Cerebral Palsy

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What is Monoplegia?: 1 extremity, rare
What is Hemiplegia?: UE and LE on 1 side
What is Paraplegia?: 2 LE
What is Quadriplegia?: UE = LE, all 4 extremities, always the trunk, poor head/neck control. UE is more involved than LE.
What is Diplegia?: UE mild + 2 LE. More LE involvement, trunk weakness and only SOME UE weakness or fixing
How is a CP classification given? Based on what? (3): Type, severity, and distribution
What is athetosis?: Slow, writhing movements of the face and extremities, especially in distal musculature. Poor midline stability. Athetosis DEVELOPS, not congenital.
What is Dystonia?: Rhythmic, twisting distortions and changes in tone involving primarily the trunk and proximal extremities. Slow uncontrolled mvmts w/ a tendency toward fixed postures.
What are Choreiform mvmts?: Rapid, irregular, jerky motions commonly seen in the face and extremities
What is Ballismus?: Coarse flailing or flinging motion of extremities characterized by a wide amplitude.
Define what Cerbral Palsy is.: A permanent, but not unchanging neurodevelopmental impairment. Caused by a non-progressive defect or lesion.
With CP, describe the lesion or defect in the brain.: Can be in a single area or in multiple areas
When does someone get CP?: Usually occurs in-utero or shortly after birth.
What symptoms does CP produce?: Produces motor impairment and possible sensory defects.

Some kids will have speech, visual impairements/processing, seizures, mental retardation and/or auditory impairments
What is the Guide reference for CP?: 5C-5D practice patterns
What are the SPED verifications for CP?: Special Education considerations in the classroom include: orthopedically impaired and multi-handicapped
What is Triplegia?: 3 extremities, usually w/ 1 UE lesser involved.
Name two types of Hypertonicity.: Spasticity and Rigidity
What is Fluctuating tone?: Flexion at some points and extension at others. Might see spasticity and hypotonicity.
What is ataxia? Midline?: Poor timing, coordination, balance. Likes to stay on midline.
What is the standardized classification form used for CP?: GMFCS - Gross Motor Function Classification Scale
Describe what Mild CP severity is.: Able to function with peers, may need more time to complete tasks
Describe what moderate CP severity is.: Difficulty meeting milestones in timely manner. Uses assistive device and more time, but can keep up w/ peers.
Describe what severe CP severity is.: Unable to complete life roles, no independent ADL's, can't play.
Describe what profound CP severity is.: No useful or purposeful movement. Completely dependent.
What are the main etiologies of CP? (4): -Maternal
-Placental
-Neonatal
-Fetal
What are some Maternal causes of CP? (4): -Poor nutrition
-Poor prenatal care
-Poor health of mother
-Infection of mother via TORCH, early infection
What are some Placental causes of CP? (3): -Insufficiency, not large enough, not enough 02 and nutrients
-Premature separation/abruption, can tear away from wall, tears blood supply
-Placenta previa, placenta delivers before the baby causing hypoxia
What are some Fetal causes of CP?: -Vascular via intraventricular defects
-CNS defect w/in baby's brain, in-utero, hydrocephalus
What does neonatal mean?: At or around birth
What are some Neonatal causes of CP?: 1. Asphyxia, lack of 02
2. Hypoxia/ischemia
3. Infection via maternal herpes simplex II
4. Hyperbilirubinemia due to immature liver that leads to high bilirubin levels, leads to athetosis
5. Intraventricular hemorrhage (grades I-IV)
6. Periventricular Leukomalcia, can be cystic or non-cystic
What are three ways that CP can be diagnosed?: 1. Birth history
2. Clincial presentation, hemiparesis, diplegia, etc.
3. Neuro-imaging, U/S, MRI to see mylination of brain
How early can CP be diagnosed?: Can be diagnosed as early as before leaving the hospital, <6mo. Can also be as late as 1-3 years for mild involvement. Depends on care/MD's that are available.
