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P ASSISTANT PROFESSOR SRINIVAS INSTITUTE OF NURSING SCIENCES
CEREBRAL PALSY: DEFINITION
Cerebral palsy is a static encephalopathy Encephalopathy = Brain Injury that is non-progressive disorder of posture and movement Variable etiologies Often associated with epilepsy, speech problems, vision compromise, & cognitive dysfunction
DAMAGE TO THE BRAIN BEFORE, DURING OR FOLLOWING BIRTH
During Pregnancy: 70-80% ´ Birthing Process: 10-20% ´ First 2-3 years of life: 10-20% ´ 2.3-2.8/1,000 CDC ´ Kokubunji in suburban Tokyo with a total population of about 100,000 2.1/1,000
CAUSES OF CP
Time (% of cases)
First trimester Second trimester
Teratogens, chromosomal abnormalities, genetic syndromes, brain malformations Intrauterine infections, problems in fetal/placental functioning
asphyxia. prematurity Meningitis. toxins ´ Not obvious (24%) . complications of labor and delivery Sepsis/CNS infection. traumatic brain injury.CAUSES OF CP Time (% of cases) ´ Causes ´ Labor and delivery (19%) Perinatal (8%) ´ ´ ´ Childhood (5%) ´ Preeclampsia.
CEREBRAL PALSY: CLASSIFICATION Various classifications of Cerebral Palsy ´ Physiologic ´ Topographic ´ Etiologic ´ Clinical .
CEREBRAL PALSY: PHYSIOLOGIC Athetoid ´ Ataxic ´ Rigid-Spastic ´ Atonic ´ Mixed ´ .
CEREBRAL PALSY: TOPOGRAPHIC Monoplegic ´ Paraplegic ´ Hemiplegic ´ Triplegic ´ Quadraplegic ´ Diplegic ´ .
Monoplegia : one limb / rare ´ Diplegia : both LL >> UL / good intelligence / prematurity ´ Hemiplegia : unilateral usually UL > LL / 33 % seizures ´ 50 % mentally retarded Triplegia : rare / usually both LL + one UL ´ Quadriplegia : total body / often mentally retarded / ´ with seizures / severe hypoxia ´ Double hemiplegia : bilateral UL > LL .
traumatic delivery. toxic ´ . infection. Rh disease. anoxia. genetic. vascular.CEREBRAL PALSY: ETIOLOGIC Prenatal (70%) Infection. congenital malformation of brain ´ Natal (5-10%) Anoxia. metabolic ´ Post natal Trauma. toxic.
Affected muscles are extremely tight stiff (5070%).wide-based gait. hypertonicity with poor posture control Dyskinetic/athetoid. uncontrollable movement (10-25%) . Loose muscles difficulty with balance and coordination (5-10%) Mixed-type/dystonic.abnormal involuntary movement/slow wormlike writhing Ataxic.CLI ICAL CLASSI ICATI ´ ´ ´ ´ ´ CP Spastic.combination of spasticity and athetosis Athetoid.Jerky.
Head to Toe .CEREBRAL PALSY: CLINICAL PRESENTATION ´ Remember that motor developmental progression is from«.
SYMPTOMS ´ ´ ´ Delay in developmental milestones in first 2 years Low muscle tone Uses only one hand or one side when crawling .
CLINICAL MANIFESTATIONS ´ Delayed gross motor development universal manifestation of CP « The discrepancy between motor ability and expected achievement tends to increase as growth advances. « Delayed development of ability to balance slows milestones « Delay in all motor accomplishments «A .
fingers. spasticity may cause child to walk and stand on toes dyskinetic CP or uncoordinated or involuntary movements (writhing tongue. . poor sucking and feeding. abnormal crawling or asymmetrical crawl. facial grimacing). truncal ataxia. head staggering. and toes. tremor on reaching. persistent tongue thrust. Hemiplegia.CLINICAL MANIFESTATIONS ´ Abnormal motor performance « « « Preferential unilateral hand use may be apparent at 6 months.
Opisthotonic postures or exaggerated back arching. Difficulty diapering due to spastic hip adductor muscles and lower extremities When pulled to a sitting position. This is an early sign of spasticity. feel stiff on dressing. .ALTERATIONS IN MUSCLE TONE ´ ´ ´ ´ Increased or decreased resistance to passive movement (abnormal muscle tone). child may extend the entire body and be rigid at hip and knee.
with the elbow pronated and slightly flexed and the hand closed. Persistent infantile resting and sleeping position is a sign of spasticity. Hemiparetic child may rest with affected arm adducted and held against torso.ABNORMAL POSTURES ´ ´ ´ ´ Children with spastic CP have abnormal posture at rest or when position is changed Infantile lying prone may have hip higher than trunk with legs and arms drawn in. .
ankle clonus. . palmar grasp Hyperreflexia.REFLEX ABNORMALITIES ´ Persistence of primitive infantile reflexes (one of the earliest signs of CP) « Tonic neck reflex « Hyperactivity or moro. plantar. stretch reflexes can be elicited from any muscle group.
