Midterm Objectives

describe cerebral palsy

• Cerebral palsy is a group of disorders that affects a person’s motor movements

• Secondary to abnormal brain development or damage to the developing brain that affects a person's ability to control their muscles

what kind of disability is CP considered

PHYSICAL disability

differentiate reasons for congenital vs acquired CP

• Congenital

  • The majority of children with CP are born with it

  • Reasons for congenital CP

    • Fetal injury

    • Genetic abnormalities

    • Brain malformations

    • Maternal infections/fever

• Acquired

  • Smaller population have CP because of an event that occurred after birth (up to the first 3 years of life)

  • Reasons for acquired CP

    • Meningitis/encephalitis

    • Stroke

    • Head injury

    • Near drowning

list risk factors and warning signs of CP in pregnancy

• Risk factors in pregnancy

  • Multiple births

  • Congenital infections

  • Rh incompatibility

  • Exposure to toxic substances

  • Premature birth

• Warning signs of CP during delivery

  • Breech

  • Distress during delivery

  • Low APGAR score

  • Jaundice

  • Seizures

describe the diagnosis of CP and its effectiveness

• Imaging may be considered if a child is showing delayed development or abnormal muscle tone

• Before 5 months, predictive tools are this effective:

  • MRI (86-89%)

  • Prechtl qualitative assessment of general movements (98%)

  • Hammersmith infant neurological examination (HINE) (90%)

• After 5 months, imaging becomes more sensitive

list movement and affected limb patterns of CP

• Types of movements with CP

  • Spasticity

  • Dyskinesia

  • Ataxia

  • Hypotonic

  • Mixed

• Types of affected limbs

  • Hemiplegic (half body)

  • Diplegic (both LE)

  • Quadriplegic (whole body)

list secondary conditions associated with CP

• Scoliosis

• Hip dysplasia with dislocation

• In-toeing (anteversion)

• Contractures

• Patellae alta

• Foot deformity

list strategies to manage hypertonia associated with CP

• Bracing

• Serial casting 

• Medications (Baclofen, benzodiazepines, etc.)

• Botulinum toxin infections

  • Type A (botox, dysport)

  • Type B (myobloc)

• Global tone management

  • Selective dorsal rhizotomy

    • Clipping some sensory nerve rootlets

  • Intrathecal baclofen

list signs of a seizure

• Eye deviation

• Lip smacking

• Staring off

• Twitching/jerking movements that can't be stopped with physical touch

• Stiffening of the body

• Followed by confusion/fatigue

differentiate focal vs generalized seizures

• Focal

  • Affect one area of the brain, causing localized symptoms

• Generalized

  • Affects both sides of the brain

    • Tonic-clonus

    • Absence

    • Myoclonic

    • Atonic

describe reasons for leg length discrepancy, how it presents, and how its managed

• Leg length discrepancy due to:

  • Congenital defect

  • Trauma

  • Overgrowth

  • Paralytic disorder (CP)

• Presents as

  • Back pain

  • Hip arthritis

  • Functional scoliosis

  • Gait inefficiency

  • Ankle equinus contracture

• Management

  • Surgery

  • Block growth plate for a period of time to allow other limb to “catch up”

describe developmental hip dysplasia, how it presents, and how its managed

• Shallow socket of the hip that leads to dysplasia → subluxation → dislocation

• Affects females more (6:1)

• Risk factors

  • 1st born, female, breech, family history

• Presents as

  • Unequal abduction, lumbar lordosis, positive galeazzi sign, trendelenburg, toe talking

• Management

  • Pavlik harness → abduction brace

  • Surgery

describe Erb’s palsy, how it presents, and how its managed

• Birth trauma of the superior brachial plexus nerve roots (C5-6)

  • Axillary, suprascapular, MC nerves

• Presents with waiters tip position

  • Adducted shoulder, IR, pronation, elbow extension

• Management

  • Passive stretching

  • Nighttime elbow splint

  • Nerve grafting

  • Lat dorsi transfer

describe Blount’s disease and how its managed

• Pathologic genu varum

  • Overload of the medial proximal tibia

• Management

  • Nothing for internal tibial torsion

  • KAFO bracing

  • Guided growth

  • Osteotomy

describe club foot and how its managed

• Idiopathic foot deformity in neonate

• Muscle contracture that leads to

  • Cavus, adductus, varus, equinus

• Management

  • Ponsetting casting (90% success)

