1. Cerebral Palsy - C.S.N.Vittal

2. Definition Collection of diverse syndromes characterized by disorders of movement and posture caused by a non-progressive injury to immature brain. It is a static encephalopathy of childhood. The insult can be failure of normal development in fetal life, or result of injury to the brain before, during or after birth. Postnatal causes include meningitis, encephalitis or head injury. 3. Cerebral Palsy The original insult to brain resulted in a fixed, static lesion affecting motor performance The insult occurred during early CNS development typically at birth or shortly after. 4. Cerebral Palsy Incidence 3.3 per 1000 live births 10% of infants born 1000 g or less at birth 5-10% incidence in preterm Birth asphyxia as a cause : only in 3 21% 5. Cerebral Palsy Causative Factors 1.1. Acute Hypoxia IschemiaAcute Hypoxia Ischemia 2.2. Chronic Hypoxia IschemiaChronic Hypoxia Ischemia 3.3. Intracranial HemorrhageIntracranial Hemorrhage 4.4. InfectionsInfections 5.5. Metabolic ToxicMetabolic Toxic 6.6. TraumaTrauma 7.7. Brain MalformationsBrain Malformations 6. Cerebral Palsy POSTER Criteria for diagnosis P = Postural / abnormal movementsP = Postural / abnormal movements O = Oropharyngeal problemsO = Oropharyngeal problems ( e.g. tongue thrusts,( e.g. tongue thrusts, swallowing abnormalities)swallowing abnormalities) S = StrabismusS = Strabismus T = ToneT = Tone ( hyper or hypotonia)( hyper or hypotonia) E = Evolutional maldevelopmentE = Evolutional maldevelopment (primitive reflexes(primitive reflexes persist or protective / equilibrium reflexes fail to develop [e.g.persist or protective / equilibrium reflexes fail to develop [e.g. lateral prop, parachute reflex])lateral prop, parachute reflex]) R = ReflexesR = Reflexes (Increased DTRs / persistent Babinskis reflex )(Increased DTRs / persistent Babinskis reflex ) Abnormalities in four of these six categories strongly point to CP 7. Cerebral Palsy Classification Physiological classification Topographic classification Etiological classification Functional Classification 1. Spastic 2. Dyskinetic 3. Ataxic 4. Atonic 5. Mixed 1. Monoplegia 2. Paraplegia 3. Hemiplegia 4. Triplegia 5. Quadriplegica 6. Diplegia 7. Double Hemiplegia 1. Prenatal e.g. Infection, metabolic, anemic, toxic, genetic 2. Perinatal e.g. Anoxic 3. Postnatal e.g. Toxins, infections 1. Class I No limitation of activity 2. Class II Dyskinetic - Slight limitation of activity 3. Class III - Moderate limitation of activity 4. Class IV No useful physical activity 8. Cerebral Palsy Classification - Neurological 1.1. Pyramidal (Spastic)Pyramidal (Spastic) 1.1. QuadriplegiaQuadriplegia 27%27% 2.2. HemiplegiaHemiplegia 21%21% 3.3. DiplegiaDiplegia 21%21% 4.4. MonoplegiaMonoplegia 5.5. TriplegiaTriplegia 2.2. ExtrapyramidalExtrapyramidal 1.1. ChoreaChorea 2.2. AthetosisAthetosis 3.3. ChoreoathetosisChoreoathetosis 4.4. AtaxiaAtaxia 5.5. DystoniaDystonia 6.6. RigidRigid 7.7. TremorTremor 3.3. MixedMixed 9. Cerebral Palsy Pathophysiology of Spasticity Primary afferent I a fibers surrounding intrafusal fibers of the muscle spindle are excited when a muscle is stretched. The I a fiber makes a monosynaptic excitatory connection with alpha motoneurons of its muscle of origin, and it similarly connects with alpha motoneurons of synergistic muscles. The I a fiber also monosynaptically connects with an inhibitory interneuron that projects directly to the alpha motoneurons of antagonist muscles. When a muscle is stretched, excitation of homonymous and synergistic motoneurons, combined with inhibition of antagonists, subserves the mechanism of reciprocal inhibition. There is evidence for impairment of this mechanism in the UMN syndrome 10. Cerebral Palsy Pathology Spastic diplegia : PVL Spastic quadriplegia : Corical, subcortical atrophy Hemiplegic CP: Gliosis & atrophy of contralateral cerebral hemisphere in