1. CEREBRAL
PALSY
By: Ida Sherri L. Corvera
BSN III - NM

2. • In 1860s, known as
"Cerebral Paralysis” or
William “Little’s Disease”
John Little
• After an English surgeon
(1810-1894)
wrote the 1st medical
descriptions

3. William
John
Little
(1810-1894)

4. CEREBRAL PALSY (CP)
• Cerebral“- Latin Cerebrum;
– Affected part of brain
• “Palsy " -Gr. para- beyond,
lysis – loosening
– Lack of muscle control

5. CEREBRAL
PALSY
• A motor function disorder
– caused by permanent, non-progressive brain lesion
– present at birth or shortly thereafter. (Mosby, 2006)
• Non-curable, life-long condition
• Damage doesn’t worsen
• May be congenital or acquired

6. CEREBRAL PALSY
A Heterogenous Group
of Movement Disorders
– An umbrella term
– Not a single diagnosis

7. CEREBRAL PALSY
A Heterogenous Group
of Movement Disorders

8. CP Affects
ements
Balance
ation Posture

9. In CP
• Muscles are unaffected
• Brain is unable to send
the appropriate
signals necessary to
instruct muscles when
to contract and relax

10. CAUSES
OF CEREBRAL PALSY

11. An insult or injury to the brain
– Fixed, static lesion(s)
– In single or multiple
areas of the motor
centers of the brain
– Early in CNS dev’t

12. CAUSES
• Development Malformations
– The brain fails to develop correctly.
• Neurological damage
– Can occur before, during or after delivery
– Rh incompatibility, illness, severe lack of oxygen
* Unknown in many instances

13. CHIEF CAUSE
Severe deprivation of oxygen or
blood flow to the brain
– Hypoxic-ischemic
encephalopathy
or intrapartal
asphyxia

14. RISK FACTORS
• Prenatal factors
– Before birth
– Maternal characteristics
• Perinatal factors
– at the time of birth to 1mo
• Postnatal factors
– In the first 5 mos of life

15. Prenatal factors
• Hemorrhage/bleeding
– Abruptio placenta
• Infections
– Rubella, cytomegalovirus,
toxoplasmosis,
• Environmental factors
• Maternal Characteristics

16. Maternal Characteristics
• Age
• Difficulty in conceiving or holding a
baby to term
• Multiple births
• History of fetal deaths/miscarriages
• Cigarette smoking >30 sticks per day
• Alcoholism and drug addiction
• Social status; mother with MR
• Mother’s medical condition

17. Perinatal Factors
• High or low BP
• Umbilical cord coil
• Breech delivery
• Over sedation of drugs
• Trauma i.e. forceps or
vacuum delivery
• Complications of birth

18. Postnatal Causes
• Trauma, head
injury
• Infections
• Lack of oxygen
• Stroke in the young
• Tumor, cyst

19. CP Cases
During After Before
Birth, Birth, Birth
5-15% 10-20% 75%
*Several causes are preventable or treatable

20. worldwide

21. Most Common Permanent
Disability of Childhood

22. TYPES
OF CEREBRAL PALSY

23. Classification of CP
According to:
1. Neurologic deficits
2. Type of movement involved
3. Area of affected limbs

24. 1. Accdg. to Neurologic Deficits
• Based on the
- extent of the damage
- area of brain damage
• Each type involves the way
a person moves

25. 3 MAIN
TYPES
1. PYRAMIDAL
- originates from the motor
areas of the cerebral cortex
2. EXTAPYRAMIDAL
- basal ganglia and cerebellum
3. MIXED

26. 2. Accdg. to Type of Movement
Photo from: Saunders, Elsvier.

27. 4 MAIN TYPES
PYRAMIDAL 1. Spastic CP
EXTAPYRAMIDAL 2. Athethoid CP
3. Ataxic CP
MIXED 4. Spastic &
Athethoid CP

28. TYPES
SPASTIC -Stiffness
ATHETOID
--Fluctuating
Uncontrolled
Tone
Movements
ATAXIC
-Unsteady,
Unsteady,
uncoordinated
uncoordinated

29. Spastic CP
• Increased muscle tone,
tense and contracted muscles
– Have stiff and jerky or
awkward movements.
– limbs are usually
underdeveloped
– increased deep tendon
reflexes
• most common form
• 70-80% of all affected

30. Types of Spastic CP
According to affected limbs:
* plegia or paresis - meaning paralyzed or weak:
• Paraplegia
• Diplegia
• Hemiplegia
• Quadriplegia
• Monoplegia –one limb (extremely rare)
• Triplegia –three limbs (extremely rare)

31. Diplegia/ Paraplegia
•both legs w/ slight •both legs
involvement
elsewhere

32. Diplegia
May also have
Contractures of
hips and knees
and
talipes equinovarus
(clubfoot).

33. Hemiplegia
limbs on only one side

34. • Hemiplegia on right side
– Hip and knee contractures
– Talipes equinus (“tip-toeing”
- sole permanently flexed)
– Asteriognosis may be present.
(inability to identify objects by
touch)

35. Quadriplegia

36. • Spastic
Quadriplegia
Characteristic “scissors”
positions of lower limbs
due to adductor spasms.

