Hoorcolleges Topics in rehabilitation
Hoorcollege 2 - cerebral palsy
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A non-progressive neurological disorder with progressive musculoskeletal pathology.
TYPES OF CP:
● spastic cerebral palsy (most common)
● dyskinetic CP = (slow and uncontrollable writing or jerky (schokkend) movements)
- Athetoid is part of the 'dyskinetic' form of cerebral palsy' and is characterized
by slow twitching and wriggling (kronkelende) involuntary movements = slow
writing.
- chorea is a characteristic of dyskinetic cerebral palsy marked by brief irregular
and involuntary movements. rapid and sudden movements
● ataxic CP = (balans en diepte perceptie), have poor coordination and unsteady
wide-based walk, tremor, and shaky movements
● mixed types
GROSS MOTOR SEVERITY
❖ level 1: walk, running, climbing stairs
❖ level 2: climbing stairs holding the railing, minimal ability to do gross motor skills like
running and jumping, long-distance and uneven terrain is difficult.
❖ level 3: using a hand-held mobility device, climb stairs using the railing or assistance,
wheelchair for long-distance.
❖ level 4: physical assistance/ powered, manual wheelchair for outdoors.
❖ level 5: manual wheelchair in all settings. are limited to maintain antigravity head and
trunk postures, and control leg and arm movement.
MANUAL ABILITY ISSUES
➢ level 1: limitations in speed and accuracy tasks but does not restrict independence.
➢ level 2: somewhat reduced speed or quality. certain activity may be avoided or be
achieved with some difficulty. does not restrict independence.
➢ level 3: performance is slow with limited success regarding quality and quantity.
activities are performed independently if they have been set up or adapted.
➢ level 4: performs parts with effort and limited success requires continuous support or
adapted equipment for partial achievements.
➢ level 5: requires total assistance
CAUSE AND TIMING
- congenital = most kids are born with it cause of: genetic abnormalities, congenital
brain malformations, maternal (moeder gerelateerd) infection/fevers or fetal injury.
- acquired = after the birth. brain infections, problems with blood flow, head injury, fall,
abuse
- damage to the white matter of the brain (Periventricular leukomalacia= PVL),
between week 26 and 34 of gestation (zwangerschap)
- brain malformation caused by fever, trauma mutations.
- fetal strokes/ blood clots (stolsels)/ weak blood vessels.
- asphyxia: al lack of O2 in the brain caused by an interruption in breathing or poor O2
supply for a length of periods. → destroys the cerebral motor cortex.
,RISK FACTORS
- during pregnancy: multiple births, infections, incompatibility (the blood type of the
baby and the mother are not the same and the body of the mother generates
antibodies that will kill the blood cells of the baby), exposure to toxic substances,
thyroid problems…
- during birth: low birthweight and premature birth, breech presentation (feet first),
vascular or respiratory problems during labor, low Apgar scores (reflexes, muscle
tones, skin color first minutes etc), jaundice (geelzucht), seizure (epilepsie)
SIGNS AND SYMPTOMS
- lack of muscle coordination
- stiffness or tight muscles
- walking on toes
- spasticity
- too floppy muscle tone
- tremors
- difficulty in precise movements
DIAGNOSIS
➢ MRI
➢ cranial ultrasound
➢ CT
➢ electroencephalogram
ACCOMPANYING ISSUES
❏ delayed growth and development
❏ seizure disorder (most common in quadri and hemiparesis)
❏ learning disability
❏ spinal deformities (scoliosis, lordosis etc) and osteoarthritis.
❏ impaired vision (scheel zien)
❏ hearing loss
❏ speech and language disorders
❏ drooling = kwijlen
❏ incontinence
❏ abnormal sensations and perception
❏ infection and long term illness (heart, lung disease)
❏ contractures
❏ malnutrition
❏ dental problems
❏ inactivity
❏ epilepsy
❏ osteopenia (poor bone density)
❏ pain
TREATMENTS
- physio
- occupational
- recreational
- speech and language
, - oral medication (botulinum toxin and baclofen)
- orthopedic surgery
- selective dorsal rhizotomy, to reduce spasticity
ARTIKEL 1 CP AISEN - Cerebral palsy: clinical care and neurological rehabilitation.
