Transcript Cerebral palsy (CP)

Cerebral palsy (CP)
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Neurology Chapter of IAP
CP
• W & W 1966-1975
• Non-specific term that include disorders
characterized by early onset and
impaired movement and posture.
• Non-progressive and may include
perceptual problems, language deficits,
and intellectual involvement.
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CP
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Neurology Chapter of IAP
Incidence
• Most common physical disability of
childhood.
• Incidence has increased since the 60’s,
maybe due to improved survival of
VLBW infants.
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Etiology
• Variety of perinatal, prenatal, and postnatal
factors contribute, either singly or
multifactorily to CP.
• Commonly thought to be due to birth
asphyxia; now known to be due to existing
prenatal brain abnormalities.
• Premature delivery is the single most
important determinant of CP.
• In 24% of cases, no cause is found.
Neurology Chapter of IAP
TABLE 40-1 Causes of CP
• Time (% of cases)
• Prenatal (44%)
– First trimester
– Second trimester
• Causes
• Teratogens,
chromosomal
abnormalities, genetic
syndromes, brain
malformations
• Intrauterine infections,
problems in
fetal/placental
functioning
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Neurology Chapter of IAP
Causes of CP
• Time (% of cases)
• Labor and delivery
(19%)
• Perinatal (8%)
• Childhood (5%)
• Causes
• Preeclampsia,
complications of labor
and delivery
• Sepsis/CNS infection,
asphyxia, prematurity
• Meningitis, traumatic
brain injury, toxins
• Not obvious (24%)
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Clinical Classification of CP
• Table 40-2, Page 1967.
• Spastic-hypertonicity with poor posture
control
• Dyskinetic/athetoid- abnormal involuntary
movement/slow wormlike writhing
• Ataxic- wide-based gait
• Mixed-type/dystonic- combination of spasticity
and athetosis
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Neurology Chapter of IAP
Clinical manifestations
• Delayed gross motor development
– A universal manifestation of CP
– The discrepancy between motor ability and
expected achievement tends to increase
as growth advances.
– Delayed development of ability to balance
slows milestones
– Delay in all motor accomplishments
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Neurology Chapter of IAP
Clinical Manifestations
• Abnormal motor performance
– Preferential unilateral hand use may be apparent
at 6 months.
– Hemiplegia, abnormal crawling or asymmetrical
crawl; spasticity may cause child to walk and stand
on toes
– dyskinetic CP or uncoordinated or involuntary
movements (writhing tongue, fingers, and toes;
facial grimacing), poor sucking and feeding,
persistent tongue thrust; head staggering, tremor
on reaching, truncal ataxia.
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Neurology Chapter of IAP
Neurology Chapter of IAP
Alterations in muscle tone
• Increased or decreased resistance to passive
movement (abnormal muscle tone).
• Opisthotonic postures or exaggerated back
arching, feel stiff on dressing.
• Difficulty diapering due to spastic hip
adductor muscles and lower extremities
• When pulled to a sitting position, child may
extend the entire body and be rigid at hip and
knee. This is an early sign of spasticity.
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Neurology Chapter of IAP
Abnormal postures
• Children with spastic CP have abnormal posture at
rest or when position is changed
• Infantile lying prone may have hip higher than trunk
with legs and arms drawn in.
• Persistent infantile resting and sleeping position is a
sign of spasticity.
• Hemiparetic child may rest with affected arm
adducted and held against torso, with the elbow
pronated and slightly flexed and the hand closed.
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Neurology Chapter of IAP
Reflex Abnormalities
• Persistence of primitive infantile reflexes
(one of the earliest signs of CP)
– Tonic neck reflex
– Hyperactivity or moro, plantar, palmar
grasp
Hyperreflexia, ankle clonus, stretch reflexes
can be elicited from any muscle group.
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Associated disabilities and
problems
• Intellectual impairment
– 70% w/in normal limits; wide range
– Tests should be carried out over a period of time.
– Children with athetosis and ataxia more intelligent.
Speech difficulties (not a sign or MR)- child has
motor and sensory defects
ADHD- (may occur)-poor attention span, marked
distractibility, hyperactive behavior
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Neurology Chapter of IAP
ASSOCIATED DISABILITIES
Seizures- generalized tonic-clonic;more in postnatally
acquired hemiplegia
Drooling- may occur and lead to wet clothing/skin
irritation
Feeding- alterations in muscle tone lead to difficulties
chewing, swallowing, talking, etc.
Address nutritional concerns.
Coughing, choking may lead to aspiration.
