Transcript Spasticity in Cerebral Palsy Pathophysiology to practice

Spasticity in Cerebral Palsy
Pathophysiology to practice
By: Hamidah Lalani, BSN, RN.
Graduate Student
Alverno College
Objectives
The learner will be able to:
Understand the functions of upper
motor and lower motor neurons
Learn definition, epidemiology and
causes of Cerebral Palsy (CP).
Understand the pathophysiology of
spasticity as it relates to Cerebral
Palsy.
Objectives
Understand the role of inflammatory
immune response in spasticity.
Understand the role of stress
response in spasticity
Identify patients needs and nursing
outcomes in caring for the patient with
spasticity.
Instructions for tutorial
Read the information carefully
followed by the question and possible
answers. Click on the answer you
think is correct. If you want to go back
to the previous slide click on the
button. If you want to go to next
question click on the bottom left
corner of the slide. If you want to start
over click on the button.
Cerebral Palsy
It is the disorder of movement and
posture that result from a nonprogressive lesion or injury of the
immature brain.
Leading cause of childhood disability
Cerebral Palsy
Occurs in 2 to 3 per 1000 live births.
Causes: prenatal, perinatal, and postnatal.
765,000 Americans have CP
9000 children are diagnosed each year
1 in 3 with very low birth weight will be
diagnosed with CP
http://www.ucp.org/ucp_generalsub.cfm/1/9/1217
Upper and Lower motorneuron
Upper motorneuron
Injury to UMN leads
to hypertonia.
Elicit deep tendon
reflex
Dorsal horn cell in
spinal column carry
information to the
brain and are also
called afferent nerve
fibers or input
association (IA).
Lower motorneuron
Injury or lesion to LMN
results in hypotonia.
Have negative
reflexes.
Ventral horn cells in
spinal column bring
information to the
muscle fibers and are
also called efferent
nerve fibers or output
association (OA).
The information sent to the brain as
input association through the spinal
cell column from the muscles goes
through:
Dorsal Horn
Ventral Horn
Right!
The dorsal horn is the input
association that brings information
from the spinal column to the brain.
Really?
The ventral horn brings information to
the muscle fiber.
Cerebral palsy is associated
with spasticity
What is Spasticity?
Velocity-dependent increase in
muscle tone with exaggerated tendon
reflexes, due to hyper excitability of
stretch reflex.
Causes
Spasticity can be caused by any insult to
the brain related to:
Trauma
Abuse
During birth
Birth defect
Genetically acquired
Secondary to other disease, e.g.
encephalitis, hydrocephalus, MS, spinal
dysreflexia, stroke.
Pathophysiology
With any brain lesion,
communication from the brain
is disrupted and the brain is
unable to inhibit the stretch
reflex.
In case of injury to the cortex
the inhibitory signals are lost
and the person experiences
hyperactivity or spascity.
http://128.104.8.50/courses/neuro/SClinic/Weakness/lmn98.JPG
Spasticity
A lag time may exist between injury
and spasticity onset
Severity may wax and wane over time
and vary by diagnosis.
Spasticity may be static (always
present) or dynamic (increase with
intentional movement) in nature.
Stress in Spasticity
Increased activity of the reticular
activating system (RAS) and its
influence on reflex circuits that
controls the muscle tone causes
increased tension in the muscle that
adds to already tight muscles.
Factors effecting stress in spasticity
Genetic predisposition
Age
Sex
Exposure to environmental stimuli
Life experiences
Diet
Social support
Stress and Immunity
Immune response is triggered by
stress.
Immunity is also compromised in
stress due to increased levels of
cortisol.
Inflammatory immune response
In the event of an inflammatory immune
response, the brain cells including
neurons produce broad spectrum
inflammatory mediators like CRP and
cytokines IL-1B and IL6 that can
cause tangles and plaques which
could in turn cause neuronal loss and
ultimately loss of movement.
In inflammatory immune response,
tangles and plaques are formed due
to the mediators like:
CPK IL- IB, IL- 6
CPK IL- 6
CPK IL- IB
Right!
CPK, IL IB and IL 6 are the
inflammatory immune mediators.
Wrong
IL – 6 is also involved in the
inflammatory response.
Wrong
IL – IB is also involved in the
inflammatory immune response.
In the event of stress, muscle tension
is increased due to the increased
activity of:
Reticular activating system
Cortical releasing factor
Right!
RAS increases muscle tension in
stress.
Wrong!
Cortical releasing factor (CRF) works
synergistically with cortisol to inhibit
the function of immune system.
The synapses that send nerve
conduction to upper extremities are
from C5 (cervical) to C8.
The L2 (lumbar) to S1(sacral)
segments are responsible for nerve
conduction to lower extremities.
Case Study
A three year old girl with a history of
shaken baby syndrome came to clinic
with complaints of not meeting her
developmental stages. A MRI of the
spine revealed injury at L3 level of the
vertebrae. The injury has affected her:
Arms
Legs
Right!
