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What is the most common cause of motor impairment in children?
What is cerebral palsy?
Disorder of motor function due to a NON PROGRESSIVE (static) lesion of the developing brain
How do the symptoms compare to the lesion?
Although the lesion is non-progressive, the symptoms EVOLVE as the nervous system develops
What are the 2 areas of motor function that CP affects?
What are the other problems that children with CP suffer from?
- Learning difficulties
- Visual impairment from errors of refraction and cortical damage
- Hearing impairment
- SAL problems – hearing loss, oro-motor incoordination, LD
- Behaviour problems
- Joint contractures, hip subluxation, scoliosis
What are the DEVELOPMENTAL problems in CP – think of the 4 domains
- Fine motor and vision: visual impairment due to refractive error and cortical damage
- Hearing, speech, language
- Behavioural, emotional
- Gross motor – spasticity
What are the problems with eyes in CP?
- Refractive error
- Cortical damage – affecting vision
What are the musculoskeletal problems in CP apart from spasticity?
What is a joint contracture?
- High resistance to passive stretch of a muscle
- Resulting from fibrosis of the tissue supporting the muscles or joints
How do you divide the causes of CP? And what % each?
- Antenatal: 80%
- Intrapartum: 10%
- Postnatal: 10%
What are the antenatal causes of CP?
- Vascular occlusion
- Cortical migration disorder
- Structural maldevelopment of the brain during gestation
- Congenital infections: rubella, CMV, toxoplasmosis
What is the main intrapartum cause of CP?
Birth asphyxia – Hypoxic Ischaemic injury
What are the post natal causes of CP?
- Preterm birth: HIE, PVL from ischaemia / intraventricular haemorrhage
- Hyperbilirubinaemia (kernicterus in basal ganglia – choreoathetoid CP)
- Head injury
- Intracranial infection: meningitis, encephalitis
What are the early features of CP?
- Abnormal limb tone/posture
- Delayed motor milestones
- Slowing of head growth
- Feeding difficulties – oromotor incoordination (slow feeding, gagging, vomiting)
- Abnormal gait
- Asymmetric hand function before 12 months of age
What happens to primitive reflexes in normal babies and in CP?
- Normally – need to disappear for motor development to progress
- CP – may persist and become obligatory
How is the diagnosis of CP made?
- Pattern of tone in limbs and trunk
- Hand function
What are the 3 main clinical types of CP?
- Ataxic hypotonic
Where is the damage in spastic cerebral palsy?
UMN (corticospinal tract)
What are the features of spastic CP?
- Spasticity: increased limb tone (clasp knife fashion)
- Brisk deep tendon reflexes
- Extensor plantar responses
What are the 3 types of spastic CP?
- Hemiplegia: unilateral involvement of arm and leg (arm>leg), face spared
If an infant has fisting of the hand, a flexed arm and pronated foream, asymmetric reaching and tiptoe walk what type of CP is that?
What may happen initially to the tone in the arms in spastic CP?
Hypotonia and flaccid then becomes spastic later
What can spastic hemiplegia sometimes be caused by?
What are the features of quadriplegia CP?
- All 4 limbs affected
- Arms > legs
- Trunk: extensor posturing
- Poor head control
- Low central tone
- Scissoring of the legs – due to excessive adduction
- Pronated forearms
- Fisted hands
What may there have been a history of in quadriplegic spastic CP?
HIE after birth
What else is quadriplegic spastic CP associated with?
- Low IQ
What is deplegia?
- Both legs affected – walking is abnormal
- Arms may be affected to certain degree
What are the 4 features of ataxic hypotonic CP?
- Trunk and limb hypotonia
- Poor balance
- Delayed motor development
- Uncoordinated movements
Where is the brain damage in ataxic hypotonic CP?
Cerebellum – so remember all cerebellar signs eg incoordination, intention tremor, ataxic gait
what is dyskinetic CP due to? – where is damage?
- Basal ganglia or extra pyramidal pathways
- Eg in kernicterus
What is the clinical presentation of dyskinetic CP?
- Delayed motor development
- Abnormal INVOLUNTARY movements appear later:
- Chorea- abrupt, jerky movements
- Athetosis – slow writhing continuous movements
- Dystonia – sustained abnormal postures
What is the management of CP?
- Community paediatrician
- Community nurse
What must be done for parents?
Accurate diagnosis and prognosis
How can increased tone be treated?
- Muscle relaxants – diazepam, baclofen
- Botulinum toxin injections to specific muscle groups
What gastro problem do CP children get?
What is common presentation to hospital in a child with CP?
Chest infection as they are less mobile, and less able to clear secretions