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OT IN PEDIA
CEREBRAL PALSY
| Term | Definition 1 | Definition 2 | PRIMARY IMPAIRMENTS | SECONDARY IMPAIRMENTS |
|---|---|---|---|---|
| CEREBRAL PALSY | ● Group of developmental motor disorders arising from a nonprogressive lesion or disorder of the brain ● Damage to 1 or more brain area that can lead to paralysis, spasticity, or abnormal control of movement or posture | ● May also accompany problems in sensation, cognition, communication, and perception. ● *Seizure Disorders | ||
| CP DIAGNOSTIC CRITERIA | 1. Permanent disorder of the development of movement and posture 2. Non progressive brain lesion 3. Acquisition of the brain injury either before birth, during, or in the first years of life (pre/postnatal history) | |||
| CORE FEATURE OF CP: | Impaired motor control. Seen as altered movement, P posture, or difficulty in postural control, leading to abnormal motor functioning and activity limitation | |||
| CP PREVALENCE | ● Most prevalent cause of persistent motor dysfunction in children ● Can be 1 in 500 births to 3 in 1000 births ● Approx. 1.5 times more common in males | ● Higher among non-Hispanic African American children and children from low to middle income families | ||
| CP ETIOLOGY | ● In CP, the origin on brain injury may occur in any of these periods. ● Neurological damage that causes CP can occur before/during birth, or before child’s 2nd year ● There is NOT A SINGLE CAUSE of CP. however, there are different risk factors | |||
| MAIN RISK FACTOR OF CP: | Prematurity | |||
| CP PRENATAL RISK FACTORS | ● Genetic disorders ● Maternal health factors ● Teratogenic agents ● Placental disruption ● Lack of growth factors affecting fetal growth in utero ● RH blood type incompatibility between mother and infant | |||
| Placental disruption | inability of the placenta to provide the developing fetus oxygen and nutrients | |||
| CP PERINATAL RISK FACTORS | ● Prenatal conditions ● Medical problems associated with prematurity ● Multiple births ● Low birth weight | |||
| CP POSTNATAL RISK FACTORS | ● Severe and untreated jaundice shortly after birth ● Infections (e.g., meningitis, encephalitis, chorioamnionitis) ● Alcohol or drug intoxication transferred during breastfeeding | ● Hypoxic ischemic encephalopathy (HIE) ● Trauma during birth or shortly after (before 2 yrs old) | ||
| Hypoxic ischemic encephalopathy (HIE) | prolonged loss of oxygen during the birthing process | |||
| CP Severity - Mild | - can move with mild fixations ○ Minimal difficulty | |||
| CP Severity - Moderate | - moves with spasticity ○ Really affects occupations ○ Can start from postural control to gms to fms | |||
| CP Severity - Severe | - inability to move | |||
| Monoplegia | - one extremity | |||
| Diplegia | - two extremities (usually LE) | |||
| Hemiplegia | - upper and lower extremities on one side | |||
| Paraplegia | - both lower extremities ○ LE and some part of the trunk | |||
| Quadriplegia | - all limbs | |||
| Tetraplegia | - all limbs and head or neck ○ Most severe | |||
| Spastic | - Velocity dependent increase in tonic stretch with exaggerated tendon jerks (most common) | |||
| Dyskinetic | ○ Choreathetoid ○ Dystonic ○ Athetosis | |||
| Choreathetoid | - mix chorea and athetoid movements | |||
| Chorea | - irregular, purposeless, quick movements. | |||
| Dystonic | - sustained muscle contraction | |||
| Athetosis | - slow, writhing, rhythmic movements in distal portions of extremities | |||
| Ataxic | - delayed initiation of movement responses, poor balance and coordination, errors in movement (rate and regularity) | |||
| Hypotonic | - decreased in tone | |||
| GMFCS Level I | Walks without limitations. Performs gross motor skills like running and jumping but speed, balance, and coordination may be impaired. | |||
| GMFCS Level II | Walks with limitations. This includes on uneven surfaces, inclines, stairs, long distances, or in crowds or confined spaces. | |||
| GMFCS Level III | Walks using a hand-held mobility device. Walks on even surfaces, indoors, and outdoors with an assistive divide. Children may use a manual wheelchair for long distances. | |||
| GMFCS Level IV | Self-mobility with limitations. Child may use powered mobility or require assistance from a caregiver. May walk short distances with a mobility device but relies primarily on wheeled mobility. | |||
| GMFCS Level V | Transported in a manual wheelchair. Child has no means of independent mobility and relies on a caregiver for all transportation needs. | |||
| CP CLINICAL FEATURES | ● Is a heterogeneous diagnosis in terms of clinical presentation, etiology, and pathology ● No one child is alike | |||
