Chapter 05.1 Cerebral Palsy Flashcards Preview

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Flashcards in Chapter 05.1 Cerebral Palsy Deck (53):
1

Cerebral Palsy: A group of disorders of the development of _______ and _______, causing activity limitations that are attributed to a _______ disturbance that has occurred in the developing fetal or infant brain.

Cerebral Palsy: A group of disorders of the development of movement and posture, causing activity limitations that are attributed to a nonprogressive disturbance that has occurred in the developing fetal or infant brain.

2

The greatest risk factor is _______; _______ _______ is the best predictor of CP in term infants.

The greatest risk factor is prematurity; neonatal encephalopathy is the best predictor of CP in term infants.

3

Risk factors include prenatal, perinatal, and postnatal infection, stroke, toxins, neonatal encephalopathy, complications of _______ (SGA, BW 800 g, IVH), maternal chorioamnionitis, fever during labor, coagulopathy or bleeding, placental infarction, thyroid disease, hyperbilirubinemia, and trauma.

Risk factors include prenatal, perinatal, and postnatal infection, stroke, toxins, neonatal encephalopathy, complications of prematurity (SGA, BW 800 g, IVH), maternal chorioamnionitis, fever during labor, coagulopathy or bleeding, placental infarction, thyroid disease, hyperbilirubinemia, and trauma.

4

CP Movement Type:
________ (70% to 85%);
________;
________;
Ataxic;
Mixed

CP Movement Type:
Spastic (70% to 85%);
Dyskinetic;
Hypotonic;
Ataxic;
Mixed

5

CP Anatomic Distribution
________ (UEx > LEx, one side of body);
________(LEx > UEx);
________ (entire body)

CP Anatomic Distribution
Hemiparesis (UEx > LEx, one side of body);
Diparesis (LEx > UEx);
Quadriparesis (entire body)

6

CP GROSS MOTOR FUNCTION CLASSIFICATION SYSTEM
Level 1. Walks _____ and _____ and climbs _____ without limitations;
Level 2. Walks _____ and _____, climbs _____ with a _____, and has limitations _____ on uneven surfaces and inclines;
Level 3. Walks _____ and _____ on a _____ surface with an _____ device; may climb stairs with a rail and use a manual _____;
Level 4. May walk short distances with assistive device but may rely on _____ mobility;
Level 5. Self-mobility severely limited;

CP GROSS MOTOR FUNCTION CLASSIFICATION SYSTEM
Level 1. Walks indoors and outdoors and climbs stairs without limitations;
Level 2. Walks indoors and outdoors, climbs stairs with a rail, and has limitations walking on uneven surfaces and inclines;
Level 3. Walks indoors and outdoors on a level surface with an assistive device; may climb stairs with a rail and use a manual wheelchair;
Level 4. May walk short distances with assistive device but may rely on power mobility;
Level 5. Self-mobility severely limited;

7

>80% have abnormal neuroimaging, most often ______ following ______ in premature infants, focal cortical infarcts secondary to MCA stroke in hemiparesis, basal ganglia and thalamic lesions in dystonic CP, brain malformations, and generalized encephalomalacia in spastic quadriparesis.;
______ more likely to show an abnormality compared with CT;
Persistence of primitive reflexes after ______ months, ______ or ______ response;
Early ______/failure to use the involved hand;
Early ______ (from tone)

>80% have abnormal neuroimaging, most often PVL following IVH in premature infants, focal cortical infarcts secondary to MCA stroke in hemiparesis, basal ganglia and thalamic lesions in dystonic CP, brain malformations, and generalized encephalomalacia in spastic quadriparesis.;
MRI more likely to show an abnormality compared with CT2;
Persistence of primitive reflexes after 6 months, asymmetry or obligatory response;
Early handedness/failure to use the involved hand;
Early rolling (from tone)

8

CP ASSOCIATED DISORDERS:
________ impairments, especially in hemiparesis;
Hearing, visual, cognitive, psychological, oralmotor, nutritional, genitourinary, respiratory, bone mineral density, and dental impairments;
Seizures in 15% to 55%;
________ dysplasia and dislocation;
Spine – ________, lordosis, and scoliosis;
Spasticity and ________;
Gait impairment: scissoring due to ________ tone, anteversion – intoeing, and psoas and hamstring tightness – crouch gait. Stiff knee ankle PF tone toe gait.