(may occur)-poor attention span. « Children with athetosis and ataxia more intelligent. Speech difficulties (not a sign or MR). hyperactive behavior « . marked distractibility.child has motor and sensory defects ADHD. wide range « Tests should be carried out over a period of time.ASSOCIATED DISABILITIES AND PROBLEMS ´ Intellectual impairment 70% w/in normal limits.
. Address nutritional concerns.alterations in muscle tone lead to difficulties chewing.may occur and lead to wet clothing/skin irritation Feeding. choking may lead to aspiration.generalized tonic-clonic.more in postnatally acquired hemiplegia Drooling.ASSOCIATED DISABILITIES Seizures. etc. Altered respiratory patterns may lead to inadequate gas exchange. talking. Coughing. swallowing.
joint contractures due to unbalanced muscle tone. Decreased Mobility « difficulties with toileting may lead to constipation « Difficult chewing bulky foods may lead to constipation « May need stool softeners or laxatives « .MOTOR IMPAIRMENT ´ Orthopedic complications Unilateral or bilateral hip dislocations. scoliosis.
ASSOCIATED PROBLEMS ´ Dental carries « « « « « « « Improper dental hygiene congenital enamel defects (hyperplasia of primary teeth) high carbohydrate intake and retention Dietary balance with poor nutritional intake Inadequate fluoride Difficulty in mouth closure and drooling Spastic or clonic movements cause gagging or biting on toothbrush .
ASSOCIATED PROBLEMS Malocclusion in 90% of children ´ Oral hypersensitivity causes resistance to good hygiene ´ Gingivitis is secondary to poor hygiene ´ Dental health further complicated by anti-seizure meds ´ Nystagmus and amblyopia common ´ May need surgery or corrective lenses « May be due to sensoneural involvement « Infants lying flat too long may have otitis media which may leads to conductive hearing loss « .
ASSOCIATED PROBLEMS ´ ´ ´ ´ ´ Mental retardation (1/2?) Vision: strabismus 1 eye turning in or out Seizures Limb shortening and scoliosis Dental Problems .
´ ´ ´ ´ ´ Hearing loss Difficulty with speech Joint contractures: Stiffening Spatial Awareness: often in one side Psychosocial challenges .
CEREBRAL PALSY: COMPLICATIONS Spasticity ´ Weakness ´ Increase reflexes ´ Clonus ´ Seizures ´ Articulation & Swallowing difficulty ´ Visual compromise ´ Deformation ´ Hip dislocation ´ Kyphoscoliosis ´ Constipation ´ Urinary tract infection ´ .
CLINICAL ASSESSMENT HIP FLEXORS Thomas test ´ easy & simple. well known problem : depends on how much is the other hip flexed .
Thomas test should be performed with knee outside at table edge to prevent false positive results .CLINICAL ASSESSMENT HIP FLEXORS With fixed knee flexion.
CLINICAL ASSESSMENT HIP FLEXORS Ely / Rectus Femoris Test .
CLINICAL ASSESSMENT HIP ROTATION .
CLINICAL ASSESSMENT KNEE FLEXION ( HAMSTRING TIGHTNESS ) .
CLINICAL ASSESSMENT POSTURE / GAIT Lying ´ Sitting ´ Standing ´ walking ´ .
CLINICAL ASSESSMENT UPPER LIMB Elbow flexion ´ Forearm pronation ´ Wrist flexion ´ Finger flexion ´ Thumb in palm ´ .
Botoxin ´ . Baclofen pumps.CEREBRAL PALSY: MANAGEMENT Neurologic and Physiatric ´ Physiotherapy ´ Occupational Therapy ´ Speech ´ Adaptive equipment ´ Surgical ´ Rhizotomy.
dantrolene (Dantrium).MEDICATION THERAPY ´ ´ Little usefulness Anti-anxiety agents may relieve excessive motion and tension (child with athetosis) « « Skeletal muscle relaxants ( methocarbamol (Tobaxin). may be used short-term for older children and adolescents. Baclofen. Diazepam (Valium) for older children and adolescents. may relieve stiffness and ease motion .
Pain Secondary conditions (seizures. lung complications). . bowel and bladder problems. Botulism toxin (Botox) used to paralyze certain muscles.MEDICATIONS ´ ´ ´ ´ Local nerve blocks to motor points of a muscle with a neurolytic agent (phenol solution) may relieve spasticity.
SURGICAL THERAPY ´ ´ ´ ´ Tendon-lengthening procedures (heel-cord) Release of spastic wrist flexor muscles Correction of hip-adductor muscle spasticity or contracture to improve locomotion Surgery is for improved function rather than cosmetic reasons and is followed by PT. .
Do not prevent nor reduce deformity .CEREBRAL PALSY ORTHOTICS Immobilization may cause atrophy ´ Night splints : . pain or stimulate reflexes in spastic muscles and relaxes the weaker apponents ² thus may increase deformity rather than reduce it ! ´ May be useful only in Athetoid ´ .may cause irritation.
12 years IQ : good Good upper limb function : for walking Underlying muscle power : not weak Walker / non-walker : surgery hardly changes state but improves gait .CEREBRAL PALSY PREREQUISITES FOR EFFECTIVE SURGERY ´ ´ ´ ´ ´ ´ ´ Type : spastic Extent : hemiplegics / diplegics : good results quadriplegics : minimal improvement Age : 3.
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