DR.P.SELVAKUMAR M.D.

ASSISTANT PROFESSOR OF PEDIATRICS

THANJAVUR MEDICAL COLLEGE
CEREBRAL PALSY

It’s a non progressive disorder of posture and movement

caused by lesion in developing fetal or infant brain often
associated with intellectual disability, epilepsy, and
special sensory organ defect like vision, speech and
hearing.
 ETIOLOGY
PRENATAL
fetus (most commonly genetic disorders),

mother (seizure disorders, mental retardation, and previous pregnancy loss),

pregnancy itself (Rh incompatibility, polyhydramnios, placental rupture, and

drug or alcohol exposure).

External factors, such as TORCH (toxoplasmosis, other agents,

rubella, cytomegalovirus, herpes simplex).

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ETIOLOGY

PERINATAL
asphyxia or trauma that occurs during labor.
Oxytocin augmentation,
umbilical cord prolapse
breech presentation.
Low-birth-weight infants (<1500 g) incidence of 60 per 1000
births compared with two per 1000 births in normal-weight infants.

Pregnancies involving multiple births

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ETIOLOGY
POSTNATAL

Hypoxic-ischemic encephalopathy,
which is characterized by hypotonia, decreased
movement, and seizures

Infections such as encephalitis and meningitis

Traumatic brain injury

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Contrary to popular belief, fewer than 10% of injuries that result in
cerebral palsy occur during the birth process
CLASSIFICATION
 PHYSIOLOGICAL
1.SPASTIC
2.DYSKINETIC
DYSTONIC
CHOREOATHETOID
3.ATAXIC
4.MIXED
CLASSIFICATION
ANATOMIC (TOPOGRAPHIC)
CLASSIFICATION
FUNCTIONAL (GMFCS)
PRINCIPLES OF DEVELOPMENT
 Development is a continuous process from conception
to maturity

 Sequence of development is the same but the rate

varies

 It is related to the maturation of the nervous system

PRINCIPLES OF DEVELOPMENT
 Development is cephalocaudal In direction

 Generalised mass activity is replaced by specific

individual responses

 Certain primitive reflex have to be lost before the

corresponding voluntary movement is acquired
PRIMITIVE REFLEXES
REFLEX AGE - ELICITABLE AGE - DISAPPEARANCE
MORO BIRTH 3 MONTHS
STEPPING BIRTH 6 WEEKS
PLACING BIRTH 6 WEEKS
SUCKING & ROOTING BIRTH 4 MONTHS (AWAKE)
7 MONTHS(ASLEEP)
PALMAR GRASP BIRTH 6 MONTHS
PLANTAR GRASP BIRTH 10 MONTHS
TONIC NECK 2 MONTHS 6 MONTHS
NECK RIGHTING 4-6 MONTHS 24 MONTHS
LANDAU 3 MONTHS 21 MONTHS
PARACHUTE 9 MONTHS PERSIST
SPASTIC HEMIPLEGIA
 One third of cerebral palsy
 Seen in Term babies
 R > L 2:1
 Arm > Leg Distal>proximal
 In early infancy – Reduced Hand Regard
Persistent Fisting
Cortical Thumb
Asymmetrical Moro
Pincer Grasp Absent
Handedness Early
SPASTIC HEMIPLEGIA
 Late features
Dyspraxia
Hemiplegic Gait
Loss Of Cortical Sensation 1/4th
Seizures 1/3rd
SPASTIC QUADRIPLEGIA
 All Limbs Are Affected (Arms > Legs)
 10 % Learn To Walk
 Bowel And Bladder Control Is Absent
 Speech And Feeding Difficulty
 Intelligence Markedly Decreased
 Epilepsy Common
 Positional Deformity - Hip Dislocation, scoliosis Due
To Gross Immobility
SPASTIC DIPLEGIA
 Common In Preterm
 Entire Body Is Affected
 Lower Limb , Trunk > Upper Limb
 Increased Tone And Scissoring Seen In Infancy
 Ambulatory Problems Later
 Mentation Is Usually Preserved
 Seizures Uncommon
DYSKINETIC / EXTRAPYRAMIDAL
 Impaired volitional activity manifested as
uncontrolled and purposeless movements that
disappear during sleep
Dystonic
Sustained muscle contraction cause twisting
and repetitive movement or abnormal posture
Eg.. Truncal twisting , facial grimacing , extreme rigidity
DYSKINETIC / EXTRAPYRAMIDAL
 CHOREO ATHETOID
Seen In Babies With Neonatal Hyperbilirubinemia
Choreiform Movements Increased During Voluntary Activity
Associated Problems – High Tone Hearing Loss
Upward Gaze Palsy
Enamel Dysplasia
Seizures Uncommon
Speech Defects Common
Intelligence Within Normal Range
ATAXIC
 Uncommon
 Defective Postural Function
 90% Learn To Walk
 Movement Incoordination For All Motor Task
 Tremor On Use Of Hands – Common
 Ass. Problems
Spasticity,athetosis,dysarthria,nystagmus
CLINICOPATHOLOGICAL CORRELATION OF
CEREBRAL PALSY
COMORBIDITIES ASSOCIATED WITH CEREBRAL
PALSY
 CNS  FEEDING PROBLEMS
 Intellectual disability 2/3rd  Dysphagia
 Epilepsy – ½  Sialorrhea
 Learning disability  GI PROBLEMS
 Behavioural problems  Gerd
 Emotional problems  Constipation
 PSYCHIATRIC PROBLEMS  URINARY PROBLEMS
 ADHD  Incontinence
 Depression  Voiding Dysfunction
 Anxiety  SPINAL PROBLEMS
 Low self esteem  Kyphosis
 EYES  Scoliosis
 Strabismus  RESPIRATORY PROBLEMS
 Nystagmus  Upper Airway Obstruction
 Refractory Errors  Chronic Aspiration
 Amblyopia  TEETH
 Malocclusion
 Dental Caries
LEVINE (POSTER) CRITERIA FOR THE
DIAGNOSIS OF CEREBRAL PALSY
1. Posturing/abnormal movement
2. Oropharyngeal problem
3. Strabismus
4. Tone ( increased / decreased)
5. Evolutional maldevelopment (primitive reflexes
persist or protective equilibrium reflex fail to develop)
6. Reflexes (DTR increased )
4/6 = CEREBRAL PALSY
INVESTIGATIONS
 LAB TESTS NOT NECESSARY TO CONFIRM
DIAGNOSIS.

