Paediatrics: Past Paper Questions

Question 1

Describe what a Myelomeningocele(Spina Bifida Aperta) is. (5)

Answer 1

1. The meninges, spinal cord and CSF protrude.
2. Paralysis of lower limbs – there is an absent reflex arc due to lesion and this often results in flaccid paralysis. (Spastic above and flacid below)
3. Sensory deficits – Impaired sensation of pain, heat, cold, touch and proprioception. Very dangerous as can develop infected sores.

4.Incontinence - The nerves supplying the bladder and bowel may be damaged. Dangerous as children experience bladder infections and this can lead to kidney failure

5.Deformities – Scoliosis; Lordosis and Kyphosis can both decrease lung function and cause pain. Contractures due to incorrect positioning.

6.Hydrocephalus – Intraventricular shunt is implanted to prevent accumulation of CSF.
Must teach them on the signs of increased intercranial pressure, Projectile vomiting, Severe headache and Sensitivity to light.

Question 2

Describe what a Meningocele(Spina Bifida Cystica) is. (5)

Answer 2

1. The meninges and CSF protrude out the vertebral column.
2. Paralysis of lower limbs – there is an absent reflex arc due to lesion and this often results in flaccid paralysis. (Spastic above and flacid below)
3. Sensory deficits – Impaired sensation of pain, heat, cold, touch and proprioception. Very dangerous as can develop infected sores.

4.Incontinence - The nerves supplying the bladder and bowel may be damaged. Dangerous as children experience bladder infections and this can lead to kidney failure

5.Deformities – Scoliosis; Lordosis and Kyphosis can both decrease lung function and cause pain. Contractures due to incorrect positioning.

6.Hydrocephalus – Intraventricular shunt is implanted to prevent accumulation of CSF.
Must teach them on the signs of increased intercranial pressure, Projectile vomiting, Severe headache and Sensitivity to light.

Question 3

Describe what Spina Bifida Oculta is. (5)

Answer 3

1. Closed” – Vertebra fail to close but there is no protrusion of spinal cord and its membranes
2. No external sign (possible tuft of hair or discolouration)
3. Child functions normally

Question 4

Describe the clinical presentation of Type 2 Spina Bifida. (10)

Answer 4

1. Paralysis of lower limbs – there is an absent reflex arc due to lesion and this often results in flaccid paralysis
2. Sensory deficits – Impaired sensation of pain, heat, cold, touch and proprioception. Very dangerous as can develop infected sores. Prone to bladder infection. Can either self catheterize or are on nappies.
3. Incontinence - The nerves supplying the bladder and bowel may be damaged. Dangerous as children experience bladder infections and this can lead to kidney failure
4. Deformities – Scoliosis; Lordosis and Kyphosis can both decrease lung function and cause pain. Contractures due to incorrect positioning.
5. Hydrocephalus – Intraventricular shunt is implanted to prevent accumulation of CSF.
   (Must teach them on the signs of increased intercranial pressure: Projectile vomiting,
   Severe headache, Sensitivity to light. )

Question 5

List the associated problems of Spina Bifida. (15)

Answer 5

Impairments:
Musculoskeletal deformities, Osteoporosis
Sensory deficits, Cognitive dysfunction
Language dysfunction, Upper limb discoordination
Visuoperceptual difficulties, Cranial nerve palsy
Spasticity, Progressive neurologic dysfunction
Seizures, Neurogenic bladder and bowel
Skin breakdown, Must teach them about pressure care (has to check every day)
Obesity.

Question 6

List the Physiotherapeutic Principles of Spina Bifida managemen. (5x3)

Answer 6

1. Prevent dislocation, contractures and deformities:
   Educate family about correct positioning and handling of lower limbs.
   Stretching of LL especially TA’ .
   Use assistive devices such as AFOs.
2. Maximise Mobility:
   Use of assistive devices.
   Strengthen upper limbs.
   Improve endurance through exercising to push wheelchair longer distances.
   Make sure they can do all their transfers .
3. Maximise Function and independance:
   Use of assistive devices.
4. Strengthen:
   Exercises to Improve stamina in upper limb muscles to improve efficiency of ADLs.

