Stanbridge - T4 - Peds - W6 - Pediatric Neurologic and Muscular Disorders
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Questions and Answers

A child with cerebral palsy (CP) is experiencing difficulty with drooling and controlling their tongue. Which secondary condition of CP is MOST likely contributing to these challenges?

  • Vision impairment affecting eye muscle coordination.
  • Spatial awareness impairment leading to neglect of the involved limb.
  • Oral motor dysfunction impacting tongue control and swallowing. (correct)
  • Enamel defects and increased cavities due to dental problems.

A child with cerebral palsy has tight muscles in their legs, limiting their range of motion. An orthopedic surgeon recommends a tenotomy. What is the PRIMARY goal of this surgical intervention?

  • To stabilize a hip dislocation and prevent further subluxation.
  • To correct scoliosis and improve spinal alignment.
  • To reduce spasticity by blocking nerve transmission to the muscles
  • To lengthen or sever tendons, releasing muscle contractures. (correct)

Which of the following BEST describes the PRIMARY mechanism of action of Botulinum toxin (Botox) injections in managing spasticity associated with cerebral palsy?

  • Blocking nerve transmission to spastic muscles, causing temporary paralysis. (correct)
  • Selectively stripping the myelin sheath of motor nerves to reduce nerve conduction velocity.
  • Increasing the reuptake of neurotransmitters to reduce nerve excitability
  • Enhancing the effects of GABA, an inhibitory neurotransmitter, in the central nervous system

A patient with cerebral palsy is prescribed oral Baclofen to manage spasticity. What is an important consideration regarding the administration of oral Baclofen?

<p>Higher doses of oral Baclofen are needed because it does not easily cross the blood-brain barrier. (D)</p> Signup and view all the answers

What is the MAIN advantage of intrathecal Baclofen pump (ITB) therapy over oral Baclofen in managing spasticity in cerebral palsy?

<p>ITB allows for lower doses of Baclofen to be delivered directly to the cerebrospinal fluid, minimizing systemic side effects. (A)</p> Signup and view all the answers

Which medication requires frequent blood tests to monitor drug levels and potential side effects?

<p>Phenytoin (Dilantin) (B)</p> Signup and view all the answers

What is the PRIMARY purpose of Selective Dorsal Rhizotomy (SDR) in the management of cerebral palsy?

<p>To reduce spasticity by selectively cutting sensory nerve fibers in the spinal cord. (A)</p> Signup and view all the answers

A child with CP is experiencing frequent seizures. According to the information provided, which class of medications would be MOST appropriate to manage this condition?

<p>Anticonvulsants (D)</p> Signup and view all the answers

Which of the following strategies is MOST appropriate for a physical therapist working with a child with TBI to manage behavioral issues?

<p>Carefully and repeatedly explaining rewards and consequences. (C)</p> Signup and view all the answers

What is the primary reason that children are more susceptible to injury in Shaken Baby Syndrome (SBS) compared to adults?

<p>Children have proportionally larger heads and weaker neck muscles. (D)</p> Signup and view all the answers

A physical therapist is treating a child diagnosed with SBS. Which long-term issue is MOST likely to be encountered during treatment?

<p>Motor and cognitive deficits (C)</p> Signup and view all the answers

Which of the following scenarios represents a condition under which Shaken Baby Syndrome (SBS) is MOST likely to occur?

<p>A caregiver becoming frustrated with a crying infant. (D)</p> Signup and view all the answers

What is the MOST important role of a physical therapist/physical therapist assistant (PT/PTA) in preventing Shaken Baby Syndrome (SBS)?

<p>Educating parents about the dangers of shaking infants. (C)</p> Signup and view all the answers

During the examination and evaluation phase of physical therapy management, which of the following would provide the MOST relevant information regarding a child's developmental progress?

<p>Prenatal and postnatal history. (D)</p> Signup and view all the answers

A physical therapist is determining a prognosis for a child with motor delays. What is the PRIMARY factor in establishing a relevant and achievable prognosis?

<p>Identified limitations and impairments. (D)</p> Signup and view all the answers

Which of the following exemplifies embedding therapy into a family’s routine with a child who has Cerebral Palsy?

<p>Performing stretches during diaper changes. (C)</p> Signup and view all the answers

What is the MOST important goal of physical therapy intervention for children with Cerebral Palsy?

