Exam

Question 1

Define Cerebral Palsy

Answer 1

• A group of permanent disorders of the development of movement and posture, causing activity limitations that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain.
• Most common childhood motor disability

Question 2

Classify the types of CP

Answer 2

• By body area:
  
  • topographic distribution of impairments in body functions and structure and atypical movement
• By movement abnormality
  
  • based on location of brain injury
• By severity
  
  • Mild, moderate, or severe

Question 3

CP classification by body area [4 types]:

Answer 3

• Diplegia:
  
  • LE more affected than UE
• Hemiplegia:
  
  • UE and LE on one side more affected
• Quadriplegia/tetraplegia:
  
  • all limbs affected
• Monoplegia:
  
  • one limb affected

Question 4

CP classification by movement abnormality [4 types]:

Answer 4

• Spastic CP
  
  • disorder of motor cortex and white matter projections
  • velocity dependent increase in muscle tone
• Dyskinetic CP
  
  • Basal Ganglia disorder
  • Dystonic Type:
    
    • Involuntary sustained or intermittent muscle contraction with repetitive movement and abnormal postures
  • Athetoid CP
    
    • Slow writhing movements of the hands and feet that prevent maintenance of stable posture
• Ataxic CP
  
  • Cerebellar involvement
  • Inability to generate normal voluntary movement that cannot be attributed to weakness or involuntary muscle activity at affected joint
  • General instability, abnormal patterns of posture, lack of coordination, rhythm, and accurate movements
• Mixed
  
  • Presence of both spastic and dyskinetic types

Question 5

List the criteria for a medical diagnosis of CP [3 criteria]:

Answer 5

• Cerebral Palsy is a clinical diagnosis
  
  1. Delayed acquisition of motor milestones
  2. abnormal muscle tone or qualitative differences in movement patterns
  3. Retention of primary reflexes beyond 6 months

Question 6

Cerebral Palsy:

• Know the prognosis for walking based on acquisition of independent sitting:

Answer 6

• If the patient can sit independently by two years old, then likely will be able to walk (Best Predictor).
  
  • If cannot sit by two years old, then walking is unlikely
• Children with Hemiplegic CP and Ataxic CP are more likely to walk
• Children with Dyskinetic and Bilateral CP are less likely to walk

Question 7

Given a child with spastic Cerebral Palsy, instruct Mom in how to ↓LE extensor tone to put on shoes

Answer 7

• (Use a variety of movements and postures to promote sensory variety
  Frequently include positions that promote full lengthening of spastic or hypoextensible muscles
  Use positions that promote functional voluntary movement of limbs)
• Bring extensors off the surface to avoid stimulating extensors
• Bend hip and knee to promote full lengthening of spastic extensors
• (Abduct and externally rotate to break up tone, then flex the knees?)

Question 8

Describe motor skill acquisition in children:

• Fitts & Posner Stages of skill acquisition

Answer 8

• Stage 1: Early (Cognitive stage)
  
  • Explorative trial and error stage
  • finding the task requirements
  • high degree of conscious involvement
  • performance is inconsistent
  • should limit the degrees of freedom
• Stage 2: Intermediate (Associative stage)
  
  • Performance is more consistent
  • Learner uses information about error to adjust performance
  • Can decrease amount of guidance and feedback can be more precise
• Stage 3: Later (Autonomous stage)
  
  • Fine tuning of performance
  • Performance is more consistent and efficient
  • Less susceptible to error from the environmental interference
  • Learn intersegmental dynamics
    
    • (i.e. motions that can get for free)
  • Should provide feedback about the quality of the movement

Question 9

Discuss the underlying neuronal principles of development and motor learning

• Neuronal group selection

Answer 9

• Neural Darwinism
  
  • Anatomy of the brain is produced during development
  • Experience selects for strengthening certain patterns of responses from the anatomic structures
  • resulting maps of the brain give rise to uniquely individual behavioral functions
• Experience-Expectant neural maturation
  
  • A developmental selection of species specific behaviors
  • Development of a repertoire of functional circuits form the basic neuro-anatomic network via selective activation
  • Genetically specified directions lead to initial synaptic connections through over-production of populations of cells that are pruned by exposure to experiences common to all members of a species
• Experience dependent neural maturation
  
  • Process by which each individual achieves uniqueness in structure and function through exposure to an individualized set of experiences

Question 10

TO BE CONTINUED

Given a case, create a PT treatment applying motor learning strategies:

Question 11

Define “developmental care”:

Answer 11

• Developmental care is an approach to individualise the care of infants to maximise neurological development and reduce long-term cognitive and behavioural problems.
• Broadly defined term used in many NICU’s and in research to describe the use of environmental interventions such as sound and light reduction along with sleep preservation or clustered care in order to support the infant’s development.