CP ASSOCIATED DISORDERS:
Sensory impairments, especially in hemiparesis;
Hearing, visual, cognitive, psychological, oralmotor, nutritional, genitourinary, respiratory, bone mineral density, and dental impairments;
Seizures in 15% to 55%;
Hip dysplasia and dislocation;
Spine – kyphosis, lordosis, and scoliosis;
Spasticity and contractures;
Gait impairment: scissoring due to adductor tone, anteversion – intoeing, and psoas and hamstring tightness – crouch gait. Stiff knee ankle PF tone toe gait

9

TREATMENT of CP
Therapy: no clear evidence for any particular approach;
________, ________, tone management, and functional training;
Spasticity management: Oral medications, Chemical neurolysis, Intrathecal baclofen;
Selective posterior rhizotomy: Sectioning of a portion of abnormal ________-________ sensory nerve rootlets to reduce excitatory input; Favorable in patients aged 3 to 8 years who have selective motor control and functional strength and lack significant contractures;
Negative effects of selective posterior rhizotomy: hypotonia usually transient, weakness, bladder dysfunction (usually transient), spine deformity including spondylolysis/listhesis, and hip dislocation;
Botulinum toxin: different dosing guidelines for children: Reported distant side effects in children with CP;
Orthopedic surgery: lengthening, transfers, and osteotomy

TREATMENT of CP
Therapy: no clear evidence for any particular approach;
Stretching, strengthening, tone management, and functional training;
Spasticity management: Oral medications, Chemical neurolysis, Intrathecal baclofen;
Selective posterior rhizotomy: Sectioning of a portion of abnormal L2-S1 sensory nerve rootlets to reduce excitatory input; Favorable in patients aged 3 to 8 years who have selective motor control and functional strength and lack significant contractures;
Negative effects of selective posterior rhizotomy: hypotonia usually transient, weakness, bladder dysfunction (usually transient), spine deformity including spondylolysis/listhesis, and hip dislocation;
Botulinum toxin: different dosing guidelines for children: Reported distant side effects in children with CP;
Orthopedic surgery: lengthening, transfers, and osteotomy

10

OUTCOMES of CP: Good prognosis for ambulation
Molnar: independent ______ by age 2 years
Badell: reciprocal ______ at 1½ to 2½ years
Fedrizzi transition: ______ to ______ by 18 months
OUTCOMES of CP: Good prognosis for ambulation
Molnar: independent sitting by age 2 years
Badell: reciprocal crawl at 1½ to 2½ years
Fedrizzi transition: supine to prone by 18 months

OUTCOMES of CP: Poor prognosis for ambulation
Bleck: presence of ______ or more primitive ______ at 18 to 24 months
Life expectancy: reduced with immobility and inability to self-feed
OUTCOMES of CP: Poor prognosis for ambulation
Bleck: presence of three or more primitive reflexes at 18 to 24 months
Life expectancy: reduced with immobility and inability to self-feed

11

Causes of CONGENITAL BRACHIAL PLEXUS PALSY:
Increase in birth ______,
Shoulder ______,
Traumatic delivery,
Breech,
Multiparous

Causes of CONGENITAL BRACHIAL PLEXUS PALSY:
Increase in birth weight,
Shoulder dystocia,
Traumatic delivery,
Breech,
Multiparous

12

Clinical Presentation of CONGENITAL BRACHIAL PLEXUS PALSY:
________ palsy − C5, 6, 7 − 80%
“Waiter's tip” (shoulder irritation and ________, elbow ________ and ________, wrist ________)

Clinical Presentation of CONGENITAL BRACHIAL PLEXUS PALSY:
Erb palsy − C5, 6, 7 − 80%
“Waiter's tip” (shoulder irritation and adduction, elbow extension and pronation, wrist flexion)

13

Clinical Presentation of CONGENITAL BRACHIAL PLEXUS PALSY:
________ palsy C7, 8, T1, rare to occur exclusively

