2. HISTORY
• The term cerebral palsy was first used in 1843 by the
English orthopedic surgeon William Little in a series of
lectures entitled “Deformities of the Human Frame”
• It was known for many years as “Little’s disease”
2
3. Dr. William John Little
William John Little (1810–1894)
was an English surgeon who is
credited with the first medical
identification of spastic diplegia,
when he observed it in the
1860s amongst children
3
7. Frederick Peterson (March 1, 1859
– July 9, 1938) was an American
neurologist and poet. Peterson
was at the forefront of
psychoanalysis in the United
States, publishing one of the first
articles of Freud and Jung's
theories of Free Association in
1909
7
8. Sigmund Freud, born Sigismund
Schlomo Freud, (6 May 1856 – 23
September 1939) was an Austrian
neurologist and the father of
psychoanalysis
8
9. ETIOLOGY
• Cerebral palsy is a heterogeneous disorder of
movement and posture that has a wide variety of
presentations, ranging from mild motor
disturbance to severe total body involvement
9
10. ETIOLOGY
• There are three distinctive features common to all
patients with cerebral palsy:
• (1) some degree of motor impairment, versus autism;
• (2) an insult to the developing brain, making it different
from conditions that affect the mature brain in older
children and adults; and
• (3) a neurological deficit that is nonprogressive, versus
other motor diseases of childhood, such as the muscular
dystrophies
10
11. ETIOLOGY
• The insult to the brain is believed to occur between the
time of conception and age 2 years, at which time a
significant amount of motor development has already
occurred
• By 8 years of age, most of the development of the
immature brain is complete, as is gait development, and
an insult to the brain results in a more adult-type clinical
picture and outcome
11
12. ETIOLOGY
• Although the neurological deficit is permanent and nonprogressive, the
effect it can have on the patient is dynamic, and the orthopaedic
aspects of cerebral palsy can change dramatically with growth and
development
• Growth, along with altered muscle forces across joints, can lead to
(1)progressive loss of motion,
(2)contracture, and eventually
(3)joint subluxation or dislocation, resulting in
(4)degeneration, that may require orthopaedic intervention
• http://www.restorativemedical.com/before_after_pics
12
13. ETIOLOGY
• Injury to the developing brain can occur at any
time from gestation to early childhood and
typically is categorized as
1)Prenatal
2)Perinatal
3)Postnatal
13
14. ETIOLOGY
• Contrary to popular belief, fewer than 10% of injuries that result in cerebral
palsy occur during the birth process, with most occurring in the prenatal
period
• A wide variety of risk factors for cerebral palsy have been identified in the
prenatal period
1. This includes risk factors inherent to the fetus (most commonly genetic
disorders)
2. Factors inherent to the mother (seizure disorders, mental retardation, and
previous pregnancy loss)
3. Factors inherent to the pregnancy itself (Rh incompatibility, polyhydramnios,
placental rupture, and drug or alcohol exposure)
14
15. ETIOLOGY
• External factors, such as TORCH syndrome
(toxoplasmosis, other agents, rubella, cytomegalovirus,
herpes simplex), also can lead to cerebral palsy in the
prenatal period
15
16. ETIOLOGY
• Cerebral palsy in the perinatal period, from
birth until a few days after birth, typically is
associated with asphyxia or trauma that occurs
during labor
• Oxytocin augmentation, umbilical cord
prolapse, and breech presentation all have
been associated with an increased occurrence
of cerebral palsy
• Only 10% of cases of cerebral palsy occur
during this time period, and most patients with
cerebral palsy have no history of asphyxia
• https://www.google.co.in/imgres?imgurl=http://cdn3.nursingcrib.com/wp-content/uploads/prolapse-cord.jpg&imgrefurl=http://nursingcrib.com/nursing-notes-
reviewer/maternal-child-health/umbilical-cord-
prolapse/&h=320&w=400&tbnid=51zrYx8aV4NFpM:&docid=hDZBIIs16RimOM&ei=9gaIVuHmFoeVuATf2a2oDw&tbm=isch&ved=0ahUKEwjhufPh0YvKAhWHCo4KHd9s
