Cerebral Palsy
Content
Mariano Marcos State University
College of Health Sciences
Department of Nursing
Cerebral Palsy
Dan Drazen Lagmay
BSN II-B
Mrs. Frayda Castro
Clinical Instructor
Cerebral Palsy
0
The word cerebral refers to the area in the brain that is affected, while
palsy means complete or partial muscle paralysis, frequently accompanied
by loss of sensation and uncontrollable body movements or tremors.
Cerebral palsy (CP) is a group of nonprogressive disorders of upper motor
neuron impairment that result in motor dysfunction. Affected children also
may have speech or ocular difficulties, seizures cognitive challenges, or
hyperactivity. Muscle spasticity can lead to orthopedic or gait difficulties.
What is Cerebral Palsy?
Cerebral palsy is non-life-threatening – With the exception of children
born with a severe case, cerebral palsy is considered to be a non-lifethreatening condition. Most children with cerebral palsy are expected to live
well into adulthood.
Cerebral palsy is incurable – Cerebral palsy is damage to the brain that
cannot currently be fixed. Treatment and therapy help manage effects on the
body.
Cerebral palsy is non-progressive – The brain lesion is the result of a
one-time brain injury and will not produce further degeneration of the brain.
Cerebral palsy is permanent – The injury and damage to the brain is
permanent. The brain does not “heal” as other parts of the body might.
Because of this, the cerebral palsy itself will not change for better or worse
during a person’s lifetime. On the other hand, associative conditions may
improve or worsen over time.
Cerebral palsy is not contagious; it is not communicable – In the
majority of cases, cerebral palsy is caused by damage to the developing
brain. Brain damage is not spread through human contact. However, a
1
person can intentionally or unintentionally increase the likelihood a child will
develop cerebral palsy through abuse, accidents, medical malpractice,
negligence, or the spread of a bacterial or viral infection.
Cerebral palsy is manageable – The impairment caused by cerebral palsy
is manageable. In other words, treatment, therapy, surgery, medications and
assistive technology can help maximize independence, reduce barriers,
increase inclusion and thus lead to an enhanced quality-of-life.
Cerebral palsy is chronic – The effects of cerebral palsy are long-term, not
temporary. An individual diagnosed with cerebral palsy will have the
condition for their entire life.
Types of Cerebral Palsy
CEREBRAL
PALSY
Pyramidal or
Spasmic
Extrapyrami
dal
Ataxi
c
2
Dyskinetic or
Athetoid
Mixed
Cerebral palsy has been classified in various ways. Traditionally, it is
divided into two main categories based on the type of neuromuscular
involvement: a pyramidal or spastic type (approximately 40% of affected
children) and an extrapyramidal type, which is further subdivided into ataxic
(approximately 10%), dyskinetic or athetoid (approximately 30%), and mixed
(10%).
A. Spastic or Pyramidal Type
Spasticity is excessive tone in the voluntary muscles that results in loss of
upper motor neurons. A child with spastic cerebral palsy has hypertonic
muscles, abnormal clonus, exaggeration of deep tendon reflexes, abnormal
reflexes such as positive Babinski reflex, and continuation of neonatal
reflexes, such as the tonic neck reflex, well past the age at these usually
disappear. If infants with CP are held in a ventral suspension position, they
arch their backs and extend their arms and legs abnormally. They fail to
3
demonstrate a parachute reflex if lowered suddenly, failing to hold out their
arms as if to break their fall. Children tend to assume a “scissor gait”
because tight adductor thigh muscles cause their legs to cross when held
upright. This involvement may be so severe that it leads to a subluxated hip.
Tightening of the heel cord usually is so severe that children walk on their
toes, unable to stretch their heel to touch the ground.
Spastic
involvement
may affect
both
extremities
on
one
side
(hemiplegia), all four extremities (quadriplegia), or primarily the lower
extremities (diplegia or paraplegia). Children with hemiplegia. Usually have
greater involvement in the arm than in the leg. This may be demonstrated by
asking the child to extend the arms and pronate them. When the child is
asked to supinate the arm, the elbow flexes on the involved side. The
involved arm may be shorter and may have smaller muscle circumference
than the other arm. Most children with hemiplagia have difficulty identifying
objects placed in their involved hand when their eyes are closed
(astereognosis).
In older children, leg involvement may be detected most easily by
examining the child’s shoes. One heel will be much more worn than the
other, because the child does not put the heel all the way down on the
involved side. On physical examination, it may be difficult to abduct the
involved hip fully, extend the knee, or dorsiflex the foot.
A child with quadriplegia invariably has impaired speech (pseudobulbar
palsy) but may or may not be cognitively challenged. Swallowing saliva may
be so difficult that the child drools and has difficulty swallowing food. Upper
extremity involvement may be limited to an abnormal, awkward hand
movement. If there is no involvement of the arms at all, this is a true spastic
paraplegia, and a spinal cord anomaly rather than a cerebral anomaly is
suggested.
4
B.
Extrapyramidal Type
1. Dyskinetic or Athetoid Type
The athetoid type of CP involves abnormal involuntary movement.
Athetoid means “wormlike.” Early in life, the child is limp and flaccid. Later,
in place of voluntary movement, children make slow, writhing motions. This
may involve all four extremities, plus the face, neck and tongue. Because of
poor tongue and swallowing movements, the child drools and speech is
difficult to understand. With emotional stress, the involuntary movements
may become irregular and jerking (choreoid) with disordered muscle tone
(dyskinetic).
