Cerebral Palsy Muscle Performance Quiz

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Questions and Answers

What is a characteristic feature of muscle performance in children with cerebral palsy?

Increased joint flexibility

Decreased ability to generate force (correct)

Decreased energy consumption

Increased ability to generate force

Which of the following is NOT a common problem associated with children who have cerebral palsy?

Hip dislocation

Increased joint mobility (correct)

Skeletal deformities

Muscle contractures

According to Wolff's Law, what occurs when there is increased loading on a bone?

The bone becomes less responsive to stress

The bone decreases in strength over time

The bone loses its structural integrity

The bone will remodel itself to become stronger (correct)

What is the term for the muscle imbalance seen in the ankle plantar flexor and dorsiflexor muscles in children with spastic type cerebral palsy?

Dynamic imbalance Signup and view all the answers

What is the typical walking pattern of children with cerebral palsy compared to their peers without cerebral palsy?

Walks later and with a higher energy cost Signup and view all the answers

What is equinus deformity primarily characterized by?

Plantar flexion malalignment of the hindfoot relative to the ankle Signup and view all the answers

Which foot deformity is the second most common in patients with cerebral palsy (CP)?

Equinoplanovalgus deformity Signup and view all the answers

What does a positive Silfverskiold Test indicate when dorsiflexion increases with the knee flexed?

Tightness in the gastrocnemius muscle Signup and view all the answers

At what age does fixed contracture begin to develop in children with equinus deformity?

6-7 years Signup and view all the answers

Which muscle is primarily indicated if dorsiflexion does not change during the Silfverskiold Test?

Soleus Signup and view all the answers

What condition is indicated by bilaterally adapting to tiptoe walking?

Equinus walking Signup and view all the answers

What factors contribute to gait disorders in patients with CP?

Weak hip abductors Signup and view all the answers

Which of the following is NOT a typical developmental stress that influences normal bone growth?

Movement variation Signup and view all the answers

What is a primary use of Dynamic Ankle-Foot Orthoses (DAFO)?

Provide medial-lateral ankle stability Signup and view all the answers

Which of the following is a characteristic of Knee-Ankle-Foot Orthoses (KAFO)?

Prevents knee hyperextension Signup and view all the answers

What is a disadvantage of using Hip-Knee-Ankle-Foot Orthoses (HKAFO) for ambulatory children?

They are bulky and difficult to manage Signup and view all the answers

What is the main purpose of a Gait Trainer?

To increase activity and participation in children at GMFCS levels 4-5 Signup and view all the answers

What is the primary function of the Hart Walker?

Aid in independent, hands-free walking Signup and view all the answers

Which device helps in improving sitting stability by increasing the base of support?

Hyperabduction Device Signup and view all the answers

What is a key feature of Upper Extremity Orthoses?

They help in contracture formation prevention Signup and view all the answers

Which statement is true about orthopedic boots?

They can cause abrasion due to equinus deformity within a short period Signup and view all the answers

What is a primary purpose of the Solid AFO (SAFO)?

To increase stability in the midstance phase Signup and view all the answers

In which condition is an articulated AFO most appropriate?

For children with controlled spasticity who can walk with a walker Signup and view all the answers

What limitation is associated with the Solid AFO?

It does not allow any ankle movement Signup and view all the answers

What is the function of the Ground Reaction AFO (GRAFO)?

To create extensor momentum during stance Signup and view all the answers

When should Ground Reaction AFO be used?

For children with crouch gait Signup and view all the answers

What is one contraindication for using an articulated AFO?

Passive dorsiflexion is less than 5 degrees Signup and view all the answers

Which AFO type allows for passive dorsiflexion during the stance phase?

Reflex AFO Signup and view all the answers

What is a consequence of knee hyperextension in children with PF spasticity?

Development of genu recurvatum Signup and view all the answers

What is a common purpose of orthoses in relation to contractures?

To control hypotonia Signup and view all the answers

Which of the following characteristics accurately describes rigid orthoses?

