Cerebral Palsy: A Permanent Neurological Disorder Affecting Body Movements and Muscle Coordination

An Outline

Etiology/ Pathophysiology

-Disorder of brain and nervous system functions

-affecting movement, coordination and posture

-usually during first few years of life

-Types include spastic, dyskinetic, ataxic, hypotonic, and mixed

-Most cases exist before birth in womb

-Infections such as rubella, varicella, toxoplasmosis, syphilis, or meningitis

-Congenital abnormalities of insufficient oxygen during birth, abnormal gene mutation or exposure to teratogens.

-Strokes due to blood clots or leakage of blood into brain

-Jaundice

Diagnositc/ lab tests

-Neurological exam

-Blood tests: platelet counts and metabolic

-CT scan, MRI and EEG of the head

-Hearing screen and Vision testing

Signs and symptoms

-Primary ones (in spastic)

-Loss of movement and weakness in muscles leading to paralysis

-Very tight muscles that do not stretch

-Abnormal gait with tendency of knees to cross and touch, walk on toes, and arms tucked in laterally to hips

-Other brain and nervous system symptoms

– dysarthria

-Hearing or vision problems

-Seizures

-Other general symptoms:

-Increased drooling along with problem swallowing

-Slower than normal growth

-Irregular breathing

-GI distress and urinary incontinence

Pharmacology

-no cure for this disorder at present

-Anticonvulsants and muscle relaxants for seizures

-Botulinum toxin type A (Botox) to help with spasticity and drooling

-Muscle relaxants such as Baclofen to reduce the intensity of tremors and spasm

Life Impact

-Bone thinning or osteoporosis, injuries from falls, hip dislocation and join contractures

-premature aging

-Pneumonia caused by choking

-Social stigma and reduced communication skills and possible decreased intelligence

–Scoliosis

-Seizures

Treatment

-Treatments are based on specific symptoms that are manifested

-Self and home care include:

-Consuming sufficient amount of food and nutrition

-For bowel issues stool softeners, fluids, and fiber rich foods

-Protecting the joints from injury

-Daily exercises

-When learning and communication issues exist:

-Glasses and hearing aids

-Muscle and bone braces

-Walking aids such as walkers and wheelchairs

-Surgery if:

-Regulate gastroesophageal reflux

-Operate on nerves from the spinal cord to lower the intensity of pain and spasm

-Place feeding tubes

-Release joint contractures

Cerebral Palsy – Affecting Movements and Coordination

Cerebral Palsy is a disorder that primarily affects the body’s movement, coordination and posture. It is caused by brain damage during perinatal period and thus could also be accompanied by deficits in intellect and learning skills. This non-progressive neurological disorder is considered “the most common permanent physical disability in the childhood” and nearly 10,000 babies develop it every year in the United States (Rosdahl & Kowalski, 2008, p. 1083).

Etiology and Pathophysiology

The word cerebral refers to the two cerebral hemispheres of the human brain that regulates motor regions and palsy refers to impairment or a paralysis. Cerebral Palsy develops during perinatal period during which the baby’s brain is trying to develop. In the womb, the fetus could suffer from mother’s Pregnancy Induce Hypertension, teratogens, abnormal gene mutations, anoxia, Rh blood incompatibility, and infections such as rubella, varicella, and, meningitis. During the birth, the baby could suffer head traumas, strokes due to blood clots or hemorrhage in the brain, premature or very low-birth weight, and abnormal attachment to placenta. After birth, the baby could suffer from all these abnormalities in addition to jaundice from high levels of bilirubin and metabolic abnormalities such as hypoglycemia (Gould, 2002, p. 492). All these can cause impair the extrapyramidal motor system of then brain but could also potentially cause the additional tissue losses in other areas leading to more variable signs and symptoms (Silvestri, 2005, p. 349).

Signs and Symptoms

Cerebral Palsy is not a muscular disorder, but a neurological disorder causing impairments in muscle movements. Therefore, its signs and symptoms are not limited to muscle weakness, joint contracture, paralysis, difficulty with precise motions such as buttoning of shirts and abnormal gait symptoms of walking on toes, with knees crossing each other or arms tucked in toward the sides. They are however the primary signs of spasticity, which is the most common type of Cerebral Palsy. Cerebral Palsy’s brain and nervous system symptoms include seizures, motor speech disorder of dysarthria, learning disability and problems with hearing and vision. Other general symptoms that may be confused with other disorders include urinary incontinence, gastrointestinal distress causing constipating and vomiting, irregular breathing and drooling, and slower rate of growth. These signs and symptoms become very noticeable as child reaches their infancy; therefore, Cerebral Palsy is often diagnosed at early age (Hoch & Kaneshiro, 2009).