What are three ways to improve prevention of CP?: 1. Improve socioeconomic health and maternal education
2. Identify maternal risk factors
3. Good NICU care
What are 4 neurologic pathophysiologies associated with CP?: 1. Intraventricular hemorrhage (IVH)
2. PVL, cystic/non-cystic
3. Encephalopathy (anoxic, hypoxic) Hypoxic Ischemic Encephalopathy (HIE)
4. Neuropathy from malformations of the CNS/brain
What are 4 neuroMUSCULAR pathophysiologies associated with CP?: 1. Decreased size of muscle fibers.
2. Decreased number of motor units.
3. Decreased firing frequency, which is increased with spasticity
4. Changes in recruitment order of motor units, producing stereotypical CP mvmts.
What is the primary system involved with CP?: Neuromuscular
What are 5 ways that the neuromuscular system is affected?: 1. Insufficient force generation
2. Tone leading to spasticity, hypotonia, rigidity
3. Hyperactive reflexes
4. Poor selective control of muscle activity, work in synergies
5. Poor anticipation of postural changes and body movements. Poor head/trunk righting.
How is the musculoskeletal systme affected with CP?: -Compensatory postures due to abnormal pull, fighting spasticity, weakness
-Contractures/deformities
-Risk for osteopenia, OA and Frx because kids don't get normal amount of loading. Don't have normal development
How is the Cardiopulmonary system affected w/ CP?: Need more endurance because patients have to work so much harder to complete a mvmt.
How is the Integumentary system affected w/ CP?: Possible skin break down due to braces, assistive devices
How is the Sensory system affected with CP?: May lose visual, auditory and body awareness.
When is the best time to test or examine a CP patient for TONE?: Best at rest or lying down. Tone changes dramatically with mvmt.
What standardized test would you use for a child with CP if you wanted to assess balance?: Pediatric Berg
How could Motor Function/learning/control be tested?: How long does it take for a child to learn a new skill.
What is a good indication of a child's cognitive level?: Do they appropriately play with an age-appropriate toy. What is their communication like? Behavior?
When looking at Functional Mvmt Patterns, what types of things should you examine?: -Tone, strength
-Patterns of mvmt, alignment, postural responses, primitive reflexes (ATNR, Moro)
-Environmental accessibility/functional skills
What types of tests and measures should a PT conduct with a CP patient?: -Outcome measures/standardized tests
-Spasticity/Modified Ashworth Scale
-Arena/Play based assessments
-Functional/Environmental assessments
-Gait analysis
-Videotape
What are some general goals for CP?: -Focus on activity/participation w/ peers
-Prevention of 2ndary impairments usually w/in the musculoskeletal system
-Maximize gross motor function
-Individualized treatment for child, CP is diff. w/ each person
-Family centered w/ parent ed.
What are interventions for hypotonia?: -Get kid as active as possible.
-Work on proximal muscles before distal muscles
-Work on endurance activities
-Child will need longer time to responsd
-Joint protection via AFO, SMO
-Monitor for athetosis and ataxia
What interventions are good for spasticity/rigidity?: -Increase AROM
-Maintain PROM
-Work proximal to distal, work more on trunk strength
-Postural alignment is due to muscular imbalances.
-Tight: hams, pf, hip add, hip ext
-Weak: hip flex/abd
What muscles are usually the most difficult to work with when dealing with spasticity?: 2 joint muscles such as the hams and gastroc
What interventions would you do with Athetosis?: Has poor midline stability, so work on proximal strengthening. Start w/ midline
What interventions would you do with ataxia?: -Weight shifting
-Reaching away from midline
What interventions would you do for dystonia?: Has strong co-contractions and gets stuck in midline.
-Work on trunk and then work distally.
