MIDTERM Flashcards
1
Q
PART 1: FAMILY CENTERED CARE
A
PART 1: FAMILY CENTERED CARE
2
Q
Family is defined by _______ and ________ elements rather than by structural or legal elements; a group of people who love and care for each other.
A
emotional and functional
3
Q
What are child rearing practices?
A
- Goal directed actions that parents engage in to promote their children’s development.
- How the parents structure the learning and caregiving home environment may promote motor development.
4
Q
The ________-______ interaction is an intimate transaction, basis for subsequent relationship, influence skill acquisition, and predicated upon the notion that child and caregiver have a dual responsibility.
A
parent-child interaction
5
Q
What are Barnard’s 4 features of successful parent-child interactions?
A
- ) Sufficient repertoire of behaviors, such as body movements and facial expressions.
- ) Contingent responses to each other.
- ) Rich interactive content in terms of play materials, positive affect, and verbal stimulation.
- ) Adaptive response patterns that accommodate the child’s emerging developmental skills.
6
Q
- Family Centered Care is a ________ approach that respects the rights and roles of the family while providing intervention.
- What is the fundamental premise of Family Centered Care?
A
- lifespan
- The child does not exist in isolation but functions within a family.
7
Q
What is the Transactional Model of Development?
A
- Reciprocal relationship between the child and the caregiving environment.
- Supportive environment may minimize biological risks.
8
Q
What is the Family Systems Theory?
A
All members are involved in each other’s lives so what happens to one member will affect the entire family.
9
Q
Adaptation to disability is a individual complex process influenced by many variables. What is the rationale for intervention?
A
Reduce levels of stress and burden of care.
10
Q
It is stressful being a parent, it is even more stressful being a parent of a child with special needs. What are some things that stress depends on? (5)
A
- ) Nature of disability.
- ) Time of onset.
- ) Family’s personal belief system.
- ) Family’s support network and resources.
- ) Number of other stressful events occurring simultaneously.
11
Q
It is stressful being a parent, it is even more stressful being a parent of a child with special needs. What are some common identified stressors? (6)
A
- ) Knowledge
- ) Transitions
- ) Future
- ) Financial
- ) Extended caregiving
- ) Healthcare environment
12
Q
What are the 4 goals of Family Centered Care?
A
- ) Support the family unit.
- ) Enhance family competence.
- ) Enhance the growth, development, and functional independence of the child through a partnership with the family and child.
- ) Care directed toward goals that are important and relevant to the family and child.
13
Q
Family Centered Care Guidelines:
- _______ is recognized as a key member of the team.
- _______ is the consumer of services and retains ultimate decision making authority.
- What is the therapists role in Family Centered Care?
A
- Family
- Family
- Empowering, communication, enabling, and supporting the child.
14
Q
What are the (3) Foundations of Service Delivery?
A
- ) Knowing the CHILD
- ) Knowing the FAMILY
- ) Knowing the ENVIRONMENT
15
Q
*Traditionally, motor development was believed to be less sensitive to changes in the home environment than cognitive and language development; however, recent findings indicate that the effect may be gradual and may not be observed until _______ age.
A
school age
16
Q
What is the PTs role in Family Centered Care? (3)
A
- Atypical motor behaviors may influence the quality of parent-child interactions.
- Child with motor difficulties often demonstrate slow responses to external stimulation.
- Share information with parents about their child’s abilities and suggestions for optimizing interactions.
17
Q
What are some characteristics of positive interactions? (4)
A
- Flexibility
- Responsiveness
- Contingency
- The ability to allow disruption, to redirect in a supportive manner, and to allow the child to initiate an action.
18
Q
The Intervention Encounter:
- Interventions with children can only be as successful as what?
- What is the overarching goal of therapy?
A
- Only as successful as what the caregiving environment has to offer.
- Optimize child’s participation in home, school, and community.
19
Q
What are the (4) guidelines for The Intervention Encounter?
A
- ) Establish a common ground for communication and information sharing.
- ) The process of information gathering should involve methods acceptable to both parties.
- ) Therapists and families should seek to create a good match among the child’s functional abilities, the family’s resources, the amount of information necessary to level the playing field, and the various environments that are important in the child’s daily life.
- ) Intervention should focus on supporting the caregiving environment and the child’s participation regardless of the severity of the disability.
20
Q
What are the (3) models of service delivery? Describe each.
A
Multidisciplinary
-Professionals work independently.
Interdisciplinary
-Professionals from different disciplines work together cooperatively.
Transdisciplinary
-Professional assumes responsibility of other disciplines for service delivery.
21
Q
What is the major cause of neurological trauma in children; disabled children are at increased risk.
A
-Child Abuse/Neglect
22
Q
Signs of abuse in the child. (7)
A
- ) Sudden change in behavior or school performance.
- ) Has not received help for physical or medical problems brought to the parents’ attention.
- ) Has learning problems or difficult concentrating that cannot be attributed to specific physical or psychological causes.
- ) Is always watchful, as though preparing for something bad to happen.
- ) Lacks adult supervision.
- ) Is overly compliant, passive, or withdrawn.
- ) Comes to school or other activities early, stays late, and does not want to go home.
23
Q
Signs of abuse in the parent. (6)
A
- ) Shows little concern for the child.
- ) Denies the existence of – or blames the child for – the child’s problems in school or at home.
- ) Asks teachers or other caregivers to use harsh physical discipline if the child misbehaves
- ) Sees the child as entirely bad, worthless or burdensome.
- ) Demands a level of physical or academic performance the child cannot achieve.
- ) Looks primarily to the child for care, attention, and satisfaction of emotional needs.
24
Q
Signs of abuse in the parent and child. (3)
A
- ) Rarely touch or look at each other.
- ) Consider the relationship entirely negative.
- ) State that they do not like each other.
25
- What are the 4 types of abuse?
| - (T/F) They are usually found separate from one another.
- Physical, Neglect, Sexual, Emotional
| - False, usually found in combination.
26
Signs of physical abuse. (6)
1. ) Unexplained burns, bites, bruises, broken bones or black eyes.
2. ) Fading bruises or other marks noticeable after an absence from school.
3. ) Seems frightened of the parents and protests or cries when it is time to go home.
4. ) Shrinks at the approach of adults.
5. ) Head and brain injuries.
6. ) Internal injuries.
27
Signs of neglect. (5)
1. ) Malnourishment including reports of hunger, nutritionally inadequate diet.
2. ) Medical neglect (parental refusal to seek/maintain necessary medical intervention or excessive cancellations)
3. ) Educational neglect (parental indifference to the child’s school attendance or cognitive development).
4. )Emotional neglect (parental indifference to child’s need for physical contact and psychological nurturance).
5. ) Evidence of poor hygiene including soiled clothing and skin, skin breakdown in diaper area.
28
Signs of sexual abuse. (7)
1. ) Behavioral (anorexia, bulimia, eneuresis, encopresis, abdominal pain without organic cause, atypical shyness, extroverted or hostile).
2. ) Difficulty walking or sitting.
3. ) Suddenly refuses to change for gym or participate in physical activities.
4. ) Nightmares.
5. ) Bizarre or unusual sexual knowledge.
6. ) Becomes pregnant or contracts VD.
7. ) Runs away.
29
Signs of emotional abuse. (5)
1. ) Extremes in behavior (overly compliant/demanding, extreme passivity/aggression).
2. ) Inappropriately adult or infantile.
3. ) Delayed physical/emotional development.
4. ) Attempted suicide.
5. ) Lack of attachment.
30
What is Munchausen Syndrome by Proxy?
Form of child abuse in which physical/mental disorder of the child is fabricated or induced by parent.
31
What are some warning signs of Munchausen Syndrome by Proxy? (8)
1. ) Persistent or recurrent illnesses for which a cause cannot be found.
2. ) Discrepancies between history and clinical findings.
3. ) S/Sx that do not occur away from parent.
4. ) Unusual symptoms that do not make clinical sense.
5. ) Persistent failure of child to tolerate or respond to medical therapy without clear cause.
6. ) Parent less concerned than physician.
7. ) Repeated hospitalizations and vigorous medical evaluations of mother or child without definitive diagnosis.
8. ) Parent who welcomes medical tests on child, even if painful.
