Week 5 Flashcards
1
Q
In what population is Duchenne Muscular Dystrophy most popular?
A
1/3500 live male births
2
Q
What kind of disorder is duchenne muscular dystrophy?
A
Most common X-linked disorder
3
Q
What is the underlying pathology of duchenne muscular dystrophy?
A
The lack of protein dystrophin, which plays a key role in maintaining the integrity of the cell membranes of skeletal and cardiac muscle, which will ultimately lead to degeneration of muscle fibers
4
Q
At what age is duchenne muscular dystrophy usually diagnosed?
A
Typical diagnosis by age 5
5
Q
What are the signs, symptoms and impairments that is seen in duchenne muscular dystrophy?
A
- Progressive weakness, that typically affects muscles in the neck, abs, interscapular(why we see a lot of winging), hip extensors
- Enlarged calves, which is known as pseudohypertrophy
- Lordosis posture
- Wide based gait/toe walking gait patten
- Clumsiness, frequent falls, and stumbling
- Gower’s sign is a very common red flag
6
Q
What is pseudohypertrophy?
A
The sign of where muscle starts to break down and gets replaced by fat and connective tissue and is most commonly seen in the calves, but can also be found in the deltoids, quads and forearm extensors
7
Q
How will a child with duchenne muscular dystrophy raises themselves up from the floor as seen with the Gower’s sign?
A
They will begin in a quadriped, to a plantar grade on hand and feet position, and in order to stand up, they will need to walk their arms up their legs
8
Q
What is the typical presentation of a 6-8 year old child with duchenne muscular dystrophy?
A
Stair climbing difficulties, and gait deviations
9
Q
What is the typical presentation of a 8-10 year old child with duchenne muscular dystrophy?
A
Decreased vital capacity, and falls
10
Q
What is the typical presentation of an adolescent with duchenne muscular dystrophy?
A
Walking is lost (age 12 typically, but can be as early as 10 and as late as 14)
11
Q
What are the medical interventions for a child with duchenne muscular dystrophy?
A
- Promoting the production of dystrophin or diminishing the consequences of hypoxia and fibrosis
- Genetic therapy research
- Steroid Therapy
12
Q
What are the characteristics of steroid therapy for the treatment of duchenne muscular dystrophy?
A
- Long term use
- Prolonged walking up to 3 years
- Improved pulmonary function
- Side effects including weight gain, growth suppression, cataracts, and osteoporosis
13
Q
When are surgical intervention methods used for a child with duchenne muscular dystrophy?
A
- Surgery for contractures that impact ADLs, or functional mobility
- Significant scoliosis
14
Q
Why is night time BiPAP a medical intervention for patients with duchenne muscular dystrophy?
A
To help with pulmonary function
15
Q
What are the activity/participation limitations seen in children with duchenne muscular dystrophy?
A
- Slower gait speed
- Difficulty rising from the floor
- Stairs
- ADLs, including dressing, eating, and self care
- Progressive difficulty keeping up with peers
16
Q
What are the PT interventions used for patients with duchenne muscular dystrophy?
A
- Family support and education
- ROM/stretching/night splinting, depending on the stage of the disease the child is in
- No eccentric exercise
- Avoid fatigue in order to avoid microtears, which can make exercise detrimental
- Submaximal, function based
- Breathing exercises
- Adapted mobility, home modifications like scooters or powered wheelchairs
- Balance the Risk:Benefit
17
Q
What are the characteristics of Becker Muscular Dystrophy?
A
- Variant of DMD
- Insufficient dystrophin
- Dx late made in childhood/adolescence
- Longevity into the forties
18
Q
What are the characteristics of Congenital Muscular Dystrophy?
A
- Has many forms
- Onset in utero or in first year
- Symptoms, and weakness will be evident in infancy
- Also a very long term functional outcomes, due to the many forms
19
Q
What causes spinal muscular atrophy and what does it result in?
A
A recessive gene, and results in the loss of anterior horn cells
20
Q
There are 4 types of spinal muscular atrophy. When is their onset?
A
- Types I – III: childhood onset
* Type IV: adult onset SMA
21
Q
What are the characteristics of SMA Type I?
A
- Also known as Werdnig-Hoffmann
- Onset 0-4 months
- Rapidly progressive
- Mortality 1-10 years
22
Q
What are the characteristics of SMA Type II?