<p>Minimize disability and promote community integration. (B)</p> Signup and view all the answers

Which intervention strategy would be MOST appropriate for addressing increased tone in a child diagnosed with Cerebral Palsy?

<p>Tone reduction techniques. (C)</p> Signup and view all the answers

A physical therapist is selecting mobility equipment for a child with Cerebral Palsy. What PRIMARY consideration guides the equipment selection process?

<p>Promoting functional motor skills and mobility. (D)</p> Signup and view all the answers

As part of their role, what is the physical therapist assistant's (PTA) MOST important action when reviewing a physical therapy evaluation written by the supervising PT?

<p>Reviewing the established goals. (A)</p> Signup and view all the answers

During a home visit, a PTA identifies several potential hazards that could impede a child's mobility. What is the PTA's MOST important responsibility?

<p>Identifying barriers and recommending modifications to make environment more accessible. (A)</p> Signup and view all the answers

When Child Protective Services (CPS) receives reports about a child's welfare, what is the primary reason for initiating an investigation?

<p>To determine if the child has been, or is at risk of being, harmed. (A)</p> Signup and view all the answers

According to the Rancho Los Amigos Levels of Cognitive Functioning, which of the following best describes level II recovery for TBI?

<p>Generalized response to pain. (A)</p> Signup and view all the answers

In the context of traumatic brain injury, when does an acceleration-dependent injury occur?

<p>When there is a sudden change in velocity, causing the brain to move within the skull. (A)</p> Signup and view all the answers

Which of the following is the hallmark sign most indicative of Shaken Baby Syndrome (SBS)?

<p>Subdural and retinal hemorrhages seen on CT scan with no signs of external abuse. (A)</p> Signup and view all the answers

In California, which of the following groups are mandated reporters of child abuse?

<p>Doctors, elementary school teachers, and many others. (C)</p> Signup and view all the answers

What is the primary focus of Chapter 8, as indicated by the learning objectives?

<p>Exploring the etiology and intervention techniques of rheumatic disorders, specifically juvenile arthritis. (C)</p> Signup and view all the answers

A physical therapist is evaluating a child with juvenile arthritis. Which intervention technique would be most appropriate to address joint stiffness and maintain range of motion?

<p>Gentle range-of-motion exercises and low-impact activities to promote joint mobility. (A)</p> Signup and view all the answers

A child with TBI at level II on the Rancho Los Amigos scale exhibits generalized responses to stimuli. Which intervention would be MOST appropriate?

<p>Providing sensory stimulation to elicit basic responses and increase awareness. (C)</p> Signup and view all the answers

The SAFE PLAY Act emphasizes the importance of concussion management plans in schools. What is the PRIMARY goal of these plans?

<p>To educate students, parents, and school staff on concussion prevention, recognition, and response. (D)</p> Signup and view all the answers

According to the CDC's guidelines for managing pediatric concussions, what is the FIRST step that should be taken if a concussion is suspected?

<p>Immediately remove the child/adolescent from play. (C)</p> Signup and view all the answers

What is the purpose of using the Child SCAT3 or SCAT3 tools when assessing a child or adolescent suspected of having a concussion?

<p>To provide a standardized measure of concussion severity appropriate for different age groups. (A)</p> Signup and view all the answers

Following a concussion, a child is recommended to rest physically and cognitively. What is the TYPICAL duration advised for this initial rest period post-injury?

<p>24-48 hours. (D)</p> Signup and view all the answers

A physical therapist is educating a family about what to expect during their child’s concussion recovery. What key information should be included?

<p>Strategies for managing headaches and guidelines for physical/cognitive activity. (B)</p> Signup and view all the answers

If a child is symptom-free within 72 hours after a concussion, what is the recommended approach for their return to academic activities?

<p>Gradual return to academic-related activities. (C)</p> Signup and view all the answers

What should be considered if a child remains symptomatic more than 7 days post-concussion?

<p>Accommodations may need to be set for the child, such as developing a return-to-learn program. (D)</p> Signup and view all the answers

The Glasgow Coma Scale (GCS) is used in emergency rooms to assess the severity of a TBI. What three areas of function does the GCS evaluate?

