CP Part 2

Question 1

what is developmental monitoring and who is primarily responsible for this

Answer 1

growth & development
- normal variation vs atypical

monitored by pediatrician/ family

Question 2

who is involved (what is the chain of referrals) w developmental and medical evals

Answer 2

primary care

refer to: developmental pediatrician, pediatric neurologist, pediatric physiatrist

PT/OT; early intervention team

Question 3

what tests are involved and why w developmental and medical evals

Answer 3

tests to determine causes
- imaging, EEG, TIMP

Question 4

what is the accuracy of the dx

Answer 4

many issues are transient (don’t want false positives) - but parents usually know

mod to severe CP more accurate than mild CP

Question 5

what are the primary goals of medical management

Answer 5

improve function
dec pain

Question 6

what are the primary foci of medical management (3)

Answer 6

spasticity management
MSK alignment
treatment of co-morbidities (ie sz)

Question 7

what is one sx w the only effective medical management and what is it

Answer 7

dystonia
- use of botox

Question 8

what is a key question to ask when it comes to spasticity management

Answer 8

is it a limiting factor?

Question 9

what management is indicated if spasticity isn’t a limiting factor and why

Answer 9

perhaps don’t intervene

spasticity isn’t necessarily a bad thing:
- can be used to stay upright, WB, amb
- can be used to transfer (ie lazy susan example)

Question 10

if spasticity is a limiting factor, what management is indicated and when

Answer 10

PT - temporary management for improved alignment as prep for functional task completion/practice

medical - when rehab isn’t enough

Question 11

what are the 4 main goals of spasticity management

Answer 11

1. improve acquisition of skills
2. prevent secondary complications
3. facilitate hygiene
4. improve voluntary control

Question 12

what are 3 factors in clinical decision making with spasticity management

Answer 12

1. severity, duration, distribution
2. co-morbidity (ie sz disorder, other health conditions)
3. other, eg cog deficits, motor control

Question 13

what are 4 related reasons to see improvement with spasticity management

Answer 13

1. medical intervention for condition
2. CNS neuroplasticity
3. motor learning
4. normal sensory input

Question 14

what is the mechanism of baclofen med and how does it act

Answer 14

analog of GABA, inhibits reflex activity
- neurotransmitter helps to inhibit neuronal activity -> helps to dec spasticity

oral baclofen - centrally acting, see side effects as a result

Question 15

what side effects are seen w oral baclofen (5)

Answer 15

drowsy
fatigue
nausea
dizziness
HA

Question 16

what is a baclofen pump and in what cases is it utilized in

Answer 16

surgically implanted in abdomen

used in GMFCS IV or V

Question 17

what are 3 spasticity meds

Answer 17

baclofen
botox
dantrolene

Question 18

what is baclofen and dantrolene doing to dec spasticity vs

Answer 18

baclofen and dantrolene
- centrally weakening abnormal ms response (via different pathways)

botox
- local temporary ms paralysis via a neuromuscular block

Question 19

what is the mechanism of dantrolene and what does this do

Answer 19

impairs release of Ca from sarcoplasmic reticulum
- dec intensity of ms contraction -> dec spasticity

Question 20

at are 2 side effects of dantrolene

Answer 20

generalized weakness
liver toxicity (LFTs to monitor)

Question 21

what is the mechanism of botox and how does it dec spasticity

Answer 21

blocks acetylcholine @NM junction
- temporary ms paralysis (axons will sprout)

Question 22

what are 5 indications for botox in spasticity

Answer 22

improve function
prevent MS complications
dec pain
improve ease of care
appearance

Question 23

what are 2 limitations of botox

Answer 23

short term
neutralizing antibodies can be developed if used too often

Question 24

what is PT’s role w botox and what does the research say

Answer 24

PT critical - stretching, bracing, functional exercise

research: improved outcomes when PT + botox vs botox alone

Question 25

how can serial casting be utilized with botox

Answer 25

takes advantage when ms paralyzed and more flaccid w botox

casting benefits:
- stretch soft tissues
- inc PROM
- future orthotic use

Question 26

what does the evidence say ab serial casting w botox

Answer 26

research is mixed as to combo of both vs either one alone
- but good outcomes clinically when both utilized

Question 27

what is selective dorsal rhizotomy (SDR) and how does this reduce spasticity

Answer 27

neurosurgery
- sensory nerve rootlets are severed which reduces spasticity

Question 28

what is PT’s role in an SDR

Answer 28

intensive PT is required
- need to have support and resources to comply w this

Question 29

what are 5 qualities making someone an ideal candidate for SDR

Answer 29

1. ambulatory spastic diplegic CP
2. spasticity > dystonia
3. adequate underlying strength
4. able to co-operate w post-op rehab
5. 4-8yo

Question 30

what is a spinal laminectomy

Answer 30

select dorsal roots that produce exaggerated motor response when stimulated
- cut/prune some of those to reduce exaggerated response

Question 31

what quality is focused on by medical management to improve MSK functioning

Answer 31

bony deformity and lever arm dysfunction
- root of many MSK problems

Question 32

what are 3 MSK disorders that require a referral to an orthopedist

Answer 32

spinal curvatures (prone to scoliosis)
hip migration
ms length restrictions

Question 33

what is often required since kids w CP are prone to scoliosis

Answer 33

some type of fixation
- rod or wiring to prevent further progression

Question 34

what is often the medical management for hip migration and what is the goal

Answer 34

surveillance
- process and frequency based on GMFCS level

goal - monitor integrity of hip joint and px for dislocation/subluxation
- looking at degree of acetabular coverage of femoral head

Question 35

what are the 3 main medical interventions for ms length restrictions and when do you see them

Answer 35

first try - surgical fascial release
last resort - retract ms itself

z-plasty - retract ms into tendon and cut in certain way to elongate ms
- *** PT really important in these cases

Question 36

what are 2 complications/considerations of neurosurgery as a medical intervention

Answer 36

1. ms tone substitute for strength
   - may be allowing GMFCS III or IV to walk “on” spasticity; if remove -> wc dependent
2. poor ability to rehab after SDR

Question 37

what are 6 complications/considerations of orthopedic surgery as a medical intervention

Answer 37

1. lengthening = weakening
2. lengthening when not necessary
3. too little surgery
4. ortho surgery w/o tone management
5. tone management w/o correction of bony abnormalities
6. any surgery w/o adequate rehab