Prepared individually with materials like polyethylene and carbon Signup and view all the answers

Inframalleolar orthoses are specifically used to manage which condition?

Moderate pes planovalgus deformity Signup and view all the answers

What condition is indicated for AFO (Ankle Foot Orthoses) use?

Moderate spasticity Signup and view all the answers

Which orthosis can partially control foot movements in the sagittal plane?

Supramalleolar orthoses (SMO) Signup and view all the answers

What is one of the main functions of the Ankle Foot Orthoses (AFO)?

Maintain the ankle in a 90-degree neutral position Signup and view all the answers

What scenario is a contraindication for foot orthoses?

Lack of voluntary dorsiflexion control Signup and view all the answers

What is a potential outcome of using orthoses for a minimum of 6 hours of stretching?

Prevention of contractures Signup and view all the answers

What should be avoided when using orthoses for hand function?

Large orthoses Signup and view all the answers

What is a potential negative effect of orthoses that cover the palmar part of the fingers?

Reduced hand function Signup and view all the answers

What is the purpose of using bilateral orthoses in children with hemiplegia?

To equalize step width and velocity Signup and view all the answers

When treating a child, how should orthoses be chosen?

According to the individual needs of the child Signup and view all the answers

What should be observed in the case of a child with equinus deformity?

Toe-walking during gait analysis Signup and view all the answers

Which gait analysis result is observed in a child with spastic diplegia and hyperflexed knees?

Crouch gait Signup and view all the answers

Which type of orthotic garment improves posture stabilization and functionality?

TheraTogs Signup and view all the answers

What is a common muscle tone characteristic in children with spastic diplegia?

Hypertonicity in the hamstrings Signup and view all the answers

Study Notes

Cerebral Palsy Orthoses

Cerebral palsy (CP) is a group of disorders causing impairments in movement, posture, and muscle tone due to brain damage
CP brain lesions in immature brains are not progressive
CP problems in the MS system are progressive.
Children with CP have an increased chance of developing complications like muscle contractures, skeletal deformities, and hip dislocation/scoliosis
Two-thirds of children with CP walk with or without walking aids.
Children with CP usually start walking later than their peers without CP, walk slower and with higher energy cost.

Musculoskeletal Problems in CP

Progressive joint contractures
Excessive muscle shortness
Torsional deformities in the hip and foot
Transfer and ambulation problems
Inability to generate force
Balance disorder
Decrease in walking speed
Decrease in stride length
Increased energy consumption
Limitations in participation in ADLS

Dynamic Muscle Imbalances

Dynamic imbalance between the calf muscles that control foot and ankle alignment.
Ankle plantar flexor muscles are overactive and ankle dorsiflexor muscles are ineffective.
Variable imbalance patterns exist between foot and ankle supination and pronation muscles.
Three common coupled foot and ankle malalignment patterns observed include equinus, equinoplanovalgus, and equinocavovarus.

Wolff's Law

Bone growth and remodeling depend on loading. If loading increases, bone remodels to become stronger.

Normal Bone Growth vs. CP

Normal bone growth involves typical developmental stresses and weight transfer.
In CP, movement variation is absent. No load is placed on the bone.
Bone and joint deformities are common.

Foot-Ankle Problems in CP

Equinus deformity (most common)
Varus deformity
Planovalgus deformity
Hyperdorsiflexion deformity
In-toeing or out-toeing
Finger problems
Gait disorders leading to inability to walk
Tone abnormalities, muscle imbalances, soft tissue contractures, bone torsion, and joint instability

Factors Causing Gait Disorders in CP

Weak Muscles:
- Tibialis anterior
- Plantar flexors
- Hip extensors
- Hip flexors
- Hip abductors
Spastic Muscles:
- Plantar flexors
- Hip adductors
- Quadriceps
- Hamstrings

Equinus Deformity

The most common foot deformity in individuals with CP.
Characterized by plantar flexion malalignment of the hindfoot in relation to the ankle. Midfoot and forefoot alignment are normal in this condition.
Results from tight calf muscles or Achilles tendons.

