CP cerebral palsy

1. CEREBRAL
PALSY
Presentation prepared by:Presentation prepared by:
Dr Mohamed AbunadaDr Mohamed Abunada
ped neurology departmentped neurology department
Dr Al Rantisi specialized ped HospitalDr Al Rantisi specialized ped Hospital

2. UN ConventionUN Convention on the Rights of the Child.on the Rights of the Child.
1989.1989.
““A disabled child has the right toA disabled child has the right to
enjoy a full and decent life, inenjoy a full and decent life, in
conditions which ensure dignity,conditions which ensure dignity,
promote self-reliance and facilitate thepromote self-reliance and facilitate the
child’s active participation in thechild’s active participation in the
community.”community.”

4. Cerebral Palsy: DefinitionCerebral Palsy: Definition
 Cerebral palsy is aCerebral palsy is a static encephalopathystatic encephalopathy
 Encephalopathy =Encephalopathy = Brain InjuryBrain Injury that isthat is non-non-
progressiveprogressive disorder ofdisorder of posture and movementposture and movement
 Variable etiologiesVariable etiologies
 Often associated with epilepsy, speech problems,Often associated with epilepsy, speech problems,
vision compromise, & cognitive dysfunctionvision compromise, & cognitive dysfunction

5. Cerebral Palsy: Little’s DiseaseCerebral Palsy: Little’s Disease
 150 years ago described by Dr. Little an150 years ago described by Dr. Little an
orthopedic surgeon and known as Little’sorthopedic surgeon and known as Little’s
DiseaseDisease
 During past 3 decades ConsiderableDuring past 3 decades Considerable
advances made in obstetric & neonataladvances made in obstetric & neonatal
care, but unfortunately there hascare, but unfortunately there has
been virtually no change in incidentbeen virtually no change in incident
of CPof CP

6. StatisticsStatistics
 According to the United Cerebral PalsyAccording to the United Cerebral Palsy
Association an estimated 500,000 have cerebralAssociation an estimated 500,000 have cerebral
palsy.palsy.
 10-20% of children with cerebral palsy acquire the10-20% of children with cerebral palsy acquire the
disorder after birth.disorder after birth.
 The average lifetime cost for a person withThe average lifetime cost for a person with
cerebral palsy totals nearly $1 millioncerebral palsy totals nearly $1 million
 Cerebral palsy is the most common cause ofCerebral palsy is the most common cause of
childhood physical disability.childhood physical disability.

7. Age of onsetAge of onset
 The brain lesions of CP occur from the fetalThe brain lesions of CP occur from the fetal
or neonatal periodor neonatal period to up to age 3 yearsto up to age 3 years..
 Insults to the brainInsults to the brain afterafter age 3 years throughage 3 years through
adulthood may manifest clinically as similaradulthood may manifest clinically as similar
or identical to CP, but, by definition, theseor identical to CP, but, by definition, these
lesions are not CP.lesions are not CP.

8. Cerebral Palsy: ClassificationCerebral Palsy: Classification
 Various classifications of Cerebral PalsyVarious classifications of Cerebral Palsy
 PhysiologicPhysiologic
 TopographicTopographic
 EtiologicEtiologic

9. Types of CP Cerebral Palsy:Types of CP Cerebral Palsy:
PhysiologicPhysiologic
 Spastic CPSpastic CP 65%65%
– stiffnessstiffness
 Flaccid CPFlaccid CP 1%1%
– floppyfloppy
 Athetoid CPAthetoid CP 5%5%
– Fluctuating toneFluctuating tone
 Ataxic CPAtaxic CP 10%10%
– Unsteady; uncoordinatedUnsteady; uncoordinated
 Mixed CPMixed CP 12%12%
– Most common is spastic athetoidMost common is spastic athetoid

10. Classification of CPClassification of CP
 TopographicalTopographical ClassificationClassification (based on the location of the motor disability)(based on the location of the motor disability)
– 1.1. quadriquadriplegiaplegia
– 2.2. didiplegiaplegia
– 3.3. paraplegiaparaplegia
– 4.4. tritriplegiaplegia
– 5.5. hemihemiplegiaplegia
– 6.6. monomonoplegiaplegia

12. Spastic hemiplegic CPSpastic hemiplegic CP
One-sided upper motor neuron deficitOne-sided upper motor neuron deficit
30 % of all CP30 % of all CP
Arm generally affected more than legArm generally affected more than leg
50 % mentally retarded50 % mentally retarded
Oromotor dysfunctionOromotor dysfunction
Possible unilateral sensory deficitsPossible unilateral sensory deficits
Visual-field deficits and strabismusVisual-field deficits and strabismus
Seizures 33 %Seizures 33 %

13. Spastic hemiplegic CPSpastic hemiplegic CP

14. Spastic diplegic CPSpastic diplegic CP
 Upper motor neuron findings in the legs more thanUpper motor neuron findings in the legs more than
the armsthe arms
 UL:UL: gross motor OKgross motor OK
minor incoordination of fine motor skillsminor incoordination of fine motor skills
 Scissoring gaitScissoring gait
 Toe walking and flexed knees are commonToe walking and flexed knees are common
 Hip problems, dislocationsHip problems, dislocations
 Learning disabilities and seizures less commonlyLearning disabilities and seizures less commonly
than in spastic hemiplegiathan in spastic hemiplegia
 Speech / intellect:Speech / intellect: normal – slightly impairednormal – slightly impaired
 Strabismus (crossed eyes) are commonStrabismus (crossed eyes) are common
 Most walk independently by 4 yearsMost walk independently by 4 years

15. Spastic diplegiaSpastic diplegia
LL :
spastic :
hip: flexion,
adduction, int. rotation
knee: flexor / extensor
spasticity
ankle: equinus
foot: pes valgus

