Test Two Study Set PTH 225

Abnormal Synergistic Patterns

(Table 15.6, p. 671) A movement synergy is an adaptive motor plan of chains of movements that result in a functional movement. It can involve just one body part, such as the movement synergy to hold pen ready to write, or it can involve the entire body such as performing a jumping jack. Abnormal movement synergies occur when the movements that are chained together do not perform a functional movement and seem to occur involuntarily. In other words, they are not consciously called up. They are the result of decreased inhibition of movement patterns generated at a level below the cerebral cortex. There generally are two: i. Flexor synergy pattern: flexion, abduction, and external rotation of a body part (upper or lower extremity, or both) ii. Extensor synergy pattern: extension, adduction, and internal rotation of a body part (upper or lower extremity or both) f. There are other movement dysfunctions that occur due to damage to the motor cortex or subcortical areas of the brain. They are grouped in a category of dystonia or dystonic movements, they are discussed in O'Sullivan and Schmitz, p. 220..

Crossed Extension Reflex

Appears at 28 weeks gestation (prenatal period); Integrated by 1-2 months

Flexor Withdraw Reflex

Appears at 28 weeks gestation (prenatal period); Integrated by 1-2 months

Traction Reflex

Appears at 28 weeks gestation (prenatal period); Integrated by 2-5 months

Moro Reflex

Appears at 28 weeks gestation (prenatal period); Integrated by 4-6 months

Plantar Grasp Reflex

Appears at 28 weeks gestation (prenatal period); Integrated by 9 months

Startle Reflex

Appears at birth (although some mothers report that babies can startle prior to birth); Persists throughout lifespan

Palmar Grasp Reflex

Appears at birth; Integrated by 4-6 months

Explain the Systems Theory of Motor Control?

Because the Reflex Theory and the Hierarchy Theory of Motor Control both have their weaknesses, scientists now believe that the control of posture and movement is due to an interaction between various brain and spinal centers, working together, but not necessarily with one level overpowering lower levels of motor pattern generation. In fact, there is much evidence supporting the reality that systems other than just the nervous system impact movement ( for example, a person who has a muscular disease that impacts only the musculoskeletal system, or a person who has advanced cardiac or vascular disease will have movement problems that have nothing at all to do with the nervous system's action). Another consideration is that posture and movement organize themselves as the person grows or changes throughout life. We will see in our unit on normal gross motor development how movement patterns change from birth through childhood, and we already know that as a person ages, their movement patterns tend to change (wider BOS, slower movements, less trunk rotation, etc.). These changes occur as the result of adaptation of the movement patterns to frequency of use (compare how well an 8-month old can creep on all fours to how well a 50 year old creeps on all-fours—the difference can be partially attributed to how frequently the 8-month old creeps compared to how frequently the 50 year-old creeps), and to changes in the other body systems. (Compare the movement patterns of a 45-year old physically fit adult male who regularly participates in 5-K races to a 45-year old obese adult male who regularly participates in sedentary activity.)

Spinal Reflex Loop

In a spinal reflex loop, some sensory experience is registered by the sensory receptor in the skin, or in the muscle, or in the tendons. This experience is sent back to the spinal cord as an electrical impulse that travels along the Afferent or sensory nerve. Once it arrives in the dorsal (or posterior) portion of the spinal cord, the sensory nerve enters the gray matter of this area, called the DORSAL HORN. There the incoming sensory neuron synapses on an INTERNEURON which carries the electrical stimulus to the ANTERIOR (or Ventral) horn of the gray matter. There the interneuron synapses on a motor neuron. The electrical stimulus then travels along the motor neuron to the muscle where it stimulates the muscle to contract resulting in a predictable movement response. All this travel and synapsing requires very little time ( as little as 0.15 seconds).

What is the most basic unit of movement in the Hierarchical Theory of Motor Control?

In this theory, the basic unit of movement, or the most primitive level of movement is the true reflex. A reflex is a motor action that occurs as the result of a specific sensory experience. For a reflex to be a true reflex the motor action that occurs must be the same action every time the sensory experience is presented. The simplest reflexes occur as a result of sensory-to-motor synapses that occur at the spinal cord level.

What types of motor responses are generated at the Cerebral Cortex level?

Movement patterns generated here occur because of conscious thought processes (at least for the first several times). These movements are quite complex and require much concentration and combination of previously learned simpler motor patterns. They include complex, highly coordinated tasks such as walking, running, performing sports skills, dancing, handwriting, keyboarding, gymnastics, and even anticipatory equilibrium responses. More about this later.

Clonus

Repeated alternating contraction and relaxation of a muscle resulting a rhythmic "beating" or shaking contraction of a body part. This is an example of a spinal level "reflex" gone haywire. Something overstretches a tendon which then results in a contraction of that muscle which stretches the tendon all over again, which elicits another contraction, etc. This can happen anywhere, but is most commonly referred to at the ankle. The presence of this "beating" is evidence that something has happened in the CNS to destroy the inhibition of the "reflex".

What types of motor responses are generated at the Midbrain level?

These are movement patterns that are very complex and tend to involve changes in posture as a result of moving the center of gravity within and out of the base of support. These movement patterns are called righting responses and protective reactions. These movement responses should remain with us throughout our lives, and in fact it is ABNORMAL if they are absent. These movement patterns are the result of stimulation to the visual, the vestibular, and the proprioceptive system that results in you automatically attempting to keep your center of gravity within your base of support. For example, when you are tipped to the right, your neck and trunk will automatically laterally bend to the left in an attempt to right your head so that your eyes are level with the horizon. Another example is when you feel yourself being forcefully shoved out of your base of support, you will employ one of three strategies to attempt to bring your center of gravity back within your base of support: i. You will employ the ankle strategy as a first line of defense to use your dorsiflexors and plantarflexors (and to a lesser degree your invertors and evertors) to attempt to pull your body back over the feet. If this doesn't work you automatically move to ii. The hip strategy: your second line of defense, used for larger displacements of the COG out of the BOS. In this strategy, the hip flexors (and sometimes knee flexors) work to collapse you out of erect stance and bring your pelvis back over your BOS, and to lower your COG because you assume a semi-crouched position. If this doesn't work, you automatically move to iii. The Protective stepping or Protective Limb extension: In this strategy, your sensory system tells your midbrain that all previous attempts at re-orienting your body over the existing base of support have been unsuccessful. Your midbrain "decides" that since attempting to adjust you back over your old BOS isn't working, maybe it's time to set up a NEW BOS, and so you take a step in the direction of the displacement. This has the effect of increasing the size of the BOS in the direction of the displacement and therefore re-orienting your COG within a newly enlarged BOS. So you don't fall. When you are standing up and this happens, you take a step and the response is known as the protective stepping response. When you are seated and you are knocked over, or you feel yourself tipping over, you extend your arm and hand to catch yourself. Your new BOS in sitting is now the area under your bottom as well as the perimeter around the hand that you extended to catch yourself with. This extension of the arm is known as protective limb extension

What types of motor responses are generated at the Brainstem level?

These movement patterns are a bit more complex than the Spinal Cord Level movement responses and typically involve movements or muscle contractions that change muscle tone and posture. (Movement of the head or body results in the muscles in a specific part of the body contracting in a specific way.) A list of these is provided in O'Sullivan and Schmitz, p. 177, Table 5.7. These movement responses to stimuli are also considered to be NORMAL in infants, but they become integrated as the child begins to move more and becomes more fluent in their movement patterns (time of integration varies from reflex to reflex).