The focus of rehabilitation treatment has recently shifted to neurological rehabilitation in
response to increasing evidence for neuroplasticity.
diagnosis on the basis of neurological examination, stable course and the absence of
underlying genetic disorder.
theory: The realization that neurodevelopment continues throughout the patients' lifespan
has led to the theory that intensive, goal-directed rehabilitation therapies would substantially
improve patients' motor function and their inclusion in the community.
causes and prevalence changed over time because of changes in prenatal and pediatric
care
brain abnormalities → important mechanism = inflammation
CP classified according to the nature of the motor impairment revealed by:
- neurological examination (paresis, dystonia, ataxia, dyskinesia, hyper and hypotonia)
- the area of presumed cerebral dysfunction (extrapyramidal = dyskinesia, coordination
deficits and abnormal postural control & pyramidal = spasticity, hypertonia and
overflow reflexes)
- and the parts of the body affected
80% shows neuroimaging abnormalities → most common white matter damage, isolated
grey matter damage is rare and combi = hemiplegie. 20% is niks te zien
markers: cramped synchronised general movements, and the absence of fidgety (onrustig)
or spontaneous movements at 2–4 months of corrected age in high-risk infants who were
born prematurely.
- cognitive deficits (50%)
- visual problems
- communication difficulties
- pain
- constipation
- motor weakness, tone abnormalities
Quality of life in adults with CP is associated with level of education, employment status, and
access to health care
patiënt help programme through life
emphasis is placed on participation by the patient and his or her family in therapeutic
decisions, taking into account their experiences.
Children and adults need comprehensive, coordinated care focused on preventing
complications (malnutrition, skin breakdown, pain) and promoting improved neurological
, function, which could ultimately improve health, quality of life, and access to education and
vocational opportunities. (ideally care should be provided by a constant team that can
assess the 1 en 2 effects of CP)
The maintenance of health in the context of primary and secondary neurological
complications must be a fundamental goal. → by multi team and All the rehabilitation
therapists need to coordinate and regularly communicate their observations to the primary
medical coordinator.
motor thresholds are low at birth but increase during the first 3 months → but a progressively
decline over the first 24 months
This finding implies that some corticospinal connections present at birth are not permanent
and withdrawal during the following 3 months, and that axonal withdrawal and corticospinal
connectivity reorganisation continue until age 2 years.
Early lesions of the motor cortex correlate with different patterns of subsequent nervous
system development. An important difference is the persistence of low thresholds for
inducing ipsilateral motor evoked potentials from the non-lesioned hemisphere while the
threshold for inducing contralateral and ipsilateral motor evoked potentials from the lesioned
hemisphere steadily increases.
competitive withdrawal = loss of connectivity in the lesioned hemisphere leading to the
intact hemisphere gaining control of both sides of the body. this adaptations improve motor
function but in most cases remain abnormalities → this is not optimum
interventions due to plasticity = important:
- Constraint of the unaffected arm, even without additional rehabilitation, can improve
function in the affected arm in children with hemiplegic CP
- training improved bimanual coordination in children aged 5–9 years with hemiplegic
CP
- Body weight-supported treadmill therapy uses intense (speed-focused), task-specific
activity to improve locomotor function.
- robot assisted activity + VR → functional strength and improve isolated movements +
better motivation (VR)
- particularly constraint-induced therapies, will ensure maximum gains in children and
adults.
Hoorcollege 2 - CP 1
normal people have contralateral control: left hemisphere and right hand
bilateral: paretic hand receives from both hemisphere signals
ipsilateral ( left hemisphere a lesion) → the brain can switch the control of the affected hand
to the other hemisphere, it can control both hands.
