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CEREBRAL PALSY
CEREBRAL PALSYCEREBRAL PALSY
DR SNEHA..DR SNEHA..
CEREBRAL PALSY
CEREBRAL PALSY
CEREBRAL PALSYCEREBRAL PALSY
• ABERRANT CONTROL OF MOVEM-ABERRANT CONTROL OF MOVEM-ENT & POSTURE ENT & POSTURE
• APPEARS EARLY IN LIFEAPPEARS EARLY IN LIFE
• SECONDARY TO CNS LESION / SECONDARY TO CNS LESION / DYSFUNCTIONDYSFUNCTION
• R/O PROGRESSIVE OR DEGENER -R/O PROGRESSIVE OR DEGENER -ATIVE BRAIN DISEASEATIVE BRAIN DISEASE
CEREBRAL PALSY
CEREBRAL PALSYCEREBRAL PALSY
GROUP OF HETEROGENOUS CLINICAL STATESGROUP OF HETEROGENOUS CLINICAL STATES
VARIABLE ETIOLOGYVARIABLE ETIOLOGY
SEVERITY – MINOR INCAPACITATION TO TOTAL SEVERITY – MINOR INCAPACITATION TO TOTAL HANDICAPHANDICAP
INCIDENCE – 2 - 2.5 PER 1000 LIVE BIRTHSINCIDENCE – 2 - 2.5 PER 1000 LIVE BIRTHS
USUAL PRESENTING COMPLAINT – SLOW USUAL PRESENTING COMPLAINT – SLOW PROGRESS IN REACHING MOTOR MILESTONES PROGRESS IN REACHING MOTOR MILESTONES AT APPROPRIATE CHRONOLOGICAL AGEAT APPROPRIATE CHRONOLOGICAL AGE
CEREBRAL PALSY
DEVELOPMENTAL DELAY
• STATIC OR PROGRESSIVE STATIC OR PROGRESSIVE ENCEPHALOPATHYENCEPHALOPATHY
• RESTRICTED TO SPECIFIC AREAS OR RESTRICTED TO SPECIFIC AREAS OR GLOBALGLOBAL
• DEVELOPMENT DELAYED OR DEVELOPMENT DELAYED OR REGRESSINGREGRESSING
CEREBRAL PALSY
KEY DEVELOPMENTAL KEY DEVELOPMENTAL MILESTONES : GROSS MOTORMILESTONES : GROSS MOTOR
• 3 MONTHS 3 MONTHS – NECK HOLDING– NECK HOLDING• 5-8 MONTHS – SITTING 5-8 MONTHS – SITTING • 9-12 MONTHS – STANDING 9-12 MONTHS – STANDING • 10-13 MONTHS - WALKING10-13 MONTHS - WALKING• 11 MONTHS – CRAWLING11 MONTHS – CRAWLING• 18 MONTHS – RUNNING18 MONTHS – RUNNING• 24 MONTHS – WALKS UPSTAIRS24 MONTHS – WALKS UPSTAIRS• 36 MONTHS – RIDES TRICYCLE36 MONTHS – RIDES TRICYCLE
CEREBRAL PALSY
KEY DEVELOPMENTAL KEY DEVELOPMENTAL MILESTONES : FINE MOTORMILESTONES : FINE MOTOR
• 4 MONTHS – GRASPS WHEN4 MONTHS – GRASPS WHEN PLACED IN HANDPLACED IN HAND• 5 MONTHS – INTENTIONAL 5 MONTHS – INTENTIONAL REACHING WITH BIDEXTROUS REACHING WITH BIDEXTROUS GRASPGRASP• 7 MONTHS – PALMAR GRASP7 MONTHS – PALMAR GRASP• 9 MONTHS – PINCER GRASP 9 MONTHS – PINCER GRASP
CEREBRAL PALSY
KEY DEVELOPMENT MILESTONES : LANGUAGES
• 1 month – Turns head to sound• 3 months – Cooing• 6 months – Monosyllables• 9 months – Bisyllables• 12 months – 2 words with meaning• 18 months – 10 words with meaning• 24 months – Simple sentence• 36 months – Telling a story
CEREBRAL PALSY
DEVELOPMENTAL MILESTONES : PERSONAL SOCIAL
• 2 MONTHS – SOCIAL SMILE2 MONTHS – SOCIAL SMILE• 3 MONTHS – RECOGNISES 3 MONTHS – RECOGNISES
MOTHERMOTHER• 6 MONTHS – SMILES AT 6 MONTHS – SMILES AT
MIRROR IMAGEMIRROR IMAGE• 9 MONTHS – WAVES BYE – 9 MONTHS – WAVES BYE –
BYEBYE• 12 MONTHS - PLAYS SIMPLE 12 MONTHS - PLAYS SIMPLE
BALL GAMEBALL GAME• 36 MONTHS – KNOWS GENDER36 MONTHS – KNOWS GENDER
CEREBRAL PALSY
DIAGNOSIS OF DEVELOPMENT DELAY : NO REGRESSION
