CEREBRAL PALSY

Define
Is defined as a :
1) Persistent but not unchanging
2) Disorder of movement, tone and posture
3) Due to non-progressive defect/lesion
4) Of immature brain
( fetal life, infancy, childhood)
( immature brain cut off take as 5 yrs AAP)

5) Commonly associated with a spectrum

of developmental disabilities such as
I. Mental retardation (60%)
II. Epilepsy (33%)
III. Visual , hearing (deafness-10%) and
speech defects
IV. Strabismus(50%)
V. Cognitive dysfunction
VI. Sensory problems
VII. Emotional and behavioral problems.

 EXCLUDING progressive pathology and

lesion of spinal cord.

INCLUDING non-progressive genetic d/s or

cong malformation

CLASSIFICATIONS
TOPOGRAPHIC
MONO
HEMI
DIPLEGIA
QUADRI
DOUBLE
HEMIPLEGIA
TRIPLEGIA

PHYSIOLOGY
SPASTIC
EXTRAPYRAMIDAL
ATAXIC
MIXED
ATONIC

FUNCTIONAL

CLASS 1 NO limitation of activity

CLASS 2 Slight limitation
CLASS 3 Moderate limitation
CLASS 4 No useful physical activity

Site of brain injury

Pathological

Periventricular leucomalacia
spastic diplegia
Stroke in utero - hemiplegia
Multifocal encephalomalacia
-quadriplegia
Cerebellar - ataxic
Basal ganglia, thalmus,
putamen - dyskinetic

Cortical
Sub cortical
Periventricular
Basal ganglia
Cerebellum
Brain stem

Severity
Motor development quotient :

= motor age / chronological age 100

>70 : minimal deviancy without delay
50-70 : mild motor disorder
<50 : classical CP

Etiological
Prenatal
I, iron def.,poor nut.
Inf, UTI, high fever
Chorioamniotis
HTN, DM
Teratogens
Poor ANC
LOW SES
Twins
Fetal vasculopathy

Perinatal
Birth asphyxia
Premature / LBW
IUGR
Hyperbilirubenemia
IVH
Sepsis, pneumonia,
meningitis
Develop.
malformation

Postnatal
CNS infections
Head injuries
Seizures
Hypoxic
damage
Hyperpyrexia
damage

Early markers of CP
SLOW head growth
Poor head control
Eye roving eyes, poor hand
regard, persistent squint.
Ear lack of auditory
response
Irritability, seizures, poor
suck, poor quality of sleep.
Extreme sensitivity to light

Cortical thumb beyond 8

weeks
Handedness before 2 yrs
Paucity of limb movements
Scissoring of lower limbs
Toe walking
Abnormal tone
Persistence of primitive
reflexes or failure to
acquire postural reflexes
Stereotypic abnormal
movements
Lack of alertness

Differential diagnosis
In the early infancy when the child is in
hypotonic phase, neuromuscular conditions like
myopathies may cause diagnostic confusion.
Children with mental retardation may have
hypotonia but do not have abnormal motor
patterns or postures

 Neurodegenerative conditions which have

onset in early infancy such as Tay-Sach
disease, Krabbe's disease, and Metachromatic
Leucodystrophy can mimic CP.
The progressive course of these conditions can
be ascertained on the basis of history, and
relevant investigation can confirm the
diagnosis.

 Dopa-responsive dystonia and organic

aciduria like glutaric aciduria may look like
dystonic CP.

Assessment of General Health

Growth, and nutritional disorders
Frequent respiratory tract infections are
common because of ineffective cough reflex.
Facial dysmorphism and other congenital
anomalies should be noted.
Skin should be inspected for neurocutaneous
stigmata.
Head circumference should be noted and
plotted .

 Reliable measures of length may be difficult to

obtain due to concomitant contractures or
scoliosis.
Alternate measures to length such as
segmental measures of upper arm and lower
leg are sometimes used.
Skinfold thickness is a useful and a less
cumbersome method of assessing nutritional
status.

Neurological Evaluation
The history of previous developmental
milestones should be obtained for all
domains of development i.e. gross & fine
motor, cognitive, speech and language and
socialization.

 A thorough neurological evaluation should be

performed which includes assessment of
cranial nerves, posture, muscle tone of
extremities, trunk and neck, deep tendon
reflexes; postural response and primitive
reflexes .
Physical examination should include the
observation of child in prone, supine, sitting,
standing, and if appropriate in walking and
climbing positions.

