cerebral palsy(CP)

Dr. Amira Ramadan Abbas

Lecturer of pediatric , faculty of medicine
Delta university

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 Objectives

üDefinition

üCauses & risk factors

üSymptoms &Clinical types of cerebral palsy

üMorbidities associated with cerebral palsy

üManagement of cerebral palsy

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cerebral palsy(CP)

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cerebral palsy(CP)

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 cerebral palsy(CP)

Definition
CP refers to a group of non progressive permanent disorder of the development of
movement and posture causing activity limitation
resulting from prenatal developmental malformations or perinatal or postnatal central
nervous system damage.
Cerebral palsy manifests before age 2 years.

Diagnosis is clinical.

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 Causes and risk factors
Congenital brain malformations
Genetic susceptibility
Hypoxic-ischemic encephalopathy
In utero or perinatal stroke
In vitro fertilization or use of assisted reproductive technology
Kernicterus
Low birth weight
Maternal disorders of clotting
Maternal-fetal infections
Multiple gestation
Neonatal seizures
Neonatal sepsis or meningitis
Postneonatal meningitis
Postneonatal traumatic brain injury
Pre-pregnancy obesity
Preterm birth

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 Risk factors in the antenatal period
Maternal epilepsy
Severe toxemia, eclampsia
Hyperthyroidism
Infections (TORCH)
Drug abuse
Bleeding in the third trimester Trauma
Incompetent cervix Multiple pregnancies
Placental insufficiency

Risk factors in the newborn period

Prematurity (gestational age less than 36 weeks)
Low birth weight (less than 2500 g)
Prolonged and difficult labor
Premature rupture of membranes
Presentation anomalies
Vaginal bleeding at the time of admission for labor
Bradycardia
Hypoxia

Risk factors in the post neonatal period

CNS infection (encephalitis, meningitis)
Hypoxia ,Seizures
Coagulopathies
Neonatal hyperbilirubinemia
Head trauma
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 The symptoms of cerebral palsy
In general, early signs of cerebral palsy include:

üDevelopmental delays. The child is slow to reach milestones such as rolling

over, sitting, crawling, and walking. ...

üAbnormal muscle tone. (floppy or too stiff.)

üAbnormal posture.

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 The symptoms of cerebral palsy
In a Baby Younger Than 6 Months of Age:
üHis head lags when you pick him up while he’s lying on his back

üHe feels stiff or floppy

üWhen held cradled in your arms, he seems to overextend his back and neck,
constantly acting as if he is pushing away from you

üWhen you pick him up, his legs get stiff and they cross or scissor

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 The symptoms of CP
üIn a Baby Older Than 6 Months of Age
She doesn’t roll over in either direction
She cannot bring her hands together
She has difficulty bringing her hands to her mouth
She reaches out with only one hand while keeping the other fisted
üIn a Baby Older Than 10 Months of Age
He crawls in a lopsided manner, pushing off with one hand and leg while dragging the
opposite hand and leg
He scoots around on his buttocks or hops on his knees, but does not crawl on all
fours

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 Types of CP

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 The type of motor impairment depends
on:
Area and extent of brain damage

Pyramidal tract

Extrapyramidal tract

Dyskinetic type

Ataxic type
Spastic type

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 Types of CP
There are 4 main types of cerebral palsy:
spastic cerebral palsy – the muscles are stiff and tight (especially when trying
to move them quickly), making it difficult to move and reducing the range of
movement that's possible
dyskinetic cerebral palsy – the muscles switch between stiffness and floppiness,
causing random, uncontrolled body movements or spasms
ataxic cerebral palsy – when a person has balance and co-ordination problems,
resulting in shaky or clumsy movements and sometimes tremors
mixed cerebral palsy – when a person has symptoms of more than one type of
cerebral palsy
.

