CEREBRAL PALSY
Q&A COUNT: 38*
DISCUSSION:
Q&A COUNT: 38*
DISCUSSION:
What is Cerebral Palsy?
CP is a permanent, non progressive disorder of tone, posture and movement due to insult to the developing brain
Note: Each and every word of this definition is very important.*
Note: Each and every word of this definition is very important.*
Types/Classification of CP
There are four types of classification - Anatomical, Physiological, Functional and Etiological
All these four are expected to be mentioned in your Diagnosis*
Note: Functional and Etiological classification are very important
Anatomical or Topographical Classification of Cerebral Palsy:
1. Monoplegia
2. Paraplegia
3. Hemiplegia
4. Quadriplegia or Tetraplegia
5. Diplegia (Tetraplegia with more weakness in lower limbs) (occurs in Preterm baby)
6. Double hemiplegia (Tetraplegia with more weakness in upper limbs)
7. Triplegia
There are four types of classification - Anatomical, Physiological, Functional and Etiological
All these four are expected to be mentioned in your Diagnosis*
Note: Functional and Etiological classification are very important
Anatomical or Topographical Classification of Cerebral Palsy:
1. Monoplegia
2. Paraplegia
3. Hemiplegia
4. Quadriplegia or Tetraplegia
5. Diplegia (Tetraplegia with more weakness in lower limbs) (occurs in Preterm baby)
6. Double hemiplegia (Tetraplegia with more weakness in upper limbs)
7. Triplegia
Physiological Classification of Cerebral Palsy:
1. Spastic CP (this is most common and kept in our exams)
2. CP with choreo-athetoid type of movements (associated with Neonatal Jaundice)
3. Ataxic CP
4. Rigid CP
5. Atonic CP
6. Hypotonic CP
7. Dystonic CP
8. Dyskinetic CP
9. Ballismic CP
10. CP with tremors
11. Mixed CP
12. Unclassified CP
FUNCTIONAL CLASSIFICATION OF CEREBRAL PALSY (very important)
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| The above picture is taken from Aruchamy Textbook of Paediatrics |
There is something called Level 5 CP - which involves loss of head and neck control - and child needs support for head and neck.*
Etiological factors in Cerebral Palsy (or) Prenatal, Perinatal and Postnatal Causes of Cerebral Palsy
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| The above picture is taken from OP Ghai Textbook of Paediatrics |
There are 4 functional grades for Cerebral Palsy. Is there any 5th grade?
Level 5 Cerebral Palsy need support for their head and neck - in addition to support for limbs
LOCALIZATION OF PART OF BRAIN INVOLVED BY HISTORY
1. History of seizures/ speech + Spastic CP - Cerebrum involvement
2. Only spastic CP - Subcortical white matter involved (Internal Capsule) (likely to be hemiplegia)
3. Spastic CP + Cranial nerve involvement - Brainstem
4. Diplegia - Central brain affected, or periventricular leukomalacia in newborn
5. Dyskinesis, Choreoathetoid - Basal Ganglia involvement
6. Nystagmus history + ataxia - Cerebellum involved
7. Paraplegia- spinal cord affected
Level 5 Cerebral Palsy need support for their head and neck - in addition to support for limbs
LOCALIZATION OF PART OF BRAIN INVOLVED BY HISTORY
1. History of seizures/ speech + Spastic CP - Cerebrum involvement
2. Only spastic CP - Subcortical white matter involved (Internal Capsule) (likely to be hemiplegia)
3. Spastic CP + Cranial nerve involvement - Brainstem
4. Diplegia - Central brain affected, or periventricular leukomalacia in newborn
5. Dyskinesis, Choreoathetoid - Basal Ganglia involvement
6. Nystagmus history + ataxia - Cerebellum involved
7. Paraplegia- spinal cord affected
Developmental milestones in CP?
GLOBAL DEVELOPMENTAL DELAY
What are the early markers of Cerebral Palsy?
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What are the late markers of Cerebral Palsy?
1. Bed sores
2. Contractures
Difference between growth and development
Growth denotes a net increase in size or mass of tissues , while development denotes maturation of functions and acquisition of skills.
Growth is due to multiplication of cells while development is due to maturation and myelination of nervous system.