16. Spastic quadriplegic CPSpastic quadriplegic CP
 All limbs affected, either full-body hypertonia or truncalAll limbs affected, either full-body hypertonia or truncal
hypotonia with extremity hypertoniahypotonia with extremity hypertonia
 Oromotor dysfunctionOromotor dysfunction
 Increased risk of cognitive difficultiesIncreased risk of cognitive difficulties
 Often mentally retardedOften mentally retarded
 SeizuresSeizures
 Legs generally affected equally or more than armsLegs generally affected equally or more than arms
 Most ( 80 % ) non walkersMost ( 80 % ) non walkers
 Categorized as double hemiplegic if arms moreCategorized as double hemiplegic if arms more
involved than legsinvolved than legs

17. Spastic cerebral palsySpastic cerebral palsy

18. Ataxic CPAtaxic CP
 Accounts for 5% to 10% of cases.Accounts for 5% to 10% of cases.
 Loss of equilibriumLoss of equilibrium
 Poor muscle coordination or unsteady gaitPoor muscle coordination or unsteady gait
 Person appears intoxicatedPerson appears intoxicated
 It is caused by damage to the cerebellumIt is caused by damage to the cerebellum

19. Ataxic CP

20. Dyskinetic (extrapyramidal) CPDyskinetic (extrapyramidal) CP
 (athetoid CP, choreoathetoid CP, and dystonic CP)(athetoid CP, choreoathetoid CP, and dystonic CP)
 Early hypotonia with movement disorder emerging at ageEarly hypotonia with movement disorder emerging at age
1-3 years1-3 years
 Arms more affected than legsArms more affected than legs
 Deep tendon reflexes usually normal to slightly increasedDeep tendon reflexes usually normal to slightly increased
 Some spasticitySome spasticity
 Oromotor dysfunctionOromotor dysfunction
 Gait difficultiesGait difficulties
 Truncal instabilityTruncal instability
 Risk of deafness in those affected by kernicterusRisk of deafness in those affected by kernicterus

21. Cerebral Palsy:Cerebral Palsy: EtiologicEtiologic
 Prenatal (70%)Prenatal (70%) Maternal characteristicsMaternal characteristics
Infection, anoxia, toxic, vascular, Rh disease,Infection, anoxia, toxic, vascular, Rh disease,
genetic, congenital malformation of braingenetic, congenital malformation of brain
 Natal (5-10%)Natal (5-10%) (at the time of birth to 1mo)(at the time of birth to 1mo)
Anoxia, traumatic delivery, metabolicAnoxia, traumatic delivery, metabolic
 Post natalPost natal (in the first 5 months of life)(in the first 5 months of life)
Trauma, infection, toxicTrauma, infection, toxic

22. Prenatal causesPrenatal causes
 Hemorrhage/bleedingHemorrhage/bleeding
 InfectionsInfections
 Environmental factorsEnvironmental factors

23. Perinatal CausesPerinatal Causes
 High or low BPHigh or low BP
 Umbilical cord coilUmbilical cord coil
 Breech deliveryBreech delivery
 Oversedation of drugsOversedation of drugs
 Trauma i.e. forceps or vacuum deliveryTrauma i.e. forceps or vacuum delivery
 *** complications of birth*** complications of birth

24. Could malpractice cause cerebral palsy?Could malpractice cause cerebral palsy?
 If a mistake is made during the birth of an infant that was theIf a mistake is made during the birth of an infant that was the
cause of cerebral palsy doctors as well as nurses can because of cerebral palsy doctors as well as nurses can be
held accountable.held accountable.
 Many doctors and nurses do not know enough aboutMany doctors and nurses do not know enough about
cerebral palsy and this can result in devastating mistakescerebral palsy and this can result in devastating mistakes
and lawsuits if a mistake is made.and lawsuits if a mistake is made.
 While caring for the expectant mother and fetus, medicalWhile caring for the expectant mother and fetus, medical
providers are responsible for assuring adequate care duringproviders are responsible for assuring adequate care during
the pregnancy, during labor and delivery, and immediatelythe pregnancy, during labor and delivery, and immediately
after the delivery of the infant. When injury does occur duringafter the delivery of the infant. When injury does occur during
the birthing process, the results can be devastating.the birthing process, the results can be devastating.
 A cerebral palsy lawyer can help you determine if medicalA cerebral palsy lawyer can help you determine if medical
malpractice caused your child's cerebral palsy.malpractice caused your child's cerebral palsy.

25. Postnatal CausesPostnatal Causes
 Trauma, head injuryTrauma, head injury
 InfectionsInfections
 Lack of oxygenLack of oxygen
 Stroke in the youngStroke in the young
 Tumor, cystTumor, cyst

26. 4 CLINICAL SIGNS OF CP4 CLINICAL SIGNS OF CP
 1. Delays in motor skills1. Delays in motor skills
 2. Abnormal tone2. Abnormal tone
 3. Abnormal posture3. Abnormal posture
 4. Presence of primitive reflexes4. Presence of primitive reflexes
Clinical manifestationsClinical manifestations

27. Clinical manifestationsClinical manifestations
 Delayed gross motor developmentDelayed gross motor development
– A universal manifestation of CPA universal manifestation of CP
– The discrepancy between motor ability andThe discrepancy between motor ability and
expected achievement tends to increase asexpected achievement tends to increase as
growth advances.growth advances.
– Delayed development of ability to balance slowsDelayed development of ability to balance slows
milestonesmilestones
– Delay in all motor accomplishmentsDelay in all motor accomplishments

28. Clinical ManifestationsClinical Manifestations
 Abnormal motor performanceAbnormal motor performance
– Preferential unilateral hand use may be apparent at 6 months.Preferential unilateral hand use may be apparent at 6 months.
– Hemiplegia,Hemiplegia, abnormal crawling or asymmetrical crawl;abnormal crawling or asymmetrical crawl;
spasticityspasticity may cause child to walk and stand on toesmay cause child to walk and stand on toes
– dyskinetic CPdyskinetic CP or uncoordinated or involuntary movementsor uncoordinated or involuntary movements
(writhing tongue, fingers, and toes; facial grimacing), poor(writhing tongue, fingers, and toes; facial grimacing), poor
sucking and feeding, persistent tongue thrust; tremor onsucking and feeding, persistent tongue thrust; tremor on
reaching, truncal ataxia.reaching, truncal ataxia.