<p>Eye opening, motor response, and verbal response. (A)</p> Signup and view all the answers

According to the Glasgow Coma Scale (GCS), what score range indicates a moderate traumatic brain injury (TBI) in a child?

<p>9-12 (B)</p> Signup and view all the answers

Which of the following is MOST indicative of a moderate to severe TBI?

<p>Partial or total impairments in cognition, memory, and motor function. (A)</p> Signup and view all the answers

Which of the following physical impairments is MOST commonly associated with traumatic brain injury (TBI)?

<p>Impaired motor planning and coordination. (A)</p> Signup and view all the answers

Vision deficits, impaired balance and the possibility of seizure activity are clinical signs of TBI. What other clinical sign can PT/PTAs educate a patient on during assessment?

<p>Risk of developing heterotopic ossification (HO). (D)</p> Signup and view all the answers

After a child with a TBI is medically stable, what is the NEXT step in their rehabilitation process?

<p>Inpatient rehabilitation. (B)</p> Signup and view all the answers

Why is it essential to educate the family and child on the risks and complications of re-injury following a concussion?

<p>To ensure they avoid the risks and understand how to prevent further harm. (B)</p> Signup and view all the answers

What is the MOST important reason to monitor a child for changes in status or evolving symptoms after a suspected concussion?

<p>To detect any deterioration that may require immediate medical intervention. (D)</p> Signup and view all the answers

A child with juvenile rheumatoid arthritis (JRA) presents with limited extension of the left knee. What secondary factor of JRA is most likely contributing to this limitation?

<p>Flexion contracture. (D)</p> Signup and view all the answers

Which of the following clinical signs is most indicative of systemic JRA rather than other subtypes?

<p>High-spiking fevers and rash. (B)</p> Signup and view all the answers

What is the primary mechanism by which chronic hyperemia in an inflamed joint contributes to skeletal overgrowth in a child with JRA?

<p>It accelerates maturation of epiphyseal plates. (A)</p> Signup and view all the answers

A patient with JRA exhibits valgus deformity in both knees, resulting in a leg length discrepancy. Which long-term complication is most likely to arise due to these skeletal deformities?

<p>Compensatory gait patterns and potential hip or back pain (C)</p> Signup and view all the answers

In polyarticular JRA, what is a distinctive characteristic regarding joint involvement?

<p>It tends to affect the same joints on both sides of the body. (C)</p> Signup and view all the answers

What observation about the prevalence of polyarticular JRA is accurate based on the provided information?

<p>It affects girls three times as often as boys. (B)</p> Signup and view all the answers

A child is diagnosed with JRA and presents with limitations in hip mobility. How might this specifically impact their gait?

<p>Compensatory pelvic tilt and trunk movement (D)</p> Signup and view all the answers

A child with JRA is experiencing accelerated maturation of epiphyseal plates due to chronic inflammation. What potential outcome should be monitored closely?

<p>Premature epiphyseal closure and stunted growth (A)</p> Signup and view all the answers

Flashcards

CP Vision Impairments

Reduced coordination of eye muscles, potentially leading to strabismus.

CP Orthopedic Issues

Deformities like contractures, scoliosis, equinovarus, and hip subluxation common in CP.

CP Dental Problems

Enamel defects and increased susceptibility to cavities common in CP patients.

CP Oral Motor Dysfunction

Impairment affecting tongue control, eating, swallowing, speech, and secretion management.

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CP Medical Management

Team of specialists (Optometrist, PT, OT, speech therapist, orthopedic surgeon)

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CP Pharmaceutical Intervention

Medications help reduce muscle tone, control seizures, and manage reflux in CP patients.

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Hypertonia Reduction Meds

Baclofen, diazepam, and dantrolene.

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Botulinum Toxin (Botox)

Blocks nerve transmission to spastic muscle.

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Shaken Baby Syndrome (SBS)

Traumatic brain injury in infants due to violent shaking, leading to brain damage, bleeding, and potential death.

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Expectations after TBI

Clear, simple expectations tailored to the child's cognitive level to aid understanding and cooperation.

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TBI Consistent strategies

Consistent schedules, routines, rewards, and consequences to aid children after TBI.

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PT for TBI

Modifying behaviors and emotional responses, adapting to cognitive delays and memory loss.

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SBS: Shaking leads to?

Violent shaking can lead to brain damage, bleeding, and potential death.

