Cerebral Palsy

Dr.Raluca Ioana Teleanu

 What is Cerebral Palsy (CP)?
• Cerebral palsy is the leading cause of childhood disability
affecting function and development.
• The term cerebral palsy (CP) was originally coined more than
a century ago and loosely translates as "brain paralysis."
• However, a precise definition has remained elusive because
cerebral palsy is not a single diagnosis but an "umbrella" term
describing nonprogressive brain lesions involving motor or
postural abnormalities that are noted during early development
– CP = STATIC ENCEPHALOPATHY
• The incidence of the condition has not changed in more than 4
decades, despite significant advances in the medical care of
neonates.
• Cerebral = brain
• Palsy = disorder of
movement
 Statistics
• According to the United Cerebral Palsy
Association an estimated 500,000 children have
cerebral palsy.
• 10-20% of children with cerebral palsy acquire the
disorder after birth.
• Cerebral palsy is the most common cause of
childhood physical disability, occurring in 2-3 out of
1000 children
ETIOLOGY
The clinical presentation of
cerebral palsy may result
from an underlying structural
abnormality of the brain;
early prenatal, perinatal, or
postnatal injury due to
vascular insufficiency; toxins
or infections; or the
pathophysiologic risks of
prematurity.
 Maternal and prenatal risk factors
• Long menstrual cycle
• Previous pregnancy loss
• Previous loss of newborn
• Maternal mental retardation
• Maternal thyroid disorder, especially iodine deficiency
• Maternal epilepsy
• History of delivering a child weighing less than 2000g
• History of delivering a child with a motor deficit,
mental retardation or a sensory deficit
Factors during pregnancy
• Polyhydramnios
• Treatment of the mother with thyroid hormone,
estrogen or progesterone
• Maternal epilepsy
• Maternal severe proteinuria or high blood pressure
• Maternal methyl mercury exposure
• Congenital malformations in the fetus
• Male sex of fetus
• Bleeding in third trimester
• Intrauterine growth retardation
• Multiple gestation
 Perinatal risk factors
• Prematurity
• Chorioamnionitis
• Nonvertex and face presentation of the fetus
• Birth asphyxia !!!
 Postnatal risk factors
• Infections (eg, meningitis, encephalitis)
• Intracranial hemorrhage (eg, due to prematurity,
vascular malformations, or trauma)
• Periventricular leukomalacia (in premature infants)
• Hypoxia-ischemia (eg, from meconium aspiration)
• Persistent fetal circulation or persistent pulmonary
hypertension of the newborn
• Kernicterus
 Symptoms of CP
• History of gross motor developmental delay in the first year of life
• Abnormal muscle tone: The most frequently observed symptom;
– the child may present as either hypotonic or, more commonly, hypertonic, with
either decreased or increased resistance to passive movements, respectively;
– children with cerebral palsy may have an early period of hypotonia followed by
hypertonia.
– A combination of axial hypotonia and peripheral hyprtonia is indicative of a
central process.
• Definite hand preference before age 1 year: A red flag for possible
hemiplegia
• Asymmetrical crawling or failure to crawl
 Symptoms of CP
• Growth disturbance → especially failure to thrive
• Increased reflexes:
– Indicating the presence of an upper motor neuron
lesion;
– this condition may also present as the persistence of
primitive reflexes
• Underdevelopment or absence of postural or
protective reflexes
• Developmental delay
• Abnormal muscle tone
• Unusual posture
Classifications of CP
• Physiologic
• Topographic
• Functional
• Etiologic
 Physiologic
• Spastic CP
• Dyskinetic CP
• Ataxic CP
• Mixed CP
(spastic&athethoid)
 Topographical
• Based on the body
segments afflicted:
– Monoplegia
– Diplegia
– Hemiplegia
– Paraplegia
– Triplegia
https://archealth.com.au/2018/05/14/cerebral-palsy-and-ageing/

– Quadriplegia
Functional classification is based on the
degree of disability in the cerebral palsy

