Cerebral palsy

Cerebral palsyCerebral palsy (CP), defined as a nonprogressive disorder of posture or movement due to a lesion in the developing brain.

• Types of CP are given different names based on the type of movement problem and the areas of the body affected:

• Spastic• Ataxic• Dyskinetic• Mixed• Quadriplegia• Diplegia • Hemiplegia 

The brain damage that causes cerebral palsy is a result of either:• Prenatal disturbance of brain cell migration • Prenatal poor myelination (insulation) of developing nerve cell fibers • Perinatal brain cell death • Postnatal non-functional or inappropriate connections (synapses)

between brain cells

CLARIFYING TERMINOLOGY ( Causes )• Brain development • Brain defects• Brain malformations • Brain lesions 

• In most cases, the cause of congenital cerebral palsy is unknown. Some possible causes are:

• Infections during pregnancy • Severe jaundice in the infant. • The physical and metabolic trauma of being born. • Severe oxygen deprivation to the brain or significant trauma to

the head during labor and delivery.

Signs and Symptoms Other symptoms of CP related to movement can include:• Tight muscles that worsen with stress, illness, and time• Tight joints that do not bend or stretch all the way, especially in the hands,

elbows, hips, knees, or ankles• Muscle weakness, or a decline in movements that the child had already been

performing• Lack of efficient movement of the legs, arms, trunk, or neck• Lack of coordination• "Floppy" muscles, especially in the neck or trunk• Muscle tremors

Other symptoms of CP related to movement can include:• Tight muscles that worsen with stress, illness, and time• Tight joints that do not bend or stretch all the way, especially in

the hands, elbows, hips, knees, or ankles• Muscle weakness, or a decline in movements that the child had

already been performing• Lack of efficient movement of the legs, arms, trunk, or neck• Lack of coordination• "Floppy" muscles, especially in the neck or trunk• Muscle tremors

Diagnosis• lack of alertness• Abnormal, high-pitched cry• Trembling of the arms and legs• Poor feeding abilities secondary to problems sucking and swallowing• Low muscle tone• Abnormal posture, such as the child favoring one side of the body• Seizures, staring spells, eye fluttering, body twitching• Abnormal reflexes.

Diagnosis

• Testing motor skills and reflexes,• Looking into medical history, and• Employing a variety of specialized tests.

Demographic Information:

• Initial Evaluation • History of Present Illness• Past Medical History• Personal, Social and Environmental History• Family History • Physical Examinations• Problem List • Treatment Plans and Management• Home Instructions, Progress notes and discharge plan.

Initial Evaluation

• Name: Melissa Wingerd• Age: 5 y/o• Sex: Female• Martial Status: Single• Address: 1306 Winding Walters Circle, Coral Springs,

Florida.• Occupation: None

• Present Therapy Schedule: School program offers OT, PT and ST 3 X / week each, for 30 minute sessions.

• School Program: Upcoming school year she will be in a multidisciplinary program at Maplewood Elementary. It is like a second year of preschool. They actually are in Coral Springs Elementary School district, but all four kids are going to return to Maplewood at least for one more year, so they can be at same school.

• Summer School Schedule: Goes to daycare.• After School Care: Goes to daycare after school.• Transportation To/From School: Mom will take them to school and daycare will

pick them up.

Therapy/Education

Rehabilitation Program(s) [In/Outpatient Since Injury]:

•  

•  She was initially transferred from North Broward Medical Center to Broward General Hospital on March 24, 1999. She remained in Broward General until the end of April, when she went back to North Broward Medical Center where she remained for approximately one week. She was then transferred to Chris Evert Children’s Hospital where she stayed from 5/18/99 – 8/17/99. She began some OT and PT while in All Children’s. Discharge summary noted the following:

• 31+ week Quadruplet B.• Congenital hydrocephalus.• Tetralogy of Fallot.• Cleft palate.• Apnea.• Retinopathy of prematurity (Resolved).

• Gastroesophogeal reflux.• Enterococcus sepsis.• IV Infiltrate right foot.• Paralyzed left diaphragm.• Small residual ventricular septal defect, mild residual pulmonic stenosis,

mild to moderate pulmonary regurgitation.• Hypochloremic metabolic alkalosis.• Nephrocalcinosis.• Nasopharyngeal reflux.

Current DisabilityDisabling Problems: (By client/family history and report. No physical examination occurred).

• Chief Complain.• Nora(Mother): My understanding with the “hydrocephalus is she will have the

shunt for the rest of her life. As a result, when she has a headache or a fever I watch a little closer because I never know if it is shunt related or not. As for the developmental delays, no one has been able to tell us what that will really mean and only time will tell. I know they are there because I have three others to compare her to. Her analytical skills, her reasoning skills, even the way she plays are just not like the other children. Melissa is consistently six plus months behind where the other children are in play activities even when she has the other children to mimic. I see a lot of discrepancies with her fine motor skills. Her sisters and brothers can write their names, while Melissa can spell her name, but she can’t even trace her name. Her siblings can color in the lines, but Melissa simply can’t. With some of her gross motor skills, she shows a problem with her balance. In hopping on one foot, riding a bike, using the trampoline, she has balance problems. In other skills, she is emerging but very much behind her siblings. She has constant problems with her asthma, especially with weather changes or if she develops a cold. She is being monitored on an annual basis for her heart, but right now everything seems to be going well. When she is a teenager, we may have to do stress tests. She tends to tire much more easily than the other children. She can’t keep up with the other children physically without a nap or without tiring. She interacts with adults better because of all her hospital stays and doctor visits. She does not do as well with peer group play.”