38. Athetoid/ Dyskinetic CP
• Fluctuating tone
– involves abnormal involuntary
movements
– that disappear during sleep and
increase with stress.
– Interferes with speaking, feeding,
reaching, grabbing, and any other
skills
– 20% of the CP cases,

39. Athetosis
• Wormlike movements
• Slow, uncontrolled motion, writhing
or twisting in character in the face,
extremities, and torso.
• Dystonia - when held as a
prolonged posture

40. Dyskinesia
– Dyskinetic movement
of mouth
– Grimacing, drooling
and dysarthria.
– Adductor spasm

41. Movements may become
choreoid
(rapid, irregular, jerky)
and
dystonic
(disordered muscle tone,
sustained muscle
contractions)
especially when stressed and during the
adolescent years.

42. Ataxic CP
• Poor balance and lack of
coordination
– Wide-based gait
– Depth perception usually
affected.
– Tendency to fall and stumble
– Inability to walk straight line.
– Least common 5-10% of cases

44. MIXED CP
• A common combination is
spastic and athetoid
• Spastic muscle tone and involuntary
movements.
• 25% of CP cases, fairly common

45. DEGREE OF SEVERITY
1. Mild CP- 20% of cases
• Moderate CP- 50%
- require self help for assisting their
impaired ambulation capacity.
• Severe CP- 30%;
-totally incapacited and bedridden
and they always need care from others.

46. Signs and
Symptoms
OF CEREBRAL PALSY

47. d.
e.
c.
f.
b.
g.
a. h.

48. Early Signs
Infancy (0-3 Months)
• Stiff or floppy posture
• Excessive lethargy or
irritability/ High pitched
cry
• Poor head control
• Weak suck/ tongue thrust/
tonic bite/ feeding difficulties

49. Early Signs
• Abnormal or prolonged
primitive reflexes
Moro’s reflex
Asymmetric tonic neck reflex
Placing reflex
Landau reflex

50. CHILD with CP
ch al
ea nt
r e
t o m es
ow elop ton
Sl v
e i l es
d m

51. Late infancy
• Inability to perform motor skills as indicated:
– Control hand grasp by 3 months
– Rolling over by 5 months
– Independent sitting by 7 months
• Abnormal Developmental Patterns:
– Hand preference by 12 months
– Excessive arching of back
– Log rolling
– Abnormal or prolonged parachute response

52. Abnormal Developmental
Patterns after 1 year of age:
• “W sitting” – knees flexed,
legs extremely rotated
• “Bottom shuffling” Scoots along the floor
• Walking on tip toe or hopping

53. Behavioral Symptoms
• Poor ability to concentrate,
• unusual tenseness,
• Irritability

54. Cerebral Palsy
• Main problem:
– Mentation and thought processes
are not always affected;
– Trapped in their bodies with their disabilities
– Ability to express their intelligence may be
limited by difficulties in communicating.

56. ASSOCIATED
PROBLEMS
OF CEREBRAL PALSY

57. • Hearing and visual
• Bladder and bowel
problems
control problems,
• Sensory integration digestive problems
problems
(gastroesophageal reflux)
• Failure-to-thrive, Feeding • Skeletal deformities,
problems dental problems
• Behavioral/emotional • Mental retardation and
difficulties, learning disabilities in
• Communication some
disorders • Seizures/ epilepsy

58. Diagnosis
OF CEREBRAL PALSY

59. A USEFUL diagnosis is
when the specific type,
affected limb,
severity and
cause, if known,
are identified

60. DIAGNOSIS
• Physical evaluation, Interview
• MRI, CT Scan EEG
• Laboratory and radiologic work up
• Assessment tools
– i.e. Peabody Development Motor Skills,
Denver Test II

61. The Peabody Development
Motor Scales
• In-depth assessment
– The subtests yield
• 6 Subtests include: a gross motor
– Reflexes quotient
– Stationary
– a fine motor
– Locomotion
quotient
– Object Manipulation
– Grasping, – a total motor
– Visual-Motor
quotient.
Integration. • Ages covered: from birth
through five years of age