The child with paralysis:

What can't they do? 1. Feel: work on positioning to avoid pressure ulcers, particularly important in the paralyzed child who is in a wheelchair and cannot feel their bottom while they are also incontinent. 2. Transition: Teach the child and caregivers how to transfer and transition using proper body mechanics 3. Actively move: Probably will need a PROM program 4. Assess skin: realm of the parent until the child is able to take over.\ 5. Use the muscles that work: build up above average strength in the upper extremities and any other muscle group that are innervated to take over the functions of the paralyzed groups 6. Bracing and adaptive equipment: assess and recommend as appropriate to the child's functional level 7. Work on postural security: The ability of the child to tolerate a variety of positions up in space even though sensation in the lower body may be absent and the child may fear falling. 8. Teach child how to fall and about shunt safety

The child with hypertonia:

What can't they do? 1. Initiate movement out of typical flexor and extensor synergy patterns: so we inhibit the muscle activity that we don't want by shaking, or tapping the antagonist, or applying sustained pressure to the tendon, or moving the child out of synergistic positions, then we add activities to encourage mobility of the muscles we need by tapping, guided movement, rhythmic initiation, pressure on the muscle bellies, etc. 2. Hold midranges of positions: Our spastic child can move rapidly from the extreme of one movement to the extreme of another, so we want to stop the movement in the midrange and encourage coactivation of both the agonist and the antagonist around the joint. This generally requires facilitation or stimulation to one group of muscles while inhibiting the opposing groups. 3. Achieve independent mobility: Look at custom wheelchairs, if the mobility problem hampers their ability to walk and seems to be a long term thing, use of assistive devices such as pediatric walkers, forearm crutches, gait trainers, etc. 4. Work on isolating movements: if the child only moves with whole limb or whole body patterns of movement, then we need to isolate the body segment we wish to address, support everything else, and facilitate that segments movement. This can be accomplished dynamically through coactivation of the muscles surrounding a body part or by external support such as a standing table or frame.

The child with hypotonia:

What can't they do? 1. Initiate movement: So do activities designed to achieve mobility—tapping, quick stretch, guided movement, rhythmic initiation, use of enticing toys to stimulate the desire to move. a. Handling: this is an NDT term that refers to the way we use our hands to facilitate the patient moving in certain ways. By how we move the child, by how we use primitive reflexes (remember how I got Michelle to roll by using her body-on-head righting responses?), by how we place our hands we tell a patient what we want moved and how we want it moved. This is a skill that requires quite a bit of specialized training to actually understand, but there is a nice summary in M&K p. 95 - 105. 2. Poor postural tone: Do activities to encourage holding a position—compression through the joints (approximation), pressure over the muscle belly, practice holding in small ranges of motion including gently tilting the trunk to see if the child can use postural righting reactions and how long the lag time is before they try. 3. Positioning: placing the patient in a way that they have to use their muscles to perform a task, whether it be a holding or postural stability task or a movement task. When positioning, you need to decide what you want, and position the child so that they are working that segment. For example, if you are interested in improving head control in a child with poor head control, you would first support the child everywhere but the neck, because that is the segment you are concentrating on. Then you want to find out how much control the child has in holding his head against the full pull of gravity. If the child cannot hold his head against the full pull of gravity, then place the child in a position where gravity is constant, such as in sitting or sidelying and work on strengthening the neck flexors and extensors in these positions. 4. Positioning to avoid contractures: In the hypotonic child, you want to position the child so they avoid forming contractures or overstretching ligaments, so you want to watch the frog-legged position, watch foot drop, watch W-sitting, watch cervical hyperextension and place the child in positions that discourage or eliminate these options. 5. Equipment: Discuss the need for adaptive equipment, splints, special positioning devices, and other things that can add to your therapy session by serving as an "extra set of hands" or to achieve carryover in the home or classroom via the position the child is in. 6. Stretching: Believe it or not, this may be necessary, simply because the child may have contracted into his position of choice and he doesn't have enough motor control to move out of these positions. 7. HEP: Vital to carryover. Must be hectic-schedule friendly and include some element of play.

Hypertonicity

When motor impulses from the cerebral cortex and the lower centers are allowed to fire too much, they result in muscles that are overstimulated and therefore "stiff" or "rigid". Therefore many of our patients with CNS lesions will have increased muscle stiffness both at rest and during movement attempts. This occurs because no motor impulses are INHIBITED therefore, too much stimulation is reaching the muscle. The area that does most of the inhibition of unwanted motor impulses is the cerebral cortex. Severe hypertonicity is generally exhibited as rigidity. In rigidity, the patient is "stuck" in a pattern due to extreme activation of one muscle group (flexors or extensors).

Hypotonicity

When not enough motor impulses reach the muscles, they do not contract enough resulting in a patient that has considerable trouble generating a movement and who has muscles that seem to be "doughy" in consistency because the resting muscle tone has decreased. This can happen because of two reasons: i. Too many motor impulses are being inhibited. Not likely, but a possibility ii. Not enough motor impulses are being generated to result in effective movement. (Most likely)

Motor Program

a circuit of nervous impulses that, when stimulated by conscious or subconscious thought processes, results in a very predictable movement sequence. Examples would be the subconscious breathing or climbing stairs.

15. What is a Gower's maneuver?

a. A hallmark sign is the Gower's maneuver depicted in M&K p. 225, Figure 8-17. In this maneuver, the child can no longer come to standing through bear stance or even ½ kneeling, but rather moves up to bear stance (hands and feet) and then uses the hands to walk his body to up right by gradually moving them up the legs.

21. What is an Individualized Education Plan (IEP) and in what treatment delivery setting would you use one?

a. An Individualized Education Plan (or Program) is also known as an IEP. This is a plan or program developed to ensure that a child with an identified disability who is attending an elementary or secondary educational institution receives specialized instruction and related services.

20. What is an Individual Family Service Plan (IFSP) and in what treatment delivery setting would you use one?

a. An Individualized Family Service Plan (IFSP) is a plan for special services for young children with developmental delays. An IFSP only applies to children from birth to three years of age.

Distinguish between BADLs, IADLs, and FMS and give some examples of each.

a. Basic Activities of Daily Living: (BADLs): Daily living skills that are necessary for an adult to manage themselves such as grooming skills (oral hygiene, bathing, dressing), toilet hygiene, feeding, and personal device care. b. Instrumental Activities of Daily Living: (IADLs): Daily living skills that are necessary for an adult to manage life and living independently. Include money management, functional communication and socialization, functional and community mobility, health maintenance. c. Functional Mobility Skills: (FMS): The skills involved in bed mobility, sitting, scooting, transfers, standing and stepping, and walking and stair climbing.

Deep Tendon Reflexes and Grades (according to the scale listed in O'Sullivan and Schmitz).

a. Biceps b. Triceps c. Brachioradialis d. Patellar e. Achilles

13. What does PT do to intervene with CF?

a. Chest PT including percussion, vibration, and postural drainage b. Breathing exercises, chest wall mobilizations, and assisted coughing and strengthening to the cough c. Overall cardiopulmonary aerobic exercise to encourage fitness and deep breathing.

