Cerebral Palsy: Symptoms, Diagnosis, and Treatment - PDF

Cerebral Palsy FT400 CNS Tx Cerebral Palsy A group of non-progressive, irreversible motor disorders caused by brain damage to an immature brain This brain damage may occur in utero (from 2nd half of pregnancy onwards), during the birth process, or in early childhood (usually the first 3 years...

Cerebral Palsy FT400 CNS Tx Cerebral Palsy A group of non-progressive, irreversible motor disorders caused by brain damage to an immature brain This brain damage may occur in utero (from 2nd half of pregnancy onwards), during the birth process, or in early childhood (usually the first 3 years of life). Etiology - think hypoxia and ischemia CP is usually due to hypoxia, which may occur via: A very premature birth Intrauterine virus (TORCH) or other infection/toxicity or source of brain damage Ischemic insults In utero or postpartum hypoxia or ischemia (next slides) In utero or postpartum trauma (next slides) Hypoxia & ischemia Hypoxia and ischemia – in utero ○ kink in the umbilical cord or the cord wrapping around the fetus’s neck ○ maldevelopment of the placenta ○ shock in the mother from an accident. Postpartum hypoxia or ischemia ○ suppression of the respiratory centres b/c of overmedication of the mother; or pneumonia, a collapsed lung or drowning of the infant Trauma Trauma to, or rupture of cerebral blood vessels ○ separation of the placenta ○ difficult or prolonged delivery ○ postpartum head injury from an accident or abuse The brain of a premature baby is particularly susceptible to hemorrhage. Strokes can occur as a result of dehydration. Presentation There is a very wide spectrum of presentations in CP Some are very mild and would be noticed only by HCPs Others are very profound and include significant disability 4 Main Types of Cerebral Palsy 1. Spastic - increased tone; accounts for 75% of all cases (most common) a. Monoplegia: 1 arm or leg b. Diplegic: usually both legs, M/C of spastic form, fully ambulatory scissor gait c. Hemiplegic: 1 side of body, usually most ambulatory d. Quadriplegic: all 4 limbs 2. Athetoid - uncontrolled movement, slow & writhing, increase with intention & stops with sleep, has trouble holding themselves upright 3. Ataxic - poor coordination, least common, due to damage to cerebellum 4. Mixed - usually spastic & athetoid Types of Cerebral Palsy Symptoms Not noticeable in early infancy - become more obvious as nervous system matures ○ Early signs are delayed milestones, persistence of primitive reflexes, in toddlers not walking or forming sentences Spasticity – most common Athetoid movements – slow and writhing Choreiform – movements are quick, uncontrolled and without purpose; do not stop with sleep Ataxia – lack of coordination and clumsiness of movements; ataxia in the face causes grimacing Symptoms Reflex movements – development reflexes not integrated Flaccidity – may be present in the first year or two then change to spasticity or athetoid movement Pain – resulting from muscular, neurological and bony changes; can be acute or chronic Postural dysfunctions – scoliosis (can lead to respiratory difficulties), hyperlordosis, hyperkyphosis Contracture formation – equinus deformity (short Achilles); internal rotation of hip, hip flexion Symptoms Permanent skeletal changes and arthritis Stenosis of cervical spine Osteoporosis Epilepsy, mental development delay and emotional disturbances Compromised tissue health – disuse atrophy >60 yrs; edema → decubitus ulcers Peripheral nerve compression – due to postural imbalances Variety of sensory losses; decreased proprioception Symptoms Perception of pain, temperature and pressure is not affected Speech – dysarthria; can be difficulty swallowing and inability to control saliva Hearing impairment Bowel and bladder function compromised Vision can be normal or limited Frustration and anger Intellect may or may not be affected Classic gait pattern “Scissors gait” due to adductor spasticity Physical exam Here is a tutorial for medical students on evaluating a patient with cerebral palsy. It is included here for you to see real life examples of the signs and symptoms as well as what they look like in assessment. https://www.ninjanerd.org/lecture/cerebral-palsy-physical-exam/ Diagnosis (according to CDC) Developmental Monitoring ○ tracking child‘s growth & development over time Developmental Screening ○ Testing motor or movement delays, lacking milestones ○ Done at 9 months, 18 months, 24 or 30 months Developmental and Medical Evaluations ○ Goal is to diagnose specific type of disorder ○ Evaluation of movement/motor delays - mm tone, reflexes, posture ○ Related conditions like intellectual disability, seizures, vision, hearing, speech problems ○ MFI, CT, X-ray, electroencephalogram (EEG) Treatment There is no cure Treatments such as physical and occupational therapy, speech therapy, drugs to control seizures, 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 Communication Some people with CP are non-verbal or non-communicative. Establishing a method of communication via a carer is most important. Yes / no / stop signal Comfort Pillow and positioning (often in a wheelchair) for support and comfort May need to accommodate high amounts of salivary secretions Massage considerations Systemic outcomes Outcome Indicated treatment Help with inhalation and rib function (particularly if scoliosis) Help with gastrointestinal motility Promote relaxation and comfort Massage considerations Musculoskeletal outcomes Outcome Indicated treatment Decrease edema (lower limb) Decrease contracture formation Decrease pain Promote joint health Promote tissue health Decrease weakness Principles - UMN lesions UMN lesions Symptom Intention Indicated treatment Hypertonia Promote relaxation Inhibitory ROODS Resistance to elongation Promote joint mobility and movement Swedish massage Promote exercise of antagonist muscle PROM Joint play Hyperreflexia Promote relaxation Inhibitory ROODS Clonus Avoid stretching Swedish massage Pathological reflexes PROM Joint play Spasticity Promote relaxation Inhibitory ROODS Overactivity of reflex arc Avoid rapid passive movement Swedish massage Normally in response to movement, Avoid stimulating muscle spindles (avoid stretching) PROM especially rapid passive movement Promote exercise of antagonist muscles and spastic muscles Joint play Promote joint mobility and movement Rigidity Promote relaxation Inhibitory ROODS Unchanging involuntary resistance to Promote joint mobility and movement Swedish massage movement Promote circulation and reduction of edema PROM Can be cogwheel or lead pipe Joint play MLD Weakness Promote relaxation Inhibitory ROODS Promote joint mobility and movement Swedish massage Promote exercise of muscles PROM Joint play Maysoon Zayid Ted Talk https://www.ted.com/talks/maysoon_zayid_i_got_99_problems_palsy_is_just_one?language=en