L11: Cerebral Palsy Flashcards
(80 cards)
1
Q
What is CP?
A
- Group of permanent disorders of the dev. of mvmt and posture→ causes activity limitations that are attributed to disturbances that occurred in the developing fetal or infant brain
2
Q
CP is Static aka
A
NON-progressive in nature
*Umbrella term for any brain injury that occurs IN and AROUND birth thru first few yrs of life
3
Q
CP results from dmg to 3 main areas:
A
- Motor Cortex
-
presentation determined by area of brain dmg (B/L or U/L) and severity
- see homonculus pics
-
presentation determined by area of brain dmg (B/L or U/L) and severity
- BG
- Cerebellum
4
Q
Causes of CP
*NOTE: exact cause for indiv. children not often known
Multiplicity of factors vs single event
Most lesions/dmg happen when?
A
2nd half gestation
5
Q
Prenatal causes CP
35%
A
Infx, inflamm, anoxia, coag disorder, genetics
6
Q
Perinatal causes CP
55%
A
asphyxia, anoxia (PVL, IVH, aspiration), met. cond’s
7
Q
Postnatal causes CP
10%
A
head injury, BI, toxicity, cerebral anoxia, CVA
8
Q
Most common causes CP happen when?
A
Perinatally
55%
- asphyxia, anoxia (PVL, IVH, aspiration), met. cond’s
9
Q
CP Clinical Presentations
4 Mvmt Disorders commonly seen
A
- Spasticity
- Dystonia
- Athetosis
- Ataxia
10
Q
CP clinical presentations
Spastic CP
A
- HypERtonia or rigidity
- MOST COMMON TYPE***
- Hemiplegic, Diplegic, Tetraplegic, Quadriplegic
- Motor cortex dmg
11
Q
MOST COMMON TYPE OF CP
A
SPASTIC!!!
12
Q
CP Clinical Presentations
Dystonia
A
- Abnorm posturing, twisting, rep. involunt. mvmts
13
Q
Clinical Presentations CP
Athetosis
A
- Writhing, distal mvmts
- Uncontrolled mvmts
- BG issue
14
Q
Clinical Presentations CP
Ataxia
“Drunken Sailor”
A
- Flailing mvmts, wide BOS/gait
- Wide base gait, balance and coord. primary issues
- Cerebellar origin
15
Q
Spastic CP
Hemiplegic
A
Arm, body and leg affected on one side
16
Q
Spastic CP
Diplegia
A
Legs affected more vs. Arms
17
Q
Spastic CP
Quadriplegia
A
Whole body affected
18
Q
CP often found in children w/ _______
A
LBW (1000-1499g)
19
Q
Dx CP made via:
A
- Neuroimaging
- Clinically dx’d
- delayed milestones
- abnorm mm tone
- abnorm mvmt patterns
PTs can contribute to clinical dx!!!
20
Q
Dx of CP
Precise dx can be diff. BUT most children dx as early as ______
A
6mos of age
21
Q
Considerations in Dx of CP
Just a few
A
- Variation in motor dev.
- Unknown origin: brain MRI
- Consideration of alternate explanations (transient dystonia)
22
Q
Prognosis for CP
*Highly variable
This type of CP more likely POSITIVE OUTCOMES
A
Hemiplegia and Ataxic CP
23
Q
Prognosis for CP
*Highly variable
This type of CP LESS LIKELY positive outcomes
A
Dyskinesia and B/L CP
(Dyskinesia== uncontrolled, involuntary mm mvmt)
24
Q
Impact of deficits in following areas contribute to prognosis of CP
A
Cog
Visual
Hearing
Sz activity
25
Other predictors for CP prognosis
## Footnote
**Greatest predictor of ambulation\*\***
IND sitting by 24mos
26
Other predictors for CP prognosis
**Functional IND ambulation _UNLIKELY_** **if this:**
Unable to IND sit @ 3yrs
27
Almost ALL children w/ CP @ higher risk for this
Communication deficits
28
Children w/ CP @ risk for:
* Cog limits
* Behavioral probs
* Comm. deficits---- **almost ALL**
* Sensation deficits
* Epilepsy
* B&B incontinence/constipation
* **Usually Quadriplegic or B/L**
29
Classification of CP
## Footnote
**KNOW THIS SCALE SYSTEM!!!**
Gross Motor Function Classification System (GMFCS)
\***ALWAYS refer to GMFCS lvl for practice→** Goals, interventions, etc..