17. What is pseudohypertrophy?

a. Child may also exhibit pseudohypertrophy. This is when the muscle belly, particularly the calf muscles seem to be hypertrophic because they are very large and well defined, but in fact they are not muscular but the muscle tissue has been replaced by fatty tissue. (M&K p. 226. Figure 8-18)

21. Know a brief definition/explanation of each of the theoretical approaches discussed in class. (Ex: The theory behind neurodevelopmental treatment is to decrease the influences of abnormal tone and coordination by using the developmental sequence and sensory stimulation.)

a. Compensatory Training Approach: In this approach, the emphasis is on the early resumption of functional independence using the uninvolved or less-involved segments for function. This concept relies heavily on using substitution patterns of movements, on modifying the environment to faciliatate learning of skills, ease of movement and optimal performance. One of the disadvantages of this approach is that the involved segments are largely ignored and this may lead to learned non-use. It also may lead to the development of splinter skills which is the ability to perform a specific task in isolation of any of its components or without being able to generalize the skill to other settings or circumstances. b. Neurotherapeutic Approaches: These approaches are focused on using therapeutic techniques to reduce sensorymotor deficits and promote motor recovery and improved function. Manual techniques are used to improve control of movement and the focus is on increasing the likelihood of "normal" patterns of movement. i. Neurodevelopmental Treatment: Developed by Karel and Berta Bobath. Initially, the Bobaths attributed the problems following neural injury to abnormal tone and coordination because of the release of abonormal postural reflexes (which occur in the lower brain centers) from the inhibitory control of the motor cortex. The focus of treatment is to promote development of control of movement by using the developmental sequence using techniques such as handling and key points of control and dynamic reflex inhibiting patterns. There is a great reliance on sensory stimulation such as kinesthetic, proprioceptive, tactile, and vestibular to bombard the CNS in order that the appropriate expected sensations of movement be relearned and correlated to movement patterns. ii. Movement Therapy: Developed by Signe Brunnstrom primarily designed to treat people who had suffered strokes. She believed that movement had to be relearned by a fairly structured series of activities, and initially she used the abnormal movement synergies to begin the concept of movement then gradually worked her patients in non-pathologic synergistic patterns. Sensory techniques that are a part of Brunnstrom's technique include stretch, tapping, stroking, and pressure, and there is a lot of verbal feedback and repetition. iii. Proprioceptive Neuromuscular Facilitation: Developed by Maggie Knott, Dorothy Voss, and Dr. Herman Kabat. Uses functional patterns of movement that are spiral and diagonal, with very precise points of contact to enhance the function of the underlying muscles and completion of the desired pattern. iv. Rood's Approach: Developed by Margaret Rood. Focused on the application of sensory stimuli to produce movement and sensory stimuli were organized according to their ability to produce a quick movement of short duration (phasic) or a sustained movement (tonic). Stimuli to promote tonic movement were used to promote positions of "holding" such as standing or sitting, whereas phasic stimuli were used to produce movement such as rolling over. c. Functional/Task Oriented Approach: AKA Motor Control/Motor Learning Approach. Based on the theoretical model that movement is not initiated as a hierarchy, that the CNS is organized around essential functional tasks and the environment in which the task is performed. In this model, movement occurs as a product of cognitive, perceptual, motor learning, and biomechanical strategies. Treatment is focused on specific functional tasks to "jumpstart" that particular functional task circuit and the task is practiced at length. This approach is not very effective for those people with severe neurological damage or severe cognitive impairments. d. Integrated approach: Using a little bit of everything to see what works best.

What other factors besides the integrity of the Central Nervous System can influence how a person moves?

a. Consciousness, Arousal, and Attention: Refer to the notes on the Sensory Testing Lab Handout. Basically, the idea here is that a person cannot be expected to move "normally" if they are not mentally alert and paying attention to what they are doing. Consciousness and arousal can be impacted by neurological diseases and injury, but also by non-disease factors such as the use of sedative medications, alcohol, or illegal drugs. Attention can also be impacted by medical diagnosis (ADHD, hyperactivity, etc.) or by other health processes including hormonal imbalances, use of excessive amounts of caffeine or other stimulants. b. Joint Integrity and Mobility: This speaks to the need to have an intact skeletal system for movement to occur. Patients with diseased joints (OA or RA) will avoid certain movement patterns due to pain or joint deformity. Patients with bone instability will avoid or are prevented from moving in certain ways due to pain or casts/braces. c. Muscle Performance: Patients with impaired muscle health or impaired muscle strength or power will not necessarily move in "normal" ways. For example, a patient who has a quadriceps muscle strength grade of 2/5 will not be able to extend the knee through the full arc of motion against gravity. However, this does not mean that the patient does not have the motor plan to extend the knee fully, it simply means that the muscle that causes the motion cannot do its job. d. Sensory Status: If the information that the sensory cortex or the lower reflex centers receive from the sensory receptors is faulty or is diminished or absent, then the motor responses will be impacted accordingly. A patient cannot respond with an appropriate movement if he/she is unaware that they need to respond. For example, a patient with diabetic neuropathy may experience absent hot/cold sensation in the feet. That same patient is at risk for sustaining a burn on the feet from submerging them in hot water because he/she is unaware that the water is too hot and fails to remove their feet before they are burned. The patient has an intact motor program for withdrawing the feet, but is unaware that he/she needs to use it.

18. What is the difference between crawling and creeping?

a. Crawl: move forward on the hands and knees or by dragging the body close to the ground. b. Creep: move slowly and carefully in order to avoid being heard or noticed.

Describe the following types of rigidity:

a. Decorticate rigidity: sustained contraction of the upper extremities in flexion and the lower extremities in extension. The UEs are flexed at the elbows, wrists, and finger and the shoulders are tightly adducted to the chest wall, while the legs are held in full extension at the hips and knees, and the ankles are plantarflexed strongly. Hips are also internally rotated. This is seen in comatose patients who have a brain lesion in the midbrain. b. Decerebrate rigidity: sustained contraction of the trunk, upper and lower extremities in full extension. In the UEs, the shoulders are adducted tightly to the chest wall, the elbows extended, forearms pronated and wrist and finger flexion. The LEs are extended fully and the ankles are plantarflexed. This is seen in comatose patients who have a brain lesion in the brainstem. c. Leadpipe rigidity is constant resistance to passive movement no matter how quickly you attempt to passively move the body part. It can effect one extremity or one side of the body, and is generally due to a brain lesion in the area of the basal ganglia. Patients with Parkinson's disease often show leadpipe rigidity. d. Cogwheel rigidity: is rigidity characterized by rachet-like jerkiness when you attempt to passively move them through an arc of motion. It is seen primarily in the upper extremities.

3. Define cerebral palsy and tell the three main ways it can occur.

a. Definition: a disorder of posture and movement that occurs secondary to damage to the immature brain before, during or immediately (within the first two years or so) following birth. It is a Static Encephalopathy because once the damage is done and the baby is stabilized, the damage does not get worse, it is not progressive. HOWEVER, as the child grows the effects of the brain damage may have changing effects on the growing body. b. For instance, because the child does not follow typical gross motor developmental progressions, he does not bear weight at the times and in the places that a non-impaired peer would, so there will be differences in the integration of reflexes and in the progression of awareness of the body in space as the proprioceptors are stimulated. Also because weight bearing will vary, the skeletal structure may not develop according to usual patterns. For example, in the CP child who does not begin to bear weight through his LEs by age 12 months, the acetabulums never deepen and the angle of the neck of the femur never increases, so the hips can easily dislocate. c. Causes: i. Injuries to the fetus can occur in a variety of ways: maternal exposure to toxins such as radiation, drugs, alcohol, infections such as herpes simplex, cytomegalovirus, or toxoplasmosis, varicella, etc. Other factors can include maternal Rh incompatibility which yields erythroblastosis fetalis, maternal trauma such as a car accident, maternal stroke, maternal diabetes or hypertension. ii. Injuries during birth: usually result in the fetus being oxygen deprived during the birth process due to breech presentation, the baby getting stuck in the birth canal, the baby's head being trapped in the birth canal, the umbilical cord being wrapped around the baby's neck and essentially "hanging" the baby when the birth process exerts tension on the umbilical cord as the baby is pushed out but the placenta remains behind, maternal hemorrhage or critical medical emergency during the birth (including seizures or heart failure), etc. iii. Injuries following birth: any kind of trauma that causes damage to the brain including child abuse, car accidents, near-drowning, near-SIDS, choking, just about anything that can cause brain damage in an adult can cause brain damage in a child.

