M Ibrahim Definition Cerebral palsy CP is a neurodevelopmental impairment caused by a nonprogressive lesion in a single or multiple locations in an immature brain The lesion leads to persistent disorders of movements and posture that appear early in the infants life before 5 years It ID: 1038330
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1. Cerebral PalsyDR. Marwa M. Ibrahim
2. Definition:Cerebral palsy (CP) is a neurodevelopmental impairment caused by a non-progressive lesion in a single or multiple locations in an immature brain. The lesion leads to persistent disorders of movements and posture that appear early in the infant's life (before 5 years). It is not a specific disease, but a group of neurological disorders of varied causes.
3. The term cerebral refers to the brain's two halves, or hemispheres, and palsy describes any disorder that impairs control of body movement. Thus, these disorders are not caused by problems in the muscles or nerves. Instead, faulty development or damage to motor areas in the brain disrupts the brain's ability to adequately control movement and posture.
4. Etiology:There is no specific cause for CP; however, there are some possible causes and risk factors for this disorder.
5. A- Pregnancy Risk Factors (Prenatal Causes):Mal-development of the brain.Maternal viral infection such as rubella.Maternal diabetes or hyperthyroidism.Maternal high blood pressure.Poor maternal nutrition.Maternal seizures, mental retardation or Rh incompatibility.Mother exposure to radiation, trauma or drug use.Incompetent cervix (premature dilation) leading to premature delivery.Maternal bleeding from placenta previa (a condition in which the placenta covers a portion of the cervix leads to bleeding as the cervix dilates) or abruption placenta (premature separation of the placenta from the uterine wall).Vascular insufficiency.Genetic abnormalities.
6. B- Delivery Risk Factors (Perinatal Causes):Brain trauma during birth such as during forceps delivery.Abnormal presentation such as breech, face, or transverse lie, which makes for a difficult delivery.Premature delivery (less than 38 weeks gestation).Low birth weight.Severely depressed (slow) fetal heart rate during labor, indicating fetal distress.
7. C- Neonatal Risk Factors (Postnatal Causes):Infection such as meningitis and encephalitis.Asphyxia – insufficient oxygen to the brain due to breathing problems or poor blood flow in the brain.Epilepsy (Seizures caused by abnormal electrical activity of the brain).Cerebrovascular accident.Jaundice (excess amounts of bilirubin circulating in the blood stream dissolve in the subcutaneous fat (the layer of fat just beneath the skin), causing a yellowish appearance of the skin and the whites of the eyes).Malnutrition.
8. Pathology: The pathology differs according to the causes of CP. The main pathological changes are: Selective neural necrosis (cerebral atrophy) and hypoxic-ischemic cerebral damage. Intracranial hemorrhage is common in premature babies (less than 38 gestation weeks) as well as after birth trauma in full term babies. Mal-development of the CNS plays a major role in the pathogenesis of CP for such as the abnormal development of corticospinal pathway in the early postnatal period.
9. Motor Disorders in CP
10. 1-Disorders of postural tone: Defective postural fixation (seen in the inability to maintain the head or trunk erect) is the most important and obvious defect in all types of CP except the mildest cases of hemiplegia. 2-Failure of suppression of primitive reflexes: Brainstem reflexes act upon the distribution of postural tone. These reflexes are the tonic labyrinthine and tonic neck reflexes, positive supporting reactions. Grasp and Moro reflexes are also primitive reflexes that may be present.
11. 3- Tone disorders: Tone may be diminished (hypotonia), increased (hypertonia) or fluctuated.4-Involuntary movements: These form the principle feature of athetosis with early hypotonia and impairment of postural fixation of the trunk.
12. 5-Failure of development of cortical reactions (postural reactions): Many of the phenomena of CP are the result of disinhibition of primitive reflexes or failure of higher centers to gain control of basic movement patterns with failure of the development of postural reactions (righting, protective and equilibrium reactions).
13. 6-Paralysis and disorders of the pattern of voluntary movements: Weakness is common in all forms of CP, even those characterized by involuntary movements. This weakness or paresis is demonstrated in the form of:Slow movement initiation.Impossible discrete movements (i.e.; abnormal synergistic movements). Mirror or associated movements.
14. Types of Cerebral Palsy: Cerebral palsy may be classified as:Spastic CP such as hemiplegia and diplegia. This type accounts for about 70 to 80% of the total CP population.Dyskinetic CP such as athetiod, dystonia and chorea. This type accounts for about 10 to 20% of the total CP population.Rare types such as ataxia and hypotonia (flaccid). This type accounts for about 5 to 10% of the total CP population.Mixed CP The most common mixed form includes spasticity and athetoid movements but other combinations are also possible.
15. [A] Spastic CPLow tone in the trunk musculatures.Hypertonia in the extremity musculatures. Its degree varies according to:Child's general condition.Child's emotional state.Temperature and health.Degree of the child's support.Positioning.
16. Severe co-contraction of the involved parts, especially around the proximal joints.Maintenance of the extremities in the mid-range.Stereotyped (patterned) and slow movements.Fearful of movements.Persistence of associated reactions.Incomplete postural reactions.Persistence of some primitive reflexes such as TNR and tonic labyrinthine reflex.
17. Weakness of the antispastic muscles due to continuous reciprocal inhibition such as weak ankle dorsiflexors by spastic triceps surae.Skeletal deformities secondary to muscle tightness and joint stiffness such as flexion knee deformity, equines ankle deformity and other skeletal deformities. These deformities are mainly due to:Imbalance of muscle activity.Lack of active functional movements.Prolonged positioning with muscles held at one length.
