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CEREBRAL PALSY
o Untreated jaundice, may lead to Medical Conditions
kernicterus (Infiltration of bilirubin into o Intellectual disability
A group of permanent disorders of the the BG and other parts of the brain and o Seizures
development of movement and posture SC) o Thyroid disease
causing activity limitations that are attributed o Severe neonatal infection Paternal and sibling factors
to non-progressive disturbances of sensation, o Placenta abruptio – sudden detachment o Advanced paternal age (often in
perception, cognition, communication and of the placenta from a normal uterine athetoid dystonic CP)
behavior as well as seizures and secondary site of implantation, associated c o Motor deficit in sibling
musculoskeletal problems pregnancy-induced HTN During Pregnancy
Etiology o Placenta pravia – placenta implanted in Preeclampsia
Perinatal Asphyxia – 6-8%, underlying cause is the lower uterine segment, risk factor Multiple pregnancies associated c:
unpreventable for placenta abruptio o Preterm delivery
Schizencephaly – segmental defect that causes Postneonatal o Poor intrauterine growth
a cleft in the brain Metabolic encephalopathy o Birth defects
Lissencephaly – decreased cerebral gyri; o Storage disorders
o Intrapartum complications
results in a smooth brain o Intermedullary metabolism disorders
During Labor
Microcephaly o Metabolic disorders
Perinatal Asphyxia
Megalocephaly o Miscellaneous disorders o Prolapsed cord
Cortical agenesis o Toxicity e.g. alcohol o Massive intrapartum hemorrhage
Apoptosis ~50% of neurons during Infections o Prolonged/traumatic delivery
midgestation o Meningitis o Large baby c shoulder dystocia
Prenatal – accounts for ~80% o Septicemia o Maternal shock
Vascular events e.g. MCA infarct (m/c) o Malaria (esp in developing countries)
Causal Factors
Maternal infections during 1st and 2nd Injuries o Prolonged second-stage labor
trimesters o CVA o Emergency Cesarean section
o Toxoplasmosis o Following surgery for congenital o Premature separation of placenta
o Others (HIV/AIDS) malformations o Abnormal fetal position
o Rubella o Near-drowning
Preterm
o Cytomegalovirus o Trauma
o Meconium-stained fluid
o Herpes o MVA
o Tight nuchal cord
Less common: metabolic disorders, maternal o Child abuse
At Birth and Newborn Period
ingestion of toxins, genetic syndromes Risk Factors
↓ BW, age at birth
Perinatal Before Pregnancy
Poor intrauterine growth
During Labor and Delivery Maternal
Low placental weight and Apgar scores (0-3
o Obstructed labor o Delayed onset of menstruation
have 81x ↑ risk of CP)
o Antepartum hemorrhage o Irregular menstruation
Neonatal seizures
o Cord prolapse o Long intermenstrual intervals
Sepsis
Other neonatal causes o Unusually short/long intervals between
Respiratory disease
o Hypoxic-ischemic encephalopathy pregnancies
Preterm Infants
o Neonatal stroke (usually MCA) o Low social class
Patent ductus arteriosus
o Severe hypoglycemia – common in o Parity of three or more in preterm
Hypotension
neonates c poor suck infants
Blood transfusion
o Relationship c previous fetal deaths
Prolonged ventilation
Pneumothorax Classification o Affected side: shoulder protraction,
Sepsis Type of movement disorder elbow flexion, wrist flexion and ulnar
Hyponatremia Spastic deviation, pelvic retraction, hip IR and
Total parenteral nutrition Hypotonic flexion, knee flexion, foot plantarflexion
Seizures Dyskinetic Quadriplegia
Parenchymal damage c appreciable ventricular Ataxic o Periventricular white matter lesions
dilation Anatomical location of limbs affected o Extensive lesions to BG and occipital
Diagnosis Hemiplegia area lead to visual impairments and
Earlier than 2 y/o, infants c abnormal muscle Diplegia seizures
tone, atypical posture, persistent primitive Quadriplegia Modified Ashworth Scale
reflexes Severity of Motor Function Sco Description
4-5 y/o for mild cases Gross Motor Function Classification System re
Key Elements: (GMFCS) – Palisano and colleagues, 1997 00 Hypotonia
o Motor skills Lev 0 Normal tone, no increase
o Neuroimaging el 1 Slight ↑ manifested by slight catch and
I Walks without restrictions, limitation in more release/minimal ↑ resistance to ROM
o Non-progressive symptoms
advanced gross motor skills 1+ Slight ↑ manifested by slight catch and
Imaging: minimal ↑ resistance to ROM for more than
o Cranial US – high-risk infants II Walks s AD; limitations in walking outdoors
and in community half of range
o MRI – 70-90% show abnormalities 2 More marked ↑ through most of ROM. But
III Walks c AD; limitations in walking outdoors
Cerebral Hemorrhages and in community affected jt easily moved
o Intraventricular Hemorrhage (IVH) – IV Self-mobility c limitations; transported/use 3 Considerable ↑, passive movement difficult
bleeding into the ventricles power mobility outdoors and in community but possible
o Germinal Matrix Hemorrhage (GMH) – V Self-mobility severely limited even c 4 Affected jt is stiff and cannot be moved
bleeding into tissue around the assistive technology Tx:
ventricles Bimanual Fine Motor Function Classification (BFMFCS) o Botulinum toxin
o Periventricular Intraventricular Fine motor and gross motor involvement in o Baclofen
Hemorrhage (PIVH) – bleeding in both children c CP are often the same o Selective dorsal rhizotomy
areas above Spastic (Pyramidal) – 75% of children c CP Dyskinetic (Extrapyramidal) – Generally uncontrolled
o Periventricular cysts (PVC) may form as M/c neurologic abnormality in pts c CP and involuntary movement
hemorrhages resolve Hypertonia in which resistance to passive Deep gray matter lesions, less periventricular
o Periventricular white matter is most movement increases with increasing velocity white matter lesions
sensitive to insult and injury between of movement Athetosis – slow and writhing involuntary
24-34 wks of gestation Diplegia – m/c form of spastic CP movements, large motions of the more
o Periventricular leukomalacia (PVL) is the o White matter infarct in periventricular proximal jts
major cause of CP in preterm infants areas caused by hypoxia o Commonly a secondary movement
o Localized damage to corticospinal tracts o ↑ lumbar lordosis, APT, (B) hip IR, (B) disorder in conjunction c spasticity
often leads to spastic diplegia, when knee flexion, intoeing, equinovalgus Chorea – jerky, abrupt movements of the limb
lesions extend laterally, quadriplegia Hemiplegia or facial muscles
often results o Periventricular white matter Choreoathetosis – jerky movements, commonly
General movements (GM) are the best abnormalities – m/c dx finding of the digits
expression of functional motor development o Cervical-subcortical lesions, brain Rigidity – resistance to both passive and active
Intellectual disability is the strongest malformations, non-progressive movement, not velocity dependent
predictor of survival of a child c CP, severity postnatal injuries Tremor – rhythmic movement of small
of physical impairments is second magnitude, usually of smaller jts
Dystonia – slow motion c torsional element
Ballismus – rarest; random motions in large,
fast patterns usually in a single limb
Ataxic – disorder of balance and control in timing of
coordinated movements
Deficits in the cerebellum
Hypotonic – often transient and might not represent a
specific type of CP