Cerebral Palsy Revalida Format

CASE: CEREBRAL PALSY DEFINITION: -A neurological disorder cause by a non-progressive brain injury or malformation that occurs while the child’s brain is under development. It primarily affects body movement and muscle coordination. P-ermanent

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O-thers (chicken pox) R-ubella (german measles) C-ytomegalovirus H-erpes Zuster PERINATAL

-asphyxia -intraventricular hemorrhage -preeclampsia

NP-on progressive (one time insult)

-respiratory prematurity

M-anageable

-sepsis/ CNS infection

EPIDEMIOLOGY:

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-most common disabling conditions affecting children

-CHORIOAMNIONIEIS

-1.5—4 per 1,000 live births - 30% among African-Americans -lower socioeconomic class= increased risk factor of CP - estimated that each year, 8,000 infants and 1,200 to 1,500 preschoolage children are diagnosed with cerebral palsy (United Cerebral Palsy Research and Educational Foundation, 2001) ETIOLOGY:

-fever during labor -bleeding -Placental infection 

POSTNATAL

-anoxia -toxin exposure -traumatic head injury -viral or bacterial meningitis BASIC MEDICAL SCIENCES: AREAS OF THE BRAIN AFFECTED:

-infections -inflammation -PREMATURITY COMMON)

(MOST

PRENATAL

-very low birth weight - infections -cytomegalovirus -evidence of stroke -chromosomal abnormalities -radiation exposure -twin or multiple pregnancies -

S-yphillis T-oxoplasmosis meat)

of

MATERNAL RISKS:

 GENERAL CAUSES:

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disorders

(uncooked

Cerebral palsy affects the cerebrum, the largest portion of the brain. The cerebrum controls voluntary movements, thinking, reasoning and emotions, as well as some specialized functions such as visual processing, speech and hearing. Damage often occurs to the cerebral motor cortex, a portion of the brain that lies at the back of the frontal lobe just before the fold that separates the frontal lobe from the parietal lobe. The abnormalities in the cerebral motor cortex disrupt the brain's ability to control both movement and posture. This results in the characteristic symptoms including a lack of muscle coordination, stiff or tight muscles, walking on the toes, muscles that appear too tight or too floppy, tremors and difficulty with precise movements. The severity of

cerebral palsy varies depending on the extent of the damage to the cerebral motor cortex. Patients with mild cerebral palsy may exhibit slightly awkward movements, while severe cerebral palsy results in the inability to walk.

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o H-erpes Zuster Perinatal o Bridge birth(butt first) o Lack of oxygen in the brain Postnatal o Falls o Trauma

SIGNS AND SYMPTOMS: -

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PATHOPHYSIOLOGY: (diagram)

1. hypoxia 2. intracerebral hemorrhage 3. Hyperbilirubinemia Grading for Severity of Pathology Grade I - isolated subependymal hemorrhage Grade II - bleeding into the ventricle without dilation Grade III - bleeding into the ventricle with dilation Grade IV - intraventricular hemorrhage with ext to the surrounding mater parenchyma -

Prenatal o Maternal History o S-yphillis o T-oxoplasmosis (uncooked meat) o O-thers (chicken pox) o R-ubella (german measles) o C-ytomegalovirus

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Tone Abnormalities o Either decreased, increased or fluctuating movements o Fluctuating tone shifts in varying degrees from hypotonic to hypertonic o Hypo(dyskinesia) o Hyper(spastic/rigid) Reflexes Abnormalities o Retained primitive infantile reflexes o delay in the acquisition of righting and equilibrium reactions occur o hypotonia (areflexia) Postural abnormalities o hypertonicity in the lower extremities=often lies supine with the hips internally rotated and adducted and the ankles plantar flexed o hypotonicity= typically lies with the hips abducted, flexed, and externally rotated because of low muscle tone, weakness in the affected muscles, and the influence of gravity Delayed motor development(universal sign for CP) o delay in the child’s ability to sit independently o often not recognized until the child fails to achieve these early motor milestones. Atypical motor performance o Child may demonstrate a variety of motor abnormalities such as  asymmetrical hand use  unusual crawling method or gait  uncoordinated reach

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difficulty sucking chewing swallowing

 Spastic Quadriplegiao Entire body in involved o UEspasticity on flexor muscles; LEspasticity on extensor muscles