30
Gross Motor Functional Classification System (GMFCS)
Details
* 5 lvl classification scale **used to det. functional capabilities for children 18yo and _younger_ w/ CP**
* Subcategories
* **Best reps child _current abilities and limitations_ in _gross motor function_ in home, school, community**
* Self-initiated mvmt emphasis on **sitting and walking**
31
GMFCS: Class. of CP
Lvls: ALL
* **Lvl 1:** Walks w/out limitations (BEST)
* **Lvl 2:** Walks WITH limitations
* **Lvl 3:** Walks using Hand-Held Mobility Device
* **Lvl 4:** Self-Mobility w/ Limitations: **May use powered mobility**
* **Lvl 5:** Transported in a Manual WC
32
GMFCS
## Footnote
**Lvl 1 :**
Walks w/out Limitations (BEST)
33
GMFCS **Lvl 2:**
Walks WITH Limitatiosn
34
GMFCS **Lvl 3:**
Walks using hand-held mobility device
35
GMFCS **Lvl 4:**
Self-Mobility w/ Limitations: May use powered mobility
36
GMFCS **Lvl 5:**
Transported in manual WC
37
GMFCS based on _____ function
CURRENT
38
Before 2 yrs…
GMFCS lvl may change
39
After 2yo
GMFCS lvl most likely to stay as is
40
Body Structure and Function (BSF) **in relation to CP**
## Footnote
**PRIMARY IMPAIRMENTS:**
**3:**
1. Aborn mm tone
2. Decd strength→ **force production, mvmt control**
3. Impaired motor control
41
BSF **in relation to CP**
**SECONDARY IMPAIRMENTS** (result from PRIMARY impairs)
* Decd mm extensibility/mm tightness
* Impaired postural control
* Skeletal deformity
* Pain
* Fatigue→ **diff to overcome pull of gravity → extra effort to do _everything_**
* Abnorm sensation (body awareness, proprio.)
42
CP is NON-progressive, BUT _____ can be
Impairments
43
BSF **PRIMARY impairments:**
## Footnote
**Abnormal Mm Tone**
**Tone vs. Spasticity**
* **Tone→** NORMAL resting tension or resistance of mm to **passive mvmt**
* **Spasticity (velocity-dependent)→** NEURAL resistance to **externally imposed mvmt** which INCs w/ INC speed of stretch and varies w/ direction of mvmt
44
More on spasticity
* Dev's over time
* Typ mvmt patterns challenging
* **Untreated will contribute to loss of mm length/_contractures_**
45
Contributing factors assoc'd w/ **abnorm mm tone:**
* Muscle innervation
* Impaired growth influences
* **Altered loading**
* Lack approp wt bearing from early infancy
* Muscle growth DOES NOT EQUAL bone growth→ bone grows faster vs muscle== hypO-extensibility
* over-lengthened mm's from mech. stretch or certain ortho sx's
46
BSF **PRIMARY impairs:**
## Footnote
**Decd strength**
* Children w/ CP unable to gen. normal voluntary force in a mm OR normal torque about a joint
* MM weakness:
* low EMG activity
* inapprop. co-activation of antagonists
* skeletal deformities
* length-tension relationships
47
BSF **PRIMARY impairs:**
## Footnote
**Impaired Motor Control**
* Poor selective control of mm activity
* reduced speed mvmt
* reduced reciprocal mvmt (remember **bunny hopping from atyp. dev.)**
* impaired ability to isolate the activation of mm's in selected patterns in resp. to voluntary postures etc.
48
BSF **SECONDARY impairs:**
## Footnote
**neg. sequelae of PRIMARY impairs**
* Decd mm extensibility
* Impaired posture control/balance
* Sk. deformity
* Pain
* Fatigue/impaired endurance
49
Activity Limits and **CP**
## Footnote
**BSF impacts activities**
**MOST have diff. w/:**
* Mobility
* Gen tasks/demands
* Self-care
* Domestic life skills
50
Participation restrictions
Children w/ CP @ higher risk of **poor participation @ _______ and in \_\_\_\_\_\_**
@ school
in community
* Decd playground access
* Decd adapted sports
* Limits in IND w/ peers
51
Contextual Factors
## Footnote
**Personal**
**\*unique to ea child**
* Age
* Sex
* Cog lvl
* Co-morbs
* Motivation lvl
* Play skills
* Attitude towards therapy
52
Contextual Factors
## Footnote
**Environmental**
**\*unique to ea child**
* Support system @ home
* Home set up
* Avail. resources
* Durable Medical Equipment (DME) needs
53
PT Exam BSF: **Strength**
## Footnote
**\*can be challenging w/ CP**
**Use if possible**
Isokinetic
HHD
MMT **when mm group is isolated consistently**
54
PT Exam BSF: Strength
## Footnote
**MOST COMMONLY utilized strength assessment for CP**
Functional Strength Assessment
* **observe motor skills**
* **STS, floor→stand, squat**
* **Timed rep. testing**
55
PT Exam BSF: **Abnorm Tone/Extensibility**
## Footnote
**BAD TO USE FOR PEDS**
MOD. ASHWORTH
\*DOES NOT quantify spasticity exclusively
56
PT Exam BSF: Abnorm MM tone/Extensibility
## Footnote
**BEST to use for PEDS**
Modified Tardieu Scale (R1/R2)
\*shows change better vs MAS
57
Barry-Albright Dystonia Scale
Rates dystonia (posturing and involunt. dystonic mvmt)
\***know it exists**
58
Mod. Tardieu Scale (R1/R2)
BEST for tone in PEDS
* Measures “**catch”** to rapid velocity== **R1**
* Captures dynamic neural component of tone
* Muscle lenght/passive ROM== **R2**
59
PT Exam BSF: **Impaired Motor Control**
* Motor assess in gravity resisted or gravity elimin'd
* Doc **qual of mvmt and deg. of isolation ability by jt**
* Hemiplegia→ compare to non-involved
60
PT Exam BSF: **Postural Control/Balance**
* Selective Control Assessment of the LE (SCALE) test
* **Postural control**
* sway/perturbs response
* visual, computerized, EMG
* **Balance→ static/dynamic, sitting/standing**
* Ped Balance Scale/Ped BERG
* **Sensory Disturbs**
* poor body aware.
