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Cerebral Palsy.pptx

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Nawaj Pathan
Nawaj Pathan

Cerebral palsy is a disorder of posture and movement caused by damage to the developing brain. It can occur before, during, or after birth from conditions like infection, lack of oxygen, or head trauma. The main types of cerebral palsy are spastic, dyskinetic, ataxic, and mixed. Symptoms vary depending on the location and severity of brain damage but may include poor muscle control, involuntary movements, weakness, and developmental delays. Treatment focuses on improving mobility, function, and quality of life through therapies, medications, surgery, and equipment. Cerebral palsy has many potential associated problems and complications that also require management.

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Cerebral Palsy 5/9/20231
Content 5/9/2023 2 Etiology and type Clinical features Differential diagnosis Management
Introduction • It’s a disorder of Posture and Movement, Occurs due to damage to immature CNS before, during or after birth. • Cerebral palsy is also called as ’Static Encephalopathy’ because it represents a problem with brain structure & function. • Once an area of the brain is damaged, the damage area does not spread to other areas of brain. 5/9/20233
• However, because of its various connections with other areas of CNS, the lack of functions of other areas & area which is damaged may interfere with the ability of functions properly. • Despite its static nature of CNS damage in C.P. clinical features of disorder may appear to change as child gets older, motor demands increases with age, motor abilities may not be able to cope up quickly enough to meet demands. • Mainly it will interfere with the functional abilities, delayed motor development, impaired muscle tone, movement patterns. • When damage occurs before birth or during birth process it is consider as ‘Congenital Cerebral Palsy’ 5/9/2023 4
• Brain damage in early gestational is more likely to produce moderate to severe motor involvement leads to Quadriplegia, whereas damage later in gestation may result in primarily lower extremity motor involvement results into Diplegia. • If brain is damaged after birth, up to 3 years of age the C.P. is considered to be Acquired.(Capute & Accardo -1996, ¾ Brain size) 5/9/2023 5
Etiology 5/9/2023 6 Incidence of C.P. ranges from 1 to 2.5/1000 live births. It is closely related to prematurity and low birth weight. C.P. can have multiple causes, some of which can be liked to a specific time period. Generally any condition that causes- Anoxia, hemorrhage or damage, to the brain can result in C.P.
Prenatal Causes Maternal infections-TORCH Placental Abnormalities, Rh Incompatibility, Maternal Diabetes, Toxemia, Brain Maldevelopment Perinatal Causes Asphyxia Prolonged labour, Breech defect, prolapsed Cord, Ruptured Blood vessels, compression of Brain, Premature separation of placenta- gravia, pravia, Prematurity, Low birth weight Post natal Causes CVA, Intraventricular Hemorrhage, brain Infections, Meningitis, Encephalitis, Seizures, Head trauma, 5/9/2023 7
Prenatal causes 5/9/2023 8 When the causes of CP is known, roots are related to problems experienced during intrauterine development, exposure to maternal infections in early gestational period can increases the risk of CP. Rh factor is found in RBC (85% populations) Rh Incompatibility developed when a mother who is Rh(-ve) delivers a baby Rh (+ve). Mother becomes sensitive to the baby’s blood & begins to make antibodies.
• The antibodies can develop the ‘kernicterus syndrome’, characterized by high frequency hearing loss, visual problems & discoloration of teeth. • It can be managed by drug- RHoGam, an immunoglobulin can be given safely after first delivery to neutralize the consequences. 5/9/2023 9
Other maternal Problems 5/9/2023 10 The other maternal problems that can place infant at risk for neurological injuries include- diabetes, toxemia during pregnancy. Diabetes can jeopardizes the metabolic deficits leads to stunted growth of the fetus, delayed tissue maturations. Toxemia in pregnancy leads to maternal high blood pressure, the fetus will be at risk of not receiving sufficient blood flow and therefore O2 .
5/9/2023 11 Maldevelopment of brain and other organ system is commonly seen in C.P. children. Teratogens is any agent or condition that causes the defect in fetus,, including radiations, drugs, toxins, infections, chronic illness. Genetic disorders and exposure to teratogens increases the risk of brain malformations.
