Cerebral palsy (CP) is a well-recognized neurodevelopmental condition beginning in early childhood and persisting throughout the lifespan. Cerebral palsy describes a group of permanent disorders of the development of movement and posture causing activity limitation that is attributed to non-progressive the disturbance that occurred in the developing fetal or infant brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication, and behavior, by epilepsy, and by secondary musculoskeletal problems. Sometimes we can identify by symptoms of children such as delayed milestones, spasticity, unable to neck control, muscle weakness. there are 4 types of CP that are dependent upon parts of brain damage.

1. Cerebral palsy
By
Dr. Krati Omar

2. Introduction
• The term cerebral palsy was first used in 1843 by the
English orthopedic surgeon William Little
• It was known for many years as
“Little’s disease”

3. Cerebral Palsy (CP)
• CP describe a group of permanent disorders of the
development of movement and posture, causing
activity limitation, that are attributed to non-
progressive disturbance that occurred in the
developing fetal or infant brain
• The motor disorders of CP are often accompanied by
disturbance of sensation, cognition, perception,
communication, and secondary problem is
musculoskeletal disorders
A report: the definition and classification of cerebral palsy April 2006, Peter Rosenbaum et.al

4. Cerebral palsy
• Cerebral palsy (CP) is a broad spectrum of motor
disability which is non progressive and is caused by
damaged to brain at or around birth
• It is a disorder which develops due to damage to CNS
• This damage can happen before, during, or
immediately after the birth of child

5. Cerebral palsy
• Damaged brain is not able to cope up with the
physical demand of growing body and the increasing
demand of the environment surrounding the child
• CP are the most common cause of childhood
disability

7. Motor disorder of CP
Musculoskeletal problem
Sensation
behavior
seizures
Perception
Cognition
Communi
cation

8. Incidence
• The prevalence of CP has consistently been reported
to be about 2-2.5 per 1000 live birth (1 in every 400
children) over the last 20 years in the western world

9. Etiology
Prenatal cause Perinatal cause Postnatal cause

10. Prenatal cause
• Vascular events such as a middle cerebral artery infract
• Maternal infection during the first and second trimester
1. Rubella
2. Cytomegalovirus
3. Toxoplasmosis
• Metabolic disorders
• Genetic syndromes
• Hypoglycemia

11. Perinatal cause
• Problems during labor and delivery
a. Obstructed labor
b. Antepartun hemorrhage
c. Cord prolapsed
• Vascular causes: occlusion of the internal carotid and
midcerebral artery during birth can lead to
hemiplegia

12. • Prematurity: premature babies are more common to
brain damage either due to trauma during delivery
and later on due to immature respiratory and
cardiovascular system
• Develop hypoxia, low blood pressure, low blood
sugar, jaundice and hemorrhage because of liver
immaturity
• Low birth weight (<2500gm.)

13. • Trauma:
a. Disproportion
b. Breech delivery
c. Forceps delivery
d. Distortion of head
e. Tearing of tentorium
• Asphyxia: it can occur by accidents and burns, Multiple
deliveries can cause asphyxia of the second or third
infant

14. Types of Pelvis

15. Postnatal cause
• Delayed cry: cause asphyxia to the brain causing CP
• Severe jaundice: Presence of high levels of bilirubin
cause basal ganglia damage leading to athetoid
cerebral palsy and high tone deafness
• Infections: meningitis, malaria and septicemia

16. Risk factors before pregnancy
• Maternal factors:
a. Delayed onset of menstruation
b. Irregular menstruation
c. Long intermenstrual intervals
d. Long intervals between pregnancies
e. Relationship with previous fetal death

17. • Medical conditions:
a. Intellectual disabilities
b. Seizures

18. Risk factor during pregnancy
• Multiple pregnancies associated with:
- Preterm delivery
- Poor intrauterine growth
- Intrapartum complication

19. Risk factor during labor
Cause of Perinatal Asphyxia
 Prolapsed cord
 Massive intrapartum hemorrhage
 Prolonged or traumatic delivery due to cephalopelvic
or abnormal presentation
 Large baby with shoulder dystocia

20. Event associated with causal factors
 Prolonged second-stage labor
 Premature separation of placenta
 Abnormal fetal position
In preterm can include:
 Meconium-stained fluid
 Tight nuchal cord

