one size does not fit all mary catherine brake turner, md, facp, faap [email protected]
TRANSCRIPT
Cerebral PalsyOne Size Does Not Fit All
Mary Catherine Brake Turner, MD, FACP, [email protected]
Define cerebral palsy
List systems often affected by cerebral palsy
List three non-surgical treatments for spasticity
Name common causes of pain in cerebral palsy
List three main roles of the primary care provider
Objectives
Review cerebral palsy and the complexities that accompany this diagnosis
Highlight special considerations for patients with cerebral palsy
Review the role of the medical home
Discuss important transition issues as patients with cerebral palsy become adults
Agenda
A group of permanent disorders of movement and posture that limit activity
Non-progressive
Insult to the developing brain
Disturbances of sensation, perception, cognition, communication, and behavior
Epilepsy and secondary MSK problems common
Definition of CP
Diagnosis is suspected by PCP
Classify based on localization and type
Assessment of associated impairments
Overall severity
Assessment for Intervention
Spasticity
Dyskinesia (dystonia and choreoathetosis)
Ataxia
Hypotonia
Type of Motor Disorder
Diplegia: Lower extremities >> upper extremities
Quadriplegia: Upper and lower extremities are affected equally
Hemiplegia: 1 side more involved than its opposite counterpart
Localization
Gross motor – ambulation
Fine motor – self-help skills
Oromotor and speech – communication, eating and drinking
Functional Motor Abilities
Level I – Speed, balance and coordination are limited
Level II- Minimal ability to perform gross motor skills such as running and jumping
Level III – May ambulate with assistive devices
Level IV – Children may achieve self-mobility using a power wheelchair
Level V – All areas of motor function are limited, no means of independent mobility
Gross Motor Function Classification System for Cerebral Palsy (GMFCS)
Chorioamnionitis
Birth weight <2000 gm
Intracranial hemorrhage
Newborn encephalopathy
Periventricular leukomalacia
Hydrocephalus
Congenital malformations
Risk Factors for Development of CP
All PCPs will encounter children with cerebral palsy in their practice
Prevalence of 3.6 per 1000
More than 100,000 children in the US are affected
More than 90% of children with severe disabilities survive to adulthood
We will see them for health maintenance, care coordination, and acute visits
Relevance to Us
30 yoM, former 26 week preemie, with CP, GMFCS Level V, mental retardation, seizure disorder, VP shunt, feed formula by a bottle
His PCP is a pediatrician, they live 1 hour away
This pediatrician has referred the patient to see me due to weight loss.
Case
A. Malnutrition
B. Obesity
C. Vitamin D deficiency
D. Gastro-esophageal reflux
E. All of the above
What nutritional issues may arise in patients with cerebral palsy?
Affected by dysphagia, GERD, delayed gastric motility, constipation
May have to rely on gastrostomy or jejunostomy tubes
+/- fundoplication
Growth/Nutrition
Special growth charts are available for CP◦ Limitation is charts are not standards for ALL
pts
Recommend WHO birth - 2 yrs and CDC 2 yrs up
Objective of plotting is to monitor trends◦ Z-scores: variation from the reference and from
each child’s own growth pattern
Growth Charts for CP
Protein (grams/kg)◦ Based on actual weight, DRI
Hydration◦ Obviously essential, helps reduce constipation
◦ Holliday-Segar method: 100, 50, 20; based on wt
Calories◦ Calculated per the BMR
Growth/Nutrition
WHO (basal needs: BMR)[W = weight (kg)]
Age (yrs) Gender Equation0-3 Male 60.9W-54
Female 61W-513-10 Male 22.7W+495
Female 22.5W+49910-18 Male 17.5W+651
Female 12.2W+746Gevena, 1985
Nutrition
14.7 cal/cm in children without motor dysfunction
13.9 cal/cm in ambulatory patients with motor dysfunction
11.1 cal/cm in non-ambulatory patients
Use arm span to estimate height
Height based method
Micronutrients
If formula is <1L/day for adolescents/adults, will need to add MVI
Consider monitoring vitamin D status
Growth/Nutrition
A. Malnutrition
B. Obesity
C. Vitamin D deficiency
D. Gastro-esophageal reflux
E. All of the above
What nutritional issues may arise in patients with cerebral palsy?
A. Malnutrition
B. Obesity
C. Vitamin D deficiency
D. Gastro-esophageal reflux
E. All of the above
What nutritional issues may arise in patients with cerebral palsy?
Malnutrition due to decreased ability to take in adequate calories
Obesity can also be an issue due to poor mobility and overfeeding via gastric tube.