Growth is measured by Anthropometry and Growth charts, while Development is measured by Developmental milestones
Growth is due to multiplication of cells while development is due to maturation and myelination of nervous system.
Growth is measured by Anthropometry and Growth charts, while Development is measured by Developmental milestones
Difference between delayed development and regression of milestones
Both presents with developmental milestones not attained appropriate for presenting age.
The difference is:
In regression of milestones, milestones have been attained normally by the child in the past. Then, all the previously attained milestones will be lost due to a disease.
In Delayed development, milestones have been never attained normally by child in the past.
Delayed development is seen in Cerebral Palsy or Post Meningitis sequelae
Regression of milestones seen in Neurodegenerative disease
Both presents with developmental milestones not attained appropriate for presenting age.
The difference is:
In regression of milestones, milestones have been attained normally by the child in the past. Then, all the previously attained milestones will be lost due to a disease.
In Delayed development, milestones have been never attained normally by child in the past.
Delayed development is seen in Cerebral Palsy or Post Meningitis sequelae
Regression of milestones seen in Neurodegenerative disease
Difference between history of Developmental Delay between CP, Post meningitis sequelae, Neurodegenerative disease
CP - All developmental milestones attained late
Post Meningitis Sequelae - At some age, fever comes and child do not attain milestones after that incident
Neuro degenerative disease - Child who attained milestones upto an age, starts to lose all previously attained milestones.
Post Meningitis Sequelae - At some age, fever comes and child do not attain milestones after that incident
Neuro degenerative disease - Child who attained milestones upto an age, starts to lose all previously attained milestones.
Difference between seizure and abnormal movements
Seizure have associated features like loss of consciousness, altered sensorium and aura.
Abnormal movements do not have such.
Also, most of the abnormal movements do not occur during sleep. Seizures can!
Abnormal movements do not have such.
Also, most of the abnormal movements do not occur during sleep. Seizures can!
Types of epilepsy/seizure
Generalized onset epilepsy:
1. Tonic clonic seizure
2. Myoclonic seizure
3. Atonic seizure
4. Spasm
5. Absence seizures
6. Tonic seizures
Focal onset epilepsy or Partial seizures:
1. Simple partial seizures
2. Complex partial seizures
Difference between seizure and epilepsy
Seizure is a "single" abnormal paroxysmal electrical activity in a brain.
Occurence of two such unprovoked seizures over a day - denotes "epilepsy"
Commonest form of seizures in a child
FEBRILE SEIZURES (check few questions about Febrile seizures under Miscellaneous section)
1. Tonic clonic seizure
2. Myoclonic seizure
3. Atonic seizure
4. Spasm
5. Absence seizures
6. Tonic seizures
Focal onset epilepsy or Partial seizures:
1. Simple partial seizures
2. Complex partial seizures
Difference between seizure and epilepsy
Seizure is a "single" abnormal paroxysmal electrical activity in a brain.
Occurence of two such unprovoked seizures over a day - denotes "epilepsy"
Commonest form of seizures in a child
FEBRILE SEIZURES (check few questions about Febrile seizures under Miscellaneous section)
Pre and post tictal symptoms?
Pre tictal - Aura, Hallucinations
Post tictal - Autonomic disturbances, Confusion, Amnesia, Headache
Post tictal - Autonomic disturbances, Confusion, Amnesia, Headache
Hypertonia - how to ask History?
Whether mother uses lot of power to change diaper or to clean baby's perineum or to seperate limbs (due to scissoring of legs)
Hypotonia - how to ask History?
Whether Lifting babies is difficult or not - baby will slip
Whether mother uses lot of power to change diaper or to clean baby's perineum or to seperate limbs (due to scissoring of legs)
Hypotonia - how to ask History?
Whether Lifting babies is difficult or not - baby will slip
Importance of Quickening in CP case?
Any Neuromuscular problem - late quickening (floppy infant)
What is Floppy infant?
Floppy infant refers to an infant with severely reduced muscle tone, most often due to an insult in the foetal or neonatal period.
There is decreased resistance to passive range of movements with variable degree of muscle weakness
Can have history of quickening felt late!
What is Floppy infant?
Floppy infant refers to an infant with severely reduced muscle tone, most often due to an insult in the foetal or neonatal period.
There is decreased resistance to passive range of movements with variable degree of muscle weakness
Can have history of quickening felt late!