32
PART 2: DEVELOPMENT OF THE INFANT BORN PREMATURELY
PART 2: DEVELOPMENT OF THE INFANT BORN PREMATURELY
33
Prematurity Background:
- Age of viability = ___-___ weeks.
- Children born
- 23-24 weeks
| - <37 weeks
34
- There is growing concern regarding the high % of children who demonstrate "_______" impairments ("new morbidities", "hidden handicaps") in cognitive, social, and motor functioning once they enter kindergarten.
- Who is at greater risk for this?
- What are (2) recommended tests?
- "minor"
- males
- MABC (Movement Assessment Battery Test) and VMI (Visual Motor Integration Test)
35
What are the (3) "types" of ages? Define each.
```
Gestational Age (GA)
-Age of infant based on mom's last menstrual period.
```
Post Conceptual Age
-Gestational age + weeks since birth.
Corrected Age
-Gestational age + weeks since birth - 40 weeks.
36
A baby is now 4 weeks old and was born 4 weeks preterm (33 weeks), what is its gestational age, post conceptual age, and corrected age?
- Gestational Age = 37 weeks (when born)
- Post Conceptual Age =41 weeks (37+4)
- Corrected Age = 1 week (41-40)
37
- Full Term = ___-___ weeks
| - Preterm = ___ weeks
- Full Term = 37-41 weeks
- Preterm = <27 weeks
- Postterm = >42 weeks
38
-ELBW =
- ELBW = <1000g
- VLBW = <1501g
- LBW = 1501-2500g
39
- Size of the infant at birth is based on what (3) things?
- What is AGA?
- What is SGA?
- What is LGA?
- What is IUGR?
- length, head circumference, and weight
- AGA = appropriate for gestational age
- SGA = small for gestational age (<10th percentile)
- LGA = large for gestational age (>90th percentile)
- IUGR = intrauterine growth retardation
40
Prematurity Characteristics:
- _____tonia
- Decrease ratio of _____ to ______ muscle fibers. What does this result in?
- Incomplete ___________. What does this result in?
- More reactive to ________ stimuli.
- Less responsive to _____.
- Hypotonia
- Type I to type II, results in muscular fatigue (esp. respiratory muscles).
- Incomplete ossification, results in greater effects of positioning and gravity.
- sensory stimuli
- pain
41
What are the (4) levels of NICU?
- Level I - Well Baby Nursery
- Level II - Special Care Nursery
- Level III - NICU
- Level IV - Regional NICU
42
- Which level NICU requires surgery for complex conditions?
- Which level NICU requires sustained life support, full range of medical specialties, and advanced imaging?
- Which level NICU involves babies <32 weeks and weighing less than 1500g which require mechanical ventilation for brief period?
- Level IV
- Level III
- Level II
43
APGAR:
- What does APGAR stand for?
- How often are scores given?
- When are APGAR scores of concern?
- Rated on scale of 0-10 with 10 being ______.
- Appearance, Pulse, Grimace, Activity, Respiration
- Scores given at 1, 5, and 10 minutes.
- Abnormal scores at 5 is concerning, 10 is very concerning.
- 10 = good
44
What are some reasons for full term infants to be in the NICU? (6)
- Substance Abuse
- Genetic Disorders
- Congenital Abnormalities
- Sepsis
- Feeding Difficulties
- Breathing Difficulties
45
What is the overarching goal of PTs in the NICU?
DO NO HARM
- NICU is a complex and specialized unit.
- Neonatologists and NICU nurses can be very protective.
46
NICU PT Examination:
- Minimize excessive _______/__________.
- Cluster care when possible. What is this?
- Consider the state of the infant via __________________.
- During assessment observe ______/_______ of behavior and duration of state.
- Includes lost of observation, consultation, conversation, and coordination.
- HANDLING/OVERSTIMULATION
- Cluster care is when multiple health care providers are working at the same time.
- Brazelton (6) States of Arousal
- range/variety of behavior
47
Tests and Measures Specific to Premature Infants. (4)
- APIB (Assessment of Preterm Infant Behavior)
- Neurological Assessment of the Preterm and Full-Term Infant
- Neonatal Individualized Developmental Care and Assessment Program
- Test of Infant Motor Performance
48
What are a few PT interventions that can be used in NICU?
- Taping
| - Splinting
49
Taping is not recommended for an infant
-32 weeks
50
- What is an indication for splinting in the NICU?
- What does it put them at risk for?
- Traction on ______/_______ can be a concern because of the weight of the splinting material.
- Infants in the NICU with documented or potential alignment and joint motion limitation concerns.
- Risks for fracture, dislocation, joint effusion, skin breakdown.
- joints/nerves
51
NICU Transition to Home:
- When is it considered?
- Why do they require long-term health care follow-up?
- When should families be included in the discharge process?
- Individually tailored to both the infant/family based on their strengths and needs.
- Goals should be communicated to the family and medical team.
- PT program modified for home implementation to promote family independence.
- Suggestions on environment (positioning, appropriate sensory experiences, developmental activities).
- Referrals should be made to community resources such as early intervention.
- When they begin to demonstrate more consistent physiologic stability.
- The families require time to learn the infant's care.
- ASAP.
52
NICU Positioning:
- The therapist can develop a plan to wean the infant of positioning supports and transition to ______ sleeping as necessary.
- Positioning supports can be for _____/________ while awake.
- Infants should be positioned on their ______ for sleeping.
- Sleeping environment should be free of what?
- Blanket rolls may be positioned behind the infant's shoulder and along the thighs while he or she is seated.
- back sleeping
- play/activities
- back
- free of soft/loose bedding and stuffed toys/animals
53
Describe the order of sensory system development in the infant? (5)
1. ) Touch
2. ) Movement
3. ) Smell/Taste
4. ) Hearing
5. ) Vision
54
Vestibular System:
- When is the vestibular system fully mature?
- Modifications with development due to synapses and dendrites. What does this mean?
- Vestibular stimulation is known to enhance ________ states.
- Mature in full-term newborn.
- Dependent of what you are exposed to.
- behavioral states
55
Olfactory and Gustatory System Development:
- Olfactory development begins at __ weeks gestation and has the ability to smell at ___ weeks.
- Gustatory development begin to mature at __ weeks.
- 5 weeks, 18 weeks
| - 13 weeks
56
Auditory System:
- Cochlea and peripheral sensory end organs are developed by ___ weeks gestation but pathways continue to mature.
- The preemie is exposed to NICU noise that may cause what (3) things?
- 24 weeks
| - cochlear damage, sleep disturbances, disturbed growth and development
57
Visual System:
- _____ mature at birth.
- From ___-___ the retina and visual cortex undergo extensive maturation and differentiation.
- At ___ weeks pupillary reflex present, may see brief eye opening and fixation on a high contrast form under low illumination.
- At ___ weeks saccadic visual following horizontally and vertically.
- At birth, vision is ___/___.
- least mature
- 24 weeks-term
- 34 weeks
- 36 weeks
- 20/400
58
Premature Infant Development (27-28 weeks):
Posture:
-Generalized _____tonia.
-Beginning of hip _______.
Handling Responses:
- Full _____ without resistance.
- No attempt at _________ when extended parallel to body.
- No attempt to ___________ with pull to sit.
- No attempt at ____ grasp.
Active Movements:
-Movements are spasmodic and involve the ______ extremity.
Posture:
- hypotonia
- hip flexion
Handling Responses:
- full PROM
- arm recoil
- align head/body
- toe grasp
Active Movements:
-whole extremity
59
Premature Infant Development (34 weeks):
Posture:
-Increase in hip _______ with ____-like position.
Handling Responses:
- Able to ______ and maintain traction with UEs. (LE traction increasing)
- _______ response demonstrated.
- Some flexion in _____/______ with effort to lift head in ventral suspension.
- _____ reflex (extend and ABD arms followed by partial adduction) (usually in response to loud sounds)
Active Movements:
- _____ vigorously during more prolonged awake states.
- Movements are __________.
- Reciprocal and now involved trunk ________.