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PT Examination & Evaluation

Systematic process including history, chart review, and assessments.

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Diagnosis and Prognosis in PT

Involves finding limitations and impairments to guide therapy planning.

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Interventions for CP (General)

Address impairments, work as a team, and integrate therapy into daily life.

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Embedding Therapy in Routines

Stretching during diaper changes exemplifies embedding therapy into routines.

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Interventions for CP (Specific)

Techniques such as positioning, ROM exercises, and caregiver education.

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PTA's Role: Review

Review written evaluations and patient files for goals and information.

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PTA's Role: Clinical Interventions

ROM exercises, therapeutic exercises and gait training.

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PTA's Role: Identify Barriers

Identifying obstacles at home and suggesting necessary changes.

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Childhelp Phone Number

A phone number to contact Childhelp.

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Child Protective Services (CPS)

Staff that investigate reports of potential harm to children.

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Rancho Los Amigos Levels

A scale measuring cognitive recovery after TBI.

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RLA Level II

Generalized response to pain.

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Acceleration-Dependent Injury

Injury from force applied to a movable head.

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Hallmark signs of SBS

Subdural and retinal hemorrhages with no external signs of abuse.

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Mandated Reporters

Doctors, teachers, and others in contact with children.

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Learning objective.

Identify the types of juvenile arthritis.

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Knee Flexion Contracture

Inability to fully extend the left knee beyond 35 degrees due to a flexion contracture.

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Polyarticular JRA

A type of JRA affecting five or more joints, both large and small.

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RF Antibodies in Polyarticular JRA

Elevated levels of rheumatoid factor antibodies are present in subtype 1 of Polyarticular JRA.

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Bilateral Joint Involvement

Polyarticular JRA affects the same joints on both sides of the body.

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Gender Disparity in Polyarticular JRA

Polyarticular JRA affects three times as many girls as boys.

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Systemic JRA

A type of JRA characterized by high-spiking fevers, rash, and potential internal organ involvement.

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Accelerated Epiphyseal Maturation in JRA

Occurs when chronic hyperemia in an inflamed joint stimulates accelerated maturation of epiphyseal plates causing skeletal overgrowth.

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Valgus Deformity in JRA

Skeletal deformities in both legs resulting in a valgus deformity at the knees leading to leg length discrepancy.

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SAFE PLAY Act

A law promoting concussion management plans in schools to educate students, parents, and staff on prevention, recognition, and response.

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First Step After Suspected Concussion

Immediately remove the child from play if a concussion is suspected.

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Concussion Assessment Tools

Tools such as Child SCAT3 (ages 5-12) or SCAT3 (ages 13+) are used to evaluate a child for a concussion.

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Post-Concussion Medical Care

After a concussion, children should be taken to a healthcare professional or doctor for evaluation.

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Treating Deficits After a Concussion

Physical, cognitive, and neurological deficits observed in a child should be assessed and treated .

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Recommended Rest After a TBI

Physical and cognitive rest for 24-48 hours is recommended after a concussion.

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PT/PTA's Role in TBI Recovery

PT/PTAs educate families on warning signs, activity management, expected recovery, headache management, and risks of re-injury.

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Return to Academics After TBI

The amount of time a child can return to academic activities if they are symptom-free following a TBI.

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Glasgow Coma Scale (GCS)

Used in ERs to rate the severity of a brain injury based on eye-opening, motor response, and verbal response.

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Severe TBI GCS Score

A score of 3-8 indicates severe injury.

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Moderate TBI GCS Score

A score of 9-12 indicates moderate injury.

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Mild TBI GCS Score

A score of 13-15 indicates mild injury.

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Impairments of Moderate to Severe TBI

Impairments in cognition, memory, language, psychosocial behavior, sensory abilities, and motor function.

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Physical Impairments of TBI

Limitations in mobility, impaired motor planning and coordination, impaired strength and ROM.

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Sensory & Safety Impairments After TBI

Vision/hearing deficits, impaired proprioception, impaired balance, decreased safety awareness, and seizure activity.

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Study Notes

Pediatric Neurological and Muscular Disorders

  • Pediatric neurological and muscular disorders include cerebral palsy, pediatric traumatic brain injury, shaken baby syndrome, rheumatic disorders, and Erb's palsy.

