Cerebral Palsy


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Cerebral Palsy

  1. 1. CEREBRAL PALSY By: Ida Sherri L. Corvera BSN III - NM
  2. 2. • In 1860s, known as "Cerebral Paralysis” or William “Little’s Disease” John Little • After an English surgeon (1810-1894) wrote the 1st medical descriptions
  3. 3. William John Little (1810-1894)
  4. 4. CEREBRAL PALSY (CP) • Cerebral“- Latin Cerebrum; – Affected part of brain • “Palsy " -Gr. para- beyond, lysis – loosening – Lack of muscle control
  5. 5. 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
  6. 6. CEREBRAL PALSY A Heterogenous Group of Movement Disorders – An umbrella term – Not a single diagnosis
  7. 7. CEREBRAL PALSY A Heterogenous Group of Movement Disorders
  8. 8. CP Affects ements Balance ation Posture
  9. 9. In CP • Muscles are unaffected • Brain is unable to send the appropriate signals necessary to instruct muscles when to contract and relax
  11. 11. 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
  12. 12. CAUSES • 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
  13. 13. CHIEF CAUSE Severe deprivation of oxygen or blood flow to the brain – Hypoxic-ischemic encephalopathy or intrapartal asphyxia
  14. 14. 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
  15. 15. Prenatal factors • Hemorrhage/bleeding – Abruptio placenta • Infections – Rubella, cytomegalovirus, toxoplasmosis, • Environmental factors • Maternal Characteristics
  16. 16. 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
  17. 17. 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
  18. 18. Postnatal Causes • Trauma, head injury • Infections • Lack of oxygen • Stroke in the young • Tumor, cyst
  19. 19. CP Cases During After Before Birth, Birth, Birth 5-15% 10-20% 75% *Several causes are preventable or treatable
  20. 20. worldwide
  21. 21. Most Common Permanent Disability of Childhood
  23. 23. Classification of CP According to: 1. Neurologic deficits 2. Type of movement involved 3. Area of affected limbs
  24. 24. 1. Accdg. to Neurologic Deficits • Based on the - extent of the damage - area of brain damage • Each type involves the way a person moves
  25. 25. 3 MAIN TYPES 1. PYRAMIDAL - originates from the motor areas of the cerebral cortex 2. EXTAPYRAMIDAL - basal ganglia and cerebellum 3. MIXED
  26. 26. 2. Accdg. to Type of Movement Photo from: Saunders, Elsvier.
  27. 27. 4 MAIN TYPES PYRAMIDAL 1. Spastic CP EXTAPYRAMIDAL 2. Athethoid CP 3. Ataxic CP MIXED 4. Spastic & Athethoid CP
  28. 28. TYPES SPASTIC -Stiffness ATHETOID --Fluctuating Uncontrolled Tone Movements ATAXIC -Unsteady, Unsteady, uncoordinated uncoordinated
  29. 29. 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
  30. 30. 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)
  31. 31. Diplegia/ Paraplegia •both legs w/ slight •both legs involvement elsewhere
  32. 32. Diplegia May also have Contractures of hips and knees and talipes equinovarus (clubfoot).
  33. 33. Hemiplegia limbs on only one side
  34. 34. • 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)
  35. 35. Quadriplegia
  36. 36. • Spastic Quadriplegia Characteristic “scissors” positions of lower limbs due to adductor spasms.
  37. 37. 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,
  38. 38. Athetosis • Wormlike movements • Slow, uncontrolled motion, writhing or twisting in character in the face, extremities, and torso. • Dystonia - when held as a prolonged posture
  39. 39. Dyskinesia – Dyskinetic movement of mouth – Grimacing, drooling and dysarthria. – Adductor spasm
  40. 40. Movements may become choreoid (rapid, irregular, jerky) and dystonic (disordered muscle tone, sustained muscle contractions) especially when stressed and during the adolescent years.
  41. 41. 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
  42. 42. MIXED CP • A common combination is spastic and athetoid • Spastic muscle tone and involuntary movements. • 25% of CP cases, fairly common
  43. 43. DEGREE OF SEVERITY 1. Mild CP- 20% of cases • Moderate CP- 50% - require self help for assisting their impaired ambulation capacity. • Severe CP- 30%; -totally incapacited and bedridden and they always need care from others.
  44. 44. Signs and Symptoms OF CEREBRAL PALSY
  45. 45. d. e. c. f. b. g. a. h.
