CP

CEREBRAL PALSY : 

CEREBRAL PALSY DR KAUSIK SUR ASSISTANT PROFESSOR DEPARTMENT OF PEDIATRICS VIVEKANANDA INSTITUTE OF MEDICAL SCIENCES KOLKATA INDIA kausiksur@gmail.com

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A persistent , but not necessarily unchanging, disorder of movement and posture as a result of non progressive disorder of immature brain

RISK FACTORS FOR CEREBRAL PALSY : 

RISK FACTORS FOR CEREBRAL PALSY PRENATAL Infections- TORCH (Spastic quadriplegia – Most common type) Fetal anoxia Maternal Diabetes Hypertension Maldevelopment of Brain (Neuronal migration defect, cerebral dysgenesis)

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PERINATAL Asphyxia (Tight nuchhal cord-> spastic quadriplegia) 5 minute APGAR ≤ 3 – 5% PROBABILITY 10 minute APGAR ≤ 3 – 17% 20 minute APGAR ≤ 3 – 57% Prematurity (Haemorrhage/hypotensive ischaemia with subsequent PVL) APH Drugs Birth Trauma Hyperbilirubinemia Intraventricular and intracerebral bleeds Hypoglycemia, dyselectrolytemia

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POSTNATAL CNS infections- Viral encephalitis, TB meningitis, Pyogenic meningitis Trauma Toxins e.g.lead, methylmercury, alcohol, cocaine Irradiation to pregnant women Anoxia due to cardiac arrest, drowning Intracranial bleed

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Most children with these risk factors do not develop CP

CLASSIFICATION : 

CLASSIFICATION ACCORDING TO TONE AND TOPOGRAPHY SPASTIC – Most common form, involves pyramidal tract dysfunction +increased tone(clasp knife )+brisk DTR Quadriplegia Diplegia Hemiplegia DYSKINETIC- Choreoathetosis Dystonic MIXED HYPOTONIC ATAXIC

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ACCORDING TO SEVERITY MILD- Physical finding but no limitation to ordinary activities MODERATE- Definite difficulty in daily activity and need for assistance devices SEVERE- Moderate to great limitation in everyday activity

SPASTIC : 

SPASTIC Most common type ↑muscle tone Tendency to develop deformity, contracture Poor development of postural mechanisms Common associated problems Squint Oral motor dysfunction(drooling) Perceptual and learning disorders Seizures

SPASTIC QUADRIPLEGIA : 

SPASTIC QUADRIPLEGIA NEUROPATHOLOGY PVL Multicystic encephalomalacia Malformations MAJOR CAUSES Ischaemia Infarction Endocrine/metabolic/genetic/developmental Developmental

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All limbs are affected, arms>legs Bowel and bladder control is absent Speech and feeding is difficult bulbar muscle involvement ↑GER, aspiration syndromes Intelligence↓↓ Epilepsy- common Dislocation of hip, pelvic tilt, scoliosis, rib deformities

SPASTIC HEMIPLEGIA : 

SPASTIC HEMIPLEGIA NEUROPATHOLOGY Stroke- in utero or neonatal MAJOR CAUSES Thrombotic disorders Infection Genetic/developmental Periventricular Hemorrhagic infarction

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Right sided hemiplegia is twice as common as left Arm more involved than leg Distal portion more impaired Early infancy- reduced hand regard, persistant fisting and cortical thumb on the affected side Assymetric moros

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Later- pincergrasp is absent on the affected side Handedness develops early Late features- Dyspraxia on the affected side Hemiplegic gait- circumduction at the hip Cortical sensation may be lost(25%) Seizure(33%)

SPASTIC DIPLEGIA : 

SPASTIC DIPLEGIA NEUROPATHOLOGY PVL(Periventricular leukomalacia) MAJOR CAUSES Prematurity Iscaemia Infarction Endocrine/metabolic(e.g.thyroid)

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Commonly seen in preterm babies with IVH and PVL Entire body is affected, though the involvement of LL and trunk is much more than UL Infancy - ↑adductor tone, scissoring Later in life- ambulatory problems Mentation- preserved Seizure- uncommon

DYSKINETIC CP : 

DYSKINETIC CP NEUROPATHOLOGY Putamen, Globus pallidus, thalamus, basal ganglia MAJOR CAUSES Asphyxia Kernickterus Mitochondrial Genetic/metabolic

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DYSTONIC Purposeful movements are affected Truncal twisting Facial grimacing Extremity rigidity

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CHOREOATHETOID Seen in babies with Neonatal Hyperbilirubinemia Choreiform movement increase during voluntary activity seen in muscles of extremities, face, neck and trunk Associated problems- High tone hearing loss Upward gaze palsies Enamel dysplasias Seizure-uncommon Speech defects- common Intelligence- normal