Poor exposure to sunlight
GERD common in CP
Nutrition Explanation
Treatment options include:◦ Decorative scarves and bibs
◦ Glycopyrrolate – risk for mucous plugs
◦ Atropine Drops – local effect
◦ Scopolamine patch
◦ Botulinum toxin injections – expensive procedure
◦ Removal of salivary glands – permanent, not recommended
Drooling
Children with CP often struggle with oral and/or pharyngeal dysphagia
Diagnose formally with a swallow study with radiology and speech pathology
Treatment may include use of Thick-It or oatmeal thickener, or reliance solely on gastrostomy tube
Swallowing
3 yoF with spastic quadriplegic CP is admitted with fever and increased WOB, no increased seizures, tolerating feeds well by g-tube, her mother has been feeding her stage III foods by mouth, she has history of a Nissen fundoplication.
Case
A. Video Swallow study
B. CT scan of the chest
C. Sputum for AFB
D. Gastric emptying study
What diagnostic procedure will likely help determine cause of her respiratory distress?
◦Aspiration (primary or secondary)
◦Upper airway obstruction
◦Infections (poor pulmonary clearance)
◦Restrictive lung disease (scoliosis)
Respiratory
Pulmonary clearance techniques may include chest percussion, cough assist, VEST therapy all with the use of bronchodilator therapy
May develop OSA or central sleep apnea
Over time may progress to need for trach and vent if severe chronic lung disease
Respiratory
A. Video Swallow study
B. CT scan of the chest
C. Sputum for AFB
D. Gastric emptying study
What diagnostic procedure will likely help determine cause of her respiratory distress?
A. Video Swallow study
B. CT scan of the chest
C. Sputum for AFB
D. Gastric emptying study
What diagnostic procedure will likely help determine cause of her infection?
Case
5 yoM with history of failure to thrive, had g-tube placed one year ago, no fundoplication, no PPI therapy, minimal weight gain since then, transferred to Vidant Medical Center from a regional hospital for intolerance of bolus G-tube feeds and intermittent coffee ground emesis. MGM reports he has intermittent emesis for past year.
A. Dental evaluationB. Reflux and gastric emptying studyC. Plain abdominal filmsD. Plot him on the CP growth chart,
determine he is still on the curve, reassure parents
E. All of the aboveF. None of the aboveG. B and C
What work up would you pursue next to evaluate this patient’s failure to thrive and feeding intolerance?
Reflux◦ Positioning upright◦ H2 or PPI therapy◦ Fundoplication
Constipation◦ Hydration and fiber ◦ Scheduled miralax◦ Suppositories
GI
Delayed gastric motility◦ Slow rate of feeds◦ EES◦ Reglan◦ Pyloroplasty
GI
A. Dental evaluationB. Reflux and gastric emptying studyC. Plain abdominal filmsD. Plot him on the CP growth chart,
determine he is still on the curve, reassure parents
E. All of the aboveF. None of the aboveG. B and C
What work up would you pursue next to evaluate this patient’s failure to thrive and feeding intolerance?
A. Dental evaluation
B.Reflux and gastric emptying studyC.Plain abdominal filmsD. Plot him on the CP growth chart, determine he
is still on the curve, reassure parentsE. All of the aboveF. None of the above
G.B and C
What work up would you pursue next to evaluate this patient’s failure to thrive and feeding intolerance?
A. Reduce muscle spasms
B. Improve functional ability
C. Reduce pain
D. Improve hygiene
E. Prevent tissue injury
F. Prevent hip migration
G. Improve cognitive functioning
When considering treatment for spasticity, which of the following is not considered a treatment goal?
Modified Ashworth Scale.
Blackburn M et al. PHYS THER 2002;82:25-34
Physical Therapy
PT, ROM exercises ◦ Enhance skill development, delay contractures◦ Time required to perform
Orthotics◦ To improve function, prevent contractures◦ Possibility of pressure sores or muscle wasting
Systemic medications ◦ Diazepam, baclofen, tizanidine, dantrolene◦ Decrease pain and muscle spasms◦ Sedation is adverse side effect
Spasticity
Botulinum toxin◦ Improve pain, improve function, help with hygiene◦ 2-3 primary muscle groups◦ Wanes after 3 months
Intrathecal baclofen pump◦ No central effect of sedation◦ Device complication
Dorsal Rhizotomy◦ Permanent◦ Improves ambulation for spastic diplegics
Spasticity
Pain arising from the hip
Clinically important leg length difference
Deterioration in ROM of hip
Increasing hip muscle tone
Deterioration in sitting or standing
Increasing difficulty with perineal care or hygiene
Hip Dysplasia
Contractures◦ Tendon clipping
Hip dislocation◦ Surgical stabilization
Scoliosis◦ Surgical repair
MSK issues requiring Orthopedics
A. Reduce muscle spasms
B. Improve functional ability
C. Reduce pain
D. Improve hygiene
E. Prevent tissue injury
F. Prevent hip migration
G. Improve cognitive functioning
When considering treatment for spasticity, which of the following is not considered a treatment goal?
