Prof.

Muhammad Haroon Hamid

MBBS (KE), FCPS, MRCP, FRCP, FRCPCH
Department of Pediatric Medicine
King Edward Medical University, Lahore
 Permanent disorder of
◦ Movement & posture due to a
◦ Non-progressive insult / injury to a
◦ Developing brain”
 Motor disorder – may be accompanied by
disturbances in
◦ sensations,
◦ perception,
◦ cognition,
◦ communication, behaviour &/or seizure disorder.
 Most common motor disability
 Incidence – 3.6 / 1000 children
 Idiopathic - 50%

 Rest according to the time of insult:

a. Intra-uterine
b. Peri-natal and post-natal
c. Infancy
A. Intrauterine:
• Bleeding
• Infections
• Thromboembolic phenomena
• Congenital malformation
• Massive irradiation
B. Perinatal And Postnatal:
• Prematurity (the lower the birth weight, the higher the
incidence)
• Birth trauma
• Intracerebral hemorrhage
• Birth asphyxia (HIE)
• Hypoglycemia
• Kernicterus
• Acidosis
C. Infancy:
• Meningitis
• Encephalitis
• Trauma
• Vascular accidents
 In severe cases - widespread cerebral atrophy
with cavity formation in sub cortical white
matter.

 Atrophy of basal ganglia - rigidity and

extrapyramidal movements

 Atrophy and gliosis of opposite cerebral

hemisphere - hemiplegia
1. Spastic forms
• Quadriplegia
• Paraplegia
• Diplegia
• Hemiplegia
2. Extrapyramidal form
• Choreoathetosis
• Dystonia
3. Atonic/ataxic forms
4. Mixed form of CP
 Quadriplegia: (20%)
◦ All four extremities involved.
◦ Most severe form.
◦ Associated with asphyxia, ischemia, infection,
metabolic.
◦ Seizures and mental retardation is common.
◦ Swallowing difficulties.
◦ Visual and speech deficits are common.
◦ Decreased spontaneous movements with spasticity in
all 4 limbs , positive babinski and exaggerated deep
tendon reflexes.
 Legs are involved more than arms.
 Associated with LBW and prematurity.
 Most common type.
 Scissoring of lower limbs.
 Delayed walking.
 Tip toe walking.
 Disuse atrophy of lower limbs.
 Brisk tendon reflexes , positive babinski and
ankle clonus.
 Intellectual development usually normal.
 Minimal risk of seizures.
 Learning disabilities and language problems may
be present.
 Decreased spontaneous movements on the affected
side.
 Associated with vascular malformations or embolic
phenomena.
 Arm is more involved than the leg.
 Delayed walking
 Growth arrest of affected limbs.
 Deep tendon reflexes are brisk with ankle clonus
and positive babinski sign.
 Cognitive function usually spared.
Triplegia:
◦ Any 3 extremities are involved.

Monoplegia:
◦ Only one limb involved.

Paraplegia:
Only legs involved.
Is not associated with a peripheral
sensory disturbance.
 Associated with kernicterus and hypoxic ischemic
encephalopathy of basal ganglia.
 15-20% of all CP patients.

Choreoathetosis:
◦ Irregular involuntary movements.
◦ Hypotonic infants with marked head lag and poor
head control.
◦ Speech usually affected.
◦ Seizures are uncommon.
◦ Hearing impairment common.
Dystonia:

 Involuntary slow twisting movement that

primarily involves the proximal muscles of
extremities , trunk and neck.
 Associated with asphyxia, kernicterus and
metabolic disorders.
Atonic Diplegia:
◦ Associated with marked hypotonia, brisk reflexes
and severe cognitive delays.

CONGENITAL CEREBELLAR ATAXIA :

◦ Inco-ordination and intention tremors.
◦ Hydrocephalus is often present.
◦ It is associated with genetic factors.
 Some children have mixed disorders
incorporating features of above disorders.
 Associated with more complications.
 FLOPPY INFANT WITH BRISK REFLEXES:
up to 6 months of age ,and then becomes hypertonic

 PERSISTENCE OF PRIMITIVE REFLEXES:

1. Moro reflex(beyond 3 months)
2. Stepping reflex beyond 6 weeks
3. Landau reflex(usually absent in cerebral palsy)

 MICROCEPHALY:
(25%of spastic quadri and diplegics)
 DELAYED SPEECH:
(due to spasticity or athetosis of tongue or to high deafness)

 SEIZURES:
60 % of patients
 MENTAL RETARDATION: 25 to 50 %

 SENSORY AND SPEECH DEFICITS:

 OTHER SIGNS:
1. Paucity of movement and facial expression
2. Scissoring of gait
3. Persistently clenched hands with thumb adducted after
first 3 months
4. Extended or crossed legs when infant is held from
armpits.
 MOSTLY CLINICAL.
 Any infant with delayed motor development
MUST be suspected as case of cerebral palsy
with or without cognitive impairment as 50%
of cerebral palsy cases have mental
retardation.
 To locate structural lesions EEG or CT scan
may be helpful.

 The best predictor of CP is presence of

echodensities in periventricular white matter
that develops into cysts.

 Hearing and visual assessment should also be

done.
1. Leukodystrophy
2. Hydrocephalus
3. Brain tumor
4. Spinal cord lesions
5. Muscular dystrophy
6. Werdnig hoffman and benign congenital
hypotonia-atonic diplegia
7. Progressive CNS disorder
 Multi-disciplinary:

1) Physical and occupational therapy

2) Control of seizures and spasticity
3) Stretching exercise
4) Surgical procedures for contractures
5) Management of associated deficits
 Parents should be taught how to handle their
child in daily activities.
 Family support is essential for emotional
growth of the child.
 For spasticity:
diazepam, dantrolene and baclofen
 Anticholinergic trihexyphenidyl is also used.
 Athetosis: levodopa
 Dystonia: carbamezapine
 Seizures: Pheno, Pheytoin, etc
 To prevent contractures.
 Tight achilles tendon is a common problem
and requires surgical treatment:
◦ Adductor tenotomy
◦ Psoas transfer and release
 Hearing
 Vision
 Learning difficulties
 Mental disorders
• Ante-natal care & monitoring
• Prompt resuscitation at birth
• Prevention of kernicterus
• Meticulous care of premature & low birth
weight infants.
• Prompt therapy of apneic episodes
• Prevention & prompt management of CNS
infections in infancy
 Depends on:
◦ Extent of disability
◦ Type of CP
◦ Rehab efforts
◦ CT / MRI findings

 Functional Potential:
◦ Physical disabilities
◦ Intellectual ability
Further Reading Material
◦ Nelson Textbook of Pediatrics
◦ Pervaiz Akber Pediatrics

For any comments / queries

◦ Email – profharoon@kemu.edu.pk