CEREBRAL

PALSY
BY: DR. RAHMA SHAHBAHAI

Introduction

In 1860s, known as
"Cerebral Paralysis or
Littles Disease

After an English surgeon

wrote the 1st medical
descriptions

William John Little (1810-1

Introduction

Cerebral- Latin Cerebrum;

Affected

part of brain

Palsy " -Gr. para- beyond,

lysis loosening

Lack

of muscle
control

Definition

motor function disorder

caused

by permanent, non-progressive brain

lesion
present

at birth or shortly thereafter. (Mosby, 2006)

Non-curable,

life-long condition
Damage doesnt worsen
May be congenital or acquired

A Heterogeneous Group
of Movement Disorders
An umbrella term
Not a single diagnosis

CP affects
Movements
Muscle Strength

Balance
Coordination
Posture

In CP

Muscles are unaffected

Brain is unable to send

the appropriate signals
necessary to instruct
muscles when to contract
and relax

CAUSES
OF 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

CAUSES
Development

Malformations

The brain fails to develop correctly.

Neurological
Can
Rh

damage

occur before, during or after delivery

incompatibility, illness, severe lack of oxygen

* Unknown in many instances

CHIEF CAUSE
CHIEF CAUSE
Severe deprivation of oxygen or
blood flow to the brain

Hypoxic-ischemic
encephalopathy
or intrapartum
asphyxia

RISK FACTORS
Prenatal
Before

factors

birth

Maternal

characteristics

Perinatal
at

the time of birth to 1mo

Postnatal
In

factors
factors

the first 5 mos of life

Prenatal factors

Hemorrhage/bleeding
Abruptio

placenta

Infections
Rubella,

cytomegalovirus,
toxoplasmosis,

Environmental factors

Maternal Characteristics

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
Mothers medical condition

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

Postnatal Causes
Trauma,

head injury
Infections
Lack of oxygen
Stroke in the young
Tumor, cyst

CP Cases

*Several causes are preventable or treatable

TYPES
OF CEREBRAL PALSY

Classification of CP
According to:
1. Neurologic deficits
2. Type of movement
involved
3. Area of affected
limbs

1. Accdg. to Neurologic Deficits

Based

on the

- extent of the damage

- area of brain damage

Each type involves the way a

person moves

3 MAIN TYPES
1.

PYRAMIDAL
- originates from the motor
areas of the cerebral cortex

2.

EXTAPYRAMIDAL
- basal ganglia and
cerebellum

3.

MIXED

2. Accdg. to Type of Movement

Photo from: Saunders, Elsvier.

4 MAIN TYPES
PYRAMIDAL
EXTAPYRAMIDAL

1. Spastic CP

2. Athetoid CP
3. Ataxic CP

MIXED
Athetoid CP

4. Spastic &

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

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)

Diplegia/ Paraplegia

Hemiplegia

Spastic

Quadriplegia

Quadriplegia

Athetoid/ Dyskinetic CP

involves abnormal involuntary movements

that disappear during sleep and increase with stress.

Athetoid-Wormlike movements

Dyskinesia -Dyskinetic movement of mouth

Slow, uncontrolled motion, twisting in character, in the face, extremities,

and torso.

drooling and dysarthria.

Dystonia - when held as a prolonged posture

20% of the CP cases,

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

MIXED CP

A common combination is

spastic and athetoid

Spastic muscle tone and involuntary movements.

25% of CP cases, fairly common

Signs and
Symptoms
OF CEREBRAL PALSY

d.

e.

c.
b.

f.
a.

h.

g.

Early Signs
Infancy (0-3 Months)

Stiff or floppy posture

Excessive lethargy or
irritability/ High pitched
cry
Poor head control
Weak suck/ tongue thrust/
tonic bite/ feeding difficulties

CHILD with CP

Behavioral Symptoms

Poor

ability to
concentrate,
unusual tenseness,
Irritability

ASSOCIATED
PROBLEMS
OF CEREBRAL PALSY

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

Diagnosis
OF CEREBRAL PALSY

1. SUBJECTIVE
-HISTORY

2. OBJECTIVE

- PHYSICAL EXAMINATION

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

DIAGNOSIS
Laboratory studies
clinical

diagnosis.

There are no definitive laboratory

studies

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

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

Others:

Electroencephalography: Important in the

diagnosis of seizure disorders

Electromyography and nerve conduction studies:

Helpful when a muscle or nerve disorder is
suspected

Treatment
OF CEREBRAL PALSY

No treatment to cure cerebral palsy.

Brain damage cannot be corrected.

Crucial

for children with

CP:
Early Identification;
Multidisciplinary
Care;
and

I. NONPHYSICAL THERAPY

The earlier we start,

the more improvement can be
made
-Health worker

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

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

Selective posterior Rhizotomy

In some cases nerves need to be severed to decrease
muscle tension of inappropriate contractions.

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

H. Other Treatment
Therapeutic electrical stimulation,
Acupuncture,
Hyperbaric therapy
Massage Therapy might help

II. PHYSICAL THERAPY

'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

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

C. Prone Development
D. Supine Development
Head control on supine and positions

Thank you for lessening.

References