9. Why does hydrocephalus generally accompany spina bifida and what is done to treat it?

a. Enlargement of the ventricles is known as hydrocephalus, and is generally treated by inserting an intraventricular peritoneal shunt. An IVP shunt is a tube that is inserted into the ventricles and then is connected to a one-way valve. When the pressure of the CSF inside the ventricles reaches a certain point, the valve opens and allows excess CSF to drain from the ventricles down a tube that is run just under the skin to the peritoneal cavity. The fluid then is released into the peritoneal cavity where it is resorbed. Usually the IVP shunt is inserted with enough tube to allow several inches of growth, but it is not uncommon for the child to need to have the shunt revised periodically. While the infant has an open fontanel, build-up of CSF can be partially accommodated by an increase in the head size, but after the fontanel closes, increased CSF leads to increased intracranial pressure. This can cause further brain damage and even death. There are some important signs of shunt malfunction in Table 7-3 on M&K p. 177. You should familiarize yourself with irritability, seizures, vomiting, lethargy, headaches, personality changes, and memory changes.

10. What are five characteristics of the Down syndrome child?

a. Features i. Hypotonia ii. Joint laxity and hyper mobility iii. Almond-shaped eyes iv. Flat, wide bridge of the nose v. Developmental delay vi. Mental retardation vii. Small mouth with what seems to be a "too-big" tongue (really the tongue is hypotonic too, and just takes up more room because it is floppy viii. Congenital heart deformity: can be life threatening; all Down syndrome children are generally screened for it at or near birth ix. Atlanto-axial deformity: Due to a malformation of the atlantoaxial joint and made worse by the fact that the ligament that holds the axis in place in the atlas is hypermobile allowing the axis too much excursion. This can result in C1 SCI if not treated properly (surgical fusion). b. Gross Motor developmental considerations: Down children will not necessarily be motivated to move, but rather will be content to sit and watch. They need external motivation. Also, when they do move, they will find a way to attain a position. They use their ligamentous laxity and closed-packed positions to substitute for muscle tone, so they may sit up by widely abducting their legs in prone and pushing back up with their hands (Figure 8-2, M&K p. 204). They may also revert to W-sitting which is pictured on M&K p. 96, Figure 5-4A. W-sitting is a very stable position that allows the child to sit independently and erect without using their trunk muscles for proximal stability. This is a particularly bad position because of the stresses it puts on the ligamentous structures in the medial knee and the posterior hip capsule, and also because of the difficulty the child has transitioning out of the position toward other positions. c. As the child with Down syndrome grows older, it is very important that fitness become a natural part of their routine. Obesity and decreased cardiopulmonary endurance are some of the main causes of decreased life expectancy in the Down population. d. People with Down syndrome can be expected to live into their sixties and seventies, presuming they have no other health problems such as HTN or cardiac issues. e. Treatment considerations: See end of this handout

5. Explain how hypoxia or ischemia can cause brain damage in an infant and tell what areas of the brain are affected and in what pattern.

a. First, any of the chemical or infectious exposures to the fetus listed above can cause malformation of the brain in its earliest stages of development. Malformations of the brain result in dysfunction of the brain and inability to move in the typical way. b. Second, when the infant's brain is deprived of oxygen, sensors in its brainstem register the lack of oxygen and set off corrective physiological functions to improve the oxygen perfusion of the brain tissue. These physiological mechanisms include increasing the heart rate and the blood pressure. When the blood pressure gets too high, the delicate capillaries and vessels surrounding the ventricles burst and hemorrhage. This results in damage to the nerve cells in this area. The nerve cells in this area are the motor cortex portion of the corticospinal tracts and are arranged according to the motor homunculus. The homunculus is oriented so that the feet and LEs are located deepest near the ventricles and then the UEs, face, mouth, and upper body are oriented at the top of the cortex and down over the side. The worse the bleed/hemorrhage, the greater the area of brain damage, so the worse the motor involvement with the least involved child having trouble only in his feet or legs (diplegia) and the more involved child having trouble throughout the body (quadriplegia). i. Prematurity: when a child is born premature, there is a good chance that the lungs are not developed sufficiently to perform adequate oxygen exchange. The fetus' alveoli are not inflated, because they have no air to breathe, and no need to breathe it. The alveoli resemble collapsed and crumpled balloons. At birth, a special substance known as surfactant allows the alveoli to fully expand and to not collapse on themselves and stick together. If the baby is born before his body makes surfactant, there is nothing to keep the alveoli fully inflated, and they collapse, severely limiting the surface area available for oxygen exchange. When this happens, the infant's brain does not get enough oxygen, and the process outlined above begins. We now have the medical technology available to squirt artificial surfactant into the lungs of preemies to help the alveoli to stay inflated, but these babies remain very fragile. c. Third, when the child is injured after birth, the brain damage occurs just like it does in adults. The brain can suffer blunt trauma in a MVA or from abuse, the child can suffer shaking injuries to the brain, and can suffer brain damage due to a lack of oxygen due to near-SIDS, near-drowning, and choking. When the child is deprived of oxygen a similar process as above begins. As the child matures and gets older, the damage from injuries may be localized and the presentation of motor deficits may be more like Hemiplegia because the brain has already specialized or differentiated to some degree.

Describe an abnormal Flexor synergy movement pattern and an abnormal Extensor synergy pattern. Include both upper and lower extremity positions/movements.

a. Flexor synergy pattern: flexion, abduction, and external rotation of a body part (upper or lower extremity, or both) b. Extensor synergy pattern: extension, adduction, and internal rotation of a body part (upper or lower extremity or both)

1. KNOW your major gross motor milestones

a. Head control: Good head control should be present by four months. This means there should be no head lag on pull to sitting and when the child is held suspended and tilted any way, they will flex the neck on the opposite side to bring the head toward midline. b. Segmental rolling: Babies roll like a log by about 4 months and show a nice roll with dissociation between the shoulder girdle and the pelvic girdle between 6-8 months. c. Sitting: Child can sit propped when placed around 6 months, and can sit independently with the hands free to play around 7 months while they can assume sitting from prone by around 8 months. d. Cruising and creeping: Crawling on all fours is NOT crawling, it is called creeping. The word crawling is reserved for pulling the body forward in prone using the forearms, also known as commando crawling. True creeping happens about 8-9 months and the child can begin to pull to standing at furniture and cruise (sidestep around furniture) by about 10 - 11 months. e. Walking: usually happens somewhere around the 1st birthday, but can happen up to 18 months and still be considered within the range of normal. Is also possible to be seen in a younger child. The rate of development varies from child to child.

4. What are the four ways abnormal tone can be manifested in a child with CP?

a. Hypotonia: very common way that the CP child initially presents. A floppy baby. The child has difficulty generating enough motor unit activity to yield functional movement or to sustain anti-gravity postures (this means the ability to hold the body up against the force of gravity pulling it down). Muscles feel mushy to palpation, and when the child is held up the body parts tend to droop down. Some CP children continue throughout life to be hypotonic, and some will show hypotonia as their resting state and then will show extreme hypertonia or spasticity when they attempt to move. Although your book does not say this, my experience is that hypotonia is generally due to diffuse brain damage that may affect many areas. b. Hypertonia: Also referred to as spasticity. Spasticity is defined as the increased resistance of a muscle group to passive stretch that is not dependent on the speed of the movement. It may appear gradually replacing initial hypotonia, or it may appear from the beginning (this usually indicates severe damage) and it may be a component of fluctuating tone. Children with hypertonia are at risk for developing joint contractures, for having hyperactive tendon reflexes, and they may also have easily elicited primitive reflexes. Usually due to damage in the motor cortex and the spasticity is due to a lack of inhibition of lower movement patterns by the motor cortex. (Just like in the stroke or head injured population i. Rigidity: a very excessive presentation of hypertonicity and is characterized by muscle stiffness that allows little to no joint movement. ii. Varying tone: the arms or legs may exhibit spasticity and the trunk and neck exhibit hypotonicity c. Athetosis: a type of disordered movement that is characterized by difficult movement of the limbs in the midranges, so that the child's movements tend to be of large excursions between the endranges of the movement. The further the limb is from the body, the worse the motor control and you see greater numbers of involuntary movements because the child is trying harder to control posture and movement. There is decreased static and dynamic postural control. You may see writhing movements of the head, face, tongue, or individual limbs or body parts like the hands or feet, OR you can see whole body patterns of writhing whenever the child attempts to move. Usually due to damage in the basal ganglia. d. Ataxia: due to damage in the cerebellum, there is a lack of coordination of movement and you see the same sorts of movement disorders that you see in the adult patient that has had damage in the cerebellum: decreased balance, decreased ability to coordinate higher gross motor activities and fine motor activities, past-pointing, poor eye-hand and eye-foot coordination. Frequently when these children learn to walk, they use a lunging pattern that makes you think that in any minute they are going to fall hard, but actually they become quite adept at balancing themselves while moving very quickly. May also be called extra-pyramidal CP.

