Cerebral Palsy

Asphyxia

(loss of blood flow) usually from problems at birth tends to damage deep grey matter structures often leading to dyskinetic forms of CP (chorea, athetosis, dystonia)

Cerebral Palsy

-A group of chronic childhood motor impairment disorders defined by specific functional characteristics rather than by the underlying cause. -Clinical features are the result of developmental disturbances that occur during early brain development leading to brain malformation or injury. -Static condition but may appear to "progress" due to maladaptive growth and development (scoliosis, contractors, increased spasticity)

Occupation Based Intervention

-An internal adaptation that occurs as the person meets a challenge within their environment / occupation -OT attempts to use both remedial and compensatory strategies to lead to increased function, participation and quality of life

CP Approaches and/or Techniques

-NDT -Constraint-induced therapy -Physical exercise to strengthen muscles and bones and to enhance motor skills and prevent contractors -Cognitive therapies (CO-OP) -Bracing, Splinting, Positioning, casting -Adaptive Equipment -Assistive Technology -Neurocognitive prosthetics (cochlear implants and DBS) -Robotics -Surgical interventions -Medications -Complementary and Alternative Therapies (acupuncture, craniosacral therapy, myofascial release, taping, diet and herbal remedies, electric stem, chiropractic treatments, message, hyperbaric oxygen therapy

Precautions and Contraindications

-Post-surgical - will be specific to the surgery -Awareness of medications and side effects -Skin integrity - potential for skin breakdown from orthotic devices and positioning over bony prominences -Possibility of seizures/aspiration -Proper positioning - scoliosis and hip subluxation

Typical Secondary Conditions or associated impairments

-Seizures - approximately 30% to 40% have a seizure disorder -Cognition/Learning - ID -Nutrition and Growth -Swallowing - increased risk for dysphagia -Gastrointestinal - high incidence of reflux and constipation and may have altered motility -Respiratory -Orthopedic - Contractures Joint Dislocations Scoliosis Osteopenia -Abnormal Tone - Spasticity and Dystonia -Vision - high incidence of eye disorders -Hearing - estimated to be 10 to 15% -Urologic - Recurrent UTI's and incontinence -Behavior/emotional problems -Speech and language deficits -Dental -Sialorrhea -Pain -Sleep

Occupations Typically Impacted

-Self-care -Functional Mobility -Communication/Learning -Social Interaction -Community -School

Occupational Therapy Involvement

-Self-care -Seating and Positioning - to help maximize their function -Gross and Fine Motor -Functional Mobility -School activities -Social Involvement -School and community access -Adaptive/Assistive Devices/Equipment - may include augmentative communication etc. -Casting/splinting

OT Interventions

-Stretching and Casting -Splinting -Botulinum toxins combined with OT -Neuromuscular Electrical Stimulation -Constraint Induced Therapy -Bimanual Intensive Training -Motor Learning / Guided Practice -Cognitive Approach / Task Analysis -Goal Oriented Training / Client Centered -ADLs and Play -Assistive Technology / Adaptive Equipment

Tone Measurement

-Tardieu - specific to spasticity -Modified Ashworth Scale - hypertonia -Hypertonia Assessment Tool (HAT) - determine the type of hypertonia present

Mixed CP

-Term used when more than one type is present. -Most common mixed pattern is spasticity combined with athetoid movements.

Practice Models for CP

-The model may be a rehabilitation, biomechanical and or developmental model. -Often times a Neurodevelopmental Approach is used with cerebral palsy. -Constraint-induced movement therapy (CI)

Spastic CP

-Unilateral (hemiplegia or hemiparesis) -Bilateral (diplegia, tetraplegia, quadriplegia)

Cerebral Palsy

-describes a group of disorders of the development of movement and posture, causing activity limitations, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders are often accompanied by disturbances of sensation, cognition, communication perception and/or by a seizure disorder -associated with disturbances of the immature or developing brain. These disturbances most often occur during fetal development or in the perinatal period, but they may also occur during the first few years after birth. - disorder of movement and posture...caused by a nonprogressive abnormality of the immature brain. -disorder of motor function. -The manifestations may change over time, however the causative lesion is still static. -The causes happens from the brain development at sometime during the developmental period

Manual Ability Classification System (MACS)

Ability to handle objects in important daily activities (eating, dressing, play/leisure) Levels 1-5 1. Handles objects easily and successfully 2. Handles most objects but with somewhat reduced quality and/or speed 3. Handles objects with difficulty; needs help to prepare and/or modify activities 4. Handles a limited selection of easily managed objects in adapted situations 5. Does not handle objects and has severely limited ability to perform even simple actions.

Ataxic CP

Abnormality in the cerebellum results in inability to maintain typical postures and perform typical movements.

Accommodative approach

Adapt the environment or task so that child can be as independent as possible with current impairment level

How do serial static splints lengthen tissues and correct deformity?