31. Alterations in muscle toneAlterations in muscle tone
 Increased or decreased resistance to passiveIncreased or decreased resistance to passive
movement (abnormal muscle tone).movement (abnormal muscle tone).
 Opisthotonic posturesOpisthotonic postures or exaggerated backor exaggerated back
arching, feel stiff on dressing.arching, feel stiff on dressing.
 Difficulty diapering due to spastic hip adductorDifficulty diapering due to spastic hip adductor
muscles and lower extremitiesmuscles and lower extremities
 When pulled to a sitting position, child may extendWhen pulled to a sitting position, child may extend
the entire body and be rigid at hip and knee. Thisthe entire body and be rigid at hip and knee. This
is anis an early sign of spasticity.early sign of spasticity.

32. Abnormal posturesAbnormal postures
 Children withChildren with spastic CP have aspastic CP have abnormal posture at rest orbnormal posture at rest or
when position is changedwhen position is changed
 Persistent infantile resting and sleeping position is a sign ofPersistent infantile resting and sleeping position is a sign of
spasticityspasticity..
 Hemiparetic child may rest with affected arm adducted,Hemiparetic child may rest with affected arm adducted,
with the elbow pronated and slightly flexed and the handwith the elbow pronated and slightly flexed and the hand
closed.closed.

34. Reflex AbnormalitiesReflex Abnormalities
 Persistence of primitive infantile reflexesPersistence of primitive infantile reflexes
((one of the earliest signs of CPone of the earliest signs of CP))
– Tonic neck reflexTonic neck reflex
– Hyperactivity or moro, plantar, palmar graspHyperactivity or moro, plantar, palmar grasp
Hyperreflexia, ankle clonus, stretch reflexes canHyperreflexia, ankle clonus, stretch reflexes can
be elicited from any muscle group.be elicited from any muscle group.

35. WARNING SIGNSWARNING SIGNS
 Physical SignsPhysical Signs
 poor head control after 3 monthspoor head control after 3 months
 stiff or rigid arms/legs, arching back, floppy or limpstiff or rigid arms/legs, arching back, floppy or limp
postureposture
 Cannot sit up without support by 8 monthsCannot sit up without support by 8 months
 Uses only one side of the body or only the arms toUses only one side of the body or only the arms to
crawlcrawl
 Behavioral SignsBehavioral Signs
 Extreme irritability or cryingExtreme irritability or crying
 Failure to smile by 3 monthsFailure to smile by 3 months
 Feeding difficultiesFeeding difficulties
– Persistent gagging or choking when fedPersistent gagging or choking when fed
– After 6 months of age, tongue pushes soft food out of theAfter 6 months of age, tongue pushes soft food out of the
mouth.mouth.

36. CEREBRAL PALSYCEREBRAL PALSY
SignsSigns
 Difficulty controllingDifficulty controlling
head when beinghead when being
picked uppicked up
 Stiff legs thatStiff legs that
crosses or scissorscrosses or scissors
when picked upwhen picked up
 Reaches with onlyReaches with only
one hand whileone hand while
keeping the other in akeeping the other in a
fistfist
 Crawls by pushingCrawls by pushing
off with one hand andoff with one hand and
leg while draggingleg while dragging
the opposite handthe opposite hand
and legand leg
 Cannot crawlCannot crawl
 Cannot stand withCannot stand with
supportsupport
More thanMore than 22
months oldmonths old
More thanMore than 66
months oldmonths old
More thanMore than 1010
months oldmonths old
More thanMore than 1212
months oldmonths old
* Seizures
* Muscle contractions
* Difficulty sucking or feeding
* Irregular breathing
* Delayed development of motor
skills, such as reaching, sitting,
rolling, crawling, walking, and so on
* Motormental retardation
* Mental retardation
* Speech problems (dysarthria)
* Visual problems
* Hearing problems
* Spasticity
* Joint contractures that slowly get worse
* Limited range of motion
* Peg teeth
SYMPTOMS

37. Associated disabilities and problemsAssociated disabilities and problems
 Intellectual impairmentIntellectual impairment
– 70% w/in normal limits; wide range70% w/in normal limits; wide range
– Tests should be carried out over a period of time.Tests should be carried out over a period of time.
– Children with athetosis and ataxia more intelligent.Children with athetosis and ataxia more intelligent.
– ADHD- (may occur) -poor attention span, markedADHD- (may occur) -poor attention span, marked
distractibility, hyperactive behaviordistractibility, hyperactive behavior
- Children with CP vary widely in their intellectual and learningChildren with CP vary widely in their intellectual and learning
capabilities.capabilities.
- Some will show the same intellectual capabilities as otherSome will show the same intellectual capabilities as other
children, in spite of their physical difficulties.children, in spite of their physical difficulties.
- Others will have some degree of intellectual disability,Others will have some degree of intellectual disability,
ranging from mild through to very significant.ranging from mild through to very significant.

38. Associated disabilities and problemsAssociated disabilities and problems
 Disorders of hearingDisorders of hearing
- People with cerebral palsy sometimes also have hearingPeople with cerebral palsy sometimes also have hearing
problems due to cortical injuryproblems due to cortical injury
- Infants lying flat too long may have otitis media which mayInfants lying flat too long may have otitis media which may
leads to conductive hearing lossleads to conductive hearing loss
 Hearing impairment occurs in approximately 12% of children
with CP.
 Occurs more commonly if the etiology of CP is related to
 very low birth weight,
 kernicterus,
 neonatal meningitis or
 severe hypoxic-ischemic insults.
 Children with CP who have MR or abnormal neuroimaging
studies are at greater risk for hearing impairment.