Posture:
-hip flexion with frog-like position
Handling Responses:
- grasp
- placing response
- elbows/knees
- Moro reflex
Active Movements:
- kicks
- purposeful
- trunk flexion
60
Premature Infant Development (40 weeks):
Posture:
-All extremities held in ______. (flexor tone of preterm infant who has reached full-term is never as great as flexor tone of infant born at term)
Handling Responses:
- Resists full _______ of the hip, knee, and shoulder.
- Arm recoil after release within __-__s.
- Easily bear weight in supported standing.
- May not __________ step like infant born at term.
- Lacks shoulder muscle tone of infant born at term; may not be able to keep _______ with pull to sit.
Active Movements:
- _______ and purposeful.
- Reflexes are _________ and _________.
- Less predictable _________/_______ than infant born full term.
- Less flexor _____tonicity resulting in greater ROM compared to full term.
Posture:
-flexion
Handling Responses:
- full extension
- 2-3s
- reciprocally step
- head alignment with pull to sit
Active Movements:
- smooth and purposeful
- consistent and complete
- sleep-wake cycles/feeding patterns
- hypertonicity
61
Background Terms:
- CP?
- RDS?
- BPD?
- ROP?
- NEC?
- ID?
- HI?
- DCD?
```
CP – cerebral palsy
RDS – respiratory distress syndrome
BPD – bronchopulmonary dysplasia
ROP – retinopathy of prematurity
NEC – necrotizing enterocolitis
ID – intellectual deficit
HI – hearing impairment
DCD – developmental coordination disorder
```
62
Medical Issues of Prematurity. (9)
- Respiratory Distress Syndrome (RDS)
- Bronchopulmonary Dysplasia (BPD)
- Patent Ductus Arteriosus (PDA)
- Hyperbilirubinemia
- Retinopathy of Prematurity (ROP)
- Necrotizing Enterocolitis (NEC)
- Chorioamnionitis
- Meconium Aspiration Syndrome
- Osteopenia
63
RDS:
- What is the pathophysiology of RDS? (3)
- What are (3) factors that increase the risk of RDS?
- How is it prevented? Why is this controversial?
- Pulmonary immaturity, Inadequate pulmonary surfactant, Increased compliance of chest wall
- Degree of prematurity (<34 weeks), Maternal diabetes (insulin interferes with surfactant production), Thoracic malformations
- Antenatal steroids to accelerate lung maturity, can result in poor neurobehavioral outcomes.
64
RDS S/Sx. (8)
- Increased RR
- Expiratory grunting
- Sternal/intercostal retractions
- Nasal flaring
- Cyanosis
- Decreased air entry on auscultation
- Hypoxia
- Hypercarbia
65
What are some interventions used for RDS? (6)
- O2 supplementation
- ECMO = extracorporeal membrane oxygenation
- CPAP = continuous positive airway pressure
- PEEP = positive end expiratory pressure
- Mechanical ventilation
- Surfactant administration prophylactically
66
What are some complications of treatment for RDS? (4)
- Barotrauma
- Volutrauma
- Atelectotrauma
- Biotrauma
67
Bronchopulmonary Dysplasia (BPD):
- Involves complication of __________ and _________.
- May go on to develop _____.
- What are some complications associated with BPD?
- immature lungs and mechanical ventilation
- CLD
- systemic hypertension, metabolic imbalance, hearing loss, ROP, nephrocalcinosis, osteoporosis, GER, early growth failure, neurodevelopmental delays
68
Patent Ductus Arteriosus (PDA):
- The ductus arteriosus usually closes within ___-___ hours after birth.
- What are the consequences in the premature infant when closure does not occur? (4)
- 10-15 hours
| - hypotension, poor perfusion, CHF, metabolic acidosis
69
Hyperbilirubinemia:
- What is this?
- Why is it common in preemies? (3)
- Accumulation of excessive bilirubin in the blood.
| - Immature hepatic function, increased hemolysis of RBC from birth injuries, possible polycythemia.
70
Retinopathy of Prematurity (ROP):
- What is this?
- Onset peaks at ___-___ weeks.
- Leading cause of visual impairment in preemies.
- Abnormal development of blood vessels which may lead to scarring and detached retina. May result in blindness.
- 34-40 weeks
71
- How many levels of ROP are there?
| - Which is the worse and involves complete detachment of the retina?
- Levels 1-5
| - Level 5
72
```
Necrotizing Enterocolitis (NEC):
-What is it?
```
The intestinal issue becomes damaged (typically due to infection) and begins to die.
73
Necrotizing Enterocolitis S/Sx. (8)
- Bloating/swelling in abdomen
- Distension
- Gastric retention
- Tenderness
- V/D
- Rectal bleeding
- Bilious drainage from enteral feeding tubes
74
Chorioamnionitis:
- What is it?
- Most common cause of ______ labor.
- Bacteria infects chorion, amnion, and amnion fluid causing infection. (infectious cause of CP)
- preterm labor
75
Meconium Aspiration Syndrome:
- What is it?
- Approximately 20% demonstrate delays at __yo.
- Early onset of respiratory distress in term or near term infants born through meconium stained amniotic fluid.
- 3yo
76
Osteopenia:
- Approximately 80% of bone is produced between ___-___ weeks gestation.
- Risk increases with decreasing _______ age and birth ________.
- Increased risk for ________ and positional deformities.
- 24-40 weeks
- gestational age and birth weight
- fracture and positional deformities
77
PART 3: INFANT BEHAVIORS
PART 3: INFANT BEHAVIORS
78
The Synactive Theory of Infant Development provides a framework for understanding the behavior of premature infants. The infant's behaviors are grouped according to what (5) "subsystems of functioning"?
- Autonomic
- Motor
- States
- Attention/Interaction
- Self-Regulatory
79
- When demands are within the infant’s current developmental expectations, ________ _____-________ behaviors are observed.
- When demands exceed the infant's expectations and threshold, _________ __________ behaviors are observed.
- organized self-regulatory behaviors
| - disorganized avoidance behaviors
80
What are some autonomic signs of stress? (12)
- Seizures
- Respiratory pauses
- Color changes to mottled, webbed, cyanotic, gray, -flushed
- Gagging, gasping
- Spitting up
- Hiccups
- Straining or actually producing a bowel movement
- Tremors, startling, twitching
- Coughing
- Sneezing
- Yawning
- Sighing
81
What are some motor signs of stress? (4)
- Motor flaccidity or "tuning out" of trunk/extremities/face.
- Motor hypertonicity with extension of trunk/legs/arms/hands and feet/face.
- Motor hypertonicity with protective maneuvers (hands on face, high guard), and hyperflexion.
- Frantic, diffuse activity.
82
In general, motor signs of stress are more ________ but can be seen with extremes of _________.
- extension
| - flexion
83
What are some state signs of distress? (8)
- Diffuse sleep or awake states with whimpering sounds, facial twitches and discharge smiling
- Strained fussing or crying
- Panicked or worried alertness
- Glassy-eyed strained alertness
- Irritability and diffuse arousal
- Rapid state oscillations
- Crying
- Eye floating; staring; active gaze averting
84
PART 4: CEREBRAL PALSY (CP)
PART 4: CEREBRAL PALSY (CP)
85
What is CP?
"CP describes 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”
86
CP has associated disturbances of what (6) areas?
- Cognition
- Behavior
- Communication
- Sensation
- Perception
- Epilepsy
87
CP Pathophysiology:
- What is the onset? (3)
- Etiology? (5)
- Other factors? (4)
Onset
- Prenatal
- Perinatal
- Postnatal
Etiology
- Hypoxic
- Ischemic
- Infectious
- Congenital
- Traumatic
Other Factors
- Preterm birth
- Uterine abnormalities
- Multiple births
- Genetics
88
What are some ways that CP is diagnosed? (4)
- Neuroimaging findings
- Clinical findings
- Risk factors
- Child does not reach milestones, demonstrates abnormal muscle tone or qualitative differences in movement patterns
89
- What are (2) outcome measures used to predict CP?
- Which is better for predicting CP in the early months?
- Which is better for predicting CP as infants age?
- Prechtl's Assessment of General Movements (GMA) and AIMS/NSMDA
- GMA = early
- AIMS/NSMDA = later
90
What is an outcome measure used to measure the severity of movement disorder (CP)?
