competency based classes for MBBS students..

1. CEREBRAL PALSY
Dr. Vinay kumar S Appannavar
Assistant Professor
Dept. Of Pediatrics , SSIMS & RC

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Development
• Brain grossly differentiates into Cerebrum and Cerebellum during
1st Trimester of embryonic life.
• Neurons begin to develop in 2nd trimester.
• By the end of 2nd trimester all neurons are formed and any
damage occurring now is irreversible.
• Synaptic connections occur in 3rd trimester.

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• Cerebral palsy is a chronic neurodevelopmental disorder.
• Some children with CP graduate from universities and
become health professionals.
• Some children with CP may be unable to roll or feed and
may be entirely dependent for all activities of daily living.
Introduction

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• First described in 1862, by William John Little, an orthopaedic
surgeon.
• Cerebral Palsy was known as Little’s Disease for decades.
• The term cerebral Palsy originated with William Osler and Sigmund
Freud.
• Incidence : About 2 per 1000 live births in high resource settings.
Introduction

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• Cerebral palsy (CP) describes a group of permanent disorders of
movement and posture causing activity limitation, that are
attributed to non progressive disturbances that occurred in the
developing fetal or immature brain.
• The motor disorders of CP are often accompanied by disturbances
of sensation, perception, cognition, communication, and behavior,
by epilepsy, and by secondary musculoskeletal problems
Definition

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• Two distinct cohorts of children present with CP.
Cohort one
Infants born preterm
Infants born at term experiencing a neonatal encephalopathy.
Cohort two
Developmental surveillance provided through a community-based workers.
Parental observation of “stiffness” or gait disturbances.
Presentation

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Prenatal (44%)
◦ First trimester
Teratogens
Chromosomal abnormalities
Genetic syndromes
Brain malformations.
Etiology
◦ Second trimester
 Intrauterine infections.
 Problems in fetal /placental
functioning

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Labor and delivery (19% )
 Preeclampsia.
 Complications of labor.
Perinatal ( 8% )
Prematurity
Sepsis / CNS infection
Birth asphyxia.
Etiology
Childhood (5%)
 Meningitis
 Traumatic brain injury.
 Toxins.
Not obvious (24%)

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01. Spastic ( 70- 80% of cases )
• Increased muscle tone
• Continuous muscle spasms and
contractions
• Abnormal walking, marked by knees
crossing in a scissor-like movement
• Joint contractures - Limited stretching
abilities
• Flexion at the elbows, wrists, and fingers
• Poor coordination and control of muscle
movements
Clinical classification

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02. Dyskinetic / Athetoid ( 15- 20% )
 Associated with damage to the Basal ganglia
 Abnormal involuntary movements
 That disappear during sleep and increase with
stress
 Interferes with speaking, feeding, reaching,
grabbing and other skills

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03. Ataxic ( 5-10 %)
 Associated with damage to the Cerebellum
 Poor balance and lack of coordination
 Wide – based gait
 Tendency to fall and stumble
 Depth perception is affected
 Inability to walk in straight line
04. Mixed / Dystonic
 Combination of spasticity and athetosis

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Functional classification of CP

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1. Motor milestones delay.
2. Unable maintain against gravity.
3. Poor hand functions.
4. Preference of one hand before the age of 2 years.
5. Global developmental delay
6. Unable to perform in the school in academic and sports activities.
7. Altered motor performance like bunny hopping, walking with equinus.
8. Poor participation of the child in daily activities like self care, eating etc.
9. Difficulty in handling the child during changing nappies.
10. Sensory issues like poor attention, perceptual disorders, mental impairment.
Clinical manifestations- Presenting history

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• Extreme irritability or crying.
• Feeding difficulties.
Behavioral signs
• Little interest surrounding
• Excessive sleeping.
Early signs
• Stiff or floppy posture.
• Excessive lethargy or irritability /high pitched cry.
• Poor head control.
• Weak suck /tongue thrust /tonic bite /feeding
difficulties.
• Persistence of primitive infantile reflexes.

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• Intellectual impairment. - MR
• Seizures. – 43 %
• Visual impairment – 28% - ocular structures affected , cortical vision impairment
• Hearing impairment – 12%
• Speech and language disorders – 38 %
• Drooling of saliva.
• Feeding difficulties. – 27% are malnourished – GERD, Impaired colonic motility, Constipation
• Voiding dysfunction - 36% - Neurogenic detrusor overactivity, detrusor sphincter dyssynergia
• Orthopaedic complications. – Osteoporosis
• Dental carries
Associated disabilities

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• Physical Assessment
• Observe LBW, preterm, and those with low Apgar scores at 5
minutes
• Observe infants who have seizures, intracranial hemorrhage,
metabolic disturbances
• Diagnosis may not be confirmed until after 6 months of age.
Diagnosis

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Red flag signs of milestones delay

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• Magnetic resonance imaging (MRI).
• Ultrasound.
• Computerised tomography (CT) scan.
• Electroencephalogram (EEG).
• Electromyogram (EMG).
• Additional tests: Vision impairment, Hearing impairment,
Speech impairments, Intellectual disabilities, Movement
disorders
Diagnosis - workup

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Medical
 To enhance functional abilities of CP child.
 Therapy is chiefly symptomatic and preventive.
The broad aims of therapy are :
 To establish locomotion, communication and self help.
 To gain optimum appearance and integration of motor functions.
 To correct associated defects as early and effectively .
 To provide educational opportunities adapted to the individual child’s needs
 To promote socialization experiences with other affected, unaffected children
Treatment

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• It is directed toward good skeletal alignment for child with spasticity.
• It can help the child's strength, flexibility, balance, motor development and
mobility.
• It uses orthotic devices, such as braces, casting and splints to support and
improved walking
Physiotherapy

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• Using alternative strategies and
adaptive equipment,
occupational therapists work to
promote the child's independent
participation in daily activities
and routines in the home, the
school and the community.
• Adaptive equipment may include
walkers, quadrupedal canes,
seating systems or electric
wheelchairs
Occupational Therapy

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• Speech-language therapist can help improve
the child's ability to speak clearly or to
communicate using sign language
Speech & Language Therapy
Recreation Therapy
• This therapy can help improve the
child's motor skills, speech and
emotional well-being.

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To reduce the effects of cerebral palsy and prevent complications:
• Analgesic drugs to reduce intense pain or muscle spasm.
• Botulinum toxin type A, used to reduce spasticity in targeted muscle of the
upper and lower extremities.
• Dantrolene sodium, baclofen, and diazepam to improve muscle coordination
and to muscle relaxation.
• Anticonvulsants drug, to relieve or stop seizures
Pharmacological therapy

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• Surgery used to correct problems with bones
and joints, by lengthening any muscles and
tendons that are too short and causing
problems.
ORTHOPEDIC SURGERY :
 To correct contracture or spastic deformities, to
provide stability for an uncontrolled joint, to
address bone malalignment, and to provide
balanced muscle power.
 Example : tendon transfer, muscle lengthening.
Surgical management

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• SDR is a surgical procedure that can help
children with severe muscle stiffness in their
legs to improve their walking
Selective Dorsal Rhizotomy (SDR)

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Take home message
 CP: Disorder of movement and posture
 Nonprogressive
 Associated disorders
 Counselling of parents
 Supportive care
 Physiotherapy
 Surgery when required

31. Thank you...☺️