Question 12

Why is Developmental Care important?

Answer 12

• It recognizes the physical, psychological and emotional vulnerabilities of premature and/or critically ill newborns.
• Developmental care has been shown to:
  
  • decrease length of stay
  • decrease hospital costs
  • improve weight gain
  • improve neuro-developmental scores at 9-12 months.

Question 13

5 subsystems of synactive theory:

• and how to assess each system

Answer 13

1. Autonomic
   
   • Assess skin color, startle/tremor reactions, heart rate, respiration rate
2. Motor
   
   • Assess posturing, motor tone, activity, movement
3. State Organization:
   
   • Assess level of CNS arousal:
     
     • sleepy/drowsy
     • awake/alert
     • fussing/crying.
4. Attention/Interaction
   
   • Availability of the infant for interacting:
     
     • alertness and the robustness of the interaction.
5. Self-Regulation:
   
   • This is the presence and success of the infant’s efforts to achieve and maintain a balance of the other four subsystems.

Question 14

Signs of stress in the Autonomic subsytem (Synactive Systems theory)

Answer 14

• Color changes
  
  • pallor, flushing (turning red), and cyanosis (turning blue)
• Changes in vital signs
  
  • heart rate, respiratory rate, blood pressure, pulse ox rate
• Visceral responses
  
  • vomiting, gagging, hiccups, passing gas
• Sneezing
• Yawning

Question 15

Motor Signs of Stress (Synactive Systems Theory)

Answer 15

• Generalized hypotonia
  
  • limp, decreased resistance to moving of the infant’s extremities
• Frantic flailing movements
• Finger splaying
  
  • holding fingers spread wide apart
• Hyperextension of extremities
  
  • arms or legs extended straight out almost in a locked position

Question 16

State Organization Signs of Stress (Synactive Systems Theory)

Answer 16

• Diffuse sleep states
  
  • lots of twitching, grimacing, not resting peacefully
• Glassy-eyed
  
  • appears to be “tuning out”
• Gaze aversion
  
  • cuts eyes to the side trying not to look at what is in front of them
• Staring
  
  • a locked gaze, usually wide open eyes
• Panicked look
• Irritability
  
  • hard to console

Question 17

Attention/Interaction Signs of Stress (Synactive Systems Theory)

Answer 17

• Infant will demonstrate stress signals of the autonomic, motor and state systems
• Inability to integrate with other sensory input
  
  • can’t look and face, listen to talking and suck a bottle at the same time

Question 18

Self-Regulatory Behaviors signs of stress (Synactive Systems Theory)

Answer 18

• These are attempts to deal with stress and regain control
  
  • Change in position
  • Hand-to-mouth
  • Grasping
  • Sucking
  • Visual locking
  • Hand clasping

Question 19

Healthy Neonate:

• Heart Rate
• Respiration Rate
• SpO2
• Blood Pressure

Answer 19

• HR: 110-140 bpm
• RR: 40-60 bpm
• SpO2: greater than 94%
• BP: 56-77 mmHg over 33-50 mmHg

Question 20

Why does developmental positioning matter?

Answer 20

• Nursing PPT
  
  • Positioning in the NICU affects the baby’s neuromuscular (motor) development.
  • Most preterm or sick infants cannot change position on their own.
  • These infants do not have muscle strength and tend to lie with arms and legs extended.
  • Being in extended position for long time can lead to abnormal tone in shoulders and hips which is directly linked to motor delays upon discharge.
• Musculoskeletal system of a preterm infant is susceptible to developmental deformities as a result of NICU positioning
• Premature infants may display instability of the autonomic nervous system in response to changes in position or lack of postural support.
• From Text:
  
  • Improves oxygenation
  • Promotes state organization
  • Stimulate the flexed midline positions of the typical full term
  • Maintain ROM

Question 21

Describe how you would position a 10 wk premature infant in supine.

