Cerebral Palsy Lecture 1

345

1 in _________ children in the U.S. have CP

non-progressive

CP results from progressive/non-progressive neurological lesion of CNS deficit

arching, torticollis, upward eye gaze, toe walking, positions relieve burning sensation (prone) etc.

GERD could cause what kinds of patterns in children:

60% irritability, poor sleep/wake cycle, excessive crying

GERD is present in approx. _______% of preterm infants describe the clinical presentation

Subependymal germinal matrix

IVH in premature infants occurs in the _______________________: subjected to spontaneous bleeding

premature infants, LBW, poor intrauterine growth (IUG), small for gestational age (SGA), low placental weight, low APGAR scores at 5 minutes

In order to determine if a child has CP: what are some questions that can be asked in the history?

IVH

PVL develops after a large ______________ secondary to venous congestion

motor

PVL often leads to _____________ abnormalities

True

T/F: CP is the most common motor disability in childhood

false! it does not decrease

T/F: antetorsion decreases with age in the CP population

True

T/F: children with spasticity often experience increase in frustration/feelings of failure and tend to be insecure, dependent

True

T/F: hypotonia with CP may give rise to spasticity or athethsis

true: unable to maintain equilibrium in any position

T/F: with severe hypertonus, righting and equilibrium reactions are absent

hypotonia

______________ usually precedes athetosis.

33-50%

________________ % of survivors of HIE have permanent deficits (CP, intellectual disability)

Periventricular Leukomalacia (PVL)

_____________________ is the major cause of death and disability from CP

cerebral palsy

a group of permanent disorders of the development of movement and posture causing activity limitation that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain:

strabismus esotropia: deviation of eyes toward midline exotropia- deviation of eyes outward

a visual/eye problem described as misalignment of the eyes; both eyes can't merge on a target- this is known as? what are the 2 types.

MRI, HINE, developmental assessment of young children

after 5 months corrected age, which tools are important to detect CP?

4 months

at around _________ months- primitive reflexes are supposed to transition to postural reactions (primitive reflexes should be integrated by this time)

12 to 24 months in high income countries and as late as 5 years in low resource setting (rarely before 1 due to neuroplasticity)

at what age can CP be diagnosed?

26-34 weeks

at what time frame during gestation is there selective vulnerability of periventricular white matter?

cocontract- lack of postural fixation lack of control in midranges

athetosis is an inability to _____________ around joints. what does this lead to?

with increase in excitement, mental or physical effort decreased with fatigue

athetosis is describe as involuntary abnormal movements present at rest, when can these movements be enhanced or decreased?

MRI, (GMs), HINE

before 5 months corrected age, which tools are important to detect CP?

cognitive impairment

children with spasticity have an increased incidence of ________________________ due to cortex damage

50%: oral motor control, language dysfunction, hearing impairment, cognitive deficits

communication disorders are seen in about ____% of children with CP: name some of these disorders

one side of the body shows abnormal tone and movement motor dysfunction often accompanied by sensory dysfunction, perceptual dysfunction and learning disorders may ignore/neglect a side or develop seizures

describe hemiplegia CP:

sitting: may assume sitting by backing up in the sagittal plane without trunk rotation, require W sit for stability standing: pull to stand via positive support (pulling up with UE), not via half-kneel and pushing up with mature LE WB

describe how a patient with moderate hypertonus may assume sitting and come to stand:

not segmentally "log roll" and without LE dissociation

describe how a patient with moderate hypertonus may roll:

spasticity, dyskinesia, ataxia, mixed

describe how you would classify CP according to motor abnormalities:

total body involvement, may be hypotonic which progresses to very high tone may be totally extended or flexed problems with vision, hearing, seizures, retardation and oral motor function often associated

describe the characteristics of quadriplegia CP:

movement is possible in proportion to spasticity present at the time may see total movement synergies of flexion and extension

describe the level of fixed posturing in a patient with moderate hypertonus:

supine: midline, rolling, rotation is difficult prone: can't prop or maintain head control sitting: cant maintain, may can for short periods

describe the significant motor delay that may be present with severe hypertonus in each of these positions: supine, prone, sitting

prematurity/PVL

diplegia CP is often associated with _______________________

may occur! or appear as change in tone with increased effort or stimulation

does primitive reflex activity occur with moderate hypertonus?

through clinical symptoms- NOT etiological can be congenital or acquired

how do you typically determine if a child has CP?

marked immaturity of primitive reflex patterns and the late integration

how does CP differ from other encephalopathies (damage to the brain or SC):

when the child attempts to move against gravity or perform more refined movements

how does atypical or impaired motor function become more noticeable with time in a child with CP?

