Test 2 Flashcards
Cerebral palsy
a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non progressive disturbances that occurred in the developing fetal or infant brain
The motor disorders are often accompanied by disturbances of sensation, perception, cognition, communication, and behavior, by epilepsy, and by secondary musculoskeletal problems
Cerebral palsy definition
brain lesion is static musculoskeletal impairment is progressive - muscle/ tendon contracture - bony torsion - hip displacement - spinal deformity
CP primary impairments
spasticity
impaired postural control
impaired selective voluntary motor control
impaired sensory processing
CP secondary impairments
muscle or tendon contractures
skeletal deformities
decreased strength
limited endurance
CP epidemiology
most common motor disability in children
- 764,000 individuals with CP in the US (adults and children)
-3.1-3.6/1000 children have CP
more common in boys than girls
cerebral palsy risk factors
low birth weight: <1500g or 3.3lbs
prematurity: 28-31 weeks
classification of CP
location of brain lesion
- pyramidal, extrapyramidal, mixed
Type of movement disorder
- athetoid, spastic, dystonic, ataxia, mixed
Extent and location of limb involvement
- monoplegia, diplegia, hemiplegia, paraplegia, tetraplegia
function (GMFCS)
spastic CP
increased tone and stiff muscles
70-80% of CP
white matter injury
Dyskinetic type CP
abnormal movement patterns
athetoid vs. chorea
10-20%
ataxic CP
abnormal movement patterns
10%
hypotonic CP
low muscle tone
10%
monoplegia
one extremity
diplegia
impairment of bilateral LE and UE
LE more involved/ impaired vs UE
Hemiplegia
impairment of UE/LE of same side of body
Triplegia
3/4 extremities involved
quadraplegia/ tetraplegia
all extremities involved
GMFCS level 1
Walks without limitations
- uses no AD
- can walk indoors and outdoors and climb stairs with no limits
- can perform usual activities such as running and jumping
- has decreased speed, balance, and coordination
GMFCS level 2
Walks with limitations
is limited in outdoor activities
has the ability to walk indoors and outdoors and climb stairs with railings
has difficulty with uneven terrain, hills, or crowds
has minimal ability to run or jump
difference between GMFCS level 1 and 2
level 2 has limitations walking long distances and balancing
level 2 may need a hand held mobility device when first learning to walk
level 2 may use wheeled mobility when traveling long distances outdoors and in the community
level 2 requires the use of a railing to walk up and down stairs
not capable of running or jumping
GMFCS level 3
uses hand held mobility device
walks with assistive mobility devices indoors and outdoors on level surfaces
may be able to climb stairs using railing
may propel a manual w.c with assistance needed for long distances or uneven surfaces
differences between GMFCS levels 2 and 3
children in level 2 are capable of walking without a hand held mobility device after age 4
level 3 need a hand held mobility device to walk indoors and use wheeled mobility outdoors and in the community
GMFCS level 4
self mobility with limitations; may use powered mobility
self mobility severely limited even with AD
uses w/c most of the time and may propel their own power w/c
difference between GMFCS level 3 and 4
level 3 can sit on their own or require at most limited external support to sit
level 3 more independent in standing transfers and walk with a hand held mobility device
level 4 function in sitting (usually sitting) but self mobility is limited)
level 4 are more likely to be transported in manual wheelchair or use powered mobility
GMFCS level 5
transported in manual w/c
physical impairments that restrict voluntary control of movt and ability to maintain head and neck position against gravity
impaired in all areas of motor function
cannot sit or stand on their own even with equipment
cannot do independent mobility
- may be able to use a power chair
difference between GMFCS 4 and 5
level 5 have severe limitations in head and trunk control and require extensive assistive technology and physical assistance
self mobility achieved only if the child can learn how to operate a powered w/c
child/ family/ caregiver interview and chart review
birth-5 yrs
- birth history; prenatal and perinatal problems
- may not be formally diagnosed until 1-2 years of age but can still demonstrate signs of CP
6-21 yrs
- focus on functional skills
Adults
- 65-90% of children with CP live into their adult years
cognition and CP
cognitive deficits are not inherent with CP
independent mobility impacts learning opportunities
CP participation
birth-12 years - play and parent/ caregiver child interactions - teacher-child and peer interactions 13-21 years - mobility needs for participation - post secondary transition - transition to adult services Adult - career/ community/ family roles
ROM and CP
observe AROM; measure PROM goniometry or clinical observation specific considerations/ muscle groups - test hip ext in knee flex/ext - problems with hip ABD/ ADD - knee ext
CP alignment and posture
