CEREBRAL PALSY

By: Ida Sherri L. CorveraBy: Ida Sherri L. Corvera

BSN III - NMBSN III - NM

• In 1860s, known as

"Cerebral Paralysis” or

“Little’s Disease”

• After an English surgeon

wrote the 1st medical

descriptions

William William John John LittleLittle

(1810-(1810-1894)1894)

William William John John LittleLittle(1810-(1810-1894)1894)

CEREBRAL PALSY (CP)

• Cerebral“- Latin Cerebrum;

– Affected part of brain

• “Palsy " -Gr. para- beyond,

lysis –

loosening

– Lack of muscle control

CEREBRAL PALSY

• A motor function disorder – caused by permanent, non-progressive brain lesion – present at birth or shortly thereafter. (Mosby, 2006)

• Non-curable, life-long condition• Damage doesn’t worsen• May be congenital or acquired

A Heterogenous Group

of Movement Disorders

CEREBRAL PALSY

– An umbrella term

– Not a single diagnosis

A Heterogenous Group

of Movement Disorders

CEREBRAL PALSY

CP AffectsMuscle

StrengthMovements

Balance

Coordination Posture

In CP

• Muscles are unaffected

• Brain is unable to send the appropriate signals necessary to instruct muscles when to contract and relax

CAUSESOF CEREBRAL PALSY

An insult or injury to the brain

– Fixed, static lesion(s)

– In single or multiple areas of the motor centers of the brain

– Early in CNS dev’t

• Development Malformations– The brain fails to develop correctly.

• Neurological damage – Can occur before, during or after delivery – Rh incompatibility, illness, severe lack of oxygen

* Unknown in many instances

CAUSES

Severe deprivation of oxygen or

blood flow to the brain

–Hypoxic-ischemic encephalopathy

or intrapartal asphyxia

CHIEF CAUSE

RISK FACTORS

• Prenatal factors – Before birth– Maternal characteristics

• Perinatal factors – at the time of birth to 1mo

• Postnatal factors– In the first 5 mos of life

Prenatal factors

• Hemorrhage/bleeding– Abruptio placenta

• Infections– Rubella, cytomegalovirus,

toxoplasmosis,

• Environmental factors

• Maternal Characteristics

Maternal Characteristics

• Age• Difficulty in conceiving or holding a

baby to term• Multiple births• History of fetal deaths/miscarriages• Cigarette smoking >30 sticks per day

• Alcoholism and drug addiction• Social status; mother with MR• Mother’s medical condition

Perinatal Factors

• High or low BP

• Umbilical cord coil

• Breech delivery

• Over sedation of drugs

• Trauma i.e. forceps or vacuum delivery

• Complications of birth

Postnatal Causes

• Trauma, head injury

• Infections

• Lack of oxygen

• Stroke in the young

• Tumor, cyst

Before Birth 75%

During Birth, 5-15%

After Birth,

10-20%

*Several causes are preventable or treatable

CP Cases

Most Common Permanent Disability of Childhood

TYPESOF CEREBRAL PALSY

Classification of CP

According to:

1. Neurologic deficits

2. Type of movement involved

3. Area of affected limbs

1. Accdg. to Neurologic Deficits

• Based on the - extent of the damage

- area of brain damage

• Each type involves the way a person moves

3 MAIN TYPES

1. PYRAMIDAL - originates from the motor areas of the cerebral cortex

2. EXTAPYRAMIDAL

- basal ganglia and cerebellum

3. MIXED

2. Accdg. to Type of Movement

Photo from: Saunders, Elsvier.

4 MAIN TYPES

PYRAMIDAL 1. Spastic CP

EXTAPYRAMIDAL 2. Athethoid CP

3. Ataxic CP

MIXED 4. Spastic & Athethoid CP

ATHETOID-Fluctuating

Tone

ATAXIC-Unsteady,

uncoordinated

SPASTIC -Stiffness

ATHETOID-Uncontrolled

Movements

ATAXIC-Unsteady,

uncoordinated

TYPES

Spastic CP

• Increased muscle tone,

tense and contracted muscles – Have stiff and jerky or

awkward movements.– limbs are usually

underdeveloped– increased deep tendon

reflexes• most common form• 70-80% of all affected

Types of Spastic CP

According to affected limbs:* plegia or paresis - meaning paralyzed or weak:

• Paraplegia • Diplegia • Hemiplegia • Quadriplegia• Monoplegia –one limb (extremely rare)• Triplegia –three limbs (extremely rare)

Diplegia/ Paraplegia•both legs•both legs w/ slight

involvementelsewhere

Diplegia

May also have

Contractures of

hips and knees

and

talipes equinovarus (clubfoot).

