MINI SEMINAR ON CEREBRAL PALSY

PT Rehab at 401October 01,2013Time: 12NN-4:00PM

Ms. Kaye Suzane A. Villaco & Ms. Jen Berlyn A. De VeraMASTER OF CEREMONY

THE SPEAKERS

Ms. Jelly R. Dela Cruz Mr. Wrangel Marl S. Peralta

Cerebral PalsyCPCerebral Paresis Muscle weakness or poor control to the brain

William John Little(1810-1894)

English Orthopedic surgeon

Series of lectures entitled “Deformities of the Human Frame” was first used in year 1849.

Sir William Oslers“The Cerebral Palsies of

Children (1889)”

Publication by Neurologist Sachs and Peterson (1890)

Sigmund Freud

Famous Psychiatrist

1893: Difficult in CP is merely a symptom of deeper effects the influence of development of the fetus.

CP is known as Little’s Disease

1st discovered classification system of CP is a puzzling disorder that affected children in the 1st year of life called “Little’s Disease” now known as “Spastic Diplegia”.

CP A group of permanent disorder of the

development of movement and posture. Causing activity limitation Attributed to non-progressive disturbance Occurred in developing fetal (fetus) or

infant brain before during of shortly after birth.

I. Epidemiology Study from Europe, the rate was more than 70

times higher in infants with birth weight < 1500g than > 2500g.

The surveillance of CP in Europe reports a M:F ratio of 1:33:1.

Severe neuromotor disability 10% of surviving infants born with gestational age ≤ 25 weeks in 1995 in U.K & Ireland and evaluated at 30 months of age.

Higher prevalence among black non-hispanic children compared with white non-hispanic children.

Most frequently incidence of CP is between 1 & 2.3 per 1000 live births.

Above incidence represents between 5% & 60% of all cases proportion inversely with the degree of development of the country.

Although early diagnosis is helpful, it can falsely elevate the incidence of CP because 50% of the children with CP diagnosed before 2 years of age can have spontaneous resolution of symptoms.

CP incidence over a 30 year period (1960-1990) has been slow decline in CP from 1960’s to the lowest incidence in 1970’s.

Children with CP diagnosed in the 1980’s & 1990’s, a greater proportion were more severely impaired.

Part 2 of I(Epidemiology

)

II. AnatomyPyramidal Motor

System

Extrapyramidal System

Part 2 of II (Anatomy)

Neonatal StrokeHypoxic Ischemic Encephalopathy

Cerebral Palsy & PVL premature infants.

Classification of CP:

1. Spastic2. Dyskinetic (Athetoid,Choreiform,Ballistic,Ataxic)3. Hypotonic 4. Mixed 5. Diplegia 6. Quadriplegia 7. Hemiplegia8. Triplegia

Motor pathway injury in patients with periventricular leukomalacia and spastic diplegia.

GABAA receptor binding pattern in age-matched patient subgroup (n = 8) compared with normal control group. The receptor binding pattern is almost the same as the binding pattern of the total patient group (uncorrected P < 0.05). CMA = cingulate motor area; PCL = paracentral lobule; VC = visual cortex.

Child with Spastic Diplegia.

Child with Spastic

Hemiplegia.

III. Pathophysiology Begins before birth. Brain injury or abnormality that happens

prenatally or during infancy. Child born prematurely or with low birth weight. Maternal illness (injuries or illness) in the child’s

infancy that affects the brain. A prenatal stroke (prevents blood flow to the part of the brain).

Cerebrum. Cerebral Palsy (muscle condition) caused by

damaged to the cerebrum. Babies that are deprived of oxygen during

labor & delivery (birth), asphyxia (oxygen deprivation) during birth was the cause of brain damage.

1980’s less than one tenth of CP cases caused by oxygen deprivation during birth.

Occurred before they were born during the first six months of pregnancy.

Part 2 of III (Pathophysiology)

Three possible reason of brain damage:1. Periventricular Leukomalacia (PVL)

• damage of the brain’s white matter• lack of Oxygen caused of destruction of

unborn baby brain cells.• pregnant mother catching an infection, such

as rubella (German Measles).• having very low blood pressure.• giving birth too early (premature birth).• consuming an illegal drug during pregnancy.