2. Ataxic Type
Children with ataxic involvement have an awkward, wide-based gait. On
neurologic examination, they are unable to perform finger-to-nose test or to
perform rapid, repetitive movements (tests of cerebellar function) or fine
coordinated motion.
3. Mixed Type
5
Some
children
show
symptoms
of
both
spasticity
and
athetoid
movements. Ataxic and athetoid movements also may be present together.
This combination results in a severe degree of physical impairment.
Prevalence and Incidence of Cerebral Palsy
Cerebral palsy affects about 1 in 278 children.
Each year, about 8,000 babies and infants are diagnosed with cerebral
palsy.
Half of people with cerebral palsy use assistive devices, including
braces, walkers, and wheelchairs, to help them be more mobile.
About 30% of children with cerebral palsy have seizures.
In the Philippines, there are more patients with CP than those with polio,
spinal lesions and other movement disorders combined which approximate
about 1-2% of the total population. Despite this, there is no government
program that addresses this condition; both in treatment and prevention.
Cause of Cerebral Palsy
While in certain cases there is no identifiable cause, typical causes
include problems in intrauterine development (e.g. exposure to radiation,
infection), asphyxia before birth, hypoxia of the brain, and birth trauma
during labor and delivery, and complications in the perinatal period or during
childhood. CP is also more common in multiple births.
Between 40 and 50% of all children who develop cerebral palsy were
born prematurely. Premature infants are vulnerable, in part because their
organs are not fully developed, increasing the risk of hypoxic injury to the
brain that may manifest as CP. A problem in interpreting this is the difficulty
in differentiating between cerebral palsy caused by damage to the brain that
6
results from inadequate oxygenation and CP that arises from prenatal brain
damage that then precipitates premature delivery.
Recent research has demonstrated that intrapartum asphyxia is not
the most important cause, probably accounting for no more than 10 percent
of all cases; rather, infections in the mother, even infections that are not
easily detected, may triple the risk of the child developing the disorder,
mainly as the result of the toxicity to the fetal brain of cytokines that are
produced as part of the inflammatory response. Low birthweight is a risk
factor for CP—and premature infants usually have low birth weights, less
than 2.0 kg, but full-term infants can also have low birth weights. Multiplebirth infants are also more likely than single-birth infants to be born early or
with a low birth weight.
After birth, other causes include toxins, severe jaundice, lead
poisoning, physical brain injury, shaken baby syndrome, incidents involving
hypoxia to the brain (such as near drowning), and encephalitis or meningitis.
The three most common causes of asphyxia in the young child are: choking
on foreign objects such as toys and pieces of food, poisoning, and near
drowning.
Some structural brain anomalies such as lisencephaly may present
with the clinical features of CP, although whether that could be considered
CP is a matter of opinion (some people say CP must be due to brain damage,
whereas people with these anomalies didn't have a normal brain). Often this
goes along with rare chromosome disorders and CP is not genetic or
hereditary.
It has been hypothetized that many cases of cerebral palsy are caused
by the death in very early pregnancy of an identical twin.
7
Risk Factors for Cerebral Palsy
Maternal health
Certain infections or health problems during pregnancy can significantly
increase the risk of giving birth to a baby with cerebral palsy. Infections of
particular concern include:
German measles (rubella), a viral infection that can be prevented with
a vaccine
Chickenpox (varicella), a viral infection that can be prevented with a
vaccine and can emerge later in life as shingles
Cytomegalovirus, a very common virus that causes flu-like symptoms
and may lead to birth defects if a mother experiences her first active
infection during pregnancy
Toxoplasmosis, a parasitic infection caused by a parasite found in soil
and the feces of infected cats
Syphilis, a sexually transmitted bacterial infection
Exposure to toxins, such as methyl mercury
Other conditions that may increase the risk of cerebral palsy, such as
thyroid problems, mental retardation or seizures
Infant illness
8
Illnesses in a newborn baby that can greatly increase the risk of cerebral
palsy include:
Bacterial meningitis, a bacterial infection that causes inflammation in
the membranes that surround the brain and spinal cord
Viral encephalitis, a viral infection that causes inflammation of the
brain
Severe or untreated jaundice, a condition that appears as a yellowing
of the skin and that occurs when certain byproducts of "used" blood
cells aren't filtered from the bloodstream
Low birthweight
Children who weigh less than 5½ pounds (2,500 grams) at birth, and
especially those who weigh less than 3 pounds, 5 ounces (1,500 grams) have
a greater chance of having CP.
Premature birth
Children who were born before the 37th week of pregnancy, especially if
they were born before the 32nd week of pregnancy, have a greater chance of
having CP. Intensive care for premature infants has improved a lot over the
past several decades. Babies born very early are more likely to live now, but
many have medical problems that can put them at risk for CP.
Multiple births
Twins, triplets, and other multiple births have a higher risk for CP,
especially if a baby’s twin or triplet dies before birth or shortly after birth.
Some, but not all of this increased risk is due to the fact that children born
9
from multiple pregnancies often are born early or with low birthweight, or
both.
Assisted reproductive technology (ART) infertility treatments
Children born from pregnancies resulting from the use of some infertility
treatments have a greater chance of having CP. Most of the increased risk is
explained by preterm delivery or multiple births, or both; both preterm
delivery and multiple births are increased among children conceived with
ART infertility treatments.
Infections during pregnancy
Infections can lead to increases in certain proteins called cytokines that
circulate in the brain and blood of the baby during pregnancy. Cytokines
cause inflammation, which can lead to brain damage in the baby. Fever in
the mother during pregnancy or delivery also can cause this problem. Some
types of infection that have been linked with CP include viruses such as
chickenpox, rubella (german measles), and cytomegalovirus (CMV), and
bacterial infections such as infections of the placenta or fetal membranes, or
maternal pelvic infections.
