Neuromuscular Assessment 2 Flashcards
What is CP?
Permanent but changeable
Caused by non progressive defect or lesion in 1 or multiple locations
Utero/during or shortly after birth
Infectious meningitis and trauma are the most common causes of acquired CP
Produces motor and possible sensory deficits
Involves 1 or more limbs and usually the trunk
Voluntary motor function deficits
Produces multiple symptoms
Anatomic sites of involvement, degree of disability, associated dysfunction and causes are heterogeneous
What are some common problems seen in children who have Cerebral Palsy
Learning disabilities in 50-70 percent
Speech disorders in 25 percetn
Auditory in 25 percent
Seizure disorders in 25 -35
Disc dengeration and cervical spine instability
Visual disturbances in 40-50%
Strabismus, esotropia, nystagmus, homonymous hemianopsia
How is CP classified?
Area of the body exhibiting impairments
Movement abnormalities resulting from brain lesions
Degree of severity of CP
Area of Body impairment Classification system
Monoplegia- involvement of one limb
Diplegia (paraplegia)- involvement in both lower limbs
Hemiplegia- upper and lower limbs on one side
Quadriplegia- equal involvement in all limbs
Molnar (85), identifies several major groups of children with CP based upon clinical signs
(4) main clinical sgins
. 1. Spastic- motor cortex hemiparesis, diplegia, quadriplegia 2. Dyskinetic- basal ganglia athetosis,(slow writhing finger movements of the the lower extermity) dystonia, choreiform movements, ballismus, tremor 3. Ataxia- cerebellar lesion 4. Atonia, hypotonic
what does spastic mean?????
showing upper motor neuron involvement (hyperreflexia, abnormal movement patterns, weakness, loss of dexterity) -motor cortex
What is athetosis
Dystonia, Choreiform, Ballisums,
Athetosis- showing signs of extrapyramidal involvement with involuntary movements slow writhing movements of face and extremities
Dystonia -rhythmic, changing tone proximally leading to slow uncontrolled movements with a tendency towards fixed postures -basal ganglia
Choreiform movements- rapid jerky movements of face and extremities
Ballismus – coarse flinging movements of extremities with wide amplitude of motion
Tremor – fine shaking of head and extremities
Rarer types of CP what does Hypotonic come from
Ataxic-
Can you have mixed types of lesions yes or no
Hypotonic- showing severe depression of motor function and weakness
Ataxic- showing signs of cerebellar involvement with ataxia (rare) -cerebellar lesion
Mixed lesions combine characteristics of spastic, athetoid and ataxic groups
Describe some characteristics of hypotonic CP think decreased muscle tone.
\Flaccidity
Extreme floppiness
Inability to generate muscle force
Transient- reclassified spasticity or athetosis
Describe some characteristics of Spascity CP
Dystonia
Resistance to passive stretch
Hyperactive stretch reflexes (hyperreflexia)
Changes in muscle structure & function
Abnormal muscle activity elicited by changes in head or body positions
UE flexion/ LE extension
Athetoid CP
Without a fixed steady position and may involve choreiform or writhing movements
Maintain fixed dystonic posture
Involuntary movements at rest and during movements
Joints often hyper mobile and dislocations occur especially if spasms are present
Ataxic CP (just think lack inability to vounlantary control muscles)
Uncommon
Hydrocephalus, head injury, encephalitis, or cerebellar tumor
Difficulty controlling rate, range, direction and force of movements
So thinking back to neuro where might the Brain lesion be and what might result if its
Coritcal Basal Ganglia lesion- think athen lives in the BG.
Cerebral Cortex-
Cerebellar
Cortical Basal ganglia thalamic loop- dyskinesia or athetosis, intermittent muscular tension of extremities or trunk, involuntary movement patterns
Cerebellar lesion- ataxia, general instability of movement
Cerebral cortex & pyramidal tracts- spasticity
Hypotonic classification- diminished resting muscle tone and decreased ability to generate voluntary muscle force
Give some examples of Single System Problems ( like think muscular system ) what are some malalignments from that
Expressed in muscular and skeletal systems damage occurred in the CNS Insufficient force generation Spasticity (vel dependent) tone Abnormal extensibility Exaggerated or hyperactive reflexes Malalignments (femoral anteversion/ femoral & tibial torsion)
Multisystem Approach think like
Expressed in the Neuromuscular system
Poor selective control of muscles
Poor regulation of activity in muscle groups in anticipation of postural changes
Decreased ability to learn unique movements
Look at page 187 tecklin
look at page 187 tecklin
Reflection on Some Standardized tools
Movement Assessment of Infants (MAI) 73.5 % in high risk populations (4 months of age)
Bayley 100% for spastic di and quadriplegia and 75% for spastic hemi at 1 year corrected age
Alberta (AIMS) 6 months
General Movement Assessment- saws few false positives
Test of Infant Motor Performance (TIMP) – early detection
Assessment of postural control
Postural activity is noted when the child has muscle activation against the supporting surfaces
Postural preparations are strategies used before a functional movement,
increase stability by changing the base of support or increasing muscle activation around a joint
Changes are in anticipation of a specific task that has been learned previously
Uses fb from completing the task prior in a feedforward manner
Assessment of postural tone
Describes the impairments of spasticity and abnormal extensibility
Abnormally high tone maybe caused by spasticity – velocity dependent over activity that is proportional to the imposed velocity of the limb movement
Stiffness- describes the resistance to movement felt when joints are moved in space
Assess during transitions and as the limb moves
Assess compensatory stiffness
Musculoskeletal assessment what are some things you look for obviously measure for ROM but, what specific ranges are you looking for???
