Cerebral Palsy
Content
Yuandalyn Gray Cerebral Palsy (CP) • Describes a group of permanent disorders of movement & posture development causing activity limitation, which is attributed nonprogressive disturbances that occurred in the developing fetal or infant brain CP is primarily a motor disorder, but the child may also have disturbances in sensation, perception, cognition, communication, and behavior. It is the major physical disability affecting functional development in children There are four types of motor dysfunction seen w/CP: spactic, dyskinetic, ataxic, & mixed are related to the location of brain insult.
• • •
Etiology: • • Most cases are caused by brain insult (complications of prematurity; prenatal, perinatal, & genetic factors; & viral infection of the fetus) Injury to the immature periventricular white matter in fetuses & premature infants is thought to be the most common cause of CP
Patho: • Very premature infants are at risk for intraventricular hemorrhage associated w/birth, resuscitation, fluctuations in cerebral blood pressure, respiratory distress syndrome, & hypoxixischemic injury. Such stressors interfere w/the autoflow of blood to the brain, leading to the rupture of blood vessels in the developing brain. When bleeding is severe enough to invade the ventricles or brain substance, the infant is at high risk for long-term neurological problems such as CP & intellectual disabilities
•
Clinical Manifestations: • • • • • Characterized by abnormal muscle tone & lack of coordination w/spasticity found in the majority of cases Symptoms vary depending on: age, area of brain involved and the extent of brain injury Other complications: hearing, speech, language impairments & seizures. Feeding may be difficult bc of oral motor involvement, including hypotonia, w/poor sucking & swallowing coordination. Clinical characteristics:
o Clinical Characteristics Hypotonia Hypertonia o Rigidity o Spasticity Ataxia Athetosis Hemiplegia Diplegia Quadriplegia
o Definitions Floppiness, increased ROM of joints, diminished reflex response Tense, tight muscles Uncoordinated, awkward, stiff movements; scissoring or crossing of the legs; exaggerated reflex reactions Irregularity in muscle coordination or actions Constant involuntary writhing motions that are more sever distally Involvement of one side the body w/the upper extremities being more dysfunctional than the lower extremities Involvement of all extremities, but the low extremities are more affected than the upper, usually spastic Involvement of all extremities w/the arms in flexion & legs in extension
•
Clinical Manifestations by type: Last page
Dsg Procedures: • • • Dx usually based on clinical findings CP is difficult to dx in the early months of life as it must be distinguished from other neurological conditions & signs may be subtle. Suspicious historical findings include an infant w/a history of prematurity (less than 1500g birth weight or less than 28wks gestation), maternal intrauterine infection, multiple birth, or anoxic event. Ultrasonography can be used to detect fetal & neonatal abnormalities of the brain such as intraventricular hemorrhage Neuromotor test that evaluate the presence of normal movement patterns and the absence of primitive reflexes & abnormal tone in young infants have been developed o o `CT scans & MRI provide information about anatomic structures & help to define cause Information about brain metabolic functioning can be obtained by positron emission tomography (PET), a functional MRI, single photon emission computed tomography (SPECT), or diffusion tensor imaging (DTI)
• •
Clinical Therapy:
•
Focuses on helping the child develop to his or her maximum level of independence. o o Referrals are made for physical, occupational, & speech therapy, as well as special education to improve motor function & ability Braces & splints, serial casting, & positioning devices (prone wedges, standers, & sidelyers) are used to promote ROM, skeletal alignment, stability, & control of involuntary movements. They also help to prevent contractures Mobility devices such as scooters, tricycles, & wheelchairs help the child to move independently & explore the environment
o •
Surgical Interventions may be required to improve function by balancing muscle power & stabilizing uncontrollable joints: o o o o Achilles tendon may be lengthened to increase ROM in the ankle, which allows the heel to touch the floor & thus improves ambulation. The hamstrings may be released to correct knee flexion contractures Other procedures may be performed to improve hip adduction or correct the foot’s natural position. A dorsal rhizotomy may be performed for spastic diplegia to cut the afferent fibers that contribute to spasticity; however some muscle weakness may result from the procedure
•
Medications o Given to control seizures, spasms (skeletal muscle relaxants, baclofen, & benzodiazepines) Diazepam, lorazepam, clonazepam given oral Dantrolene given oral Baclofen administered orally or by intrathecal pump to decrease muscle spasticity Botulinum toxin injections (type A) into specific muscles is a new therapy that helps to temporarily control spasticity.
