Cerebral palsy is a group of disorders that affect movement and posture as a result of non-progressive damage to the developing brain. It has an incidence of 3 per 1000 children and is commonly caused by cerebral malformations in developed countries and perinatal asphyxia in developing countries. Clinically, it presents with delayed development, abnormal muscle tone and posture, seizures, and intellectual disability. Diagnosis involves assessing developmental history and physical signs of spasticity, contractures, and hyperreflexia. Management is multi-disciplinary and includes medications, physiotherapy, orthotics, and occasionally surgery. Prognosis depends on severity of deficits and early intervention, with earlier ability to sit associated with later ability to

1. Cerebral Palsy
in Children
Definition, Epidemiology, Etiology, Clinical Features,
Diagnosis, Assessment, Management, Prognosis and Prevention
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

2. (God Almighty speaking to Prophet Muhammad (PBUH)
Say, “It is He who created and nurtured you;
and given you the hearing, the vision, and the thinking.
But rarely do you pay gratitude.”
The Holy Quran; surah Al-Mulk 67:23
In the name of Our Creator Allah, the most Gracious, the most Merciful

3. CNS

4. Brain

5. Our perceptions and Movements

6. Evaluation
of the Child with
Neurological Symptoms

7. CNS – Abnormal Symptoms
• Convulsions
• Altered Consciousness
• Delayed development
• Intellectual handicap
• Speech problem
• Motor weakness / Walking problem
• Sensory changes
• Headache
• Unable to see / listen

8. History – Ask about Symptoms
• Neurological Symptoms –
• Onset
• Frequency
• Severity
• Progression
• Birth history
• Development history
• Family history

9. CNS – Abnormal Signs
• Developmental milestones (in relation to age)
• Impaired Conscious level (GCS)
• Convulsions
• Intellectual impairment (retardation / handicap)
• Motor weakness / Paralysis / Paresis
• Abnormal gait
• Abnormal movements
• Visual impairment
• Auditory impairment

10. CNS Examination
in Children

11. Examination of CNS in Children
• OBSERVE – observe the child
• General Physical Examination
• Developmental Examination
• NEUROLOGICAL EXAMINATION –
• Higher Mental Functions
• Cranial Nerves
• Motor System
• Sensory system
• Skull and Spine
• SOMI

12. Developmental Examination

13. Child Development

14. Areas of Development
 Posture and locomotion
 Vision and manipulation
 Hearing and speech
 Personal and social

15. Areas of Development
 Posture and locomotion
 Vision and manipulation
 Hearing and speech
 Personal and social

16. Milestones of Development
Posture and locomotion
 3 months – Head control
 6 months – Roll over
 9 months -– sit without support
 12 months – stand / walk held

17. Milestones of Development
Vision and manipulation (eye – hand coordination)
 3 mo – Eyes fix and follow
 6 mo – Hand approach to hold
 9 mo -– Finger grasp
 12 mo – Release object in examiner’s hand

18. Milestones of Development
Hearing and Speech
 3 mo – Response to voice
 6 mo – Turn to sound
 9 mo -– Babbles
 12 mo – One word

19. Milestones of Development
Personal Social
 3 mo – Smile
 6 mo – Shows likes and dislikes
 9 mo – Stranger anxiety
 12 mo – Waves bye-bye

20. Neurological Examination

21. NEUROLOGICAL EXAMINATION
• Higher Mental Functions
• Cranial Nerves
• Motor System
• Sensory system
• Skull and Spine
• SOMI

22. Higher Mental Functions
• Conscious Level (Glasgow Coma Scale)
• Recognition and Response
• Behavior and activity
• Speech
• Memory

23. Cranial Nerves
• Visual focusing and following
• Light reflex
• Facial Movements
• Response to sound
• Sucking and Swallowing
• Palate movement and Gag reflex

24. Motor System
• Presence of spontaneous voluntary movements in
infant
• Size and Nutrition of muscles
• Tone
• Power
• Deep Tendon Reflexes
• Planter Reflex
• Gait
• Co-ordination
• Involuntary Movements

25. Sensory System
• Touch
• Pain
• Temperature
• Position
• Vibration

26. Skull & Spine
• Shape of skull
• Anterior fontanel
• Occipito-frontal Circumference (OFC)
• Spine – Curvature, local swelling

