Comprehensive and simple presentation on cerebral palsy for undergraduates and post graduates.

1. Cerebral Palsy
Dr Tushar Jagzape
Pediatrics
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2. • A 15 month old baby brought with history of
not able to sit without support, inability to
speak and convulsions.
• Is it cerebral palsy?
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3. Learning objectives
• At the end of this session the learners should
be able to:
– Define cerebral palsy
– Enumerate etiology for cerebral palsy
– Describe the classification of cerebral palsy
– Describe clinical features of cerebral palsy.
– Describe in short the management of cerebral
palsy.
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4. Introduction:
• Common cause of development delay.
• Incidence 3.6 per 1000 children
• Male : female = 1.4: 1
• Prevalence difficult to estimate and incidence
unchanged.
• John Little – Orthopedic surgeon -1862
• Little`s disease.
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5. Definition
• Group of permanent disorders of movement
and posture causing activity limitation, that
are attributed to non progressive
disturbances in the developing fetal or infant
brain.
• Non progressive neuromotor disorder of
cerebral origin.
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6. • Accompanied by disturbances of
– sensation,
– perception,
– cognition,
– communication
– behavior
– epilepsy and secondary musculoskeletal problems
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7. • In all cases the following must be true…
– Cerebral palsy is the result of a brain lesion.
– The brain lesion must be fixed and non
progressive.
– The abnormality of the brain result in motor
impairment
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8. Etiology :
• Prenatal (70%)
Infection, anoxia, toxic, vascular, Rh disease, genetic,
congenital malformation of brain
• Perinatal (5-10%)
Anoxia, traumatic delivery, metabolic, Fetal
distress,Premature delivery,
• Post natal
Trauma, infection, Sepsis in neonatal period,
Hyperbilirubinemia (Kernicterus)Bronchopulmonary dysplasia
and prolonged ventilation in preterm infants.
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9. Clinical manifestations:
A) Physiologic / according to motor deficit
– Spastic cerebral palsy (65%)
• Qudriplegia, Diplegia, hemiplegia
• Seizures are common
• Mental status - variable
– Hypotonic (Atonic) (5%)
• Tendon reflexes – normal or brisk
• Cerebellar involvement – reflex – absent, ataxia , intention tremor
• Mental status – may be normal
– Extrapyramidal CP (30%)
• Choreathetosis, dystonia, tremors , rigidity
• Deafness,
• Mental retardation
– Mixed type
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11. B) Gross motor functional classification score
Level-I Minimal restriction of activity
Level-II Activities carried out with minimal assistance or
support
Level-III Activities carried out with the help of assisted
mobility devices.
Level-IV Can function in sitting, but require extensive use of
mobility devices-limited independence.
Level-V Lack of independence even in basic antigravity
postural control.

12. C) Classification according to patients
therapeutic requirements
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Class Therapy required
Class I No active treatment required
Class II Requires minimal bracing and treatment
Class III Requires bracing and services of cerebral palsy team
Class IV Requires long tem institionalization and management

13. Associated features
System involved Features
Eye Refractive error, strabismus, gaze palsy, ROP, cataract,
coloboma, partial or complete blindness
Ear Partial or complete deafness,
Speech Dysarthria, aphasia,
Seizures GTCS, Focal, multiple types, refractory
Intelligence Mild to profound mental retardation
GIT Constipation, feeding difficulties, incontinence, GER
Sensory Asteriognosis, spatial disorientation
Teeth Malocclusion, caries
Miscellaneous Behavior problems, recurrent infections, inadequate
thermoregulation, Critcheley`s sign – persistent adductor
thumb
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14. Diagnosis
• Suspect – development delay associated with posture
and tone abnormality
• Evaluate
– Perinatal history
– Detailed neurological and developmental examination
• DQ = avg age of attainment / observed age at attainment x
100
• DQ < 70 %
– Assessment of language and learning disabilities
– Neuroimaging
– EEG
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15. Levine ( poster) criteria
P- Posturing/ abnormal movement
O- oropharyngeal problems (normaly tongue thrust and
swallowing abnormality)
S- strabismus
T – tone ( hyper to hypo)
E- Evolutional maldevelopment(persistent primitive reflexe or
protective / equilibrium reflexes fail to develop (parachute
reflex)
R – reflexes ( increased deep tendon/ persistent Babinski )
Four out of 6 strongly points to CP

