Cerebral Palsy

 
Cerebral palsy is one of the most complexes of the common permanent disabling
conditions. Research in this area is directed at adapting biomedical technology to
help people with cerebral palsy cope with the activities of daily living and
achieve maximum function and independence. Cerebral palsy is a disorder of
movement, muscle tone, or posture that is caused by damage that occurs to the
immature, developing brain, most often before birth.
 
Patient Information:
 
The patient is a 19-year-old male. Her mother verbalized that the patient was
exhibiting loneliness at home. The patient required social stimulation as well as
daily assistance with his activities in daily living. The patient and his mother just
recently moved from Kingston. His mother added that she was looking for a local
agency that will connect her son with others and provide the supports needed. 
 
Analysis of the case:
 
The relevant information that we can get from the case presented is the following -
signs of loneliness, the requirement of social stimulation, and the need for
assistance in carrying the daily living activities. We will also try to find out how the
environment can affect the patient. Now we will analyze, relate, and categorize
these manifestations, and come up with our management plan for the patient.
 
Let us first understand the disease by knowing its pathophysiology:
 
Pathophysiology
 
Given the complexity of prenatal and neonatal brain development, injury or
abnormal development may occur at any time, resulting in the varied clinical
presentations of cerebral palsy (whether due to a genetic abnormality, toxic or
infectious etiology, or vascular insufficiency).
 

 Cerebral injury before the 20th week of gestation can result in a neuronal
migration deficit.
 Injury between the 26th and 34th weeks can result in periventricular
leukomalacia (foci of coagulative necrosis in the white matter adjacent to the
lateral ventricles).
 Injury between the 34th and 40th weeks can result in focal or multifocal cerebral
injury.
 Brain injury due to vascular insufficiency depends on various factors at the time
of injury, including the vascular distribution to the brain, the efficiency of cerebral
blood flow and regulation of blood flow, and the biochemical response of brain
tissue to decreased oxygenation.
 Before term, the distribution of fetal circulation to the brain results in the tendency
for hypoperfusion to the periventricular white matter.
 Hypoperfusion can result in germinal matrix hemorrhages or periventricular
leukomalacia.
 Between weeks 26 and 34 of gestation, the periventricular white matter areas
near the lateral ventricles are most susceptible to injury.
 Because these areas carry fibers responsible for the motor control and muscle
tone of the legs, injury can result in spastic diplegia (ie, predominant spasticity
and weakness of the legs, with or without arm involvement to a lesser degree).
 At term, when circulation to the brain most resembles adult cerebral circulation,
vascular injuries at this time tend to occur most often in the distribution of the
middle cerebral artery, resulting in a spastic hemiplegic cerebral palsy.
 However, the term brain is also susceptible to hypoperfusion, which mostly
targets watershed areas of the cortex (eg, end zones of the major cerebral
arteries), resulting in spastic quadriplegic cerebral palsy.
 The basal ganglia also can be affected, resulting in extrapyramidal or dyskinetic
cerebral palsy.

Statistics and Incidences

 
The incidence of cerebral palsy has not changed in more than 4 decades, despite
significant advances in the medical care of neonates.
 

 In developed countries, the overall estimated prevalence of cerebral palsy is 2-

2.5 cases per 1000 live births.
 In the developing world, the prevalence of cerebral palsy is not well established
but estimates are 1.5-5.6 cases per 1000 live births.
 Lower socioeconomic status and male sex may be increased risk factors for
cerebral palsy.
 Approximately 30-50% of patients with cerebral palsy have mental retardation,
depending on the type.
 Approximately 15-60% of children with cerebral palsy have epilepsy, and
epilepsy is more frequent in patients with spastic quadriplegia or mental
retardation.

Causes
 
Although the cause of cerebral palsy cannot be identified in many cases, several
causes are possible.
 

 Brain damage. It may be caused by damage to the parts of the brain that control
movement; this damage generally occurs during the fetal or perinatal period,
particularly in premature infants.
 Interference with oxygen supply. Any process that interferes with the oxygen
supply to the brain, such as separation of the placenta, compression of the cord,
or bleeding, may cause cerebral palsy.
 Maternal infection. Infection that occurs to the mother during the prenatal
period, like cytomegalovirus, toxoplasmosis, or rubella, may lead to cerebral
palsy.
 Nutritional deficiencies. Nutritional deficiencies that may affect brain growth
during the prenatal period could cause cerebral palsy.
 Kernicterus. Kernicterus is a condition that causes brain damage caused by
jaundice resulting from Rh incompatibility.
 Teratogenic factors. Teratogenic factors such as drugs and radiation can cause
cerebral palsy.
 Prematurity. Prematurity because immature blood vessels predispose the
neonate to cerebral hemorrhage.

