Cerebral Palsy
Content
Cerebral Palsy Definition "Cerebral palsy" is a general term for a group of disorders that appear during the firstfew years of life and affect a child's ability to coordinate body movements. Cerebralpalsy can cause muscles to be weak and floppy, or rigid and stiff. In Europe and the United States, cerebral palsy occurs in about two to four out of every 1,000 births. Babies born prematurely or at low birth weights are at higher risk. The disorder is usually caused by brain injuries that occur early in the course of development. Cerebral palsy isn't curable. However, getting the right therapy for your child can make a big difference. Symptoms In general, children with cerebral palsy exhibit a wide variety of signs and symptoms, ranging from mild to severe. They may include: Lack of muscle coordination when performing voluntary movements (ataxia) Stiff muscles and exaggerated reflexes (spasticity) Asymmetrical walking gait, with one foot or leg dragging Variations in muscle tone, from too stiff to too floppy Excessive drooling or difficulties swallowing, sucking or speaking Tremors Difficulty with precise motions, such as writing or buttoning a shirt The brain injury causing cerebral palsy doesn't change with time, so the symptoms usually don't worsen with age. Other neurological disorders — such as mental retardation or seizures — also may occur in children with cerebral palsy. Causes Most cases of cerebral palsy are believed to be caused by problems that occur beforethe baby is born, although some cases have been linked to brain injuries or infectionsduring the first few months or years of life. Doctors can't always determine the rootcause of the brain damage that results in cerebral palsy. Potential causes include: Infections Cerebral palsy has been linked to a variety of infectious diseases occurring either in the mother during pregnancy or in the infant during the first few months of life.
Maternal illnesses that have been linked to cerebral palsy include: German measles (rubella). Also known as "three-day measles," rubella can be prevented with a vaccine. Chickenpox (varicella). Associated with the later development of shingles, chickenpox can be prevented with a vaccine. Cytomegalovirus. Up to 80 percent of the population has been infected with this virus, which causes flu-like symptoms, by the age of 40. Most people have mild symptoms that come and go throughout their lives. If a woman experiences her first bout of cytomegalovirus during pregnancy, it may cause birth defects. Toxoplasmosis. A parasite found in the soil and in the feces of infected cats, toxoplasmosis can harm the fetuses of women who are infected during pregnancy. Syphilis. A sexually transmitted disease, syphilis can harm the fetuses of infected women. Infant illnesses that have been linked to cerebral palsy include: Meningitis. Meningitis causes inflammation in the membranes that surround the brain and spinal cord. The bacterial form of the disease is the most dangerous. Viral encephalitis. Encephalitis causes inflammation in the brain itself. Viral encephalitis is the most common variety. Congenital abnormalities Some children have cerebral palsy because their brains didn't develop properly whilein the womb. In most cases, doctors don't know why this happens. In some instances,however, mutations in the genes responsible for brain development can prevent thebrain from developing normally. Exposure to toxins, radiation or infections increasesthe risk. Strokes Although strokes are more commonly associated with older people, they can happen at any age — even before birth. Strokes can occur when clots in the placenta interrupt the flow of blood to the baby. Strokes can also occur if malformed or weak blood vessels leak blood into the brain.
Lack of oxygen For many years, doctors and researchers believed that cerebral palsy was caused by alack of oxygen during birth. Now they believe that only a small number of cases arecaused by problems during labor and delivery. Severe jaundice Jaundice is common in newborns. But severe cases of untreated jaundice can harm the brain permanently and may result in cerebral palsy.
Risk factors Most children with cerebral palsy don't have any apparent problems during development in the womb and birth. But some factors may increase the risk of cerebral palsy: Premature birth. A normal pregnancy lasts 40 weeks. Babies who are born less than 37 weeks into the pregnancy are at higher risk of cerebral palsy. The earlier the baby is born, the greater the risk of cerebral palsy. Low birth weight. Babies who weigh less than 5.5 pounds (2.5 kilograms) are at higher risk of developing cerebral palsy. This risk increases as birth weight falls. Breech births. Babies who are in a feet-first position (breech presentation) at the beginning of labor are more likely to have cerebral palsy. Multiple babies. The risk of cerebral palsy increases with the number of babies sharing the uterus. If one or more of the other babies die, the chances that the survivors may develop cerebral palsy increase. Toxic substances. Babies whose mothers were exposed to toxins, such as mercury, during pregnancy are at higher risk of having cerebral palsy. Mother's health. Women who have thyroid problems, mental retardation or seizures are at higher risk of having a baby with cerebral palsy. Complications Besides difficulty with movement and posture, cerebral palsy may result in: Contractures. This condition occurs when the muscles pull so tightly on the
bones that the affected limb curls in. Severe contractures can result in joint deformities or dislocation. Malnutrition. Swallowing or feeding problems can make it difficult for someone who has cerebral palsy, particularly an infant, to get enough nutrition. Some children with cerebral palsy will have multiple handicaps and may require long term care. Some of the associated problems may include: Difficulty with vision, hearing and speech Dental problems Mental retardation Seizures Abnormal sensation or perception Urinary incontinence
Preparing for your appointment While you might first discuss your child's symptoms with your family doctor, he or she will probably refer you to a neurologist for further evaluation. What you can do Because appointments can be brief, plan ahead and write a list that includes: Detailed descriptions of your child's symptoms Questions you want to ask the doctor What to expect from your doctor In addition to a physical exam, your doctor may also check your child's neurological health by testing his or her: Reflexes
Muscle strength Muscle tone Senses of touch and sight Coordination Balance Your child may also be screened for: Mental retardation Vision problems Hearing impairment Speech and language disorders Tests and diagnosis Early signs of cerebral palsy may be present from birth. But if signs and symptomsare mild, it may be difficult to make a definite diagnosis before the age of 4 or 5. Inmost cases, cerebral palsy is diagnosed by age 1 or 2. Diagnostic tests may include: Brain scans If your baby is born prematurely and is at high risk of cerebral palsy, your doctor may suggest a cranial ultrasound because it is the least intrusive of the imaging techniques used to visualize the brain. Cranial ultrasound, however, provides a less detailed image than does a CT scan or an MRI. An MRI reveals the most details, which help determine a cause and a prognosis. Cranial ultrasound. This test uses high frequency sound waves to obtain images of the soft tissues inside the skull. Cranial ultrasound is painless and takes between 15 and 30 minutes to complete. CT scan. This test uses a computer to combine X-ray images taken from many different angles to produce cross-sectional views of your child's brain.
