CEREBRAL PALSY

DEFINITION
• Cerebral Palsy (C.P) is a persistent disorder of
posture and/or movement, due to a non-
progressive damage to the developing brain.

• May be associated with convulsion, abnormal vision,

hearing or intellect
• The damage may occur in utero, during the birth
process, or during the first few years of life.

• Although the brain lesion is non-progressive, the

motor disorder evolves over time and the clinical
presentation may change accordingly.

2
 AETIOLOGY
Insult may be prenatal, natal or post natal
Causes:
• Prematurity
• Maternal factors: Intrauterine inflammation,
chorioamnionitis, Maternal fever, IUGR, placental
abnormalities, alcohol.
• Kernicterus
• Infections: Congenital TORCH, GBS meningitis,
• Congenital malformation
• Metabolic
• Genetic: Inherited Cytokine polymorphisms (in TNF-
alpha and mannose-binding lectin genes, IL-6 gene)
• Trauma
• Birth asphyxia

3
 CP & BIRTH ASPHYXIA??
• Only a minority (6-28 percent) of cerebral palsy are due to
perinatal asphyxia [Hagberg et al., 2001; Nelson and Grether 1998]
• Important cause of cerebral palsy:
– Intrapartum hypoxia-ischemia
– Neonatal stroke (ischemic perinatal infarction and
sinovenous thrombosis) during perinatal or neonatal [Lynch
and Nelson, 2001
• Ischemic perinatal stroke is responsible for 28–50 percent of
hemiplegic CP in term infants [Humphreys et al., 2000;
Uvebrant, 1988; Wu et al., 2003; Bax et al., 2006
• Neonatal sinovenous thrombosis due to systemic illness,
polycythemia, coagulation abnormalities, and extracorporeal
membrane oxygen (ECMO)
4
IVH
cPVL
 CLASSIFICATION
May be based on:
– Tone abnormality
– Type of movement disorder (ataxia, dystonia,
choreoathetosis)
– Severity of functional limitation
– Associated impairments (seizures, cognitive, hearing,
vision and behavioralal)
– Anatomic and radiological findings
– Parts of body affected (e.g., diplegia, hemiplegia,
quadriplegia)
– Neuroimaging findings

7
 CLASSIFICATION
PHYSIOLOGIC: TOPOGRAPHIC:
• Spastic: Motor cortex • Monoplegia
• Athetoid: Basal Ganglia • Paraplegia
• Ataxic: Cerebellar • Diplegia(legs>arms)
• Rigid: Basal Ganglia • Hemiplegia(arms>legs)
• Atonic • Double Hemiplegia
• Mixed • Quadriplegia
• Unclassified

8
9
How they present

10
 CLINICAL FEATURES
SPASTIC DIPLEGIA
• Common in preterms
• Increased tone in lower limbs
• Delay in sitting, standing, walking
• Scissoring
• More common in preterm

SPASTIC HEMIPLEGIA
• Common with perinatal stroke
• Noted after 3-5 mo of age, maybe in 2nd yr
• Arm>Leg
• Leg spasticity develops later (about 1yr)
• Upper limb: distal> proximal
• Better cognitive development
• Walk by 2 yrs
11
SPASTIC QUADRIPLEGIA

• Legs>Arms
• Tone increased, early opisthotonus
• Supra nuclear bulbar palsy : articulation & swallowing
defect
• corticospinal tract involvement: brisk DTR, ankle clonus,
and extensor plantar signs.
• 33% walk after 3 yrs
• The incidence of auditory, visual, motor, and learning
disability is much higher
• Seizures
• 25% need total care
12
EXTRA PYRAMIDAL ATONIC
• Chorioathetoid • Tone reduced
• Dystonic • Posture near normal
• Ataxic
• Rigidity, tremor
• Inability to reach out

13
 ASSOCIATED FEATURES

• Myopia, Squint
• Hearing loss
• Aphasia, dysarthria, dyslalia
• Asteriognosis
• Intellectual Disability
• Behaviour abnormality
• Learning disorders
• Seizures