  46. 46. Early Signs Infancy (0-3 Months) • Stiff or floppy posture • Excessive lethargy or irritability/ High pitched cry • Poor head control • Weak suck/ tongue thrust/ tonic bite/ feeding difficulties
  47. 47. Early Signs • Abnormal or prolonged primitive reflexes Moro’s reflex Asymmetric tonic neck reflex Placing reflex Landau reflex
  48. 48. CHILD with CP ch al ea nt r e t o m es ow elop ton Sl v e i l es d m
  49. 49. 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
  50. 50. 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
  51. 51. Behavioral Symptoms • Poor ability to concentrate, • unusual tenseness, • Irritability
  52. 52. 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.
  54. 54. • Hearing and visual • Bladder and bowel problems control problems, • Sensory integration digestive problems problems (gastroesophageal reflux) • Failure-to-thrive, Feeding • Skeletal deformities, problems dental problems • Behavioral/emotional • Mental retardation and difficulties, learning disabilities in • Communication some disorders • Seizures/ epilepsy
  55. 55. Diagnosis OF CEREBRAL PALSY
  56. 56. A USEFUL diagnosis is when the specific type, affected limb, severity and cause, if known, are identified
  57. 57. DIAGNOSIS • Physical evaluation, Interview • MRI, CT Scan EEG • Laboratory and radiologic work up • Assessment tools – i.e. Peabody Development Motor Skills, Denver Test II
  58. 58. The Peabody Development Motor Scales • In-depth assessment – The subtests yield • 6 Subtests include: a gross motor – Reflexes quotient – Stationary – a fine motor – Locomotion quotient – Object Manipulation – Grasping, – a total motor – Visual-Motor quotient. Integration. • Ages covered: from birth through five years of age
  59. 59. 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
  60. 60. ASSESSMENT
  62. 62. a. History Taking –Include all that may predispose an infant to brain damage or CP •Risk factors •Psychosocial factors •Family adaptation
  63. 63. 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
  64. 64. 2. OBJECTIVE - Physical Examination
  65. 65. CRITERIA P osturing / Poor muscle control and strength O ropharyngeal problems O S trabismus/ Squint S T one (hyper-, hypotonia) T E volutional maldevelopment E eflexes (e.g. increaseddeep tendon) R R *Abnormalities 4/6 strongly point to CP
  66. 66. 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.
  67. 67. Upon extension of extremities on vertical suspension of the infant, If infant back bend backwards like and arch may indicate CP is severe
  68. 68. Oropharyngeal problems Speech, swallowing breathing, drooling, feeding poorly
  69. 69. Strabismus • Squint
  70. 70. Tone • Hypertonia - rigid, tense • Hypotonia – floppy or flaccid
  71. 71. 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
  72. 72. • Present at birth, normally disappears after 3 or 4 months (some say 6months) Alternative Names: Startle response; Startle reflex; Embrace reflex
  73. 73. Asymmetric tonic neck reflex "fencing position“ -- head to one side, arm & leg on that side extended, opposite limbs flexed.
  74. 74. Athetosis and persistent asymmetric tonic reflex.
  75. 75. 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.
  76. 76. 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.
  77. 77. 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.
  78. 78. Reflexes Eg. Increased/ exaggerated deep tendon
  79. 79. Treatment OF CEREBRAL PALSY
  80. 80. - No treatment to cure cerebral palsy. - Brain damage cannot be corrected. • Crucial for children with CP: –Early Identification; –Multidisciplinary Care; and –Support
  81. 81. I. Nonphysical Therapy “The earlier we start, the more improvement can be made” -Health worker
  82. 82. • 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.
  83. 83. Baclofen • Delivered directly to the spinal fluid • Using a pump • To avoid brain effects
  84. 84. 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.
  85. 85. Selective posterior rhizotomy In some cases nerves need to be severed to decrease muscle tension of inappropriate contractions.
  86. 86. 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
  87. 87. 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.
  88. 88. E. Special Education - To meet the child's special needs - Improve learning. - Vocational training can help prepare young adults for jobs
  89. 89. 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.
  90. 90. 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. .
  91. 91. H. Other Treatment - Therapeutic electrical stimulation, - Acupuncture, - Hyperbaric therapy - Massage Therapy might help
  92. 92. II. Physical Therapy '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
  93. 93. 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
  94. 94. C. Prone Development D. Supine Development o Head control on supine and positions
  96. 96. NURSING RESPONSIBILITIES C. Functioning as a member of the health team
  97. 97. 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
  98. 98. 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
  99. 99. 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.
  100. 100. 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
  101. 101. - 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.
  102. 102. 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.
  103. 103. - 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.
  104. 104. 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.
  105. 105. "Time and gravity are enemies of very aging body, especially mine." - Adult with CP THANK YOU FOR PATIENTLY LISTENING!!!
  106. 106. 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. http://www.unescap.org/esid/psis/disability/d ecade/publications/z15005s3/z1500520.htm ECONOMIC 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