Jaundice and kernicterus
Jaundice is the yellow color seen in the skin of many newborns. Jaundice
happens when a chemical called bilirubin builds up in the baby’s blood.
When too much bilirubin builds up in a new baby’s body, the skin and whites
of the eyes might look yellow. This yellow coloring is called jaundice. When
severe jaundice goes untreated for too long, it can cause a condition called
kernicterus. This can cause CP and other conditions. Sometimes, kernicterus
results from ABO or Rh blood type difference between the mother and baby.
This causes the red blood cells in the baby to break down too fast, resulting
in severe jaundice.
10
Birth complications
Detachment of the placenta, uterine rupture, or problems with the
umbilical cord during birth can disrupt oxygen supply to the baby and result
in CP.
Manifestations
Impairments resulting from cerebral palsy range in severity, usually in
correlation with the degree of injury to the brain. Because cerebral palsy is a
group of conditions, signs and symptoms vary from one individual to the
next.
The primary effect of cerebral palsy is impairment of muscle tone,
gross and fine motor functions, balance, control, reflexes, and posture. Oral
motor dysfunction, such as swallowing and feeding difficulties, speech
impairment, and poor muscle tone in the face, can also indicate cerebral
palsy. Associative conditions, such as sensory impairment, seizures, and
learning disabilities that are not a result of the same brain injury, occur
frequently with cerebral palsy. When present, these associative conditions
may contribute to a clinical diagnosis of cerebral palsy.
The most common early sign of cerebral palsy is developmental delay.
Delay in reaching key growth milestones, such as rolling over, sitting,
crawling and walking are cause for concern. Practitioners will also look for
signs such as abnormal muscle tone, unusual posture, persistent infant
reflexes, and early development of hand preference.
Many signs and symptoms are not readily visible at birth, except in
some severe cases, and may appear within the first three to five years of life
as the brain and child develop.
11
If the delivery was traumatic, or if significant risk factors were encountered
during pregnancy or birth, doctors may suspect cerebral palsy immediately
and observe the child carefully. In moderate to mild cases of cerebral palsy,
parents are often first to notice if the child doesn’t appear to be developing
on schedule. If parents do begin to suspect cerebral palsy, they will likely
want to consult their physician and ask about testing to begin ruling out or
confirming cerebral palsy or other conditions.
Most experts agree; the earlier a cerebral palsy diagnosis can be made,
the better. However, some caution against making a diagnosis too early, and
warn that other conditions need to be ruled out first. Because cerebral palsy
is the result of brain injury, and because the brain continues to develop
during the first years of life, early tests may not detect the condition. Later,
however, the same test may, in fact, reveal the issue.
Eight Clinical Signs of Cerebral Palsy
Since cerebral palsy is most often diagnosed in the first several years of
life, when a child is too young to effectively communicate his or her
symptoms, signs are the primary method of recognizing the likelihood of
cerebral palsy.
Cerebral palsy is a neurological condition which primarily causes
orthopedic impairment. Cerebral palsy is caused by a brain injury or brain
abnormality that interferes with the brain cells responsible for controlling
muscle tone, strength, and coordination. As a child grows, these changes
affect skeletal and joint development, which may lead to impairment and
possibly deformities. The eight clinical signs of cerebral palsy involve:
12
1.
Muscle Tone
2.
Movement Coordination and Control
3.
Reflexes
4.
Posture
5.
Balance
6.
Fine Motor Function
7.
Gross Motor Function
8.
Oral Motor Dysfunction
In some instances, signs become more apparent when the child experiences
developmental delay or fails to meet established developmental milestones.
Developmental Delay
Developmental Milestones
Signs:
Not blinking at loud noises by one month
Not sitting by seven months
Not turning head toward sounds by four months
Not verbalizing words by 12 months
Seizures
Walking with an abnormal gait
Symptoms:
Choking
Difficulty grasping objects
Difficulty swallowing
Fatigue
Inability to focus on objects
Inability to hear
Pain
13
Assessment
The diagnosis of CP is based on history and physical assessment. Any
episode of possible anoxia during prenatal life or at birth should be
documented. Determining the extent of involvement in an infant can be
difficult, because a neurologic assessment in infants is difficult. The full
extent of the disorder is, therefore, may be recognizable only when the child
is older and attempts more complex motor skills, such as walking. All infants
need careful neurologic assessment during the first year of life so that small
signs of impairment can be tracked and also so that the child can be
monitored closely for further testing and assessment.
Children with all forms of CP may have sensory alteration such as
strabismus, refractive disorders, visual perception problems, visual field
defects and speech disorders such as abnormal rhythm or articulation. They
may show an attention deficit disorder or autism. Deafness caused by
kernicterus occurs in connection with athetoid CP. Cognitive challenge and
recurrent seizures also frequently accompany all types of disorder.
A skull radiograph or ultrasound may show cerebral asymmetry.
However, the skull shape usually s normal. A CT or MRI scan usually is
negative. The EEG may be abnormal. But the pattern is highly variable. The
abnormality may be asymmetry or a spike seizure discharge. An abnormality
is noteworthy but is not diagnostic in itself.
Management of Cerebral Palsy
Prevention of Cerebral Palsy
Although there is no cure for cerebral palsy, many risk factors exist
that can increase the likelihood of a child developing cerebral palsy. The
focus of preventing cerebral palsy is in alleviating or minimizing risk. But if a
14
mother is having a baby, she can take steps to ensure a healthy pregnancy
and carry the baby to term, thus lowering the risk that your baby will have
CP.