5.Prevention and treatment of pressure sores:
Check daily.
Educate family and patient.
Strengthen arms and teach methods for relieving pressure.
The kids wont be able to tell if the shoes are comfortable.

Question 7

List the associated Outcome Measures of Spina Bifida. (15)

Answer 7

Impairments:
Musculoskeletal deformities, Osteoporosis
Sensory deficits, Cognitive dysfunction
Language dysfunction, Upper limb discoordination
Visuoperceptual difficulties, Cranial nerve palsy
Spasticity, Progressive neurologic dysfunction
Seizures, Neurogenic bladder and bowel
Skin breakdown, Must teach them about pressure care (has to check every day)
Obesity.

Question 8

Discuss the associated problems of Cerebral Palsy (CP), and how they would affect the
management of a child with CP. (15)

Answer 8

1.Spastic muscles are perceived as excessively stiff & taut.

2.Hemiplegia: Tone increase of the upper limb: arm bent with a stiff or floppy hand. Of the lower limb: may walk on tip toe or outside of the foot.

3.Diplegia: Usually affects lowe limbs and may develop contractures of the hips, knees, ankles and talipes equinovarus (clubfoot).

4.Quadroplegia: Arms, head and mouth may twist. May never be able to walk. Knees press together. feet and toes urn inward. Present with scissoring of the lower limbs.

5.Dyskinetic (athetosis): present with intermittent muscular tension of the extremities or trunk & involuntary movement patterns.

6.The condition is not progressive but as the patient matures, the symptoms may change.

7.General instability of movement in ataxia, produced by a cerebellar lesion. Wide gait with a tendency to fall and an inability to walk in a straight line.

8.Hypotonia characterised by diminished resting muscle tone & decreased ability to generate voluntary muscle force.

9.Deformities develop as a result of hyper- or hypotonia and prolonged hold of a certain position.

10.Contractures of the hip flexors and adductors and the hamstrings and internal rotation of the hip and femoral anteversion.
May develop hyperextension of the knee to compensate for tight Achilles tendon.

11.Kyphosis may develop as a sequelae to tight hamstrings or hyperlordosis as a compensatory balance mechanism, in addition many develop dislocation of their joints and spinal curvature.

12.Hip subluxation or dislocation can cause significant morbidity in terms of pain & difficulty with postural control, creating limitations in sitting, standing and walking & hygiene & personal care considerations.

13.As association between hip dislocation & spinal curvature and children with a windswept deformity of the hip & pelvis, where the hip is subluxated or dislocated and the pelvis rests in obliquity & rotation, present as a precursor to spinal curvature.

14.Patients experience pain arising from musculoskeletal, gastrointestinal, muscle and respiratory sources.

15. Patients have difficulty with communication and may drool due to lack of facial control.

Question 9

Give a brief overview of the milestones that babies with typical development achieve by the end of their first year of life. (10)

Answer 9

1.Picks up objects using opposition
2.Places things in a container
3.Deliberate release
4.Imitates words/Uses single words
5.Moves in & out of sitting more quickly
6.Wide base of support for sit to stand
7.Handedness begins to develop
8.Base narrows if one hand held
9.May walk on toes
10.Sequencing in & out of positions improves

Question 10

Define muscle tone and discuss the four types of tone that may be present in a child
diagnosed with cerebral palsy. (5x=15)

Answer 10

Muscular tone can defined as ‘the tension in the relaxed muscle’ or ‘the resistance, felt by the examiner during passive stretching of a joint when the muscles are at rest.

Hypertonus/ Spastic:
Muscles are perceived as excessively stiff & taut, especially during attempted
movement results from involvement of the motor cortex or white matter projections
to & from the cortical sensori motor areas of the brain.

Hypotonia
Characterised by diminished resting muscle tone & decreased ability to generate
voluntary muscle force.