Goniometric measurements
Evaluate mobility of the spine
Flexion in supine
Extension, lat flexion, & rotation in sitting
Thoracic movements
Breathing cycle/ motion of thorax- note lack of downward slant of ribs, poor rib cage fixation leading to sternal depression, lack of thoracic expansion = shallow respiratory efforts
Focus on facilitating antigravity control of axial extensors and flexor muscles (oblique abdominals for forceful expiration needed for coughing and sneezing
What are some things that you notice in the Shoulder region with CP patients. think like rounded shoulders.
Shoulder girdle / UE
Poor trunk extension
Results in rounding of the thoracic spine/ tight pectoralis major & rectus abdominus muscles
Dynamic scapula stability fails to develop
Fixed scapulae in a downward rotation with forward tipping resulting in restricted sterno and acromioclavicular joint movements
Limited passive flexion,abd, ext rot of shoulder with the utilization of shoulder elevation
Limited extension of ue distal joint movements
Examination of the hip
Tight hip flexors, add, internal rot with resultant limitations in hip extension, abd, and ext rot
Thomas test – identify flexion contractures of hip
Ortolani click for congenital hip dislocation or shorter femoral length
Femoral anteversion how much is the shaft twisted on the neckfor an adult what about an child with CP
Torsion or internal rotation of the femoral shaft on the femoral neck
Birth 40 degree of anteversion (transcondylar axis of the femur and the femoral axis of the neck)
Adult 15 degrees of femoral anteversion
CP increased anteversion
Examination of the Knee
May have limited knee flexion or extension
Tibial torsion
Birth 4 degrees of ext rot
Adults 14 degrees of ext rot
Where the measurement for LE length
from ASIS to medial malleous and 1 -2 cm is normal range I believe is what she was going for.
Evaluation of gait the forever ? “when will my child walk?”
Watt et al. 89, predications at 2 yrs of age increased accuracy for early prognosis of walking status
Age of sitting, type of CP, presence of tonic labyrinthine, ATNR, symmetrical tonic neck and Moro reflexes, foot placement and parachute postural reactions significantly correlated with ambulation at 8yrs of age.
High stepping, slow lurching gait, small steps, uneven steps, simultaneous flexion of hip/knee/ankle, limited hip extension/ankle DF, knee hypertension in stance, internal rot & add
Classic gait patterns of CP gait
Limited asymmetric pelvic tilt or rotation
Use excessive head, neck, upper trunk & UE mobility
Flexed hips during stance
Excessive adduction & internal rotation of hip (Medial aspect of knees may approximate)
Knees either flexed or hyper extended during stance
Feet in valgus
Plantarflexed
Speed of walking is half that of aged matched
Limbs on involved side are retracted or rotated posterior
No arm swing & involved UE held in hyperextension at shoulder with elbow flexion
What the components of a goal
the ABCDES of goals basically
Remember objectives (short term goals) do not need to be components of long term goals but they need to be logically connected and have…
Subject
An observable action verb
An observable functional performance with a beginning and an end point
Conditions under which the performance will be met (circumstances & environment)
Criteria or how well the client performs this function
Therapeutic intervention
Window of opportunity” to reduce primary impairments and prevent secondary impairments Force production Spasticity Hypoextensibility Casting and orthoses
Therapeutic Exercise How to progress resistance in infants and how to progress to endurance activities always remember dual tasking is great for these patients
Strength progressions Gravity eliminated movements-against gravity Alter amount of assistance Endurance progressions Increase number of reps Increase length of time of exercise Coordination progressions Dual tasks
Therapeutic Exercise How to progress resistance in infants and how to progress to endurance activities always remember dual tasking is great for these patients
Strength progressions Gravity eliminated movements-against gravity Alter amount of assistance Endurance progressions Increase number of reps Increase length of time of exercise Coordination progressions Dual tasks