2. During the first six months of pregnancy the embryo/fetus is particularly vulnerable to abnormal brain development.• caused by mutations in the genes

responsible for brain development infections, such as toxoplasmosis (parasite infection), herpes-like viruses and trauma to unborn baby’s head.

3. Intracranial Hemorrhage (bleeding inside the brain caused by the unborn baby having a stroke).• bleeding in the brain can stop the supply of

blood to vital brain tissue, becomes damaged or it dies.

• factors cause a stroke in a baby during pregnancy & during the birth:

Blood clot in the placenta that blocked the flow of blood (clotting disorder) *see figure 1*Mother had pre-edampsia emergency cesarean (vacuum extraction used during delivery). Premature birth or low-weight baby.

FIG.1

Clotting Disorder.

Factors Contribute to a high risk of CP:Multiple births.Damage placenta.Sexually Transmitted Disease (STDs).Consumption of alcohol by the pregnant motherExposure to other toxic substances by the pregnant

mother.The pregnant mother did not eat properly.Random malformation of the baby’s brain.Small pelvic structure of the mother.Breek delivery.Brain damage after birth(infection such as meningitis,

a head injury, a drowning accident or poisoning).

IV. Clinical ManifestationDuring the first 3 years of life.Child with CP have sign and symptoms:

developmental milestones (crawling, walking or speaking).

Crawls in unusual way.

Abnormal muscle tone.

• Muscle Tone – automatic ability to tighten and relax muscle when required.

Muscles are Flaccid (soft)

 Muscles are Hypertonic

(stiff)

Difficulty of feeding and sucking.

Feeding problems The baby may have difficulties with sucking, swallowing and chewing. She may choke or gag often. Even as the child gets bigger, these and other feeding problems may continue.Difficulties in taking care of the baby or young child. Her body may stiffen when she is carried, dressed, or washed, or during play. Later she may not learn to feed or dress herself, to wash, use the toilet, or to play with others. This may be due to sudden stiffening of the body, or to being so floppy she 'falls all over the place'.The baby may be so limp that her head seems as if it will fall off. Or she may suddenly stiffen like a board, so that no one feels able to carry or hug her.

Lies down in awkward position.

Easily startled.

Favors one side of the body over the other.

Over developed or undeveloped muscles (has floppy or shift

movement).At birth a baby with cerebral palsy is often limp and floppy, or may even seem normal.Baby may or may not breathe right away at birth, and may turn blue and floppy. Delayed breathing is a common cause of brain damage.Slow development Compared to other children in the village, the child is slow to hold up his head, to sit, or to move around.

Bad coordination & balanced (ataxia).

The child who has 'ataxia', or poor balance, has difficulty beginning to sit and stand. She falls often, and has very clumsy use of her hands. All this is normal in small children, but in the child with ataxia it is a bigger problem and lasts longer (sometimes for life).Because children who have mainly a balance problem often appear more clumsy than disabled, other children are sometimes cruel and make fun of them.

Involuntary, slow writing movements (athetosis).

Muscle are stiff & contract abnormally (spastic paralysis).

The child who is 'spastic' has muscle stiffness, or 'muscle tension'. This causes part of his body to be rigid, or stiff. Movements are slow and awkward. Often the position of the head triggers abnormal positions of the whole body. The stiffness increases when the child is upset or excited, or when his body is in certain positions.The pattern of stiffness varies greatly from child to child.

Hearing problems. Problem with eyesight. Bladder control problems. Bowel movement control problems.Seizures. Problem swallowing. Range of movement are limited.

V. Clinical Evaluation: Diagnostic

Clinical findings- motor abnormality.• tone• reflex• posture• motor performance• weak cry and suck

Weak cry and sucking of Infants.

Irritability

Lethargy

The baby may cry a lot and seem very fussy or 'irritable'. Or she may be very quiet (passive) and almost never cry or smile.

Lethargy in babies is not easy to diagnose. However, sleeping for longer periods of time than normal, or a feeling of tiredness even after taking a long nap, are all signs of lethargy in babies. One can determine whether a baby is lethargic by noticing its behavioral changes. Lethargic babies, also referred to as listless babies, appear to lack enthusiasm. The baby seems sluggish and drowsy, which can be a sign of serious illness such as pneumonia.