39. Associated disabilities and problemsAssociated disabilities and problems
 Disorders of VisionDisorders of Vision
 Visual impairments and disorders of ocular motility areVisual impairments and disorders of ocular motility are
common (28%) in children with CP.common (28%) in children with CP.
 There is an increased presence ofThere is an increased presence of
 strabismus,strabismus,
 amblyopia,amblyopia,
 nystagmus,nystagmus,
 optic atrophy, andoptic atrophy, and
 refractive errors.refractive errors.
 People with cerebral palsy may have squints (People with cerebral palsy may have squints (Strabismus)Strabismus) maymay
need surgery or corrective lensesneed surgery or corrective lenses
 Visual-field abnormalitiesVisual-field abnormalities due to cortical injurydue to cortical injury
 Retinopathy of prematurity (ROP), which may lead to retinalRetinopathy of prematurity (ROP), which may lead to retinal
detachment, will need surveillance throughout early adult life.detachment, will need surveillance throughout early adult life.

40.  Epilepsy:Epilepsy:

41. Associated conditions epilepsyAssociated conditions epilepsy
 Approximately 45% of children with CP developApproximately 45% of children with CP develop
epilepsy.epilepsy.
 In none of the retrospective studies involving 2014In none of the retrospective studies involving 2014
children was there evidence that the EEG waschildren was there evidence that the EEG was
useful in determining the etiology of the child’s CP.useful in determining the etiology of the child’s CP.
 There is no evidence to make any recommendationThere is no evidence to make any recommendation
whether an EEG should be ordered to screen forwhether an EEG should be ordered to screen for
epileptiform abnormalities for the child with CP whoepileptiform abnormalities for the child with CP who
does not have a history of seizures.does not have a history of seizures.
 An EEG should be obtained when a child with CPAn EEG should be obtained when a child with CP
has a history or examination features suggesting thehas a history or examination features suggesting the
presence of epilepsy or an epileptic syndrome .presence of epilepsy or an epileptic syndrome .

42.  Speech difficultiesSpeech difficulties
 Because the muscles of the mouth may be affected, someBecause the muscles of the mouth may be affected, some
people with cerebral palsy may find talking difficult.people with cerebral palsy may find talking difficult.
 Because of bilateral corticobulbar dysfunction in many CPBecause of bilateral corticobulbar dysfunction in many CP
syndromes, speech and other impairments related to oral-syndromes, speech and other impairments related to oral-
motor dysfunction are common.motor dysfunction are common.
 Some people may be mildly affected whilst others cannot saySome people may be mildly affected whilst others cannot say
any words at all.any words at all.
 Oral-motor problems including feeding difficulties, swallowingOral-motor problems including feeding difficulties, swallowing
dysfunction and drooling may lead to potential seriousdysfunction and drooling may lead to potential serious
impacts on nutrition and growth, oral health respiration andimpacts on nutrition and growth, oral health respiration and
self-esteem.self-esteem.
 People who cannot speak clearly may use a communicationPeople who cannot speak clearly may use a communication
board or electronic communication device.board or electronic communication device.

43.  Eating and drinking difficultiesEating and drinking difficulties
Cerebral palsyCerebral palsy may affect the muscles that open and closemay affect the muscles that open and close
the mouth and move the lips and the tongue. Somethe mouth and move the lips and the tongue. Some
children have difficulty chewing and swallowing certainchildren have difficulty chewing and swallowing certain
foods.foods.
 Failure to thriveFailure to thrive
 GERD and associated aspiration pneumoniaGERD and associated aspiration pneumonia
 ConstipationConstipation
Due to decreased MobilityDue to decreased Mobility
o difficulties with toileting may lead to constipationdifficulties with toileting may lead to constipation
o Difficult chewing bulky foods may lead to constipationDifficult chewing bulky foods may lead to constipation
o May need stool softeners or laxativesMay need stool softeners or laxatives
 DroolingDrooling
 Dental cariesDental caries

44.  Respiratory :Respiratory :
 Increased risk of aspiration pneumoniaIncreased risk of aspiration pneumonia
because of oromotor dysfunctionbecause of oromotor dysfunction
 Chronic lung disease/bronchopulmonaryChronic lung disease/bronchopulmonary
dysplasiadysplasia
 Bronchiolitis/asthmaBronchiolitis/asthma

45. SkinSkin :: Decubitus ulcers and soresDecubitus ulcers and sores
Orthopedic :Orthopedic :
 Unilateral or bilateral hip dislocations,Unilateral or bilateral hip dislocations,
 scoliosis,scoliosis,
 joint contractures due to unbalancedjoint contractures due to unbalanced
muscle tone.muscle tone.

46.  Mental retardation (30-50%)Mental retardation (30-50%)
 Attention-deficit/hyperactivity disorderAttention-deficit/hyperactivity disorder
 Learning disabilitiesLearning disabilities
 Impact on academic performance and self-esteemImpact on academic performance and self-esteem
 Increased prevalence of depressionIncreased prevalence of depression
 Sensory integration difficultiesSensory integration difficulties
 Increased prevalence of progressive developmentIncreased prevalence of progressive development
disorder or autismdisorder or autism
 Cognitive/psychological/behavioralCognitive/psychological/behavioral

47. INVESIGATIONSINVESIGATIONS
 The diagnosis of CP is generally madeThe diagnosis of CP is generally made
based on thebased on the clinical picture.clinical picture.
 The 2004 American Academy of NeurologyThe 2004 American Academy of Neurology
(AAN) practice parameter on CP suggests(AAN) practice parameter on CP suggests
laboratory studies if certain findings arelaboratory studies if certain findings are
presentpresent

48. HistoryHistory
 CP diagnosis begins with a history of grossCP diagnosis begins with a history of gross
motor developmental delay in the first yearmotor developmental delay in the first year
of lifeof life
 CP frequently manifests as early hypotoniaCP frequently manifests as early hypotonia
for the first 6 months to 1 year of life,for the first 6 months to 1 year of life,
followed by spasticity.followed by spasticity.

49. Prenatal historyPrenatal history
 Thorough history for maternalThorough history for maternal
diseases , medications ,diseases , medications ,
irradiation , prenatal care , previousirradiation , prenatal care , previous
abortions………abortions………

50. Perinatal historyPerinatal history
 gestational age ,gestational age ,
 presentation of the childpresentation of the child
 delivery type,delivery type,
 birth weight,birth weight,
 ApgarApgar score, andscore, and
 complications in the neonatalcomplications in the neonatal
period………...period………...

