A brief introduction to the topic cerebral palsy, prepared by Dr Yash Oza, PG resident in MS Orthopaedics Etiology, Classification, assessment, diagnosis, treatment

1. CEREBRAL PALSY
Dr Yash Oza
PG resident in MS Orthopaedics

2. Introduction
 Definition:
 CP is defined as a disorder of movements and posture
caused by non specific progressive defect or lesion in
immature brain.
 Incidence :
 2 to 4 individuals for every 1000 births

3. Brain Development
 The brain grossly differentiate into recognizable cerebrum, cerebellum
and other structures during the 1sy trimester.
 Neurons begins to delevop in 2nd trimester
 Reflex movements can be detected by 15th week.
 By the end of 2nd trimester, all neurons are formed and any damage is
irreversible.
 Glialization starts in 2nd trimester.
 Synaptic connection occurs in 3rd trimester.

4. Etiology of CP
1. Prenatal Causes
2. Perinatal Causes
3. Postnatal Causes

5. 1. Prenatal Causes
 Congenital Infection : TORCH (toxoplasmosis, rubella,
cytomegalovirus, herpes simplex, and other organisms
including syphilis, parvovirus, and Varicella zoster. )
 Cerebral Malformation
 Obstetrical Complication : Pre-eclampsia, Eclampsia,
Abruptio placenta, Placenta Previa, Plecentak
Infarction.
 Maternal Ds : Pneumonia, Cardiorespiratory diseases,
Thyroid dysfunction, DM
 Abuse of drugs : Alcohol, Tobacco, Marijuana, Cocaine

6. 2. Perinatal Causes
 Prematurity
 LBW
 Complicated delivery
 Asphyxia
 Cerebral Trauma
 Hyper bilirubinemia
 Blood incompatibilities
 Infection : Meningitis, Herpes Simplex
 Sever hypoglycemia

7. 3. Post Natal Causes
 Infection : Meningitis, Encephalitis
 Head Injury
 Aspiration
 Asphyxia
 Seizures
 Near Drowning
 Fibrocystic Diseases
 Cardiac arrest
 CVA
 Cyanotic congenital heart Ds
 Sickle cell Ds
 Vascular malformation

8. Classification
 Based on Movements Disorder
 Based on Geographic Distribution
 Based of Functional status of patient

9. Classification based on
Movements disorder
1. Spasticity:
 Abnormal muscle contraction in response to stretch
 Lesion in pyramidal system of brain
 Increased muscle tone
 Increased stretch reflex
 Types : Phasic & Tonic
2. Rigidity
 Involuntary, Sustained, Non stretch dependent contraction of muscle
 Lesion in basal ganglia & Extrapyramidal System
 May be either extensor(more often) or flexor rigidity

10. 3. Involuntary movements (Dyskinesia)
 Athetoid : Purposeless, continuous, uniform, slow writhing movements
 Choreic : Gross, Fast, Arrhythmic movements of sudden beginning
 Dystonia : Intermittent twitching movements, distorted posture and
position induced by attempted voluntary movements. Followed by
relaxation
4. Ataxia
 Lack of balance and coordination
 Gait abnormality
 Lesion in cerebellar tracts
5. Hypotonia
 It is seen in early stages from where the child passes in course of
development of choreoathetosis, ataxia, or even spasticity
6. Mixed

11. Classification based on
Geographic Distribution
1. Monoplegia
 One extremity involved, usually lower
2. Hemiplegia
 Both Extremities on same side involved
 Usually Upper extremity involvement > Lower
3. Paraplegia
 Both lower extremities equally involved
4. Diplegia
 Lower extremities more involved than upper
 Fine-motor and sensory abnormality in upper limb

12. 5. Quadriplegia
 All extremities involved equally
6. Double Hemiplegia
 All extremities involved
 Upper > Lower
7. Total Body
 All extremities severely involved
 No Head/Neck controll

13. Classification based on
Functional Status of patient
1. Propped sitter : Need brace for sitting and usually need
surgical correction of hip
2. Self Propped sitter : Can maintain sitting momentarily
and need support
3. Independent sitter : Can manage sitting without
orthotic devices.

14. Symptoms in General
 Seizures
 Muscle Contraction
 Difficulty in sucking or feeding
 Irregular Breathing
 Delayed Developmental milestones
 Motor mental retardation
 Speech abnormalities
 Hearing impairments
 Spasticity
 Progressive joint contractures
 Limited ROM
 Peg teeth
 Bladder Dysfunction – urinary incontinence

15. ASSESSEMENT OF CHILD WITH CP
 S.O.A.P (Subjective Objective Assessment Plan) Outline of
child with CP includes following,
 Brief History
 Functional Level – gross motor
 Neuromotor status
 ROM
 Strength
 Sensory
 Respiratory / Endurance
 CVS
 Skin
 Socio-Emotional/ Behavior

16. Investigations
 CT Scan
 MRI
 Cranial ultrasound
 Gait analysis

17. Differential Diagnosis
 Tumors, Neurodegenerative disorders to be considered
if normal delivery, normal development for few months
then deterioration

18. Treatment
 Goal of Treatment
 To have productive lives as adult in communication,
education, mobility and ambulation.
 Treatment ranges from observation, physical therapy,
medication to the surgery

