1. Cerebral Palsy Victor Politi, M.D., FACP
Medical Director, SVCMC, School of Allied Health Professions, Physician Assistant Program

2. Cerebral Palsy
"Cerebral" refers to the brain and "palsy" to a disorder of movement or posture.
It is neither progressive nor communicable

3. Overview
Cerebral palsy is a general term that describes a group of disorders that appear in the first few years of life and affect a child's ability to coordinate body movements.
This results in difficulties in movement and posture.
Cerebral palsy has different causes, and affects each person differently, therefore people with cerebral palsy have varying individual needs.

4. Overview
Cerebral palsy is the most common physical disability in childhood.
It is estimated 2 to 3 people out of every 1000 will have cerebral palsy.
This condition is not hereditary and there is no cure.
Many causes of cerebral palsy are still not known or understood.
Injury or changes to the developing brain are associated with cerebral palsy.

6. Overview
The muscles of speech, swallowing and breathing may be involved.
Intellectual disabilities (mental retardation) and seizures can also occur, but these problems are not always present.

7. There are about 500,000 persons who have cerebral palsy in the United States

9. Overview
In the early months of life it is sometimes difficult to determine if a child has cerebral palsy.
The condition may only be identified when a child experiences delays with the movement and postural development needed for sitting and standing.

10. Overview
Cerebral palsy is characterized by an inability to fully control motor function.
Depending on which part of the brain has been damaged and the degree of involvement of the central nervous system, one or more of the following may occur ---

11. Overview spasms tonal problems involuntary movement
disturbance in gait and mobility
Seizures
abnormal sensation and perception
impairment of sight, hearing or speech
mental retardation

12. Overview 1. The cortex – 2. The basal ganglia – 3. The cerebellum –
controls thought, movement and sensation.
An abnormality in the movement area of the cortex can result in spastic cerebral palsy
2. The basal ganglia –
helps movement become organized, graceful and economical.
An abnormality can result in athetoid cerebral palsy
3. The cerebellum –
coordinates movement, posture and balance.
An abnormality can result in ataxic cerebral palsy

13. What part of the body is affected?
Hemiplegia - the leg and arm on one side of the body are affected.
Diplegia - both legs and both arms are affected but the legs are significantly more affected than the arms. Children with diplegia usually have some clumsiness with their hand movements.
Quadriplegia - both arms and legs are affected. The muscles of the trunk, face and mouth can also be affected.

15. Types of cerebral palsy
There are three major types of cerebral palsy:
Spastic cerebral palsy
Athetotic cerebral palsy
Ataxic cerebral palsy

16. Types of Cerebral Palsy
Some children have signs and symptoms of more than one type of cerebral palsy, which may be referred to as a mixed form of the condition.

17. Spastic cerebral palsy
Most children with cerebral palsy have spastic cerebral palsy.
This form of the condition causes muscles to stiffen, which makes movement difficult.

18. Spastic cerebral palsy
It can affect both legs (spastic diplegia), or it can affect one side of the body (spastic hemiplegia).
In the most severe cases, all four limbs and the trunk are affected (spastic quadriplegia).

19. Athetotic cerebral palsy
10 to 20 percent of people with cerebral palsy have this form, which is also referred to as extrapyramidal cerebral palsy.

20. Athetotic cerebral palsy
It affects the entire body and often causes uncontrolled, slow movements.
children with athetoid cerebral palsy often have very weak muscles or feel floppy when they are carried.

21. Ataxic cerebral palsy
This is the least common of the major types of cerebral palsy.
It affects balance and coordination.
characterised by unsteady, shaky movements or tremor.

22. Ataxic cerebral palsy
People with ataxic cerebral palsy have difficulty using muscles to achieve balance and coordinated movement.

23. Signs and Symptoms
In general, children with cerebral palsy exhibit a wide variety of signs and symptoms, ranging from mild to severe.

24. Signs and Symptoms
These signs and symptoms don't worsen with age. They may include:
Ataxia (a lack of muscle coordination when performing voluntary movements)
Spasticity (stiff muscles and exaggerated reflexes)
Asymmetrical walking gait, with one foot or leg dragging
Variations in muscle tone, from too stiff to too floppy
Excessive drooling or difficulties swallowing, sucking or speaking
Tremors
Difficulty with precise motions, such as writing or buttoning a shirt

25. Signs and Symptoms
Some children with cerebral palsy have severe mental retardation, but others are extremely bright.
Many need a wheelchair and extensive, lifelong care, but some require little or no special assistance.

26. Causes
Cerebral palsy results from an abnormality in or injury to the cerebrum — the largest area of the brain, which controls sensation and voluntary motor function.

27. Causes
Although cerebral palsy affects movement, the underlying problem originates in the brain, not in the muscles themselves.

28. Causes
A small number of children with cerebral palsy acquire the disorder after birth.
In these cases, sometimes a specific reason for the neurological problem can be pinpointed.
For example, cerebral palsy can develop following an illness during early infancy, such as bacterial meningitis. It can also be the result of a head injury.

29. Causes
The cause of most cases of congenital cerebral palsy are not understood.
For many years, it was believed that cerebral palsy was caused by a lack of oxygen during birth. However, it is now believed that only a small number of cases are caused by problems during labor and delivery.