• Predominant Speech Delay bilateral hippocampal sclerosis congenital bilateral perisylvian syndrome hearing impairment infantile autism
CEREBRAL PALSY
DIAGNOSIS OF DEVELOPMENT DELAY: NO REGRESSION
• Predominant motor delay ataxia hemiplegia hypotonia neuromuscular disorders paraplegia
CEREBRAL PALSY
DIAGNOSIS OF DEVELOPMENT DELAY : NO REGRESSION
• Global developmental delay cerebral malformations chromosomal disturbances intrauterine infections perinatal disorders progressive encephalopathies
CEREBRAL PALSY
PROGRESSIVE ENCEPHALOPATHY : ONSET < 2• Acquired immunodeficiency syndrome
encephalopathy
• Disorders of amino acid metabolism
• Disorders of lysosomal enzymes
• Niemann Pick disease type A
• Sulfatase deficiency disorders
• Carbohydrate-deficient glycoprotein syndrome
CEREBRAL PALSY
PROGRESSIVE ENCEPHALOPATHY : ONSET < 2• Mitochondrial disorders
• Neurocutaneous syndromes
• Other disorders of gray matter
• Other disorders of white matter
• Progressive hydrocephalus
CEREBRAL PALSY
Causes of Apparent Regression in Static Encephalopathy
• Increasing spasticity (1st year)
• New onset movement disorders (2nd year)
• New onset seizures
• Parental misperception of attained milestones
• Progressive hydrocephalus
CEREBRAL PALSY
HYPOTHYROIDISM
• Congenital hypothyroidism : 1:4000 livebirths
• Early diagnosis & treatment imperative
• Gestation > 42 weeks
• Birth weight > 4 kg
• Wide-open posterior fontanelle,constipation,jaundice,poor temperature control,umblical hernia
CEREBRAL PALSY
HYPOTHYROIDISM
• Edema of eyes,hand,feet
• Large tongue
• Diagnosis – low serum thyroxine & high TSH levels
• Management – thyroxine 24-50 g/d
CEREBRAL PALSY
ETIOPATHOGENESIS OF CP
• Cerebral malformations• Perinatal hypoxia• Birth trauma• Metabolic disturbances• Infections - intrauterine / acquired• Stroke • Intracerebral haemorrhage• Arterioveinous malformations• Hydrocephalus • Periventricular leukomalacia• Genetic disorders
CEREBRAL PALSY
CEREBRAL PALSY - FORMS
• Spastic CP –
Spastic quadriparesis
Spastic diplegia
Spastic hemiplegia
• Hypotonic CP
• Extrapyramidal CP
CEREBRAL PALSY
Differential Diagnosis of Infantile Hypotonia
• Cerbral hypotonia Benign congenital hypotonia Chromosome disorders Prader – Willi syndrome Trisomy Chronic non progressive encephalopathy Cerebral malformation Perinatal distress Postnatal disorders
CEREBRAL PALSY
INFANTILE HYPOTONIA
• Spinal cord disorders
• Spinal muscular atrophies
• Polyneuropathies
• Neuromuscular transmission disorders
• Fiber-type disproportion myopathies
• Metabolic myopathies
• Muscular dystrophies
CEREBRAL PALSY
NEUROLOGIC EXAMINATION
• Goals – assess development & integrity of the nervous system
- determine location & cause of suspected dysfunction
• Impediments – patient’s age & willingness to cooperate
- complexity of complete neuro. exam.
- fluctuating nature of neuro. exam.
