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Pediatrics > CP > Flashcards

CP Flashcards

1
Q

How is CP diagnosed?

A

Not one thing diagnoses:

  1. dx through imaging - MRI; lesion doesn’t necessarily correlate with degree of disability, amt of damaged wh matter does; US to dx bleeds
  2. formalized testing
  3. clinical assessement/ observation - doesn’t meat motor milestones, exhibits abnormal m tone, or qualitative diff in movement
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2
Q

Where is the damage for spastic, athetoid, ataxic an hypotonic CP?

A
  • Spastic = motor cortex or wh matter projections to and from cortical sensorimotor areas
  • athetoid = BG (intermittent m tension and involuntary movement patters)
  • ataxic = cerebellar (instability of movement)
  • hypotonic = unknown where lesion is (diminished resting tone and decr ability to generate m force)
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3
Q

What are key predictors that decrease life span in a child with CP?

A
  1. Decreased mobility

2. poor feeding

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4
Q

When is most of the motor potential achieved for GMFCS level 1? level 5?

A

1 - 90% motor potential achieved by 5
5 - motor potential achieved by 3
- motor potential = basic developmental skills, postural control

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5
Q

How can you prognose walking capability in children with CP?

A
  1. Persistence of Primitive Reflexes (Bleck) - greater persistence = bad
  2. Type of CP - hemi = high prob, quad = low prob
  3. Sitting without support (Molnar and Gordon) and pulling to stand by 2 years of age
  4. Creeping on hands and knees and rate of acquisition of motor milestones before 30 mo.
  5. Independent transfer of sitting to standing and standing to sitting in young children = strength as predictor (biggest factor)
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6
Q

CP characterized by:

  • Early lack of physiological flexion
  • Weak postural muscles
  • As child fights gravity, extremities demonstrate increased mm tone
  • Transitional vertebrae become hypermobile; the rest become hypomobile
  • Inappropriate sequencing and coactivation of synergists and antagonists
A

Spastic

  • reduced reciprocal inhibition of antagonist motoneuron pools by Ia affarents, decreased presynaptic inhibition of Ia afferents, decreased nonreciprocal inhibition by Ib afferents; Reciprocal inhibition is reduced
  • Decreased force production may be due to Mechanical changes in the muscle rather than to increased stretch reflex from spasticity
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7
Q

CP characterized by:

  • Hypotonic early
  • Not capable of midrange control**
  • Movement can trigger pathological reflexes and/or synergies
  • Asymmetrical
  • Visual disorganization severe
  • Extensor tone is dominant-although total flexion is not unusual
  • Reduced risk of contractures
A

Athetoid

- midrange control - can get on POE, but can’t reach; can walk but can’t reach and bend knee in static standing

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8
Q

CP characterized by:

  • Not often a problem from birth
  • Usually problems with gait and upright control
A

Ataxic

- more of a problem when upright

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9
Q

CP characterized by:

  • Undiagnosed degenerative disorder
  • Precursor to athetosis
  • Not uncommon to see hypotonic trunk in spastic, athetoid, and ataxic types
A

hypotonic

- usually mixed with outer CP types

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10
Q

What are primary impairments in CP?

A
  1. Changes in muscle tone - Hyperactive Reflexes
  2. Impaired Postural stability
  3. Impaired Motor Coordination
  4. Insufficient Force Production (both primary and secondary)
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11
Q

What are secondary impairments in CP?

A
  1. Decreased ROM - Joints commonly at risk for contracture*; Shoulder adductors, elbow, wrist, and finger flexors, hip flexors and adductors, knee flexors, ankle PF’s
  2. Decreased Force Production - Poor selective control of muscle activity; UMN lesion makes it difficult to fire a single m and enough m units in that m (No significant correlation between spasticity and weakness)
  3. Poor muscle regulation in anticipation of postural changes and movement
  4. Difficulty learning unique movements due it inability to produce isolated motor movements
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12
Q

When do secondary impairments begin to present?

A

as young as 18-30 months

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13
Q

What are some of the potential Clinical Manifestations of these secondary impairments?

A

Orthopedic malignment

- torsion, hip subluxation, scoliosis, calcaneovalgus, equinovarus, windswept hips, pelvic obliquities

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14
Q

During an eval, what parts of a child’s history is especially improtant to include in children with CP?

A
  1. Parents concerns
  2. Prenatal, Birth, and Post Natal history
  3. US or MRI imaging
  4. Medications
  5. PMH including hospitalizations and surgeries
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15
Q

What should you ask about in regards to nutrition?

A

What, how, and how much intake

  • make referral recommendations SLP:
  • is the child able to manage secretions?
  • speech/ lang/ cog
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16
Q

What should you observe for posture?

A
  1. How is the infant/child held? and/or in what device are they positioned
  2. Resting and Active?
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17
Q

What should you observe for voluntary movements?

A
  1. Normal/Abnormal patterns of movement?

