Cerebral Palsy (CP)

Hey guys, in this lesson we are going to talk about Cerebral Palsy. CP is the most common cause of developmental disability in kids. It’s a static disorder, meaning that it doesn’t progress over time. Medical care of CP is all about optimizing function and minimizing complications. So, let’s get started looking at how we do that!

Let’s start by just getting a solid understanding of what causes CP and how it affects kids. The actual specific cause can be anything that causes injury to the brain. The most common is anoxia- meaning that the brain went without oxygen for a certain amount of time.

When this damage occurs, the location of the damage will impact how it presents, but generally it affects movement, coordination and can cause abnormal posturing.

There are 4 different types Spastic, Dyskinetic, Ataxic and Mixed.

Spastic CP causes stiff muscles and contractures. It is the most common and the part of the brain that is damaged is the cerebral cortex. Dyskinetic causes uncontrolled movements and the part of the brain affected is the basal ganglia. Ataxic causes poor balance and coordination and the cerebellum is damaged. And mixed is obviously a combination of the three.

Other terms that are used to describe CP are hemiplegia, (half of the body, right or left side is affected), Diplegia (half of the body, upper or lower is affected), quadriplegia (all four extremities are affected), monoplegia (only one limb is affected). For example, a child who has spasticity in one arm would be diagnosed with spastic monoplegia cerebral palsy.

Cerebral palsy isn’t always evident at birth. It usually presents over time within the first year or so of life with general gross motor developmental delays. In other lessons I’ve talked about how important it is to be patient with your assessment in kids. Specifically, I’ve said how important it is to take time to watch a child breath to get the full clinical picture. Well, I would say the same is true for a child’s neuro and musculoskeletal assessment. Take time to watch a child move and play in their environment and you won’t miss the subtle things that can help us diagnose CP early.

Things we are looking for are abnormal movements, abnormal posturing, abnormal muscle tone and abnormal reflexes. Examples of involuntary movements are persistent tongue thrusting, writhing and jerking. Examples of abnormal posturing are spasticity in a hand or foot. You can see in the photo what that might look like. In infancy you may see abnormal positioning of the legs, so scissoring of the legs which indicates increased tone (legs are extended, stuff and crossing over each other) or frog logs which indicates decreased or poor tone (the legs are floppy and and open at the hips). For abnormal tone you're looking for signs of decreased tone and/or increased tone. Examples of decreased tone are a floppy baby, with poor head and neck control. Examples of increased tone are a rigid baby who frequently arches its back. Reflexes are usually hyper and newborn reflexes may persist beyond the normal time which is 6 months.

Again most of these will present in the first year of life as abnormal motor development so if you need a refresher on what is considered normal, check out the infant growth and development lesson.

As I said CP is a static problem. The damage to the brain itself is not getting any better or worse, but these kids do experience a lot of fluctuations in their health and wellness because there are a lot of problems that come alongside these issues with movement, tone and coordination. They may end up needing a lot of surgeries and hospitalizations for these issues, so I wanted to just quickly make you aware of diagnoses that are often associated with CP.

Learning disabilities and decreased cognitive function occur in about 30-50% of patients. And many children with CP will also have epilepsy, vision & hearing problems, reflux, constipation, failure to thrive due to difficulty with feeding, contractures and chronic pain.

So common reasons you may come into contact with these kids as a nurse are 1) Their seizure medicine isn’t working as well and they are having frequent seizures again 2) Their seizure medications are making them constipated and they have an impaction that needs clearing out 3) They have aspirated and have a respiratory infection because of their reflux 4) They’ve come into hospital for g-tube placement because they keep losing weight. 5) They’ve come into hospital for an orthopedic surgery to help with contractures or other MSK problems.

So, you can see that therapeutic management of CP is very patient specific and totally depends on the severity of the disability and what other diagnoses they have in addition to the CP. A multidisciplinary approach is essential to make sure that all of these issues are being addressed. PT, OT and Speech and Language Therapists are really important players in this to help kids reach their full potential. The goal is to maximize mobility and communication. We want kids to be as independent as possible and minimize the amount of time they are in hospital.

Common medications for kids with CP are valium, baclofen, botulinum injection, these are used to help with muscle spasms and contractures that are super painful for kids. They are also likely to be taking anti-seizure medications, reflux meds and laxatives to help prevent constipation.

From a nursing point of view, there can be a lot going on with these patients, a lot of meds, a lot of equipment, a lot of diagnoses. And the thing is, they live with this ALL the time. They have a routine. Their parents have a way they like for things to be done. So my best piece of advice is to straightaway talk to the family and find out what their preferences are then pass these preferences on other nurses during shift change. This makes life easier for everyone and keeps the families from feeling like they are constantly repeating themselves.

Your priority nursing concepts for a pediatric patient with Cerebral Palsy are functional ability, mobility and human development.
Let’s recap your major learning points for this lesson.

CP is physical disability caused by injury to the brain that affects movement, coordination and posture. In your assessment, you really want to pay close attention to how the child is moving and playing, looking for spastic or flaccid muscles, any changes to gait or crawling and abnormal movements like writhing or jerking. It usually presents in the first year of life a developmental delay caused either by poor tone or increased tone, so make sure you refresh on infant development. Other diagnoses that are associated with CP that can complicate are are learning disabilities, reflux, constipation, epilepsy and vision and hearing problems. Treatment is interdisciplinary with the goal of maximizing function. PT, OT, and speech therapist are a huge part of this process. Medications that are commonly prescribed to help with spasticity and pain are valium, baclofen and botulinum (Botox).

That's it for our lesson on Cerebral Palsy. Make sure you check out all the resources attached to this lesson. Now, go out and be your best self today. Happy Nursing!