Mini Med School: Cerebral Palsy

 
 
 
 
Objectives:
At the end of the class you will be able to:

1. Discuss the types of CP, the causes and prevention.
2. Describe the care of the person with CP.
3. Define some of the common terms associated with CP.

What is Cerebral Palsy?
Cerebral palsy is often called simply CP. Cerebral refers to the "brain" and palsy is "poor voluntary control and muscle weakness". CP is a serious problem that leads to involuntary body movements, poor coordination, and stiff muscles.
Children with CP have trouble when they try to walk, crawl or grab onto things. Some children may also have trouble with vision, speech, and hearing. Others may have seizures, poor mental ability, trouble with bowel and bladder control, eating and feeding. CP is a disorder. It is not a disease.
The term CP includes several muscle problems all of which result from damage to one or more parts of the person's brain. This damage can happen before birth or up to the age of 5 years old. There is no cure for CP but good care can help the person to function in the best way possible for the person.
Who Has CP?
CP is rare. Less than 2 out of 1,000 children have CP. About one in 100 babies who are small or premature have CP. (Merck, 2005-2010). In the United States, 764,000 people have one or more signs of CP. 8,000 babies and 1,200 to 1,500 pre-school children are diagnosed with CP every year. (United Cerebral Palsy, 2001-2010)
What Causes CP?
Things like the flu are caused by a single germ that is known. As said above, CP is not a disease. The cause of it is still not very clear. But, CP is found in infants and children that:

• are born before the full 9 months of pregnancy;
• are born very small and with a low birth weight;
• have a blood type or a blood factor that is different from their mother's;
• have a mother who got an infection like the German measles when they were pregnant, especially during the early stage;
• had a physical or growth problem before they were born;
• had trouble and trauma during birth;
• got a yellow color of the skin and liver problems (jaundice) soon after birth;
• have brain damage just before birth, during birth or just after birth; or
• had a lack of oxygen during birth, just before birth or after birth. (Merck, 2005-2010; United Cerebral Palsy, 2001-2010)

About 70% of CP happens because the child's brain was damaged in the mother's uterus before they were born. Why this has happened is not clearly known. (United Cerebral Palsy, 2001-2010).
CP can also come from a bad injury after birth if the young child:

• does not get enough fluid and becomes dehydrated, or
• gets a bad infection of the brain or spinal cord, or
• had a bad car accident, or
• had a bad fall. (Merck, 2005-2010; United Cerebral Palsy, 2001-2010)

Can CP Be Prevented?
Some cases of CP can be prevented when women who can have babies get the proper treatment and care.
Some of the things are:

• get the measles shot;
• get the Rh factor shot 72 hours after a baby is born so that her next babies will not get CP;
• get good care so that the baby will not be born too early;
• stay away from infections;
• take only medicines that are necessary;
• avoid X-rays;
• get good nutrition;
• get treatment for diabetes and anemia if they have it and
• keep the baby safe so they do not have an accident, like a fall. (United Cerebral Palsy, 2001-2010)

The Forms of CP
Children with CP are not able to control their muscles and their coordination. Muscles get tight. The person loses voluntary movement. They may have walking problems, swallowing and speech problems depending on what part of the brain has been damaged.
There are 4 kinds of CP. They are:

1. Spastic,
2. Athetoid,
3. Ataxic, and
4. Mixed forms.

Spastic CP
About 70% to 80% of CP cases are spastic CP. This kind of CP can be mild or it can be very severe. The arms and/or legs are not fully developed. The muscles are weak, stiff and tense. At times the arms or legs become so tight and tense that they bend up against the body (contracture). In the beginning, muscles are weak and without tone. After that, the muscles become stiff and tense.
Some children who have the mild form of this kind of CP may have problems during only some activities. Some may only have a problem when they run or walk. Those with a severe form of this CP can have paralysis of:

• both legs (diplegia),
• one side of the body (hemi-paresis) or
• the entire body.