C_UQMwgxKAEwAQ
• https://www.google.co.in/imgres?imgurl=http://cdn3.nursingcrib.com/wp-content/uploads/prolapse-cord.jpg&imgrefurl=http://nursingcrib.com/nursing-notes-
reviewer/maternal-child-health/umbilical-cord-
prolapse/&h=320&w=400&tbnid=51zrYx8aV4NFpM:&docid=hDZBIIs16RimOM&ei=9gaIVuHmFoeVuATf2a2oDw&tbm=isch&ved=0ahUKEwjhufPh0YvKAhWHCo4KHd9s
C_UQMwgxKAEwAQ
16
17. ETIOLOGY
• Although cerebral palsy often is associated with low
Apgar scores during this period, many neonates have
low scores because of other conditions, such as genetic
disorders, that are completely unrelated to asphyxia
• Low-birth-weight infants (<1500 g) are at dramatically
increased risk of cerebral palsy, with an incidence of 60
per 1000 births compared with two per 1000 births in
infants of normal weight
17
18. ETIOLOGY
• This increased incidence is believed to be due to the
fragility of the periventricular blood vessels, which are
highly susceptible to physiological fluctuations during
pregnancy
• These fluctuations, which include hypoxic episodes,
placental pathology, maternal diabetes, and infection,
can injure these vessels and lead to subsequent
intraventricular hemorrhages
18
20. ETIOLOGY
• These injuries are graded on a scale from I to IV,
with an increased incidence of neurological
consequences such as hydrocephalus and
cerebral palsy in grade III (bleeding into
ventricles with dilation) and grade IV (bleeding
into brain substance)
20
21. GRADING OF PERIVENTRICULAR LESIONS
I
BLEEDING CONFINED TO GERMINAL
MATRIX
II BLEEDING EXTENDS INTO VENTRICLES
III
BLEEDING INTO VENTRICLES WITH
DILATATION
IV BLEEDING INTO BRAIN SUBSTANCE
21
22. A, In spastic diplegia and
periventricular
leukomalacia, the leg is
more affected than the
hand and face. There is
no cortical injury
B, In spastic hemiplegia,
the arm is often more
affected than the leg.
Because of cortical
involvement, seizures and
cognitive issues may
occur
http://clinicalgate.com/cerebral-palsy-4/
22
23. ETIOLOGY
• Hypoxic-ischemic encephalopathy, which is
characterized by hypotonia, decreased movement, and
seizures, is a common cause of cerebral palsy during the
postnatal period
• Meconium aspiration and persistent fetal circulation with
true ischemia are the most common causes of hypoxic-
ischemic encephalopathy
23
25. Classification
• Because of the wide variability in presentation and types
of cerebral palsy, there is no universally accepted
classification scheme
• Cerebral palsy can be classified by the
(1) clinical physiological picture, the region of the body
affected, or
(2) the neuroanatomical region of the brain that was injured
• It also can be classified
(3) temporally in relation to the time of birth, as previously
described
25
26. Geographical Classification
• The anatomical region of the body affected with the
movement disorder should be identified
• It is difficult to completely classify because some
extremities may be only subtly involved and a patient’s
pattern of involvement can change over time
26
27. MONOPLEGIA HEMIPLEGIA PARAPLEGIA DIPLEGIA QUADRIPLEGIA
DOUBLE
HEMIPLEGIA
TOTAL BODY
One extremity
involved, usually
lower
Very Rare
Both extremities on
same side involved
Usually upper
extremity involved
more than lower
extremity
30% patients
Both lower
extremities equally
involved
Very Rare
Lower extremities
more involved than
upper extremities
Fine-motor/sensory
abnormalities in
upper extremity
50% patients
All extremities
involved equally
Normal head/neck
control
All extremities
involved, upper
more than lower
All extremities
severely involved
No head/neck
control
27
28. Monoplegia
• Monoplegia is very rare and
usually occurs after meningitis
• Most patients diagnosed with
monoplegia actually have
hemiplegia with one extremity
only very mildly affected
28
29. Hemiplegia
• In hemiplegia, one side of the
body is involved, with the upper
extremity usually more affected
than the lower extremity
• Patients with hemiplegia,
approximately 30% of patients
with cerebral palsy, typically have
sensory changes in the affected