Scanning is painless and takes about 30 minutes. If your child can't hold still for the scanning, he or she may be given a light sedative. MRI. Using radio waves and a powerful magnet, an MRI can produce detailed images of the brain. This test is painless, but it is noisy and can take up to anhour to complete. If your child can't hold still long enough for this test, he orshe may be given a sedative. Electroencephalogram (EEG) If your child has had seizures, your doctor may recommend an electroencephalogram(EEG) to check for epilepsy. In an EEG test, a series of electrodes must be affixed toyour child's scalp. The procedure is painless and records the electrical activity insideyour child's brain. Lab tests Your child's blood may need to be checked to help rule out other conditions — suchas blood-clotting disorders that can cause strokes — that may mimic cerebral palsysigns and symptoms. Lab tests may also screen for genetic or metabolic problems. Treatments and drugs The brain abnormality or damage that underlies cerebral palsy doesn't worsen with time, but children with cerebral palsy often require long term care. The type and amount of treatment depend on how many problems your child has and how severe they are. Medications Muscle relaxants. Oral medications — such as diazepam, baclofen, dantrolene and tizanidine — are usually the first option to relax stiff, contracted muscles. Side effects may include drowsiness and upset stomach. Baclofen can also be delivered directly to the fluid surrounding the spinal cord via a pump surgically implanted into the abdomen. Botulinum toxin type A (Botox). Injections of botulinum toxin directly into spastic muscles also can help relieve the muscle spasms and contractures common to cerebral palsy. However, these injections have, in rare instances, caused serious problems with swallowing and breathing, particularly in children with cerebral palsy. Therapies Physical therapy. Muscle training and exercises may help your child's strength, flexibility, balance, motor development and mobility. Braces or splints may be recommended for your child. Some of these supports are used to help with function, such as improved walking. Others may stretch stiff muscles to help prevent contractures.
Occupational therapy. Using alternative strategies and adaptive equipment, occupational therapists work to promote your child's independent participationin daily activities and routines in the home, school and community. They mayalso address difficulties with feeding and swallowing.
Speech therapy. Speech therapists help improve your child's ability to speak clearly or to communicate using sign language. They can also teach your childto use special communication devices — such as a board covered with picturesof everyday items and activities. Sentences can be constructed by pointing tothe pictures. Surgical or other procedures Orthopedic. Children with severe contractures or deformities may need surgery on tendons, bones or joints to place their arms and legs in their correct positions. This can make it easier to use a walker, braces or crutches. Severing nerves. In some severe cases, when other treatments haven't helped, surgeons may cut the nerves serving the spastic muscles. This relaxes the muscle and reduces pain, but can also cause numbness. Coping and support When a child is diagnosed with a disabling condition, the whole family faces new challenges. Here are a few tips for caring for your child and yourself: Foster your child's independence. Encourage any effort at independence, no matter how small. Just because you can do something faster and quicker doesn't mean you should. Be an advocate for your child. You are an important part of your child's health care team. Don't be afraid to speak out on your child's behalf or to ask tough questions of your physicians, therapists and teachers. Find support. A circle of support can make a big difference in helping you cope with cerebral palsy and its effects. As a parent, you may feel grief and guilt over your child's disability. Your doctor can help you locate support groups, organizations and counseling services in your community. Your child may benefit from family support programs, school programs and counseling. Prevention
Most cases of cerebral palsy can't be prevented, despite the best efforts of parents and doctors. But, if you're pregnant, you can take these steps to keep healthy and minimize the possibility of pregnancy complications: Make sure you're immunized. Immunization against diseases such as rubella may prevent an infection that could cause fetal brain damage. Take care of yourself. The healthier you are heading into a pregnancy, the less likely you'll be to develop an infection that may result in cerebral palsy. Seek early and continuous prenatal care. Regular visits to your doctor during your pregnancy are a good way to reduce health risks to you and yourunborn baby. Seeing your doctor regularly can help prevent premature birth,low birth weight and infections.
