1. Cerebral Palsy A collection of diverse syndromes characterized by disorder of movement and posture caused by a non-progressive injury to the immature brain. A change in muscle tone at rest and in activity.

2. Manifestations Floppy infant/Increase tone Delayed motor development Poor sucking Persistent primitive reflexes

3. per 1,000 live births Incidence 1 - 2.3 Prevalence 5.2

4. Factors that Increase Incidence Low birth weight: <2,500g Gestational age: <32 weeks Maternal Factors – Mental retardation – Seizure disorder – Hypothyroidism – 2 or more prior fetal deaths – Siblings with motor deficits – 3rd trimester bleeding

5. Most Common Antecedent Fetal bradycardia Fetal growth retardation Low placental weight Fetal malformation Neonatal seizures Premature placental separation Newborn encephalopathy

6. Etiology Brain injury that occurs prenatal, perinatal or postnatal period. Premature infants (immaturity in fragile brain vasculature, physical stress). Watershed zone next to the lateral ventricles are particularly vulnerable.

7. Clinical Diagnosis High risk history - “POSTER” clinical presentation Posture – FSP, ESP, opisthotonus, scissoring Oral Motor - tongue thrust, tonic bite Strabismus Tone (While awake and not struggling) Evolution of Postural Reactions Reflexes – MSRs, clonus, Babinski

8. Diagnosis Confirmed by MRI Other tests - Metabolic, biochemical, genetic testing - Developmental assessment and screening tests - Denver Developmental Screening, Beyley Scale - Intellectual evaluation - Standford Binet scale - Motor function measures - GMFM, Pedi, weeFim, Quest

9. Classification By limb affectation 1. Monoplegia 2. Diplegia 3. Hemiplegia 4. Quadriplegia

10. Classification By muscle tone 1. Spastic - The most common type - Increased in muscle tone - Affects ¾ of all CP - Sometimes presents as lead pipe rigidity - Signs of UMN Lesion (Babinski, hyperactive reflexes)

11. 2. Dyskinetic - With involuntary movements - Impairments in postural stability - Fluctuating tone a. Athetoid - Slow writhing posturing - Basal ganglia damage - Hyperbilirubinemia (Rh and ABO incompatibility) - Severe anoxia

12. b. Choreiform c. Ballistic d. Ataxic - Rare - Mimic cerebellar dysfunction 3. Hypotonic - Needs to be differentiated from other causes of neonatal hypotonia (SMA, metabolic, genetic syndromes) - Most often is the initial presentation of Cerebral Palsy spastic and extrapyramidal type

13. 4. Mixed - Most often spastic plus athetoid type

14. Gross Motor Functional Classification Level 1 Walks without Restriction Limitation in high level skill Level 2 Walks without assistive devices Limitation in walking outdoors Level 3 Walks with devices Limitation in walking outdoors Level 4 Limited mobility Power mobility outdoors Level 5Very limited mobility even with assistive technology