Clinical Presentation of CONGENITAL BRACHIAL PLEXUS PALSY:
Klumpke C7, 8, T1, rare to occur exclusively

14

Clinical Presentation of CONGENITAL BRACHIAL PLEXUS PALSY:
Spontaneous recovery in ________% to ________%

Clinical Presentation of CONGENITAL BRACHIAL PLEXUS PALSY:
Spontaneous recovery in 50% to 90%

15

Associated Injuries of CONGENITAL BRACHIAL PLEXUS PALSY
Facial palsy,
__________,
Clavicle or __________ fracture,
Torticollis,
Cervical spine injury,
Diaphragmatic paralysis,
Horner syndrome (with lower plexus injury),
Examination and Testing

Associated Injuries of CONGENITAL BRACHIAL PLEXUS PALSY
Facial palsy,
Cephalohematoma,
Clavicle or humerus fracture,
Torticollis,
Cervical spine injury,
Diaphragmatic paralysis,
Horner syndrome (with lower plexus injury),
Examination and Testing

16

Sensory of CONGENITAL BRACHIAL PLEXUS PALSY
Reflexes;
ROM;
EDX studies in the first few days, then after several months for re-innervation; ________ present in insensate areas; preganglionic lesion/ root avulsion;
MRI

Sensory of CONGENITAL BRACHIAL PLEXUS PALSY
Reflexes;
ROM;
EDX studies in the first few days, then after several months for rein-nervation; SNAP present in insensate areas; preganglionic lesion/ root avulsion;
MRI

17

Treatment of CONGENITAL BRACHIAL PLEXUS PALSY
Goals are to normalize limb function, optimize nerve regeneration, and allow elbow flexion and shoulder stabilization;
Early pinning to avoid shoulder stretch and gentle ROM to consider pain due to ______ ______;
Position to increase awareness, ROM, splinting, and developmental training;
Surgery indicated if antigravity strength not present at the elbow at ______ months ______;
Other literature cites early surgical intervention between age 3 and 9 months;
Neurosurgery – neurolysis of scar and fibrotic tissue, end-to-end anastomosis, nerve transfer sural or great auricular, and end-to-side neurorrhaphy;
Orthopedic: tendon releases and transfers

Treatment of CONGENITAL BRACHIAL PLEXUS PALSY
Goals are to normalize limb function, optimize nerve regeneration, and allow elbow flexion and shoulder stabilization;
Early pinning to avoid shoulder stretch and gentle ROM to consider pain due to traumatic neuritis;
Position to increase awareness, ROM, splinting, and developmental training;
Surgery indicated if antigravity strength not present at the elbow at 6 months 10;
Other literature cites early surgical intervention between age 3 and 9 months;
Neurosurgery – neurolysis of scar and fibrotic tissue, end-to-end anastomosis, nerve transfer sural or great auricular, and end-to-side neurorrhaphy;
Orthopedic: tendon releases and transfers

18

Complications of CONGENITAL BRACHIAL PLEXUS PALSY
______ ______;
______;
Developmental concerns;
Glenoid dysplasia with posterior subluxation (reduced ER);
Cosmetic;
Pain may be indicated by biting the limb (possibly more in children who had surgery)

Complications of CONGENITAL BRACHIAL PLEXUS PALSY
Muscle atrophy;
Contracture;
Developmental concerns;
Glenoid dysplasia with posterior subluxation (reduced ER);
Cosmetic;
Pain may be indicated by biting the limb (possibly more in children who had surgery)

19

Prognosis of CONGENITAL BRACHIAL PLEXUS PALSY
Recovery by ______ months is a good indicator for normal function,
Poor-grade elbow flexion at ______ months may be predictive

Prognosis of CONGENITAL BRACHIAL PLEXUS PALSY
Recovery by 3 months is a good indicator for normal function,
Poor-grade elbow flexion at 6 months may be predictive

20

DEVELOPMENTAL MILESTONES at 2 months
Raises ______ when prone,
Turns to voice, ______, and responsive smile

DEVELOPMENTAL MILESTONES at 2 months,
Raises head when prone
Turns to voice, coos, and responsive smile

21

DEVELOPMENTAL MILESTONES at 4 months
Lifts head and chest in prone and _____ _____ prone to supine;
Reaches for objects and brings hand to _____ and mouth;
_____.