Nursing Management: 1. Prevent physical injury by providing the child with a safe environment, appropriate toys, andprotective gear (helmet, kneepads) if needed.2. Prevent physical deformity by ensuring correct use of prescribed braces and other devices and byperforming R O M exercises.3. Promote mobility by encouraging the child to perform age-and condition-appropriate motor activities.4. Promote adequate fluid and nutritional intake.5. Foster relaxation and general health by providing rest periods.6. Administer prescribed medications which may include sedatives, muscle relaxants andanticonvulsants.7. Encourage self-care by urging the child to participate in activities of daily living (A DL s) (e.g.using utensils and implements that are appropriate for the child¶s age and condition).8. Facilitated communication o T alk to the child deliberately ad slowly, using pictures to reinforce speech when needed. o Encourage early speech therapy to prevent poor or maladaptive communication habits. o Provide means of articulate speech such as sign language or a picture board. o T echnology such as computer use may help children with severe articulation problems.9. As necessary, seek referrals for corrective lenses and hearing devices to decrease sensorydeprivation related to vision and hearing losses.10.
H elp promote a positive self-image in the child: o Praise his accomplishments o S et realistic and attainable goals o Encourage and appealing physical appearance o Encourage his involvement with age and condition- appropriate peer group activities.11. Promote optimal family functioning o Encourage family members to express anxieties, frustrations and concerns and to exploresupport networks. o Provide emotional support and help with problem solving as necessary. o Refer the family to support organizations such as the United Cerebral Palsy Association.12. Prepare the child and family for procedures, treatments, appliances and surgeries if needed.13. Assist in multidisciplinary therapeutic measures designed to establish locomotion,communication and self-help, gain optimal appearance and integration of motor functions; correct
associated defects as effectively as possible and provide educational opportunities based on theindividual¶s needs and capabilities. Therapeutic measures include: o B races to help prevent or reduce deformities, increase energy of gait, and controlalignment. o Motorized devices to permit self-propulsion. o O rthopedic surgery to correct deformities and decrease spasticity (medications are nothelpful for spasticity). o Medications to control possible seizure activity or attention deficit disorder. o S peech therapy and physical therapy.14. Inform parents but their child will need considerable help and patience in accomplishing eachnew task. o Encourage them not to focus solely on the child¶s inability to accomplish certain tasks. o
Urge them to relax and demonstrate patience. o Explain the importance of providing positive feedback.15. Encourage the family to seek appropriate functional, adaptive and vocational training for thechild.16. Encourage family members to achieve balance in their lives between caring for their disabledchild and other family and personal matters. Cerebral Palsy Symptoms The signs of cerebral palsy are usually not noticeable in early infancy but become more obvious as thechild’s nervous system matures. Early signs include the following: • Delayed milestones such as controlling head, rolling over, reaching with one hand, sitting withoutsupport, crawling, or walking • Persistence of “infantile” or “primitive” reflexes, which normally disappear 3-6 months after birth • Developinghandednessbefore age 18 months: This indicates weakness or abnormal muscle toneon one side, which may be an early sign of CP.Problems and disabilities related to CP range from very mild to very severe. Their severity is related to theseverity of the brain damage. They may be very subtle, noticeable only to medical professionals, or maybe obvious to the parents and other caregivers. • Abnormal muscle tone: Muscles may be very stiff (spastic) or unusually relaxed and “floppy.” Limbsmay be held in unusual or awkward positions. For example, spasticlegmuscles may cause legs tocross in a scissor-like position. • Abnormal movements: Movements may be unusually jerky or abrupt, or slow and writhing. Theymay appear uncontrolled or without purpose. • Skeletal deformities: People who have cerebral palsy on only one side may have shortened limbson the affected side. If not corrected by surgery or a device, this can lead to tilting of thepelvicbonesandscoliosis(curvature of thespine). • Joint contractures: People with spastic cerebral palsy may develop severe stiffening of the jointsbecause of unequal pressures on the joints exerted by muscles of differing tone or strength. • Mental retardation: Some, although not all, children with cerebral palsy are affected by mentalretardation. Generally, the more severe the retardation, the more severe the disability overall. • Seizures: About one third of people with cerebral palsy have seizures. Seizures may appear earlyin life or years after the brain damage that causes cerebral palsy. The physical signs of a seizure maybe partly masked by the abnormal movements of a person with cerebral palsy. • Speech problems: Speech is partly controlled by movements of muscles of the tongue, mouth,andthroat. Some individuals with cerebral palsy are unable to control these muscles and thus cannotspeak normally. • Swallowing problems: Swallowing is a very complex function that requires precise interaction of many groups of muscles. People with cerebral palsy who are unable to control these muscles will haveproblems sucking, eating, drinking, and controlling their saliva. They may drool. An even greater riskisaspiration, the inhalation into the lungs of food or fluids from the mouth or nose. This can causeinfection or even suffocation. • Hearing loss : Partial hearing loss is not unusual in people with cerebral palsy. The child may notrespond to sounds or may have delayed speech. • Vision problems: Three quarters of people with cerebral palsy havestrabismus, which is the turningin or out of one eye. This is due to weakness of the muscles that control eye movement. These peopleare often nearsighted. If not corrected, strabismus can lead to more severe vision problems over time. • Dental problems: People with cerebral palsy tend to have morecavitiesthan usual. This resultsfrom both defects intoothenamel and difficulties brushing the teeth. • Bowel and/or bladder control problems: These are caused by lack of muscle control.
