Cerebral palsy
Cerebral palsy: Excerpt from Professional Guide to Diseases (Eighth Edition)
The most common cause of crippling in children, cerebral palsy (CP) is a group of neuromuscular disorders resulting from prenatal, perinatal, or postnatal CNS damage. Although nonprogressive, these disorders may become more obvious as an affected infant grows older. Three major types of CP occur — spastic, athetoid, and ataxic — sometimes in mixed forms. Motor impairment may be minimal (sometimes apparent only during physical activities such as running) or severely disabling. Associated defects, such as seizures, speech disorders, and mental retardation, are common. The prognosis varies; in cases of mild impairment, proper treatment may make a near-normal life possible.
Causes and incidence
See Causes of cerebral palsy, for a more detailed description of the causes of CP. Incidence is slightly higher in premature neonates (anoxia plays the greatest role in contributing to CP) and in neonates who are small for their gestational age. CP is slightly more common in males than in females. For every 1,000 births, 2 to 4 neo-nates are affected.
Spastic cerebral palsy is the most common type of CP, affecting about 50% of CP patients.Athetoid cerebral palsy affects about 20% of CP patients, ataxic cerebral palsy accounts for another 10% of these patients, and the remaining 20% of patients are mixed, with a combination of symptoms.
Signs and symptoms
Spastic cerebral palsy is characterized by hyperactive deep tendon reflexes, increased stretch reflexes, rapid alternating muscle contraction and relaxation, muscle weakness, underdevelopment of affected limbs, muscle contraction in response to manipulation, and a tendency to contractures. Typically, a child with spastic CP walks on his toes with a scissors gait, crossing one foot in front of the other.
In athetoid cerebral palsy, involuntary movements — grimacing, wormlike writhing, dystonia, and sharp jerks — impair voluntary movement. Usually, these involuntary movements affect the arms more severely than the legs; involuntary facial movements may make speech difficult. These athetoid movements become more severe during stress, decrease with relaxation, and disappear entirely during sleep.
Ataxic cerebral palsy is characterized by disturbed balance, incoordination (especially of the arms), hypoactive reflexes, nystagmus, muscle weakness, tremor, lack of leg movement during infancy, and a wide gait as the child begins to walk. Ataxia makes sudden or fine movements almost impossible.
Some children with CP display a combination of these clinical features. In most, impaired motor function makes eating (especially swallowing) difficult and retards growth and development. Up to 40% of these children are mentally retarded, about 25% have seizure disorders, and about 80% have impaired speech. Many also have dental abnormalities, vision and hearing defects, and reading disabilities.
Diagnosis
Early diagnosis is essential for effective treatment and requires precise neurologic assessment and careful clinical observation during infancy. Computed tomography scan and magnetic resonance imaging can reveal structural or congenital abnormalities. Suspect CP whenever an infant:
❑has difficulty sucking or keeping the nipple or food in his mouth
❑seldom moves voluntarily or has arm or leg tremors with voluntary movement
❑crosses his legs when lifted from behind rather than pulling them up or “bicycling” like a normal infant
❑has legs that are difficult to separate, making diaper changing difficult
❑persistently uses only one hand or, as he gets older, uses hands well but not legs.
Infants at particular risk include those with low birth weight, low Apgar scores at 5 minutes, seizures, and metabolic disturbances. However, all infants should have a screening test for CP as a regular part of their 6-month checkup.
Treatment
CP can’t be cured, but proper treatment can help affected children reach their full potential within the limitations set by this disorder. Such treatment requires a comprehensive and cooperative effort involving physicians, nurses, teachers, psychologists, the child’s family, and occupational, physical, and speech therapists. Home care is usually possible. Treatment usually includes interventions that encourage optimum development:
❑Braces or splints and special appliances, such as adapted eating utensils and a low toilet seat with arms, help these children perform activities independently.
❑An artificial urinary sphincter may be indicated for the incontinent child who can use the hand controls.
❑Range-of-motion exercises minimize contractures.
❑Orthopedic surgery may be indicated to correct contractures. Botulinum toxin has been shown to reduce or delay the need for surgery.
❑Phenytoin, phenobarbital, or another anticonvulsant may be used to control seizures.
❑Muscle relaxants or neurosurgery may be required to decrease spasticity.
Children with milder forms of CP should attend a regular school; severely afflicted children may need special classes.
Special considerations
A child with CP may be hospitalized for orthopedic surgery or for treatment of other complications.
❑Speak slowly and distinctly. Encourage the child to ask for things he wants. Listen patiently and don’t rush him.
❑Plan a high-calorie diet that’s adequate to meet the child’s high-energy needs.
❑During meals, maintain a quiet, unhurried atmosphere with as few distractions as possible. The child should be encouraged to feed himself and may need special utensils and a chair with a solid footrest. Teach him to place food far back in his mouth to facilitate swallowing.
❑Encourage the child to chew food thoroughly, drink through a straw, and suck on lollipops to develop the muscle control needed to minimize drooling.
❑Allow the child to wash and dress independently, assisting only as needed. The child may need clothing modifications.
❑Give all care in an unhurried manner; otherwise, muscle spasticity may increase.
❑Encourage the child and his family to participate in the plan of care so they can continue it at home.
❑Care for associated hearing or visual disturbances, as necessary.
❑Give frequent mouth care and dental care, as necessary.
❑Reduce muscle spasms that increase postoperative pain by moving and turning the child carefully after surgery; provide analgesics as needed.
❑After orthopedic surgery, provide cast care. Reposition the child often, check for foul odor, and ventilate under the cast with a cool air blow-dryer. Use a flashlight to check for skin breakdown beneath the cast. Help the child relax, perhaps by giving a warm bath, before reapplying a bivalved cast.
To help the parents:
❑Encourage them to set realistic individual goals.
❑Assist in planning crafts and other activities.
❑Stress the child’s need to develop peer relationships; warn the parents against being overprotective.
❑Identify and deal with family stress. The parents may feel unreasonable guilt about their child’s handicap and may need psychological counseling.
❑Refer the parents to supportive community organizations. For more information, tell them to contact the United Cerebral Palsy Association or their local chapter.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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