Cerebral Palsy

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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

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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

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Classification

• Physiologic
• Spastic (65) Athetoid (30)
• Rigidity Ataxia
• Tremor Atonic/hypotonic
• Mixed unclassified

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Anatomical classification

• Monoplegia Paraplegia
• Hemiplegia Triplegia
• Quadriplegia Diplegia
• Double hemiplegia

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Etiological classification

• Prenatal
• Congenital anomalies
• Maternal
• Torch infection,Chorioamnionitis,
• Maternal sepsis, UTI
• Temperature during labor
• Toxemias of pregnancy

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Perinatal Causes

• Birth trauma
• Perinatal asphyxia lt10
• LBW babies (prematurity IUGR)-due to
  intracerebral hge, periventricular leukomalacia

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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

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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)

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Clinical manifestations

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

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Common Presentations

• persistence of NN reflexes ,
• Exaggerated jerks
• Adductor spasms
• gait tip toe
• Epilepsy

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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

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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
  
  
  

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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

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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

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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

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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

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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

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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

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Diagnosis

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

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Treatment

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

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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

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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

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Treatment

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

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Treatment

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

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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

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Treatment

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

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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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