CEREBRAL

PALSY

Semester 10
Most Common Permanent
Disability of Childhood
 • In 1860s, known as

"Cerebral Paralysis” or
“Little’s Disease”

• After an English surgeon

•  Little believed that cerebral

palsy resulted from post-partum
asphyxia, which distorted the
blood flow and in this way
damaged the child's brain

WILLIAM JOHN
LITTLE
(1810-1894)
 MODERN DEFINITION OF CP
• A persistent, but not unchanging disorder of movement and
posture due to a non progressive disorder of the immature brain
(that is, under two years of age)

 Cerebral" refers to the brain

 "Palsy" to a disorder of movement or posture

 Gr. para- beyond lysis – loosening
 Lack of muscle control

Cerebral Palsy is an injury to the brain (cerebral) causing the muscles not
to work in a normal way (palsy)
 CEREBRAL
PALSY

A motor function disorder

 caused by permanent, non-progressive brain lesion
 present at birth or shortly thereafter(Mosby, 2006)

Non-curable, life-long condition

According to a recent definition CP “describes a group of permanent disorders
of the development of movement and posture, causing activity limitation, that
are attributed to non-progressive disturbances that occurred in the developing
fetal or infant brain
The motor disorders of cerebral palsy are often accompanied by disturbances
of sensation, perception, cognition, communication, and behaviour; by
epilepsy; and by secondary musculoskeletal problems”
CEREBRAL PALSY

A Heterogenous Group
of Movement Disorders
 CAUSES
OF CEREBRAL PALSY
 An insult or injury to the brain

– Fixed, static lesion(s)

– In single or multiple areas of the motor
centers of the brain
– Early in CNS development Severe
deprivation of oxygen or blood flow to
the brain
– Hypoxic-ischemic
 ETIOLOGY
Prenatal(MC) Perinatal Postnatal

Iron def., poor –nut. Birth asphyxia •CNS infections

Inf, UTI, high fever Anoxia •Head injuries
Chorioamniotis Breach/vacuum/forcep •Seizures
delivery •Hypoxic damage
HTN, DM
Premature / LBW •Hyperpyrexia
Teratogens
IUGR damage
Rh + •Stroke
Hyper bilirubenemia
Twins
Intraventricular
Fetal vasculopathy hemorrrhage
Maternal drugs/smoking Sepsis, pneumonia,
Develop. Malformation, meningitis
 CLASSIFICATION OF
CP
According to:
1. Neurologic deficits
2. Type of movement involved
3. Area of affected limbs
 1. ACCORDING TO NEUROLOGIC
DEFICITS
• Based on the
- extent of the damage
- area of brain damage

• Each type involves the way a person moves

 3 MAIN TYPES
1. PYRAMIDAL
- originates from the motor areas of
the cerebral cortex
2. EXTAPYRAMIDAL
- basal ganglia and cerebellum

3. MIXED
 CLASSIFICATION BASED ON TOPOGRAPHICAL
DISTRIBUTION

• Monoplegia/monoparesis means only one limb is affected. It is believed this

may be a form of hemiplegia/hemiparesis where one limb is significantly
impaired.
• Diplegia/diparesis usually indicates the legs are affected more than the arms;
primarily affects the lower body.
• Hemiplegia/hemiparesis indicates the arm and leg on one side of the body are
affected.
• Paraplegia/paraparesis means the lower half of the body, including both legs,
is affected.
• Triplegia/triparesis indicates three limbs are affected. This could be both arms
and a leg, or both legs and an arm. Or, it could refer to one upper and one lower
extremity and the face.
• Quadriplegia/quadriparesis means that all four limbs are involved.
 SPASTIC CP
• Increased muscle tone,
tense and contracted muscles
• Have stiff and jerky or awkward movements
• limbs are usually underdeveloped
• increased deep tendon reflexes
• most common form
• 70-80% of all affected
 DIPLEGIA/ PARAPLEGIA

