Cerebral Palsy Introduction PDF

08/11/2024, 12:54 Cerebral Palsy Introduction - Physiopedia Cerebral Palsy Introduction Definition Cerebral Palsy (CP) is a disorder of movement and posture that appears during infancy or early childhood resulting from damage to the br...

08/11/2024, 12:54 Cerebral Palsy Introduction - Physiopedia Cerebral Palsy Introduction Definition Cerebral Palsy (CP) is a disorder of movement and posture that appears during infancy or early childhood resulting from damage to the brain. The damage to the brain is permanent and cannot be cured but the earlier we start with intervention the more improvement can be made.Any non-progressive central nervous system (CNS) injury occurring during the first 2 (some say 5) years of life is considered to be CP. There are several definitions of CP within the literature, although these may all vary slightly in the way they are worded they are all similar and can be summarised to: Cerebral Palsy is a group of permanent, but not unchanging, disorders of movement and/or posture and of motor function, which are due to a non-progressive interference, lesion, or abnormality of the developing/immature brain. This definition specifically excludes progressive disorders of motor function, defined as loss of previously acquired skills in the first 5 years of life. Cerebral Palsy - (DETAILED) Overview Time Frame of Brain Injury A diagnosis of CP is given if the brain damage arises during one of the following periods: 1. Prenatal Period - Conception to the onset of labour 2. Perinatal Period - 28 weeks intrauterine to 7 days 3. Postnatal Period -First two (and some say five) years of life After the age of 5 we speak of stroke or traumatic brain injury. Epidemiology and Aetiology Unfortunately, it is difficult to access and clarify the prevalence and incidence rate of disabilities in poor-resource settings (Gladstone, 2010). Not only the prevalence of childhood disability is on the rise and CP is one of the costliest chronic conditions, but also life expectancies are improving, which increases the burden of CP (Papavasiliou, 2009). For comparison, in the USA, there are approximately 700'000 children with CP, 2-5/ 1000 born. Cerebral palsy is the most common motor disability in childhood. The aetiology of CP is very diverse and multifactorial. The causes are congenital, genetic, inflammatory, infectious, anoxic, traumatic and metabolic. The injury to the developing brain may be prenatal, natal or postnatal. As much as 75%-80% of the cases are due to prenatal injury with less than 10% https://www.physio-pedia.com/Cerebral_Palsy_Introduction#:~:text=Krista Eskay-,Definition,more improvement can be made. 1/10 08/11/2024, 12:54 Cerebral Palsy Introduction - Physiopedia being due to significant birth trauma or asphyxia. The most important risk factor seems to be prematurity and low birth weight with risk of CP increasing with decreasing gestational age and birth weight. Population-based studies from around the world report prevalence estimates of CP ranging from 1.5 to more than 4 per 1,000 live births or children of a defined age range. Recent advances in neonatal management and obstetric care have not shown a decline in the incidence of CP. With a decline in infant mortality rate, there has actually been an increase in the incidence and severity of CP. The incidence in premature babies is much higher than in term babies. Cerebral palsy is more common among boys than among girls and more common among black children than among white children. Most of the children identified with CP have Spastic cerebral palsy (77, 4%). Over half of the children identified with CP (58, 2%) can walk independently, 11, 3% walks using a handheld mobility device and 30, 6% has limited or no walking ability. Many children with CP also do have at least one co-occurring condition (e.g. 41% Epilepsy). The incidence of CP has not declined despite the improved perinatal and obstetric care. Even at centres where optimal conditions exist for perinatal care and birth asphyxia is relatively uncommon, the incidence of CP in term babies has remained the same. The overall prevalence worldwide has increased during the last decades because of increased survival rates. Here are some facts on the epidemiology of CP: The incidence is 2-2,5/1000 live births in Western Countries The prevalence varies between 1-5/1000 babies in different countries. There are no reliable statistics from Asian countries. Some affected children do not survive Aetiology Improved medical care has decreased the incidence of CP among some children. Medical advances have also resulted in the survival of children who previously would have died at a young age. The type of cerebral palsy has also changed: In the 60’s Athetoid / Dyskinetic CP accounted for approximately 20% of children with CP. Today only 5 to 10% have this type, with spastic cerebral palsy now accounting for 80-90% of children with CP. This decrease is mainly due to advances in the treatment of hyperbilirubinemia (Bilirubin is toxic to cells of the brain. If a baby has severe jaundice, there's a risk of bilirubin passing into the brain ie. acute bilirubin encephalopathy. Prompt treatment may prevent significant lasting damage). The increase of spastic cerebral palsy is predominantly a result of higher