Altered respiratory patterns may lead to inadequate
gas exchange.
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Motor Impairment
• Orthopedic complications
– Unilateral or bilateral hip dislocations, scoliosis, joint
contractures due to unbalanced muscle tone.
Decreased Mobility
– difficulties with toileting may lead to constipation
– Difficult chewing bulky foods may lead to constipation
– May need stool softeners or laxatives
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Associated Problems
• Dental carries
– Improper dental hygiene
– congenital enamel defects (hyperplasia of primary
teeth)
– high carbohydrate intake and retention
– Dietary balance with poor nutritional intake
– Inadequate fluoride
– Difficulty in mouth closure and drooling
– Spastic or clonic movements cause gagging or
biting on toothbrush
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Associated Problems
• Malocclusion in 90% of children
• Oral hypersensitivity causes resistance
to good hygiene
• Gingivitis is secondary to poor hygiene
• Dental health further complicated by
anti-seizure meds
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Associated problems
• Nystagmus and amblyopia common
– May need surgery or corrective lenses
– May be due to sensoneural involvement
– Infants lying flat too long may have otitis
media which may leads to conductive
hearing loss
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Diagnostic Studies
• Physical Assessment
• Observe LBW, preterm, and those with
low Apgar scores at 5 minutes.
• Observe infants who have seizures,
intracranial hemorrhage, metabolic
disturbances
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DX studies
• Since control of movement does not
occur until late infancy, dx may not be
confirmed until after 6 months of age.
• See Box 4-4, page 1968 for warning
signs
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WARNING SIGNS
• Physical Signs
• poor head control after 3 months
• stiff or rigid arms/legs, arching back, floppy
or limp posture
• Cannot sit up without support by 8 months
• Uses only one side of the body or only the
arms to crawl
Neurology Chapter of IAP
Warning Signs
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Behavioral Signs
Extreme irritability or crying
Failure to smile by 3 months
Feeding difficulties
– Persistent gagging or choking when fed
– After 6 months of age, tongue pushes soft
food out of the mouth.
Neurology Chapter of IAP
Therapeutic management
• Box 40-5, Wong 1970.
• PHYSICAL THERAPY
– Most commonly used treatments.
– Goal is good skeletal alignment for the spastic
child.
– For the child with athetosis, training in purposeful
acts, even in the face of involuntary motion
– Maximum development of proprioceptive sense for
the child with ataxia.
– Orthotic devices (braces, splints, casting).
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Neurology Chapter of IAP
OCCUPATIONAL THERAPY
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Training in ADL’s along developmental lines.
Sitting to walking; feeding to cooking.
Important to incorporate play into program
Adaptive equipment (utensils for functional
use, i.e., eating, writing), computers, etc.
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Neurology Chapter of IAP
Speech/Language therapy
• Early speech training by
speech/language pathologist !
– Before child develops poor habits
– Advice parents to follow directions of
therapist
– May need to force child to use tongue/lips
in eating
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Special Education
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Determined by child’s needs
Early intervention programs
Individualized Education Program (IEP)
Specialized learning programs and
support services in schools
• Socialization to promote self-concept
development
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Surgical Intervention
• Reserved for child who does not
respond to conservative therapy!
– Or whose spasticity causes progressive
deformities
Orthopedic surgery
– correct contractures or spastic deformities
– provide stability for uncontrolled joint
– provide balanced muscle power
Neurology Chapter of IAP
Surgical Therapy
• Tendon-lengthening procedures (heel-cord)
• Release of spastic wrist flexor muscles
• Correction of hip-adductor muscle spasticity
or contracture to improve locomotion
• Surgery is for improved function rather than
cosmetic reasons and is followed by PT.
Neurology Chapter of IAP
Medication Therapy
• Little usefulness
• Anti-anxiety agents may relieve excessive
motion and tension (child with athetosis)
– Skeletal muscle relaxants ( methocarbamol
(Tobaxin), dantrolene (Dantrium), Baclofen, may
be used short-term for older children and
adolescents.
– Diazepam (Valium) for older children and
adolescents, may relieve stiffness and ease motion
Neurology Chapter of IAP
Medications
• Local nerve blocks to motor points of a
muscle with a neurolytic agent (phenol
solution) may relieve spasticity.
• Botulism toxin (Botox) used to paralyze
certain muscles.
• Pain
• Secondary conditions (seizures, bowel and
bladder problems, lung complications).
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Service Coordination
• Case Management!
• Important for collaboration of all health
professionals, services, therapies!
• Child needs support!
• Family needs support!
Neurology Chapter of IAP