MC Content: Cerebral Palsy

Question 1

Define Cerebral Palsy?

Answer 1

A group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing foetal or infant brain.

Note: Irreversible ie once the part of the brain is damaged it’s damaged (therefore also non-progressive).

Question 2

What are the antenatal risk factors for CP?

Answer 2

• Prematurity and low birth weight
• Intrauterine infections (can cause initiation of pre-mature labour and the baby is susceptible to the damage caused by those infections)
• Multiple gestation (one baby can dominate the blood and nutrient supply from the mother)
• Pregnancy complications eg haemorrhage, pre-eclampsia, premature placental abruption, placenta previa, etc can put the baby at risk of neurological concern

Question 3

What are the perinatal risk factors for CP?

Answer 3

• Birth asphyxia eg umbilical cord entangled around the neck is going to result in hypoxia = part of the brain can die
• Complicated labour and delivery

Question 4

What are the post-natal risk factors for CP?

Answer 4

• Non-accidental injury
• Head trauma
• Meningitis/encephalitis
• Cardio-pulmonary arrest (circulation isn’t going to the brain)

Question 5

How many people are living with CP in Australia? How often is a child born with CP in Australia?

Answer 5

34,000 living with CP
1 child born every 20hrs with CP in Aus

Question 6

What two pathologies is a premature neonatal brain susceptible to?

Answer 6

Intraventricular haemorrhage (IVH) & periventricular leukomalacia (PVL)

Question 7

What is IVH?

Answer 7

Intraventricular haemorrhage: bleeding into the ventricles of the brain. The blood vessels around the ventricles develop late in 3rd trimester, thus pre-term infants have underdeveloped periventricular blood vessels, predisposing them to increased risk of IVH. The risk of CP increases with the severity of IVH.

Question 8

What is PVL?

Answer 8

Periventricular leukomalacia: brain damage that adversely affects white matter, causing cell death, creating empty spaces in that part of the brain. The periventricular white matter sends nerve impulses that control motor function. Spasticity, cognitive impairment and vision issues often result from PVL. Approx 60-100% babies with PVL will be diagnosed with CP.

Question 9

How is Cerebral Palsy categorised in terms of motor types?

Answer 9

Spastic
Dyskinetic
Ataxic

Question 10

What is spastic CP?

Answer 10

Damage to motor cortex
Muscles appear stiff and tight
Altered motor control (70-80% will have this type)

Question 11

What is dyskinetic CP?

Answer 11

Damage to the basal ganglia
Characterised by involuntary movements
Different types eg dystonia (uncontrollable muscle contraction)

Question 12

What is ataxic CP?

Answer 12

Damage to the cerebellum
Characterised by shaky movements (affects balance and sense of positioning in space). Coordination is impaired.

Question 13

What are the categories of CP?

Answer 13

Quadriplegia bilateral: 4 limbs affected. The muscles of the trunk face and mouth are often affected
Diplegia/bilateral: 2 limbs affected. The arms may be affected to a lesser extent
Hemiplegia/unilateral: one side of the body (one arm/one leg) is affected

Order of prevalence: diplegia/bilateral, hemiplegia/unilateral & quadriplegia bilateral

Question 14

How does tone present in spastic CP?
What normally happens to the upper limbs?
What normally happens at the lower limbs?

Answer 14

• Hypertonia or increased muscle tone
• Upper limbs will flex (elbow, wrist, fingers) = difficulty in ADLs using hands eg dressing & eating
• Lower limb = difficulty with standing/sitting upright, transfer, moving eg walking and running
• Hip flexion, adduction or scissoring of thighs, flexion at knees, equinovarus foot posture

Question 15

What is the risk of adduction in CP patients?

Answer 15

Complications relating to posterior dislocation of the hip even just from a seated position

Question 16

What is equinovarus foot posture? What is it a result of?

Answer 16

Toes point downwards and inwards with the heel off the ground - this results from tightness in the calf muscle.

Question 17

What are some typical motor symptoms in hemiplegia CP?

Answer 17

Baby just responds with one hand, finishes the food only on half the side of the plate (occurs due to heminopia), only high fives with one hand, etc

Other signs
- Circumductive gait: reduced flexion on affected side requires swinging the leg outward to clear the ground.
- Early handedness: Decreased use of affected side; early preference for unaffected hand.

Question 18

What are some typical motor symptoms in diplegia CP?

Answer 18

Scissor gait: increased tone in the hip adductor muscles causes legs to adduct past midline (like a pair of scissors) when the child is lift by the upper body.

Commando crawl: normal alternating movement of hands while crawling but drags legs behind due to lower limb weakness

Question 19

What are some typical motor symptoms in quadriplegia CP?

Answer 19

• Wont be able to sit or stand independently (affects all limbs)
• Often affects swallowing
• High likelihood of seizures and cognitive impairment

Question 20

What are some typical motor symptoms in extrapyramidal CP?

Answer 20

• Involuntary contraction of all the muscle groups, difficulty with speech and swallowing (issue with the extra pyramidal tracts)
• Normally intelligence and low risk of seizures
• upper body is slightly more affected than lower body

Question 21

Prevalence & etiology of spastic hemiplegia?

Answer 21

25% of CP
Etiology: Stroke or IVH

Question 22

Prevalence & etiology of spastic diplegia?

Answer 22

35% of CP
Etiology: PVL

Question 23

Prevalence & etiology of spastic quadriplegia?

Answer 23

20% of CP
Etiology: PVL

Question 24

Upper motor neuron signs (relevant to spastic hemiplegia, spastic diplegia & spastic quadriplegia)

Answer 24

• Spasticity
• Hyperreflexia
• Clonus
• Babinski sign

Question 25

Prevalence & etoiology: Athetoid/extrapyramidal. Are there UMN signs?

Answer 25

15% of CP
Etiology: Birth asphyxia

Question 26

Ataxic CP: key signs?

Answer 26

• Coordination impaired (unstead, shaky movements, tremor)
• Balance impaired
• Can affect upper and lower limb eg standing, walking, running all disturbed
• Commonly given weighted spoons so they can balance it without spilling
• Speech and swallowing can be affected eg slurred speech
• Struggle focusing their eyes

Question 27

Dyskinetic CP: key signs? Three types?

Answer 27

• Dyskinetic (Athetoid) CP: trouble controlling muscle movement- twisting, abrupt movements.
• Change or fluctuation of the tone quite rapidly (fluctuating between hypotonicity and hypertonicity)

Three types
* Dystonia: involves involuntary muscle contractions that lead to twisting and repeating movements
* Athetosis: slow, writhing movements
* Chorea: irregular, abrupt movements (whole body is shaking, difficult to swallow, irregular movement)

Question 28

Cerebral Palsy (babies): key signs?

Answer 28

Cerebral Palsy signs (babies)
* Low muscle tone (baby feels ‘floppy’ when picked up)
* Unable to hold up his/her own head while lying on their stomach/ sitting position
- At 3 months of age if the child is not able to clear off their nose they won’t be able to breathe (red flag)?
* Muscle spasms or feeling stiff eg during nappy changes
* Poor muscle control, reflexes and posture eg not maintain posture in a high chair, shifting to one side/preferring one side
* Delayed development (can’t sit up or independently roll over by 6 months = red flag
* Feeding or swallowing difficulties eg choking
* Prefers to use one side of their body eg latching to one breast, or just lies on one side, etc

Question 29

Key physical development concerns for CP in young children?

Answer 29

Not walking by 12-18 months (tippie toes walking, sole of one foot is generally not worn) & not speaking simple sentences by 24 months.