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Pediatrics > L11: Cerebral Palsy > Flashcards

L11: Cerebral Palsy Flashcards

1
Q

What is CP?

A
  • Group of permanent disorders of the dev. of mvmt and posture→ causes activity limitations that are attributed to disturbances that occurred in the developing fetal or infant brain
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2
Q

CP is Static aka

A

NON-progressive in nature

*Umbrella term for any brain injury that occurs IN and AROUND birth thru first few yrs of life

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3
Q

CP results from dmg to 3 main areas:

A
  1. Motor Cortex
    1. presentation determined by area of brain dmg (B/L or U/L) and severity
      1. see homonculus pics
  2. BG
  3. Cerebellum
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4
Q

Causes of CP

*NOTE: exact cause for indiv. children not often known

Multiplicity of factors vs single event

Most lesions/dmg happen when?

A

2nd half gestation

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5
Q

Prenatal causes CP

35%

A

Infx, inflamm, anoxia, coag disorder, genetics

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6
Q

Perinatal causes CP

55%

A

asphyxia, anoxia (PVL, IVH, aspiration), met. cond’s

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7
Q

Postnatal causes CP

10%

A

head injury, BI, toxicity, cerebral anoxia, CVA

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8
Q

Most common causes CP happen when?

A

Perinatally

55%

  • asphyxia, anoxia (PVL, IVH, aspiration), met. cond’s
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9
Q

CP Clinical Presentations

4 Mvmt Disorders commonly seen

A
  1. Spasticity
  2. Dystonia
  3. Athetosis
  4. Ataxia
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10
Q

CP clinical presentations

Spastic CP

A
  • HypERtonia or rigidity
    • MOST COMMON TYPE***
    • Hemiplegic, Diplegic, Tetraplegic, Quadriplegic
  • Motor cortex dmg
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11
Q

MOST COMMON TYPE OF CP

A

SPASTIC!!!

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12
Q

CP Clinical Presentations

Dystonia

A
  • Abnorm posturing, twisting, rep. involunt. mvmts
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13
Q

Clinical Presentations CP

Athetosis

A
  • Writhing, distal mvmts
  • Uncontrolled mvmts
  • BG issue
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14
Q

Clinical Presentations CP

Ataxia

“Drunken Sailor”

A
  • Flailing mvmts, wide BOS/gait
  • Wide base gait, balance and coord. primary issues
  • Cerebellar origin
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15
Q

Spastic CP

Hemiplegic

A

Arm, body and leg affected on one side

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16
Q

Spastic CP

Diplegia

A

Legs affected more vs. Arms

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17
Q

Spastic CP

Quadriplegia

A

Whole body affected

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18
Q

CP often found in children w/ _______

A

LBW (1000-1499g)

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19
Q

Dx CP made via:

A
  • Neuroimaging
  • Clinically dx’d
    • delayed milestones
    • abnorm mm tone
    • abnorm mvmt patterns

PTs can contribute to clinical dx!!!

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20
Q

Dx of CP

Precise dx can be diff. BUT most children dx as early as ______

A

6mos of age

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21
Q

Considerations in Dx of CP

Just a few

A
  • Variation in motor dev.
  • Unknown origin: brain MRI
  • Consideration of alternate explanations (transient dystonia)
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22
Q

Prognosis for CP

*Highly variable

This type of CP more likely POSITIVE OUTCOMES

A

Hemiplegia and Ataxic CP

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23
Q

Prognosis for CP

*Highly variable

This type of CP LESS LIKELY positive outcomes

A

Dyskinesia and B/L CP

(Dyskinesia== uncontrolled, involuntary mm mvmt)

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24
Q

Impact of deficits in following areas contribute to prognosis of CP

A

Cog

Visual

Hearing

Sz activity

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25
Q

Other predictors for CP prognosis

Greatest predictor of ambulation**

A

IND sitting by 24mos

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26
Q

Other predictors for CP prognosis

Functional IND ambulation UNLIKELY if this:

A

Unable to IND sit @ 3yrs

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27
Q

Almost ALL children w/ CP @ higher risk for this

A

Communication deficits

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28
Q

Children w/ CP @ risk for:

A
  • Cog limits
  • Behavioral probs
  • Comm. deficits—- almost ALL
  • Sensation deficits
  • Epilepsy
  • B&B incontinence/constipation
    • Usually Quadriplegic or B/L
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29
Q

Classification of CP

KNOW THIS SCALE SYSTEM!!!

A

Gross Motor Function Classification System (GMFCS)

*ALWAYS refer to GMFCS lvl for practice→ Goals, interventions, etc..