A
- Childhood onset
- 6-12 mos
- Initial progression is quick, then slowly progressive
- Longevity in to adulthood
23
Q
What are the characteristics of SMA Type III?
A
- Also known as Kugelberg-Welander disease
- Onset 1-10 years
- Slowly progressive, mild/moderate impairment
24
Q
What does PT interventions mostly focus on for muscular dystrophies?
A
- Family support and education
- Similar management
- Driven by patient abilities and goals
- Functional independence
- Interventions at a submax intensity
- Posture and breathing control
- Adaptive mobility
- Environmental modifications in the home, school and work
25
What are the characteristics of metatarsus adductus?
• Commonly found in newborns
26
What causes metatarsus adductus?
Packaging deformity or posture of the infants feet while in utero which can be due to the position of the baby in utero r being stuck for a period of time for any number of reasons
27
What is the physical presentation of metatarsus adductus?
Adducted forefoot, curved lateral border and neutral heel
| • “bean shape” sole of foot
28
What are the classifications(ability of the foot to reduce or flex past midline) of metatarsus adductus?
* Flexible: reduces past midline and has normal ROM
* Moderately Flexible: might get to midline, but does not have full ROM
* Severe: rigid, not reducable and can't get to midline
29
What are the treatment options of metatarsus adductus?
```
• Class I corrects by 4-6mos
(90-95% of all cases)
• Class II might be treated with stretching or corrective shoes, some facilitation of active eversion and DF. HEP
• Class III casting or surgery,
corrective shoes
```
30
What does the acronym CAVE stand for in reference to the presentation of clubfoot?
* C: Cavus (supinated midfoot)
* A: Adductus (forefoot is adducted medially)
* V: Varus (hindfoot is in calcaneal varus)
* E: Equinus (lack of dorsiflexion)
31
There is a wide spectrum of presentations for clubfoot, from a mild, postural form to a severe, rigid deformity. What is a severe/rigid presentation usually associated with?
Usually associated with arthrogryposis, myelomeningocele, Larsen syndrome, or other underlying disorder
32
How is clubfoot diagnosed?
Often dx prenatally via ultrasound
33
What are the treatment approaches for clubfoot?
• Best results if initiated within 24-72 hours from birth; but not
emergent. Typical treatment starts a week to 2 weeks after birth
• Ponsetti Casting/serial casting --> splinting and stretching x 3 months --> nighttime bracing 2-4 years
• French Physical Therapy Method (same with casting but with tape and done daily, successful in inpatient settings)
• Surgery: posterior Achilles
tenotomy- lengthening of the achilles tendon
• “Hybrid” models
34
What are the mechanical causes of Developmental Dysplasia of the Hip (DDH)?
A condition where a baby is typically breached(feet down) at birth, and there is less room for the feet to move
35
What are some other causes of Developmental Dysplasia of the Hip (DDH)?
Maternal hormonal influence, so it is seen more in females, because it is said that females are more receptive to the mom's hormones of estrogen and relaxin, making their ligaments looser and more flexible, thus increasing risk of subluxation and dislocation
36
What are the environmental causes for Developmental Dysplasia of the Hip (DDH)?
Swaddling practices and cultural differences in child bearing
37
What are the ROM presentations of patients with Developmental Dysplasia of the Hip (DDH)?
* Most infants have 75-90 degrees of abduction
* Significant asymmetry of 5-10 degrees of ABD can indicate hip dysplasia
* Asymmetrical thigh folds, apparent femoral shortening (galeazzi sign), positive barlow/ortalani tests
* Difficulty changing diapers
38
What are the ortiloni and barlow tests?
Tests performed on the baby's hips, to put the hip in a position of risk of dislocation, so if the baby has hip dysplasia, a clunk of the hip relocating and dislocating will be felt. They become less useful as the baby gets older
39
What is the difference between the clinical signs: click and a clunk seen in children with Developmental Dysplasia of the Hip (DDH)?
- A clunk is the sound of the hip dislocating and relocating
- Clicks are sounds of the joint space moving and some relative instability. They are very common to find in the 1st 3-7 days of life
40
True or False
Clicks are more concerning than clunks
FALSE, Clicks are NOT more concerning than clunks. Clunks are definitely more concerning
41
What type of diagnostic testing should be done in the newborn population with suspicion of Developmental Dysplasia of the Hip (DDH)?
