1. CEREBRAL PALSY: An Integrated Approach
Michael J. Ward, MD
Associate Professor, CHS
Orthopedics and Rehabilitation Medicine
University of Wisconsin Medical School
March 1, 2014

2. Cerebral Palsy: An Integrated Approach
Integrated Whole Person Perspective
Integrated Treatment Team Perspective
Integrated Medical Approach to Problems

3. MULTIDISCIPLINARY TEAM
MD: Rehabilitation, Developmental Pediatrics
Nursing
PT, OT , Speech Evaluations
Community resources:
Family,
School,
Equipment vendor
AFCH specialists:
Orthopedic Surgery,
Neuropsychology,
Neurology
Neurosurgery, Audiology, Feeding, Social Work, Psychology, CASC

4. WHAT IS CEREBRAL PALSY? ?

5. Modern consensus definition:
Group of disorders of movement and posture
Non-progressive etiology
Damage to the fetal or infant brain
Often accompanied by co-occurring problems with sensation, perception, communication, and/or behavior and/or seizure disorder
Bax 2005 DMCN

6. WHAT IS CEREBRAL PALSY?
Diagnosis of Cerebral Palsy has 4 requirements:
1. Non-progressive impairment
2. Immature or developing
3. Brain (cerebral)
4. Abnormal motor development (palsy)

7. DIAGNOSIS: Non-progressive
Excludes conditions which cause ongoing brain injury over time
Also excludes conditions which resolve
However, symptoms can transform through the life span even when the primary brain injury remains the same
CP is non-progressive, but not unchanging

8. DIAGNOSIS: Immature or developing brain
When does development end?
Embryonic formation of organs
Birth
2-3 years: Brain myelination completed
7-9 years: Maturation of motor skills
16-18 years: Physical maturity
Social maturity
Injury causing CP occurs before or around birth

9. DIAGNOSIS: Immature brain
Presentation of symptoms in CP:
Typically by 6-12 months
Mild cases may not be noticed until months
-Early abnormal motor signs in infants can disappear and would not be called CP

10. DIAGNOSIS: Brain impairment
Excludes diseases of spinal cord or muscles, etc.
Includes many different types of brain injuries

11. DIAGNOSIS: Brain injury
Most common source of injury:
Complex series of events in the brain set in motion after birth among newborns with prematurity and very low birth weight
Currently largest single etiology of cerebral palsy

12. DIAGNOSIS: Brain injury
Prematurity and low birth weight often associated with a brain change called PVL:
Periventricular leukomalacia
Peri = around
Ventricular = deep brain fluid spaces
Leuko = white matter
Malacia = thinning

13. DIAGNOSIS: MRI with Periventricular leukomalacia
Normal brain PVL

14. DIAGNOSIS: Etiology Includes a range of other types of brain injury:
Birth hypoxia Brain malformation
Prenatal stroke Encephalitis
Hyperbilirubinemia Other
Can be caused by a combination of factors
Occasionally the factors are not known

15. Cerebral Palsy: Cranial imaging findings
Bax JAMA 2006

16. DIAGNOSIS: Disturbance of motor development
Presenting motor symptoms also vary
Delayed motor milestones: not required
Spasticity: common but not required
Abnormal involuntary movements
Decreased quality of motor control

17. DIAGNOSIS: Disturbance of motor development
CP is usually described by type of motor problem
Spastic types most common, and described by distribution
Quadriplegic: both arms and both legs
Hemiplegic: Arm and leg on both sides
Diplegic: Both legs more impaired than both arms

18. DIAGNOSIS Disturbance of motor development
CP is usually described by type of motor problem
Other types:
Dystonic
Dyskinetic (choreoathetosis)
Ataxic

19. DIAGNOSIS: Types by motor pattern

20. DIAGNOSIS: Disturbance of motor development
There is partial correlation between etiology and type of motor problem:
MRI abnormality Motor problem
PVL Diplegia
Birth Hypoxia Quadriplegia and dystonia
Prenatal stroke Hemiplegia

21. DIAGNOSIS: MRI with Periventricular leukomalacia
Normal brain PVL

22. DIAGNOSIS: Disturbance of motor development
Required for diagnosis
The definition is mute on sensory, cognitive, or behavioral dysfunction, but…
CP is not an exclusively motor condition

23. CEREBRAL PALSY Associated concerns
Cognitive
Cognitive impairment 40-60%
Learning disabilities common
Attention deficit disorder
Other behavioral disturbances
Language disorders