Sleeping, - There are two categories of children to talk about here, the first is the child who cannot sleep. The second is the child who can sleep but does notdo so at the correct times. The effect is the same for the parents who have tostay awake to ensure the child's well-being. In the first category, the child has a neurological reason why he cannot sleep, - he perhaps for some reason does not produce enough serotonin, or maybe he overproduces 'noradrenaline.' In the second category it could be the child's body clock which is askew, or it might besensory oversensitivity which is preventing him from sleeping. Ultimately this child will sleep, usually when he collapses from exhaustion. Teeth, Dental problems can occur, especially if the child is hypersensitive to t ouch in his mouth, or if he produces excess saliva, or grinds his teeth. Teeth grinding, - Apart from being like the Chinese water torture for the personhaving to listen to it, this can cause dental pain for the child who does it. Often, it is done when the child feels stressed and more often than not is linkedto overproduction of saliva. a
CEREBRAL PALSY Definition: It refers to a group of nonprogressive disorders of upper motor neuron impairment thatresult in motor dysfunction. Affected children also may have speech or ocular difficulties,seizures, cognitive challenges, or hyperactivity. Types: CP has been classified invarious ways. Traditionally, it isdivided two main categories based onthe type of neuromuscular involvement:a pyramidal or spastic type(approximately 40% of affectedchildren) and an extra-pyramidal type,which is further subdivided into ataxic(approximately 10%), dyskinetic orathetoid (approximately 30%), andmixed (10%). 1. Spastic Type ± it is an excessive tone in the voluntary muscles (loss of upper motor neurons). The child with spastic CP has hypertonic muscles,abnormal clonus, exaggeration of deep tendon reflexes, abnormal reflexes such aspositive Babinski reflex, and continuation of neonatal reflexes, such as the tonic neckreflex, past the age at which these usually disappears. Spastic involvement may affectboth extremities on one side (hemiplegia), all four extremities (quadriplegia), andprimarily the lower extremities (diplegia or paraplegia). Most children with hemiplegiahave difficulty identifying objects placed in their involved hand when their eyes areclosed (astereognosis) 2.Dyskinetic or Athetoid Type ± it involves abnormal involuntary movement. Athetoidmeans wormlike. Early in life, the child is limp and flaccid. Later, in place of voluntarymovements, he or she makes slow, writhing motions. This may involve all fourextremities, plus the face, neck, and tongue. Because of poor tongue and swallowingmovements, the child drools and speech is difficult to understand. With emotional stress,the involuntary movements may become irregular and jerking (choreoid) with disorderedmuscle tone (dyskinetic). 3. Ataxic Type ± the child have an akward, wide-based gait. On neurologic examination,they are unable to perform the finger-to-nose test or to perform rapid, repetitivemovements (tests of cerebellar function) or fine coordinated motions. 4. Mixed Type ± some children show symptoms of both spasticity and athetoid movements.Ataxic and athetoid movements also may be present together. This combination results ina severe degree of physical impairment.
Causes:The exact causes of most cases of CP are unknown, but many are the result of problems during pregnancy in which the brain is either damaged or doesn't develop normally. This can bedue to infections, maternal health problems, or something else that interferes with normal braindevelopment. Problems during labor and delivery can cause CP in some cases. Premature babies ² particularly those who weigh less than 3.3 pounds (1,510 grams) ²have a higher risk of CP than babies that are carried full-term, as are other low birth weightbabies and multiple births, such as twins and triplets.
Brain damage in infancy or early childhood can also lead to CP. A baby or toddler mightsuffer this damage because of lead poisoning, bacterial meningitis, malnutrition, being shaken asan infant (shaken baby syndrome), or being in a car accident while not properly restrained.
Causes:The exact causes of most cases of CP are unknown, but many are the result of problems during pregnancy in which the brain is either damaged or doesn't develop normally. This can bedue to infections, maternal health problems, or something else that interferes with normal braindevelopment. Problems during labor and delivery can cause CP in some cases. Premature babies ² particularly those who weigh less than 3.3 pounds (1,510 grams) ²have a higher risk of CP than babies that are carried full-term, as are other low birth weightbabies and multiple births, such as twins and triplets. Brain damage in infancy or early childhood can also lead to CP. A baby or toddler mightsuffer this damage because of lead poisoning, bacterial meningitis, malnutrition, being shaken asan infant (shaken baby syndrome), or being in a car accident while not properly restrained.