HYPOTONIC CP : 

HYPOTONIC CP Marked motor delay,↓tone,MR Often confused with floppy infant(preserved or brisk DTR differentiate it from LMN cause of floppiness It is a temporary phase before hypertonicity or dystonia eventually develops

ATAXIC CP : 

ATAXIC CP Relatively uncommon Defective postural function Disturbed equilibrium making sustained control against gravity difficult Movement incordinated for all motor tasks, tremor on use of hands Associated problems- Spasticity Athetosis Dysarthria Nystagmus

MIXED CP : 

MIXED CP Spasticity+Choreoathetosis- most common Athetosis+ataxia- may occour

ASSOCIATED PROBLEMS IN CHILDREN WITH CP : 

ASSOCIATED PROBLEMS IN CHILDREN WITH CP NEUROLOGICAL Mental retardation (30-70%) Cortical sensory deficits Visual Problems – refractive errors, strabismus, field defect, amblyopia, nystagmus Hearing problems Epilepsy- (33%) Communication disorders- Dysarthria, central processing problems

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GASTROINTESTINAL Oropharyngeal dysphagia-OMD (50%)- May be the first sign of CP Poorly coordinated tongue and jaw movement, delay in initiation of swallowing Oral tactile hypersensitivity-> react to feed or touch on mouth with grimacing, gagging or spitting and refusal to feed Poor neuromuscular coordination -> cannot protect their airway while feeding and may aspirate Inability to handle oral secretion-> drooling GE Riflux Constipation Malnutrition Drooling of saliva

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ORTHOPEDIC Equinus Hip sublaxation/dislocation Scoliosis Hamstring contracture

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MISCELLANEOUS Sleep problems Lower urinary tract dysfunction Emotional and behavioral problems- ADHD, Emotional lability, depression

WARNING SIGNS SUGESTIVE OF CP : 

WARNING SIGNS SUGESTIVE OF CP Paucity of movements or excessive and disorganized behavior Stereotyped behavior Hypotonicity with frog posture or hypertonicity Feeding problems Hyperextension of head and neck Consistent fisting of hand Delayed development Deviant development e.g. hand preference before the age of 12 months, sitting in w posture

CONDITIONS THAT MIMIC CP : 

CONDITIONS THAT MIMIC CP Paraplegias, quadriplegias due to trauma, neural tube defects, familial degenerations, atlantoaxial instability Mental retardation, speech disorders Slowly progressive degenerative brain disorders e.g.metabolic disorders- aminoacidurias like glutaric acidemia type 1, peroxisomal disorders like adrenomyeloneuropathy, mitochondrial disorders Neuromuscular disorders e.g . Musculodystrophies(ataxic)

ASSESSMENT : 

ASSESSMENT PHYSICAL EXAMINATION Observation of child in prone and supine position Facial dysmorphism Other congenital anomalies

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ASSESSMENT OF CURRENT LEVEL OF FUNCTIONING AND PREVIOUS DEVELOPMENT Done in all areas of development- gross motor, fine motor, cognitive, speech and language, social and adaptive THROUGH NEUROLOGICAL EXAMINATION Cranial nerves Posture Deep tendon reflexes

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ASSESSMENT OF MUSCLE TONE AND NEONATAL REFLEXES Popliteal angle- Scarf sign- Adductor angle-

DEVELOPMENTAL REFLEXES : 

DEVELOPMENTAL REFLEXES

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ASSESSMENT OF INTELECTUAL FUNCTION Age appropriate nonverbal intelligence tests Informal observation of the childs interaction with his mother Observing him play with toys- information regarding cognition, speech and language ability

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Testing intelligence using conventional tests is often erroneous in children with CP , because of associated motor problems and visual, hearing and speech defects

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ASSESSMENT OF VISION AND HEARING

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ASSESSMENT OF FEEDING AND NUTRITION Mode of feeding The texture of food Chokes/coughs while feeding Duration of feeding Modified barium swallow or Video fluoroscopic examination Calculation of dietary need ANTHROPOMETRY- Weight, Height, Skinfold thickness

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ORTHOPEDIC PROBLEMS- look for Hip sublaxation Pelvic obliquity Scoliosis Contracture of hamstring muscles and tendoachillis In ambulatory children- observation of gait in clinic- information about coordination and musculoskeletal abnormalities

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ASSESSMENT OF HOME SITUATIONS Family size Financial resources Family support

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Do not feel compelled to give a diagnostic level at the first examination Do not hesitate to change it if so needed on subsequent assessment