PG - CP

• Cerebral Palsy (CP) is also known as "Little's disease" and is a disorder of movement and posture caused by a non-progressive injury to the immature brain
• It is defined as a group of disorders of the development of movement and posture, causing activity limitations attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain
• Three major criteria for the diagnosis of cerebral palsy include:

  • A neuromotor control deficit that alters movement or posture
  • A static brain lesion
  • Acquisition of the brain injury either before birth or in the first/second year of life
• The epidemiology of cerebral palsy includes:

  • Approximately 1-2.3 cases per 1000 live births, with a higher prevalence in males than females
  • 5.2 cases per 1000 live births at 1 year of age
  • Premature low birth weight is a risk factor
  • In the Philippines, it affects 1-2% of the population
• Classification of Cerebral Palsy:

  By tone abnormalities:

  • Spastic
  • Dyskinetic (Athetoid, Choreoathetoid, Ballistic, Ataxic)
  • Hypotonic
  • Mixed
• Classification of Cerebral Palsy by the area of the brain affected:

  • Spastic: motor cortex (pyramidal)
  • Athetoid: basal ganglia (extrapyramidal)
  • Ataxic: cerebellum
• Classification of Cerebral Palsy by body parts involved:

  • Monoplegia (one limb; arm)
  • Diplegia (all limbs; both legs > arms)
  • Triplegia (three limbs; both arm and a leg)
  • Quadriplegia (all four limbs)
  • Hemiplegia (one side; arm > leg)
• Gross Motor Functional Classification of Cerebral Palsy:

  • Level 1: walks without restriction, limitations in high-level skills
  • Level 2: walks without devices, limitations walking outdoors
  • Level 3: walks with devices, limitations walking outdoors
  • Level 4: limited mobility, power mobility outdoors
  • Level 5: very limited self-mobility, even with assistive technology
• Spastic CP characteristics (cerebral cortex; corticospinal)

  • Hypertonicity (clasp knife)
  • Abnormal postures and movements with mass patterns of flexion/extension
  • Imbalance of tone across joints leading to contractures and deformities
  • Associated with visual, auditory, cognitive, and oral motor deficits
• Athetoid CP characteristics (basal ganglia; kernicterus)

  • Generalized decreased muscle tone (floppy baby syndrome)
  • Combination of hypertonia and hypotonia
  • Poor functional stability, especially in proximal joints
  • Ataxia and incoordination when assuming upright positions
  • Tonic reflexes may be persistent (ATNR, STNR, TLR)
• Ataxic CP characteristics (cerebellum)

  • Low postural tone with poor balance
  • Wide-based stance and gait
  • Intention tremor of hands
  • Uncoordinated movement
  • Poor visual tracking and speech articulation problems
• Etiology of Cerebral Palsy:

  • Brain injury leading to CP can occur in the prenatal, perinatal, or postnatal period
  • Most causes of CP occur in the prenatal period
• Risk Factors Associated with CP:

  • Include gestational age, birth weight, maternal history, factors during gestation, and fetal factors
• Pathophysiology of Cerebral Palsy:

  • Involves immaturity, fragile brain vasculature, and physical stresses of prematurity leading to brain injury
• Clinical Manifestations of Cerebral Palsy:

  • Include hypotonia, motor delay, UMNL signs, tone abnormalities, retention of primitive reflexes, muscle weakness, abnormal posture, sensory issues, and associated impairments
• Associated Impairments in Cerebral Palsy:

  • Sensory, visual, hearing, cognitive, psychological, seizures, oromotor, GI, bowel and bladder, nutrition, respiratory, musculoskeletal issues
• Associated impairments of Cerebral Palsy (CP) include:

  • Nutrition: malnutrition/obesity
  • Respiratory: ineffective cough, risk for respiratory tract infections (RTI), pneumonia
  • Osteopenia, osteoporosis
  • Musculoskeletal: contractures, equinovarus, hip dislocation, spinal deformities, hip dysplasia, windswept deformity, thumb in palm deformity, leg length discrepancy
  • Gait deformities
• Common gait deviations and their potential effects:HIP:

  • Increased adductor tone: scissoring; difficulty in advancing leg during swing phase
  • Increased tone of the Iliopsoas
  • Increased femoral anteversion: intoeing; false genuvalgus; compensatory external tibial torsion
  • Abductor weakness: Trendelenburg gait
• Complications of Cerebral Palsy (CP) include:

  • Contractures
  • Bony deformities
  • Pneumonia
  • Aspiration
  • Constipation/fecal impaction
  • Fractures
• Diagnosis of CP:

  • Historically based on patient's history and physical examination
  • Neuroimaging is warranted when the etiology has not been established
  • MRI is preferred over CT scan
  • Cranial ultrasound for premature infants to evaluate periventricular leukomalacia (PVL)
• Prognosis of CP:

  • Not progressive
  • Ability to live independently varies depending on the severity of the disability
  • Persons with CP can expect to have a normal life expectancy, with survival associated with the ability to ambulate, roll, and self-feed
• Functional prognosis indicators for eventual ambulation in CP:

  • Good predictive signs:
  • Attainment of independent sitting by 2 years
  • Presence of fewer than three primitive reflexes at 18 months of age
  • Ability to crawl on hands and knees by 1.5 to 2.5 years old
  • Ability to transition from supine to prone by 18 months
  • Poor predictive sign: children who are unable to sit by 4 years
• Differential diagnosis and medical/pharmacologic interventions for CP:

  • Muscle relaxants: Baclofen, Dantrolene sodium, Benzodiazepines, Alpha 2 Adrenergic Agonist (Tizanidine, Clonidine)
  • Anticholinergics: Glycopyrrolate
  • Stimulants: Methylphenidate (Ritalin)
  • Chemical denervation: IM botulinum toxin injection, Phenol injections
  • Anticonvulsants: Barbiturates (Phenobarbital), Benzodiazepines (Diazepam, Clonazepam), Valproates (valproic acid)
• Surgical managements for CP:

  • Orthopedic procedures
  • Insertion of a baclofen pump (ITB)
  • Peripheral Nerve Block
  • Selective Dorsal Rhizotomy
  • Botulinum Toxin A
  • Insertion of shunts
• Gestational Hypertension

  • New hypertension presenting after 20 weeks of pregnancy without significant proteinuria , BP levels return to normal within 3 mos postpartum
  • greater than or equal to 300 mg
• Preeclampsia

  • New hypertension presenting after 20 weeks of pregnancy with significant proteinuria
• Severe Preeclampsia

  • Severe hypertension presenting after 20 weeks of pregnancy with proteinuria with 1 symptom of either headache, blurred vision, upper abdominal pain
• Eclampsia

  • Complication of preeclampsia characterized by convulsion and coma
• Gestational Diabetes

  • caused by as insulin resistance
  • symptoms disappear following delivery
  • monitoring post partum for development of DM type 2
• Oligohydramnios

  • decreased amniotic fluid
  • Intruterine growth restriction
  • Craniofacial, limb abnormalitues/anomalies
• Polyhydramnios

  • increased amniotic fluid
  • Fetal malposition
  • Cord prolapse, premature birth
• Placental Abruption - separation of placenta (blood dissolves the placenta)

  Placenta Previa - misplacement of the placenta

  • low implantation
  • partial placenta previa
  • total placenta previa
• Grades of Intraventricular Hemorrhage in Premature Brain

  1. Isolcated to germinal matrix
  2. c normal ventricular size
  3. c ventricular dilatation
  4. c parenchymal hemorrhage
• Common gait deviations and their potential effects:

  • KNEE:
  • Decreased hamstring length: crouched gait
  • Hamstring/quadriceps co-contraction: stiff knee gait
• Common gait deviations and their potential effects:

  • ANKLE:
  • Increased gastrocsoleous tone/contracture: toe walking; genu recurvatum; difficulty in clearing foot during swing
  • Internal tibial torsion: intoeing; ineffective push off
  • External tibial torsion: out toeing; ineffective push off
  • Varus: increased ankle supination (plantarflexion, inversion, adduction) in stance or swing
  • Valgus: increased pronation (dorsiflexion, eversion, abduction) in stance or swing; midfoot break
• Shunt Routes

  • VENTRICULO-PERITONEAL - Peritoneal Cavity
  • VENTRICULO-ATRIAL - Right Atrium
  • VENTRICULO-PLEURAL - Pleural Cavity
  • VENTRICULO-CISTERNAL - Cisterna Magna
  • VENTRICULO-SUBGALEAL - Subgaleal Space
  • LUMBAR-PERITONEAL - Peritoneal Cavity
• Pathway of CSF Flow

  • Come - Choroid plexus
  • Lets - Lateral ventricle
  • Migrate - Monroe (foramen)
  • To - Third ventricle
  • Spain - Sylivius (aqueduct)
  • For - Fourth ventricle
  • Money - Magendie (foramen)
  • Love - Luschka (foramen)
  • Sex - Subarachnoid space
  • Ah! - Arachnoid villi