Precipitating Factors: Teratogens/toxins Brain malformations Intrauterine infection injury to the cerebellum, the basal ganglia or the motor cortex Etiology: Idiopathic
Insult to the
Static lesions leaved in the brain
Developmental defect
Infarction
Middle cerebral artery occlusion in a neonate
Trauma during or after delivery
CNS relies in ininterrupted supply of blood, O2, and glucose
O2 fails to convert glucose into energy
Acidosis
Infarction IVH Subarachnoid Necrosis in in white matter and subdural cerebral hemorrhage cortex
Alters muscle tone
Muscle stretch reflexes Primitive reflexes Postural reactions
Maternal illnesses that have been linked to cerebral palsy include: German measles (rubella). Also known as "three-day measles," rubella can be prevented with a vaccine. Chickenpox (varicella). Associated with the later development of shingles, chickenpox can be prevented with a vaccine. Cytomegalovirus. Up to 80 percent of the population has been infected with this virus, which causes flu-like symptoms, by the age of 40. Most people have mild symptoms that come and go throughout their lives. If a woman experiences her first bout of cytomegalovirus during pregnancy, it may cause birth defects. Toxoplasmosis. A parasite found in the soil and in the feces of infected cats, toxoplasmosis can harm the fetuses of women who are infected during pregnancy. Syphilis. A sexually transmitted disease, syphilis can harm the fetuses of infected women. Infant illnesses that have been linked to cerebral palsy include: Meningitis. Meningitis causes inflammation in the membranes that surround the brain and spinal cord. The bacterial form of the disease is the most dangerous. Viral encephalitis. Encephalitis causes inflammation in the brain itself. Viral encephalitis is the most common variety. Congenital abnormalities Some children have cerebral palsy because their brains didn't develop properly whilein the womb. In most cases, doctors don't know why this happens. In some instances,however, mutations in the genes responsible for brain development can prevent thebrain from developing normally. Exposure to toxins, radiation or infections increasesthe risk. Strokes Although strokes are more commonly associated with older people, they can happen at any age — even before birth. Strokes can occur when clots in the placenta interrupt the flow of blood to the baby. Strokes can also occur if malformed or weak blood vessels leak blood into the brain.
Lack of oxygen For many years, doctors and researchers believed that cerebral palsy was caused by alack of oxygen during birth. Now they believe that only a small number of cases arecaused by problems during labor and delivery. Severe jaundice Jaundice is common in newborns. But severe cases of untreated jaundice can harm the brain permanently and may result in cerebral palsy.
Risk factors Most children with cerebral palsy don't have any apparent problems during development in the womb and birth. But some factors may increase the risk of cerebral palsy: Premature birth. A normal pregnancy lasts 40 weeks. Babies who are born less than 37 weeks into the pregnancy are at higher risk of cerebral palsy. The earlier the baby is born, the greater the risk of cerebral palsy. Low birth weight. Babies who weigh less than 5.5 pounds (2.5 kilograms) are at higher risk of developing cerebral palsy. This risk increases as birth weight falls. Breech births. Babies who are in a feet-first position (breech presentation) at the beginning of labor are more likely to have cerebral palsy. Multiple babies. The risk of cerebral palsy increases with the number of babies sharing the uterus. If one or more of the other babies die, the chances that the survivors may develop cerebral palsy increase. Toxic substances. Babies whose mothers were exposed to toxins, such as mercury, during pregnancy are at higher risk of having cerebral palsy. Mother's health. Women who have thyroid problems, mental retardation or seizures are at higher risk of having a baby with cerebral palsy. Complications Besides difficulty with movement and posture, cerebral palsy may result in: Contractures. This condition occurs when the muscles pull so tightly on the
bones that the affected limb curls in. Severe contractures can result in joint deformities or dislocation. Malnutrition. Swallowing or feeding problems can make it difficult for someone who has cerebral palsy, particularly an infant, to get enough nutrition. Some children with cerebral palsy will have multiple handicaps and may require long term care. Some of the associated problems may include: Difficulty with vision, hearing and speech Dental problems Mental retardation Seizures Abnormal sensation or perception Urinary incontinence
Preparing for your appointment While you might first discuss your child's symptoms with your family doctor, he or she will probably refer you to a neurologist for further evaluation. What you can do Because appointments can be brief, plan ahead and write a list that includes: Detailed descriptions of your child's symptoms Questions you want to ask the doctor What to expect from your doctor In addition to a physical exam, your doctor may also check your child's neurological health by testing his or her: Reflexes
Muscle strength Muscle tone Senses of touch and sight Coordination Balance Your child may also be screened for: Mental retardation Vision problems Hearing impairment Speech and language disorders Tests and diagnosis Early signs of cerebral palsy may be present from birth. But if signs and symptomsare mild, it may be difficult to make a definite diagnosis before the age of 4 or 5. Inmost cases, cerebral palsy is diagnosed by age 1 or 2. Diagnostic tests may include: Brain scans If your baby is born prematurely and is at high risk of cerebral palsy, your doctor may suggest a cranial ultrasound because it is the least intrusive of the imaging techniques used to visualize the brain. Cranial ultrasound, however, provides a less detailed image than does a CT scan or an MRI. An MRI reveals the most details, which help determine a cause and a prognosis. Cranial ultrasound. This test uses high frequency sound waves to obtain images of the soft tissues inside the skull. Cranial ultrasound is painless and takes between 15 and 30 minutes to complete. CT scan. This test uses a computer to combine X-ray images taken from many different angles to produce cross-sectional views of your child's brain.