MCA region Dyskinetic CP : Status marmoratus Ataxic CP : Cerebellar lesions Developmental malformation 11. Cerebral Palsy Spastic Cerebral Palsy (Pyramidal) 12. Cerebral Palsy POSITIVE SYMPTOMS Spasticity increased muscle tone exaggerated tendon jerks stretch reflex spread to extensors repetitive stretch reflex discharges; clonus Released flexor reflexes Babinski response mass synergy patterns NEGATIVE SYMPTOMS Loss of finger dexterity Weakness inadequate force generation slow movements Loss of selective control of muscles and limb segments RHEOLOGIC CHANGES IN SPASTIC MUSCLE Stiffness Contracture Fibrosis Atrophy 13. Cerebral Palsy Dyskinetic Cerebral Palsy (Extra Pyramidal) Prominent involuntary movements or fluctuating muscle tone, with 2 Types: Mainly Hyperkinetic choreoathetosis Mainly Dystonic Tension athetosis Variable rigidity Distribution usually symmetric in all limbs 14. Cerebral Palsy Dyskinetic Cerebral Palsy (Extra Pyramidal) Dystonic choreoathetoid Infancy hypotonia head lag feeding difficulties droolinmg of saliva . Childhood athetosis , dystonia , arms , legs ,neck & trunk Associated problems speech defects , deafness Normal I.Q 15. Cerebral Palsy Spastic Cerebral Palsy Common (50-75%) Persistent NNRs Cortical thumb Extensor postures Scissoring UMN signs Pseudo bulbar palsy 16. Cerebral Palsy Spastic Cerebral Palsy 17. 17 18. Spastic Diplegia Pre term Lower limbs > upper limbs Commando crawl Difficulty in diaper changing I.Q normal UMN signs Delayed walking 19. Hemiplegia Decreased spontaneous movements Early hand preference Delayed walking Upper limb > lower limbs UMN signs Circumduction gait Associated problems 20. Cerebral Palsy Athetotic Cerebral Palsy 21. Cerebral Palsy Ataxic Cerebral Palsy Cerebellum Hypotonia Hyporeflexia Intention tremor Ataxia Normal IQ 22. Cerebral Palsy Atonic Hypotonia DTR brisk Plantar extensor Mental retardation severe 23. Cerebral Palsy Associated Disabilities 1.1. Disturbed mental developmentDisturbed mental development 2.2. SeizuresSeizures (in 1/3, mostly with spastic)(in 1/3, mostly with spastic) 3.3. Growth retardationGrowth retardation 4.4. Ophthalmologic abnormalitiesOphthalmologic abnormalities (strabismus, amblyopia, nystagmus,(strabismus, amblyopia, nystagmus, refractive errors in 75% of cases)refractive errors in 75% of cases) 5.5. Sensory impairmentSensory impairment 6.6. Hearing impairmentHearing impairment 7.7. Speech impairmentSpeech impairment 8.8. Gait disturbancesGait disturbances 9.9. Failure to thriveFailure to thrive 10.10. GERGER 11.11. Behavioural and emotional problemsBehavioural and emotional problems 24. Cerebral Palsy Diagnosis : CLINICAL Diagnostic EvaluationDiagnostic Evaluation 1.1. Detailed historyDetailed history 2.2. Thorough neurological examinationThorough neurological examination 3.3. Routine blood testsRoutine blood tests 4.4. Metabolic screeningMetabolic screening 5.5. X-RaysX-Rays 6.6. EEGEEG 7.7. CT brainCT brain 8.8. MRIMRI 25. Cerebral Palsy Difficult to diagnose clinically in 1st year Hypotonia is more common than hypertonic and spasticityHypotonia is more common than hypertonic and spasticity Early abundance of primitive reflexes may confuse the clinicalEarly abundance of primitive reflexes may confuse the clinical picturepicture An infant has a limited variety of volitional movements forAn infant has a limited variety of volitional movements for evaluationevaluation Substantial myelination takes months to evolve and may delaySubstantial myelination takes months to evolve and may delay the clinical picture of abnormal tone and increased DTRsthe clinical picture of abnormal tone and increased DTRs Many children who develop CP do not have identifiable riskMany children who develop CP do not have identifiable risk factors; most cases are not related to labor and delivery eventsfactors; most cases are not related to labor and delivery events 