Cerebral Palsy Flashcards
What is the definition of cerebral palsy?
- static encephalopathy which is non-progressive(once off insult)
- it is a disorder of motion or posture,secondary to an insult to the developing brain
What are the 5 motor abnormalities that we can expect from cerebral palsy
1, spastic (77-93% most common)
- Dyskinetic (2-15% abnormal movements)
- Ataxic (2-8% unsteadiness)
- Hypotonic (uncommon 0,7-2,6%)
- Mixed (spasticity with movement disorder)
What are the characteristics of dystonia?
- involuntary, sustained and intermittent movement
- abnormal postures at res or with activity
- same postures are repeated
- exacerbated by anxiety
- resolves with sleep
- tone generally increased
What do we use to classify the severity of cerebral palsy?
Gross motor function classification system
What are the causes of cerebral palsy?
- Prenatal
- infection(TORCHES)
- intracranial cerebral malformations
- toxins(tik)
- chromosomal abnormalities
- cerebrovascular incidents
What are the perinatal causes of cerebral palsy?
- Perinatal
- birth asphyxia -usually spastic quadriplegia
- prematurity -usually spastic diplegia
- birth trauma
- metabolic-hypoglycaemia
- kernicteris
- hypoxic/ischaemic encephalopathy
What are the post-natal causes of cerebral palsy?
- infection(meningitis, encephalitis)
- vascular malformations (thrombosis, embolism, strokes)
- toxins/drugs
- trauma (head injury)
- post-cardiac arrest
- metabolic (hypocalcaemia, hypoglycaemia, hyponatraemia, hypernatraemia)
What are the most NB questions to ask on history?
- Developmental hx
- Social and family hx-how this is affecting them
- Birth hx-moms previous birth hx, delivery, neonatal
- Developmental status, milestones, communication, speech, feeding, seizures
What do we focus on on general examination?
- General exam-dysmorphism+anthropometry
- Neuro: posture, movement, asymmetry, behaviour, eye signs(nystagmus,squint)
- Respiratory: recurrent chest infections-unable to cough and because of aspiration pneumonia
- Abdomen: constipation, fecal impaction
- Musculoskeletal: contractures, hip dislocation
What is the management of CP patients?
- Multi-disciplinary team NB NB
- social worker, physio, dietician,orthopedic surgeon, occupational therapy - Manage spasticity
- baclofen, Botox, oral diazepam - Manage constipation and reflux
- Control seizures
- Optimize vision and hearing
-baby usually presents with central hypotonia even if they have peripheral hypertonia
When does CP usually occur?
Between birth and 5 years old
Which parts of the brain are usually involved?
- The motor cortex
- Basal ganglia
- Cerebellar cortex
- Brain stem
What is the incidence of cp?
2-5 per 1000 worldwide
What are the spastic CP’sbroken up into?
- Tonic
2. Phasic
What is tonic CP?
- This is due to prolonged contraction of the muscles that it causes contractures
- type 1 muscle fibers are involved
- tonic and phasic can co-exist but tonic overrides eventually
What is phasic CP?
This is when the type 2 muscle fibers stretch from their usual short and relaxed state
-causes brisk tendon reflexes, clonus, clasp knife response
What is spastic hemiplegia?
- subdivision of spastic hemiplegia
- only one side is affected
- strong association with prematurity, birth asphyxia and placental insufficiency
- usually left side affected most
- 99% should be able to walk
Is language affected in spastic hemiplegia?
No-the neonatal brain is plastic
What is spastic diplegia?
-subdivision of spastic CP
-affects the legs more than the arms
Cerebral in origin
What is dyskinetic CP?
- involves the basal ganglia and the subsequent pathways
- chorea and athetosis
- the mature motor cortex and basal ganglia usually inhibit primitive responses like the asymmetrical tonic neck reflex, primitive walking and primitive swimming but when these are damaged the reflexes still exist
- the movements are usually slow and laboured
There are different types of dystonia:
- Flexor
- Extensor-most common
- the arms are usually extended and internally rotated, the wrists are flexed and the fingers extended
- extension of the feet (equinous deformity of the feet and big toe pointing up) - Alternating
- Hemiplegia dystonia
At what age do we start to see dystonia?
At 4 months of age
What part of the brain is involved in hypotonia?
Cerebellum and the pathways
How does hypotonia CP present?
- involves motor learning, fine motor movements like picking up a glass of water
- may present with/without ataxia
- may be caused by genetic factors that pre-dispose a child to a hypotonic cerebellum
When does the cerebellum develop?
Postnatally
What is mixed CP?
-it can involve all 3 but is usually truncal hypotonia with either spastic or dystonic limbs
How do we diagnose CP?
Some of the most early signs of CP include:
- delay in motor milestones
- hypertonia/hypotonia
- persistence of certain posturing(asymmetrical neck tonic reflex)
- clumsiness
What are the clinical signs of CP?
- Fisting with the thumb in adduction in the palm
- Scissoring of the feet with toe walking
- Feeding and drooling
- Opisthotonous position due to excessive truncal and nuchal tone
- Deep tendon reflexes (with brisk ankle clonus and positive babinksi sign)
- Truncal hypotonia (head lag or pull to sit lagged)
- Resp: lung infections
- Gastrointestinal exam: constipation and fecal impaction
- Musculoskeletal:contractures, hip dislocations
What associated can we expect in CP patients?
- Intellectual disabilities
- Behavioral problems
- Epilepsy
- Feeding and nutrition problems
- Language, vision, hearing abnormalities
- Increased risk of aspiration pneumonia
What is the management of CP?
-multi-disciplinary
Physiotherapist, speech therapist, dietician, orthopods, paediatric neurology, social worker
-we can also give botulinum injection
-Diaezapm and baclofen for the for the abnormal tone
-surgery(tendone stretching in places like the Achilles tendon)
What is dysarthria?
Difficulty in forming or pronouncing words because the muscles used to pronounce words are damaged or paralyzed
How can we classify spastic CP morphologically?
- Bilateral- diplegia and quadriplegia
2. Unilateral-monoplegia and hemiplegia
How can we classify dyskinetic CP morphologically?
- Hypokinetic-rigid or dystonia (focal, segmental ,generalised)
- Hyperkinetic-chorea, dystonia and athetosis
What is dystonia?
Involuntary muscle contractions that cause repetitive or twisting movements
- exacerbated by anxiety
- resolves with sleep
- the same movements are repeated
What is chorea?
Abnormal involuntary movement with brief, abrupt, irregular , unpredictable movements
What is athetosis?
-slow, involuntary, convoluted, writhing movements of the fingers, hands and toes
What is the specific correlation between the type of CP and the type of insult that occurred?
- Birth asphyxia in a term baby can cause dystonic or spastic quadriplegia
What is the correlation between a premature infant?
Spastic diplegia
Neonatal hypoglycaemia?
Ataxia
Severe kernicterus
Choreo-athetoid
Tb meningitis?
Spastic hemiplegia/dystonia
