Cerebral Palsy

Question 1

CP Definition

Answer 1

Static encephalopathy

- Non-progressive brain injury causing posture and movement disorders

Question 2

What is CP often a/w? (4)

Answer 2

• Epilepsy
• Speech problems
• Vision compromise
• Cognitive dysfunction

Question 3

Associated Conditions (9)

Answer 3

• Sensorineural and conductive hearing loss
• Visual acuity impairement
• Somatosensory impairments
• Cognitive/development disability
• Language/learning disabilities
• M/S impairments
• Cardiorespiratory impairments
• GI/Nutritional impairments
• Skin- decubitus ulcers

Question 4

Prenatal Causes of CP (13)

Answer 4

• Exposure to toxins/drugs
• Infections or fever
• HIV/STDrisk
• Vaginal bleeding
• Abnormal fetal movement
• Preeclampsia (especially proteinuria)
• Breech position
• Poor maternal weight gain
• Premature labor
• Fetal distress
• Intrauterine Growth Retardation (IUGR)
• Prenatal testing
• Placental disorders

Question 5

Perinatal Causes of CP (6)

Answer 5

• Premature delivery
• Neonatal resuscitation
• Low Apgar scores
• Traumatic birth
• Neonatal encephalopathy (seizures, lethargy, hypotonia)
• Complicated neonatal course

Question 6

(2)Postnatal Causes of CP

Answer 6

• Severe infection

- Trauma

Question 7

T or F it is a red flag if a baby favors one hand over the other before they are 1 year old.

Answer 7

True

Question 8

Growth and Development (4)

Answer 8

• Significant delay of motor mile stones
• Persistent primitive reflexes
• Delayed or absent development of protective reflexes
• Delays in language, play, social, and adaptive behavior

Question 9

CP Presentation

Answer 9

• Hx of motor development delay in 1st yr
• Decreased tone followed by spasticity
• Definite hand preference before age 1
• Asymetric crawling or failure to crawl
• Growth disturbances, underweight

Question 10

Pyramidal (5)

Answer 10

• Two groups of nerve fibers responsible for voluntary movements.
• Communicate the brain’s movement intent to the nerves in the spinal cord to stimulate the act of moving.
• Results in increased muscle tone.
• Referred to as upper motor neuron damage
- Spasticity

Question 11

Extrapyramidal (4)

Answer 11

• Injury occurred outside the tract in areas such as the basal ganglia, thalamus, and cerebellum.
• Main characteristic is involuntary movement
• Divided into ataxic and dyskinetic
- Flaccid

Question 12

Hemiplegia

Answer 12

Upper and lower extremity on one side of the body

Question 13

Diplegia

Answer 13

Four extremities, legs more affected than the arms

Question 14

Quadriplegia

Answer 14

Four extremities plus the trunk, neck and face

Question 15

Triplegia

Answer 15

Both lower extremities and one upper extremity

Question 16

Monoplegia

Answer 16

One extremity (rare)

Question 17

Gross Motor Function Classification System (GMFCS)

Answer 17

1. ambulate w/no limitations
2. ambulates w/out devices, limitations
3. ambulates w/assistive devices
4. self mobility limited, technology helps
5. self mobility severe limited even with technology

Question 18

Spastic CP

Answer 18

• Most common type

Question 19

Spastic CP Hypertonia (2)

Answer 19

• increased muscle resistance to passive motion

* Inability of some spinal nerve receptors to properly receive GABA

Question 20

3 Anatomical Types of Spastic CP

Answer 20

Hemiplegia
Diplegia
Quadriplegia

Question 21

Spastic CP Hemiplegia (10)

Answer 21

• Seizure disorders
• Affected limbs may be thinner and shorter
• Intelligence
• Average intelligence decreased
• Left hemiplegia is lower then right hemiplegia
• May have unexplained aggressiveness and hyperactivity
• Homonymous hemianopsia (affecting the field of vision on the side of the affected limb)
• Strabismus
• Astereognosis
• Proprioceptic loss

Question 22

Spastic CP Diplegia (6)

