Cerebral Palsy - notes PDF

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CEREBRAL PALSY (CP) CP is a group of neuromuscular conditions that affects one’s motor abilities due to damage to the motor areas of the brain. It is a non-progressive, lifelong impairment of movement and coordination that develops before, during or immediately after birth. The type and severity depends on the location and amount of brain damage. Areas usually affected are: 

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Motor cortex o planning, control, and execution of voluntary movements o controlling precision of movement and site where voluntary motor actions originate. (Spasticity) Basal ganglia o responsible for planning and programming the motor commands of movement (integration of various movements –athetosis) Cerebellum o not initiate movement, but it contributes to coordination, precision, and accurate timing o It receives input from sensory systems of the spinal cord and from other parts of the brain, and integrates these inputs to fine tune motor activity o Cerebellar damage produces disorders in fine movement, equilibrium, posture, and motor learning.[regulating balance and muscle coordination] (Ataxia)

Causes o o o o

Idiopathic (not 100% sure of the cause) Pre-natally (before birth-premature birth, maternal infections) Peri-natally (during birth –any complications) Post-natally (brain tumors, brain injuries due to falls, epileptic, fever, etc) Before the age of 3 months

Terminology associated with muscle tone and posture Muscle Tone

Hypertonicity Hypotonicity Fluctuating tone Postural Tone

-Level of tension that exists in muscle at a given moment -During “normal” development we have the ability to increase or reduce muscle tone to perform a movement/maintain posture -High Muscle tone -Increased tightness as in spasticity, rigidity, or muscle spasms -Low Muscle tone -Decreased tension or floppiness (muscles are soft and limp) -Muscle tone fluctuates between states of hyper and hypotonicity -Common in Athetosis, ataxia, tremor -Maintained by constant feedback being sent from the nerve endings

in every sensory organ to the brain and back to the muscles involved in controlling postural tone Many persons with CP don’t acquire the same control over the muscle tone in their predominantly affected muscle groups. Movement ability ROM Posture Muscle tone Muscle contraction ability

Gross motor functional class scores (GMFCS) Level 1: Walks w/o limitations Level 2: Walks w/ limitations Level 3: Walks using hand-held mobility device Level 4: Self-mobility w/ limitations; may use powered mobility Level 5: Transported in manual wheelchair

Movemen control Movement capacity

Anatomical System (doesn’t take head/neck &/ trunk dysfunction into account; problems with fine motor control)

Hemiplegia: 35-40%   

One side is predominantly affected (don’t assume that the function of the less affected side is ‘normal’ Modify/Compensate activities to accommodate dysfunction Try develop a balanced physique and optimize functional ability

Diplegia:   

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All 4 limbs are affected , but one is more affect than the other Considered a mild sub-set of quadriplegia Legs predominantly affected:  Some can walk and run (compete as ambulant/wheelchair)  Obtain as much functional ability (stable base) Arms predominantly affected:  Some can walk/run, others require wheelchair (propel with feet)  Obtain as much functional ability (stability)

Quadriplegia: 15-20%  

Total body affected Severity of dysfunction can vary considerably from mild to severely affected

Neuromuscular System Uncommon/rare for an athlete to be one/other in isolation, however one type usually predominates and the athlete is ‘categorised’ into that type. Situations when no one type predominates =mixed (Combo of spasticity and athetosis is most common) Spasticity- 50-70%      

Damage to motor cortex and cortical tracts Further damage to basal ganglia and cerebellum exacerbates spasticity Hypertonicity (muscles feel and look stiff) Location and variation of degree of affection Usually involves arm flexors (E.g.biceps) and/or leg extensors (E.g. quadriceps) Level may vary depending on: posture, positioning, emotional factors (stress), temperature and pre-movement stretching

Athetosis- 20-30%   

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Affects all muscles involved in movement/motor tasks (throughout body) Fluctuating muscle tone Damage to basal ganglia is mostly the reason for athetosis (planning and programming of motor commands) thus “interference” of neural impulses being sent to muscles Severe athetosis: continuous, involuntary, slow, repetitive, writhing movements throughout body (obvious in distal joints i.e. fingers, wrists, toes, ankles) Mild athetosis: unwanted movements that are only apparent when individual attempts tp perform specific ‘motor tasks’ (E.g. attempting to stand, unwanted head and arm movements, not necessary to perform task) Poor control of muscles involved in speech and swallowing (dysarthriadifficult/unclear articulation= slurring) Many persons with athetosis use wheelchairs

Ataxia: 5-10%      

Hypotonia and low postural tone Cerebellar – vestibular – origin (regulating balance and muscle coordination) Difficulty maintaining balance, posture &/ trunk control= ‘unsteady’ (Over use of arm movements to help with balance) Disturbances of coordination of voluntary movements (errors in rate, range, strength & direction) =clumsy Uneven walking surface can be problematic due to body-awareness difficulties Compared to athetosis the movements are short, rigid and jerky

Tremor: 1-2%   

Involuntary rhythmic movements of various body parts (mostly in extremities, i.e. hands and feet) Unintentional (continuous) or intentional (when movement attempted) Affect fine motor skills (require precise movement patterns)