26. Cerebral Palsy Behavioural problems that arose suspicion & possibility Excessive irritability, constant crying, sleep difficulties (severeExcessive irritability, constant crying, sleep difficulties (severe colic in 25%)colic in 25%) Early feeding difficulties in coordinating suck and swallow,Early feeding difficulties in coordinating suck and swallow, frequent spitting up and poor weight gainfrequent spitting up and poor weight gain Jittery and jumpy behaviour esp. at times other than whenJittery and jumpy behaviour esp. at times other than when hungryhungry Early startled behaviourEarly startled behaviour Stiffness when handled, esp. duding dressing, diapering andStiffness when handled, esp. duding dressing, diapering and handwashinghandwashing Paradoxically precocious development, such as early rollingParadoxically precocious development, such as early rolling (laterally sudden, reflexive roll than a volitional) or stiff legged(laterally sudden, reflexive roll than a volitional) or stiff legged standing with support of an infant with spastic diplegia.standing with support of an infant with spastic diplegia. 27. Cerebral Palsy Assessment 1.1. HistoryHistory 2.2. Delayed milestonesDelayed milestones 3.3. Historic cluesHistoric clues 4.4. Slow head growthSlow head growth 5.5. Persistent NNRPersistent NNR 6.6. PersistentPersistent asymmetryasymmetry 28. Cerebral Palsy Historic cluesHistoric clues 1.1. Toe walkingToe walking 2.2. Strong development of LT. or Rt.Strong development of LT. or Rt. Handedness before 1 yr. ageHandedness before 1 yr. age 3.3. Obligatory fisting or cortical thumbObligatory fisting or cortical thumb posture before 3 mo. ageposture before 3 mo. age 29. Cerebral Palsy Symptoms 1.1. symptoms due to loss of selective motorsymptoms due to loss of selective motor control;control; 2.2. symptoms due to abnormal muscle tone;symptoms due to abnormal muscle tone; 3.3. symptoms due to imbalance between musclesymptoms due to imbalance between muscle agonists and antagonists; andagonists and antagonists; and 4.4. symptoms due to impaired balance.symptoms due to impaired balance. 30. Cerebral Palsy Differential Diagnosis 1.1. Nerurodegenerative disordersNerurodegenerative disorders 2.2. HydrocephalusHydrocephalus 3.3. ICSOLICSOL 4.4. Muscular disordersMuscular disorders 31. Cerebral Palsy TreatmentTreatment Cerebral palsy can not be cured, but treatment can often improve the childs capabilities that they may enjoy near normal lives if their neurological Problems are properly managed. 32. Cerebral Palsy Assessment for Management - >Assessment for Management - > To evaluate the functional disabilities of the child To ascertain already acquired or developed abilities of the child To identify the problems that can affect the rehabilitation process STEPS of ASSESSMENT: Proper medical history & Examination Developmental assessment Functional assessment: Barthel Index: Assessment of the ability that the person is having with regard to some specific activities of daily life like brushing, combing, bathing, eating, moving from one place to another, dressing, etc. 33. Cerebral Palsy Management goal - >Management goal - > Aim: To maximize function, minimize contracture and other complications and delay surgery Multidisciplinary approach Physiotherapy Occupational therapy Speech therapy Orthopedic & surgical Rehabilitation Counseling 34. Cerebral Palsy Management goal - >Management goal - > The child with cerebral palsy will become an adult with cerebralThe child with cerebral palsy will become an adult with cerebral palsy.palsy. Searching for cures will only bring disappointment.Searching for cures will only bring disappointment. Instead, help the child become an adult who can live with herInstead, help the child become an adult who can live with her disability and be as independent as possible.disability and be as independent as possible. Rather than try to treat the symptoms of cerebral palsy, we can do more for the child if we help her with development of movement, communication, self-care and relationships with others. Help the child just enough that she can learn to do more for herself. 