Ultrasound
42
After 2-3 months of life, what is the typical presentation of the child with Developmental Dysplasia of the Hip (DDH)?
Limited hip abduction is usually the only sign of dysplasia. Diagnostic test of an x-ray will be performed, because there will be more ossification of the bones
43
After more than 18 months of life, what is the typical presentation of the child with Developmental Dysplasia of the Hip (DDH)?
Gait deviations
• Waddle (if the dislocation is bilateral)
• Limp ( if the dislocation is unilateral
44
True or False
There is usually pain involved with Developmental Dysplasia of the Hip (DDH)?
False, there is usually NO pain involved with Developmental Dysplasia of the Hip (DDH)?
45
How is Developmental Dysplasia of the Hip (DDH) treated from new born to 9months?
Pavlik Harness. A soft flexible harness that is worn for a few months until we get acetabular deepening. The child can be bathed and dressed in this harness
46
How is Developmental Dysplasia of the Hip (DDH) treated from 6-18months?
Closed Reduction/Spica Cast. General anesthesia is used for when the orthopedist relocates the hip and applies spica cast for 3-4 months
47
How is Developmental Dysplasia of the Hip (DDH) treated for children older than 18 months?
Open Reduction / Spica Cast. Opening the joint space, sometimes tendon lengthening is done. Spica cast is applied for 3-4 months
48
What is the most common cause of acute limping in the toddler/young child population?
Infection, with the most common being osteomyelitis and septic arthritis
49
What are the characteristics of osteomyelitis as seen in the toddler/young child population?
```
• Bone infection
• Typically bacterial infection
(spread infection, trauma,
spontaneous)
• Sudden and rapid onset
• Mostly affects long bones/LE
```
50
What is the treatment for osteomyelitis as seen in the toddler/young child population?
IV and oral antibiotics, following surgical incision and drainage (I&D)
51
What are the characteristics of septic arthritis as seen in the toddler/young child population?
* Infection of the joint space
* Bacterial
* Destruction of articular cartilage
* 80% occur in LE
52
What is the treatment for septic arthritis as seen in the toddler/young child population?
Joint aspiration and oral/IV
| antibiotics
53
What is Legg Calve Perthes?
Ischemic Necrosis/AVN of the femoral head, which happens more commonly in males than in females, and is usually unilateral and generally self- limiting, with re-vascularization occurring over time
54
What are the symptoms of Legg Calve Perthes?
* Limp
* Pain in groin/anteromedial thigh
* Trendelenburg/abductor lurch type gait
* Limited hip abduction and internal rotation
55
What are the treatment goals of Legg Calve Perthes?
Prevent deformation of the femoral head and maintain ROM. This can be done through PT interventions such as:
- Strengthening of the hip musculature, PROM and AROM exercises, orthosis, or a petri casting(immobilizing the hip to prevent further damage)
OR surgery, which is usually the last resort. Total hip replacement if enough necrosis has ocurred
56
What is a Slipped Capital Femoral Epiphysis (SCFE)?
A condition where the growth plate of the proximal femoral physis is weak and becomes displaced. **slipping of the growth plate from the femoral head)
57
What are the subgroups of Slipped Capital Femoral Epiphysis (SCFE)?
* Acute: immediate onset of pain, xray is taken and is diagnosed
* Acute on Chronic: ongoing diffuse LE pain, typically of the knee and groin, and the child might have an antalgic gait or limping
* Chronic: very diffuse, and poorly localized typical knee pain that doesn't get better until a xray is performed
58
What is the population typically affected by Slipped Capital Femoral Epiphysis (SCFE)?
* Hispanic > White
* Males > Females
* Related to puberty (10-16y/o males, 9-15 females)
* Bilateral in up to 60% of cases
59
How is Slipped Capital Femoral Epiphysis (SCFE) typically treated?
Treatment usually with pinning
• Early decompression and fixation of the growth plate to reduces the risk of AVN
• Prophylactic pinning can be considered, due to the benefits
• PT: strength, ROM, progress weight bearing
60
What is the usual presentation of a child with Slipped Capital Femoral Epiphysis (SCFE)?
* Obesity due to sedentary lifestyle
* Antalgic gait
* Diffuse LE knee pain(before any sign of hip pain)
61
What is Osgood Schlatter Syndrome?
