Cerebral%20Palsy

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Cerebral Palsy

• Victor Politi, M.D., FACP
• Medical Director, SVCMC, School of Allied Health
  Professions, Physician Assistant Program

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Cerebral Palsy

• "Cerebral" refers to the brain and "palsy" to a
  disorder of movement or posture.
• It is neither progressive nor communicable

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Overview

• Cerebral palsy is a general term that describes a
  group of disorders that appear in the first few
  years of life and affect a child's ability to
  coordinate body movements.
• This results in difficulties in movement and
  posture.
• Cerebral palsy has different causes, and affects
  each person differently, therefore people with
  cerebral palsy have varying individual needs.

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Overview

• Cerebral palsy is the most common physical
  disability in childhood.
• It is estimated 2 to 3 people out of every 1000
  will have cerebral palsy.
• This condition is not hereditary and there is no
  cure.
• Many causes of cerebral palsy are still not known
  or understood.
• Injury or changes to the developing brain are
  associated with cerebral palsy.

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Overview

• The muscles of speech, swallowing and breathing
  may be involved.
• Intellectual disabilities (mental retardation)
  and seizures can also occur, but these problems
  are not always present.

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• There are about 500,000 persons who have cerebral
  palsy in the United States

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Overview

• In the early months of life it is sometimes
  difficult to determine if a child has cerebral
  palsy.
• The condition may only be identified when a child
  experiences delays with the movement and postural
  development needed for sitting and standing.

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Overview

• Cerebral palsy is characterized by an inability
  to fully control motor function.
• Depending on which part of the brain has been
  damaged and the degree of involvement of the
  central nervous system, one or more of the
  following may occur ---

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Overview

• spasms
• tonal problems
• involuntary movement
• disturbance in gait and mobility
• Seizures
• abnormal sensation and perception
• impairment of sight, hearing or speech
• mental retardation

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Overview

• 1. The cortex
• controls thought, movement and sensation.
• An abnormality in the movement area of the cortex
  can result in spastic cerebral palsy
• 2. The basal ganglia
• helps movement become organized, graceful and
  economical.
• An abnormality can result in athetoid
  
  cerebral palsy
• 3. The cerebellum
• coordinates movement, posture and balance.
• An abnormality can result in ataxic
  cerebral palsy

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What part of the body is affected?

• Hemiplegia - the leg and arm on one side of the
  body are affected.
• Diplegia - both legs and both arms are affected
  but the legs are significantly more affected than
  the arms. Children with diplegia usually have
  some clumsiness with their hand movements.
• Quadriplegia - both arms and legs are affected.
  The muscles of the trunk, face and mouth can also
  be affected.

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Types of cerebral palsy

• There are three major types of cerebral palsy
• Spastic cerebral palsy
• Athetotic cerebral palsy
• Ataxic cerebral palsy

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Types of Cerebral Palsy

• Some children have signs and symptoms of more
  than one type of cerebral palsy, which may be
  referred to as a mixed form of the condition.

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Spastic cerebral palsy

• Most children with cerebral palsy have spastic
  cerebral palsy.
• This form of the condition causes muscles to
  stiffen, which makes movement difficult.

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Spastic cerebral palsy

• It can affect both legs (spastic diplegia), or it
  can affect one side of the body (spastic
  hemiplegia).
• In the most severe cases, all four limbs and the
  trunk are affected (spastic quadriplegia).

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Athetotic cerebral palsy

• 10 to 20 percent of people with cerebral palsy
  have this form, which is also referred to as
  extrapyramidal cerebral palsy.

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Athetotic cerebral palsy

• It affects the entire body and often causes
  uncontrolled, slow movements.
• children with athetoid cerebral palsy often have
  very weak muscles or feel floppy when they are
  carried.

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Ataxic cerebral palsy

• This is the least common of the major types of
  cerebral palsy.
• It affects balance and coordination.
• characterised by unsteady, shaky movements or
  tremor.

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Ataxic cerebral palsy

• People with ataxic cerebral palsy have difficulty
  using muscles to achieve balance and coordinated
  movement.

