Download Cerebral palsy (CP) - IAP Neurology Chapter

Cerebral palsy (CP)
•
Neurology Chapter of IAP
CP
• W & W 1966-1975
• Non-specific term that include disorders
characterized by early onset and
impaired movement and posture.
• Non-progressive and may include
perceptual problems, language deficits,
and intellectual involvement.
Neurology Chapter of IAP
CP
•
Neurology Chapter of IAP
Incidence
• Most common physical disability of
childhood.
• Incidence has increased since the 60’s,
maybe due to improved survival of
VLBW infants.
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Etiology
• Variety of perinatal, prenatal, and postnatal
factors contribute, either singly or
multifactorily to CP.
• Commonly thought to be due to birth
asphyxia; now known to be due to existing
prenatal brain abnormalities.
• Premature delivery is the single most
important determinant of CP.
• In 24% of cases, no cause is found.
Neurology Chapter of IAP
TABLE 40-1 Causes of CP
• Time (% of cases)
• Prenatal (44%)
– First trimester
– Second trimester
• Causes
• Teratogens,
chromosomal
abnormalities, genetic
syndromes, brain
malformations
• Intrauterine infections,
problems in
fetal/placental
functioning
Neurology Chapter of IAP
Neurology Chapter of IAP
Causes of CP
• Time (% of cases)
• Labor and delivery
(19%)
• Perinatal (8%)
• Childhood (5%)
• Causes
• Preeclampsia,
complications of labor
and delivery
• Sepsis/CNS infection,
asphyxia, prematurity
• Meningitis, traumatic
brain injury, toxins
• Not obvious (24%)
Neurology Chapter of IAP
Clinical Classification of CP
• Table 40-2, Page 1967.
• Spastic-hypertonicity with poor posture
control
• Dyskinetic/athetoid- abnormal involuntary
movement/slow wormlike writhing
• Ataxic- wide-based gait
• Mixed-type/dystonic- combination of spasticity
and athetosis
Neurology Chapter of IAP
Neurology Chapter of IAP
Clinical manifestations
• Delayed gross motor development
– A universal manifestation of CP
– The discrepancy between motor ability and
expected achievement tends to increase
as growth advances.
– Delayed development of ability to balance
slows milestones
– Delay in all motor accomplishments
Neurology Chapter of IAP
Neurology Chapter of IAP
Clinical Manifestations
• Abnormal motor performance
– Preferential unilateral hand use may be apparent
at 6 months.
– Hemiplegia, abnormal crawling or asymmetrical
crawl; spasticity may cause child to walk and stand
on toes
– dyskinetic CP or uncoordinated or involuntary
movements (writhing tongue, fingers, and toes;
facial grimacing), poor sucking and feeding,
persistent tongue thrust; head staggering, tremor
on reaching, truncal ataxia.
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Neurology Chapter of IAP
Neurology Chapter of IAP
Alterations in muscle tone
• Increased or decreased resistance to passive
movement (abnormal muscle tone).
• Opisthotonic postures or exaggerated back
arching, feel stiff on dressing.
• Difficulty diapering due to spastic hip
adductor muscles and lower extremities
• When pulled to a sitting position, child may
extend the entire body and be rigid at hip and
knee. This is an early sign of spasticity.
Neurology Chapter of IAP
Neurology Chapter of IAP
Abnormal postures
• Children with spastic CP have abnormal posture at
rest or when position is changed
• Infantile lying prone may have hip higher than trunk
with legs and arms drawn in.
• Persistent infantile resting and sleeping position is a
sign of spasticity.
• Hemiparetic child may rest with affected arm
adducted and held against torso, with the elbow
pronated and slightly flexed and the hand closed.
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Neurology Chapter of IAP
Reflex Abnormalities
• Persistence of primitive infantile reflexes
(one of the earliest signs of CP)
– Tonic neck reflex
– Hyperactivity or moro, plantar, palmar
grasp
Hyperreflexia, ankle clonus, stretch reflexes
can be elicited from any muscle group.
Neurology Chapter of IAP
Associated disabilities and
problems
• Intellectual impairment
– 70% w/in normal limits; wide range
– Tests should be carried out over a period of time.
– Children with athetosis and ataxia more intelligent.
Speech difficulties (not a sign or MR)- child has
motor and sensory defects
ADHD- (may occur)-poor attention span, marked
distractibility, hyperactive behavior
Neurology Chapter of IAP
Neurology Chapter of IAP
ASSOCIATED DISABILITIES
Seizures- generalized tonic-clonic;more in postnatally
acquired hemiplegia
Drooling- may occur and lead to wet clothing/skin
irritation
Feeding- alterations in muscle tone lead to difficulties
chewing, swallowing, talking, etc.
