonia
- Athetoid
What is spasticity?
- Velocity dependent increase in tonic stretch reflexes, with exaggerated tendon jerks resulting from hyper excitability of the stretch reflex
- Background muscle activity present on EMG
What are the features of spasticity?
- Could be a compensation for weakness
- Structural changes occur within the muscle cells causing muscle stiffness (hypertonia)
- Changes with speed of movement, emotion, effort or posture
What is hypo-extensibility due to in spasticity?
- Spasticity
- Adaptive changes in muscle
- Alteration in growth
What are stiff movements due to in spasticity?
- Hypoextensibility
- Changes in biomechanics
- Lack of ability to generate sufficient force in appropriate muscle groups
What are the measures for spasticity?
- ASAS: Australian Spasticity Assessment Measure
- HAT: Hypertonicity Assessment Tool
- Tardieu: Used in musculo-skeletal assessment for R1 and R2 measures
- Ashworth: Measure of muscle tone
What are the features of the ASAS?
- Scored on diagrammatic representation of the body
- Incorporates elements of Ashworth & Tardieu scale
What are the features of the HAT?
- 7 point scale which differentiates between the 4 limbs
- Measures dystonia, spasticity & rigidity
- Scores are 0 (negative) or 1 (positive)
• Used with ASAS to give a clear picture of the areas of the body affected & type of movement disorder
What is athetosis?
Involuntary writhing movements distally associated with low muscle strength and low tone
What is the modified Tardieu scale?
- Measures R1: Angle where catch occurs at V3
- Measures R2: Angle of full PROM at V1
- Difference between R1 & R2 is an indicator for botox
What are the features of dystonia?
- Basal ganglia abnormality
- Abnormal muscle tone
- Co-contractions
- Involuntary twisting postures
- Variable but not present in sleep
- Worse with voluntary action, stress, pain, fatigue and startle
- Distribution: Focal or generalised
- Sustained or intermittent postures
What are the differences between dystonia, spasticity & athetoid?
- Dystonia: Tone variable, nil hyper-reflexia or contracture
- Spasticity: Nil tone variability, does have hyper-reflexia & contracture
- Athetoid: Nil tone variability, hyper-reflexia or contracture
What is the “circle of spasticity”?
- Increased muscle tone causes
- Increased muscle stiffness causes
- Muscle contracture causes
- Increase muscle tone
Also affected by:
- Bony lever arm maladaptation
- Altered biomechanics
What is the pathology of contracture?
- Inappropriate neurological activity
- Spasticity
- Reduced muscle excursion
- *need to intervene here
- Failure of muscle growth, adaptive changes in muscle & change of bone shape
- Restricted joint range leads to joint instability
- Cartilage damage
- Painful arthritis
What does the musculoskeletal assessment of CP include?
- UL & LL R1/R2
- Spine: scoliosis, kyphosis
- Pelvis: Anterior/posterior tilt or obliquity which impacts on sitting posture
What is the CPUP?
- Incorporates all aspects of assessment for all disciplines
- Gold standard assessment & follow up of all children with CP in ACT/NSW
- Uses assessment measures detailed in this lecture