A. Reduce muscle spasms
B. Improve functional ability
C. Reduce pain
D. Improve hygiene
E. Prevent tissue injury
F. Prevent hip migration
G. Improve cognitive functioning
When considering treatment for spasticity, which of the following is not considered a treatment goal?
A. Constipation
B. Reflux
C. Extremity fracture
D. Hip dysplasia
E. Muscle spasm
The most common cause of pain in patients with CP is:
Pain in children with CP is under-recognized and thus undertreated
Affects quality of life
Challenges include difficulty communicating and multiple etiologies of pain
Pain –Evidence Based Medicine
Cross-sectional study looked at 252 patients with CP ages 3-19
Questionnaire, including Health Utilities Index 3 pain subset, completed by primary caregiver
Treating physician was asked to identify the presence of pain and provide a clinical diagnosis if applicable.
Characteristics of Pain
92% response rate
55% reported some pain on the HUI3, with 24% reporting that their child experienced pain that affected some level of activity
Physicians reported pain in 39%
Identified hip dislocation/subluxation (27%), dystonia (17%), and constipation (15%) as the most frequent causes of pain.
Characteristics of Pain
A. Constipation
B. Reflux
C. Extremity fracture
D. Hip dysplasia
E. Muscle spasm
The most common cause of pain in patients with CP is:
A. Constipation
B. Reflux
C. Extremity fracture
D. Hip dysplasia
E. Muscle spasm
The most common cause of pain in patients with CP is:
Provide primary care – preventative and acute
Chronic care
Care coordination◦ Subspecialists◦ Home nursing
Sign care plan◦ Order supplies
ICD code 343.9◦ Social work, can help with community resources◦ School
Revisit role of PCP
Help to identify adult primary care and specialists
School through age 21 with IEP The ARC - http://www.thearc.org/ Vocational rehabilitation Discuss sexuality Advance directives Palliative care Alternative care givers Insurance Equipment
Transition
American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians-Society of Internal Medicine. A consensus statement on health care transitions for young adults with special health care needs. Pediatrics. 2002; 110:1304-1306.
Etz, CL, Telfair J. (2007) Health Care Transitions: An Introduction. CL Betz, WM Nehring (Eds.),. Promoting Health Care Transitions for Adolescents with Special Health Care Needs and Disabilities (pp. 1-16). Baltimore: Paul H. Brooks Publishing Co.
Fehlings D, Switzer L. Informing evidence-based clinical practice guidelines for children with cerebral palsy at risk of osteoporosis: a systemic review. Developmental Medicine and Child Neurology. 2012, 54: 106-116.
Liptak GS, Murphy NA. Clinical Report: Providing a primary Care Medical Home for Children and Youth With Cerebral Palsy. Pediatrics. 2011, 128: e1321 – 1329.
National Collaborating Centre for Women's and Children's Health (UK). Spasticity in Children and Young People with Non-Progressive Brain Disorders: Management of Spasticity and Co-Existing Motor Disorders and Their Early Musculoskeletal Complications. London: RCOG Press; 2012 Jul. (NICE Clinical Guidelines, No. 145.)
References
Samour PQ, King K. Handbook of Pediatric Nutrition. 3rd ed. Sudbury, MA. Jones and Bartlett Publishers, Inc. 2005.
V Marchand; Canadian Paediatric Society Nutrition and Gastroenterology Committee. Paediatr Child Health 2009;14(6):395-401 Poster: Aug 1 2009 Reaffirmed: Feb 1 2014.
Mehta et al.; Defining Pediatric Malnutrition: A Paradigm Shift Toward Etiology-Related Definitions; J Parenter Enteral Nutrition, published online 25 March 2013.
Penner M, Xie WY. Characteristics of Pain in Children and Youth With Cerebral Palsy. Pediatrics. 2013, 132: e407-413.
Shaw, TM, DeLaet DE. Transition of Adolescents to Young Adulthood for Vulnerable Populations. Pediatrics in Review. 2010;31;497-505.
Slide from Blackburn M et al. PHYS THER 2002;82:25-34
References