Assessment and Diagnostic Findings

 
The diagnosis of cerebral palsy is generally made based on the clinical picture;
there are no definitive laboratory studies for diagnosing the condition, only studies,
including the following, to rule out other symptom causes:
 

 Thyroid function studies. Abnormal thyroid function may be related to

abnormalities in muscle tone or deep tendon reflexes or to movement disorders.
 Lactate and pyruvate levels. Abnormalities may indicate an abnormality of
energy metabolism (ie, mitochondrial cytopathy).
 Ammonia levels. Elevated ammonia levels may indicate liver dysfunction or
urea cycle defect.
 Organic and amino acids. Serum quantitative amino acid and urine quantitative
organic acid values may reveal inherited metabolic disorders.
 Chromosomal analysis. Chromosomal analysis, including karyotype analysis
and specific DNA testing, may be indicated to rule out a genetic syndrome if
dysmorphic features or abnormalities of various organ systems are present.
 Cerebrospinal protein. Levels may assist in determining asphyxia in the
neonatal period; protein levels can be elevated, as can the lactate-to-pyruvate
ratio.
 Cranial ultrasonography. Can be performed in the early neonatal period to
delineate clear-cut structural abnormalities and show evidence of hemorrhage or
hypoxic-ischemic injury.
 Computed tomography scanning of the brain. In infants, helps to identify
congenital malformations, intracranial hemorrhage, and periventricular
leukomalacia or early craniosynostosis.
 Magnetic resonance imaging of the brain. The diagnostic neuroimaging study
of choice because this modality defines cortical and white matter structures and
abnormalities more clearly than does any other method; MRI also allows for the
determination of whether appropriate myelination is present for a given age.
  
Clinical Manifestations
 
Signs of cerebral palsy include the following:
 
Developmental delay. History of gross motor developmental delay in the first
year of life.
Abnormal muscle tone. The most frequently observed symptom; the child may
present as either hypotonic or, more commonly, hypertonic, with either decreased
or increased resistance to passive movements, respectively; children with cerebral
palsy may have an early period of hypotonia followed by hypertonia; a
combination of axial hypotonia and peripheral hypotonia is indicative of a central
process.
Hand preference. Definite hand preference before age 1 year: A red flag for
possible hemiplegia.
Problems in crawling. Asymmetrical crawling or failure to crawl.
Growth disturbance. There is a growth disturbance especially in failure to thrive.
Increased reflexes. Indicating the presence of an upper motor neuron lesion; this
condition may also present as the persistence of primitive reflexes.
Problems in reflexes. Underdevelopment or absence of postural or protective
reflexes
 
The patient is 19-year-old, for us to appreciate more his condition, we need
to discuss Cerebral Palsy in Adulthood:
 
Adults with Cerebral Palsy
 
There are many adults with cerebral palsy who go on to lead independent lives.
How much independence they have will vary with each case. Adults with less
severe types of cerebral palsy may be able to live on their own and work full-time
jobs. Others with more severe forms of cerebral palsy, like in the case of our
patient, or coexisting conditions may require full-time assistance to complete
daily tasks. While an individual's cerebral palsy will not decline as they get older,
there are a few things that can impact their overall health and wellness. As we
took notes from the clinical manifestation of the patient, we find that the two
factors that have the biggest effect on adults with cerebral palsy
are motor and intellectual impairments. The most common challenges that
adults with cerebral palsy experience are:
 

 Premature aging
 Walking or swallowing disorders
 Post-impairment syndrome
 Mental health conditions
 Challenges in the workplace
 If more than one of the above issues persists, this can impact an individual's
overall well-being as an adult. However, cerebral palsy is not thought to be a life-
threatening condition on its own. Symptoms of cerebral palsy can be
managed through various forms of therapy, alternative treatment methods, or
surgery. Between about 20 to 40 years old (in the case of our patient, he is 19-
year-old), most adults with cerebral palsy will experience some form of premature
aging. This is due to the excess strain and stresses their bodies go through just to
complete everyday tasks. 
 