survival rates for (very small premature) babies. The most common cause of CP is idiopathic which means that the cause of damage to the brain during pregnancy is not known. Risk Factors There are different risk factors for each stage at which a child might develop CP. These can be broken down into Prenatal, Perinatal and Postnatal. Prenatal Prematurity (Gestational age less than 36 weeks) Low Birth Weight (less than 2500 g), which could be due to poor nutritional status of the mother Maternal epilepsy Hyperthyroidism Infections (TORCH = Toxoplasmosis, Other (Syphilis, Varicella-Zoster, Parvovirus B19,) Rubella, Cytomegalovirus (CMV), Herpes Simplex Virus) Severe Toxemia, Eclampsia Drug Abuse Trauma Multiple Pregnancies Placental Insufficiency Perinatal https://www.physio-pedia.com/Cerebral_Palsy_Introduction#:~:text=Krista Eskay-,Definition,more improvement can be made. 2/10 08/11/2024, 12:54 Cerebral Palsy Introduction - Physiopedia Premature Rupture of Membranes Prolonged and Difficult Labour Vaginal Bleeding at the time of admission for labour Bradycardia Postnatal (0-2 years) Central Nervous System infection (encephalitis,meningitis) Hypoxia Seizures Coagulopathies Neonatal Hyperbilirubinemia Head Trauma There is no way to predict which child’s brain will be damaged by one of these factors or to what the extent of the damage will be. None of these factors always results in brain damage and even when brain damage occurs, the damage does not always result in CP. For example: Some children may have an isolated hearing loss from their meningitis, others will have severe intellectual disability and some will have CP. Classification of Cerebral Palsy The practice of classifying conditions, such as cerebral palsy, is important because it allows cases with similar characteristics, to be grouped together. It is important to classifiy the different features of CP, as this helps to set realistic expectations and influences the treatment​​. Cerebral palsy is often classified based on several factors, including severity, topographical distribution (which body parts are affected), muscle tone, and functional ability. Severity can be classified as mild, moderate, or severe. This classification is broad and lacks specific criteria, but it provides a simple way of communicating the scope of impairment​​. Topographical distribution refers to which parts of the body are affected. It is a useful classification when combined with motor function classification, as it provides a description of how and where a person is affected by cerebral palsy, which can guide treatment protocols​​. Muscle tone refers to the effects of cerebral palsy on muscle tone and how muscles work together. Two terms used to describe muscle tone are hypertonia (increased muscle tone, often resulting in very stiff limbs, associated with spastic cerebral palsy) and hypotonia (decreased muscle tone, often resulting in loose, floppy limbs, associated with non-spastic cerebral palsy)​. A more recent development in the classification of cerebral palsy is the functional classification system, which focuses on the functional abilities of children in the domains of cognition, self-care, mobility, and social aspects. There are several classification systems within this, including the Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MAC), and the Communication Function Classification System (CFCS)​ ​. These systems can be used by professionals and parents alike to observe different developmental areas and develop goals and interventions​​. The GMFCS, in particular, is a widely used tool that assesses self-initiated movements in sitting, walking, and wheeled mobility. This system classifies children into five ordinal levels across five age bands, with an emphasis on the child's typical performance in different settings. The age bands considered in this system are less than 2 years of age, 2 to 4 years, 4 to 6 years, 6 to 12 years, and 12 to 18 years. The levels of distinction focus on functional abilities and the use and type of aids to achieve mobility​​. There are also other more recent tools for classifying cerebral palsy, such as the Swedish Classification (SC) and the Surveillance of Cerebral Palsy in Europe (SCPE), both of which require the clinician to identify the predominant motor disorder. Although the SC and SCPE tools can assist in describing a child’s presentation, they do not provide any criteria for recording the functional abilities of the child. Identifying, describing, and classifying a child’s functional abilities can also enhance the reliability of diagnosing children with cerebral palsy. The Swedish Classification (SC) of Cerebral Palsy adopts a topographical descriptive approach. It describes the type of muscle tone (spastic, dyskinetic, ataxic, or mixed) and the number and distribution of the affected limbs (monoplegia, hemiplegia, diplegia, tetraplegia, and quadriplegia). The Surveillance of Cerebral Palsy in Europe (SCPE) further developed this concept and proposed a new classification of cerebral palsy subtypes in 2000. The SCPE classification system offers a decision flow chart to assist in classification into neurological and topographical categories, with well- defined symptoms and requirements provided for each neurological category. Unlike the SC, the SCPE