Dyskinetic/ Athetosis:
Indicates involvement of the basal ganglia and may at times present with
intermittent muscular tension of the extremities or trunk & involuntary movement
patterns

Ataxic:
Produced by a cerebellar lesion and general instability of movement.

Mixed:
Symptoms of spasticity & dyskinesia are both present

Question 11

Explain the three groups of reactions that work together to form the normal postural control mechanism. (15)

Answer 11

All degrees of reciprocal innervation:
Co contraction and reciprocal action of agonists, antagonists and synergists allow for
well coordinated patterns of posture & movement.

-Righting Reactions:
*Orient the head in space.
*Allow body parts to be restored to normal alignment following rotation.
*Gives us:
Basis of head & trunk control .
Alignment.
Rotation about the body axis.
Postural orientation & adjustment.

-Equilibrium Reactions:
*Reactions that maintain & restore balance during activities
*Overlap with righting reactions
*May only result in tonus changes
*On greater displacement are seen as counter movements of varying ranges to
restore centre of gravity & alignment
*Develop after learning of posture

-Protective Reactions:
*Last line of defense in the mature CNS
*Link between righting & equilibrium reactions
*Consist of extension movements of the limbs in the same direction as the force
which displaces the body’s centre
*Come into play when:
Centre of gravity is displaced too far for the equilibrium & righting reactions to act
Speed of the displacement is too great for the equilibrium reactions to come into
play.

Question 12

Describe the features of paediatric hypotonia. (5)

Answer 12

Hypotonia
Characterised by diminished resting muscle tone & decreased ability to generate
voluntary muscle force, decreased activity tolerance, decreased strength, rounded
shoulder posture, hypermobile joints, increased flexibility, poor attention and
motiviation, and gait deviations.

Question 13

Define Cerebral Palsy. (5)

Answer 13

(1)Describes a group of permanent disorders of the development of movement & posture.
(2)Causes activity limitation, that are attributed to
(3)non-progressive disturbances that occurred in the developing foetal or infant brain.
(4)The motor disorders of CP are often accompanied by disturbances of sensation, perception, cognition, communication, and behaviour , by epilepsy, and by secondary musculoskeletal problems.
(5)Most of all the main complications experienced are fluctioations, hyper or hypo tonus.
(6)Although the damage to the motor brain is static, the motor manifestations are often dynamic in nature due to fact that brain maturation continues through childhood, resulting in a dynamic clinical picture despite a static pathology.

Question 14

Give a brief overview of the gross motor milestones babies achieve during the first
trimester (0-3 months). (10)

Answer 14

1.Can smile.

2.Symmetrical kicking.

3.Flexion abduction of limbs.

4.Head control developing: flexion activates, abdominals.

5.Dissociation of head from eyes.

6.Antigravity flexor control starting to develop.

7.Propping on forearms.

8.Pushes distally for proximal control.

9.Antigravity extensor control is developing.

10.Elongation of head and neck flexors with extension of neck.

Question 15

Give a brief overview of the gross motor milestones babies achieve during the second
trimester (4-6 months). (10)

Answer 15

1.Combination of flexion & extension against gravity, with easy interaction between the
two.

2.Dissociation between two sides of the body.

3.Beginning of rotation

4.Building up of tone stability

5.Can get hands to feet in supine

6.Can push up on extended arms in prone

7.Can roll

8.Can sit alone when propped

9.Has developed head & trunk control

10. Practicing antigravity control in standing

Question 16

Give a brief overview of the gross motor milestones babies achieve during the third trimester(7-9 months). (10)

Answer 16

1. Movement against gravity.
2. Sequences of movement.
3. Movement through space.
4. Can sit independently.
5. Starts to crawl.
6. Moving in & out of sitting.
7. Pulls to stand.
8. Stands with support.
9. Practice of rotation in standing.
10. Does not have full control in going down to the floor.