Cerebral Palsy (CP)

  • Cerebral Palsy (CP) is covered within Chapter 5.
  • PTA Guide Pattern 5C is impaired motor function and sensory integrity associated with non-progressive disorders of the CNS.
  • CP is a broad term describing chronic conditions affecting posture and movement control.
  • It is a permanent, non-progressive neurological disorder.
  • CP results from faulty development, injury, or damage to motor areas of the brain.
  • Early signs of CP typically appear before age 3.

CP Pathology

  • Congenital CP is caused by a permanent brain insult during prenatal, perinatal, or postnatal periods.
  • Premature births and low birth weights increase the risk of CP.
  • Congenital CP can arise from various conditions, including:
    • Infections during pregnancy (CMV, rubella) damaging the developing fetus's CNS.
    • Severe, untreated neonatal hyperbilirubinemia leading to brain damage and athetoid CP.
    • Rh incompatibility causing the mother's immune cells to attack the fetus, resulting in jaundice.
    • Hypoxic ischemic encephalopathy due to lack of oxygen to the brain.
    • Stroke or hemorrhage in the fetus, with premature infants at higher risk.
    • Toxicity from drug or alcohol abuse during pregnancy.
    • Kidney infections and UTI's in the mother leading to brain damage in the infant.
    • Multiple pregnancies (twins, triplets, or more) at higher risk.
  • Acquired Cerebral Palsy results from brain damage within the first months or years of life and can result from:
    • Brain infections like encephalitis or meningitis.
    • Head trauma or injury from falls, auto accidents, or child abuse.

CP Classification

  • The 3 different classification systems for CP include:
    • Quality/severity of muscle tone and movement.
    • Pattern of motor impairment or involvement.
    • Gross Motor Functional Classification System.

CP Classification: Muscle Tone

  • Classification is based on quality/severity of muscle tone and movement.
  • Muscle tone is the resistance to movement in a muscle, reflecting underlying tension, similar to a rubber band.
  • Muscle tone maintains body posture and allows movement through changes.
  • Tone in different muscle groups must be balanced for smooth movement; for example, flexing the arm requires increased tone in the biceps and decreased tone in the triceps.
  • CP is classified into different types based on muscle tone:
    • Spastic CP.
    • Hypotonic CP.
    • Athetoid CP.
    • Ataxic CP.

Types of Muscle Tone in CP

  • Spastic CP involves hypertonia, increased resistance to passive stretch (velocity-dependent), and abnormal neurologic reflexes including clonus and hyperactive DTR, leading to contractures and abnormal posturing. Spasticity is a hallmark of CP.
  • Hypotonic CP presents with poorly defined muscles, decreased responses to DTR, hypermobile joints, floppy limbs, head lag, and easy fatigue.
  • Athetoid CP (dyskinetic) involves fluctuating tone, writhing movements, stiffening, and abnormal postures resulting in dystonia.
  • Ataxic CP presents with poor balance and coordination, jerky movements, and a gait pattern with a wide base of support, mimicking a drunken gait.

Modified Ashworth Scale

  • The Modified Ashworth Scale quantitatively measures muscle tone, ranging from 0 (no increase) to 4 (affected part(s) rigid in flexion or extension).

CP Classification: Motor Involvement

  • Plegia is used to designate whether four limbs, two limbs, one limb, or half the body is affected
  • Hemiparesis/hemiplegia affects one arm and one leg on the same side.
  • Tetraparesis (quadriplegia) involves all four extremities.
  • Diplegia involves both lower extremities with little or no upper extremity involvement.
  • Triplegia affects both lower extremities and one upper extremity or both upper extremities with one lower extremity.
  • Monoplegia affects only one limb, usually an arm.

CP Classification: Gross Motor Function

  • GMFCS categorizes the degree of severity or functional capability
  • GMFCS provides a qualitative, objective measure of motor prognosis based on categorized levels, from one to five, that depend on child's skills and not age.

