OTD 306 Cerebral Palsy

cerebral palsy (CP)

nonprogressive and permanent brain disorder that affects muscle tone, posture, balance, coordination, and movements; may be congenital or acquired

congenital (85-90%)

Is the majority of cerebral palsy congenital or acquired?

males (1:4)

Is CP more common in males or females?

spastic (82.9%)

What is the most common type of CP?

risk factors

The following are _____ factors for CP:

• low birth weight

• premature birth

• multiple births

• assistive reproductive technology (ART)

• infections during pregnancy (toxoplasmosis, chicken pox, rubella, cytomegalovirus, bacterial infections of placenta, pelvic floor or fetal membranes)

• exposure to toxic substances (alcohol, drugs, smoking, poisons)

• maternal medical conditions (thyroid problems, intellectual disability, seizures)

• complicated labor and delivery

• jaundice and kernicterus

periventricular leukomalacia (PVL)

brain damage to the white matter surrounding the brain's ventricles (including necrosis and cysts), most common in premature infants, caused by a lack of blood flow or oxygen to the vulnerable white matter during development; altered transmission of signals on ascending (sensory) and descending (motor) pathways

may cause

• motor disorders

• delayed cognitive development

• coordination problems

• vision and hearing impairments

PVL

What is the abbreviation for periventricular leukomalacia?

periventricular leukomalacia

What does PVL stand for?

hypoxic-ischemic encephalopathy (HIE)

a condition that occurs when the brain does not receive enough oxygen and blood flow; leads to permanent damage in parts of the brain

may cause

• developmental delays

• intellectual disabilities

• epilepsy

• cerebral palsy

• heart problems or cardiac arrest

HIE

What is the abbreviation for hypoxic-ischemic encephalopathy?

hypoxic-ischemic encephalopathy

What does HIE stand for?

intraventricular hemorrage

What does IVH stand for?

IVH

What is the abbreviation for intraventricular hemorrhage?

1, 5, 10

At what intervals (in minutes) after birth is the Apgar assessment administered?

Apgar score

assessment of how baby is doing at 1, 5, and 10 minutes after birth

• appearance

• pulse

• grimace

• activity

• respiration

each sign is rated 0-2

appearance, pulse, grimace, activity, respiration

Name the 5 components of an Apgar score

intraventricular hemorrhage (IVH)

bleeding around or inside the ventricles of the brain, which can put pressure on the nerve cells and cause damage; most commonly occurs within first few days of life, especially in premature or very low birth weight infants

grades 1-2 likely result in no complications

grades 3-4 may lead to

• enlarged ventricles and hydrocephalus

• cerebral palsy (spasticity)

• hearing loss

• vision problems

• learning disabilities

hydrocephalus

an abnormal buildup of cerebrospinal fluid, causing ventricles to widen, putting harmful pressure on brain tissue; can interfere with normal brain growth and development and lead to permanent brain damage

hyperbilirubinemia

a condition where there is an excessive amount of bilirubin in the blood; occurs when newborn’s liver is immature and cannot keep up with bilirubin load; may result in jaundice

bilirubin

yellow pigment produced when red blood cells break dow; normally processed by liver; accumulation may result in hyperbilirubinemia and jaundice

liver

Where is bilirubin normally processed?

jaundice

yellow coloring of skin and eyes that appears 2-5 days after birth as a result of hyperbilirubinemia

kernicterus (bilirubin encephalopathy)

conduction that occurs when noncunjugated bilirubin is deposited in specific brain areas, causing yellow staining of affected brain tissue and permanent damage

jaundice (usually appears 2-5 days after birth)

What is a visible sign of hyperbilirubinemia?

sequela (plural sequelae)

a long-term pathological condition that results as a consequence of a previous disease, injury, or medical intervention

tone

degree of tension/resistance when a muscle is stretched

hypertonicity

increased resistance; rigid and stiff; difficulty moving through range of motion (ROM)

hypotonicity

little to no resistance; floppy and slippery; hypermobility at joints, sometime beyond expected ROM

dystonia

involuntary or irregular contractions that can cause twisting motions or other repetitive movements; triggered by physiological changes, startle, emotional state, sleepiness, cognitive load, etc.

