Cerebral Palsy is a STATIC encephalopathy and may
be defined as a non-progressive disorder of posture
and movement, often associated with epilepsy and
abnormality of speech, vision and intellect resulting
from a defrct or lesion of the developing brain.
MAGNITUDE OF THE PROBLEM
• Cerebral palsy is the most common cause of chronic motor
disability that begins in childhood.
• It is difficult to estimate the precise magnitude of the problem
since milder cases are likely to be missed.
• It is the most common childhood physical disability
and affects 2 to 2.5 children per 1,000 born in the
• The exact incidence and prevalence from our country
is not known.
Idiopathic (no known cause of damage to brain during pregnancy) - is the
most common cause.
CP could be classified on the basis of underlying cause of cerebral palsy-
BLEEDING IN THE 3RD TRIMESTER
CNS INFECTIONS (MENINGITIS, ENCEPHALITIS)
Head trauma from shaken baby syndrome (child abuse)
during the 1ST year of life
Lead poisoning during the 1st two years of life
This is determined on the basis of the nature of the
movement disorder, muscle tone, and anatomic
A single patient may have more than one
type. Spastic CP is the most common, accounting for
about two thirds of cases.
Pyramidal (or spastic) CP: This type is characterized
by neurologic signs of upper motor neuron damage
with increased "clasp knife" muscle tone, increased
deep tendon reflexes, pathologic reflexes, and spastic
Extrapyramidal (nonspastic or dyskinetic) CP: This
type is characterized by prominent involuntary
movements or fluctuating muscle tone, with
choreoathetosis as the most common subtype.
Distribution is usually symmetric among the four limbs.
• Hypotonic CP: This type manifests as generalized
muscle hypotonia that persists with normal or increased
deep tendon reflexes. Many patients with this condition
develop cerebellar deficits of incoordination and ataxia,
and about one third of patients have severe retardation.
• Ataxic CP: Primarily cerebellar signs are seen.
• Mixed types
This is based on which limbs are involved.
• Monoplegia – Only one limb is involved.
• Paraplegia – Both the legs are involved
• Hemiplegia – Both upper and lower limbs are
involved on one side
• Triplegia – Three limbs are involved
• Quadriplegia – all the four limbs are involved
• Diplegia – The lower limbs are more involved
than the upper limbs.
GROSS MOTOR FUNCTIONAL CLASSIFICATION
EARLY SIGNS OF CEREBRAL PALSY
Paucity of movement or excessive
& disorganized movements
Persistent tone abnormalities
Hyperextension of head & neck
Consistent fisting of hands
beyond 2 months
Delayed social smile
Reduced growth of head size
Early sign of hand preference in
the 1st yr of life
Persistent moro’s reflex beyond
6months of age
• Involvement of the arm and leg on one side of the body
• Upper extremity more severly involved
• Constitutes 20% of cases with spastic CP
• Manifests from 4th month – 2nd yr of life
• Incomplete Moro’s or Premature development of
handedness could be early symptom
• M/C form of CP
• Functional prognosis good as compared to other
• Underdevelopment of affected side is common
• Will crawl with affected arm tucked under the trunk
and pushing self with the sound arm
• Cortical thumb
• Patients with diplegia have motor abnormalities in all four
extremities, with the lower extremities more affected
than the upper.
• The close proximity of the lower extremity tracts to the
ventricles most likely explains the more frequent
involvement of the lower extremities with periventricular
• The child uses the arms in a normal
reciprocal fashion but tends to drag
the legs behind more as a rudder
(commando crawl) rather than using
the normal four-limbed crawling
• If the spasticity is severe, application
of a diaper is difficult because of the
excessive adduction of the hips.
• Spastic quadriplegia is the most severe form of CP because of marked
motor impairment of all extremities and the high association with
mental retardation and seizures.
• In quadriplegia, all four extremities are equally involved, and many
patients have significant cognitive deficiencies that make care more
• Head and neck control are usually present, which helps with
communication, education, and seating.
• Athetoid cerebral palsy is less common than spastic
• This type is most likely to be associated with birth
• It is caused by an injury to the extrapyramidal tracts
and is characterized by dyskinetic, purposeless
movements that may be exacerbated by
• The clinical picture varies based on the level of
excitement of the patient. In pure athetoid cerebral
palsy, joint contractures are uncommon.
• Affected infants are characteristically hypotonic with poor head
control and marked head lag and develop increased variable tone
with rigidity and dystonia over several years.
• Feeding may be difficult, and tongue thrust and drooling may be
• Speech is typically affected because the oropharyngeal muscles are
• Seizures are uncommon, and intellect is preserved in many patients.
• The trunk muscles and the proximal portion of the limb
muscles are predominantly affected.
• Movements may be slow and persistent.
• Abnormal movements invoving the head and neck area.
• Hypotonicity of lower limb muscles.
