Cerebral Palsy 

Definition:
Non-progressive abnormality of the movements and posture leading to activity limitation due to multiple disturbances to the fetal or infant brain. Rarely hereditary.

  • Usually associated with other comorbidities and impairments e.g.: cognitive, communication, and perception impairment, or seizures and epilepsy.

  • Most common cause of Motor impairment in children. 

 

Epidemiology:

  • According to community-based study done in 2011, CP is one of the most common neurological disorders in Saudi children with prevalence rate of 23.4/10000.

  • According to the ADDM, the prevalence of CP in the US is 1 in 323 children.

  • Prevalence is high among twins and premature births.

 

Causes:

  • Majority of the cases (>50%) are idiopathic. 

  • If a cause was identified, it is classified as following:

Study guide:

Preterm infants are more prone to ischemia and/or intraventricular hemorrhage.

With increase survival for preterm births, the CP incidence has increased.

Clinical Presentation:
General features:

  • Abnormal limb\trunk posture.

  • Abnormal tone in infancy.

  • Delayed motor milestones.

  • Slow head growth.

  • Oromotor incoordination, slow feeding, gagging, and vomiting.

  • Abnormal gait.

  • Asymmetric hand function in <12 month of age.

  • Seizure disorders.

  • Behavioral disorders.

  • Vision, hearing impairment, and speech deficit.

 

Clinical subtypes of CP:

  •  Spastic:

    • Damage to the UMN: pyramidal and\or corticospinal tracts.

    • ↑ Deep tendon reflexes (Babiniski sign, and hyperreflexia).

    • 90% of the cases have intellectual disability.

    • 3 main types:

Type

Description

Notes

Hemiplegia

  • Unilateral

  • Arms>legs

  • Sparing face

  • Arms: fisting, flexion, pronated forearm, and asymmetric hand function.

  • Tiptoe walking on the affected side.  

​Usually present at 4-12 months.

Diplegia

  • Both Legs > arms

  • Hands are normal only functional impairment

  • Abnormal walking. 

Usually seen with preterm infants.

Quadriplegia

  • All 4 limbs are affected equally

  • Opisothonus of the trunk

  • Poor head control

  • Low central tone

  • Severe form of CP

  • Usually as a result of perinatal HIE 

  • Associated with: seizures, microcephaly, moderate to severe intellectual impairment

  • Dyskinetic:

    • Involuntary movements mainly seen with stress or activity and disappear during sleep.

    • Primitive motor reflexes dominance.

    • Can be: chorea, athetosis, or dystonia. (Please refer to movement disorder study guide). 

    • Floppiness, and poor trunk control.

    • Usually present at the end of the first year of age.

    • Often caused by HIE (now) and hyperbilirubenemia (past).

  • ​​Ataxic:

    • Genetic contribution.

    • Caused by acquired brain injury to the cerebellum and its connections.

    • Early trunk and limbs hypotonia with poor balance and ataxic gait.

  • Mixed: 

    • Non-specific CP symptoms.

    • Mostly associated with CP complications and comorbidities. 

70-80% of all CP patients are classified as spastic CP 

Diagnosis: 

  • CP is a clinical diagnosis based on the history and physical examination.

    • The diagnosis is usually established by the age of 18 months old. 

  • Other tests:

    • Not necessary to establish the diagnosis.

    • MRI is diagnostic in older children, and can be used to localize and establish the extent of the lesion and impairment. 

 

Management: 

  •  Multidisciplinary team approach.

  • Intense physical and occupational therapy to improve the motor skills.

  • For general spasticity:

    • Oral benzodiazepine, dantrolene, or baclofen.

  • For localized spasticity:

    • Botox injections. 

  • CP cannot be cured. 

Prognosis:

  • 58% of patients will walk independently.

  • The survival rate is highly variable and dependent on the extent of the motor impairment. 

Not all CP patients have intellectual

 impairment

References:

  • Shah, Samir S, Jeanine C Ronan, and Brian Alverson. Step-Up To Pediatrics. Print.

  • Cvetnic, William G, Eduardo Pino, and Christine E Koerner. USMLE Step 2 CK Pediatrics. [New York]: Kaplan, 2011. Print.

  • Kliegman, Robert. Nelson Textbook Of Pediatrics. Print.

  • Lissauer, Tom, Graham Clayden, and Alan Craft. Illustrated Textbook Of Paediatrics. Edinburgh: Mosby, 2012. Print.

  • Cdc.gov,. 'Data And Statistics | Cerebral Palsy | NCBDDD | CDC'. N.p., 2015. Web. 24 Nov. 2015.

  • Uptodate.com,. 'Management And Prognosis Of Cerebral Palsy'. N.p., 2015. Web. 24 Nov. 2015.

  • Al Salloum AA, et al. 'The Prevalence Of Neurological Disorders In Saudi Children: A Community-Based Study. - Pubmed - NCBI'. Ncbi.nlm.nih.gov. N.p., 2015. Web. 24 Nov. 2015.

  • Le T, Bhushan V, Singh Bagga H. First aid for the USMLE step 2 CK. New York: McGraw-Hill Medical; 2012.

First author:      Roaa Amer

Reviewers:        Lama Al Luhidan

                         Haneen Al Farhan

Format Editor : Adel Yasky

​Audio recording:
​Read by: Nada Alhassan
Directed by: Rana Alzahrani
​Audio production: Bayan Alzomaili