35. Cerebral Palsy Management goalsManagement goals Developing some form of locomotion Developing independence in ADL Developing adequate communication skills These goals are achieved through following steps by various forms of therapy with physical therapy forming the main stay: Improving / facilitationg the childs motor development Preventing the weakness or deterioration of muscles that can follow lack of use (disuse atrophy) Avoid contractures 36. Cerebral Palsy ManagementManagement 37. Cerebral Palsy ManagementManagement 38. Cerebral Palsy Management of spasticityManagement of spasticity 1. Use of exercise & occupational therapy 2. Electrical stimulation 3. Drugs 39. Cerebral Palsy Medications to reduce spasticityMedications to reduce spasticity 1. Benzodiazepines (increase the affinity of GABA to the GABA-A receptor complex) 0.25 to 5 mg / d 2. Baclofen (GABA agonist) 1 mg / kg 3. Dantrolene Sodium (acts at the muscle fiber, affecting the release of calcium from the sarcoplasmic reticulum of skeletal muscle and thus reducing muscle contraction) 0.5 mg / kg 4. Tizanidine (central alpha2-noradrenergic agonist, inhibition of the H-reflex, may facilitate inhibitory actions of glycine & reduce release of excitatory amino acids and substance P ) 5. Chemodenervation 1. injections of botulinum toxin type A 2. phenol & alcohol 40. Cerebral Palsy Botulinum toxin There are seven antigenically distinct neurotoxins: A, B, C, D, E, F, and G BTX-A has FDA approval for strabismus, blepharospasm, and hemifacial spasm BTX is considered by many as the treatment of choice for blepharospasm, oromandibular dystonia, cervical dystonia, and spasmodic dysphonia, and provides marked relief of other focal dystonias and involuntary muscular contractions Proper choice of dose and administration site are the most important determinants of a favorable response to BTX treatment Clinical effects are seen within 1 week of injection. Benefits last 3-6 months 41. Cerebral Palsy Botulinum toxin (BTX-A ) in CP Injection of 1.0 U/kg of BTX-A (BOTOX) into the medial and lateral gastrocnemius of each leg resulted in an improvement in gait pattern vs. placebo (Koman et al.) 42. Cerebral Palsy Chemical Neurolysis Criteria BTA Phenol Method of injection Into the muscle belly, EMG to identify the muscle Into motor pint, EMG necessary to identify the motor joint Mechanism of action Neuromuscular blockade Destruction of axons Side effects Resistance on repeated injections Pain, dysesthesias Repeatability ++ ++ Cost High cost Very low cost 43. Cerebral Palsy Surgical Management Neurosurgery for Spasticity selective dorsal rhizotomy (SDR) or selective posterior rhizotomy. Orthopedic Surgery for Spasticity contracture release tendon transfer osteotomy arthrodesis 44. Cerebral Palsy Nursing ManagementNursing Management 1.1. ResponsibilitiesResponsibilities 1.1. Functioning as a member of health care teamFunctioning as a member of health care team 2.2. Provide counseling and education to parentsProvide counseling and education to parents 3.3. Promoting physical and psychological healthPromoting physical and psychological health 4.4. Assist in feeding and toilet trainingAssist in feeding and toilet training 5.5. Assist in physical therapyAssist in physical therapy 6.6. Preventing child abusePreventing child abuse 7.7. Counseling for educational and vocational pursuitsCounseling for educational and vocational pursuits 8.8. Providing child care during hospitalizationsProviding child care during hospitalizations 45. Cerebral Palsy What the child can do -What the child can do - Can the child:Can the child: Lift her head? hold it up? sit? roll over? Pull herself along the floor in any way possible? crawl? walk? How does the child use her hands?How does the child use her hands? Can she grasp things and hold on; let go; use both hands together (or only one at a time)? Can she use her fingers to pick up small stones or pieces of food? How much can the child do for herself?How much can the child do for herself? Can she feed herself; wash herself; dress herself? Is she 'toilet trained'? What can the child do in the home or in the fields to help the family? 