Cerebral Palsy (CP) Quiz

Cerebral Palsy (CP)

• CP is a group of permanent disorders of movement and posture, causing activity limitations, attributed to non-progressive disturbances in the developing fetal or infant brain.
• Motor disorders of CP are often accompanied by disturbances of sensation, perception, cognition, communication, and behavior, as well as seizures and secondary musculoskeletal problems.

Types of Cerebral Palsy

• Pyramidal CP: indicates damage to the pyramidal tract, which is a key component of movement impairments.
• Extrapyramidal CP: indicates injury outside the pyramidal tract, in areas such as the basal ganglia, thalamus, and cerebellum.

Etiology

• There is no single specific cause of CP; rather, potential causes occur in the prenatal, perinatal, and postnatal periods.
• Prenatal causes include:
  • Vascular events (e.g., middle cerebral artery infarct)
  • Maternal infections (e.g., rubella, toxoplasmosis)
  • Metabolic disorders
  • Maternal ingestion of toxins
  • Rare genetic syndromes
• Perinatal causes include:
  • Obstructed labor
  • Antepartum hemorrhage
  • Cord prolapse
  • Other neonatal causes (e.g., hypoxic–ischemic encephalopathy, neonatal stroke, severe hypoglycemia, untreated jaundice, severe neonatal infection)
• Postneonatal causes include:
  • Metabolic encephalopathy
  • Storage disorders
  • Intermedullary metabolism disorders
  • Metabolic disorders
  • Miscellaneous disorders (e.g., toxicity, infections, meningitis, septicemia, malaria)

Risk Factors

• Present before pregnancy:
  • Maternal factors (e.g., delayed onset of menstruation, irregular menstruation, long intermenstrual intervals)
  • Medical conditions (e.g., intellectual disability, seizures, thyroid disease)
  • Paternal and sibling factors (e.g., advanced paternal age, motor deficit in sibling)
• Present during pregnancy:
  • Prenatal conception to the onset of labor
  • Perinatal period (28 weeks intrauterine to 7 days postnatal)
  • Postnatal first 2 years of life

Diagnosis and Prognosis

• Signs and symptoms of CP may be apparent in early infancy.
• Infants presenting with abnormal muscle tone, atypical posture, and movement with persistence of primitive reflexes may be diagnosed earlier than 2 years of age.
• Milder cases of CP may not be diagnosed until 4 to 5 years of age.
• Evaluation of the child's motor skills, neuroimaging, and evidence that symptoms are not progressing are key elements of diagnosis.

Clinical Findings

• Dysarthria: a motor speech disorder characterized by weakness or difficulty controlling muscles of the mouth, face, and respiratory system.
• Enuresis: involuntary or unintentional urination, typically during sleep.
• FTT: Failure to Thrive, characterized by a child not growing or gaining weight as expected for their age and gender.
• High Basal Metabolic Rate: an individual burns more calories while at rest compared to others of the same age, gender, and weight.
• Equinus Contracture: limited flexibility or extension of the ankle joint, causing the foot to point downwards excessively.
• Fasciculation: involuntary contractions or twitching of small groups of muscle fibers.
• Biarticular: a muscle that crosses and acts upon two joints.
• Monoarticular: a muscle that crosses and acts upon only one joint.
• Contracture: permanent shortening or tightening of a muscle, tendon, or other soft tissues, leading to decreased flexibility and range of motion in a joint.
• Tightness: a sensation of tension or limited flexibility in muscles or other soft tissues around a joint.

Examination

• Fasciculation
• Atrophy
• Involuntary movement
• Musculoskeletal examination (PROM):
  • Muscle tone (normal, + hyper, - hypo)
  • Contracture
  • Deformity
• Primitive reflexes:
  • ATNR (4m)
  • Grasp reflex (5m)
  • Planter reflex (10m)
  • Moro reflex
  • Protective reflex
  • Landau reflex (5m)
  • Parachute reflex (8-9m)

Gait in CP

• Hemiplegic gait:
  • No hip/knee flexion
  • Ankle dorsiflexion
  • Circumduction
• Diplegic gait:
  • A. Jump gait:
    • Hip flexion and adduction
    • Knee flexion and ankle plantarflexion
  • B. Crouch gait:
    • Hip flexion and adduction
    • Increased knee flexion and ankle hyperdorsiflexion during stance
  • C. Stiff knee gait:
    • Decreased knee flexion in swing phases due to spastic knee extensor
  • D. Scissoring knee gait:
    • Hip flexion and severe adduction
    • Internal rotation
    • Knee flexion and ankle plantarflexion
• Trunk lurching gait:
  • Weakness in hip abductor muscles
  • Side-to-side walking

Lower Limb Problems Related to Gait in CP

• Hip rotational profile and pelvic obliquity:
  • Anteversion
  • Retroversion
  • Pelvic obliquity
    • Un-leveled ASIS
    • Scoliosis
    • Leg length discrepancy
    • Hip abductor muscle weakness
• Knee:
  • Genu varus/ genu valgum
  • Tibial torsion (knee rotation)
  • Tightness muscles (e.g., hamstring, gastrocnemius)
• Ankle and foot:
  • Equinus
  • Talipes
  • Pes

Cerebral Palsy (CP)

• CP is a group of permanent disorders of movement and posture, causing activity limitations, attributed to non-progressive disturbances in the developing fetal or infant brain.
• Motor disorders of CP are often accompanied by disturbances of sensation, perception, cognition, communication, and behavior, as well as seizures and secondary musculoskeletal problems.

