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

1. Nakhieeran Nallasamy
Azreen Onny
Nirmalatiban Parthiban (The Expert)

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. • 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. 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. • 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.  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.  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. Dyskinetic CP
• Damage to the basal
ganglia
1. Chorea
2. Athetosis
3. Dystonia

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. 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. 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. 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. 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

15. 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

16. 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

17. 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

18. 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

19. THANK YOU!!!