 This is followed by assessment of the

current level of functioning in all these
domains and assessment of self help and
adaptive skills in daily activities such as
feeding, dressing, brushing teeth .

Disorder in Movement and

Posture
Among the most clinically useful primitive
reflexes are Moro, Tonic labyrinthine and
ATNR

Postural reactions are sought in each of 3

categories: righting, protection and
equilibrium.

Muscle Tone
Abnormality of tone is an integral part of
CP.
Hypertonia in CP may be purely due to
spasticity (pyramidal ) or else due to
dystonia (extrapyramidal).

Assessment of Cognition and

Behavior
Metal retardation was found the commonest
associated problem in children with CP
Conventional tests of intelligence may prove
erroneous in children with CP because of motor
and communication deficits.
Age appropriate non-verbal intelligence tests
have to be administered for this purpose.

Assessment of Vision and

Hearing
In children with hearing impairment with associated
microcephaly and congenital heart disease should be
looked for other stigmata of TORCH infection.
In cases with dyskinetic CP, presence of hearing
impairment may point to kernicterus as a cause of CP.
Sensorineural hearing loss is a prominent feature of
CP due to Iodine deficiency in endemic areas.

Assessment of Speech and

Language
These may be due to hearing impairment,
cognitive deficits, or oromotor dysfunction

Difficulty in communication by language or

gestures further compound behavior
problems.

Assessment of Feeding and

Nutrition
Oromotor dysfunction, inability to self
feed , and inability to request for food due
to communication disorder result in
feeding problems and poor nutritional
status in children with CP .
Gastro-esophageal reflux or
choking/coughing while feeding which may
further cause aversion to food .

 Child should also be assessed for tongue

thrust or tonic bite, hypersensitivity to
touch, drooling of saliva and dental
hygiene.

Orthopedic Problems
Hip subluxation, scoliosis, equinus deformity, and
contractures of hamstring muscles and tendoachilles.
Reduced bone density and propensity to fractures with
trivial trauma is common
Equinus deformity is the most common
musculoskeletal abnormality in patients with CP.
It is due to fixed or spastic contracture of gastrocnemius
and causes the typical tip toe or toe heel gait in children
with CP.

 Epilepsy: Epilepsy is more common in

children with CP. In a population based study

38% of children with CP had epilepsy

Children with CP caused by CNS

malformations, CNS infection, and grey matter
damage have been reported to show a higher
frequency of epilepsy than children with CP of
other aetiology, and also had less chance of
becoming seizure-free

Role of Neuroimaging
Neuroimaging (MRI preferred to CT) is
recommended in children with cerebral
palsy in order to establish structural brain
abnormality which may further help in
finding the etiology and giving prognosis

Disabling conditions be evaluated on multiple axes

Pathophysiology (underlying disease);

Impairment (clinically observable abnormality) ;
Functional limitations (effect on task performance);
Disability (effect on daily living) and
Societal limitations (effect on life time opportunities).

Since CP is a changing disorder it is evident that

some limitations may not be evident early in life but
manifest in the school age or later.

 Assessment of Home Situations:

Evaluation is not complete without the
assessment of the home situation such as
family size, financial resources and family
support.

 Child rearing conditions that support and enrich

early development can compensate for many
biological deficits.

On the other hand, poverty, illiteracy in parents,

large family size, frequent change in residence,
non-availability of special rehabilitation centers
may deprive the child of appropriate care.

 The hemiplegic type of CP has the best prognosis for

walking with 95% walking by 3 years compared to
40% of other groups.

Age of sitting is a good guide to prognosticate about

walking. A child who is able to sit unsupported at 2
years will eventually be able to walk.
On the contrary, a child whose sitting is delayed
beyond 3 years has remote prospects for functional
outdoor walking

 Management - The pediatrician's initial

role consists of making a correct
diagnosis,determining the etiology, and
identification of the type, extent and
severity of the neuromotor deficit as well
as of associated problems

(i) Breaking the news

ii) Comprehensive assessment

a multidisciplinary team comprising of a neuro-developmental
pediatrician as the team-leader,
physiotherapist,
occupational therapist,
clinical psychologist,
speech pathologist,
orthopedic surgeon,
otorhinolaryngologist,
ophthalmologist,
teacher,
play therapist and
social worker is required,
preferably under one roof.