• Arms may have near normal strength and coordination.
• Often associated with slow attainment of motor
• Manifestations of both spastic and extrapyramidal
• Often an ataxic component is present.
• Have mild to moderate degree of choreoathetosis.
Cerebral palsy can be diagnosed using Levine (POSTER)
criteria. POSTER stands for –
P - Posturing/abnormal movements
O - Oropharyngeal problems (e.g., tongue thrusts, swallowing
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
• In a child with cerebral palsy motor deficit is always
• The usual presenting complaint is that child is not reaching
motor milestones at the appropriate age.
• Medical history establishes that the child is not losing
• This history, combined with a neurologic examination
establishing that motor deficit is due to a cerebral
abnormality, establishes the diagnosis of cerebral palsy.
• Serial examinations may be necessary if the history is
• Other causes of neonatal hypotonia include muscular
dystrophies, spinal muscular atrophy, Down's
syndrome, spinal cord injuries.
Laboratory tests are not necessary to establish the
diagnosis. Workup is helpful for assessment of recurrence
risk, implementation of prevention programs, and medico
Metabolic and genetic testing should be considered if on
follow-up the child has -
• Evidence of deterioration or episodes of metabolic
• No etiology determined by neuroimaging
• Family history of childhood neurologic disorder associated
with cerebral palsy
• Developmental malformation on neuroimaging
• An EEG should be obtained when a child with cerebral
palsy has a history suggestive of seizures.
• Children with cerebral palsy should be screened for
ophthalmologic and hearing impairments, speech and
• Nutrition, growth, and swallowing function should be
• Neuroimaging is recommended if the etiology has not
been established previously; for example, by
• MRI, when available, is preferred to CT scanning
because of higher yield in suggesting an etiology, and
timing of the insult leading to cerebral palsy.
What other conditions are associated
with cerebral palsy?
Neurological problems associated with cerebral palsy
• Seizures and epilepsy ( As many as half of all
children with CP have one or more seizures.)
• Behavior problems
• Mental retardation ( Mental impairment is more
common among those with spastic quadriplegia than
in those with other types of cerebral palsy.)
• Communication disorder
• Gastroesophageal reflux
• Tooth decay and gum disease
• Bladder control problems
• Spinal deformities and osteoarthritis (Spinal deformities
can make sitting, standing, and walking difficult and cause
chronic back pain. Pressure on and misalignment of the joints
may result in osteoporosis)
• Contractures. Muscles can become painfully fixed
into abnormal positions, called contractures, which
can increase muscle spasticity and joint deformities in
people with CP.
• Frequent fractures
A LARGE AND EXTENSIVE CARE TEAM
SURROUNDS THE FAMILY WITH A
CHILD WHO HAS CEREBRAL PALSY.
• These care providers are roughly organized around
the educational system, primary medical care
provider, the cerebral palsy specialized medical team,
and community support services.
Significant overlap and good communication provide
the best resources to the child and the family.
• Because of the heterogeneous nature of cerebral
palsy, it is difficult to make generalized statements
regarding treatment, and it is best to have an
individualized approach to each patient and his or
Four basic treatment principles exist -
• The first is that although the central nervous system injury,
by definition, is nonprogressive, the deformities caused by
abnormal muscle forces and contractures are progressive.
• The second, which can be a source of frustration, is that
the treatments currently available correct the secondary
deformities only and not the primary problem, which is the
• The third is that the deformities typically become worse
during times of rapid growth. For some patients, it may be
beneficial to delay surgery until after a significant growth
spurt to decrease the risk of recurrence.
• The fourth is that operative or nonoperative treatment
should be done to minimize the impact it has on the
patient's socialization and education.
There are various ways to modify the home environment so
that your child will have more independence and things will
be easier on parents too. Example-
• Replace doorknobs with lever door handles.
• Replace entrance steps with ramps.
• Install a hinged arm support for help with toileting.
• Rearrange furniture in order to remove obstructions.
CHOOSING APPROPRIATE SEATING
Strollers, feeding chairs, tumble form sets, headrests,
seating supports, and corner chairs—all of these are
forms of adaptive seating that may benefit children with
PRESSURE MANAGEMENT AWARENESS
For children who use wheelchairs, the need to change
positions or relieve pressure, particularly on their
buttocks or ischial tuberosities, is critical. If is not
relieved, skin breakdown or pressure sores can occur.
If the child is not standing between 18 and 24 months, it is
necessary to start a child standing even when she does not
have adequate head or upper body control to stand alone.
Standing is important because
it allows the child to do some
weight bearing through the
legs, which in turn helps make
the bones stronger and
stimulates the development of
motor coordination and head
WALKERS AND GAIT TRAINERS
• There are no absolute indicators for initiating the use
of a walker.