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Signs and Symptoms

• In general, children with cerebral palsy exhibit
  a wide variety of signs and symptoms, ranging
  from mild to severe.

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Signs and Symptoms

• These signs and symptoms don't worsen with age.
  They may include
• Ataxia (a lack of muscle coordination when
  performing voluntary movements)
• Spasticity (stiff muscles and exaggerated
  reflexes)
• Asymmetrical walking gait, with one foot or leg
  dragging
• Variations in muscle tone, from too stiff to too
  floppy
• Excessive drooling or difficulties swallowing,
  sucking or speaking
• Tremors
• Difficulty with precise motions, such as writing
  or buttoning a shirt

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Signs and Symptoms

• Some children with cerebral palsy have severe
  mental retardation, but others are extremely
  bright.
• Many need a wheelchair and extensive, lifelong
  care, but some require little or no special
  assistance.

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Causes

• Cerebral palsy results from an abnormality in or
  injury to the cerebrum the largest area of the
  brain, which controls sensation and voluntary
  motor function.

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Causes

• Although cerebral palsy affects movement, the
  underlying problem originates in the brain, not
  in the muscles themselves.

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Causes

• A small number of children with cerebral palsy
  acquire the disorder after birth.
• In these cases, sometimes a specific reason for
  the neurological problem can be pinpointed.
• For example, cerebral palsy can develop following
  an illness during early infancy, such as
  bacterial meningitis. It can also be the result
  of a head injury.

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Causes

• The cause of most cases of congenital cerebral
  palsy are not understood.
• For many years, it was believed that cerebral
  palsy was caused by a lack of oxygen during
  birth. However, it is now believed that only a
  small number of cases are caused by problems
  during labor and delivery.

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Causes

• Identifiable causes of congenital cerebral palsy
  include
• Maternal infection during pregnancy, such as
  rubella or other viral infections
• Severe jaundice in newborns, which may be caused
  by infection, severe bruising or problems with
  red blood cells due to ABO or Rh incompatibility
• Abnormal brain development before birth,
  resulting from genetic causes or metabolic
  disorders
• Disturbance to brain circulation before birth,
  caused by an artery spasm or blood clot, similar
  to a stroke in adults

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Risk Factors for Developing Cerebral Palsy

• Infection of mother during pregnancy
• including rubella (German measles) and other
  infections in the womb
• Premature delivery or low birth weight
• premature babies have immature brain tissue that
  is susceptible to injury
• Inadequate oxygen or blood flow to the brain in
  the mother's womb or during delivery
• Rh disease

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Risk Factors for Developing Cerebral Palsy

• Congenital (birth) defects
• Head trauma
• (including shaken baby syndrome)
• Jaundice in the newborn baby
• Or it may occur early in life as a result of an
  accident, lead poisoning, viral infection, child
  abuse, or other factors

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Risk Factors for Developing Cerebral Palsy

• A less common type is acquired cerebral palsy
• head injury is the most frequent cause, usually
  the result of motor vehicle accidents, falls, or
  child abuse.

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Screening and diagnosis

• Early signs of cerebral palsy may be present from
  birth, but it's often difficult to make a
  definite diagnosis during the first six months.
• Cerebral palsy is generally diagnosed by age 1 or
  2.

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Screening and diagnosis

• A physician will generally observe the child and
  discuss their physical and behavioral
  development. Reflexes, muscle tone and movements
  will be checked
• Additional tests may rule out other disorders
  that can cause movement problems.
• CT
• MRi
• Genetic and/or metabolic blood work-up

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Screening and diagnosis

• Referrals
• pediatric neurologist
• developmental pediatrician
• physiatrist

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Complications

• Besides difficulty with movement and posture,
  cerebral palsy may result in these health
  problems
• Development of joint deformities or dislocation,
  if there's considerable spasticity
• Nutrition problems, if there are swallowing or
  feeding difficulties

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Complications

• Some children with cerebral palsy will have
  multiple handicaps and may require long-term
  care. Some of the associated problems may
  include
• Difficulty with vision, hearing and speech
• Dental problems
• Mental retardation
• Seizures
• Abnormal sensation or perception
• Incontinence

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Treatment

• The brain abnormality or damage that underlies
  cerebral palsy doesn't worsen with time, but
  children with cerebral palsy often require
  long-term care.
• The type and amount of treatment depend on how
  many problems the child has and how severe they
  are.