* decd proprio/kinesth. aware
* be traditional, use toys
61
PT Exam BSF: **Endurance**
* **Submaximal** endurance walk and w/c mobility
* 10 meter walk/roll test
* 6min walk/roll test
* 600 yd walk/run test
* 6 min push test
* **Maximal Exercise Testing:** shuttle run timed, cycling, erg.
* PEDS RPE
62
PT Exam Activity Limitations: **Functional Mobility**
* Assess functional tasks
* bed/mat mob, transfers, floor ←→ standing, stairs, ambulation
63
PT Exam Activity Limitations: **Functional Mobility**
## Footnote
**Common gait devs in CP**
1. Scissor
2. Equinus→ diplegia, hemiplegia
1. Tip-toe walk one foot only
3. Crouch
64
PT Exam Activity Limits: **Gait**
* Gait Analysis→ 3D instrumented
* Comprehensive includes clinical exam of body function and structures
* improves CDM
* **Gold Standard for gait research and optimizing outcomes**
* costly and questionable validity for daily function
65
Pt Exam Activity Limitations: **Gross Motor Standardized Assessments**
## Footnote
**GOLD STANDARD FOR CHILDREN W/ CP**
Gross Motor Function Measure
GMFM\*\*\*\*\*
66
Pt Exam Activity Limitations: **Gross Motor Standardized Assessments**
* GMFM\*\* → **GOLD STANDARD**
* OTHERS:
* **GMA → patho mvmt quals characteristic of CP in first few mos of life**
* **AIMS**
* **Prechtl's Assessment of Gen Mvmt**
* **early mos**
* **Test of Infant Motor Performance (TIMP)**
* **infants→4mos**
* **Neuro-Sensory Motor Developmental Assessment**
67
Pt Exam Activity Limitation Standardized Assessments
## Footnote
**Following look @ _Activity Limits:_**
* Timed distance tests
* TUG
* Timed Up and Down Stairs
* Activity Scale for Kids
* PEDI
* WeeFIM
68
Standardized Measures for **Participation**
* Child Engagement in Daily Life
* Assess of Life Habits (LIFE-H)
* Childrens Assessment of Participation and Enjoyment
* School Function Assess (SFA)
* QoL:
* Peds QL-**CP Module**
69
Med interventions for CP
## Footnote
**2 Categories:**
1. Sx
2. Pharma
70
Common Sx Procedures
* Distal femoral ext osteotomy
* **Tendon lengthening proc's often performed**
* **HS, Heel cords, adductors**
* Tendon transfers→ feet
* Spinal fusion for nmsk scoliosis
* Femoral and pelvic hip osteotomies
* Ganz
* **Varus Derotational Osteotomy (VDRO)**
71
VDRO
Sx procedure for what?
Children w/ In-Toe
72
VDRO
In-Toeing result of ….
Too much **medial femoral torsion (MFT)**
**→ lack of torque producing activation of glutes/hip rotators==== lack of untwisting of femur**
73
VDRO
Children IN-Toe why?
to maintain femoral head in acetabulum → otherwise will dislocate
74
VDRO proc properly aligns what?
Femoral head INTO acetabulum
75
Typ developing hip joint vs. hip joint w/ too much MFT/anteversion
see pics
Ante= forward
Retro=backward
76
VDRO Why??
* By school age (3yrs)→ Hip rotation should be approx. 1:1 (45d/45deg= 90deg)
* **Children w/ CP tend to have _too much_ MFT**
77
Common meds in **children w/ CP**
* Spasticity mgmt meds
* Anti-epilectics
* Mm relaxers
* GI
* constipation
78
Spasticity Mgmt
## Footnote
**Botulinum Toxin A (Botox) Injections**
**\*WIDELY used for mgmt of CP**
* Widely used for mgmt of CP
* **Effects last up to 4mos w/ _peak effect 2wks after injection_\*\*\***
79
Other Spasticity Meds besides botox:
* Baclofen
* **Watch for SEs!!**
* Phenol Alcohol Blocks
* Selective Dorsal Rhizotomy (SDR)
80
See Word Doc for PT interventions for CP
\*\*\*\*\*\*\*