Application of gentle forces sustained for extended periods of time

COMMON Medications - for controlling spasticity

Baclofen - Side effects - sedation, confusion Botox Intrathecal baclofen (ITB)

Which type of medical intervention (medication) is used to reduce spasticity through an injection directly into the muscle?

Botox

Gross Motor Function Classification System (GMFCS)

Can help understand prognosis of walking and also can provide insight on postural supports which may be needed for efficiency with engaging in other activities.

Spastic CP

Children demonstrate hypertonia and muscle spasticity. This may be caused by a lesion to the primary motor cortex. The effects often associated with clonus, an extensor plantar response, and persistent primitive reflexes (i.e., ATNR). Associated with poor control of voluntary movement.

CP diagnosis

Delayed or absent development of postural reactions creating difficulty with rolling over, sitting, postural control and walking.

Causes of CP

Disruption of the development of -neuronal networks in cortical and subcortical pathways that control movement. -Understanding the underlying cause improves overall management. -Preterm many times periventricular white matter is injured causing spastic forms of CP(abnormal increase in muscle tone)

Dyskinetic CP

Dystonic CP Choreoathetotic

Which of the following is a common compensatory strategy used by children with cerebral palsy while reaching and grasping?

Excessive trunk movements including trunk extension and lateral flexion

Other Impairments associated w/ CP

Intellectual Disability Visual impairments Hearing impairments Speech-language disorders Seizures Feeding and growth impairments Behavior-emotional disorders Sensory processing differences

What type of movement would you expect to see upon observation of a 4-year-old girl with athetoid type cerebral palsy (CP)?

Large sudden fluctuations, "jerky" movements with poor midrange control

Which statement best reflects why children with cerebral palsy may have speech and language problems?

Lesions affecting primary motor and temporal lobe

What is a common scale used to determine the level of functional hand use in a child diagnosed with cerebral palsy?

Manual Ability Classification System (MACS)

Which approach has the most evidence to support its use in occupational therapy for children with cerebral palsy?

Motor control

Constraint Induced Therapy

Restraint of the uninvolved hand Intensive practice Goals -Improve spontaneous use and motor control of involved UE -Improve bilateral hand use -Improve psychological condition by increasing control of UE Outcomes -Many variations in protocol and assessment use -Need more research to determine if it is evidence based practice

According to the medical record, Jenny had damage to her primary motor cortex during birth trauma. She has been receiving OT, PT, and SLP since birth. The therapist observed the following during the initial evaluation: ◾Abnormal movements and atypical reflexes present (ie. ATNR) ◾Hypertonicity in her arms with spasticity greater in her right bicep, wrist flexors, and thumb adductor ◾Hypertonicity in her legs with spasticity greater in hip adductors, hamstrings, and gastroc/soleus ◾Delayed or absent righting and equilibrium responses Why type of cerebral palsy does Jenny have?

Spastic

Most common type of CP

Spastic CP

Athetosis

The child exhibits slow, writhing, involuntary motor movements in combination with abrupt, irregular and jerky movements

Compensation for limited movements due to spasticity

They may experience difficulty dissociating shoulder movements for reach and grasp and compensate by laterally flexing (avoiding rotation) and extending the trunk (as rotational movements are more difficult for them).

Courtney is a 6 month old infant whose mother tells the OT, Courtney is left handed just like her father; she reaches with her left hand, waves with her left hand and rarely uses her right hand. How does the OT interpret this information?

This is worrisome; Courtney should be evaluated further

What is not considered an essential feature of constraint induced movement therapy for children with cerebral palsy?

Three children per group

Remedial approach

Work on a specific skill to improve function

Typically not diagnosed until the child is what age or so due to presence of delays in motor development and abnormalities may not be present until the child is older.

a year or so

Cognitive Orientation to Daily Occupational Performance (CO-OP)

child chooses goal, focus on interaction between person, environment and occupation. Analyze child doing task, correct performance problems not underlying skills, using cognitive strategies- ASK DON"T TELL. Work toward acquisition, generalization and transfer.

GMFCS

determines level of gross motor functioning.

MACS

determines the level of hand use

NDT

improve postural control and stability, helps with positioning and handling techniques

Athetoid CP

involuntary movements and abnormal muscle tone throughout the body

Botulinum neurotoxin, commonly called Botox

more specific approach to reducing muscle tone, with injections delivered directly to a spastic muscle.

NDT

most common method of motor therapy

Shaping

motor objective is approached in small steps (made more difficult with speed accuracy) feed back is provided

Assessments for CP

observations questionaries' Callier-Azusa Scale TVPS SPM QNST

Injury to the cerebellum

poor balance, posture, decreased fine motor, and ataxic gait

Key feature is persistence of what: typically developing child these would begin to be suppressed.

primitive reflexes

What is not a cause of cerebral palsy in children?

socioeconomic status

Activity based practice

whole tasks, fun motivating to child; child problem solves through the task with assistance