51. Developmental historyDevelopmental history
This should reviewThis should review
gross motorgross motor,,
fine motorfine motor,,
languagelanguage, and, and
social milestonessocial milestones from birth untilfrom birth until
the time of evaluation.the time of evaluation.

52. Current medical historyCurrent medical history
 This should include a review ofThis should include a review of
systems to evaluation for thesystems to evaluation for the
multiple complications that canmultiple complications that can
occur with CPoccur with CP

53. Summary of AAN recommendationsSummary of AAN recommendations
Diagnostic Assessment of the ChildDiagnostic Assessment of the Child
with Cerebral Palsywith Cerebral Palsy
1.1. Neuroimaging is recommended in the evaluation of a childNeuroimaging is recommended in the evaluation of a child
with CP if the etiology has not been established, for examplewith CP if the etiology has not been established, for example
by perinatal imaging (Level A, class I and II evidence).by perinatal imaging (Level A, class I and II evidence).
2.2. MRI, when available, is preferred to CT scanning because ofMRI, when available, is preferred to CT scanning because of
the higher yield of suggesting an etiology and timing of insultthe higher yield of suggesting an etiology and timing of insult
leading to CP (Level A, class I -III evidence).leading to CP (Level A, class I -III evidence).
3.3. Metabolic and genetic studies shouldMetabolic and genetic studies should notnot be routinelybe routinely
obtained in the evaluation of the child with CP (Level B, classobtained in the evaluation of the child with CP (Level B, class
II and III evidence).II and III evidence).

54. Summary of AAN recommendationsSummary of AAN recommendations
Diagnostic Assessment of the ChildDiagnostic Assessment of the Child
with Cerebral Palsywith Cerebral Palsy
4.4. If the clinical history or findings on neuroimaging doIf the clinical history or findings on neuroimaging do
not determine a specific structural abnormality or ifnot determine a specific structural abnormality or if
there are additional and atypical features in thethere are additional and atypical features in the
history or clinical examination, metabolic and genetichistory or clinical examination, metabolic and genetic
testing should be considered .testing should be considered .
5.5. Detection of a brain malformation in a child with CPDetection of a brain malformation in a child with CP
warrants consideration of an underlying genetic orwarrants consideration of an underlying genetic or
metabolic etiology .metabolic etiology .

55. Summary of AAN recommendationsSummary of AAN recommendations
Diagnostic Assessment of the ChildDiagnostic Assessment of the Child
with Cerebral Palsywith Cerebral Palsy
6.6. Because the incidence of unexplained cerebral infarctionBecause the incidence of unexplained cerebral infarction
seen with neuroimaging is high in children with hemiplegicseen with neuroimaging is high in children with hemiplegic
CP, diagnostic testing for a coagulation disorder should beCP, diagnostic testing for a coagulation disorder should be
considered . There is insufficient evidence to be precise asconsidered . There is insufficient evidence to be precise as
to what studiesto what studies should be ordered.should be ordered.
7.7. An EEG should not be obtained for the purpose ofAn EEG should not be obtained for the purpose of
determining the etiology of CP .determining the etiology of CP .

56. Summary of AAN recommendationsSummary of AAN recommendations
Diagnostic Assessment of the ChildDiagnostic Assessment of the Child
with Cerebral Palsywith Cerebral Palsy
8.8. An EEG should be obtained when a child with CPAn EEG should be obtained when a child with CP
has a history or examination features suggesting thehas a history or examination features suggesting the
presence of epilepsy or an epileptic syndrome .presence of epilepsy or an epileptic syndrome .
9.9. Because of the high incidence of associatedBecause of the high incidence of associated
conditions, children with CP should be screened forconditions, children with CP should be screened for
mental retardation, ophthalmologic and hearingmental retardation, ophthalmologic and hearing
impairments, and speech and language disorders .impairments, and speech and language disorders .
10.10. Nutrition, growth, and other aspects of swallowingNutrition, growth, and other aspects of swallowing
dysfunction should be monitored.dysfunction should be monitored.
Further specific evaluations are warranted if screeningFurther specific evaluations are warranted if screening
suggests areas of impairment.suggests areas of impairment.

58. Diagnostic ProceduresDiagnostic Procedures
 InterviewInterview
 Physical evaluationPhysical evaluation
 MRIMRI
 CT ScanCT Scan
 EEGEEG
 Laboratory and radiologic work upLaboratory and radiologic work up
 Assessment tools i.e. Peabody DevelopmentAssessment tools i.e. Peabody Development
Motor Skills, BruininxMotor Skills, Bruininx

59. DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
 CP is a diagnosis of exclusion.CP is a diagnosis of exclusion.
 Typical symptoms and signs of CP, such as earlyTypical symptoms and signs of CP, such as early
hypotonia, spasticity, and dystonia and/orhypotonia, spasticity, and dystonia and/or
choreoathetosis, may be present in other conditions.choreoathetosis, may be present in other conditions.
 These include neurodegenerative diseases, inbornThese include neurodegenerative diseases, inborn
errors of metabolism, developmental or traumaticerrors of metabolism, developmental or traumatic
lesions of the brain or spinal cord, neuromuscular orlesions of the brain or spinal cord, neuromuscular or
movement disorders, and neoplasm.movement disorders, and neoplasm.
 Some conditions, especially those that are slowlySome conditions, especially those that are slowly
progressive, may be misdiagnosed as CPprogressive, may be misdiagnosed as CP

60.  Thus, all children with manifestations of CP should beThus, all children with manifestations of CP should be
evaluated for a possible underlying cause.evaluated for a possible underlying cause.
 Situations in which another diagnosis, such as aSituations in which another diagnosis, such as a
neurodegenerative disease or metabolic disorderneurodegenerative disease or metabolic disorder, is, is
likely includelikely include
 Positive family history of the neurologic conditionPositive family history of the neurologic condition
 Loss of developmental milestonesLoss of developmental milestones
 Ataxia, involuntary movements, oculomotor abnormalitieAtaxia, involuntary movements, oculomotor abnormalitie
 Rapid deterioration of neurologic signsRapid deterioration of neurologic signs
 Marked worsening during periods of catabolismMarked worsening during periods of catabolism

