Cerebral palsy

 Definition
o A permanent disorder of motor function (movement and posture), due to a non-
progressive abnormality in the developing brain.

 Epidemiology
o The MCC of motor impairment in children
o Incidence: 2: 1000

 Etiology
o Antenatal causes – 80%
1. Cerebrovascular hemorrhage or ischemia
2. Cortical migration disorders
3. Structural maldevelopment of the brain
4. Genetic syndrome
5. Congenital infections
o Hypoxic Ischemic Encephalopathy HIE – 10%
o Postnatal causes – 10%
1. Meningitis/Encephalitis/encephalopathy
2. Head trauma
3. Hypoglycemia
4. Hyperbilirubinemia
5. Hydrocephalus
▲ PT infants are especially vulnerable to brain damage (periventricular
leukomalacia) due to ischemia, IV hemorrhage, venous infarction.

 Clinical features
o Motor dysfunction presents usually early from birth
1. Abnormal limb and trunk posture and tone
2. Asymmetric hand function
3. Abnormal gait
4. Delayed motor milestone
5. Feeding difficulties
6. Persistence of primitive reflexes
o Categories of CP (according to neurological features)
1. Spastic – 90%
2. Dyskinetic – 6%
3. Ataxic – 4%
o Motor disorders of CP are often associated with disturbances of cognition,
communication, vision, sensation, and seizures.
1. Spastic CP
o UMN damage
o Increased limb tone and brisk DTR: the hallmark of spasticity is dynamic catch,
velocity dependent (the faster the muscle stretched the higher the resistance),
clasp knife
o Unilateral-Hemiplegia
1. Unilateral involvement of the arm and leg: the arm is more affected than
the leg; the face is spared
2. Presentation:
 Age of presentation: 4-12 mo
 Fisting of hand, flexed arm, pronated forearm; asymmetric
reaching, hand function, toe pointing
 Tiptoe (toe-heel) walk
 GMFCS 1, 2
3. Etiology: perinatal MCA infarct. Unremarkable birth hx; no evidence of
HIE; usually antenatal cause
o Bilateral-Diplegia
1. All four limbs are affected, but the legs are affected to a much greater
degree than arms, because the legs motor fiber are closest to the ventricles
2. Presentation:
 Young child: walking on the toes, scissoring of the legs (due to
excessive adduction of hips)
 Older child: crouch gait pattern
 GMFCS 1-3
3. Etiology: Damage to periventricular areas, periventricular leukomalacia,
associated with prematurity
o Bilateral-Quadriplegia
1. All four limbs are affected.
2. Presentation:
 The truck is involved with tendency to opisthotonos (extensor
posturing); poor head control.
 Severe form of CP, often associated with seizures, microcephaly,
intellectual impairment
 GMFCS 4-5
3. etiology: Extensive damage to periventricular areas involving the cortex;
there may be a hx of HIE

2. Dyskinetic CP
o Involuntary, uncontrolled, stereotyped movements
1. Chorea: irregular, sudden, brief, non-repetitive movements
2. Athetosis: slow, writhing, distal movements such as fanning of the fingers
 3. Dystonia: simultaneous contraction of both agonist and antagonist muscles
giving a twisting appearance
o Presentation:
1. Floppiness and poor trunk control
2. open mouth; internally rotated, extended arms
3. Abnormal movements appear at the age of 1 year
4. GMFCS 4-5
o Etiology: HIE (perinatal asphyxia); kernicterus in the past

3. Ataxic (hypotonic) CP
o Presentation:
1. Early: Hypotonia, poor balance, delayed motor development
2. Late: Incoordinate movements, intention tremor, ataxic gait
o Etiology: Most are genetically determined, but may be due to acquired brain
injury to cerebellum

 Investigations
o Clinical diagnosis
o MRI is not required to make the diagnosis, but may assist in identifying the cause.

 Management
o Botulinum toxin injections in muscles
o Selective dorsal rhizotomy
o Intrathecal baclofen
o Deep brain stimulation