DEVELOPMENTAL MILESTONES at 4 months
Lifts head and chest in prone and rolls over prone to supine;
Reaches for objects and brings hand to midline and mouth;
Laughs.

22

DEVELOPMENTAL MILESTONES at 6 months
_____ without support,
_____ objects and transfers,
_____.

DEVELOPMENTAL MILESTONES at 6 months
Sits without support,
Grasps objects and transfers,
Babbles.

23

DEVELOPMENTAL MILESTONES at 9 months
_____ alone and tries to crawl and stand,
Emerging _____ grasp with index finger and thumb,
Understands no and bye and babbles repeated sounds (da-da).

DEVELOPMENTAL MILESTONES at 9 months
Sits alone and tries to crawl and stand,
Emerging pincer grasp with index finger and thumb,
Understands no and bye and babbles repeated sounds (da-da).

24

DEVELOPMENTAL MILESTONES at 10 months
_____ to stand and _____,
Finger feeds.

DEVELOPMENTAL MILESTONES at 10 months
Pulls to stand and cruises,
Finger feeds.

25

DEVELOPMENTAL MILESTONES at 12 months
_____ alone,
Points at objects and neat pincer,
Single words.

DEVELOPMENTAL MILESTONES at 12 months
Walks alone,
Points at objects and neat pincer,
Single words.

26

DEVELOPMENTAL MILESTONES at 15 months
Comes to _____ unsupported,
Builds tower of two cubes,
Says four to six words.

DEVELOPMENTAL MILESTONES at 15 months
Comes to stand unsupported,
Builds tower of two cubes,
Says four to six words.

27

DEVELOPMENTAL MILESTONES at 24 months
Walks on stairs with _____,
Follows two-step commands.

DEVELOPMENTAL MILESTONES at 24 months
Walks on stairs with rail,
Follows two-step commands.

28

DEVELOPMENTAL MILESTONES at 30 months
_____.

DEVELOPMENTAL MILESTONES at 30 months
Jumps.

29

DEVELOPMENTAL MILESTONES at 3 years
Pedals _____ and ascends stairs with alternating feet,
Copies a _____,
Knows name and gender.

DEVELOPMENTAL MILESTONES at 3 years
Pedals tricycle and ascends stairs with alternating feet,
Copies a circle,
Knows name and gender.

30

DEVELOPMENTAL MILESTONES at 4 years
Descends _____ with alternating feet,
Tripod pencil grip.

DEVELOPMENTAL MILESTONES at 4 years
Descends stairs with alternating feet,
Tripod pencil grip.

31

Epidemiology and Risk Factors of SCI SPECIFIC TO PEDIATRICS
3% to 5% of all SCIs occur in children under age _____ years.
20% of SCIs under age _____ years.
In children under age 9 years, boys are four times more likely to be affected compared with girls.
Racial difference in those over 15 years: overall increased risk for African Americans and Hispanic Americans.

Epidemiology and Risk Factors of SCI SPECIFIC TO PEDIATRICS
3% to 5% of all SCIs occur in children under age 15 years 13.
20% of SCIs under age 20 years.
In children under age 9 years, boys are four times more likely to be affected compared with girls.
Racial difference in those over 15 years: overall increased risk for African Americans and Hispanic Americans.

32

Causes of SCI SPECIFIC TO PEDIATRICS
1. _____ _____ _____,
2. _____, under 10 years,
3. Sports, 15 to 16 years,

Causes of SCI SPECIFIC TO PEDIATRICS
1. Motor vehicle accident,
2. Falls, under 10 years,
3. Sports, 15 to 16 years.

33

Facts about SCI SPECIFIC TO PEDIATRICS
_____-_____ level most common,
Developing spine is more mobile, favoring stretch injury to ligaments without bony fracture,
Head size relatively large, resulting in higher cervical injuries,
Management – area of difference from adult,
Deep vein thrombosis prophylaxis not clear in children,
Younger children with high lumbar or thoracic levels may be ambulatory with bracing but become more wheelchair dependent at adolescence (more energy efficient).

