an overview of cerebral palsy = الشلل الدماغي
TRANSCRIPT
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CEREBRAL
PALSYBY: DR. RAHMA SHAHBAHAI
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William John Little (1810-1894)
In 1860s, known as
"Cerebral Paralysis” or
“Little’s Disease”
After an English surgeon
wrote the 1st medical
descriptions
Introduction
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Cerebral“- Latin Cerebrum;
Affected part of brain
“Palsy " -Gr. para- beyond,
lysis – loosening
Lack of muscle control
Introduction
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A motor function disorder caused by permanent, non-progressive brain lesion
present at birth or shortly thereafter. (Mosby, 2006)
Non-curable, life-long condition
Damage doesn’t worsen
May be congenital or acquired
Definition
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A Heterogeneous Group
of Movement Disorders
– An umbrella term
– Not a single diagnosis
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Muscle Strength
Movements
Balance
Coordination
Posture
CP affects
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In CP
Muscles are unaffected
Brain is unable to send the
appropriate signals
necessary to instruct muscles
when to contract and relax
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CAUSESOF CEREBRAL PALSY
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An insult or injury to the brain
– Fixed, static lesion(s)
– In single or multiple
areas of the motor
centers of the brain
– Early in CNS dev’t
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CAUSES
Development Malformations The brain fails to develop correctly.
Neurological damage Can occur before, during or after delivery
Rh incompatibility, illness, severe lack of oxygen
* Unknown in many instances
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CHIEF CAUSE
Severe deprivation of oxygen or
blood flow to the brain
–Hypoxic-ischemic
encephalopathy
or intrapartum
asphyxia
CHIEF CAUSE
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RISK FACTORS
Prenatal factors Before birth
Maternal characteristics
Perinatal factors at the time of birth to 1mo
Postnatal factors In the first 5 mos of life
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Prenatal factors
Hemorrhage/bleeding
Abruptio placenta
Infections
Rubella, cytomegalovirus,
toxoplasmosis,
Environmental factors
Maternal Characteristics
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Maternal Characteristics
Age
Difficulty in conceiving or holding a baby to term
Multiple births
History of fetal deaths/miscarriages
Cigarette smoking >30 sticks per day
Alcoholism and drug addiction
Mother’s medical condition
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Perinatal Factors
High or low BP
Umbilical cord coil
Breech delivery
Over sedation of drugs
Trauma i.e. forceps or vacuum
delivery
Complications of birth
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Postnatal Causes
Trauma, head injury
Infections
Lack of oxygen
Stroke in the young
Tumor, cyst
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Before
Birth 75%
During
Birth, 5-15%
After
Birth,
10-20%
*Several causes are preventable or treatable
CP Cases
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TYPESOF CEREBRAL PALSY
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Classification of CP
According to:
1. Neurologic deficits
2. Type of movement
involved
3. Area of affected
limbs
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1. Accdg. to Neurologic Deficits
Based on the - extent of the damage
- area of brain damage
Each type involves the way a person
moves
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3 MAIN TYPES
1. PYRAMIDAL
- originates from the motor
areas of the cerebral cortex
2. EXTAPYRAMIDAL
- basal ganglia and
cerebellum
3. MIXED
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2. Accdg. to Type of Movement
Photo from: Saunders, Elsvier.
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4 MAIN TYPES
PYRAMIDAL 1. Spastic CP
EXTAPYRAMIDAL 2. Athetoid CP
3. Ataxic CP
MIXED 4. Spastic &
Athetoid CP
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Spastic CP
Increased muscle tone,
tense and contracted muscles Have stiff and jerky or
awkward movements.
limbs are usually underdeveloped
increased deep tendon reflexes
most common form
70-80% of all affected
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Types of Spastic CP
According to affected limbs:* plegia or paresis - meaning paralyzed or weak:
Paraplegia
Diplegia
Hemiplegia
Quadriplegia
Monoplegia –one limb (extremely rare)
Triplegia –three limbs (extremely rare)
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Diplegia/ Paraplegia Hemiplegia Quadriplegia
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Athetoid/ Dyskinetic CP
involves abnormal involuntary movements
that disappear during sleep and increase with stress.
Athetoid-Wormlike movements
Slow, uncontrolled motion, twisting in character, in the face, extremities, and torso.
Dyskinesia -Dyskinetic movement of mouth
drooling and dysarthria.
Dystonia - when held as a prolonged posture
20% of the CP cases,
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Ataxic CP
Poor balance and lack of coordination
Wide-based gait
Depth perception usually affected.
Tendency to fall and stumble
Inability to walk straight line.
Least common 5-10% of cases
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MIXED CP
A common combination is
spastic and athetoid
Spastic muscle tone and involuntary movements.