o
Minimize gastrointestinal side effects (cimetidine or ranitidine )
Nsg Considerations: • • Goal of nursing care is to support the early identification of children w/CP & then provide supportive care to promote cognitive, motor, & social functioning. Assessment:
o o o o o
Be alert whose histories indicate an ↑ risk for CP for developmental delays at each healthcare visit any orthopedic, visual, auditory, or intellectual deficits should be noted For the presence of newborn primitive reflexes, which may persist beyond normal age in a child w/CP Identify infants that appear to have an abnormal muscle tone or abnormal posture (head lag beyond 6months or age, arched back, poor trunk control & balance, toe walking or scissoring) Asymmetric or abnormal crawling by using two or three extremities indicates a motor problem Hand dominance prior to 18months of age is another sign of motor problem.
o
o •
Record dietary Intake & height & weight percentiles for children suspected to have or dx w/condition
Nsg Dx: (depends on type of CP, child symptoms & age, & family situation o o o o o o Risk for constipation r/t low intake of fiber & fluids & insufficient physical activity Impaired tissue integrity r/t decreased physical mobility & limited self-care ability Impaired verbal communication r/t hearing & or speech impairment Impaired home maintenance r/t child’s developmental disability & inadequate support system Chronic pain r/t spasticity & stretching exercises to prevent contractures Delayed growth & development r/t lack of muscle strength or limited social interaction
•
Planning & Implementation: o o o Bc CP can range from mild to severe & involve numerous manifestations, interventions need to be adapted to the child & family. Also see Care Plan on p.1363 Nursing care focuses on providing: Provide Adequate Nutrition: children w/CP requires high-calorie diets or supplements to diet (Rationale: bc of feeding difficulties associated w/spasticity or hypotonia). Give small amts of soft foods at a time (Rationale: many children have difficulty chewing & swallowing & are at risk for aspiration). Feeding
utensils w/large, padded handles may be easier for child to use. Make sure child gets adequate fluids (Rationale: child may not be able to communicate thirst). Children w/severe CP may require a gastrostomy tube (Rationale: to obtain adequate nutrition). Adequate fiber is needed (Rationale: to prevent constipation), & some may need a bowel management program (Rationale: to treat chronic constipation). Maintain Skin Integrity: take special care to protect bony prominences from friction & injury & pressure sores. Monitor splints & braces for proper fit, & skin under them for redness (if skin is red, the braces or splints should be removed & not worn until redness is gone). Proper body alignment should be maintained at all times (support child w/pillows, towels, & bolsters whether the child is in bed or chair). Use splints & braces to help support child & reduce the risk for contractures. Support the head & body of a floppy infant. Promote Physical Mobility: ROM exercises are essential to maintain joint flexibility & prevent contractures. Consult w/PT and assist w/recommended exercises for the child. Teach parents to position child to foster flexion rather than extension so that interaction w/environment can be enhanced (e.g., child can bring objects closer to the face). Encourage parents to bring the child’s adaptive appliances use in the hospital; however, secure the child’s appliances as it may be difficult for the family to get them replaced if lost. Refer parents to the appropriate resources for help w/the acquisition of adaptive devices. Consider the use of relaxation training to manage pain associated w/spasticity & stretching exercises. Promote Safety: teach parents importance of using safety belts w/children in strollers & wheel chairs. Determine if an adaptive car safety seat is needed so child can be safely transported. A helmet should be worn by child w/chronic seizures to protect form further injury during seizures. Promote Growth & Development: use terminology appropriated for child’s developmental level. Help child develop a positive self image to ensure emotional health & social growth. Children w/hearing impairment may need referral to learn American Sign Language or other communication methods. Provide audio & visual activities for the child who has quadriplegia. Adaptive & assistive technology may be needed to promote mobility & communication. Foster Parental knowledge: teach parents about disorder & arrange session to teach them about all of the child’s special needs. Teach administration, desired effects, & side effects of medications prescribed for seizures. Make sure parents are aware of the need for dental care bc enamel defects & malocclusion commonly occur in children w/CP and hyperplasia occurs when anticonvulsants are prescribed Provide Emotional Support: refer parents to individual & family counseling if appropriate. Listen to parents’ concerns & encourage them to express their feeling
& ask questions. Explain what they can expect regarding future treatment. Work w/other healthcare professionals to help families adjust to this chronic disease Care in the Community: Children w/CP need continuous support in the community. A case manager such as the parent or nurse is often needed to coordinate care. Parents may need financial assistance to provide child’s needs & obtain appliances such as braces or customized wheelchair. Children need new adaptive devices, ongoing development assessment & care planning. (Please read section p.1365 to much to type and repetitive). Evaluation: effective management of constipation, identification of successful communication techniques for child, & integration of the child into school, recreation, & social activities.