  • Posteromedial release

  • Talectomy

describe torticollis and how its managed

• SCM muscle contracture

  • Head tilt up and out

• Management

  • Passive stretching (90-95% effective)

  • SCM lengthening

describe scoliosis and how its managed

• Coronal plane spinal deformity

• Strong genetic contribution

• Management

  • Curves <25 degrees: observation

  • Curves 25-45 degrees: thoracolumbosacral orthosis

  • Curved 45+ degrees: posterior spinal fusion

describe legg-calve-perthes disease, how it presents, and how its managed

• avascular necrosis of the proximal femoral epiphysis in children

• More common in males (5:1)

• Rarely bilateral

• Presents as

  • Painless limp

  • Loss of IR and abduction

  • Trendelenburg gait

  • Leg length discrepancy

• Management

  • Activity restriction

  • PT

describe slipped capital femoral epiphyses (SCFE), how it presents, and how its managed

• The femur slips out of the growth plate due to the growth plate becoming weakened and unstable

  • Can present as hip/groin pain, medial knee or quad pain, limp, obligate ER

  • Management

    • Immediate NWB and hospital admission

    • Surgery

describe down syndrome and how it presents

• Autosomal chromosomal conditions associated with an extra chromosome 21

• Maternal age is the primary risk factor

• Increased risk of developing Alzheimer’s, AA instability

• Presentation

  • Facial features, small stature, reduce muscle tone

  • Slower development in motor skills, cognitive abilities, and speech

  • Heart defects, GI problems, hearing/vision impairments, abnormal brain findings

describe osteogenesis imperfecta and how it presents

• Brittle bone disease

• Type 1 collagen mutilation leads to decreased ECM in bone, skin, and tendon resulting in fragile bones and increased turnover

• 75% of cases are inherited

• Presentation

  • History of fractures, blue sclera of the eye, easy bruising, joint hypermobility

• Types

  • 1: mild

    • Most common form

  • 2: lethal

    • Most severe form

  • 3: severe

    • Extremely short stature

  • 4: moderate

    • Osteoporosis and bowed legs

describe arthrogryposis multiplex congenita (AMC) and how it presents

• Multiple congenital contractures present at birth characterized by decreased fetal movement with intact skeletal development

• Presentation

  • Involvement in all four extremities

  • Joint contractures

  • Muscle weakness

  • Functional limitations

describe muscular dystrophy and how it presents

• Group of genetic muscle diseases characterized by progressive degeneration of muscle tissue

• All forms are inherited through genetic transmission, mostly affects males

• Presentation

  • Symmetric muscle wasting, progressive weakness, increasing deformity and disability with age, gower’s sign

describe the 3 types of spinal muscular atrophy (SMA)

• SMA 1: werdnig-hoffman disease

  • Earliest onset

  • Profound hypotonia “floppy baby”

  • Most severe with rapid progression

  • Death within 2 years

• SMA 2: Chronic werding-hoffman disease

  • Onset 7-18 months

  • Intermediate severity

  • Shortened lifespan

  • Sit independently but never achieve ambulation

• SMA 3: Kugelberg-welander disease

  • Onset after 3 years

  • Mildest form with slow progression

  • Near-normal life expectancy

  • Achieve independent ambulation

describe the management of and PT implications of down syndrome

• Management

  • Address specific medical issues

  • Family education and support

  • Multidisciplinary rehab

• PT implications

  • Safety awareness

    • AA instability

  • Respiratory considerations

  • Cardiac monitoring

  • Neurological vigilance

describe the management of and PT implications of osteogenesis imperfecta

• Management

  • Pharmacological

  • Surgical

  • Respiratory system monitoring

• PT implications

  • Education

  • Fracture assessment

  • Lightweight splints

  • Mild PROM

describe the management of and PT implications of arthrogryposis multiplex congenita (AMC)

• Management

  • Early PT and OT

  • Surgical interventions

  • Serial casting

  • Custom hand splints

• PT implications

  • Education

  • Early intervention

  • Functional training

  • Environmental adaptations

describe the management of and PT implications of muscular dystrophy

• Management

  • Pharmacologic (corticosteroids, etc.)