• If child is able to hold up head independently, sitting
in a chair with minimal support, and being able to
stand and accept weight through the legs are a few of
the basics that are needed.
• These specialized techniques encourage active use of
appropriate muscles and diminish involvement of muscles
not necessary for the completion of a task.
• Improvements in efficiency can include decreased
energy used during a task, decreased work required
of the muscles during a task, and habituation of new
patterns of movement.
• Occupational, speech, and physical therapists as well
as educators can use NDT.
Muscle strength is related to motor performance and should
be an integral part of a rehabilitation program that addresses
other impairments which inhibit motor performance in this
population, such as muscle–tendon shortening, spasticity,
and coordination deficits.
The North American Riding for the
Handicapped Association (NARHA) has
defined hippotherapy as “The use of the
movement of a horse as a tool by
therapists to address impairments,
functional limitations and disabilities in
patients with neuro musculoskeletal
• The relief of hypertonus in the spastic type of CP is one of the major
advantages of aquatic therapy.
• When a body is immersed in warm water (92°to 96°F), its core
temperature increases, causing reduction in gamma fiber activity,
which in turn reduces muscle spindle activity, facilitating muscle
relaxation and reducing spasticity, thus resulting in increased joint
range of motion and consequently creating better postural
A great way to start gait
training, especially after
surgical procedures, is pool
walking. This means the pool
needs to have handles
available in the water at the
M.O.V.E. (MOBILITY OPPORTUNITIES VIA
• It is an activity-based curriculum designed to teach individuals
basic functional motor skills needed for adult life.
• The MOVE curriculum provides a framework for teaching the skills
necessary for individuals with disabilities to gain greater physical
• Physical and occupational therapies are useful for promoting
mobility and the use of the upper extremities for activities of
• Speech language pathologists promote acquisition of a
functional means of communications.
• Communication skills may be enhanced by the use of
Bliss symbols, talking typewriters, electronic speech
generating devices, and specially adapted computers
including artificial intelligence computers to augment
motor and language function.
• Several oral medications have been used to reduce tone, including
diazepam, baclofen, dantrolene, tizanidine, and clonidine.
• Although they can decrease spasticity, their sedating side effects
are not well tolerated in Children.
• Intrathecal baclofen has been shown to reduce spasticity with
fewer side effects.
INTRATHECAL BACLOFEN PUMPS
• Use of intrathecal baclofen in the
pediatric patient having CP has
yielded as good a reduction in
tone as dorsal rhizotomy and
does not represent an ablative
procedure. This is important
because, unlike rhizotomies, it is
• GABA agonist -Acts on spinal cord neurons
• inhibits release of excitatory neurotransmitter at level of
• Dose : 2 mg/kg/day, can be given intrathecally
• ADR : hypotonia of trunk muscles, dec alertness, dec
appetite, vomiting, aggravates epilepsy
• Withdrawal: Rebound spasticity
BOTULINUM TOXIN A (BTA)
• Blocks acetylcholine release, with a loss of motor
• Effect – 3 to 4 months
• Multiple site intramuscular injections for selected
• Effective only for dynamic spasticity
• Helps delay surgery beyond 8 yrs of age
• ADR : painful injection
• systemic effects- laryngeal weakness, bladder
Upper Extremity Procedures
1. Shoulder Adductor, Extension, and External Rotator Lengthening
2. Humeral Derotation Osteotomy (in patients with severe abduction external rotation
3. Elbow Flexion Contracture Release
4. Pronator Release or Transfer
5. Flexor Carpi Ulnaris Transfer for Wrist Flexion Deformity
6. Proximal Row Carpectomy and/or Wrist Fusion
7. Thumb Adductor Lengthening
A rhizotomy procedure in which the roots of the spinal nerves
are divided produces considerable improvement in selected
patients with severe spastic diplegia.
1. Posterior Spinal Fusion with Unit Rod
2. Anterior Spinal Release
• Hip Procedures- Iliopsoas Lengthening, Adductor and
Iliopsoas Lengthening with Proximal Hamstring Lengthening.
• Knee Operative Procedures- Hamstring Lengthening
• Foot and Ankle Procedures- Gastrocnemius Lengthening,
Tendon Achilles Lengthening
MANAGEMENT OF ASSOCIATED CONDITIONS
Strabismus is normally treated by correcting the visual
acuity in each eye, either with glasses or by patching. If a
significant strabismus remains even after these
therapies, then surgery is indicated.
Problems: Tongue thrusting
Drooling of saliva
Risk of aspiration
Mgt: Upright position during and after feeds
Thickening of feeds
Drugs - antacids, prokinetics, H2 blockers
Antireflux surgery – fundoplication
For sialorrhea - glycopyrrolate
• Constipation –
Risk of acquired megacolon
Increased fluid intake, varied diet, lactulose, enema
• Incontinence –
Patient toilet training may be attempted according to
stage of development