Scanning is painless and takes about 30 minutes. If your child can't hold still for the scanning, he or she may be given a light sedative. MRI. Using radio waves and a powerful magnet, an MRI can produce detailed images of the brain. This test is painless, but it is noisy and can take up to anhour to complete. If your child can't hold still long enough for this test, he orshe may be given a sedative. Electroencephalogram (EEG) If your child has had seizures, your doctor may recommend an electroencephalogram(EEG) to check for epilepsy. In an EEG test, a series of electrodes must be affixed toyour child's scalp. The procedure is painless and records the electrical activity insideyour child's brain. Lab tests Your child's blood may need to be checked to help rule out other conditions — suchas blood-clotting disorders that can cause strokes — that may mimic cerebral palsysigns and symptoms. Lab tests may also screen for genetic or metabolic problems. Treatments and drugs The brain abnormality or damage that underlies cerebral palsy doesn't worsen with time, but children with cerebral palsy often require long term care. The type and amount of treatment depend on how many problems your child has and how severe they are. Medications Muscle relaxants. Oral medications — such as diazepam, baclofen, dantrolene and tizanidine — are usually the first option to relax stiff, contracted muscles. Side effects may include drowsiness and upset stomach. Baclofen can also be delivered directly to the fluid surrounding the spinal cord via a pump surgically implanted into the abdomen. Botulinum toxin type A (Botox). Injections of botulinum toxin directly into spastic muscles also can help relieve the muscle spasms and contractures common to cerebral palsy. However, these injections have, in rare instances, caused serious problems with swallowing and breathing, particularly in children with cerebral palsy. Therapies Physical therapy. Muscle training and exercises may help your child's strength, flexibility, balance, motor development and mobility. Braces or splints may be recommended for your child. Some of these supports are used to help with function, such as improved walking. Others may stretch stiff muscles to help prevent contractures.
Occupational therapy. Using alternative strategies and adaptive equipment, occupational therapists work to promote your child's independent participationin daily activities and routines in the home, school and community. They mayalso address difficulties with feeding and swallowing.
Speech therapy. Speech therapists help improve your child's ability to speak clearly or to communicate using sign language. They can also teach your childto use special communication devices — such as a board covered with picturesof everyday items and activities. Sentences can be constructed by pointing tothe pictures. Surgical or other procedures Orthopedic. Children with severe contractures or deformities may need surgery on tendons, bones or joints to place their arms and legs in their correct positions. This can make it easier to use a walker, braces or crutches. Severing nerves. In some severe cases, when other treatments haven't helped, surgeons may cut the nerves serving the spastic muscles. This relaxes the muscle and reduces pain, but can also cause numbness. Coping and support When a child is diagnosed with a disabling condition, the whole family faces new challenges. Here are a few tips for caring for your child and yourself: Foster your child's independence. Encourage any effort at independence, no matter how small. Just because you can do something faster and quicker doesn't mean you should. Be an advocate for your child. You are an important part of your child's health care team. Don't be afraid to speak out on your child's behalf or to ask tough questions of your physicians, therapists and teachers. Find support. A circle of support can make a big difference in helping you cope with cerebral palsy and its effects. As a parent, you may feel grief and guilt over your child's disability. Your doctor can help you locate support groups, organizations and counseling services in your community. Your child may benefit from family support programs, school programs and counseling. Prevention
Most cases of cerebral palsy can't be prevented, despite the best efforts of parents and doctors. But, if you're pregnant, you can take these steps to keep healthy and minimize the possibility of pregnancy complications: Make sure you're immunized. Immunization against diseases such as rubella may prevent an infection that could cause fetal brain damage. Take care of yourself. The healthier you are heading into a pregnancy, the less likely you'll be to develop an infection that may result in cerebral palsy. Seek early and continuous prenatal care. Regular visits to your doctor during your pregnancy are a good way to reduce health risks to you and yourunborn baby. Seeing your doctor regularly can help prevent premature birth,low birth weight and infections.
