Neuro Peds - 02 - CP - Treating Flashcards
1
Q
what are the stages of Physical Therapy as they pertain to CP?
A
Stage 1: Early Intervention - Common Assessment Tools to ID CP Stage 2 and 3: - Outpatient Center Based Programs - Pre School and School Physical Therapy Stage 4: Adulthood
2
Q
what is the duration of Stage 1 - Early Intervention?
A
the first three years
3
Q
what happens during Stage 1 - Early Intervention?
A
- you see the most gains with therapeutic gains – many diagnoses, not just CP
- federally funded state run org. CDSA is what it is called around here. Or PIE.
- Accurate diagnosis at 8 months, over diag at 4 months
Natural environment – don’t take anything in that you don’t mean to leave.
IFSP – individualize family specialized plan
don’t need nursing to get physical therapy
Each state has different testing tool
Here is Peabody – show 30% delay in one area or 25% in two or more areas to qualify for services. With age adjustment.
4
Q
What is IFSP?
A
Individualized Family Service Plan
IFSP – developed with the family – PT will write two evals – one for legal/ insurance and one for family
5
Q
what happens during Stage 2/Stage 3?
A
- Transition to school services
- IEP individualized education plan at school
- If cognitive is fine, and do well in classes, can’t get PT at school
- If something happens, maybe get 501
- Or, outpatient therapy
6
Q
what happens during Stage 4?
A
Adult – Medicaid is great, but slow with equipment
7
Q
what is the PTA’s role as caregiver?
A
Family leads the charge!
PT will have ideas, but if family doesn’t agree, goals will need to change.
Educate family or change goals
You will be calling a thousand people when you are working with kids
PTA will need to express thoughts out loud, not just in note
As a team member, proficient in skills, aware of additional things. If things are not going as expected, notice it and bring it up to PT. Diagnosis could change
8
Q
What are the physical therapy goals?
A
Goals – positioning, development of functional skills, promote sensorimotor development, postural awareness, educate parent, foster infant/parent interaction
Be aware that it is overwhelming – parent might shut down – interaction shuts down – help them
9
Q
what are some general obstacles to motor development?
A
Muscle Tone Abnormal Movement Patterns Reflexes Lack of Motor Control and Coordination Muscle Weakness Abnormal Sensory Awareness
10
Q
What kind of muscle tone will most CP patients have?
A
hypertonicity
- the spastic, dependent on velocity kind
11
Q
what is the treatment approach for hyper tone?
A
break it up!
flex the ankle and knee and hip.
get the pt sitting up
12
Q
why does the CP patient have abnormal movement?
A
difficulty co-contracting
reflexes persistent or absent
no reciprocal movement
13
Q
which reflexes are likely to persist?
A
ATNR
STNR
startle
14
Q
what are some general therapy activities for the patient with CP?
A
- Bearing weight with good posture
- Controlled Weight Shifting -in good posture
- Closed Kinetic Chain Exercises
- Joint Stabilization
- Functional Skills
15
Q
what are treatment strategies for Spastic CP?
A
- Improving base of support - wide to narrow
- Head and trunk alignment with postural activities (neck strength)
- Gaining mobility
- Getting the child to move
16
Q
What are treatment strategies for Hemiplegic CP?
A
- Work towards a more correct midline (ML) perception of the head and trunk
- Stability for both sides
- Work towards midline then away from midline; using uninvolved side to lead at first
17
Q
what are treatment strategies for Athetoid CP?
A
- Building postural control in trunk
- Weight bearing in midline
- Isolate head movement from trunk
- Be careful with wording/volume
- Thoracic extension with rotation
- Joint approximation
- Weighting extremities
- Shifting upper body over lower body
18
Q
why is it important to be careful with wording while treating Athetoid CP?
A
need to be easy for kid to understand
volume changes can cause startle/extensor thrust
– so not just the words but how you say them
19
Q
what is the most important strategy in treating Athetoid CP?
A
trunk and posture
Isolate head from trunk – because using eyes and head to move, which controls trunk.
– do things that involve just moving head
20
Q
what is important about treating for thoracic extension and rotation in treating child with Athetoid CP?
A
child with Athetoid CP is hunched.
21
Q
what is the difference between adaptive device and assistive device?