Compare and contrast the following aspects of feedback as it applies to motor learning:

a. Intrinsic: This feedback occurs as a natural result of the movement and would be experienced by anyone performing that movement. (The person would feel the movement and know the accuracy, or they would see the product of the movement and be able to judge the accuracy, or they would hear the outcome of the movement and known the accuracy of the movement, etc.) b. Extrinsic, augmented: This feedback is through additional sensory cues not necessarily experienced in any environment other than the learning environment. (Outside verbal prompts by a coach or teacher, manual cues to move in a certain way, biofeedback cues, etc.) c. Concurrent feedback: Also known as Formative Feedback. Occurs while the task is being performed with the purpose of adjusting the performance while it is going on. Is most useful to correct a task where it is important to know how to PERFORM the task. For example, to improve a hurdler's technique so that her speed may be increased, it is important to intervene in the middle of the practice to correct a bad form so that the overall task is improved and the speed increases. d. Terminal feedback: Also known as Summative Feedback. Occurs after the task is completed with the purpose of adjusting for FUTURE performances. Is most useful to correct a task where it is important to get a particular RESULT or PRODUCT. For example, it is important to evaluate the quality of a cake after it has been baked and then to adjust the process for future cakes, to improve the quality of the future cake, since you can't change the one you have already baked. e. Type of feedback: Feedback type needs to be chosen based upon the sensory integrity of the learner (it makes no sense to give visual cues to a learner who has visual impairments), and upon the stage of Motor Learning—what type of sensory input should the learner be relying on at this stage in the process? f. Frequency of feedback: i. Frequent feedback: increases the speed of accuracy, but decreases how well the learner retains the skill ii. Randomized feedback: slows the speed of accuracy, but increases how well the learner retains the skill. iii. Summed feedback: Given after a specific number of trials (every other one, every fifth one, etc.) iv. Faded feedback: Feedback begins after every trial and then slowly becomes less frequent. v. Bandwidth feedback: Feedback is given only when the performance falls outside a given area of error. In other words, only when the performance is bad enough to warrant feedback. vi. Delayed feedback : Feedback is given after a brief time delay (3 seconds or so). This allows the learner to perform some self-evaluation before being given outside feedback. Should not be so long that the learner has forgotten the attempt, and should not be separated from the task by other practices (the learner will be confused about what the feedback is directed toward). vii. Immediate feedback: Given right after the task is completed—may prevent the learner from processing the task internally. viii. Withdraw external, augmented feedback only when you are sure that the learner has developed sufficient intrinsic feedback to self-correct effectively.

Discuss how each of the following teaching strategies should be used in each stage of motor learning:

a. Introducing the task: During the Cognitive Stage the learner must know what it is that he/she is expected to do. This requires several strategies: i. Figure out what your learner knows about the task: Do they have prior experience with something similar? (This could be good or bad—they may have learned incorrectly or they may have negative experiences with the skill.) The learner won't learn the task if they are not motivated to learn, if the task is not important to them, if they don't desire to learn, or if it seems (or is) unrealistic to learn. ii. Demonstrate the task EXACTLY as it should be done: This includes with the correct equipment; demonstrating mimicking any limitations, such as NWB or weak body parts; as quickly as the task should be performed to be functional; and smoothly coordinated (don't break it down into parts here). This gives the learner a Reference of correctness or an example of how the task should look. iii. If possible, try using a former patient with similar problems to serve as an "Expert Model": This person can provide insight into issues that you, as a non-impaired person, may not be aware of or may not be able to demonstrate. iv. During early practice, give clear and CONCISE verbal instructions: Do not overload your learner with wordy commands—Verbal diarrhea!!!!! v. Don't correct every error that the learner makes: Allow the learner to do some self-reflection using visual feedback (in a mirror) as a guide. This also allows for learner to do some problem-solving. b. Guidance: This is how you physically assist your learner during the task. i. In the cognitive phase: hands-on guidance of the body or body part is helpful because it limits errors and gives tactile and kinesthetic feedback about movement. Your hands can support the moving body part and give the learner security and make them feel safe.. However, the key here is this: GIVE ONLY AS MUCH ASSISTANCE AS NEEDED AND REMOVE THE ASSISTANCE AS SOON AS POSSIBLE. This prevents the learner from depending upon you for the motion. ii. In the Associative phase: Hands-on guidance should be phased out in favor of the learner using proprioception for feedback regarding accuracy. As the task becomes faster and in more ballistic (quick, rapidly alternating) tasks, hands-on guidance is less helpful and may restrict development of the motion. iii. In the Autonomous phase: Hands-on guidance should be minimal to absent. c. Active decision-making: Throughout the motor learning process the learner should be encouraged to make decisions about the accuracy of their performance. They should ask themselves questions like: i. What is the intended outcome of this movement? ii. What problems did I face during the movement? iii. How do I need to correct the problems in order to be successful? iv. If the task is complex, the learner should be able to identify the components or steps of the task. v. What order do the steps or components go in? vi. This active decision making should become more and more important as the motor learning process proceeds. It should be especially prioritized during the associative phase. d. Verbal Reinforcement: Verbal prompts and corrections should be used most during the Cognitive and Associative Phases of learning. Toward the middle and end of the Associative Phase, Verbal Reinforcement should be tapered off in favor of the learner's own proprioceptive sensory feedback. Sustaining verbal reinforcement too long results in learners becoming overdependent upon you for approval of accuracy of performance. Later on, during the Autonomous stage, use of verbal distractions can be helpful as a way of making sure the learner can perform when being distracted by outside, non-relevant stimuli.

14. How does a child contract Duchenne's Muscular Dystrophy

a. Is an X-linked recessive trait expressed in boys and carried by girls. These children lack a particular gene that produces the protein dystrophin. This results in the muscle cell membrane becoming weak, allowing destruction of the muscle cell. Another protein, nebulin, prevents proper alignment of actin and myosin, so contraction of the muscle fibers is difficult. When the muscle fibers break down, they are replaced by fat and connective tissue.