| CP CLINICAL FEATURES: MOTOR | ● Abnormal postural tone, control and patterns ○ Movement difficulties like in GMS & FMS ○ Domino effect in the development | ● Persisting primitive reflexes, not developed righting, equilibrium and protective extension reactions ○ In CP it is common to present with persisting primitive reflexes — mostly not integrated ● Upper limb function difficulties | ||
| CLINICAL FEATURES: SENSORY | ● Visual ● Hearing ● Vision should be taken into consideration when planning for evaluation and intervention especially for motor/play/ADLs — matters if to know if have enough visual functions to be utilized | ● Hearing is also to be taken into account; some have both hearing and visual problems | ||
| CLINICAL FEATURES: SENSORY ● Visual | ○ Blindness: total/partial blindness ○ Refractive errors (might need corrective lenses), visual acuity problems, strabismus, diplopia (double vision) | |||
| Visual perceptual problems: | depth perception, constancy, spatial relations | |||
| Abnormal use of vision: | use of monocular vision, poor use of central vision; preferential use of peripheral vision | |||
| CP CLINICAL FEATURES: SENSORY INTEGRATION | ● Poor sensory processing ● Difficulty in movement: Limited body awareness and body scheme ● Problems with bilateral coordination | ● Problems with stereognosis, two-point discrimination ● Consider sensory processing and problems of the child with their motor problems | ||
| CP CLINICAL FEATURES: COGNITIVE AND LANGUAGE | ● Intellectual disability: cognitive and language impairments ● Specific Learning Disorders | |||
| Specific Learning Disorders | ○ Caused by a focal brain lesion, language and cognition may or may not be affected | |||
| Specific Learning Disorders - Frontal: | cognitive abilities; memory, receptive functions | |||
| Specific Learning Disorders - Temporal: | language and speech development - decreased speech production, poor articulation, and decreased speech intelligibility (Dysarthria) | |||
| CP CLINICAL FEATURES: OTHER AREAS | ● Problems in Executive Functions ○ Attention, memory, RI — all higher-level cognitive functions ○ Problems in process skills ○ Emotional lability | ● Seizures: take into account the timing (for their medications); activities might trigger their seizures ● Oromotor Impairments: accompany w/ dysphagia problems | ||
| Muscle weakness or hypotonicity | Contracture in a joint (eg., elbow, wrist, hip, knee, ankle) | |||
| Muscle tightness of hypertonicity | Poor or unsteady gait or mobility | |||
| Spasticity | Impairment of visual processing, hearing, or speech | |||
| Involuntary movement | Difficulty with bladder and bowel control | |||
| Weakness of eye muscles | Intellectual disability, learning disability | |||
| Abnormal muscle tone in facial musculature | Problems with breathing because of postural difficulties and weakness in trunk muscles | |||
| Impaired sensation in affected limbs | Skin integrity- increased risk of pressure sores | |||
| Possible seizure disorder | Difficulty in feeding, eating, and swallowing | |||
| CP SPASTIC QUADRIPLEGIA | ● Limited eye movement ● Poor head control ● Total extensor pattern; opisthotonos ● Poor regulation of arousal level (seizures) ● Poor survival function ● Oromotor difficulties: poor suck and swallow, GERD, constipation ● Shallow breathing | ● Primary sensory deficits (visual and auditory) ● Limited repertoire of movement ● Extreme hypersensitivity ● Poor body awareness ● Poor adaptation ● Multiple contractures and deformities; prone to dislocation and subluxation; extreme immobility | ||
| CP SPASTIC DIPLEGIA | ● Poor body scheme ● Limited hand skills ● Insufficient BOS ● Visual perceptual skill deficits ● Most of the time LE is more involved ● Does not necessarily mean there's no tone | |||
| CP SPASTIC HEMIPLEGIA | ● One side of the body is affected ● Asymmetry ● Visual field problems ● Developmental disregard – natural preference d/t difficulty in movement, strong hand will be the preferred/dominant side | |||
| CP ATHETOSIS | ● Hallmarks: Fluctuating tone (fluctuating spastic & hypo), asymmetry, involuntary movement ● Poor midline orientation ● Poor grading of movement ● Poor coordination of movement (eye-hand coordination, and general coordination) | |||
| OT PROCESS - EVALUATION | ● Why do we need to learn the conditions and its classical picture? ● What are its implications when we conduct our evaluation and intervention? ● For children with CP, what skills or occupations should we put more emphasis on? | |||