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30
Q

Gross Motor Functional Classification System (GMFCS)

Details

A
  • 5 lvl classification scale used to det. functional capabilities for children 18yo and younger w/ CP
  • Subcategories
  • Best reps child current abilities and limitations in gross motor function in home, school, community
  • Self-initiated mvmt emphasis on sitting and walking
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31
Q

GMFCS: Class. of CP

Lvls: ALL

A
  • Lvl 1: Walks w/out limitations (BEST)
  • Lvl 2: Walks WITH limitations
  • Lvl 3: Walks using Hand-Held Mobility Device
  • Lvl 4: Self-Mobility w/ Limitations: May use powered mobility
  • Lvl 5: Transported in a Manual WC
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32
Q

GMFCS

Lvl 1 :

A

Walks w/out Limitations (BEST)

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33
Q

GMFCS Lvl 2:

A

Walks WITH Limitatiosn

34
Q

GMFCS Lvl 3:

A

Walks using hand-held mobility device

35
Q

GMFCS Lvl 4:

A

Self-Mobility w/ Limitations: May use powered mobility

36
Q

GMFCS Lvl 5:

A

Transported in manual WC

37
Q

GMFCS based on _____ function

A

CURRENT

38
Q

Before 2 yrs…

A

GMFCS lvl may change

39
Q

After 2yo

A

GMFCS lvl most likely to stay as is

40
Q

Body Structure and Function (BSF) in relation to CP

PRIMARY IMPAIRMENTS:

3:

A
  1. Aborn mm tone
  2. Decd strength→ force production, mvmt control
  3. Impaired motor control
41
Q

BSF in relation to CP

SECONDARY IMPAIRMENTS (result from PRIMARY impairs)

A
  • Decd mm extensibility/mm tightness
  • Impaired postural control
  • Skeletal deformity
  • Pain
  • Fatigue→ diff to overcome pull of gravity → extra effort to do everything
  • Abnorm sensation (body awareness, proprio.)
42
Q

CP is NON-progressive, BUT _____ can be

A

Impairments

43
Q

BSF PRIMARY impairments:

Abnormal Mm Tone

Tone vs. Spasticity

A
  • Tone→ NORMAL resting tension or resistance of mm to passive mvmt
  • Spasticity (velocity-dependent)→ NEURAL resistance to externally imposed mvmt which INCs w/ INC speed of stretch and varies w/ direction of mvmt
44
Q

More on spasticity

A
  • Dev’s over time
  • Typ mvmt patterns challenging
  • Untreated will contribute to loss of mm length/contractures
45
Q

Contributing factors assoc’d w/ abnorm mm tone:

A
  • Muscle innervation
  • Impaired growth influences
  • Altered loading
    • Lack approp wt bearing from early infancy
    • Muscle growth DOES NOT EQUAL bone growth→ bone grows faster vs muscle== hypO-extensibility
    • over-lengthened mm’s from mech. stretch or certain ortho sx’s
46
Q

BSF PRIMARY impairs:

Decd strength

A
  • Children w/ CP unable to gen. normal voluntary force in a mm OR normal torque about a joint
    • MM weakness:
      • low EMG activity
      • inapprop. co-activation of antagonists
      • skeletal deformities
        • length-tension relationships
47
Q

BSF PRIMARY impairs:

Impaired Motor Control

A
  • Poor selective control of mm activity
    • reduced speed mvmt
    • reduced reciprocal mvmt (remember bunny hopping from atyp. dev.)
    • impaired ability to isolate the activation of mm’s in selected patterns in resp. to voluntary postures etc.
48
Q

BSF SECONDARY impairs:

neg. sequelae of PRIMARY impairs

A
  • Decd mm extensibility
  • Impaired posture control/balance
  • Sk. deformity
  • Pain
  • Fatigue/impaired endurance
49
Q

Activity Limits and CP

BSF impacts activities

MOST have diff. w/:

A
  • Mobility
  • Gen tasks/demands
  • Self-care
  • Domestic life skills
50
Q

Participation restrictions

Children w/ CP @ higher risk of poor participation @ _______ and in ______

A

@ school

in community

  • Decd playground access
  • Decd adapted sports
  • Limits in IND w/ peers
51
Q

Contextual Factors

Personal

*unique to ea child

A
  • Age
  • Sex
  • Cog lvl
  • Co-morbs
  • Motivation lvl
  • Play skills
  • Attitude towards therapy
52
Q

Contextual Factors

Environmental

*unique to ea child

A
  • Support system @ home
  • Home set up
  • Avail. resources
  • Durable Medical Equipment (DME) needs
53
Q

PT Exam BSF: Strength

*can be challenging w/ CP

Use if possible

A

Isokinetic

HHD

MMT when mm group is isolated consistently

54
Q

PT Exam BSF: Strength

MOST COMMONLY utilized strength assessment for CP

A

Functional Strength Assessment

  • observe motor skills
  • STS, floor→stand, squat
  • Timed rep. testing
55
Q

PT Exam BSF: Abnorm Tone/Extensibility

BAD TO USE FOR PEDS

A

MOD. ASHWORTH

*DOES NOT quantify spasticity exclusively

56
Q

PT Exam BSF: Abnorm MM tone/Extensibility

BEST to use for PEDS

A

Modified Tardieu Scale (R1/R2)

*shows change better vs MAS

57
Q

Barry-Albright Dystonia Scale

A

Rates dystonia (posturing and involunt. dystonic mvmt)

*know it exists

58
Q

Mod. Tardieu Scale (R1/R2)