Before becoming pregnant, it's important to maintain a healthy diet
and make sure that any medical problems are managed properly. As soon as
a woman knows that she is pregnant, proper prenatal medical care (including
prenatal vitamins and avoiding alcohol and illegal drugs) is vital. If the
mother is taking any medications, these must be reviewed by her doctor and
clarify if there are any side effects that can cause birth defects.
Controlling diabetes, anemia, hypertension, seizures, and nutritional
deficiencies during pregnancy can help prevent some premature births and,
as a result, some cases of cerebral palsy.
Once the baby is born there are actions that the mother can take to
lower the risk of brain damage, which could lead to CP. Never shake an
infant, as this can lead to shaken baby syndrome and brain damage. If riding
in a car, make sure the baby is properly strapped into an infant car seat
that's correctly installed — if an accident occurs, the baby will be as
protected as possible.
Be aware of lead exposure in the house, as lead poisoning can lead to
brain damage. Remember to have the child get his or her immunizations on
time — these shots protect against serious infections, some of which can
cause brain damage resulting in CP.
Treatment of Cerebral Palsy
15
Currently there's no cure for cerebral palsy, but a variety of resources
and therapies can provide help and improve the quality of life for kids with
CP.
Different kinds of therapy can help them achieve maximum potential in
growth and development. As soon as CP is diagnosed, a child can begin
therapy for movement, learning, speech, hearing, and social and emotional
development.
In addition, medication, surgery, or braces can help improve muscle
function. Orthopedic surgery can help repair dislocated hips and scoliosis
(curvature of the spine), which are common problems associated with CP.
Severe muscle spasticity can sometimes be helped with medication taken by
mouth or administered via a pump (the baclofen pump) implanted under the
skin.
A variety of medical specialists might be needed to treat the different
medical conditions. (For example, a neurologist might be needed to treat
seizures or a pulmonologist might be needed to treat breathing difficulties.) If
several medical specialists are needed, it's important to have a primary care
doctor or a CP specialist help you coordinate the care of your child.
A team of professionals will work with you to meet your child's needs.
That team may include therapists, psychologists, educators, nurses, and
social workers.
Therapy for Cerebral Palsy
Physical therapy, occupational therapy, speech and language therapy,
along with adaptive equipment, are popular treatment options for children
with cerebral palsy. Used within a coordinated, comprehensive treatment
16
plan, therapy plays a vital role in managing the physical impairment while
maximizing mobility potential. Therapy is employed to manage impairment
(primarily spasticity, contractures and muscle tone), manage pain, and
provide optimum quality-of-life by fostering functionality, self-care, and
independence. Therapy also wields mental, emotional, academic, and social
benefits for those with cerebral palsy.
If implemented as part of an early intervention program while the child
is still developing, some therapy for cerebral palsy can lessen the impact of
impairment and minimize the child’s potential for developing associative
conditions.
Therapy can be used alongside other treatment options, such as drug
therapy,
surgery,
assistive
technology,
complementary
medicine
and
alternative interventions.
When the multidisciplinary team of practitioners determines the child’s
care plan goals, they will determine appropriate therapy options. Over time,
as the child develops and as conditions arise, other therapies may also be
considered.
Therapy is not limited to the child. Therapy can be helpful to caregivers
and parents, as well. For instance, nutrition counseling can help a caregiver
understand the dietary needs of the child. Behavioral therapy can help a
parent learn how to best reinforce the child’s therapy progress in a positive
manner.
17
Risk Factors
Maternal infections or
health Problems during
pregnancy
Infant Illness
Premature Birth
Asphyxia before Birth
Low Birth Weight
Multiple Births
Assisted reproductive
technology (ART) infertility
treatments
Birth complications
18
REFERENCES
Cause / Etiology
Pilliteri PhD., RN., PNP., A., Maternal & Child Health Nursing
Unknown
(6th ed) Volume 2, 2010, pages 1459-1460
http://cerebralpalsy.org/about-cerebral-palsy/what-iscerebral-palsy/
http://cerebralpalsy.org/about-cerebral-palsy/symptoms/
http://www.cdc.gov/ncbddd/cp/causes.html
http://www.mayoclinic.com/health/cerebralpalsy/DS00302/DS
BRAI
ECTION=risk-factors
N
http://pediatrics.about.com/od/cerebralpalsy/a/409_cp_stats.
Brain Damage/
Insult
htm
http://philippinecerebralpalsy.org/about_cerebral
Brain Cell
http://www.cerebralpalsysource.com/Types_of_CP/index.html
Death
CEREBRAL
CORTEX
Underdeveloped or
disrupted corticospinal
tract
Spastic
muscles
CEREBELLU
M
Disrupted
extrapyramidal
system
Suppresion
of
propioceptiv
e responses
Impaired
ability to
coordinate
motor control
Disruption of
brain's ability to
integrate
sensory
Disruption of
brain ability to
integrate
coordination
and muscle
Hypertonia of the
muscles signalled by
nerves
Blocked effective
movement
MIDBRAI
N
Damaged
cerebellum
Impaired GABA
absorption in the
nerves affected
Muscles become active
together
Lesions on the
motor areas of
the brain
SPASTIC
C.P.
