Presentation on Cerebral Palsy by Dr. Alpana

1. CEREBRAL PALSY
Dr Alpana Kondekar
Assistant Professor, Pediatric Neurodevlopmental Clinic
Faculty –Autism screening and Certification
Department of PediatricsT.N.M.C & B.Y.L.Nair Hospital

2. Cerebral Palsy = Brain Paralysis
• Definition
• Prevalence
• Etiology
• Classifications
• Clinical Presentation
• Treatments

3. Cerebral Palsy: Definition
• Cerebral palsy is a static encephalopathy that is non-progressive disorder
of posture and movement of Variable etiologies
• Often associated with epilepsy, speech problems, vision compromise, &
cognitive dysfunction
• In all cases the following must be true…
• Cerebral palsy is the result of a brain lesion. Therefore, the spinal cord and
muscles are structurally and biochemically normal.
• The brain lesion must be fixed and non progressive. Thus, all of the
progressive neuro degenerative disorders are excluded from the
definition.
• The abnormality of the brain result in motor impairment.

4. Cerebral Palsy: Prevalence
• 2-4/1000; 7-10,000 new babies each yr
• 150 years ago described by Dr. Little an
orthopedic surgeon and known as Little’s
Disease
• During past 3 decades considerable advances
made in obstetric & neonatal care, but
unfortunately there has been virtually no
change in incident of CP

5. Cerebral Palsy: Etiologic
• Prenatal (70%)
Infection, anoxia, toxic, vascular, Rh disease,
genetic, congenital malformation of brain
• Perinatal (5-10%)
Anoxia, traumatic delivery, metabolic,Fetal
distress,Premature delivery,
• Post natal
Trauma, infection, Sepsis in neonatal
period,Bronchopulmonary dysplasia and
prolonged ventilation in preterm infants.

6. Cerebral Palsy: Topographic
• Monoplegic
• Hemiplegic
• Quadraplegic
• Diplegic

10. Cerebral Palsy: Classification
• 1. Spastic (70-80% of cases). Further classified by the following
descriptions of extremity involvement:
a) Quadriplegia (10-15%): All 4 extremities are
affected equally along with the trunk
b) Diplegia (30-40%): Lower extremities are affected
to a greater degree than the upper extremities
c) Hemiplegia (20-30%): Involvement is observed on 1 side
of the body, including an arm and a leg
d) Monoplegia (rare): Involvement is noted in 1 limb,
either an arm or a leg
• 2. Dyskinetic (10-15% of cases). Characterized by abnormal
movements
• 3. Ataxic (<5% of cases). Characterized by unsteadiness

11. Spastic hemiplegic CP
• One-sided upper motor neuron deficit
• Arm generally affected more than leg; possible early hand
preference or relative weakness on one side; gait possibly
characterized by circumduction of lower extremity on
affected side
• Specific learning disabilities
• Oromotor dysfunction
• Possible unilateral sensory deficits
• Visual-field deficits (eg, homonymous hemianopsia) and
strabismus
• Seizures

13. Spastic diplegic CP
• Upper motor neuron findings in the legs more
than the arms
• Scissoring gait pattern with hips flexed and
adducted, knees flexed with valgus, and
ankles in equinus, resulting in toe walking
• Learning disabilities and seizures less
commonly than in spastic hemiplegia

15. Spastic quadriplegic CP
• All limbs affected, either full-body hypertonia or
truncal hypotonia with extremity hypertonia
• Oromotor dysfunction
• Increased risk of cognitive difficulties
• Multiple medical complications Seizures
• Legs generally affected equally or more than arms
• Categorized as double hemiplegic if arms more
involved than legs

16. Dyskinetic (extrapyramidal) CP
• Early hypotonia with movement disorder emerging
at age 1-3 years
• Arms more affected than legs
• Deep tendon reflexes usually normal to slightly
increased
• Some spasticity
• Oromotor dysfunction
• Gait difficulties
• Truncal instability
• Risk of deafness in those affected by kernicterus

17. How to recognize cerebral palsy
• EARLY SIGNS:

18. • Slow development • Hand preference

19. • Feeding problems • Difficulty in putting the
diaper

20. • Communication
difficulties
• Hearing difficulties

21. TYPICAL SPASTIC POSITIONS WHEN LYING
ON THE BACK:

23. Cerebral Palsy: Complications
• Spasticity
• Weakness
• Increase reflexes
• Clonus
• Seizures
• Articulation &
Swallowing difficulty
• Visual compromise
• Deformation
• Hip dislocation
• Kyphoscoliosis
• Constipation
• Urinary tract infection

