Nakhieeran Nallasamy

Azreen Onny

Nirmalatiban Parthiban (The Expert)

• Abnormality of movement and posture, causing activity limitation attributed to non-progressive disturbances that occurred in the developing fetal or infant brain

• Most common cause of motor impairment in children – 2 per 1000 live births

• CP term - Brain injuries up to 2 years of age

• <2 - Acquired brain injury as diagnosis

• Underlying cause is static - resulting motor disorder may evolve -> deterioration

• Motor disorders accompanied by:– Cognition

– Communication

– Perception

– Sensation

– Behaviour & seizure disorder

– Secondary MSK problems

• Diagnosis: – Distribution of the motor disorder

– Movement type

– Cause

– Any associated impairment

Spastic CP

• Damage to upper motor neurone(pyramidal/corticospinal tract) pathway

• Limb tone is persistently increased (spastic) a/w:

• Brisk deep tendon reflexes

• Extensor plantar responses

• Spastic tone – velocity dependent -> dynamic catch

• May suddenly yield under pressure - ‘clasp knife’

• Limb involvement – unilateral or bilateral (asymmetrical signs)

• Spasticity – present early; can even be seen in the neonatal period

• Sometimes -> initial hypotonia, esp. head & trunk

• THREE main types of spastic CP:

– Hemiplegia

– Quadriplegia

– Diplegia

Hemiplegia

• Unilateral involvement of arm and leg (Arm>Leg; Face spared)

• Often present at 4-12 months with:

– Fisting of the affected hand

– Flexed arm; Pronated forearm

– Asymmetric reaching or hand function

– Subsequently -> tip-toe walk (toe-heel gait)

• Initially flaccid & hypotonic, but increased tone becomes the predominant sign

• In some, caused by neonatal stroke; strokes -> hemianopia

Quadriplegia

• All four limbs; often severe

• Trunk – opisothonus, poor head control, low central tone

• Severe CP a/w seizures, microcephaly and moderate or severe intellectual impairment

Diplegia

• All four limbs (Leg>Arm) -> Hand function normal

• Motor difficulties in arms -> functional use of hands

• Walking is abnormal

• a/w preterm birth due to periventricular brain damage

Dyskinetic CP

• Damage to the basal ganglia

1. Chorea

2. Athetosis

3. Dystonia

Definition

• “Dance-like” irregular, involuntary, brief and abrupt movements

Features

• Mild: Fidgety, clumsy

• Severe: Wild, violent movements with large amplitude (“Ballism”)

• Speech, movement and swallowing disturbances

Chorea

Definition

• Slow writhing movements occurring more distally (Fanning of fingers)

Features

• Fluctuations of muscle tones

• Activities using hand and feet disturbed

• Muscles of face and tongue may be affected (grimacing, drooling, speech, breathing, swallowing problem)

• Worsen when moving and emotional stress

Athetosis

Dystonia

Definition• Simultaneous contraction of agonist

and antagonist muscles of the trunk and proximal muscles

• “Twisting” appearance• 2 types: Focal and generalised

Features• Repetitive and sustained movements• Awkward postures• Rapid or slow movements (painful)• Speech and swallowing difficulties

(generalised)• Increase when tired, anxious, tense

or emotional

Sensory tricksSpecific movements or sensations which may suppress the unwanted movements Example;= Touching face or chin with hand or finger

Choreoathetoid CP

Definition

• Chorea + Athetosis

• Abnormal, uncontrollable, writhing movements of arms and legs

Features

• Variable muscle tone (common: hypotonia)

• Activated by stress, laughing or attempt to move

Ataxic (Hypotonic) CP

• Due to acquired brain injury (cerebellum and the connections)

Features• Ipsilateral and symmetrical• Early trunk and limb hypotonia• Poor balance • Delayed motor development• Incoordination• Intention tremor• Ataxia

Cerebral Palsy Management

Multidisciplinary approachChild development services

Pediatrician

-Investigation, diagnosis

-Continuing medical management

-Coordinating input from other agencies

Physiotherapist

-Balance and mobility (aids- motorised

wheelchair/frame)

-Postural maintenance

-Prevention of joint contractures

Speech and language therapist

-Augmentation and alternative communication

(Makaton sign)

Occupational therapist

-Activities of daily living (ADL)- feeding, washing,

toileting , seating

Psychologist

-Cognitive testing

-Behavior management

-Education advice

Specialist health visitor/Social worker

- Helps coordinate MDT

-Advocate for child and family

Clinical Multidisciplinary approach

Rehabilitation

Physiatrist

-Rehabilitation medicine specialist

-Management (sialorrhea, insomnia)

Orthopedic surgeon

-Correct structural deformities

-Spasticity (tenotomy, a tendon-lengthening

procedure)

Neurologist and neurosurgeons

-Treatment patients with seizures

-Treat hydrocephalus, spasticity

Geneticists

-To rule out other disorders

-Evaluate for genetic syndrome (dysmorphic features, multiple

organ abnormalities)

Gastroenterologist, nutritionist

-manage feeding/swallowing difficulties, GERD, asses

nutritional statusPulmonologists

-Bronchopulmanory dysplasia

Recurrent aspiration

Pediatricians

Management of abnormal movements Target : spasticity, dystonia, myoclonus

Baclofen

-Orally or intrathecallyto treat spasticity

-gamma aminobutyricacid- to activate GABA

Anticonvulsants (benzodiapenes,

diazepam)- to treat myoclonus

Phenol intramuscular neurolysis

-Large muscles

-Limited to nerves with motor innervation as it may result in

sensory dysasthesia

-To block nerve conduction

Botulinum toxin

-Treat for spasticity

-Should be considered lower extremities

-Allow range of motions

-Blocks the release of acetylcholine

Intrathecal baclofen pump insertion

-Placed in anterior abdominal wall and connects to a catheter to subarachnoid of spinal cord-Allows more local inhibition and fewer adverse effects than oral baclofen

Selective dorsal rhizotomy-To treat for spaticity-Surgical ablation of sensory nerve roots. -It decreases spasticity by decreasing reflexive motor neuron activation-Targets nerves that do not receive gamma aminobutryic acid – cause of overfiring –hypotonia

Stereotactic basal ganglia -May improve rigidity, tremor

Orthopedic surgical team-Scoliosis and hip dislocation are common require surgery-Tendon lengthening-spastic muscle imbalance-Osteotomy to realign limbs-femoral neck, tibia -Reconstructive surgeries to release contractures, stabilize joints

THANK YOU!!!