Pediatrics Test 1: Lecture 2

Question 1

things to keep in mind when performing a neuromuscular peds exam

Answer 1

be diligent with following new tests/measures

need a detailed knowledge of typical motor development

exam/interventions should be based on developmental model

Question 2

things to keep in mind when considering a peds neuromuscular intervention

Answer 2

intervention should focus on age appropriate functional motor behaviors; don’t necessarily have to stick to strict developmental sequence (i.e. don’t have to crawl before they walk)

assess impairments in body structure to determine reasons for activity restrictions

major intervention goal = improve motor ability and participation in home, school, and community

Question 3

when testing a kid’s motor behaviors when they have a neuromuscular condition they can be variable. This can be attributed to what factors

Answer 3

fluctuating/abnormal mm tone

poor motor coordination

medications

factors related to fatigue, age, behavior, pain, attention, etc

Question 4

testing considerations with neuromuscular exam in kids

Answer 4

test items may need to be repeated in a single session and again in later sessions to determine the most common behavior

kid may have concomitant deficits and/or emotion/behavior problems - may be hard to determine if these things are also affecting motor behavior

Question 5

kids with neuromuscular disabilities are organized by testing categories; these include what

Answer 5

age range for tests and recommended use based on 3 major testing purposes (discriminative, predictive, and evaluative)

Question 6

impairement of body structures and functions within diagnoses varies greatly and depends on

Answer 6

location
severity
age at time of injury
motor behaviors kid learns to use
practice
available support

Question 7

what is mm tone and how does it relate to kids with NM disabilities

Answer 7

active mm contraction

readiness to move

kids with NM disabilities can be hyper or hypo

can fluctuate resulting in involuntary movements like athetosis and ataxia

Question 8

what intrinsic changes are related to hypertonia

Answer 8

contracture of collagen tissues

decrease in viscoelastic properties of mm tissue

collagen accumulation in mm

changes in mm fibers (atrophy; especially of type II)

decreased force production in mm cells

Question 9

what happens when there is a decreased facilitation of polysynaptic reflexes and what might a kid do to compensate

Answer 9

may result in weakness and pareis during movement in individuals with hypertonia

kid may compensate by using co-contraction to create sufficient tension for postural control and movement

Question 10

sx/drug interventions to help with hypertonia

Answer 10

goal = lower excitation in motor neuron pools

selective dorsal rhizotomy

intracathecal or oral baclofen

botox

Question 11

what happens once spasticity is reduced via sx or meds

Answer 11

normal movement does NOT automatically emerge

underlying secondary MSK changes ,weakness, and contractures can still impede movement in addition to learned motor patterns

learned motor patterns also do not disappear once the spasticity is removed; it’s important to understand under what conditions sx/meds are best and will be most effective

Question 12

examples of standardized assessments in infants

Answer 12

Harris Infant Neuomotor Test (HINT)

Test of Infant Motor Performance (TIMP)

Alberta Infant Motor Scale (AIMS)

Question 13

infant standardized tests that help predict the likelihood of CP

Answer 13

TIMP

General Movement Assessment (GMA)

Hammersmith Infant Neurological Examination (HINE)

Question 14

developmental tests for older children typically look at what types of factors

Answer 14

complex balacnce/coordination

SLS

hopping

gallop

jump patterns

skipping

fine and gross motor

Question 15

examples of assessment for young kids

Answer 15

Bayley Scales of Infant Development

Gross Motor Function Measure

Peabody Developmental Motor Scales, 2nd edition

moderate to good reliability - might be used for discriminative, evaluative, and predictive purposes

Question 16

what is one of the few tests of motor performance that is for older kids ages 4-21

Answer 16

Bruininks-Oseretsky Test of Motor Proficiency

Question 17

functional tests that examine child’s activity and participation levels

Answer 17

pediatric evaluation of disability inventory (PEDI)

PEDI computer adaptive test (PEDI-CAT)

childhood health assessment questionnaire (CHAQ)

clinical observation of motor and postural skills (COMPS)

goal attainment scaling (GAS)

school function assessment (SFA)

Question 18

what is the timed obstacle ambulation test

Answer 18

TOAT

obstacle course tha requires the child to move across different floor surfaces; step up, down, over; duck under obstacles; negotiate through turns and narrow path