19. Physical Therapy
1. Therapeutic Exercises
2. Neurodevelopmental Treatment
 Child initiated movements and tasks.
 The therapist will do preparatory work to enable the child to perform the
task (e.g, Muscle elongation)and may initially facilitate and guide the
movements as needed to decrease/prevent abnormal compensatory
movements.
 Gradually the therapist does less and less as the child takes over
3. Sensory Integration
 Providing the opportunity to experience a variety of controlled sensory
inputs to encourage the production of adaptive response

21. 4. Therapeutic Nerve stimulation
 Indication
 Muscle disuse atrophy
 Status post Cast
 Long term bracing
 Stats post surgical intervention
 Contraindication
 Obesity
 Child less than 2 years
 Program Length
 Treat until muscle are used functionally
 Return to treatment when child enters puberty
 Mild Involvement : 18-24 months
 Moderate/Severe involvement : 3-4 years

22. Equipments

23. Non-Surgical Therapy
 Oral Muscle Relaxants:
 Diazepam
 Dantrolene
 Baclofen
 Neuromuscular Blocks (Botox)
 Intrathecal baclofen

24.  Intrathecal baclofen
 Produce reduction in tone of muscle
 Implantable pumps filled with baclofen are surgically
inserted into anterior abdominal wall & dose of
medication is titrated
 Requires refilling 3 monthly
 Baclofen is GAMA agonist and it acts at spinal cords level
to impede the release of excitatory neurotransmitter that
causes spasticity

25.  Neuromuscular Blocks
 Botulinum A Toxin (botox) is proven to be useful
neuromuscular blockade in treatment of agonist and
antagonist imbalance
 It is injected into the dominant agonist muscle at the
nerve terminal to cause temporary paralysis for 3-6
months.

26. Orthotic Devices
 Orthotic devices are designed to relieve several conditions, including:
 Knee or hip subluxation, dislocation
 Spastic movement
 Correct, limit or prevent deformities
 Low-tone pronation (fallen arches, outward-turned foot due to
muscle weakness)
 High-tone pronation (high arch, outward-turned foot due to
increased muscle tone)
 Swing-phase inconsistency (erratic movements in the foot)
 Drop-foot (drop of the front of the foot due to weakness)
 Eversion (outward turn)
 Inversion (inward turn)

27.  Generally, there are two categories of orthotics:
1. Functional Orthotics – designed to support abnormal
biomechanics, correct various foot deformities and
support function.
2. Accommodative Orthotics – generally considered over-
the-counter orthotics – braces, splints, casts, gait
plates, night bars and heel/arch supports – that are
used by the general public to relieve foot pain, relieve
sensitive areas, reduce pressure, redistribute weight
and address minor foot problems.
Orthotic device textures can be:
Rigid
Semi-soft
Soft
Orthotic devices are made from
several materials, including:
Metal
Carbon fibers
Leather
Metals
Plastic
Plastic polymers
Rubber

28.  Foot orthotics
 Ankle-Foot Orthotics- Called AFO
 Hip-Knee-Ankle-Foot Orthotics – Called HKAFOs
 Knee-Ankle Orthotics – Called KAFOs
 Knee Orthotics
 Spinal Orthotics
 Trunk-Hip-Knee-Ankle-Foot Orthotics – Sometimes called
THKAFOs
FOOT ORTHOTICS
AFO

29. KAFO HKAFO
THKAFO
KO
SPINAL ORTHOSIS

30. Surgical Treatment
 There are several common types of orthopedic surgical procedures
used to treat children with CP.
 Osteotomy. This type of surgery is used to make improvements to
joints. A surgeon can realign bones to help a child with movement
and posture. The effect is often greater mobility and independence,
and less pain from joints moving incorrectly.
 Muscle lengthening. Tightness in muscles makes movements difficult
and painful for children with CP. Surgery can lengthen and release
muscles so that they are less stiff and a child can move better.
 Tendon lengthening. The same can be said for tendons, the
connective tissue that attaches muscles to bones. When tendons are
too tight, it restricts movement and causes pain.

31.  Tendon or muscle cutting. It may sound damaging, but
cutting muscles or tendons can actually relieve
tightness and pain, while also improving movements and
reducing spasticity. A cut tendon can also be replaced
by donor tissue.
 Arthrodesis. This is an aggressive type of surgery used
to treat severe cases of spasticity and reduced mobility.
It involves permanently fusing bones together. This can
help reduce spasms, and can also make walking easier.
 Scoliosis repair. Some children have or develop a spinal
curvature, and that may worsen over time (especially
when they are not ambulatory.) This can be repaired
surgically to assist with posture and movement, as well
as prevent respiratory problems.

32.  Selective dorsal rhizotomy (SDR)
 Cutting the nerves in the spinal column responsible for
muscle stiffness.
 It is the only surgery that permanently reduces spasticity.
 SDR is typically recommended in severe cases of spasticity
when other treatments have failed to make an impact.
 Children with spasticity in the legs (spastic diplegia) tend
to benefit more than children with spasticity in other
locations (quadriplegia, hemiplegia).

33. Thank you