  • Gene therapy and stem cell

  • Multidisciplinary approach

  • Adaptive equipment

• PT implications

  • Preserve function and mobility

  • Promote independence for as long as possible

  • Adapt environment and provide assistive devices

describe the management of and PT implications of spinal muscular atrophy (SMA)

• Management

  • Respiratory management

  • Orthopedic management

  • Nutritional support

  • Multidisciplinary approach

• PT implications

  • Cognitive considerations

  • Skin protection

  • Respiratory management

  • Positioning and mobility

  • Orthotic management

  • Therapeutic interventions

list contraindications for individuals with down syndrome

Avoid exaggerated neck flexion, extension, or rotation, trampolines, etc.

• due to AA instability

list contraindications for individuals with osteogenesis imperfecta

• Do not stretch or aggressive ROM

• Avoid high impact activities

• Avoid resistive exercises

list contraindications for individuals with muscular dystrophy

Do not exercise to fatigue and avoid DOMS

describe spina bifida, risk factors, and surgical management

• Failure of neural tube closure during weeks 3-4 of embryonic development

• Risk factors

  • Genetic factors

  • Maternal factors

  • Environmental factors

• Surgical management

  • In-utero repair

    • 19-25 weeks gestation

  • Postnatal repair

    • 24-48 hours after birth

list and describe common comorbidities associated with spina bifida

• Hydrocephalus

  • Excess CSF in brain ventricles

• Arnold-Chiari II malformation

  • Cerebral tonsils herniate below foramen magnum

• Hydromyelia

  • Dilation of central canal with CSF

• Sydringomyelia

  • Fluid filled cavity in spinal cord

differentiate spina bifida occulta vs aperta

• Spina bifida occulta (closed lesions)

  • Do not see the defect from the outside

  • Least involved

  • Noticed by dimpling or hairy patch at end of the cord

  • Meningocele: cyst filled with cerebrospinal fluid outside the body

  • Lipmeningocele: fatty tumor encroaching on the spinal cord

• Spinal bifida aperta (open lesions)

  • Visible from the outside

  • Myelomeningocele: Spinal cord tissue within the cyst

list S&S of shunt failure

• Any age

  • Seizures

  • Altered mental status

  • Fever

  • Loss of acquired skills

  • Swelling along shunt tract

  • Changes in tone

• Infants

  • Bulging fontanelle

  • Prominent scalp veins

  • Downward gaze

• Children and adults

  • Headache

  • Nausea and vomiting

  • Visual disturbances

  • Lethargy

describe management of bladder dysfunction and bowel dysfunction for those with spina bifida

• Bladder dysfunction management

  • Clean intermittent catheterization

  • Anticholinergic medications

  • Botox injections

• Bowel dysfunction management

  • Timed bowel program

  • Dietary modifications

  • Stool softeners or fiber

differentiate spastic vs flaccid bladder

• Spastic bladder

  • UMN

  • Lesion above conus medullaris

  • Frequently, involuntary contractions

  • Small capacity, high pressure

• Flaccid bladder

  • LMN

  • Lesion as conus medullaris or cauda equina

  • Inability to void voluntarily

  • Large capacity, low pressure

list the role of PT in the NICU

• Identify impairments in body function and structure that contribute to activity limitations and participation restrictions

• Determine the developmental status of the infant

• Assess infant’s response to stress and their ability to self-regulate

• Skilled positioning interventions

• Environmental adaptations to optimize growth and development

list and describe the common diagnoses associated with prematurity

• Respiratory conditions

  • Respiratory distress syndrome (RDS)

• Cardiac Conditions

  • Pulmonary atresia

• Neurologic Diagnoses

  • Intraventricular hemorrhage (IVH)

  • Periventrical leukomalacia (PVL)

    • Cerebral white matter injury

  • Hypoxic ischemic encephalopathy (HIE)