CEREBRAL PALSY
NEUROLOGIC EXAMINATION
• Children v/s adult - more observation, considerable flexibility,greater patience,less reliance on instructions that children easily misunderstand
• Repeated examination
• Thoughtful examination
CEREBRAL PALSY
Neurologic Exam. : Mental Status
• methodologic approach
- comprehension – responses to “who”, ”what”, ”when”, ”where”
- memory,organisation & language skills – story telling
- naming – identify colours / handy objects
- reading / writing
CEREBRAL PALSY
Neuro Exam. : Cranial Nerves
• IInd Cranial nerve visual acuity – blink to bright light
- snellens chart visual field – finger counting by
confrontation fundoscopy
CEREBRAL PALSY
Neuro Exam. : Cranial Nerves
• IIIrd,IVth &VI th – position of eyes at rest - abnormal eye movements at rest &
during fixation - nystagmus - pupils , light reflex - ptosis - cover - uncover test - doll’s eye movement
CEREBRAL PALSY
Neuro. Exam. : Cranial Nerves
• Vth & VIIth – facial sensation
- facial weakness
- lacrimation , salivation
- blink reflex
- jaw jerk
CEREBRAL PALSY
Neuro. Exam. : Cranial Nerves
• VIIIth – hearing assessed behaviorally or by standardised measures
- audiometry – low threshold
• IXth, Xth & XIIth – phonation, articulation, swallowing
- palatal movements
- tongue atrophy / fasciculations
CEREBRAL PALSY
Neurologic Exam. : Motor
• Identify handedness/dominance - appears around 1 year age - early appearance – unilateral weakness• Posture,Tone - • Abnormal movements – chorea, dystonia, tics,
stereotypies• Muscle bulk – atrophy,hypertrophy, fasciculations• Strength• Gait• Coordination
CEREBRAL PALSY
Neurologic Exam. : Reflexes
• Deep tendon reflexes - sluggish or absent – peripheral nerve, muscle or
cerebellar involvement brisk – brain or spinal cord involvement• Developmental reflexes – rooting reflex– disappears by 3 months moro’s reflex – disappears by 4 months asymmetric tonic neck reflex – 4-6 months tonic labyrinthine reflex – 6 months grasp reflex – 6 months plantar grasp reflex – 10 months
CEREBRAL PALSY
Neurologic Examination
• Neurocutaneous markers – hypopigmented spots, café-au-lait spots, angiomas,
dorsal midline – dimple, angioma, tuft of hairs• Head growth – birth(35 cm), 3 months(40 cm),
9 months(45 cm),3 years (50 cm)
- macrocephaly – familial, megalencephaly, hydrocephalus
- microcephaly – perinatal insult to brain, IUGR, genetic syndrome
CEREBRAL PALSY
Neurologic Examination
• Spine
• Autonomic abnormality
• Abdomen – hepatosplenomegaly
• Heart – congenital/valvular defects
CEREBRAL PALSY
DIAGNOSTIC ASSESSMENT
• Presenting complaint – motor Presenting complaint – motor milestones not attained at milestones not attained at appropriate chronological ageappropriate chronological age• Brain abnormality – pre- peri- or Brain abnormality – pre- peri- or postnatally postnatally • Worldwide incidence of CP – 2-Worldwide incidence of CP – 2-2.5/1000 livebirths2.5/1000 livebirths• CP – 33% hemiplegic, 44% diplegic CP – 33% hemiplegic, 44% diplegic , 6% quadriplegic , 6% quadriplegic• CP – a syndrome with many CP – a syndrome with many etiologiesetiologies
CEREBRAL PALSY
DIAGNOSTIC ASSESSMENT
• Common etiologies with prenatal onset – intrauterine infection, stroke, toxaemia, placental abruption
• Perinatal onset – hypoxic – ischemic encephalopathy, kenicterus, trauma
• Postnatal onset – infection, trauma, hydrocephalus
CEREBRAL PALSY
DIAGNOSTIC ASSESSMENT
Accurate determination of etiology of CP - specific implications regarding treatment,prognosis & management of associated conditions.
- assessment of recurrence risk, counseling of families & implementation of prevention programs & in MLCs
Common associated problems – epilepsy, mental retardation, speech & language disorders, and ophthalmologic & hearing impairments
CEREBRAL PALSY
DIAGNOSTIC ASSESSMENT
• Neuroimaging recommended - if etiology not established
• MRI preferred to CT scan – eitology and timing of insult leading to CP
• Potentially treatable lesions identified – hydrocephalus, porencephaly, AVmalformations, subdural haematomas & hygromas, vermian tumor
CEREBRAL PALSY
DIAGNOSTIC ASSESSMENT
• Metabolic & genetic testing – certain congenital malformations ( lissencephaly, schizencephaly,pachygyria) are ever increasingly associated with specific genetic disorders.
• Neurometabolic disorders may masquerade as CP.
