Medical Speech Pathology Exam Part II

What Is Cerebral Palsy?  How Is It Treated?  Various Types Of Cerebral Palsy And Their Characteristics. 
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Explain what CP is, using terms like nonprogressive, immature, cerebral, and palsy. [387-388]
a developmental non-progressive neuromuscular disorder caused by damage to the immature brain centers.
Cerebral- brain centered, Palsy- lack of muscle control, Non-progressive- disease doesn’t get worse over time, Immature- not fully developed
About how many children per thousand live births have CP? [388]
Prevalence: 2-2.5 per 1000, about ½ born prematurely
Which conditions cause the neurological damage of Cerebral Palsy? [388-389]
About 40% of CP cases are unknown causes.
Prenatal: Include radiation exposure, or an intrauterine infection, teratogenic drugs (drug-induced), and chromosomal abnormalities
•In later pregnancy-Abruptio Placentia (premature detachment)
Perinatal: factors causing the baby to be born too early
•Complications during labor and delivery-Asphyxia (lack of oxygen due to disrupted blood flow--ischemia--and oxygen supply--hypoxia)
Postnatal: catch an infection as they get delivered
-Virus-Sepsis (such as toxoplasmosis: a parasitic infection)-Complications during labor and delivery-Asphyxia (lack of oxygen)
Which neurologic system(s) get damaged in CP? [389]
-The white matter (the wiring) of the brain in the pathways used for motor control ( Upper Motor Neuron system), and thus deficient neural connections (gray matter, the connections for the wires).
-The UMN system is not in a single place in the brain but is several inter-connected brain centers. It's made up of the pyramidal tract of cortico-spinal nerve cells and the extrapyramidal system. The pyramidal neurons link the cortical motor strip on the pre-central gyrus with the nuclei (nerve cell junctions) of the lower motor neurons, the nerve cells connecting with the muscles. They directly control movement (by sending messages to the nerves that cause muscle cells to fire), set muscle tone, and integrate or override reflexes.
What are positive and negative signs in CP diagnosis? [389]
Positive: Refer to the presence of atypical neuromotor features, such as increased or decreased muscle tone, atypical reflex patterns, and involuntary movements.
Negative:Absent or deficient neuromotor functions, including poor motor control, poor balance, weakness, and easy fatigability.
Explain spasticity and the ATNR.[389-391]
Spasticity: A group of neuromotor signs that are seen in association with disturbances in the pyramidal component of the motor control system.
- If the UMN doesn’t inhibit the spinal reflex, we get spastic hypertonicity (muscle tone) and exaggerated reflex responses. Controlled muscle action relies on agonist-antagonist relations. When you move a limb muscle, the agonist, the muscle on the other side of the bone, the antagonist, is stretched. This stretch-detection message is sent to the spinal cord and passed to neurons which then fire to cause antagonist muscle cells to contract, to give a measured, calibrated, controlled action. This is called the stretch reflex. However, when there is spasticity, the stretch reflex—the reaction of the antagonist muscle – over-reacts. Thus when the person tries to extend a limb, there is an over-reactive flexion of the limb. This pattern of over-reaction is called spasticity.

ATNR (Asymmetric tonic neck reflex): As the head is turned to one side, arm and leg on that side extend, arm and leg on the other side flex.
Briefly, what are chorea, athetosis, dystonia, and ataxia? [391]
Dyskinesia: Involuntary movements – rapid, random and jerky (called chorea) or slow and writhing (called athetosis) extra mvmts –
Extra paramatel damage: voluntary mvmts.
Chorea – really quick, jerky and random mvmts.
Athetosis: random mvmts. – slow and writhing (twist)
There may be rigid posturing in the trunk and neck (Dystonia). Sometimes movements cannot be controlled in time and direction, leading to gross incoordination, called Ataxia.
What are hemiplegia, paraplegia, and quadriplegia? [393]
Hemiplegia: One side of the body is more affected than the other; usually, the arm is more affected than the leg.
Paraplegia: Both legs are damaged
Quadriplegia: all four limbs and usually the trunk and muscles that control the mouth, tongue, and pharynx are affected.
How many of the people with CP have intellectual impairment? seizures? speech, language, or hearing impairments? [395]
Intellectual Impairment: About 50%
Seizures: About 40%
Hearing, Speech, and Language Impairments: About 30%

