CP & ABIs (TBI vs. Non-TBI)

__________: group of PERMANENT disorders of the development of movement and posture --> activity limitations

Cerebral palsy (CP)

Children w/ CP experience activity limitations, which are attributed to __________ (progressive vs. nonprogressive) disturbances that occurred in the developing fetal or infant brain

Nonprogressive

True or false: CP is the MOST common childhood motor disability (bonus: what are some risk factors)

TRUE!! -- risk factors include premature birth <28 weeks (35% of all CP) and low birth weight 2.2-3.3 lbs

What is the EXACT cause of CP?

Usually known & multifactorial (but, essentially, disturbances to the developing brain affect cell migration and brain development)

What are some proposed causes of CP? (hint: 12x)

1. Infections (ex: toxoplasmosis or cytomegalovirus)

2. Oxygen deprivation

3. Placental issues

4. Strokes

5. Inflammation

6. Uterine growth restriction

7. Maternal trauma or vascular issues

8. Premature birth (involves white matter injury and intra-ventricular hemorrhage in the brain's sensory-motor pathways)

9. Prolonged rupture of membranes --> intra-uterine infections

10. Multiple pregnancies

11. Postnatal steroids

12. Genetic AND environmental causes

Small birth weight as a risk factor for CP relates to __________ or __________, while large birth weight as a risk factor for CP relates to difficult deliveries and increased risk of stroke

Infections OR maternal health issues

Why are multiple gestations (i.e., 2+ babies) a risk factor for CP?

Heightened risk of prematurity and potential vascular collapse of one twin --> affecting the surviving infant's development

A diagnosis of CP involves which comprehensive assessments?

1. Neuro eval

2. Neuroimaging

3. Observation of posture and movement patterns

What are some key diagnostic tools to include when determining the presence of CP?

1. MRI (grey OR white matter lesions)

2. General Movement Assessment (GMA) (observational tool that aids in early diagnosis of CP)

3. Hammersmith infant Neuro Exam (HINE) (another observational tool that aids in early diagnosis)

What are some SPECIFIC signs that indicate the need to refer a child for a CP diagnosis? (hint: 6x)

1. Hand preference <12 months old

2. Stiffness or tightness in the legs 6-12 months old

3. Keeping hands fisted >4 months old

4. Persistent head lag >4 months old

5. Not able to sit w/o support >9 months

6. Consistent asymmetry of posture and movements >4 months

What are some common classification systems for CP? (hint: 7x)

1. Gross Motor Function Classification System - Expanded & Revised (GMFCS - E&R)

2. Manual Ability Classification System (MACS)

3. Communication Function Classification System (CFCS)

4. Eating and Drinking Abilities Classification System (EDACS)

5. Visual Function Classification System

6. Diplegia/ Hemiplegia/ Quadriplegia

7. Spastic/ Dyskinetic/ Ataxic/ Mixed

__________: classification system that evaluates a child's gross motor function in various settings; emphasizes the child's self-initiated movement; descriptions are broad and do NOT cover all aspects of motor function and are DIFFERENT in each level based on age range

Gross Motor Function Classification System- Expanded & Revised (GMFCS- E&R)

Which age groups are included under the GMFCS- E&R?

1. <2 years

2. 2 to < 4 years

3. 4 to < 6 years

4. 6 to < 12 years

5. 12 to 18 years

__________: classification system that assesses hand use (how children handle objects and LOA); distinctions b/w levels are based on their ability to manipulate objects INDEPENDENTLY

Manual Ability Classification System (MACS)

Which age group(s) is the MACS appropriate for?

Ages 4-18

__________: classification system that assesses communication (speech, gestures, and alternative methods); distinctions are based on effectiveness, pace, and interactions w/ others

Communication Function Classification System (CFCS)

Which age group(s) is the CFCS appropriate for?

Ages 2-18

__________: classification system that assesses the eating and drinking abilities (includes assistance needed to bring food and drink to the mouth); differences determined by the individual's ability to handle food and drink in the mouth and coordinate breathing and swallowing

Eating and Drinking Abilities Classification System (EDACS)

Which age group(s) is the EDACS appropriate for?

