Cerebral Palsy Paralytic Disorders POLIOMYELITIS MYELOMENINGOCELE

1. CerebralPalsy ParalyticDisorders POLIOMYELITIS MYELOMENINGOCELE ARTHROGRYPOSISMULTIPLEXCONGENITA BRACHIALPLEXUSPALSY

2. Cerebral Palsy

3. ETIOLOGY (1) Some degree of motor impairment is present (2) an insult to the developing brain has occurred (3) a neurological deficit is present that is nonprogressive

4. The insult to the brain is believed to occur between the time of conception and age 2 years, at which time a significant amount of motor development has already occurred.

5. neurological deficit is Permanent Nonprogressive .

6. PREVALENCE: amount and quality of prenatal care, the socioeconomic condition of the parents, the environment, obstetrical and pediatric care the mother and child receive. prevalence = 0.6 to 7cases per 1000 live births

7. prenatal, perinatal, postnatal. Contrary to popular belief, fewer than 10% of injuries that result in cerebral palsy occur during the birth process.

8. prenatal fetus(most commonly genetic disorders), mother (seizure disorders, mental retardation, and previous pregnancy loss), pregnancy itself (Rh incompatibility, polyhydramnios, placental rupture, and drug or alcohol exposure). Externalfactors, such as TORCH (toxoplasmosis, other agents, rubella, cytomegalovirus, herpes simplex).

9. perinatal asphyxia or trauma that occurs during labor. Oxytocin augmentation, umbilicalcord prolapse breech presentation. Low-birth-weight infants (<1500 g) incidence of 60 per 1000 births compared with two per 1000 births in normal-weight infants. periventricular blood vessels. Pregnanciesinvolvingmultiplebirths

10. white matter

11. postnatal Hypoxic-ischemicencephalopathy, persistent fetal circulation with true ischemia meconium aspiration which is characterized by hypotonia, decreased movement, and seizures Infections such as encephalitis and meningitis Traumatic brain injury

13. Geographical Classification

14. Monoplegia very rare usually occurs after meningitis. Most patients diagnosed with monoplegia actually have hemiplegia

15. Diplegia most common 50% premature infants intelligence normal Most children with diplegia walk eventually although walking is delayed usually until around age4 years

16. Hemiplegia 30%, typically have sensory changes Hemiplegic patients also may have a leg-length discrepancy

17. Quadriplegia significant cognitive deficiencies that make care more difficult. Head and neck control which helps with communication, education, and seating. Treatment goals straight spine level pelvis, located mobile hips, plantigrade feet that..

18. Total Body profound cognitive deficits head and neck control. full-time assistance for activities of daily living and specialized seating systems to assist with head positioning. Drooling, dysarthria, and dysphagia

19. Paraplegia is very rare triplegia

21. Physiological Classification

23. different pathways of the brain are myelinated at different times, spastic diplegia 8 to 10 months of age; hemiplegia, 20 months of age athetoidcerebralpalsy, after 24 months of age.

25. DIAGNOSIS History and physicalexamination are the primary… spastic paraparesis and congenital ataxia. Ancillary studies, such as radiographs, hematological studies, . Diagnosis of cerebral palsy before age 2 years can be very difficult. Transient dystonia of prematurity is a condition characterized by increased tone in the lower extremities between 4 and 14 months old and often is confused with cerebral palsy.

26. DIAGNOSIS Knowledge of normal motor developmental milestones and primitive reflexes allows identification of children who are delayed in their motor development. Motor development usually occurs in a cephalad-to-caudal pattern, starting with swallowing and sucking, which are present at birth, and proceeding to sphincter control, which occurs at 24 to 36 months of age. Primitivereflexpatterns of motor activity that are outgrown as part of the normal maturation process persist longer than normal and in some cases permanently in children with cerebral palsy. Neurological quotient can be determined, which is useful in determining prognosis and treatment.

27. Prognostic Factors If a child has not learned to walk by age 8 years, and he or she is not limited by severe contractures, it is unlikely he or she will ever walk at all. sitting independently before age 2 years was not a good predictor of ultimate ambulatory ability, but the inability to sit independently by 4 years predicted nonambulation Bleck used the presence or absence of primitive reflexes to determine prognosis for ambulation for children with cerebral palsy

29. ASSOCIATED CONDITIONS In one study, adults with cerebral palsy ranked what was most important to them: education and communication activities of daily living Mobility Ambulation Because of the often complex nature of these conditions, a multidisciplinary team approach to patients with cerebral palsy is essential.

30. ASSOCIATED CONDITIONS mental impairment or learning disability (40%); seizures (30%); complex movement disorders (20%); visual impairment (16%); malnutrition and related conditions (15%) hydrocephalus (14%). Bulbar involvement can lead to drooling, dysphagia, and speech difficulties, which can limit cognitive and social development further. Many children with cerebral palsy (50% in some series) have significant visual difficulties, with 7% having a severevisualdefect. Common visual disturbances include myopia, amblyopia, strabismus, visual field defects, and cortical blindness. Hearingloss has been reported to occur in 10% to 25% of children with cerebral palsy, which can exacerbate communication and learning difficulties further. Hearing screenings, similar to visual screenings, should be part of the routine evaluation of patients with cerebral palsy.