A
Adaptive technologies refer to special versions of already existing technologies or tools, usually used by people with disabilities such as limitations to vision, hearing, and mobility.
Assistive technology is a broader term encompassing any light-, mid-, or high-tech tool or device that helps people with disabilities perform a tasks with greater ease and/or independence.
22
Q
why won’t a child with Athetoid CP be using an assistive device?
A
because of the highly fluctuating tone
because he needs to walk with hands clasped
23
Q
what are treatment strategies for Ataxic CP?
A
- Establish visual attention and sustained visual gaze - to retrain brain and eyes
- Visual attention combined with movement - train away from watching feet
- in to Midline then out of Midline
- Use actual situations for learning; can’t generalize
24
Q
what are treatment strategies for Hypotonic CP?
A
- Alignment - they are so floppy
- Repetitive joint approximation - weight/unweight to get joints to develop as they should
- Vestibular, Vibration - wake up system
- Active trunk with rotation - need child to actively do this himself.
- Abdominals - airplanes, supermans, fun planks
- Weight shifting with alignment - controlled mobility
25
what are some tips for Supine Positioning?
Bent knees and flexed upper trunk
-bend the knees first, get them out of extension
Encourage midline play
26
what are some tips for Side Lying Positioning?
Decreases tonic reflexes
- most neutral for head
- but don't allow too much lateral neck flexion
Preps for rolling and coming to sit
- can do manual between shoulder and hip – add resistance.
- make sure they are elongated – not all curled up on the side
27
what are some tips for Prone Positioning?
- Increases UE weight bearing
- Stretch to LEs - really posterior tilt pelvis
- Promotes eye-hand relationships
- Promotes protective extension and weight shifting - move toys farther out
- Help with crawling and other reciprocal activities
28
What Will You Work On To Achieve Independent Sitting
- Proximal stability
- Balance reactions
- Rotation - Dissociate trunk from LE – break up extensor tone - may need special seating to break up tone
- Muscle length/extensibility
- Pelvic mobility
29
why will you work on achieving independent sitting?
great for function
can do ADLs
work on balance here before in standing
30
why is Quadruped position important?
- Promotes both UE and LE weight bearing
- Increases core strength
- Encourages dissociation
- Hemiplegia – using both sides – gets them out of bottom scoot
- Controlled mobility
31
what are some tips for Quadruped positioning?
- encourage Weight bearing though UE
- Break up the extensor response
- Extend wrist and fingers
- Weight shifting back and forth
- Keep back flat/neutral - works on core strength – avoid sagging
- There is fancy equipment, or just use a sheet – especially good in home therapy (pvc pipe)
- Dissociation – weight shift side to side
32
why is Kneeling position important?
- Encourages dissociation - Upper LE doing diff than lower LE
- Stretches hip flexors
- Increase balance responses
usually Tall Kneel - facilitate extensor strength
33
What Will You Work On to Achieve Independent Standing?
- Proximal stability
- Tissue Extensibility
- Decreased primitive reflexes
- Increased sensory awareness
- Balance reactions
- Muscle activation/co-activation - to get away from sway
- Weight shifting
- Rotation
- Increased abductor strength
- Full foot flat for weight bearing
Some kids will use their moving muscles for standing, which is not really standing
34
What are the 3 Predictors of that a child with CP will achieve Gait?
Vision
Type of CP
which Milestones are acheived by the age of two
35
What are the hoped for Predictor of Gait Milestones by age 2?
- sitting independently
- scooting on the bum
and by 2 1/2 - 3, crawling
36
What kind of Vision is a good Predictor of Gait?
intact vision
37
What kind of CP indicates "least likely to walk"?
Athetoid
then Spastic Quad
remember to take into account how involved the patient is
38
name some causes of
| Gait Pathology
- Spasticity
- Abnormal Motor Control
- Decreased strength
- Loss of ROM
- Loss of sensation
- Bony deformity
39
why do bony deformities occur?
hypertonic muscles pull on the bones, causing misshape
and wear and tear
not enough of the good weight bearing
40
what are three common bony deformities?
- femoral anteverson/antitorsion
- internal tibial torsion
- subtalar joint breakdown
41
describe
| femoral anteversion/antitorsion; internal tibial torsion
inward twisting of the femor or tibia
- should remodel with normal weight bearing
- the CP kids are not doing normal weight bearing
42
what is often used to prevent Subtalar Breakdown?
