CEREBRAL

PALSYBY: DR. RAHMA SHAHBAHAI

William John Little (1810-1894)

In 1860s, known as

"Cerebral Paralysis” or

“Little’s Disease”

After an English surgeon

wrote the 1st medical

descriptions

Introduction

Cerebral“- Latin Cerebrum;

Affected part of brain

“Palsy " -Gr. para- beyond,

lysis – loosening

Lack of muscle control

Introduction

A motor function disorder caused by permanent, non-progressive brain lesion

present at birth or shortly thereafter. (Mosby, 2006)

Non-curable, life-long condition

Damage doesn’t worsen

May be congenital or acquired

Definition

A Heterogeneous Group

of Movement Disorders

– An umbrella term

– Not a single diagnosis

Muscle Strength

Movements

Balance

Coordination

Posture

CP affects

In CP

Muscles are unaffected

Brain is unable to send the

appropriate signals

necessary to instruct muscles

when to contract and relax

CAUSESOF CEREBRAL PALSY

An insult or injury to the brain

– Fixed, static lesion(s)

– In single or multiple

areas of the motor

centers of the brain

– Early in CNS dev’t

CAUSES

Development Malformations The brain fails to develop correctly.

Neurological damage Can occur before, during or after delivery

Rh incompatibility, illness, severe lack of oxygen

* Unknown in many instances

CHIEF CAUSE

Severe deprivation of oxygen or

blood flow to the brain

–Hypoxic-ischemic

encephalopathy

or intrapartum

asphyxia

CHIEF CAUSE

RISK FACTORS

Prenatal factors Before birth

Maternal characteristics

Perinatal factors at the time of birth to 1mo

Postnatal factors In the first 5 mos of life

Prenatal factors

Hemorrhage/bleeding

Abruptio placenta

Infections

Rubella, cytomegalovirus,

toxoplasmosis,

Environmental factors

Maternal Characteristics

Maternal Characteristics

Age

Difficulty in conceiving or holding a baby to term

Multiple births

History of fetal deaths/miscarriages

Cigarette smoking >30 sticks per day

Alcoholism and drug addiction

Mother’s medical condition

Perinatal Factors

High or low BP

Umbilical cord coil

Breech delivery

Over sedation of drugs

Trauma i.e. forceps or vacuum

delivery

Complications of birth

Postnatal Causes

Trauma, head injury

Infections

Lack of oxygen

Stroke in the young

Tumor, cyst

Before

Birth 75%

During

Birth, 5-15%

After

Birth,

10-20%

*Several causes are preventable or treatable

CP Cases

TYPESOF CEREBRAL PALSY

Classification of CP

According to:

1. Neurologic deficits

2. Type of movement

involved

3. Area of affected

limbs

1. Accdg. to Neurologic Deficits

Based on the - extent of the damage

- area of brain damage

Each type involves the way a person

moves

3 MAIN TYPES

1. PYRAMIDAL

- originates from the motor

areas of the cerebral cortex

2. EXTAPYRAMIDAL

- basal ganglia and

cerebellum

3. MIXED

2. Accdg. to Type of Movement

Photo from: Saunders, Elsvier.

4 MAIN TYPES

PYRAMIDAL 1. Spastic CP

EXTAPYRAMIDAL 2. Athetoid CP

3. Ataxic CP

MIXED 4. Spastic &

Athetoid CP

Spastic CP

Increased muscle tone,

tense and contracted muscles Have stiff and jerky or

awkward movements.

limbs are usually underdeveloped

increased deep tendon reflexes

most common form

70-80% of all affected

Types of Spastic CP

According to affected limbs:* plegia or paresis - meaning paralyzed or weak:

Paraplegia

Diplegia

Hemiplegia

Quadriplegia

Monoplegia –one limb (extremely rare)

Triplegia –three limbs (extremely rare)

Diplegia/ Paraplegia Hemiplegia Quadriplegia

Athetoid/ Dyskinetic CP

involves abnormal involuntary movements

that disappear during sleep and increase with stress.

Athetoid-Wormlike movements

Slow, uncontrolled motion, twisting in character, in the face, extremities, and torso.

Dyskinesia -Dyskinetic movement of mouth

drooling and dysarthria.

Dystonia - when held as a prolonged posture

20% of the CP cases,

Ataxic CP

Poor balance and lack of coordination

Wide-based gait

Depth perception usually affected.

Tendency to fall and stumble

Inability to walk straight line.

Least common 5-10% of cases

MIXED CP

A common combination is

spastic and athetoid

Spastic muscle tone and involuntary movements.

