1. Neurology Chapter of IAP
Cerebral palsy (CP)
Neurology Chapter of IAP

2. Neurology Chapter of IAPCP
W & W
Non-specific term that include disorders characterized by early onset and impaired movement and posture.
Non-progressive and may include perceptual problems, language deficits, and intellectual involvement.
Neurology Chapter of IAP

3. Neurology Chapter of IAPCP
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Incidence
Most common physical disability of childhood.
Incidence has increased since the 60’s, maybe due to improved survival of VLBW infants.
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Etiology
Variety of perinatal, prenatal, and postnatal factors contribute, either singly or multifactorily to CP.
Commonly thought to be due to birth asphyxia; now known to be due to existing prenatal brain abnormalities.
Premature delivery is the single most important determinant of CP.
In 24% of cases, no cause is found.
Neurology Chapter of IAP

6. Neurology Chapter of IAP
TABLE 40-1 Causes of CP
Time (% of cases)
Prenatal (44%)
First trimester
Second trimester
Causes
Teratogens, chromosomal abnormalities, genetic syndromes, brain malformations
Intrauterine infections, problems in fetal/placental functioning
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Causes of CP
Time (% of cases)
Labor and delivery (19%)
Perinatal (8%)
Childhood (5%)
Not obvious (24%)
Causes
Preeclampsia, complications of labor and delivery
Sepsis/CNS infection, asphyxia, prematurity
Meningitis, traumatic brain injury, toxins
Neurology Chapter of IAP

9. Clinical Classification of CP
Table 40-2, Page 1967.
Spastic-hypertonicity with poor posture control
Dyskinetic/athetoid- abnormal involuntary movement/slow wormlike writhing
Ataxic- wide-based gait
Mixed-type/dystonic- combination of spasticity and athetosis
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11. Clinical manifestations
Delayed gross motor development
A universal manifestation of CP
The discrepancy between motor ability and expected achievement tends to increase as growth advances.
Delayed development of ability to balance slows milestones
Delay in all motor accomplishments
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13. Clinical Manifestations
Abnormal motor performance
Preferential unilateral hand use may be apparent at 6 months.
Hemiplegia, abnormal crawling or asymmetrical crawl; spasticity may cause child to walk and stand on toes
dyskinetic CP or uncoordinated or involuntary movements (writhing tongue, fingers, and toes; facial grimacing), poor sucking and feeding, persistent tongue thrust; head staggering, tremor on reaching, truncal ataxia.
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16. Alterations in muscle tone
Increased or decreased resistance to passive movement (abnormal muscle tone).
Opisthotonic postures or exaggerated back arching, feel stiff on dressing.
Difficulty diapering due to spastic hip adductor muscles and lower extremities
When pulled to a sitting position, child may extend the entire body and be rigid at hip and knee. This is an early sign of spasticity.
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Abnormal postures
Children with spastic CP have abnormal posture at rest or when position is changed
Infantile lying prone may have hip higher than trunk with legs and arms drawn in.
Persistent infantile resting and sleeping position is a sign of spasticity.
Hemiparetic child may rest with affected arm adducted and held against torso, with the elbow pronated and slightly flexed and the hand closed.
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Reflex Abnormalities
Persistence of primitive infantile reflexes (one of the earliest signs of CP)
Tonic neck reflex
Hyperactivity or moro, plantar, palmar grasp
Hyperreflexia, ankle clonus, stretch reflexes can be elicited from any muscle group.
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21. Associated disabilities and problems
Intellectual impairment
70% w/in normal limits; wide range
Tests should be carried out over a period of time.
Children with athetosis and ataxia more intelligent.
Speech difficulties (not a sign or MR)- child has motor and sensory defects
ADHD- (may occur)-poor attention span, marked distractibility, hyperactive behavior
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23. ASSOCIATED DISABILITIES
Seizures- generalized tonic-clonic;more in postnatally acquired hemiplegia
Drooling- may occur and lead to wet clothing/skin irritation
Feeding- alterations in muscle tone lead to difficulties chewing, swallowing, talking, etc.
Address nutritional concerns.
Coughing, choking may lead to aspiration.
Altered respiratory patterns may lead to inadequate gas exchange.
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Motor Impairment
Orthopedic complications
Unilateral or bilateral hip dislocations, scoliosis, joint contractures due to unbalanced muscle tone.
Decreased Mobility
difficulties with toileting may lead to constipation
Difficult chewing bulky foods may lead to constipation
May need stool softeners or laxatives
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Associated Problems
Dental carries
Improper dental hygiene
congenital enamel defects (hyperplasia of primary teeth)
high carbohydrate intake and retention
Dietary balance with poor nutritional intake
Inadequate fluoride
Difficulty in mouth closure and drooling
Spastic or clonic movements cause gagging or biting on toothbrush
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Associated Problems
Malocclusion in 90% of children
Oral hypersensitivity causes resistance to good hygiene
Gingivitis is secondary to poor hygiene
Dental health further complicated by anti-seizure meds
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Associated problems
Nystagmus and amblyopia common
May need surgery or corrective lenses
May be due to sensoneural involvement
Infants lying flat too long may have otitis media which may leads to conductive hearing loss
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Diagnostic Studies
Physical Assessment
Observe LBW, preterm, and those with low Apgar scores at 5 minutes.
Observe infants who have seizures, intracranial hemorrhage, metabolic disturbances
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DX studies
Since control of movement does not occur until late infancy, dx may not be confirmed until after 6 months of age.
See Box 4-4, page 1968 for warning signs
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WARNING SIGNS
Physical Signs
poor head control after 3 months
stiff or rigid arms/legs, arching back, floppy or limp posture
Cannot sit up without support by 8 months
Uses only one side of the body or only the arms to crawl
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Warning Signs
Behavioral Signs
Extreme irritability or crying
Failure to smile by 3 months
Feeding difficulties
Persistent gagging or choking when fed
After 6 months of age, tongue pushes soft food out of the mouth.
Neurology Chapter of IAP

