cerebral palsy child with cast

tralalaRN · Apr 25, 2011

And yes, the baclofen would help with muscle relaxation. However, how is it being administered? There is oral Baclofen, or it can be adm by baclofen pump, which many kids with CP have. However, the baclofen pump has to be set by medical staff, and it might not be set at a level that will actually work for casting or post op care. If it is oral baclofen, it would be easier to adjust.

TJacob · Apr 25, 2011

You are right, they are children first, I should have worded that better.

He is wheel chair bound and Im not sure on the casting, I think youre right though.

Ive read alot about botox injections, perhaps thats something that would help since it weakens muscles for 3-4 months which may also ease the pain. The baclofen I believe is oral, it only said that the mother listed the meds but didnt know the dosage.

Oxygen.. He has very limited use of his upper extremities. All it says about his cognitive development is he likes his blue bunny tucked under his arm and only communicates by pointing, smiling for yes and looking down for no. He goes to a special education school. He is 10 but only weighs 25.2 kg and 104 cm so he is relatively small. I thought about the tent too but wasnt sure. That might be easier to defend but I wasnt sure if he was too big.

Im having such a difficult time with this plan because nothing is very clear.

Again, thank you so much for your insight!!!

tralalaRN · Apr 25, 2011

I think you are doing great with this, although I'm certain it doesn't feel like it as it is pretty involved.

Yep - I would go with the crib. You can defend this by the fact that kids with CP are almost ALWAYS followed by pediatric orthopaedic surgeons and rehab staff. With that said, CP clinics are in large hospitals with generally larger peds units. They would most likely have large cribs that would support an 02 tent, and especially since he is smaller, I would go for that. In addition, if a parent or family member is unable to stay with the child, he should be on a monitor and in a room visible from the nurses' station in the event of a seizure, or better yet, a bedside sitter.

Yes, botox is used sometimes for tx of spastic CP - with mixed results. The botox is injected into the offending muscles that are tight in order to somewhat paralyze them, and allow the weaker muscles to gain strength. However, if it is a child with CP who walks, this can really interfere with their mobililty, as they've been depending on these muscles - now they have been substantially weakend. Botox injections are absolutely brutal to witness, as many many injections are given up and down the legs.

Sorry, another no no - don't use "wheelchair bound" . .it's "uses a wheelchair" or "wheelchair user". .I know, it's picky stuff, but to the disability community, these things are important:)

You're doing great. I'll keep checking back tonight if you have more ques.

tralalaRN · Apr 25, 2011

Another thought - even though this child doesn't walk, it is often highly recommended that they do weight-bearing, as this helps to keep their hip joints in place. Spasticity on the hip joints over time tends to dislocate the hips. So in order for the child to do weight bearing such as in a stander, they have to be able to wear lower leg braces to properly allign the feet. This is why it is important to try and have good range of motion in the ankles. .so they can fit into the lower leg braces (ankle foot orthotics), in order to get them into a proper standing position. Very much a domino effect going on with this.

Also with hospital care with a patient like this - they should have padding around the inside of the crib so they don't hurt themselves in the event of a seizure. Did she say what type of seizures this child may have? If it is status epilepticus (doesn't come out of the seizure on his own), emergency meds would need to be kept close by to administer by IV. If at home, he may have something like rectal diastat to bring him out of the seizure.

Whew! What a complicated case study for you!

TJacob · Apr 26, 2011

:) got ya... HE uses a wheel chair reflects that this is a person, wheelchair bound ignores the person. Ill let my instructor know too as it was her phrase.

I have no idea what to say then. I need two complications of a child with cerebral palsy that has casts and a medication can help with one of these complications. I keep going back to her question of "what can the muscles not do when in a cast?" I think they would still be spastic. I know serial casting is used to prevent contracture and lengthen the muscle.

I emailed my instructor again, she said its not botox, phenol or baclofen. It must be for pain. At this point, Im going to just accept getting this question wrong but I apprecaite all your help. And like I said, with all this research, Ive learned a LOT about the disorder and a many ways of treating different problems. More than I would have otherwise lol.