27. SOMI – Signs of Meningeal Irritation
• Bulging Anterior fontanel
• Neck rigidity
• Kernig's sign
• Brudzinski's sign

28. Clinical Presentation
of
CNS diseases

29. CNS disease – Clinical Presentation
• Seizures / Convulsions / Fits
• Impaired Conscious level
• Developmental delay
• Intellectual handicap
• Neurological Paralysis / Paresis (motor weakness )
• Neuromuscular disorders / Hypotonia
• Movement disorders
• Headache
• Regression of acquired milestones
• Behaviour problems

30. Developmental delay
and
Intellectual handicap

31. Developmental delay / Intellectual handicap
Etiology
• Perinatal Brain Damage (HIE) (Hypoxic Ischemic
Encephalopathy)
• Postnatal Brain damage (e.g. Meningitis)
• Cerebral Malformations (e.g. agenesis of corpus callosum)
• Chromosomal disorders (e.g. Down syndrome)
• Genetic syndromes (single gene defects)
• Degenerative brain diseases (Leukodystrophy)
• Hypothyroidism (Cretinism)
• Severe Systemic Diseases (cardiac, renal, malnutrition)

32. Developmental delay / Intellectual handicap
Clinical Presentation
• Cerebral Palsy
• Delayed development
• Intellectual disability

33. Cerebral Palsy
in Children
Definition, Epidemiology, Etiology,
Clinical Features, Diagnosis, Assessment,
Management, Prognosis and Prevention

34. Friday, October 29, 2021 CEREBRAL PALSY by DR. NAVEED ANJUM 34
Cerebral Palsy – Clinical Description
Damage to
Developing Brain
Disorder of
Movement
and Posture
Non-
progressive

35. Cerebral Palsy
Definition
• Cerebral Palsy is a group of disorders of movement and
posture causing activity limitation due to non-progressive
disturbances in the developing fetal or infant brain.
• Cerebral Palsy affects mainly movement produced by
skeletal muscles and posture of the body
• Cerebral Palsy results in delayed development
• Cerebral Palsy causes activity limitation
• Cerebral Palsy is produced by damage to developing fetal or
infant brain

36. Cerebral Palsy
Epidemiology
• Incidence: 3 / 1000 children
• Predisposing Factors / Etiology
• Most common cause in developed countries is a Cerebral
malformation
• Most common cause in developing countries is Perinatal
Asphyxia

37. Cerebral Palsy
Etiology
Pre – natal
Cerebral
malformations
Chorio-
amnionitis
TORCH
infections
Peri – natal
Perinatal
asphyxia
Preterm
VLBW
Post –natal
Meningitis
Intra-cranial
hemorrhage
Cerebrovascular
accidents
Kernicterus

38. Cerebral Palsy
Types
• Spastic CP – 80 %
-- (Hypertonia, hyper-reflexia)
– Cerebral cortex, Upper Motor Neurons most affected
• Dyskinetic CP – 10 %
-- (Choreo-athetoid movements) – Basal ganglia most affected
• Ataxic / Hypotonic CP – 5 %
- (hypotonia, ataxia) – Cerebellum most affected
• Mixed CP – 5 %

40. Cerebral Palsy
Spastic Type

41. Hemi-
plegia
(25%)
Spastic
diplegia
(35%)
Spastic
quadri-
plegia
Para
Plegia
Mono
plegia
Double
Hemi
Plegia
Cerebral Palsy - Limbs affected

42. Cerebral Palsy
Clinical Features, Diagnosis,
Associated Problems,

43. Case Scenario
Clinical History
• A 3 year old child presents with inability to walk.
• Development History
• Child started sitting at 18 months of age. He has not started
walking
• He is able to move forward in a sitting position with help of his
arms
• He recognizes his parents and has started speaking few words
• Birth History
• He was born at a clinic after a term pregnancy
• He had delayed cry after birth, and remained in hospital for few
days
• There is history of seizures in first week of life, and later during
febrile illnesses

44. Case Scenario
Clinical Examination
• On examination, his OFC is 46 cm
• Internal squint is seen in eyes
• There is drooling of saliva from the mouth
• Motor system examination shows hypertonia and hyper-reflexia
• He stands with support on his toes with legs crossed
• He can take a few steps sideways holding on to furniture
• What is your most likely diagnosis ?
• Cerebral Palsy (spastic type)

45. Cerebral Palsy
Clinical Features - Symptoms
• Delayed development
Posture and locomotion
Vision and manipulation
Hearing and speech
Personal and social
• Stiffness of muscles / neck extended / arching of back
• Seizures
• Unable to take solid foods
• Constipation

