Cerebral PalsyCerebral Palsy

Definition:Definition:

It is static non progressive It is static non progressive disorder of posture and movement disorder of posture and movement resulting from defect or lesion of the resulting from defect or lesion of the developing brain developing brain

2/1,000 population2/1,000 populationFirst described almost 150 yrs ago by First described almost 150 yrs ago by

Little ,an orthopedic surgeonLittle ,an orthopedic surgeon

Association of CPAssociation of CP

Association of CP-Association of CP-

■■MR MR ■■ Epilepsy-25- Epilepsy-25-35%35%

■■ Speech defect 50% Speech defect 50% ■■ Deafness-10% Deafness-10%

■■ Visual defect-20% Visual defect-20% ■■ Dental Dental problemproblem

■■ Behavioral disorder 40%Behavioral disorder 40%

■■ Orthopedic problem Orthopedic problem ■■ Drooling Drooling

ClassificationClassification

Physiologic: Physiologic: Spastic (65%) Spastic (65%) ■■ Athetoid Athetoid

(30%)(30%)Rigidity Rigidity ■■ Ataxia AtaxiaTremor Tremor ■■

Atonic/hypotonicAtonic/hypotonicMixed Mixed ■■ unclassified unclassified

Anatomical classificationAnatomical classification

Monoplegia Monoplegia ■ ■ ParaplegiaParaplegiaHemiplegia Hemiplegia ■ Tri■ TriplegiaplegiaQuadriplegia Quadriplegia ■ ■ DiplegiaDiplegiaDouble hemiplegiaDouble hemiplegia

Etiological classificationEtiological classificationPrenatal: Prenatal:

■■ Congenital anomaliesCongenital anomalies

■■ Maternal: –Maternal: –

Torch Torch infection,Chorioamnionitis,infection,Chorioamnionitis,

Maternal sepsis, UTIMaternal sepsis, UTI

Temperature during laborTemperature during labor

Toxemias of pregnancyToxemias of pregnancy

Perinatal CausesPerinatal Causes

Birth traumaBirth traumaPerinatal asphyxia <10%Perinatal asphyxia <10%LBW babies (prematurity IUGR)-due LBW babies (prematurity IUGR)-due

to intracerebral hge, periventricular to intracerebral hge, periventricular leukomalacialeukomalacia

Postnatal causesPostnatal causes

Infections-Meningitis, EncephalitisInfections-Meningitis, EncephalitisTrauma- Head injury, Subdural Trauma- Head injury, Subdural

hemotomahemotomaToxic – kernicterusToxic – kernicterusCerebrovascular -thrombosis of Cerebrovascular -thrombosis of

C.vesselsC.vesselsEndocrine and metabolic- Endocrine and metabolic-

hypothyroidism, hypoglycemia, hypothyroidism, hypoglycemia, hypocalcemia, dyselectrolytehypocalcemia, dyselectrolyte

Gross PEM in early infancyGross PEM in early infancy

Functional classificationFunctional classification

Class I- No limitation of activityClass I- No limitation of activityClass II- Slight to moderate limitation Class II- Slight to moderate limitation

(20%)(20%)Class III- Moderate to great limitation(50%)Class III- Moderate to great limitation(50%)Class IV – No useful physical activity (30%)Class IV – No useful physical activity (30%)

Clinical manifestationsClinical manifestations

Common presentation :Common presentation :Delayed milestones with indifferent Delayed milestones with indifferent

looklookFisting of hands with extended Fisting of hands with extended

extremitiesextremitiesMicrocephaly, Mental retardationMicrocephaly, Mental retardationBehavioral abnormalitiesBehavioral abnormalitiesVisual, hearing, speech defectsVisual, hearing, speech defects

Common PresentationsCommon Presentations

persistence of NN reflexes ,persistence of NN reflexes ,Exaggerated jerksExaggerated jerksAdductor spasms Adductor spasms gait –tip toegait –tip toeEpilepsyEpilepsy

Spastic hemiplegiaSpastic hemiplegia

Arms often more involved than leg-Arms often more involved than leg-difficulty in hand manipulation is difficulty in hand manipulation is obvious by 1 yrobvious by 1 yr

Delayed walking -18-24 moDelayed walking -18-24 moEquinovarus deformity of foot, walks Equinovarus deformity of foot, walks

on tip toes because of increased toneon tip toes because of increased toneAffected upper limbs has dystonic Affected upper limbs has dystonic

posture when child runsposture when child runs

Spastic hemiplegiaSpastic hemiplegia

Deep tendon reflexes increased, ankle Deep tendon reflexes increased, ankle clonus, babinski sign +clonus, babinski sign +

1/31/3rdrd have seizure disorder have seizure disorder25% have MR25% have MRCT/MRI- atrophic cerebral hemisphere CT/MRI- atrophic cerebral hemisphere

with dilated lateral ventriclecontralateral with dilated lateral ventriclecontralateral to the affected side to the affected side

Spastic DiplegiaSpastic Diplegia

Bilateral spasticity of legsBilateral spasticity of legs11stst noticed when infant begins to noticed when infant begins to

crawl-tends to drag the legs behind crawl-tends to drag the legs behind more ( commando crawl)more ( commando crawl)

Severe spasticity –application of diaper Severe spasticity –application of diaper is difficult due to excess adduction of is difficult due to excess adduction of hipships

Brisk reflexes, ankle clonusBrisk reflexes, ankle clonusScissoring posture of lower extremity Scissoring posture of lower extremity

when suspended by axillawhen suspended by axilla

Spastic DiplegiaSpastic Diplegia

Walking tiptoes, disuse atropy ,impaired Walking tiptoes, disuse atropy ,impaired growth of lower extremitygrowth of lower extremity

