A group of motor impairment syndromes resulting from disorders of early brain development and often associated with epilepsy and abnormalities of speech, vision and intellect

1. CEREBRAL PALSY

2. Introduction
• Historically known as static encephalopathy
• A group of motor impairment syndromes
resulting from disorders of early brain
development.
• Often associated with epilepsy and
abnormalities of speech, vision and intellect.
• However, many children and adult with CP
function at a high educational and vocational
level without sign of cognitive dysfunction

3. Epidemiology
• CP is the most common and costly form of
chronic motor disability
• Prevalence: 2/1000
• Prevalence of CP is increased in low birth
weight infants (<1000g)
• CP incidence higher in premature and twin
birth

4. Aetiology
Caused by developmental, genetic, metabolic,
ischemic, infections
•Infection
- German measles
- Shingles
•Diabetes
•Toxemia of
pregnancy
•Rh incompatibility
•Asphyxia
•Birth injury
•Prematurity
Antenatal
factors (80%)
Intrapartum
(10%)
Postpartum
(10%)
• Very high fever
• Brain infection
• Head injury
• Lack of oxygen
• Poisoning
• Intracranial
hemorrhage or
blood clot

5. Risk Factors
• Before Pregnancy:
- History of fetal wastage
- Long menstrual cycle
- Maternal thyroid disorder
- Family history of mental
retardation
• During Labor and Delivery:
- Premature separation of
placenta
• During Early Postnatal Period:
- Newborn hypoxic ischemic or
bilirubin (kernicterus)
encephalopathy
• During Pregnancy:
- Low socioeconomic status
- Tx of mother with thyroid
hormone, estrogen or
progesterone
- Maternal seizure disorder
- Polyhydramnios
- Eclampsia
- Bleeding in 3rd trimester
- Twin gestation
- Congenital malformation
- Fetal growth retardation
- Abnormal fetal presentation

6. Classification
Physiologic
identify forms of motor
impairment
Spastic CP
Dyskinetic CP
Ataxic CP
Mixed CP
Distribution
identify location of
musculoskeletal involvement
Spastic diplegia
Spastic
quadriplegia
Spastic hemiplegia

8. Spastic CP
• The most common form of CP
(70-80%)
• Due to injury to upper motor
neurons of pyrimidal tract
• Often exhibit truncal hypotonia
in 1st year of life

9. •Characterized by at least 2 of following:
-Abnormal movement pattern
-Increased tone
-Pathologic reflexes (Babinski, hyperreflexia)

10. Dyskinetic CP
• 10-15%
• Result of injury to basal ganglia (associated
with kernicterus)
• Characterized by variable tonal abnormalities
& involuntary movement (athetosis, chorea)
• Fewer seizures & >normal cognitive function

11. Ataxic CP
• <5% of CP cases – rare
• Results from cerebellar injury
• Abnormalities of voluntary movement and
balance
• Wide-based, unsteady gait, abnormal muscle
tone

12. Mixed CP
• 10-15% of all cases
• > 1 type of motor pattern is
present & when 1 pattern
does not clearly dominate
another
• Associated with >
complications: sensory
deficits, seizures, cognitive-perceptual
impairments

13. Dystonic CP
• Uncommon
• Characterized by reduced activity and stiff
movement (hypokinesia) and hypotonia

14. Choreoathetotic CP
• Rare
• Caused by excess hyperbilirubinemia
• Dominated by increased and stormy
movement (hyperkinesia) and hypotonia

15. Clinical Manifestations
• Spectrum of developmental abnormalities
• Mental retardation
• Epilepsy
• Motor handicap

16. •Visual, hearing, speech, cognitive &
behavioral abnormalities

17. Spastic diplegia
• 25-35%
• Bilateral spasticity of legs
• 1st noted when infant begins to crawl
• Child uses arm normally but drag the legs
behind
• Application of diaper is difficult
• Unable to sit

18. • On examination:
- Brisk reflexes
- Ankle clonus
- Bilateral Babinski sign
- Scissoring posture of lower extremities
• Delayed walking
• Feet in equinovarus
• Walk on tiptoe
• Disuse atrophy

19. Spastic hemiplegia
• Decreased spontaneous movements on
the affected side
• Show hand preference at very early age
• Difficulty in hand manipulation
• Delayed walking
• Circumductive gait
• Growth arrest in hand and thumbnails
• Equinovarus of foot
• Walks on tiptoe

20. • Ankle clonus
• Babinski sign
• Increase deep tendon reflexes
• Weakness of hand and foot dorsiflexors
• 1/3 have seizure, cognitive abnormalities

21. Spastic quadriplegia
• The most severe form
• Marked motor impairment of all
extremities
• Mental retardation & seizure
• Swallowing difficulty

22. • Increased tone and spastic
• Decreased spontaneous movement
• Brisk reflexes
• Plantar extensor response
• Flexion contraction of knee and elbow
• Speech & visual abnormalities
• Athetosis

23. Athetoid CP
• Less common
• Dyskinetic CP
• Associated with birth asphyxia
• Hypotonic with poor head control, head lag

24. • Increased variable tone with rigidity and
dystonia
• Feeding difficulty, tongue thrust, drooling

26. Diagnosis
• History and PE should preclude
progressive disorder of CNS,
degenerative disease, metabolic
disorders, spinal cord tumor,
muscular dystrophy
• MRI scan of brain or spinal cord
• Test of hearing and visual function
• Genetic evaluation

27. Management
• CP cannot be cured
• Family support – educate parents

28. • Adjunctive therapy:
- Physiotherapy
- Occupational therapy
- Speech therapy
• Surgery
• Psychologist or psychiatrist

29. •Adaptive equipment

30. • Drugs:
- Oral dantrolene sodium, benzodiazepines,
baclofen – treat spasticity
- Botulinum toxin
- Levodopa

31. Thank you!!
References:
• Kliegman, Behrman, Jenson & Stanton (2007). Nelson
Textbook of Pediatrics. 18th Edition
• Kliegman, Jenson, Marcdante & Berhman (2006). Nelson
Essentials of Pediatrics. 5th Edition