1. Cerebral Palsy Definition: Definition: It is static non progressive disorder of posture and movement resulting from defect or lesion of the developing brain It is static non progressive disorder of posture and movement resulting from defect or lesion of the developing brain 2/1,000 population 2/1,000 population First described almost 150 yrs ago by Little,an orthopedic surgeon First described almost 150 yrs ago by Little,an orthopedic surgeon

2. Association of CP Association of CP- Association of CP- ■ MR ■ Epilepsy-25-35% ■ MR ■ Epilepsy-25-35% ■ Speech defect 50% ■ Deafness-10% ■ Speech defect 50% ■ Deafness-10% ■ Visual defect-20% ■ Dental problem ■ Behavioral disorder 40% ■ Behavioral disorder 40% ■ Orthopedic problem ■ Drooling

3. Classification Physiologic: Physiologic: Spastic (65%) ■ Athetoid (30%) Spastic (65%) ■ Athetoid (30%) Rigidity ■ Ataxia Rigidity ■ Ataxia Tremor ■ Atonic/hypotonic Tremor ■ Atonic/hypotonic Mixed ■ unclassified Mixed ■ unclassified

4. Anatomical classification Monoplegia ■ Paraplegia Monoplegia ■ Paraplegia Hemiplegia ■ Tri plegia Hemiplegia ■ Tri plegia Quadriplegia ■ Diplegia Quadriplegia ■ Diplegia Double hemiplegia Double hemiplegia

5. Etiological classification Prenatal: Prenatal: ■ Congenital anomalies ■ Congenital anomalies ■ Maternal: – ■ Maternal: – Torch infection,Chorioamnionitis, Torch infection,Chorioamnionitis, Maternal sepsis, UTI Maternal sepsis, UTI Temperature during labor Temperature during labor Toxemias of pregnancy Toxemias of pregnancy

6. Perinatal Causes Birth trauma Birth trauma Perinatal asphyxia <10% Perinatal asphyxia <10% LBW babies (prematurity IUGR)-due to intracerebral hge, periventricular leukomalacia LBW babies (prematurity IUGR)-due to intracerebral hge, periventricular leukomalacia

7. Postnatal causes Infections-Meningitis, Encephalitis Infections-Meningitis, Encephalitis Trauma- Head injury, Subdural hemotoma Trauma- Head injury, Subdural hemotoma Toxic – kernicterus Toxic – kernicterus Cerebrovascular -thrombosis of C.vessels Cerebrovascular -thrombosis of C.vessels Endocrine and metabolic- hypothyroidism, hypoglycemia, hypocalcemia, dyselectrolyte Endocrine and metabolic- hypothyroidism, hypoglycemia, hypocalcemia, dyselectrolyte Gross PEM in early infancy Gross PEM in early infancy

8. Functional classification Class I- No limitation of activity Class I- No limitation of activity Class II- Slight to moderate limitation (20%) Class II- Slight to moderate limitation (20%) Class III- Moderate to great limitation(50%) Class III- Moderate to great limitation(50%) Class IV – No useful physical activity (30%) Class IV – No useful physical activity (30%)

9. Clinical manifestations Common presentation : Common presentation : Delayed milestones with indifferent look Delayed milestones with indifferent look Fisting of hands with extended extremities Fisting of hands with extended extremities Microcephaly, Mental retardation Microcephaly, Mental retardation Behavioral abnormalities Behavioral abnormalities Visual, hearing, speech defects Visual, hearing, speech defects

10. Common Presentations persistence of NN reflexes, persistence of NN reflexes, Exaggerated jerks Exaggerated jerks Adductor spasms Adductor spasms gait –tip toe gait –tip toe Epilepsy Epilepsy

11. Spastic hemiplegia Arms often more involved than leg- difficulty in hand manipulation is obvious by 1 yr Arms often more involved than leg- difficulty in hand manipulation is obvious by 1 yr Delayed walking -18-24 mo Delayed walking -18-24 mo Equinovarus deformity of foot, walks on tip toes because of increased tone Equinovarus deformity of foot, walks on tip toes because of increased tone Affected upper limbs has dystonic posture when child runs Affected upper limbs has dystonic posture when child runs

12. Spastic hemiplegia Deep tendon reflexes increased, ankle clonus, babinski sign + Deep tendon reflexes increased, ankle clonus, babinski sign + 1/3 rd have seizure disorder 1/3 rd have seizure disorder 25% have MR 25% have MR CT/MRI- atrophic cerebral hemisphere with dilated lateral ventriclecontralateral to the affected side CT/MRI- atrophic cerebral hemisphere with dilated lateral ventriclecontralateral to the affected side

13. Spastic Diplegia Bilateral spasticity of legs Bilateral spasticity of legs 1 st noticed when infant begins to crawl- tends to drag the legs behind more ( commando crawl) 1 st noticed when infant begins to crawl- tends to drag the legs behind more ( commando crawl) Severe spasticity –application of diaper is difficult due to excess adduction of hips Severe spasticity –application of diaper is difficult due to excess adduction of hips Brisk reflexes, ankle clonus Brisk reflexes, ankle clonus Scissoring posture of lower extremity when suspended by axilla Scissoring posture of lower extremity when suspended by axilla