-GMFCS
91
What are some movement disorder types of CP? (6)
- Spastic (increased tone/stiffness)
- Ataxia (lack of muscle control/coordination)
- Athetoid (involuntary writhing movements)
- Hypotonic (decreased muscle tone)
- Mixed
- Dyskinetic (uncontrolled involuntary muscle movement)
92
Describe the GMFCS levels of movement disorder. (5)
- Level 1 = Walks without limitations.
- Level 2 = Walks with limitations.
- Level 3 = Walks using a hand-held mobility device.
- Level 4 = Self-mobility with limitations (may use powered mobility)
- Level 5 = Transported in manual WC.
93
What are the types of CP? (4)
- Spastic/Hypertonic
- Dyskinetic
- Ataxia
- Hypotonic
94
Spastic/Hypertonic CP:
- Makes up ___% of CP.
- Stiffness is usually greater _________.
- ________ dependent resistance may or may not be present.
- Abnormal/limited movement _________.
- Excessive ___-________ and/or ___________ leading to limited ROM.
- Abnormal timing and grading of muscle activation.
- Abnormal postural responses.
- Difficulty maintaining activity of certain muscle groups.
- 75%
- velocity dependent
- synergies
- co-activation and/or reciprocal inhibition
95
Spastic CP Implications:
- Implications for MSK System? (3)
- Implications for Sensory Perceptual System? (3)
- Implications for CV and Respiratory System? (2)
- Implications for Oral Motor? (1)
MSK System
- Limited ROM
- Weakness
- Deformities
Sensory Perceptual System
- Decreased tactile, kinesthetic, vestibular and proprioceptive awareness
- Difficulty discriminating
- Upward visual gaze
CV and Respiratory Systems:
- Poor CV fitness due to decreased mobility
- Reduced breath support with flared ribs and tight rectus abdominus
Oral Motor:
-Drooling, poor articulation, difficulty feeding
96
Dyskinetic CP:
- Includes _________, ________, and ______. What is each?
- Implications for MSK System? (3)
- Tremor- Involuntary shaking movement
- Rigidity- Resistance to both active and passive movement throughout range in both agonist and antagonist.
- Athetosis- Abnormal muscle contractions causing involuntary writhing movements.
MSK System
- Significant asymmetry
- Joints may be hypermobile
- Frequent TMJ problems
97
Ataxia CP:
- May occur in combination with ________ and/or _______.
- Ineffective postural alignment, anticipatory postural adjustments, abnormal postural stability.
- Often _________ with impaired force during active movement and tremor.
- spasticity and/or athetosis
| - hypotonic
98
Ataxia implications for MSK System? (3)
- Tend to rely on ligaments for stability
- Relies on vision for balance
- Postural insecurity
99
Hypotonic CP:
- May be permanent or a transient condition in the evolution of athetosis or spasticity.
- _________ resting muscle tension.
- ________ ability to generate voluntary muscle force.
- ________ joint flexibility.
- Postural instability.
- ________ usually favored over _________.
- diminished
- decreased
- excessive
- extension usually favored over flexion
100
Hypotonix implications for MSK System? (3)
- Stability gained through end-range positioning.
- Contractures develop secondary to position of the arms and legs.
- Rib cage at risk to become flat due to gravity.
101
________ CP may develop from hypotonic CP.
Spastic CP
102
Diplegia:
- Are legs or arms more involved?
- ___% are preterm deliveries.
- ______ ambulation potential.
- legs
- 50%
- great ambulation potential
103
Hemiplegia:
| -___% are prenatal in origin.
-50%
104
What is the difference between positive signs and negative signs?
- Positive Signs- Behaviors that are present and not expected in the typical population.
- Negative Signs- Behaviors that are absent because of the pathophysiology.
105
CP Diagnosis:
- Nearly all who eventually walk do so by age ___.
- Key predictors of reduced life expectancy include lack of ________ and _______ difficulty.
- GMFCS Level 5 reach 90% of motor potential by age ___.
- GMFCS Level 1 reach 90% of motor potential by age ___,
- _______ and persistent tonic neck ________ are poor prognostic indicators for ambulation.
- 8
- lack of mobility and feeding difficulties
- 3
- 5
- rigidity and persistent tonic neck reflexes
106
PART 5: CP INTERVENTIONS
PART 5: CP INTERVENTION
107
What are some neuromedical interventions for CP? (6)
- Muscle Relaxants
- Neuromuscular Blocks
- Selective Dorsal Rhizotomy
- Stem Cell Therapy/Regenerative Therapy
- Intrathecal Baclofen Pump
- Orthopedic Surgery
108
Neuromuscular Blocks:
- When are they used?
- How long does botox last?
- Must be used in combination with what?
- Used when problem in balancing agonist/antagonist activity.
- 3-6 months
- therapy
109
Selective Dorsal Rhizotomy:
- What is this?
- Patient selection is critical and team approach is mandatory.
See which nerves are resulting in spasticity and cut them. Cut a little to not cause low tone and B/B dysfunction.
110
Intrathecal Baclofen Pump:
| -What is the criteria for selection of baclofen pump? (6)
- Moderately severe spasticity.
- Sufficient body mass.
- Appropriate goals. (decrease pain, improve ease of caregiving, prevent worsening of deformity)
- Family committed to follow up.
- Patient free of infection and medically stable.
- Successful baclofen trial.
111
Orthopedic Surgery:
- What is the PTs goal with orthopedic surgery?
- Want to avoid __________ surgeries.
- What are some general goals of surgery? (3)
- Delay surgery but assist in determining the optimum timing.
- avoid repeated surgeries on same muscle
- Improve function, decrease discomfort, prevent structural changes that may become disabling
112
Spine Interventions:
- What are the indications for a posterior spinal fusion?
- Prefer to delay this until when?
- Indications include curve approaching 90 degrees when the child is sitting with difficulty sidebending back toward the middle or when restricting lungs.
- Prefer to wait until after puberty.
113
Hip Subluxation vs Dislocation.
- Subluxation = The head of the femur moves out of its normal, centered position in acetabulum but not over the edge completely.
- Dislocation = The ball slides out of the socket altogether.
114
Hip Subluxation:
- What are the reasons for a hip subluxation? (3)
- What are the S/Sx of hip subluxation? (4)
1. ) Lack of changes in the neonatal hip.
2. ) Lack of LE WB in multiple positions.
3. ) Muscle imbalance. (hip ADD more active than ABD, hip flexor contractures)
1. ) Limited/painful ROM
2. ) Leg shortening on subluxed side
3. ) Limping
4. ) Refusing to bear weight/walk
115
Hip Dislocation:
| -What are the S/Sx of hip dislocation? (7)
1. ) Severe pain in hip/knee
2. ) Hip swelling
3. ) Obvious deformity
4. ) Muscle spasms
5. ) Weakness
6. ) Numbness
7. ) Lack of WB
116
What are some conservative treatments of the hip? (5)
- Passive muscle stretching
- Splinting
- Positioning
- E-stim
- Muscle activation
117
What are surgical treatments of the hip? (4)
- Soft tissue transfer and/or releases involving ADD, iliopsoas, and/or proximal HS (small incision to make it easier to relax)
- Femoral/pelvic osteotomy (individually or together)
- Resection of femoral head/neck
- Arthrodesis and arthroplasty
118
Stander Recommendations:
GMFCS II:
-When: ___-___m until onset of independent ambulation or ___-___y if ROM decreases.
-Dosage: __x/week for ___m
GMFCS III:
- When: ___m-___y, 7-8 if ROM decreases, or ___y if crouch gait appears.
- Dosage: ___x/week for ___-___m
GMFCS IV and V:
- -When: ___m-_________
- Dosage: ___x/week for ___-___m
GMFCS II:
- When: 9-12m until onset of independent ambulation or 7-8y if ROM decreases.
- Dosage: 3x/week for 45m
GMFCS III:
- When: 9-12m - 5y, 7-8 if ROM decreases, or 15y if crouch gait appears.
- Dosage: 5x/week for 60-90m
GMFCS IV and V:
- -When: 9-12m - adulthood
- Dosage: 5x/week for 60-90m
119
General Standing Recommendations:
- All children with risk for hip dysplasia need to stand in _______ (___-___ degrees) and neutral hip flexion.
