cerebral palsy
ABBR: CP
An umbrella term for a group of nonprogressive but frequently changing motor impairment syndromes secondary to lesions or anomalies of the brain arising in the early stages of its development. CP is a symptom complex rather than a specific disease. For the vast majority of children born at term in whom CP later develops, the disorder cannot reasonably be ascribed to birth injury or hypoxic-ischemic insults during delivery. CP rarely occurs without associated defects such as mental retardation (60% of cases) or epilepsy (50% of cases). CP is classified by the extremities involved and the type of neurological dysfunction present, such as spastic (50%), hypotonic, dystonic, athetotic (20%), ataxic (10%), or a combination of these. Early recognition and promotion of optimal development assist the child to realize his or her potential.
Incidence: In the U.S., about 10,000 children are born each year with CP.
Causes: Risk factors have been divided into several groups: those factors occurring before pregnancy, such as an unusually short interval (less than 3 months) or an unusually long interval since the previous pregnancy; those factors occurring during pregnancy, including physical malformations, twin gestation, abnormal fetal presentation, fetal growth retardation, brain asphyxia during labor and delivery, intracranial bleeding, cerebral dysgenesis (malformation of brain cells and tracts and often resulting from genetic anomalies or exposure to toxic substances), disorders of myelin; maternal or fetal infections, or maternal hypothyroidism; and perinatal factors such as prematurity, premature separation of the placenta, or newborn encephalopathy. Nonetheless among infants with one or more of these risk factors, 95% do not have CP.
Symptoms and Signs: All infants and children, esp. those at risk for CP (low birth weight, low Apgar scores at 5 min, seizures, metabolic disturbances), are assessed for delays in attaining developmental milestones. This type of assessment can provide valuable clues to recognizing CP. CP should also be suspected in infants who have difficulty sucking or keeping a nipple or food in their mouths; who seldom move voluntarily or have arm or leg tremors with voluntary movement; who cross their legs when lifted from behind rather than bicycling or pulling them up; or who have legs that are difficult to separate (making diapering problematic).
Diagnosis: It is not possible to diagnose CP in the neonatal period, and early clinical diagnosis is complicated by the changing pattern of the disease in the first year of life. Many patients have impaired swallowing and /or drooling. Impaired speech is present in about 80% of these children, and many also have dental abnormalities, deficits in vision and /or hearing, and reading disabilities.
Treatment: Therapy is directed to maximizing function and preventing secondary hand icaps. Essential to the outcome of patients with CP is establishing good hand function, which helps compensate for other motor deficits. Broad therapeutic goals include establishing locomotion, communication, self-help, and gaining optimum appearance and integration of motor functions; correcting associated deficits as effectively as possible; and providing educational opportunities adapted to the individual child's needs and capabilities. Antianxiety agents may be employed to relieve excessive motion and tension. Botulinum toxin helps to reduce contractures. Skeletal muscle relaxants may be given to decrease spasticity. Anticonvulsants are used for children experiencing seizure activity, and dextroamphetamine may improve performance in hyperactive, dyskinetic children.
SEE: Nursing Diagnoses Appendix.
Patient Care: The individualized therapeutic plan usually involves a variety of settings, facilities, and specially trained personnel, including the parents, who are taught to hand le their child's condition properly. A specially trained physical therapist designs an individualized program of exercises and other treatment modalities to meet the child's specific problems and needs and to stimulate the child to achieve functional goals. A speech therapist is an important team member and initiates speech training early before the child develops poor communication habits. Eye and ear specialists deal with visual and auditory deficits. Dental care is esp. important and should start as soon as teeth erupt. Braces and other mobilizing devices help prevent or reduce deformities, control alignment, and permit self-propulsion. An orthopedic surgeon intervenes when spasticity causes progressive deformities. Nurses in pediatric facilities and community settings are involved in all aspects of therapeutic management and provide support and encouragement. They teach the child (as appropriate) and the parents about the desired and adverse effects of any medications used in the therapeutic regimen.
A wide variety of technical aids are available to help improve the child's function. They include electromechanical toys, microcomputers, voice synthesizers, and other devices the child can control. Passive range of motion, stretching, and elongation exercises are valuable at any age. Training in activities of daily living and manual skills is based on the child's developmental level and functional abilities. Manual activities are started early to improve the child's motor function and to provide sensory experiences and environmental information. The child is encouraged to feed himself or herself, using specially designed utensils and placing food well back in the mouth to aid swallowing. A high-calorie diet should be provided to meet the child’s high-energy status. Thoroughly chewing food, drinking through a straw, and sucking on lollipops all help in developing muscle control, and minimizing drooling. Washing and dressing independently are also encouraged, with clothing modified to aid this independence rather than carrying out these tasks for the child. Parents are taught to assist only when necessary and then in an unhurried manner because hurried movements tend to increase muscle spasticity. Play is incorporated into the therapeutic program.
The child's needs and potential determine his or her educational requirements, which range from attendance at regular school to special classes or facilities designed to meet his or her needs. The teaching team develops an individual educational prescription (IEP), which they communicate to parents and others involved in the child's learning. Special Olympics and other community programs can enable the child to participate in competitive sports, adding an extra dimension to physical activities. The child should also be encouraged to participate in artistic programs, games, and other activities. Parents should be advised against overprotection and helped to recognize the child’s need to establish relationships with other children. A valuable intervention on the part of health care professionals is providing the family with emotional support, helping them to cope with the disorder and to connect with other families. Parent groups share concerns and problems and provide practical information as well as comfort. United Cerebral Palsy Association Inc. (800-692–4453 [cerebralpalsy.org]) provides a variety of services for children with CP and their families. Local chapters can be contacted through a local telephone directory or health department.
Throughout treatment, health care providers and the child's family continually reassess and evaluate the child's status by observing movements and speech, self-care and other activities, school attendance and performance, interactions with others and choice of activities, and behaviors and responses to challenges. The child and family are interviewed regularly about their feelings and concerns and are supported in coping with the condition.