A traction apophysitis of the tibial tubercle. There is repetitive strain, chronic avulsion of the secondary ossification center of the tibial tuberosity, so the bone cartilage is being pulled away, it continues to grow, ossify, enlarge, the quad tendon pulls it away, it continues to ossify and enlarge, until there is a tender bump at the tibial tuberosity
62
What is the typical presentation of osgood Schlatter Syndrome?
* Boys 12-15 years old
* Girls 8-12 years old
* Boys > Girls
* Frequently bilaterally
* Highly active (21% active vs 4.5% non-active)
63
True or False
After the acute phase of osgood schlatter syndrome, pain is mild and intermittent
True, After the acute phase of osgood schlatter syndrome, pain is mild and intermittent
64
After the acute phase, during what types of activity is osgood Schlatter Syndrome most painful?
* Jumping
* Kneeling (direct contact)
* Tenderness, local swelling, prominence of area of tibial tuberosity
65
What is the course of symptoms of osgood Schlatter Syndrome?
Calm, spontaneous resolution/ self-limiting nature 90% of pts
• Symptoms may “wax and wane” 12-14 mos
66
What can PT intervention contribute in a patient with osgood Schlatter Syndrome?
PT intervention can help reduce the severity of the symptoms time it take to go away, as it is typically self limiting
67
What are the PT treatments used for patients with osgood Schlatter Syndrome?
```
• Ice
• Mild activity modification
• Strengthening of:
- Quadriceps (low intensity -> high intensity)
- Hamstrings
- Hip abductors/external rotators
• Improve flexibility of
- Hamstrings
- Iliotibial-Band
- Gastroc/soleus complex
```
68
What is sever's disease?
Calcaneal apophysitis from the achilles tendon. Similar to osgood Schlatter Syndrome
69
What is the usual presentation of sever's disease?
* 7-10 years old, also present ages 10-14
* Local tenderness
* Reproduced with resistance of plantarflexion
* Self-limiting
70
What are the treatment options for sever's disease?
* Orthosis
* Heel cups
* Heel lift
* Reduced activity
* Achilles tendon stretching
* Manual mobilization
* Ice/medication
71
What is torticollis?
A postural deformity of the neck, where there is unilateral shortening or fibrosis of the SCM
72
What are the characteristics of torticollis?
* Head tilt to one side (cervical lateral flexion)
| * Neck rotated to opposite side (cervical rotation)
73
How is torticollis named/described?
Based on the side of tilt (involved SCM). Example: RIGHT torticollis = infant rests in RIGHT lateral flexion and LEFT cervical rotation “ipsilateral lateral flexion and contralateral rotation
74
What is the incidence/prevalence of torticollis?
* 3rd most common MSK condition in newborns
* 1 in every 250 live births
* Male to female ratio 3:2
* Right side > left side affected
75
What is the etiology of torticollis?
Intrauterine crowding and malposition of the infant in utero.
–History of difficult birth in 30-60% of cases
–53% first-born children
–High incidence of traumatic delivery
76
What are the characteristics of the SCM tumor subtype of torticollis?
```
Torticollis + small palpable tumor
• Most severe passive ROM limitations
• Non-malignant
• Appears 14-21 days after birth
• Disappears by 4-8 months -> replaced with fibrous band, making this the most difficult type to treat
```
77
What are the characteristics of the muscular subtype of torticollis?
* Tightness of SCM
* No palpable mass
* Passive ROM limitations
78
What are the characteristics of the postural subtype of torticollis?
* Infant’s postural preference
* Most mild and common presentation
* No tightness / Passive ROM limitations, unless it persist, in which case they will develop a muscular torticollis
* No palpable mass
79
How is torticollis diagnosed?
It is diagnosed using the presentation/ subtype and the age of initial diagnosis, which results in the determination of the time required to resolve ROM limitations
80
What are the characteristics for the treatment of torticollis?
* Earlier treatment = shorter treatment episodes
* Later treatment (>3-6 months old) or those with SCM mass = longer treatment episodes and/or risk for invasive interventions
81
How is torticollis identified in children?
* Typically noticed first by parent or pediatrician
* Pediatrician may provide initial education on positioning and stretching
* If not resolved, then referral to PT is done
82
What are the risk of torticollis?