The functional abilities of children with

Cerebral Palsy vary immensely in the domains
of cognition, self-care, mobility and social
aspects.
However, the classification of gross motor
function in children with Cerebral Palsy has
proven to be successful.
 Physiologic
• Spastic CP
• Dyskinetic CP
• Ataxic CP
• Mixed CP
(spastic&athethoid)
https://www.physio-pedia.com/Cerebral_Palsy_Introduction
 Spastic CP
• Result from damage to motor areas of the
cerebrum;
• characterized by increased muscle tone,
primarily of flexors and internal rotators,
which might lead to permanent contractures
and bone deformities
 Spastic CP

https://medium.com/@cpcerebralpalsy/spastic-cerebral-palsy-disorder-in-children-92a10999b5c6
 Hemiplegia
• one-sided upper motor neuron deficit
• arm generally affected more than leg;
• possible early hand preference or relative
weakness on one side;
• gait possibly characterized by circumduction of
lower extremity on the affected side
• Specific learning disabilities
• oromotor dysfunction
• possible unilateral sensory deficits
• visual-field deficits (eg, homonymous
hemianopsia) and strabismus
• seizures
 Diplegia
• often have a period of hypotonia
followed by extensor spasticity in the
lower extremities, with little or no
functional limitation of the upper
extremities →upper motor neuron
findings in the legs more than the arms
• Scissoring gait pattern with hips flexed
and adducted, knees flexed with valgus,
and ankles in equinus, resulting in toe
walking
• Learning disabilities and seizures less
commonly than in spastic hemiplegia
https://www.abclawcenters.com/practice-areas/types-of-birth-injuries/cerebral-palsy/birth-injuries-and-spastic-cerebral-palsy/what-is-spastic-diplegia/
Quadriplegia /Tetraplegia
• All limbs affected, either full-body
hypertonia or truncal hypotonia with
extremity hypertonia
• Oromotor dysfunction
• Increased risk of cognitive difficulties
• Multiple medical complications (see
Complications under Prognosis)
• Seizures
• Legs generally affected equally or more
than arms
• Categorized as double hemiplegic if arms
more involved than legs
 Physiologic
• Spastic CP
• Dyskinetic CP
• Ataxic CP
• Mixed CP
(spastic&athethoid)
Athethoid /Dyskinetic /Extrapyramidal CP
• A condition that occurs when there is damage in the basal ganglia
→ results in an overflow of motor impulses to the muscles →
abnormal regulation of tone, abnormal postural control and
coordination deficits.
• Abnormal movement patterns may increase with stress or
purposeful activity

https://sethu.in/cerebral-palsy/
Dyskinetic (extrapyramidal) CP
• Early hypotonia with movement disorder
emerging at age 1-3 years
• Arms more affected than legs
• Deep tendon reflexes usually normal to slightly
increased
• Some spasticity
• Oromotor dysfunction
• Gait difficulties
• Truncal instability
• Risk of deafness in those affected by
kernicterus
 Physiologic
• Spastic CP
• Dyskinetic CP
• Ataxic CP
• Mixed CP
(spastic&athethoid)
 Ataxic CP
• Condition that occurs when there is
damage to the cerebellum (which
normally regulates balance and muscle
coordination).
• Diagnosed when the child attempts to
walk.
• Muscles show abnormal degrees of
hypotonia. https://www.physio-pedia.com/Cerebral_Palsy_Introduction

• Lack of balance and coordination

necessary for proper arm and leg
movement causing a wide-based gait to
be exhibited.
https://www.dinf.ne.jp/doc/english/global/david/dwe002/dwe00211.html
https://www.dinf.ne.jp/doc/english/global/davd/dwe002/dwe00211.html
 Functional

• Individuals are
placed into one
ability class
according to the
severity of the
disability.
• Important system for
physical education
teachers because it
categorizes the
individuals according
to their disability
levels.
 Common problems
• Seizures
• Spastic or rigid muscles
• Contractures may develop
when restricted range of
motion is severe
• Hyperactive Stretch Reflex
• Scissoring gate or
hemiplegic gate
• Persistence of unwanted
primitive reflexes and
tremors
• Involuntary movement
(e.g., constant,
unpredictable, purposeless
movement)
• May exhibit both hypertonic
and hypotonic muscle tone
• Low postural tone; may be
able to walk unaided,
usually with arms held out
to the sides
• Often under or over
reaches
• Falls and stumbles easily
 Cognitive Domain
• loss of perceptual ability
• difficulty with speech
• learning disability
• mental retardation
 Cranial Imaging Studies
• Neuroimaging studies can help to evaluate brain damage
and to identify persons who are at risk for cerebral palsy.
• Ultrasonography can delineate clear-cut structural
abnormalities and show evidence of hemorrhage
or hypoxic ischemic injury
– neonatal cranial ultrasonography provides information about the
ventricular system, basal ganglia, and corpus callosum, as well
as diagnostic information on intraventricular hemorrhage and
hypoxic-ischemic injury to the periventricular white matter.
• Brain CT/MRI helps to identify congenital malformations,
intracranial hemorrhage, and periventricular
leukomalacia more clearly than ultrasonography.
Diagnosis - Levine criteria -POSTER:
P - Posturing/abnormal movements
O - Oropharyngeal problems (e.g., tongue thrusts,
swallowing abnormalities)
S - Strabismus
T - Tone (hyper- or hypotonia)
E - Evolutional maldevelopment (primitive reflexes
persist or protective equilibrium reflexes fail to
develop
R - Reflexes (increased deep tendon
reflexes/persistent Babinski's reflex)