46. Cerebral Palsy
Clinical Features - Signs
• Microcephaly
• Drooling of saliva, difficulty in swallowing
• Neck extended / arching of back
• Fisting of hands
• Scissoring of legs
• Spasticity of muscles – hypertonia, hyper-reflexia
• Reduced range of movement of skeletal muscles
• Persistence of primitive reflexes
• Abnormal position and posture of the body
• Secondary musculoskeletal problems

47. Cerebral Palsy
Diagnosis
• History –
• Patient complaints – Delayed Development
• Birth History – fetal distress, delayed cry, meningitis in infancy
• Family History – No H/O delayed development in other sibs
• Physical signs –
• Microcephaly
• Drooling of saliva, difficulty in swallowing
• Fisting of hands
• Scissoring of legs
• Spasticity of muscles – hypertonia, hyper-reflexia

48. Cerebral Palsy
Differential Diagnosis
• Neuro-muscular disorders (Infantile spinal muscular
atrophy)
• Myopathies and muscular dystrophies (congenital
myopathy, Duchene muscular dystrophy)
• Genetic diseases – syndromes (chromosomal disorders,
single gene defects)
• Neuro-metabolic disorders (e.g. biotinidase deficiency)
• CNS degenerative disorders (leukodystrophy, hereditary
spastic paraplegia)
• Hypothyroidism (Cretinism)

49. Cerebral Palsy
Patient Evaluation
• Birth History – Perinatal hypoxia
• Development history – delay in one or more areas
• Developmental disabilities of child
• Posture, movements and mobility
• Vision
• Hearing and speech
• Behavior
• Associated problems

50. Cerebral Palsy
Associated problems
• Epilepsy – 50%
• Intellectual disability – 50%
• Learning problems
• Squint
• Poor response to sound
• Poor speech and communication
• Swallowing difficulties
• Constipation
• Altered somatic sensations
• Behavior problems
• Positional deformities and contractures

51. Cerebral Palsy
Investigations
• Developmental evaluation
• Physiotherapy evaluation
• Occupational therapy evaluation
• Eyes / Vision evaluation
• Hearing evaluation
• Teacher evaluation
• CT / MRI Brain – normal / enlarged ventricles /
periventricular leukomalacia
• EEG - seizures

52. Cerebral Palsy – CT Brain
Atrophy and Infarctions

53. Cerebral Palsy
Management, Prognosis and Prevention

54. Cerebral Palsy
Multi-disciplinary Management
• Pediatrician / Pediatric Neurologist
• Psychologist / Developmental therapist
• Physiotherapist
• Occupational therapist
• Ophthalmologist
• Audiologist
• Teacher
• Rehabilitation specialist
• Orthopedic surgeon

55. Cerebral Palsy
Medications
• Seizures: Anti-epileptics
-- Phenobarbitone, Leviteracetam, Sodium valproate,
• Spasticity: Muscle Relaxants
-- Baclofen
-- Tizanidine
• Constipation: Laxatives
-- Mineral oil / Prune juice
-- Lactulose / Lactitol
• Micronutrients – Vitamins and minerals

56. Cerebral Palsy
Physiotherapy and Rehabilitation
Physiotherapy
• Positioning of body – to relax the muscles
• Passive Exercises – range of motion
• Active movements – teaching daily activities
Occupational therapy
• Hand function techniques, Feeding techniques
Speech therapy
• Language and Communication skills
Rehabilitation therapy
• Splints / Orthotic supports, Walking aids

57. Cerebral Palsy
Surgery
• Usually performed by 10 years of age
• Relieve the contractures –
= Tendo-achilles
= Adductors
• Strengthen the weak movements – tendon transfer

58. Cerebral Palsy
Prognosis
• Severity – of neurological deficits
• Management – Early diagnosis and Effective Management
• Progress of child – if the child is able to sit by 2 years of age,
he is expected to walk by 5 years of age

59. Cerebral Palsy
Prevention
 Efficient medical care during Pregnancy
 Prevention of Birth asphyxia during birth of baby
 Early management of Neonatal disorders
 Effective management of Neurological diseases in infancy

60. UN Convention on the Rights of the Child
1989
“A disabled child has the right to enjoy
a full and decent life,
in conditions which
ensure dignity,
promote self-reliance
and
facilitate the child’s active participation
in the community.”

61. Prof Imran Iqbal
Fellowship Pediatric Neurology-1991
Royal Children Hospital, Melbourne, Australia