Hemiplegialimbs on only one side

• Hemiplegia on right side

– Hip and knee contractures

– Talipes equinus (“tip-toeing”

- sole permanently

flexed)

– Asteriognosis may be present.

(inability to identify objects by

touch)

Quadriplegia

•Spastic Quadriplegia

Characteristic “scissors” positions of lower limbs due to adductor spasms.

Athetoid/ Dyskinetic CP

• Fluctuating tone– involves abnormal involuntary

movements

– that disappear during sleep and

increase with stress.

– Interferes with speaking, feeding,

reaching, grabbing, and any other

skills

– 20% of the CP cases,

Athetosis

• Wormlike movements

• Slow, uncontrolled motion, writhing or twisting in character in the face, extremities, and torso.

• Dystonia - when held as a prolonged posture

Dyskinesia

– Dyskinetic movement of mouth

– Grimacing, drooling and dysarthria.

– Adductor spasm

Movements may become

choreoid (rapid, irregular, jerky)

and

dystonic (disordered muscle tone,

sustained muscle contractions)

especially when stressed and during the adolescent years.

Ataxic CP

• Poor balance and lack of coordination– Wide-based gait– Depth perception usually

affected.– Tendency to fall and stumble– Inability to walk straight line.– Least common 5-10% of cases

MIXED CP

• A common combination is

spastic and athetoid

• Spastic muscle tone and involuntary movements.

• 25% of CP cases, fairly common

DEGREE OF SEVERITY

1. Mild CP- 20% of cases

2. Moderate CP- 50%

- require self help for assisting their impaired ambulation capacity.

3. Severe CP- 30%;

-totally incapacited and bedridden and they always need care from others.

Signs and Symptoms

OF CEREBRAL PALSY

a.

b.

c.

d.e.

f.

g.

h.

Early Signs

• Stiff or floppy posture

• Weak suck/ tongue thrust/ tonic bite/ feeding difficulties

• Poor head control

• Excessive lethargy or irritability/ High pitched cry

Infancy (0-3 Months)

• Abnormal or prolonged primitive reflexes

Moro’s reflexAsymmetric tonic neck reflex

Placing reflexLandau reflex

Early Signs

CHILD with CP

Slow to re

ach

developmental

milesto

nes

Late infancy• Inability to perform motor skills as indicated:

– Control hand grasp by 3 months– Rolling over by 5 months– Independent sitting by 7 months

• Abnormal Developmental Patterns: – Hand preference by 12 months– Excessive arching of back– Log rolling– Abnormal or prolonged parachute response

Abnormal Developmental Patterns after 1 year of age:

• “W sitting” – knees flexed,

legs extremely rotated

• “Bottom shuffling” Scoots along the floor

• Walking on tip toe or hopping

Behavioral Symptoms

• Poor ability to concentrate,

• unusual tenseness,

• Irritability

Cerebral Palsy

• Main problem: – Mentation and thought processes

are not always affected;– Trapped in their bodies with their disabilities– Ability to express their intelligence may be

limited by difficulties in communicating.

ASSOCIATED PROBLEMSOF CEREBRAL PALSY

• Hearing and visual problems

• Sensory integration problems

• Failure-to-thrive, Feeding problems

• Behavioral/emotional difficulties,

• Communication disorders

• Bladder and bowel control problems, digestive problems

(gastroesophageal reflux)• Skeletal deformities,

dental problems• Mental retardation and

learning disabilities in some

• Seizures/ epilepsy

DiagnosisOF CEREBRAL PALSY

A USEFUL diagnosis is

when the specific type,

affected limb,

severity and

cause, if known,

are identified

DIAGNOSIS

• Physical evaluation, Interview

• MRI, CT Scan EEG

• Laboratory and radiologic work up

• Assessment tools – i.e. Peabody Development Motor Skills,

Denver Test II

The Peabody Development Motor Scales 

• In-depth assessment • 6 Subtests include:

– Reflexes– Stationary– Locomotion– Object Manipulation– Grasping, – Visual-Motor

Integration.