• Metabolic or genetic causes of CP occur infrequently
CEREBRAL PALSY
DIAGNOSTIC ASSESSMENT
• Metabolic and genetic studies should not be routinely obtained in evaluation of child with CP
• Metabolic or genetic testing should be considered -
If clinical history or findings do not determine a specific structural abnormality or if there are additional and atypical features
Detection of brain malformation in a child with CP
CEREBRAL PALSY
Clinical Indications for Chromosome Analysis
• Genitourinary ambigious genitalia polycystic kidney• Head and Neck high nasal bridge hyper/hypotelorism microphthalmia mongoloid slant occipital scalp defect small mandible small/fish mouth small/low - set ears upward slant of eyes webbed neck
CEREBRAL PALSY
Clinical Indications for Chromosome Analysis
• Limbs abnormal dermatoglyphics low set thumb overlapping fingers polydactyly radial hypoplasia rocker-bottom feet
CEREBRAL PALSY
DIAGNOSTIC ASESSMENT
• Coagulopathies – Hemiplegic CP – prenatal or perinatal cerebral infarction
• Stroke etiology in children – coagulopathy, congenital heart disease,infections
• Factor V Leiden deficiency, anticardiolipin/antiphospholipid antibodies, Protein C or Protein S deficiency
CEREBRAL PALSY
DIAGNOSTIC ASSESSMENT
• Associated conditions – mental retardation (52%) epilepsy (45%) ophthalmologic defects (28%) speech & language disorders (38%) hearing impairment (12%)
CEREBRAL PALSY
Diagnostic Assessment : Ophthlmologic Defects
strabismus
amblyopia
nystagmus
optic atrophy
refractory errors
CEREBRAL PALSY
DIAGNOSTIC ASSESSMENT
• EEG – should not be done to determine the etiology of CP
- should be done if history & physical exam. of the child with CP suggest presence of epilepsy or epileptic syndrome
• All CP children should be screened for MR,ophthlmologic &hearing impairments and speech & language disorders
• Nutrition, growth ,swallowing - monitored
CEREBRAL PALSY
MANAGEMENT
• Rationale & strategies for a comprehensive & goal directed approach to caring for CP patients focus on 4 main areas –
1. Communication & education
2. Mobility
3. Physical fitness
4. Independence
CEREBRAL PALSY
Management : Communication & Education
• Most important & most neglected priorities• Irreversible brain injury (periventricular
leukomalacia, cerebral haemorrhage, hypoxic ischemic encephalopathy ) – threatens CP child’s education & intellect
• Telling parents Bad News – badly has profound & long lasting negative impact on the child’s outcome that extends beyond the structural damage to child’s brain
CEREBRAL PALSY
Management : Communication & Education
• It is not possible to make bad news sound good
• Goal for first visit – Establish that the child’s development is not normal & Share the parents concern
• Further discussion during next visit• Parents want to know – will he walk, need
special schools, live alone? What can I do to help my child ?
CEREBRAL PALSY
• Communication
It allows us relay our most basic needs Communication is essential to our very quality of lifeTo learn effectively – one must have opportunity &means to communicateCommunication requires ability to gather information from one’s environment through visual, auditory & tactile sensationEvery CP child should be evaluated by trained pediatric ophthalmologist
Management : optimizing communication
CEREBRAL PALSY
Management : optimizing communication
• Delayed speech – evaluation by trained paediatric audiologist & otolaryngologist ( to correct treatable causes of hearing loss)
• Alternative means of communication - augmented communication devices
• Children with speech abnormality – enrolled for early speech & language therapies
CEREBRAL PALSY
Management : Optimizing Education
Accesible classroom & computer technology Coordinated efforts of parents, school officials & physicians Exchanging stairs for ramps/elevators, widening of doors, improving seating systems, providing aides to assist children who need them Computer technology – level playfield for children with motor & speech impairment
CEREBRAL PALSY
Management : Mobility
• Major determinant of one’s independence
• CP individuals tend to become less mobile as they reach adulthood
• Cost of immobility – progressive deformity, contracture, chronic pain, severe bone loss, fracture, scoliosis, hip dislocation, reduced cardiovascular fitness, obesity, depression
CEREBRAL PALSY
Management : Mobility
Preventing immobility requires concerted effort-Optimise Biomechanics, Tone management,Strength,Balance, and Physical fitness-Assisted mobility – greatly augments person’s mobility & independence( Crutches, Canes, Walker,Normal & Powered Wheelchairs)
CEREBRAL PALSY
Management : Mobility
• Biomechanics – Stretching,
weightbearing, orthotics ,
bracing, serial casting,
Btx , orthopedic surgery
CEREBRAL PALSY
Management : Mobility – Tone management
• Management of Spasticity – primary focus for many physicians
• Tone reduction alone should not be the goal : improve & maximise function
• Determine whether positive symptoms(hyperreflexia, clonus, increased tone) are the source of functional impairment