62. Denver Test II
• Developmental Screening Test
• Cover 4 general functions:
– personal social (eg. smiling),
– fine motor adaptive (eg. grasping & drawing)
– language (eg. combining words)
– gross motor (eg. walking)
Ages covered: from birth to 6 years

63. ASSESSMENT

64. 1. SUBJECTIVE
- INTERVIEW

65. a. History Taking
–Include all that may predispose
an infant to brain damage or CP
•Risk factors
•Psychosocial factors
•Family adaptation

66. b. Child’s Health
History
• Often admitted to hospitals for corrective
surgeries and other complications.
– Respiratory status
– Motor function
– Presence of fever
– Feeding and weight loss
– Any changes in physical state
– Medical regimen

67. 2. OBJECTIVE
- Physical Examination

68. CRITERIA
P osturing / Poor muscle control and strength
O ropharyngeal problems
O
S trabismus/ Squint
S
T one (hyper-, hypotonia)
T
E volutional maldevelopment
E eflexes (e.g. increaseddeep tendon)
R
R *Abnormalities 4/6 strongly point to CP

69. P osturing / Poor muscle
control and strength
• Test hand strength by lifting the child off
the ground while the child holds the
nurses hands.
• Observe for presence of limb deformity, as
decreased use of extremity leads to
shortening.

70. Upon extension of extremities on vertical
suspension of the infant,
If infant back bend backwards like and arch
may indicate CP is severe

71. Oropharyngeal problems
Speech,
swallowing
breathing,
drooling,
feeding poorly

72. Strabismus
• Squint

73. Tone
• Hypertonia - rigid, tense
• Hypotonia – floppy or flaccid

74. Evolutional maldevelopment
• Delays in motor skills
– such as rolling over, sitting, crawling, and
walking
• Size for age.
• Persistence of primitive reflexes or
parachute reflex fail to develop

75. • Present at birth, normally disappears after
3 or 4 months (some say 6months)
Alternative Names:
Startle response; Startle reflex; Embrace reflex

76. Asymmetric tonic neck reflex
"fencing position“
-- head to one side, arm & leg on that side
extended, opposite limbs flexed.

77. Athetosis
and
persistent asymmetric tonic reflex.

78. Placing Reflex
• When the dorsal (back) side of the hand or foot is placed
on the edge of a surface, such as a table, the infant will lift
the extremity and place it on the flat surface.

79. Landau Reflex
• When the infant is held in a horizontal prone position, the infant will
lift head and extend the neck and trunk. When the neck is passively
flexed, the entire body will flex. This reflex is present by 6 months
and hypotonicity (low tone) indicates motor system deficits.

80. Parachute Reflex
• When held around the waist in a horizontal prone position and then lowering
the infant slowly, head first to the surface. By age 6 to 8 months the infant
should respond by extending the arms and hands to break the “fall”. If this
response is asymmetrical it indicates an unilateral motor abnormality.

82. Reflexes
Eg. Increased/ exaggerated deep tendon

83. Treatment
OF CEREBRAL PALSY

84. - No treatment to cure cerebral palsy.
- Brain damage cannot be corrected.
• Crucial for children with CP:
–Early Identification;
–Multidisciplinary Care; and
–Support

85. I. Nonphysical Therapy
“The earlier we start,
the more improvement can be made”
-Health worker

86. • General management
- Proper nutrition and personal care
B. Pharmacologic
Botox, Intrathecal, Baclofen
- control muscle spasms and seizures,
Glycopyrrolate -control drooling
Pamidronate -may help with osteoporosis.

87. Baclofen
• Delivered directly to
the spinal fluid
• Using a pump
• To avoid brain effects

88. C. Surgery
-To loosen joints,
-Relieve muscle tightness,
- Straightening of different twists or
unusual curvatures of leg muscles
- Improve the ability to sit, stand, and
walk.

89. Selective posterior rhizotomy
In some cases nerves need to be severed to decrease
muscle tension of inappropriate contractions.

90. How it Works
• A major operation, takes approximately four hours
to complete.
• The sensory nerve fibers in the spinal cord,
usually between the bottom of the rib cage and
the top of the hips are divided
• The nerve fibers are then stimulated and the
responses of the leg muscles are observed.
• Those that have an abnormal or excessive
response are severed.
• Those with a normal response are left intact.
• Intensive rehabilitation is required after the
surgery, usually up to six weeks, followed by
physical therapy on an ongoing basis

93. D. Physical Aids
Orthosis, braces and splints
- Keep limbs in correct alignment
- Prevent deformities.
Positioning devices
-Enable better posture
Walkers, special scooters, wheelchairs
- make it easier to move about.