Toe walking and a scissor walk are seen in this kind of CP. Speech problems are also seen. One kind of speech problem called dysarthria is sometimes present. These children are not able to say words in the correct way. (Merck, 2005-2010; United Cerebral Palsy, 2001-2010)
Athetoid CP
This kind of CP is seen in 20% of children with CP. Slow, unusual, and involuntary movement is seen in the hands, arms, legs and feet as well as with the body's trunk. Jerky and sudden movements may occur. The face and the tongue can also be affected. The person may make strange faces (grimace) and drool saliva from their mouth. They can also have a problem with talking. The person may not be able to speak words in the correct way.
These movements happen mostly when the person is nervous and tense. They go away when the person is sleeping or resting. (Merck, 2005-2010; United Cerebral Palsy, 2001-2010)
Ataxic CP
This kind of CP is seen in only about 5% to 10% of children with CP. It is rare. It affects the person's balance. The child may only be able to walk with their feet far apart so that they do not fall. They may also have trouble doing things like reaching for a toy or writing their name. The child's hand may begin to shake very fast when they try to touch a toy or try to write their name. (Merck, 2005-2010; United Cerebral Palsy, 2001-2010)
This kind of CP may lead to:

• weak muscles,
• an unsteady walk,
• rapid movements, and
• no control over this movement. (Merck, 2005-2010; United Cerebral Palsy, 2001-2010)

Mixed Form CP
A few children may have more than one form of CP. For example, a child may have both athetoid and spastic CP. (Merck, 2005-2010; United Cerebral Palsy, 2001-2010)
The Signs of CP
Doctor's and parents do not always know that the new baby has CP until months after they are born. In fact, the signs of CP may not be seen until the child is a year old. The signs, however, do appear by the time the child is 1½ years old.
CP is first seen when the baby or young child is not able to crawl, walk, sit, and roll over at the age they are expected to. CP signs are seen when a 8 month old baby is still not able to roll over. It may be first seen when a 18 month child is still not able to crawl on the floor.
Other early signs are:

• weakness on one side of the body
• a sitting position that is not normal
• muscles that do not have a normal tone or firmness (hypotonia)
• muscles that are very stiff (hypertonia)

Muscles are floppy and weak when they do have little tone. Muscles are stiff and rigid when they are hypertonic. Babies with CP may start their life with floppy muscles. Their muscles may then become stiff after a couple of months of life. (Merck, 2005-2010; United Cerebral Palsy, 2001-2010).
How Is CP Diagnosed by The Doctor?
Doctors diagnose CP after the young child shows slow muscle development and weakness. Some of the other things that the child's doctor may see are:

• reflexes of an infant when the child is no longer an infant;
• over active reflexes;
• poor tone;
• poor posture;
• favoring one hand or another before that should happen naturally.

ACT, MRI and ultrasound of the brain are also done. Lab tests are also done so other disorders can be ruled out. (Merck, 2005-2010; United Cerebral Palsy, 2001-2010)
The Problems Seen in Children With CP
Almost 25% of children with CP have seizures. Most of these children have spasticity. Some of the other problems seen in children with CP are:

• poor sight;
• poor hearing;
• a gaze upward;
• hemiplegia;
• paraglegia;
• quadriplegia;
• a short attention span;
• hyperactivity; and
• mental retardation.

Children that have spastic hemiplegia or paraplegia have normal mental ability and thinking. These children are often able to go to school and live a life that is close to normal with proper care and treatment. They can also have children of their own.
Children with spastic quadriplegia or the mixed form of CP have mental retardation. (Merck, 2005-2010; United Cerebral Palsy, 2001-2010)
The Treatment of CP
CP patients can lead close to normal lives with treatment and care. The goal of care for these patients is to help them be as independent as they can. Care should be started right after the person has been diagnosed with CP.
The health care team that works with these children includes:

• doctors,
• nurses,
• physical therapists,
• occupational therapists,
• therapy aides,
• speech therapists,
• social workers
• eye doctors,
• personal care aides,
• teachers, and
• family members.

Children with mild mental and physical problems can, and should, go to regular schools. Others may have to go to a special school. Total independence is often not possible for some. They may need help with certain things, like the activities of daily living, for their whole life.
Some of the activities of daily living that the person with CP may need help with are:

• dressing,
• baths,
• feeding,
• walking and exercise.