Answer 22

• Most common form of the spastic forms
• Most are fully ambulatory with scissor’s gate
• May have dysarthria
• May be affected if neonatal asphyxia or jaundice of pre-maturity
• Epilepsy
• Intelligence (many have normal range and some have had above average ability

Question 23

Spastic CP Quadriplegia (8)

Answer 23

• All four limbs relatively equally affected
• Can have Triplegia
• Speech
• Hearing
• Often myopia and cataracts of prematurity (vision)
• Perception
• Epileptic fit once or twice in their childhood, often associated with an infective illness
• The level of intelligence has some relationship to the severity of the
handicap (intelligence)

Question 24

Non-Spastic CP Dyskinetic (6)

Answer 24

• Hypertonia and hypotonia
• Slow, wriggly, or sudden quick movements of the feet, arms, hands, or face muscles
• Constantly changing muscle tone – poor balance
• Dysarthria, dysphagia, and drooling accompany the movement problem
• Mental status: generally normal (severe dysarthria makes communication difficult and leads the observer to think that
the child has intellectual impairment)
• Sensorineural hearing dysfunction

Question 25

Non-Spastic CP Ataxic (6)

Answer 25

* Hypotonia during first 2 years of life * Muscle tone becomes normal; ataxia becomes apparent toward the age of 2-3 years * Dysmetria * Visual or auditory processing difficulty * Hypotonia and tremors * Impairment of motor skills like writing, typing, or using scissors

Question 26

Mixed CP

Answer 26

* It is possible to have both spastic and non-spastic | * Often certain limbs will be effected by spasm while others by athetosis

Question 27

Prenatal Hx from Mother (10)

Answer 27

- Prenatal exposure to illicit drugs, toxins or infections - Maternal diabetes - Acute maternal illness - Trauma - Radiation exposure - Prenatal care - Fetal movements - Hx of early frequent spontaneous abortions - -- Parental consanguinity (incest) - Family history of neurologic disease

Question 28

Perinatal Hx (11)

Answer 28

- Child’s gestational age at birth - Presentation of the child and delivery type - Birth weight - Apgar score Complications in the neonatal period: - Intubation time - Presence of intracranial hemorrhage on neonatal ultrasound - Feeding difficulties - Apnea - Bradycardia - Infections - Hyperbiliruninemia

Question 29

CP Developmental Hx

Answer 29

Review gross motor, fine motor, language, and social milestone from birth until time of evaluation

Question 30

What Gross motor milestones are we concerned with? (4)

Answer 30

* Head control at 2 months * Rolling at 4 months * Sitting at 6 months * Walking at 1 year

Question 31

CP- PE

Answer 31

* Microcephaly * Limb length discrepancies * Cataracts * Retinopathy * Congenital heart defects * Hypotonia/hypertonia * Hyperreflexia

Question 32

CP Diagnostic Testing (5)

Answer 32

* Rule out other neurologic disorders * Depending on presentation * MRI * EEG * Genetic Testing

Question 33

Supportive Tx (2)

Answer 33

Team Approach!! • Primary care provider, dentist, social worker, OT, PT, neurology, pulmonology, gastroenterology • Family centered: Goal of obtaining maximum function and potential in physical, occupational and speech ability

Question 34

CP Differential Diagnosis (7)

Answer 34

* Genetic Disease (e.g. Rett syndrome) * Degenerative nervous disorders * Muscle diseases * Metabolism disorders (e.g. glutaric aciduria type 1) * Nervous System Tumors * Brachial Plexus injury * Transient toe-walking

Question 35

Overal Treatments of CP

Answer 35

• Nutrition • Safety • Exercise • Glasses • Hearingaids • Muscle and bone braces • Walkingaids/Wheelchairs • Anticonvulsants to prevent or reduce the frequency of seizures • Botulin toxin to help with spasticity and drooling • Muscle relaxants (baclofen) to reduce tremors and spasticity • Assistive technology • Spinal cord stimulation • Feeding tubes • Release joint contractures • Surgery for GERD • Physical therapy & Occupational therapy • Speech therapy • Monitor burnout of parents and other care providers • Stem Cell in the future?