cerebral palsy: an integrated approach
DESCRIPTION
CEREBRAL PALSY: An Integrated Approach. Michael J. Ward, MD. Associate Professor, CHS Orthopedics and Rehabilitation Medicine University of Wisconsin Medical School March 1, 2014. Cerebral Palsy: An Integrated Approach. Integrated Whole Person Perspective - PowerPoint PPT PresentationTRANSCRIPT
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CEREBRAL PALSY: An Integrated Approach
Michael J. Ward, MDAssociate Professor, CHS
Orthopedics and Rehabilitation MedicineUniversity of Wisconsin Medical School
March 1, 2014
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Cerebral Palsy: An Integrated Approach
Integrated Whole Person PerspectiveIntegrated Treatment Team PerspectiveIntegrated Medical Approach to Problems
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MULTIDISCIPLINARY TEAMMD: Rehabilitation,
Developmental PediatricsNursing
PT, OT , Speech Evaluations
Community resources:Family, School,
Equipment vendor
AFCH specialists:Orthopedic Surgery,Neuropsychology,
Neurology
Neurosurgery, Audiology, Feeding,
Social Work, Psychology, CASC
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WHAT IS CEREBRAL PALSY?
?
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Modern consensus definition:
–Group of disorders of movement and posture–Non-progressive etiology–Damage to the fetal or infant brain
–Often accompanied by co-occurring problems with sensation, perception, communication, and/or behavior and/or seizure disorder
Bax 2005 DMCN
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WHAT IS CEREBRAL PALSY?
Diagnosis of Cerebral Palsy has 4 requirements:1. Non-progressive impairment 2. Immature or developing3. Brain (cerebral)
4. Abnormal motor development (palsy)
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DIAGNOSIS: Non-progressive
Excludes conditions which cause ongoing brain injury over time
Also excludes conditions which resolveHowever, symptoms can transform through the life
span even when the primary brain injury remains the same
CP is non-progressive, but not unchanging
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DIAGNOSIS: Immature or developing brain
When does development end?– Embryonic formation of organs– Birth– 2-3 years: Brain myelination completed– 7-9 years: Maturation of motor skills– 16-18 years: Physical maturity – Social maturity
Injury causing CP occurs before or around birth
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DIAGNOSIS: Immature brain
Presentation of symptoms in CP:– Typically by 6-12 months– Mild cases may not be noticed until 12-18 months
-Early abnormal motor signs in infants can disappear and would not be called CP
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DIAGNOSIS: Brain impairment
Excludes diseases of spinal cord or muscles, etc.
Includes many different types of brain injuries
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DIAGNOSIS: Brain injury
Most common source of injury:Complex series of events in the brain set in motion after birth among newborns with prematurity and very low birth weight
Currently largest single etiology of cerebral palsy
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DIAGNOSIS: Brain injury
Prematurity and low birth weight often associated with a brain change called PVL:
Periventricular leukomalacia
Peri = aroundVentricular = deep brain fluid spacesLeuko = white matterMalacia = thinning
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DIAGNOSIS:MRI with Periventricular leukomalacia
Normal brain PVL
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DIAGNOSIS: Etiology
Includes a range of other types of brain injury:
Birth hypoxia Brain malformationPrenatal stroke EncephalitisHyperbilirubinemia Other
Can be caused by a combination of factorsOccasionally the factors are not known
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Cerebral Palsy: Cranial imaging findings
PVLGray matterBasal gangliaMalformationMiscellaneousNormal
Bax JAMA 2006
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DIAGNOSIS: Disturbance of motor development
Presenting motor symptoms also vary– Delayed motor milestones: not required– Spasticity: common but not required– Abnormal involuntary movements– Decreased quality of motor control
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DIAGNOSIS: Disturbance of motor developmentCP is usually described by type of motor problem
Spastic types most common, and described by distribution– Quadriplegic: both arms and both legs– Hemiplegic: Arm and leg on both sides– Diplegic: Both legs more impaired than both arms
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DIAGNOSIS Disturbance of motor developmentCP is usually described by type of motor problem
Other types:– Dystonic– Dyskinetic (choreoathetosis)– Ataxic
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DIAGNOSIS: Types by motor pattern
ExtrapyramidalOtherDiplegicQuadriplegicHemiplegic
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DIAGNOSIS: Disturbance of motor developmentThere is partial correlation between etiology and type
of motor problem:
MRI abnormality Motor problemPVL DiplegiaBirth Hypoxia Quadriplegia and dystoniaPrenatal stroke Hemiplegia
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DIAGNOSIS:MRI with Periventricular leukomalacia
Normal brain PVL
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DIAGNOSIS: Disturbance of motor development
Required for diagnosis The definition is mute on sensory, cognitive, or
behavioral dysfunction, but…
CP is not an exclusively motor condition
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CEREBRAL PALSY Associated concerns
Cognitive– Cognitive impairment 40-60%– Learning disabilities common– Attention deficit disorder– Other behavioral disturbances– Language disorders
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CEREBRAL PALSY Associated concerns
Sensory abnormalities:– Hearing loss 7-12%– Abnormal control of eye motions 20-60%– Visual impairment overall 80%– Visuoperceptual abnormality also frequent– Tactile impairment 50-75%– Balance system impairment
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CEREBRAL PALSY Associated medical concerns
Seizures 30-50%
Autonomic nervous system also affected:– Abnormal digestive motility– Temperature instability and cold or hot limbs– Bladder dysfunction– Breathing irregularities
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CEREBRAL PALSY Associated concerns
Secondary problems: Gastrointestinal– Malnutrition– Growth delays– Gastric reflux– Constipation– Swallowing difficulties– Drooling– Dental changes
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CEREBRAL PALSY Associated concerns
Many orthopedic complications:– Osteoporosis and fractures (even in children)– Scoliosis – Joint deformities– Musculoskeletal pain
Associated skin problems– Skin pressure ulcers– Moisture related skin problems
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PROGNOSIS
WILL MY CHILD ?????????