ATAXIC CEREBRAL
PALSY
19
Impaired
corticobulbar
tract
Partial/Complet
e loss of
control of facial
and jaw
musclulature,
swallowing and
tongue
movements
Impaired
basal
ganglia
Disruption of
the brain's
ability to
decide
which
behavior is
to be
ATHETOID CEREBRAL
PALSY
College of Health Sciences
Department of Nursing
Cerebral Palsy
Dan Drazen Lagmay
BSN II-B
Mrs. Frayda Castro
Clinical Instructor
Cerebral Palsy
0
The word cerebral refers to the area in the brain that is affected, while
palsy means complete or partial muscle paralysis, frequently accompanied
by loss of sensation and uncontrollable body movements or tremors.
Cerebral palsy (CP) is a group of nonprogressive disorders of upper motor
neuron impairment that result in motor dysfunction. Affected children also
may have speech or ocular difficulties, seizures cognitive challenges, or
hyperactivity. Muscle spasticity can lead to orthopedic or gait difficulties.
What is Cerebral Palsy?
Cerebral palsy is non-life-threatening – With the exception of children
born with a severe case, cerebral palsy is considered to be a non-lifethreatening condition. Most children with cerebral palsy are expected to live
well into adulthood.
Cerebral palsy is incurable – Cerebral palsy is damage to the brain that
cannot currently be fixed. Treatment and therapy help manage effects on the
body.
Cerebral palsy is non-progressive – The brain lesion is the result of a
one-time brain injury and will not produce further degeneration of the brain.
Cerebral palsy is permanent – The injury and damage to the brain is
permanent. The brain does not “heal” as other parts of the body might.
Because of this, the cerebral palsy itself will not change for better or worse
during a person’s lifetime. On the other hand, associative conditions may
improve or worsen over time.
Cerebral palsy is not contagious; it is not communicable – In the
majority of cases, cerebral palsy is caused by damage to the developing
brain. Brain damage is not spread through human contact. However, a
1
person can intentionally or unintentionally increase the likelihood a child will
develop cerebral palsy through abuse, accidents, medical malpractice,
negligence, or the spread of a bacterial or viral infection.
Cerebral palsy is manageable – The impairment caused by cerebral palsy
is manageable. In other words, treatment, therapy, surgery, medications and
assistive technology can help maximize independence, reduce barriers,
increase inclusion and thus lead to an enhanced quality-of-life.
Cerebral palsy is chronic – The effects of cerebral palsy are long-term, not
temporary. An individual diagnosed with cerebral palsy will have the
condition for their entire life.
Types of Cerebral Palsy
CEREBRAL
PALSY
Pyramidal or
Spasmic
Extrapyrami
dal
Ataxi
c
2
Dyskinetic or
Athetoid
Mixed
Cerebral palsy has been classified in various ways. Traditionally, it is
divided into two main categories based on the type of neuromuscular
involvement: a pyramidal or spastic type (approximately 40% of affected
children) and an extrapyramidal type, which is further subdivided into ataxic
(approximately 10%), dyskinetic or athetoid (approximately 30%), and mixed
(10%).
A. Spastic or Pyramidal Type
Spasticity is excessive tone in the voluntary muscles that results in loss of
upper motor neurons. A child with spastic cerebral palsy has hypertonic
muscles, abnormal clonus, exaggeration of deep tendon reflexes, abnormal
reflexes such as positive Babinski reflex, and continuation of neonatal
reflexes, such as the tonic neck reflex, well past the age at these usually
disappear. If infants with CP are held in a ventral suspension position, they
arch their backs and extend their arms and legs abnormally. They fail to
3
demonstrate a parachute reflex if lowered suddenly, failing to hold out their
arms as if to break their fall. Children tend to assume a “scissor gait”
because tight adductor thigh muscles cause their legs to cross when held
upright. This involvement may be so severe that it leads to a subluxated hip.
Tightening of the heel cord usually is so severe that children walk on their
toes, unable to stretch their heel to touch the ground.
Spastic
involvement
may affect
both
extremities
on
one
side
(hemiplegia), all four extremities (quadriplegia), or primarily the lower
extremities (diplegia or paraplegia). Children with hemiplegia. Usually have
greater involvement in the arm than in the leg. This may be demonstrated by
asking the child to extend the arms and pronate them. When the child is
asked to supinate the arm, the elbow flexes on the involved side. The
involved arm may be shorter and may have smaller muscle circumference
than the other arm. Most children with hemiplagia have difficulty identifying
objects placed in their involved hand when their eyes are closed
(astereognosis).
In older children, leg involvement may be detected most easily by
examining the child’s shoes. One heel will be much more worn than the
other, because the child does not put the heel all the way down on the
involved side. On physical examination, it may be difficult to abduct the
involved hip fully, extend the knee, or dorsiflex the foot.
A child with quadriplegia invariably has impaired speech (pseudobulbar
palsy) but may or may not be cognitively challenged. Swallowing saliva may
be so difficult that the child drools and has difficulty swallowing food. Upper
extremity involvement may be limited to an abnormal, awkward hand
movement. If there is no involvement of the arms at all, this is a true spastic
paraplegia, and a spinal cord anomaly rather than a cerebral anomaly is
suggested.
4
B.
Extrapyramidal Type
1. Dyskinetic or Athetoid Type
The athetoid type of CP involves abnormal involuntary movement.
Athetoid means “wormlike.” Early in life, the child is limp and flaccid. Later,
in place of voluntary movement, children make slow, writhing motions. This
may involve all four extremities, plus the face, neck and tongue. Because of
poor tongue and swallowing movements, the child drools and speech is
difficult to understand. With emotional stress, the involuntary movements
may become irregular and jerking (choreoid) with disordered muscle tone
(dyskinetic).
2. Ataxic Type
Children with ataxic involvement have an awkward, wide-based gait. On
neurologic examination, they are unable to perform finger-to-nose test or to
perform rapid, repetitive movements (tests of cerebellar function) or fine
coordinated motion.