25% of CP cases, fairly common

Signs and

SymptomsOF CEREBRAL PALSY

a.

b.

c.

d.

e.

f.

g.

h.

Early Signs

• Stiff or floppy posture

• Weak suck/ tongue thrust/

tonic bite/ feeding difficulties

• Poor head control

• Excessive lethargy or

irritability/ High pitched cry

Infancy (0-3 Months)

CHILD with CP

Behavioral Symptoms

Poor ability to concentrate ,

unusual tenseness,

Irritability

ASSOCIATED

PROBLEMS

OF CEREBRAL PALSY

Hearing and visual problems

Sensory integration problems

Failure-to-thrive, Feeding

problems

Behavioral/emotional

difficulties,

Communication disorders

• Bladder and bowel control

problems, digestive

problems

gastroesophageal reflux

• Skeletal deformities, dental

problems

• Mental retardation and

learning disabilities

• Seizures

Diagnosis

OF CEREBRAL PALSY

1. SUBJECTIVE

-HISTORY

2. OBJECTIVE

- PHYSICAL EXAMINATION

CRITERIA

P osturing / Poor muscle control and strength

O ropharyngeal problems

S trabismus/ Squint

T onia: hyper- hypo

E volutional maldevelopment

R eflexes e.g Increased deep tendon

*Abnormalities 4/6 strongly point to CP

DIAGNOSIS

Laboratory studies

clinical diagnosis.

There are no definitive laboratory studies

To rule out other causes:

Thyroid function studies: Abnormal thyroid function may be

related to abnormalities in muscle tone or deep tendon reflexes

or to movement disorders

Lactate and pyruvate levels: Abnormalities may indicate an

abnormality of energy metabolism (ie, mitochondrial cytopathy)

Ammonia levels: Elevated ammonia levels may indicate liver

dysfunction or urea cycle defect

Organic and amino acids: may reveal inherited metabolic

disorders

Chromosomal analysis: if dysmorphic features or abnormalities

Cerebrospinal protein: levels may assist in determining asphyxia in

the neonatal period

Imaging studies

Cranial ultrasonography: evidence of

hemorrhage or hypoxic-ischemic injury

CT of brain: congenital malformations,

intracranial hemorrhage, and periventricular

leukomalacia or early craniosynostosis.

MRI of the brain: The diagnostic neuroimaging

study of choice

defines cortical and white matter structures and

abnormalities more clearly than does any other

method

determination of whether appropriate myelination is

present for a given age

Others:

Electroencephalography: Important in the diagnosis

of seizure disorders

Electromyography and nerve conduction studies:

Helpful when a muscle or nerve disorder is

suspected

TreatmentOF CEREBRAL PALSY

- No treatment to cure cerebral palsy.

- Brain damage cannot be corrected.

Crucial for children with CP:

Early Identification;

Multidisciplinary Care; and

Support

“The earlier we start,

the more improvement can be made”

-Health worker

I. NONPHYSICAL THERAPY

A. General management- Proper nutrition and personal care

B. Pharmacologic Botulinum toxin : for children with cerebral palsy with spasticity

antiparkinsonian drugs (eg, anticholinergic and dopaminergic drugs)

antispasticity agents (eg, baclofen) have primarily been used in the

management of dystonia, anticonvulsants,

antidopaminergic drugs, and antidepressants have also been tried

C. Surgery

-Intrathecal baclofen pump

insertion: To treat spasticity and/or

dystonia

-Selective dorsal rhizotomy: To treat

velocity-dependent spasticity

- Orthopedic surgical intervention: To

treat scoliosis, joint contractures or

dislocation

Selective posterior RhizotomyIn some cases nerves need to be severed to decrease muscle

tension of inappropriate contractions.

D. Physical Aids

Orthosis, braces and splints

Positioning devices

Walkers, special scooters, wheelchairs

E. Special Education

F. Rehabilitation Services- Speech and

occupational therapies

G. Family Services -Professional support

H. Other Treatment

- Therapeutic electrical stimulation,

- Acupuncture,

- Hyperbaric therapy

- Massage Therapymight help

'The ultimate long-term goal is realistic independence.

To get there we have to have some short-term goals.Those being a working communication system, education to his potential,

computer skills and, above all, friends'.

- Parent of boy with CP

II. PHYSICAL THERAPY

A.Sitting

-Vertical head control and

control of head and trunk .

B. Standing and walking

-Establish an equal distribution of

weight on each foot, train to

use steps or inclines

C. Prone Development

D. Supine Development

Head control on supine and positions

Thank you for lessening.

References