Cerebra palsy ug class- Dr. Ramya -Assistant Professor of Pediatrics, MGMCRI

1. Cerebral Palsy

2. Overview
• Definition
• Pathogenesis
• Clinical features
• Associated problems
• Differential diagnosis
• Management
• Prognosis

3. Cerebral palsy (CP)

4. Definition
• It is a heterogeneous group of disorder with
persistent disorder of movement and posture
caused by non progressive defects or lesions
of immature brain.
• Non-specific term
• Non-progressive and may include perceptual
problems, language deficits, and intellectual
involvement.

5. CP history
• Dr William John Little detected this disorder
first in 1860.
• Sometimes known as Little’s disease.
• Incidence has increased since the 1960 ’s,
maybe due to improved survival of VLBW
infants.

6. Incidence
• Most common physical disability of childhood.
• Incidence has increased since the 60’s, maybe
due to improved survival of VLBW infants.
• Difficult to estimate accurate incidence.
• Approximately 1-2 /100 live births in India.

7. Etiology
• Variety of perinatal, prenatal, and postnatal factors
contribute, either singly or multifactorily to CP.
• Commonly thought to be due to birth asphyxia; now
known to be due to existing prenatal brain
abnormalities.
• Premature delivery is the single most important
determinant of CP.
• In 24% of cases, no cause is found.

8. TABLE 40-1 Causes of CP
• Time (% of cases)
• Prenatal (44%)
– First trimester
– Second trimester
• Causes
• Teratogens, chromosomal
abnormalities, genetic
syndromes, brain
malformations
• Intrauterine infections,
problems in
fetal/placental
functioning,coagulation &
thrombosis

9. Causes of CP
• Time (% of cases)
• Labor and delivery (19%)
• Perinatal (8%)
• Childhood (5%)
• Not obvious (24%)
• Causes
• Preeclampsia,
complications of labor and
delivery, multiple births.
• Sepsis/CNS infection,
asphyxia, prematurity,
acid base imbalance,
indirect
hyperbilirubinemia,
• Meningitis, traumatic
brain injury, toxins

10. Pathogenesis
• Selective neuronal Necrosis
• Parasagittal brain injury
• Status marmatosus
• Cerebellar nuclei invovlvement
• Periventricular leucomalacia

11. Clinical Classification of CP
• Spastic-hypertonicity with poor posture control
• Hypotonic – despite pyramidal features infants are
hypotonic.
• Dyskinetic/athetoid- abnormal involuntary
movement/slow wormlike writhing
• Ataxic- wide-based gait
• Mixed-type- combination of spasticity and athetosis

12. Clinical manifestations
• Delayed gross motor development
– A universal manifestation of CP
– The discrepancy between motor ability and
expected achievement tends to increase as
growth advances.
– Delayed development of ability to balance slows
milestones
– Delay in all motor accomplishments

14. Clinical Manifestations
• Abnormal motor performance
– Preferential unilateral hand use may be apparent at 6
months.
– Hemiplegia, abnormal crawling or asymmetrical crawl;
spasticity may cause child to walk and stand on toes
– dyskinetic CP or uncoordinated or involuntary movements
(writhing tongue, fingers, and toes; facial grimacing), poor
sucking and feeding, persistent tongue thrust; head
staggering, tremor on reaching, truncal ataxia.

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

19. Abnormal postures
• Children with spastic CP have abnormal posture at rest or
when position is changed
• Infantile lying prone may have hip higher than trunk with legs
and arms drawn in.
• Persistent infantile resting and sleeping position is a sign of
spasticity.
• Hemiparetic child may rest with affected arm adducted and
held against torso, with the elbow pronated and slightly flexed
and the hand closed.

20. Reflex Abnormalities
• Persistence of primitive infantile reflexes (one
of the earliest signs of CP)
– Tonic neck reflex
– Hyperactivity or moro, plantar, palmar grasp
Hyperreflexia, ankle clonus, stretch reflexes can be
elicited from any muscle group.

21. Associated disabilities and problems
• Intellectual impairment
– 70% w/in normal limits; wide range
– Tests should be carried out over a period of time.
– Children with athetosis and ataxia more intelligent.
Speech difficulties (not a sign or MR)- child has motor and
sensory defects
ADHD- (may occur)-poor attention span, marked
distractibility, hyperactive behavior

22. ASSOCIATED DISABILITIES
Seizures- generalized tonic-clonic;more in postnatally
acquired hemiplegia
Drooling- may occur and lead to wet clothing/skin irritation
Feeding- alterations in muscle tone lead to difficulties
chewing, swallowing, talking, etc.
Address nutritional concerns.
Coughing, choking may lead to aspiration.
Altered respiratory patterns may lead to inadequate gas
exchange.

23. Motor Impairment
• Orthopedic complications
– Unilateral or bilateral hip dislocations, scoliosis, joint contractures due
to unbalanced muscle tone.
Decreased Mobility
– difficulties with toileting may lead to constipation
– Difficult chewing bulky foods may lead to constipation
– May need stool softeners or laxatives

24. Associated Problems
• Dental carries
– Improper dental hygiene
– congenital enamel defects (hyperplasia of primary teeth)
– high carbohydrate intake and retention
– Dietary balance with poor nutritional intake
– Inadequate fluoride
– Difficulty in mouth closure and drooling
– Spastic or clonic movements cause gagging or biting on
toothbrush

25. Associated Problems
• Malocclusion in 90% of children
• Oral hypersensitivity causes resistance to good
hygiene
• Gingivitis is secondary to poor hygiene
• Dental health further complicated by anti-
seizure meds

26. Associated problems
• Nystagmus and amblyopia common
– May need surgery or corrective lenses
– May be due to sensoneural involvement
– Infants lying flat too long may have otitis media
which may leads to conductive hearing loss