Neurology Chapter of IAP Cerebral palsy (CP). Neurology Chapter of IAP CP W & W 1966-1975 Non-specific term that include disorders characterized by early

Neurology Chapter of IAP

Cerebral palsy (CP)

•


CP

• W & W 1966-1975

• 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.


CP

•


Incidence

• Most common physical disability of childhood.

• Incidence has increased since the 60’s, maybe due to improved survival of VLBW infants.


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.


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



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


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



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



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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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.



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.



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.


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



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.


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


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


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


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


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


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


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


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.


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).



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.



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


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


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


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.


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


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).


Service Coordination

• Case Management!

• Important for collaboration of all health professionals, services, therapies!

• Child needs support!

• Family needs support!

Documents

Neurology Chapter of IAP Cerebral palsy (CP). Neurology Chapter of IAP CP W & W 1966-1975 Non-specific term that include disorders characterized by early