SMO
| - because it's a shame to have to fuse a growing bone. and the problem would still be there.
43
real quick, name the four Stance Events of the Gait Cycle
Foot Strike
Weight Acceptance
Mid-stance
Push off
44
also, name the three Swing Events of the Gait Cycle
Acceleration
Mid-swing
Deceleration
45
Gait Cycle: describe Foot Strike
Stance - Foot Strike:
initial floor contact is typically made with the heel
foot then lowers to the ground, controlled by eccentric contraction of the tibialis anterior
46
Gait Cycle: describe Weight Acceptance
Stance - Weight Acceptance:
the foot is flat on the ground,
weight comes over the stance foot and the opposite limb initiates swing
47
Gait Cycle: describe Mid-Stance
Stance - Mid-Stance:
body weight is directly over the stance leg and the swing leg is about to pass in front of the stance leg.
very little muscle activity occurs here.
48
Gait Cycle: describe Push off
Stance - Push off:
heel comes off the ground as the body weight moves over the forefoot
the ankle is plantarflexing to propel the body forward.
49
Gait Cycle: describe Acceleration
Swing - Acceleration:
| hip flexors actively advance the swinging leg and knee flexion is passive for the most part
50
Gait Cycle: describe Mid-swing
Swing - Mid-swing:
momentum produced in the early swing
inertia of the limb allows the swinging leg to advance with minimal muscle activity
51
Gait Cycle: describe Deceleration
Swing - Deceleration:
| swinging limb is slowed by eccentric hamstring muscles activity as the leg prepares once again for floor contact
52
What are some common Gait Abnormalities with CP?
Inadequate ROM and Spasticity - Crouched Gait
CP: foot flat initial contact
Limited swing phase knee motion - Rectus femoris spasticity
Weakness
53
what CP gait will be the most common?
Crouched
| - because spastic diplegic
54
which weak muscle is culprit in extensive plantarflexion
weak tibialis anterior
spastic gastroc
or both
55
what kind of gait will you see due to spastic rectus femoris?
limited swing phase
toe drag
circumduction
trendeleburg lurch
56
if excessive plantarflexion, what do you expect to see in gait?
smaller steps
slower cadence
poor balance
flat foot/hyperextension of the knee
57
what is AFO intended to fix?
promote better heel strike
58
what are the 5 gait qualities?
```
Stability in Stance
Foot clearance during swing
Pre-positioning of foot for heel strike
Step length
Energy Conservation
```
59
What Happens in Pathological Gait?
* Stability in stance is compromised – smaller surface area in step
* Insufficient foot clearance during swing – weak tib ant, rectus femoris spasticity
* Inappropriate pre-positioning of the foot swing for initial floor contact – no heel strike (just roll over the foot)
* Inadequate step length – because of everything else, smaller steps, poor control in stance phase
* Poor energy conservation – expending so much more energy because of all above. Bad alignment.
60
what are some statistics about gait she especially told us?
In general a child with CP expends 2SD more than TD.
Mild hemiplegia expend 30% more energy.
Spastic diplegia will spend 75% more energy without assistive device. With device it is increased!
61
what is an effect of toe walking?
poor energy conservation
62
Foot slap indicates which muscle weakness?
Tibialis Anterior
63
Excessive dorsiflexion indicates what bad gait?
crouch
64
In Knee Stance gait, flexion deformity is secondary to_________
overactivity of hamstrings
| - ground reaction behind knee, knee gets pushed into more flexion
65
how to treat rotational deformity?
exercises to strengthen external rotators
| get pt up and standing in Appropriate position to prevent drastic deformity
66
Spasticity rectus femoris - !! Means loss of swing phase?
Rectus femoris keeps knee extended
67
what is indicated by scissor gait?
decreased abductors
| increased adductors
68
internally rotated walk caused by two things:
bony deformity
| spasticity
69
name some compensatory measures used in abnormal CP gait
- Weight shifts (lurches)
- Trendelenburg
- Circumduction
- Plantar
- IR hip
70
what is most common orthotic in CP
AFO
71
how is AFO fitted?