Diagnostics and Lab Testings

Even though the Cerebral Palsy signs and symptoms start to manifest between age 1 and 2, it remains difficult for clinician to diagnose the disorder before the child reach 5 years of age. This is due to very subtle differences of brain anatomy and motor movement capabilities of an infant with Cerebral Palsy and the one without. Majority of the diagnostic testings are done on head to view the brain. They include ultrasound technique to view brain images using high frequency waves, CT scan taking X-ray images of the brain from various angles to produce a cross-sectional view, MRI using magnets and radio waves to create detailed brain image, and EEG using electrodes to receive information about electrical signals exchanged between different parts of the brain. Blood tests are usually not required for Cerebral Palsy diagnostic; but sometimes they can help to rule out or understand the etiology such as stroke – too much blood can cause hemorrhagic stroke and too little can lead to ischemic stroke. Normal platelet count for children ranges between 150,000 and 400,000 platelets per microliter. Blood test can also help screen for metabolic values such as glucose or calcium levels, which are necessary for normal growth and development and sometimes deficient in child with Cerebral Palsy (MayoClinic Staff, 2008). These supplemental tests can be useful in determining medications which can be indicated and contraindicated.

Treatment and Interventions

Since there is no cure for Cerebral Palsy, treatment and interventions can be used to help reduce the symptoms and other associated complications.

Pharmacological Treatments 

Muscle relaxants such as Baclofen can be used as an anticonvulsant and help relax muscles with tremors and spasms. But it can cause rare but serious adverse effects with swallowing and breathing (MayoClinic Staff, 2008). Many of these muscle relaxant drugs can cause side effects such as dizziness, drowsiness, fatigue and weakness; therefore, it is important to observe the patients for these symptoms. It is also recommended to assess the muscle spasticity before, during and after the administration of this drug (Deglan & Vallerand, 2008).

Non-pharmacological Interventions

When Cerebral Palsy is severe enough, surgery may be deemed necessary in cases when it is important to regulate gastroesophageal reflux, place feeding tubes in those who have problem swallowing, and operate on spinal cord nerves to lower the intensity of pain and spam, and relieve join contractures (MayoClinic Staff, 2008).

Nursing Interventions based on Life Impact

As a nurse, we can only treat signs and symptoms within our scope of practice. But it doesn’t limit the interventions we can apply to help people with Cerebral Palsy as this neurological disorder impacts life in wide ranges from delayed gross development, feeding difficulties from dysphagia, bone thinning, premature aging, to social stigma associated with reduced communication skills and possible intelligence deficit. For that reason, nurse will have to use a multi-disciplinary approach by involving occupation, speech, education, recreational and physical therapies within the care plan. Assess vision and hearing losses, and offer glasses and hearing aids if prescribed one. With gait issues, apply recommendations from physical therapists about using walkers and wheel chair. Encourage the child to communicate in his or her developmental age level rather than chronological age to be able to better interact with others. Provide a safe and secure environment by removing hazardous objects from the surroundings for those who are at risk for falls; wearing protecting helmet can be helpful for Cerebral Palsy patients to prevent injuries from seizures. Assess nutrition intake and offer thicken liquid and pureed diet according to dietician and physician recommendations for those with dysphagia. Offer braces, cushions, and supportive devices for any extremities that is recommended by therapists (Silvestri, p. 349).

Alternative Therapy

Neuromuscular Electrical Stimulation (NMES) is an electrical stimulation of nerves and muscles. It is commonly used for muscle weakness caused by disuse atrophy in adjunct physical therapy (Lucinda Baker, 2000). It is also known as Therapeutic (threshold) Electrical Stimulation (TES). It is used by trained clinicians, usually neurologists, to observe the electrical stimulation generating a neuromuscular feedback. Luigi Galvan, an Italian Physician, was the first person used electrical stimulation from a surgical instrument using battery to make a frog’s muscle twitch in 1770 (Geral E. Loeb, 2005). In 1961, Dr. Wladmir Liberson proposed the use of electrical stimulation to treat footdrop in patients. In 1998, NESS (Neuromuscular Electrical Stimulation System) device was developed in Israel to reduce spasticity and strengthen the muscles (Judy Itzkovich, 1998). Its benefits include reduction in spasticity and risk of aspiration, improved ROM functioning and muscle strengths, and improvement in swallowing. It is contraindicated in Patients with pacemakers, pregnancy, epilepsy, cancerous tissue on the region and severely demented people who aren’t able to follow the directions.

In a pilot research study that was published by Northwestern University in Chicago, NMES was shown to help improve the muscle movements in people affected by Cerebral Palsy (Kamper, 2006). Subjects in this study were able to increase their voluntary wrist extension ROM on average by 14 degrees in six weeks and 34 degrees after three months of the therapy.

References:

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Rosdahl, C. B., & Kowalski, M. T. (2008). Textbook of Basic Nursing (9th ed., pp. 1083-1084).

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