85

in children with CP, postural reactions are greatly delayed or don't develop in _______%.

longitudinal growth (especially radius, humerus and tibia)

in regards to growth disturbances, which direction does it affect the most? which bones are most affected?

early

infants with CP require an _____________ diagnosis because motor and cognitive gains are greater from diagnostic-specific early intervention

40%: seen more in spastic quadriplegia, rigidity and atonia

intellectual disability is seen in about _________ of children with CP: which type of CP is more prone to have this?

Athetosis

involuntary, slow, writhing, purposeless movements related to the cortical/basal ganglia loop is known as:

cortex/basal ganglia

involvement of ___________________ in an MRI or severe abnormal EEG indicate poor prognosis following HIE

yes, walking is possible scissor gait is common, increased stability through tone, BOS is decreased descreased LE dissociation, pelvic mobility, trunk rotation, poor weight shifting usually only with AD (AFOs, walker) etc.

is walking/ambulation possible with moderate hypertonus? if so, describe their pattern:

50-75%

learning disability is seen in about ______% of children with CP

6-8: will show up when they start to move against gravity

moderate hypertonus may seem to have normal movement for __________ months

w-sit, bunny hop etc. ---> leads to flexion contractures

moderate hypertonus may use abnormal movement patterns such as:

2nd half: if it is in the first it is usually a miscarriage

most lesions due to CP occur in the __________________ of gestation

strabismus (exotropia or esotropia), homonymous hemianopia, nystagmus (ataxia)

name eye/visual problems that may be seen with a child with CP:

hemiplegia, diplegia, quadriplegia= cortex athetoid, dystonic= basal ganglia ataxic= cerebellum

name the location of the brain damage involved with each of these types of CP: hemiplegia, diplegia, quadriplegia, athetoid, dystonic, ataxic

75%

prenatal etiology of CP is responsible for ______% of CP cases

inversely

prevalence of CP is ___________________ associated with gestational age and birth weight (BW)

35% generalized: absence (petit mal), tonic-clonic (grand mal), partial (starts in one part, may spread)

seizure disorders are seen in about ________% of children with CP: name the types often seen

quadriplegic (some hemiplegic/diplegic)

severe hypertonus is primarily seen in which type of CP?

reflex: dominates motor activity and determines patterns of movement, excess posture

severe hypertonus results in _____________ dominated movements

sensation, perception, cognition, communication and behavior, epilepsy and by secondary MSK problems

the motor disorders of CP are often accompanied by disturbances of:

decreased WB

tibial torsion/fibular migration does not occur due in the CP population due to:

25%

visual/eye problems are seen in about _______% of children with CP

hip dislocation, contractures, scoliosis

what MSK challenges may occur to a child with quadriplegia CP?

problems during labor and delivery (antepartum hemorrhage, cord prolapse, obstructed labor, placenta previa or abruption), neonatal hypoxic-ischemic encephalopathy (HIE), severe hypoglycemia, infection

what are some reasons why CP may occur perinatal?

neonatal infections (meningitis, septicemia) trauma associated with accidental/non-accidental injury

what are some reasons why CP may occur postnatal?

congenital brain malformation (agenisis of the corpus callosum), vasular events, maternal viral/bacterial infections, hereditary or genetic conditions, maternal health status and nutrition (drugs, alcohol, tobacco, untreated DM), severe RH incompatibility

what are some reasons why CP may occur prenatal?

diplegia, hemiplegia, quadriplgia, monoplegia and triplegia based on extremity involved but also affects head, neck and trunk

what are the 5 ways to classify CP according to anatomical distribution?

