spasticity in cerebral palsy pathophysiology to practice l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Spasticity in Cerebral Palsy Pathophysiology to practice PowerPoint Presentation
Download Presentation
Spasticity in Cerebral Palsy Pathophysiology to practice

Loading in 2 Seconds...

play fullscreen
1 / 67

Spasticity in Cerebral Palsy Pathophysiology to practice - PowerPoint PPT Presentation


  • 801 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Spasticity in Cerebral Palsy Pathophysiology to practice' - Thomas


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
spasticity in cerebral palsy pathophysiology to practice

Spasticity in Cerebral PalsyPathophysiology to practice

By: Hamidah Lalani, BSN, RN.

Graduate Student

Alverno College

objectives
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.
objectives3
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
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
Cerebral Palsy
  • It is the disorder of movement and posture that result from a non-progressive lesion or injury of the immature brain.
  • Leading cause of childhood disability
cerebral palsy6
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 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).

slide8
The information sent to the brain as input association through the spinal cell column from the muscles goes through:

Dorsal Horn

Ventral Horn

right
Right!
  • The dorsal horn is the input association that brings information from the spinal column to the brain.
really
Really?
  • The ventral horn brings information to the muscle fiber.
what is spasticity
What is Spasticity?
  • Velocity-dependent increase in muscle tone with exaggerated tendon reflexes, due to hyper excitability of stretch reflex.
causes
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
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.
spasticity
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
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
Factors effecting stress in spasticity
  • Genetic predisposition
  • Age
  • Sex
  • Exposure to environmental stimuli
  • Life experiences
  • Diet
  • Social support
stress and immunity
Stress and Immunity
  • Immune response is triggered by stress.
  • Immunity is also compromised in stress due to increased levels of cortisol.
inflammatory immune response
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.

slide21
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

right22
Right!
  • CPK, IL IB and IL 6 are the inflammatory immune mediators.
wrong
Wrong
  • IL – 6 is also involved in the inflammatory response.
wrong24
Wrong
  • IL – IB is also involved in the inflammatory immune response.
slide25
In the event of stress, muscle tension is increased due to the increased activity of:

Reticular activating system

Cortical releasing factor

right26
Right!
  • RAS increases muscle tension in stress.
wrong27
Wrong!
  • Cortical releasing factor (CRF) works synergistically with cortisol to inhibit the function of immune system.
slide28
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
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

right30
Right!
  • Legs are affected if the injury is between L2 and S1.
wrong31
wrong
  • Injury between C5 and C8 affects arms.
slide32
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

right33
Right!
  • Upper motorneuron causes the hypertonia or spasticity.
wrong34
Wrong!
  • Injury to lower motorneuron causes weakness or hypotonia.
neuromuscular junction
Neuromuscular Junction

http://en.wikipedia.org/wiki/Neuromuscular_Junction

slide36
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.
slide37
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

right38
Right!
  • Acetylecholine is the neurotransmitter participates in the contraction of the skeletal muscle.
really39
Really?
  • A synapse helps with action potential in neurons and muscles.
wrong40
Wrong!
  • A receptor like cholinergic receptor attaches to the (acetylecholine) neurotransmitter to initiate the muscle contraction.
what is muscle tone
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
Muscle Spindle

http://en.wikipedia.org/wiki/File:Skeletal_muscle.jpg

slide43
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.
slide44
When the neurotransmitter reaches the post synaptic terminal Intrafusal muscle fibers get the information to:

Stretch the muscle

Contract the muscle

right45
Right!
  • The intrafusal fiber is responsible for lenghtening the muscle fiber .
wrong46
Wrong!
  • The extrafusal muscle is responsible for muscle contraction.
case study47
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

right48
Right!
  • Phasic excitatory pathway effects all reflexes.
wrong49
Wrong!
  • Tonic excitation effects the movement and contraction of the muscle like extention and flexion of the arm.
slide50
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

right51
Right!
  • Descending inhibitory pathway modulates with the excitatory pathway and helps stop the contraction and allows the muscle to relax.
wrong52
Wrong!
  • Descending excitatory pathways help contract the muscle.
nursing outcome
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
Mobility
  • Provide resources for better mobility depending on patients’ ambulatory status. Example, wheel chair (manual, electric), braces for legs, therapy.
slide55
Pain
  • Pain is caused by constantly contracting muscles.
  • Relaxing the muscles through therapy, exercises etc
nutrition
Nutrition
  • Good nutrition should be provided to prevent skin breakdown
slide57
Among all the nursing intervention the following is the most important problem that requires nursing intervention.

Mobility

Pain

Skin integrity

correct
Correct!
  • Skin breakdown is caused by immobility and should be prevented to prevent further complications.
treatment
Treatment
  • Medication management:
    • Baclofen
    • Dantrolene
    • Clonidine
    • Tizanidine
injections
Injections
  • Botox (Botullinum toxin A)
  • Phenol
  • Myobloc (Botullinum toxin B)
intrathecal baclofen pump patient teaching baclofen trial pump implant follow up alarm refill
Intrathecal baclofen pump

Patient teaching

Baclofen trial

Pump implant

Follow-up

Alarm

Refill

Surgical Intervention

http://www.medtronic.com/statements/terms/index.htm#copyrights-trademarks

resources
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
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
References

Alexander, T., Hiduke, R.J., Stevens, K.A., (1999). Rehabilitation Nursing; Procedures Manual. Chicago, Il: McGraw-Hill companies.

Chin, P.A., Finocchiaro, D., Rosebrough, A., (1998). Rehabilitation Nursing Practice. Azusa, CA: McGraw-Hill companies.

Fishman, M.A. (October 1st, 2008). Neurological examination in children. UpToDate, 16.3, Retrieved 2/6/2009, from http://www.uptodate.com/online/content/topic.do?topickey=ped_neur/2836&view=print

Kirshblum, MD. S., Campagnolo, MD. D.I., Delisa, MD., J.A., (2002). Spinal Cord Medicine. Philadelphia, PA.: Lippincott Williams & Wilkins.

references continued
References continued..

Lynch, MD, PHD, D., Waldman, MD, A., (10/1/2008). Pelizaeus-Merzbacher Disease. UpToDate, 16, Retrieved 2/17/2009, from http://www.uptodate.com/online/content/topic.do?topickey=demyelin/6613&view

Moorhead, S., Johnson, M., Maas, M., (2004). Nursing Outcomes Classification (NOC) 3rd ed.

Porth, C. M. (2005). Pathophysiology Concepts of Altered Health States. Philadelphia, PA: Lippincott Williams & Wilkins.

Simon, R.P., Aminoff, M.J., Greenberg, D.A., (1996). Clinical Neurology. USA: Lange Medical Books/Mcgraw-Hill.

Wu, MD, MPH, Y. (10/1/2008). Etiology and pathogenesis of neonatal encephalopathy. UpToDate, 16, Retrieved 2/6/2009, from http://www.uptodate.com/online/content/topic.do?topickey=ped_neur/2836&view=print