18. TerminologyAffected Body Parts1- Quadriplegia.Four limbs.2- Hemiplegia.One side of the body.3-Double Hemiplegia.Upper limbs are more affected than lower limbs.4- Diplegia.Quadriplegia with mild involvement of the upper limbs.5- Triplegia.Three extremities.6- Paraplegia. Both lower limbs.7-Monoplegia.One limb only.Topographical Classification for Spastic CP
19. Spastic hemiplegia:Weakness or paresis with tremors or uncontrollable shaking of the limbs on one side of the body.The arm is generally affected more than the leg.Learning disabilities, vision problems, seizures, and dysfunction of the muscles of the mouth and tongue are classic symptoms.Many kids with hemiplegia are able to walk and run, although they may look a little awkward or have a limp.
20. Double hemiplegia:It is used to describe CP when it affects all four limbs but with asymmetry between the right and left sides. It has also been used to describe instances in which there is more involvement in the arm than in the leg.
21. Spastic diplegia:The legs are more affected than the arms.The legs often turn in and cross at the knees. This causes a scissors gait (toe-walking), in which the hips are flexed, the knees nearly touch, the feet are flexed, and the ankles turn out from the leg.Learning disabilities and seizures are less common than in spastic hemiplegia.
22. Because their upper bodies are usually not affected they have good ability to hold themselves upright and good use of their arms and hands. Intelligence is often normal or borderline.In addition there is difficulty with balance and coordination.Delayed muscle growth and spasticity cause their leg muscles to be short, and as a result the range of motion can decrease as a child grows and the joints become stiff.
23. Spastic quadriplegia:Kids with quadriplegia have trouble moving all the parts of their bodies, their face and trunk as well as their arms and legs, and may need a wheelchair to get around. There is usually associated with mental defect. Because of the problems controlling the muscles in their face and upper body, they also have trouble talking and eating. Convulsions are common.
24. [B] Athetoid CPInvoluntary movements (uncontrolled slow, writhing movements affecting the hands, feet, arms or legs and in some cases the muscles of the face and tongue causing grimacing and drooling). These uncontrolled movements often increase during emotional stress and disappear during sleep.Fluctuating level of muscle tone. Started with early hypotonia.Muscle spasm.Inability to hold segment at various points within the ROM.
25. Impairment of postural fixation of the trunk.Asymmetry in both posture and movements.Head, trunk and the upper extremities are usually more involved than the lower extremities.Over activity of the tonic neck and tonic labyrinthine reflexes.Movements of the head affect trunk and limbs.Incomplete righting, equilibrium and protective reactions.Dysarthria.
26. [C] Ataxic CPHypotonia, however sometimes there is hypertonia.Poor co-contraction and sustained holding posture.Incoordination, Dysmetria, intention tremorsPoorly coordinated postural reactions.Difficult balance and lurching staggering gait (walk unsteadily with wide-based gait).
27. [D] Hypotonic CPExtensive hypotonia for all body.It is usually transient and being reclassified as spasticity, athetosis, ataxia or mixed type.Loss of head and trunk control.Presence of respiratory problems.Dysphasia and drooling.Developmental delay.
28. Associated Disorders to CP Children
29. 1-Visual Problems: Strabismus that is common in diplegic and quadriplegic CP.Nystagmus that is common in ataxic CP.2-Mental Retardation: It is common in most of the CP children with higher incident in quadriplegic children.
30. 3-Communication Disorders: They may be secondary to:Poor oral motor control of speech.Central language dysfunction.Hearing impairment.Cognitive deficits.4-Drooling:It interferes with eating, speech, self-image and social activities.It may cause skin soreness and infection.
31. 5-Dysphagia:It leads to inadequate fluid and caloric intake (protein-calorie malnutrition). The development of eating and drinking behaviors may be impaired in the CP children by the presence of:Poor head and trunk control.Poor grasp.Persistence of infantile primitive reflexes such as extensor thrust and ATNR.Poor coordination.Hypersensitivity with lack of awareness of the presence of food in the mouth.Drooling.Abnormal respiration.Abnormal or limited movements of the tongue, jaw, lips and soft palate.
32. 6-Seizures or Epilepsy:About 50% of the CP children have epilepsy. In seizure, the pattern of the electrical activity in the brain is disrupted by uncontrolled bursts of electricity. There are two types of seizure:Tonic-Clonic Seizure: The disruption of the brain electrical activity may spread throughout the brain. Clinically, the patient cries out then there are loss of consciousness, twitching of legs and arms, convulsive body movements and loss of bladder control.
33. Partial Seizure: The disruption is confined to just one part of the brain. It may be simple or complex, which are demonstrated clinically as follows:Simple partial seizure: muscle twitches, chewing movements, numbness or tingling.Complex partial seizure: hallucination, staggering, automatic and purposeless movements with impaired consciousness or confusion.
34. 7-Growth Problems: Failure to "thrive" syndrome is common on moderate and severe CP especially quadriplegic type. In this syndrome, children seem to lag behind in growth and development despite having enough food. The causes for this syndrome may be:Damage to the brain centers controlling growth and development.Poor nutrition.Clinically there are:Too little weight in babies.Abnormal shortness in young children.Shortness and lack of sexual development in teenagers.
35. 8-Abnormal Sensation and Perception:Impaired touch and pain senses.Astreognosis.
36. Thank You