Cerebral Palsy (Material for First Exam)

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 developing fetal or infant brain.

Cerebral Palsy

• Permanent

• Non-progressive

• Appears early in life

• Cerebral Palsy is…..

Individuals with CP may experience disturbances in:

All the above

Communication and behavior

Individuals with CP may experience disturbances in:

• 35 to 50% have accompanying seizures and some intellectual disabilities (IQ < 70)

  • Developmentally delayed

Individuals with Cerebral Palsy may. experience disturbances in:

Individuals with Cerebral Palsy may also exhibit difficulties with:

All the above

• Vision issues

  • Strabismus (descries with vision between their right and left eye)

• Dental issues

  • Malocclusion: abnormal bite

Individuals with Cerebral Palsy may also exhibit difficulties with:

Three main characteristics:

All the above

Muscle weakness:

All the above

Deficits in “reciprocal inhibition” ( can not control the balance between the muscles you want to contract and do not want to contract)

Muscle Weakness:

Small muscles overall, Small muscle fiber diameter, and Small muscles overall & small muscle fiber diameter

Issues with the muscle itself:

• Fewer Sacromeres

  • The sarcomeres that exist are longer than normal – this leads to less than optimal myosin-actin overlap​

  • Decreased elasticity​

  • Spasticity: muscle weakness & muscle stiffness -> Hypertonia- high muscle tone (more common) (an abnormal increase in muscle tone, leading to muscle stiffness, rigidity, and difficulty moving) -> Hypotonia (low muscle tone) (less common) ("floppy infant syndrome" or low resistance to muscle stretch at rest)​.

Issues with the muscles itself:

Excessive sway observed during balance exercises​

Balance:

• Weak spastic muscles that assist in balance​

• Abnormal sequencing of muscles that assist in balance​

• Balance

  • Some causes include:​

• Kyphosis​

• Scoliosis​

• Balance

  • Spinal deformities also contribute to:​

Gait

all the above​

• Toe flexion​

• Increased cadence (step rate)​

• Movement in all planes is increased​

  • Balance strategies are compromised​

​

Gait:

• Occurs in 90% of cases​

• < 20 wks:​

  • Typical cause: virus​

  • Consequences: microcephalus (prevent the growth of the brain), hydrocephalus (fluid buildup in the brain)​

• Noxious events that cause damage to make up _____% of individuals with CP. How many weeks, cause (1) & consequence (2)?

• Occurs in 90% of cases

• 26-32 wks:​

  • Typical cause: hemorrhage, leukomalacia (a lot of build up of white matter damage in the brain)​

  • Consequence: white matter damage​

Noxious events that cause damage to make up _____% of individuals with CP. How many weeks, cause (2) & consequence (1)?

• Occurs in 90% of cases

  • 3rd trimester and neonatal period:​

  • Typical cause: hypoxia (lack of oxygen to the fetus or newborn paper) and ischemia (lack of oxygen to an organ)​

  • Consequence: gray matter damage​

Noxious events that cause damage to make up _____% of individuals with CP. How many trimesters, cause (2) & consequence (1)?

• Occurs in 10% of cases​

• Improper brain development​

• Occurs at 1st and/or 2nd trimester​

• Caused by genetic abnormality or inadequate blood supply to brain​

_____% suffer from ____ ______ _______ Trimester? Causes (2)?

​

Risk Factors - Postnatal: Can occur up to 2 yrs of age:

All the Above​​

Risk Factors - Postnatal: Can occur up to 2 yrs of age:

All the above

• Toxins​

• Hyperbilirubinemia: death of red blood cells​

Risk Factors - Postnatal: Can occur up to 2 yrs of age:

• 2 to 5

• 1,000

____ to _____ infants affected per _____ births ​

82.3 per 1,000 live births​

Highest prevalence: age < 28 weeks​

0.35 per 1,000 live births

Lowest prevalence: age > 36 weeks​

• boys

• girls

• 1.4:1 

Prevalence higher in ____ vs. _____with a ratio of ________.​

• More

• girls

• boys

Autoimmune diseases are ______prevalent in _____ than _____.​

70

______% will develop ability to walk ​

90

_____% of children survive to adulthood ​

• Additional issues:​

  • Cervical disc degenerations​

  • Decreases Bone Mineral Density (BMD)​

  • Poor joint alignment​

  • Fatigue

  • Pain​

    • Typically moderate to severe​

    • Located in legs, back, shoulders, neck​​

Adults with CP​

35​

Adults with CP: _____% have reduced ability to perform ADL's​

75

Adults with CP: _____% discontinue ambulation by age 25​

• Physiological ​

• Clinical presentation​

• Anatomical ​

• Functional ​

Classifications​

• Pyramidal​

  • Cerebral cortex​

Classification: Physiological

​

• Basal ganglia, thalamus​

Classification-Physiological:Extrapyramidal

• Mixed​

  • Combination

Classification: Physiological

velocity-dependent (if you move slowly the ROM is increased, but if you move quickly you will experience more resistance & little movement) increase in resistance to passive  movement (you are moving the patient) (4 out of 5 people present with spasticity)​

