NURSING

1. CEREBRAL PALSY
PRESENTER :-
SHILPA JOSHI

2. • In 1860s, known as “cerebral palsy” or “little’s
disease” after an English surgeon William John Little
wrote the 1st medical description..
• Cerebral word is derived from Latin cerebrum : affected
part of brain and palsy from Greek para – beyond , lysis
– loosening i.e. lack of muscle control.

3. • Cerebral palsy is a motor function disorder :-
• Caused by permanent, non-progressive brain lesion.
• It can be present at birth or shortly thereafter.
• It is incurable, lifelong condition, damage doesn’t worsens and it may
be congenital or acquired.
• It is a heterogenous group of movement disorders . C.P. is an umbrella
term not a single diagnosis.
• In C.P. muscles are unaffected, brain is unable to send the appropriate
signals necessary to instruct muscles when to contract and relax.

6. • CAUSES :-
• 1. 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 deviation
• 2. Developmental malformations –
• The brain fails to develop correctly.
• 3. Neurological damage –
• Can occur before , during or after delivery.
• Rh incompatibility, illness, severe lack of oxygen etc.
• 4. Severe deprivation of oxygen or blood flow to the brain –
• HIE (hypoxic-ischemic encephalopathy or intrapartal asphyxia)

8. • RISK FACTORS :-
• 1. Prenatal factors –
• Hemorrhage/bleeding –
• Abruptio placetna
• Infections –
• Rubella, cytomegalovirus, toxoplasmosis
• Environmental factors
• Maternal characteristics -
• Age
• 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.

9. • 2.Perinatal factors –
• High or low BP
• Umbilical cord coil
• Breech delivery
• Oversedation of drugs
• Trauma i.e. forceps or vacuum delivery
• Complications of birth
• 3.Postnatal causes –
• Trauma, head injury
• Infections
• Hypoxia
• Stroke in young age
• Tumor, cyst

10. • TYPES OF CEREBRAL PALSY –
• According to :
• 1.Neurological deficits
• 2.Types of movement involved
• 3.Areas of affected limbs
• 1.According to Neurological deficits –
• Based on the – extent and area of brain damage
• Each type involves the way a person moves.
• 3 main types are :-
• Pyramidal
• Originates from motor areas of the cerebral cortex
• Spastic CP

12. • Extrapyramidal
• Basal ganglia and cerebellum
• Athethoid CP
• Ataxic CP
• Mixed
• Spastic and athethoid CP

13. • SPASTIC CP :-
• Increased muscle tone, tense and contracted muscles.
• Have stiff jerky or awkward movements.
• Limbs are usually underdeveloped,
• Increased deep tendon reflexes.
• Most common from 70-80 % of all affected children.
• 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.

14. • Diplegia / paraplegia –
• Both legs with slight involvement elsewhere both legs. May also have contracture of hips and knees and
talipes equinovarus ( clubfoot).
•
• Hemiplegia –
• Limbs only on one side affected,
• Hip and knee contractures
• Quadriplegia –
• Upper body usually normal or with very minor signs
• Child may develop contractures of ankles and feet.
• When the child walks his arms, head and even his mouth may twist strangely.
• Children with all 4 limbs affected often have such severe brain damage that they never are able to walk.
• Legs and feet turned inward.

16. • Spastic quadriplegia –
• Characteristic “scissors” position of limbs due to adductor spasm.
• Dyskinesia –
• Dyskinetic movement of mouth
• Grimacing, drooling and dysarthria.
• Adductor spasm.
• 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

19. • Mixed CP –
• A common combination is spastic and athethoid
• Spastic muscle tone and involuntary movements.
• 25% 0f CP cases, fairly common.
• Degree of severity –
• 1.Mild CP -20% of cases
• Not require help for assisting their impaired ambulation capacity.
• 2.Moderate CP -50%
• Requires self help for assisting their impaired ambulation capacity.
• 3.Severe CP –
• Totally incapacitated and bedridden and they always need care from others.

20. • Sign and symptoms –
• Posture or balance problem’
• Loss of control or coordination
• Abnormal tone
• Abnormal strength
• Abnormal reflexes
• Persistent motor delay
• Cognitive deficit
• Associated handicaps.

22. • 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
• 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

23. • 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
• Behavioural symptoms –
• Poor ability to concentrate
• Unusual tenseness, irritability.

