Sensory Spinal Pathways, Pain Terminology, & Pain Scales for Children

• Babinski

• Flexor withdrawal

• Crossed extension

• Traction

• Grasp

• Primary support

What are the primitive spinal reflexes?

• Toe extension

• Toe fanning

What is the babinski reflex?

Flexor withdrawal reflex

When a noxious stimulus is applied to the sole of the foot, the toes extend, ankle dorsiflexes, and LE flexes

Crossed extension reflex

When a noxious stimulus is applied to the sole of the foot, the stimulated leg flexes and opposite leg adducts and extends

Traction reflex

Pulling forearm leads to UE flexion with head lag

Grasp reflex

Pressure to palm of hand or foot leads to flexion of fingers or toes

Primary support reflex

When weight-bearing through balls of feet, extensor tone increases through LE’s and trunk

• Asymmetrical tonic neck reflex

• Symmetrical tonic neck reflex

What are the tonic/brainstem reflexes?

Asymmetrical tonic neck reflex (ATNR)

Rotation of head produces flexion of opposite UE and extension of ipsilateral UE

Symmetrical tonic neck reflex (STNR)

• Flexion of head produces flexion of UE and extension of LE

• Extension of head produces extension of UE and flexion of LE

Associated reactions

Strong voluntary contraction in one body segment produces involuntary movement in another resting extremity

• Fasciculus cuneatus

• Fasciculus gracilis

• Dorsal spinocerebellar tract

• Ventral spinocerebellar tract

• Anterior spinothalamic tract

• Lateral spinothalamic tract

What are the ascending spinal tracts?

Fasciculus cuneatus

Sensory tract for trunk, neck, and UE proprioception, vibration, two-point discrimination, and graphesthesia

Fasciculus gracilis

Sensory tract for trunk and LE proprioception, vibration, two-point discrimination, and graphesthesia

Dorsal spinocerebellar tract

Sensory tract that ascends to cerebellum for ipsilateral subconscious proprioception, tension in muscles, joint sense, posture of the trunk and LEs

Ventral spinocerebellar tract

Sensory tract that ascends to the cerebellum, with some fibers crossing and subsequently recrossing at level of pons for ipsilateral subconscious proprioception, tension in muscles, joint sense, and posture of trunk, UEs, and LEs

Anterior spinothalamic tract

Sensory tract for light touch and pressure

Lateral spinothalamic tract

Sensory tract for pain and temperature sensation

• Anterior corticospinal

• Lateral corticospinal

What are the descending tracts?

Anterior corticospinal tract

Pyramidal motor tract responsible for ipsilateral voluntary, discrete, and skilled movements

Lateral corticospinal tract

Pyramidal motor tract responsible for contralateral voluntary fine movement

Sensory Integration and Praxis Test (SIPT)

• Sensorimotor assessment for children aged 4 years to 8 years and 11 months, with mild to moderate learning impairments

• Measures:

  • Balance

  • Proprioception

  • Tactile sensation

  • Control of specific movements

Bayley Scales of Infant and Toddler Development Revision (BSID)

Comprehensive developmental assessment that is used from birth until age of 42 months

Pediatric Evaluation of Disability Inventory (PEDI)

• Interview or questionnaire regarding activities of daily living (ADLs)

• Detects functional limitations in self-care, mobility, and social functioning and the need for caregiver assistance

• Used for children from 6 months to 7 years old

Functional Independence Measure for Children (WeeFIM)

• Assesses functional performance in self-care, mobility or locomotion, and communication

• Used for children 6 months to 7 years old

School Function Assessment (SFA)

• Monitors student performance on activities that affect academic and social functioning in elementary school

• Measures participation, task support, and activity performance in school setting

• Used for students from kindergarten through 6th grade

APGAR Score

Standardized assessment to evaluate the physical condition of the newborn infant

• Appearance

• Pulse

• Grimace

• Activity

• Respiration

What are the 5 components of the APGAR score?

• 1 minute after birth

• 5 minutes after birth

• 10 minutes after birth if score is <7, or if any component scored a 0

When is the APGAR score reassessed?

• Blue appearance

• Absent pulse

• No grimace response

• Flaccid muscle tone/activity

• Absent respiration

What indicates 0 points each on the APGAR score?