95. E. Special Education
- To meet the child's special needs
- Improve learning.
- Vocational training can help prepare
young adults for jobs

96. F. Rehabilitation Services- Speech
and occupational therapies may
improve the ability to speak, and
perform activities of daily living and to
do some suitable works to have their
own income.

97. G. Family Services
- Professional support helps a patient
and family cope with cerebral palsy.
- Counselors help parents learn how to
modify behaviors.
- Caring for a child with cerebral palsy
can be very stressful.
- Some families find support groups
helpful.
.

98. H. Other Treatment
- Therapeutic electrical stimulation,
- Acupuncture,
- Hyperbaric therapy
- Massage Therapy might help

99. II. Physical Therapy
'The ultimate long-term goal is realistic independence. To
get there we have to have some short-term goals.
Those being a working communication system, education to his potential,
computer skills and, above all, friends'.
- Parent of boy with CP

100. A.Sitting
- Vertical head control and
control of head and trunk.
B. Standing and walking
- Establish an equal distribution of
weight on each foot, train to use steps
or inclines

101. C. Prone Development
D. Supine Development
o Head control on supine and positions

102. NURSING
RESPONSIBILITIES

103. NURSING RESPONSIBILITIES
C. Functioning as a member of the
health team

104. B. Providing counseling and education
for the parents and promote optimal
family functioning
- Encourage family members to express
anxieties, frustrations and concerns
- Provide emotional support and help with
problem solving as necessary.
- Explore support networks. Refer them to support
organizations

105. C. Promoting physical and psychological
health
- Administer prescribed medications
- Encourage self-care by urging the child to participate
in activities of daily living (ADLs) (e.g. using utensils
and implements that are appropriate for the child’s
age and condition).
- Provide rest periods to foster relaxation. Provide safe
& appropriate toys
- As necessary, seek referrals for corrective lenses
and hearing device to decrease sensory deprivation
related to vision and hearing losses

106. D. Assisting with feeding management
and toilet training
- Promote adequate fluid and nutritional intake.
 Position upright after meals
- During meals, maintain a quiet, unhurried atmosphere
with as few distractions as possible. The child may need
special utensils and a chair with a solid footrest
- Teach him to place food far back in his mouth to facilitate
swallowing.
- Encourage the child to chew food thoroughly, drink
through a straw, and suck on a lollipop between meals to
develop the muscle control needed to minimize drooling.

107. E. Assisting with rehabilitation therapies
(physical, occupational and speech)
- Promote mobility by encouraging the child to
perform age-and condition-appropriate motor
activities
- Inform parents but their child will need considerable
help and patience in accomplishing each new
task.
- Encourage them not to focus solely on the child’s
inability to accomplish certain

108. - Explain the importance of providing positive
feedback.
- Facilitated communication. Talk to the child
deliberately and slowly, using pictures or sign
language to reinforce speech when needed
- Technology such as computer use may help
children with severe articulation problems.

109. F. Providing counseling for educational
and vocational pursuits
G. Preventing child abuse
H. Providing care during hospitalization
- Prepare the child and family for
procedures, treatments, appliances and
surgeries if needed. Assign the child a
room with children in the same age-
group.

110. - Prevent physical injury by providing the
child with a safe environment, appropriate
toys, and protective gear (helmet, kneepads)
if needed.
J. Prevent physical deformity by ensuring
correct use of prescribed braces and other
devices and by performing ROM exercises.

111. K. Promote a positive self-image in the
child:
- Praise his accomplishments
- Set realistic and attainable goals
- Encourage and appealing physical appearance
- Encourage his involvement with age and
condition appropriate peer group activities.

112. "Time and gravity
are enemies of very aging body,
especially mine." - Adult with CP
THANK YOU FOR PATIENTLY
LISTENING!!!

114. Werner, David. Disabled Village Children: A
guide for community health workers,
rehabilitation workers, and families
http://www.dinf.ne.jp/doc/english/global/david/dwe002/dwe00201.
http://www.unescap.org/esid/psis/disability/d
ecade/publications/z15005s3/z1500520.htm
ECONOMIC AND SOCIAL COMMISSION FOR
ASIA AND THE PACIFIC
Production and distribution of assistive
devices for people with disabilities:
Supplement3
- Chapter 5&6 -
ST/ESCAP/1774
UNITED NATIONS PUBLICATION
Sales No. E.98.II.F.7
Copyright © United Nations 1997
ISBN: 92-1-119775-9