14
 COMPLICATIONS
Gastrointestinal and nutritional
•Failure to thrive (feeding and swallowing difficulties )
•Obesity
•Constipation
•Gastroesophageal reflux with associated aspiration
pneumonia
•Dental caries
Respiratory
•Increased risk of aspiration pneumonia
•Bronchial pulmonary dysplasia
•Bronchiolitis/asthma
Skin
• Decubitus ulcers and sores

15
 COMPLICATIONS: CONTINUED
• Orthopedic
– Contractures
– Hip dislocation
– Scoliosis
• Neurological
Seizures
• Cognitive/psychological/behavioral
– (ADHD)
– mental retardation
– specific learning disabilities
– Impact on academic performance and self-esteem
– Depression
– Autism
• Hearing loss (kernicterus)
• Vision
– Visual acuity decrease
– Visual field abnormalities due to cortical injury
– Strabismus
• Sensory integration difficulties

16
 DIAGNOSIS
Clinical :
• Must be early
• Mark out high risk cases
1. Abnormal Neonatal Neurological examination
2. Poor sucking/swallowing
3. Seizures
4. Apnea
5. Slow growth of head
6. Abnormal CT scan

17
 Approach
• Identify high risk cases
• Rule out progressive disease & neuro-degenerative
disease
• Establish diagnosis
• Assess motor ability: Gross Motor Function
Classification System (GMFCS)
• Classification of CP
• Assess for associated problems

18
 Follow-up High Risk Cases
• General Examination
• Neurological assessment: specially tone
• Development assessment
• Hearing
• Vision

19
 INVESTIGATIONS
• USG Brain: within 24hrs,then after 4-7 ds in preterm &14 ds
in term
• CT Brain: moderate/prolonged encephalopathy, seizures.
2nd CT at 2-6wks
• MRI
• EEG
• BERA
• Regular EYE checkup with Fundus examn
• Thyroid function tests
• Metabolic screen
• Chromosomal study

20
 MANAGEMENT
EARLY INTERVENTION:
the key to success
• Breaking the news :
a full account of the condition and possible associated
problems should be explained. A follow up visit planned
within next few days
• Comprehensive Assessment:
Assess the functional capacity of the child (GMFCS)
Functionally oriented treatment goals set tailored to the
needs of the individual child should be planned.
21
 Multi-Disciplinary Approach
Team comprising of
• Neuro-developmental pediatrician(team-leader)
• physiotherapist
• occupational therapist
• clinical psychologist
• speech pathologist
• orthopedic surgeon
• otorhinolaryngologist
• ophthalmologist
• teacher
• play therapist
• social worker
• MOTHER : the pivot
preferably under one roof
22
 Drugs:
• Baclofen- acts at the level of spinal cord neurons and
enhances GABA activity.
(1.25 - 2.5 mg BD orally and increased gradually upto a
maximum of 30 mgm/day, not recommended in children with
seizures
• Diazepam-small dose given half an hour before PT
• Tizanidine: an alpha 2 adrenergic agent
• Dantrolene sodium: acts on calcium channels
• Botulinum Toxin
• Levo-dopa: for relief of athetosis and dystonia
• Carbamezepine or trihexyphenidyl : for dystonia

23
 SURGERY
• Dorsal rhizotomy
• Laminectomy (L2-Si)
• Tendon lengthening and transfer and
arthrodesis
• Thalamotomy for athetoid CP
• Stereotactic dentatomy and chronic cerebellar
stimulation via implanted electrodes have
been tried
24
 Management of Associated Problems
• Epilepsy : Anticonvulsants
• Speech and Hearing Problems
• Visual Problems: Early corrective intervention by
ophthalmologist
• Feeding and Nutrition Dietary modification with a high fibre
diet and plenty of fluids are helpful.

• Excessive Salivation: Oral exercises. Atropine and benztropine

• Behaviour problems- Some children have aggression,
hyperactivity and destructive behaviour. Behaviour
modification techniques and parental counselling are
helpful.Drugs include stimulants like methylphenidate,
antipsychotics like haloperidol, and other pharmacological
agents.
• Sleep Problems: chloral hydrate, Melatonin 2 mg

25