Orthosis Timing for CP

At 18–24 months: Walking with equinus
Until ages 4–5: Equinus walking without fixed contracture
By 6–7 years: Fixed contracture begins to develop

Bilateral tiptoe walking can be a compensatory mechanism for hemiparetic cases.

Equinoplanovalgus Deformity

Second most common foot deformity in individuals with CP.
Includes equinus deformity of the hindfoot and pronation deformities in the midfoot and forefoot.

Equinocavovarus Deformity

Includes equinus deformity of the hindfoot and supination deformities in the midfoot and forefoot.

Silfverskiold Test

Used to distinguish accompanying muscle tension and assess the cause for ankle dorsiflexion limitation.
The test is evaluated in knee extension and flexion.
Increased dorsiflexion during knee flexion indicates gastrocnemius muscle tightness.
No change in dorsiflexion during knee position change suggests tightness in deep structures like the soleus muscle or joint capsule.

Crouch Gait

Weakness in the extensor muscles of the lower extremities is a characteristic of this type of gait
Weakness in plantar flexors contributes to the Crouch Gait
Knee extension deficit is evident
Tight or spastic hamstrings
Hip flexion contracture
Iatrogenic gait due to surgeries

Purpose of Orthoses

Prevent deformities and contractures
Control muscle hypotonia and stiffness
Prevent or delay surgery
Support surgery
Provide functionality

Tardieu et al. (1988)

Contractures can be prevented with minimal 6 hours of stretching.

Orthosis Texture Types

Rigid: prepared individually with rehearsal made of materials like polyethylene, carbon, lamination, and metals.
Semi-rigid
Soft: standard sizes prepared by series production. Made from materials like fabric, elastic fabric, and neoprene.

Foot Orthoses:

Improves ground contact.
Not effective in plantarflexion/dorsiflexion control.
Used in planovalgus/planovarus deformities.
Inframalleolar and supramalleolar types are used.

Inframalleolar Orthoses

Doesn’t control sagittal plane movements of the ankle.
Used to control moderate pes planovalgus deformity.

Supramalleolar Orthoses (SMO)

Extends from toes to above the malleoli.
Partially controls foot movements in the sagittal plane.
Treats medio-lateral instability of the subtalar joint, varus/valgus deformity, mild to moderate spasticity.

Foot Orthoses: Indications and Contraindications

Indications: Medio-lateral instability of subtalar joint, midfoot deformity, mild to moderate spasticity
Contraindications: Lack of voluntary dorsiflexion control, lack of heel strike, fixed equinus deformity, moderate to severe spasticity

Ankle-Foot Orthoses (AFOs)

Basic orthosis for children with spastic diplegia.
Used to maintain ankle in 90-degree neutral position.
Prevents drop foot during swing phase.
Ensures appropriate range of motion and functional improvements.
Can indirectly stabilize the knee and hip joints.
Various types exist, prescribed based on specific needs

Solid AFO (SAFO)

Prevents ankle movement.
Covers the entire back of the leg.
Extends from below the fibular head to metatarsal heads.
Used for plantar flexor, invertor or evertor muscle spasticity
Used for mild crouch gait and moderate/severe medio-lateral ankle instabilities
Increases stability in the midstance phase.

Articulated AFO

Contains a joint.
Useful for CP children who have enough stability to walk with a walker.
Prevents plantar flexion by gaining dorsiflexion.
Used for cases where spasticity is under control and the child has selective movements

PF Spasticity and Genu Recurvatum

Plantar flexion spasticity can cause genu recurvatum (knee hyperextension).
A stop in plantar flexion at 2-5 degrees of dorsiflexion can help to control genu recurvatum.
If possible, control the knee joint movements indirectly through the ankle joint. Avoid the usage of KAFO.

Circumduction Gait

The aim and goal of orthosis should be functionality.
Knee joint unable to flex, impacting the quality of walking.
Resulting gait is circumduction.