All patients with CP should do as much as they can. This helps to increase the person's independence and self esteem. It also lowers the work load for the family members.
Some patients with CP may also get:

• medicine,
• surgery to improve muscles and prevent further lack of function; and/or
• braces for support and to prevent further loss of function. (United Cerebral Palsy, 2001-2010)

Care of the Child With CP

 
 
 
 
Restorative and Rehabilitation Care
A doctor writes an order for this treatment and care. After this, the physical therapist, occupational therapist and/or speech therapist see the patient or resident so that they can:

• think about and find the best way to go about the care that the doctor has ordered and
• decide on the goals of the care for the patient or resident.

The goals can include being able to:

• eat on their own using special plates and utensils if needed,
• get in and out of the bath tub or shower with a shower chair and grab rails if needed,
• climb up stairs safely,
• grab things,
• have increased muscle strength, and
• communicate with others with the spoken word.

Patients work with the healthcare team to decide on these goals. The person with CP must be work to reach these goals on a daily basis. How well the person is reaching these goals is documented on a flow sheet, progress note or another tool, as used at your place of work.
Where is This Care Given?

 
 
 
This care can be given to the patient in the hospital, in the nursing home, in a group home, in a rehabilitation hospital, in an outpatient center and in the person's own home.
The place of care is based on the patient, their needs and the choices that there are in the area where the person lives.
Who Gives This Care?
Most of this care is provided by physical therapists, occupational therapists and speech therapists. Some rehab centers also have assistants and aides to help with this care. These people are given special training so that they are able to help the person to reach their goals.
The Role of Physical Therapy

 
 
 
 
 
Physical therapists give the person:

• range of motion exercise,
• muscle strengthening,
• general conditioning exercises,
• coordination exercises,
• transfer training, and
• ambulation help.

Range of Motion Exercise
Physical therapy provides range of motion exercise to help the person to move their joints fully after a long period of bed rest, or immobility, and when the person has a disorder like CP. Pain and the lack of full movement occur when a joint does not have normal range of motion.
There are three (3) kinds of range of motion exercise. They are:

• Active Range of Motion. Active range of motion is used when the person is able to do full range of motion to one or more parts of their body without the help of another. Nursing assistants and other members of the team may simply have to remind the person to do these exercises and to watch the person to make sure that they are doing them in the right way.
• Active Assistive Range of Motion. This range of motion is used when a person needs some help doing full range of motion to one or more parts of the body because their muscles are too weak or stiff to do them on their own. The nursing assistant and other members of the team will have to help this person with their range of motion.
• Passive Range of Motion. Passive range of motion is used for people who cannot move one or more parts of their body at all. The nursing assistant and other members of the team will have to do full range of motion for the person without any help from the patient.

Weights are sometimes used with active range of motion and active assistive range of motion.
Active assistive and passive range of motion exercises are done in a gentle, slow way so you do not hurt or harm the joints and bones. If the person gets pain, stop. These exercises are NOT done to the point of pain. They should also NOT be done to an area that has a broken bone that has not been taken care of.

Muscle Strengthening
These exercises are used for patients and residents of all ages.
The goal of these exercises may be to get the person strong enough to perform some basic activities of daily living, such as combing one's hair. These exercises help to bring weak muscles to their best possible strength. These exercises are also done with weights for some people.
General Conditioning Exercises
General conditioning exercises are done in order to:

• increase the function of the heart and lungs,
• to maintain range of motion and
• to increase muscle strength.

Nursing assistants and other members of the team often help and/or remind the patient or resident to perform these exercises.
Coordination Exercises
These exercises are mostly used for patients that need help to use their hands or to walk with good balance and gait.
For example, a person that has CP may need these exercises in order for them to be able to pick up a spoon and place it in their mouth. Or, they may need these exercises so that they will be able to walk in a balanced and safe manner.
Transfer Training
 
 
 
This training helps people to be able to go safely from the bed to the chair, from the bed or chair to the toilet or from a sitting to a standing position. When a person is not able to do these transfers they must depend on others for help in this area.
The goal of this training is to help the person move about in a safe way without the help of others. 
Ambulation Exercises
These exercises help the patient to walk safely without the help of another person. Some people may have to use a cane, splint, brace, crutches or a walker.
Some patients may have to have range of motion, balance, and muscle strengthening and/or coordination exercises before ambulation exercises can be started. At times a splint or brace may also be needed. Many people also practice with parallel bars, like the ones above, and/or a gait or ambulation belt.
Once the person is able to walk safely on a flat and level surface, they may then practice how to walk up and down stairs using a handrail. When a person walks up the stairs they should put their good leg up on the stair and then bring up the weak one.
Physical Therapy Treatments
Some of the treatments that physical therapist use are:

• heat therapy,
• cold therapy,
• water therapy,
• electrical nerve therapy,
• traction, and
• massage therapy.