Answer 21

• Therapeutic
  
  • a flexed mid-line position
  • foot bracing
  • correct contour of developing spine
• Non-therapeutic
  
  • Boundaries too low/flat/ineffective
    
    • causes infants to lie flat with head to the side and extremities sprawled
    • Leads to positional deformities and atypical development
  • Boundaries too high
    
    • Legs hang over edge
    • Does not allow for foot bracing
    • Can cause hyperflexion or hyperextension
  • Hyperextension of neck overstretches neck flexors and leads to difficulty with head centering, downward eye gaze, and hand coordination to mouth
  • Nonmidline head positions can cause an elongated skull and can increase risk of IVH in extremely low birthweight patients

Question 22

Musculoskeletal implications for developmental positioning:

Answer 22

• Optimal position is fetal position (flexed and midline)
• Allows for proper spinal curvature development
• Prevents muscle shortening of scapular muscles, which enables infants to bring toys/hands to mouth or to self feed later
• Allows for self soothing with fingers/hands by mouth
• Prevents bow legs and hip dysplasia

Question 23

Describe correct prone positioning

Answer 23

• Shoulders rounded with arms tucked under body
• Hands by/near face
• Boudaries to prevent loss of position
• Foot bracing
• NO FROG LEGS (HIP ABDUCTION)

Question 24

• Define Spina Bifida

Answer 24

• Defective development of any part (especially the lower parts) of the spinal cord
• Also called myelodysplasia
• Classified as:
  
  • Aperta (open)
  • Occulta (closed)

Question 25

Given a case with Spina Bifida, how would you evaluate his safety for walking community distances?

(Campbells PT for Children; Box 23.2, p. 566)

Answer 25

• Evaluate
  
  • Endurance
    
    • sufficient at a functional speed for average community distances
    • Adequate for play and recreational activities
    • Adequate for long-distance community distances
  • Efficiency
    
    • Record hear rate and calculate energy expenditure
    • Record normal and fast walking paces
    • Adequate speed to cross intersections
    • Is typical pace practical for community distances?
  • Effectiveness:
    
    • Independent with transfers
    • Able to maneuver in all directions
    • Able to step and climb over obstacles
    • Able to reach and lift items from shelves
  • Safety
    
    • Good stability and balance?
    • Observes joint and skin protection?
    • Safe on wet or slippery surfaces?
    • Can maneuver around obstacles?
    • ABle to maneuver in congested areas?
    • Safe on uneven terrain (curbs, inclines, steps)?

Question 26

Discuss the ADL implications for a child with neurogenic bowel and bladder:

Answer 26

• Bladder inteventions strategies are directed toward the goal of infection free social continence with preservation of renal function
• For most individuals effective bladder intervention is acheived with clean intermittent catheterization on a regularly timed schedule for voiding.
• PT must be aware of the method used for urine drainage as it can impact wheelchair positioning, transfer techniques, and orthoses
  
  • assistive devices should not interfere with performance of urine drainage techniques

Question 27

Define Arthrogyposis Multiplex Congenita

Answer 27

• Non Progressive neuromuscular syndrome that is present at birth.
  
  • characterized by severe joint contractures, muscle weakness, and fibrosis.
• Although the child’s condition does not deteriorate as a result of the primary diagnosis, the long term sequelae of AMC can be very disabling.
• Activity limitations occur in mobility and self care skills that can can lead to varying degrees of participation restrictions.
• Arthrogryposis is defined by the presence of contractures in two or more body areas

Question 28

Most affected body parts in Arthrogryposis (most affected to least affected)

Answer 28

• Foot
• Hip
• Wrist
• Knee
• Elbow
• Shoulder

Question 29

ICF Framework for Arthrogryposis: Anterior Horn Damage

• Body Structure Impairments, Body Functions, Activity Limitations, Participation:

Answer 29

• Body Structures
  
  • Prenatal damage to anterior horn cells → neurological and muscle damage.
• Body Functions:
  
  • Joint contractures
  • Fibrotic joint capsule
• Activity Limitations:
  
  • Limited mobility
  • Limited transfers
  • Limited independence in ADLs
• Participation impairments:
  
  • Limited ability to play with peers.
  • Inability to live independently.
• Environmenttal Factors
  
  • Accessibility of home/school etc for mobility devices or for ADL’s
  • Level of social support
• Personal factors
  
  • Demographics
  • Personal coping style
  • motivation
  • habits

Question 30

ICF Framework for Arthrogryposis: Scar tissue and fibrotic tissue do not grow and stretch as much as healthy muscles.

Body Structure Impairments, Body Functions, Activity Limitations, Participation:

Answer 30

• Scar tissue and fibrotic tissue do not grow and stretch as much as healthy muscles.
• Scar tissue and fibrotic tissue do not grow and stretch as much as healthy muscles.