If birth history includes:
• Longer birth length
• Multiple gestation (twins, triplets, etc)
• Birth trauma (use of instruments for delivery)
• Facial asymmetry
• Plagiocephaly
2+ of these risk factors = referral for preventative care/parent education
83
What is plagiocephaly?
A persistent flattening pressure on the contralateral posterior cranium, due to abnormal forces placed on the soft infant skull. This is almost always accompanied with craniofacial asymmetry and is the most common associated condition with torticollis
84
What are the presentations of plagiocephaly?
- Ipsilateral ear shift forward
| - Facial features of the contralateral side appear smaller/ less to developed
85
True or False
The more severe torticollis, the less severe plagiocephaly
FALSE, The more severe torticollis, the MORE severe plagiocephaly
86
What is type 1 plagiocephaly?
Type 1: Craniosynostosis
–Premature fusion of ≥1 suture of the skull. This is a red flag and is NOT treated by PT. They may or may not have a torticollis, but their cranial symmetries are not aligned
87
What is type 2 plagiocephaly?
Positional/Deformational
–Occipital flattening
–Abnormal external forces applied to soft infant skull
88
What are the subjective history components of the examination of a child with torticollis?
* Age at initial visit
* Age of onset of symptoms
* Pregnancy history including maternal sense of whether the baby was stuck in one position during the final 6 weeks of pregnancy
* Delivery history including birth presentation (cephalic or breech)
* Use of assistance during delivery such as forceps or vacuum suction
* Head/postue/preference and changes in the head/face
* Family history of torticollis or any other congenital or developmental conditions
* Other known or suspected medical conditions
* Developmental milestones appropriate for age
89
What are some other causes of asymmetry that may present as torticollis?
* Hip dysplasia
* Scoliosis
* Clavicle fracture
* Brachial Plexus Injury
* Congenital/genetic conditions
* Reflux
* Craniocynostosis
90
True or False
When we have a L torticollis, we usually have a R plagiocephaly and vice versa
True, When we have a L torticollis, we usually have a R plagiocephaly and vice versa
91
How do we measure PROM in patients with torticollis?
* Arthrodial Protractor
| * Big Protractor(to measure lateral flxeion)/Bubble Inclinometer/Therapist Observation
92
How do we measure AROM in patients with torticollis in a child younger than 3 months?
* Head rotation in supine
* Enticed by toys/sounds
* Emergence of lateral head righting asymmetry. As you tilt the baby from vertical, they are going to have the natural tendency to go back upright. So if you tilt the baby to the R, they will move to the L and vice versa
93
How do we measure AROM in patients with torticollis in a child older than 3 months?
* Observe functionally in supine and prone
* Sit on therapist’s lap/therapist on rotating stool (infant’s nose as it approaches shoulder)
* Neck flexion/extension(is it symmetric)
94
What are the other activities to observe in a child with torticollis?
* Focus on objects/face
* Visually locate objects in entire visual field
* Laterally track objects R -> L and L -> R through midline
* Horizontal tracking
* Convergence of the eyes as they get older
* Separating eye gaze from head movement as they get older
* Reaching/Swiping with both UE
* Equal hands to mouth
* Hands to body and hands to midline
* Reciprocal kicking
* Pull-to-sit maneuver (maintain head at midline)
95
What is used to measure plagiocephaly?
Cranial Vault Asymmetry Index (CVAI). Measure in mm at 30 degs from center of nose (outer edge of eyebrows)
96
What are the characteristics of level 1 on the plagiocephaly severity scale?
* Clinical presentation: All symmetry within normal limits
* Recommendation: No treatment required
* CVAI: <3.5
97
What are the characteristics of level 2 on the plagiocephaly severity scale?
* Clinical presentation: minimal asymmetry in one posterior quadrant, and no secondary changes
* Treatment recommendation: repositioning program
* CVAI: 3.5-6.25
98
What are the characteristics of level 3 on the plagiocephaly severity scale?
• Clinical presentation:
- Two quadrant involvement
- Moderate to severe posterior quadrant flattening
- Minimal ear shift and/or anterior involvement
• Treatment recommendation: Conservative treatment including repositioning and cranial remolding orthosis(based on age and history)
• CVAI: 6.25-8.75
99
What are the characteristics of level 4 on the plagiocephaly severity scale?