TJacob · Apr 26, 2011

I was only told seizures. Yes, very complicated. I can usually critically think these things through but this one has me stuck!! Perhaps the casts are on for his feet/ankles and not contracture. But the answer would still be the same, what complications are associated with casts and children with CP and what meds would help? I emailed her a third time lol. Ill see if she throws me a bone or not :)

I wanted to ask you about something you said... "skin breakdown is an issue for someone as you described. The only time my daughter ever ever had a pressure ulcer, was when she was in leg casts. Very important to move them with all that weight from the casts." So I want to add that skin breakdown is a complication but its not associated with altered sensation, is it just from having the cast in general, not specific to the disorder of CP?

My instructor said its a med that controls pain and muscle spasms. I thought valium but both that and baclofen say not to take with eachother because they both increase CNS depression. Ill ask her.

Ill let you know how this turns out :) youve been a great help!!

tralalaRN · Apr 26, 2011

Perhaps she is looking for a medication like Skelaxin - a muscle relaxant? Maybe we're reading too much into this? When legs are casted, obviously, the muscles are not able to move. Could it be that simple? There would still be spasming going on though, as the casting forces the muscles into unnatural positioning - positioning that the child's muscles are not able to achieve on their own.

Yes, frequent repositioning is very very important to prevent pressure ulcers. The weight of the casts really is problematic. Also, even though these kids are said to be "quadriplegic" - it doesn't mean that they can't move at ALL, it just means that someone who has spastic quariplegia has some involvement in all extremities. They may have different degrees - moderate or severe in legs with mild in upper extremities. So quadriplegia in the case of CP does NOT mean complete paralysis.

Ok - good luck on this - will be anxious to hear what happens with all of your hard work here!

tralalaRN · Apr 26, 2011

Also - there really is no "altered sensation" with CP. All of the children I have known who have CP in varying degrees have no altered sensation. They feel pain as anyone else does. There can be no comparison from spinal cord injuries where there is no sensation or is altered sensation below the level of the spinal injury, vs CP where there is no spinal cord injury but damage to the motor cortex in the brain. (The signals are scrambled from the brain to the muscle nerves).

Prematurity, btw is the leading cause of CP. Very very very common among tiny preemies d/t high incidence of brain damage occuring from IVH, hypoxia and the NICU environment in general. The fetal brain develops the most during the last 3 months of pregnancy - if a baby is born 4 months early, they are spending their last 3+ months in the NICU being prodded, poked and assaulted very frequently - very high incidence of CP and other disabilities in this population.

The skin breakdown in those with more severe CP where they are unable to move at all, or not very much, or when adding the weight of leg casts, comes from being in one spot too long. My daughter who is more severe, does not walk at all, was still able to roll over and sit up on her own, but not with casts on - the weight of that was too much for her to manage, so we had to be very careful about positioning. We used things like pillows under her legs and rotated her from side to side - she did get a pressure ulcer on her sacrum, so that was dressed with a bandage and we then used sheepskin under her.

Melliott311 · Nov 11, 2013

I know this is really late and you are far done with the project but for anyone who is looking for answers in this post maybe this can help!

I just had a patient with this problem the other day. You are on the right track with muscle spasms. If you think about their legs being in a cast, especially in a position that they are not necessarily use to, it would be putting tension and lengthening muscles that arent accustomed to that position. So think about when you are stretching out muscles before a workout before they are warm- you stretch them out for 30 second or so and it feels good, but it stresses the muscle and it feels better when you relax and stop stretching. Well, when you put a child in a cast, it is essentially forcing them to be in a "stretching position" for good. So a lot of times when you see that patient and you have given them pain meds and they still act as though they are in pain, look at their legs, are they twitching? Can you see spasms? That is their muscles saying, stop! I don't want to be stretched anymore! And it can be very uncomfortable, especially for a child. Think about if someone held your leg in an uncomfortable stretch position for an extended length of time, your leg would start spasming, wanting to come back to a relaxed more neutral position. In my patient's case, we gave him vallium and clonazepam, because that is what worked for him. It caused the muscles to relax which decreased his discomfort tremendously. Hope this helps!