31. ASSOCIATED CONDITIONS Seizures(30%), most commonly patients with : hemiplegia, quadriplegia, postnatally acquired syndromes. Osteopenia with increased risk of fracture also is common in children with cerebral palsy, especially children who are more severely affected. The nonoperative and operative treatment of these fractures Bisphosphonates have been shown in small studies

32. ASSOCIATED CONDITIONS Severe medical problems, such as aspirationpneumonia and profound feeding problems, can lead to malnutrition, immunesuppression, and metabolicabnormalities. Gastroesophagealreflux often can be managed medically and with positioning, but fundoplication may be necessary. Enteral feeding augmentation often is necessary because of swallowing dysfunction and the risk of aspiration pneumonia. This can be done with a gastrostomy or jejunostomy tube. Emotionalproblems add to these associated conditions. The child's self-image plays an important role, especially in adolescence, when the differences between the affected child and peers become more apparent. Communicationdifficulties also may affect self-image at this stage. As young adulthood is reached, concerns about employment, self-care, sexual function, marriage, childbearing, and caring for aging parents may become emotional stressors.

33. TREATMENT a multidisciplinary team approach Four basic treatment principles exist. 1- cp is nonprogressive, the deformities are progressive. 2-treatments currently available correct the secondary deformities only and not the primary problem. 3-deformities typically become worse during times of rapid growth. 4-operative or nonoperative treatment should be done to minimize the impact it has on the patient's socialization and education.

34. TREATMENTNonoperative splinting and bracing physical therapy, most common agents =diazepam and baclofen, which act centrally, dantrolene, which acts at the level of skeletal muscle. Baclofen mimics the action of g-aminobutyric acid, a powerful inhibitory neurotransmitter centrally and peripherally, whereas diazepam potentiates the activity of g-aminobutyric acid. Dantrolene acts at the level of skeletal muscle develop profound weakness, hepatotoxicity Newtrend intrathecal baclofen and intramuscular botulinum toxin injections

35. TREATMENT

36. TREATMENT Botulinum toxin a potent neurotoxin, of which there are seven serotypes, produced byClostridium botulinum.. Contraindications BTX-A therapy include known resistance or antibodies, fixed deformity or contracture, concurrent use of aminoglycoside antibiotics, failure of previous response, and certain neurological conditions such as myasthenia gravis

37. TREATMENT Physical therapy The therapist plays a crucial role in all aspects of care, including identifying children who may have cerebral palsy, treating their spasticity and contractures, fabricating splints and simple braces, providing family education and follow-up, acting as a liaison with the school and other health care providers, and implementing home stretching and exercise programs with the patients and their families. Bracing, The most commonly used braces for the treatment of cerebral palsy include ankle-foot orthoses, hip abduction braces, hand and wrist splints, and spinal braces or jackets. A patient-centered approach should be used. The goals of bracing for an ambulatory child differ from the goals for a child with severe involvement. Bracing of the lower extremities, most commonly with ankle-foot orthoses, is common in patients with cerebral palsy.

38. TREATMENTOperative (1)correct static or dynamic deformity, (2) balance muscle power across a joint (3) reduce spasticity (neurectomy), and (4) stabilize uncontrollable joints. Often, procedures can be combined—an adductor tendon release can be done at the time of pelvic osteotomy for hip subluxation .

39. TREATMENT

40. TREATMENT HIP In patients with cerebral palsy, all hips should be considered abnormal until proved otherwise Deformities of the hip in patients with cerebral palsy range from mild painless subluxation to complete dislocation with joint destruction, pain, and impaired mobility. prevalence of hippain in 234 patients (mean age 28 years old) was 47% It has been estimated that progressive hipinstability occurs in approximately 15%. commonly severely affected patients and patients with spastic quadriplegia

42. TREATMENT KNEE Hip and Knee Relationships Pelvic, hip, knee, ankle, and foot deformities are interrelate because of the muscles that cross both joints, the “two-joint muscles.” Flexionis the most common knee deformity in patients with cerebral palsy and frequently occurs in ambulatory children.

45. POLIOMYELITIS

46. POLIOMYELITIS POLIOMYELITIS

47. POLIOMYELITIS a viralinfection localized in the anterior horn cells of the spinal cord and certain brainstem motor nuclei. One of three types of poliomyelitis viruses

48. poliomyelitis vaccine, the incidence of acute anterior poliomyelitis in the Western world has decreased dramatically. Live oral poliovirus vaccine (OPV) Inactivated poliovirus vaccine (IPV) OPV remains the vaccine of choice for global eradication in many parts of the world, specifically

49. Pathological Findings When the poliomyelitis virus invades the body through the oropharyngeal route, it multiplies…. The incubationperiod is 6 to 20 days. .

50. The anterior horn motor cells may be damaged directly by viral multiplication or toxic by-products of the virus or indirectly by ischemia, edema, and hemorrhage in the glial tissues surrounding them.