Question 31

Physical Therapy: Athrogryposis during infancy

Answer 31

• Notes:
  
  • Most involved in newborn period
• Examine
  
  • ROM
    
    • stretching and ROM
  • strength
    
    • developmental play
  • motor milestones
  • Standing
    
    • initiate with standing frame progresses to independent standing in the frame
• Intervention:
  
  • Stretch 3-5 sets per day with 3-5 reps.
    
    • Hold 20-30 sec.
  • Interventions should be incorporated into ADLs
  • Proper positioning
  • Splinting

Question 32

Physical Therapy: Athrogryposis during school age

Answer 32

• ROM:
  
  • Goal: increase independence in mobility
  • Intervention: Stretch 2x/day during dressing and bathing.
    
    • Have child participate by counting and positioning
• Functional strength:
  
  • Goal: minimal bracing
• Locomotion
  
  • Goals: assistive devices

Question 33

Physical Therapy: Athrogryposis during adolescence

Answer 33

• Notes:
  
  • Many children are in classroom
• Examine
  
  • PT looks at need for adaptive equipment
  • Evaluates ADL skills
  • School Function Assessment instrument may be used
• Goals:
  
  • As indicated on the IEP

Question 34

Intellectual Disability vs. Cognitive Impairment

Answer 34

• Intellectual Disability/Developmental Delay
  
  • limits a person’s ability to learn and function in daily life.
  • Originates before 18-21 yrs of age
  • IQ = 2 SD (standard deviations) below the X (i.e. <70-75) as assessed by the Stanford-Binet
• Children with DD may have a hard time:
  
  • letting others know what they need
  • taking care of themselves.
• Children with DD may:
  
  • learn and develop more slowly than peers
  • take longer to learn to walk, talk, dress, eat without help.
  • have trouble in school
  • have trouble remembering, solving problems, understanding social rules, seeing the results of their action.
• Cognitive Impairment
  
  • The person previously had normal cognitive function. Now they have problems with thought processes (e.g. forgetfulness, concentration difficulties)
  • Causes:
    
    • Alzheimer’s
    • TBI
    • PTSD

Question 35

Contrast fitness of people with cognitive impairment to fitness of the general population.

Answer 35

• Cognitive Impairment/Developmental Disability
  
  • Lower levels of cardiovascular fitness than those without impairments.
  • Weaker than those without impairments.
• Down Syndrome:
  
  • Weaker than people with cognitive impairment.
  • ↓ grip strength compared to norms.
  • ↓ knee extension strength
• Cerebral Palsy:
  
  • Lower cardio-respiratory fitness than the general population.
  • LE muscle strength 37% of normal.

Question 36

TO BE CONTINUED:

Design a Plan of Care to improve the fitness of a case with Down syndrome who is over-weight and has degenerative arthritis of the left hip

Question 37

What learning challenges do you have to take into consideration in treating children with cognitive impairments?

Answer 37

• The more severe the cognitive impairment, usually the more severe the motor delay.
• They learn fewer numbers of things at a time.
• They need more repetitions.
• They have greater difficulty generalizing.
• They have greater difficulty maintaining skills if not practiced regularly.
• They have slower response time.
• They have a more limited variety of responses.

Question 38

You are testing a Special Olympic athlete for aerobic endurance. What signs of respiratory distress would you look for during the test?

Answer 38

• shortness of breath
• cyanosis
• restlessness
• coughing
• wheezing
• stupor
• dizziness
• apnea
• cheyne-stokes
• increased BP
• tachycardia
• (Also monitor SpO2)

Question 39

FUNFitness Flexibility tests

Answer 39

• Hip Flexors
  
  • modified Thomas Test
• Hamstrings
  
  • Passive knee extension in supine
• Ankle dorsiflexors
  
  • Passive dorsiflexion in supine
• Functional shoulder mobility
  
  • Apley’s test

Question 40

FUNFitness Strength Tests

Answer 40

• Leg Muscles
  
  • Timed stands
• Abdominal Muscles
  
  • Partial Sit-Up
• Hand and Forearm
  
  • Hand-Grip test
• Triceps/Shoulder stabilizers
  
  • Seated Push-up

Question 41

FUNFitness Tests for Balance

Answer 41

• Balance with the assistance of visual cues
  
  • Single Leg Stance with eyes open
• Balance without the assistance of visual cues.
  
