Cerebral palsy Flashcards
What is the epidemiology of cerebral palsy (CP)?
Most common childhood movement disorder
2.1/1000 live births
What are some prenatal causes of CP?
Prenatal = most common c.80% - but some unidentifiable
Periventricular leukomalacia (PVL) i) Damage to white matter, probably secondary to ischemic injury in watershed areas (e.g. from maternal hyper/hypotension)
Maternal infection
i) CMV, rubella, chicken pox, toxoplasmosis
Foetal CVA
i) Ischemic or haemorrhagic
Foetal head injury
Genetics
i) 2% of CP
What are some perinatal causes of CP?
Hypoxia during delivery
Serious head injury
Haemorrhage - including periventricular leukocytosis (?)
Premature infants are also at an increased risk (?)
What are some post-natal causes of CP?
Infection
i) Meningitis, encephalitis
Serious head injury or NAI (shaken babies)
Hypoxic brain injury
i) Choking or nearly drowning
Significant hypoglycaemia
CVA
Significant up to 2yrs
What are some risk factors for developing CP?
Premature birth
i) Before 37th weeks; before 32wks even higher; low birth weight
Twin/multiple pregnancy
Emergency caesarean section
Mother 35yrs<
Maternal HTN/HoTN
Severe jaundice - Kernicterus (bilirubin encephalopathy due to very high levels of unconjugated bilirubin which can cross BBB, deposit in basal ganglia - cannot be conjugated by glucoronidation until several months old)
What are the the four types of CP and how do they present?
- Spastic (most common - 70-80%): higher muscle tone = tight/stiff muscles/movement difficult + clonus; persistent primitive reflexes e.g. Babinski; seizures
Due to - UMN lesions in the corticospinal tract and/or motor cortex (neurons unable to properly absorb/produce GABA
- Dyskinetic: muscles switch between stiffness and floppiness, causing random uncontrolled movements and spasms
- Ataxic (least common): balance and coordination problems, tremors
- Mixed
When does someone with CP typically present and how do their symptoms evolve?
Aren’t usually obvious immediately following birth but become apparent during the first few years of life e.g. delays in reaching milestones (6-9 months may start to show)
Neurological symptoms do not advance with further ageing (but effects on MSK may worsen with time)
Symptoms are very variable in severity; some may be unilateral, some only in the lower limbs, some in who body
What are some typical motor features of spastic CP?
Hypertonia/hypotonia; limb weakness; myoclonus; clumsiness; muscle spasm; hand tremor; tiptoe walking – Achilles tightening or scissoring gate – hip adductor tightening
Frequently dislocating hips; low trauma fracture (usually legs)
What can be some non-motor features of CP?
Learning disability – up to 50%; communication and speech problems (BUT IMPORTANT TO CHECK WHEN IN CONSULTATION)
Feeding and swallowing difficulties; drooling – mouth infections, impaired speech; GORD
Constipation, urinary incontinence
Sleep problems
Scoliosis
Eye problems – reduced vision, squint, uncontrollable eye movements; hearing loss
Pain - from deficits or medical procedures
Associated with increased risk of lots of other disorders as the child ages e.g. osteoporosis, cardio- and cerebrovascular disease, cancer, mental health problems etc.
How do you investigate CP?
Medical and developmental Hx of the child
Obstetric + post-natal Hx
Definitive Dx is usually clinical but may take time until symptoms have had a chance to develop completely
- dangers in making diagnosis too soon as other causes for symptoms can be missed
If cause of CP is obviously postnatal e.g. RTA - then CT/MRI head to see where development will progress
Imaging: cranial USS; MRI/CT head (following trauma, hydrocephalus, AVM, subdural haematoma etc)
Other: EEG; EMG; bloods – to rule out differentials (metabolic causes)
What therapists are useful in CP?
PT
i) Trying to avoid contractures (muscles shortening w/loss of ROM)
SALT
i) For drooling and eating as well as communication
OT
i) For maximising independence at home, school and work
Dietitians
i) Choking, aspiration and malnutrition are risks; dietary change to soft/liquid food; NG/PEG in severe
Psychotherapy
(also community paeds, neurology, opthalmology, audiology, ENT, education, social services)
What medications are useful for spasticity?
Baclofen/Diazepam
Can have an intrathecal baclofen pump
BOTOX-A injections - improve movement and reduce muscle pain for several weeks (serious SE’s: respiratory difficulties, generalised weakness and dysphagia - more common in severe CP and in children)
Salivary/secretion control - hyoscine path (behind ear) - changed every 72hrs, can be cut in half/quarters in children
What surgeries can be used in CP?
Contracture release
Relocations of hips
Scoliosis correction – rods and pinning
Urinary incontinence – various procedures (suprapubic catheter, mitrofanoff)
Selective dorsal rhizotomy
i) Cutting selected spinal nerves to reduce leg stiffness and improve walking
Why does CP only show up after a certain time?
UMN lesions - increased muscle tone - muscle contracture - bone shortening - increased likelihood of dislocation and fracture etc
Different parts of the brain develop at different points - lesions in hear areas will be noticed when these parts of the brain should be developing
The lesions themselves are non-progressive but the consequences are
What’s the prognosis for CP?
Difficult to predict - brain is plastic - but should have an idea by age five if they’re continuing to miss milestones
MRI after recovering from post natal traumas can also help indicate likelihood of development