Rigidity: 2-4%  

Severe form of spasticity (continuous muscle tension) Results in:  Severe hypertonicity and reduction in ROM  Quadriplegia (arms, legs, spine ‘fixed’ in extension)  Resistance to general movement (even passive); flexion being extremely difficult and painful (where movement is possible= labored and mechanical)

CPISRA- Classification System (CP international Sport & Recreation Association) Class CP1

CP2

CP3

CP4

CP5

CP6

CP7

CP8

General Symptoms Severe spastic/athetoid - Tetraplegia Non-functional lower body, no trunk control and limited function in the upper body Moderate to severe spastic/athetoidTetraplegia Fair trunk stability, have differing functional ability in the upper and lower extremities Moderate spastic tetraplegia/ severe hemiplegia Moderate spasticity of lower extremity; fair trunk stability; moderate limitations to function in the dominant arm Moderate to severe spastic diplegia Moderate to severe involvement of lower extremities, good trunk dynamics, minimal upper body involvement Moderate Spastic Diplegia Minimal to moderate spasticity in one/ both lower extremities (able to run) Moderate athetosis and ataxia Good trunk and upper extremity; poor throwing and grasping Lower extremity improves from walking, to running to cycling. True ambulatory hemiplegia Mild to moderate affected upper extremity; mildly affected lower extremity Minimally affected diplegia, hemiplegia, athetosis or monoplegia

Locomotion Electric w/chair or assistance

Can propel manual w/chair slowly

Able to propel manual w/chair Ambulate w/ assistance

Ambulate short distances

Ambulates well w/ assistive devices Ambulates well w/o assistive devices

Ambulatory

Ambulatory

Exercise response o CP tend to have higher lactate, HR and BP response for given sub maximal workload than AB peers o Peak Physiological responses – 20% lower o Reduced mechanical efficiency for spastic CP reported o Training does decrease risk factors and improves self-image, acts of daily living and lessens severity of symptoms Training athletes with CP Variables Medical history & clearance

Biomechanics

Strength

Bio motor ability Power; Speed, Coordination; Balance

Metabolic Training

Flexibility

Training Implications • Increase risk of CVD • Previous Operations (E.g. tendon lengthening) • Medication (spasticity, epilepsy, botox) • Increased biomechanical risk (ROM, Posture & Muscle Tone) • Tendonitis (overuse injuries) • Assistive devices • Past: strength training forbidden (thought to increase spasticity) • Current: strength training can be beneficial (E.g eccentric training; antagonist strengthening) • Stretch the spastic muscle groups often during strength training session (PNF stretch excellent) • Start with closed chain movements (low in complexity and speed) • Ensure good biomechanics (or adapt) • Training load to be defined Training Implications • Movements involving fast muscle contractions will be difficult (Co-contraction, muscle coordination, balance, reaction time) • Simple to complex (start with low intensity and complexity) • Be patient (it does improve) • Biomechanical difficulties is taken into consideration, aerobic & anaerobic ability should improve (potential of the CP6-CP8: good aerobic ability) • Breathing might be affected • Fatigue quicker (inefficient movement/asymmetrical movements) • Rest periods important (intermittent training) • Decrease spasticity (stretching) • Difficult to improve the stretch reflex

• PNF & AIS (Active isolated stretching)- good • Passive/Assistive stretching – difficult

‘Abnormal’ Reflex activity 85% of CP1-4 and 50% CP5-8 are affected. Exaggerated (hyperactive) stretch reflexes ‘Normal’ function of the stretch reflex is to prevent injury (muscles &/joints). CP (ataxia) stretch reflex is triggered throughout any movements performed, results in inaccurate and jerky movements. This can be detrimental to sports performance and general movement, gradual stretching before competition (don’t activate stretch reflex). Retention of primitive reflexes Use of primitive reflexes to enhance performance (HP athletes) may be in conflict with some therapeutic programmes (try eliminate influence of this reflex). a) Asymmetrical Tonic Neck Reflex (ATNR): head is turned to one side =extension of limbs on same side & flexion of limbs on opposite side) b) Symmetrical Tonic Neck Reflex (STNR): head is moved to chest =flexion of arms & extension of legs (normal disappearance at 4-6 months old); CP can control in upright position but not kneeling; w/chair CP use to propel chair c) Grasp reflex: pressure/stimulus to palms/ hyperextended wrist =fingers grasping (appear 1st 4 weeks after birth, fully integrated by 6 months old) d) Positive support reaction: pressure/stimulus to balls of feet =hip, knee extension & foot plantar flexion (normal 3-10 months old); CP affect ambulation, gait, cause lordosis (narrow base of support) e) Crossed extension reflex: movement of one leg reflexively affects other (1 leg flexes =extension in other) f) Tonic Labyrinthine Reflex (TLR): i. Prone: strong flexion of all major joints and inability to overcome (i.e. lift up head, free arms from underneath) ii. Supine: strong extension in all major joints and inability to move out of position (i.e. bring chin/knees to chest) g) Moro and startle reflexes: i. Startle is triggered by loud noises, frights, sudden movements (head flung back, arms & legs spread and come together) ii. Moro results in similar action: babies/CP occurs when head not supported =flop backwards when moved (not normal for adults to retain moro reflex)...