Perinatal Causes 5/9/2023 12 An infant may experience the asphyxiations results from anoxia (lack of O2), during labor and delivery. Prolonged or difficult labor because of breech presentations(bottom first) or prolapsed umbilical cord contributes to asphyxia. Its considered as commonest cause of C.P.
5/9/2023 13 The other two biggest risk factors for C.P. are prematurity and low birth weight. Fetus born with weight 1500g has 30 times high risk of developing C.P. A gestational age has less than 37 weeks with low birth weight are considered as compounding risk for the neurological deficits. Birth weight <1500g is also a strong risk factor for C.P. Thus full term baby weighing <1500 grams may be at the risk for C.P.
Postnatal causes 5/9/2023 14 An infant or toddler may acquire brain damage secondary to cerebral hemorrhage, trauma, infections, anoxia This is very common in road traffic accidents, shaken baby syndrome, whereas meningitis, encephalitis, inflammatory diseases contributes 60% in development of C.P.
Types of C.P. 5/9/2023 15 Distribution of involvement Type of Abnormal muscle tone and Movement
Distribution of involvement 5/9/2023 16
All 4 limbs are involved Upper extremities and lower extremities, Results from B/L brain damage U.L.>>>L.L. Also has difficulty in head and trunk control, less chances of becoming ambulated Trunk control is also affected to some extent Deformities, contractures are common. 5/9/2023 17
All 4 limbs affected Results from B/L brain damage LL>>> UL, sometimes spared With assistive devices can be mobilised 5/9/2023 18
One side of body affected Unilateral brain damage Usually mobile, trunk control affected to lesser extent Good prognosis with moderate to high IQ 5/9/2023 19 Hemiplegic C.P.
According to movement differences Spastic Dyskinetic Dystonia Athetoid Mixed Ataxic 5/9/2023 20
Spastic • Spasticity occurs in 75% of all children with CP including diplegia, hemiplegia, quadriplegia. • It is found approximately 40% in quadriplegia, 17% diplegia, 21% hemiplegia. • Spasticity is a complex motor abnormality often described as hypertonicity in which resistance to passive movements increases with change of velocity of movement. • Spasticity, hyperactive stretch reflex, responds to variety of treatments like BOTOX, Baclofen, Release surgery, Dorsal Rhizotomy. • Spasticity causes significant changes such as- longitudinal growth of muscle fiber, decrease the muscle volume, muscle unit size, muscle fiber type. 5/9/2023 21
• Furthermore it causes secondary changes like hip dislocation, scoliosis, knee contractures, excessive torsional malalignment of femur, tibia, leads to effortful gait patterns, difficulty in sitting positions, self care activities. 5/9/2023 22
Diplegia • Most common type of CP. • White matter infract in the periventricular areas due to hypoxia leads to diplegic CP. • Affects bilateral lower limbs which results into difficulty in gait, balance, co-ordination. • In standing these patients shows excessive lumbar lordosis, anterior pelvic tilt, bilateral internal rotations, knee flexion, in toeing and equinovalgus deformities and foot positions. • There is slight difference in UE and LE functioning with this form of CP, UE and trunk is less affected than LE. • Gait difficulties such as crouched posture, equinus posture are the greatest concern for these children. 5/9/2023 23
• Bilateral spasticity and weakness in LE increases the energy expenditures during ambulation, poor co-ordination and endurance in lower limbs collectively results into restricted functional mobility within home and in community level. • These patients often require assistive devices like posterior walker, crutches, scooter wheelchair for mobility. • These patients generally have normal cognition but may have social and emotional difficulties. 5/9/2023 24
Hemiplegia • It is subtype of C.P in which the child’s upper & lower extremity on the same side of the body get affected. • Four main types of lesions results into hemiplegic C.P. 1. Periventricular white matter abnormalities( Most Common) 2. Cervical- subcortical lesions. 3. Brain malformations. 4. Non-progressive post natal injuries/complications. • The UE are more affected than LE with more distal involvement than proximal. • Spasticity on affected side decreases muscle and bone growth which further decreases ROM, hence hemiplegic CP are more tend for contractures and limb length discrepancies. 5/9/2023 25
