Cerebral Palsy Definition



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Cerebral Palsy
Definition:

  • Umbrella term covering a group of non-progressive, but often changing, motor impairment syndromes secondary to lesions or anomalies of the brain arising in the early stages of its development (Mutch 1992)

  • non-progressive disorder of posture and movement as a result of an injury or anomaly in the developing brain ( 0 -4yrs)

  • prevalence : 2.5 per 1000

  • primarily a motor disorder but other problems common:

    • speech disorders

    • learning disorders (60%)

    • hearing loss (20%)

    • visual problems (20%) squints (30%)

    • epilepsy (30 -50%)

    • Behavioural problems


Aetiology:

  1. Antenatal (80%)




  1. Intrapartum (10%)

    • Birth trauma/asphyxia




  1. Postnatal (10%)

    • IVH

    • Meningitis/encephalitis

    • Head trauma / NAI

    • Symptomatic hypoglycaemia

    • Hydocephalus

    • Kernicterus

Types:

  1. Spastic (75%)

    • Damage to the upper motor neuron pyramidal pathway

    • Hypotonia of the trunk and limbs initially, then changes to increased tone in a clasp knife pattern

    • Brisk deep tendon reflexes and extensor plantar responses

Subtypes:

    • Hemiplegia – usually arm < leg ( 1/6 have malformation on MRI Brain)

    • Quadriplegia – arms > legs

    • Diplegia – legs > arms

    • Monoplegia




  1. Ataxic (15%) - pure and mixed with other forms

      • Signs are symmetrical

  2. Dyskinetic (5%) – choreoathetosis

    • Floppiness, delayed motor development with abnormal movements

    • Intellect relatively unimpaired

    • Tends to occur in term infants

    • Dystonia of extremities occurs frequently

  3. Atonic - involvement of the cerebellar pathways

    • brisk tendon reflexes

    • often enlarged ventricles on neuroimaging

  1. Mixed

History and Examination:

History:


  • Possible causes

  • Impact of disorder on child and family

  • Steps taken to minimise the effects of the disorder and improve child’s health and quality of life

Antenatal hx / Birth Hx:



  • Infections during pregnancy

  • Bleeding during pregnancy

  • Exposure to drugs/toxins

  • PET

  • Diabetes

  • Labour and mode of delivery

  • Gestation

  • Paediatrician present at the delivery?

  • Birthweight

  • Fetal movements

  • Ventilated?

  • Seizures?

  • Brain scans?

  • Jaundice / exchange transfusions

  • Neonatal meningitis

Does Mother have an intellectual disability? ( associated with high incidence of CP)


Presentation

  • Abnormal tone and posturing in early infancy

  • Delayed motor milestones

  • A floppy baby (often precedes the development of hypertonicity)

  • Feeding problems

  • Delayed language

  • Irritability

  • Seizures

Developmental history



  • Motor milestones delayed

  • Early development of hand preference

  • Often associated problems (nystagmus, strabismus, vision impairment, hearing impairment, etc.,)

Associated non-motor problems



  • Visual impairment, strabismus

  • Hearing impairment and hearing aids

  • Speech

  • Mobility

  • Deformity

  • Continence and constipation

  • Feeding problems

  • Seizures and anticonvulsant meds

  • Recurrent chest infections

Special aids



  • Glasses

  • Hearing aid

  • Splints

  • Special shoes

  • Wheelchair

  • Communication aids

  • Special modifications to house


Examination:

Aim to define the type of CP

The severity – how is the child’s ability to function affected

( focus on what the child CAN do rather than cannot do)

Measure OFC – microcephaly or hydrocephalus can be present

Do full neurological exam focusing on:



  • Posture

      • Arm flexed,fisting and leg extended in hemiplegia

      • Scissoring of spastic diplegia – when standing the child’s body is tilted forward and the hips and knees flexed; when sitting the back is arched

      • Windswept posture of a very inactive child, (associated with dislocation of the hips)

  • Tone

    • Increased in 75% of cases

    • Clasp knife spasticity – demonstrated by extending the elbow and stretching biceps or pronation/supination of the wrist

    • Hypotonic initially (younger babies)

    • In atonic CP, reflexes normal or increased




  • Power

If power is severely reduced look for:

Contractures

Scars ( post repair of contractures)

Trophic changes




  • Reflexes (hypertonic group)

    • Brisk deep tendon reflexes

    • Clonus

    • Extensor plantars

    • Check for persistence of primitive reflexes




  • Cerebellar function (ataxic type 10%)




  • Involuntary movements

      • Athetosis- commonest (five subtypes)

        • Tension, dystonic, choreiform, ballismus, rigid

      • Tremor

      • Truncal dystonia

      • Extensor spasms

      • Pharyngeal incoordination – drooling and dysarthria


Management:

  • Multidisciplinary team

paediatricians, Physios, O.T’s, SLT, psychologist,

surgeons, orthopaedic surgeons, social workers, PHN,



dentist

  • Treatments for spasticity

    • Orthosis

    • Baclofen

    • Botulinum toxin

    • Benzodiazepines

    • Dantrolene

    • Surgery – selective dorsal rhizotomy

- intrathecal baclofen


  • Parent training of child handling – feeding, dressing, sleep,

  • Severe cases – may need to modify homes, wheel chair access, aids for sitting/standing/posture

  • Placement in schools with appropriate facilities

  • Family support


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