hypotonia

Infants with CP often start with what type of tone abnormality? (hypotonia, hypertonia, dystonia)

primitive reflexes

involuntary motor responses originating from central nervous system present at birth, which facilitates survival; integrated as brain matures in normal development

retained

CP may result in _____ primitive reflexes.

asymmetric tonic neck reflex (ATNR)

primitive reflex

• appearance: when baby’s head is turned to one side, arms/legs on side to which head is turned extend while opposite arm/leg flex

• purpose: assists with movement through the birth canal at delivery and is important for cross pattern movements

• appears: birth

• integrates: 6 months

• signs of retention: decreased hand eye coordination, poor handwriting, uncoordinated gait, poor balance, poor visual motor skills and tracking, problems with math and reading, difficulty crossing midline

asymmetric tonic neck reflex (should integrate by 6 months)

What does ATNR stand for?

6 months

At what age should the asymmetric tonic neck reflex (ATNR) integrate?

extend, flex

During the asymmetric tonic neck reflex (ATNR), when the head is turned to one side, the arm/leg on the side to which the head is turned ____ while the opposite arm/leg ____.

symmetrical tonic neck reflex (STNR)

primitive reflex

• appearance: when baby is looking upward, legs flex and arms extend; when baby is looking downward, legs extend and arms flex

• purpose: foundational for crawling

• appears: 6-9 months

• integrates: 9-11 months

• signs of retention: poor posture in standing, poor seated posture, ape-like walk, low muscle tone, W sitting position common, sloppy/messy eater, poor hand/eye coordination

STNR

What is the abbreviation for symmetrical tonic neck reflex?

symmetrical tonic neck reflex

What does STNR stand for?

9-11 months

At what age should the symmetric tonic neck reflex (STNR) integrate?

flex, extend

During the symmetrical tonic neck reflex (STNR), when baby is looking upward, legs _____ and arms ____.

extend, flex

During the symmetrical tonic neck reflex (STNR), when baby is looking downward, legs _____ and arms ____.

upward

During the symmetrical tonic neck reflex (STNR), when baby is looking upward, legs flex and arms extend.

downward

During the symmetrical tonic neck reflex (STNR), when baby is looking downward, legs extend and arms flex.

tonic labyrinthine reflex

What does TLR stand for?

TLR

What is the abbreviation for tonic labyrinthine reflex?

tonight labyrinthine reflex (TLR)

primitive reflex

• appearance: when baby’s neck is flexed forward, arms and legs also flex inward and curl into body (in supine position, flexor tone dominates); when baby’s neck is extended backwards, arms and legs expand in “superman” position (in prone position, extension tone dominates)

• purpose: foundational for postural stability for large muscle groups

• appears: in utero

• integrates: 3.5 years

• signs of retention: decreased balance, poor spatial awareness, toe walking, hypermobility of joints, weak muscles, poor posture, motion sickness, poor ability to climb, atypical head position (forward or to side)

3.5 years

At what age should the tonic labyrinthine reflex integrate?

flexor

During the tonic labyrinthine reflex, ____ tone dominates in the supine position.

extension

During the tonic labyrinthine reflex, ____ tone dominates in the prone position.

asymmetrical tonic neck reflex (ATNR), symmetrical tonic neck reflex (STNR), tonic labyrinthine reflex (TLR), positive supporting reflex (PSR)

Name 4 primitive reflexes that main be retained in individuals with CP

positive supporting reflex

What does PSR stand for?

PSR

What is the abbreviation for positive supporting reflex?