3. Mixed Type
5
Some
children
show
symptoms
of
both
spasticity
and
athetoid
movements. Ataxic and athetoid movements also may be present together.
This combination results in a severe degree of physical impairment.
Prevalence and Incidence of Cerebral Palsy
Cerebral palsy affects about 1 in 278 children.
Each year, about 8,000 babies and infants are diagnosed with cerebral
palsy.
Half of people with cerebral palsy use assistive devices, including
braces, walkers, and wheelchairs, to help them be more mobile.
About 30% of children with cerebral palsy have seizures.
In the Philippines, there are more patients with CP than those with polio,
spinal lesions and other movement disorders combined which approximate
about 1-2% of the total population. Despite this, there is no government
program that addresses this condition; both in treatment and prevention.
Cause of Cerebral Palsy
While in certain cases there is no identifiable cause, typical causes
include problems in intrauterine development (e.g. exposure to radiation,
infection), asphyxia before birth, hypoxia of the brain, and birth trauma
during labor and delivery, and complications in the perinatal period or during
childhood. CP is also more common in multiple births.
Between 40 and 50% of all children who develop cerebral palsy were
born prematurely. Premature infants are vulnerable, in part because their
organs are not fully developed, increasing the risk of hypoxic injury to the
brain that may manifest as CP. A problem in interpreting this is the difficulty
in differentiating between cerebral palsy caused by damage to the brain that
6
results from inadequate oxygenation and CP that arises from prenatal brain
damage that then precipitates premature delivery.
Recent research has demonstrated that intrapartum asphyxia is not
the most important cause, probably accounting for no more than 10 percent
of all cases; rather, infections in the mother, even infections that are not
easily detected, may triple the risk of the child developing the disorder,
mainly as the result of the toxicity to the fetal brain of cytokines that are
produced as part of the inflammatory response. Low birthweight is a risk
factor for CP—and premature infants usually have low birth weights, less
than 2.0 kg, but full-term infants can also have low birth weights. Multiplebirth infants are also more likely than single-birth infants to be born early or
with a low birth weight.
After birth, other causes include toxins, severe jaundice, lead
poisoning, physical brain injury, shaken baby syndrome, incidents involving
hypoxia to the brain (such as near drowning), and encephalitis or meningitis.
The three most common causes of asphyxia in the young child are: choking
on foreign objects such as toys and pieces of food, poisoning, and near
drowning.
Some structural brain anomalies such as lisencephaly may present
with the clinical features of CP, although whether that could be considered
CP is a matter of opinion (some people say CP must be due to brain damage,
whereas people with these anomalies didn't have a normal brain). Often this
goes along with rare chromosome disorders and CP is not genetic or
hereditary.
It has been hypothetized that many cases of cerebral palsy are caused
by the death in very early pregnancy of an identical twin.
7
Risk Factors for Cerebral Palsy
Maternal health
Certain infections or health problems during pregnancy can significantly
increase the risk of giving birth to a baby with cerebral palsy. Infections of
particular concern include:
German measles (rubella), a viral infection that can be prevented with
a vaccine
Chickenpox (varicella), a viral infection that can be prevented with a
vaccine and can emerge later in life as shingles
Cytomegalovirus, a very common virus that causes flu-like symptoms
and may lead to birth defects if a mother experiences her first active
infection during pregnancy
Toxoplasmosis, a parasitic infection caused by a parasite found in soil
and the feces of infected cats
Syphilis, a sexually transmitted bacterial infection
Exposure to toxins, such as methyl mercury
Other conditions that may increase the risk of cerebral palsy, such as
thyroid problems, mental retardation or seizures
Infant illness
8
Illnesses in a newborn baby that can greatly increase the risk of cerebral
palsy include:
Bacterial meningitis, a bacterial infection that causes inflammation in
the membranes that surround the brain and spinal cord
Viral encephalitis, a viral infection that causes inflammation of the
brain
Severe or untreated jaundice, a condition that appears as a yellowing
of the skin and that occurs when certain byproducts of "used" blood
cells aren't filtered from the bloodstream
Low birthweight
Children who weigh less than 5½ pounds (2,500 grams) at birth, and
especially those who weigh less than 3 pounds, 5 ounces (1,500 grams) have
a greater chance of having CP.
Premature birth
Children who were born before the 37th week of pregnancy, especially if
they were born before the 32nd week of pregnancy, have a greater chance of
having CP. Intensive care for premature infants has improved a lot over the
past several decades. Babies born very early are more likely to live now, but
many have medical problems that can put them at risk for CP.
Multiple births
Twins, triplets, and other multiple births have a higher risk for CP,
especially if a baby’s twin or triplet dies before birth or shortly after birth.
Some, but not all of this increased risk is due to the fact that children born
9
from multiple pregnancies often are born early or with low birthweight, or
both.
Assisted reproductive technology (ART) infertility treatments
Children born from pregnancies resulting from the use of some infertility
treatments have a greater chance of having CP. Most of the increased risk is
explained by preterm delivery or multiple births, or both; both preterm
delivery and multiple births are increased among children conceived with
ART infertility treatments.
Infections during pregnancy
Infections can lead to increases in certain proteins called cytokines that
circulate in the brain and blood of the baby during pregnancy. Cytokines
cause inflammation, which can lead to brain damage in the baby. Fever in
the mother during pregnancy or delivery also can cause this problem. Some
types of infection that have been linked with CP include viruses such as
chickenpox, rubella (german measles), and cytomegalovirus (CMV), and
bacterial infections such as infections of the placenta or fetal membranes, or
maternal pelvic infections.