• Negative symptoms (underlying weakness & loss of agility ) most disabling of motor symptoms associated with CP
• Spasticity may assist in function
CEREBRAL PALSY
Management : Mobility - Tone management
• Initial & periodic evaluation by Interdisciplinary team
• Appropriateness of a modality depends on multiple factors – Age
- Complicating medical issues ( seizures, pain, rapid development of contracture, prior response to therapy)
- Familial & societal factors including compliance & cost factors
CEREBRAL PALSY
Management : Mobility –Tone management
• Oral medication – Baclofen,Tizanidine, Benzodiazepines - tone reduction modest & rarely sufficient - best for spasms, sleep disturbances, adjunctive in seizure disorder
CEREBRAL PALSY
Management : Mobility – Tone management
• Botulin toxin ( BTX ) – Neurotoxins that prevent depolarisation at neuromuscular junctions
• Therapeutic goal of btx injections in spastic CP – complete or partial paralysis of specific target (agonist ) muscles affecting a spastic joint while leaving antagonist muscles unaffected
• Joint forces become more balanced & functional passive range of motion restored
CEREBRAL PALSY
Management : Mobility – Tone management - BTX
• BTX inj. should be accompanied by aggressive physiotherapy to increase muscle strength & dexterity
• Safe & well tolerated• Response seen in 3-4 days & maintained for 3-4
months or longer• Primary criteria – presence of persistent or
dynamic hypertonia in the absence of significant fixed deformity regardless of anatomic site or distribution of palsy
CEREBRAL PALSY
Management : Mobility – Tone management - BTX
• Indications for BTX
• Upper limbs
- persistent thumb in palm or thumb adduction
- wrist posture preventing effective hand use
- tight elbow flexion
- tone in shoulder extensors or external rotators significantly limit functional mobility
CEREBRAL PALSY
Management : Mobility – Tone management - BTX
• Lower limbs – dynamic equinus persisting through out the gait cycle
- knee hyperextension secondary to overactive plantar flexors
- significant scissoring or adduction at hips In either UL or LL relative muscle
weakness may be a contraindication for BTX therapy & should be thoroughly assessed
CEREBRAL PALSY
Management : Strength & Balance
• Goal directed physical therapy + daily home exercise programme• Help the patient to develop wide variety of exercises & activities to strengthen specific muscle group, improve balance(sitting, standing,static & dynamic)&maintain &improve muscle or tendon length.
CEREBRAL PALSY
Management : Mobility – Strength & Balance
• Sports & aerobic exercisesshould be included as part oftheir daily routine• Weight training & resistive exercises build muscle mass& with proper supervision besafely performed without worsening their spasticity• Electrical stimulation of muscles
CEREBRAL PALSY
For CP individuals having the stamina to move can mean the difference between dependence & independence
CEREBRAL PALSY
Management : Physical Fitness
• Cardiovascular fitness is vital to health & well being
• Wide variety of sports & athletic activities ( swimming, water aerobics, basketball, soccer, snow & waterskiing, dance & martial arts) – promote overall strength & improve balance
• Regular aerobic conditioning – protects one’s health, increases energy levels & endurance
• For CP individuals having the stamina to move can mean the difference between dependence & independence
CEREBRAL PALSY
Management : Independence
Ability to make one’s own choices in life and pursue one’s own dreams , is the goal for any child ,including persons with disabilities
CEREBRAL PALSY
CP – is a group of heterogenous clinical states with variable (pre-,peri-,or postnatal) etiology -Aberrant control of movement & posture -Static encephalopathy -Presents early in life
Neuro. Exam – Assess development & integrity of nervous system -Determine location & cause of suspected dysfunction
CEREBRAL PALSY
Diagnostic assessment – Accurate determination of etiology - Look for associated problems – epilepsy, MR, speech& language defects,and visual & hearing impairments
Neuroimaging – if etiology not established - MRI preferred to CT scan where possible - Metabolic & genetic testing, Coagulopathy tests - in select group of patients - EEG – if epilepsy or epileptic syndrome suspected - All CP patients should be evaluated by trained paediatric ophthalmologist -All CP children with speech delay be evaluated by trained audiologist and paediatric otolaryngologist
CEREBRAL PALSY
CEREBRAL PALSY
However none of these interventions will make a truly significant impactUnless we work to create a world in which all children are permitted to thrive to their Greatest potential ,a world in which “accessibility” applies to buildings doorways,& sidewalks as well as to all opportunities life has to offer.
CEREBRAL PALSY
DO YOU NEED HELP?
DESIGN a home programme for yourChild based upon what you have learnt
START your programme
BE CONSISTENT in whatever you do
KEEP A SIMPLE DIARY of the changes you observe and the questions you have
LEARN MORE about how you can help your child
CEREBRAL PALSY
CEREBRAL PALSY