Past Medical History• Shunt surgery at five weeks of age. Revision done one week later. She had a

shunt infection in November of 1999 with a revision and she had a shunt malfunction in May of 2000 with a revision. Cleft palate surgery done February of 2000. She has had follow-up Flap surgery done in relation to the cleft palate in February of 2004

• She had one heart surgery to correct the Tetralogy of Fallot. This was successful.• She has had repetitive ear infections and could not pass hearing exams. So she

had tubes placed in her ears.• She had eye muscle surgery done in December of 2003. This was to correct

crossed eyes

Developmental Delay

• Seizure Disorder Type: None

• Surgeries Performed: Shunt and shunt revisions, tonsillectomy, tubes in ears, gastrostomy when she was a baby, strabismus surgery and cleft palate

surgery. Anticipated: Possible shunt revisions if malfunctions. 50% of

strabismus surgeries have to be repeated.

Daily Care• Current Attendant and/or Nursing Care: Parental care and daycare. Bowel/Bladder Program: Potty trained. She will wear a pull-up at night. Self-stimulating Behaviors: None.

• Motor Skills Bring Hands to Midline: Yes. Grasp (Left/Right): Intact. Grasp with thumb & forefinger: Yes. Voluntary purposeful movements (upper & lower extremities): Yes. Sit unassisted: Yes.

• Hold head erect: Yes.• Roll front to back: Yes.• Roll back to front: Yes.• Pull self upright: Yes.• Drink from cup: Yes.• Drink from bottle: No.• Tube feeding schedule: No.• Ambulate: Wide based gait with some balance deficits

• Assist in dressing: Yes.• Perform household chores: No, not even at an age related

level. It is difficult for her to follow multi-step instructions.• Perform personal hygiene: She can bathe herself with

assistance.• Crawl: Yes.• Ascend/descend stairs: With hand-holding assistance.

Social Skills

• Smile: Yes.• Laugh out loud: Yes.• Dintinguish family from strangers: Yes.• Demand personal attention: Yes.

Long-Term Care Options

• Facility/Home Care: Home care.• Anticipated Treatments : Nothing scheduled as far as

treatment interventions. She has her regular physician visits scheduled and those will continue.

Physical Limitations

• Loss of Tactile Sensation: Tactile sensation is intact. She is very sensitive on bottoms of her feet.

• Reach: Normal reaching ability with full range of motion.• Lift: She does not have the muscle strength to lift at a peer related ability. She can lift,

but weight amount is limited.• Prehensile/Grip: Normal grip strength.• Sitting: Normal ability to sit. She does have difficulty sitting still for long periods of

time.• Standing: She can stand at a age appropriate level. • Walking/Gait: She does walk with a somewhat wide based gait. She has some balance

deficits. Gait is not smooth. Running is more difficult. She does fall frequently.

• Bend/Twist: Bending and twisting at the waist is an emerging skill, but at this time she will primarily bend at the knees and stoop to pick something up.

• Kneel: She can do this at age appropriate level.• Stoop/Squat: She can do this at age appropriate level.• Climb: She can climb stairs, but she needs standby assistance and usually hand

holding. Descending stairs is much more precarious than ascending.• Balance: Balance deficits. Balance is fair, but improving.• Breathing: She has Asthma. Bronchial Pulmonary Dysplasia. When she gets a cold it

compromises her breathing. Seasonal allergies. Nebulizer used during colds and seasonal allergies only. Mom estimates episodes requiring Nebulizer treatments about six times per year.

• Headaches: She has recently complained of headaches. This was the first time she had ever complained of a headache. They went to ER and the shunt was checked and it was functioning well.

• Vision: She has had eye muscle surgery for strabismus in both eyes. She does not wear glasses, vision tested and they feel she is near sighted but not bad enough to require corrective lenses at this time. Monitoring every 6 months.

• Hearing: She has PE tubes in both ears. She has a mild hearing loss in both ears. Not sure what level. No need for correction at this time.

• Driving: Possible candidate in the future. Will need handicapped evaluation.• Physical Stamina (average daily need for rest or reclining): She tires much

more easily than her siblings. She has to have a nap.

Environmental Influences• Problems on exposure to:Air Conditioning: No. Heat: Yes, sweats profusely. Cold: No. Wet/Humid: Yes, Asthma. Sudden Changes: Yes, Asthma. Fumes: Yes, Asthma. Noise: Yes, very short attention span in noisy environments. Stress: No, very social child. Other: She has more difficulty interacting with peers than she does with adults.

Medical Summary

• Melissa Wingerd is a 5-year-old Caucasian female who was born with Tetralogy of Fallot, hydrocephalus and a cleft palate. She was one of quadruplets conceived through invitro fertilization. She has a VP shunt in place and is developmentally delayed.