Jaundice and kernicterus
Jaundice is the yellow color seen in the skin of many newborns. Jaundice
happens when a chemical called bilirubin builds up in the baby’s blood.
When too much bilirubin builds up in a new baby’s body, the skin and whites
of the eyes might look yellow. This yellow coloring is called jaundice. When
severe jaundice goes untreated for too long, it can cause a condition called
kernicterus. This can cause CP and other conditions. Sometimes, kernicterus
results from ABO or Rh blood type difference between the mother and baby.
This causes the red blood cells in the baby to break down too fast, resulting
in severe jaundice.
10
Birth complications
Detachment of the placenta, uterine rupture, or problems with the
umbilical cord during birth can disrupt oxygen supply to the baby and result
in CP.
Manifestations
Impairments resulting from cerebral palsy range in severity, usually in
correlation with the degree of injury to the brain. Because cerebral palsy is a
group of conditions, signs and symptoms vary from one individual to the
next.
The primary effect of cerebral palsy is impairment of muscle tone,
gross and fine motor functions, balance, control, reflexes, and posture. Oral
motor dysfunction, such as swallowing and feeding difficulties, speech
impairment, and poor muscle tone in the face, can also indicate cerebral
palsy. Associative conditions, such as sensory impairment, seizures, and
learning disabilities that are not a result of the same brain injury, occur
frequently with cerebral palsy. When present, these associative conditions
may contribute to a clinical diagnosis of cerebral palsy.
The most common early sign of cerebral palsy is developmental delay.
Delay in reaching key growth milestones, such as rolling over, sitting,
crawling and walking are cause for concern. Practitioners will also look for
signs such as abnormal muscle tone, unusual posture, persistent infant
reflexes, and early development of hand preference.
Many signs and symptoms are not readily visible at birth, except in
some severe cases, and may appear within the first three to five years of life
as the brain and child develop.
11
If the delivery was traumatic, or if significant risk factors were encountered
during pregnancy or birth, doctors may suspect cerebral palsy immediately
and observe the child carefully. In moderate to mild cases of cerebral palsy,
parents are often first to notice if the child doesn’t appear to be developing
on schedule. If parents do begin to suspect cerebral palsy, they will likely
want to consult their physician and ask about testing to begin ruling out or
confirming cerebral palsy or other conditions.
Most experts agree; the earlier a cerebral palsy diagnosis can be made,
the better. However, some caution against making a diagnosis too early, and
warn that other conditions need to be ruled out first. Because cerebral palsy
is the result of brain injury, and because the brain continues to develop
during the first years of life, early tests may not detect the condition. Later,
however, the same test may, in fact, reveal the issue.
Eight Clinical Signs of Cerebral Palsy
Since cerebral palsy is most often diagnosed in the first several years of
life, when a child is too young to effectively communicate his or her
symptoms, signs are the primary method of recognizing the likelihood of
cerebral palsy.
Cerebral palsy is a neurological condition which primarily causes
orthopedic impairment. Cerebral palsy is caused by a brain injury or brain
abnormality that interferes with the brain cells responsible for controlling
muscle tone, strength, and coordination. As a child grows, these changes
affect skeletal and joint development, which may lead to impairment and
possibly deformities. The eight clinical signs of cerebral palsy involve:
12
1.
Muscle Tone
2.
Movement Coordination and Control
3.
Reflexes
4.
Posture
5.
Balance
6.
Fine Motor Function
7.
Gross Motor Function
8.
Oral Motor Dysfunction
In some instances, signs become more apparent when the child experiences
developmental delay or fails to meet established developmental milestones.
Developmental Delay
Developmental Milestones
Signs:
Not blinking at loud noises by one month
Not sitting by seven months
Not turning head toward sounds by four months
Not verbalizing words by 12 months
Seizures
Walking with an abnormal gait
Symptoms:
Choking
Difficulty grasping objects
Difficulty swallowing
Fatigue
Inability to focus on objects
Inability to hear
Pain
13
Assessment
The diagnosis of CP is based on history and physical assessment. Any
episode of possible anoxia during prenatal life or at birth should be
documented. Determining the extent of involvement in an infant can be
difficult, because a neurologic assessment in infants is difficult. The full
extent of the disorder is, therefore, may be recognizable only when the child
is older and attempts more complex motor skills, such as walking. All infants
need careful neurologic assessment during the first year of life so that small
signs of impairment can be tracked and also so that the child can be
monitored closely for further testing and assessment.
Children with all forms of CP may have sensory alteration such as
strabismus, refractive disorders, visual perception problems, visual field
defects and speech disorders such as abnormal rhythm or articulation. They
may show an attention deficit disorder or autism. Deafness caused by
kernicterus occurs in connection with athetoid CP. Cognitive challenge and
recurrent seizures also frequently accompany all types of disorder.
A skull radiograph or ultrasound may show cerebral asymmetry.
However, the skull shape usually s normal. A CT or MRI scan usually is
negative. The EEG may be abnormal. But the pattern is highly variable. The
abnormality may be asymmetry or a spike seizure discharge. An abnormality
is noteworthy but is not diagnostic in itself.
Management of Cerebral Palsy
Prevention of Cerebral Palsy
Although there is no cure for cerebral palsy, many risk factors exist
that can increase the likelihood of a child developing cerebral palsy. The
focus of preventing cerebral palsy is in alleviating or minimizing risk. But if a
14
mother is having a baby, she can take steps to ensure a healthy pregnancy
and carry the baby to term, thus lowering the risk that your baby will have
CP.