Question 19

testing conditions for the pediatric clinical test of sensory interaction on balance (P-CTSIB)

Answer 19

1. eyes open normal surface - vision, vestibular, somatosensory available
2. eyes closed normal surface - no vision
3. dome normal surface - compromised vision
4. eyes open foam surface - somatosensory compromised
5. eyes closed on foam - no vision; compromised somatosensory
6. dome, foam surface - vision and somatosensory compromised

Question 20

youngest survivable gestational age

Answer 20

22-25 weeks

Question 21

when in gestation are major brain structures present

Answer 21

24 weeks

lack of O2 to brain can result from minor stress to infants system

Question 22

hypoxemia

Answer 22

decrease in amount of oxygen in blood

often occurs with ischemia

Question 23

ischemia

Answer 23

decreased vascular perfusion to a tissue bed such as the brain

often occurs simultaneously with hypoxemia

Question 24

asphyxia

Answer 24

most severe lack of O2

“without pulse”

prolonged = results in hypotension and ischemia causing cellular death - usually leads to permanent disability

Question 25

major brain areas involved in movement generation and control

Answer 25

subcortical nuclei cerebellum cortex basal ganglia

Question 26

things that can cause CP

Answer 26

unknown genetic alterations causing neurological malformations lack of O2 at or around birth or during early development insults/trauma to head

Question 27

what is selective neuronal necrosis

Answer 27

in full term infant = neuronal injury with characteristic pattern in CNS early neuronal changes occur within 24-36 hours of injury signs of cell necrosis within several days over next several weeks - macrophages will consume necrotic cells with severe lesions, a cavity may form in cerebral cortex that becomes a fluid filled cyst

Question 28

what is CP

Answer 28

most common peds disability general term for CNS insult gross motor classification system (5 levels)

Question 29

characteristics of CP

Answer 29

primary CNS disorder; motor disabilities due to early damage of brain in areas controlling motor behaviors characteristic ortho impairments associated with a GMFCS level such as scoliosis or hip dysplasia kids with CP often have more variability in the size of mm fibers, type of mm fibers/composition, atrophy, decreased vascularization, increased extracellular space, and increase in fatty and connective tissue deposit in mm

Question 30

do CP lesions progress

Answer 30

no sequelaw may vary as child ages as a result of the development of atypical motor habits used by the child to compensate for poor motor/posture control and motor learning deficits

Question 31

how are kids with CP classified

Answer 31

1. distribution of motor disability -quadraplegia = all limbs involved -hemi = one side -diplegia = primarily LEs 2. type of mm tone or motor control disorder - spastic = exaggerated reflexes with abnormal patterns posture/mvmt - dyskinetic = atypical patterns of posture and involuntary uncontrolled reoccuring stereotyped mvmt -dystonic = involuntary, sustained, intermittent mm contraction with repetitive mvmt and abnormal posture - athetosis = slow continuous writhing movements - ataxic = inability to generate normal or expected voluntary mvmt trajectories not due to weakness or involuntary mm activity - mixed = spasticity and dyskinesia

Question 32

secondary to the brain insult, what other S&S are typical with CP kids

Answer 32

hearing impairments sensory impairments seizures functionally = problems with sustaining postural control in prone, sitting, and standing; trouble with complex movements wide range of limits/restrictions

Question 33

what are hyperkinetic movements

Answer 33

unwanted excess movements

Question 34

dystonia

Answer 34

in reference to hypertonia... increased tone not always present in dystonia movement disorder in which involuntary sustained or intermittent mm contractions cause a twisting and repetitive movements and/or abnormal postures

Question 35

chorea

Answer 35

on going random appearing sequence of one or more discrete movements or movement fragments vary in timing, duration, direction, and body location distinguish from dystonia by unpredictable and continuous nature of movement distinguish from atheosis by presence of discrete movements within the continuing sequence of movement

Question 36

tremor definition

Answer 36

rhythmic back and forth or oscillating involuntary movement about joint axis relative symmetry in speed can be resting, postural, or action tremor intention tremor = cerebellar dysfunction; worsening when reach target; can resemble dysmetria