Nursing Management: 1. Prevent physical injury by providing the child with a safe environment, appropriate toys, andprotective gear (helmet, kneepads) if needed.2. Prevent physical deformity by ensuring correct use of prescribed braces and other devices and byperforming R O M exercises.3. Promote mobility by encouraging the child to perform age-and condition-appropriate motor activities.4. Promote adequate fluid and nutritional intake.5. Foster relaxation and general health by providing rest periods.6. Administer prescribed medications which may include sedatives, muscle relaxants andanticonvulsants.7. Encourage self-care by urging the child to participate in activities of daily living (A DL s) (e.g.using utensils and implements that are appropriate for the child¶s age and condition).8. Facilitated communication o T alk to the child deliberately ad slowly, using pictures to reinforce speech when needed. o Encourage early speech therapy to prevent poor or maladaptive communication habits. o Provide means of articulate speech such as sign language or a picture board. o T echnology such as computer use may help children with severe articulation problems.9. As necessary, seek referrals for corrective lenses and hearing devices to decrease sensorydeprivation related to vision and hearing losses.10.
H elp promote a positive self-image in the child: o Praise his accomplishments o S et realistic and attainable goals o Encourage and appealing physical appearance o Encourage his involvement with age and condition- appropriate peer group activities.11. Promote optimal family functioning o Encourage family members to express anxieties, frustrations and concerns and to exploresupport networks. o Provide emotional support and help with problem solving as necessary. o Refer the family to support organizations such as the United Cerebral Palsy Association.12. Prepare the child and family for procedures, treatments, appliances and surgeries if needed.13. Assist in multidisciplinary therapeutic measures designed to establish locomotion,communication and self-help, gain optimal appearance and integration of motor functions; correct
associated defects as effectively as possible and provide educational opportunities based on theindividual¶s needs and capabilities. Therapeutic measures include: o B races to help prevent or reduce deformities, increase energy of gait, and controlalignment. o Motorized devices to permit self-propulsion. o O rthopedic surgery to correct deformities and decrease spasticity (medications are nothelpful for spasticity). o Medications to control possible seizure activity or attention deficit disorder. o S peech therapy and physical therapy.14. Inform parents but their child will need considerable help and patience in accomplishing eachnew task. o Encourage them not to focus solely on the child¶s inability to accomplish certain tasks. o
Urge them to relax and demonstrate patience. o Explain the importance of providing positive feedback.15. Encourage the family to seek appropriate functional, adaptive and vocational training for thechild.16. Encourage family members to achieve balance in their lives between caring for their disabledchild and other family and personal matters. Cerebral Palsy Symptoms The signs of cerebral palsy are usually not noticeable in early infancy but become more obvious as thechild’s nervous system matures. Early signs include the following: • Delayed milestones such as controlling head, rolling over, reaching with one hand, sitting withoutsupport, crawling, or walking • Persistence of “infantile” or “primitive” reflexes, which normally disappear 3-6 months after birth • Developinghandednessbefore age 18 months: This indicates weakness or abnormal muscle toneon one side, which may be an early sign of CP.Problems and disabilities related to CP range from very mild to very severe. Their severity is related to theseverity of the brain damage. They may be very subtle, noticeable only to medical professionals, or maybe obvious to the parents and other caregivers. • Abnormal muscle tone: Muscles may be very stiff (spastic) or unusually relaxed and “floppy.” Limbsmay be held in unusual or awkward positions. For example, spasticlegmuscles may cause legs tocross in a scissor-like position. • Abnormal movements: Movements may be unusually jerky or abrupt, or slow and writhing. Theymay appear uncontrolled or without purpose. • Skeletal deformities: People who have cerebral palsy on only one side may have shortened limbson the affected side. If not corrected by surgery or a device, this can lead to tilting of thepelvicbonesandscoliosis(curvature of thespine). • Joint contractures: People with spastic cerebral palsy may develop severe stiffening of the jointsbecause of unequal pressures on the joints exerted by muscles of differing tone or strength. • Mental retardation: Some, although not all, children with cerebral palsy are affected by mentalretardation. Generally, the more severe the retardation, the more severe the disability overall. • Seizures: About one third of people with cerebral palsy have seizures. Seizures may appear earlyin life or years after the brain damage that causes cerebral palsy. The physical signs of a seizure maybe partly masked by the abnormal movements of a person with cerebral palsy. • Speech problems: Speech is partly controlled by movements of muscles of the tongue, mouth,andthroat. Some individuals with cerebral palsy are unable to control these muscles and thus cannotspeak normally. • Swallowing problems: Swallowing is a very complex function that requires precise interaction of many groups of muscles. People with cerebral palsy who are unable to control these muscles will haveproblems sucking, eating, drinking, and controlling their saliva. They may drool. An even greater riskisaspiration, the inhalation into the lungs of food or fluids from the mouth or nose. This can causeinfection or even suffocation. • Hearing loss : Partial hearing loss is not unusual in people with cerebral palsy. The child may notrespond to sounds or may have delayed speech. • Vision problems: Three quarters of people with cerebral palsy havestrabismus, which is the turningin or out of one eye. This is due to weakness of the muscles that control eye movement. These peopleare often nearsighted. If not corrected, strabismus can lead to more severe vision problems over time. • Dental problems: People with cerebral palsy tend to have morecavitiesthan usual. This resultsfrom both defects intoothenamel and difficulties brushing the teeth. • Bowel and/or bladder control problems: These are caused by lack of muscle control.