Extends 10-15 mm distal to the head of the fibula
Should not pinch behind the knees at any time
Should maintain subtalar joint neutral position
72
why might the PT choose SMO over AFO?
maybe the flexing of ankle is just fine, and only the subtalar joint needs attention
73
What are some general treatment guidelines?
Try it out first - probably won't work
Wait-Patience! - let kid do for himself
Grade your handling - let kid do for himself
Move center of gravity with both hands - hands on or near!
Slumping and asymmetrical posture are human - realize that perfection won't come
Do not repeat an activity too much - can't get bored
Play and wait
Let the child choose the toy/activity - within reason
Vary the requirements of the activity - same activity will cover multiple goals
74
what are some "Things to Remember"
- Do activities that affect tone first before positioning - ramp up or calm down as needed First
- Do not force the arms or legs - do not crank
- Do not bounce a child with spasticity on a ball on their tip toes: it will increase tone
- Tell the child what you are about to do - even if he is nonverbal or nonresponsive
- Do not pick a child up under the arms
- Handle the child slowly
- Give as little support as is needed to be safe
75
how do you choose the toy for the fluctuating toned child?
- Heavier toys to help facilitate greater proximal stability and give sensory feedback about limb position - weighted toy
- Toys with resistance
- Keep toys within a small range of space to decreased extreme movements
76
how do you choose the toy for the hypertoned child?
- Light toys - normal, not weighted
- Moving through mediums will help child feel fluid sensations of movement
- Spread toys out to allow for changes in COG and weight shifting
- Change up placement of toys
77
how will you know there is improvement?
improved gait
improved posture
improved balance
improved transistion
78
what is the long list of signs of improvement in the quality of movement?
- Decreased latency of response
- Increased speed of movement with good quality of posture
- Increased ability to sustain an activity
- Increased task completion
- Increased number of adaptive responses - New surfaces, Protective responses
- Improved motivation - More exploration, Increased number of self initiated trials
- Improved symmetry of posture and of movement
- Improved level of independence
- Advanced motor milestones
- Increased weight shifts
- Increased independent/spontaneous rotation
- Increased visual focus
- Power
79
how many therapists in Weight Treadmill Training?
likely at least two
80
what is happening with Weighted Treadmill Training?
reorganization in the brain
| homunculus is filling in
81
what kind of practice is necessary to reorganize the brain?
Mass Practice
82
how does constraint induced therapy work?
bind up the good extremity,
| make them use the bad one
83
list the 6 major treatment approaches for the neurological patient
- Patterning
- Neurodevelopmental Therapy
- Rood Theory
- Proprioceptive Neuromuscular Facilitation (PNF)
- Sensory Integration Therapy
- Motor Control/Motor Learning Approach
84
the low-down on Patterning:
Doman-Delacato
Normal movement based on primitive patterns
Move child through these patterns
85
the low-down on NDT
guiding movements with key points of control
| NDT biggest known therapy with children
86
the low-down on PNF
not used as much with children, as we are not wanting to add resistance
Based on normal motor development
Utilizes diagonal and spiral movement patterns
Increases facilitation of the proprioceptive system
Examples:
- Quick stretch
- Contract relax
- Hold relax
87
the low-down on Sensory Integration Therapy
```
well, senses are integrated into the therapy
snoezelen room
some kids need more sensory input
all kinds - tactile, verbal, vestibular
needed for motor planning
```
88
the low-down on Rood theory
Based on four stages of normal development
- mobility, stability, controlled mobility, skill
- must progress through sequentially
Appropriate sensory information or input
P.T. uses specific stimuli to facilitate responses
Stimuli to facilitate mobility
- light stroking, brushing, icing, and joint compression are used to facilitate movement.
Stimuli to facilitate stability
Stimuli to inhibit
- joint approximation (light compression)
- neutral warmth, pressure on tendon insertion
- slow rhythmical movement to inhibit unwanted movement (i.e., spasticity).
89
why choose prone stander over supine stander?
prone would be used for child who has chance to walk
90
why choose sit-stand stander?
functional
| for child who can self-transfer
91
what is difference between stroller and wheelchair?
not-self propelled vs self-propelled
| some support vs better support
92
rear-wheel walker good, why?
better posture
| better access to tables and such
93
rear-wheel walker bad, why?
child could forget it is there
| not as helpful if child is fearful to move