Ages 3-adult

__________: classification system that assesses how the child uses vision to see, direct gaze, recognize, interact, and explore; distinguished by level of independence in using vision effectively and extent of external support required to carry out ADLs related to vision

Visual Function Classification System

Which age group(s) is the Visual Function Classification System appropriate for?

Ages 1-19

What is the MOST common classification system for CP?

GMFCS- E&R

__________: LE affected > UE

Diplegia

__________: UE + LE affected on ONE side of the body

Hemiplegia

__________: all limbs affected

Quadriplegia or tetraplegia

__________: arises from motor cortex or white matter involvement --> abnormal posture and movement patterns

Spastic

__________: involves the BG --> atypical patterns of posture and involuntary, uncontrolled, recurring, and occasionally stereotyped movements

Dyskinetic

Which subtypes fall under "dyskinetic"? (hint: __________ = involuntary, sustained or intermittent muscle contractions w/ repetitive movements and abnormal posture AND __________ = slow, continuous writhing movements)

Dystonic & athetotic

__________: involves the cerebellum --> instability to generate normal or expected voluntary movement trajectories --> instability and uncoordinated movements

Ataxic

Spasticity is caused by __________ and __________ mechanisms w/ pathological mechanisms including reduced reciprocal inhibition of anatagonist motor neuron pools, decreased presynaptic inhibition, and decreased non-reciprocal inhibition

Supraspinal and intraneuronal

True or false: spasticity is always a negative characteristic

FALSE!!--can have negative OR positive effects, depending on the muscle group and activity

What are some common characteristics associated w/ CP?

1. Abnormal muscle tone: hyper/ hypotonia, spasticity

2. ROM deficits/ contractures

3. Muscle weakness/ imbalances

4. Skeletal malalignment and decreased bone density

5. Poor selective control of muscle activity

6. Disorganized postural control

Why are contractures common in children w/ CP?

Muscles may NOT keep pace w/ bone growth --> contractures @ shoulders, elbows, hips, knees, ankles

Why is muscle weakness/ imbalances common in children w/ CP?

Struggle to produce normal function, force, or joint torque --> trouble w/ tasks requiring strength, power, or sustained effort

In children w/ CP, muscle weakness is greatest in __________ (distal vs. proximal) muscles and at __________ (faster vs. slower) speeds

Distal; faster

Why is skeletal malalignment and decreased bone density common in children w/ CP?

Conditions like spasticity, reflex issues, muscles weakness, and imbalances --> abnormal forces on the bones, ligaments, and their joints --> impacts spinal and limb alignment (esp. during growth spurts)

Risk of __________ (spinal pathology) increases w/ age and severity of CP

Scoliosis

Alignment and bone density can also affect __________ in children w/ CP

Positioning, respiratory status, pain, and skin integrity

Hip __________ are common in children w/ CP due to limited WB and weakness

Hip subluxation and dislocation

Due to reduced activity, meds, poor nutrition, and genetics, children w/ CP are at a greater risk for __________ and __________ (hint: think about bone density)

Low bone density fractures and osteoporosis

What impacts muscle development in children w/ CP?

Altered innervation, limited growth, and changed loading patterns --> reduced volume, length, AND strength

PT evaluation: CP

1. Birth history

2. Age of onset

3. Developmental milestones

4. Functional mobility and ROS (CVP, neuro, integ, MSK, GI/GU, etc.)

5. Informally assess for vision/hearing deficits

6. Observe posture, preferred movement patterns, compensatory strategies

7. Assess pain: FLACC, numeric pain scale, Wong-Baker FACES, etc.

8. Objective measures

9. Outcome measures

Objective measures: CP

PROM/AROM, tone, muscle strength, gait, CP endurance, balance, vital signs

Outcome measures: CP

GMFM-88/66, PEDI, AIMS, PDMS-2/3, Pediatric Balance Scale, BOT-2, 2/6MWT, Timed Up/down stairs, TUG, SCALE, COP

PT interventions: CP

1. Age-appropriate gross motor skills

2. Strengthening

3. ROM (integrated in activities)

4. Postural control/ balance/ coordination

5. Aerobic endurance/ energy conservation

6. Transfer/ gait training

7. Promote good sleep practices

8. Positioning

9. AD training (if applicable)

10. Orthotics training (if applicable)

11. Assist in modifications of activities at home, school, gym, or community

12. Hippotherapy

What are "F-words" in terms of interventions for children?