Types of Cerebral Palsy

• Pyramidal CP: indicates damage to the pyramidal tract, which is a key component of movement impairments.
• Extrapyramidal CP: indicates injury outside the pyramidal tract, in areas such as the basal ganglia, thalamus, and cerebellum.

Etiology

• There is no single specific cause of CP; rather, potential causes occur in the prenatal, perinatal, and postnatal periods.
• Prenatal causes include:
  • Vascular events (e.g., middle cerebral artery infarct)
  • Maternal infections (e.g., rubella, toxoplasmosis)
  • Metabolic disorders
  • Maternal ingestion of toxins
  • Rare genetic syndromes
• Perinatal causes include:
  • Obstructed labor
  • Antepartum hemorrhage
  • Cord prolapse
  • Other neonatal causes (e.g., hypoxic–ischemic encephalopathy, neonatal stroke, severe hypoglycemia, untreated jaundice, severe neonatal infection)
• Postneonatal causes include:
  • Metabolic encephalopathy
  • Storage disorders
  • Intermedullary metabolism disorders
  • Metabolic disorders
  • Miscellaneous disorders (e.g., toxicity, infections, meningitis, septicemia, malaria)

Risk Factors

• Present before pregnancy:
  • Maternal factors (e.g., delayed onset of menstruation, irregular menstruation, long intermenstrual intervals)
  • Medical conditions (e.g., intellectual disability, seizures, thyroid disease)
  • Paternal and sibling factors (e.g., advanced paternal age, motor deficit in sibling)
• Present during pregnancy:
  • Prenatal conception to the onset of labor
  • Perinatal period (28 weeks intrauterine to 7 days postnatal)
  • Postnatal first 2 years of life

Diagnosis and Prognosis

• Signs and symptoms of CP may be apparent in early infancy.
• Infants presenting with abnormal muscle tone, atypical posture, and movement with persistence of primitive reflexes may be diagnosed earlier than 2 years of age.
• Milder cases of CP may not be diagnosed until 4 to 5 years of age.
• Evaluation of the child's motor skills, neuroimaging, and evidence that symptoms are not progressing are key elements of diagnosis.

Clinical Findings

• Dysarthria: a motor speech disorder characterized by weakness or difficulty controlling muscles of the mouth, face, and respiratory system.
• Enuresis: involuntary or unintentional urination, typically during sleep.
• FTT: Failure to Thrive, characterized by a child not growing or gaining weight as expected for their age and gender.
• High Basal Metabolic Rate: an individual burns more calories while at rest compared to others of the same age, gender, and weight.
• Equinus Contracture: limited flexibility or extension of the ankle joint, causing the foot to point downwards excessively.
• Fasciculation: involuntary contractions or twitching of small groups of muscle fibers.
• Biarticular: a muscle that crosses and acts upon two joints.
• Monoarticular: a muscle that crosses and acts upon only one joint.
• Contracture: permanent shortening or tightening of a muscle, tendon, or other soft tissues, leading to decreased flexibility and range of motion in a joint.
• Tightness: a sensation of tension or limited flexibility in muscles or other soft tissues around a joint.

Examination

• Fasciculation
• Atrophy
• Involuntary movement
• Musculoskeletal examination (PROM):
  • Muscle tone (normal, + hyper, - hypo)
  • Contracture
  • Deformity
• Primitive reflexes:
  • ATNR (4m)
  • Grasp reflex (5m)
  • Planter reflex (10m)
  • Moro reflex
  • Protective reflex
  • Landau reflex (5m)
  • Parachute reflex (8-9m)

Gait in CP

• Hemiplegic gait:
  • No hip/knee flexion
  • Ankle dorsiflexion
  • Circumduction
• Diplegic gait:
  • A. Jump gait:
    • Hip flexion and adduction
    • Knee flexion and ankle plantarflexion
  • B. Crouch gait:
    • Hip flexion and adduction
    • Increased knee flexion and ankle hyperdorsiflexion during stance
  • C. Stiff knee gait:
    • Decreased knee flexion in swing phases due to spastic knee extensor
  • D. Scissoring knee gait:
    • Hip flexion and severe adduction
    • Internal rotation
    • Knee flexion and ankle plantarflexion
• Trunk lurching gait:
  • Weakness in hip abductor muscles
  • Side-to-side walking

Lower Limb Problems Related to Gait in CP

• Hip rotational profile and pelvic obliquity:
  • Anteversion
  • Retroversion
  • Pelvic obliquity
    • Un-leveled ASIS
    • Scoliosis
    • Leg length discrepancy
    • Hip abductor muscle weakness
• Knee:
  • Genu varus/ genu valgum
  • Tibial torsion (knee rotation)
  • Tightness muscles (e.g., hamstring, gastrocnemius)
• Ankle and foot:
  • Equinus
  • Talipes
  • Pes