Heat Therapy
Heat performs several roles. Heat:

• increases the flow of blood to a body part,
• helps to lower joint stiffness and pain,
• decreases spasms of the muscles, and
• stops swelling.

Heat therapy is often used for short term and chronic problems such as strains, sprains, spasms and neurological problems.
Heat can be given in one of two (2) ways:

• Superficial
• Deep

Superficial heat is given by using a heating pad, hot pack, a wax bath to a limb, like a hand, a warm water bath or whirlpool and with infrared heat using a lamp. Hot packs are used very often for heat therapy. When you apply a hot pack it must be wrapped in towels to protect the skin from a burn.
Deep heat is given with ultrasound and diathermy.
Ultrasound is done with sound waves. These sound waves go deep into the body's tissues and it produces heat. This form of therapy is used when the patient has:

• poor range of motion,
• a muscle problem, like CP, and
• back pain.

It is NOT used on areas that have dead tissue, such as a pressure sore or an area that is infected. It is also NOT used on eyes, ears, spinal cord, heart, brain or broken bones.
All heat must be given with great care. Heat can burn the skin of the person, especially when the patient or resident does not feel heat because of poor nerves and when they are not mentally able to tell a person that they feel the burn.
Cold Therapy
Sometimes cold is used right after an injury occurs. For example, the doctor may order cold for 48 or 72 hours after a person strains or sprains their ankle.
Cold performs the following roles. It:

• decreases blood flow to the area and
• stops swelling just after an injury has occurred.

Cold must also be given with care. It, too, can cause tissue damage (frost bite) and a lowered body temperature. Cold may be applied locally using an ice bag, a cold pack, or some fluids like ethyl chloride. Cold is NOT placed over areas of the body that do NOT have a good blood supply.
Water Therapy

 
 
 
Water therapy uses moving water to:

• apply heat to an area,
• help wound healing,
• help with pain and to
• relax the muscles.

This therapy is often used just before range of motion exercises so that the muscles are relaxed and the patient can be free of pain while going through range of motion.
Some water therapy is given using a Hubbard tank that is a very large whirlpool bath. The water is usually heated to from 96° to 104° F. Some patients and residents may feel weak and tired after water therapy so safety must be maintained. At times the person's blood pressure may drop while in the whirlpool
Electrical Nerve Stimulation
Muscles do NOT work in the correct way when nerves that contract muscles get damaged. Electrical nerve stimulation, using small electrodes, contracts these muscles to keep them from going into a spasm, something that often happens when a person has hemiplegia as the result of CP. It also prevents muscles from shrinking, or atrophy, when they are not being used for one reason or another.
Some patients are given transcutaneous electrical nerve stimulation (TENS) by the physical therapist, according to the doctor's orders. The patient in their own home can even use this small machine after they, or a family member, is taught about how to use it. They are often used for back pain, arthritis, sprains and other disorders.
Traction
Traction is the use of a weight and pulley system to decrease muscle spasm and to keep bones in proper alignment. Traction can be used in all settings, including the home. Some traction is used on a continuous basis and other traction is used just for short periods of time.
Massage
Massage is also done by physical therapists. Massage helps to reduce pain and swelling. It is used for patients and residents that have a fracture, sprain, strain or nerve injury. Many people with low back pain, arthritis, bursitis, neuritis, hemiplegia, paraplegia, multiple sclerosis, and cerebral palsy are helped with massage. 
The Role of Occupational Therapy
Occupational therapists, like physical therapists, are part of the rehabilitation and restorative care team. A patient's or resident's doctor writes an order for occupational therapy when the person can be helped in terms of their functioning, particularly in terms of performing the activities of daily living.
Some of the activities of daily living that the occupational therapist helps the person do are:

• Dressing
• Grooming
• Mouth care
• Bathing and/or showering
• Feeding self
• Cooking meals
• Getting around and caring for the home

Some people need special assistive devices to do the activities of daily living. For example, a person may need special gripping devices to pick items up off the floor. Others may need special forks and eating utensils to better pick up food from their plate. Some may need special plates with high sides to hold food on the plate when a person has trouble with a spoon or a fork. Still others may need to have their clothing made with larger buttons or Velcro strips when they cannot dress using small buttons and zippers on their clothes.
Occupational therapists teach residents, patients and their family members how to use these special assistive devices so the person can be as independent as possible with the activities of daily living.
Nursing assistants should help their patients and residents with their activities of daily living, as planned by the occupational therapist and other members of the rehab team. For example, nursing assistants should help their patients and residents with dressing, brushing their teeth and using any special devices that they have.
The Role of Speech Therapy
Speech therapists help their patients with communication. They also help patients with a swallowing disorder, something that often happens after a stroke.
These therapists also use assistive devices. For example, they may use a word board so that a patient who cannot speak can communicate their needs to others.
Doctors write orders for speech therapy when the person is not able to talk with and communicate with others. Some of these patients or residents are not even able to make their own basic needs known to those that care for them. For example, a patient or resident knows that they are hungry or have to use the bathroom but they are not able to say it.
Nursing assistants should encourage the patient or resident to speak whenever this is possible. When the person cannot speak, the nursing assistant and other team members should give the patient or resident the communication tool that they have been given by the speech therapist. For example, if a person has a word board, encourage them to use it. 
Some of the Devices Used for Restorative and Rehabilitation Care
Splints
Splints are specially made items for a patient or resident to prevent a deformity, such as a contracture, and to promote function. Some examples of splints are hand splints, a wrist splint and a foot drop splint.
Self-help Devices
Self-help devices help the patient or resident to be able to function in a safe way and independent way even though they have a disorder or a physical problem.
Some self-help devices are:

• walkers,
• canes,
• shower chairs,
• grab bars on the side and the back of the bathtub or toilet,
• graspers or reachers to lift items up from the floor,
• special eating utensils with built-up handles to help the person feed themselves,
• special combs and brushes so that the person can groom themself,
• shoehorns to help a person get dressed even though they do not have full range of motion,
• raised sitting chairs, raised toilet seats, and chair leg extenders help people safely transfer without the help of another person and
• cups with lids and special plates with deep centers and weight helps people eat their meal without spills.

Rehabilitation and restorative care play a very important part of healthcare.
The Parents of a CP Child
A chronic disability, like CP, affects about 10% of all children in the United States. Many of these children have pain. They have to go to the doctor's office often and they go to the hospital more than children who do not have a disability. It is hard for them to play and interact with other children. Other children may avoid them and say unkind things to them.
Parents of a child with a disability may feel guilty about having a less than perfect child. These parents may get angry, depressed, sad and guilty. They may be over worked with the care that the child needs.
These parents also need the help of healthcare professionals. They need to be taught about the child's health problem and how to care for them. One source of help and information for parents is the United Cerebral Palsy Association.
References
Berman, Audrey, Shirlee Snyder, Barbara Kozier and Glenora Erb. (2010). Kozier &Erb's Fundamentals of Nursing: Concepts, Process, and Practice. 8th Edition. Pearson Prentice Hall.
 

Hockenberry, Marilyn J. and David Wilson. (2010).Wong's Essentials of Pediatric Nursing. 8th Edition. Elsevier Mosby.

Merck & Co. (2002-2010). "Cerebral Palsy". [online]. 
http://www.merck.com/mmpe/sec19/ch283/ch283b.html

Merck & Co. (2002-2005). “The Chronically Disabled Child". [online].www.merck.com/mrkshared/mmanual/section19/chapter257/257b.jsp#A019-257-0312

Nettina, Sandra M. (2009). The Lippincott Manual of Nursing Practice. 7th Ed. Lippincott, Williams and Wilkins.
United Cerebral Palsy (2001-2010). Cerebral Palsy - Facts & Figures" 
www.ucp.org/ucp_generaldoc.cfm/1/9/37/37-37/447
Copyright © 2005 Alene Burke & Associates