• Typical posture seen in hemiplegic CP are as follows- protracted shoulders. Elbow flexion, wrist flexion, ulnar deviations, pelvic retractions, internal rotations & flexion, knee flexion and forefoot planta-flexion. • These children achieves all Gross and fine motor milestones but not within typical time frame. • Two widely used slandered assessments used to evaluate the UE functioning in children SHUEE and assisting hand assessment (AHA). • Cognitive functions is typical in these children, may require minimal equipments or self care orthotics devices such as canes. 5/9/2023 26
Quadriplegia • It is subtype of C.P. in which volitional muscle control of all Four limbs get severely affected. • It is often accompanied by neck and trunk regions. • Periventricular white matter lesions are common findings seen in most of the neuroimaging findings in children with quadriplegic CP. • Lesions affecting the basal ganglia, occipital area often leads results into visual impairments & seizures. • Cognition ranges from normal to extremely affected. • Gross and fine motor skills vary in children from ambulatory within home with assistive devices to dependent for all. • Assistive devices may need throughout life span such as- standers, wheelchairs, bath system, toilet systems, mechanical elevators. • Home modifications should be advice for children with severe disabilities to maximize independence level, mobility, transitions. 5/9/2023 27
Dyskinetic • Dyskinesia and movement disorders results into uncontrolled and involuntary movements which includes athetosis, rigidity, tremors, dystonia, ballismus, choreoathetosis. • Deep gray matter lesions often affected majorly, whereas periventricular white matter lesions may also affect to lessor extents. • Athetosis is characterized by involuntary movements that are slow, writhing; abnormal in timing, direction and usually large motions at proximal joints. • Pure athetoid is rare to find in routine clinical practice, often found with chorea. • Cortical-basal ganglia- thalamic loop act as sensory sensory and motor feed forward and feedback mechanism circuit gets affected in athetosis. • Individuals with athetosis typically initiate and attempt control of movement with the jaw and head. 5/9/2023 28
• The cognitive abilities of these children tends to have normal but ignored due to associated dysarthria.(Normal to above normal intelligence). • Tremor, a rhythmic movement of small magnitude, usually of the smaller joints, rarely occurs as an isolated disorder in CP but rather in combination with athetosis or ataxia. • Dystonia is characterized by a slow motion which involves one limb or the entire body and in which the pattern itself may change over time, whereas Ballismus is the most rare movement disorder and involves random motion in large, fast patterns usually of a single limb. • Choreoathetosis involves jerky movement, commonly of the digits and varying in the ROM 5/9/2023 29
Ataxic • Ataxic CP is primarily a disorder of balance and control in the timing of coordinated movements along with weakness, incoordination, a wide-based gait, and a noted tremor; results due to deficits in the cerebellum and often occurs in combination with spasticity and athetosis. • Children with ataxia have difficulty with transference of skills, and may be benefitted from a specific task-oriented approach to treatment. E.g. sit stand, stepping, weight transfers. 5/9/2023 30
Assessment • To understand the nature of atypical movement and motor control pattern that seen in children with CP, the physical therapist must understand the importance of motor control against gravity, the development of postural control, and the musculoskeletal development in typically developing children. • The purpose of the assessment in CP is • To discover the functional abilities and strengths of the child. • Determine the primary and secondary impairments and discover the desired functional and participation outcomes of the child and family. • The therapist must use an integrated and organized approach by doing observation of child, his interactions, handling of the child in order to get an accurate baseline of the child’s functional status. 5/9/2023 31
5/9/2023 32 • Data Collection • Date of birth Date of assessment Chronologic age/adjusted age Reason for referral Relevant medical history Overview of function (a few sentences) Family and environmental characteristics Contextual factors (conditions and restraints on function) Assistive technology/adaptive equipment • Examination • Morphology Functional skills and the capacity for change Gross motor control Communications Fine motor control Social skills/control of behaviour Objective test results Observation of posture and movement Individual system review related to function Neuromuscular Musculoskeletal Sensory Respiratory
