Cerebral palsy

Non progressive motor disorders caused by damage or maldevelopment of the brain that occurs prenatally, peri-natally or postnatally. Although the lesion won’t worsen with time, simultaneous development of brain and nervous system in the presence of lesions so the brain is not able to cope up with the physical demands of a growing child.

Causes-

AntenatalNeonatalPostnatal
Marriage in between close relativesPremature birthDelayed cry
Intrauterine viral infection, commonly of RubellaOcclusion of internal carotid or mid cerebral arterySevere jaundice causes damage to basal ganglia
Trauma to motherTrauma during delivery can be due to disproportion, breech presentation, etcFall of baby after birth
Hypoglycemia in fetus which can be due to diabetic motherBirth asphyxia occur by accidents, burns, knotted umbilical cord, prolapsed cordInfection like meningitis or encephalitis

Classification of CP-

  1. Topographical classification-
  1. Quadriplegia 
  2. Diplegia
  3. Paraplegia
  4. Triplegia
  5. Hemiplegia
  6. Monoplegia 

2. Diagnostic types-

  1. Spastics- 
  • Clasp knife type of spasticity which changes with change in position. Due to increase in tone reflex, clonus and jerks are also increased.
  • Spasticity results in Scissoring gait (extension, adduction and internal rotation)
  • There is no isolated movement possible so a mass movement pattern is seen.
  • They also have abnormal body posture due to contractures and deformity.
  • Their IQ is also low
  1. Athetoids or dyskinesias-
  •  Due to attack of jaundice after birth, damage to basal ganglia leads to slow, purposeless, wormlike, involuntary movements which often present at rest and increase with excitement, fear or efforts.
  • They lack coordination and fine movements
  • They have high IQ and are extroverts but have emotional lability
  • They have hearing problem due to kernicterus
  • They have dysarthria and paralysis of gaze
  1. Ataxias-
  •  Occurs due to cerebellar damage resulting in imbalance and incoordination.
  • Children compensate for lack of balance by excessive balance saving reaction of the upper limb.
  • They have clumsy and dissymmetric voluntary movements.
  • They also have hypotonia, nystagmus, diadokokinesia, dysarthria, intentional tremors and pendular tendon jerks.
  • They have low IQ with visual and hearing problem
  1. Rigid and Dystonics
  • They show constant twisting type of movements
  1. Mixed types

3. According to severity

  1. Mild- Child is independent and is only clumsy with non-motor handicap.
  2. Moderate- Partially independent but requires aids for most activities.
  3. Severe- Child is totally dependent.

Evaluation-

  • Physical and neurologic examination should include detailed assessment of development.
  • The first step in the evaluation for suspected CP is a comprehensive history, including a detailed account of potential risk factors and family history. A thorough history of developmental milestones is also important.
  • The earliest indication of CP may be a delay in the disappearance of primitive infantile reflexes.
  • It can be difficult to make a definitive diagnosis in infants less than 6 months old.
  • Neurological examination including tone, reflexes and spasticity.
  • spasticity is classified using 

tools such as Gross Motor Function Classification System and Modified Ashworth scale.

  • Imaging- screening cranial ultrasonography on all infants <30 weeks gestation between 7 and 14 days of age and again between 36 and 40 weeks’ postmenstrual age.
  • MRI showing abnormalities in thalamus and basal ganglia showed strong association with adverse outcomes including the diagnosis of cerebral palsy.

Associated disorder-

  • sensory impairment
  • Visual impairment
  • Hearing impairment
  • Cognitive impairment
  • Psychological impairment
  • Oromotor impairment
  • Epilepsy impairment
  • Nutritional disorders
  • Genitourinary disorder
  • Respiratory disorder
  • Bone and mineral density disorders
  • Musculoskeletal disorder-
  1. foot-equinovarus deformity, hallux valgus deformity 
  1. Knee- knee flexion contractures due to hamstring spasticity, genu valgum, patella alta 
  2. Hip- hip dysplasia , windswept deformity ( adduction deformity of elevated hip and abduction deformity of opposite hip ) 
  1. Spine- kyphosis, lordosis, scoliosis
  2. Upper extremity- adduction and internal rotation of shoulder , elbow fracture contraction , forearm pronation deformities , flexion with ulnar deviation of wrist , swan neck  deformity , 

hyperextension of MCP and IP joint

  1. Gait impairment

Differential diagnosis-

  • Down’s syndrome
  • Prader-Willi syndrome
  • Angelman syndrome
  • Floppy child syndrome

Management-

Medical management-

  • Generalized spasticity-diazepam, baclofen, tinazidine or dantrolene.
  • Localized spasticity- injection of botulinum A toxin.
  • Dystonia- trihexyphenidyl, botulinum or levodopa.
  • Anti-epileptic- Phenytoin, Carbamazepine, Valproate, Phenobarbital.

Physiotherapy management-

  • Developing rapport with parents and patients: As patient and family coordination is essential for treatment protocol to be followed and for its acceptance in daily living activities.
  • Hypotonia- For cases with hypotonicity slow relaxed passive movements, sustained passive stretch, cryotherapy over the muscle (15 – 20 minutes), stimulation of antagonist muscle and vibrations are used.
  • Hypertonia- weight bearing, joint compression, rhythmic stabilization,cryotherapy in brisk manner and tapping can be used.
  • Maintains muscle properties- Home exercises, functional activities and stretching is essential to prevent muscle shortening and atrophy.
  • Developing postural reactions- Postural reactions consist of righting reactions, protective extension and equilibrium reactions. First right reactions are developed by a child by the orientation of the head in space so that his eyes and mouth are horizontal regardless of his position. Then protective extension of the head develops and lastly an equilibrium reaction emerges which helps the patient to counteract the opposing force and enable them to maintain balance. These postural reactions are important for a child to move freely, so to develop postural reactions various exercises on vestibular ball and tilt board are beneficial.
  • Sensory integration- This is the ability to recognise various senses and can be developed by giving various objects of different colors, size, weight, texture etc. to a child.
  • Oromotor control training- Common oromotor problems are: drooling, problems in sucking, swallowing, body movements associated with speech, jaw, hyper or hypo sensitivity and inadequate tongue movements. Hence the therapy should consist of good neck control, developing good trunk control.
  • Muscle relaxation- Massage therapy can help in relaxation of tense muscles and also to strengthen them.
  • Lower limb orthoses- Inhibitive or dynamic foot orthosis to support weak structures and improve postural balance.

Reference-

  • Vinod K Paul and Arvind Bagga ( Ghai essential pediatrics)
  • Jan S. Tecklin ( Pediatric physical therapy)
  • Michael A. Alexander, Dennis J. Matthews ( Pediatric rehabilitation principles and practice)
  • Glady Samuel Raj ( Physiotherapy in neuro conditions)
  • Patrica A. Downie ( Cash’s textbook of neurology for physiotherapists )