5-6 months

At what age should the positive supporting reflex (PSR) integrate?

positive supporting reflex (PSR)

primitive reflex

• appearance: when ball of foot touches surface, legs extend and stiffen to allow for standing and weight bearing

• appears: birth

• integrates: 5-6 months

• signs of retention: difficulty standing and walking

hypotonia

Areflexia may be seen in individuals with _____. (hypertonia or hypotonia).

areflexia

diminished or absent reflexes; may be seen in individuals with hypotonia

scoliosis, kyphosis, lordosis

Name three posture abnormalities

scoliosis

lateral curvature of the spine

kyphosis

posterior curvature of the thoracic spine

lordosis

anterior curvature of the lumbar spine

kyphosis (posterior curvature of thoracic spine)

Which posture abnormality may be described as “hunchback”

spastic, dyskinetic (athetoid), ataxic, hypotonic, mixed

What are the 5 types of CP?

athetoid

What is another name for the dyskinetic type of CP?

dyskinetic

What is another name for the athetoid type of CP?

mixed

What is the second most common type of CP?

spastic

• most common type of CP

• caused by damage to motor cortex and pyramidal tracts

• contractures, exaggerated reflexes, stiff muscles, jerky/repeated movements

• 3 subtypes: hemiplegia/hemiparesis, diplegia/diparesis, quadriplegia/quadriparesis

spastic hemiplegia/hemiparesis, spastic diplegia/diparesis, spastic quadriplegia/quadriparesis

What are the 3 subtypes of spastic CP?

motor cortex, pyramidal tracts

Spastic CP is caused by damage to which 2 locations in the brain?

spastic

Which type of CP is caused by damage to the motor cortex and pyramidal tracts?

spastic hemiplegia/hemiparesis

• subtype of spastic CP in which only one side of body (arm, hand, leg) is affected

• speech delays are possible

• intelligence is usually normal

spastic diplegia/diparesis

• subtype of spastic CP which mainly affects legs

• intelligence and language are usually normal

spastic quadriplegia/quadriparesis

• most severe subtype of spastic CP

• affects arms, legs, neck

• difficulty walking and speaking

• may have moderate to severe intellectual and developmental disability

stereogenesis

identification of objects by the sensation of touch alone

graphethesia

ability to recognize identify writing on the skin purely by the sensation of touch alone

kinesthesia

detection of body position and movements via proprioceptors

stereogenesis, graphethesia, kinesthesia

Name 3 deficits in sensation that may accompany spastic CP

spastic

Stereogenesis, graphethesia, and kinesthesia are all deficits in sensation that may accompany what subtype of CP? (spastic, mixed, dyskinetic, hypotonic, ataxic)

basal ganglia, cerebellum

Dyskinetic (athetoid) CP is caused by damage to which 2 locations in the brain?

dyskinetic (athetoid)

• subtype of CP caused by damage to basal ganglia and/or cerebellum

• fluctuating tone, uncontrollable movements (writing or twisting movements)

• Overactive facial and/or tongue muscles (drooling, grimacing)

• Sitting/walking difficult

• intelligence is usually normal

• 3 subtypes: dystonia, athetosis, chorea

dystonia, athetosis, chorea

What are the 3 subtypes of dyskinetic (athetoid) CP?

dystonia

subtype of dyskinetic CP that involves twisting, repetitive movements that are usually stimulated when initiating a voluntary movement

athetosis

subtype of dyskinetic CP that involves slow, writing movements with extreme fluctuations, causing difficulty in maintaining posture

chorea

subtype of dyskinetic CP that involves abrupt, fidgety, unpredictable movements

cerebellum

Ataxic CP is caused by damage to which location in the brain?

cerebellum

Hypotonic CP is caused by damage to which location in the brain?

mixed

What is the second most common type of CP?

mixed

second most common type of CP; combination of symptoms from different CP types

ataxic

• subtype of CP caused by damage to cerebellum

• affects balance, depth perception, coordination

• unsteady gait, shakiness, tremors

• difficulty with fine motor tasks

hypotonic

• subtype of CP caused by damage to cerebellum

• low muscle tone and hypermobile joints and ligaments

• poor balance and stability affecting body coordination and movements

aphasia

impairments of language, including speaking, writing, reading, and listening

dysphagia

difficulty swallowing

visual field

what a person sees when looking straight ahead

visual field loss

occurs if one cannot see 180 degrees in either direction; 3 types

hemianopia, central loss, peripheral loss

What are the 3 types of visual field loss

hemianopia

loss to right/left or upper/lower visual field

central loss

blind spot in center of vision

peripheral loss

sight loss at edges of vision

esotropia

eye turns inward

exotropia

eye turns outward