CLASSIFICATIONS: -

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Topographical distribution (body part/ motor function classification system) o Mono-one limb o Diplegia-severely involve LE, less affectation of UE o Hemi-one side of the body o Para-only LE (cognitively okay) o Tri-three extremities involved o Tetrafour (3 parts severely affected, one part less) Classification according to Movements disorders: o Spastic o Athetoid o Ataxic

Spastic     

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Hypertonicity Most common (70-80% of the cases of CP) Result of Upper Motor Neuron Involvement Retained primitive reflexes in affected areas of the body Impact on motor function: o Mild impairmentdoes not interfere with functional limits o Severe – Inability to reach and grasp Contractures leading to deformity are common

Categorized Anatomically:  Spastic Hemiplegia – o One entire side of the body including neck, head and trunk. o UE is usually affected o Early signs – dragging one side of body  Spastic Diplegia – o Both LE, o mild coordination, tremors or less severe in UE o Bunny hop- rely on the arms for support

Dystonia -Abnormality in muscle tone Athetosis Most common type of dyskinesia or dystonia  Slow, Writhing involuntary movements  Involuntary and uncontrolled movements  10-20% of the cases of CP  Basal Ganglia involvement Choreiform 

 Abrupt, Jerky distal movements Ataxia    

Unsteadiness and difficulties with balance Involvement of Cerebellum Much less common Characterized by: o Wide-based, staggering, unsteady gait o Walk quickly (compensate for lack control and stability) o Clumsy controlled movements o Intention Tremors

Gross motor classification system

function

Level 1: walks without restriction, limitations in high level skills • Walks independently by age 2 years without devices • Walks as preferred mobility by age 4 • Difficulty with speed, coordination, and balance for high-level tasks Level 2: walks without devices, limitations walking outdoors • Sits with hand support by age 2 • Crawls reciprocally or walks with device as preferred mobility by age 4

• Uses hands to get up from the floor or a chair by age 6 • Walks without devices indoors by age 6 Level 3: walks with devices, limitations walking outdoors • Sits with support by age 2 • Cruises by age 4, walks with device short distances • Does stairs with help by age 6 • Walks indoors with a device by age 12

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-Children typically develop motor skills craniocaudally. A child will first develop neck control, then upper trunk control, and then lower trunk control. DIFFERENTIAL DIAGNOSIS: 

Traumatic brain injury is one of the leading causes of acquired disability and death in infants and children. Falls and motor vehicular accidents are common unintentional causes. Children are more vulnerable to injury through deformation and fracture of the skull, thus causing injury to the brain. In children, some neurologic deficits after head trauma may not manifest for many years. Impairments of children with TBI occur at different degrees. Symptoms can vary greatly depending on the extent and location of the brain injury. Some symptoms include spasticity of muscles, motor incoordination, fatigue, impairment in communication skills, balance problems, and short-term memory deficits.

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Stroke can also occur in children. Pediatric stroke is one of the leading causes of death in children. Children who suffer from pediatric stroke have a high chance of developing cerebral palsy. Perinatal, neonatal, infant and childhood stroke are some of the most common causes of hemiplegia, hemiparesis, or hemiplegic cerebral palsy in children. Like adults, pediatric stroke fall into two categories: hemorrhagic and ishemic. Children are equally at risk for both of these types. It is difficult for the child to express when they are experiencing something since pediatric stroke mostly occur in children less than one year old.

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Muscular Dystrophy may also be mistaken for cerebral palsy

Level 4: limited mobility, power mobility outdoors • Rolls by age 2 years • Sits with hand support by age 4 • May walk short distances indoors with device, poor balance • Preferred independent mobility is a wheelchair by age 12 Level 5: very limited self-mobility, even with assistive technology • Needs help to roll by age 2 • Does not attain independent mobility by age 12 • With high-level assistive technology, may learn to use power mobility COURSE AND PROGNOSIS:  MOLNAR PROGNOSTICATION INDEX  Based on the type of CP o Best- spastic hemiplegia or ataxia o Poor-quadriplegic  Based on onset of sitting o Good- if px can sit by 2 years o Fair- if px can sit between 2-4 years o Poor- if px cannot sit by 4 years old  Based on onset of standing o Good- if px can stand by 4 years old o Fair- if px can stand bet. 4-6 years old o Poor- if px cannot stand by 6 years old  BLECK’S PROGNOSIS: o Good- if at 1 year old there is (+) parachute reflex and no primitive reflex.