Fitness, function, friends, family, fun, and future!

Studies have shown that treating __________ > spasticity may be beneficial for children w/ CP

Strength > spasticity (ex: 1-3 sets of 6-15 reps at 50-85% 1-RM on 2-4x/week over 12-16 weeks)

Evidence has shown no clinically sig. long-term effect on joint ROM resulting from __________ SO integrate it INTO activities

Stretching (note: additionally, some studies indicates that shortened muscles do NOT require stretching, since the sarcomere is already overstretched and damaged, so strengthen instead!!)

__________ (medication) assists in reducing spasticity and improving the ability to lengthen muscles, BUT some are against it due to its long-term effects, including neurogenic atrophy & sarcopenia

Botox

What is the GENERAL consensus in terms of PT interventions for children w/ CP?

There is NOT a single correct method!! Work closely w/ families to choose the MOST appropriate treatment for each child at the right moment and align them w/ the child's goal's and the family's preferences!!

PT Goals: CP

HEP, strength, ROM, functional mobility and abilities, improve PA tolerance, adapting equipment/ AD and orthotics use/ schedules, family education/ involvement, pre/ post op

Prognosis/rehab potential: CP

Depends on severity (ex: 2 y/o w/ severe impairments = 40% chance of living to 20 vs. child w/ mild impairments = 99% chance); better mgmt. of feeding/ swallowing and medical care improves life expectancy

Which factors play a role in prognosis for a child w/ CP?

Growth, nutrition, PA, fatigue, sleep, pain, mental health, respiratory issues

True or false: many children w/ CP will grow and transition into adulthood

TRUE!!--however, health issues like accelerated aging, frailty, and chronic conditions like OA and CVD pose additional challenges

Which factors impact a child's ability to achieve their goals w/ CP in adulthood?

Cognition, communication, and support

__________ is the leading cause of death in children

Acquired brain injury

Congenital brain injuries are diagnosed as __________, while acquired brain injuries occur OUTSIDE of the perinatal period

Cerebral palsy (CP)

Acquired brain injuries may affect children __________ (better vs. worse) than adults

Worse

Why do acquired brain injuries affect children WORSE than adults?

Ongoing development of their brain means that injuries disrupt the brain's ability to develop fully (i.e., when the brain is injured before full maturity, there can be long-term difficulties in meeting new demands socially, emotionally, cognitively, and/or physically)

Which conditions fall under "traumatic" acquired brain injuries?

Penetrating (open) vs. non-penetrating (closed)

Which conditions fall under "non-traumatic" acquired brain injuries?

Anoxic, brain tumor, CVA, illness or inflammation

What is the MOST common cause of TBIs in children?

1. Falls

2. MVAs

3. Struck by/against object

__________ = ~1300 cases of TBIs in children per year in the US, w/ 25% being fetal

Shaken baby syndome

In terms of severity, which is the MOST common when it comes to TBIs in children?

Mild (concussion) @ 70-90% of all ED visits for TBI (w/ many going unreported, unrecognized, or untreated)

__________ brain injury: 15% of TBIs, LOC <24 hours, GCS 9-12

Moderate brain injury

__________ brain injury: 2% of TBIs, LOC >24 hours, GCS 3-8

Severe brain injury

__________ injury (TBI): sheer forces, direct impact, or penetration

Primary injury

__________ injury (TBI): cascade of events FOLLOWING the initial injury, such as excitotoxicity, apoptosis, increased ICP, edema, increased free radicals, and abnormal immune responses

Secondary injury

Children's brain is more prone to __________ and inability to __________

Edema and inability to autoregulate

Prognosis: TBIs in children

Mortality occurs in 24% of cases!! BUT 50% w/ severe and 90% w/ moderate TBI = good prognosis

Prognosis: predictive factors for children w/ TBIs

Posttraumatic amnesia (4 weeks or less = 85% chance of a GOOD prognosis vs. >4-8 weeks = <10% chance of a favorable outcome) and LOC (>11 days = POOR prognosis)

What are the 4 MAIN categories of non-traumatic brain injuries in children?

