CEREBRAL PALSY By: Norhafizah AhmadPaediatrician HTJS

In 1860s, known as "Cerebral Paralysis or Littles DiseaseAfter an English surgeon wrote the 1st medical descriptionsWilliam John Little(1810-1894)

William John Little(1810-1894)

CEREBRAL PALSY (CP)Cerebral- Latin Cerebrum;Affected part of brain

Palsy " -Gr. para- beyond, lysis looseningLack of muscle control

CEREBRAL PALSY

A motor function disorder caused by permanent, non-progressive brain lesion present at birth or shortly thereafter. (Mosby, 2006)

Non-curable, life-long conditionDamage doesnt worsenMay be congenital or acquired

A Heterogenous Group of Movement DisordersCEREBRAL PALSY

An umbrella term Not a single diagnosis

A Heterogenous Group of Movement DisordersCEREBRAL PALSY

CP AffectsMuscle StrengthMovementsBalanceCoordinationPosture

In CPMuscles are unaffected

Brain is unable to send the appropriate signals necessary to instruct muscles when to contract and relax

CAUSESOF CEREBRAL PALSY

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 devt

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 instancesCAUSES

Severe deprivation of oxygen or blood flow to the brain

Hypoxic-ischemic encephalopathy or intrapartal asphyxia

CHIEF CAUSE

RISK FACTORSPrenatal factors Before birthMaternal characteristics

Perinatal factors at the time of birth to 1mo

Postnatal factorsIn the first 5 mos of life

Prenatal factorsHemorrhage/bleedingAbruptio placentaInfectionsRubella, cytomegalovirus, toxoplasmosis, Environmental factors Maternal Characteristics

Maternal Characteristics

AgeDifficulty in conceiving or holding a baby to termMultiple birthsHistory of fetal deaths/miscarriagesCigarette smoking >30 sticks per dayAlcoholism and drug addictionSocial status; mother with MRMothers medical condition

Perinatal FactorsHigh or low BPUmbilical cord coilBreech deliveryOver sedation of drugsTrauma i.e. forceps or vacuum deliveryComplications of birth

Postnatal Causes

Trauma, head injuryInfectionsLack of oxygenStroke in the youngTumor, cyst

*Several causes are preventable or treatableCP Cases

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0.75

0.1

0.15

Before Birth 75%

During Birth, 5-15%

After Birth, 10-20%

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Affects both sexes worldwide

TYPESOF CEREBRAL PALSY

Classification of CPAccording to: 1. Neurologic deficits2. Type of movement involved3. Area of affected limbs

Accdg. to Neurologic DeficitsBased on the - extent of the damage- area of brain damage

Each type involves the way a person moves

3 MAIN TYPESPYRAMIDAL - originates from the motor areas of the cerebral cortex2. EXTAPYRAMIDAL - basal ganglia and cerebellum

3. MIXED

2. Accdg. to Type of MovementPhoto from: Saunders, Elsvier.

4 MAIN TYPESPYRAMIDAL1. Spastic CP

EXTAPYRAMIDAL 2. Athethoid CP 3. Ataxic CP

MIXED4. Spastic & Athethoid CP

Spastic CPIncreased muscle tone, tense and contracted muscles Have stiff and jerky or awkward movements.limbs are usually underdeveloped increased deep tendon reflexesmost common form70-80% of all affected

Types of Spastic CP According to affected limbs:* plegia or paresis - meaning paralyzed or weak:

Paraplegia Diplegia Hemiplegia QuadriplegiaMonoplegia one limb (extremely rare)Triplegia three limbs (extremely rare)

Diplegia/ Paraplegiaboth legsboth legs w/ slight involvementelsewhere

Diplegia

May also have Contractures ofhips and knees and talipes equinovarus (clubfoot).

Hemiplegialimbs on only one side

Hemiplegia on right side

Hip and knee contractures Talipes equinus (tip-toeing- sole permanently flexed)Asteriognosis may be present. (inability to identify objects by touch)

Quadriplegia

Spastic Quadriplegia

Characteristic scissors positions of lower limbs due to adductor spasms.

Athetoid/ Dyskinetic CP Fluctuating toneinvolves abnormal involuntary movements that disappear during sleep and increase with stress.Interferes with speaking, feeding, reaching, grabbing, and any other skills 20% of the CP cases,

AthetosisWormlike movements

Slow, uncontrolled motion, writhing or twisting in character in the face, extremities, and torso.

Dystonia - when held as a prolonged posture

Dyskinesia

Dyskinetic movement of mouth

Grimacing, drooling and dysarthria.

Adductor spasm

Movements may become choreoid (rapid, irregular, jerky) and dystonic (disordered muscle tone, sustained muscle contractions)

especially when stressed and during the adolescent years.

Ataxic CPPoor balance and lack of coordinationWide-based gaitDepth perception usually affected.Tendency to fall and stumble Inability to walk straight line.Least common 5-10% of cases

MIXED CPA common combination is spastic and athetoid

Spastic muscle tone and involuntary movements.

25% of CP cases, fairly common

DEGREE OF SEVERITY1. Mild CP- 20% of cases

Moderate CP- 50% - require self help for assisting their impaired ambulation capacity.

Severe CP- 30%; -totally incapacited and bedridden and they always need care from others.

Signs and SymptomsOF CEREBRAL PALSY

a.b.c.d.e.f.g.h.

CHILD with CP

Cerebral Palsy

Main problem: Mentation and thought processes are not always affected;Trapped in their bodies with their disabilitiesAbility to express their intelligence may be limited by difficulties in communicating.

ASSOCIATED PROBLEMSOF CEREBRAL PALSY

Hearing and visual problemsSensory integration problems Failure-to-thrive, Feeding problemsBehavioral/emotional difficulties,Communication disorders

Bladder and bowel control problems, digestive problems(gastroesophageal reflux)Skeletal deformities, dental problemsMental retardation and learning disabilities in someSeizures/ epilepsy

Oropharyngeal problemsSpeech, swallowing breathing,drooling, feeding poorly

Dietary issues with Cerebral PalsyFeeding, Eating, Drinking and Swallowing Difficulties (FEDS)Lengthy Feeding TimesOro-motor DifficultiesSelf-FeedingSensory DifficultiesGastroesophageal RefluxConstipation

THANK YOU FOR PATIENTLY LISTENING!!!"Time and gravity are enemies of very aging body, especially mine." - Adult with CP

**William John LittleHe is an English surgeonSuffered childhood poliomyelitis with residual left lower extremity paraparesis, complicated by severe talipes He 1st identified Cerebral Palsy in his publication "On the Deformities of the Human Frame" in the 1860sOne of the first to bridge the gap between neurology and orthopaedicsCP was then known as "Cerebral Paralysis" or Littles Disease*William John LittleHe is an English surgeonSuffered childhood poliomyelitis with residual left lower extremity paraparesis, complicated by severe talipes He 1st identified Cerebral Palsy in his publication "On the Deformities of the Human Frame" in the 1860sOne of the first to bridge the gap between neurology and orthopaedicsCP was then known as "Cerebral Paralysis" or Littles Disease*****CP affectd*******According to affected limbs

Diplegia Both legs and both arms are affected, but the legs are significantly more affected than the arms. Children with diplegia usually have some clumsiness with their hand movements. Hemiplegia The leg and arm on one side of the body are affected. Quadriplegia Both arms and legs are affected. The muscles of the trunk, face and mouth can also be affected.

*Athetosis: slow, sinuous, writhing involuntary movements (ie flexion, extension, pronation, supination of fingers and hands). Not present during sleep. **