| OT PROCESS - CRITICAL PERIODS OF DEVELOPMENT | ● Time during early postnatal life when the development and maturation of functional properties of the brain, its ‘plasticity’ is strongly dependent on experience or environmental influences. ● Early intervention is very important | |||
| OT PROCESS - CONSIDERATIONS | ● Positioning ● Arousal level ● Medication | |||
| EVALUATION: SUBJECTIVE | ● Maternal history ● Developmental history ● Other things to consider: ○ Medications – name, for what, dosage, frequency, effects ○ Ancillary or medical procedures done | |||
| EVALUATION: OBJECTIVE | ● Occupations ● Neuromusculoskeletal functions ○ Reflexes, ROM, tone, strength ○ Posture and balance ○ Head, trunk and pelvic control ○ Transitioning and mobility patterns ○ Orthotic device ○ Equipment of device use ○ GMS, AGMS, FMS | ● Sensory functions, perceptual functions ○ Some have accompanying visual and hearing problems ○ May present SI problems d/t limited exploration ● Process skills, mental functions ● Social interaction skills | ||
| OT PROCESS - INTERVENTIONS | ● Current evidence suggests adaptive equipment training (compensatory strategies & environmental modifications), casting and orthotics, constraint-induced movement therapy, functional and goal-directed therapy, and bimanual training for children with CP | |||
| INTERVENTION: ADAPTIVE EQUIPMENT TRAINING | ● Depends on the needs of the child and skills present/available ● Understand the strengths of the kid to recommend the best adaptive equipment or environmental modification for the kid at school or at home ● Considerations: ○ Motor skills | ○ Sensory functioning ○ Environment ○ Child’s position when using it ○ Family’s ability to transport the adaptive equipment ○ Set up needed to use it ○ Ease of cleaning the device/maintenance ○ Finances ● Work w/ interdisciplinary team members | ||
| INTERVENTION: CASTING, ORTHOTICS, AND SPLINTING ● Goal: | To improve function, support a body part, prevent joint contracture, or relieve pain in a specific joint | |||
| INTERVENTION: CASTING, ORTHOTICS, AND SPLINTING | ● May also be used to reduce unsafe behaviors ● Client and family education on the purpose and goals for the orthosis, provide instructions for donning, doffing, and cleaning, determine an optimal wearing schedule that fits the family’s routines | |||
| Serial static splints for contractures | – best if applied continuously for periods greater than 6 hours | |||
| INTERVENTION: CIMT | ● For children with hemiplegia (CP) ● Targets the functional use of the child’s affected upper extremity through engagement in intensive practice, shaping and grading of targeted movements, | and restricting use of the unaffected, stronger upper extremity to push weak/affected extremity ● Know the components and needed prerequisite skills for the child to participate in CIMT | ||
| CIMT 5 essential components: | ○ Constraint of the unaffected upper limb ○ High dosage of repetitive task practice (3 to 6 hours of therapy per day over several consecutive days) ○ The use of shaping techniques | ○ Therapy provided in a natural setting ○ A transition or post-CIMT program to maintain gains acquired during CIMT program | ||
| INTERVENTION: PAMS (Physical Agent Modalities) ● Goal: | increasing muscle length and strength and reducing spasticity, target pain reduction | |||
| INTERVENTION: PAMS (Physical Agent Modalities) | ● Electrical stimulation and hot/cold therapy ● IMPORTANT: use in conjunction with a functional activity ● Risk of burn | |||
| INTERVENTION: POSITIONING, HANDLING, AND NDT | ● Determine the safest and most efficient positioning and handling techniques ● What are some examples of NDT techniques that you can use? (Recall on your motor control and NDT topics during lab) ● What are its goals? | |||
| NDT | ○ Prevent or correct atypical / associated movements ○ Key point of control ○ Facilitating postural tone and control ○ Facilitating correct movement patterns | |||
| INTERVENTION: AREAS OF OCCUPATION | ● Feeding, eating and swallowing (Dysphagia management) ○ Proper positioning ○ Decrease sensitivity ○ Mouth closure, correct chewing pattern ○ Dysphagia | |||
| INTERVENTION: MEDICAL-BASED | ● Pharmaceutics, recommend surgeries, or apply specific medical interventions ● Target: Spasticity or tone ● Muscle relaxants medicine | |||
| Baclofen | ■ Oral or injected ➢ To reduced the muscle tone | |||
| Botox | ■ Botulinum Neurotoxin injections ■ To reduce the tone, and injected directly in the spastic muscle ➢ 1 week after for the effect ➢ Last 3-4 months | |||
| Surgeries | ■ If contractures cannot be remediate: ➢ Tendon transfers ➢ Muscle releases ➢ Osteotomies ■ It lengthens or shortens the specific body structures to improve the overall alignment and position of the kid. |
Created by:
avemaria