CEREBRAL PALSY ● Untreated jaundice

- Group of permanent disorders of the development of ● Severe neonatal infection

movement & posture
- Causes activity limitations that are attributed to POSTNEONATALLY Acquired CP
nonprogressive disturbances that occurred in the Metabolic Encephalopathy
developing fetal or infant brain ● Storage disorders
● Intermedullary metabolism disorders
Motor Disorders ● Metabolic disorders
- Often accompanied by disturbances of sensation, ● Misc. disorders
perception, cognition, communication and behavior as ● Toxicity (alcohol)
well as seizures and secondary musculoskeletal Infections
problems ● Meningitis
● Septicemia
Comorbidities in ages 5-8 y/o: ● Malaria (developing countries)
40% ➜ mental retardation Injuries
75% ➜ slow learners, persons w/ learning disabilities ● Cerebrovascular accident
35% ➜ epilepsy ● Following surgery for congenital malformations
20% ➜ visual impairment ● Near-drowning
9% ➜ hydrocephalus ● Trauma
13% ➜ combo of 2 impairments ● Motor vehicle accident
15% ➜ combo of 3 impairments ● Child abuse such as shaken baby syndrome
25% ➜ difficulty with speech
25% ➜ hearing impairments
40-50% ➜ increased frequency of visual impairments

Diagnosed with CP if insult occurred:

a. Prenatally (75%)
- Majority of CP in developing countries
- Not associated w/ significant neonatal
encephalopathy
b. Perinatally (6-8% ➜ perinatal asphyxia)
c. Postnatally (10-18%)

*Diagnosed w/ CP throughout infancy and early childhood

ETIOLOGY
- No single specific cause
- Potential causes:
● Occur in prenatal stage of development
● Grouped with congenital problems in the perinatal /
neonatal, and in postnatal / postneonatal time period

PRENATAL Causes of CP
● Vascular events such as a middle cerebral artery
infarct
● Maternal infections during the first and second
trimesters such as rubella, cytomegalovirus,
toxoplasmosis
● Less common: metabolic disorders, maternal
ingestion of toxins, and rare genetic syndromes

PERINATAL Causes of CP
Problems During Labor and Delivery
● Obstructed labor
● Antepartum hemorrhage
● Cord prolapse
Other neonatal causes
● Hypoxic-ischemic encephalopathy
● Neonatal stroke (usually middle of cerebral artery)
● Severe hypoglycemia
Congenital Problems that result in CP (Infant & child)
1. Schizencephaly
- Segmental defect that causes cleft in brain
2. Lissencephaly
- Defect in neuronal migration that normally
goes toward the periphery of the brain
- Results in smooth brain
- Aka decreased cerebral gyri
3. Microcephaly & megalocephaly
4. Cortical dysgenesis
- Disorder of brain cortex formation
- Defects in the normal formation and
remodeling of synapses

*Approx. Half of created neurons die off (apoptosis) during

MIDGESTATION
*axons and synapses are also eliminated during first 10 YRS
or more of normal development
*neural elements that best persist = fit the environment
*changes in formation of developing NS = infant with CP

➜ Plasticity / Equipotentiality
- Greater ability of uninjured part to assume the
function of injured part of brain
- Immature brain has more of this
- Response to injury is different & makes diagnosis &
prognosis difficult

DIAGNOSIS & PROGNOSIS

● Signs & symptoms apparent in EARLY INFANCY
● Infants may be diagnosed earlier than 2 y/o when:
○ Abnormal muscle tone
○ Atypical posture
○ Movement w/ persistence of primitive
reflexes
● Milder cases of CP = diagnosed 4-5 y/o
● Evaluation
○ Motor skills
○ Neuroimaging (cranial US, CT, MRI) - show
loc & type of brain damage
○ Evidence that symptoms are not progressing
● Clinical findings + neuroanatomy

➜ Neuroimaging
1. Cranial ultrasound
- High-risk preterm infant
- Less invasive
2. Computed tomography
3. Magnetic resonance imaging
- Preferred
- Provides greater detail of brain tissue &
structure
- 70-90% with CP have abnormalities here