extremities as well
29
30. Hemiplegia
• Severe sensory changes, especially in the upper
extremity, are a predictor of poor functional outcome
after reconstructive surgery
• Hemiplegic patients also may have a leg-length
discrepancy, with shortening on the affected side, which
can be treated with contralateral epiphysiodesis or leg
lengthening
30
31. Diplegia
• Diplegia is the most common
anatomical type of cerebral palsy,
constituting approximately 50% of all
cases
• Patients with diplegia have motor
abnormalities in all four extremities,
with the lower extremities more
affected than the upper
31
32. Diplegia
• The close proximity of the lower extremity tracts to the
ventricles most likely explains the more frequent
involvement of the lower extremities with periventricular
lesions
• This type of cerebral palsy is most common in premature
infants; intelligence usually is normal
• Most children with diplegia walk eventually, although
walking is delayed usually until around age 4 years
32
33. Quadriplegia
• In quadriplegia, all four extremities are equally
involved and many patients have significant
cognitive deficiencies that make care more difficult
• Head and neck control usually are present, which
helps with communication, education, and seating
• Treatment goals for patients with quadriplegia
include
(1)a straight spine and level pelvis,
(2)located mobile hips with 90 degrees of flexion for
sitting and 30 degrees of extension for pivoting,
(3)plantigrade feet that can fit in shoes,
(4)and an appropriate wheelchair
33
34. Total Body
• Patients with total body involvement typically
have profound cognitive deficits in addition to
loss of head and neck control
• These patients usually require full-time
assistance for activities of daily living and
specialized seating systems to assist with
head positioning
• Drooling, dysarthria, and dysphagia also are
common and complicate care
34
35. Other Types
• Some patients have a double
hemiplegia pattern as a result of
bleeding in both hemispheres of the
brain
• It often is difficult to differentiate this
from diplegia or quadriplegia; however,
in double hemiplegia, the upper
extremities typically are more involved
than the lower
35
36. Other Types
• Paraplegia is very rare and is
characterized by bilateral lower
extremity involvement with—in contrast
to diplegia — completely normal gross
and fine motor skills in the upper
extremity
• Many patients diagnosed with
paraplegia actually are diplegic with
very mildly involved upper extremities
36
37. Other Types
• Although occasionally mentioned, triplegia, the
involvement of three extremities, probably does not exist
• With careful examination, most patients believed to have
triplegia actually have subtle motor deficits of the least
involved limb
37
38. Physiological Classification
• Most patients with cerebral palsy have
recognizable patterns of movement that also can
be classified
• An understanding of normal brain development
is important
• During the first trimester, the immature brain
separates into the gross structures, including the
cerebrum, cerebellum, and medulla
38
40. Physiological Classification
• Neurons begin to form in the second trimester, and the
total number of neurons an individual eventually has are
present at the end of this time frame
• Any neurons lost from this point forward are
irreplaceable
40
41. Physiological Classification
• Synaptic connections and
myelination begin during the
third trimester and continue
through adolescence in a highly
organized fashion
• As these synapses develop,
and myelinization continues,
primitive reflexes disappear and
more mature motor patterns
arise
41
42. Physiological Classification
• Because of this continued development after birth, many
injuries to the newborn nervous system go unrecognized
until the absence of expected patterns can be detected
• Because different pathways of the brain are myelinated
at different times,
1. spastic diplegia usually is not detected until 8 to 10
months of age;
2. hemiplegia, 20 months of age;