• Musculoskeletal/Orthopedic Diagnoses

  • Club foot

  • Fractures

  • Brachial plexus injury

  • Torticollis

  • Head shape

    • Scaphocephaly / doliocephaly (narrow head)

what are the long-term implications of prematurity on development

• Increased risk of CP

• Cognitive delays or motor delays

• Respiratory issues

define premature birth, gestational age, chronological age, and adjusted/corrected age

• Premature birth: infant born at <37 weeks gestation

• Gestational age: the age of a pregnancy

• Chronological age: refers to the age of the infant since birth

• Adjusted/corrected age: chronological age reduced by the number of weeks born prematurely

define low, very low, and extremely low birth weights

• Low birth weight: 1501-2500 grams

• Very low birth weight: 1000-1500 grams

• Extremely low birth weight: <1000 grams

list the principles of developmental care

• Environmental interventions

  • Ex. reducing noise levels, light levels, etc.

• Clustering cares

• Kangaroo care with caregivers

  • Skin to skin contact

• Pain management

describe the functions of each part of the brain (frontal, parietal, temporal, occipital, cerebellum, brain stem)

• Frontal lobe – Thinking, planning, movement, and speech

• Parietal lobe – Processes touch, pain, and body position

• Temporal lobe – Hearing, memory, and language

• Occipital lobe – Vision

• Cerebellum – Balance and coordination.

• Brainstem – Breathing, heart rate, and swallowing

describe meningitis

• Inflammation of the meninges of the brain and spinal cord

• Affects dura mater, arachnoid, pia mater

• Can be viral or bacterial

  • Viral

    • Self limiting and typically benign

    • Less severe

    • Occurs days or weeks after exposure

  • Bacterial

    • Neurologic and medical emergency

    • More severe

    • Inflammation initially in subarachnoid space then spreads

describe encephalitis

• Acute inflammation of brain tissue → cerebral edema

• Affects grey matter

• Caused by viral invasion

  • Commonly mosquitos and ticks

describe brain tumors

• Space occupying lesion

• Compression of brain tissue that leads to cerebral edema and increased intracranial pressure

• Types of brain tumors

  • Meningioma, glioblastoma, astrocytoma, pituitary adenoma, hemangioblastoma, medulloblastoma, neuroma

list the locations of intraspinal tumors

• Extradural (45%)

  • Completely outside of the spinal cord and dura mater

• Extramedullary-intradural (45%)

  • Within the dura mater but outside of the spinal cord

• Intramedullary-intradural (5%)

  • Within the spinal cord and dura mater

describe ALS and its presentation

• Muscle wasting and sclerosis of anterior and lateral corticospinal tracts

• Affects upper and lower motor neurons

• There are 4 types depending on the location

• Presentation

  • Cognitive deficits

    • Attention, memory, problem solving, visual perception

  • UMN signs

    • Spasticity, weakness of UE extensors and LE flexors, positive clonus and babinski

  • LMN signs

    • Asymmetric distal to proximal weakness, facial weakness, muscle cramps and stiffness, progressive difficulty breathing

what is spared from ALS

eye movements, sensation, bladder/bowel function

differentiate the treatment of viral vs bacterial infections of the CNS

• Viral

  • Treatment of symptoms (medication for headache, nausea, etc.)

• Bacterial

  • Antibiotics immediately

  • Dexamethasone to reduce inflammation

  • Steroids to reduce intracranial pressure

why is there concern for both benign and malignant tumors of the CNS

Benign tumors can be considered malignant due to their location even though they are not malignant in nature

list S&S of meningitis and encephalitis

• Meningitis symptoms

  • Headaches, muscle fatigue, nausea/vomiting, paleness, fever, seizures, stiff neck

  • Kernig’s sign and Brudzinski’s sign

• Encephalitis symptoms

  • Headache, nausea/vomiting, altered consciousness or coma, agitation, focal neurological signs, seizures

list S&S of brain tumors and intraspinal tumors

• Brain tumor symptoms

  • Headache, vision changes, cognitive/behavioral changes, nausea/vomiting, seizures, weakness

• Intraspinal tumor symptoms

  • Poorly localized pain, weakness, sensory changes, bladder/bowel changes, spasticity, hyper/hypo reflexia

list PT implications of ALS

• Screening

• Long, low load stretching

• Positioning

• Bracing

• Assistive devices

• Consider your goals

• Home evaluation