Explain the basic treatment principles for a patient who:

a. Lacks responsiveness i. Comatose Patient: 1. Program is designed to increase the patient's responsiveness to external stimuli a. Environmental Stimuli: Pleasant, non-noxious, familiar b. Structured Stimuli: Careful monitoring of patient's response to gradually presented stimuli i. One at a time with a delay to monitor patient's response (changes in vitals, level of agitation or alertness ii. Watch closely for signs of overstimulation ii. Agitated Patient: 1. Program is designed to calm patient. a. Environmental Stimuli: calm, reduced sensory input b. Routine c. Redirect outbursts d. Redirect perseveration b. Lacks mobility i. Goal is to create movement: 1. Begin with a Wide BOS and a low COG (bed or mat activities). Patient will feel safe and secure. 2. Progress to higher postures: sitting, quadruped, kneeling, standing 3. Causes of decreased mobility: hypertonia, contractures, pain, hypotonia, weakness, motor programming difficulties, decreased responsiveness to external stimuli 4. Techniques: a. Quick stretch b. Tapping c. Resistance d. Approximation e. Manual Contacts f. Light Touch g. Dynamic Verbal Commands h. Active Assisted Movements i. Therapeutic Guiding c. Lacks stability i. Goal is to create the ability to hold positions: 1. Begin with weight-bearing postures . 2. Causes of decreased stability: hypotonia, spasticity, decreased strength, impaired voluntary control, hypermobility, hypersensitivity, increased arousal. 3. Techniques: a. Quick stretch b. Tapping c. Resistance d. Approximation e. Manual Contacts f. Dynamic Verbal Commands g. Alternating Isometrics h. Rhythmic Stabilization i. Slow-Reversal Hold j. Place and Hold k. Using Theraband or weights to increase the proprioceptive input at a joint and increase stim to contract around a joint l. Bouncing on a Swiss Ball m. Aquatic Therapy d. Lacks controlled mobility i. Goal is to create the ability to hold positions while moving.: 1. Begin with reversals of movement. 2. While maintaining a static posture, one limb is freed to move through space. 3. Causes of decreased controlled mobility: Tonal imbalances, ROM restrictions, Impaired voluntary control, hypermobility, impaired reciprocal actions of the agonist/antagonists, or impaired proximal stabilization. 4. Techniques: a. Movements with directional changes b. Light tracking resistance c. Initial assistance to the posture d. Exercise the eccentric movement first e. Progress to concentric movement f. Slow-reversals and slow-reversal hold g. Repeated contractions h. Agonist reversals e. Lacks skill i. Goal is to assist patient in developing highly coordinated movements which are energy-efficient.: 1. Hands-on approach will be limiting to patient. 2. Techniques: a. Coordination Tasks b. Multilimb Tasks c. Tasks that focus on postural control mechanisms d. Agility Tasks e. Tasks that focus on Timing f. Some PNF

Compare and contrast the following aspects of practice as it applies to motor learning:

a. Massed versus Distributed Practice: Massed practice means that during a learning session there is more practice and fewer rest intervals. The problems with massed practice include fatigue, decreased performance and risk of injury. Best for learners with high motivation levels, and when the learner has sufficient endurance, attention, and concentration to withstand the practice session. Distributed Practice means that the practice time is equal to or less than the rest intervals. Studies show that overall learning increases with Distributed Practice, but the overall practice sessions are longer. Best for learners who have limited ability to perform or have limited endurance. Also good when the learner's motivation may be low, if they have a short attention span, poor concentration, or difficulty with motor planning. b. Blocked versus Random Practice: Blocked practice refers to practice around one task performed over and over without practicing something else. Random Practice refers to a learning session where several tasks are practiced in no particular order. Random practice has been shown to be better for retention of motor skills over the long-term, and although it may take longer to master the skill, the ability to transfer the skill to other similar tasks is improved. This is probably because the learner is used to sorting through a variety of motor tasks to find the most appropriate one since that is what they do in a randomized practice session. c. Practice Order: This refers to the sequence in which tasks are practiced. i. Blocked order: repeated practice of tasks in a specific order (task 1, task 1, task 1; task 2, task 2, task 2; task 3, task 3, task 3). Tends to result in improved early acquisition of skills. ii. Serial order: practicing in a repeating order: 1,2,3;1,2,3;1,2,3; Produces better retention and generalization of skills iii. Random order: practicing in no particular order: 1,3,2;2,1,3;3,2,1; Produces better retention and generalization of skills. d. Mental Practice: a practice where the learner imagines or visualizes performing the task without actually physically doing it. Has been found to be effective in learning new motor skills, and is good for patients who fatigue easily or who cannot physically practice independently. It can be good for learners who become anxious at the idea of physically practicing a task. It is important to make sure that the learner has a good understanding of the task before they mentally practice it, and they should verbally review the steps of the task for accuracy before practicing it. e. Part versus whole learning: Complex tasks can be broken down into parts for learning and practice. The different component parts are then practiced individually, can be chained together in smaller tasks, and finally the entire task is practiced as a whole. For individuals who are struggling to learn the task, it is important to practice the component parts in order (practicing components in a random order will confuse the learner). It is also important to continue to reinforce how the parts fit together into a whole. In order to practice effectively, the instructor must first carefully analyze the entire task and then break it down into sensible parts that are separate and distinct. Part versus whole practice is most effective with tasks that can be broken down into discrete parts. For example, teaching a person how to self-propel a wheelchair can be broken down into the parts of unlocking the brakes, placing the hands on the push rims, pushing the rims forward and downward, turning, parking and setting the brakes, etc. This is a task that can be easily broken down into parts. However, teaching a learner the task of running is not easily broken down into parts (first lift your foot, then advance it, then put it down, etc.). Continuous tasks are not best for part vs. whole learning, but tasks that have a beginning, middle and end are.

What are the four ways neural plasticity occurs and define each.

a. Neural Regeneration: We used to believe that the CNS was unable to heal or to regenerate function. We now know that this is not true. There is a capability of healing and there can be healing and changes that occur on the neuroanatomical, the neurochemical, and the neuroreceptive levels. Scientists are just beginning to understand the types of healing and repair that are possible. b. Cortical Remapping: Different and underused areas of the brain can take over the function of damaged tissue c. Parallel cortical maps: The CNS has back-up or "understudy"systems that can become operational when the primary system breaks down. d. Functional Substitution: Areas of the brain are capable of becoming reprogrammed for another function. This explains the increase in sensitivity to other stimuli when one type of sensation is lost.