3. and athetoid cerebral palsy, after 24 months of age
• It is important to keep this in mind because a child ’s
pattern may change over time
42
43. Physiological Classification
• Physiologically, cerebral palsy can be divided into a
(1)spastic type, which affects the corticospinal (pyramidal) tracts, and
(2)an extrapyramidal type, which affects the other regions of the
developing brain
• The extrapyramidal types of cerebral palsy include
(1)athetoid A
(2)choreiform C
(3)ataxic X
(4)rigid R
(5)hypotonic H
43
44. Spastic
• Spastic is the most common form of cerebral
palsy, constituting approximately 80% of cases,
and usually is associated with injury to the
pyramidal tracts in the immature brain
• Spasticity, or the velocity-dependent increase in
muscle tone with passive stretch, is caused by
an exaggeration of the normal muscle passive
stretch reflex
44
48. Athetoid
• Athetoid cerebral palsy is caused by an injury to the extrapyramidal
tracts and is characterized by dyskinetic, purposeless movements
that may be exacerbated by environmental stimulation
• The clinical picture varies based on the level of excitement of the
patient
• In pure athetoid cerebral palsy, joint contractures are uncommon;
the results of soft tissue releases, in contrast to those seen in
spastic cerebral palsy, are unpredictable, and the procedures have a
high complication rate
• With the improvements in prevention of Rh incompatibility leading to
kernicterus, the incidence of athetoid cerebral palsy is decreasing
• Dystonia, characterized by increased overall tone and distorted
positioning in response to voluntary movements, or hypotonia also
can occur with athetoid cerebral palsy
48
49. Choreiform
• Choreiform cerebral palsy is characterized by continual
purposeless movements of the patient’s wrists, fingers,
toes, and ankles
• This continuous movement can make bracing and sitting
difficult
49
50. Ataxic
• Ataxic cerebral palsy is very rare and probably is
the most often misdiagnosed type
• It is characterized by the disturbance of
coordinated movement, most commonly walking,
as a result of an injury to the developing
cerebellum
50
51. Rigid
• Patients with rigid cerebral palsy are the most hypertonic
of all cerebral palsy patients
• This hypertonicity occurs in the absence of hyperreflexia,
spasticity, and clonus, which are common in spastic
cerebral palsy
• These patients have a “cogwheel” or “lead pipe” muscle
stiffness that often requires surgical release
• When a surgical release is done, it is essential not to
overweaken the muscle, which would cause the opposite
deformity to occur
51
52. Hypotonic
• Hypotonic cerebral palsy is characterized by weakness
in conjunction with low muscle tone and normal deep
tendon reflexes
• Many children who ultimately develop spastic or ataxic
cerebral palsy pass through a hypotonic stage lasting 1
or 2 years before the true nature of their brain injury
becomes apparent
• Persistent hypotonia can lead to difficulties with sitting
balance, head positioning, and communication
52
53. Mixed
• Many patients with cerebral palsy have features of more
than one type and are referred to as having mixed
cerebral palsy
• Patients with mixed cerebral palsy usually show signs of
pyramidal and extrapyramidal deficits
• The final clinical appearance is determined by the
relative components of spasticity, athetosis, and ataxia
53
54. Mixed
• Surgical releases in this group can be less predictable,
especially when a large athetoid or ataxic component is
present
• Palisano et al. developed the Gross Motor Function
Classification System to help resolve these classification
difficulties
54
56. Mixed
• This five-level numeric grading system, which
has been found to be a reliable and stable
method of classification and prediction of motor
function for children 2 to 12 years old, takes into
account functional limitations for assistive
devices, such as walkers and wheelchairs, and
the quality of movement based on age
• The emphasis of this scale is on self-initiated
movement and walking and sitting function
56