Classification-Clinical Presentation: Spasticity​

involuntary contractions resulting in atypical postures

Classification-Clinical Presentation: Dyskinesia

slow, continuous, repetitive torsions​

Dyskinesia:Athetosis

sudden, short, irregular movements

Dyskinesia: Chorea

intermittent contractions following a pattern​

Dyskinesia: Dystonia

Loss of full control of body movements

Classification-Clinical Presentation: Ataxia

• one limb is affected ​

  • Usually an arm​

Classification- Anatomical: Monoplegia

• both limbs are affected​

  • Both arms or both legs

Classification- Anatomical: Diplegia

• one side of the body is affected​

• Arm more severely disabled than leg ​

Classification- Anatomical: Hemiplegia

• three limbs are affected ​

  • Most often both arms and one leg ​

Classification- Anatomical: Triplegia

• all four limbs are affected ​

  • Usually associated with mental disability

Classification- Anatomical: Tetraplegia

functional abilities

Classification-Function (GMFM)-Related Services (PT,OT)​: Questionnaire designed and validated to measure change in _______ over time ​

• Lying & rolling​

• Sitting​

• Crawling & Kneeling​

• Standing ​

• Walking, running & jumping​

Classification-Function (GMFM)-Related Services (PT,OT)​: Five dimensions

• Is ambulatory without the need of support ​

  • Has decreased speed, balance, coordination​

GMFM Classification System​: Level 1

• Is ambulatory with the need of some support ​

  • Minimal ability to run and jump​

GMFM Classification System​: Level 2

• Needs assistive mobility devices to be ambulatory ​

  • May use a manual wheelchair on their own

GMFM Classification System​: Level 3

• Ambulation severely limited, even with assistive devices ​

  • Uses wheelchair most of the time​

GMFM Classification System​: Level 4

• Has physical impairments that restrict voluntary control of movement​

  • Cannot maintain head and neck position ​

  • Impaired in all areas of motor function ​

GMFM Classification System​: Level 5

How well can you do these gross motor skills 

What is the purpose of GMFM?

• CV, metabolic responses, and submaximal

  • Heart rate (increase)​

  • Blood pressure  (increase)​

  • Lactate concentrations (increase)​

Exercise Response-Aerobic: Higher ______ and ________ at a given ________ workrate ​​

• 10-20%

  • Reduced mechanical efficiency​

  • Physical work capacity (can be 50% lower)​

Exercise Response-Aerobic: Lower peak physiological responses by _______%

• typically measured using the Wingate Test​

  • Peak and mean muscle power​

  • Local muscle endurance​

Exercise Response: Anaerobic ​

limited

Exercise Response-Anaerobic: Motor performance is ______by peak muscle power and local muscle endurance​

• GMFM​

  • Accounts for 64% of variability seen in Dim E​

  • Measuring power is importance because it directly relates to motor performance ​

Exercise Response- Anaerobic: Mean muscle power correlates more significantly with

• Like children, most adults with CP cannot reach true VO2max with exercise testing​

• Adults with athetospastic CP had similar VO2peak vs. predicted VO2max during multistage, sub-maximal cycle ergometer testing​

  • VO2peak = 17.7 + 6.0 ml/kg/min​

  • Predicted VO2max = 19.4 + 6.8 ml/kg/min

VO2peak vs. VO2max in Adults​

• Increased local muscle fatigue ​

  • High muscle tone​

  • Reduced venous return ​

  • Inhibited muscle lactate clearance during exercise ​

Why the Lower Peak ​Physiologic Response to Exercise?

• Involuntary movements​

  • Increased cardiovascular stress than able-bodied peers at similar workrates ​

Why the Lower Peak ​Physiologic Response to Exercise?

• High level of coactivation ​

  • Elevated energy expenditure during submaximal exercise ​

  • Venous Return​

  • Skeletal muscle pump ( in cp the brain does not communicate well due to spasticity)​

  • One way valves (vasoconstriction)​

  • Respiratory pump ( in cp this is also restricted)​

  • Venous pooling

  • Liver gets rid of lactate and turns it into carbohydrates​

Why the Lower Peak ​Physiologic Response to Exercise?

• Poor exercise habits ​

  • Weakness​

  • Reduced muscle mass

Why the Lower Peak ​Physiologic Response to Exercise?

• Lower efficiency of breathing ​

  • Higher VE​

  • Chest wall distortion due to respiratory muscle spasticity ​

  • Due to spasticity in the muscles it is hard for people with CP to breathing using their respiratory muscles because they may always be contracting​

Why the Lower Peak ​Physiologic Response to Exercise?