61. Care of CP PatientCare of CP Patient
 ActivityActivity
 RehabilitationRehabilitation
 treatmenttreatment
ManagementManagement is directed atis directed at alleviatingalleviating
symptomssymptoms that are caused by damage to thethat are caused by damage to the
brain and helping the childbrain and helping the child achieve maximumachieve maximum
potential in growth and developmentpotential in growth and development

63. Treatment TeamTreatment Team
 People involved in the planning, treatment, andPeople involved in the planning, treatment, and
decision-making of an individual with cerebraldecision-making of an individual with cerebral
palsypalsy
– Healthcare professionals who are involved with theHealthcare professionals who are involved with the
individualindividual
– Family and other caregiversFamily and other caregivers
– Teachers who know the individualTeachers who know the individual
– RehabilitationRehabilitation Cooperation between pediatricCooperation between pediatric
neurologists psychiatrists , orthopedists ,neurologists psychiatrists , orthopedists ,
gastroenterologists, neurosurgeons . ENT specialist andgastroenterologists, neurosurgeons . ENT specialist and
pulmonogists is crucial for any intercurrent problem andpulmonogists is crucial for any intercurrent problem and
for rehabilitation.for rehabilitation.

64. Treatment strategies andTreatment strategies and
interventionsinterventions
 Physical, occupational, speech therapyPhysical, occupational, speech therapy
 Special educationSpecial education
 Feeding managementFeeding management
 OrthosisOrthosis
 SurgerySurgery
 Pharmacologic i.e botox injection, anti spasticityPharmacologic i.e botox injection, anti spasticity
drugsdrugs
 Family and patient counseling programFamily and patient counseling program
 Others: acupuncture, hyperbaric thx.Others: acupuncture, hyperbaric thx.

65. TreatmentsTreatments
Nutritional SupportNutritional Support
 Early Nutritional Support In one cohort study of 490Early Nutritional Support In one cohort study of 490
premature infants discharged from the NICU, the ratepremature infants discharged from the NICU, the rate
of growth during hospital stay was related toof growth during hospital stay was related to
neurological function at 18 and 22 months of age. Theneurological function at 18 and 22 months of age. The
study found a significant decrease in the incidence ofstudy found a significant decrease in the incidence of
cerebral palsy in the group of premature infants withcerebral palsy in the group of premature infants with
the highest growth velocity. This study suggests thatthe highest growth velocity. This study suggests that
adequate nutrition and growth playadequate nutrition and growth play a protectivea protective role inrole in
the development of cerebral palsy.the development of cerebral palsy.
 Nutritional counseling may help when dietary needsNutritional counseling may help when dietary needs
are not met because of problems with eating certainare not met because of problems with eating certain
foods.foods.

66. Physical therapy (PT)Physical therapy (PT)
 Physical therapy (PT)Physical therapy (PT) programs are designed toprograms are designed to
encourage the patient to build a strength baseencourage the patient to build a strength base
1. for improved gait and volitional movement,1. for improved gait and volitional movement,
2. together with stretching programs to limit2. together with stretching programs to limit
contractures.contractures.
Many experts believe that life-long physicalMany experts believe that life-long physical
therapy is crucial to maintain muscletherapy is crucial to maintain muscle tone,tone,
bone structure, and prevent dislocation of thebone structure, and prevent dislocation of the
joints.joints.

67. OCCUPATIONAL THERAPY (OT)OCCUPATIONAL THERAPY (OT)
 helps adults and childrenhelps adults and children
 Training in ADL’s along developmentalTraining in ADL’s along developmental
lines to live as independently as possible.lines to live as independently as possible.
 Sitting to walking; feeding to cooking.Sitting to walking; feeding to cooking.
 Important to incorporate play into programImportant to incorporate play into program
 Adaptive equipment (utensils for functionalAdaptive equipment (utensils for functional
use, i.e., eating, writing), computers, etc.use, i.e., eating, writing), computers, etc.

68. Orthotic devicesOrthotic devices
 Orthotic devicesOrthotic devices such assuch as ankle-footankle-foot
orthoses (AFOs)orthoses (AFOs) are often prescribed toare often prescribed to
minimize gait irregularities.minimize gait irregularities.
 AFOs have been found to improve severalAFOs have been found to improve several
measures of ambulation, including reducingmeasures of ambulation, including reducing
energy expenditure and increasing speed.energy expenditure and increasing speed.

70. Speech/Language therapySpeech/Language therapy
 Early speech training by speech/languageEarly speech training by speech/language
pathologist !pathologist !
 Speech therapy often starts before a childSpeech therapy often starts before a child
begins school and continues throughout thebegins school and continues throughout the
school yearsschool years
– Before child develops poor habitsBefore child develops poor habits
– Advice parents to follow directions of therapistAdvice parents to follow directions of therapist
– May need to force child to use tongue/lips inMay need to force child to use tongue/lips in
eatingeating

71. Special EducationSpecial Education
 Determined by child’s needsDetermined by child’s needs
 Early intervention programsEarly intervention programs
 Individualized Education Program (IEP)Individualized Education Program (IEP)
 Specialized learning programs and supportSpecialized learning programs and support
services in schoolsservices in schools
 Socialization to promote self-conceptSocialization to promote self-concept
developmentdevelopment

72. Surgical InterventionSurgical Intervention
 Reserved for child who does not respond toReserved for child who does not respond to
conservative therapy!conservative therapy!
– Or whose spasticity causes progressiveOr whose spasticity causes progressive
deformitiesdeformities
Orthopedic surgeryOrthopedic surgery
– correct contractures or spastic deformitiescorrect contractures or spastic deformities
– provide stability for uncontrolled jointprovide stability for uncontrolled joint
– provide balanced muscle powerprovide balanced muscle power

73. Surgical TherapySurgical Therapy
 Tendon-lengthening procedures (heel-cord)Tendon-lengthening procedures (heel-cord)
 Release of spastic wrist flexor musclesRelease of spastic wrist flexor muscles
 Correction of hip-adductor muscle spasticity orCorrection of hip-adductor muscle spasticity or
contracture to improve locomotioncontracture to improve locomotion
 Surgery is for improved function rather thanSurgery is for improved function rather than
cosmetic reasons and is followed by PT.cosmetic reasons and is followed by PT.