Infant born prematurely

or low of birth

weight.

OBLIGATORY PRIMITIVE REFLEXES

Tonic neck reflexes including the asymmetric tonic neck reflexes.

The Moro.

The spastic subtype of CP is the most common affecting approximately 75% of children with CP.

Child with flexor

posturing.

Child with Opisthotonic Posturing.

*Note: the athenoid posturing of hands.

Child with Extensor

Posturing & Scissoring .

In 2004 an international multidisciplinary group revise the current classification system. A report on the “Definition & classification of CP, April 2006”-Four major dimensions of classification be used:

1. Motor abnormalities including the nature & typology of the motor disorder (specifically the dominant type categorized as spasticity, dystonia, choreoatretosis or ataxia), as well as functional motor abilities (GMFCS & MACS to objectively delineate the function between lower & upper extremities).

2. Accompanying impairments such as those involving hearing, vision, cognition & behavior, as well as later-onset musculoskeletal issues & seizures.

3. Anatomic distribution (including each limb, the trunk & the oropharynx) & neuroimaging findings.

4. Causation & timing, which should only be documented when there is “reasonably firm evidence” of a clearly identified cause or timing of injury.

*The group also recommended that the terms diplegia & quadriplegia be eliminated because they are subjective & do not provide information on truncal or bulbar involvement.

Assessment Instruments. to quantify and monitor developmental

milestone and skills.

Child Health Questionnai

re.

The Gross Motor Function

Classification System (GMFCS)

Most widely used functional classification system.

A five-level scale with four age bands that stratifies children based on gross motor ability.

Have excellent interrater reliability for both children younger than 2 years & children 2 to 12 years of age.

Palisano et al recently developed the expanded & revised GMFCS, which include a 12 to 18 year age & revision of the 6to 12 year age band.

Gross Motor Functional Classification System

Level 1: Walks without restriction, limitations in

High-Level Skills.• Walks independently by

age 2 years without devices.

• Walks as preferred mobility by age 4.

• Difficulty with speed, coordination and balance for high-level task.

Level 2: Walks without devices,

limitations in walking outdoors.

• Sits with the hand support by age 2.

• Craws reciprocally or walks with device as preferred mobility by age 4.

• Use hands to get up from the floor or a chair by 6.

• Walks without devices indoors by age 6.

Level 3: Walks with devices,limitations walking

outdoors.• Sits with support by age 2.• Cruises by age 4, walks with

device short distance.• Does stairs with help by age

6.• Walks indoors with a device

by age 12.Level 4: Limited Mobility, Power Mobility outdoors.• Rolls by age 2 years.• Sits with hand support by age

4.

• May walk short distances indoors with device, poor balance.

• Preferred independent mobility is a heel chair by age 12.

Level 5: Very limited Self- Mobility, even with Assistive Technology.• Needs help to roll by age 2.• Does not attain independent

mobility by age 12.• With high-level technology,

may learn to use power mobility.

Manual Ability Classification System

(MACS).

Analogous scale to classify functional upper extremity.

Five-level scale that classifies how children with CP, ages 4 to 18 years, use their hands when handling objects.

Magnetic Resonance Imaging (MRI)

Nuclear Magnetic Resonance Imaging

(NMRI).

Can aid in determining whether the injury was prenatal, perinatal or post natal.

Targeted laboratory test and cerebral imaging using tomography, MRI and ultrasound.

VI. Differential Diagnosis & Treatment.A. Diagnosis

• Acute Poliomyelitis - an acute viral disease

usually caused by a polio virus & marked clinically by fever, sore throat, headache, vomitting & often stiffness of the neck.

- major illness of poliomyelitis that affect CNS, stiff neck, pleocytosis in spinal fluid & perhaps paralysis.

• Becker’s Muscular Dystrophy - a group of disease causing

muscle weakness (affects only male).

Part 2 of VI(a) (Differential Diagnosis & Treatment)

• Charcot- Marie-Tooth Syndrome

- also known as Charcot-Marie-Tooth Neutropathy , hereditary motor and sensory neuropathy (HMSN) & peroneal muscular atrophy (PMA).

