Cerebral Palsy Flashcards
Define Cerebral Palsy
An umbrella term that encompasses a group of permanent movement and posture disorder that limit activity
Most commonly results in spasticity, but can also incorporate disorders of sensation, perception, cognition, communication, and behaviour.
What are the types of cerebral palsy
Spastic (70%): hemiplegia, diplegia, quadriplegia (UMN)
Dyskinetic (Basal ganglia + substantia nigra)
Ataxic (Cerebellar)
Mixed
What causes cerebral palsy
Acquired pathology within the developing brain
Centrally-mediated abnormal muscle tone → spasticity
Hypoxic ischaemic encephalopathy (40% of cases)
Prematurity
Multiple gestation
Maternal infection, congenital infection
Congenital brain malformation
Postnatal meningitis or sepsis
Intraventricular haemorrhage
What are the prenatal, perinatal, and postnatal risk factors for cerebral palsy
Pre: multiple gestation, maternal infection, placental abruption
Peri: preterm birth, low birth weight, HIE, sepsis, resp. distress, intraventricular haemorrhage
Post: head injuries, meningitis
What % of infants born prior to 26 weeks develop CP
35%
What are the symptoms of cerebral palsy
Early:
Unusual fidgety movements, asymmetry, paucity
Hypotonia, spasticity, dystonia (fluctuating)
Motor development delayed (head control, rolling, crawling)
Feeding difficulties: poor weight gain, choking while eating, long meal times
Recurrent chest infection (aspiration)
Drooling
Later:
Delayed motor milestones
Delayed speech development
Delayed cognitive/intellectual development
Persisten toe-walking
Spasticity when they attempt activities
What are the differentials for cerebral palsy
Brain tumour
Dystonia
Muscular dystrophy
Myelodysplasia
Spinal stenosis
What are the signs of cerebral palsy on examination
General examination - Pay attention to movement and muscle tone
Newborn head circumference
Excessive stiffness or floppiness
Absent or abnormal fidgety movements
Exaggerated amplitude, speed, jerkiness
Persistent cramped synchronous movements <3yo
Absence of fidgety movements at 3-4 months
Response to visual stimuli and sounds, level of arousability
Neurological
Spasticity (after 2yo)
Clonus
Excessive plantar flexion (spastic hemiplegia)
Reflexes
Lack of parachute reaction
Lack of foot placement reaction
What investigations are done for cerebral palsy
The Hammersmith Infant Neurological Examination (HINE) for children 2-24 months
Prechtl’s Assessment of General Movements (GMs)
GMFCS (Gross motor function classification system)
± MRI head: white matter damage, basal ganglia/deep grey matter damage, focal infarcts
What is the overall management for cerebral palsy
Refer to child development service for multidisciplinary assessment: Risk factors + abnormal motor features | delayed motor milestones | persistent toe walking
MDT management (paediatric, nursing, physiotherapy. occupational, SALT, dietician, psychologist)
Priorities:
○ Parent education
○ Seating, positioning
○ Ambulation
○ Education: Education Health Care Plan (EHCP)
○ Feeding/nutrition
○ Social/emotional well-being
+ regular review of: eating, drinking, swallowing, SAL, height and weight, drooling, pain, sleep, mental health, GORD, epilepsy, constipation
What treatments can be used for the motor symptoms of cerebral palsy
Hydrotherapy (heated pool + exercise)
Physiotherapy
Botulinum toxin A (help walking)
Selective dorsal rhizotomy (SDR) - surgical procedure
Intrathecal baclofen therapy (muscle relaxant given into the spinal fluid)
Orthopaedic surgery (resistant contracture or bony deformity)
Oral diazepam (for significant spasticity from mid-childhood)
How are the following features of Cerebral palsy managed: drooling, pain, sleep disturbance, speech issues, nutrition issues
Excessive drooling → Glycopyrronium bromide (oral or enteral tube)
* High-dose botulinum toxin A injection to the salivary glands
* Salivary gland surgery
Pain → step-wise pain management
Sleep disturbance → 1. optimise sleep hygiene 2. Trial melatonin (off licence)
Speech issues → sign language, speech boards, laptops, tablets
Nutrition issues →NG tube, jejunostomy, gastostomy considerations
What are the complications of cerebral palsy
Feeding difficulties (50%) → poor growth
Sialorrhoea/drooling - can be affected by positioning, medication history, reflux, dental issues
Aspiration and recurrent chest infection
Vomiting, regurgitation, gastro-oesophageal reflux
Osteopenia, osteoporosis ( vit D deficiency or compromised nutritional status)
Constipation
Incontinence - impaired motor control of bladder muscles
Visual impairment
Hearing impairment - 1 in 10
Epilepsy - 1 in 3 people to 1 in 2 people
Learning disability - IQ <70 in 1 in 2 people
Communication difficulties
Behavioural difficulties
Sleep-disturbance
Pain
What is the prognosis for cerebral palsy
Permanent condition where the functional and neurological manifestations of the condition evolve over time, despite the underlying brain lesion being non-progressive
The more severe the physical, functional, or cognitive impairment, the greater likelihood of reduced life expectancy
The majority of children survive into adulthood (20 year survival rate 87-94%)
Which motor milestones raise suspicion of cerebral palsy when delayed
Not sitting by 8 months
Not walking by 18 months
Early asymmetry of hand function (hand preference) before 1 year
Not climbing stairs step over step by 3yo