74. Cerebral palsyCerebral palsy
Prerequisites forPrerequisites for effectiveeffective
surgerysurgery
 Type :Type : spasticspastic
 Extent :Extent : hemiplegics / diplegics : good resultshemiplegics / diplegics : good results
quadriplegics : minimal improvementquadriplegics : minimal improvement
 Age :Age : 3- 12 years3- 12 years
 IQ :IQ : goodgood
 Good upper limb function :Good upper limb function : for walkingfor walking
 Underlying muscle power : not weakUnderlying muscle power : not weak
 Walker / non-walker :Walker / non-walker :
surgery hardly changes state but improves gaitsurgery hardly changes state but improves gait

75. Cerebral palsyCerebral palsy
Timing For Orthop SurgeryTiming For Orthop Surgery
 For structural changesFor structural changes : Early: Early
e.g. Hip subluxation , usually <5 yearse.g. Hip subluxation , usually <5 years
 To improve gait :To improve gait :
defer until walking ( independently / with aids )defer until walking ( independently / with aids )
until gait pattern developsuntil gait pattern develops
walking : 18 – 21 months in hemiplegiawalking : 18 – 21 months in hemiplegia
3 – 4 years in spastic diplegia3 – 4 years in spastic diplegia
 Optimum time of lower extremity surgeryOptimum time of lower extremity surgery
5 – 7 years:5 – 7 years: can analyze and observe gait patterncan analyze and observe gait pattern

76. Cerebral palsyCerebral palsy
Timing For Orthop SurgeryTiming For Orthop Surgery
 Surgery isSurgery is NOT “The Last Resort”NOT “The Last Resort”
( not after all other methods failed !)( not after all other methods failed !)

77. Drug therapyDrug therapy
Indicated forIndicated for
1.1. Control of epilepsyControl of epilepsy
2.2. Control of abnormal movementsControl of abnormal movements
3.3. Botulinium toxin injectionBotulinium toxin injection
4.4. Muscle relaxantsMuscle relaxants
5.5. To treat intercurrent problemsTo treat intercurrent problems

78. Medication TherapyMedication Therapy
SpasticitySpasticity ManagementManagement
 Anti-anxiety agentsAnti-anxiety agents may relieve excessive motionmay relieve excessive motion
and tension (child with athetosis)and tension (child with athetosis)
– Skeletal muscle relaxantsSkeletal muscle relaxants
1.1. dantrolenedantrolene (Dantrium),(Dantrium),
2.2. BaclofenBaclofen, may be used short-term for older children and, may be used short-term for older children and
adolescents.adolescents.
3.3. DiazepamDiazepam (Valium) for older children and adolescents,(Valium) for older children and adolescents,
may relieve stiffness and ease motionmay relieve stiffness and ease motion

79. MedicationsMedications
 Local nerve blocksLocal nerve blocks to motor points of a muscleto motor points of a muscle
with a neurolytic agent (phenol solution) maywith a neurolytic agent (phenol solution) may
relieve spasticity.relieve spasticity.
 Botulism toxin (Botox)Botulism toxin (Botox) used to paralyze certainused to paralyze certain
muscles.muscles.
 PainPain
 Secondary conditions (seizures, bowel andSecondary conditions (seizures, bowel and
bladder problems, lung complications).bladder problems, lung complications).

81. SPASTICITY MANAGEMENTSPASTICITY MANAGEMENT
OralOral
therapytherapy
ITBITB
SDRSDR
SurgerySurgery
BTX-ABTX-A
FOCALFOCAL
PERMANENTPERMANENTREVERSIBLEREVERSIBLE
GENERALGENERAL
PhysiotherapyPhysiotherapy
OrthosesOrthoses
PhysiotherapyPhysiotherapy

82. MUSCLE &
TENDON
BRAIN
SPINAL CORD
Valium
Baclofen – Oral & Intrathecal
Selective Dorsal Rhizotomy
Botulinum toxin A
Spasticity ManagementSpasticity Management
Orthopaedic Surgery

83. NEW TECHNOLOGIES IN REHABILITATIONNEW TECHNOLOGIES IN REHABILITATION
BOTULINUM TOXIN ABOTULINUM TOXIN A
 Protein product of Cl. botulinumProtein product of Cl. botulinum
 Chemical block of Ach release from nerve terminalChemical block of Ach release from nerve terminal
 Effects start 1-3 daysEffects start 1-3 days
 Peak at 2-6 weeksPeak at 2-6 weeks
 Highly variableHighly variable
– Age, degree of spasticity, therapy, otherAge, degree of spasticity, therapy, other
Mode of action – botulinum toxin A

84. Cerebral palsyCerebral palsy
Botulinum-A toxinBotulinum-A toxin
 Acts at myo-neural junctionsActs at myo-neural junctions
inhibits exocytosis of Acetylcholineinhibits exocytosis of Acetylcholine
 Inject selected muscles at multiple sitesInject selected muscles at multiple sites
 Spasticity reduction may last up to 6 monthsSpasticity reduction may last up to 6 months
 Reversible , painless , minimal side effectsReversible , painless , minimal side effects
 Most patients still require lengthening for permanentMost patients still require lengthening for permanent
correctioncorrection
 Role :Role : - Facilitates physiotherapy and mobilization- Facilitates physiotherapy and mobilization
- Delays surgical management- Delays surgical management
- Trial to determine effects of specific- Trial to determine effects of specific
proposed surgical treatmentproposed surgical treatment