25% of CP cases, fairly common
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Signs and
SymptomsOF CEREBRAL PALSY
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a.
b.
c.
d.
e.
f.
g.
h.
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Early Signs
• Stiff or floppy posture
• Weak suck/ tongue thrust/
tonic bite/ feeding difficulties
• Poor head control
• Excessive lethargy or
irritability/ High pitched cry
Infancy (0-3 Months)
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CHILD with CP
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Behavioral Symptoms
Poor ability to concentrate ,
unusual tenseness,
Irritability
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ASSOCIATED
PROBLEMS
OF CEREBRAL PALSY
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Hearing and visual problems
Sensory integration problems
Failure-to-thrive, Feeding
problems
Behavioral/emotional
difficulties,
Communication disorders
• Bladder and bowel control
problems, digestive
problems
gastroesophageal reflux
• Skeletal deformities, dental
problems
• Mental retardation and
learning disabilities
• Seizures
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Diagnosis
OF CEREBRAL PALSY
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1. SUBJECTIVE
-HISTORY
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2. OBJECTIVE
- PHYSICAL EXAMINATION
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CRITERIA
P osturing / Poor muscle control and strength
O ropharyngeal problems
S trabismus/ Squint
T onia: hyper- hypo
E volutional maldevelopment
R eflexes e.g Increased deep tendon
*Abnormalities 4/6 strongly point to CP
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DIAGNOSIS
Laboratory studies
clinical diagnosis.
There are no definitive laboratory studies
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To rule out other causes:
Thyroid function studies: Abnormal thyroid function may be
related to abnormalities in muscle tone or deep tendon reflexes
or to movement disorders
Lactate and pyruvate levels: Abnormalities may indicate an
abnormality of energy metabolism (ie, mitochondrial cytopathy)
Ammonia levels: Elevated ammonia levels may indicate liver
dysfunction or urea cycle defect
Organic and amino acids: may reveal inherited metabolic
disorders
Chromosomal analysis: if dysmorphic features or abnormalities
Cerebrospinal protein: levels may assist in determining asphyxia in
the neonatal period
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Imaging studies
Cranial ultrasonography: evidence of
hemorrhage or hypoxic-ischemic injury
CT of brain: congenital malformations,
intracranial hemorrhage, and periventricular
leukomalacia or early craniosynostosis.
MRI of the brain: The diagnostic neuroimaging
study of choice
defines cortical and white matter structures and
abnormalities more clearly than does any other
method
determination of whether appropriate myelination is
present for a given age
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Others:
Electroencephalography: Important in the diagnosis
of seizure disorders
Electromyography and nerve conduction studies:
Helpful when a muscle or nerve disorder is
suspected
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TreatmentOF CEREBRAL PALSY
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- No treatment to cure cerebral palsy.
- Brain damage cannot be corrected.
Crucial for children with CP:
Early Identification;
Multidisciplinary Care; and
Support
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“The earlier we start,
the more improvement can be made”
-Health worker
I. NONPHYSICAL THERAPY
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A. General management- Proper nutrition and personal care
B. Pharmacologic Botulinum toxin : for children with cerebral palsy with spasticity
antiparkinsonian drugs (eg, anticholinergic and dopaminergic drugs)
antispasticity agents (eg, baclofen) have primarily been used in the
management of dystonia, anticonvulsants,
antidopaminergic drugs, and antidepressants have also been tried
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C. Surgery
-Intrathecal baclofen pump
insertion: To treat spasticity and/or
dystonia
-Selective dorsal rhizotomy: To treat
velocity-dependent spasticity
- Orthopedic surgical intervention: To
treat scoliosis, joint contractures or
dislocation
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Selective posterior RhizotomyIn some cases nerves need to be severed to decrease muscle
tension of inappropriate contractions.
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D. Physical Aids
Orthosis, braces and splints
Positioning devices
Walkers, special scooters, wheelchairs
E. Special Education
F. Rehabilitation Services- Speech and
occupational therapies
G. Family Services -Professional support
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H. Other Treatment
- Therapeutic electrical stimulation,
- Acupuncture,
- Hyperbaric therapy
- Massage Therapymight help
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'The ultimate long-term goal is realistic independence.
To get there we have to have some short-term goals.Those being a working communication system, education to his potential,
computer skills and, above all, friends'.
- Parent of boy with CP
II. PHYSICAL THERAPY
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A.Sitting
-Vertical head control and
control of head and trunk .
B. Standing and walking
-Establish an equal distribution of
weight on each foot, train to
use steps or inclines
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C. Prone Development
D. Supine Development
Head control on supine and positions
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Thank you for lessening.
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References