Drooling of saliva - Normal or not? How to say whether its abnormal?
Can be both normal or abnormal
Normal phenomenon - starts at 4-5 months, decreases at 1.5 years
Minimal until 2.5-3 years
Abnormal - if drooling is more even at 2.5-3 years or if there is persistent drooling after 3 years
Persistent drooling can be due to:
1. Mental Retardation
2. Bulbar and pseudo-bulbar palsy
3. Facial nerve palsy
Normal phenomenon - starts at 4-5 months, decreases at 1.5 years
Minimal until 2.5-3 years
Abnormal - if drooling is more even at 2.5-3 years or if there is persistent drooling after 3 years
Persistent drooling can be due to:
1. Mental Retardation
2. Bulbar and pseudo-bulbar palsy
3. Facial nerve palsy
Causes for GLOBAL developmental delay:
- Rubella
- Cerebral Palsy
EXAMINATION:
Neuro cutaneous markers
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| The above picture is taken from Aruchamy Textbook of Paediatrics |
Why there is no need to measure HC after 5 years in a normal child?
Head circumference attains adult size around 5-6 years. So HC cannot denote child's growth after 5 years - thus insignificant measure for growth monitoring after 5 years.
When HC should be measured after 5 years?
In case of Cerebral Palsy - HC should be measured for MICROCEPHALY (even when the child is >5 years old)
What is Microcephaly and Macrocephaly?
HC less than -3 SD : Microcephaly
HC more than 3 SD: Macrocephaly
Microcephaly - 2 Types ?
Primary and Secondary Microcephaly
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| The above picture is taken from Aruchamy Textbook of Paediatrics |
Root values of JERKS
Biceps reflex C5,C6
Supinator reflex C5,C6
Triceps reflex C6,C7,C8
Knee jerk L2,L3,L4
Ankle jerk S1,S2
Supinator reflex C5,C6
Triceps reflex C6,C7,C8
Knee jerk L2,L3,L4
Ankle jerk S1,S2
Plantar reflex in children?
Positive Babinski sign (Extensor Plantar Reflex) - due to lack of myelination in Corticospinal tract upto 2 years
Positive Babinski sign (Extensor Plantar Reflex) - due to lack of myelination in Corticospinal tract upto 2 years
Cranial nerve examination in Paediatrics
CN 1 - Subjective test requiring co-operation from child (done as same as in adults); In newborns, check if baby can turn towards smell of breastmilk
CN 2 - Check for gross vision** + Visual acuity + Color vision + Visual field + Light reflex + Menace reflex
CN 3 - Same as adults + check for Doll's eye movement
CN 4,5,6 - Same as adults
CN 7 - same as adults + Sucking reflex**
CN 8 to 12 - Same as adults
Test for Gross Vision:
Test if the child is able to recognize parents or objects or strangers, test whether child smiles at mother or not
Test if the child is able to follow objects
Menace Reflex:
Fingers are taken towards eyes. There should be normal blinking and withdrawl of head away from the stimulus
Doll's eye movement:
Turn the head to one side. When brainstem is intact, eye balls move in a direction opposite to that of head movement
The reflex involves 3 COMPONENTS
1. Opening of hands* and
2. Sudden abduction and extension of arms*
3. This is followed by - anterior flexion at shoulder joint
Moro reflex disappears by 3-6 months*
Gestational Age of appearance of 3 components of Moro reflex and its importance
Hand opening - 28 weeks
Extension and abduction - 32 weeks
Anterior flexion - 37 weeks
Significance:
3rd component of Moro reflex is absent in Preterm, due to weak antigravity muscles
List of Immature Newborn reflexes
MANAGEMENT:
MODEL CASE SHEET:HISTORY:
EMG, EEG
CN 2 - Check for gross vision** + Visual acuity + Color vision + Visual field + Light reflex + Menace reflex
CN 3 - Same as adults + check for Doll's eye movement
CN 4,5,6 - Same as adults
CN 7 - same as adults + Sucking reflex**
CN 8 to 12 - Same as adults
Test for Gross Vision:
Test if the child is able to recognize parents or objects or strangers, test whether child smiles at mother or not
Test if the child is able to follow objects
Menace Reflex:
Fingers are taken towards eyes. There should be normal blinking and withdrawl of head away from the stimulus
Doll's eye movement:
Turn the head to one side. When brainstem is intact, eye balls move in a direction opposite to that of head movement
How to do Moro reflex? (or) What are the 3 components of Moro reflex?
