Cerebral Palsy

Question 1

Define Cerebral Palsy (CP)

Answer 1

Persistent BUT not changing disorder of posture and movement, caused by damage to the developing nervous system, before or during birth or in the early months of infancy

Question 2

Risk factors for CP

Answer 2

• Multiply pregnancy (twins, triplets)
• Birth asphyxia / hypoxia (10%)
• Greater abnormalities during pregnancy than in labour
• Vascular accidents
• Foetal malformation syndromes
• During first year of life: Cerebral infection, head injury, epilepsy

Question 3

Epidemiology of CP (Incidence & Prevalence)

Answer 3

2-2.5 / 1000 live births in NZ

- Approx. 7000 people have some degree of CP (1/3 under age of 21 years)

Question 4

Pathophysiology of CP

Answer 4

Initial neurological LESION the child sustains remains unchanged (non-progressive)
- Effects of this lesion on other systems (e.g. musculo) can be debilitating (progressive)

Question 5

Lesion Location of CP

Answer 5

Can be identified by CT or clinical presentation

• Premotor - Motor Cortex = Spastic
• Cerebellum = Ataxic
• Basal Ganglia = Dyskinetic

Question 6

Progression of CP

Answer 6

Once primary causes identified, no progression.

- Secondary impairments evolve during time

Question 7

Clinical Presentation of CP

Answer 7

DEPENDENT ON AREA AND EXTENT OF CNS AFFECTED

• Spastic (70-80%)
• Diplegia
• Hemiplegia
• Quadriplegia
• Athetoid (dyskinesia) CP - Basal Ganglia
• Ataxic CP - cerebellar
• Mixed CP

Question 8

Spastic CP

Answer 8

Primary and supplementary motor and sensory cortex

• Present with stiff muscles and movements may look jerky and stiff
• Messages sent to muscles incorrectly through damaged part of brain
• Spasticity arises as result of damage to bundles of neurons in brain and spinal cord called: corticospinal and corticobulbar tracts

Question 9

Diplegia CP

Answer 9

Increased muscle tone in legs; little or no movement in arms (BILATERAL)
- 2 limbs affected (LEGS)
Femoral anteversion, Tibial torsion, may have hyperextension (compensate for tight tendo-archilles), kyphosis (balance mechanism)
- Arms may be affected to lesser extent

Question 10

Hemiplegia CP

Answer 10

Spasticity in arm, leg and trunk on ONE side (UNILATERAL)

• Underdevelopment of affected side (smaller limbs and leg shortening)
• Equinus of foot, ankle, flexion of elbow, wrist and fingers

Question 11

Quadriplegia CP

Answer 11

All FOUR limbs involved (both arms and legs)

• Muscles of trunk, face and mouth often affected)
• Possibility of dislocation / subluxation of hip (60% of non-walkers by age 5)
• Spinal curvature

Question 12

Athetoid (dyskinesia) CP - Basal Ganglia

Answer 12

Damage to Basal Ganglia (10%-20% of cases)

• Characterised by involuntary movements (out of a person’s control)
• Uncontrolled, purposeless, slow, writhing movements
• Muscles which change from floppy to tense
• May affect face or tongue (resulting in drooling)

Question 13

Ataxic CP - Cerebellar

Answer 13

Characterised by low muscle tone and poor coordination of movements (shaky movements)

• Affects 5%-10% of cases and balance and sense of positioning in space (depth perception)
• Results in poor co-ordination, unsteady, wide based gait

Question 14

Mixed CP

Answer 14

About 10% of all cases and has SEVERAL AREAS OF BRAIN INVOLVED

Question 15

Diagnosis of CP

Answer 15

Based on px. history and physical examination

- CT & MRI when aetiology of CP not estanblished

Question 16

Interdisciplinary Management of CP

Answer 16

Medication

• Anticonvulsants
• Antispasmotics (Blocking of excitatory effect of sensory input - Intrathecal baclofen, Botulinum toxin (Botox) - blocking release of synaptic vesicles = blocking synapse at neuromuscular junction - Lasts 3 months

Soft Tissue Surgery
- Release of tendon, muscle or connective tissue

Orthotics:
- Maintain length, prevent further deformity, improve joint alignment, biomechanics and function

Serial Casting
- Short periods, frequent reapplication over 6 weeks - effective in lengthening shortened muscles

Strength Training
- ACSM guidelines (3 x 8-12 reps, 2x/week; light-mod load (30-60% 1RM to 70-85% 1RM)

Positioning
- Active, passive

Task Specific Training
- May improve muscle activation patterns and allow patients to learn improved motor control strategies

Contsraint Induced Movement Therapy (CIMT)
- 1-6hrs during play / day; 4-7 weeks

Question 17

Prognosis of CP

Answer 17

Reduced life expectancy - 90% survival into teens and 20s (immobility and severe learning difficulties main influencing factor)

Question 18

Outcome measures of CP

Answer 18

Gross Motor Function Classification System (GMFCS)
- 5 levels based on child’s ability to perform gross motor skills and assistance required when mobilising in a variety of conditions (stairs, distanced, altered terrain, inclines)

Functional Mobility Scale (FMS)
- Considers assistance the person requires over 5, 50, and 500 metres

Manual Ability Classification System (MACS)

Gross Motor Function Measure (GMFM)

Gait Analysis (spacial temporal gait parameters, Kinematics, Kinetics, EMG, energy consumption)