CEREBRAL PALSY

Rachael Weigand

Overview

Cerebral palsy (CP) is defined as “a group of disorders of the development of movement and posture, causing activity limitation that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of CP are often accompanied by disturbances of sensation, cognition, communication, perception, or behavior, and may be accompanied by a seizure disorder” (Jackson Allen, Vessey, & Schapiro, 2010, p. 326). The damage to the brain is nonprogressive; however, the effects of CP can worsen with time, growth, and maturity.

CP occurs in approximately two out of every 1,000 births and is the most common physical disability in childhood (Kirby et al., 2011). The incidence, prevalence, and most common causes of cerebral palsy vary over time because of continuing changes in prenatal and pediatric care. CP is a chronic disorder affecting multiple different body systems. Many different elements must be dealt with to manage children diagnosed with this disorder, including motor disability.

Background

The classification of CP is based on the type and distribution of the motor disruption. The damage has occurred in the motor cortex and pyramidal tracts in the brain. The severity and distribution of the neurological impairments vary significantly among children. There are four types of movement disorders seen in children with CP. These types are spastic, dystonia, athetosis, and ataxia. Children can fall under a “mixed” category, but only if there is a clear description of each type of movement disorder present (Jackson Allen et al., 2010).

Spasticity is characterized by increased muscle tone and is the most common motor difficulty (Hasnat & Rice, 2015). The signs of spastic CP include persistent primitive reflexes, such as an ongoing Moro reflex, rooting reflex, palmar reflex, exaggerated stretch reflexes, positive Babinski reflex, ankle clonus, and development of contractures as the child grows (Jackson Allen et al., 2010). Spastic CP affects 70% to 80% of children with CP (Delgado et al., 2010). Spasticity can be further broken down based on limb distribution, diplegia, hemiplegia, or quadriplegia.

Diplegia refers to the dysfunction of all extremities with the lower extremities more affected than the upper extremities. Children with spastic diplegia may have relatively intact hand function (Glader & Barkoudah, 2017). Hemiplegia is dysfunction of one side of the body, with the upper extremity more affected than the lower extremity. Quadriplegia refers to all extremities affected by increased muscle tone. These quadriplegic children are often severely handicapped with deficits of intellectual disability, communication, vision, epilepsy, feeding difficulties, and possible pulmonary disease (Glader & Barkoudah, 2017).

40Dystonia is defined as slow and twisting, abnormal movements of the trunk or extremities that may involve abnormal posturing and can remain in that position. Dystonia can occur in dyskinetic CP, but is also commonly present in spastic CP. Dyskinesia is described as abnormal involuntary movements after initiation of voluntary movements. Children experience manifestations of rigid muscle tone when awake, although experiencing decreased tone when asleep or idle. In athetosis, the basal ganglia are damaged that is illustrated by slow, writhing movements. Choreoathetoisis is a form of athetosis that includes erratic, rapid, and random movements (Jackson Allen et al., 2010).

Many risk factors are associated with the development of CP. Risks can occur during the prenatal period, birth, perinatal, childhood, or an unknown period. Prematurity and low birth weight represents the largest risk factors. In addition, risk factors that could be prevented include teratogens and infections during pregnancy. CP is multifactorial, and many risk factors can contribute to its development (Jackson Allen et al., 2010). Lastly, for babies who are born at full term, risks for CP development include placental abnormalities, birth defects, low birth weight, meconium aspiration, instrumental/emergency Caesarean delivery, birth asphyxia, neonatal seizures, respiratory distress syndrome, hypoglycemia, and neonatal infection (McIntyre et al., 2012).

There are many associated problems related to CP, which include disabilities with motor function, cognitive function, feeding and nutrition, bowel and gastrostomy-tube dependence, bladder, dental, osteoporosis, pulmonary, skin, pain, behavioral, and emotional and intellectual disability (Jackson Allen et al., 2010). Epilepsy occurs in about 25% to 45% of patients with CP, and seizures are most commonly seen in spastic quadriplegia and hemiplegia (Glader & Barkoudah, 2017). Children with CP can get tired or frustrated faster than other children without the disorder. Owing to the prolonged reflexes, children can overreact to stimulation much more frequently. They also can become more demanding or uncooperative (Jackson Allen et al., 2010).

Clinical Aspects

ASSESSMENT

The evaluation of children who are suspected of CP begins with a thorough history and physical examination. It is diagnosed based on physical, functional, and developmental abilities. There is no specific test confirming the diagnosis. Clinical manifestations noted are delayed gross motor development, abnormal cognitive performance, alterations of muscle tone, abnormal postures, reflex abnormalities, and other associated disabilities such as learning disability, seizures, and sensory impairment (Jackson Allen et al., 2010).

