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Cerebral palsy ,it's types and management
- 1. Cerebral Palsy 1861-62.a British surgeon named William John Little . Littles Disease The term cerebral palsy was first used by Sir William Osler, a British medical doctor in the late 1800's 1897, Dr. Sigmund Freud published papers describing his beliefs about the origins of Little's Disease. His scientific observations were later proved correct, but were not accepted until the late 1980's.
- 2. Cerebral palsy refers to permanent, nonprogressive and occasionally evolving, disorders of tone, movement or posture, caused by an insult to the developing brain. It is the most common chronic motor disability in childhood, affecting 2-3 infants per 1000 live births. While perinatal asphyxia was considered the most common cause, it accounts for less than 10% of cases.
- 3. Causes Genetic or prenatal Structural malformations of nervous system Congenital or intrauterine infections Maternal or obstetric complications Teratogens Perinatal Birth asphyxia Prematurity; low birth weight Birth trauma; intracranial hemorrhage Hyperbilirubinemia; hypoglycemia Central nervous system (CNS) infection Postnatal CNS infection Hypoxia Trauma; toxins
- 5. Clinical Features MC presentation - developmental delay. Physical findings persistence of neonatal reflexes, increased tone, fisting with cortical thumb, scissoring of legs, toe-walking, abnormal posture and gait, abnormal movements and/ or hyperreflexia. Common comorbidities intellectual disability, microcephaly, seizures, behavioral problems, difficulty in speech, language, swallowing or feeding, blindness, deafness, squint, malnutrition, sleep disturbances excessive drooling Contractures - initially dynamic and later fixed
- 6. Classification Topographical: quadriplegic, hemiplegic, monoplegic or diplegic, Physiological: spastic, hypotonic, dyskinetic, ataxic or mixed. Spastic Palsy may be quadriplegic, diplegic or hemiplegic Dyskynetic palsy may be choreoathetoid or dystonic.
- 7. Spastic quadriplegia is the most common type of cerebral palsy in India. It is often caused by perinatal asphyxia or neonatal illness. Common comorbidities are intellectual disability, seizures, pseudobulbar palsy, microcephaly, squint or visual disturbances, speech abnormalities and deformities. Spastic diplegia is the second most common type, and is linked to prematurity. Intellect is often preserved. Spastic hemiplegic palsy usually results from a vascular insult or perinatal stroke. Early hand preference is a clue. These children are usually mobile. They may have preserved or impaired intellect. Dyskinetic or extrapyramidal palsy may result from asphyxia or kernicterus. Rigidity, dystonia, dyskinesia and drooling are prominent while intellect is relatively preserved. Ataxic palsy is caused by cerebellar malformations and is associated with other cerebellar signs. (DANISH-Mnemonic) Hypotonia is usually a phase, lasting several years during early childhood before the features of spasticity become obvious. Mixed CP refers to a presentation including both spastic and extrapyramidal features.
- 8. Diagnostic Considerations based on the clinical picture diagnosis should be deferred until the child is age 2 years or older. (As the brain continues to develop postnatally, abnormalities of motor tone or movement in the first several weeks or months after birth may gradually improve over the first year of life (or even later). a Collaborative Perinatal Project found that almost 50% of individuals diagnosed with cerebral palsy and 66% of children diagnosed with spastic diplegia outgrew findings that were suggestive of cerebral palsy. by age 7 years.
- 9. Approach to a patient with CP History & Physical examination Evaluation for probable aetiology Classification by features GMFCS/GMFM Score for prognosis Identify associated problems Develop a T/t program
- 10. MANAGEMENT EARLY INTERVENTION Physical & Occupational therapy should be started as early as possible- preferably in the learning years Therapy Approaches : * Neurodevelopmental Treatment (Bobath) * Sensorimotor Approach (Rood) * Evolutionary development (Fay) * Sensory Integration (Ayres) * Patterning Therapy (Doman-Delacato) --------------------------------------------------- * Adeli suit * Constraint-induced movement therapy * Hyperbaric Oxygen (HBOT) * Equine assisted therapy (Hippotherapy)
- 11. MANAGEMENT STRATEGIES Intervention for abnormal tone Oral medications Serial casting/orthosis Chemodenervation-phenol, Botulinum toxin Selective dorsal rhizotomy Intrathecal baclofen Orthopaedic surgery If 2-3 muscles are the problem>>consider Botulinum toxin If dysfunction mainly in the lower limbs>>consider SDR If many muscles are involved>>Intrathecal baclofen may be considered
- 12. MANAGEMENT STRATEGIES EQUIPMENT CONCERNS Sitters esp. CP chair, with or without adaptive seating Standing frames Walkers Wheelchairs Devices for ADL Orthoses- incl. Tone reducing orthosis OTHER INTERVENTIONS FES & Biofeedback to train specific muscles Drugs to control drooling of saliva & bladder problems Special education
- 13. Common concerns in children Care Incontinence Spasticity Contracture GE Reflux Skin protection Scoliosis Hip development Lower extremity development