24. • CP Main problem:-
• Mentation and thought processes are not always affected; child is trapped in their body with their disabilities ,
• Ability to express their intelligence may be limited by difficulty In communicating.
• Associated problems –
• Hearing and visual problems
• Sensory integration problems
• FTT (failure to thrive)
• Feeding problems
• Behavioural / emotional difficulties
• Communication disorders
• Bladder and bowel control problem
• GERD
• Skeletal deformities
• Mental retardation and learning disabilities in some
• Seizures/ epilepsy

25. • Diagnosis :-
• A useful diagnosis is when the specific type, affected limb , severity, and
cause , if known are identified.
• Physical evaluation, interview
• MRI, CT scan EEG
• Laboratory and radiologic work up
• Assessment tools
• i.e. Peabody development motor skills, Denver test 2 etc.

26. • the Peabody developmental motor scales :=
• in depth assessment 6 subtests include:
• Reflexes
• Stationary
• Locomotion
• Object manipulation
• Grasping
• Visual-motor integration
• This subtest yields a
• gross motor quotient,
• a fine motor quotient
• and a total motor quotient
• ages covered : from birth through five years of age.

27. • Denver test 2 :-
• Developmental screening test
• Covers 4 general functions –
• Personal social (smiling)
• Fine motor adaptive (eg. Grasping and drawing)
• Language (eg. Combining words)
• Gross motor (eg. Walking)
• Ages covered from birth to 6 years.
• Denver test 2 :-
• 1. subjective (interview)
• a. history taking :- includes all that may predispose an infant to brain damage or CP
• Risk factors
• Psychosocial factors
• Family adaptation

28. • b. child’s health history :- often admitted to hospital for corrective
surgeries and other complications.
• Respiratory status
• Motor functions
• Presence of fever
• Feeding and weight loss
• Any changes in physical state
• Medical regimen.

29. • 2. Objective :-
• Physical examination
• Criteria ---
• P osturing/ poor muscle control and strength
• O ropharyngeal problems
• S trabismus/ squint
• T one (hyper/ hypotonia)
• E volutional maldeveloment
• R eflexes (e.g. increased deep tendon )
• Abnormalities 4/6 strongly point to CP

31. • Oropharyngeal problems –
• Speech, swallowing, breathing, drooling and poor feeding.
• Appearance of strabismus (impaired side to side movement )
• Evolutional maldevelopment –
• Delay in motor skills , such as rolling over, sitting , crawling and walking.
• Size for age
• Persistence of primitive reflexes or parachute reflex fail to develop
• Asymmetric tonic neck reflex “fencing position” – head to one side, arm and leg on that side extended ,
opposite limbs flexed.
• Test for ataxia – hold a toy or finger in front of the child and ask him to touch it on the first try. The child
with ataxia cannot do it.
• Increased or exaggerated deep tendon reflex

33. • Treatment :-
• No treatment to cure CP.
• Brain damage cannot be corrected.
• Crucial for children with CP:
• Early identification
• Multidisciplinary care and
• Support
• 1. Nonphysical therapy
• A. General management
• - Proper nutrition and personal care
• B. Pharmacologic
• Botox, intrathecal, baclofen
• - Controls muscle spasm and seizures
• - Delivered directly to the spinal fluid to avoid brain effects.
• Glycopyrrolate – control drooling
• Pamidronate – may help with osteoporosis.

34. • C. Surgery :-
• - To loosen joints,
• - Relieve muscle tightness
• - Straightening of different twists or unusual curvatures of leg muscles
• - Improves the ability to sit , stand and walk.
• Selective posterior rhizotomy :-
• Is used to improve spasticity (muscle stiffness) in cerebral palsy. In some cases
nerves need to be served to decrease muscle tension of inappropriate contraction.
• Intensive rehabilitation is required after the surgery , usually up to 6 weeks, followed
by physical therapy on an ongoing basis.

35. • D. Physical aids :-
• Orthosis, braces and splints
• - Keeps limbs In correct alignment
• - Prevent deformities
• Positioning devices
• - Enable better postures
• Walkers, special scooters, wheel chairs
• - Makes 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.

36. • 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.
• Counsellors help parents learn how to modify behaviours.
• Caring for a child with CP can be very stressful .
• Some families find support groups help.
• H. Other treatments –
• Therapeutic electrical stimulation ,
• Acupuncture
• Hyperbaric therapy
• Massage therapy might help.

37. • 2. 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.
• 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
• - Head control on supine and positions.