– The subtests yield a gross motor quotient

– a fine motor quotient

– a total motor quotient.

• Ages covered: from birth through five years of age

Denver Test II

• Developmental Screening Test

• Cover 4 general functions: – personal social (eg. smiling), – fine motor adaptive (eg. grasping & drawing)– language (eg. combining words)– gross motor (eg. walking)

Ages covered: from birth to 6 years

ASSESSMENT

1. SUBJECTIVE

- INTERVIEW

a. History Taking

–Include all that may predispose an infant to brain damage or CP

•Risk factors

•Psychosocial factors

•Family adaptation

b. Child’s Health History

• Often admitted to hospitals for corrective surgeries and other complications.

– Respiratory status – Motor function– Presence of fever– Feeding and weight loss – Any changes in physical state – Medical regimen

2. OBJECTIVE

- Physical Examination

CRITERIAP osturing / Poor muscle control and strength

O ropharyngeal problems

S trabismus/ Squint

T one (hyper-, hypotonia)

E volutional maldevelopment

R eflexes (e.g. increaseddeep tendon)

*Abnormalities 4/6 strongly point to CP

PO S

TER

P osturing / Poor muscle control and strength

• Test hand strength by lifting the child off the ground while the child holds the nurses hands.

• Observe for presence of limb deformity, as decreased use of extremity leads to shortening.

Upon extension of extremities on vertical suspension of the infant,

If infant back bend backwards like and arch

may indicate CP is severe

Oropharyngeal problems

Speech,

swallowing

breathing,

drooling,

feeding poorly

Strabismus

• Squint

Tone

• Hypertonia - rigid, tense

• Hypotonia – floppy or flaccid

Evolutional maldevelopment

• Delays in motor skills – such as rolling over, sitting, crawling, and

walking

• Size for age.

• Persistence of primitive reflexes or parachute reflex fail to develop

• Present at birth, normally disappears after 3 or 4 months (some say 6months)

Alternative Names: Startle response; Startle reflex; Embrace reflex

Asymmetric tonic neck reflex "fencing position“

-- head to one side, arm & leg on that side extended, opposite limbs flexed.

Athetosis and

persistent asymmetric tonic reflex.

Placing Reflex

• When the dorsal (back) side of the hand or foot is placed on the edge of a surface, such as a table, the infant will lift the extremity and place it on the flat surface.  

Landau Reflex

• When the infant is held in a horizontal prone position, the infant will lift head and extend the neck and trunk.  When the neck is passively flexed, the entire body will flex.  This reflex is present by 6 months and hypotonicity (low tone)  indicates motor system deficits.   

Parachute Reflex

• When held around the waist in a horizontal prone position and then lowering the infant slowly, head first to the surface.  By age 6 to 8 months the infant should respond by extending the arms and hands to break the “fall”.  If this response is asymmetrical it indicates an unilateral motor abnormality.

Reflexes

Eg. Increased/ exaggerated deep tendon

TreatmentOF CEREBRAL PALSY

- No treatment to cure cerebral palsy.

- Brain damage cannot be corrected.

• Crucial for children with CP:

–Early Identification;

–Multidisciplinary Care; and

–Support

“The earlier we start, the more improvement can be made”

-Health worker

I. Nonphysical Therapy

A. General management - Proper nutrition and personal care

B. Pharmacologic

Botox, Intrathecal, Baclofen

- control muscle spasms and seizures, Glycopyrrolate -control drooling

Pamidronate -may help with osteoporosis.

Baclofen

• Delivered directly to the spinal fluid

• Using a pump

• To avoid brain effects

C. Surgery

-To loosen joints,

-Relieve muscle tightness,

- Straightening of different twists or unusual curvatures of leg muscles

- Improve the ability to sit, stand, and walk.

Selective posterior rhizotomy In some cases nerves need to be severed to decrease

muscle tension of inappropriate contractions.

How it Works• A major operation, takes approximately four hours

to complete. • The sensory nerve fibers in the spinal cord,

usually between the bottom of the rib cage and the top of the hips are divided

• The nerve fibers are then stimulated and the responses of the leg muscles are observed.

• Those that have an abnormal or excessive response are severed.

• Those with a normal response are left intact.• Intensive rehabilitation is required after the

surgery, usually up to six weeks, followed by physical therapy on an ongoing basis

D. Physical Aids

Orthosis, braces and splints - Keep limbs in correct alignment - Prevent deformities.