Sleeping, - There are two categories of children to talk about here, the first is the child who cannot sleep. The second is the child who can sleep but does notdo so at the correct times. The effect is the same for the parents who have tostay awake to ensure the child's well-being. In the first category, the child has a neurological reason why he cannot sleep, - he perhaps for some reason does not produce enough serotonin, or maybe he overproduces 'noradrenaline.' In the second category it could be the child's body clock which is askew, or it might besensory oversensitivity which is preventing him from sleeping. Ultimately this child will sleep, usually when he collapses from exhaustion. Teeth, Dental problems can occur, especially if the child is hypersensitive to t ouch in his mouth, or if he produces excess saliva, or grinds his teeth. Teeth grinding, - Apart from being like the Chinese water torture for the personhaving to listen to it, this can cause dental pain for the child who does it. Often, it is done when the child feels stressed and more often than not is linkedto overproduction of saliva. a
CEREBRAL PALSY Definition: It refers to a group of nonprogressive disorders of upper motor neuron impairment thatresult in motor dysfunction. Affected children also may have speech or ocular difficulties,seizures, cognitive challenges, or hyperactivity. Types: CP has been classified invarious ways. Traditionally, it isdivided two main categories based onthe type of neuromuscular involvement:a pyramidal or spastic type(approximately 40% of affectedchildren) and an extra-pyramidal type,which is further subdivided into ataxic(approximately 10%), dyskinetic orathetoid (approximately 30%), andmixed (10%). 1. Spastic Type ± it is an excessive tone in the voluntary muscles (loss of upper motor neurons). The child with spastic CP has hypertonic muscles,abnormal clonus, exaggeration of deep tendon reflexes, abnormal reflexes such aspositive Babinski reflex, and continuation of neonatal reflexes, such as the tonic neckreflex, past the age at which these usually disappears. Spastic involvement may affectboth extremities on one side (hemiplegia), all four extremities (quadriplegia), andprimarily the lower extremities (diplegia or paraplegia). Most children with hemiplegiahave difficulty identifying objects placed in their involved hand when their eyes areclosed (astereognosis) 2.Dyskinetic or Athetoid Type ± it involves abnormal involuntary movement. Athetoidmeans wormlike. Early in life, the child is limp and flaccid. Later, in place of voluntarymovements, he or she makes slow, writhing motions. This may involve all fourextremities, plus the face, neck, and tongue. Because of poor tongue and swallowingmovements, the child drools and speech is difficult to understand. With emotional stress,the involuntary movements may become irregular and jerking (choreoid) with disorderedmuscle tone (dyskinetic). 3. Ataxic Type ± the child have an akward, wide-based gait. On neurologic examination,they are unable to perform the finger-to-nose test or to perform rapid, repetitivemovements (tests of cerebellar function) or fine coordinated motions. 4. Mixed Type ± some children show symptoms of both spasticity and athetoid movements.Ataxic and athetoid movements also may be present together. This combination results ina severe degree of physical impairment.
Causes:The exact causes of most cases of CP are unknown, but many are the result of problems during pregnancy in which the brain is either damaged or doesn't develop normally. This can bedue to infections, maternal health problems, or something else that interferes with normal braindevelopment. Problems during labor and delivery can cause CP in some cases. Premature babies ² particularly those who weigh less than 3.3 pounds (1,510 grams) ²have a higher risk of CP than babies that are carried full-term, as are other low birth weightbabies and multiple births, such as twins and triplets.
Brain damage in infancy or early childhood can also lead to CP. A baby or toddler mightsuffer this damage because of lead poisoning, bacterial meningitis, malnutrition, being shaken asan infant (shaken baby syndrome), or being in a car accident while not properly restrained.
Causes:The exact causes of most cases of CP are unknown, but many are the result of problems during pregnancy in which the brain is either damaged or doesn't develop normally. This can bedue to infections, maternal health problems, or something else that interferes with normal braindevelopment. Problems during labor and delivery can cause CP in some cases. Premature babies ² particularly those who weigh less than 3.3 pounds (1,510 grams) ²have a higher risk of CP than babies that are carried full-term, as are other low birth weightbabies and multiple births, such as twins and triplets. Brain damage in infancy or early childhood can also lead to CP. A baby or toddler mightsuffer this damage because of lead poisoning, bacterial meningitis, malnutrition, being shaken asan infant (shaken baby syndrome), or being in a car accident while not properly restrained.
Precipitating Factors: Teratogens/toxins Brain malformations Intrauterine infection injury to the cerebellum, the basal ganglia or the motor cortex Etiology: Idiopathic
Insult to the
Static lesions leaved in the brain
Developmental defect
Infarction
Middle cerebral artery occlusion in a neonate
Trauma during or after delivery
CNS relies in ininterrupted supply of blood, O2, and glucose
O2 fails to convert glucose into energy
Acidosis
Infarction IVH Subarachnoid Necrosis in in white matter and subdural cerebral hemorrhage cortex
Alters muscle tone
Muscle stretch reflexes Primitive reflexes Postural reactions