Intellectual development normalIntellectual development normalMinimal seizures Minimal seizures

CT/MRI-periventricular leukomalacia of CT/MRI-periventricular leukomalacia of white matter mainly lower limb fibreswhite matter mainly lower limb fibres

Spastic quadriplegiaSpastic quadriplegia

Most severe form ,most commonMost severe form ,most commonAll extremities severely impairedAll extremities severely impairedHigh association with MR and seizureHigh association with MR and seizureSupranuclear bulbar palsies+--Supranuclear bulbar palsies+--

aspiration pneumoniaaspiration pneumoniaFlexion Contractures of knees and Flexion Contractures of knees and

elbowselbowsSpastic quadriplegia + athetosis Spastic quadriplegia + athetosis

+mixed CP+mixed CP

Athetoid CPAthetoid CP

Relatively rare these days due to Relatively rare these days due to aggressive management of aggressive management of hyperbilirubinemiahyperbilirubinemia

H/o NNJ += hypermyelination of H/o NNJ += hypermyelination of basal ganglia called status basal ganglia called status marmoratusmarmoratus

Initially hypotonic, poor head Initially hypotonic, poor head control,marked head lag,feeding control,marked head lag,feeding difficulty,drooling +difficulty,drooling +

Athetoid CPAthetoid CP

After age 1yr –athetoid movements After age 1yr –athetoid movements become evidentbecome evident

Speech is affected (slurred, voice Speech is affected (slurred, voice modulation impaired) due to modulation impaired) due to involvement of oropharyngeal musclesinvolvement of oropharyngeal muscles

Upper motor neuron signs –not presentUpper motor neuron signs –not presentSeizure uncommonSeizure uncommon Intellect -preservedIntellect -preserved

Rigidity/Ataxia/TremorRigidity/Ataxia/Tremor

Uncommon varietyUncommon varietyFeatures og extrapyramidal lesionFeatures og extrapyramidal lesionLead pipe or cogwheel type Lead pipe or cogwheel type Always associated with MRAlways associated with MRAtaxia:Ataxia:Mostly congenital due to cerebellar Mostly congenital due to cerebellar

malformationmalformationTremorTremor- constant severe coarse - constant severe coarse

tremortremor

DiagnosisDiagnosis

HistoryHistoryExaminationExaminationSerology-TORCH/VDRLSerology-TORCH/VDRLX-ray skull-intracranial calcificationX-ray skull-intracranial calcificationEEG EEG Ct/MRICt/MRITest of hearing ,visionTest of hearing ,vision IQ testIQ test

TreatmentTreatment

Multidisciplinary approach –Multidisciplinary approach –pediatrician playing the main rolepediatrician playing the main role

Physiotherapist Orthopedic Physiotherapist Orthopedic surgeonsurgeon

Speech therapist ENT surgeonSpeech therapist ENT surgeonNeurologist Social workerNeurologist Social workerDevelopmental psychologist Developmental psychologist

TreatmentTreatment

Counselling-teach parents-daily activities Counselling-teach parents-daily activities like feeding, carrying, dressing, bathing, like feeding, carrying, dressing, bathing, playing, physiotherapy to limit abnormal playing, physiotherapy to limit abnormal muscle tonemuscle tone

Physiotherapy :-Physiotherapy :-

For arms-physio to start by age 6 For arms-physio to start by age 6 monthsmonths

For legs-for effective weight bearing and For legs-for effective weight bearing and wt transferwt transfer

TreatmentTreatment

Grasping ,release movements of Grasping ,release movements of hands, reciprocal movements of feet hands, reciprocal movements of feet for walking, vocalised breathing for for walking, vocalised breathing for speech, parallel walking bars speech, parallel walking bars bicycles, special chair, grasping and bicycles, special chair, grasping and releasing gamesreleasing games

Massage, exercise and hydrotherapyMassage, exercise and hydrotherapy

TreatmentTreatment

Adaptive equipments-walkers, poles Adaptive equipments-walkers, poles standing frames, motorized wheel standing frames, motorized wheel chair, special feeding devices, chair, special feeding devices, modified typewritersmodified typewriters

Communication skills- use of Communication skills- use of symbols, specially adapted symbols, specially adapted computerscomputers

TreatmentTreatment

Ophthalmologist-strbismus, Ophthalmologist-strbismus, nystagmus, optic atrophynystagmus, optic atrophy

Orthopedics :-Orthopedics :-

Hip, knee contractures-surgical Hip, knee contractures-surgical releaserelease

Occupational therapy:-Occupational therapy:-

Simple movements for self help- Simple movements for self help- feeding, dressingfeeding, dressing

TreatmentTreatment

Educational therapy:Educational therapy:Mild MR – ordinary schoolMild MR – ordinary schoolSevere MR, severe disabilities-special Severe MR, severe disabilities-special

schoolschoolSocial therapy-Social therapy-

social and emotional support to social and emotional support to familyfamily

Rehabilitation and vocational guidanceRehabilitation and vocational guidance

TreatmentTreatment

Symptomatic-Symptomatic-

anticonvulsants for seizuresanticonvulsants for seizuresMuscle relaxants- Muscle relaxants-

benzodiazapines ,dantrolene sodium, benzodiazapines ,dantrolene sodium, Baclofen Baclofen

Preventable causes shoud be Preventable causes shoud be preventedprevented

PrognosisPrognosis

10-50%-have seizure10-50%-have seizureSquint-50%,visual handicap-30% Squint-50%,visual handicap-30%

optic atrophy and cortical blindnessoptic atrophy and cortical blindnessWalk by age of three, if not then Walk by age of three, if not then

unlikely that useful function will be unlikely that useful function will be gainedgained