• Clinical presentation:
- Two or three quadrant involvement
- Severe posterior quadrant flattening
- Moderate ear shift
- Anterior involvement including noticeable orbit asymmetry
• Treatment recommendation: Conservative treatment including cranial remolding orthosis
• CVAI: 8.75-11
100
What are the characteristics of level 5 on the plagiocephaly severity scale?
• Clinical presentation:
- Three or 4 quadrant involvement
- Severe posterior quadrant flattening
- Anterior involvement including noticeable orbit and cheek asymmetry
• Treatment recommendation: Conservative treatment including cranial remolding orthosis
• CVAI: >11
101
What is the typical intervention for plagiocephaly?
```
HELMET THERAPY
• Outer shell = light-weight plastic
• Inner layer = foam
• Snug over prominence and hollow where the head is flat
• Worn 23hrs/day
```
102
What are the commonly used developmental testing in the infant population with plagiocephaly?
* Peabody Developmental Motor Scale
| * Alberta Infant Motor Scale
103
What are the characteristics of the Alberta Infant Motor Scale?
* Ages: 0-13months
* High concurrent validity with Bailey & Peabody
* High inter-rater reliability
* Predictive ability in detecting infants at risk for long-term abnormal motor development
104
What are the characteristics of the Peabody Developmental Motor Scale?
```
• Inter-rater reliability: r = .96
• Test-retest reliability:
- Age 2-11 months r = .89
- Age 12-17 months r = .96
• Sensitive to change as compared to the Bailey Motor Scale
```
105
What is the purpose of stretching as an intervention for torticollis/plagiocephaly?
Improve cervical PROM
106
How should lateral flexion stretching be done in a child with torticollis/plagiocephaly?
― Infant supine
―Stabilization inferiorly through shoulder
―Head gently laterally flexed (ear to shoulder)
107
How should cervical rotation stretching be done in a child with torticollis/plagiocephaly?
―Infant supine
―Stabilize anterior shoulder
―Head gently rotated (chin to shoulder)
108
What is the purpose of muscle performance as an intervention for torticollis/plagiocephaly?
Strengthen & build endurance of contralateral SCM. Promote rotation and lateral flexion to the other side
109
How strengthening be done in a child with torticollis/plagiocephaly?
```
― Active & Active Assisted ROM
―Sitting, prone, supine
―Promote ipsilateral rotation with use of:
- Toys
- Parents
- Mirror
- Visual tracking
- Feeding
- Auditory stimuli
―Feeding
―Righting reactions in upright postures, rolling, sidelying (effected SCM placed downward)
```
110
___ is a great HEP for children with torticollis/plagiocephaly?
*Tummy time* is a great HEP for children with torticollis/plagiocephaly?
111
What are the benefits of tummy time?
Prone position: bilateral neck flexor elongation, strengthens neck and spine extensors
• Decreases pressure on skull
112
How long should a baby spend during tummy time?
30+ minutes/day
113
What are the general recommendations for a baby during tummy time?
* Keep him company on the floor
* Place him tummy down on parent’s chest
* Prone propping with a Boppy
114
What are some environmental adaptations that can be done to help a child with torticollis/plagiocephaly?
* Carrying positions
* Alternating crib position
* Changing table configuration
* Car seat to promote midline
* Placing toys/stimulation to one side
115
What are some other types of treatment to use for torticollis/plagiocephaly?
* Microcurrent
* Mykinetic stretching
* Kinesiotaping
* TAMO approach
* TOT collar/ soft foam collars/customfabricated cervical orthosis
116
When conservative treatment of torticollis/plagiocephaly doesn't work, we opt to surgery. What is the ideal age of surgery and what are the goals?
```
1-4 years old
• Goal of surgery:
–Complete release of short muscle
–Restore cervical ROM and mechanics
–Preserve neurovascular structures
–Improve craniofacial asymmetry
```
117
What are the mechanisms of the use of botox in the treatment of torticollis/plagiocephaly?
• Inhibits release of acetylcholine -> Reduction of muscle activity -> More successful stretching
program/easier to strengthen
opposing neck musculature
118
What is the most common cause of perinatal brachial plexus injury and what is the incidence?
A traction injury during delivery. • Incidence 0.38 to 5.1 per 1000
119
What are the risk factors for a perinatal brachial plexus injury?
