Chapter 11 Cerebral Palsy
PATHOPHYSIOLOGY
Cerebral palsy (CP) is a nonspecific term used to characterize abnormal muscle tone, posture, and coordination caused by a nonprogressive lesion or injury that affects the immature brain. CP may result from a variety of prenatal, perinatal, and postnatal factors, although CP results most commonly from either existing perinatal brain abnormalities or postnatal injury. The actual brain abnormality may arise from a variety of causes: anatomical malformations of the brain, atrophy, vascular occlusion, loss of neurons, or low brain weight. Anoxia, which is often secondary to other causative mechanisms, is the most significant factor in the pathologic state of brain damage. Predisposing risk factors include multiple-gestation births, maternal infections, and maternal and fetal thrombophilic conditions. CP is frequently classified according to the functional categories used to describe the neuromuscular abnormalities or dysfunction. Clinical classification of CP is presented in Box 11-1.
Box 11-1 Clinical Classification of Cerebral Palsy
1. Spastic cerebral palsy (CP) is the most common form (80% of cases). It is characterized by hypertonicity and poor postural control, balance, and coordination. Gross and fine motor skills are impaired. Spastic CP is further classified according to the part of the body affected:
2. Dyskinetic/Athetoid CP is characterized by a movement disorder and results from Rh incompatibility and hypoxic ischemic encephalopathy. Characteristics include the following:
3. Ataxic CP is characterized by a wide-based gait, and rapid, repetitive movements that are poorly performed.
4. Mixed type/dystonic—combination of spasticity and athetosis.
CLINICAL MANIFESTATIONS
LABORATORY AND DIAGNOSTIC TESTS
Refer to Appendix D for normal values and ranges of laboratory and diagnostic tests.
1. Clinical examination to identify tone abnormalities; frequently hypotonicity followed by hypertonicity, postural abnormalities, and delayed motor development
2. Cranial ultrasonography to detect hemorrhagic and hypoxic ischemic insults
3. Computed tomography to detect central nervous system lesions
4. Magnetic resonance imaging to detect small lesions
5. Positron emission tomography and single photon emission computed tomography—to visualize brain metabolism and perfusion
MEDICAL MANAGEMENT
The overall goal of medical management is to develop a rehabilitation plan to promote optimal functioning. This includes assisting the child to gain new skills and anticipating potential complications. A multidisciplinary team approach is required. Most children identified with a delay or risk for delay are enrolled in an early intervention program (EIP) and receive physical, occupational, and speech therapy as indicated (Appendix G). As children grow from the infancy and toddler stages, treatments support the functional goals set. These treatments include therapeutic exercises, splinting, serial casting, bracing, and use of mobility aids and adaptive devices to provide functional independence. Surgical procedures such as osteotomies or tendon lengthening or tendon transfer may be performed. Antispasmodic drugs may be given orally or injected into the nerves to decrease spasticity. Neurologic procedures are used only in selected cases. Dorsal rhizotomy and botulinum toxin type A have been used successfully in the treatment of spasticity. Intrathecal baclofen administration via an implanted infusion pump has also been effective in the treatment of spasticity.
NURSING INTERVENTIONS
1. Promote maximal functioning of joints.
2. Provide and instruct parents and child on the use of adaptive equipment for activities of daily living.
3. Ensure adherence with use of ambulatory aids (i.e., walker, crutches, orthoses).
4. Anticipate and assess for pain and fatigue from increased muscle tone and spasticity.
5. Position to prevent contractures.
6. Direct performance of active and passive range of motion exercises.
7. Make appropriate referrals to speech, physical, occupational, and nutritional therapy, social services and child life specialist, and hospital teacher as needed.
8. Encourage verbalization of feelings about altered body image.
9. Encourage social interaction with peers.
10. Collaborate with educational specialist in individualized education plan (IEP) and/or 504 planning to promote achievement of educational goals (see Appendix G).