32. Therapeutic management
Box 40-5, Wong 1970.
PHYSICAL THERAPY
Most commonly used treatments.
Goal is good skeletal alignment for the spastic child.
For the child with athetosis, training in purposeful acts, even in the face of involuntary motion
Maximum development of proprioceptive sense for the child with ataxia.
Orthotic devices (braces, splints, casting).
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OCCUPATIONAL THERAPY
Training in ADL’s along developmental lines.
Sitting to walking; feeding to cooking.
Important to incorporate play into program
Adaptive equipment (utensils for functional use, i.e., eating, writing), computers, etc.
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36. Speech/Language therapy
Early speech training by speech/language pathologist !
Before child develops poor habits
Advice parents to follow directions of therapist
May need to force child to use tongue/lips in eating
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Special Education
Determined by child’s needs
Early intervention programs
Individualized Education Program (IEP)
Specialized learning programs and support services in schools
Socialization to promote self-concept development
Neurology Chapter of IAP

38. Surgical Intervention
Reserved for child who does not respond to conservative therapy!
Or whose spasticity causes progressive deformities
Orthopedic surgery
correct contractures or spastic deformities
provide stability for uncontrolled joint
provide balanced muscle power
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Surgical Therapy
Tendon-lengthening procedures (heel-cord)
Release of spastic wrist flexor muscles
Correction of hip-adductor muscle spasticity or contracture to improve locomotion
Surgery is for improved function rather than cosmetic reasons and is followed by PT.
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Medication Therapy
Little usefulness
Anti-anxiety agents may relieve excessive motion and tension (child with athetosis)
Skeletal muscle relaxants ( methocarbamol (Tobaxin), dantrolene (Dantrium), Baclofen, may be used short-term for older children and adolescents.
Diazepam (Valium) for older children and adolescents, may relieve stiffness and ease motion
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Medications
Local nerve blocks to motor points of a muscle with a neurolytic agent (phenol solution) may relieve spasticity.
Botulism toxin (Botox) used to paralyze certain muscles.
Pain
Secondary conditions (seizures, bowel and bladder problems, lung complications).
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Service Coordination
Case Management!
Important for collaboration of all health professionals, services, therapies!
Child needs support!
Family needs support!
Neurology Chapter of IAP