• both legs w/
•both legs
slight involvement
elsewhere
•May also have
Contractures of
hips and knees
•And talipes
equinovarus
(clubfoot)
HEMIPLEGIA
limbs on only one side
Hemiplegia on right side

 Hip and knee contractures

 Talipes equinus (“tip-toeing”
 -sole permanently
flexed)
 Asteriognosis may be present.
QUADRIPLEGIA
 Spastic Quadriplegia

Characteristic “scissors” positions of

lower limbs due to adductor spasms.
 ATHETOID/ DYSKINETIC CP
Fluctuating tone
 involves abnormal involuntary movements
 that disappear during sleep and increase with stress
 Interferes with speaking, feeding, reaching, grabbing,
and any other skills
20% of the CP cases, Wormlike movements

Slow, uncontrolled motion, writhing or twisting in

character in the face, extremities, and torso

Dystonia - when held as a prolonged posture

 drooling and dysarthria
 Adductor spasm
Athetoid
Two main types:

Choreo Athetosis
Dystonic Athetosis

• Movements may become

• choreoid (rapid, irregular, jerky)
• dystonic (disordered muscle tone,
sustained muscle contractions)
• Both have uncontrolled
involuntary movements
throughout the body, including
the facial muscles
 TYPES OF ATHETOID CP
• Athetoid cerebral palsy may be given other distinctions to further classify the
condition based on the specific type of involuntary movement.
• The various types of athetoid CP include:
• Dystonia – Slow, rotational movement of the torso, arm or leg.
• Chorea – Sudden involuntary movements, especially in fingers and toes.
• Athetosis – Sluggish, writhing movements, mainly in fingers and face.
• Choreoathetoid – A combination of chorea and athetosis.
• Ataxia – Loss of balance and coordination.
• Rigidity – High muscle tone due to hypertonia causes restricted movement.
• Dyskinesia – General term to describe involuntary movements. Athetoid CP is often
interchangeably referred to as dyskinetic CP for this reason.
 ATAXIC CP
Poor balance and lack of
coordination
 Wide-based gait
 Depth perception usually
affected.
 Tendency to fall and stumble
 Inability to walk straight line.
 Intention tremor
 Difficulty in judging distance
 Difficulty with quick movements
 Difficulty with precise movements

 Least common 5-10% of cases

 MIXED CP

• A common combination is

spastic and athetoid

• Spastic muscle tone and involuntary movements.

• 25% of CP cases, fairly common

 DEGREE OF SEVERITY

1. Mild CP- 20% of cases

2. Moderate CP- 50%

- require
self help for assisting their impaired
ambulation capacity.

3. Severe CP- 30%;

-totally incapacited and bedridden and they
always need care from others.
 DENVER TEST II

• Developmental Screening Test

• Cover 4 general functions:
• personal social (eg. smiling),
• fine motor adaptive (eg. grasping & drawing)
• language (eg. combining words)
• gross motor (eg. walking)

Ages covered: from birth to 6 years

SIGNS AND SYMPTOMS;
DIAGNOSIS
of CEREBRAL PALSY
 HISTORY + EXAM
 Include all that may • Often admitted to hospitals for corrective surgeries
and other complications.
predispose an infant to
brain damage or CP – Respiratory status
– Motor function
 Risk factors – Presence of fever
 Psychosocial factors – Feeding and weight loss
 Family adaptation – Any changes in physical state
– Medical regimen

Posturing / Poor muscle control and strength

Oropharyngeal problems(drooling?swallowing?
feeding?)
Strabismus/ Squint
Tone (hyper-, hypotonia)Muscle strength testing
Evolutional maldevelopment
Reflexes (e.g. increased deep tendon)
 d.
e.
c.

f.
b.

g.
a. h.
 EARLY SIGNS
Infancy (0-3 Months)
• Stiff or floppy posture
• Excessive lethargy or irritability/ High pitched cry
• Poor head control
• Weak suck/ tongue thrust/ tonic bite/ feeding difficulties
 CHILD WITH CP

c h l
a t a
re en
to m
ow o p es
Sl e l n
v o
de lest
i
m
 ABNORMAL DEVELOPMENTAL
PATTERNS AFTER 1 YEAR OF AGE:

• “W sitting” – knees flexed,

legs extremely rotated

• “Bottom shuffling” Scoots along the floor

• Walking on tip toe or hopping
ASSOC. CONDITIONS
Hearing and visual problems
Sensory integration problems
Failure-to-thrive, Feeding
problems
Behavioral/emotional
difficulties,
Communication disorders
• Bladder and bowel control
problems,
• digestive problems
(gastroesophageal reflux)
• Skeletal deformities, dental
problems
• Mental retardation and
learning disabilities in some
• Seizures/ epilepsy
 DIAGNOSIS
• Physical evaluation, Interview
• MRI, CT Scan EEG
• Laboratory and radiologic work up
• Assessment tools
• i.e. Peabody Development Motor Skills,
Denver Test II
 TREATMENT
OF CEREBRAL PALSY
 TREATMENT
STRATEGIES
• There are several categories of conditions associated with cerebral
palsy, including:
• Primary conditions
• Secondary conditions
• Associative conditions
• Co-mitigating Factors
 CONT..
• Primary conditions or symptoms of cerebral palsy include impaired
motor control (gross, fine and oral), impaired motor coordination
and poor muscle tone, balance and posture
 CONT…
• Secondary Conditions
• Secondary conditions are the result of primary conditions and are
only present because of the cerebral palsy.

• Secondary conditions often associated with CP include difficulty

feeding and swallowing, poor nutrition and respiratory issues,
among other
 CONT..
• Associative Conditions
• Associative conditions are those that commonly co-occur
with cerebral palsy, but are not caused by the same brain
injury or malformation.
• Associative conditions of CP hearing impairment (these
can be secondary conditions in some cases),
intellectual and learning disabilities, and epilepsy,
among others.
• Co-mitigating Factors
CONT…

• Co-mitigating factors are conditions that are unrelated to

cerebral palsy. These conditions often coexist with cerebral
palsy, but the reason why is not yet known. Co-mitigating
factors of cerebral palsy.(autism and ADHD)
- No treatment to cure cerebral palsy.
- Brain damage cannot be corrected.

• Crucial for children with CP:

• Early Identification;
• Multidisciplinary Care; and
• Support
I. Nonphysical Therapy

“ THE EARLIER WE START, THE MORE IMPROVEMENT CAN

BE MADE”

HEALTH WORKER
A. General management
- Proper nutrition and personal care

B. Pharmacologic
Intrathecal, Baclofen
- control muscle spasms and seizures,
Glycopyrrolate -control drooling
Pamidronate -may help with osteoporosis.
 BACLOFEN
Oral delivery was common but sedation is more, so Intrathecal Baclofen
Using a pump Delivered directly to the spinal fluid
GABA agonist – inhibits release of excitatory neurotransmitter at level
of spinal cord.

It is commonly used in a starting dose of 1.25 - 2.5 mg BD orally

To avoid brain effects
C. Surgery
Orthopedic Procedures
Usually multiple deformities at different joints
• To loosen joints,
-Relieve muscle tightness,
- Straightening of different twists or unusual curvatures of leg muscles
- Improve the ability to sit, stand, and walk.
 Walker cp

D. Physical Aids

Orthosis, braces and splints

- Keep limbs in correct
alignment
- Prevent deformities.
- Ankle foot orthosis, knee
ankle foot orthoses

Positioning devices
-Enable better posture

Walkers, special
wheelchairs
- make it easier to move
about.
Active exercises
- Passive ROM exercises
- Passive stretching
- Bracing
Spiral thigh brace
 E. Special Education Rehabilitation

- To meet the child's special needs

- Improve learning.

- Vocational training can help prepare young adults

for jobs
H. Other Treatment

- Therapeutic electrical stimulation,

- Massage Therapy might help
 
THANKS