1. The Child with Motor Weakness
Neurology Module
Pediatrics II

2. Cerebral Palsy - Objectives
At the end of this topic you should be able to:
provide a clear definition of cerebral palsy;
discuss aetiological and risk factors associated with cerebral palsy;
explain the clinical features and associated impairments common to cerebral palsy;
demonstrate an understanding of diagnostic methods;
recognize the various methods of effectively managing cerebral palsy.

3. The Floppy Baby J.M., 17-month-old boy admitted because of cough
Born preterm at 7 months age of gestation by a repeat Caesarean section; BW=1.3 kg; Apgar score not known to mother but resuscitation was reportedly done. He developed sepsis and stayed in the NICU for a month.
Discharged with difficulty in feeding such that he
would often cough while sucking.

4. Case: J.M., 17 months old He was never able to regard, hold head,
roll over, use his hand purposively, babble
or startle.
He had one episode of febrile seizure.

5. Case: J.M., 17 months old Pertinent Physical Examination Findings:
Wt=5.95 kg(<P5) Length=65.5cm(<p5) HC=42cm(<P5)
awake but oblivious to surroundings, shrill cry,
does not alert nor startle to sound, tongue midline,
crackles over both lungs
Head lag on traction maneuver, slips through on vertical suspension, truncal hypotonia, loops over on horizontal suspension
Spastic limbs, limited movement of both lower extremities with +++ DTRs

6. Salient Points 17 months old, with developmental delay Preterm birth
(+) Neonatal asphyxia
(+) Infection
(+) History of seizures
Marked developmental delay
Neurologic abnormalities - truncal hypotonia with spastic limbs, weakness of both lower extremities

7. QUESTION #1: Is there a neurologic disease?
Yes, as evidenced by the abnormal
neurologic examination.

8. QUESTION #2: Where is the lesion?
The abnormalities in the tone (hypotonia) and movement (diplegia) point to the motor system.
Weakness can be due to lesions in the :
1. Central nervous system – Upper motor neuron
(spasticity, hyperreflexia); may be accompanied by
cerebral manifestations (seizures, cognition,
language and sensory problems)
2. Peripheral nervous system – Lower motor neuron
(decreased to absent reflexes, flaccid)

9. QUESTION #2: Where is the lesion?
J.M appears to have an upper motor lesion
specifically the cerebral hemispheres.

10. QUESTION #3: What is the nature of the lesion?
Disorders of the motor system may be:
1. Acute - strokes/vascular metabolic disorders
infection
2. Chronic - cerebral palsy (static)
congenital CNS lesion
degenerative disorders
(progressive)

11. CEREBRAL PALSY
Refers to a group of disorders characterized by motor abnormalities (tone, posture or movement) which are neither progressive nor episodic.
The brain lesions are static and result from disorders of early brain development, usually insults in the perinatal period.
They are not progressive but the symptoms may change in time.

12. CEREBRAL PALSY Clinical manifestations:
1. Delay in development – i.e. poor head control, delays in gross motor or fine motor development
2. Motor deficit – depending on the area of the brain involved and usually the risk factors present
3. Associated developmental disabilities – mental retardation, epilepsy, visual, hearing, speech and behavioral abnormalities

13. Types of Cerebral Palsy and the Major Causes
Physiologic
Topographic
Etiologic
Functional
Spastic
Athetoid
Rigid
Ataxic
Tremor
Atonic
Mixed
Unclassified
Monoplegia
Paraplegia
Hemiplegia
Triplegia
Quadriplegia
Diplegia
Double
hemiplegia
Prenatal
(e.g., infection, metabolic, anoxia, toxic, genetic, infarction)
Perinatal
(e.g., anoxia)
Postnatal
(e.g. toxins, trauma, infection)
Class I –
no limitation of activity
Class II – slight to moderate limitation
Class III – moderate to great limitation
Class IV –
no useful physical activity

14. Topographic Classification
Diplegia
Hemiplegia
Quadriplegia
More Affected
Less Affected

15. Physiologic Classification
Hypotonic Cerebral Palsy

16. Physiologic Classification
Spastic Diplegic
Cerebral Palsy

17. Diagnosis
1. Thorough history, developmental assessment, physical and neurological examinations
2. Hearing and vision screening
3. EEG if with seizures
4. If no possible etiology or risk factors for CP, may do diagnostic tests as:
Neuroimaging – CT/MRI
Metabolic screening
Chromosomal study

18. Differential Diagnosis
1. Motor delays from congenital structural lesions
2. Progressive disorders of the brain – white matter diseases
3. Muscle disorders- myopathies,
dystrophies.

19. Management Multidisciplinary Pediatrician Neurologist
Rehabilitation specialists
Physical and occupational therapists
Developmental psychologists
Education specialists
Orthopedic surgeons
Social workers

20. Thank you!