Contraindications of Articulated AFO

Crouch gait: Does not correct crouched posture with increased dorsiflexion and knee flexion.
Strong extensor posture
Passive dorsiflexion does not reach 5 degrees

Ground Reaction AFO (GRAFO)

Inarticulated orthosis that is a closed version of AFO, from the front.
Prevents tibia from shifting forward during stance.
Creates extensor momentum that typically arises from the quadriceps muscle.
Commonly used in crouch gait

Posterior Leaf Spring AFO

Passes behind the malleolus.
Formed by cutting off edges (from malleoli location) of a solid AFO.
Allows for stretch.
Resists plantar flexion
Allows 10° of passive dorsiflexion in stance phase.
Prevents drop foot in swing phase.

Dynamic AFO (DAFO)

Often used in CP.
Made from flexible, thin thermoplastic material.
Provides medial/lateral ankle stability.
Controls supination and pronation.
Allows for dorsiflexion/plantarflexion.
Thought to reduce abnormal PF movements and inhibit hypertonus.

Orthopedic Boots

Use instead of orthotics? (no)
Does not prevent equinus deformity.

KAFO (Knee-Ankle-Foot Orthoses)

Rare orthosis type
Aims to control knee movements via the ankle joint.
Purpose: Preventing knee hyperextension; Providing knee extension; Helping standing.
Does not provide functional mobility.

Immobilizer

Resting splint for knee extension.

HKAFO (Hip-Knee-Ankle-Foot Orthoses)

Usually for non-ambulatory children
Maintain and increase hip joint range of motion.
Position hip to prevent subluxation and dislocation

HKAFO (Ambulatory Children)

Use for reducing hip hyperadduction in children with scissoring gait or to increase sitting balance.

Hyperabduction Device

Used to improve sitting stability in children with scissor gait.
Hip-abduction orthoses may improve sitting stability by increasing the base of support.

Gait Trainer

For children at GMFCS levels 4-5.
Increases activity and participation.
No severe contracture is present.

Hart Walker

Walking aid for children at GMFCS levels 4-5.
Allows independent walking (hands-free).
Provides external balance support.
Aids participation efforts.

Upper Extremity Orthoses

Used for upper extremity impairments, insufficient to be used solo to resolve issues.
Prevents deformity, development, progression of contractures during and after post-operative rehabilitation.
Used mainly for stabilization, mostly at night, in order to not restrict functionality.
Avoid use on palm/volar area of the fingers, tactile and sensory stimulation to prevent neglect of damaged area.

Spinal Orthoses

Used to support sitting independently.
Thoracolumbosacral type orthoses used
Not effective for scoliosis management

TheraTogs

Flexible, dynamic orthotic garment.
Improves posture stabilization.
Purpose is to correct/prevent deformities and improve functionality.

Symmetrical Approach for Orthoses Selection

Even with hemiplegia, focus on symmetrical weight transfer and support for both sides of the body.
Bilateral orthoses are advised for effective support and gait.

Night-Time Orthosis Use

Do not force orthosis use if it is not tolerated.
Orthosis tolerance issues may spread through the day.

Orthosis Selection Principles

Determine the best type of orthosis based on the individual needs of the child, not just on the disease/condition
Not every orthosis works for all cases

Case Study -1

6-year-old boy with spastic diplegia.
Equinus deformity present in both feet.
Limited ankle dorsiflexion, but increases with knee flexion (Silfverskiold test positive)
Toe-walking, short step length, decreased walking speed, dynamic imbalance.
Tibialis anterior weakness; gastrocnemius spasticity

Case Study -2

7-year-old girl with spastic diplegia.
Hyperflexed knees, fatigue during walking, imbalance when standing, difficulty in long distances.
Crouch gait, constantly flexed knees and increased dorsiflexion in ankles with small hip flexion
Hamstring spasticity, quadriceps weakness.
Forward tibia displacement, causing energy consumption during gait.

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Description

Test your knowledge on muscle performance characteristics and common issues related to children with cerebral palsy. This quiz covers concepts such as Wolff's Law, foot deformities, and specific tests related to muscular imbalances. Gain insights into the unique physical challenges faced by these children.