1. Anoxic/hypoxic

2. Brain tumors

3. CVA

5. Infection or inflammation (i.e., encephalitis and meningitis)

What is the MOST common cause of anoxic/hypoxic brain injury in children?

Drowning (leading cause of accidental death in 0-4 yr olds)

What are the consequences of an anoxic/hypoxic brain injury caused by drowning?

Reduced lung function, impaired ventilation and blood flow, collapsed lung tissue, and airway constriction

What are other causes of anoxic/hypoxic brain injury?

Cardiac arrest, carbon monoxide poisoning, acute respiratory failure, hanging

Prognosis: anoxic/hypoxic brain injury

Most children who are conscious when admitted to inpatient rehab achieve some level of independence by discharge (however, only 1/2 of those in a vegetative state regain a degree of independence)

In children post-anoxic/hypoxic brain injury, __________ function suffers MORE than physical function

Cognitive

True or false: outcomes are LESS favorable for children w/ anoxic brain injury vs. TBI

TRUE!!--60% recovery rate vs. 90%, respectively

What is a NEGATIVE sign of prognosis in children post-anoxic brain injury?

Early seizures

What is "PSH" in relation to anoxic/ hypoxic brain injury?

Paroxysmal sympathetic hyperactivity, or a distressing cluster of s/s

What is the MOST sig. predictor of prognosis post-anoxic/hypoxic brain injury?

Duration of unconsciousness

__________: leading cause of cancer death in children

Brain tumors (2nd most common type of childhood cancer as well BUT relatively rare)

What are common impairments of children w/ brain tumors?

Ataxia, spasticity, hemiparesis, peripheral neuropathies, steroid myopathies, avascular necrosis, posterior fossa syndrome, balance issues

25% of children w/ __________ --> mutism, ataxia, hypotonia, and emotional instability

Medulloblastomas

While __________ are the MOST prevalent type of brain tumor, __________ are the most frequent MALIGNANT brain tumor

Astrocytomas vs. medulloblastomas

What causes brain tumors?

UNKNOWN!! (but, certain genetic disorders are OCCASIONALLY involved)

Studies have shown links b/w maternal consumption of __________ during pregnancy and prenatal exposure to __________ and brain tumors

Cured meats; ionizing radiation or residential pesticides

Meanwhile, __________ supplementation may offer PROTECTION against childhood brain tumor development!!

Folate

Prognosis: brain tumors

Depends on the type of tumor (ex: children w/ posterior fossa syndrome typically exhibit overall improvement BUT they may retain motor speech production impairments) and medical tx of tumor (ex: craniotomy or craniectomy may increase risk in the case of a fall!!)

Prognosis worsens for children <__________, those w/ incomplete tumor removals, and those who are experiencing recurrence in their brain tumors

<3 years old

Strokes are more common in children <5 years old w/ __________ CVAs being slightly more common

Ischemic

True or false: risk factors for pediatric CVA are the same as adult CVA

FALSE!!--they ARE different!!

What are risk factors for pediatric CVA?

Blood vessel pathologies, congenital heart disease, systemic infections, blood disorders, Sickle Cell Disease (100x more likely to have a stroke than children w/o it), thrombophilia, neurofibromatosis, Wiliam's Syndrome, and Trisomy 21

Prognosis: pediatric strokes

Mortality rate varies from 20-25%

__________ CVA may have a higher rate of recurrence vs. the alternative

Hemorrhagic

Pediatric strokes increase the risk of __________, especially following a hemorrhagic stroke

Epilepsy

What are common long-term effects of acquired brain injuries?

Memory problems, impulsivity, attention issues, executive function disorders, emotional challenges, physical impairments, difficulty managing schedules, difficulty w/ reasoning skills

__________ dysfunction: may experience s/s such as dizziness, postural instability, balance impairments, or difficulty w/ visual focus and gaze stabilization (ranges from 14-81% after injury and decreases to just over 10% by 6-8 months)

Vestibular dysfunction

__________ and __________ are two common secondary effects of acquired brain injuries

Chronic pain and decreased endurance (resting HR higher and HRV lower w/ poor response to exercise)

Post-acquired brain injury, clinical __________ rates can be as high as 36%, and other emotional problems may also increased aggression, social difficulties, and oppositional defiant behavior disorders

Depression