Cerebral palsy

  • Cerebral palsy is a persistent qualitative motor disorder which appears before age three and is due to non-progressive damage to the brain.
  • The cerebral palsies of childhood are predominantly motor syndromes
  • an abnormality of movement or posture and tone which is usually not progressive
  • commonly associated with sensory abnormalities, cognitive deficits and epilepsy.
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Cerebral palsy is caused by a lesion that is permanent and non-progressive.
Possible causes of cerebral palsy include:
  1. cerebral malformation. Up to 60% of cerebral palsy is due to early prenatal abnormality.
  2. trauma - birth, postnatal
  3. hypoxia
  4. kernicterus
  5. hypoglycaemia
  6. infection
  7. cerebrovascular accident
  8. poisoning
  9. toxins
  10. HIV infection

Clinical features general to cerebral palsy

  1. poor sucking ability
  2. increased or decreased muscle tone
  3. abnormal reflexes - persisting beyond the appropriate time
  4. irritability
  5. convulsions (epilepsy occurs in about 60% of cases)
  6. drowsiness
Symptoms that may be reported by the parents of an affected infant include:
    1. no head control at 3 months
    2. not sitting without support at 10 months
    3. stiff on handling
    4. development of hand preference before one year


Types of cerebral palsy

Ataxic cerebral palsy
Ataxic cerebral palsy accounts for approximately 10% of cerebral palsy cases.
The main clinical features are:
  • cerebellar ataxia e.g. uncoordinated movements
  • loss of power and hypotonia
  • tremor

Dyskinetic /choreoathetoid cerebral palsy (Congenital)
  • accounts for about 10% of all cases of cerebral palsy
  • cerebral palsy ocurs following kernicterus and hypoxia.
  • characterised by involuntary movements, usually chorea, athetosis and dystonia of the limbs, trunk, face and bulbar muscles.
  • The onset of this condition is delayed for some months after birth.
  • Initially there is hypotonia, then active reflexes in infancy developing to choreoathetosis in childhood.
  • The severity of the choreoathetosis can vary from mild incoordinate movements to constant writhing movements resulting in complete helplessness.
  • Intellect may be normal but communication may be difficult because of marked dysarthria, and in the case of kernicterus, deafness.

spastic cerebral palsy

General features of this type of cerebral palsy are brisk tendon reflexes and extensor plantar responses.
There are three types of spastic cerebral palsy.

1. Little's disease

  • congenital stiffness of the limbs due to failure of development of the pyramidal tracts.
  • This condition may be seen as a complication in infants born prematurely.

clinical features


  • both legs are spastic, weak and clumsy, and are held usually in extension and adduction.



  • typical scissor gait due to severe spasticity.



  • lesser involvement of the arms, face and bulbar muscles.



  • There is a delay in motor development and there is often mental retardation.



  • brisk tendon reflexes and an extensor planter response



  • child may have frequent falls, be clumsy, and show a lack of agility.



  • children tend to wear their shoes out on the toes and have difficulty in running



  • 2. Infantile hemiplegia

    • noted at birth to first six months of life ,there is often an abrupt onset.
    • probably is caused by a cerebrovascular accident in utero or in the perinatal period.
    • It occurs: in boys > girls, and affects the right side > left side ( 2: 1)

    clinical features

    • spastic weakness of baby's arms and legs
    • growth arrest ( apparent after 6 months of paresis)
    • Sensory abnormalities ( 60% of cases)
    • Epilepsy is a common
    • No mental retardation

    3. Double hemiplegia (quadriplegia)

    • Form of cerebral palsy resulting in bilateral spastic weakness of face, arm and leg
    • The main feature is that in contrast to spastic diplegia the arms are severely affected, as well as the legs.
    • In severe disease there is persistent fisting of the thumb with hypertonia and hyperreflexia.
    • Rigidity, as opposed to spasticity, is the dominant feature.

    Associated conditions

    1. mental handicap: about 60% of children
    2. epilepsy occurs in about 60% of cases.
    3. visual impairment occurs in about 20% ( errors of refraction, diffuse amblyopia or optic atrophy)
    4. hearing loss, usually sensorineural.
    5. there is also a high incidence of speech disorders among patients with cerebral palsy, due to problems of incoordination of tongue, palate and lip muscles, as well as a result of hearing losses or perceptual defects.

    Management

    based on a multi-disciplinary approach
    • physiotherapy: to encourage normal motor development, to inhibit abnormal motor development and to prevent contractures.
    • speech therapy : to help with drooling, speech or communication with sign
    • occupational therapy :  to address problems such as dressing and adaptation of the home environment


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