Classification & Type of Insult
Clinical Manifestations
Clinical Therapy
Spastic Cerebral cortex or pyramidal Tract injury (75%) cases.
Dyskinetic Extrapyramidal, basal ganglia Injury (10-15%) cases.
Ataxic Cerebellar (extrapyramidal) Injury (5-10%) cases.
Mixed Injuries to multiple areas
Persistent hypertonia, rigidity that relates to location of brain damage (e.g., hemiplegia, diplegia, or quadriplegia) Exaggerated deep tendon reflexes Leads to contractures & abnormal curvature of spine Abnormalities of muscle tone that affect entire body Involuntary movements Tremors, difficulty w/fine & purposeful motor movements Exaggerated posturing May exhibit rigid muscle tone when awake & normal or decreased muscle tone when sleep; inconsistent muscle tone that may change hour to hour or day to day Abnormalities of voluntary movement involving balance & position of the trunk & limbs Difficulty controlling hand & arm movements during reaching (overshooting or past-pointing) Increased or decreased muscle tone Hypotonia in infancy Muscle instability & wide-based unsteady gait no dominant motor pattern unique compensatory movements & posture to maintain control over specific neuromotor deficits combination of characteristics from other types
Braces & splints to prevent contractures, braces to manage scoliosis Tone-reducing casts to keep spastic muscle in stretched position Static positioning devices to promote skeletal alignment Adaptive equipment for mobility & positioning Surgery to lengthen tendons, reduce spasticity Diazepam, baclofen, dantrolene to control spasticity Nerve blocks Botulinum toxin injections into the nerve muscle junction to control spasticity Physical & occupation therapy to promote improved muscle tone & better motor control for function Speech therapy to address oral motor problems Carefully designed seating to promote function & reduce contractures & joint deformities Mobility options-tricycle, walker, wheelchair Early intervention programs Individualized education plan Assistive technology such as a computer
• • •
Etiology: • • Most cases are caused by brain insult (complications of prematurity; prenatal, perinatal, & genetic factors; & viral infection of the fetus) Injury to the immature periventricular white matter in fetuses & premature infants is thought to be the most common cause of CP
Patho: • Very premature infants are at risk for intraventricular hemorrhage associated w/birth, resuscitation, fluctuations in cerebral blood pressure, respiratory distress syndrome, & hypoxixischemic injury. Such stressors interfere w/the autoflow of blood to the brain, leading to the rupture of blood vessels in the developing brain. When bleeding is severe enough to invade the ventricles or brain substance, the infant is at high risk for long-term neurological problems such as CP & intellectual disabilities
•
Clinical Manifestations: • • • • • Characterized by abnormal muscle tone & lack of coordination w/spasticity found in the majority of cases Symptoms vary depending on: age, area of brain involved and the extent of brain injury Other complications: hearing, speech, language impairments & seizures. Feeding may be difficult bc of oral motor involvement, including hypotonia, w/poor sucking & swallowing coordination. Clinical characteristics:
o Clinical Characteristics Hypotonia Hypertonia o Rigidity o Spasticity Ataxia Athetosis Hemiplegia Diplegia Quadriplegia
o Definitions Floppiness, increased ROM of joints, diminished reflex response Tense, tight muscles Uncoordinated, awkward, stiff movements; scissoring or crossing of the legs; exaggerated reflex reactions Irregularity in muscle coordination or actions Constant involuntary writhing motions that are more sever distally Involvement of one side the body w/the upper extremities being more dysfunctional than the lower extremities Involvement of all extremities, but the low extremities are more affected than the upper, usually spastic Involvement of all extremities w/the arms in flexion & legs in extension
•
Clinical Manifestations by type: Last page
Dsg Procedures: • • • Dx usually based on clinical findings CP is difficult to dx in the early months of life as it must be distinguished from other neurological conditions & signs may be subtle. Suspicious historical findings include an infant w/a history of prematurity (less than 1500g birth weight or less than 28wks gestation), maternal intrauterine infection, multiple birth, or anoxic event. Ultrasonography can be used to detect fetal & neonatal abnormalities of the brain such as intraventricular hemorrhage Neuromotor test that evaluate the presence of normal movement patterns and the absence of primitive reflexes & abnormal tone in young infants have been developed o o `CT scans & MRI provide information about anatomic structures & help to define cause Information about brain metabolic functioning can be obtained by positron emission tomography (PET), a functional MRI, single photon emission computed tomography (SPECT), or diffusion tensor imaging (DTI)