Address nutritional concerns.
Coughing, choking may lead to aspiration.
Altered respiratory patterns may lead to inadequate
gas exchange.
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Motor Impairment
• Orthopedic complications
– Unilateral or bilateral hip dislocations, scoliosis, joint
contractures due to unbalanced muscle tone.
Decreased Mobility
– difficulties with toileting may lead to constipation
– Difficult chewing bulky foods may lead to constipation
– May need stool softeners or laxatives
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Associated Problems
• Dental carries
– Improper dental hygiene
– congenital enamel defects (hyperplasia of primary
teeth)
– high carbohydrate intake and retention
– Dietary balance with poor nutritional intake
– Inadequate fluoride
– Difficulty in mouth closure and drooling
– Spastic or clonic movements cause gagging or
biting on toothbrush
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Associated Problems
• Malocclusion in 90% of children
• Oral hypersensitivity causes resistance
to good hygiene
• Gingivitis is secondary to poor hygiene
• Dental health further complicated by
anti-seizure meds
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Associated problems
• Nystagmus and amblyopia common
– May need surgery or corrective lenses
– May be due to sensoneural involvement
– Infants lying flat too long may have otitis
media which may leads to conductive
hearing loss
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Diagnostic Studies
• Physical Assessment
• Observe LBW, preterm, and those with
low Apgar scores at 5 minutes.
• Observe infants who have seizures,
intracranial hemorrhage, metabolic
disturbances
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DX studies
• Since control of movement does not
occur until late infancy, dx may not be
confirmed until after 6 months of age.
• See Box 4-4, page 1968 for warning
signs
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WARNING SIGNS
• Physical Signs
• poor head control after 3 months
• stiff or rigid arms/legs, arching back, floppy
or limp posture
• Cannot sit up without support by 8 months
• Uses only one side of the body or only the
arms to crawl
Neurology Chapter of IAP
Warning Signs
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Behavioral Signs
Extreme irritability or crying
Failure to smile by 3 months
Feeding difficulties
– Persistent gagging or choking when fed
– After 6 months of age, tongue pushes soft
food out of the mouth.
Neurology Chapter of IAP
Therapeutic management
• Box 40-5, Wong 1970.
• PHYSICAL THERAPY
– Most commonly used treatments.
– Goal is good skeletal alignment for the spastic
child.
– For the child with athetosis, training in purposeful
acts, even in the face of involuntary motion
– Maximum development of proprioceptive sense for
the child with ataxia.
– Orthotic devices (braces, splints, casting).
Neurology Chapter of IAP
Neurology Chapter of IAP
OCCUPATIONAL THERAPY
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Training in ADL’s along developmental lines.
Sitting to walking; feeding to cooking.
Important to incorporate play into program
Adaptive equipment (utensils for functional
use, i.e., eating, writing), computers, etc.
Neurology Chapter of IAP
Neurology Chapter of IAP
Speech/Language therapy
• Early speech training by
speech/language pathologist !
– Before child develops poor habits
– Advice parents to follow directions of
therapist
– May need to force child to use tongue/lips
in eating
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Special Education
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Determined by child’s needs
Early intervention programs
Individualized Education Program (IEP)
Specialized learning programs and
support services in schools
• Socialization to promote self-concept
development
Neurology Chapter of IAP
Surgical Intervention
• Reserved for child who does not
respond to conservative therapy!
– Or whose spasticity causes progressive
deformities
Orthopedic surgery
– correct contractures or spastic deformities
– provide stability for uncontrolled joint
– provide balanced muscle power
Neurology Chapter of IAP
Surgical Therapy
• Tendon-lengthening procedures (heel-cord)
• Release of spastic wrist flexor muscles
• Correction of hip-adductor muscle spasticity
or contracture to improve locomotion
• Surgery is for improved function rather than
cosmetic reasons and is followed by PT.
Neurology Chapter of IAP
Medication Therapy
• Little usefulness
• Anti-anxiety agents may relieve excessive
motion and tension (child with athetosis)
– Skeletal muscle relaxants ( methocarbamol
(Tobaxin), dantrolene (Dantrium), Baclofen, may
be used short-term for older children and
adolescents.
– Diazepam (Valium) for older children and
adolescents, may relieve stiffness and ease motion
Neurology Chapter of IAP
Medications
• Local nerve blocks to motor points of a
muscle with a neurolytic agent (phenol
solution) may relieve spasticity.
• Botulism toxin (Botox) used to paralyze
certain muscles.
• Pain
• Secondary conditions (seizures, bowel and
bladder problems, lung complications).
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Service Coordination
• Case Management!
• Important for collaboration of all health
professionals, services, therapies!
• Child needs support!
• Family needs support!
Neurology Chapter of IAP