CEREBRAL PALSY

CEREBRAL PALSY
Chronic disability of central nervous system origin characterised by aberrant control of movement of posture, appearing early in life and not the result of progressive neurological disease.

Spastic:

Upper motor neurone lesion.

Hemiplegia:
Diplegia:

UMNL of one side of body.

UMNL of all four limbs but legs more than arms. May be symmetric or asymmetric.

Quadriplegia:

Equal involvement of arms and legs.

Rigidity:

tone throughout range of movement.

Dyskinesia: Involuntary movements and changes in muscle tone. Damage to basal ganglia and extraphyomides pathways.
Athetosis: Slow writhing movements of limbs. Extension and fanning of fingers and extension of wrist. Quick jerky movements of trunk and prox, limb muscles.

Chorea:

Paraplegia:

Legs involved only.

Double Hemiplegia:

Bilateral UMNL. Arms and legs. Also pseudobulbar palsy.

One Limb.

Monoplegia:

Cerebral Palsy Rates

Multiple births 7.5 / 1000 live births

Singletons
1500gr or less

2.1 / 1000 live births

80 / 1000

Types of Cerebral Palsy

Spastic Hemiplegia Diplegia Quadriplegia

Ataxic Dyskinetic Dystonic Chored-Athetoid Hypokinesia Hypertonia Hyperkinesia Hypotonia

Dysequilibrium Syndrome
1.

Difficulty in maintaining an upright position and in experiencing the position of the body in space.
Autosomal recessive.

2.

CEREBRAL PALSY
1.
2. 3. 4. 5.

6.
7.

Hemiplegia. Double Hemiplegia. Diplegia (hypotonic, dystonic, spasticity, ataxic). Ataxia. Dysequilibrium Syndrome. Dyskinetic. Mixed.

Of 229 children cerebral palsy at 1 year of age, more than were free of motor handicap at 7 years.

COLLAB, Perinatal Project

Early Signs of Cerebral Palsy

1.

Birth History
a) b) c) d) e) Prematurity. Seizures. Low apgars. Intracranial haemorrhage. Periventricular leucomalacia.

2. 3.

Delayed Milestones Abnormal Motor Performance

a) Handedness. b) Reptilian crawl. c) Toe waking.

Early Signs of Cerebral Palsy

4.
5. 6.

Altered Tone.
Persistence of primitive reflexes. Abnormal posturing.

Prenatal Associations with Cerebral Palsy

Placental insufficiency. Brain malformation. Congenital infection. Chromosomal defects. Exposure to toxins. Abnormality of neuronal migration.

PLACENTA
1.

Correlation of placenta infarction or thrombosis with ischaemic lesions in the brains of babies who have suffered intrauterine or early neonatal deaths.
11 / 15 placental slices from 15 patients with Cerebral Palsy contained thrombosis.

2.

THROMBOPHILIA & CEREBRAL PALSY

a) b)

c)

d)

Thrombosis in placental circulation. Coagulation abnormalities in mother and foetus Factor V Leiden Mutation which is responsible for activated protein C resist (APCR). Foetal and neonatal stroke have been reported in presence of maternal anticardiolipin antibodies. 20 / 31 children with cerebral palsy had one or more disorders of coagulation in neonatal blood spot analysis.

ANTENATAL
Maternal infection & cerebral palsy
a)

Maternal fever> 38oc + Chorioamnionitis associated with risk of cerebral palsy.

b)

Inflammatory markers in children with cerebral palsy.

Cerebral Palsy
1.
2. 3. 4. 5. 6.

Fall in incidence of Cerebral Palsy in low birth weight babies. in incidence in babies 2.5-4kg (2/3 of cases). Excess boys (C58%). in incidence of dyskinetic cerebral palsy. in lowest socio-economic groups. Maternal age and parity.
U shaped curve < 20 years - > 34 years. 4 children or >.

7.

Breach delivery.

Cerebral Palsy Associated Disabilities

Mental retardation 1/3 N. 1/2 I.Q. < 55. Epilepsy 20-50% > generalised. Speech disorders 50% delay/dysarthria. Vision and hearing 25%. Behaviour abnormalities. Learning difficulties.

Common Management Problems in Cerebral Palsy

1.

Feeding Problems:
Failure to suck. Tongue trusting, gagging and choking. Vomiting and regurgitation.

2. 3. 4.

5.
6.

Dribbling. Constipation. Crying, screaming and sleep disturbances. Chilblains and cold injury. Growth.

Treatment of Cerebral Palsy

1.
2.

Parent guidance. Physiotherapy

Bobath method. Peto. Doman-Delacato.

3. 4. 5. 6.

Orthopaedic. Speech and Occupational Therapy. Medical. Psychiatric.

Management of Spasticity in Cerebral Palsy

1.

Oral Medicines:

Baclofen Diazepam Tizanidine Dantrolene

2. 3. 4.

Intrathecal Baclofen. Botulinum Toxin. Selective Posterior Rhizotomy.

Botulinum Toxin
1.
2.

3.
4.

Produced by bacterium clostridium Botulinum. Blocks release of Acetylcholine from cholinergic nerve terminals. Duration of effects, 3-4 months. Adverse effects: muscle weakness.
Allergic reaction rare. Autonomic Dysfunction. Occasional flu like symptoms. Antibody development.

Preventio
1.
2. 3. 4. 5.

6.

Antenatal and Neonatal care. Early detection and advice. Drugs. Immunization and screening. Genetic counselling. Health education.