CP and Post-impairment Syndrome
 
Post-impairment syndrome is a fairly common condition among adults with
cerebral palsy. Identifying this condition can be difficult, as many of the symptoms
mimic those of cerebral palsy and other related conditions. Symptoms of the post-
impairment syndrome are:
 

 Weakness due to muscle abnormalities, bone deformities, overuse syndromes,

and arthritis
 Increased pain
 Fatigue
 Repetitive strain injuries

Individuals with cerebral palsy use more energy than able-bodied people when
walking or moving around. This can cause the post-impairment syndrome. The
best way to avoid developing this condition is by working with various therapists
throughout early adulthood, such as an occupational therapist, who will work to
strengthen these muscles over time.
 
Functional Limitation
 
According to a study conducted in the Netherlands, 70% of young adults with
cerebral palsy between the ages of 18 and 22 reported challenges with activities
of daily living including difficulties in self-care, productivity, and leisure activities,
especially involving recreation, leisure, meal preparation, and housework.
 
Adolescents with cerebral palsy gradually exhibit a progressive decline in strength
and functional reserve through adult life. Prior to the age of 35 years, the ability to
walk decreases in adults with cerebral palsy despite acquired ambulation during
adolescence. Deterioration in Gross Motor Functional Classification System
(GMFCS) levels is most evident in the late 20s and early 30s, and dependence
and perceived difficulties in activity influence adults with cerebral palsy. It has
been reported that the ambulatory function deteriorates in adulthood, which is
likely due to new medical age-related challenges in patients with cerebral palsy
based on the fact that the GMFCS level remained almost stable in individuals with
cerebral palsy until the age of 21 years.
  
Limitations in functional activity were found to be a major restricting factor for
social participation in young adults with cerebral palsy Although intellectual
disability rather than GMFCS level in children is known to have a significant
impact on social participation, there is a lack of evidence to support this finding in
adults with cerebral palsy. Further, work participation is restricted in adults with
cerebral palsy who do not suffer from an intellectual disability, and further
research is required to encourage increased participation in society and in the
workplace.
 
Cerebral Palsy and The Workplace
 
Considering the patient's age (19), we can assume that the patient is still
studying. We can relate the situation of the patient and in his school with another
person and his workplace.  As any other young adult, those with cerebral place
may experience issues in the school or workplace. This is because day-to-day
activities, such as talking or walking, can become more demanding for individuals
with cerebral palsy as they reach middle age. This can impact their performance in
school or the workplace.
 
Under the Americans with Disabilities Act (ADA) of 1990, all individuals with
mental or physical impairment are entitled to equal opportunities and
independence. This means that individuals living with cerebral palsy cannot be
discriminated against in job interviews, school applications, or in the workplace for
their condition. With this in mind, employers are required to provide "reasonable
accommodations" for employees with disabilities. These accommodations include:
 

 Assistive technology or programs, such as spell checkers

 Adjusted work schedules
 Frequent rest periods
 Working within close proximity to restrooms, office machines, parking lots, etc.
 Use of a service dog
 Use of a personal care attendant
 Telephone assistance devices
 Writing or typing aids/grips

Role of Teacher
 
Educators, therapists, parents, and students with cerebral palsy can work together
to create an educational plan. This may include setting up an individualized
education program (IEP)  to help students reach their full potential. Plans may
include therapy, a classroom aide, and more. As a child grows, this plan will
change.
To support students in your classroom:
 
 Keep walkways open. Make your classroom easy to move through and free of
obstacles. Students may need extra help moving around or reaching things.
 Be aware of seating arrangements, and adjust if they aren't working. Kids with
CP who are self-conscious of uncontrolled movements or other differences may
want to sit in the back or away from others. Try to put kids near other students
who encourage them to be involved in activities.
 Give extra time, if needed. Some students may need more time to travel between
classes, complete assignments or activities, and take tests. They might need
extra bathroom breaks too. Talk to the student and parent to find out what's best.
 Have a plan for missed instruction, assignments, and testing. Students with
cerebral palsy may miss class time to go to doctor visits or to see the school
nurse take medicine. Know how the student will make up for a missed time.
 Talk about and celebrate differences. Students with cerebral palsy want to be
accepted like everyone else. But sometimes they are targeted by others who see
them as "different." Talk about and celebrate differences, and focus on the
interests that people with cerebral palsy share. Be mindful of bullying, and keep a
zero-tolerance policy for that behavior.
 Be prepared for medical emergencies by planning ahead with parents. Know
what to do and who to call if a student with cerebral palsy has a medical
emergency or event, like a seizure.