- Maintain excellent biomechanical alignment (esp of _____/_____)
- What is an AD that can help with this?
- ABD (15-30 degrees)
- head/spine
- Swash Brace (standing, walking, and sitting hip orthoses)
120
Knee Interventions:
- What is the most common contracture at the knee?
- What can this lead to? (3)
- Hamstring contracture
| - contracted muscle, contracted capsule, shortening of sciatic nerve
121
What are some conservative treatments of the knee? (4)
- Botox
- Soft immobilizers
- Casting
- Standing regime
122
Hamstring Contracture Surgical Indications:
- _______ sitting due to tight hamstrings
- Fixed knee ______ contracture
- Popliteal angle >___ degrees
- Knee flexion of ___-___ degrees at foot contact/midstance.
- kyphotic
- flexion
- >40 degrees
- 20-30 degrees
123
Ankle/Foot Interventions:
- What contractures are most common at ankle?
- Pes Valgus = ______/____/________. What are some causes of pes valgus? (3)
- Varus deformity is more common in _________. What are some causes of this? (2)
- PF contractures
- eversion/PF/ABD. Caused by spastic peroneals, PF contracture, neonatal talar position
- hemiplegia. Caused by weak peroneals or spastic post/ant tibialis
124
What is a SMO?
A more flexible, plastic version of an AFO that allows some movement.
125
What are the goals of interventions for CP during infancy? (8)
1. ) Focus on educating family, facilitating caregiving and caregiver interaction.
2. ) Promote optimal sensorimotor experiences and skills.
3. ) Address current as well as potential problems.
4. ) Promote caregivers’ skill, ease and confidence in handling and caring for their infant. (positioning, carrying, feeding, dressing)
5. ) Incorporate therapeutic activities into daily routines.
6. ) Use variety of movements and postures to promote sensory variety.
7. ) Frequently include positions that promote the full lengthening of spastic or hypoextensible muscles.
8. ) Use positions that promote functional voluntary movement of limbs with as little assistance as possible.
126
- What are the goals of interventions for CP during preschool? (4)
- What are some considerations at this age?
1. ) Prevent secondary impairments.
2. ) Optimize gross motor skills, fitness, play, communication, self care, and problem solving.
3. ) Muscles stretched/loaded daily, bones need compressive forces, CV system need to be used at moderately intense levels.
4. ) Integrity of hip joints major concern. (prevent dislocation)
- Children begin to interact with the outside world.
- Impairments may limit socialization and participation.
- Parents are more aware of differences.
127
- What are the goals of interventions for CP during school age/adolescence? (4)
- What are some considerations at this age?
1. ) Participation
2. ) Maintenance
3. ) Prevention
4. ) Progressive resistance training
- For most, optimal level of functioning has been achieved.
- Potential changes include weight gain, pain, loss of muscle extensibility, puberty, cumulative physical overuse, and more demanding lifestyle.
128
PART 6: TORTICOLLIS AND PLAGIOCEPHALY
PART 6: TORTICOLLIS AND PLAGIOCEPHALY
129
- Torticollis is the 3rd most common congenital MSK anomaly after __________ and ________.
- Cranial deformity occurs in up to ___% of babies diagnoses with torticollis.
- Early treatment is crucial, 80% of skull growth occurs by age ___.
- congenital hip dysplasia and club foot
- 90%
- 2
130
Torticollis Risk Factors. (9)
- Breech Position***
- Difficult Labor and Delivery***
- Large birth weight
- Male
- Multiple births
- Primiparous mother (1st birth)
- Use of vacuum or forceps
- Nuchal cord
- Maternal uterine abnormalities
131
Torticollis is associated with what (3) other abnormalities?
- Hip Dysplasia
- Club Foot
- CBPI (Congenital Brachial Plexus Injury)
132
__-__ children who present with torticollis posture have a non-muscular etiology. List some non-muscular etiologies. (9)
-1/5
- Klippel-Feil Syndrome
- CBPI
- Ocular lesions
- Sandifer Syndrome
- Dystonic Syndromes
- Posterior Fossa Pathology
- Postencephalitis
- ACM (Arnold Chiari Malformation)
- Syringomyelia
133
Torticollis is an initial sign of this pathology which usually occurs in older children and is associated with symptoms of HA, N/V.
Posterior Fossa Pathology
134
Congenital Muscular Torticollis is a neck deformity involving shortening of the __________ that is detected at or shortly after birth.
SCM
135
What are the (4) subtypes of Congenital Muscular Torticollis?
1. ) SCM Tumor
2. ) Muscular Torticollis
3. ) Postural Torticollis
4. ) Postnatal Torticollis
136
_______ Torticollis:
- Tightness but no palpable mass.
- Normal X-rays.
- Head tilt, ROM limitations, cervical muscle imbalance.
Muscular Torticollis
137
__________ Torticollis:
- Discrete mass palpable within the SCM muscle.
- Normal X-rays.
- Histologic tissue changes include excessive fibrosis, hyperplasia, and atrophy.
SCM Tumor (Torticollis)
138
__________ Torticollis:
- No mass, no tightness of SCM.
- Normal X-rays.
- Dead tilt, no PROM limitations, AROM limitations, cervical muscle imbalance.
Postural Torticollis
139
How is torticollis severity classified?
US images based on degree of muscle fibrosis and fiber orientation.
140
What are some characteristics of Torticollis? (7)
- Ipsilateral mandibular asymmetry
- Ear displacement
- Plagiocephaly
- Scoliosis
- Pelvic asymmetry
- Congenital dislocated hip
- Foot deformity
141
What are some motor characteristics of Torticollis? (5)
- Difficulty centering head in supine.
- Bias toward extension and asymmetry.
- Visual gaze toward side of head turning.
- Prone position altered forearm WB with more weight over ear, trunk, and pelvis on affected side.
- Cascade of abdominals, trunk, and extremity righting.
142
Torticollis Changes in Body Structure:
- Decreased _________ cervical rotation.
- Decreased _________ cervical lateral flexion.
- decreased ipsilateral rotation
| - decreased contralateral lateral flexion
143
What are some functional activities and participation difficulties that may be present with torticollis? (6)
- Breastfeeding
- Looking to the involved side to scan environment
- Reaching for a toy
- Maintaining sitting
- Creeping
- Ambulating
- Decreased interaction with environment and caregivers on the involved side
144
What are some other muscles that may be affected by torticollis?
- Platysma
- Scalenes
- Hyoids
- Tongue
- Facial muscles
145
Torticollis Secondary Impairments.
1. ) Asymmetry of eyes (ipsilateral eye smaller)
2. ) Recessed eyebrow and zygoma on ipsilateral side
3. ) Deviation of chin point and nasal tip
4. ) Cranial base deformation (occurs as early as 1 month)
5. ) Trunk curvature
6. ) Persistence of ATNR
7. ) Windswept hips
8. ) Elevated shoulders
9. ) Visual neglect
10. ) Decreased ipsilateral body awareness
146
Torticollis Red Flags. (9)
- Age of presentation greater than 6 months
- Pain
- Neurological findings
- Associated syndromes (Down Syndrome, Skeletal dysplasia)
- Trauma
- Inflammatory or infectious history
- Alternating sides
- Atypical position – such as rotation and lateral bending to same side
- Late onset
147
Torticollis Conservative Management:
- AROM or PROM?
- Caregiver training in ROM and _________.
- Strengthening
- Developmental activities
- Duration dependent on what (3) things?
- Both AROM and PROM
- ROM and positioning
- Duration dependent on age, severity, and family circumstances.
148
Torticollis Precautions. (4)
1. ) Monitor for signs of STRESS.
2. ) Maintain neck in NEUTRAL sagittal/transverse planes while stretching.
3. ) Keep stretching GENTLE.
4. ) Use AGE APPROPRIATE distractions to prevent distress.
149
TOT Collar Indications:
- ___m or older.
- Constant head tilt of __ degrees or greater for more than 80% of awake time.
- Perform all movement transitions and motor skills with constant ___________.
- Adequate _______ and ___________ reactions.
- 4m or >
- 5 degrees or >
- head tilt
- PROM and head righting reactions
150
Microcurrent:
- Low intensity alternating current applied over ____.