!!!! 4/6 → suggestive CP

 Differential Diagnoses
• Inherited Metabolic Disorders Overview
• Intellectual Disability
• Metabolic Myopathies
• Metabolic Neuropathy
• Traumatic Peripheral Nerve Lesions
• Tumors of the Conus and Cauda Equina
• Vascular Malformations of the Spinal Cord
?
?
?
 How to Manage Cerebral Palsy
• Management is directed at alleviating
symptoms that are caused by damage to the
brain and helping the child achieve maximum
potential in growth and development.
Affects on the family

frustration

disappointment

anger
Management
!!!!! individualised
→ needs a MUTIDISCIPLINARY TEAM

 neurologist
 rehabilitation medicine specialists
 pediatrician + FAMILY
 psychoterapist
 neurosurgeon
 orthopedic surgeon
 gastroenterologist/nutritionist
 ophtalmologist
 ENT specialist
 social worker
 etc
 Treatment and Therapy
• Since cerebral palsy is so
diverse the treatment of it
can vary greatly from one
individual to another.
• There is no cure, but there
are many therapies to help
people better handle their
condition
– Physical therapy
– Occupational therapy
– Botox
– ??? Stem cells
• The focus of treatment is
on helping the individual
reach his/her highest level
of independence.
• Individualized plans for
treating C.P. should be
centered around the needs
of the individual.
 Other interesting ways to treat
cerebral palsy
• Dolphin therapy:
– Developed by American psychologist David E.
Nathanson around 1978
– Allows children with cerebral palsy to step into a
different environment and interact with the
dolphin in a way that is both playful as well as
constructive for that child.
 Space Suit Therapy

• Becoming increasingly popular for individuals with

cerebral palsy.
• The suit is also known as Therasuits or Therapy
suits and it resembles an outfit that was originally
developed by the Russians that helped their
astronauts maintain their muscle tone while they
were in space.
 Something to Keep in Mind
• In an Australian study, most medical students
have a very limited knowledge of CP

• They also have negative attitudes toward

individuals with cerebral palsy as a result
 Devastating costs....
• According to
http://www.cerebralpalsysource.com, an
“…estimated lifetime expense of living
with cerebral palsy is approximately
$921,000 a person.”
 References
• Aicardi’s Diseases of the Nervous System in Childhood, 4th
Edition- Alexis Arzimanoglou, Anne O’Hare, Michael Johnston
and Robert Ouvrier – Wiley, 2018
• Swaiman's pediatric neurology : principles and practice- 6th
Edition- Kenneth Swaiman Stephen Ashwal Donna Ferriero Nina
Schor Richard Finkel Andrea Gropman Phillip Pearl Michael
Shevell, Elsevier, 2017
• Volpe's Neurology of the Newborn 6th Edition, Joseph
Volpe Terrie Inder Basil Darras Linda S. de Vries Adre du
Plessis Jeffrey Neil Jeffrey Perlman, Elsevier, 2017
• https://www.uptodate.com/contents/cerebral-palsy-epidemiology-
etiology-and-prevention
• https://www.uptodate.com/contents/cerebral-palsy-clinical-
features-and-classification
 ADDITIONAL SOURCES

• https://www.youtube.com/watch?v=uD7nKhiLB40
• https://www.youtube.com/watch?v=7fUGWKM32hE
• https://www.youtube.com/watch?v=pm6BnzsqQbQ
• https://www.youtube.com/watch?v=eEVgREQc6vo
• https://www.youtube.com/watch?v=PlsAVgztrX4