  • Single Leg Stance with eyes closed
• Balance that allows use of visual cues, but perturbs body position
  
  • Functional Reach Test

Question 42

FUNFitness Tests for Aerobic fitness

Answer 42

• Two-minute step
• Five Minute Wheel

Question 43

Define Duschenne’s Muscular Dystrophy

Answer 43

• A recessive X-linked fatal disease of progressive weakness of the skeletal and respiratory muscles.
• Loss of muscle contraction is due to destruction of myofibrils
  
  • Lack of dystrophin
  • muscle fibers tear under the force of contration when dystrophin is not present
  • also alters the permeability of the sarcolemma disrupting homeostasis of muscle cells
  • Contractile tissue is replaced with fat and fibrosis

Question 44

Stages of Duschenne’s Muscular Dystrophy

Answer 44

• Ambulatory Phase
  
  • Early
  • Later – Ambulatory with Assistive Devices
• Non-Ambulatory Phase
  
  • Early – wheelchair mobility
  • Later

Question 45

[TO BE CONTINUED] Design an intervention plan for (given a case study) for a teen with muscular dystrophy:

Answer 45

Intervention Considerations (Per Dr. Pope’s Slides)

• Sub-maximal aerobic exercise/activity
  
  • Endurance exercise in adolescence should be focused more on upper extremity than LE
  • Utilize ADL’s as opportunity for endurance exercise
    
    • Swimming or water exercise
• Sub-maximal, gentle functional strengthening/activity
  
  • may continue to use swimming, low resistance strength training

Question 46

Why is assistive technology important for children with physical disabilities?

Answer 46

• Increases, maintains, improves individuals functional status
• Promotes the development and acquisition of skills that a client lacks as a result of disease or injury

Question 47

What is the current physical activity recommendation for children and adolescents?

Answer 47

• One hour or more of physical activity?

Question 48

What percentage of children and adolescents are considered to be either overweight or obese in the USA currently?

Answer 48

• CHILDREN: 18.8
• ADOLESCENTS: 17.4
• Or, from Dr. Pope’s slides:
  
  • 1/3 (33%)

Question 49

Given a case, determine the child’s weight category (underweight, normal, overweight, obese), set a nutrition/activity goal, and design a treatment plan to increase the child’s physical activity.

Answer 49

• BMI: kg/m(2)
  
  • Obese: 95th percentile and above
  • Overweight: Between 85th and 95th percentile
  • Normal: 5th to under the 85th percentile
  • Less than the 5th percentile
• Nutrition goal:
  
  • Use a food diary
• Activity goal:
  
  • Use an activity diary
• Tx plan for activity goal
  
  • Assess readiness for change
  • Assess social support/environmental barriers
  • Determine baseline activity level
    
    • Reduce sedentary behaviors
    • Increase activity levels gradually by about 10 minutes until performance levels are met…then maintain.
  • Educate regarding healthy eating choices:
    
    • Nutrient density rather than energy density
    • Meat/Fish = deck of cards
    • Grains/Pasta = size of baseball
    • Fruits/Veggies = any amount
    • Dairy: single servings

Question 50

Give an example of a child on whom a supermalleolar orthotic (SMO) might be used?

Answer 50

• Effects of supramalleolar orthoses on postural stability in children with Down syndrome.
  
  • Dev Med Child Neurol. 2004 Jun;46(6):406-11.
  • Martin K.
• This study explored the effects of a flexible supramalleolar orthosis (SMO), indicated to decrease pronation associated with hypotonia, on postural stability in children with Down syndrome.
• This study explored the effects of a flexible supramalleolar orthosis (SMO), indicated to decrease pronation associated with hypotonia, on postural stability in children with Down syndrome.

Question 51

Two commonly seen variations in Arthrogryposis

Answer 51

• Variation 1
  
  • flexed and dislocated hips
  • extended knees
  • clubfeet
    
    • legs often described as “jackknifed”
  • internally rotated shoulders
  • flexed elbows
  • flexed and ulnarly deviated wrists
• Variation 2
  
  • Abducted and externally rotated hips
  • flexed knees
  • clubfeet
    
    • legs often described as frog like
  • internally rotated shoulders
  • extended elbows
  • flexed and ulnarly deviated wrists

Question 52

Fixed deformity

Answer 52

• permanent changes that have occurred in the bones, muscles, ligaments, or tendons

Question 53

Flexible deformity

Answer 53

• external resistance can move an affected joint and reduce a deformity.

Question 54

Define “Natural Environment”

Answer 54

• “settings that are natural or normal for the child’s age peers who have no disabilities.”
• settings that are natural and typical for children without disabilities and their families; varieties of setting where children live, learn and play; and where children, their families and their care providers participate in everyday routines and activities important to them.