30. Causes Identifiable causes of congenital cerebral palsy include:
Maternal infection during pregnancy, such as rubella or other viral infections
Severe jaundice in newborns, which may be caused by infection, severe bruising or problems with red blood cells due to ABO or Rh incompatibility
Abnormal brain development before birth, resulting from genetic causes or metabolic disorders
Disturbance to brain circulation before birth, caused by an artery spasm or blood clot, similar to a stroke in adults

31. Risk Factors for Developing Cerebral Palsy
Infection of mother during pregnancy
including rubella (German measles) and other infections in the womb
Premature delivery or low birth weight
premature babies have immature brain tissue that is susceptible to injury
Inadequate oxygen or blood flow to the brain in the mother's womb or during delivery
Rh disease

32. Risk Factors for Developing Cerebral Palsy
Congenital (birth) defects
Head trauma
(including shaken baby syndrome)
Jaundice in the newborn baby
Or it may occur early in life as a result of an accident, lead poisoning, viral infection, child abuse, or other factors

33. Risk Factors for Developing Cerebral Palsy
A less common type is acquired cerebral palsy:
head injury is the most frequent cause, usually the result of motor vehicle accidents, falls, or child abuse.

34. Screening and diagnosis
Early signs of cerebral palsy may be present from birth, but it's often difficult to make a definite diagnosis during the first six months.
Cerebral palsy is generally diagnosed by age 1 or 2.

35. Screening and diagnosis
A physician will generally observe the child and discuss their physical and behavioral development. Reflexes, muscle tone and movements will be checked
Additional tests may rule out other disorders that can cause movement problems. CT
MRi
Genetic and/or metabolic blood work-up

36. Screening and diagnosis
Referrals
pediatric neurologist
developmental pediatrician
physiatrist

37. Complications
Besides difficulty with movement and posture, cerebral palsy may result in these health problems:
Development of joint deformities or dislocation, if there's considerable spasticity
Nutrition problems, if there are swallowing or feeding difficulties

38. Complications
Some children with cerebral palsy will have multiple handicaps and may require long-term care. Some of the associated problems may include:
Difficulty with vision, hearing and speech
Dental problems
Mental retardation
Seizures
Abnormal sensation or perception
Incontinence

39. Treatment
The brain abnormality or damage that underlies cerebral palsy doesn't worsen with time, but children with cerebral palsy often require long-term care.
The type and amount of treatment depend on how many problems the child has and how severe they are.

40. Treatment
The goal of treatment is to help the child reach his or her maximum potential.
Reaching this goal typically requires a multidisciplinary team working together to address issues of social and emotional development, communication, education, nutrition and mobility.

41. Treatment Physical therapy –
Muscle training and exercises may help improve strength, balance and mobility and lead to greater independence.
Braces, splints or casts may be used to improve hand and leg function and prevent contractures — a condition in which muscles become fixed in a rigid, abnormal position.

43. Treatment Occupational therapy-
Focuses on helping the child learn skills for daily living.
May involve hand skills and self-care skills such as feeding and dressing

44. Treatment Speech therapy –
A speech therapist may be able not only to help the child speak better, but also to improve eating skills.

45. Treatment Vision and hearing aids –
eyeglasses or surgery to correct a condition such as cross-eye or other inability of the eyes to focus together properly (strabismus).
Hearing aids may help correct any hearing problems.

46. Treatment Medications –
These may include muscle relaxants to ease muscle stiffness and anticonvulsants to reduce seizures.
Injections of botulinum toxin (Botox) directly into spastic muscles also may be helpful

47. Treatment
Surgery –
severe contractures may require surgery on muscles, tendons, nerves or joints to place arms and legs in their correct positions. This can make it easier to use a walker, braces or crutches.

48. Treatment
Children with severe spasticity who haven't responded to oral medications may also benefit from surgical procedures.
Dorsal rhizotomy - a procedure in which surgeons identify and cut a portion of the spinal sensory roots that control the leg muscles. .

49. Treatment
Intrathecal baclofen – an intraspinal infusion catheter is placed and connected to a reservoir placed under the skin. This mechanism continuously pumps small amounts of an antispasticity medication called baclofen into the fluid around the spinal cord.

50. Treatment
These surgeries require careful screening and an expert team of health professionals, including pediatric neurosurgeons, orthopedic surgeons, pediatric neurologists, pediatric physiatrists and physical therapists

51. Treatment Assistive technology –
Assistive technology includes such small things as rails, grab bars, magnifiers, and Velcro grips attached to forks and pens to make them easier to grasp.
It also includes high-tech tools, such as customized wheelchairs, voice communication devices, computer software programs, and positioning equipment that puts a child in the correct posture to sit or stand with other kids or family members.

52. Prevention
For more than a century, doctors have hoped that by somehow improving labor and birth practices, they could reduce the incidence of cerebral palsy.

53. Prevention
But these rates have remained fairly constant, despite increased prenatal care, electronic fetal monitoring, prenatal ultrasound and increased use of Caesarean section delivery over the past 25 years.

54. Prevention
Fewer babies now develop cerebral palsy as a consequence of birth injury.
However, larger numbers of extremely premature babies survive, and some will develop cerebral palsy

55. Prevention
Most cases of cerebral palsy can't be prevented, despite the best efforts of parents and doctors.

56. Long Term Goals
Although it is not "curable" through education, therapy, and applied technology people with cerebral palsy can lead productive lives.

57. Long Term Goals
Cerebral palsy cannot be cured. However, quality of life can be improved for most children if they receive support and coordinated care, which may include a variety of experts.

58. Long Term Goals
Different kinds of therapy (physical therapy, occupational therapy, speech therapy) help children to maximize their potential activities at various stages of development.

59. Long Term Goals
Coordinated treatment of disorders such as seizures and spasticity are crucial in helping children with cerebral palsy lead a healthier life.

60. Long Term Goals
Medical research is working toward improving diagnosis, treatment, and prevention of cerebral palsy.