2. Be able to discuss the abilities of the child at the following ages:

a. Newborn to three months i. As stated above the newborn is in a position of extreme physiologic flexion. The newborn cannot lift the head against gravity. Most of weight is born on the head and face, and the head is not completely turned to the side but about half sidelying with weight born on the cheek and side of the nose. ii. Neck and trunk extension begins and eventually by 3 months the baby can lift his head to about 45 degrees from the neutral. iii. By three months the arms have come from being tucked up under the trunk and flexed strongly to allowing some weight bearing on the forearms, although the child is not fully in prone on elbows (See figure 4-21 on p. 70) iv. In supine the zero to three month old child shows random arm and leg movements that may look like stretching or may look like kicking. v. In pull to sitting, the head lags behind the body. vi. Child may accidentally flip over as a unit when stretching or kicking, but it isn't a true, purposeful roll (M&K, Figure 4-24, p. 71). b. Four to five months i. Four Months: 1. Baby now lifts the head past 90 degrees from neutral in prone and can look forward, so there is actually a combination of movements occurring called cervical extension (extension from C3-C7) coupled with capital flexion (C1 and C2). This allows the child the ability to lie prone and keep the eyes aligned with the horizon. 2. Head remains in line with the body on pull to sitting (Figure 4-27 A) 3. Baby is able to bring the hands to midline and play with them and watch them. They may "combine" their hands on one toy, indicating an awareness of two hands that can manipulate the object (figure 4-25) 4. Head righting is brisk. Child can tilt head toward the opposite side when tilted in vertical suspension. (Figure 4-26) 5. Child now assumes nice prone on elbows (Figure 4-22) 6. Rolling happens by flipping over, usually from tummy to back because the child has raised up high on prone on elbows and his head gets out of midline and he falls over. It occurs later from supine to prone, and usually as a result of playing with the feet in the mouth and falling over to sidelying. ii. Five Months: 1. Baby can now anticipate on pull to sitting and will flex neck so that head is slightly in front of the body 2. Child can assume prone pivot or prone "airplane" position (Figure 4-29) 3. Child can also assume prone on extended upper extremities with the weight shifted down toward the lower abdomen (Figure 4-30) 4. In prone on extended upper extremities, the baby may begin shifting weigh subtly through the shoulder girdle in preparation for reaching which begins the pivot in prone. Moms and dads begin to find their baby turned opposite to the way they placed him to go to sleep. 5. Begins foot to hand and foot to mouth play 6. Reciprocal kicking begins. c. Six months i. Reaching in prone emerges fully. ii. Head and trunk righting responses emerge as a flexion of the side opposite to the way the child is being tilted. iii. When the child is held under the abdomen in prone suspension, the arms, legs and head are all held above the midline of the trunk, (landau reaction, Figure 4-33A) iv. The child now easily segmentally rolls and will frequently "play" in sidelying, rolling back and forth from mostly prone to mostly supine. This is excellent for development of abdominal oblique muscles. (Figure 4-34) v. Child can sit when placed, propped on his arms with a fully kyphotic trunk (figure 4-38A) d. Eight to nine months i. Eight Months: 1. Child can easily sit independently without upper extremity support and may begin assuming sitting from a quadruped position by sitting back across on of his "haunches". 2. Child can also reach out of his base of support for a toy and return to upright sitting without falling over by using a combination of trunk righting and protective limb extensions. 3. Creeping usually emerges around 8-9 months ii. Nine Months: 1. Creeping becomes fluent 2. Transitions in and out of sitting also become fluent 3. Child generally creeps into furniture, pulls to kneeling and then standing at furniture, and may begin to cruise (sidestep around furniture, first in straight lines, then around corners, and eventually between pieces of near furniture, such as the couch and the coffee table). This can happen in the 10-11 month range. e. Twelve months i. Toddler will continue to refine the skills of 9 months, and if they are feeling confident, they may stand without support for several seconds, usually with hands in high guard and with feet wide apart for a wide BOS. ii. Independent steps generally occur as one step first, and then a series of quick steps that are designed to keep from falling since you have displaced your COG in front of your BOS and you don't know how to control it. iii. During walking, the arms are held in high guard (Figure 4-45 A & B) f. Sixteen to eighteen months i. Toddler refines his gait to having more control over stopping and starting, to moving the hands to mid- and low guard and eventually to no guard, allowing the child to walk and carry a toy. Speed of gait may increase, but it never becomes a true run, and a reciprocal arm swing begins to emerge indicating compensatory derotation of the shoulder girdle on the pelvic girdle. ii. Toddler begins to explore stairs by creeping up and either creeping down backward or sliding down on their bottom. They can ascend stairs by stepping if they hold on to an adult's hand. iii. Child will come to stand independently in the center of the floor, (without pulling up) usually using the bearstance to standing transition versus the ½ kneel to standing transition. (Figure 4-46). iv. Child will jump down from a step, leading with one foot. g. Two years. i. Gait continues to mature with the step lengths increasing, the reciprocal arm swing now a fluent skill, and there is limited time spent in double-limb stance, with a more typical pattern of swing phase and stance phase. ii. Child will ascend and descend stairs using a mark-time pattern, with or without a rail, depending on the degree of practice. iii. True running with a flight phase when neither foot is in contact with the support surface emerges iv. Child will jump down from a step leading with two feet

7. Describe the three types of spina bifida.

a. Spina bifida occulta: a deformity in the complete closure of the spinal column occurs, with no other structural problems. This may be as simple as an incompletely formed lamina, or an absence of a dorsal spinous process with absence of one or both lamina. (See Figure 7-1C) There is no resultant functional deficit and, in fact, the person may never know he has a defect. It is also possible that this deformity may not show up until adulthood when a low back injury sends the person to the doctor or for an X-ray when the deformity is identified and may or may not be the cause of the low back problem. b. Spina bifida cystica: a deformity in the complete closure of the spinal column occurs that allows protrusion of the meninges only with cerebrospinal fluid (a meningocele). (Figure 7-1D) Again, no functional deficit is noted, but repair is usually indicated due to the presence of the cyst of CSF and the lack of stability of the vertebral column. c. Myelomeningocele: a deformity in the complete closure of the spinal column occurs and allows a protrusion of the meninges, CSF, and part of the spinal cord or cauda equina. (Figure 7-1E). This results in partial or complete motor and sensory loss below the spinal level where the myelomeningocele occurs. The cyst that bulges off the back can be covered with skin or may be open to the air, making the child at risk for infection and meningitis. These lesions are stabilized and repaired soon following birth by fusing the spinal segments involved, and grafting to stabilize them, as well as closure of the cyst. i. Other locations: It is possible to have a deformity or malformation of the neural tube in other areas besides the low back where myelomeningocele occurs. 1. Anencephaly: when the area of the neural tube that doesn't form is the brain. The infant may be miscarried or may be carried to term and delivered. Usually the child lives only a few hours and has only a brainstem, with no higher midbrain or cortical structures. 2. Encephalocele: when the defect occurs at the cervical area or in the occipital area of the skull.

What are the three ways that function can be recovered after CNS injury?

a. Spontaneous Recovery: This is when function is restored to structures in the CNS as a result of healing and repair. It occurs in the time immediately following the injury. b. Function-Induced Recovery: This is the restoration of the ability to perform a function or movement in the same way or a similar way to how it was performed before the injury. This recovery occurs as a result of changes in activities and the environment. (This is what we are attempting to do in PT.) c. Compensation: Using new motor patterns and adapting the remaining motor patterns to substitute for missing patterns. Old movement patterns are performed in a new manner. For example, if a patient who has had a stroke can no longer use their right arm and they were right-hand dominant, they may learn to write and perform most fine motor tasks with the left hand.

What are the four stages of motor control and explain each.

a. Stage One: Mobility: This is the initiation of movement by a body part. The movements are pretty uncoordinated and random, without purpose. These movements may occur as reflex responses to stimuli instead of intentional movement. In adults, mobility can be strongly influenced by the presence or absence of sufficient ROM or strength to accomplish a desired movement. b. Stage Two: Stability: This is the ability to maintain a position against gravity. For example, can the person hold up their head? Can they sit unsupported? Can they stand quietly? In order for a person to hold a position, they must be able to contract muscles isometrically and usually they must contract muscles on both sides of the joints (both flexors and extensors) in order to hold the body part in the middle of a range (think of holding the elbow flexed at 90 degrees—the biceps is working to flex the elbow against gravity, but the triceps is also working to keep the elbow flexed only to 90 degrees, and not fully). Stability also usually depends upon the ability of the core, postural muscles to work together to give the person a stable proximal segment (the core muscles must all work together to allow for us to hold up our heads, to sit up unsupported, and to stand erect). i. Now that our person can actually move a body part, and can hold a position, we need for them to be able to control their movements: c. Stage Three: Controlled Mobility (this is aka Mobility Superimposed upon Stability): This is the ability to hold a position while moving within that position, usually to achieve a weight shift or to perform a controlled task. Can the person sit up and maintain sitting while leaning forward to reach for the telephone on the table beside them? Can the person maintain upright erect stance while shifting his weight onto one foot in order to take a step? Can a person hold their shoulder and elbow steady while reaching to a shelf for a book? All of these tasks require that the person be able to HOLD while moving, and in most instances the movement is not rapid or gross, but is rather well controlled. d. Stage Four: Skill: The highest level of refinement of a movement. It requires that the person be able to refine the movement while it is in progress, changing the task and the movement as required. For example, can the person change their position, their posture, their balance, and the task all at the same time? For example, can the person stand up and then go up a flight of stairs. The task requires a change of posture (sit to stand to walking to climbing), a change in position (sitting with both hips and knees flexed, to standing with both hips and knees extended, to flexing and extending the hips and knees reciprocally) and an on-going change in balance as the base of support is constantly switching from left to right and the COG is moving forward. Skill is when the movement is highly coordinated and allows the person to investigate and interact with the physical and social environment.