• Evaluation • List client’s competencies Areas of concern System impairments Ineffective posture and movement Functional limitations • Barriers to participation • Analyse each level and how they interrelate, creating the functional limitations of the client • Analyse the potential for change according to the findings 5/9/2023 33
5/9/2023 34
Associated problems • Sensory Impairments • Epilepsy • Visual problems • Hearing loss • Cognitive Impairments • Psychological Impairments • Oromotor Impairments • Nutritional Disorders 5/9/2023 35
• Genitourinary Disorders • Respiratory Disorders • Bone and Mineral Density Disorders • Musculoskeletal Disorders • Gait Impairments 5/9/2023 36

More Related Content

Cerebral Palsy.pptx

  • 2. Content 5/9/2023 2 Etiology and type Clinical features Differential diagnosis Management
  • 3. Introduction • It’s a disorder of Posture and Movement, Occurs due to damage to immature CNS before, during or after birth. • Cerebral palsy is also called as ’Static Encephalopathy’ because it represents a problem with brain structure & function. • Once an area of the brain is damaged, the damage area does not spread to other areas of brain. 5/9/20233
  • 4. • However, because of its various connections with other areas of CNS, the lack of functions of other areas & area which is damaged may interfere with the ability of functions properly. • Despite its static nature of CNS damage in C.P. clinical features of disorder may appear to change as child gets older, motor demands increases with age, motor abilities may not be able to cope up quickly enough to meet demands. • Mainly it will interfere with the functional abilities, delayed motor development, impaired muscle tone, movement patterns. • When damage occurs before birth or during birth process it is consider as ‘Congenital Cerebral Palsy’ 5/9/2023 4
  • 5. • Brain damage in early gestational is more likely to produce moderate to severe motor involvement leads to Quadriplegia, whereas damage later in gestation may result in primarily lower extremity motor involvement results into Diplegia. • If brain is damaged after birth, up to 3 years of age the C.P. is considered to be Acquired.(Capute & Accardo -1996, ¾ Brain size) 5/9/2023 5
  • 6. Etiology 5/9/2023 6 Incidence of C.P. ranges from 1 to 2.5/1000 live births. It is closely related to prematurity and low birth weight. C.P. can have multiple causes, some of which can be liked to a specific time period. Generally any condition that causes- Anoxia, hemorrhage or damage, to the brain can result in C.P.
  • 7. Prenatal Causes Maternal infections-TORCH Placental Abnormalities, Rh Incompatibility, Maternal Diabetes, Toxemia, Brain Maldevelopment Perinatal Causes Asphyxia Prolonged labour, Breech defect, prolapsed Cord, Ruptured Blood vessels, compression of Brain, Premature separation of placenta- gravia, pravia, Prematurity, Low birth weight Post natal Causes CVA, Intraventricular Hemorrhage, brain Infections, Meningitis, Encephalitis, Seizures, Head trauma, 5/9/2023 7
  • 8. Prenatal causes 5/9/2023 8 When the causes of CP is known, roots are related to problems experienced during intrauterine development, exposure to maternal infections in early gestational period can increases the risk of CP. Rh factor is found in RBC (85% populations) Rh Incompatibility developed when a mother who is Rh(-ve) delivers a baby Rh (+ve). Mother becomes sensitive to the baby’s blood & begins to make antibodies.
  • 9. • The antibodies can develop the ‘kernicterus syndrome’, characterized by high frequency hearing loss, visual problems & discoloration of teeth. • It can be managed by drug- RHoGam, an immunoglobulin can be given safely after first delivery to neutralize the consequences. 5/9/2023 9
  • 10. Other maternal Problems 5/9/2023 10 The other maternal problems that can place infant at risk for neurological injuries include- diabetes, toxemia during pregnancy. Diabetes can jeopardizes the metabolic deficits leads to stunted growth of the fetus, delayed tissue maturations. Toxemia in pregnancy leads to maternal high blood pressure, the fetus will be at risk of not receiving sufficient blood flow and therefore O2 .
  • 11. 5/9/2023 11 Maldevelopment of brain and other organ system is commonly seen in C.P. children. Teratogens is any agent or condition that causes the defect in fetus,, including radiations, drugs, toxins, infections, chronic illness. Genetic disorders and exposure to teratogens increases the risk of brain malformations.
  • 12. Perinatal Causes 5/9/2023 12 An infant may experience the asphyxiations results from anoxia (lack of O2), during labor and delivery. Prolonged or difficult labor because of breech presentations(bottom first) or prolapsed umbilical cord contributes to asphyxia. Its considered as commonest cause of C.P.