• Pink body with blue extremities

• Pulse <100 bpm

• Grimace response

• Some flexion with activity

• Slow, shallow breathing

What indicates 1 point each on the APGAR score?

• Pink appearance

• Pulse of 100-140 bpm

• Cough or sneeze grimace response

• Active motion of extremities

• Good, crying irregular

What indicates 2 points each on the APGAR score?

8-10

What is a normal score for the APGAR score?

5-7

What score requires blow-by oxygen on the APGAR score?

3-4

What score requires bag and mask ventilation for the APGAR score?

SCM tightness

What is torticollis?

• Congenital

• Acquired

What are the two types of torticollis?

Spasmodic SCM muscle

What is acquired torticollis?

Stretch neck into extension, left side bending, and right rotation

If a baby has right torticollis, how do you treat it?

Plagiocephaly

• Prolonged positioning creates pressure on skull

• Parallelogram-shaped skull with ipsilateral occipital flattening and contralateral bulging

• Tendency to lie on one side flattens the skull and shifts it forward

• Education about prolonged supine positioning and congenital muscular torticollis (CMT)

• More successful with early intervention (Before 3 months)

• Neck AROM and PROM

• Use positioners, seats, and swings

What are interventions for plagiocephaly?

Cranial Remodeling

• Helmet

• Worn 20-23 hours per day for 2-7 months

• Best if started at 4-6 months

• Hemorrhage under ventricles

• Hypoxic encephalopathy

• Malformation or trauma of CNS

What are the primary causes of nonprogressive encephalopathy?

Nonprogressive encephalopathy

What is the pathology of cerebral palsy?

By area of body

How is cerebral palsy classified?

Monoplegia cerebral palsy

One Limb is affected

Diplegic cerebral palsy

Bilateral LEs is affected

Hemiplegic cerebral palsy

UE and LE of one side is affected

Quadriplegic cerebral palsy

All 4 extremities are affected

• Spasticity

• Dystonia

• Ataxia

• Athetoid

• Hypotonia

• Rigidity

What are the movement disorders?

Spasticity

• Velocity-dependent

• Increased tone in antigravity muscle

• Lesion of motor cortex

• Increased tone in antigravity muscle

• Abnormal postures or movements with mass patterns of flexion and extension

• Contractures and deformities

• Crouched gait or toe walkers

What are the impairments of spasticity?

• Hip flexors

• Hip adductors

• Hip internal rotators

• Knee flexors

• Ankle plantar flexors

What LE muscles are commonly affected by spasticity?

• Scapular retractors

• Glenohumeral extensors

• Glenohumeral adductors

• Elbow flexors

• Forearm pronators

What UE muscles are commonly affected by spasticity?

Dystonia

Involuntary movements with sustained contractions

Ataxia

• Coordination or timing disorder

• Lesion of cerebellum

• Instability of movement

• Low postural tone with poor balance

• Wide base of support

• Intention tremors in hand

• Follows initial hypotonia

• Nystagmus

• Poor visual tracking

What are characteristics of ataxia?

• Spastic

• Athetoid

What types of CP can ataxia occur with?

Athetoid cerebral palsy

• Slow writhing movements

  • Wormlike

  • Involuntary

• Fluctuating muscle tone

• Distal UE commonly involved

• Poor functional stability, especially in proximal joints

• Persistent primitive reflexes

How does athetoid cerebral palsy usually present?

• Facilitate co-contraction patterns

• Encourage control in voluntary movement

How do you treat athetoid cerebral palsy?

Hypotonia

Decreased muscle tone

Rigidity

• Resistance at low speeds

• Not dependent on movement velocity

• Hemiplegic

• Diplegic

What forms of CP have regional involvement?

• Quadriplegic

• Athetoid

• Dystonic

• Ataxic

What types of CP have global/total body involvement?

• Hemiplegic

• Diplegic

• Quadriplegic

What types of CP are spastic?

• Athetoid

• Dystonic

What types of CP are dyskinetic?

• Hemiplegic

• Diplegic

• Quadriplegic

What types of CP are pyramidal?

• Athetoid

• Dystonic

• Ataxic

What types of CP are extrapyramidal?