➜ Neuroimaging is unremarkable:
● Mitochondrial & metabolic disorders
● Transient dystonia
➜ Cerebral hemorrhages
- Assoc. w/ CP
● Intraventricular hemorrhage (IVH): Bleeding into
tissue around ventricles
● Germinal matrix hemorrhage (GMH): bleeding into
tissue around ventricles
● Periventricular intraventricular hemorrhage (PIVH):
bleeding into both areas
● Periventricular cyst (PVC): may form in same areas
as acute hemorrhage resolves
- Known risk factors: mechanical ventilation & injury
during critical periods of brain dev’t
◊ There are known risk factors for hemorrhages including
mechanical ventilation and injury during critical periods of brain
development.
◊ Notably, periventricular white matter is most sensitive to insult
and injury between 24 and 34 weeks of gestation.
◊ Hemorrhages are graded in increasing severity from I
through IV.
◊ The grade of bleed alone cannot predict the development or
severity of CP.
◊ Palmer indicated that cranial ultrasound should be used for
low-birth-weight infants to detect grades III and IV
hemorrhages, IVH, cystic periventricular leukomalacia (PVL),
and ventricular enlargement
◊ After term age, cranial ultrasound and MRI are used to
identify cystic PVL and ventriculomegaly, which are associated
with subsequent development of CP.
◊ PVL is the major cause of CP in infants born preterm.
◊ The extent and location of white matter damage can lead to
different subtypes of CP.
◊ Localized damage to the cortical spinal tracts often results in
spastic diplegia, and when the lesions extend laterally,
quadriplegia is often the result.
◊ It is understood that a neurologic examination alone is
insufficiently
sensitive enough or specific enough for early detection of CP.
◊ The quality of an infant’s “general movements” (GMs) have
been used by doctors and researchers to evaluate brain
function.
◊ A predominance of cramped synchronous GMs and absence
of normal fidgety movements of limbs, neck, and trunk were
predictive of CP at 2 to 3 years of age with a sensitivity of
100% and a specificity of 92.5% to 100%.
◊ Clearly, abnormal GMs at the fidgety age (2 to 4 months
postterm)
implies a total absence of the elegant, dancing complexity of
fidgety movements and predicts CP with an accuracy of 85%
to 98%.
◊ GMs can be predictive of later CP and are the best
expression of functional motor development. GMs are
analogous to later functional motor milestones and may also
predict severity, as the earlier the GMs are recognized, the
more severe the later limitations in motor function.
◊ Others have found cognitive abilities to be linked with the
severity of CP and to be predictive of many outcomes.
◊ indicated that intellectual disability was the single strongest
predictor of survival of the child with CP (profoundly mentally
retarded
children with CP do not live into adulthood) and that the
second most important factor impacting life expectancy was
the severity of the physical impairments.
◊ the life expectancy of children with CP and found, from
multiple sources, that the causes of mortality related most
commonly to the respiratory and circulatory systems, certain
cancers, and neurologic complications.
CLASSIFICATION OF CP
Type of Movement Disorder
1. Spastic
2. Hypotonic
3. Dyskinetic
4. Ataxic
Anatomical Location of Limbs Affected
1. Hemiplegia (one arm & leg ipsilaterally)
2. Diplegia (both LEs)
3. Quadriplegia (all four limbs + back, neck)
Scope of Motor Dysfunction
● Gross Motor Function Classification System (GMFCS)
- b/w ages 6 & 12
Level I Walks w/o restrictions
Limitation in more advanced gross motor skills
Level II Walks w/o assistive devices
Limitations in walking outdoors & in community
Level III Walks w/ assistive mobility devices
Limitations in walking outdoors & in community
Level IV Self-mobility w/ limitations
Children are transported or use power mobility
outdoors & in community
Level V Self-mobility is severely limited even w/ use of
assistive technology
- developed to fill the need to have a standardized
system to measure the “severity of movement
disability” in children with CP
● Level I describes the child with the most independent
function, where he or she can perform all the activities
of his or her age-matched peers, albeit with some
difficulty with speed, coordination, and balance.
● Level V describes the child who has difficulty
controlling his or her head and trunk posture in most
positions and in achieving any voluntary control of
movement
✦ Spastic CP
- Approx. 75% of children with CP
- Most common neurologic abnormality
● 40% or 44 ➜ quadriplegia
● 17% or 33 ➜ diplegia
● 21% or 23 ➜ hemiplegia
- Hypertonia in which resistance to passive movement
increases with increasing velocity of movement
MODIFIED ASHWORTH SCALE
Score Description of Muscle Tone
00 Hypotonia
0 Normal tone, no increase in tone
1 Slight increase in tone manifested by a slight catch
and release or minimal increased resistance to joint
range of motion
1+ Slight increase in tone manifested by a slight catch
& minimal increased resistance to joint ROM for
more than half the joint range
2 More marked increase of tone through most of the
whole joint range, but the affected joint is easily
moved
3 Considerable increase in muscle tone; passive
movement difficult but possible
4 Affected joint is stiff & cannot be moved
Spasticity
- Hyperactive stretch reflex
- Responsive to variety of treatments: botulinum toxin,
baclofen, selective dorsal rhizotomy, orthopedic
surgery
- Causes histologic changes: decreased longitudinal
growth of muscle fibers, decreased volume of muscle,
change in muscle unit size, change in muscle fiber
type
- Secondary disorders: hip dislocation, scoliosis, knee
contracture, torsional malalignments of femur & tibia
- Effects on function: effortful gait patterns, difficulty
assuming & sustaining seated positioning, difficulty
performing self-care activities (toileting, bathing,
dressing, self-feeding)
✦ Diplegia
- Most common form of spastic CP
- white matter infarct in the periventricular areas
caused by hypoxia can lead to spastic diplegic CP
- primarily affects bilateral LEs, resulting in issues with
gait, balance, and coordination
- In standing, children with diplegia often present with
an increased lumbar spine lordosis, anterior pelvic tilt,
bilateral hip internal rotation, bilateral knee flexion,
intoeing, and equinovalgus foot position
- a discrepancy between upper extremity (UE) and LE
function in children with this form of CP, with the LEs
being more affected than the UEs and trunk
- Gait deficits such as equinus and crouched gait
posture tend to be the area of greatest concern for
these children
- Owing to bilateral LE spasticity and weakness, energy
expenditure is much greater during ambulation,
resulting in poor endurance and decreased functional
mobility at home and within the community.
- Children with diplegia generally have normal cognition
but may have some social and emotional difficulties
- Children with diplegia often require assistive devices
such as a posterior walker, or lofstrand crutches
- A scooter or wheelchair may be necessary for
long-distance mobility
✦ Hemiplegia
- subtype of spastic CP in which the child’s upper and