24. What is not a cerebral palsy ?

25. Mimics of Cerebral Palsy:Conditions
• presenting with true muscle weakness
– Muscular dystrophies: Duchenne and Becker types
– Infantile neuro-axonal dystrophy
– Mitochondrial cytopathies
– Cerebral white matter diseases may present in the first year with hypotonia
and developmental delay, with spasticity and metal retardation occurring
later.
• Conditions with significant dystonia or involuntary movements:
– DOPA responsive dystonia
– Hallervordan Spatz Disease
– Pyruvate dehydrogenase deficiency
– Glutaric aciduria type I
– Leigh syndrome
– Juvenile neuronal ceroid lipofuscinosis
– Rett syndrome
– Pelizaeus-Merzbacher disease
– Lesch Nyhan Syndrome

26. Mimics of Cerebral Palsy:Conditions
Conditions with predominant diplegia or quadriplegia:
Adrenoleukodystrophy
Adrenomyeloneuropathy
Arginase deficiency
Metachromatic leukodystrophy
Hereditary progressive spastic paraplegia
Holocarboxylase synthetase deficiency
Prenatal iodine deficiency ("neurological cretinism")
Conditions with ataxia (Ataxic CP is Rare)
Angelman syndrome
Niemann-Pick disease type C
Ataxia-telangiectasia (Louis-Barr syndrome)
Ponto-cerebellar hypoplasia or atrophy
Chronic/adult GM2 gangliosidosis
Mitochondrial cytopathy (NARP mutation)
Posterior fossa tumours
X-linked spino-cerebellar ataxia

27. Evaluation
Detailed history, including birth, family, developmental
history, and physical exam
Deveopmental evaluation
Screening for sensory deficit
Neuroimaging?
CT scan (77% abnormal yield) –useful if abnormal,
potentially treatable lesion (e.g. Hydrocephalus, AVM)
MRI (89% abnormal yield)—higher abnormal yield that CT,
useful to pinpoint timing of brain injury (pre/peri/postnatal),
often suggests etiology.
Metabolic and genetic testing?
(Hyperarginemia, glutaric acidurea, and homocystinurea are
among common treatable metabolic causes of cerebral palsy).
Coagulation studies? hemiplegic CP

28. Cerebral Palsy
• Mobility
• Communication
• Learning
• Self Care
• Self Direction
• Independent Living
• Economic Sufficiency

29. Current scenario in India
The usual medical advice currently given to parents of
children with CP is one of the following:
• CP is incurable: so don't waste money on treatment.
• Unsubstantiated but well publicised alternative
modalities claiming to "cure the brain without side-
effects", e.g., homeopathy, herbal or biochemic pills,
oil massges or biofeedback
• Refer to physiotherapist for further management
and physicians take no further active role in
treatment

30. The team of medical professionals who are
going to treat a child with CP must have:
• Knowledge of normal anatomy and physiology,
particularly with respect to ambulation
• A good understanding of the functional pathology
present in CP
• Realistic goals / objectives for treatment that are
shared commonly by the patient, family, and others
concerned with the child's welfare
• Knowledge and ability to carry out any of the
treatments that are required
• A facility with the resources to carry out the necessary
evaluations / treatments

31. Cerebral Palsy: Management
• Neurologic and Physiatric
• OT and PT
• Speech
• Adaptive equipment
• Surgical
• Rhizotomy, Baclofen pumps, Botoxin

32. Multidisciplinary CP clinics
centers that provide a dedicated, trained and
qualified multidisciplinary team comprising of,
1. Developmental Pediatrician,
2. Pediatric Orthopedic Surgeon,
3. Pediatric Neurologist
4. Neurosurgeon,
5. Physiotherapist,
6. Occupational Therapist and Orthotist.

33. Specific Spasticity Management
surgery
Oral medications
Physiotherapy

34. Cerebral palsy
Clinical Assessment
Hip Adductors
Hip abduction / knees extended Hip abduction / knees flexed
The Gracilis

35. Cerebral palsy
Clinical Assessment
Ankle

36. Modified ashworth scale
00 No increase in muscle toneNo increase in muscle tone
11 Slight increase in muscle tone, manifested by a catch andSlight increase in muscle tone, manifested by a catch and
release or by minimal resistance at the end range of motionrelease or by minimal resistance at the end range of motion
when the part is moved in flexion or extension/abduction orwhen the part is moved in flexion or extension/abduction or
adduction, etc.adduction, etc.
1+1+ Slight increase in muscle tone, manifested by a catch, followedSlight increase in muscle tone, manifested by a catch, followed
by minimal resistance throughout the remainder (less thanby minimal resistance throughout the remainder (less than
half) of the ROMhalf) of the ROM
22 More marked increase in muscle tone through most of theMore marked increase in muscle tone through most of the
ROM, but the affected part is easily movedROM, but the affected part is easily moved
33 Considerable increase in muscle tone, passive movement isConsiderable increase in muscle tone, passive movement is
difficultdifficult
44 Affected part is rigid in flexion or extension (abduction orAffected part is rigid in flexion or extension (abduction or
adduction, etc.)adduction, etc.)

