The Child with Motor

Weakness
Neurology Module
Pediatrics II
 Cerebral Palsy - Objectives
► At the end of this topic you should be able
to:
 provide a clear definition of cerebral
palsy;
 discuss aetiological and risk factors
associated with cerebral palsy;
 explain the clinical features and
associated impairments common to
cerebral palsy;
 demonstrate an understanding of
diagnostic methods;

 The Floppy Baby
► J.M.,
17-month-old boy admitted because of
cough

► Born preterm at 7 months age of gestation

by a repeat Caesarean section; BW=1.3 kg;
Apgar score not known to mother but
resuscitation was reportedly done. He
developed sepsis and stayed in the NICU for
a month.

► Discharged with difficulty in feeding such

that he
would often cough while sucking.
 Case: J.M., 17 months old
► He was never able to regard, hold
head,
roll over, use his hand purposively,
babble
or startle.

► He had one episode of febrile seizure.

 Case: J.M., 17 months old

Pertinent Physical Examination

Findings:
► Wt=5.95 kg(<P5) Length=65.5cm(<p5)
HC=42cm(<P5)
awake but oblivious to surroundings, shrill cry,
does not alert nor startle to sound, tongue midline,
crackles over both lungs

► Head lag on traction maneuver, slips through on

vertical suspension, truncal hypotonia, loops over
on horizontal suspension

► Spastic limbs, limited movement of both lower

extremities with +++ DTRs
 Salient Points
► 17 months old, with developmental delay
► Preterm birth
► (+) Neonatal asphyxia
► (+) Infection
► (+) History of seizures
► Marked developmental delay
► Neurologic abnormalities - truncal hypotonia
with spastic limbs, weakness of both lower
extremities
 QUESTION #1: Is there a
neurologic disease?
► Yes, as evidenced by the abnormal
neurologic examination.
 QUESTION #2: Where is the
lesion?
► Theabnormalities in the tone (hypotonia)
and movement (diplegia) point to the motor
system.

► Weakness can be due to lesions in the :

1. Central nervous system – Upper motor neuron
(spasticity, hyperreflexia); may be accompanied
by
cerebral manifestations (seizures, cognition,
language and sensory problems)
2. Peripheral nervous system – Lower motor
neuron
(decreased to absent reflexes, flaccid)
QUESTION #2: Where is the
lesion?
► J.M appears to have
an upper motor
lesion
specifically the
cerebral
hemispheres.
 QUESTION #3: What is the
nature of the lesion?
► Disordersof the motor system may be:
1. Acute - strokes/vascular
metabolic disorders
infection
2. Chronic - cerebral palsy (static)
congenital CNS lesion
degenerative disorders
(progressive)
 CEREBRAL PALSY
► Refers to a group of disorders characterized
by motor abnormalities (tone, posture or
movement) which are neither progressive
nor episodic.

► Thebrain lesions are static and result from

disorders of early brain development,
usually insults in the perinatal period.

► They
are not progressive but the symptoms
may change in time.
 CEREBRAL PALSY
► Clinical
manifestations:
1. Delay in development – i.e. poor head
control, delays in gross motor or fine motor
development
2. Motor deficit – depending on the area of
the brain involved and usually the risk
factors present
3. Associated developmental disabilities –
mental retardation, epilepsy, visual,
hearing, speech and behavioral
abnormalities
Types of Cerebral Palsy and the
Major Causes
Physiologic Topographic Etiologic Functional
Spastic Monoplegia Prenatal Class I –
Athetoid Paraplegia (e.g., infection, no limitation of
metabolic, activity
Rigid Hemiplegia anoxia, toxic, Class II –
Ataxic Triplegia genetic, slight to
infarction)
Tremor Quadriplegi moderate
a Perinatal limitation
Atonic
Diplegia
(e.g., anoxia) Class III –
Mixed moderate to
Postnatal
Unclassified Double great
(e.g. toxins,
hemiplegia limitation
trauma,
infection) Class IV –
no useful
Topographic Classification

Diplegia Hemiplegi Quadriplegi

a a

More
Affected
Less
Affected
Physiologic Classification

Hypotonic Cerebral
Palsy
Physiologic Classification

Spastic Diplegic
Cerebral Palsy
 Diagnosis
► 1. Thorough history, developmental
assessment, physical and neurological
examinations
► 2. Hearing and vision screening
► 3. EEG if with seizures
► 4. If no possible etiology or risk factors for
CP, may do diagnostic tests as:
Neuroimaging – CT/MRI
Metabolic screening
Chromosomal study
 Differential Diagnosis
1. Motor delays from congenital
structural lesions
2. Progressive disorders of the brain –
white matter diseases
3. Muscle disorders- myopathies,
dystrophies.
 Management
► Multidisciplinary
1. Pediatrician
2. Neurologist
3. Rehabilitation specialists
4. Physical and occupational therapists
5. Developmental psychologists
6. Education specialists
7. Orthopedic surgeons
8. Social workers
Thank
you!