• •
Clinical Therapy:
•
Focuses on helping the child develop to his or her maximum level of independence. o o Referrals are made for physical, occupational, & speech therapy, as well as special education to improve motor function & ability Braces & splints, serial casting, & positioning devices (prone wedges, standers, & sidelyers) are used to promote ROM, skeletal alignment, stability, & control of involuntary movements. They also help to prevent contractures Mobility devices such as scooters, tricycles, & wheelchairs help the child to move independently & explore the environment
o •
Surgical Interventions may be required to improve function by balancing muscle power & stabilizing uncontrollable joints: o o o o Achilles tendon may be lengthened to increase ROM in the ankle, which allows the heel to touch the floor & thus improves ambulation. The hamstrings may be released to correct knee flexion contractures Other procedures may be performed to improve hip adduction or correct the foot’s natural position. A dorsal rhizotomy may be performed for spastic diplegia to cut the afferent fibers that contribute to spasticity; however some muscle weakness may result from the procedure
•
Medications o Given to control seizures, spasms (skeletal muscle relaxants, baclofen, & benzodiazepines) Diazepam, lorazepam, clonazepam given oral Dantrolene given oral Baclofen administered orally or by intrathecal pump to decrease muscle spasticity Botulinum toxin injections (type A) into specific muscles is a new therapy that helps to temporarily control spasticity.
o
Minimize gastrointestinal side effects (cimetidine or ranitidine )
Nsg Considerations: • • Goal of nursing care is to support the early identification of children w/CP & then provide supportive care to promote cognitive, motor, & social functioning. Assessment:
o o o o o
Be alert whose histories indicate an ↑ risk for CP for developmental delays at each healthcare visit any orthopedic, visual, auditory, or intellectual deficits should be noted For the presence of newborn primitive reflexes, which may persist beyond normal age in a child w/CP Identify infants that appear to have an abnormal muscle tone or abnormal posture (head lag beyond 6months or age, arched back, poor trunk control & balance, toe walking or scissoring) Asymmetric or abnormal crawling by using two or three extremities indicates a motor problem Hand dominance prior to 18months of age is another sign of motor problem.
o
o •
Record dietary Intake & height & weight percentiles for children suspected to have or dx w/condition
Nsg Dx: (depends on type of CP, child symptoms & age, & family situation o o o o o o Risk for constipation r/t low intake of fiber & fluids & insufficient physical activity Impaired tissue integrity r/t decreased physical mobility & limited self-care ability Impaired verbal communication r/t hearing & or speech impairment Impaired home maintenance r/t child’s developmental disability & inadequate support system Chronic pain r/t spasticity & stretching exercises to prevent contractures Delayed growth & development r/t lack of muscle strength or limited social interaction
•
Planning & Implementation: o o o Bc CP can range from mild to severe & involve numerous manifestations, interventions need to be adapted to the child & family. Also see Care Plan on p.1363 Nursing care focuses on providing: Provide Adequate Nutrition: children w/CP requires high-calorie diets or supplements to diet (Rationale: bc of feeding difficulties associated w/spasticity or hypotonia). Give small amts of soft foods at a time (Rationale: many children have difficulty chewing & swallowing & are at risk for aspiration). Feeding
utensils w/large, padded handles may be easier for child to use. Make sure child gets adequate fluids (Rationale: child may not be able to communicate thirst). Children w/severe CP may require a gastrostomy tube (Rationale: to obtain adequate nutrition). Adequate fiber is needed (Rationale: to prevent constipation), & some may need a bowel management program (Rationale: to treat chronic constipation). Maintain Skin Integrity: take special care to protect bony prominences from friction & injury & pressure sores. Monitor splints & braces for proper fit, & skin under them for redness (if skin is red, the braces or splints should be removed & not worn until redness is gone). Proper body alignment should be maintained at all times (support child w/pillows, towels, & bolsters whether the child is in bed or chair). Use splints & braces to help support child & reduce the risk for contractures. Support the head & body of a floppy infant. Promote