The patient is exhibiting loneliness and requires social stimulation, this

goes to show that his mental health is affected:
 
Cerebral Palsy and Mental Health
 
A condition like cerebral palsy can make the stresses of life a bit more
overwhelming. Similarly, individuals with cerebral palsy have a tendency to
become shy in social situations out of fear of being bullied or teased by others.
This can lead to the development of an array of mental health conditions. The
most common disorders found in adults with cerebral palsy are depression and
anxiety disorders. Early signs of depression are:
 

 Not sleeping or sleeping too much

 Not eating or eating too much (binge-eating disorder)
 Talking about death or self-harming
 A lack of desire to complete activities that once brought enjoyment

Early signs of anxiety are:

 

 Rapid heartbeat
 Being "jumpy" or unable to sit still
 Dizziness, shakiness, excessive sweating, or nausea
 Avoiding doing things involving other people or unfamiliar places
 Being overly worried about small things

While depression and anxiety are the most common disorders found in adults with
cerebral palsy, they are still at risk of developing any other mental health
condition. An unfortunate result of having such a physically pronounced condition
like cerebral palsy is that sometimes mental and emotional health can be
overlooked by doctors and specialists during exams. The best way to address an
adult with cerebral palsy who may also have a co-occurring mental health
condition is by being proactive in tracking any observable signs. The next step
is to ensure they receive a full evaluation by a medical professional, who can
conduct various tests in order to determine the mental health condition/s at hand.
 
Cerebral Palsy Care Plan
 
Physical Therapy
 
Physical therapy is often the first step in treating cerebral palsy. It can help
improve motor skills and can prevent movement problems from getting worse over
time. Physical therapy implements strength and flexibility exercises, heat
treatment, massages, and special equipment to the patient with cerebral palsy
more independence. There are many benefits of physical therapy, from improving
mobility to preventing future issues such as contractures and joint dislocations by
keeping the body strong and flexible. Physical therapy can improve:
 

 Coordination
 Balance
 Strength
 Flexibility
 Endurance
 Pain management
 Posture
 Gait
 Overall health

Occupational Therapy
 
Occupational therapy can help the patient develop or recover the skills needed to
lead independent, satisfying lives. The "occupation" in occupational therapy does
not refer to one's profession. Rather, it refers to the everyday activities that give
life meaning. Occupational therapy involves using functional activities to
progressively improve functional performance. Occupational therapy exercises
focus on the following skill areas:
 
 Fine Motor Control - Improves hand dexterity by working on hand muscle
strength.
 Upper Body Strength and Stability - Exercise focuses on strengthening and
stabilizing the trunk (core), shoulder, and wrist muscles through exercises.
 Visual-Motor Skills - Improves hand-eye coordination.
 Visual Perception - These activities improve the ability to understand, evaluate
and interpret what's being seen. 
 Self-Care - Improves the ability to perform activities of daily living and helps the
patient to be more independent at home, at school, and in the community.
Exercises can be as simple as practicing these ADLs, like brushing their teeth,
getting dressed, and self-feeding.
 

Orthopedic management and Technological Aids

 
Braces are used as supportive and control measures to facilitate muscle training,
to reinforce weak or paralyzed muscles, or to counteract the pull of antagonistic
muscles; orthopedic surgery sometimes is used to improve functionality and to
correct deformities, such as the release of contractures and the lengthening of
tight heel cords.
 
Devices range from simple items, such as wheelchairs and specially constructed
toilet seats, to completely electronic cottages furnished with a computer, a tape
recorder, a calculator, and other equipment that facilitates independence and
useful study or work; feeding aids such as spoons with enlarged handles for easy
grasping or with bent handles that allow the spoon to be brought easily to the
mouth.
 
Pharmacologic Therapy
 
Numerous medications, including the following, may relieve the movement
difficulties associated with cerebral palsy:
 
Botulinum toxin with or without casting. Botulinum toxin (Botox) type A may
reduce spasticity for 3-6 months and should be considered for children with
cerebral palsy with spasticity.
 
Phenol intramuscular neurolysis. This agent can be used for some large
muscles or when several muscles are treated, but phenol therapy is permanent.
 