Physiotherapy (P.T.) P.T. especially when started early in life, is

helpful in promoting normal motor development,
and preventing deformity and contractures.
In the young child it aims at reducing abnormal
patterns of movement and posture and
promoting the normal ones so as to enable the
child to gain maximal functional independence.
A number of techniques have been used for this
purpose. The neurodevelopmental Bobath
technique is commonly used.

 It consists of guiding the child through

normal sequences of motor development,
inhibition of primitive and abnormal
reflexes,
re-inforcement of normal postural reflexes
and
facilitation of normal movements.

Occupational Therapy
The role of P.T. and O.T. are so closely linked that
they could infact be considered together.
The occupational therapist is usually better trained
to advise on activites of daily living like feeding,
bathing, dressing, toilet training etc, and the
equipment needed to facilitate these.
Co-ordination and sensory-perceptual integration
can be taught and multisensorial stimulation
provided through peg board, blocks and other toys
of different colours, textures, sizes and shapes, and
producing different sounds

Play Therapy: It is the use of a natural activity

with a young child, to help him consolidate the
levels of development that he has reached and
encourage him to move on, to the next level.
Parents are taught to break down each activity
into its simplest components and make the
child practice it in a real life situation. It then is
not considered as an 'exercise' but becomes a
way of life.

Assistive and adaptive devices :

Various simple modifications like angled
spoons, two handled cups etc can be
made to help the child.
Old stools and boxes can be adapted to
provide support during sitting
Parallel bars can be constructed with logs
of wood to help gait training.
Standing frames and prone boards are a
useful intermediate stage in mobilization.

 A number of high technology devices like

programmed wheel chairs, electronic
feeding devices, various access systems,
computerized speech systems and
cochlear implants are available

 Splints, Casts and Calipers: Specially

designed shoes, ankle-foot orthoses
(AFO) and calipers
AFOs, are particularly useful in children
with spastic diplegia who have dynamic
spasticity with tendo- achilles (TA)
tightening.

Management of Spasticity:
Proper P.T. given regularly considerably reduces
spasticity and improves function.
(i) Drugs:
Baclofen - acts at the level of spinal cord
neurons and enhances GABA activity.
It is commonly used in a starting dose of 1.25 2.5 mg BD orally and increased gradually upto a
maximum of 30 mgm/day, monitored by a clinical
response.
It is not recommended in children with seizures
as it may provoke them. (

 ii) Diazepam- a small dose given half an hour

before PT is effective in some cases especially
where anxiety increases spasticity. Its
disadvantage is that it may cause unacceptable
drowsiness.
(iii) Tizanidine an alpha 2 adrenergic agent and
(iv) Dantrolene sodium which acts on calcium
channels have also been used, but experience
with them is limited.

 Baclofen has also been used intrathecally

using implantable infusion pumps.
It may be helpful in cases of severe
spasticity or disabling total body dystonia

 Botulinum Toxin: (BTA): is derived from Claustridium

botulinum.
It causes muscle relaxation by blocking the release of
acetylcholinesterase, with loss of motor end plates.
As affected nerve roots sprout to form new junctions,
the relaxing effect reverses over 3-6 months.
It is more often used in children with spastic diplegia.

 Surgery: Surgery is useful in some children with

spasticity, especially where mainly the lower limbs
are involved.
Tendon lengthening and transfer and arthrodesis are
some of the procedures commonly performed.
Generally multilevel surgery is required and is done
after 8 years of age.
Simultaneous availability of intensive physiotherapy
is essential.

 Dorsal rhizotomy which involves selective

resection of posterior nerve roots from L 2_ to S 2
It may be helpful in children with severe lower limb
spasticity, with sufficient trunk control and some
form of forward locomotion.
Its advantage must be weighed carefully against
the sensory losses that may occur after the
procedure.

 Relief of athetosis and dystonia - is difficult

occasionally levo-dopa for severe
athetosis and carbamezepine for dystonia
may be helpful.
Thalamotomy for athetoid CP, stereotactic
dentatomy and chronic cerebellar
stimulation via implanted electrode .

Management of Associated
Problems.

 Parent Counselling : This is one of the

most important aspects because parents
are pivotal in the management of their
child.
It is an ongoing process, as the parents
need to be counseled periodically at
various stages of their child's
development.