BEST for tone in PEDS

A
  • Measures “catch” to rapid velocity== R1
  • Captures dynamic neural component of tone
  • Muscle lenght/passive ROM== R2
59
Q

PT Exam BSF: Impaired Motor Control

A
  • Motor assess in gravity resisted or gravity elimin’d
  • Doc qual of mvmt and deg. of isolation ability by jt
  • Hemiplegia→ compare to non-involved
60
Q

PT Exam BSF: Postural Control/Balance

A
  • Selective Control Assessment of the LE (SCALE) test
  • Postural control
    • sway/perturbs response
    • visual, computerized, EMG
  • Balance→ static/dynamic, sitting/standing
    • Ped Balance Scale/Ped BERG
  • Sensory Disturbs
    • poor body aware.
    • decd proprio/kinesth. aware
      • be traditional, use toys
61
Q

PT Exam BSF: Endurance

A
  • Submaximal endurance walk and w/c mobility
    • 10 meter walk/roll test
    • 6min walk/roll test
    • 600 yd walk/run test
    • 6 min push test
  • Maximal Exercise Testing: shuttle run timed, cycling, erg.
    • PEDS RPE
62
Q

PT Exam Activity Limitations: Functional Mobility

A
  • Assess functional tasks
    • bed/mat mob, transfers, floor ←→ standing, stairs, ambulation
63
Q

PT Exam Activity Limitations: Functional Mobility

Common gait devs in CP

A
  1. Scissor
  2. Equinus→ diplegia, hemiplegia
    1. Tip-toe walk one foot only
  3. Crouch
64
Q

PT Exam Activity Limits: Gait

A
  • Gait Analysis→ 3D instrumented
    • Comprehensive includes clinical exam of body function and structures
      • improves CDM
      • Gold Standard for gait research and optimizing outcomes
      • costly and questionable validity for daily function
65
Q

Pt Exam Activity Limitations: Gross Motor Standardized Assessments

GOLD STANDARD FOR CHILDREN W/ CP

A

Gross Motor Function Measure

GMFM*****

66
Q

Pt Exam Activity Limitations: Gross Motor Standardized Assessments

A
  • GMFM** → GOLD STANDARD
  • OTHERS:
    • GMA → patho mvmt quals characteristic of CP in first few mos of life
    • AIMS
    • Prechtl’s Assessment of Gen Mvmt
      • early mos
    • Test of Infant Motor Performance (TIMP)
      • infants→4mos
    • Neuro-Sensory Motor Developmental Assessment
67
Q

Pt Exam Activity Limitation Standardized Assessments

Following look @ Activity Limits:

A
  • Timed distance tests
  • TUG
  • Timed Up and Down Stairs
  • Activity Scale for Kids
  • PEDI
  • WeeFIM
68
Q

Standardized Measures for Participation

A
  • Child Engagement in Daily Life
  • Assess of Life Habits (LIFE-H)
  • Childrens Assessment of Participation and Enjoyment
  • School Function Assess (SFA)
  • QoL:
    • Peds QL-CP Module
69
Q

Med interventions for CP

2 Categories:

A
  1. Sx
  2. Pharma
70
Q

Common Sx Procedures

A
  • Distal femoral ext osteotomy
  • Tendon lengthening proc’s often performed
    • HS, Heel cords, adductors
  • Tendon transfers→ feet
  • Spinal fusion for nmsk scoliosis
  • Femoral and pelvic hip osteotomies
    • Ganz
    • Varus Derotational Osteotomy (VDRO)
71
Q

VDRO

Sx procedure for what?

A

Children w/ In-Toe

72
Q

VDRO

In-Toeing result of ….

A

Too much medial femoral torsion (MFT)

→ lack of torque producing activation of glutes/hip rotators==== lack of untwisting of femur

73
Q

VDRO

Children IN-Toe why?

A

to maintain femoral head in acetabulum → otherwise will dislocate

74
Q

VDRO proc properly aligns what?

A

Femoral head INTO acetabulum

75
Q

Typ developing hip joint vs. hip joint w/ too much MFT/anteversion

A

see pics

Ante= forward

Retro=backward

76
Q

VDRO Why??

A
  • By school age (3yrs)→ Hip rotation should be approx. 1:1 (45d/45deg= 90deg)
  • Children w/ CP tend to have too much MFT
77
Q

Common meds in children w/ CP

A
  • Spasticity mgmt meds
  • Anti-epilectics
  • Mm relaxers
  • GI
    • constipation
78
Q

Spasticity Mgmt

Botulinum Toxin A (Botox) Injections

*WIDELY used for mgmt of CP

A
  • Widely used for mgmt of CP
  • Effects last up to 4mos w/ peak effect 2wks after injection***
79
Q

Other Spasticity Meds besides botox:

A
  • Baclofen
    • Watch for SEs!!
  • Phenol Alcohol Blocks
  • Selective Dorsal Rhizotomy (SDR)
80
Q

See Word Doc for PT interventions for CP

A

*******

Pediatrics (27 decks)

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