Clinical Signs of CP

  • Clinical manifestations may change as the child grows.
  • Many children with CP have normal intelligence, but face difficulties with motor control or movement.
  • CP may manifest as mild clumsiness or awkwardness, or severe inability to walk.
  • Common clinical signs of CP include:
    • Difficulty maintaining normal posture.
    • Decreased coordination.
    • Affected muscle tone.
    • Difficulty with speech/drooling.
    • Difficulty with fine motor tasks.
    • Involuntary movements.
    • Gross motor delays.
    • Decreased balance skills.
    • Influence of tonic reflexes that hamper development and affect tone
  • Influence of Tonic Reflexes:
    • ATNR predisposes scoliosis and, in extreme cases, hip dislocation on the flexed side, preventing rolling and crossing the midline
    • STNR may cause the child to bunny hop on hands and knees due to limited ability to get into quadruped and creep on all fours
    • TLR increases flexor tone in prone and increased extensor tone in supine, impairing the infant's ability to develop anti-gravity motion.
  • Common Warning Signs of Cerebral Palsy:
    • Over 2 months: Head lags with pull to sit, muscles or joint movement feels stiff, generally feels floppy, hypotonic, or joints are hypermobile extensor tendencies: the child seems to overextend the back and neck, constantly acts as if pushing away when held, legs may get stiff and cross when picked up.
    • Over 6 months: Continues to have the asymmetric tonic neck reflex and reaches out with one hand while the other remains fisted.
    • Over 10 months: Crawls in a lopsided manner, pushing off with one hand and leg while dragging the opposite hand and leg, scoots on buttocks or hops on knees but does not crawl on all fours.

Secondary Conditions Associated with Cerebral Palsy

  • About 1 in 3 children with CP will develop a seizure disorder.
  • Cognitive/Intellectual Impairment- Approximately 30% of children with CP have issues with this.
  • Vision impairments- Decrease coordination of eye muscles, strabismus, and visual perceptual problems.
  • Orthopedic issues- contractures, scoliosis, equinovarus, and hip subluxation.
  • Dental problems- enamel defects, and more cavities.
  • Hearing loss- Complete or partial.
  • Oral motor dysfunction- Tongue control, eating, swallowing, babbling, talking, difficulty handling secretions (drooling).
  • Spatial awareness impairment- Kinesthesia and proprioception issues including neglect of involved limb.

Management of CP

  • Medical management involves a multidisciplinary approach, including optometrists, PTs, OTs, speech therapists, and orthopedic surgeons.
  • Pharmaceutical intervention includes medications to decrease tone, control seizures, and manage reflux.
  • Surgical intervention may involve gastric tube placement, baclofen pump insertion, selective dorsal rhizotomy, or correction/prevention of orthopedic deformities such as contractures, hip dislocation/subluxation, and scoliosis.
  • Medications used for CP include:
    • For reduction of hypertonia/spasticity: Baclofen, diazepam, and dantrolene.
    • Botulinum toxin injections blocks nerve transmission to spastic muscles.
    • Phenol injections strips myelin
  • For seizure disorders: Phenobarbital, phenytoin (Dilantin) or Tegretol, Depakote, or Zarontin
  • Intrathecal baclofen preferred method due to no side affects
    • Smaller doses can produce same effect
    • Delivered directly to cerebrospinal canal -Administers a constant flow of medicine -Implanted under subcutaneous fat in abdomen
  • In selective dorsal rhizotomy, Peacock et al. (1987) began advocating the use of this procedure in which dorsal roots in the spinal cord are identified by electromyographic response.
    • Dorsal roots are selectively cut to decrease synaptic, afferent activity to decrease spasticity
    • The patient requires intense physical therapy to maximize strength, range of motion, and functional skills post-operatively.
    • Ideal candidates for Selective posterior or dorsal rhizotomy (SDR) are children with spastic diplegia or hemiplegia with moderate motor control and an IQ of 70 or above.
    • Physical therapy reduces the risk of weakness/incoordination once spasticity is gone.

Physical Management of CP

  • Examination and evaluation should include history, social history, prenatal and postnatal history, developmental milestones, standardized testing, clinical observations, assessment of primitive reflexes and postural reactions.
  • Diagnosis and prognosis: limitations and impairments will aid in establishing and determining the prognosis.
  • Interventions for CP:
  • Addressing identified impairments and functional limitations.
    • Working as a team is essential
    • The family should incorporate home integration/therapy into their daily routines.
    • Limit or minimize disability in the community.
    • Tone reduction, positioning, ROM and strength and handling techniques.
  • Wheelchair prescription and mobility training.
  • Educators should train the caregivers/parents
  • Recommendations should help modify any barriers to create a more accessible environmen

The PTA's Role

  • Review the written PT Evaluation including the goals established.
  • Review other pertinent and applicable information in the patient's file/chart.
  • Clinical interventions, such as ROM, ther-ex, SI, gait training, positions to reduce tone, caregiver/parent education or training should be used.
  • Identify barriers and recommend home modifications, if needed.
  • Provide verbal feedback to the PT and to document accurately.
  • Gross Motor Functional Classification System Level I is the highest functioning level for an infant or child.

