Cerebral Palsy (C.P.)

1. Cerebral Palsy (C.P.) By Sarah Hart u0604985

2. Learning outcomes • Describe what CP is. • List the conditions that generally accompany CP. • Describe the aetiology of the condition, and presentations in patients. • Management and treatment options of CP patients.

3. Description of CP • Umbrella term used to describe a wide range of different causative factors and describing an evolving disorder of motor function secondary to a non progressive pathology of an immature brain. • Defined as • “a persistent but not unchanging disorder of posture and movement, caused by damage to the developing nervous system, before, during or after birth or in the early months of infancy” Griffith and Clegg 1988 • Higher prevalence in low birth weight children. • Survival rate is at it’s best particularly in preterm births. • Damage to the brain can occur before, during or after delivery. • Causes are:- • REDUCED OXYGEN TO THE BRAIN • REDUCED GLUCOSE IN THE BLOOD • INFECTIONS

4. Associated conditions • Visual impairments • Reduced visual field, squint and refractive errors • Auditory impairments • Children who have neurological problems due to intrauterine (in uterus) infection or meningitis have increased risk of auditory problems. • Reduced balance mechanism • Epilepsy • Disorder of the brains function characterised by recurrent seizures that have a sudden onset. • Brain is unable to regulate its electrical discharge. • Seizures are split into 2 categories • Partial- affects part of the brain i.e. one lobe, person doesn’t lose consciousness • Generalised- affects the whole brain and person will lose consciousness • Tonic- spasm/ Clonic- convulsions • Dysphasia- expressive

5. Aetiology • 5 types of CP • Tetraplegic CP • Diplegic CP • Hemiplegic CP • Dyskinetic CP • Congenital CP

6. Tetraplegic • Tetraplegic- • Also known as quadriplegic, preterm infants who have this condition also have post haemorrhagic hydrocephalus ( Increase in CSF fluid within ventricles of the brain). Causes range for intrauterine infections, malformations, fetal encephalopathy's and perinatal hypoxic ischaemic encephalopathy. • Tetraplegic group are most severely affected, as they are unable to acquire and retain abilities in lying, sitting or standing without initial training and ongoing support. • Abnormalities in muscle tone are apparent as well as secondary changes i.e. contractures. • Difficulty in speech and communication

7. Diplegic • Diplegic • Characteristically seen in pre-term babies with haemorrhagic infarctions in the periventricular areas of the brain. • Underlying mechanism is thought to be periventricular leucomalacia and periventricular haemorrhagic venous infarction (Periventricular Leucomalacia is the description of how a premature baby's brain looks on a scan that has suffered damage from lack of blood and oxygen. It means 'white soft areas around the water spaces of the brain'. Periventricular Leucomalacia (PVL) can lead to visual impairment) • Diplegic group have use of their hands and arms, readily acquire sitting balance, difficulty in standing and walking, possible problems with gait during growth spurts as they have a flex/add gait. No problems with speech or communication.

8. Hemiplegic • Hemiplegic • 2nd commonest syndrome in pre-term and term infants. • Hemiplegia most commonly results from events early in the 3rd trimester of pregnancy involving poor blood supply. Malformation/infarction of the area of the brain per fused by the middle cerebral artery. • Tend to reject the affected side and lean towards the unaffected side, early intervention can result in unnecessary limitations, discomfort and deformities in later life as adults.

9. Dyskinetic • Dyskinetic- • Fluctuating dystonia (abnormal muscle contractions) and choroeathetoid (aimless/involuntary movements) • Basal ganglia pathology appears to be the basis of the dyskinesia, sever or prolonged birth asphyxiation can also lead to problems in the cortical, sub-cortical and basal ganglia regions, resulting in a number of clinical presentations • Encephalopathy due to the toxic effects of bilirubin, as in kernicterus. • Kernicterus is damage to the brain centres of infants caused by increased levels of unconjugated-indirect bilirubin which is free (not bound to albumin). This may be due to several underlying pathologic processes • Patients surviving kernicterus have severe permanent neurologic symptoms (choreoathetosis, spasticity, muscular rigidity, reduced postural control, ataxia, cognition deficits).

10. Congenital ataxias • Congenital ataxia- • Prenatal origin that is often genetic, although acquired haemorrhagic cerebellar lesions have been described • Imaging shows developmental abnormalities especially the vermis (It is the site of termination of the spinocerebellar pathways that carry subconscious proprioception) of the brain.

11. Medical treatment options • Drug treatments- • Medications are used to attenuate the motor disorder, baclofen- spascity, benzhexol, benztropine and levadopa derivatives for other tonal problems. • Botox can be used as well to target specific muscles. • Neurosurgery- • Dorsal rhizotomy- partial sectioning of the lumbrosacral dorsal rootlets of the spinal cord is a treatment for spasticity, used more in US than UK. • Orthopaedic management- • Scoliosis correction. • Muscle releases to prevent contractures can be used.

12. Physiotherapy management • Effective management requires careful assessment, treatment and management planning and evaluation of outcome measurements to assess appropriateness of treatment. • Test of motor impairments (TOMI)- measures the performance of daily life motor skills such as static/dynamic balance, ball skills and fine motor skills • Functional motor assessment scale (FMAS)- reliable/valid for assessing gross motor skills • Gross motor function measurement (GMFM)- assesses the effectiveness of physiotherapy.

13. Treatment approaches • Bobath approach • Conductive education • Sensory integration therapy • Hare approach • Vojta technique • None of these treatment approaches are advocated so the physio must keep up to date with different approaches • Physiotherapy programmes should be precise and focus on the basic problem of postural deficit.

14. Treatment approaches contd. • Reduce sustained postures • Maximise function • Prevent pressure sores • Maintain soft tissue length • Reduce discomfort and noxious stimuli • Seating systems-Important to assess each client for a seat if needs be, specific matrix chairs can be custom built for clients to support their posture. • Management of muscle tone- correct handling, positioning, passive stretching • Splinting • Hydrotherapy

15. Handling techniques for abnormal tone.