  • 13. 5/9/2023 13 The other two biggest risk factors for C.P. are prematurity and low birth weight. Fetus born with weight 1500g has 30 times high risk of developing C.P. A gestational age has less than 37 weeks with low birth weight are considered as compounding risk for the neurological deficits. Birth weight <1500g is also a strong risk factor for C.P. Thus full term baby weighing <1500 grams may be at the risk for C.P.
  • 14. Postnatal causes 5/9/2023 14 An infant or toddler may acquire brain damage secondary to cerebral hemorrhage, trauma, infections, anoxia This is very common in road traffic accidents, shaken baby syndrome, whereas meningitis, encephalitis, inflammatory diseases contributes 60% in development of C.P.
  • 15. Types of C.P. 5/9/2023 15 Distribution of involvement Type of Abnormal muscle tone and Movement
  • 17. All 4 limbs are involved Upper extremities and lower extremities, Results from B/L brain damage U.L.>>>L.L. Also has difficulty in head and trunk control, less chances of becoming ambulated Trunk control is also affected to some extent Deformities, contractures are common. 5/9/2023 17
  • 18. All 4 limbs affected Results from B/L brain damage LL>>> UL, sometimes spared With assistive devices can be mobilised 5/9/2023 18
  • 19. One side of body affected Unilateral brain damage Usually mobile, trunk control affected to lesser extent Good prognosis with moderate to high IQ 5/9/2023 19 Hemiplegic C.P.
  • 20. According to movement differences Spastic Dyskinetic Dystonia Athetoid Mixed Ataxic 5/9/2023 20
  • 21. Spastic • Spasticity occurs in 75% of all children with CP including diplegia, hemiplegia, quadriplegia. • It is found approximately 40% in quadriplegia, 17% diplegia, 21% hemiplegia. • Spasticity is a complex motor abnormality often described as hypertonicity in which resistance to passive movements increases with change of velocity of movement. • Spasticity, hyperactive stretch reflex, responds to variety of treatments like BOTOX, Baclofen, Release surgery, Dorsal Rhizotomy. • Spasticity causes significant changes such as- longitudinal growth of muscle fiber, decrease the muscle volume, muscle unit size, muscle fiber type. 5/9/2023 21
  • 22. • Furthermore it causes secondary changes like hip dislocation, scoliosis, knee contractures, excessive torsional malalignment of femur, tibia, leads to effortful gait patterns, difficulty in sitting positions, self care activities. 5/9/2023 22
  • 23. Diplegia • Most common type of CP. • White matter infract in the periventricular areas due to hypoxia leads to diplegic CP. • Affects bilateral lower limbs which results into difficulty in gait, balance, co-ordination. • In standing these patients shows excessive lumbar lordosis, anterior pelvic tilt, bilateral internal rotations, knee flexion, in toeing and equinovalgus deformities and foot positions. • There is slight difference in UE and LE functioning with this form of CP, UE and trunk is less affected than LE. • Gait difficulties such as crouched posture, equinus posture are the greatest concern for these children. 5/9/2023 23
  • 24. • Bilateral spasticity and weakness in LE increases the energy expenditures during ambulation, poor co-ordination and endurance in lower limbs collectively results into restricted functional mobility within home and in community level. • These patients often require assistive devices like posterior walker, crutches, scooter wheelchair for mobility. • These patients generally have normal cognition but may have social and emotional difficulties. 5/9/2023 24
  • 25. Hemiplegia • It is subtype of C.P in which the child’s upper & lower extremity on the same side of the body get affected. • Four main types of lesions results into hemiplegic C.P. 1. Periventricular white matter abnormalities( Most Common) 2. Cervical- subcortical lesions. 3. Brain malformations. 4. Non-progressive post natal injuries/complications. • The UE are more affected than LE with more distal involvement than proximal. • Spasticity on affected side decreases muscle and bone growth which further decreases ROM, hence hemiplegic CP are more tend for contractures and limb length discrepancies. 5/9/2023 25
  • 26. • Typical posture seen in hemiplegic CP are as follows- protracted shoulders. Elbow flexion, wrist flexion, ulnar deviations, pelvic retractions, internal rotations & flexion, knee flexion and forefoot planta-flexion. • These children achieves all Gross and fine motor milestones but not within typical time frame. • Two widely used slandered assessments used to evaluate the UE functioning in children SHUEE and assisting hand assessment (AHA). • Cognitive functions is typical in these children, may require minimal equipments or self care orthotics devices such as canes. 5/9/2023 26