lower extremity on the same side of the body are
affected
◊ Four main types of brain lesions result in hemiplegic CP
1. Periventricular white matter abnormalities have been
reported as the most common diagnostic finding in
children with hemiplegic CP
2. Cervical–subcortical lesions, brain malformations, and
nonprogressive postnatal injuries have also been
identified as the main causes of hemiplegia
- UE is typically more affected than the LE, and both
tend to have more distal involvement than proximal
involvement.
- Muscle spasticity on the affected side decreases
muscle and bone growth, resulting in decreased
range of motion (ROM)
- children with hemiplegia often present with
contractures and limb-length discrepancies on the
involved side
- affected side of the child with hemiplegia often
presents with shoulder protraction, elbow flexion, wrist
flexion and ulnar deviation, pelvic retraction, hip
internal rotation and flexion, knee flexion, and forefoot
contact only due to plantarflexed foot
- Children with hemiplegia tend to achieve all gross and
fine motor milestones but not within the typical time
frame
- For example, children with hemiplegia tend to walk
between 18 and 24 months but present with gait
deficits.
- Additionally, acquisition of bimanual hand skills is
delayed because of the neurologic impairment of the
affected side
- For example, children with hemiplegia are able to cut
food using a fork and knife, but only after hours of
extensive guided practice during occupational therapy
and at home
- Two widely known standardized assessments are
used to evaluate the quality of UE function in children
 with hemiplegia: the SHUEE and the Assisting Hand
Assessment (AHA)
- Cognitive function is typically normal in these children,
and as adults they are able to work and participate in
a variety of professional settings with spastic
hemiplegia have been found to have social and
emotional deficits.
- These include emotional disorders in 25%, conduct
disorders in 24%, pervasive hyperactivity in 10%, and
situational hyperactivity in 13%
- Overall, children with hemiplegia require minimal
equipment or self-care/school accommodations.
- They may benefit from orthotics, assistive devices
such as a cane, adaptive self-care equipment, or
accommodations due to visual impairments.
✦ Quadriplegia
- volitional muscle control of all four extremities is
severely impaired
- often accompanied by neck and trunk involvement
- Like diplegic CP, periventricular white matter lesions
are the most frequently observed neuroimaging
finding in children with quadriplegic CP
- Extensive lesions affecting the basal ganglia or
occipital area often lead to visual impairments and
seizures, both commonly seen in children with this
subtype of CP
- Cognition can vary from normal to severely impaired
and is unique to each child with quadriplegia
- It is important to note that children with quadriplegia
who are unable to speak are often regarded as being
cognitively impaired
- once provided a means of effective communication,
some are able to express their level of understanding
and critical thinking
- Gross and fine motor abilities vary widely for children
with quadriplegia, from being ambulatory for
household distances with an assistive device to being
dependent for all care.
- The equipment needs for these children are
considerable through the life span
- Common equipment recommendations include
mechanical lift systems, wheelchairs, standers, gait
trainers/walkers, feeding systems, bath systems, and
toileting systems.
- Home modifications should be considered for children
with severe disabilities to maximize the child’s
independence with transfers and mobility, to ease
caregiver strain, and improve safety for the child and
caregiver.
✦ Dyskinetic
- result in generally uncontrolled and involuntary
movement that includes athetosis, rigidity, tremor,
dystonia, ballismus, and choreoathetosis
- Common abnormalities found in imaging include deep
gray matter lesions and, to a lesser extent,
periventricular white matter lesions
- Athetosis always has involuntary movements that are
slow and writhing; abnormal in timing, direction, and
spatial characteristics; and are usually large motions
of the more proximal joints.
- Athetosis is rare as a primary movement disorder and
is most often found in combination with chorea.
- Athetosis is most commonly a secondary movement
disorder in conjunction with spasticity
- The cortical–basal ganglia–thalamic loop is a sensory
and motor feed-forward and feedback circuit and
when impaired results in athetosis.
- Older individuals with athetoid CP are at risk for
acquiring devastating neurologic deficits owing to
intervertebral disc degeneration and instability in their
cervical spines
- Individuals with athetosis typically initiate and attempt
control of movement with the jaw and head
- This eventually causes musculoskeletal changes such
as cervical instability, potential high spinal cord
injury, temporomandibular joint dysfunction, and
or spinal stenosis
- when athetosis is the primary movement disorder, the
cognitive ability of these children tends to be
underestimated owing to associated dysarthria
- tend to have normal to above-normal intelligence
- Rigidity is much less common and is felt as
resistance to both active and passive movement and
is not velocity dependent.
- Tremor, a rhythmic movement of small magnitude,
usually of the smaller joints, rarely occurs as an
isolated disorder in CP but rather in combination with
athetosis or ataxia
- Dystonia is a slow motion with a torsional element
that may involve one limb or the entire body and in
which the pattern itself may change over time
- Ballismus is the most rare movement disorder and
involves random motion in large, fast patterns usually
of a single limb
- Choreoathetosis involves jerky movement,
commonly of the digits and varying in the ROM.
✦ Ataxic
◊ Ataxic CP is primarily a disorder of balance and control in
the timing of coordinated movements along with
weakness, incoordination, a wide-based gait, and a noted
tremor.
◊ This type of CP results from deficits in the cerebellum and
often occurs in combination with spasticity and athetosis.
◊ The cerebellum is a major sensory processing center, and
when impaired, ataxia will result.
◊ Children with ataxia have difficulty with transference of skills,
and may benefit from a specific task-oriented approach to
treatment.
◊ For example, to master stepping onto and off the school bus,
it is most effective to practice the skill using bus steps.
7. Hypotonic
◊ Hypotonia in a child with CP can be permanent but is more
often transient in the evolution of athetosis or spasticity and
might not represent a specific type of CP.
◊ For example, an infant who presents with generalized
hypotonia through the trunk and extremities will often develop
spasticity beginning distally and progressing proximally.
◊ Hypotonia is typically correlated with congenital
abnormality, such as lissencephaly.
◊ A common mixed tone pattern is seen in some children with
quadriplegia, with spasticity evident in the Les and severe
hypotonia in the trunk and neck.

