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Cerebral Palsy

7 min read

References:

  1. Wong’s Nursing Care of Infants and Children, 11th Edition, ISBN 978-0-323-54939-4, by Marilyn J. Hockenberry, David Wilson, and Cheryl C. Rodgers (pp. 1300-1310)

Cerebral palsy (CP) has been defined as a disorder of posture and movement from static brain injury perinatally or postnatally, which limits activity. In addition to motor disorders, the condition often involves disturbances of sensation, perception, communication, cognition, and behavior; secondary musculoskeletal problems; and epilepsy. The etiology, clinical features, and course vary and are characterized by abnormal muscle tone and coordination as the primary disturbances.

  • CP is the most common permanent physical disability of childhood, and the incidence is reported to range from 1.5 to over 4 per 1000 live births in various studies in the United States. The highest prevalence were found among infants born weighing 1000 to 1400 g at birth; the prevalence of CP was higher among infants before completion of 28 weeks of gestation.
  • A variety of prenatal, perinatal, and postnatal factors contribute to the development of CP, singly or multifactorially. The human brain undergoes development during the prenatal period and up to 2 years of age. A brain insult or injury during this period may result in CP. However, as many as 80% of CP are possibly due to unknown prenatal factors. In general, infants exposed to maternal and perinatal infections are at increased risk for the development of CP as a result of the effects on the developing brain.

Clinical Manifestations

Clinical Classification

  1. Motor abnormalities—Nature and typology of the motor disorder; functional motor abilities
  2. Associated impairments—Seizures; hearing or vision impairment; attentional, behavioral, communicative, and/or cognitive deficits; oral motor and speech function
  3. Anatomic and radiologic findings—Anatomic distribution or parts of the body affected by motor impairments or limitations; radiologic findings sometimes including white matter lesions or brain anomaly noted on computed tomography (CT) or magnetic resonance imaging (MRI)
  4. Causation and timing—Identification of a clearly identified cause such as a postnatal event (e.g., meningitis, traumatic brain injury)

The alert observer may suspect CP when a child demonstrates some of the groups of manifestations:

  1. Delayed Gross Motor Development
    1. A universal manifestation
    2. Delay in all motor accomplishments
    3. Increases as growth advances
    4. Delays more obvious as growth advances
  2. Abnormal Motor Performance
    1. Very early preferential unilateral hand preference at approximately 6 months of age. Normally, hand dominance develops by the preschool years.
    2. Abnormal and asymmetric crawl
    3. Standing or walking on toes
    4. Uncoordinated or involuntary movements
    5. Poor sucking
    6. Feeding difficulties
    7. Persistent tongue thrust
  3. Alterations of Muscle Tone
    1. Increased or decreased resistance to passive movements
    2. Opisthotonic posturing (arching of back)
    3. Feels stiff on handling or dressing
    4. Difficulty in diapering
    5. Rigid and unbending at the hip and knee joints when pulled to sitting position (early sign)
  4. Abnormal Postures
    1. Maintains hips higher than trunk in prone position with legs and arms flexed or drawn under the body
    2. Scissoring and extension of legs with feet plantar flexed in supine position
    3. Persistent infantile resting and sleeping position
    4. Arms abducted at shoulders
    5. Elbows flexed
    6. Hands fisted
  5. Reflex Abnormalities
    1. Persistence of primitive infantile reflexes
    2. Obligatory tonic neck reflex at any age
    3. Nonpersistence beyond 6 months of age
    4. Persistence or hyperactivity of the Moro, plantar, and palmar grasp reflexes
    5. Hyperreflexia, ankle clonus, and stretch reflexes elicited in many muscle groups on fast, passive movements
  6. Associated Disabilities
    1. Altered learning and reasoning
    2. Seizures
    3. Impaired behavioral and interpersonal relationships
    4. Sensory impairment (vision, hearing)

Diagnostic Evaluation

Infants at risk according to known etiologic factors associated with CP warrant careful assessment during early infancy to identify the signs of muscular dysfunction as early as possible. The neurologic examination and history are primary modalities for diagnosis.