Pediatric Traumatic Brain Injury (TBI)

  • Pediatric TBI is covered within chapter 6
  • PTA Guide Pattern 5C is impaired motor function and sensory integrity associated with non-progressive disorders of the CNS.
  • It is classified as a "traumatically induced physiologic disruption of brain functioning, resulting in partial or total impairments of areas of functioning.
  • In the US, it is the leading cause of death and injury-related disabilities among children and young adults
  • Mechanisms of Injury include MVA with or without a car seat, MVA vs pedestrian , sports injuries, anoxia, seizure disorders, SBS, CVA, tumors/neoplasms, near drowning, infections, and hydrocephalus.
  • Primary injuries: are related to the forces that occur at the time of the initial impact; they can be grouped by the acceleration factors: -Acceleration-dependent injuries happens when a force if applied to a movable head and may be rotational or translational nature. -Translational injury causes lateral movement of both skull and the brain in response to a force applied to the side of the skull -Rotational injury- when the brain remains stationary on a moving, rotating skull
    • Coup injury- Occurs at point of impact and when the brain strikes the skull
    • Contrecoup Injuries occurs when the brain strikes the skull

What Are the Clinical Signs of a TBI?

  • Secondary injuries include scalp injuries, skull fractures, cerebral edema, epidural/acute subdural hematomas and increased ICP, as well as subarachnoid hemorrhages.
  • Mild TBI: Defined by any period of loss of consciousness of 30 mins or less, any loss of memory for events before or after the accident, altered mental status at the time of the accident, any focal neurological deficit of 30 mins or less and a GCS score of 13-15 after 30 mins, or posttraumatic amnesia of no more than 24 hours and concussions are mild TBIs.
    • Mild TBI: The symptoms are divided into early-appearing signs and symptoms including headaches as well as nausea and vomiting and late-appearing signs and symptoms which happen days after including slowed or impaired information processing.
  • Moderate TBI: Loss of consciousness and/or posttraumatic amnesia of greater than 30 minutes but less than 24 hours.
  • Severe TBI: Loss of consciousness and post traumatic amnesia lasting greater than 24 hours a GCS score of less than 8.
  • Common impairments with both moderate and severe brain injuries include the physical, cognitive, sensory, speech, language, personality, and behavioral domains.

Mild TBI in Pediatrics

  • Information regarding concussion and mild TBI is found on the APT APTA and the CDC websites
  • The CDC estimates nearly 3.8 million incidences of sports-related concussions occur every year
  • Assessment should include treatment of any physical, cognitive, and neurological deficits.
  • If a concussion is suspected in a pédiatrie athlete:
    • Remove child from play immediately (coach/parent need to now the signs)
    • Assess and treat any physical, cognitive and neurological deficits Various assessment tools used are CT scans, Various tools used (i.e., ACE- acute concussion evaluation), There is potential need for admission to hospital for Monitoring.
  • The injured person needs to rest.
    • Physical and cognitive rest is recommend for 24-48 hr period.
    • Child can be discharged from ER or hospital
  • The child needs to take education to parents caregiver for home care.
  • Physical Therapists need to provide education of:
    • The importance of PT/PTA to educate family and child around what to look for during recovery.
    • How to identify and recognize warning signs.
    • How to ensure activities are physical and cognitive activity is maintained and manage appropriately.
    • Expected course of recovery and return to learn/play
    • Guidelines for headache management -The child need to recognize that significant difficulties should not persist past 1-3 months with re-injury risks identified.
  • The child show recommendations for returning back to school/play. -The injured can be permitted to return to academic activities or play with in 72hours of with no symptoms of injury. -If the child reports that after 7 day of injury symptoms continue the child may need to modify school to a return to learn program.