Question 37

dysmetria

Answer 37

inaccurate movements leading to repeated over corrective attempts

Question 38

ataxia

Answer 38

gross lack of coordinated movements that generally originates from damage to cerebellum child with ataxia generally has normal strength and no hypertonia, but movements are jerky and inaccurate can be limb, trunk, or gait ataxia depending on where the cerebellar lesion is

Question 39

how to look at coordination of voluntary movements in kids

Answer 39

often difficult; requires complex computer equipment (measures kinematics, kinetics, and EMG during movements like gait and reach) video based tech can measure duration, accceleration, and types of leg movement in infants; can see subtle differences in movement in kids to determine if movements are typical or atypical

Question 40

clinical testing of the neuromuscular system to look at coordination of voluntary movements in kids with CP usually involves what

Answer 40

methods of observational analysis of motor coordination during balancing i.e. therapist can place child on a movable surface, move the surface under the child, and subjectively grade the motor response caused by the perturbation tests like this are informative but reliability is questionable

Question 41

spine related problems in kids with CP

Answer 41

15% incidence of scoliosis lack of stability and decreased amount of movement places child's spine in atypical postures for prolonged periods resulting in flexible or fixed deformities

Question 42

pelvis/hip related problems in kids with CP

Answer 42

result from bony abnormalities, alignment, and shape and mm abnormalities hypertonicity around hip (common with spastic CP) of hip flexion, adduction, IR can lead to atypical posture, bony alignment, ROM limits, and hip dislocations PPT often occurs with tight HS and results in trunk flexion

Question 43

foot/ankle problems common with kids with CP

Answer 43

reduced DF = most common impairment (bc shortened gastroc) inability to generate sufficient stability at ankle child assumes PF position

Question 44

interventions for kids with CP

Answer 44

provide WBing opportunities - promotes bone modeling and increased ROM deficits in ROM change normal skeletal alignment and decrease fluidity and efficiency of movement (want to help ROM as best you can) decisions to use AFO should be carefully considered and individualized to each child tendon lengthening or transfers if ROM and splinting are unsuccessful strength training; positive benefits in gait characteristics, endurance, and functional activities

Question 45

describe the neurodevelopmental treatment

Answer 45

1940s; Karl and Berta Bobath focus shift from ortho to neuro sensory and motor impairments like abnormal tone interpreted as release phenomena controlled by lower centers of the hierarchical nervous system skilled handling to reduce tone and facilitate normal movement integrate current motor learning principles and emphasizes the goal of gradual reducing the reliance on passive handling techniques little formal evidence on effectiveness

Question 46

describe the sensory integration theory

Answer 46

Jean Ayres in 1960s addresses the sensory processing and motor/perceptual deficits of kids with learning disabilities states that motor learning is dependent on the ability to take in sensory info derived from the environment and from movement of the body, process and integrate these inputs in the CNS, and use this info to plan and produce organized behavior

Question 47

describe the cognitive education theory

Answer 47

not considered a PT intervention but peds therapists may be involved Andras Peto (Hungarian neurologist) developed in 1940s holistic approach to development and edu of children with neuro dysfunction not a therapy system but a system of edu that aims to teach kids to be active and self reliant participants in the world

Question 48

evidence based treatment for CP kids

Answer 48

bimanual training constraint induced movement therapy context focused therapy fittness training strength training goal directed training home exercise programs improve motor activity performance and cardiovascular endurance kids with CP often use assistive devices

Question 49

what is autism spectrum disorder

Answer 49

complex developmental condition limits in social interaction, communication, and restricted or repetitive behaviors that interfere with a child's ability to function

Question 50

describe sensory abnormalities with ASD

Answer 50

between 40-90% of kids with ASD have them 95% have processing impairments may be over-responsive to typical sensory input (hypersensitivity) or under responsive (hypo) some kids have hypo and hyper at the same time responses may fluctuate so interventions can be complicated

Question 51

describe the rate of fine/gross motor defiicts in kids with ASD and how PT can help

Answer 51

63% of kids had decreased fine and gross motor skills (measured by peabody) this qualifies kids for early intervention PTs should be involved with screening kids in schools; often PT is underutilized