• Increased ratio of type 1 to type 2 fibers​

  • Anaerobic exercise is negatively impacted​

  • More type 1 fibers are hanging around ​

Why the Lower Peak ​Physiologic Response to Exercise?

• Strength of quadriceps correlates positively with GMF and walking speed ​

  • Protocols that use isometric (holds), isokinetic (same speed) and isotonic (Same force) exercises can lead to similar improvements in strength vs. healthy youth ​​

  • Spasticity does not increase ​

Strength Training

walking or running

Exercise Training: Mode​

2-4x / week​

Exercise Training: Frequency

60-75% HRpeak or 50% VO2peak​

Exercise Training: Intensity

>30 min / week​

Exercise Training: Session duration

• 1st group: 8-9 months​

• 2nd group: 3 months ​

Exercise Training: Study duration

• 15-40%

• aerobic capacity ​

Exercise Training-Study duration results: ______ ↑ in __________.

• ↑ ability to participate in physical activity ​

• ↑ quality of life (QoL)​

Exercise Training​-Long duration (8-9 months) can lead to:

• 9 months of aerobic exercise, 4x/week, 45min/session can improve peak aerobic power by 32%

Exercise Training​: ______ months, _______ weeks, _______ min/session can improve peak aerobic power by ______%

​

• 6-8 weeks, 3x/week ​

  • A year of exercise training ​

Exercise Training​: Training _______ weeks, _______ week can increase muscle strength

Calculating workload is difficult​

Exercise Testing-Cardiorespiratory: Wheelchair ergometry​​

Start @ 0-15 W at 30-50 rpm, ↑ 5-10 W every 1-2 min​

Exercise Testing-Cardiorespiratory: Arm ergometry

Start @ 25-50 W at 50-60 rpm, ↑ 15-25 W every 2 min​

Exercise Testing-Cardiorespiratory: Leg cycle ergometry ​

• 3 stages, 5 min/stage, 2-3 min rest / between stages​

• 1st: handrail support (if needed) @ walking speed; 2nd and 3rd: no support with ↑ speed/grade​

Exercise Testing-Cardiorespiratory: Treadmill ​

• Repetition maximum ​

  • 1RM may not be appropriate​

  • 8RM or 25RM can be used to estimate 1RM​

    • Good indicators of dynamic muscle strength and endurance​

• Another less reliable method: max repetitions in 1 min

• Handheld dynanometry​

  • Good indicator of isometric muscle strengt​

Exercise Testing: Musculoskeletal​

​

• Can be used to measure joint angles during passive or active motion ​

• Only use one plane at a time​

Exercise Testing-Flexibility: Goniometers​

Good for measuring low back / hip flexibility​

Exercise Testing-Flexibility: Sit-and-reach test​

Assesses shoulder flexibility​

Exercise Testing-Flexibility: Apley’s scratch test​

• Suppresses rapid, excessive neuron firing​

• Risk: depresses CNS​

• Side effects: Irritability, dizziness, nausea, weight loss​

Medications: Anti-seizure ​

• Decreases muscle tone ​

• Risk: act systematically ​

• Side effects: drowsiness and lethargy ​

Medications: Antispasmotics​

• Usually performed from ages 6-8​

• Attempt to correct muscle and joint contractures ​

  • Shortened muscles that limit ROM​

• Attempt to correct torsional deformities in long bones ​

  • Cause legs to be turned outward during gait​

Interventions: Orthopedic surgery ​

Ankle-foot braces

Interventions: Orthoses​

Treats contractures​

Interventions​: Lower Limb casting ​

Aims to improve QoL by optimizing level of activity and participation

Interventions​: Neurodevelopment treatment techniques ​

• Improves upper limb motor activities ​

• More commonly done in Hemiplegia ​

Interventions​: Constraint-induced manual therapy

Equine-assisted activities, therapies

Interventions​: ____ ___ __ and _________

• Cutting and removing portion of dorsal nerve root from L1 to S1 to reduce spasticity​

• Most common in spastic diplegics whose lower limbs are affected ​

Interventions: Selective Dorsal Rhizotomy​

• Used in those mild to moderately affected​

• Reduces spasticity by paralyzing the muscle ​

  • Prevents release of acetylcholine ​

Interventions: Botulinum Toxin A (Botox)​

• Ambulatory: arm, leg ergometry, swimming​

• Non-ambulatory: arm ergometry

Exercise Programming: Aerobic (exercise)

• Severe:​ 40-50% HRR or VO2R ​

• Less severe:​ 50-80% HRR or VO2R

Exercise Programming: Aerobic (intensity)

3-5 days/week​

Exercise Programming: Aerobic (Frequency​)