Related to underlying etiologyRelated to motor, cognitive and sensory abilities
Risks v absolutes in early periodRequires serial discussions
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MOTOR DELAYS: GMFCSGross Motor Classification System
Track curves of motor development in children with CP from early milestones to adult skills achievement.
Predicts general trends at 5 functional levels
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MOTOR DELAYS:
GMFCS: Gross Motor Classification Systemfor mobility
MACS: Manual Abilities Classification Systemfor hand function
CFCS: Functional Communication Scalefor speech
All describe 5 functional ability levels
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MOTOR DELAYS: GMFCS
Level I: Walks without limitationsLevel II: Walks with limitationsLevel III: Ambulation with device onlyLevel IV: Limited mobility, power wheelchairLevel V: Dependent manual wheelchair
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GMFCS
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MOTOR DELAYS:REHABILITATION INTERVENTIONS
Physical therapyOrthopedic surgerySpasticity reductionCasting/splintingBracingMobility aids
Help but do not change the GMFCS level (usually)
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Combining all of this provides a more complete description of CP:
Type: SpasticDistribution: QuadriplegicEtiology: VLBW and prematurityMRI Imaging: Periventricular leukomalaciaFunctioning: GMFCS V, MACS IV, CFCS IIIAssociated: Cognitive, visual, orthopedic,
etc.
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Modern consensus definition:
–Group of disorders of movement and posture–Non-progressive etiology–Damage to the fetal or infant brain
–Often accompanied by co-occurring problems with sensation, perception, communication, and/or behavior and/or seizure disorder
Bax 2005 DMCN
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WHAT IS THE MOST COMMON MEDICAL PROBLEM
ADDRESSED WITH CHILDREN WHO HAVE CEREBRAL PALSY?
?
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CONSTIPATION:Contributing factors
Poor hydration, poor hydration, poor hydrationPoor dietary fiber intakeImpaired GI motilityBehavioral/developmental levelPhysical access to toilet, safe sitting positionSensory processing
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CONSTIPATION:Treatment approaches
Fluids, fluids, fluidsIncreased dietary fiberSwallow abilities and feeding behaviors importantOral or rectal medicationsBathroom access and support on the toiletBehavioral approaches to toileting based on cognitive abilities and developmental level
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MULTIDISCIPLINARY TEAMMD: Rehabilitation,
Developmental PediatricsNursing
PT, OT , Speech Evaluations
Community resources:Family, School,
Equipment vendor
AFCH specialists:Orthopedic Surgery,Neuropsychology,
Neurology
Neurosurgery, Audiology, Feeding,
Social Work, Psychology, CASC
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TEAM SUPPORT ACROSS THE LIFESPAN
Newborn Follow-up Clinic: child at risk
Neuromotor Development Clinic: child with delay
Cerebral Palsy Clinic: child with disability
Transition to adult providers
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TEAM SUPPORT ACROSS THE LIFESPAN
Newborn Follow-up Clinic: child at riskFeeding Clinic, Audiology, Resource center
Neuromotor Development Clinic: child with delayOrthopedic Surgery, Neurology, Genetic Evaluations
Cerebral Palsy Clinic: child with disabilitySpasticity and Movement Disorder clinic, CASC
Transition to adult providersDVR, Guardianship, Independent Living
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Cerebral Palsy: An Integrated Approach
Integrated Whole Person PerspectiveIntegrated Treatment Team PerspectiveIntegrated Medical Approach to Problems