16. How to recognize cerebral palsy
• EARLY SIGNS:

17. • Slow development • Hand preference

18. • Feeding problems • Difficulty in putting the
diaper

19. • Communication
difficulties
• Hearing difficulties

20. TYPICAL SPASTIC POSITIONS WHEN LYING
ON THE BACK:

22. Differential diagnosis
• Neurodegenerative disorders
• Hydrocephalous and subdural effusion
• Muscle disorders
• Ataxia telengiectasia
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23. Treatment
– Mobility
– Communication
– Learning
– Self Care
– Self Direction
– Independent Living
– Economic Sufficiency
1. Developmental
Pediatrician,
2. Pediatric Orthopedic
Surgeon,
3. Pediatric Neurologist
4. Neurosurgeon,
5. Physiotherapist,
6. Occupational Therapist
and Orthotist.
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Multidisciplinary approach (spoke wheel)

24. Symptomatic treatment :
• Seizures – Anticonvulsants
• Muscle relaxants –
– Benzodizepines – diazepam (0.01-0.3 mg/kg/day)
– Baclofen – (0.2-2 mg/kg /day q bid or tid),
intrathecal
– Dantrolene sodium (0.5-10 mg/kg/day bid)
• DOPA responsive dystonia – Segawa syndrome
– levodopa (0.5-2 mg/kg/day)
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25. • Trihexyphenidyl = 0.25 mg/day divided bid ,tid
– dystonia
• Reserpine (0.01-0.02 mg/kg/day qbid) or
Tetrabenzine (12.5-25 mg q bid ,tid) – for
hyperkinetic movement disorders
• Botulinum toxin-
– specific group of muscles
• Salivary glands for drooling (Atropine and benztropine )
• Rhizotomy selective
• Tendon release surgery
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26. • Physiotherapy :
– Massage, exercise
– Encouraging basic movements
– Aids – orthosis
– Stretching exercises
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27. Try to find ways for the child to be in positions that correct
or are opposite to his abnormal ones.

30. Ankle Foot Orthoses(AFO)

31. Occupational therapy.
• Focus on the development of fine motor skills
and self-care skills.
• To promote child's independent participation
in daily activities and routines in the home,
school and community.
• Also address difficulties with feeding and
swallowing.

32. Speech therapy.
• Hearing assessment – BERA or PTA
• For receptive (understanding) part of speech and
language as well as the expressive part (talking).
• Ability to communicate using alternative means such
as an augmentative communication device or sign
language.
• Speech therapists may also help with difficulties
related to feeding and swallowing.

33. • Visual problems – refrative errors , strabisms
• Behaviour problems & Sleep Problems
– Behaviour modification techniques and parental
counselling are helpful.
– Drugs methylphenidate, haloperidol and other
pharmacological agents.
– Use of night sedatives, like chloral hydrate for a
few days may help.
– Melatonin 2 mg half an hour before sleep can also
be tried.
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34. Feeding and Nutrition
• Bulbar palsy, involuntary movements, tone problems, handling and
seating difficulties
• Chewing difficulty, gastro-oesophageal reflux leading to repeated
aspirations.
• Special feeding techniques and prokinetics may be required.
Gastrostomy
• Lack of mobility and gut hypotonia - constipation. Dietary
modification - high fibre diet and plenty of fluids
• Excessive Salivation: Oral exercises are taught to the child. Atropine
and benztropine have been used occasionally for temporary relief.
• Nutritional supplements – iron and multivitamins

35. • Parent counseling
– An honest appraisal of the child's condition is
essential.
– Parents must learn that 'treatment' is a continuous
process;
• Education and training
– Indivualized
– The ultimate aim of management in C.P is to help the
child achieve his optimal developmental potential and
to integrate him as a useful member in the society.
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36. • Prognosis
– depends on associated handicaps
– Family response, educational and therapeutic
facilitis
• Prevention
– Good ANC/ Intranatal and /PNC care
– Proper treatment of perinatal hypoxia,
hyperbilirubinemia
– Magnesium sulphate to mothers,
– Therapeutic hypothermia
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37. Summary
• Umbrella term for disorder of movement and
posture
• Non – progressive but dynamic
• Prematurity is an increase risk
• Spastic CP is the commonest
• Multidisciplinary treatment
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