Discuss the perceptual disturbances common in CP, such as hyperirritable attention, perceptual rigidity, dissociation, object use, and initiatory delay.
Hyperirritable attention: unable to refrain from reacting to various stimuli; short attention span, restlessness, impulsivity
Perceptual Rigidity: desire to have environment and schedule unchanging
Dissociation: can’t put pieces of a situation together into a whole, separate figure from ground
Object Use: manipulates objects in a stereotyped and more-or-less random fashion
Initiatory Delay: Difficulties in initiating movements, where child may comprehend but not be able to show it for awhile.
Emotional Lability: excessive emotion; autonomic response where we get an over response in terms of emotion that’s not related to their emotion they’re having. It’s a hyperexcitatory response comprised of flushing, incongruous laughing, gagging, crying, etc. You’ll get unrealistic attitude, or excessive fears, lack of motivation, etc.
Discuss the emotional disturbances common in CP such as lability, attitudes, fears, and motivation.
lability- autonomic response compromised of flushing incongruous laughing, gagging etc.
attitudes- unrealistic
motivation-lack of
About what percent of people with CP become self-supporting? in sheltered workshops? partially independent & at home? fully dependent? [405]
Self Supporting-10%
In Sheltered workshops-40%
Partially independent & at home-35%
Fully dependent-15%
Nowadays, what helpful thing can drugs do for a person with CP (regarding spasticity, and how it works)? [401]
Muscle Relaxation- Valium( Used to tone down CNS and indirect muscle relaxation)
Baclofen and dantrium- reduce spasticity by acting on muscle fibers and neuromuscular junction
*Some success has been seen by implanting drug delivery pumps, which can administer a smaller but more effective dose of baclofen without the side-effects of a larger dose.
What is a neurolytic procedure and how do they work to help people with CP? [400-401]
Block muscle impulses in stretch relex arc by injecting chemicals (such as botox) at the entry of the nerve to the muscle.
They target spasticity in particular muscle groups. They're used for diagnostic purposes. It also allows for more effective application of physical therapy to improve range of motion and function and may make it possible to postpone orthopedic surgery.
How can surgery help people with CP? [402-403]
Orthopedic- disconnects, lengthens or transfers affected muscle
Neurologic- have tried ventrolateral thalamotomy or electrode-stimulator implants but not with much success
-Improves ability to sit or walk
-Less chance of hip dislocation
Sublaxation-release of hip adductor muscles
What can braces do to help people with CP? [397]
  • -Can control involuntary movements that interfere with function
  • -Maintain an adequate range of motion
  • -Prevent contractures (a tightening of muscle, tendons or ligaments, where elastic fibers are replaced by harder fibers
  • -Provide needed stabilization for sitting, standing and walking
  • -Compensate abnormal posture
  • -Body splints stabilize trunk and limbs
  • -Hand splints keep hand open
  • -AFO (ankle foot orthosis): stabilizes the position of the foot and provides a consistent stretch to the Achilles tendon.
What is NDT and what does it try to do? [396]
Neurodevelopment therapy: Employed by both occupational and physical therapists, provides the child with sensorimotor experiences that enhance the development of more typical movement patterns. Individualized program of positioning, therapeutic handling, and play is developed for the child.
Program goals include the normalization of tone and the improved control of movement during functional activities.
What problems with breathing occur in (some) people with CP?
  • -Breathing rate high and irregular (instead of eventually dropping like with most children)
  • -Reverse breathing (chest may sink instead of expand with inhalation)The diaphragm muscle is active but the muscles of the anterior chest wall are not, so that the chest actually sinks during inspiration.
  • -Noisy breathing due to pharyngeal occlusion caused by muscle spasms
Which laryngeal problems with occur in (some) people with CP?
-Lack of integration between breathing and trying to use voice (dysprosody)
  • -Hypo-nasality (because soft palate hasn’t closed)
  • -Spasmodic contraction or dilation of the glottis
  • -Athetosis of laryngeal musculature
  • -The mandible is pulled partially out and off its articulatory facets
  • -An overflow of arm and shoulder muscle tension to vocal mechanism
Which articulation problems are associated with spasticity? with athetosis?
-Sometimes the jaw deviates laterally, or the tongue can't be elevated, or tongue movement is inaccurate or slow.
Athetosis: Movement is slow and labored, difficult to move tongue, jaw muscles get hyperactive stretch reflex.
--Spasticity: there will be involuntary movement, jerky and arrhythmic, even extra vocal clicks and noises.
What could the physical therapist (PT) and the occupational therapist (OT) do to help a person with CP? [396-398]
PT (physical therapist)
  • optimal seating
  • stabilizers
  • strategies for relaxation
  • Assess muscular impairments and design/impairments strategies for overcoming or minimizing them
  • general motor skills

OT (occupational therapist)
  • Chewing
  • Sucking
  • Swallowing
  • Feeding
  • Fine Motor Skills
Discuss both the benefits and the limitations of using an augmentative/alternative communication system.
The client struggles with spoken language -
So you provide them with augmentative communication systems, which simplifies their language
You provide them with an alternative - which is using a mode of communication different than spoken language. This may be restricting (which is a limitation) however, if it provides them with a way to communicate (even if it isn’t the most ideal) then it is something worth using (a benefit).

First goal: ask how much will you emphasize speech and oral communication. This is the most versatile option that we have. But ask, is it achievable with what this child has to work with?
Vs. written language – can they “linguistically” do something – in terms of typing and writing.
Vs. simple system: pictures, pointing to what you want, bliss symbols and
Look at each component and assess:
Voice, articulation, breathing – and how do these components work together
How much cognitive and perceptual support do they have? Do they have supportive parents?
And relying on your own spiritual intuition. We don’t want to under-estimate it, but we also don’t want to be unrealistic in a way that will lead to frustration and failure. Take a simple view of what you have and the resources you have to use, and then look at the emotional capabilities of the client. Think about what is most realistic to accomplish.

**Something is better than nothing, and more is better than less.

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