Rancho Los Amigos Levels of Cognitive Functioning

  • The Glasgow Coma Scale and is the most common scoring system used to describe the level of consciousness it is based on motor, verbal and eye opening ability.
  • A score of 3 indicates a severe TBI while a score of 15 indicates a mild TBI
  • A Level 1 corresponds to no response, level 2 corresponds to a generalized response, while a level 3 is a localized response to light or sound. -With each increase in level come increased independence to respond appropriately to the environment
  • Intervention:
    • coma stimulation can be initiated to increase arousal as appropriate -Increase attention and following of simple one-step commands -increase eye contact upon request
    • increase activation of trunk and extremity musculature with purpose and intention of movement Need to avoid overstimulation

Physical Therapy Treatment:

  • Kinesthetic and proprioceptive awareness, positioning, splinting or application of orthotics may help patients with TBIs.
  • The team (including involved family and caregivers) will utilize sensory integration techniques and mobility training, balance training, and safety activities to support progress.
  • It is critical to maximize independence by incorporating functional mobility training, self-care activities, and community activities into the plan to ensure patient and family support and reintegration. Adaptations for cognitive delays and memory loss may also help maximize success.
  • Postural issues, maladaptive patterns, and abnormal tone or synergies, should be addressed re-education of developmental motor skills appropriate for infant/child's age.

Shaken Baby Syndrome (SBS)

  • Shaken baby syndrome is chapter 7
  • It is a non-accidental TBI
  • Is considered a form of abuse, where the brain is shaken back and forth inside the skull.
  • The resulting acceleration and deceleration creates damage to the circulatory structures leading to bleeds.
  • Hallmark signs- subdural and retinal hemorrhages, accompanied by the absence of signs of external abuse.
    • The child might be pale or suffer convulsion/seizure, be irritable, sleepiness or lethargy .
    • The physician assess and check for airway, breathing, and circulations is working as expected and is going to be monitored closely the is child stabilize with medications then monitored more frequently.
  • It is can be diagnosed wit MRI or CT scan and can lead to death or severe injury
    • The physician has a deep evaluation of the child is neurology or injuries.

PT/PTA Assessment and Intervention

  • PT/PTA's may encounter these patients in the acute phase for post traumatic intervention followed by rehabilitation and continued services throughout their lifespan.
  • PT/PTA's must be familiar with the signs. aerobic capacity and endurance, posture, arousal, assist, device, cranial integrity , gait balance, motor development, ventilation, skin integrity, ROM, muscle sensory and self care.
  • Intervention: A PTA/PT will offer a therapy plan which consist of Rom exercise, positioning or splint, managing abdominal tones and promoting improve mobility .

Mandated Reporter

  • California Professionals Required to Report: Penal Code § 11165.7 Mandated reporters include the following: Firefighters and police officers, Teachers and school district administrators,All healthcare professionals nurses, physicians, PT/PTAS (including PTA students), social workers, psychologists, clergy, athletic coaches, foster parents,

Rhumatic Disorder

  • Juvenile Rheumatoid Arthritis is marked by joint information and stiffness for more than six weeks in childless than -The body mistakenly attacks own tissue but it is not known why so many. There are 3 types.
  • pauciarticular which affects 4 or fewer joints .risk fore iridicylitis, usually affects lare joints and it affects 5 times as likely for girls then boys.
  • Polyarticular if affects 5 or more joints as well and this usually affects joints on both sides of the body. This effects three time more girls than boys, high rhematiod factors is usually present as well/ Systemic JRA: still's diesiese/
  • There is joint involvement in the skin In the end these children can suffer skeleta abnormities like lemg length discrepancy. Apophyseal joint disease and scoliosis. They can have a difficy developning there mandlbula which affect feeding and speech. Joint protection strategies

Brachial Plex Birth injuries

  • In1-2 babies born every 1,000 according to AAOS. Caused if infants neck is streched
  • Signs and symptom
  • The child usually with the loss of motor / sensory functions with loss of motion as ivel they are not able to use there elbows or forearms. Change position with extremities turn with flexing of hand a "waiter" tips. Physical can help with APROM weight shifting, develop milestone, and technique. The child will be require to be in a splint. it can take up 2 years to regrow damage neurons but the child should improve with these types of injuries

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