Legs are affected if the injury is
between L2 and S1.
wrong
Injury between C5 and C8 affects
arms.
It was determined during the physical
examination and history from her
guardian that she cannot walk. The
tone in her legs was increased and
she had spasticity. The injury
therefore is in:
Upper motorneuron
Lower motorneuron
Right!
Upper motorneuron causes the
hypertonia or spasticity.
Wrong!
Injury to lower motorneuron causes
weakness or hypotonia.
Neuromuscular Junction
http://en.wikipedia.org/wiki/Neuromuscular_Junction
Acetylcholine a neurotransmitter,released
at the synaptic junction binds itself to the
cholinergic receptors in the post synaptic
terminal and provide information to the
skeletal muscle.
Cholinergic receptors are of two types:
nicotinic and muscarinic. Nicotinic are
found in the skeletal muscles and helps
with receiving acetylcholine.
Acetylecholine binds with cholenergic
receptors in the post synaptic junction
to provide information for contraction
to the skeletal muscle. Acetylecholine
is a:
Neurotransmitter
Synapse
Receptor
Right!
Acetylecholine is the neurotransmitter
participates in the contraction of the
skeletal muscle.
Really?
A synapse helps with action potential
in neurons and muscles.
Wrong!
A receptor like cholinergic receptor
attaches to the (acetylecholine)
neurotransmitter to initiate the muscle
contraction.
What is Muscle tone?
It is the tension in a muscle caused by
the passive movement of the joint and
it is very important for the muscle
movement.
Intrafusal muscle fibers lengthens the
the muscle.
Extrafusal muscle fibers contracts the
muscle.
Muscle Spindle
http://en.wikipedia.org/wiki/File:Skeletal_muscle.jpg
Tonic reflexes are polysynaptic and
help with movement and tone of the
muscle through the descending
excitatory signals from brain.
Phasic reflexes are monosynaptic and
exhibit reflexes like deep tendon
reflex.
When the neurotransmitter reaches
the post synaptic terminal Intrafusal
muscle fibers get the information to:
Stretch the muscle
Contract the muscle
Right!
The intrafusal fiber is responsible for
lenghtening the muscle fiber .
Wrong!
The extrafusal muscle is responsible
for muscle contraction.
Case study
A fifteen year old girl with a history of
premature twin birth and diagnosed
with cerebral palsy came to clinic. On
physical examination, the doctor was
unable to elicit knee jerk reflex. Which
pathway is interrupted?
Tonic excitatory
Phasic excitatory
Right!
Phasic excitatory pathway effects all
reflexes.
Wrong!
Tonic excitation effects the movement
and contraction of the muscle like
extention and flexion of the arm.
Both her arms were stretched out and
the doctor was unable to flex them.
Which of the following pathways was
interrupted?
Descending excitatory
Descending inhibitory
Right!
Descending inhibitory pathway
modulates with the excitatory pathway
and helps stop the contraction and
allows the muscle to relax.
Wrong!
Descending excitatory pathways help
contract the muscle.
Nursing Outcome
The most important nursing
intervention in the care of patient with
spasticity is the prevention of skin
breakdown.
Keep the skin clean, and dry through
good hygiene, position changes,
support in pressure areas.
Mobility
Provide resources for better mobility
depending on patients’ ambulatory
status. Example, wheel chair (manual,
electric), braces for legs, therapy.
Pain
Pain is caused by constantly
contracting muscles.
Relaxing the muscles through
therapy, exercises etc
Nutrition
Good nutrition should be provided to
prevent skin breakdown
Among all the nursing intervention the
following is the most important
problem that requires nursing
intervention.
Mobility
Pain
Skin integrity
Correct!
Skin breakdown is caused by
immobility and should be prevented to
prevent further complications.
Pain is controlled with medications.
Mobility is provided with the use of
wheel chair or walker.
Treatment
Medication management:
Baclofen
Dantrolene
Clonidine
Tizanidine
Injections
Botox (Botullinum toxin A)
Phenol
Myobloc (Botullinum toxin B)
Surgical Intervention
Intrathecal baclofen pump
Patient teaching
Baclofen trial
Pump implant
Follow-up
Alarm
Refill
http://www.medtronic.com/statements/terms/index.htm#copyrights-trademarks
Resources
Orthotics – AFO, SMO, body brace
Therapy – Physical, occupational,
speech, aqua therapy, hippo therapy.
Self accommodating equipment –
Wheel chair (electronic vs. manual),
walker
Augmentative communication
Goals
Functional - hygiene
Mobility
Comfort – free of pain
Skin integrity
Cognition
Communication
Psychosocial coping – family integrity
Nutritional status – oral vs.G.T
Sleep disturbances – related to medication
Behavior - medication
References
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Rehabilitation Nursing; Procedures
Manual.
Chicago, Il: McGraw-Hill companies.
Chin, P.A., Finocchiaro, D., Rosebrough, A., (1998).
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Kirshblum, MD. S., Campagnolo, MD. D.I., Delisa, MD.,
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