-Work on flexibility, may need to stabilize trunk
-Work on COG and midline
What interventions would you do with a quadriplegia?: -Proximal strength
-Head control
-Eventually distal work with weight bearing activities
What interventions would you do w/ a diplegia?: Work on trunk and LE, monitor UE function
What interventions would you do w/ a hemiplegia?: Encourage use of involved side by using bi-manual skills via toy selection/activities. i.e. carry a tray w/ both hands
For infant/toddlers (0-3years) what intervention considerations should be made?: -Work w/ family in home/outpatient
-Promote parent's skill and comfort level w/ working with child
-Facilitate development and skills: postural stability, mobility and positioning
-Assistive devices, orthotics
-Developmental sequence vs. function
Preschool (3-5years) intervention considerations?: -Increase functional independence
-Develop a plan for education (IEP)
-Age approp. development in function and mobility via strength, endurance, transfers
-Adaptive equip, orthotics
-Modify environment
-Play-based interventions
-Medical mgmt/team approach
School aged children (K-12) interventions?: -Functional skills are PRIORITY
-Monitor developmental changes of child
-Gear treatment towards family/patients wants/interests
-Address societal/environmental barriers
-Maintain status of musculoskeletal system, strengthening
-Include child in setting goals. IEP
-Mobility vs. Endurance
-School/community accessibility
-Medical mgmt
What interventions would assist transitions into adulthood?: -Promote independence in home, workplace, school, community
-Life skills, activities
-Focus on activity/participation via force generation, hyperextensibility/hypoextensibility, endurance
-Access to community resources, government programs, independent living, vocational education
What is a growth issue to watch for related to bone/muscle?: Bone grows faster than muscle, causing contractures
What are two pharmacological interventions typically used for CP?: Baclofen and BOTOX
What is Baclofen? Name two ways it is administered.: Muscle relaxant that acts on the CNS and is similar to GABA (inhibitory)
1. Oral 2. Intrathecal
What are some side effects of oral Baclofen.: -May cause sedation and seizures
-Could have increased scoliosis due to decreased tone
How does the intrathecal Baclofen work?: A pump is inserted under the skin w/in the fascia in abdomen, w/o erosion of iliac crest/rib. A catheter goes into subarchnoid space, migrates down and decreases spasticity. Delivers smaller doses than oral Baclofen and has no SE.
What special considerations have to be taken with an intrathecal Baclofen pump?: Child must be old enough. Requires hospitalization. Can get infected.
What is the lifespan of a Baclofen pump?: 5-7 years
How does Botox help w/ spasticity? How is it administered?: It is injected into muscles and works at the neuromuscular junction. Inhibits the release of AcH at synaptic terminal.
How long does the effects of Botox last?: 2-6 months
What is the dosage of Botox determined by?: Weight of patient
What ages can receive Botox? At what ages is it most effective?: 18 mo. to 2 years. It buys time before having a surgical muscle release.
What is the long term effect of Botox on the muscles?: Nerves resprout and the joint loses it's springy end feel and becomes tight. Loses elasticity.
What is selective dorsal rhizotomy?: Neurosurgical procedure that clips the lamina of the vertebrae, folds back the spinous processes and cuts the dorsal nerve roots.
What long term effects does a selective dorsal rhizotomy have? Precautions?: It is PERMANENT! Will not perform below S1, so PF will still be spastic. Hams/achilles will require a lengthening surgery. Requires 1 wk hospital stay and PT starts on the 3rd or 4th day. Requires sign. rehab time
Do's and Don'ts with a SDR.: -Avoid ham stretch for 4 weeks due to pull on spinal cord.
-Do rolling and crawling for proximal strength
Qualification for SDR?: Cannot have had any previous orthopedic surgeries.
What interventions are used for seizure control?: Meds
What are some special considerations necessary for feeding/oral motor?: If patient has poor trunk stability and strength, a GI button is not a good idea.

Consider # of calories burned w/ taxing mvmts
Gait analysis is important prior to surgery, planning treatment sessions. Use a ...: videotape

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