postural symmetry hip joint integrity LE alignment Leg length discrepancy scoliosis growth overuse syndromes
CP and bone health
at risk for osteoporosis and osteopenia
Adults with CP have increased stress and strain on their bodies over time
early development of OA
individuals with CP are at an increased risk for pain with causes including:
surgical procedural GI orthopedic Neuromuscular rehabilitative
Pain assessment- FLACC
Face legs activity cry consolability
Spastic CP and standing
up on toes
knees extended
hips ADD and IR
pelvis in anterior tilt
crouched posture and CP
ankle DF
knee flex
hip ADD, FLEX, IR
sitting posture with CP
with decreased hamstring ROM
- knees in flexion
- posterior pelvic tilt
- compensatory lumbar and thoracic kyphosis
- neck hyperextension
Scoliosis and CP
seen in 25% of children with CP
increased incidence with increased CP severity
results from:
- decreased stability
- atypical postures
- atypical muscle pull or muscle imbalances
- leg length inequality–> pelvic asymmetry
pelvic and hip problems with CP
result from:
- body abnormalities
- alignment
- muscle abnormalities, length, function
- ROM limitations
- hypertonicity–> hip flexion, AD, IR
Pelvic alignment abnormalities and CP
obliquity–> leg length inequality
posterior pelvic tilt–> limited hamstring ROM
anterior pelvic tilt–> hip flexor tightness
hip subluxation or dislocation and CP
18-50% of kids with CP
from both bony and muscular factors
with CP, delayed motor milestones, decreased WB forces at an early age
- hip instability
- atypical muscle pull/ spasticity: decreased ABD rom and hip flexion contractures
- critical ROM for hip stability: 30 deg ABD and avoid hip flexor contractors >20-25 deg
torsional conditions and CP
foot angle progression
femoral anteversion and retroversion
tibial torsion
- thigh, foot axis
decreased DF ROM and CP
due to shortened gastroc - hypertonicity - decreased stability around the ankle - PF position during WBing Concerns: - affects positioning in orthoses or shoes - significantly reduces BOS
equinovalgus and CP
flatfoot
breakdown of longitudinal arch
decreases ankle/ foot balance reactions
motor control and balance and CP
delayed reactive and anticipatory postural control and postural sway
may lower the COG by flexing the knees with feet in either excessive PF or DF
greater reliance on prox muscles for balance
- hip and stepping strategies more than ankle
difficulty maintaining postural control in stationary postures
sensory function and CP
clinical observation
responses and reactions to tactile, auditory, visual, and vestibular stimuli
alterations in proprioception, vision, and vestibular information and integration
- sensory feedback may be inaccurate,delayed, and/or insufficient for assisting with learning more coordinated movement
balance assessment and CP
reaching and playing in sitting, standing, walking
balance during transition between positions
objective measures
- Movement assessment of infants
- pediatric balance scale
- early clinical assessment of balance
- pediatric reach test
ambulation dysfunction classification in CP
jump - hip and knee flexion in stance - PF in stance Crouched - hip and knee flexion throughout stance - gastroc insufficiency Recurvatum - knee hyperextension mid to late stance Stiff - decreased flexion in swing
spasticity in CP
Tardieu's R1 and R2 R1- point of first catch - dynamic end point - dependent on patient position - tested with fast velocity R2- passive length - equivalent to PROM - full range when muscle at rest and tested with velocity as slow as possible
timing errors in muscle recruitment in CP due to
inability to use selective voluntary motor control
recruit both agonist and antagonist simultaneously
impaired reciprocal inhibition
disorderly and slower motor unit recruitment
- not completely activated
- decreased force production and weakness
Reinforcement of abnormal neural circuits
- from repetitive abnormal movement patterns
timing errors in muscle recruitment in CP results in
delayed initiation of movement
decreased rate of force production
prolonged muscle contraction
disrupted timing of agonist to antagonist activation
difficult dissociating individual limb or joint movements
CP- compensate for weak musculature and poor posture control by doing what?
actively co contracting or fixing muscles
- decreases DF to be controlled during activities
- continued use of co contraction may lead to further muscle weakness, joint contractors, and poor postural and prime movement control
Gross motor function measure
clinical measure to evaluate change in gross motor function
use with natural history to guide treatment
samples motor skills that are typical of normal developmental milestones up to age 5
GMFM dimensions
lying and rolling sitting crawling and kneeling standing walking, running, jumping
GMFM scoring
4 point scoring system for each item 0- does not initiate 1- partially initiates 2- partially completes 3- completes
GMFCS 1,2,3 treatment goals
development of gross motor skills
- standing, walking, running, jumping, etc.