Fair- if at 1 year old there is (+) parachute and 1 primitive reflex Poor- if at 1 year old there is (+) parachute reflex and 2 primitive reflexes

but in muscular dystrophy, there is no spasticity, but patients can develop contractures. There are various subtypes, including Duchenne's, Becker's, and limb girdle. Child may be weak at birth or may have apparent normal development until approximately 3 years of age followed by a progressive loss of function and muscle weakness. There may be a positive family history. Examination reveals a positive Gowers' sign with regression of walking ability. Becker's type is less debilitating and manifests later in childhood. Limb girdle type may not present until late teens or 20s. 

With familial/primary dystonia, onset of muscular deformity occurs after several years of normal development. It presents with sustained periods of muscle contraction and dystonia but without development of contractures. There may be abrupt and violent movements. Patients may even sit on their limbs. This may be mistaken for the dyskinetic type. Determining tests may be done as this condition has positive family history.

LAB TESTS: -

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Magnetic resonance imaging (MRI) or computed tomography (CT) scan : o provide evidence of hydrocephalus o help determine the location and extent of structural lesions o help rule out other conditions Electroencephalogram (EEG)used to determine the cause of cerebral palsy but should be obtained if there is an indication that the child may be having seizures.

SPECIAL TESTS:  Reflex Testing – M – Moro reflex

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A – ATNR S – STNR S – Stepping reflex P – Parachute reflex E – Extensor thrust N – Neck righting on body

MEDICAL/PHARMACOLLOGICAL MANAGEMENT: - Oral medications used to reduce spasticity in severe cases with mixed results such as: o diazepam (Valium) o dantrolene (Dantrium) o baclofen have been. -

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Intrathecal caclofen infusion (ITB) administered through a pump implanted in the abdominal wall to the spinal cord fluid= more effective than oral medications in reducing severe spasticity and dystonia in cerebral palsy. injection of botulinum toxin (Botox) into muscles. o Spasticity is reduced for a period of 3 to 6 months after injection. o Botox is injected into specific muscles, which, in addition to reducing tone, increases range of motion and reduces deformities as well as provides an opportunity to work on muscle strengthening. o Minimal side effects, however, its long term effectiveness on function

SURGICAL MANAGEMENT: 1. Gastroenterology Surgery a. Nasogastric tube – tube placed through the nose to introduce food to the stomach b. Gastrostomy tube – tube inserted through the abdominal wall to the stomach allowing uninterrupted feeding 2. Hearing Surgery a. Hearing aids – amplify sounds without distortions b. Radio aids – the use of microphone and transmitters

3. Medicine Related Surgery a. Baclofen Pump – a device about the size of a hockey puck implanted in the abdomen that is connected to the spinal cord with a thin tube that threads under the skin b. Lumbar puncture 4. Neurosurgery a. Baclofen Pump b. Selective Dorsal Rhizotomy – a procedure where 30-50 percent of sensory nerves are cut to decrease spasticity 5. Orthopedic Surgery a. Any surgery that is done on bones, ligaments, joints, tendons, muscles and nerves i. Considered as last resort when other less invasive treatments and therapies have been exhausted ii. The focus is to manage impairment, control pain, optimize independence and self-care, maximize movement, balance and coordination and maintain functionality. OT APPLICATION FOR’S: NDT -

To facilitate normal pattern of movements and postural tone and inhibits spasticity.

Developmental -

assists the child in achieving mastery of life tasks and the ability to cope as efficiently as possible with the life expectations made of him or her through the mechanisms of selected input stimuli and availability of practice in a suitable environment.

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used to identify if child’s skills are at par with child’s age help in identifying the appropriate activities given during intervention

Acquisitional -

Focuses on skill acquisition for optimal performance in the environment. Allows the child to acquire and learn the skills the child needs to participate in the different occupations.

Rehab -

Allows the person to perform the different occupation through the use of compensatory strategies, adaptive devices and environmental modifications.