 USG,CT,MRI – FOR ETIOLOGY AND PROGNOSIS

AND RULING OUT ALTERNATIVE DIAGNOSIS.

 EEG.

 METABOLIC SCREENING, KARYOTYPING,GENETIC

PROBE STUDIES IF REQUIRED
COUNSELLING OF THE FAMILY
 Not a mental illness
 Not always associated with intellectual disability
 Not contagious
 Not inherited
 Not curable
TO MINIMISE DISABILITY AND IMPROVE Q.O.L
MANAGEMENT
 MULTIDISICIPLINARY APPROACH

 GOAL – To decrease complication

To enhance acquisition of new skills
MANAGEMENT
 PHYSIOTHERAPY
1. Specific Training Of Actions Such As Sitting ,
Standing , Walking And Stepping
2. Exercises Designed To Increase Muscle Strength
3. Prevention Of Contracture
4. Control Of Movement
MANAGEMENT
 OCCUPATIONAL THERAPY
Help The Child Develop Fine motor Skills – Dressing,
Feeding, Writing And Other Living Task

 SPEECH AND LANGUAGE THERAPY

Helps To Develop Communication Skills
MANAGEMENT
 VISUAL
Check for refractory errors and eye exercises
 EPILEPSY
Antiepileptic Drugs ( Avoid Phenobarbitone )
Haloperidol For Decreasing Movements In
Choreoathetoid Cerebral Palsy
Carbamazepine , Trihexiphenidine For Dystonia
MANAGEMENT
PLASTER CASTING AND ORTHOSES
• LOWER LIMB ORTHOSES
TONE REDUCING PLASTER CAST
POLYPROPYLENE ANKLE FOOT
ORTHOSES
TO REDUCE IMPAIRMENT OF ABNORMAL
JOINT MOVEMENT AND PREVENT IMPAIRMENT
OF MUSCLE CONTRACTURE
TO FACILITATE FUNCTION
TREATMENT OF SPASTICITY IN
CEREBRAL PALSY
 DIAZEPAM

 BACLOFEN - ORAL AND INTRATHECAL

 BOTULINUM TOXIN A INJECTION

FOCAL DOSE DEPENDENT REVERSIBLE CHEMODENERVATION
OF MUSCLE
EXPENSIVE AND TEMPORARY
 SELECTIVE DORSAL RHIZOTOMY
LAMINOPLASTY FROM L1 TO S1 AND SECTION OF 20 -40% DORSAL
NERVE ROOTS USEFUL IN SUBSET OF PATIENTS WITH CP
WHAT IS NEWER MANAGEMENT IN
CP
 SEMLARASS – Dr. Deepak Sharan India
Single Event
Multi Level
Lever Arm Restoration – correction of hip
subluxation,femoral anteversion,severe torsion,hind foot
valgus.
Antispasticity – myofacial surgery
Surgery – 4-8 years
 PREVENTION OF CEREBRAL PALSY
RUBELLA VACCINE
PERICONCEPTIONAL FOLATE
ANTI D (for RH incompatiblity)]
EXCHANGE TRANSFUSION FOR SEVERE JAUNDICE
ANTENATAL USG – CPD – LSCS
EMERGENCY LSCS FOR FETAL DISTRESS
IODINISED SALT
MAG SULPHATE FOR PRETERM LABOUR
MECHANICAL VENTILATION FOR PRETERM
INDUCING HYPOTHERMIA FOLLOWING ACUTE
HYPOXIA