Facts about SCI SPECIFIC TO PEDIATRICS
C5-C8 level most common,
Developing spine is more mobile, favoring stretch injury to ligaments without bony fracture,
Head size relatively large, resulting in higher cervical injuries,
Management – area of difference from adult,
Deep vein thrombosis prophylaxis not clear in children,
Younger children with high lumbar or thoracic levels may be ambulatory with bracing but become more wheelchair dependent at adolescence (more energy efficient).

34

Epidemiology of SPINA BIFIDA
Risk of having a child with NTD − 0.1% to _____%.
Recurrence if one child has NTD − 2% to _____%.
Recurrence if two children have NTD − 10% to _____%.

Epidemiology of SPINA BIFIDA
Risk of having a child with NTD − 0.1% to 0.2%
Recurrence if one child has NTD − 2% to 5%
Recurrence if two children have NTD − 10% to 15%

35

Risk Factors of SPINA BIFIDA
Environmental – ________ in first 28 days from maternal fever, hot tubs, or sauna
Occupation – ________ exposure, health care workers, and agriculture
Nutritional – folate deficiency (folate ________ mg/day for women of child-bearing years; ________ mg/day prior to conception and through first trimester if previous child with spina bifida or high risk (has maternal diabetes or on valproate))
Maternal – ________ and ________
Maternal medications: ________ ________, antiretroviral drugs, isotretinoin, and ________.

Risk Factors of SPINA BIFIDA
Environmental – hyperthermia in first 28 days from maternal fever, hot tubs, or sauna
Occupation – solvent exposure, health care workers, and agriculture
Nutritional – folate deficiency (folate 0.4 mg/day for women of child-bearing years; 4 mg/day prior to conception and through first trimester if previous child with spina bifida or high risk (has maternal diabetes or on valproate))
Maternal – obesity and diabetes
Maternal medications: valproic acid, antiretroviral drugs, isotretinoin, and methotrexate.

36

Etiology of SPINA BIFIDA
Failure of ________ ________ ________.
________ ________ ________ starts mid-cervical and proceeds caudal and rostral by day 27.

Etiology of SPINA BIFIDA
Failure of neural tube closure.
Neural tube closure starts mid-cervical and proceeds caudal and rostral by day 27.

37

Diagnosis of SPINA BIFIDA: Prenatal screening:
_______ elevated,
high-resolution US splaying of pedicles and _______ and _______ sign,
_______.

Diagnosis of SPINA BIFIDA: Prenatal screening:
α-fetoprotein elevated,
high-resolution US splaying of pedicles and lemon and banana sign,
amniocentesis.

38

Diagnosis of Spina bifida occulta:
bony defect without herniation of _____ elements,
incidental in 5% to 36% of adults,
may have _____ _____, dimple, sinus, or nevus,
may be associated with _____ _____ and bowel/bladder.

Diagnosis of Spina bifida occulta:
bony defect without herniation of neural elements,
incidental in 5% to 36% of adults,
may have hair patch, dimple, sinus, or nevus,
may be associated with tethered cord and bowel/bladder.

39

Diagnosis of Meningocele
bony defect with herniation of meninges but not _____ tissue,
<10% of cases,
examination normal.

Diagnosis of Meningocele
bony defect with herniation of meninges but not neural tissue,
<10% of cases,
examination normal.

40

Diagnosis of Meningomyelocele:
herniation of _____ and _____ elements,
associated with Chiari type 2 malformation in 90%,
hydrocephalus in 80% to 90%,
75% lumbosacral.

Diagnosis of Meningomyelocele:
herniation of meninges and neural elements,
associated with Chiari type 2 malformation in 90%,
hydrocephalus in 80% to 90%,
75% lumbosacral.

41

Diagnosis of Caudal regression:
absence of ______ and parts of ______ spine,
risk factor – maternal ______,
syrinx, anorectal stenosis, renal, cardiac, and external genitalia.

Diagnosis of Caudal regression:
absence of sacrum and parts of lumbar spine,
risk factor – maternal diabetes,
other risk factors: syrinx, anorectal stenosis, renal, cardiac, and external genitalia.