With baby supported in supine position, head is allowed to fall backward for a few centimetres.The reflex involves 3 COMPONENTS
1. Opening of hands* and
2. Sudden abduction and extension of arms*
3. This is followed by - anterior flexion at shoulder joint
Moro reflex disappears by 3-6 months*
Gestational Age of appearance of 3 components of Moro reflex and its importance
Hand opening - 28 weeks
Extension and abduction - 32 weeks
Anterior flexion - 37 weeks
Significance:
3rd component of Moro reflex is absent in Preterm, due to weak antigravity muscles
List of Immature Newborn reflexes
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| The above picture is taken from Aruchamy Textbook of Paediatrics |
MANAGEMENT:
Diagnosis of CP - Imaging done:
MRI is the imaging of choice
It is preferred over CT
MRI reveals etiological factors - captures brain parenchyma and also hydrocephalus
CT can find mass lesion with edema or acute bleeding with head trauma
It is preferred over CT
MRI reveals etiological factors - captures brain parenchyma and also hydrocephalus
CT can find mass lesion with edema or acute bleeding with head trauma
Multi disciplinary approach in management of CP
CP child is managed by multi disciplinary inputs from various departments:
1. Paediatrician
2. Neurologist
3. Physiotherapist
4. Occupational therapist
5. Clinical psychiatrist (for low IQ)
6. Orthopedic surgeon (to manage contractures and stiffness)
7. Speech therapist
8. Ophthalmologist
9. ENT specialist
10. Social worker
11. Special educator
*******
CP child is managed by multi disciplinary inputs from various departments:
1. Paediatrician
2. Neurologist
3. Physiotherapist
4. Occupational therapist
5. Clinical psychiatrist (for low IQ)
6. Orthopedic surgeon (to manage contractures and stiffness)
7. Speech therapist
8. Ophthalmologist
9. ENT specialist
10. Social worker
11. Special educator
*******
MODEL CASE SHEET:HISTORY:
1) Demography - Name, Age, Gender, Area, Order of Birth, Consanguinity, Informant and reliability
2) Chief complaints - Delayed developmental milestones since birth
So, I would like to start from Antenatal history**
So, I would like to start from Antenatal history**
3) Antenatal History - any obstetric complications, any TORCH infections, Teratogenic drug intake, folic acid intake in first trimester to prevent neural tube defects*
4) Birth History (no significant role in this case)
H/O Birth asphyxia, preterm, LBW, Birth trauma, neonatal jaundice
H/O Birth asphyxia, preterm, LBW, Birth trauma, neonatal jaundice
5) Postnatal History (breastfeeding/weaning) (any trauma or meningitis history?)
6) Developmental History - all 4 milestones delay (Global developmental delay)
6) Developmental History - all 4 milestones delay (Global developmental delay)
7) History of presenting illness:
Tone: Hypertonia (difficulty to change diapers, wash perineum, commando crawling)
Hypotonia (difficulty in lifting baby)
Power in Upper limbs: any difficulty in Lifting hand above head, mixing food, buttoning of shirts?
Power in Lower limbs: any difficulty in walking, standing, walking without slippers getting slipped?
Any H/O early hand preference - within one year of age
Sensory system history:
Pain - able to feel injection pain, able to feel mosquito bite?
Touch - able to feel cloth, able to respond when mother touches him/her?
Temperature - able to respond to warm/cold water?
H/O seizures, speech disturbances - cortex involvement
H/O swaying to one side while walking - cerebellum
Cranial nerves history:
CN2 - able to see/recognize mother or strangers?
CN5 - able to chew food?
CN7 - able to close eyes?, no deviation of angle of mouth, drooling of saliva (can be normal upto 2.5-3 years)
CN8 - able to hear?
CN9,10 - no nasal regurgitation
Ask for H/O involuntary movements
Ask for H/O headache, nausea, vomiting, seizures, if any
Hypotonia (difficulty in lifting baby)
Power in Upper limbs: any difficulty in Lifting hand above head, mixing food, buttoning of shirts?
Power in Lower limbs: any difficulty in walking, standing, walking without slippers getting slipped?