37. Gross motor functional classification score
Level-ILevel-I Minimal restriction of activityMinimal restriction of activity
Level-IILevel-II Activities carried out with minimal assistanceActivities carried out with minimal assistance
or supportor support
Level-IIILevel-III Activities carried out with the help of assistedActivities carried out with the help of assisted
mobility devices.mobility devices.
Level-IVLevel-IV Can function in sitting, but require extensiveCan function in sitting, but require extensive
use of mobility devices-limited independence.use of mobility devices-limited independence.
Level-VLevel-V Lack of independence even in basic antigravityLack of independence even in basic antigravity
postural control.postural control.

38. Physical therapy
Aim
• To help child reach his or her maximum potential for
functional independence through a variety of
approaches including, exercise, mobility training
,orthotics or braces, and use of other equipment.
• Muscle training and exercises may help child's
strength, flexibility, balance, motor development and
mobility, as well as ease caregiving.

39. Try to find ways for the child to be in positions that correct
or are opposite to his abnormal ones.

42. Oral Pharmacotherapy:
Trihexyphenidyl
 Can be useful in children with dystonia
 Suppresses an overactivity of central cholinergic
effects in dystonia
 Dosage: start at a low dosage and work up every
two weeks (0.5 mg bid - work up to tid and
increase until effect noted) - can get up to doses
of 40 mg
 Side Effects: constipation, urinary retention

43. Botulinum toxin injection
• 2-8 years of age with relatively mild global spasticity
• lower extremity spasticity that causes difficulty with
walking.
• Children > approximately 4 years of age who have
severe spasticity in a localized area.
• Rated I or II on GMFCS** if difficulty is in lower
extremities.
• Rated I to V on GMFCS** if difficulty is in upper
extremities.

44. Dosing Guideline Recommendations
Biceps: 1U/kg
Brachioradialis: 0.75U/kg
Finger/Wrist Flexors: 1.5U/kg
Pronator teres: 0.75U/kg
Thumb adductor: 0.3U/kg (max 10U)
Thumb opponens: 0.3U/kg (max 10U)

45. Baclofen pump
• Children approximately 3 years of
age and older who are large enough
to accommodate an abdominal
implant.
• Severe spasticity that causes pain or
major positioning or care problems.
• Children with spasticity that is
greater in lower extremities or who
have a
• combination of other movement
disorders and spasticity.
• • Rated Level IV or V on GMFCS.**

47. Occupational therapy.
• Focus on the development of fine motor skills
and self-care skills. Using exercises, facilitated
practice, alternative strategies and adaptive
equipment.
• To promote child's independent participation
in daily activities and routines in the home,
school and community.
• Also address difficulties with feeding and
swallowing.

48. Speech therapy.
• A speech therapist works with child on both the
receptive (understanding) part of speech and
language as well as the expressive part (talking).
• Speech therapists help improve child's ability to
speak clearly or communicate using alternative
means such as an augmentative communication
device or sign language.
• Speech therapists may also help with difficulties
related to feeding and swallowing.

49. Hearing Problems
• Hearing impairment is very common in children with
CP; (sensorineural loss or secretory otitis media or
both ).
• A complete evaluation by an audiologist and speech
pathologist is needed in all children with CP.
• Brain stem evoked responses may help in children
who are too young or are unable to co-operate for
audiometry.
• Early use of hearing aids and speech stimulation
techniques can help prevent or minimize speech and
language problems. Appropriate speech therapy is
needed for children with speech problems

50. Orthopedic Surgery.
Deformity Commonly done procedure
Hip flexion (Fixed flexion
deformity > 15 degrees)
Lengthening of Ilio-psoas tendon at
insertion to lesser trochanter
Hip adduction (Passive hip
abduction after Medial
Hamstring lengthening of
< 30 degrees)
Adductor tenotomy and Obturator
neurectomy
Knee flexion (Popliteal
angle > 40 degrees under
anaesthesia)
Eggers procedure (transfer of Hamstrings
to femoral condyle)
Increased femoral
anteversion (Internal
rotation gait and external
rotation in extension < 30
degrees, with excessive
internal rotation of hip)
Adductor tenotomy and Obturator
neurectomy (for a presumed scissoring gait)