Physical Mobility: ROM exercises are essential to maintain joint flexibility & prevent contractures. Consult w/PT and assist w/recommended exercises for the child. Teach parents to position child to foster flexion rather than extension so that interaction w/environment can be enhanced (e.g., child can bring objects closer to the face). Encourage parents to bring the child’s adaptive appliances use in the hospital; however, secure the child’s appliances as it may be difficult for the family to get them replaced if lost. Refer parents to the appropriate resources for help w/the acquisition of adaptive devices. Consider the use of relaxation training to manage pain associated w/spasticity & stretching exercises. Promote Safety: teach parents importance of using safety belts w/children in strollers & wheel chairs. Determine if an adaptive car safety seat is needed so child can be safely transported. A helmet should be worn by child w/chronic seizures to protect form further injury during seizures. Promote Growth & Development: use terminology appropriated for child’s developmental level. Help child develop a positive self image to ensure emotional health & social growth. Children w/hearing impairment may need referral to learn American Sign Language or other communication methods. Provide audio & visual activities for the child who has quadriplegia. Adaptive & assistive technology may be needed to promote mobility & communication. Foster Parental knowledge: teach parents about disorder & arrange session to teach them about all of the child’s special needs. Teach administration, desired effects, & side effects of medications prescribed for seizures. Make sure parents are aware of the need for dental care bc enamel defects & malocclusion commonly occur in children w/CP and hyperplasia occurs when anticonvulsants are prescribed Provide Emotional Support: refer parents to individual & family counseling if appropriate. Listen to parents’ concerns & encourage them to express their feeling
& ask questions. Explain what they can expect regarding future treatment. Work w/other healthcare professionals to help families adjust to this chronic disease Care in the Community: Children w/CP need continuous support in the community. A case manager such as the parent or nurse is often needed to coordinate care. Parents may need financial assistance to provide child’s needs & obtain appliances such as braces or customized wheelchair. Children need new adaptive devices, ongoing development assessment & care planning. (Please read section p.1365 to much to type and repetitive). Evaluation: effective management of constipation, identification of successful communication techniques for child, & integration of the child into school, recreation, & social activities.
Classification & Type of Insult
Clinical Manifestations
Clinical Therapy
Spastic Cerebral cortex or pyramidal Tract injury (75%) cases.
Dyskinetic Extrapyramidal, basal ganglia Injury (10-15%) cases.
Ataxic Cerebellar (extrapyramidal) Injury (5-10%) cases.
Mixed Injuries to multiple areas
Persistent hypertonia, rigidity that relates to location of brain damage (e.g., hemiplegia, diplegia, or quadriplegia) Exaggerated deep tendon reflexes Leads to contractures & abnormal curvature of spine Abnormalities of muscle tone that affect entire body Involuntary movements Tremors, difficulty w/fine & purposeful motor movements Exaggerated posturing May exhibit rigid muscle tone when awake & normal or decreased muscle tone when sleep; inconsistent muscle tone that may change hour to hour or day to day Abnormalities of voluntary movement involving balance & position of the trunk & limbs Difficulty controlling hand & arm movements during reaching (overshooting or past-pointing) Increased or decreased muscle tone Hypotonia in infancy Muscle instability & wide-based unsteady gait no dominant motor pattern unique compensatory movements & posture to maintain control over specific neuromotor deficits combination of characteristics from other types
Braces & splints to prevent contractures, braces to manage scoliosis Tone-reducing casts to keep spastic muscle in stretched position Static positioning devices to promote skeletal alignment Adaptive equipment for mobility & positioning Surgery to lengthen tendons, reduce spasticity Diazepam, baclofen, dantrolene to control spasticity Nerve blocks Botulinum toxin injections into the nerve muscle junction to control spasticity Physical & occupation therapy to promote improved muscle tone & better motor control for function Speech therapy to address oral motor problems Carefully designed seating to promote function & reduce contractures & joint deformities Mobility options-tricycle, walker, wheelchair Early intervention programs Individualized education plan Assistive technology such as a computer