- promotion and maintenance of ms integrity
- prevention of secondary impairments
- enhancement of functional postures and movement
- maintenance of optimal levels of fitness and overall health
GMFCS 4 and 5 treatment goals
early continuous postural management programs
use equipment as needed
sitting- 6mos of age
standing- 12 mos of age
infant interventions for CP
educate families
- provide support with acceptance and coping
- promote parent’s abilities to care for and interact with their child
Remain realistic about the prognosis and efficacy of PT while remaining hopeful and providing options for interventions
Address handling and positioning needs
facilitate optimal sensorimotor experiences and skills
- postural stability
- smooth mobility
preschool interventions for CP
promote functional independence development of locomotor, cognitive, communication, fine motor, self care, and social abilities prevent secondary impairments optimize gross motor skills promote independent mobility
school age, adolescent, and adult interventions for CP
maintain achieved level of activity participation in age appropriate activities/ interests health promotion and physical activity prevent secondary impairments considerations: - growth - pain - decreasing muscular ROM - puberty - cumulative physical overuse - more active and independent lifestyle
context focused therapy interventions for CP
participation based
address changing or adapting environmental factors to help increase the child’s participation and improve performance of activities
rationale for positioning with CP
improves head position and control
increases arm control
improves ability to eat, digest, and breathe
postural alignment
facilitates social interactions
improves ability to listen, speak, and communicate
encourage motor development, exploration, and play
physiological benefits to supported standing with CP
improved bone density improved hip stability improved LE ROM improved spasticity allows for more typical remodeling of the head of the femur and the acetabulum
AFOs and CP
controls PF
maintain longitudinal arch
reduce hyperextension during stance
eliminates movement of the ankle
disuse atrophy of the ankle musculature
Serial casting and CP
3-6 weeks of successive casting
decreases resistance to passive stretch
increased DF ROM
helps eliminate heel cord contracture
tendon lengthening and CP
cut in the tendon allows it to elongate
gastrocnemius, hamstrings,hip adductors
tendon transfers and CP
moves the tendon to a new attachment on the bone allowing a more relaxed position and/or more efficient pull
UE- extensor muscles (primarily wrists)
femoral derotational osteotomy and CP
used to achieve better alignment of the head of the femur and the acetabulum
selective dorsal rhizotomy and CP
sensory nerve rootlets from the LE are cut selectively to create a balance between eliminating spasticity and preserving function
post surgery need PT to work on increasing strength
GMFCS 3 and 4
botox and spasticity
neuromuscular junctions near the injection sites inactivated for up to 4 months
common muscles targeted:
- gastrocnemius, hamstrings, hip flexors, hip adductors, upper extremities
Baclofen and spasticity
reduces spasticity mainly in LE
improvements in function and ease of caregiving
may cause drowsiness
passive stretching and CP
may be beneficial before and after exercise to warm up and prevent injury
NOT effective in increasing ROM, reducing spasticity, or improving walking efficiency in children with spasticity
- maintaining current muscle length requires the muscles to be elongated for 6+ hours per day
- low load prolonged stretching is more effective than manual
strength training and CP
does NOT increase spasticity
weakness impacts function
isotonic training more effective than isokinetic
functional physical training and CP results in improvements in what?
aerobic endurance anaerobic capacity walking distance agility muscle strength functional ambulation
body weight supported treadmill training and CP
improves gross motor function and functional mobility in children with CP following orthopedic surgery
may be effective to improve gait, endurance, and walking
not enough evidence to support earlier independent walking or improved functional outcomes
CIMT/ forced use therapy and CP
functional training of more affected UE while less affected UE is restrained
improve hand function in those with hemiplegia
improvement in motor performance, daily function, and reaching, and health related QOL compared with traditional therapy
hippotherapy and CP
improved
- trunk/ hip muscle symmetry
- posture and stability
- balance
- reaching
- gross motor function
- walking and gait
- running and jumping
conductive education and CP
integrates education and rehab goals
conductors teach children to gain control over movements and to learn new movements for improved function
repetition, verbal guidance, and rhythm