Any H/O early hand preference - within one year of age
Sensory system history:
Pain - able to feel injection pain, able to feel mosquito bite?
Touch - able to feel cloth, able to respond when mother touches him/her?
Temperature - able to respond to warm/cold water?
H/O seizures, speech disturbances - cortex involvement
H/O swaying to one side while walking - cerebellum
Cranial nerves history:
CN2 - able to see/recognize mother or strangers?
CN5 - able to chew food?
CN7 - able to close eyes?, no deviation of angle of mouth, drooling of saliva (can be normal upto 2.5-3 years)
CN8 - able to hear?
CN9,10 - no nasal regurgitation
Ask for H/O involuntary movements
Ask for H/O headache, nausea, vomiting, seizures, if any
8) Past History - not specific for this case
9) Diet History (no significant role in this case)
10) Family History - usually none
11) Socio-environmental History (Socio economic class & Environmental history) (no significant role in this case)
12) Immunization History (no significant role in this case)
13) Contact History (no significant role in this case)
14) Allergy History (no significant role in this case)
EXAMINATION:
1) General examination - posture can be scissoring of legs (due to hypertonia)
2) Vitals - Normal
3) Anthropometry - Microcephaly*
4) Head to Toe examination - Normal, mention about neuro-cutaneous markers
5) Systemic examination - all 4 systems
CNS:
Motor system - for spastic diplegia, all 4 limbs will be affected with more involvement of lower limbs
Tone - increased
Bulk - normal or decreased
Power - 3/5 or lower
Reflexes - Superficial reflexes lost, DTR exagerated, Plantar reflex - extensor plantar response
Gait - cannot be examined usually
Cerebellum- cannot be examined
Sensory system - cannot be examined
Cranial nerve examination: Usually normal*
Immature reflexes - atleast do Moro reflex*
Other systems - Normal
Motor system - for spastic diplegia, all 4 limbs will be affected with more involvement of lower limbs
Tone - increased
Bulk - normal or decreased
Power - 3/5 or lower
Reflexes - Superficial reflexes lost, DTR exagerated, Plantar reflex - extensor plantar response
Gait - cannot be examined usually
Cerebellum- cannot be examined
Sensory system - cannot be examined
Cranial nerve examination: Usually normal*
Immature reflexes - atleast do Moro reflex*
Other systems - Normal
DIAGNOSIS
1. A case of Cerebral Palsy with:
(a) Spastic Diplegia
(b) Functional grade - 3*
(c) Associated with etiological factors like - birth trauma, asphyxia, preterm baby (say) with:
2. Normal Immunization status (or) not immunized upto date,
3. Normal Anthropometry (or) mention abnormal anthropometric measure,
4. Protein deficit in %, Calorie deficit in % (or) No protein or calorie deficit,
5. Normal Developmental status (or) Developmental delay with DQ of ___%,
6. (And Mention if any) poor socio-environmental conditions like _____
1. A case of Cerebral Palsy with:
(a) Spastic Diplegia
(b) Functional grade - 3*
(c) Associated with etiological factors like - birth trauma, asphyxia, preterm baby (say) with:
2. Normal Immunization status (or) not immunized upto date,
3. Normal Anthropometry (or) mention abnormal anthropometric measure,
4. Protein deficit in %, Calorie deficit in % (or) No protein or calorie deficit,
5. Normal Developmental status (or) Developmental delay with DQ of ___%,
6. (And Mention if any) poor socio-environmental conditions like _____
INVESTIGATIONS
Imaging - CT brain, MRI brainEMG, EEG
TREATMENT (Multi disciplinary approach)
CP child is managed by multi disciplinary inputs from various departments:
1. Paediatrician
2. Neurologist
3. Physiotherapist
4. Occupational therapist
5. Clinical psychiatrist (for low IQ)
6. Orthopedic surgeon (to manage contractures and stiffness)
7. Speech therapist
8. Ophthalmologist
9. ENT specialist
10. Social worker
11. Special educator
1. Paediatrician
2. Neurologist
3. Physiotherapist
4. Occupational therapist
5. Clinical psychiatrist (for low IQ)
6. Orthopedic surgeon (to manage contractures and stiffness)
7. Speech therapist
8. Ophthalmologist
9. ENT specialist
10. Social worker
11. Special educator