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Treatment

• The goal of treatment is to help the child reach
  his or her maximum potential.
• Reaching this goal typically requires a
  multidisciplinary team working together to
  address issues of social and emotional
  development, communication, education, nutrition
  and mobility.

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Treatment

• Physical therapy
• Muscle training and exercises may help improve
  strength, balance and mobility and lead to
  greater independence.
• Braces, splints or casts may be used to improve
  hand and leg function and prevent contractures
  a condition in which muscles become fixed in a
  rigid, abnormal position.

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Treatment

• Occupational therapy-
• Focuses on helping the child learn skills for
  daily living.
• May involve hand skills and self-care skills such
  as feeding and dressing

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Treatment

• Speech therapy
• A speech therapist may be able not only to help
  the child speak better, but also to improve
  eating skills.

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Treatment

• Vision and hearing aids
• eyeglasses or surgery to correct a condition such
  as cross-eye or other inability of the eyes to
  focus together properly (strabismus).
• Hearing aids may help correct any hearing
  problems.

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Treatment

• Medications
• These may include muscle relaxants to ease muscle
  stiffness and anticonvulsants to reduce seizures.
  
• Injections of botulinum toxin (Botox) directly
  into spastic muscles also may be helpful

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Treatment

• Surgery
• severe contractures may require surgery on
  muscles, tendons, nerves or joints to place arms
  and legs in their correct positions. This can
  make it easier to use a walker, braces or
  crutches.

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Treatment

• Children with severe spasticity who haven't
  responded to oral medications may also benefit
  from surgical procedures.
• Dorsal rhizotomy - a procedure in which surgeons
  identify and cut a portion of the spinal sensory
  roots that control the leg muscles.
• .

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Treatment

• Intrathecal baclofen an intraspinal infusion
  catheter is placed and connected to a reservoir
  placed under the skin. This mechanism
  continuously pumps small amounts of an
  antispasticity medication called baclofen into
  the fluid around the spinal cord.

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Treatment

• These surgeries require careful screening and an
  expert team of health professionals, including
  pediatric neurosurgeons, orthopedic surgeons,
  pediatric neurologists, pediatric physiatrists
  and physical therapists

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Treatment

• Assistive technology
• Assistive technology includes such small things
  as rails, grab bars, magnifiers, and Velcro grips
  attached to forks and pens to make them easier to
  grasp.
• It also includes high-tech tools, such as
  customized wheelchairs, voice communication
  devices, computer software programs, and
  positioning equipment that puts a child in the
  correct posture to sit or stand with other kids
  or family members.

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Prevention

• For more than a century, doctors have hoped that
  by somehow improving labor and birth practices,
  they could reduce the incidence of cerebral
  palsy.

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Prevention

• But these rates have remained fairly constant,
  despite increased prenatal care, electronic fetal
  monitoring, prenatal ultrasound and increased use
  of Caesarean section delivery over the past 25
  years.

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Prevention

• Fewer babies now develop cerebral palsy as a
  consequence of birth injury.
• However, larger numbers of extremely premature
  babies survive, and some will develop cerebral
  palsy

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Prevention

• Most cases of cerebral palsy can't be prevented,
  despite the best efforts of parents and doctors.

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Long Term Goals

• Although it is not "curable" through education,
  therapy, and applied technology people with
  cerebral palsy can lead productive lives.

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Long Term Goals

• Cerebral palsy cannot be cured. However, quality
  of life can be improved for most children if they
  receive support and coordinated care, which may
  include a variety of experts.

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Long Term Goals

• Different kinds of therapy (physical therapy,
  occupational therapy, speech therapy) help
  children to maximize their potential activities
  at various stages of development.

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Long Term Goals

• Coordinated treatment of disorders such as
  seizures and spasticity are crucial in helping
  children with cerebral palsy lead a healthier
  life.

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Long Term Goals

• Medical research is working toward improving
  diagnosis, treatment, and prevention of cerebral
  palsy.

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