Question 17

Give a brief overview of the gross motor milestones babies achieve during the fourth trimester (10-12 months). (10)

Answer 17

1. Activity refinement:
   – Dissociation.
   – Selectivity.
   – Balance.
   – Manipulation.
2. Further anti gravity progression:
   – Standing balance.
   – Cruising.
   – Walking.
   – Climbing.
3. Improved proximal stability:
   – Hand function.
   – Balance reactions.

4.Movement variety.

5. Grading of movement into gravity.
6. Cruises.
7. Developing balance in standing.
8. Problem solving in new situations.
9. May walk on toes.
10. Sequencing in & out of positions improves.

Question 18

Define muscle tone. (2)

Question 19

Describe the four types of muscle tone that may be seen in a child with
cerebral palsy. (8)

Answer 19

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Question 20

Moses is a nine year old boy with moderate Spastic diplegia who is under your care.
You are worried about his gait pattern and have noticed that increased muscle tone
in his knee flexors and ankle plantar flexors are inhibiting his progress.
Discuss the surgical and non-surgical procedures available that could assist him in
reaching his full potential. (10)

Answer 20

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Question 21

Define spinal muscular atrophy Type Il. (5)

Answer 21

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Question 22

Using physiotherapy principles, explain how you would treat a child with this
condition. (spinal muscular atrophy Type II) (10)

Answer 22

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Question 23

Explain postural tone in terms of the normal postural control mechanism. (5)

Answer 23

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Question 24

Name and discuss the three groups of reactions that work together to form the normal postural control mechanism. (15)

Answer 24

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Question 25

Mpho presents with quadriplegic hypotonia cerebral palsy.
Describe the features you would see in Mpho and discuss her physiotherapy management. (15)

Answer 25

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Question 26

Johnathan has recently been diagnosed with Duchennes Muscular Dystrophy. Explain the condition to his mother. (5)

Question 27

List some of the signs that could indicate a delay in development during this
trimester? (5)

Question 28

A child is brought to you, as his parents are worried that he is not developing
appropriately and may have cerebral palsy.

Question 29

A child is brought to you, as his parents are worried that he is not developing
appropriately and may have cerebral palsy.

Question 30

A child is brought to you, as his parents are worried that he is not developing
appropriately and may have cerebral palsy.
What abnormal signs and patterns of movement would you assess for? (12)

Answer 30

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Question 31

Define cerebral palsy. (3)

Question 32

James is a five year old boy who presents with severe spasticity in all four limbs due
to cerebral palsy.
Explain the physiotherapy treatment principles for severe spasticity. (10)

Answer 32

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Question 33

Define myelomeningocoele is and list three possible clinical signs associated with
this syndrome. (5)

Question 34

Give a brief overview of the milestones babies achieve during the third trimester of their first year. (5)

Question 35

Describe some of the signs that could indicate a delay in development during this
trimester? (third trimester of the first year) (5)

Question 36

A child is brought to you as his parents are worried that he is not developing appropriately and may have cerebral palsy.
Describe the patterns of movement that could be visible in this child. (12)

Answer 36

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Question 37

Discuss spinal muscular atrophy and the principles of physiotherapy management. (10)

Answer 37

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Question 38

Describe what a meningocele is and name three clinical characteristics of this condition. (5)

Question 39

An eight year old child with Duchenne’s Muscular Dystrophy has been referred to you.
Explain this condition. (5)

Question 40

An eight year old child with Duchenne’s Muscular Dystrophy has been referred to you.
Using physiotherapy principles explain how you wouid treat this child. (10)

Answer 40

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Question 41

Discuss the four types of muscle tone that may be present in a child diagnosed with
Cerebral Palsy. (12)

Answer 41

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Question 42

Define spasticity. (2)

Question 43

Discuss the pathology of spasticity in terms of the neural and non-neural
components. (8)

Question 44

A child with developmental co-ordination disorder (DCD) has been referred to you.
Discuss this condition and the physiotherapy principles of how you would treat this child. (20)

Answer 44

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.