Question 52

other S&S of ASD in kids aside from social skills

Answer 52

hypotonia gait dysfunction toe walking decreased posture control dyspraxia

Question 53

what does evidence suggest could be an early predictor of ASD before specific dx signs occur

Answer 53

early motor delay

Question 54

ways to help increase participation in kids with ASD

Answer 54

sensory integration sensory based interventions relationship based interventions

Question 55

what is developmental coordination disorder

Answer 55

overall deficit in motor control and motor learning specifically, lack of predicted control of movements described as internal modeling deficits

Question 56

interventions for developmental coordination disorder

Answer 56

task specific interventions based on motor learning principles neuromuscular task training which accentuate the use of augmented feedback for learning, memory cues, and practice in varied environments fitness activities and karate have good research

Question 57

what is cognitive orientation to daily performance and what is this intervention often used for

Answer 57

often used to improve motor performance in kids with DCD focuses on increasing performance of child using a problem solving approach with task specific strategies

Question 58

explain what factors are important when collaborating with the child, family, and other team members of kids who have a DCD dx

Answer 58

1. explain the nature of the disorder 2. provide strategies for controlling sensory input to make learning more successful 3. devise appropriate consistent behavioral consequences to support the child in trying activities

Question 59

what do longitudinal studies on kids with DCD suggest

Answer 59

some problems may decrease with age but they usually do not disappear

Question 60

describe the pathophysiology of down syndrome

Answer 60

most common chromosomal abnormality in kids; 90% have extra chromosome on chromosome pair 21 neuropathological differences: - small/smooth brain (76% of normal) especially in frontal lobe - small cerebellum and brainstem (66% of normal) intellectual deficits can affect motor abilities visual/vestibular deficits can affect postural control

Question 61

common comorbidities with down syndrome

Answer 61

respiratory issues GI issues cardiovascular issues endocrine issues immune health problems MSK issues neurological issues hearing loss visual deficits ortho limits GU issues sensory limits

Question 62

describe the physiological structure difference of neurons in those with down syndrome

Answer 62

structural difference in spines of pyramidal neurons lack of myelination of neurons in cortex and cerebellum decrease neurons in hippocampus increase in alzheimer's neurofibrillary tangles with age

Question 63

what are common reasons you may see a down syndrome pt in PT

Answer 63

short stature pes planus hip dysplasia ligamentous laxity patellar dislocation low mm tone (hypotonus) alantoaxial instability ligamentous laxity

Question 64

common problems that develop with adults with down syndrome (usually due to excessive wear and tear on joints)

Answer 64

patellofemoral instability genu valgus pes planus hip instability

Question 65

hypoextensibility of connective tissues in those with down syndrome results in what

Answer 65

decreased rebound of tissue

Question 66

low mm tone in those with down syndrome usually has what affect

Answer 66

decreased effectiveness of stretch reflex because the proprioceptors are not at a hight state of readiness to respond

Question 67

examples or recommended interventions for down syndrome pts may include

Answer 67

strengthening using resistive training balance training treadmill gait training orthotic management associated BMI issues = ongoing aerobic conditioning and promotion of wellness

Question 68

orthotics that may be used with down syndrome

Answer 68

supramalleolar orthotics used to improve postural stability and lower extremity alignment prevent secondary deformities that can result from malalignment and overuse ** do not want to give orthotics before they are able to ambulate independently; may negatively impact child's motor skill development

Question 69

rates of TBI in kids

Answer 69

kids 0-4 have highest risk (due to fall) children under 17 were among those most likely to sustain a TBI due to blunt force trauma by an object

Question 70

what is a closed head TBI and what are the implications of this

Answer 70

occurs focally at point of impact and diffusely reverberations occur to the brain within the cranium or shearing forces cause by initial blow ischemic damage can occur after initial trauma if child stops breathing

Question 71

what is cerebral edema (associated with TBI) and what are ways to manage it

Answer 71

occurs due to bilogical products leaking from dead cells immune system products sent by body to combat damage and can destroy the remaining unharmed brain tissue if left uncontrolled shunting and medication to releave ICP can improve outcomes

Question 72

S&S associated with kids with TBI

Answer 72

show some cognitive, emotional, behavioral control problems attributed to frontal and temporal lobes to shearing force damage can include hyperactivity, distractibility, involving poor ability to filter out unimportant sensory stimuli in the environment difficulty with visual perception

