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

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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-life-threatening 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 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.

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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

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CEREBRAL PALSY

Pyramidal or Spasmic Extrapyramidal

Ataxic 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 demonstrate a parachute reflex if

lowered suddenly, failing to hold out their arms as if to break their fall. Children tend to assume

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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.

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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

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.

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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 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

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have low birth weights. Multiple-birth 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.

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

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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

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

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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 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

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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.

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.

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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:

1. Muscle Tone

2. Movement Coordination and Control

3. Reflexes

4. Posture

5. Balance

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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

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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 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,

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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

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

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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 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.

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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.

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Cause / Etiology

Unknown

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

Brain Damage/ Insult

BRAIN

REFERENCES

Pilliteri PhD., RN., PNP., A., Maternal & Child Health Nursing (6th ed) Volume

2, 2010, pages 1459-1460

http://cerebralpalsy.org/about-cerebral-palsy/what-is-cerebral-palsy/

http://cerebralpalsy.org/about-cerebral-palsy/symptoms/

http://www.cdc.gov/ncbddd/cp/causes.html

http://www.mayoclinic.com/health/cerebralpalsy/DS00302/

DSECTION=risk-factors

http://pediatrics.about.com/od/cerebralpalsy/a/409_cp_stats.htm

http://philippinecerebralpalsy.org/about_cerebral

http://www.cerebralpalsysource.com/Types_of_CP/index.html

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