CNS - Cerebral Palsy

• Cerebral Palsy (CP) is covered

Cerebral Palsy Definition

• CP refers to a group of non-progressive, irreversible motor disorders resulting from brain damage to an immature brain.
• Brain damage can occur in utero (from the second half of pregnancy), during birth, or in early childhood (typically the first 3 years of life).

Etiology

• CP is commonly due to hypoxia.
• Possible causes include:
  • Premature birth.
  • Intrauterine virus (TORCH) or other infection/toxicity leading to brain damage
  • Ischemic insults.
  • Hypoxia or ischemia in utero or postpartum
  • Trauma in utero or postpartum

Hypoxia and Ischemia

• These can occur in utero due to:
  • Kink in the umbilical cord or the cord wrapping around the fetus' neck.
  • Maldevelopment of the placenta.
  • Shock in the mother from an accident.
• Postpartum hypoxia or ischemia may be caused by:
  • Suppression of respiratory centers due to overmedication of the mother
  • Pneumonia, a collapsed lung, or drowning of the infant.

Trauma

• Trauma can lead to the rupture of cerebral blood vessels.
• This can occur due to:
  • Separation of the placenta.
  • Difficult or prolonged delivery.
  • Postpartum head injury from an accident or abuse.
• Premature babies are highly susceptible to hemorrhage.
• Strokes can occur as a result of dehydration.

Presentation

• CP presents with a wide spectrum of symptoms, ranging from mild to profound disability.
• Mild cases may only be noticeable by healthcare professionals.

Main Types of Cerebral Palsy

• Spastic: Characterized by increased tone, accounting for ~75% of cases.
  • Monoplegia: Affects one limb (arm or leg).
  • Diplegia: Typically affects both legs, common in spastic form, results in a scissor gait.
  • Hemiplegia: Affects one side of the body, is often ambulatory.
  • Quadriplegia: Affects all four limbs.
• Athetoid: Involves uncontrolled, slow, writhing movements that increase with intention and stop with sleep; individuals have difficulty holding themselves upright.
• Ataxic: Characterized by poor coordination, is the least common type, results from damage to the cerebellum.
• Mixed: Commonly a combination of spastic and athetoid types.

Symptoms

• Symptoms are often not noticeable in early infancy and become more obvious as the nervous system matures.
• Early signs may include:
  • Delayed milestones.
  • Persistence of primitive reflexes.
  • Toddlers not walking or forming sentences.
• Other symptoms:
  • Spasticity.
  • Athetoid movements (slow and writhing).
  • Choreiform movements (quick, uncontrolled, and without purpose that do not stop with sleep).
  • Ataxia (lack of coordination and clumsiness); facial ataxia can cause grimacing.
• Reflex movements due to unintegrated developmental reflexes.
• Flaccidity that may transition to spasticity or athetoid movement.
• Pain due to muscular, neurological, and bony changes.
• Postural dysfunctions like scoliosis, hyperlordosis, and hyperkyphosis. Scoliosis can lead to respiratory difficulties.
• Contracture formation, like equinus deformity (short Achilles), internal hip rotation, and hip flexion.
• Additional symptoms:
  • Permanent skeletal changes and arthritis.
  • Stenosis of the cervical spine.
  • Osteoporosis.
  • Epilepsy, mental development delay, and emotional disturbances.
  • Compromised tissue health (disuse atrophy >60 years; edema leading to decubitus ulcers).
  • Peripheral nerve compression from postural imbalances.
  • Sensory losses; decreased proprioception.
  • Speech difficulties.
  • Hearing impairment.
  • Bowel and bladder function compromised.
  • Visual impairment.
  • Frustration and anger
  • Intellect may or may not be affected.

Classic Gait Pattern

• A "scissor gait" is observed due to adductor spasticity, resulting from spastic paralysis of the hip adductor muscles.

Diagnosis (according to CDC)

• Diagnosing CP involves:
  • Developmental Monitoring: Tracking a child’s growth and development over time.
  • Developmental Screening: Assessing for motor or movement delays and lacking milestones, at 9, 18, 24, or 30 months.
  • Developmental and Medical Evaluations: Defining the specific type of disorder and related conditions like intellectual disability, seizures, vision, hearing, and speech problems.

Treatment

• There is no cure for CP.
• Treatments include:
  • Physical and occupational therapy and speech therapy to control seizures.
  • Drugs to relax muscle spasms and alleviate pain.
  • Surgery to correct anatomical abnormalities or release tight muscles.
  • Braces and other orthotic devices.
  • Wheelchairs and rolling walkers.
  • Communication aids.

Massage Considerations

• For people with CP establishing a method of communication with a carer is important as they are non-verbal/non-communicative.
• Comfort:
  • Support and comfort with pillows and positioning (often in a wheelchair).
  • Accommodate high amounts of salivary secretions

Massage Considerations: Systemic Outcomes

• Help with inhalation and rib function, specifically in scoliosis cases.
• Help with gastrointestinal motility.
• Promote relaxation and comfort

Massage Considerations: Musculoskeletal outcomes

• Decrease edema (in the lower limb).
• Minimizes contracture formation.
• Decrease pain.
• Promote joint health.
• Promote tissue health.
• Reduce weakness