Myelodysplasia Part 2

Question 1

Prevention of Secondary

Orthopedic Deformities for wheelchair:

Answer 1

Seat cushion design.
Biking gloves for community mobility.
Environmental adaptations to minimize overhead reaching.
Angle desktop for improved postural alignment.

Question 2

Prevention of Secondary

Orthopedic Deformities for ambulatory:

Answer 2

Angle walker/crutch handgrips to avoid wrist hyperextension.
Avoid excessive wrist pressure to prevent carpal tunnel syndrome.
Knee joint deterioration/arthritis – possible long-term effects of surgical interventions and weightbearing on insensate joints

Question 3

Co-morbidities

Answer 3

neurogenic bowel/bladder
cognitive and perceptual dysfunction
language dysfunction
visuoperceptal deficits
seizures
upper limb dyscoordination
skin breakdown
osteoporosis
obesity
cranial nerve palsies
latex allergies

Question 4

Neurogenic bowel/bladder

Answer 4

Bowel/bladder incontinence common; fewer than 5% develop voluntary sphincter control
Anal sphincter (S2-S4) - flaccid, hypotonic, or spastic

Question 5

What causes bladder dysfunction?

Answer 5

bladder wall and bladder dyssynergy

Question 6

What is upper limb dyscoordination attributed to?

Answer 6

cerebellar ataxia, secondary to hydrocephalus, or ‘motor learning deficits due to use of upper limbs for balance and support

Question 7

What percentage have seizures?

Answer 7

10-30% of cases

Question 8

What causes skin breakdown?

Answer 8

loss of sensation, prolonged sitting, ill-fitting orthoses, circulation
Decubitus ulcers - 95% occurrence by young adulthood

Question 9

Perineal decubiti:

Answer 9

over apex of kyphotic curve

Question 10

Cranial Nerve Palsies

Answer 10

Cranial nerves IX, X may cause swallowing difficulties, apneic episodes, symptomatic Arnold Chiari II malformation that can be life threatening

Question 11

PT exam in infancy:

Answer 11

participation restrictions

exam of impairments

Question 12

PT exam in toddlers and preschoolers

Answer 12

strength
weightbearing
gait training
Focus on improving independence, efficiency, and effectiveness of ADL, dressing and toileting by kindergarten
skin inspection

Question 13

PT in school age and adolscence:

Answer 13

joint and postural alignment, muscle strength, prevent contracture
bracing
WC mobiity
gait training
flexibilty
focus on independent, safe and efficient mobility

Question 14

Mobility Prognosis for thoracic level:

Answer 14

No volitional lower limb movement.
Possible strong upper limb, upper thoracic, neck muscles.
Other CNS involvement, i.e., cognitive deficits possible

Question 15

Mobility Prognosis for T10 or above:

Answer 15

Weak lower trunk musculature affecting unsupported sitting balance, respiratory function.
Maintain spinal, pelvic, lower limb alignment.
Sliding board wheelchair transfers

Question 16

Mobility Prognosis for T12:

Answer 16

Strong trunk, good sitting balance, weak hip hiking.

Ambulation using a parapodium for exercise only, w/c for functional household and community mobility

Question 17

Mobility Prgnosis for L1-L2 lesions:

Answer 17

short distance household ambulation using KAFOs or RGOs and upper limb support early; wheelchair use after age 10
Weak hip movements, flexion and adduction

Question 18

L2 function:

Answer 18

hip flexors, adductors, rotators (grade 3) may cause dislocation

Question 19

Mobility Prgnosis for L3:

Answer 19

Strong hip flexion/adduction, weak hip rotation.
Weak knee extension, if grade 3 may ambulate with KAFOs and forearm crutches (household, short community distances).
Wheelchair - long community distances, primary mobility in adulthood.
60% achieve independent living, 20% participate in full time competitive employment

Question 20

Mobility Prgnosis for L4:

Answer 20

Antigravity knee flexion, knee extension usually strong.
Grade 4 ankle dorsiflexion with inversion.
Medial HS and anterior tibialis (grade 3).
Calcaneal deformities (unopposed tibialis anterior).
Learning to walk - KAFOs, walker, or both.
Functional ambulators - AFOs, forearm crutches, w/c for long distances.
Many stop ambulating in adolescence; knee and ankle valgus deformities, elbow/wrist pain.
Patellar tendon-bearing, ground reaction force orthotic protects knee and increases knee extension moment.
Prognosis for independent living similar to L3

Question 21

Mobility Prognosis for L5:

Answer 21

Grade 3 lateral HS strength and either grade 2 gluteus minimus/medius (L4-S1), grade 3 posterior tibialis (L5-S1), or grade 4 peroneus tertius (L4-S1).
Antigravity knee flexion and weak hip extension using HS.
Possible weak abduction and plantar flexion with inversion, strong dorsiflexion with eversion, or both.
Hindfoot valgus or calcaneal foot deformities; weak toe movement.
Ambulate without orthoses - foot alignment, substitute for lack of push-off.
Gluteal lurch typical.
Upper limb support for community distances.
Wheelchair - long distances, rough terrain.
80% independent living, 30% employed full time, 20% part-time

Question 22

Mobility Prognosis for S1:

Answer 22

At least two of the following: gastroc/soleus (grade 2), gluteus medius (grade 3), or gluteus maximus (grade 2).
Hip stability allows walking without orthoses or upper limb support.
Weak push-off when running or climbing stairs. Mild-mod gluteal lurch. Crutch use may improve pelvic and hip kinematics. Strong toes.
Increased gait deviations/activity limitations after adolescent growth spurt.
Foot deformities not common, but AFOs provide medial-lateral ankle stability for adequate push-off

Question 23

Mobility Prognosis for S2, S2-S3 and no loss levels:

Answer 23

Plantar flexors at least grade 3 and gluteals grade 4.
Decreased push-off and stride length in rapid walking or running.
‘No loss’ level - normal bowel and bladder function and lower limb strength (MMT); possible functional deficits.
Orthoses maintain subtalar neutral, optimize muscle length and ankle function

Question 24

Best predictor of ambulation?

Answer 24

iliopsoas strength

Question 25

Best predictor of requirements for aids/orthoses

Answer 25

gluteus medius (hip abduction)

Question 26

Key Muscle Groups for

Community Ambulation

Answer 26

Iliospoas
Gluteus strength
Quads
Anterior Tibialis
Hamstrings