Cerebral Palsy Flashcards
What is cerebral palsy?
non-progressive disorder of motion and/or posture, secondary to an insult in the developing brain
How is CP classified?
according to the type of neuromotor dysfunction
Name the different classes of CP?
- Spastic
- subgroups: monoplegic, diplegic, triplegic, quadriplegic - Dyskinetic
- extrapyramidal; subgroups: athetosis, chorea, rigidity or dystonia - Ataxic
- Atonic
- Mixed
- subgroups: spastic-athetoid, ataxic-spastic
Important areas to consider for each child?
- Classification
- Function severity
- The underlying aetiology
- Prognosis
Clinical presentation?
- abnormal limb and/or trunk posture and tone in infancy with delayed motor milestones this may be accompanied by slowing of head growth
- feeding difficulties, with locomotor incoordination, slow feeding, gagging and vomiting
- abnormal gait once walking is achieved
- asymmetric hand function before 12 months
What could the underlying aetiology be?
- Unknown (over one-third)
- Prenatal problems
e.g. cerebral malformations, intrauterine TORCH infection, placental insufficiency, or chromosomal anomalies - Perinatal problems
e.g. prematurity, asphyxia, kernicterus - Postnatal problems
e.g. trauma, cerebrovascular accident, intracranial infections.
Spastic cerebral palsy types?
- unilateral (hemiplegia)
- bilateral (quadriplegia)
- bilateral (diplegia)
What to ask with regards to current symptoms in CP cases?
- Vision
e.g strabismus, myopia, hemianopia - Hearing
- Speech
- Seizures
e.g. type, duration, treatment/side effects, compliance, last seizure - Other problems
- urinary incontinence, constipation, chest infections, pressure sores
What to ask with regards to current functioning in CP cases?
- Intellectual abilities (or present developmental status)
- current placement regarding education, domestic
- Behaviour
e.g. hyperactivity, affect, depression - Communication problems
e.g. expressive or receptive; dysphasia; dysarthria; athetoid movements - Activities of daily living
e.g. bathing, cleaning teeth, combing hair, dressing, writing and other hand usage, toileting etc. - Feeding and nutrition
e.g. suckling and swallowing ability, tube feeds, gastro-esophageal reflux, aspiration, failure to thrive - Mobility
- gait pattern, wheelchair mobility
- skeletal problems (e.g. kyphoscoliosis, hip sublaxation, contractures, unequal leg length)
- Abnormal posture
Spastic CP: unilateral (hemiplegia)?
- unilateral involvement of arm and leg (arm affected more and face spared)
- 4 - 12 months of age
- fisting of affected hand gt
Developmental history in CP cases?
- Age at which milestones achieved
- Quality of attainment, e.g. bottom shuffling, bunny-hopping in gross motor development
- Early hand preference in fine motor
Family history in CP cases?
family history of CP
Questions to ask on management of CP?
- Recent/past management in hospital
- Usual treatment at home
- Daily routine
- Frequency of therapies (e.g physiotherapy), compliance with therapy
Questions to gauge the understanding of problems and prognosis?
- Degree of knowledge regarding CP
- Questions of resuscitation
- by parents and siblings
Important signs in examination of the child with CP under general observation?
- Dysmorphic features (e.g chromosomal anomalies).
- Posture (e.g. fisting, increased extensor tone, hemiplegia, quadriplegia)
- Movement
- Asymmetry (e.g. hemiatrophy)
- Behaviour (e.g lack of interaction with environment, crying)
- Eye signs (e.g. squint)
- Bulbar signs (e.g. dysarthria, drooling)
- Interventions (e.g nasogastric tube)
- Clothing (e.g. nappies in a child over 4 years old)
- Peripheral aids (e.g. wheelchairs)
Parameters of dysmorphic features?
- Head circumference (often obvious microcephaly)
- Weight (often failing to thrive)
- Height (usually decreased)
- Progressive centile charts
Types of movement seen under general observation?
- Involuntary
e.g choreathetoid movements, dystonic spasms, seizures - Voluntary
e.g. gait: wide base, up on toes, hemiplegic, diplegic
What is seen on a standard gait examination?
- Toe walking
- scissor walking
- early hand preference
What is seen on a standard gait examination?
If they cant walk but can crawl?
look for abnormal crawling pattern:
1. Those with spastic diplegia or quadriplegia
– buttock crawling
- ‘bunny-hopping’ (jumping while on knees);
2. Those with hemiplegia
– asymmetrical crawl
Gross motor assessment of CP?
- lying supine, pull to sit
- to assess head lag and grasp - Sitting
- assess sitting ability - Hold up vertically, under the axillae
- to detect increased tone
- scissoring
- automatic walking - Ventral suspension
- to detect increased extensor tone - Place prone
- to detect back arching
Upper and lower limb examination of a CP case?