21. Symptoms of CP
Abnormal
strength
Associated
handicapPosture
and
balance
Persistent
motor delay
Abnormal
reflexes
Abnormal
tone
Loss of
control
Cognitive
deficit

22. Diagnosis
• Cranial ultrasound : High risk preterm infants
• Computed tomography (CT)
• Magnetic resonance imaging (MRI): Brain tissue and
structures

23. Classification
Topographical
classification
According to
type
Diaplegia
Hemiplegia
Quadriplegia
Spastic
Athetoid
Ataxic
mixed

25. Diaplegia
Hypoxia
A white
matter infarct in
the periventricular
areas
Spastic
Diaplegia

26. Diaplegia
• Involvement of four limbs with leg more affected
than hands
• Disturbance in gait
• Balance problem
• Coordination

27. Anterior
pelvic tilt
Bilateral hip
internal
rotation
Bilateral knee
flexion
Equinovalgus
foot position

28. Hemiplegia
• It is a subtype of spastic CP
• Involvement of one side of body (upper and lower limb)
• Periventricular white matter abnormalities cause
hemiplegic CP
• Upper extremity is more affected then lower extremity
• More distal involvement then proximal involvement

29. Hemiplegia
• Muscle spasticity on the affected side decreases
muscle and bone growth
• Decrease range of motion (ROM)
• contractures and limb-length discrepancies on the
involved side

30. Posture of children with hemiplegic CP
• Shoulder protraction
• Elbow flexion
• Wrist flexion and ulnar deviation
• Pelvic retraction
• Hip internal rotation and flexion
• Knee flexion and
• Forefoot contact only due to plantar flexed foot

32. Quadriplegia
• Involvement of four limbs
• In this arms are more affected than leg
• It is also called double Hemiplegia
• Extensive lesions affecting the basal ganglia or
occipital area often lead to visual impairments and
seizures

35. Spastic CP
• Spasticity occurs in approximately 75% of all children
with CP
• “Hypertonia in which resistance to passive
movement increases with increasing velocity of
movement.”

36. Spastic CP

37. Athetoid CP
• Athetoid cerebral palsy children exhibits slow,
purposeless, involuntary movements which flow into
each other.
• It occurs due to basal ganglia damage commonly
seen in children who suffers from an attack of
jaundice following birth.
• They may follow abnormal pattern
• The tone in these children generally fluctuates

38. Athetoid CP

39. Ataxic CP
• Ataxic CP is primarily a disorder of balance and
control in the timing of coordinated movements
along with weakness, incoordination a wide-based
gait, and tremor
• This type of CP results from deficits in the cerebellum

40. Ataxic CP

41. Hypotonic CP

42. Gross motor function classification system
(GMFCS)
• GMFCS created by Palisano and colleagues in 1997
• It is a classification system based on gross motor
function of children with CP 12 to 18 year
• The GMFCS was develop to measure the “severity of
movement disability” in children with CP
• There are five levels in the test

43. GMFCS levels

44. • Level I Walks at home, school, outdoors, and in the
community
• Climbs stairs without using a railing
• Performs gross motor skills such as running and jumping
with limitations of speed, balance, and coordination
• Level II Walks in most settings; difficulties in walking
when carrying objects
• Uses physical assistance, hand‐held walking devices
when there are difficulties with long distances, inclines,
climbs stairs using a railing.

45. • Level III Walks with hand‐held mobility devices in most
indoor settings; limitations in walking outdoors.
• Climbs stairs using a railing with supervision or
• assistance. Use of wheeled mobility over long distances
and depending on arm function may self‐propel a manual
wheelchair for sports
• Level IV Walks short distances with physical assistance or
uses powered mobility.
• At school and in the community children are transported
in a manual wheelchair or use power mobility.

46. • Level V Transported in a manual wheelchair in all
settings. Some achieve self‐mobility using powered
mobility with extensive adaptation of seating.
Children have limited control of head, trunk, arms,
and legs.

47. References
• Pediatric physical therapy, Jan S. Tecklin, fifth edition page no.
187-194
• Physiotherapy in Neuro-conditions, Glady Samuel Raj page no.
233-249
• Treatment of cerebral palsy and motor delay, Sophie Levitt ,
Ann Addition, 6th edition page no. 1-24
• Physical therapy for children, Robert J. Palisano et al, fifth
edition, page 450
• Neurologic Intervention for Physical Therapist Assistants,
Martin Kessler, page 362-370

48. Thank you