NCM 109-Cerebral Palsy

CEREBRAL PALSY

Brain Tumor
Non-progressive brain lesions involving motor or postural abnormalities
that are noted during early development
A group of disorders of the development of movement and posture causing
activity limitations that are attributed to non-progressive disturbances that
occurred in the developing fetal or infant brain.

Age of onset - The brain lesions of CP occur from the fetal or neonatal period to
up to age 3 years
• Lesion location - CP is restricted to lesions of the brain only
Etiology and risk factors

• The etiology of CP is not well understood

Risk factors for CP are multifactorial and can include:

 preterm birth,
 multiple gestation,
 IUGR,
 male sex,
 low Apgar scores,
 intrauterine
 maternal thyroid abnormalities,
 prenatal strokes,
 birth asphyxia,
 maternal methyl mercury exposure,
 and maternal iodine deficiency
Classification and types

• CP is classified according to resting tone and what limbs are involved

Typical types of CP
1. Spastic CP, due to cortex/pyramidal tract lesions, is the most common
type & accounts for approximately 80% of cases

Spastic CP is characterized by:

1.spasticity ,
2. hyperreflexia,
3. clones,
4. Babinski reflex
1.Spastic hemiplegia - CP predominantly affecting one side of the body,
with upper extremity spasticity more than lower extremity spasticity
(e.g., right side involved with right arm more so than right leg)

2.Spastic diplegia - CP affecting bilateral lower extremities more than

upper extremities

• 3.Spastic quadriplegia - CP affecting all 4 extremities (full body)

Extra pyramidal or dyskinetic CP
CP is characterized more by abnormal involuntary movements.
CP with extra pyramidal signs characterized by abnormal movements;
hyper tonicity often is associated
Mixed CP - CP with no single specific tonal quality predominating; typically
characterized by a mixture of spastic and dyskinetic components

• Hypotonic CP - CP with truncal and extremity hypotonia with hyperreflexia

and persistent primitive reflexes; thought to be rare

Functional classification depending on functional limitations divide patients

into:

A.mild,
B.moderate,
C.severe types
Frequency - In developed countries prevalence of CP is 2-2.5 cases per
1000 live births

In the developing world, the prevalence of CP is 1.5-5.6 cases per 1000

live births.

Race - CP affects persons of all races.

Lower socioeconomic status may be an increased risk factor for CP

• Sex- Male sex may be a risk factor for CP

Clinical history

• CP diagnosis begins with a history of gross motor developmental delay

in the first year of life .
CP frequently manifests as early hypotonia for the first 6 months to 1
year of life, followed by spasticity.
Prenatal history
Perinatal history
Developmental history
Physical findings –
1. abnormal neck or truncal tone (decreased or increased, depending on
age and type of CP);
2. asymmetric posture, strength, or gait; or abnormal coordination
3. Reflexes
4. spasticity
5.. motor dysfunction such as Athetosis , Dystonia, Chorea
Classic physical presentations of the different types of CP:

Spastic hemiplegic CP
1.One-sided UMN deficit
2.Arm generally affected more than leg; possible early hand preference/relative weakness on one side;
3. gait possibly characterized by circumduction of lower extremity on affected side
4.Specific learning disabilities
5.Oromotor dysfunction
6.unilateral sensory deficits
7.Visual-field deficits (eg. homonymous hemianopsia) and strabismus
8.Seizures
Spastic diplegic CP
1.UMN findings
2.legs more than the arms
3.Scissoring gait pattern with hips flexed and adducted, knees flexed with valgus,
and ankles in equinus, resulting in toe walking
4.Learning disabilities
5. seizures less commonly than in spastic hemiplegia
Spastic quadriplegic CP
• All limbs affected, either full-body hypertonia or truncal hypotonia with
extremity hypertonia
• Oromotor dysfunction
• Increased risk of cognitive difficulties
• Multiple medical complications
• Seizures
• Legs generally affected equally or more than arms
• Categorized as double hemiplegic if arms more involved than legs
Dyskinetic (extrapyramidal) CP
1.Early hypotonia with movement disorder emerging at age 1-3 years
2.Arms more affected than legs
3.Deep tendon reflexes usually normal to slightly increased
• Some spasticity
• Oromotor dysfunction
• Gait difficulties
• Truncal instability
4.Risk of deafness in those affected by kernicterus
Differential Diagnoses

1. Inherited Metabolic disorders

2. Traumatic Peripheral Nerve Lesions

3. Hereditary spastic paraplegias

Laboratory Studies

• The diagnosis of CP is generally made base on the clinical picture

• Cranial ultrasonography
• CT scanning of the brain
• MRI of the brain
• Electromyography and nerve conduction studies
• EEG
cerebral palsy treatment

