cerebral palsy lecture notes

1. Lecture notes 4: Cerebral Palsy
Definition
 Cerebral palsy is a heterogeneousdisorderofmovementand posture that has a wide
variety ofpresentations,rangingfrom mildmotor disturbance to severe total body
involvement
Etiology/Risk factors
 Mainlydue to Obstetrical Reasons- Prenatal,Perinatal and Postnatal Injury
 Prenatal
o Long menstrual cycle
o Previouspregnancyloss
o Previouslossof newborn
o Maternal mental retardation
o Maternal thyroiddisorder,especiallyiodinedeficiency
o Maternal seizure disorder
o childweighinglessthan2000 g at birth
o deliveringachildwithamotor deficit,mentalretardation,ora sensorydeficit
 Perinatal
o Prematurity
o Chorioamnionitis (inflammationdue toinfection)
o Nonvertex andface presentationof the fetus (the Positionof the babywhenits
labor)
o Birthasphyxia(umbillical cordwrappedaroundthe fetal neck)
 Postnatal
o Infections(eg,meningitis,encephalitis,TORCHSYNDROME)
o Intracranial hemorrhage (eg,due toprematurity,vascularmalformations,ortrauma)
o Periventricularleukomalacia(inpremature infants)
o Hypoxia-ischemia(eg,frommeconiumaspiration)
o Persistentfetalcirculationorpersistentpulmonaryhypertensionof the newborn
o Kernicterus

2.  Geographical Classification (Clinical Picture)
 Monoplegia
o One extremityisaffected
o involved,usuallylower
o VeryRare
Hemiplegia
o Both extremitiesonsame side involved
o Usuallyupperextremityinvolvedmore thanlowerextremity
o 30% patients
o Severe sensorychanges
o may have a leg-lengthdiscrepancy,with shorteningonthe affected
side
Paraplegia
o Both lowerextremitiesequallyinvolved
o VeryRare
Diplegia
o Both lowerextremitiesmore involvedthanupperextremities
o Fine-motor/sensoryabnormalitiesinupperextremity
o 50% patients

3. Quadriplegia
o All extremitiesinvolved EQUALLY
o Normal Headand NeckControl
Double Hemiplegia
o All extremities involved,uppermore thanlower
o Due to BleedinginBothHemispheresof the brain.
o If you compare thisto Diplegiaits lowermore thanupper**
Total Body
o All extremitiesseverelyinvolved
o No head/neckcontrol
o Needsalot of work,management
This woulddefinitelybe a question.Will give youthe diagrams and you will have to diagnose and
say what it is :)

4. PhysiologicClassification
o Spastic-80%, due to injuryatthe Pyrimidial tracts,Increase of M.Tone
o Athetoid- injurytoat the Extrapyramidial tracts,Dyskineticmovements, Increase of
M.tone/Dystonia.
o Choreiform-continual purposelessmovementsof the patient’s wrists,fingers,toes,and
ankles,bracingandsittingdifficult.( RememberTaylorswiftShake itoff :^)
o Ataxic-disturbance of coordinatedmovement,mostcommonlywalking,asaresultof an
injurytothe developingcerebellum
o Rigid-Hypertonicmuscles,Cogwheel/Leadpipe stiffness
o Hypotonic- Low tone muscles,difficultinsitting,balance,headpositioningand
communication.
Diagnosis
• History –Obstetrical Hx aswell,andFamilyHx.
• Clinical examination-See belowforthe reflexesetcetc.
• MRI/CT
• Coagulation- forinfarction
• EEG
• EMG/NerveConduction
Clinical Picture in General
o Bladder and bowel control problems,digestive problems
o (gastroesophageal reflux)
o Skeletal deformities, dental problems
o Mental retardation and learningdisabilitiesinsome
o Seizures/epilepsy
o Hearing and visual problems
o Sensoryintegration problems
o Failure-to-thrive,Feedingproblems
o Behavioral/emotional difficulties,
o Communicationdisorders
Physical Examination
You always needto assess:
– Reflexes
– Stationary
– Locomotion
– ObjectManipulation
– Grasping,
– Visual-MotorIntegration.

5. Criteria: 4/6 strongly point out to CP.
o Posturing/ Poor muscle control and strength
o Oropharyngeal problems
o Strabismus/ Squint
o Tone (hyper-,hypotonia)
o Evolutional maldevelopment
o Reflexes(e.g.increaseddeeptendon)
• Posture-Testhandstrengthbyliftingthe childoff the groundwhilethe childholdsthe
nurseshands.Observe forpresence of limbdeformity,asdecreaseduse of extremityleads
to shortening.
• Oropharyngeal -Speech,Swallowing,breathing,drooling,feedingpoorly
• Strabismus- presentor not?
• Tone- Hypertonic (rigid/Tense) ,Hypotonic(floppy/Flaccid)
• Moro Reflex-liftthe bae itwill feels as if it is falling.
• Placing Reflex-Edgeof the Table,babywill trytoplace itsfeetsonit
• Landau Reflex-holdbabyinhorizontal plane,ptwillliftthe headandextendthe neck.
• Visual Intergration- holdup a toy , pt cant touch itas theyare Ataxic- Cerebellum
Coordinationissues.
Treatment
o General management
- Propernutritionandpersonal care
o B. Pharmacologic
o Botox, Intrathecal, Baclofen
 control muscle spasmsandseizures,
o Glycopyrrolate -control drooling
o Pamidronate -may helpwithosteoporosis.
o C. Surgery
-To loosenjoints,
-Relieve muscletightness,
- Straighteningof differenttwistsor unusual curvaturesof legmuscles
- Improve the abilitytosit,stand,andwalk.
Physical Aids
Orthosis,braces and splints
Keeplimbsincorrectalignment

6. Preventdeformities.
Positioningdevices
-Enable betterposture
Walkers,special scooters,wheelchairs
- make iteasierto move about.