- Tone - Palpate for muscle bulk in each muscle group and evaluation of contractures
e.g. tight hip adductors, and tendo-achilles - Power – assess voluntary movement, functional power
e.g. grasp of toys - Reflexes - Clonus, upgoing planters
Assessing potential complications of CP?
- Measure the head
e.g. for microcephaly, or macrocephaly due to hydrocephalus - Check vision, visual fields and ocular movement
e.g. myopia, squint - Check the hearing
e.g. for sensorineural deafness - Check the ears
e.g. for chronic serous otitis media - Check the gag reflex (bulbur palsy)
- Look at the teeth (for dental carries)
- Look at the back (for kyphoscoliosis)
- Inspect and auscultation the chest (for chest infection)
- Palpate the abdomen (for constipation)
- Examine the hips (for dislocation)
Functional assessment of complications in CP?
- Screen nutritional status
- demonstrate fat and protein stores - Perform a functional assessment for activities of daily living
e.g. offer cup, spoon, fork, comb, tooth brush, ask to put on a piece of clothing)
Investigations of CP?
Investigation will depend on the type of CP
1. TORCH screen (including HIV), in infants, for intrauterine infections
2. MRI or CT scan of the brain where indicated
Team required for management of a CP patient?
A multidisciplinary team
1. Social worker
2. Occupational therapist
3. Physiotherapist
4. Speech therapist
5. Orthopedic surgeon
6. Psychologist
General nursing in management of a CP patient?
- Tube feeds
- Treatment for gastro-oesophageal reflux
- Attention to skin for pressure sores
- Attention to toileting
Orthopedic management of CP?
- Physiotherapy
- occupational therapy
- splints
- orthoses
Importance of Physiotherapy, occupational therapy and orthopedic management?
- To maintain range of movement and function (trunk and limbs)
- Optimize abilities to cope with activities and daily living
- Prevent contractures
Importance of Physiotherapists and occupational therapists?
To enabling the child to perform the activities of daily living (ADLs)
1. Dressing (which vary with the different types of CP),
2. Mobility aids
3. Furniture
4. Bathroom fittings
Importance of splinting?
to prevent contractures
Importance of splinting?
to prevent contractures
What is orthoses?
an external device or apparatus, such as abraceorsplint, used inorthopedicsto support orimmobilizethe spine orlimbs
Importance of orthoses?
- Improve function
- Prevent deformities
- The ankle-foot orthosis is commonly used to prevent ankle deformity improve gait pattern
What problems with regards to nutrition to children with CP usually have?
- fail to thrive
- Gastro-eosophageal reflux
- Impaired swallowing
- These children will require assessment and therapy by NGT
Social implications in care for a CP child?
- Behaviour disorders (e.g. attention deficit disorder, depression)
- Siblings may be neglected
- Burdens on the parents
- Time spent
What burden is put on parents caring for a CP child?
- Emotionally
- Financially
- hospitalizations
- aids including wheelchairs
- home modifications for ease of mobility and functional activities - Physically
How we can help the family of CP patients?
- giving the parents the opportunity to detail their problems, offering to organize contact with social worker to discuss these
- To get the true impression of the time burden, ask the mother how much time is spent on the child’s needs each day
What is time usually spent on in caring for a CP patient?
- Feeding the child
- Performing physiotherapy
- Occupational therapy
- Administering medications
Orthopedic procedural management of CP?
- Correction of deformities
- Prevention of deformities
- Improves cosmesis
Examples of orthopedic operations in a CP child?
- Hamstring releases (relieve knee contractures)
- Lengthening of tendoachilles equinus deformity
- Surgery for scoliosis
Visual impairment of a CP patient?
- Squint (50-60%)
- Decreased visual acuity
- Visual field defects.
Management of visual impairment in a CP child?
1.Referral to an ophthalmologist is necessary
2. spectacles for refractive errors
3. Patching the good eye for squint to prevent permanent amblyopia
Note: Permanent amblyopia occurs after the age of 6 years.
Management of hearing impairment of a CP patient?
Mild: does not require intervention
Moderate: requires hearing aids
Severe: requires special education for the deaf
Problems with schooling in CP children?
How to manage it?
- Some degree of intellectual impairment
- Physical disability.
- Many require special educational assistance
- Each district or region has its own centre
Drug management in CP?
- Anticonvulsants
- Antispastic drugs (e.g. diazepam, baclofen, dantrolene)
- Can be tried with to decrease spasticity - Anticholinergic drugs (atropine) may be used for excessive drooling