2. Does effort to move result in increased tone?

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18
Q

What should you observe for mobility?

A
  1. Primary means of mobility.. Or are they held or carried the entire time
  2. Independent or assist
  3. Assistive Device?
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19
Q

What should you assess for the musculoskeletal part of the examination?

A
  1. ROM - R1/R2 and capsular tightness
  2. Strength - extremities, core, movement isolation, m testing (?); need voluntary isolated control
  3. Special tests - Ryder’s, femoral and tibial torsion, foot angle, etc.
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20
Q

What should you assess for the neuromotor part of the examination?

A
  1. M tone - m ash worth scale; activities that result in more/ less tone
  2. Primitive reflexes and how they interfere - ATNR, Moro, and Startle most important
  3. Development of postural rxns - Supine, prone, sitting, 4 point, standing; Righting/Equilibrium; Protective**
  4. Sensory - Sensation, vestibular, proprioception
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21
Q

What should you assess for the combined musculoskeletal and neuromotor part of the examination?

A
  1. Muscle Function
    - Co-activation/Reciprocal inhibition
    - Initiate/sustain/terminate movement
    - Concentric/ Eccentric/ Isometric
    - Weight Bearing and Weight shifts
    - Rotation
    - Compensatory Patterns: What happens because of abnormal tone, sensation etc.; Can it be corrected with orthotics, therapy, lenses etc.
  2. Posture - Alignment and Control
22
Q

What should you assess for the mobility/ gait part of the examination?

A
  1. Rolling/creeping/gait pattern
  2. Balance/Safety?
  3. Wheelchair vs. Ambulation
  4. Effort/Energy
    - ENVIRONMENTAL EXPLORATION is the most important factor for the child
23
Q

What should you assess for the GM and fxn part of the examination?

A
  1. Qualitative and Quantitative
  2. Developmental positions - Supine, prone, sitting, 4 point, tall kneel, standing
  3. Weight bearing and Weight shifting
  4. GM and FM skills - Including environmental obstacles; Observation or Standardized test
24
Q

What are some other areas to make sure to examine?

A
  1. Auditory
  2. Body Awareness
  3. Response to touch and handling
  4. Respiratory/ endurance/ Cardiovascular!!!!
  5. Social-emotional
25
Q

When should we be seeing children with CP and how often?

A
  • need early intervention during critical periods (where curve is, GMFCS 4 and 5 plateau early, level 2 may need more therapy to reach full potential)
  • see them 1-2 times per week in curves
  • receive episodic care after
26
Q

What are intervention goals for working with children with CP?

A
  1. Prevention of Limited Participation
  2. Minimize the effects of impairments on activity and participation
  3. Preventing or limiting secondary impairments** - Prevent of prolong need for surgical intervention
  4. Maximizing motor function
  5. Maximizing functional skills (primarily mobility)
  6. Prevent environmental deprivation
27
Q

What are typical impairments in children with CP?

A
  1. Lack of trunk rotation**
  2. Asymmetry**
    - Spasticity (tightness), weakness, decreased postural control, decreased mobility, decreased play and exploration, decreased cardiovascular fitness, hyper or hyposensory, abnormal static and dynamic postures
28
Q

What are the general treatment principles for increased m tone?

A
  1. Increase movement
  2. Decrease the negative impacts of increased or decreased mm tone
  3. Gradually work them back into positions when child gains more control
  4. Work out of a total pattern (Isolation)
  5. Get them in a posture and have them hold it
  6. Incorporate into everyday life through motor learning
29
Q

What are the general treatment principles for athetoid and ataxic tone??

A
  1. Develop midrange control or provide it
  2. Therapists OR equipment is needed to initially give the postural control
  3. Prevent positions/movements that that totally disorganize the system-extension
  4. Head control for visual organization
  5. Emphasize symmetry
  6. Consider increasing proprioception through weighted equipment/apparel
  7. Provide upper extremity weight bearing
    - athetoid tone = emphasize proprioception (i.e., weight to arm for reaching)
30
Q

Can you do strengthening interventions if a child has spastic cp?

A

yes

  • strengthening does not increase spasticity
  • spastic m’s can be strengthened
31
Q

Should you stretch someone with CP?

A

you can but..

  • increased length may not translate in function; limited evidence to support annual stretching in and its increase in ROM, reduction in spasticity, and improvement in walking efficiency
  • needs to be prolonged stretch (AFO, knee immobilizer, etc. or serial casting); addition of botox is possible; does not help if contracture is present
  • BEST way to effect m elongation is through ACTIVE MOVEMENT!
32
Q

Should children with CP exercise?

A

Yes! activity is essential:

  • signif improvement in aerobic and anaerobic capacity agility m strength
  • signif improvement in participation and HRQOL
33
Q

What are the exercise recommendation for children with CP?