46. Cerebral Palsy What the child can do -What the child can do - 47. Cerebral Palsy Nursing ManagementNursing Management First, with the help of parents & family observe the child carefullyFirst, with the help of parents & family observe the child carefully to see:to see: what the child can do.what the child can do. what he looks like when he moveswhat he looks like when he moves and when he is in different positions.and when he is in different positions. what he cannot do, and whatwhat he cannot do, and what prevents him from doing it.prevents him from doing it. 48. Cerebral Palsy Nursing ManagementNursing Management Promoting Physical & Psychological HealthPromoting Physical & Psychological Health 1.1. Encourage health maintenanceEncourage health maintenance 2.2. Providing for nutritional needsProviding for nutritional needs 3.3. Encouraging rest and relaxationEncouraging rest and relaxation 4.4. Preventing infection and injuryPreventing infection and injury 5.5. Promoting positive self-imagePromoting positive self-image 6.6. Encouraging self helpEncouraging self help 49. Cerebral Palsy Feeding ManagementFeeding Management 1.1. Three finger jaw controlThree finger jaw control 2.2. Correction of poor neckCorrection of poor neck control by physicalcontrol by physical therapy or adaptivetherapy or adaptive equipment lessensequipment lessens droolingdrooling 50. Cerebral Palsy Assisting Physical TherapyAssisting Physical Therapy Goals of physicalGoals of physical therapy:therapy: 1.1. To improve postureTo improve posture 2.2. To preventTo prevent contractures &contractures & skeletal deformitiesskeletal deformities 3.3. To maintain andTo maintain and improveimprove independent motorindependent motor performanceperformance 51. Cerebral Palsy Assisting Physical TherapyAssisting Physical Therapy Whatever the child is doing (lying, sitting, crawling, standing) try to encourage positions so that: her head is straight up and down. her body is straight (not bent, bowed, or twisted). both arms are straight and kept away from the sides. both hands are in use, in front of her eyes. she bears weight equally on both sides of her body - 52. Cerebral Palsy Assisting Physical TherapyAssisting Physical Therapy If her arm repeatedly bends up, encourage her to reach out and hold objects Or she may need a post to hold on to. Encourage her to reach out and hold objects It she bends backward a lot, she needs actions that bend her head, body, and shoulders forward, like these. 53. Cerebral Palsy Assisting Physical TherapyAssisting Physical Therapy 54. Story of MeenuStory of Meenu 55. Story of MeenuStory of Meenu 56. Story of MeenuStory of Meenu 57. Story of MeenuStory of Meenu 58. Story of MeenuStory of Meenu 59. Story of MeenuStory of Meenu 60. Story of MeenuStory of Meenu 61. Cerebral Palsy Management Summary We should encourage each family to observe the specific needs and possibilities of their disabled child, to understand the basic principles of the therapy needed, and then to look for ways to adapt the therapy to the childs and familys daily life. 62. Cerebral Palsy - Summary Group of heterogeneous clinical states Variable etiology Severity minor incapacitation to total handicap Mental retardation variable severe in spastic QP Management holistic approach - Family to be involved 63. Thank QThank Q - CSN Vittal