- Followed by ________.
- Less sessions required and less crying.
- SCM
| - stretching
151
Kinesiotaping:
| -______ but promising results when applied to relax affected side.
Weak
152
Torticollis Surgical Management:
- Considered if improvement not evident after ___m of conservative intervention.
- What are the indications for surgical management? (3)
- What are (2) procedures performed?
- 6m
- residual head tilt, deficits of PROM greater than 15 degrees, tight muscular band or tumor
- Release (z-plasty) of SCM, Botox injections
153
Torticollis Discharge Guidelines:
- _____ AROM/PROM.
- Maintain midline ___% of the time.
- No _________ patterns.
- Equal and age appropriate ____________.
- Full PROM/AROM
- 95%
- compensatory
- head righting
154
Torticollis Prognosis:
- Most cases resolve within ___m.
- ___-___% of cases are resolved with conservative treatment.
- 6m
| - 90-99%
155
What is plagiocephaly?
“Malformation of the head marked by an oblique slant to the main axis of the skull.”
-Term is also applied to any condition characterized by a persistent flattened spot on the back or side of the head (flat head syndrome)
156
Plagiocephaly vs Brachycephaly vs Scaphocephaly.
Plagiocephaly
-Anterior progression of the ear on the same side as the flattened occiput.
Brachycephaly
-The head is disproportionately wide.
Scaphocephaly
-Head is disproportionately long and narrow.
157
____________ refers to the early fusion of the suture of the bones of the skull. What can this result in?
Craniosynostosis
| -Restricts and distorts growth of the skull which may result in increased ICP.
158
__________ Plagiocephaly = the occiput, frontal bone, and full face become deformed by the molding forces induced by in utero constraint caused by compression of the fetal cranium between the maternal pelvic bone and lumbar sacral spine in the last trimester.
__________ Plagiocephaly = concordant with CMT
- Deformational Plagiocephaly
| - Acquired Plagiocephaly
159
Cranial facial asymmetry that is present at __m of age has a high probability of persisting into adolescence and adulthood.
6m
160
Traditionally plagiocephaly was regarded as a ______ condition but recent research demonstrated increased prevalence of gross motor delay, lower developmental scores at preschool age, increased use of special ed and therapy by school age.
comsetic
161
Plagiocephaly Medical Management:
- 80% of head growth occurs before ___m.
- Ideal for repositioning to be effective is in the first ___m.
- If asymmetry still obvious at ___m, may need cranial remodeling band treatment.
- 12m
- 3m
- 6m
162
With Dynamic Orthotic Cranioplasty (DOC), where do we want total contact with the skull? Where do we want relief of pressure?
Providing total contact over prominent areas of the skull and providing relief inside the orthosis where growth is desired.
163
What are the contraindications for Cranial Orthoses? (4)
- Craniosynostosis
- Unshunted hydrocephalus
- Children beyond 18 months of corrected age
- Babies under 3 months of age
164
PART 7: GENETIC DISORDERS
PART 7: GENETIC DISORDERS
165
When to make a referral based of of family Hx?
- History of dysmorphology, brain malformations, epilepsy, abn CT, EEG. abnormal tone, weakness, motor control, dyscoordination, delayed development, sensory disturbances
- Children with global DD, even in absence of dysmorphisms, should be referred.
166
List of Genetic Disorders. (10)
1. ) Down Syndrome
2. ) Marfan Syndrome
3. ) Prader Willi Syndrome
4. ) Angelman's Syndrome
5. ) Fragile X Syndrome
6. ) Turner Syndrome
7. ) Rett Syndrome
8. ) Neurofibromatosis
167
Down Syndrome:
- What is the etiology?
- What is the biggest risk factor?
- Trisomy 21
| - Nearly all associated with advanced maternal age.
168
Down Syndrome Clinical Presentation.
- Hypoplasia common element of DS
- Craniofacial features that are hypoplastic
- Diastasis recti and general hypermobility
- C1/C2 instability
- Simian crease
- Linear growth deficits (6-24m) mostly due to leg length reduction
- Delayed skeletal maturation
- Overweight and obese
- Vision/Hearing (iris speckling, nystagmus, hearing loss)
- CHD (40%), septal heart defects
- GI involvement
- Developmental and intellectual delays
- Hypothyroidism (40%) that can look like AD
- Alzheimer by age 40
169
Marfan Syndrome:
| -What is the etiology?
-defective CT in skeleton, eyes, and CV system
170
Marfan Syndrome Clinical Presentation.
Skeletal
-long limbs, fingers, toes; hyperextensible joints; deformed chest
Eyes
-dislocated lenses due to lax suspensory ligaments in eye
CV
-aortic dilation with valve regurgitation and aneurysm
171
Cri-du-Chat:
| -What is the etiology?
-missing part of chromosome 5
172
Cri-du-Chat Clinical Presentation.
VERY SMALL KITTEN
- "cry of the cat"
- low birth weight
- hypotonia
- feeding difficulties
- microcephaly (small head)
- mod-sev cognitive impairments
173
Prader Willi Syndrome:
- Inherited from mother or father?
- What is the etiology?
- Father
| - Deletion of part of chromosome 15
174
Angelman Syndrome:
- Inherited from mother or father?
- What is the etiology?
- Mother
| - Deletion of part of chromosome 15
175
Prader Willi Clinical Presentation.
- Overeating/obesity concern
- Behavioral Issues (temper tantrums, stubbornness, obsessive-compulsiveness
- Wide range of cognitive involvement (low-normal-sev)
176
Angelman Syndrome Clinical Presentation.
HAPPY PUPPET SYNDROME
- puppet like gait
- ataxia
- frequent and inappropriate laughter
- seizure/sleep disorders
- love water
177
Williams Syndrome:
| -What is the etiology?
-Disturbance in elastin gene.
178
Williams Syndrome Clinical Presentation.
- Elfin like face (w/ wide mouth and full lips)
- CV disease
- ADHD, mild cognitive impairments
- Musically talented
179
Fragile X Syndrome:
- Does it affect males or females more?
- Leading cause of what?
- Males
| - Leading hereditary cause of developmental learning disorders
180
Fragile X Syndrome Clinical Presentation.
- Large ears
- Long face
- Hyperextensible joints
- Flat feet
181
Turner Syndrome:
| -What is the etiology?
-Females only, born with only 1 X chromosome
182
Turner Syndrome Clinical Presentation.
3 Characteristic Impairments
- sexual infantilism
- congenital webbed neck
- cubitus valgus
183
Rett Syndrome:
| -Almost exclusively in females, why?
-Males who have it die.
184
Rett Syndrome Clinical Presentation.
R FOR ROLLERCOASTER
- Infants initially seem healthy in first 6m then rapidly regress in motor, language, and psychosocial functions.
- Fits of screams and crying common by 18-24m.
- After rapid deterioration it becomes somewhat stable.
185
Neurofibromatosis:
| -What is the etiology?
-Condition that causes tumors (generally non-cancerous) to grow anywhere in the nervous system.
186
Neurofibromatosis Clinical Presentation.
- Cafe-au-lait spots
- Fibromas
- Lich nodules in the eyes
187
PART 8: MYELOMENINGOCELE
PART 8: MYELOMENINGOCELE
188
Development of the NS Background:
- Describe the nervous system development from the neural plate.
- Neural tube closure begins in cervical region and proceeds ________ to ________.
- Closure completed by ___th day.
- Neural plate → Neural Tube → Brain and Spinal Cord
- cranially to caudally
- 26th
189
Spina Bifida:
- What is it?
- There is no definitive cause, however, it may be affected by ___________ and _________ factors.
- What is the incidence rate?
- Defect in neural tube closure and overlying posterior vertebral arches.
- genetic predisposition and environmental factors
- 2/1000
190
What are the (2) types of Spina Bifida?
- Occulta
| - Cystica
191
- Spina Bifida _______ = Failure of the neural tube and vertebral arches to close with cystic protrusion of the meninges with or without the spinal cord.
- Spina Bifida _______ = Failure of the vertebral arches to meet and fuse in 3rd month.
- Spina Bifida Cystica
| - Spina Bifida Occulta
192
Spina Bifida Occulta commonly occurs at the __________ area.
lumbosacral
193
What are the characteristics of Spina Bifida Occulta?