A
  1. Promote participation in regular physical activity and sports
  2. General training repertoire should include functional muscle strengthening, agility, anaerobic components, and balance
  3. The focus of physical training should include high-intensity interval training interchanged with periods of active rest
34
Q

What are the exercise contraindications for children with CP?

A
  1. Should not participate in physical activities or sport when the child has uncontrolled epilepsy
  2. Should not participate in physical activities or sport when the child has severe osteoporosis
35
Q

Synopsis:

  • Limitations in activity and participation are modifiable, interventions are targeted at body structure and function
  • “Handling” to guide movements is key
  • Specific “handling” techniques to achieve outcomes
  • Active carryover by client is essential
  • Understanding how abnormal development departs from typical development allows PT to anticipate undesirable postures and movements
  • Motor and sensory processes are linked, therefore, both must be treated
A

NDT

  • quick stretch, tapping, stroking, vibration for underactive m’s
  • reciprocal inhibition, prolonged stretch, deep pressure, rotation for overactive m’s
36
Q

What are the basic principles for using your hands while performing NDT?

A
  1. Never push, pull or force: FACILITATE
  2. Facilitate to guide-let the baby do the rest
  3. WAIT for the baby to respond and participate
  4. Hands tell the baby how you want him/her to move
37
Q

What are indications for adaptive equipment for children with CP?

A
  1. Decrease recruitment of spasticity
  2. Maintain alignment
  3. Initiate a weight shift
  4. Support a movement
  5. Aid smooth transitions
  6. Increase mobility
  7. Increase Activity/Participation
  8. Improve Play
38
Q

True or false: The more distal the support, the more the client actively works

A

True

39
Q

What does body weight support gait training do for children with CP?

A

improves motor control

  • decr. energy expenditure, incr walking velocity
  • intensive, 30 mins, 2x day for 2 weeks
40
Q

What are the benefits of a gait trainer?

A
  1. bear weight on both feet
  2. develop weight-shifting skills and balance
  3. improve quality of movement
  4. incr lower body strength
    - gator gait trainer complete helps improve endurance and overall GM abilities needed for walking
    - Mulholland walkabout gait trainer = spring assisted ambulating device which allows freedom of mvmnt while offering stability and support; can offer gradual WB adjustments
41
Q

Is there evidence for estim use for children with CP?

A

NMES and TES appears to be supported, but needs to be used in conjunction with direct intervention

42
Q

What are some alternative interventions that can be used for children with CP?

A
  1. Aquatics
  2. Hippotherapy
  3. Virtual Reality
  4. Community Activities - Yoga, Karate, Dance tumbling, music
43
Q

What are tx goals for infants with CP?

A
  1. Facilitate caregiving
  2. Promote optimal sensorimotor experiences and skills
  3. Educate the family
    Positioning, carrying, feeding, 4. and dressing techniques that promote symmetry, limit abnormal posturing and movement, facilitate full lengthening of the muscles
  4. Normal movement
44
Q

What are tx strategies for infants with CP?

A
  1. Trunk Rotation
  2. Disassociation of body segments
  3. Weight shifting
  4. Weight bearing - Adaptive equipment; Clinical decision making…When do you begin
  5. Mobility - How will you achieve?
  6. Isolated movements
45
Q

What is the typical LE standing posture of infants with CP?

A
  1. Asymmetric WB (oblique or retracted pelvis), one short leg, one weaker leg
  2. Hip flexion, adduction, IR, knee flexion, ankle DF, and forefoot abd (crouch)
  3. Knees ext., hips flexed (ant. tilt) adducted and IR, ankle PF (heels off floor)
  4. Hips flexed, knees hyperext., ankles PF (heels on floor) with pronation
46
Q

What are the targeted preschool outcomes for children with CP?

A
  1. Reduce primary impairments and prevent secondary impairments that will limit Activity and Participation
  2. Postural alignment leading to control
  3. Teamwork to establish goals
  4. Functional mobility in all environments
47
Q

What are preschool interventions for children with CP?

A
  1. Increase force generation- Increase demands for production of both concentric and eccentric muscle force
  2. Reduce influence of spasticity on body structure and function and activity/ participation: Dorsal rhizotomy, Baclofen, Botulinim Toxin
48
Q

What are potential limitations for PT with children with CP who are school-aged/ adolescent?

A
  1. Difficult years
  2. May be tired of PT
  3. Self awareness
  4. Less potential for further progress
  5. Surgical interventions
    6 Endurance low
49
Q

What are the outcomes for children with CP who are school-aged/ adolescent?

A
  1. Prevent further contractures
  2. Bone growth exceeds muscle growth
  3. Independence around school
  4. Look ahead toward later life
  5. Improve strength
    - find what motivates them
50
Q

What are the interventions for children with CP who are school-aged/ adolescent?

A
  1. Consultation
  2. Critical periods = Episodic Care
  3. Improving Motion
  4. Mobility & Endurance
  5. Management post skeletal maturation
  6. Drivers training

Pediatrics (19 decks)

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