Antiparkinsonian, anticonvulsant, antidopaminergic, and antidepressant
agents. Although antiparkinsonian drugs (eg, anticholinergic and dopaminergic
drugs) and antispasticity agents (eg, baclofen) have primarily been used in the
management of dystonia, anticonvulsants, antidopaminergic drugs, and
antidepressants have also been tried.
 
 Nursing Management
 
1. Assessment
 
We must interview and observe the patient, his mother, and the family to
determine the patient's needs, the level of development, and the stage of family
acceptance and to set realistic long-range goals. We must conduct a history
review. Patient history and maternal history often reveal the possible cause of
cerebral palsy.
 
2. Nursing Diagnosis
 
Based on the assessment data of the patient, the major nursing diagnoses
include:
 

 Risk for injury related to spasms, uncontrolled movements, and seizures.

 Impaired physical mobility related to spasms and muscle weakness.
 Changes in growth and development related to neuromuscular disorders.
 Impaired verbal communication related to difficulty in articulation.
 Self-care deficit related to muscle spasms, increased activity, cognitive
changes.
 Deficient knowledge related to home care and therapeutic needs.

3. Nursing Care Planning and Goals

 
Major goals for the patient with cerebral palsy include:
 

 Verbalize feelings related to self-esteem.

 Develop adequate coping mechanisms.
 Demonstrate knowledge of the condition and the treatment plan.
 Achieve age-appropriate growth, behaviors, and skills to the fullest extent
possible.
 Express positive feelings about himself.
 Maintain optimal functioning within the limits of the visual or hearing impairment.
 Remain oriented to person, place, time, and situation.
 Consume adequate daily calories as required.
 Maintain joint mobility and ROM.
 Family members will discuss how the patient's condition has affected the family's
daily life.

4. Nursing Interventions
 
Nursing interventions for the patient with cerebral palsy are:
 
 Ensure therapeutic communication. To ease the change of environment, the
nurse needs to communicate with the family to learn as much as possible about
the child's activities at home.
 Enhance self-esteem. Assist the patient to increase his personal judgment of
self-worth.
 Provide emotional support. Provide reassurance, acceptance, and
encouragement during times of stress.
 Strengthen family support. Utilize the family's strengths to influence the
patient's health in a positive direction.
 Prevent injury. Prevent physical injury by providing a safe environment.
 Prevent deformity. Prevent physical deformity by ensuring the correct use of
prescribed braces and other devices and by performing ROM exercises.
 Encourage mobility. Promote mobility by encouraging the patient to perform
age-and condition-appropriate motor activities.
 Increase oral fluid intake. Promote adequate fluid and nutritional intake.
 Manage sleep and rest periods. Foster relaxation and general health by
providing rest periods.
 Enhance self-care. Encourage self-care by urging the child to participate in
activities of daily living (ADLs) (e.g. using utensils and implements that are
appropriate for the child's age and condition).
 Facilitate communication. Talk to the child deliberately and slowly, using
pictures to reinforce speech when needed; encourage early speech therapy to
prevent poor or maladaptive communication habits; and provide means of
articulate speech such as sign language or a picture board.
 Enforce therapeutic measures. Assist in multidisciplinary therapeutic measures
designed to establish locomotion, communication, and self-help, gain an optimal
appearance, and integration of motor functions.

5. Evaluation
 
Evaluation of our nursing care plan would prove to be successful if evidenced by:
 

 Verbalization of feelings related to self-esteem.

 Development of adequate coping mechanisms.
 Demonstration of knowledge of the condition and the treatment plan.
 Achievement of age-appropriate growth, behaviors, and skills to the fullest extent
possible.
 Expression of positive feelings about himself.
 Maintenance of optimal functioning within the limits of the visual or hearing
impairment.
 Orientation to person, place, time, and situation.
 Consummation of adequate daily calories as required.
 Maintenance of joint mobility and ROM.
 Swallowing without pain or aspiration.
 Family members' discussion on how the patient's condition has affected the
family's daily life.

Conclusion

In addition to early detection and habilitation or rehabilitation of children with

cerebral palsy, transition to adulthood has been highlighted as an important issue
in the past 10 to 20 years. Aging in this population is an emerging issue. As there
is no known cure for cerebral palsy, finding proper health care and continued
support is essential to improving an individual's quality of life. By establishing the
best ways to manage their symptoms, young people with cerebral palsy will be
able to make the most out of life as they mature into adulthood.