Specific clinical signs that warrant suspicion of CP include poor head control and clinched hands at 3 months, no side protective reflexes at 5 months, extended Moro and atonic neck reflexes past 6 months, no parachute reflex after 10 months, crossing of the midline to reach objects before 12 months, and hand preference before 18 months (Jackson Allen et al., 2010). Behavioral 41manifestations during infancy such as irritability, weak cry, poor extraction, excessive sleep patterns, and little interest in surroundings may indicate CP. A diagnosis is not given till the child is 18 to 24 months old because of development and the rapid changes that can occur. Research shows that it is difficult to diagnose a specific CP syndrome till around age 5 because many of the developmental milestones have not been reached to see the true delays caused by CP (Glader & Barkoudah, 2017).

NURSING INTERVENTIONS, MANAGEMENT, AND IMPLICATIONS

Children diagnosed with CP may experience impaired physical mobility related to decreased muscle strength and control, sensory/perceptual alteration related to cerebral damage, altered nutrition—less than body requirements related to difficulty in chewing, swallowing, high metabolic needs, and seizure activity. Children may experience ineffective management of therapeutic regimens related to excessive demands made on the family. The children have complex care needs. They may experience diversional activity deficit related to poor social skills, altered learning, language development, and reasoning (Sparks & Taylor, 2011).

The first objective is the early identification of CP and then to accelerate the process of referrals to the proper community resources (Liptak & Murphy 2011). Positive signs of CP that nurses may observe are ongoing primitive reflexes and absent or delayed developmental milestones. Nurses need to be aware of the basic red flags that indicate CP.

Basic management of children with CP requires a patient and family-centered medical home, physiotherapy, physical therapy, speech therapy, occupational therapy, and orthotics. Treatment goals are aimed at promoting social and emotional development, communication, education, nutrition, mobility, and maximal independence in activities of daily living (Glader & Barkoudah, 2017). After proper assessment of the child and his or her needs, interventions should be implemented beginning with the least invasive method. Studies show that effective treatments include medications; functional therapies, including physiotherapy, occupational therapy, speech therapy, and constraint-induced movement therapy; orthoses, casting and splinting; weight-bearing exercises; and multilevel orthopedic surgery (Jackson Allen et al., 2010).

A primary goal of management is to increase the child’s function. Nurses should promote optimal growth and development, maximize the joint range of motion, optimize muscle control and balance, provide means of communication, means of locomotion, and promote childhood independence (Jackson Allen et al., 2010). Research has also shown that the combination of interventions from all areas of management can improve a child’s function, self-care, and activities of daily living.

OUTCOMES

Children with CP often struggle with dysphagia and therefore may not meet nutritional requirements (Liptak & Murphy 2011). A child’s ability to feed himself or 42herself can range based on the severity of the child’s condition. The degree of oral motor function, however, may require tube feeding. Gastroesophageal reflux disease (GERD) is also common in children with this condition, and nurses should assess risk for aspiration. Educating families on this issue as well as appropriate posturing when eating is a key intervention. Drooling can be excessive and persistent in children with CP. Psychosocially, the excessive drooling can be embarrassing. Working with the children to help them swallow, remind them how to swallow, and assessment of posture (i.e., head control, positioning, and mouth closure) can help maintain the secretions.

Evidence shows that high-quality health care for children with CP depends on collaborations among parents, health care providers, including dentists, and community agencies (i.e., educational services, recreational programs, and parent groups) with ongoing monitoring of the child’s health and function (Liptak & Murphy, 2011, p. e1324). Optimizing health and well-being for children with CP and their families involves family-centered care provided in the medical home (Liptak & Murphy 2011). If an infant or child is hospitalized, the nurse should maintain the at-home regimen as much as possible.

There are a variety of notable responsibilities that a parent must take on when raising and caring for a child with CP. The first aspect addressed is the psychological effect on siblings and parents. There is a direct impact on the quality of life that affects the family members of the child who is suffering from CP. The family often requires psychological help and support. The nurse should help guide children and their families in the right direction to help find a strong support system, including parent support and advocacy groups, respite programs, and community programs for recreational and adaptive sports (Liptak & Murphy 2011).

Summary

CP is the most common motor disability condition in children and adolescents. It represents a distressing and difficult condition that is experienced by a multitude of families throughout the world. However, with proper treatment and care, this disease can be combatted to preserve a high level of function and a suitable quality of life. Providers and families affected by this disease must work together to treat diagnosed children with the utmost personal, financial, and medical responsibility.

Delgado, M. R., Hirtz, D., Aisen, M., Ashwal, S., Fehlings, D. L., McLaughlin, J., . . . Vargus-Adams, J. (2010). Practice parameter: Pharmacologic treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology, 74, 336–343. doi:10.1212/WNL.0b013e3181cbcd2f

Glader, L., & Barkoudah, E. (2017). Clinical features and classification of cerebral palsy. In C. A. Armsby, UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-features-and-classification-of-cerebral-palsy

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