OT EVALUATION: o o o o o o o o o o

Modified Ashworth Scale (MAS) Goniometry Manual Muscle Testing Reflex Testing WeeFIM Sensory Integration and Praxis Test (SIPT) Pediatric Evaluation of Disability Inventory (PEDI) Quality of Upper Extremity Skills Test (QUEST) Functional Independence Measure School Function Assessment

OT ASSESSMENT: o

OCCUPATIONS AND ACTIVITIES AFFECTED:  Self-care: -Child usually has difficulty performing basic activities of daily living such as eating independently, dressing, toileting, grooming and hygiene, and lacks the ability to be mobile. -Child usually needs assistance to develop and achieve independent living status.  Productivity: -Child’s play skills may be delayed due to lack of

exploratory play behaviour. -Child may need assistance in adapting the working environment to his or her own abilities. Child may have difficulty with schoolwork such as learning how to read and how to write.  Leisure -Child may need assistance in exploring leisure options -Child may need assistance in adapting the leisure environment to his or her own abilities  Cognitive -Child may have learning disabilities related to perceptual disorders -Child may have difficulty in learning due to mental retardation  Psychosocial -Child may become depressed and express feelings of hopelessness and helplessness -Child may have poor self-image and low selfesteem -Child may have inadequate coping skills and become easily frustrated -Child may have limited opportunities for self-expression -Child may have difficulty developing social relations OT INTERVENTION  Self-care -Promote oral motor skills to facilitate feeding -Suggest clothing adaptations that may facilitate independent dressing positions that during dressing

-Suggest various promotes stability

-Suggest adaptive equipment that may facilitate activities of daily living such as bolsters, wedges, aids for standing and side lying,

adapted chairs, mobility aids.

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 Productivity -Increase opportunities for play development. Adapted toys and computer aided games and toys may expand the child’s play environment. -Encourage parents, caregivers or teachers to assign responsibilities and duties for child to perform -Explore vocational interests and career options -Encourage development of independent living skills

 Leisure -Explore leisure interests -Develop leisure skills by providing opportunities to participate in activities.  Cognitive -Increase attending behavior and attention span. -Instruct the child to instruct others regarding need for assistance. -Use of computers may facilitate learning tasks and improve the person’s ability to function.  Psychosocial -Provide a safe environment in which the person can experience movement without fear. -Provide opportunities for socialization. -Assist in development of functional communication and language skills. -Help the family identify community resources. -Facilitate improvement of self-image`

-Encourage development of social skills. 

Eight general methods inhibit spasticity:

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o Passive elongation o Limb dissociation

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o Normal weight shifts o Normal limb movements free in space

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o Positioning o Orthotics

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o Reflex-inhibiting patters. These methods are administered in three stages: o First stage: §

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To use handling techniques to give the sensation of what normal tone and movement feel like

o Second stage:

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§ To let the patient initiate movement during a purposeful activity while the occupational therapist maintains inhibition or facilitation o Third stage: § To fade control from proximal key points of control, like the scapula or pelvis, to distal key points of control, like the hand or foot. 

Adaptive devices o Use of a jelly bean switch which is a single switch to those patients who can only perform movement such as press and release to a switch. o Use of zipper pull to compensate for difficulty in stabilizing the hand.

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Use of alternative and augmentative communication to patients who has difficulty in speaking verbally such visual bridges. Use of keyguard when patient has difficulty in pressing on or more keys on the keyboard. Use onscreen keyboard and mouse for typing when the patient has the ability to use one hand. Use of page “fluffers” such as foam, sponges, giant paper clips, clothespin to provide physical access to the texts in books. Use of book holders for stabilization. Change the font size and color, magnification, contrast for patient with visual-perceptual problems.

Orthotics o Use of splint such as AFO, KAFO, resting hand splint, dynamic splint, wrist cock-up splint, antispasticity and deformity splint to improve function and reduce or prevent deformity. Environmental modification o Provide grab bars in private bathroom to facilitate safety of the patient. Wheelchair modification o Detachable leg rests to facilitate w/c transfers o Arm trough for upper extremity to facilitate w/c proper positioning Adapted procedures o Propel w/c using sound arm and leg to substitute for loss of lower extremity ROM Safety education

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Use verbal cues to attend to affected side to compensate for hemianopsia. Turn on cold water before hot to compensate for sensory loss of limbs.

Roles of OT The roles of an occupational therapist in treating a client with Cerebral Palsy are the following: -

To improve function, develop compensatory strategies, and encourage independence

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To achieve optimal development

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Provide early intervention

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Improving infant-caregiver interaction, family support for coping, and home modifications

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Provide age-appropriate play levels

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Parental education for handling a child at home

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Promoting motor and other developmental skills