What is Cerebral

Palsy?
This is amovement disorderthat results from anonprogressive lesion ofmotor pathways.
The brain controls all that we do. Different parts of
the brain control the movement of every muscle of the
body. In cerebral palsy, there is damage to, or lack of
development in, one of these areas of the brain

In red, the primary motor cortex,

part of the Precentral Gyrus

Can new Symptoms develop?

Although it is a non progressive disorder, new
deficiencies can make themselves know as the child
grows and fails to develop certain milestones.

 Although often described as a movement/posture disorder, it is often

accompanied bylearning difficulties,and other signs of
developmental delay.
The specific symptoms will depend on where the lesion is.It can
affectany part of the brain e.g. cerebellar disorder, basal ganglia
disorder, cerebral etc etc. The distribution of other symptoms is:
Learning difficulties 60%
Epilepsy 40%
Squint 30%
Visual impairment (any kind) 20%
Hearing impairment 20%
Speech and language disorders
Behavioural disorders
Feeding problems
Joint disorders
Contractures
Subluxation
Scoliosis

The Gross Motor Function

Classification System
The Gross Motor Function Classification System
(GMFCS) is a method of describing the range of gross
motor function in children with cerebral palsy.
It describes five 'levels' of motor function, with a
particular emphasis on abilities and limitations in the
areas of sitting, standing and walking.
Children with GMFCS levels I and II walk independently,
children with GMFCS level III require sticks, elbow
crutches or walking frames, and children with GMFCS
levels IV and V usually require a wheelchair.

Various types of Cerebral palsy

Spastic cerebral palsy
This is the most common type of cerebral palsy. Spasticity means stiffness or tightness of muscles. The muscles are stiff because the messages to the muscles are
relayed incorrectly from the damaged parts of the brain.
It can be:

Hemiplegic
Unilateral one arm and one leg involved
Arm usually affected more than leg
Face unaffected
Typical presentation 4-12 months:
Closed fist
Flexed arm, possibly extended leg
Sometimes called themagic carpet sign when you lift the baby, the legs will be extended at 90 to the trunk the
baby looks like it is sitting on a magic carpet.
Asymmetrical!

Abnormalgaitmay be present as the child grows typically a toe-heel (tip-toe)gaiton the affected side.
Typically not associated with a birth of post-natal injury, although a neonatalstrokemight sometimes be
the cause.

Various types of Cerebral palsy

Spastic
UMN lesions in corticospinal or pyramidal tract
Quadriplegic
All four limbs affected
Usually severe
Again, arms may be affected more than legs
Poor head control
Typically associated with seizures,microcephaly(small head) andmoderate to severe intellectual
impairment.
May be a history of hypoxic-ischaemic encephalopathy
Diplegic
All four limbs are usually affected, but thelegs are usually much worse than the arms.Hand function may
appear normal.
Abnormalgait/ walking

Various types of Cerebral palsy

Dyskinetic Cerebral Palsy
Dyskinesia fluctuating muscle tone. This gives rise toinvoluntary limb
movements.
Due to basal ganglia(or associated extrapyramidal tract) damage
in the past was often associated withhyperbilirubinaemiaas a result ofrhesus disease of
the newborn.

Usually affects all four limbs

May be especially apparent when stressed
Types of involuntary movement
Chorea irregular, sudden, solitary
Dystonia and athetosis simultaneous contraction then relaxation of opposing muscle groups.
Dystonia involvement of the trunk and proximal limbs, this is the term used for sustained muscle contractions
that frequently cause twisting or repetitive movements, or abnormal postures
Athetosis involvement of the distal limbs

In this type of cerebral palsy, intellectual ability may be unaffected.

Various types of Cerebral palsy

Ataxic Hypotonic Cerebral Palsy
Typically symmetrical signs
Hypotonia, poor balance and delayed motor development
Unco-ordinated movements
Tremor
May be a cerebellar lesion
Rarest Type
Mixed types
Many children do not have just one type, but a mixture of several
of these movement patterns.

Epidemiology
1 in 2000 live births
The most common cause of motor impairment in
childhood.

Causes
Most cases the cause is unidentifiable
Of those identified:
80%antenatal causes:
Gene deletions
Antenatal infection :TORCHESZ, CMV, Rubella
Vascular occlusion
Failure of cortical migration
At birth, screening for haematological disorders may
be necessary to exclude an antenatal / post-natal
stroke.

Causes
10%hypoxic ischaemic birth injury
Also bear in mind that antenatal disease can result in a
difficult birth! Thus it is not always clear what the exact
cause is. This can be differentiated with the use of CT
scanning to look for cysts these take 10 days to form
thus if it is truly birth injury, they wont be present on
CT within the first few days of life.

Causes
10%post-natal
Pre-term babies are particularly at risk as they are more likely
to suffer fromPeriventricular leucomalacia (PVL).This
occurs secondary to ischaemia, or haemorrhage.
Other post-natal causes include:

Head injury
Meningitis
Encephalitis
Encephalopathy
Hypoglycaemia
Hydrocephalus
Hyperbilirubinaemia

Presentation
May present at birth, and most commonly seen in infancy as motor
milestones are missed, but sometime diagnosis may be delayed. It is not
unknown for diagnosis to be as late as age 6-8 in some cases.
Signs:
Floppy Baby reduced muscle tone in the neonate. This is in contrast to
the increased muscle tone seen in older children with CP.
Increased muscle tone seen in older children, consistent with anUMN
lesion.Reflexes may be normal/brisk.Always check the tongue for
fasciculations!

Feeding difficulties due to poor co-ordination. There may be slow

feeding, vomiting and gagging.
Delayed motor milestones
Baby may be a late crawler / walker
May have an abnormalgaitwhen they do learn to walk

Presentation
Asymmetric hand movement in normal children
hand preference is not seen until at least 12 months of
age. Hand preference before this age isalways
pathological.
Persistence of primitive reflexes eg. Stepping
reflex, Moro etc
Patterns of symptoms there are four patterns of
symptoms that correspond to the type of motor
function affected:
Spastic lesion is in the pyramidal or corticospinal tract
70% of cases.
Dystonic lesion is in the basal ganglia 10%