51. Deformity
Commonly done
procedure
Tibial torsion, usually
external (tibial
rotation deformity >
20 degrees, measured
with knee in 90 degree
flexion)
Tibial derotational
osteotomy
Ankle plantarflexion
(equines not
correctable to neutral
under anaesthesia)
Open z-lengthening of
Tendoachilles
Talipes Equinovalgus
Grice procedure (Extra-
articular fusion of
subtalar joint)
Talipes Equinovarus
Transfer of Tibialis
Anterior or Posterior

53. Bilateral rotational osteotomies
)tibial torsion

54. Neurosurgery –
Selective Dorsal Rhizotomy (SDR)
• This neurosurgical operation involves a laminoplasty
from L1 to S1 and section of 20% to 40% of the
dorsal nerve rootlets.
• The selection criteria includes pure spasticity, good
selective motor control, adequate underlying muscle
strength, age 4 years to 7 years, and diagnosis of
spastic diplegia due to prematurity
• Long-term effects (scoliosis, lordosis, hip dislocations
and foot deformities)

55. Assistive technology
• A range of devices and gadgets can help with
communication, mobility and daily tasks.
• Assistive technology includes such small things as
rails, grab bars, magnifiers, and Velcro grips attached
to forks and pens to make them easier to grasp.
• It also includes more expensive, high-tech tools, such
as customized wheelchairs, voice communication
devices, computer software programs, and
positioning equipment that puts a child in the correct
posture to sit or stand with other kids or family
members.

56. Orthotics, Casts and Splints
Most children with CP will be prescribed orthotics, casts or
splints to supplement their therapy programs. These help to
provide stability, keep joints in position, and help stretch
muscles.

57. Assisted Mobility devices
Mobility Devices include:
wheelchairs (manual, power and sports)
scooters
specially made bicycles and tricycles
walkers and crutches

58. Ankle Foot Orthoses(AFO)

59. Epilepsy
• Seizures occur in about a third of children with C.P.
• it was found that epilepsy was seen in 35% cases,
most often in children with spastic hemiplegia (66%)
followed by quadriplegia (43%) and diplegia (16%).
• Seizures were difficult to control and polytherapy
was required in 38%.
• Most children with CP had onset of seizures in the
first or second year of life.
• A significant correlation was found between mental
retardation, microcephaly and frequency of seizures.

60. Visual Problems.
• Almost half of children with CP have visual
problems. The commonest are strabismus and
refractory errors. Early corrective intervention
by an Ophthalmologist is essential.

61. Behaviour problems & Sleep Problems
• Some children with CP may have problematic
aggression and at times hyperactivity and destructive
behaviour.
• Behaviour modification techniques and parental
counselling are helpful.
• Drugs methylphenidate, antipsychotics like
haloperidol and other pharmacological agents.
• A number of children with CP have difficulty in
sleeping and irregular sleep rhythms. Use of night
sedatives, like chloral hydrate for a few days may
help. Melatonin 2 mg half an hour before sleep can
also be tried.

62. Feeding and Nutrition
• Bulbar palsy, involuntary movements, tone problems,
handling and seating difficulties
• They may ' spit out' food because of tongue thrust and
difficulty in swallowing.
• Chewing may be difficult and a number of them have gastro-
oesophageal reflux leading to repeated aspirations.
• Special feeding techniques and prokinetics may be required.
gastrostomy may be needed to provide nutrition to the child.
• Principles of providing a balanced diet, alongwith an
adequate supply of vitamins and iron remain the same as for
a normal child.
• Lack of mobility and gut hypotonia may lead to constipation
in some children. Dietary modification with a high fibre diet
and plenty of fluids are helpful.
• Excessive Salivation: Oral exercises are taught to the child.
Atropine and benztropine have been used occasionally for
temporary relief.

63. Education and Training
• Education, prevocational and vocational training are
important aspects of rehabilitation.
• These need to be individualized according to the
child's abilities, as determined by detailed
assessment.
• Currently there is considerable emphasis on inclusive
education. While it may be Guidance should be
provided to the parents regarding availability of
appropriate schools and training institutions.
• The ultimate aim of management in C.P is to help the
child achieve his optimal developmental potential
and to integrate him as a useful member in the
society.

64. Parent Counselling
• An honest appraisal of the child's condition is
essential.
• The clinician should endeavour to provide a balanced
account of the child's problem but simultaneously
emphasize the child's abilities so as to help
channelize the parents' thought process towards
positive goals.
• Parents must learn that 'treatment' is a continuous
process; however it can be broken down into a
number of short term constructive goals- attainment
of these brings a sense of achievement and a hope of
progress.

72. Thank you