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Cerebral Palsy

Cerebral Palsy. Definition: It is static non progressive disorder of posture and movement resulting from defect or lesion of the developing brain 2/1,000 population First described almost 150 yrs ago by Little ,an orthopedic surgeon. Association of CP. Association of CP-

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Cerebral Palsy

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  1. Cerebral Palsy • Definition: It is static non progressive disorder of posture and movement resulting from defect or lesion of the developing brain • 2/1,000 population • First described almost 150 yrs ago by Little ,an orthopedic surgeon

  2. Association of CP • Association of CP- ■MR ■ Epilepsy-25-35% ■ Speech defect 50% ■ Deafness-10% ■ Visual defect-20% ■ Dental problem ■ Behavioral disorder 40% ■ Orthopedic problem ■ Drooling

  3. Classification • Physiologic: • Spastic (65%) ■ Athetoid (30%) • Rigidity ■ Ataxia • Tremor ■ Atonic/hypotonic • Mixed ■ unclassified

  4. Anatomical classification • Monoplegia ■ Paraplegia • Hemiplegia ■ Triplegia • Quadriplegia ■ Diplegia • Double hemiplegia

  5. Etiological classification • Prenatal: ■ Congenital anomalies ■ Maternal: – Torch infection,Chorioamnionitis, Maternal sepsis, UTI Temperature during labor Toxemias of pregnancy

  6. Perinatal Causes • Birth trauma • Perinatal asphyxia <10% • LBW babies (prematurity IUGR)-due to intracerebral hge, periventricular leukomalacia

  7. Postnatal causes • Infections-Meningitis, Encephalitis • Trauma- Head injury, Subdural hemotoma • Toxic – kernicterus • Cerebrovascular -thrombosis of C.vessels • Endocrine and metabolic- hypothyroidism, hypoglycemia, hypocalcemia, dyselectrolyte • Gross PEM in early infancy

  8. Functional classification • Class I- No limitation of activity • Class II- Slight to moderate limitation (20%) • Class III- Moderate to great limitation(50%) • Class IV – No useful physical activity (30%)

  9. Clinical manifestations • Common presentation : • Delayed milestones with indifferent look • Fisting of hands with extended extremities • Microcephaly, Mental retardation • Behavioral abnormalities • Visual, hearing, speech defects

  10. Common Presentations • persistence of NN reflexes , • Exaggerated jerks • Adductor spasms • gait –tip toe • Epilepsy

  11. Spastic hemiplegia • Arms often more involved than leg-difficulty in hand manipulation is obvious by 1 yr • Delayed walking -18-24 mo • Equinovarus deformity of foot, walks on tip toes because of increased tone • Affected upper limbs has dystonic posture when child runs

  12. Spastic hemiplegia • Deep tendon reflexes increased, ankle clonus, babinski sign + • 1/3rd have seizure disorder • 25% have MR • CT/MRI- atrophic cerebral hemisphere with dilated lateral ventriclecontralateral to the affected side

  13. Spastic Diplegia • Bilateral spasticity of legs • 1st noticed when infant begins to crawl-tends to drag the legs behind more ( commando crawl) • Severe spasticity –application of diaper is difficult due to excess adduction of hips • Brisk reflexes, ankle clonus • Scissoring posture of lower extremity when suspended by axilla

  14. Spastic Diplegia • Walking tiptoes, disuse atropy ,impaired growth of lower extremity • Intellectual development normal • Minimal seizures • CT/MRI-periventricular leukomalacia of white matter mainly lower limb fibres

  15. Spastic quadriplegia • Most severe form ,most common • All extremities severely impaired • High association with MR and seizure • Supranuclear bulbar palsies+--aspiration pneumonia • Flexion Contractures of knees and elbows • Spastic quadriplegia + athetosis +mixed CP

  16. Athetoid CP • Relatively rare these days due to aggressive management of hyperbilirubinemia • H/o NNJ += hypermyelination of basal ganglia called status marmoratus • Initially hypotonic, poor head control,marked head lag,feeding difficulty,drooling +

  17. Athetoid CP • After age 1yr –athetoid movements become evident • Speech is affected (slurred, voice modulation impaired) due to involvement of oropharyngeal muscles • Upper motor neuron signs –not present • Seizure uncommon • Intellect -preserved

  18. Rigidity/Ataxia/Tremor • Uncommon variety • Features og extrapyramidal lesion • Lead pipe or cogwheel type • Always associated with MR • Ataxia: • Mostly congenital due to cerebellar malformation • Tremor- constant severe coarse tremor

  19. Diagnosis • History • Examination • Serology-TORCH/VDRL • X-ray skull-intracranial calcification • EEG • Ct/MRI • Test of hearing ,vision • IQ test

  20. Treatment • Multidisciplinary approach –pediatrician playing the main role • Physiotherapist Orthopedic surgeon • Speech therapist ENT surgeon • Neurologist Social worker • Developmental psychologist

  21. Treatment • Counselling-teach parents-daily activities like feeding, carrying, dressing, bathing, playing, physiotherapy to limit abnormal muscle tone • Physiotherapy :- For arms-physio to start by age 6 months For legs-for effective weight bearing and wt transfer

  22. Treatment • Grasping ,release movements of hands, reciprocal movements of feet for walking, vocalised breathing for speech, parallel walking bars bicycles, special chair, grasping and releasing games • Massage, exercise and hydrotherapy

  23. Treatment • Adaptive equipments-walkers, poles standing frames, motorized wheel chair, special feeding devices, modified typewriters • Communication skills- use of symbols, specially adapted computers

  24. Treatment • Ophthalmologist-strbismus, nystagmus, optic atrophy • Orthopedics :- Hip, knee contractures-surgical release • Occupational therapy:- Simple movements for self help- feeding, dressing

  25. Treatment • Educational therapy: • Mild MR – ordinary school • Severe MR, severe disabilities-special school • Social therapy- social and emotional support to family • Rehabilitation and vocational guidance

  26. Treatment • Symptomatic- anticonvulsants for seizures • Muscle relaxants- benzodiazapines ,dantrolene sodium, Baclofen • Preventable causes shoud be prevented

  27. Prognosis • 10-50%-have seizure • Squint-50%,visual handicap-30% optic atrophy and cortical blindness • Walk by age of three, if not then unlikely that useful function will be gained

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