1. VP shunt- ventricles to abdomen 2. VA shunt- ventricles to atrium of heart (not first choice)

what are the two types of shunts that can be used to treat obstructive hydrocephalus in CP children:

anatomic distribution, motor abnormalities (functional motor abilities), causation and timing, accompanying impairments (vision/hearing loss)

what are the ways/categories to classify CP?

white matter necrosis, softening and cavitation

what is PVL?

Nissen fundoplication: stitching upper part of the stomach to prevent regurgitation

what is a common surgical treatment for GERD?

cause is not fully understood: can occur prenatal, perinatal or postnatal

what is the cause of CP and when does it usually occur during the birthing process?

depressed, unresponsiveness, failure to breathe spontaneously, seizure, systematic organ dysfunction

what is the clinical presentation of HIE:

spasticity= pyramidal tract lesion rigidity= extrapyramidal tract lesion

what is the difference between spasticity and rigidity in regards to pyramidal tract lesions:

term infants: neuronal necrosis of the cortex preterm infants: intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL)

what is the difference between term and preterm infants in regards to HIE and the location of injury:

spasticity= reciprocal inhibition of antagonist rigidity= both agonist and antagonist muscles are equally affected

what is the difference between the agonist/antagonist muscles with spasticity and rigidity?

therapeutic hypothermia (32-30 degrees C conditions) 24 to 48 hours

what is the medical management of HIE:

Motor dysfunction

what is the most obvious limitation in a patient with CP?

decreased O2 and blood supply to the brain

what is the pathophysiology of HIE (hypoxic/ischemic encephalopathy):

dyskinesia

what is the term used to describe athetosis and dystonia:

communication disorders, feeding problems, sensory processing difficulties, seizures, intellectual disability, learning disability, visual problems, growth disturbances, development of structure alignment, social/emotional delays

what other impairments may you see in a patient with CP besides motor dysfunction?

hemiplegia and diplegia; some quadriplegia

which anatomical location of CP is moderate hypertonus most often seen?

grade 1

which grade of IVH: hemorrhage into the germinal matrix

Grade 3

which grade of IVH: hemorrhage into ventricles with dilation

Grade 2

which grade of IVH: hemorrhage into ventricles without dilation

Grade 4

which grade of IVH: hemorrhage intro ventricles and white matter

anti-gravity muscles of extremities that work the hardest against gravity (UE flexors and LE extensors)

which muscle groups does spasticity involve the most?

black>white

which race is more likely to have CP?

moderate

which type of hypertonus is most often seen?

long held postures (hip/knee flexion contractures, kyphosis, scoliosis, hip dislocation)

why is deformity common with severe hypertonus?

decreased- muscle atrophy occurs with age

with CP, cross sectional growth of the limbs are ______________________

LE>UE, however it is still total body involvement one side may be more affected than the other

with diplegia CP, the __________ are usually more affected than the ________________

Equilibrium: protective reactions may be slow or delayed

with moderate hypertonus, righting reactions are present or partially develop, however, _________________ reactions never fully develop

LE movement restriction and lack of trunk rotation

with moderate hypertonus, tilting reactions and postural fixation are not fully developed due to:

emotions, increased effort, loss of balance may increase tone

with moderate hypertonus, tone seems normal or even hypotonic at rest, but reaches severe level of hypertonus with what kinds of stimulation?

the degree of brain maturation at the time of the insult

with neonatal HIE: what does the pattern of brain injury depend on?

adduction, extension and IR

with severe hypertonus, describe the typical LE posturing:

end ranges! cant get to mid range this is opposite of spasticity

with severe hypertonus, where is movement limited to?

mid-ranges (wont really move to end ranges)

with spasticity, ROM is limited but it is available in __________________

sudden excitement, change of body position, increased speed of movement, tonic reflex or associated reactions

with spasticity, increased hypertonus may result from what actions?

in the cerebral cortex and pyramidal tracts- UPPER motor neuron lesion

with spasticity, where is the damage in the brain?

abnormal tone and maintained immature motor pattern, poor development of the normal postural reflex mechanism, delayed developmental milestones, abnormal neurological findings in neonate period

with the developmental evaluation of a child, what are some things to look for to see if the child may have CP?