Before becoming pregnant, it's important to maintain a healthy diet
and make sure that any medical problems are managed properly. As soon as
a woman knows that she is pregnant, proper prenatal medical care (including
prenatal vitamins and avoiding alcohol and illegal drugs) is vital. If the
mother is taking any medications, these must be reviewed by her doctor and
clarify if there are any side effects that can cause birth defects.
Controlling diabetes, anemia, hypertension, seizures, and nutritional
deficiencies during pregnancy can help prevent some premature births and,
as a result, some cases of cerebral palsy.
Once the baby is born there are actions that the mother can take to
lower the risk of brain damage, which could lead to CP. Never shake an
infant, as this can lead to shaken baby syndrome and brain damage. If riding
in a car, make sure the baby is properly strapped into an infant car seat
that's correctly installed — if an accident occurs, the baby will be as
protected as possible.
Be aware of lead exposure in the house, as lead poisoning can lead to
brain damage. Remember to have the child get his or her immunizations on
time — these shots protect against serious infections, some of which can
cause brain damage resulting in CP.
Treatment of Cerebral Palsy
15
Currently there's no cure for cerebral palsy, but a variety of resources
and therapies can provide help and improve the quality of life for kids with
CP.
Different kinds of therapy can help them achieve maximum potential in
growth and development. As soon as CP is diagnosed, a child can begin
therapy for movement, learning, speech, hearing, and social and emotional
development.
In addition, medication, surgery, or braces can help improve muscle
function. Orthopedic surgery can help repair dislocated hips and scoliosis
(curvature of the spine), which are common problems associated with CP.
Severe muscle spasticity can sometimes be helped with medication taken by
mouth or administered via a pump (the baclofen pump) implanted under the
skin.
A variety of medical specialists might be needed to treat the different
medical conditions. (For example, a neurologist might be needed to treat
seizures or a pulmonologist might be needed to treat breathing difficulties.) If
several medical specialists are needed, it's important to have a primary care
doctor or a CP specialist help you coordinate the care of your child.
A team of professionals will work with you to meet your child's needs.
That team may include therapists, psychologists, educators, nurses, and
social workers.
Therapy for Cerebral Palsy
Physical therapy, occupational therapy, speech and language therapy,
along with adaptive equipment, are popular treatment options for children
with cerebral palsy. Used within a coordinated, comprehensive treatment
16
plan, therapy plays a vital role in managing the physical impairment while
maximizing mobility potential. Therapy is employed to manage impairment
(primarily spasticity, contractures and muscle tone), manage pain, and
provide optimum quality-of-life by fostering functionality, self-care, and
independence. Therapy also wields mental, emotional, academic, and social
benefits for those with cerebral palsy.
If implemented as part of an early intervention program while the child
is still developing, some therapy for cerebral palsy can lessen the impact of
impairment and minimize the child’s potential for developing associative
conditions.
Therapy can be used alongside other treatment options, such as drug
therapy,
surgery,
assistive
technology,
complementary
medicine
and
alternative interventions.
When the multidisciplinary team of practitioners determines the child’s
care plan goals, they will determine appropriate therapy options. Over time,
as the child develops and as conditions arise, other therapies may also be
considered.
Therapy is not limited to the child. Therapy can be helpful to caregivers
and parents, as well. For instance, nutrition counseling can help a caregiver
understand the dietary needs of the child. Behavioral therapy can help a
parent learn how to best reinforce the child’s therapy progress in a positive
manner.
17
Risk Factors
Maternal infections or
health Problems during
pregnancy
Infant Illness
Premature Birth
Asphyxia before Birth
Low Birth Weight
Multiple Births
Assisted reproductive
technology (ART) infertility
treatments
Birth complications
18
REFERENCES
Cause / Etiology
Pilliteri PhD., RN., PNP., A., Maternal & Child Health Nursing
Unknown
(6th ed) Volume 2, 2010, pages 1459-1460
http://cerebralpalsy.org/about-cerebral-palsy/what-iscerebral-palsy/
http://cerebralpalsy.org/about-cerebral-palsy/symptoms/
http://www.cdc.gov/ncbddd/cp/causes.html
http://www.mayoclinic.com/health/cerebralpalsy/DS00302/DS
BRAI
ECTION=risk-factors
N
http://pediatrics.about.com/od/cerebralpalsy/a/409_cp_stats.
Brain Damage/
Insult
htm
http://philippinecerebralpalsy.org/about_cerebral
Brain Cell
http://www.cerebralpalsysource.com/Types_of_CP/index.html
Death
CEREBRAL
CORTEX
Underdeveloped or
disrupted corticospinal
tract
Spastic
muscles
CEREBELLU
M
Disrupted
extrapyramidal
system
Suppresion
of
propioceptiv
e responses
Impaired
ability to
coordinate
motor control
Disruption of
brain's ability to
integrate
sensory
Disruption of
brain ability to
integrate
coordination
and muscle
Hypertonia of the
muscles signalled by
nerves
Blocked effective
movement
MIDBRAI
N
Damaged
cerebellum
Impaired GABA
absorption in the
nerves affected
Muscles become active
together
Lesions on the
motor areas of
the brain
SPASTIC
C.P.
ATAXIC CEREBRAL
PALSY
19
Impaired
corticobulbar
tract
Partial/Complet
e loss of
control of facial
and jaw
musclulature,
swallowing and
tongue
movements
Impaired
basal
ganglia
Disruption of
the brain's
ability to
decide
which
behavior is
to be
ATHETOID CEREBRAL
PALSY