Question 73

factors that glascow coma scale measures

Answer 73

eye opening verbal response motor response

Question 74

interventions for kids as they are coming out of a coma following TBI

Answer 74

want active movement in response to passive ROM and sensory stimuli sensory stimulation - cutaneous (brushing/tapping), auditory (talking/music), visual (use of lights and bright colored objects), gustatory (tastes), and olfactory (diff odors) all of the above may trigger child to come out of coma

Question 75

common impairments seen with kids post TBI

Answer 75

decreased balance and gait speed increased step length variety

Question 76

what is spina bifida

Answer 76

split spine indicates that bony structures of the spinal vertebrae fail to close over the posterior aspect of the spinal cord at some level or levels during neurulation (around week 3-4 of gestation)

Question 77

what is myelodysplasia

Answer 77

displacement of some tissue in a sac that protrudes through this posterior opening of the spinal vertebra degree to which neural elements are involved in this protrusion and the level of the spinal cord affected define the severity of the loss of motor and sensory function around and below that level

Question 78

what is spina bifida occulta (closed)

Answer 78

malformation of one or more vertebrae is malformed most cases, this one does not cause impairments

Question 79

what is a meningocele

Answer 79

a sac protrudes at spinal opening containing spinal fluid and meninges but no neural tissue LMN damage is likely

Question 80

what is a myelomeningocele

Answer 80

protruding sac contains spinal fluid, meninges, and neural tissue

Question 81

treatment of a myelomeningocele and the pros/cons

Answer 81

in utero or post birth, protruding tissue is excised and spinal opening is surgically closed at 26 weeks in utero: pros = decreases need for postnatal ventriculoperitoneal shunting, hindbrain herniation, and improved motor function cons = risk of ruptured membrane during pregnancy, preterm delivery, and unknown urologic function

Question 82

etiology of myelomeningocele

Answer 82

unknown thought to be a combo of genetics and environment relationship between inadequate vitamins and folic acid intake in neural tube defects

Question 83

how can open lesions of MM be detected

Answer 83

before birth mother's erum alpha fetoprotein levels ultrasound amniocentesis (more invasive)

Question 84

S&S of spina bifida kids

Answer 84

mix of LMN and brain dysfunction affects motor control learning and functional motor ability 51-65% of kids with myelodysplasia develop hydrocephalus bowel/bladder problems common visual deficits (especially if kid has hydrocephalus)

Question 85

what is arnold chiari or chiari II malformation

Answer 85

brainstem is displaced inferiorly beyond foramen magnum partial blockage of passage of CSF from brain to SC

Question 86

likelihood of walking in kids with spina bifida based on location of lesion

Answer 86

thoracic and high lumbar lesions - kids may start walking; less than 20% still walking by 9 years midlumbar level lesions = more likely to walk; 40-70% still walking by 9 sacral lesions = reach and maintain functional ambulaiton with ADs and/or orthotics

Question 87

overall goals for intervention with kids with spina bifida

Answer 87

1. strengthen innervated mm and teach compensatory movement patterns and posture control necessary for kid to achieve functional movement 2. prevention of further MSK problems, LE contractures, OA, scoliosis, or pain 3. prevent skin breakdown due to loss of sensation

Question 88

interventions for spina bifida that do not have adverse effects

Answer 88

E-stim, exercise training, and motor skill training lead to improvements in strength with no adverse effects

Question 89

how to determine the type of mobility that should be encouraged with kids with spina bifida

Answer 89

must be individualized to pt according to - child/family desires - social issues - energy consumption for different types of mobility -cognitive development encourage assistance with early mobility; mobility development linked to some cognitive abilities (depth perception, cause and effect links, and object permanence)

Question 90

describe brachial plexus injuries in kids and the general outcomes expected

Answer 90

at birth or in older kids after trauma 2 most common types: Erb's palsy (C5 and C6) and Klumpke Palsy (C8 and T1) good prognosis with early therapy for Erb most kids recover triceps, biceps, deltoid, and wrist ext function by 6 moths long term difficulty is likely if there is not significant recovery by 6 months