* Shoulder dystocia (catching of the shoulder)
* Birth weight >90th percentile
* Prolonged labor
* Breech delivery
120
A perinatal brachial plexus can occur at any level and the severity can range greatly. What are the ranges of severity?
* Neurapraxia (temp conduction block; axons intact)
* Axonotmesis (axon injury; endoneurium intact)
* Neurotmesis (rupture)
121
What are the levels in which a perinatal brachial plexus injury can occur?
* Nerve rootlets attached to the SC
* Ant or Post nerve rootlets
* Spinal nerve
122
Because the brachial plexus axon grows about 1mm/day, how long will it take for any regrowth in the upper arm to happen?
• 4-6 months
123
Because the brachial plexus axon grows about 1mm/day, how long will it take for any regrowth in the lower arm and hand to happen?
7-9 months
124
How long will full recovery from a perinatal brachial plexus injury take?
Recovery may occur for up to 2-4 years. Studies are inconsistent in reporting and defining recovery
125
___ is the most common perinatal brachial plexus injury
*Erb's palsy* is the most common perinatal brachial plexus injury
126
What levels are affected in erb's palsy and what is the typical presentation/posture?
• C5-6
• “Waiter’s Tip” resting posture
The rhomboids, deltoids, rotator cuff muscles, all the way to the biceps and wrist extensors in the waiter's tip posture
127
What levels are affected in global palsy?
C5-T1. All of them
128
What levels are affected in klumpke’s palsy and what is the typical presentation/posture?
C8-T1
| • Muscles of the finger intrinsics and wrist are affected
129
What levels are affected in Horner’s Syndrome?
T1 root avulsion
130
What is Horner’s Syndrome?
A disruption of sympathetic ganglion
131
What are the symptoms of Horner’s Syndrome?
* Deficient sweating on affected side of face
* Recession of the eyeball
* Abnormal pupillary contraction
* Myosis (constricted pupil)
* Ptosis
132
What are some of the anatomical changes seen overtime in a child with a perinatal brachial plexus injury?
* Flattening of humeral head
* Humeral head hypoplasia
* Shortened clavicle
* Irregular glenoid fossa
* Posterior subluxation
* Contractures of internal rotators due to the muscles imbalance between the internal and external rotators
* Changes to glenohumeral: scapulothoracic ratio
133
What are some of the activity/participation limitations seen in a child with a perinatal brachial plexus injury?
* Transitions over both sides equally
* Balance and protective reactions
* Prone, crawling and creeping skills
* Reach to grasp skills
* Bilateral arm skills (catching, lifting)
* ADLs requiring bimanual skill
134
Microsurgery can be used for the treatment of perinatal brachial plexus injury. What is the age in which this is usually done and what are the types of surgery that is done?
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For infants 3-8 months old or younger
• Nerve transfers
• Nerve grafting
• Neuroma dissection
• Neurolysis
• End to end anastomosis of nerve ends
```
135
What are some of the orthopedic surgery which may be considered in the treatment of perinatal brachial plexus injury?
* Tendon transfers
* Lengthenings
* Osteotomies
136
What are the components of the PT examination of a child with perinatal brachial plexus injury?
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• ROM
• Motor/muscle activation
• Posture (neck, trunk)
• Sensory status
• Developmental Skills
• Visual skills
• Frequent re-exam to document recovery and aid in
program planning and prognosis
```
137
What are the ways that we can document pain in children with perinatal brachial plexus injury?
* FLACC: Face, Legs, Activity, Cry and Consolability
| * Wong-Baker Faces Scale
138
What are the interventions used in early infancy for the treatment of perinatal brachial plexus injury?
* Protect impaired extremity
* Support spontaneous recovery
* Prevent secondary impairments
* Minimize pain
* Promote typical movement patterns
* Family education
* Home program
139
What are some additional rehab considerations used for children with perinatal brachial plexus injury?
* ROM/stretching
* Strengthening
* Botox
* Kinesiotape
* Sensory awareness
* Orthotics
* Constraint-Induced Movement Therapy
* E-stim
140
What are the long- term outcomes of perinatal brachial plexus injury?
• May present with lifelong activity limitations,
orthopedic disorders and pain
• Outcomes research focusing on quality of life would be helpful
• Physical therapists may encounter individuals with
limitations resulting from a brachial plexus injury well
past infancy and childhood.