- genetically and clinically heterogeneous group of inherited disorder of the PNS characterized by progressive loss of muscle tissue and touch sensation across various parts of the body.

Part 3 of VI(a) (Differential

Diagnosis &Treatment)

• Kugelberg - welander spinal muscular

atrophy. - a rare inherited disorder

causing progressive degeneration of the anterior horn cells of the spinal cord.

Part 4 of VI(a) (Differential

Diagnosis &Treatment)

• Neonatal Brachial Plexus Palsies.

- first known description (1799): infant with bilateral arm weakness.

- 1870’s: cases of upper trunk nerve injury, attributing the findings to traction on the upper trunk, now called Erb’s Palsy (or Duchenne – Erb’s Palsy).

- 1885: injury to the C8-T1 nerve roots.

Part 5 of VI(a) (Differential

Diagnosis &Treatment)

• Stroke Motor Impairment.

- partial or total loss of function of a body, usually limb(s).

- result in muscle weakness, poor stamina, lack of muscle control or total paralysis.

Part 6 of VI(a) (Differential

Diagnosis &Treatment)

• Traumatic Brain Injury (TBI) - also known as intracranial

injury. - occurs when an external force

traumatically injures the brain. - head injury usually refers to

TBI, but a broader category because it can involve damage to structures other than the brain, such as scalp and skull.

- males sustain TBI more frequently than do females.

- causes include: falls, vehicle, accidents and violence.

Part 7 of VI(a) (Differential

Diagnosis &Treatment)

VI. Differential Diagnosis & TreatmentB. Treatments

• Ultrasound - identify very preterm babies at

risk of CP.• MRI - detecting while matter lesions in

older children. - demonstrating the various

injuries (asphyxia) & anomalies that cal lead to CP.

• CT scanning - provide information about

structural congenital malformations & vascular abnormalities & hemorrhages especially in babies.

• Evoked Potentials - electral signals produced

by the nervous system in response to sensory stimuli.

- measuring them can help to detect abnormalities of hearing and vision.

• EEG - detect damage from

hypoxia and vascular insult.

• Badofen - relieves muscle spasm. - given orally.• Dantrolence - work better than Badofen

when muscle spasm is severe.

• Physical method of spasticity relief include heat, cold and vibration.

• Splinting can help to improve range of movements of joints; this can be particularly effective for ankle joints.

Part 2 of VI(b) (Differential Diagnosis &Treatment)

VII. Physical Therapy Management.•Therapeutic ManagementoPhysical Therapy (PT) - one of the most important aspect of CP

therapy. - first referral made in CP child’s

treatment. - In general, PT trained to work with child

to enable them to obtain maximum physical function.

- focus mainly on activities involving the legs such as walking, braces, using crutches & rehabilitation after surgery.

- helps a child’s family through reducing stress caused by caring for the child.

PHYSICAL THERAPY PROGRAM

Age of 4 Training for positioning, movement, feeding, play and self calming. Through playing the skill of CP patient developed.

Age of 5

Self care, maintaining daily routines socialization. Physical activity and plans for the child's schooling and future careers.

Adulthood, age 18+

They lived highly functional adults. Experiencing a muscle and joint pain. Exercise routine to stay strong and to minimize joint issues.

RAFFLE

TIME!!!

Documentation Committee:

Mr. Gideon LuczonMr. Kent Anthony Tumaca

Program Committee:Ms. Manna Keziah Coquilla Ms. Kaye Suzane Villaco

Technical Committee: Ms. Sharmaine Joyce

SebastianMs. Jen Berlyn De Vera

Food Committee:ALL MEMBERS

Research Committee:Ms. Jelly Dela Cruz & the members

GROUP 4: CPB.S PT 2A1-1

Leader:Dela Cruz, Jelly R.

Members:Coquilla, Manna

Keziah De Vera, Jen Berlyn

Luczon, GideonMarabe, Arjohn

Peralta, Wrangel MarlSebastian,

Sharmaine JoyceTumaca, Jent AnthonyVillaco, Kaye Suzane