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Cerebral palsy

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A little bit of information on cerebral palsy and its management.

Published in: Health & Medicine
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Cerebral palsy

  1. 1. Nakhieeran Nallasamy Azreen Onny Nirmalatiban Parthiban (The Expert)
  2. 2. • Abnormality of movement and posture, causing activity limitation attributed to non-progressive disturbances that occurred in the developing fetal or infant brain • Most common cause of motor impairment in children – 2 per 1000 live births • CP term - Brain injuries up to 2 years of age • <2 - Acquired brain injury as diagnosis • Underlying cause is static - resulting motor disorder may evolve -> deterioration
  3. 3. • Motor disorders accompanied by: – Cognition – Communication – Perception – Sensation – Behaviour & seizure disorder – Secondary MSK problems • Diagnosis: – Distribution of the motor disorder – Movement type – Cause – Any associated impairment
  4. 4. Spastic CP • Damage to upper motor neurone (pyramidal/corticospinal tract) pathway • Limb tone is persistently increased (spastic) a/w: • Brisk deep tendon reflexes • Extensor plantar responses • Spastic tone – velocity dependent -> dynamic catch • May suddenly yield under pressure - ‘clasp knife’
  5. 5. • Limb involvement – unilateral or bilateral (asymmetrical signs) • Spasticity – present early; can even be seen in the neonatal period • Sometimes -> initial hypotonia, esp. head & trunk • THREE main types of spastic CP: – Hemiplegia – Quadriplegia – Diplegia
  6. 6.  Hemiplegia • Unilateral involvement of arm and leg (Arm>Leg; Face spared) • Often present at 4-12 months with: – Fisting of the affected hand – Flexed arm; Pronated forearm – Asymmetric reaching or hand function – Subsequently -> tip-toe walk (toe-heel gait) • Initially flaccid & hypotonic, but increased tone becomes the predominant sign • In some, caused by neonatal stroke; strokes -> hemianopia
  7. 7.  Quadriplegia • All four limbs; often severe • Trunk – opisothonus, poor head control, low central tone • Severe CP a/w seizures, microcephaly and moderate or severe intellectual impairment  Diplegia • All four limbs (Leg>Arm) -> Hand function normal • Motor difficulties in arms -> functional use of hands • Walking is abnormal • a/w preterm birth due to periventricular brain damage
  8. 8. Dyskinetic CP • Damage to the basal ganglia 1. Chorea 2. Athetosis 3. Dystonia
  9. 9. Chorea Definition • “Dance-like” irregular, involuntary, brief and abrupt movements Features • Mild: Fidgety, clumsy • Severe: Wild, violent movements with large amplitude (“Ballism”) • Speech, movement and swallowing disturbances
  10. 10. Athetosis Definition • Slow writhing movements occurring more distally (Fanning of fingers) Features • Fluctuations of muscle tones • Activities using hand and feet disturbed • Muscles of face and tongue may be affected (grimacing, drooling, speech, breathing, swallowing problem) • Worsen when moving and emotional stress
  11. 11. Dystonia Definition • Simultaneous contraction of agonist and antagonist muscles of the trunk and proximal muscles • “Twisting” appearance • 2 types: Focal and generalised Features • Repetitive and sustained movements • Awkward postures • Rapid or slow movements (painful) • Speech and swallowing difficulties (generalised) • Increase when tired, anxious, tense or emotional Sensory tricks Specific movements or sensations which may suppress the unwanted movements  Example; = Touching face or chin with hand or finger
  12. 12. Choreoathetoid CP Definition • Chorea + Athetosis • Abnormal, uncontrollable, writhing movements of arms and legs Features • Variable muscle tone (common: hypotonia) • Activated by stress, laughing or attempt to move
  13. 13. Ataxic (Hypotonic) CP • Due to acquired brain injury (cerebellum and the connections) Features • Ipsilateral and symmetrical • Early trunk and limb hypotonia • Poor balance • Delayed motor development • Incoordination • Intention tremor • Ataxia
  14. 14. Cerebral Palsy Management Multidisciplinary approach Child development services Pediatrician -Investigation, diagnosis -Continuing medical management -Coordinating input from other agencies Physiotherapist -Balance and mobility (aids- motorised wheelchair/frame) -Postural maintenance -Prevention of joint contractures Speech and language therapist -Augmentation and alternative communication (Makaton sign) Occupational therapist -Activities of daily living (ADL)- feeding, washing, toileting , seating Psychologist -Cognitive testing -Behavior management -Education advice Specialist health visitor/Social worker - Helps coordinate MDT -Advocate for child and family
  15. 15. Clinical Multidisciplinary approach Rehabilitation Physiatrist -Rehabilitation medicine specialist -Management (sialorrhea, insomnia) Orthopedic surgeon -Correct structural deformities -Spasticity (tenotomy, a tendon-lengthening procedure) Neurologist and neurosurgeons -Treatment patients with seizures -Treat hydrocephalus, spasticity Geneticists -To rule out other disorders -Evaluate for genetic syndrome (dysmorphic features, multiple organ abnormalities) Gastroenterologist, nutritionist -manage feeding/swallowing difficulties, GERD, asses nutritional status Pulmonologists -Bronchopulmanory dysplasia Recurrent aspiration Pediatricians
  16. 16. Management of abnormal movements Target : spasticity, dystonia, myoclonus Baclofen -Orally or intrathecally to treat spasticity -gamma aminobutyric acid- to activate GABA Anticonvulsants (benzodiapenes, diazepam)- to treat myoclonus Phenol intramuscular neurolysis -Large muscles -Limited to nerves with motor innervation as it may result in sensory dysasthesia -To block nerve conduction Botulinum toxin -Treat for spasticity -Should be considered lower extremities -Allow range of motions -Blocks the release of acetylcholine
  17. 17. Intrathecal baclofen pump insertion -Placed in anterior abdominal wall and connects to a catheter to subarachnoid of spinal cord -Allows more local inhibition and fewer adverse effects than oral baclofen Selective dorsal rhizotomy -To treat for spaticity -Surgical ablation of sensory nerve roots. -It decreases spasticity by decreasing reflexive motor neuron activation -Targets nerves that do not receive gamma aminobutryic acid – cause of overfiring – hypotonia Stereotactic basal ganglia -May improve rigidity, tremor Orthopedic surgical team -Scoliosis and hip dislocation are common require surgery -Tendon lengthening-spastic muscle imbalance -Osteotomy to realign limbs-femoral neck, tibia -Reconstructive surgeries to release contractures, stabilize joints
  18. 18. THANK YOU!!!

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