What are the three stages of motor learning and explain each.

a. The Cognitive Phase: During this phase, the task is completely new to the learning and cognitive processing and thinking play a huge role in learning the task. The person is concerned with "what to do" and uses a lot of FEEDBACK to learn how accurately they are performing the desired task. When learning, persons rely heavily on visual feedback (what does it look like) and verbal instructions and corrections. If a person has cognitive limitations, this part of motor learning will proceed more slowly than in persons without cognitive limitations. The purpose of this stage is NOT mastery of the task, but merely acquiring it. b. The Associative Phase: During this phase, cognition is still important, but the learner now begins to associate a successful task with one that achieves the goal successfully. This stage includes lots of practice and the emphasis is not so much on "what do I need to do" and more on "How do I need to do it". Sensory feedback is crucial to this phase, with a move away from verbal instruction and correction and away from visual feedback and a greater reliance on proprioception. There should be multiple practice opportunities. The movement should improve in speed and efficiency (faster and with fewer extra movements) and it should be practiced in a variety of settings. This phase is the longest of the phases because the most practice occurs here. c. The Autonomous Stage: By this point the motor task should be fairly automatic, with little attention being paid to the individual components, and minimal conscious awareness of the task. The learner can perform the task equally well in all environments and generally should be error free, even when highly distracted. In fact, at this level the person may be more cognitively absorbed by how to use the motor task to achieve a larger goal, for example how to win a game or interpret a dance.

12. What are the two areas primarily affected in the person with cystic fibrosis? Describe what is not working or wrong in each area.

a. The pancreas: does not excrete enzymes to break down fat or protein, resulting in nutritional problems. Once diagnosed, the child will take oral enzyme supplements, but a hallmark of CF is a mucousy, smelly, bulky stool. Malnutrition and weight gain is a lifelong problem. b. The lungs: excessive mucous is formed and it is especially thick and difficult to move. It pools in the lungs and makes a good culture medium for bacteria and virus growth which lead to multiple episodes of pneumonia. The child has great difficulty mobilizing and producing respiratory secretions. The repeated pneumonias result in scarring in the lungs and obstruction of some of the smaller airways. This leads to a type of COPD, chronic bronchitis and closure of the bronchioles. Has been treated with some success with lung transplants, but the progressive lung disease also affects the heart leading to right-sided heart failure and the person may need a heart-lung transplant.

Explain how feedback works with respect to motor control. Explain how feedforward works with respect to motor control.

a. This concept of the sensory information resulting from the movement being analyzed by the midbrain and then the midbrain causing modifications to the CURRENT motor program is called FEEDBACK (aka CLOSED LOOP MODEL OF MOTOR CONTROL). Feedback is a relatively slow process, in the world of neurotransmission, so movements that are being learned for the first time may end up being slow and very labored. b. There are movements that need to be fast in order to be functional. These movements are monitored and adjusted by what is known as a FEEDFORWARD (aka OPEN LOOP MODEL OF MOTOR CONTROL) mechanism. In these movements, the following occurs: i. Something stimulates a movement: someone yells "Duck!" or you put your hand on a hot surface, or you step on a tack. ii. You move, usually in a very gross, all or nothing way such as falling down, jerking your hand back, pulling your leg up, etc. iii. Success is achieved: you avoided being hit in the head by a hockey puck, sustaining third degree burns to your hand, impaling your foot on a thumbtack and contracting tetanus. iv. Your sensory system sends information back to your brain to say "mission accomplished, no significant injury sustained" v. This is now stored in your "motor program library" as a successful motor plan and will be used again, should the situation arise again. (Feed forward: the sensory input will impact FUTURE action, not the one currently being experienced) vi. Of course, if you did not successfully avoid injury, that is registered as well, and the same motor program you used before will be modified before it is used again, or it will be tossed out altogether. 1. Feedback and Feedforward are diagrammed for you in Martin and Kessler, p. 41, Figure 3-7.

Differentiate between an upper motor neuron lesion and a lower motor neuron lesion, with respect to Central Nervous System injuries or disease.

a. Upper Motor Neuron (UMN): This term refers to areas of the motor control system that are in the central nervous system. So any part of the motor control system that is in the spinal cord, brainstem, and cerebral cortex. The kind of diseases or injuries that would be considered to be UMN lesions would be strokes, TBI, Spinal cord injuries, etc. b. Lower Motor Neuron (LMN): This term refers to areas of the motor control system that are outside of the CNS. Therefore the parts of the nervous system that would be considered to be LMN are cranial nerves (after they leave the brain or brainstem), the interneurons in the anterior horn, spinal nerve roots and peripheral nerves. The kinds of diseases or injuries that would be considered to be LMN lesions are polio, peripheral nerve injuries (like bruised or severed peripheral nerves), peripheral neuropathy (like diabetic neuropathy), or radiculopathy.

16. What is W-sitting and why is it a poor positioning option?

a. W-sitting is a very stable position that allows the child to sit independently and erect without using their trunk muscles for proximal stability. This is a particularly bad position because of the stresses it puts on the ligamentous structures in the medial knee and the posterior hip capsule, and also because of the difficulty the child has transitioning out of the position toward other positions.

19. What is cruising?

a. a young child's action of walking while holding on to furniture or other structures, prior to learning to walk without support.

Tone

a. the amount of contraction of a muscle at rest. The degree to which muscle fibers are being stimulated to contract even at rest. It can be considered to be the resistance of a muscle to passive stretch while the individual is attempting to relax. This is a NORMAL state. There is a wide variability in the resting tone in normal people. Some people are on the high end of normal, and generally can be very tense or antsy. They may also be very hyperactive types who have trouble sitting still. Some people are more "laid-back" and generally 'floppier". They may conform to whatever is supporting them, or "slouch". Your body has learned to compensate for your individual resting tone state, so that when a movement is being stimulated, a sufficient number of muscle fibers are stimulated to produce the movement. b. When a patient sustains an injury to the nervous system, they generally have changes in their muscle tone (either in a particular body part, or in the entire body) which fall outside the normal range and into the abnormal range. We call this pathological level of tone hypertonicity, hypotonicity, or dystonia, depending upon how it changes.

Symmetrical Tonic Labyrinthine Reflex (TLR/STLR)

i. Testing process: Place subject in prone or supine ii. Positive result: When placed prone, see flexion of trunk and all extremities; when placed supine, see extension of trunk and all extremities . iii. Negative result: Arm and leg position does not seem to be impacted by position of head iv. Appears at birth-2 months; Integrated by 6 months

Symmetrical Tonic Neck Reflex (STNR)

i. Testing process: Place subject in quadruped; Have subject flex neck. Have subject extend neck. (If subject cannot follow commands, passively flex/extend neck.) ii. Positive result: With neck extension, arms extend, and legs flex to sit on "haunches". With neck flexion, arms flex and legs extend. iii. Negative result: Arm and leg position does not seem to be impacted by position of head iv. Appears at 4-6 months; Integrated by 8-12 months

Positive Support Reflex

i. Testing process: Place subject in upright supported standing position ii. Positive result: Legs extend rigidly and accept significant percentage of body weight. iii. Negative result: Legs do not extend rigidly and do not accept body weight (knees flex and legs collapse). iv. Appears at 35 weeks gestation; Integrated by 6 months

Associative Reactions Reflex

i. Testing process: Resist any active movement in a part of the body. ii. Positive result: An automatic movement in another part of the body (unassociated with the initial resisted movement) occurs. iii. Negative result: No automatic movements occur. iv. Appears at birth to 3 months; Integrated by 8-9 months, or maybe never

Asymmetrical Tonic Neck Reflex (ATNR)

i. Testing process: Turn head to one side or the other and hold it there ii. Positive result: Arm and leg on the face side extend; arm and leg on the skull side flex iii. Negative result: Arm and leg position does not seem to be impacted by position of head iv. Appears at birth; Integrated by 4-6 months

Motor Plan

is an idea for a movement that is a combination of motor programs. Examples would be swinging at and hitting a softball and then running to first base.

Neural Plasticity

the ability of the central nervous system (CNS) to adapt in response to changes in the environment or lesions.

Motor Memory

where we store successful motor programs for use when we need them, Kind of like a personal library of successful motor plans that we have used before for different movements or motor plans.