  • Neuroimaging of the child with suspected brain abnormality and CP is now recommended for diagnostic assessment, with MRI being a strong predictor of CP when performed at term (corrected age).
  • Metabolic and genetic testing is recommended if no structural abnormality is identified by neuroimaging.

Early Recognition

Early recognition is made more difficult by the lack of reliable neonatal neurologic signs. Diagnosis often cannot be confirmed until the age of 1 or 2 years. Establishing a diagnosis may be easier with the persistence of primitive reflexes: either the asymmetric tonic neck reflex or persistent Moro reflex (beyond 4 months of age), and the crossed extensor reflex.

Therapeutic Management

The goals of therapy for children with CP are early recognition and promotion of an optimum developmental course to enable affected children to attain their potential within the limits of their dysfunction. The disorder is permanent, and therapy is chiefly symptomatic and preventive. Therapy is individualized, but the broad aims are to:

  • Establish locomotion, communication, and self-help skills.
  • Gain optimum appearance and integration of motor functions.
  • Correct associated defects as early and effectively as possible.
  • Provide educational opportunities adapted to the individual child’s needs and capabilities.
  • Promote socialization experiences with other affected and unaffected children.
  1. Mobilizing Devices are often used by many children with CP. They take form in various orthotics to prevent or reduce deformity, increase energy efficiency of gait, and control alignment. These include braces, splints, casting, molded orthoses, wheeled scooter boards, wheeled go-carts, strollers, boards, standing devices, etc.
  2. Technical Aids are available to improve the functioning of children with CP. These include electromechanical toys that employ the concept of biofeedback and operate from a head unit— the toy is manipulated only when the head and trunk are in correct alignment. These can also enhance eye-hand coordination.
    • Voice synthesizers can help children with speech difficulties speak. Smart phones and tablets with speech applications are appropriate for some children.
  3. Associated Problems also require attention, as children with CP often have sensory deficits that warrant the attention of appropriate specialists. Speech-language therapy, regular dental visits and dental prophylaxis. Other problems such as constipation, poor bladder control, urinary retention, chronic respiratory tract infections, aspiration pneumonia, gastroesophageal reflux, abnormal muscle tone, immobility, altered positioning skin problems due to altered positioning, poor nutrition and immobility, and hip dislocation are all reported in CP.
  4. Physical Therapy: one of the most common used treatment modalities in children with CP. It is directed towards good skeletal alignment for the child with spasticity; training in purposeful acts for the child with athetosis; and gait training and maximum development of proprioceptive sense for the child with ataxia.
  5. Speech Therapy: Speech training under the supervision of an SLP begins early, before the child learns poor habits of communication. Parents and others help by following the directions of the speech therapist. Feeding techniques to develop the use of the lips and tongue in eating facilitate speech. If severe dysarthria is present, nonverbal communication (e.g., sign language) may be learned.

Occupational Therapy

Training in manual skills and activities of daily living (ADLs) proceeds along developmental lines and according to the child’s functional level.

  1. Adaptive Equipment
    • Utensils for functional use (e.g., eating, writing)
    • Switches
    • Computers
  2. Speech-Language Therapy
    • Oral-motor skills
    • Adaptive communication techniques
  3. Special Education
    • Early intervention programs
    • Specialized learning programs and support services in school
    • Socialization to promote self-concept development
  4. Surgical Intervention
    • Orthopedic (e.g., tendon transfers, muscle lengthening, spinal deformities)
    • Neurologic (e.g., neurectomies)
    • Selective dorsal rhizotomy
    • Feeding (e.g., gastrostomy)
    • Dental
  5. Medication Therapy
    • Medications to treat the following: spasticity, pain, secondary conditions (e.g., seizure disorder, chronic constipation, urinary tract infections, gastroesophageal reflux)
    • Primary care for health supervision and acute childhood illnesses
  6. Behavioral Therapy: Care coordination of specialized services and community resources in collaboration with the child’s family

Nursing Care Management

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