Positioning devices -Enable better posture

Walkers, special scooters, wheelchairs - make it easier to move about.

E. Special Education

- To meet the child's special needs - Improve learning.

- Vocational training can help prepare young adults for jobs

F. Rehabilitation Services- Speech and occupational therapies may improve the ability to speak, and perform activities of daily living and to do some suitable works to have their own income.

G. Family Services

- Professional support helps a patient and family cope with cerebral palsy.

- Counselors help parents learn how to modify behaviors.

- Caring for a child with cerebral palsy can be very stressful.

- Some families find support groups helpful.

. 

H. Other Treatment

- Therapeutic electrical stimulation,- Acupuncture,- Hyperbaric therapy - Massage Therapy might help

 

'The ultimate long-term goal is realistic independence. To get there we have to have some short-term goals.

Those being a working communication system, education to his potential,

computer skills and, above all, friends'. - Parent of boy with CP

II. Physical Therapy

A.Sitting

- Vertical head control and control of head and trunk.

B. Standing and walking

- Establish an equal distribution of weight on each foot, train to use steps or inclines

C. Prone Development

D. Supine Development

o Head control on supine and positions

NURSING RESPONSIBILITIES

NURSING RESPONSIBILITIES

A. Functioning as a member of the health team

B. Providing counseling and education for the parents and promote optimal family functioning

- Encourage family members to express anxieties, frustrations and concerns

- Provide emotional support and help with problem solving as necessary.

- Explore support networks. Refer them to support organizations

C. Promoting physical and psychological health

- Administer prescribed medications

- Encourage self-care by urging the child to participate in activities of daily living (ADLs) (e.g. using utensils and implements that are appropriate for the child’s age and condition).

- Provide rest periods to foster relaxation. Provide safe & appropriate toys

- As necessary, seek referrals for corrective lenses and hearing device to decrease sensory deprivation related to vision and hearing losses

D. Assisting with feeding management and toilet training

- Promote adequate fluid and nutritional intake.Position upright after meals

- During meals, maintain a quiet, unhurried atmosphere with as few distractions as possible. The child may need special utensils and a chair with a solid footrest

- Teach him to place food far back in his mouth to facilitate swallowing.

- Encourage the child to chew food thoroughly, drink through a straw, and suck on a lollipop between meals to develop the muscle control needed to minimize drooling.

E. Assisting with rehabilitation therapies (physical, occupational and speech)

- Promote mobility by encouraging the child to perform age-and condition-appropriate motor activities

- Inform parents but their child will need considerable help and patience in accomplishing each new task.

- Encourage them not to focus solely on the child’s inability to accomplish certain

- Explain the importance of providing positive

feedback.

- Facilitated communication. Talk to the child deliberately and slowly, using pictures or sign language to reinforce speech when needed

- Technology such as computer use may help children with severe articulation problems.

F. Providing counseling for educational and vocational pursuits

G. Preventing child abuse

H. Providing care during hospitalization - Prepare the child and family for

procedures, treatments, appliances and surgeries if needed. Assign the child a room with children in the same age-group.

I. Prevent physical injury by providing the child with a safe environment, appropriate toys, and protective gear (helmet, kneepads) if needed.

J. Prevent physical deformity by ensuring correct use of prescribed braces and other devices and by performing ROM exercises.

K. Promote a positive self-image in the child:

- Praise his accomplishments

- Set realistic and attainable goals

- Encourage and appealing physical appearance

- Encourage his involvement with age and condition appropriate peer group activities.

THANK YOU FOR PATIENTLY LISTENING!!!

"Time and gravity are enemies of very aging body, especially mine." - Adult with CP

Werner, David. Disabled Village Children: A guide for community health workers, rehabilitation workers, and families

http://www.dinf.ne.jp/doc/english/global/david/dwe002/dwe00201.htmlhttp://www.unescap.org/esid/psis/disability/decade/publications/z15005s3/z1500520.htmECONOMIC AND SOCIAL COMMISSION FOR

ASIA AND THE PACIFIC Production and distribution of assistive

devices for people with disabilities: Supplement3 - Chapter 5&6 -ST/ESCAP/1774

UNITED NATIONS PUBLICATION Sales No. E.98.II.F.7

Copyright © United Nations 1997 ISBN: 92-1-119775-9