1. Physical therapy- Physical therapy is used to decrease spasticity, strengthen

underlying muscles, and teach proper or functional motor patterns
2.Occupational therapy- is used much in the same way as physical therapy, primarily
focusing on the hands and arms.
3.Exercise therapy - exercise increases the amount of oxygen delivered to the brain and
can alleviate stress. Swimming can be quite beneficial during cerebral palsy treatment,
preferably in a warmer than average pool.
Movements performed in water will be easier and more effective at exercising muscles
4. Hippotherapy - also known as horseback riding
5. speech and language therapy - Speech and language therapy is used for
spoken and alternative types of communication, such as sign language or
computers.
6. Therapeutic electrical stimulation (TES) -
which is administered at night while the patient sleeps. The TES treatment has
been proven to add more muscle fiber
7. hyperbaric oxygen therapy (HBO)-
pure oxygen in circulated in a pressurized tank, can restore function to nerve
cells that border the area of brain damage, rejuvenating them to a functional
degree.
8. Botox- usually associated with wrinkle reduction in cosmetic surgery. Botox
can be used effectively to reduce spasticity in muscles
NCP for CP
1. Impaired Physical Mobility related to decreased muscle strength and control
Goal- The child will attain maximum physical abilities possible.
Priority Intervention: Exercise Therapy, Joint Mobility: Use of active and passive body
movement to maintain joint flexibility.

 Perform development assessment and record age of achievement of milestones (e.g.,

reaching for objects, sitting)
R- Delayed development milestones are common with cerebral palsy. Once one milestone is
achieved, interventions are revised to assist in the next skill necessary.
 Plan activities to use gross and fine motor skills (e.g., holding pen or eating utensils, toys
positioned to encourage reaching and rolling over)
R- Many activities of daily living and play activities promote physical development.
 Allow time for the child to complete activities
R- The child may perform tasks more slowly than most children.
 Perform range-of-motion exercises every 4 hours for the child unable to move body parts. Position
the child to promote tendon stretching (e.g., foot plantar flexion instead of dorsiflexion, legs
extended instead of flexed at knees and hips)
R- Promotes mobility and increased circulation, and decreases the risk of contractures.
 Arrange for and encourage parents to keep appointments with a rehabilitation therapist.
R- A regular and frequently reevaluated rehabilitation program assists in promoting development.
 Teach the family to maintain appropriate brace wear.
R- Adaptive devices are often necessary to maximize physical mobility.

Suggested Outcome: Joint Movement—Active: Range of motion of joints with self limited movement
The child reaches maximum physical mobility and all developmental milestones.
NCP
2. Sensory/Perceptual Alteration: Visual or Auditory related to cerebral damage.

Goal: The child will receive and benefit from varied forms of sensory and perceptual input.
Priority Intervention: Communication Enhancement: Visual Deficit or Auditory Deficit: Assistance
with accepting or learning alternative methods for living with diminished vision or hearing.
 Facilitate eye and auditory examinations by specialist. Promote the use of adaptive devices
(glasses, contact lenses, hearing aids), and encourage recommended return visits to specialists.
R- Adaptive devices often enhance sensory input. These devices need frequent changes as the child
grows.
 Maximize the use of intact senses (e.g., describe verbally the surroundings to a child with poor
vision, allow touching of objects, provide visual materials to enhance learning in the child with
impaired hearing, use computers to promote communication).
R- Other senses can compensate for those that are impaired.
Suggested Outcome: Body Image: Positive perception of own appearance and body functioning.
The child receives adequate sensory/perceptual input to maximize developmental outcome.
3. Altered Nutrition: Less than Body Requirements related to difficulty in chewing and swallowing and high
metabolic needs
Goal: The child will receive nutrients needed for normal growth.
Interventions:
 Monitor height and weight and plot on a growth grid. Perform hydration status assessment.
R- Insufficient intake can lead to impaired growth and dehydration.
 Teach the family techniques to promote caloric and nutrient intake:
 Position the child upright for feedings.
 Place foods far back in the mouth to overcome tongue thrust.
 Use soft and blended foods.
 Allow extra time and quiet environment for meals.
R- Special techniques can facilitate food intake.
 Perform frequent respiratory assessment. Teach the family to avoid aspiration pneumonia. Teach care of
gastrostomy and tube feeding technique as appropriate
R- Aspiration pneumonia is a risk for the child with poor swallowing. Special feeding techniques may be
needed.
Suggested Outcome: Nutritional Status: Extent to which nutrients are available to meet metabolic needs.
The child shows normal growth patterns for height, weight, and other physical parameters.
4. Diversional Activity Deficit (Child) related to poor social skills

Goal: The child will engage in adequate diversional activity to maximize growth and development.
Priority Intervention: Recreation Therapy: Purposeful use of recreation to promote relaxation and enhancement
of social skills.
 Refer the family to early childhood stimulation programs. Encourage contact with other children. When
hospitalized, place the child in a room with other children when possible.
R- The child needs a variety of activities and contact with other children and adults to maximize development.
 Work with the local school to develop an individualized education plan that allows the child contact with
other children and a variety of activities.
R- Public schools must provide an individualized education plan. Parents may need assistance to interact
effectively with the school system.
 Investigate recreational programs for children with disabilities and share information with the parents.
R- Recreational programs for children with disabilities may promote social experiences and physical activity
Suggested Outcome: Play Participation: Use of activities as needed for enjoyment, entertainment, and
development by children.
The child engages in activities that maximize development.
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