Assessment of the infant and child with CP

◊ believe that a diagnosis of very mild CP should be possible at
8 months of age.
◊ Identification depends on a combination of suspicious and
abnormal signs revealed during comprehensive assessment
of attainment of motor achievements, neurologic signs,
primitive reflexes,
and postural reactions.
◊ Infants and children with persistent subtle or mild signs
should be monitored closely until the possible outcome is clear.

◊using the Movement Assessment in Infants (MAI), found

certain items that can help distinguish the infant with CP from
the uninvolved infant at 4 months of age.
◊ Items of diagnostic value include neck hyperextension
and shoulder retraction, ability to bear weight on the forearms
while prone, ability to maintain a stable head position
in supported or independent sitting, and the infant’s ability
to flex the hips actively against gravity.

◊ Seven of the 17 MAI items that Harris found highly significant

predictors for CP are observational items.
◊ Both Harris and Milani- Comparetti found that watching the
infant move against gravity is of greater diagnostic value than
intrusive handling or attempts to stimulate a response.
◊ Rose-Jacobs et al.33 evaluated whether the MAI predicted
2-year cognitive and motor development status measured by
the Mental and
Psychomotor Scales of the Bayley Scales of Infant
Development.
◊ They found that the MAI appears to be valid for use with
infants born at term who are at risk of developmental delay.
◊ This test may be a useful tool to help clinicians make
decisions about the provision of intervention services.
◊ In order to understand the atypical movement and motor
control that occurs in children with CP, the therapist must
understand the acquisition of motor control against
gravity, the development of postural control, and the
musculoskeletal development in typically developing
children.
◊ The purpose of the assessment is to discover the functional
abilities and strengths of the child, determine the primary and
secondary impairments (compensations used because of the
primary impairments), and discover the desired functional and
participation outcomes of the child and family.
◊ The therapist must use an organized approach to the
observation of, interaction with, and handling of the child in
order to get an accurate baseline of the child’s functional
abilities.