Cerebral Palsy = Brain Paralysis

Complications of Neurodevelopmental Mental Disorders Cognitive Dysfunction Motor Dysfunction Seizures Behavior Dysfunction

Definition Cerebral palsy is a symptom complex, (not a disease) that has multiple etiologies. CP is a disorder of tone, posture or movement due to a lesion in the developing brain. Lesion results in paralysis, weakness, incoordination or abnormal movement Not contagious, no cure. It is static, but it symptoms may change with maturation

Cerebral Palsy Brain damage Occurs during developmental period Motor dysfunction Not Curable Non-progressive (static) Any regression or deterioration of motor or intellectual skills should prompt a search for a degenerative disease Therapy can help improve function

Cerebral Palsy There are 2 major types of CP, depending on location of lesions: Pyramidal (Spastic) Extrapyramidal There is overlap of both symptoms and anatomic lesions.

Epidemiology The overall prevalence of cerebral palsy ranges from 1.5 to 2.5 per 1000 live births. The overall prevalence of CP has remained stable since the 1960’s. Likewise the expected decrease in CP as a result of C-section and fetal monitoring has not happened.

Epidemiology Due to the increased survival of very low birth weight preemies, the incidence of spastic diplegia has increased. Choreoathetoid CP, due to kernicterus, has decreased. Multiple gestation carries an increased risk of CP.

Distribution of the Types of CP Cerebral Palsy Frequency of Distribution Nonspastic (extrapyramidal and mixed types) 23% Spastic CP (total) 77% Spastic Diplegia 21% Spastic Hemiplegia Spastic Quadriplegia

The severity Cerebral Palsy can be classified by how severe it’s effects on movement and muscle tone are Severe : 혼자 독립적으로 일상생활을 할 수 없으며 항상 보조기와 보 호자가 필요 Moderate : 약간의 도움으로 일상생활을 수행할 수 있고 완전한 활동 을 위해 보조기의 착용이 필요 Mild : 독립적으로 일상생활을 수행할 수 있고 보조기 착용없이 보행가 능 All three areas (movement, body part and severity) are then joined together to classify or describe the type of Cerebral Palsy eg: Severe spastic hemiplegia.

Cerebral Palsy : Etiologic Prenatal (70%) Infection, anoxia, toxic, vascular, Rh disease, genetic, congenital malformation of brain Natal (5-10%) : 난산 Anoxia, traumatic delivery, metabolic(jaundice etc) Post natal Trauma, infection, toxic

Natal 전치태반 (Placenta previa)

Natal 둔위분만(Breech delivery)

Natal 겸자분만 (forceps delivery)

Post natal meningitis

Post natal hydrocephalus

Cerebral Palsy: Classification Various classifications of Cerebral Palsy Physiologic Topographic Etiologic

Cerebral Palsy: Physiologic Athetoid Ataxic Rigid-Spastic Atonic Mixed

Cerebral Palsy: Topographic Monoplegic Paraplegic Hemiplegic Triplegic Quadraplegic Diplegic

Cerebral Palsy : Clinical Presentation Remember that motor developmental progression is from…. Head to Toe

Types of Cerebral Palsy Pyramidal (Spastic) Quadriplegia- all 4 extremities Hemiplegia- one side of the body Diplegia- legs worse than arms Paraplegia- legs only Monoplegia- one extremity

According to Pattern of involvement Monoplegia : one limb / rare Diplegia : both LL >> UL / good intelligence / prematurity Hemiplegia : unilateral usually UL > LL / 33 % seizures 50 % mentally retarded Triplegia : rare / usually both LL + one UL Quadriplegia : total body / often mentally retarded / with seizures / severe hypoxia Double hemiplegia : bilateral UL > LL

Cerebral palsy Spastic Diplegia The most common type Speech / intellect: normal – slightly impaired UL(gross motor well done) minor incoordination of fine motor skills LL (spastic) hip : flexion, adduction, int. rotation knee : flexor / extensor spasticity /or equal ankle : equinus foot : pes valgus Most walk independently by 4 years

Cerebral palsy Spastic Hemiplegia 30 % of all CP One side affection upper > lower extremity 50 % mentally retarded 33 % seizures

Cerebral palsy Spastic Quadriplegia All four limbs involved – and trunk Often mentally retarded With seizures Most ( 80 % ) non walkers

Cerebral palsy Clinical Assessment : Upper Limb Elbow flexion Forearm pronation Wrist flexion Finger flexion Thumb in palm

Cerebral palsy Clinical Assessment : Upper Limb Wrist palmar-flexed Wrist dorsi-flexed

Extrapyramidal ; Divided into Dyskinetic and Ataxic types Athetosis- slow writhing, wormlike Chorea- quick, jerky movements Choreoathetosis- mixed Hypotonia- floppy, low muscle tone, little movement Ataxic CP Results from damage to the cerebellum Ataxia- tremor & drunken- like gait

Anatomy Pyramidal Lesion is usually in the motor cortex, internal capsule and/or cortical spinal tracts. Extrapyramidal Lesion is usually in the basal ganglia, Thalamus, Subthalamic nucleus and/or cerebellum.

Comparison of Symptoms Pyramidal Extrapyramidal Tone increased alternating Type of tone spastic rigid DTR’s normal to increased Clonus Present occ. present Contractures early late Primitive Reflexes delayed persistent Involuntary movements rare frequent

Cerebral Palsy: Complications Spasticity Weakness Increase reflexes Clonus Seizures Articulation & Swallowing difficulty Visual compromise Deformation Hip dislocation Kyphoscoliosis Constipation Urinary tract infection

Associated Problems Mental Retardation Communication Disorders Neurobehavioral Seizures Vision Disorders Hearing loss Somatosensation (skin sensation, body awareness) Temperature instability Nutrition Drooling Dentition problems Neurogenic bladder Neurogenic bowel Gastroesophageal reflux Dysphagia Autonomic dysfunction

Cerebral Palsy: Management Neurologic and Physiatric OT and PT Speech Adaptive equipment Surgical Rhizotomy, Baclofen pumps, Botoxin

Medical Management Growth Persons with CP often have struggle to gain or maintain weight. Failure to Thrive is a common problem. Before diagnosing Failure to thrive, an accurate Body Mass Index must be obtained, but an accurate height is difficult to obtain in a person with severe contractures. In such cases, arm span calculations may be used and a growth chart is available to determine percentiles standardized to age and gender.

Medical Management Orthopedic Problems Scoliosis Hip Dislocations Contractures Osteoporosis

Medical Management Oromotor Dysfunction Especially common in persons with Extrapyramidal CP and Spastic quadriplegia Language delay/Speech delays Drooling Dysphagia Aspiration

Gastrointestinal Dysmotility Medical Management Gastrointestinal Dysmotility Delayed gastric emptying Gastroesophageal reflux Pain Chronic aspiration Constipation These disorders are interrelated and compound one another.

Spasticity Management Medical Management Spasticity Management Management of spasticity does not fix the underlying pathology of CP, but it may decreased the sequelae of increased tone. Over time, the spasticity leads to: musculoskeletal deformity scoliosis hip dislocation contractures Pain Hygiene problems

Treatment of Spasticity Medications Valium Dantrium Baclofen Clonidine Clonazepam BOTOX

Cerebral Palsy What is substantially disabling Cerebral Palsy? Mobility Communication Learning Self Care Self Direction Independent Living Economic Sufficiency

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