14. Spastic Diplegia Walking tiptoes, disuse atropy,impaired growth of lower extremity Walking tiptoes, disuse atropy,impaired growth of lower extremity Intellectual development normal Intellectual development normal Minimal seizures Minimal seizures CT/MRI-periventricular leukomalacia of white matter mainly lower limb fibres CT/MRI-periventricular leukomalacia of white matter mainly lower limb fibres

15. Spastic quadriplegia Most severe form,most common Most severe form,most common All extremities severely impaired All extremities severely impaired High association with MR and seizure High association with MR and seizure Supranuclear bulbar palsies+--aspiration pneumonia Supranuclear bulbar palsies+--aspiration pneumonia Flexion Contractures of knees and elbows Flexion Contractures of knees and elbows Spastic quadriplegia + athetosis +mixed CP Spastic quadriplegia + athetosis +mixed CP

16. Athetoid CP Relatively rare these days due to aggressive management of hyperbilirubinemia Relatively rare these days due to aggressive management of hyperbilirubinemia H/o NNJ += hypermyelination of basal ganglia called status marmoratus H/o NNJ += hypermyelination of basal ganglia called status marmoratus Initially hypotonic, poor head control,marked head lag,feeding difficulty,drooling + Initially hypotonic, poor head control,marked head lag,feeding difficulty,drooling +

17. Athetoid CP After age 1yr –athetoid movements become evident After age 1yr –athetoid movements become evident Speech is affected (slurred, voice modulation impaired) due to involvement of oropharyngeal muscles Speech is affected (slurred, voice modulation impaired) due to involvement of oropharyngeal muscles Upper motor neuron signs –not present Upper motor neuron signs –not present Seizure uncommon Seizure uncommon Intellect -preserved Intellect -preserved

18. Rigidity/Ataxia/Tremor Uncommon variety Uncommon variety Features og extrapyramidal lesion Features og extrapyramidal lesion Lead pipe or cogwheel type Lead pipe or cogwheel type Always associated with MR Always associated with MR Ataxia: Ataxia: Mostly congenital due to cerebellar malformation Mostly congenital due to cerebellar malformation Tremor- constant severe coarse tremor Tremor- constant severe coarse tremor

19. Diagnosis History History Examination Examination Serology-TORCH/VDRL Serology-TORCH/VDRL X-ray skull-intracranial calcification X-ray skull-intracranial calcification EEG EEG Ct/MRI Ct/MRI Test of hearing,vision Test of hearing,vision IQ test IQ test

20. Treatment Multidisciplinary approach –pediatrician playing the main role Multidisciplinary approach –pediatrician playing the main role Physiotherapist Orthopedic surgeon Physiotherapist Orthopedic surgeon Speech therapist ENT surgeon Speech therapist ENT surgeon Neurologist Social worker Neurologist Social worker Developmental psychologist Developmental psychologist

21. Treatment Counselling-teach parents-daily activities like feeding, carrying, dressing, bathing, playing, physiotherapy to limit abnormal muscle tone Counselling-teach parents-daily activities like feeding, carrying, dressing, bathing, playing, physiotherapy to limit abnormal muscle tone Physiotherapy :- Physiotherapy :- For arms-physio to start by age 6 months For arms-physio to start by age 6 months For legs-for effective weight bearing and wt transfer For legs-for effective weight bearing and wt transfer

22. Treatment Grasping,release movements of hands, reciprocal movements of feet for walking, vocalised breathing for speech, parallel walking bars bicycles, special chair, grasping and releasing games Grasping,release movements of hands, reciprocal movements of feet for walking, vocalised breathing for speech, parallel walking bars bicycles, special chair, grasping and releasing games Massage, exercise and hydrotherapy Massage, exercise and hydrotherapy

23. Treatment Adaptive equipments-walkers, poles standing frames, motorized wheel chair, special feeding devices, modified typewriters Adaptive equipments-walkers, poles standing frames, motorized wheel chair, special feeding devices, modified typewriters Communication skills- use of symbols, specially adapted computers Communication skills- use of symbols, specially adapted computers

24. Treatment Ophthalmologist-strbismus, nystagmus, optic atrophy Ophthalmologist-strbismus, nystagmus, optic atrophy Orthopedics :- Orthopedics :- Hip, knee contractures-surgical release Hip, knee contractures-surgical release Occupational therapy:- Occupational therapy:- Simple movements for self help- feeding, dressing Simple movements for self help- feeding, dressing

25. Treatment Educational therapy: Educational therapy: Mild MR – ordinary school Mild MR – ordinary school Severe MR, severe disabilities-special school Severe MR, severe disabilities-special school Social therapy- Social therapy- social and emotional support to family social and emotional support to family Rehabilitation and vocational guidance Rehabilitation and vocational guidance

26. Treatment Symptomatic- Symptomatic- anticonvulsants for seizures anticonvulsants for seizures Muscle relaxants- benzodiazapines,dantrolene sodium, Baclofen Muscle relaxants- benzodiazapines,dantrolene sodium, Baclofen Preventable causes shoud be prevented Preventable causes shoud be prevented

27. Prognosis 10-50%-have seizure 10-50%-have seizure Squint-50%,visual handicap-30% optic atrophy and cortical blindness Squint-50%,visual handicap-30% optic atrophy and cortical blindness Walk by age of three, if not then unlikely that useful function will be gained Walk by age of three, if not then unlikely that useful function will be gained