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 Clinical types:

ü 1- Spastic with poor posture control ( UMN):

- Anormal persistence of neonatal reflexes

- Spasticity become more evident as child grow
- Tendon reflexes are brisk
- Babiniski sign is positive after age 2 years

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 Clinical types:

2- Dyskinetic; abnormal involuntary uncontrolled movements:

Dystonic and choreoathetoid ( Basal ganglia)

3- Ataxic; loss of coordination resulting in ataxia and trembling (

Cerebellum)

4- Mixed

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 Topographic classification of spasticity:

- Quadreplegic ( 28 % )
- Diplegic ( 53 % )
- Hemiplegic ( 10 % )
- Others ( 9 % ): Paraplegic, Monoplegic, Triplegic)

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 Types of CP

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Even patients with the same motor impairment
are not the same
That is why the development of functional scales has
been an important step in management of CP patients

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 Gross Motor Function Classification System GMFCS

Level 1 Walks with no limitation

Level 2 Walks with limitation

Level 3 Walks using a hand-held mobility device

Level 4 Self-mobility with limitations

Level 5 Transported in a wheelchair

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 Screening and Diagnosis
Developmental Monitoring
Developmental monitoring (also called surveillance) means tracking a child’s
growth and development over time.
Developmental Screening
During developmental screening a short test is given to see if the child has specific
developmental delays,
Developmental and Medical Evaluations
The goal of a developmental evaluation is to diagnose the specific type of disorder
that affects a child

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 Screening and Diagnosis
Brain scans
cranial U/S ,MRI brain– CT brain
Other tests
an EEG– where small pads are placed on the scalp to monitor brain activity and
check for signs of epilepsy
an electromyogram (EMG) – where tiny needles are gently inserted into the
muscles and nerves to check how well they're working
Blood test – to check for problems that can cause similar symptoms to CP

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 Morbidities Associated with Children with CP

Cognitive Impairment 60%

Visual Impairment and
Hearing Loss
50%

Epilepsy 40%
CP Patients

Feeding, Growth, and

Endocrine Problems
25%

Sensory Impairments 20%

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 Treatment of CP

There is no cure for CP but treatment can improve the lives of those who have the
condition.
It is important to begin a treatment program as early as possible.
treatments include
medicines; surgery; braces; and physical, occupational, and speech therapy.

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 Management of the child with CP requires a multidisciplinary
approach
Aim: to maximize function and minimize the development of secondary problems.

Neurologists
Motor Physiotherapists
Motor Impairments
Impairments Orthopedics
Occupational therapists

Cognitive
School system for disables
Impairment Neuropsychology

Ophthalmology
Visual Impairment and Audilogy
Hearing Loss

Speech and language therapists

Speech and
language
deficits

Dietitians
Feeding, Growth, and Surgeons
Endocrine Problems

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Management of spasticity in children with CP
1-Physiotherapy and Orthoses

2-Oral Medications
Baclofen
Diazepam
Clonazepam
3-Local injections in the muscles
Botulinum Toxin
4-New techniques
Intrathecal Baclofen (pump)
Selective dorsal rhizotomy
Selective peripheral neurotomy
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Management of spasticity in children with CP

1-Physiotherapy and Orthoses

Physiotherapy tries to improve

Postural control
Muscle strength
Range of motion
Decreasing spasticity and contracture
Motor control
Balance

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Management of spasticity in children with CP

1-Physiotherapy and Orthoses

Goals of brace prescription

Prevent deformity
Keep joint in a functional position
Stabilize the trunk and extremities
Facilitate selective motor control
Decrease spasticity

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Management of spasticity in children with CP

Botulinum Toxin ( BTX)

2-Botulinum toxin blocks
acetylcholine release. The axon
BTX terminal has normal amount of
acetylcholine but the end-plate is
not functional.

Acetylcholine Axon terminal

synaptic cleft.
1-Muscle contraction depends on acetylcholine
release from the axon terminal into the synaptic
cleft.

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Management of spasticity in children with CP

Botulinum Toxin ( BTX)

Eventually the original end-plate regains

function as the effect of toxin wears off.

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