24. CEREBRAL PALSY Associated concerns
Sensory abnormalities:
Hearing loss 7-12%
Abnormal control of eye motions 20-60%
Visual impairment overall 80%
Visuoperceptual abnormality also frequent
Tactile impairment 50-75%
Balance system impairment

25. CEREBRAL PALSY Associated medical concerns
Seizures 30-50%
Autonomic nervous system also affected:
Abnormal digestive motility
Temperature instability and cold or hot limbs
Bladder dysfunction
Breathing irregularities

26. CEREBRAL PALSY Associated concerns
Secondary problems: Gastrointestinal
Malnutrition
Growth delays
Gastric reflux
Constipation
Swallowing difficulties
Drooling
Dental changes

27. CEREBRAL PALSY Associated concerns
Many orthopedic complications:
Osteoporosis and fractures (even in children)
Scoliosis
Joint deformities
Musculoskeletal pain
Associated skin problems
Skin pressure ulcers
Moisture related skin problems

28. PROGNOSIS WILL MY CHILD ????????? Related to underlying etiology
Related to motor, cognitive and sensory abilities
Risks v absolutes in early period
Requires serial discussions

29. MOTOR DELAYS: GMFCS Gross Motor Classification System
Track curves of motor development in children with CP from early milestones to adult skills achievement.
Predicts general trends at 5 functional levels

30. MOTOR DELAYS:
GMFCS: Gross Motor Classification System for mobility MACS: Manual Abilities Classification System for hand function CFCS: Functional Communication Scale for speech All describe 5 functional ability levels

31. MOTOR DELAYS: GMFCS
Level I: Walks without limitations Level II: Walks with limitations Level III: Ambulation with device only Level IV: Limited mobility, power wheelchair Level V: Dependent manual wheelchair

32. GMFCS

33. MOTOR DELAYS: REHABILITATION INTERVENTIONS
Physical therapy
Orthopedic surgery
Spasticity reduction
Casting/splinting
Bracing
Mobility aids
Help but do not change the GMFCS level (usually)

34. Combining all of this provides a more complete description of CP:
Type: Spastic Distribution: Quadriplegic Etiology: VLBW and prematurity MRI Imaging: Periventricular leukomalacia Functioning: GMFCS V, MACS IV, CFCS III Associated: Cognitive, visual, orthopedic, etc.

35. Modern consensus definition:
Group of disorders of movement and posture
Non-progressive etiology
Damage to the fetal or infant brain
Often accompanied by co-occurring problems with sensation, perception, communication, and/or behavior and/or seizure disorder
Bax 2005 DMCN

36. WHAT IS THE MOST COMMON MEDICAL PROBLEM ADDRESSED WITH CHILDREN WHO HAVE CEREBRAL PALSY?

37. CONSTIPATION: Contributing factors
Poor hydration, poor hydration, poor hydration
Poor dietary fiber intake
Impaired GI motility
Behavioral/developmental level
Physical access to toilet, safe sitting position
Sensory processing

38. CONSTIPATION: Treatment approaches
Fluids, fluids, fluids
Increased dietary fiber
Swallow abilities and feeding behaviors important
Oral or rectal medications
Bathroom access and support on the toilet
Behavioral approaches to toileting based on cognitive
abilities and developmental level

39. MULTIDISCIPLINARY TEAM
MD: Rehabilitation, Developmental Pediatrics
Nursing
PT, OT , Speech Evaluations
Community resources:
Family,
School,
Equipment vendor
AFCH specialists:
Orthopedic Surgery,
Neuropsychology,
Neurology
Neurosurgery, Audiology, Feeding, Social Work, Psychology, CASC

40. TEAM SUPPORT ACROSS THE LIFESPAN
Newborn Follow-up Clinic: child at risk
Neuromotor Development Clinic: child with delay
Cerebral Palsy Clinic: child with disability
Transition to adult providers

41. TEAM SUPPORT ACROSS THE LIFESPAN
Newborn Follow-up Clinic: child at risk
Feeding Clinic, Audiology, Resource center
Neuromotor Development Clinic: child with delay
Orthopedic Surgery, Neurology, Genetic Evaluations
Cerebral Palsy Clinic: child with disability
Spasticity and Movement Disorder clinic, CASC
Transition to adult providers
DVR, Guardianship, Independent Living

42. Cerebral Palsy: An Integrated Approach
Integrated Whole Person Perspective
Integrated Treatment Team Perspective
Integrated Medical Approach to Problems