- Overlying skin may be marked by dimple, pigmentation, or patch of hair.
- Usually associated with no neurological or musculoskeletal dysfunction.
- However, there in a higher incidence than normal of urinary tract disorders.
194
What are the (4) subtypes of Spina Bifida Cystica?
Meningocele/myelocele
-Spinal Cord remains in vertebral canal but it may be abnormal.
Lipomeningocele
-Superficial fatty mass in low lumbar or sacral area, high incidence of B&B dysfunction due to tethered cord.
Myelomeningocele
- Extensive spinal cord abnormalities.
- Most common in thoracic and lumbosacral regions.
Anencephaly
-Cranial end of neural tube does not fuse.
195
Myelomeningocele Clinical Presentation.
- Loss of sensory and motor function
- Orthopedic abnormalities
- Hydrocephalus
- Brain/Spinal Cord abnormalities
- B&B dysfunction
- Cognitive Impairment/Learning Issues
- Integumentary Impairment
- Disturbed Growth and Development
- Psychosocial Issues
196
With Myelomeningocele, loss of sensory and motor function are dependent on what (4) things?
1. ) Degree of spinal cord abnormality.
2. ) Traction or stretch on spinal cord.
3. ) Trauma to exposed neural tissue during delivery.
4. ) Postnatal damage resulting from drying or infection of the neural plate.
197
Sensory Impairment:
- Sensation below level off lesion is ______, may not exactly match level of lesion.
- Deficits in what (3) areas?
- impaired
| - kinesthetic, proprioceptive, and somatosensory
198
Motor Impairment:
| -What are the (2) main types of motor dysfunction?
- Type 1: Complete loss of function below level of lesion resulting in flaccid paralysis, loss of sensation, and absent reflexes.
- Type 2: Mixture of flaccidity and spasticity.
199
What are a few orthopedic problems caused by Myelomeningocele? (2)
- Deformity/Contractures
| - Osteoporosis
200
What symptom is present in 80-90% of cases and involves VA/VP shunt for treatment?
Hydrocephalus
201
Shunt Malfunctioning Signs (Infants). (11)
-Bulging fontanelle
-High-pitched cry
-Vomiting
-Irritability
-Change in appetite
-Lethargy
-“Sunset” sign
-Seizures
-Edema, redness along shunt
-Excessive growth of head
-Thinning of skin over
scalp
202
Shunt Malfunctioning Signs (Toddlers). (8)
- Vomiting
- Lethargy
- Irritability
- Seizures
- HA
- New nystagmus
- Edema, redness along shunt tract
- New squint
203
Shunt Malfunctioning Signs (Schood-Aged). (10)
- HA
- Vomiting
- Lethargy
- Seizures
- Irritability
- Decreased school perf
- Edema, redness along shunt tract
- Personality changes
- Memory changes
- Handwriting changes
204
What is Arnold Chiari Malformation (ACM)?
Brainstem and cerebellum herniate through foramen magnum usually into upper cervical canal.
205
What are the symptoms of ACM? (7)
- Respiration
- Paralysis of vocal cords
- Bulbar dysfunction
- Apnea
- Swallowing
- Abnormal gag
- UE weakness
206
What is a treatment for ACM?
Decompression surgery
207
Hydromyelia:
- What is it?
- What is the cause?
- What is the effect?
- Dilation of the center canal of spinal cord. May be focal, multiple, or diffuse.
- May be a consequence of untreated or inadequately treated hydrocephalus.
- May cause pressure necrosis of SC, leading to muscle weakness and scoliosis.
208
What are the symptoms of Hydromyelia? (4)
- Rapidly progressive scoliosis
- UE weakness
- Spasticity
- Ascending motor loss in LE
209
What are some treatments for Hydromyelia?
- shunt revision
- posterior cervical decompression
- central canal to pleural cavity with flushing device
210
What is Tethered Cord?
Pathological fixation of the SC in an abnormal caudal location.
211
What are the symptoms of Tethered Cord? (4)
- decreased strength
- development of LE spasticity
- back pain at sit of sac closure
- change in urological function
212
Spina Bifida Interventions.
- ROm
- MMT
- Sensory testing
- Developmental testing
- Positioning and equipment needs
- Education for family/child
- Balance
- Coordination
- Reflexes
- Muscle tone
- Skin condition
213
Age Specific Issues (Prenatal):
- Possible diagnosis, referral to EI.
- Possible sac closure in _______.
- ________ to prevent trauma to neural sac.
- PT intervention including education and assistance with referrals.
- utero
| - C-section
214
Age Specific Issues (Newborn):
- Sac closure within ___-___.
- _______ procedure.
- 24-48h
| - shunt procedure
215
Age Specific Issues (Infant/Toddler):
- Facilitate developmental sequence
- Prevent deformity
- Home program
- Early weight bearing – watch alignment
- Skin care
- Emphasize balance and equilibrium in -sitting/standing/core strength
- Importance of fine motor skills
216
Age Specific Issues (Toddler/Preschool):
- Emphasize progressive LE weight bearing/gait training activities, self care
- EI and school based programs, community programs, adapt normal equipment/activities as necessary
- Bladder training
- MMT – antigravity control in developmental positions, during play, weighted toys
- Sensory – can start assessing light touch and position changes as cognitive and language skills permit
217
Age Specific Issues (Adolescent):
- By 6, children become aware of their differences
- Constantly reevaluate – body grows, muscle strength and length does not keep up, equipment needs change, skin and ROM issues may increase as more time is spent sitting
- Independent community mobility a necessity – wheel chair prescriptions if not already
- Great changes in adolescence – prepare family
218
Impairments by SC Level (Thoracic):
- Possible Muscle Function?
- Possible Secondary Impairments?
- Orthoses Needed?
- Interventions?
Possible Muscle Function
-Abdominals, Intercostals, Erector Spinae
Possible Secondary Impairments
-Flaccid LE ("frog leg" position)
Orthoses Needed
- Total contact orthosis for standing
- Resting AFO
Interventions
- Prone positioning
- Daily ROM
- Gentle wrapping
- Surgical interventions (ITB, hip ER, knee flexors)
219
Impairments by SC Level (L1-L3):
- Possible Muscle Function?
- Possible Secondary Impairments?
- Orthoses Needed?
Possible Muscle Function
- String hip flexors
- Strong ADD
Possible Secondary Impairments
- Requires bracing to stand
- Hip dislocation/dubluxation
Orthoses Needed
- Parapodium
- Swivel walker
- A-frame
- RGO
- HKAFO
220
Impairments by SC Level (L4-L5):
- Possible Muscle Function?
- Orthoses Needed?
Possible Muscle Function
- Strong hip flex/ADD
- Some hip ABD
- Some foot intrinsics
- Medial HS
- Ant/tib
Orthoses Needed
- Twister cable (due to rotation)
- KAFO if quads weak
- Floor reaction AFO
221
Impairments by SC Level (S1-S5):
- Possible Muscle Function?
- Possible Secondary Impairments?
- Orthoses Needed?
- Interventions?
Possible Muscle Function
- Balance at hips/knees
- Hip extensors/lateral HS (full/partial innervation)
- Strong glute med/medial HS/quads
- Gastroc-Soleus may be weak
Possible Secondary Impairments
- Crouched gait with increased weight gain
- Hip instability
Orthoses Needed
-AFO for gastroc-soleus
Interventions
-Aggressive treatment for hip instability
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Psychosocial Adjustment:
- ___-___: Parents may be in shock/denial. May misinterpret or reject information.
- ___-___: Very stressful, lost of doctor's appointments/hospitilizations.
- ___-___: Concerns about toilet training, social acceptability.
- ___: Child more aware of disability.
- ________: B&B management, sexual issues, Female (ograsm/infertility) Males (sterile with small testicles/penises)
- 0-6m
- 6-18m
- 2 years- school age
- 6 years
- adolescence
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PART 9: MUSCULAR DYSTROPHIES AND SPINAL MUSCULAR ATROPHY
PART 9: MUSCULAR DYSTROPHIES AND SPINAL MUSCULAR ATROPHY
224
- Neuromuscular diseases include disorders of the ________, _________, and _________,
- Is there a cure?