85. BotoxBotox
 * Botulinum Toxin A (Botox) injections into* Botulinum Toxin A (Botox) injections into
muscles that are either spastic or havemuscles that are either spastic or have
contractures, the aim being to relieve thecontractures, the aim being to relieve the
disability and pain produced by thedisability and pain produced by the
inappropriately contracting muscle.[35]inappropriately contracting muscle.[35]

87. Cerebral palsyCerebral palsy
BaclofenBaclofen
 Oral : mixed reports/ side effects/ not selectiveOral : mixed reports/ side effects/ not selective
 GABA agonist – inhibits release of excitatoryGABA agonist – inhibits release of excitatory
neurotransmitter at level of spinal cordneurotransmitter at level of spinal cord
 Continuous intrathecal – implantable pumpContinuous intrathecal – implantable pump
 Good results in releasing spasticity, andGood results in releasing spasticity, and
improving functionimproving function
 Complications of pump and catheterComplications of pump and catheter
 Needs specialized centersNeeds specialized centers

88. Intrathecal Baclofen - ITBIntrathecal Baclofen - ITB
 Severe spasticity in children with cerebral palsySevere spasticity in children with cerebral palsy
 Test dose then implantationTest dose then implantation

89. Selective Dorsal RhizotomySelective Dorsal Rhizotomy
* Cutting nerves on the limbs most affected by* Cutting nerves on the limbs most affected by
movements and spasms. This procedure,movements and spasms. This procedure,
called a rhizotomy, "rhizo" meaning root andcalled a rhizotomy, "rhizo" meaning root and
"tomy" meaning "a cutting of" from the"tomy" meaning "a cutting of" from the
Greek suffix 'tomia' reduces spasms andGreek suffix 'tomia' reduces spasms and
allows more flexibility and control of theallows more flexibility and control of the
affected limbs and joints.affected limbs and joints.

90. Cerebral palsyCerebral palsy
Selective Dorsal RhizotomySelective Dorsal Rhizotomy
 30 – 50 % of abnormal dorsal rootlets L2 - S130 – 50 % of abnormal dorsal rootlets L2 - S1
 Followed by intensive physiotherapyFollowed by intensive physiotherapy
 Results encouragingResults encouraging
 May cause hyperlordosis / hip subluxationMay cause hyperlordosis / hip subluxation
 Best for :Best for : spastic diplegia, 4-8 yrs, no previousspastic diplegia, 4-8 yrs, no previous
surgery, no contractures, no extra pyramidal signssurgery, no contractures, no extra pyramidal signs
 ? Not enough alone? Not enough alone
 Orthopedic procedures obtain similar resultsOrthopedic procedures obtain similar results

92. Hydrotherapy: SwimmingHydrotherapy: Swimming
 The effects of the water give children aThe effects of the water give children a feeling offeeling of
weightlessnessweightlessness, which has been suggested as a, which has been suggested as a
way to reduce tone and allow these children toway to reduce tone and allow these children to
access better motor control.access better motor control.
 Hydrotherapy is a reasonable modality for gaitHydrotherapy is a reasonable modality for gait
training, especially in a heavy child who may betraining, especially in a heavy child who may be
able to walk in water with relative weightlessnessable to walk in water with relative weightlessness
from the floatation effects.from the floatation effects.
 There are no reports comparing hydrotherapy withThere are no reports comparing hydrotherapy with
standard therapy.standard therapy.

93. CEREBRAL PALSYCEREBRAL PALSY
TreatmentsTreatments
Individualized
PLAN
Physical
Therapy
Medical
Drugs
Surgical
Technique
Occupational
Therapy
Wherein a team of health care professionals
works with the child and family to identify the
child's needs and create an individualized
treatment plan to help the child reach his or her
maximum potential.
• Improves motor skills
• Muscle strength
• Prevents contractures
• May be implemented
with braces, splints or
casts.
• To ease spasticity
• Oral drugs not very
effective
• Injectable drugs such
as BOTOX
• Pump implanted
inside the skin that
continuously delivers
BACLOFEN
• Selective Dorsal
Rhizotomy
• Speech therapy
• Skills required for
daily living - feeding
and dressing

94. Technology and Cerebral PalsyTechnology and Cerebral Palsy
 Assistive technologyAssistive technology
– ComputersComputers
– Communication boards with words or symbolCommunication boards with words or symbol
systemssystems
– Bikes or scootersBikes or scooters
– Motorized wheelchairsMotorized wheelchairs

95. Other interesting ways to treatOther interesting ways to treat
cerebral palsycerebral palsy
 Dolphin therapy:Dolphin therapy:
– Developed by American psychologist David E.Developed by American psychologist David E.
Nathanson around 1978Nathanson around 1978
– Allows children with cerebral palsy to step into aAllows children with cerebral palsy to step into a
different environment and interact with thedifferent environment and interact with the
dolphin in a way that is both playful as well asdolphin in a way that is both playful as well as
constructive for that child.constructive for that child.

96. Dolphin Therapy (Continued)Dolphin Therapy (Continued)
– Research has shown that dolphins who are one of theResearch has shown that dolphins who are one of the
most intelligent animals are actually able to recognizemost intelligent animals are actually able to recognize
the child’s deficiency which helps the child create athe child’s deficiency which helps the child create a
connection with the dolphin.connection with the dolphin.
– The connection has been known to help the child relaxThe connection has been known to help the child relax
as well as an openness to learn and heal that can helpas well as an openness to learn and heal that can help
lead to developmental progress.lead to developmental progress.
– http://www.metacafe.com/watch/714493/dolphin_thhttp://www.metacafe.com/watch/714493/dolphin_th

97. Space Suit TherapySpace Suit Therapy
 Becoming increasingly popular for individuals withBecoming increasingly popular for individuals with
cerebral palsy.cerebral palsy.
 The suit is also known as Therasuits or TherapyThe suit is also known as Therasuits or Therapy
suits and it resembles an outfit that was originallysuits and it resembles an outfit that was originally
developed by the Russians that helped theirdeveloped by the Russians that helped their
astronauts maintain their muscle tone while theyastronauts maintain their muscle tone while they
were in space.were in space.