• Tight tibialis posterior and soleus muscles

• Insufficient force generation

• Tone abnormalities

• Poor selective control of muscle activity in anticipation of postural changes

• Primitive reflexes are persistent

• Increased difficulty with precise movements

• Presence of random involuntary movements

• Lack coordination of voluntary movements

What are MSK problems associated with all forms of CP?

• Vision

• Hearing

• Speech

What are sensory processing issues associated with all forms of CP?

• Behavioral deficits

• Cognitive deficits

What other issues do all forms of CP have?

• Prevent contractures and scoliosis

• Maximize gross motor functional level

• Handling

• Management of spasticity

• Lengthening procedures

• Muscle transfers

• Osteotomies

What are interventions/goals for kids with CP?

• Static positioning

• Dynamic patterns of movement

• Elongate spastic hamstrings and heel cords

• Serial casting

• Pay special attention to ROM during growth spurts

How do we prevent contractures and scoliosis in kids with CP?

• Facilitate functional motor skills

• WB and postural challenges to increase muscle tone and strength

• Use orthoses as needed

How do we maximize gross motor functional levels in kids with CP?

Carry child in sitting position

What is the best way to carry a child with CP who has strong extensor tone throughout the body?

• Promotes visual attending, use of UE, and social interaction

• Preferred posture so shoulders are forward

• Does not allow axial hyperextension

• Keeps hips and knees flexed

• Encourages as much head and trunk control as possible

How does carrying a child with CP and strong extensor tone in the sitting position help?

• Oral medications

• Intrathecal baclofen pump

• Neurosurgery

• Peripheral nerve block

• Botox

What are ways to manage spasticity?

• Achilles tendon

• Hamstrings

• Iliopsoas

• Hip adductors

What muscles are commonly lengthened in kids with CP?

• Posterior rollator with 4 wheels

• Wheelchair

• Prone and supine standers

What equipment is common for kids with CP?

• Good prognosis if child can sit independently by 2 years of age

• Child will most likely walk by 8 years of age if they are going to walk

What is the prognosis for kids with CP?

Based on self-initiated movement with emphasis on sitting, transfers, and mobility

What is the gross motor function classification system (GMFCS) for CP?

GMFCS Level 1

• Walk without restriction

• Limitations in advanced gross motor skills

GMFCS Level 2

• Walk without AD

• Limitations walking outdoors and in the community

GMFCS Level 3

• Walk with AD

• Limitations walking outdoors and in the community

GMFCS Level 4

• Self-mobility limited

• Power mobility outdoors and in the community

GMFCS Level 5

• Self-mobility severely limited even with assistance

• May use standing frame for WB

• Wheelchair-bound

Spina Bifida

• Neural tube defect resulting in vertebral and/or spinal cord malformation

• Linked to maternal decreased folic acid intake, infection, or excessive alcohol and/or drugs

• Irritability

• Vomiting

• Decreased muscle tone

• Seizures

• Headache

• Redness along shunt

What are s/s of shunt malfunction?

• Cystica

• Asperta

• Occulta

What are the types of spina bifida?

• Cystica

• Asperta

What types of spina bifida have visible or open lesions?

Myelomeningocele

Contains cerebrospinal fluid (CSF), spinal cord tissue, and nerve fibers

Meningocele

Cyst includes CSF but spinal cord is intact

Menigocele

What can lead to tethered cord syndrome?

Tethered cord syndrome

Tissue attachments that limit the movement of the spinal cord within the spinal column

• Scoliosis

• Urinary incontinence

• Low back pain worse with activity and relieved with rest

What are S/S of meningocele?

Spina bifida occulta

• Closed legion

• No spinal cord involvement

• Can be a visible sign over the defect, such as atypical skin pigmentation, large dimple, or tuft of hair

• Otherwise asymptomatic

• Muscle paralysis and imbalance from deformities and contractures

• Tethered cord syndrome

• Sensory loss

• Cognitive impairments

• L4-L5 lesions

• Latex allergy

What are impairments of spina bifida?

• Kyphoscoliosis

• Shortened hip flexors and adductors

• Flexed knees

• Pronated feet

What are S/S of muscle paralysis and imbalance from deformities and contractures in kids with spina bifida?

• Spasticity

• Increased tone

• Buttocks pain

• Increased scoliosis

• Weakened leg muscles

What are the S/S of tethered cord syndrome?