42

Management of SPINA BIFIDA
Closure in the first ______ to ______ hours of life,
In utero repair reported,
Rehabilitation management for ______ training, mobility, and ______ prevention,
Use of bracing depending on level of deficit, wheelchair, seating, and standers.

Management of SPINA BIFIDA
Closure in the first 24 to 48 hours of life,
In utero repair reported,
Rehabilitation management for developmental training, mobility, and deformity prevention,
Use of bracing depending on level of deficit, wheelchair, seating, and standers.

43

Deficits of SPINA BIFIDA
Motor and sensory deficits can be ______.

Deficits of SPINA BIFIDA
Motor and sensory deficits can be asymmetric.

44

Deficits of SPINA BIFIDA
Thoracic – ______ spared except ______,
kyphoscoliosis from weak trunk occurs in 80% to 100%.
LEx contractures from position and wheelchair mobility.

Deficits of SPINA BIFIDA
Thoracic – UEx spared except T1,
kyphoscoliosis from weak trunk occurs in 80% to 100%.
LEx contractures from position and wheelchair mobility.

45

Deficits of SPINA BIFIDA
L1-3 : hip ______ and ______ present; leads to early hip ______ and ______. may ambulate with bracing (______ and ______) and AD if young but stop due to high energy cost.
L4-5: late hip dislocation and scoliosis in 5% to 10%
L5 ______ foot,
L4 ______.

Deficits of SPINA BIFIDA
L1-3 : hip flex and abduction present; leads to early hip dislocation and scoliosis. may ambulate with bracing (HKAFO and RGO) and AD if young but stop due to high energy cost.
L4-5: late hip dislocation and scoliosis in 5% to 10%
L5 calcaneus foot,
L4 calcaneovarus.

46

Bladder Peds
bladder capacity:
first year of life: weight in kg × 7 to 10 mL;
age 1 to 12 years: (age + 2) × 30 mL;
teens/adult: ______ mL

Bladder Peds
bladder capacity:
first year of life: weight in kg × 7 to 10 mL;
age 1 to 12 years: (age + 2) × 30 mL;
teens/adult: 400 mL

47

Bladder studies in Peds:
newborn – baseline _____, _____, and _____;
repeat sono every 3 months in first year, 2×/year in second year, and then yearly;
urodynamics and VCUG at 3 months, then at 1 year, 2 to 3 years, and then every 2 years or for change in status

Bladder studies in Peds:
newborn – baseline US, urodynamics, and Voiding cystourethrogram;
repeat sono every 3 months in first year, 2×/year in second year, and then yearly;
urodynamics and VCUG at 3 months, then at 1 year, 2 to 3 years, and then every 2 years or for change in status

48

Neurogenic bladder treatment − CIC (Clean Intermittent Self-Catheterization by age 5 years if adequate _______ use and cognition), _______ medications, Botulinum toxin, _______, bladder augmentation.

Neurogenic bladder treatment − CIC (Clean Intermittent Self-Catheterization by age 5 years if adequate hand use and cognition), oral medications, Botulinum toxin, vesicostomy, bladder augmentation.

49

Cognitive function, learning problems − higher level > _______ with hydrocephalus having more severe structural brain anomalies.

Cognitive function, learning problems − higher level > T12 with hydrocephalus having more severe structural brain anomalies.

50

Shunt malfunction – _______, _______, _______ changes, concentration difficulty, or other neurological findings

Shunt malfunction – headaches, vomiting, personality changes, concentration difficulty, or other neurological findings

51

Tethered cord – _______, decreased _______, _______, deterioration in neurological status, bowel/bladder changes, contractures, gait deviations, and back pain in only 20% but is the symptom that can improve after surgery.

Tethered cord – spasticity, decreased strength, scoliosis, deterioration in neurological status, bowel/bladder changes, contractures, gait deviations, and back pain in only 20% but is the symptom that can improve after surgery.

52

Diastematomyelia – sagittal _______ of the spinal cord.

Diastematomyelia – sagittal cleavage of the spinal cord.

53

Syringomyelia – in up to 40%, most often _______ Scoliosis or decreased function above lesion level.

Syringomyelia – in up to 40%, most often cervical Scoliosis or decreased function above lesion level.