- What is the PTs role?
- motor neuron, neuromuscular junction, and muscle
- No, but this does not mean no treatment!
- Assist in identification, treatment of impairments, activity limitations, and participation restrictions.
225
Duchenne's Muscular Dystrophy (DMD):
- One of the most prevalent and disabling.
- Death usually due to __________ or ____________ insufficiency.
- Many are surviving into 30s.
- Incidence between 1 in 3500 _____ births.
- respiratory or cardiorespiratory insufficiency
| - male births
226
What is the etiology of DMD?
Sex-linked recessive genetic disorder involving loss of dystrophin.
227
DMD Clinical Presentation. (5)
-Insidious
-Gower's Sign
-Muscular Atrophy (progressive proximal muscle weakness, esp hip/knee extensors)
Waddling Gait
-Contractures
-Intellectual Impairments/emotional disturbance
228
DMD Tests and Measures. (5)
- Northstar Ambulatory Assessment
- The Performance of Upper limb for Duchenne
- Brook Scale
- Vignos Scale-Box 12.2
- Egen Klassifikation Scale
229
DMD Prognosis:
- ______________ closely related to muscle strength and predictive loss of ambulation.
- 10MWT >__s and inability to rise from the floor predicts loss of ambulation within 2 years.
- 10MWT >__s predicts loss of ambulation within 1 year.
- ______ exercises and _________ are detrimental.
- Timed Functional Activities
- 10MWT >9s = 2 years
- 10MWT >12s = 1 year
- Eccentric exercises and immobilization
230
DMD Pt's Role. (5)
- Early diagnosis (may be the 1st to see child!)
- Education, referral, support the family.
- Prolong function, prevent contractures and deformities, adapt equipment, encourage peer and community interaction.
- PAIN control
- Weight control, sleep/respiratory concerns, B&B concerns
231
What are the (3) types of Spinal Muscle Atrophy (SMA)?
- Infantile Werdnig-Hoffman
- Intermediate Type II
- Juvenile Kugelberg-Welander
232
What is the etiology of SMA?
Autosomal recessive disorders effecting anterior horn. Associated with wasting and weakness of muscles with no sensory disturbances.
233
Infantile (Type 1) SMA:
- Almost always noted in first ___m of life.
- Often decreased fetal movement.
- _____tonia but appear alert and responsive.
- Difficulty feeding, respiratory distress.
- Muscle wasting, few spontaneous movements.
- _____s decreased or absent.
- Limited lifespan, respiratory failure- dependent on aggressiveness of treatment.
- 3m
- hypotonia
- DTRs decreased/absent
234
Intermediate (Type 2) SMA:
- Also affects _______ but not as severely.
- Floppy, ______ to develop milestones.
- Usually diagnosed ___-___m of age.
- Weak _____/________ with muscle atrophy.
- FEW have feeding problems.
- Fine extremity tremors.
- May or may not learn to walk.
- Most require orthotic intervention.
- infants
- slow to develop milestones
- 3-6,
- trunk/extremities
235
Juvenile Kugelberg-Welander (Type 3) SMA:
- Diagnosed between ___-____.
- ______ progressive weakness with _____ impairment.
- ________ muscles usually involved first.
- 1-10 year
- slowly progressive weakness, mild impairment
- proximal
236
SMA Tests and Measures. (4)
- Timed Gowers
- CHOP- INTEND- type II
- The Expanded Hammersmith Functional Motor scale – type II or III
- Revised Upper Limb Module for SMA
237
PART 10: ASSISTIVE TECHNOLOGY
PART 10: ASSISTIVE TECHNOLOGY
238
2-year-old child diagnosed with Cerebral Palsy requires an assistive device and the mother asks you which device would be warranted. Considering the child’s restrictions and abilities, which would be the most accurate choice:
a. A gait trainer for a child that is full weight bearing w/ available ROM for reciprocal steps
b. A posterior (reverse) walker for a child that has within normal upright posture.
c. A walker for a child that can take reciprocal full weight bearing steps.
d. A gait trainer for a child that has poor trunk and LE strength and diminished cognitive ability.
c. A walker for a child that can take reciprocal full weight bearing steps.
239
This equipment would be chosen for a child that requires an assistive device that offers the least amount of restriction and a variety of gait patterns.
a. Gait trainer
b. Walker
c. Wheelchair
d. Loftstrand Crutch
d. Loftstrand Crutch
240
Which is FALSE regarding positioning system equipment used for pediatrics:
a. Used for positions such as supine, prone, and standing.
b. Used for children between 0-36 months of age.
c. Used for children with low tone, developmental delay, premature birth, weakness.
d. Used to build static strength in a variety of positions.
a. Used for positions such as supine, prone, and standing.
241
All of the below are characteristics of Lofstrand crutches EXCEPT:
a. Reduce pressure under the axilla
b. Least restrictive assistive device
c. Allows for a variety of gait patterns
d. Provides the largest base of support
d. Provides the largest base of support
242
Positioning systems are great to work on which of the following
a. Building static strength in a variety of positions
b. Working on transfer training to achieve different positions
c. Assisting the child in standing for feeding, occupational therapy, and physical therapy
d. Assisting with proper extremity positioning during gait only if they are partial weight bearing
a. Building static strength in a variety of positions
243
You are treating a 3 year old female patient with spastic diplegia. The patient is able to maintain sitting with UE support, but she is unable to maintain standing without assistance. She is able to climb up onto a bench with assistance, preferring to initiate with her R hip, and she is able to reciprocally crawl forward toward a toy. Which of the following equipment prescriptions would be the LEAST appropriate for this child?
a. Stander
b. Gait trainer
c. Stroller
d. Bath chair
c. Stroller
244
Which of the following patients would be MOST likely to benefit from a walker?
a. A 3 year old male who is able to stand with intermittent UE assistance and demonstrates reciprocal crawling
b. An 8 month old male who demonstrates difficulty maintaining independent sitting
c. A 2 year old female who is unable to creep forward toward a toy
d. A 14 month old female who has demonstrated significant limitations in hip ROM but is able to stand with support
a. A 3 year old male who is able to stand with intermittent UE assistance and demonstrates reciprocal crawling
245
PART 11: PT UNDER IDEA
PART 11: PT UNDER IDEA
246
```
Jan is a new-hire PT who just began working with Early Intervention. On her first day, she says “I love this job! This is so relaxing… just working with children all day. YAY!”. Her frizzy-haired, wide-eyed coworker turns her chair slowly around and says “...you have got to be off-your-rocker because Early Intervention services have to begin within ______ days from IFSP authorization… this is the most stressful job in the world!!!” Fill in the blank with the correct choice below.
A.) 45
B.) 30
C.) 2
D.) 60
```
B.) 30
247
Jan is now an experienced Early Intervention clinician. Because of her well-fought decades of back-breaking pediatric care, Jan knows that:
A.) The family’s culture and beliefs should be questioned consistently.
B.) Services are standardized across all patients with no room for changes.
C.) Children perform best if viewed as a child first, rather than someone with special needs.
D.) Children are best supported within the community and family is best supported within the child.
C.) Children perform best if viewed as a child first, rather than someone with special needs.
248
Jan is now a distinguished professor at Wingate University teaching DPT 2’s premature development. After her lecture, one student asked “what’s 1 thing you wish you'd known earlier as a new-grad pediatric PT?” Jan, without hesitation, said:
A.) “Get out now”
B.) “You’ll make more money elsewhere”
C.) “The kids aren’t worth the hassle”
D.) “Schedule your tougher kids in between your easier kids so you have breaks throughout your day”
D.) “Schedule your tougher kids in between your easier kids so you have breaks throughout your day”
249
Who is likely NOT considered a member of the Individualized Education Program (IEP) Team?
a. single mom parent
b. student in kindergarten
c. special education teacher
c. school psychologist
b. student in kindergarten
250
True/False: Children with disabilities should always be separated from the regular educational environment in order to meet their specific educational needs with supplementary aids and services.
False
251
Which of the following is NOT something that education PT evaluations are based on?
a. Input from IEP team
b. Examination/Measurement
c. Classroom/Campus observation
d. Strength deficits
d. Strength deficits