  • 27. Quadriplegia • It is subtype of C.P. in which volitional muscle control of all Four limbs get severely affected. • It is often accompanied by neck and trunk regions. • Periventricular white matter lesions are common findings seen in most of the neuroimaging findings in children with quadriplegic CP. • Lesions affecting the basal ganglia, occipital area often leads results into visual impairments & seizures. • Cognition ranges from normal to extremely affected. • Gross and fine motor skills vary in children from ambulatory within home with assistive devices to dependent for all. • Assistive devices may need throughout life span such as- standers, wheelchairs, bath system, toilet systems, mechanical elevators. • Home modifications should be advice for children with severe disabilities to maximize independence level, mobility, transitions. 5/9/2023 27
  • 28. Dyskinetic • Dyskinesia and movement disorders results into uncontrolled and involuntary movements which includes athetosis, rigidity, tremors, dystonia, ballismus, choreoathetosis. • Deep gray matter lesions often affected majorly, whereas periventricular white matter lesions may also affect to lessor extents. • Athetosis is characterized by involuntary movements that are slow, writhing; abnormal in timing, direction and usually large motions at proximal joints. • Pure athetoid is rare to find in routine clinical practice, often found with chorea. • Cortical-basal ganglia- thalamic loop act as sensory sensory and motor feed forward and feedback mechanism circuit gets affected in athetosis. • Individuals with athetosis typically initiate and attempt control of movement with the jaw and head. 5/9/2023 28
  • 29. • The cognitive abilities of these children tends to have normal but ignored due to associated dysarthria.(Normal to above normal intelligence). • Tremor, a rhythmic movement of small magnitude, usually of the smaller joints, rarely occurs as an isolated disorder in CP but rather in combination with athetosis or ataxia. • Dystonia is characterized by a slow motion which involves one limb or the entire body and in which the pattern itself may change over time, whereas Ballismus is the most rare movement disorder and involves random motion in large, fast patterns usually of a single limb. • Choreoathetosis involves jerky movement, commonly of the digits and varying in the ROM 5/9/2023 29
  • 30. Ataxic • Ataxic CP is primarily a disorder of balance and control in the timing of coordinated movements along with weakness, incoordination, a wide-based gait, and a noted tremor; results due to deficits in the cerebellum and often occurs in combination with spasticity and athetosis. • Children with ataxia have difficulty with transference of skills, and may be benefitted from a specific task-oriented approach to treatment. E.g. sit stand, stepping, weight transfers. 5/9/2023 30
  • 31. Assessment • To understand the nature of atypical movement and motor control pattern that seen in children with CP, the physical therapist must understand the importance of motor control against gravity, the development of postural control, and the musculoskeletal development in typically developing children. • The purpose of the assessment in CP is • To discover the functional abilities and strengths of the child. • Determine the primary and secondary impairments and discover the desired functional and participation outcomes of the child and family. • The therapist must use an integrated and organized approach by doing observation of child, his interactions, handling of the child in order to get an accurate baseline of the child’s functional status. 5/9/2023 31
  • 32. 5/9/2023 32 • Data Collection • Date of birth Date of assessment Chronologic age/adjusted age Reason for referral Relevant medical history Overview of function (a few sentences) Family and environmental characteristics Contextual factors (conditions and restraints on function) Assistive technology/adaptive equipment • Examination • Morphology Functional skills and the capacity for change Gross motor control Communications Fine motor control Social skills/control of behaviour Objective test results Observation of posture and movement Individual system review related to function Neuromuscular Musculoskeletal Sensory Respiratory
  • 33. • Evaluation • List client’s competencies Areas of concern System impairments Ineffective posture and movement Functional limitations • Barriers to participation • Analyse each level and how they interrelate, creating the functional limitations of the client • Analyse the potential for change according to the findings 5/9/2023 33
  • 35. Associated problems • Sensory Impairments • Epilepsy • Visual problems • Hearing loss • Cognitive Impairments • Psychological Impairments • Oromotor Impairments • Nutritional Disorders 5/9/2023 35
  • 36. • Genitourinary Disorders • Respiratory Disorders • Bone and Mineral Density Disorders • Musculoskeletal Disorders • Gait Impairments 5/9/2023 36