system divides spastic cerebral palsy into either upper or lower limb divisions, with either bilateral or unilateral involvement. https://www.physio-pedia.com/Cerebral_Palsy_Introduction#:~:text=Krista Eskay-,Definition,more improvement can be made. 3/10 08/11/2024, 12:54 Cerebral Palsy Introduction - Physiopedia However, there is still some uncertainty of the validity and reliability of these classifications. According to Rosenbaum et al., children with cerebral palsy should continue to be classified by the predominant type of tone or movement abnormality, such as spasticity, dystonia, choreoathetosis, or ataxia. They also recommend any other tone or movement abnormalities observed be classified as secondary based on their anatomical distribution of features. Sub-types of Cerebral Palsy Many children with CP have a mixed form of cerebral palsy. Here the definition and classification used as agreed in Europe. More information on definitions, outcome of some studies, exchange of information on clinical practice on CP in Europe you can find, after registering here. The Surveillance of Cerebral Palsy in Europe was established in 1998. Anatomical Classifications Anatomical classification are as follows: Unilateral: One side of the body is affected Bilateral: Both sides of the body are affected Spastic cerebral palsy: are used to distinguish between quadriplegia, diplegia and hemiplegia. Spastic cerebral palsy is either bilateral or unilateral. Dyskinetic cerebral palsy and ataxic cerebral palsy: always involve the whole body (bilateral). Spasticity Spasticity is defined as an increase in the physiological resistance of muscle to passive motion. It is part of the upper motor neuron syndrome characterized by hyperreflexia, clonus, extensor plantar responses and primitive reflexes. Spastic cerebral palsy is the most common form of CP. Approximately 80% to 90% of children with CP have spastic cerebral palsy. https://www.physio-pedia.com/Cerebral_Palsy_Introduction#:~:text=Krista Eskay-,Definition,more improvement can be made. 4/10 08/11/2024, 12:54 Cerebral Palsy Introduction - Physiopedia Spastic cerebral palsy is characterized by at least two of the following symptoms, which may be unilateral (hemiplegia) or bilateral: An abnormal pattern of posture and/or movement Increased tone (not necessarily constantly) Pathological reflexes (hyperreflexia or pyramidal signs e.g. Babinski response) Traditionally we recognized three types of spastic CP: 1. Hemiplegia 2. Diplegia 3. Quadriplegia. Hemiplegia (Unilateral) With hemiplegia, one side of the body is involved with the upper extremity generally more affected than the lower. Seizure disorders, visual field deficits, tactile agnosia, and proprioceptive loss are likely. Twenty percent of children with spastic cerebral palsy have hemiplegia. A focal traumatic, vascular, or infectious lesion is the cause in many cases. A unilateral brain infarct with posthemorrhagic porencephaly (cysts or cavities within the cerebral hemisphere) can be seen on Magnetic Resonance Imaging (MRI). Diplegia (Bilateral) With diplegia, the lower extremities are severely involved and the arms are mildly involved. Intelligence usually is normal, and epilepsy is less common. Fifty per cent of children with spastic cerebral palsy have diplegia. A history of prematurity is usual. Diplegia is becoming more common as more low- birth-weight babies survive. MRI reveals mild Periventricular Leukomalacia (PVL). Quadriplegia (Bilateral) With quadriplegia, all four limbs, the trunk and muscles that control the mouth, tongue and pharynx are involved. Thirty percent of children with spastic cerebral palsy have quadriplegia. More serious involvement of lower extremities is common in premature babies. Some have perinatal hypoxic ischemic encephalopathy. MRI reveals Periventricular Leukomalacia (PVL). Dyskinetic CP Abnormal movements that occur when the child initiates movement are named Dyskinesias. Dysarthria, Dysphagia and drooling accompany the movement problem. Intellectual development is generally normal, however severe dysarthria makes communication difficult and leads the outsider to think that the child has intellectual impairment. Sensorineural hearing dysfunction also impairs communication. Dyskinetic cerebral palsy accounts for approximately 10% to 15 % of all cases of CP. Hyperbilirubinemia or severe anoxia causes basal ganglia dysfunction and results in Dyskinetic cerebral palsy. Dyskinetic cerebral palsy is characterised by the following Symptoms: Abnormal pattern of posture and/or movement, and Involuntary, uncontrolled, recurring, occasionally stereotyped movements of affected body parts https://www.physio-pedia.com/Cerebral_Palsy_Introduction#:~:text=Krista Eskay-,Definition,more improvement can be made. 5/10 08/11/2024, 12:54 Cerebral Palsy Introduction - Physiopedia Dyskinetic cerebral palsy may be either: Dystonic cerebral palsy, dominated by both hypokinesia and hypertonia, or Choreoathetotic cerebral palsy, dominated by both hyperkinesia and hypotonia Ataxic CP Ataxia is loss of balance, coordination and fine motor control. Ataxic children cannot coordinate their movements. They are hypotonic during the first 2 years of life. Muscle tone becomes normal and ataxia becomes apparent toward the age of 2 to 3 years. Children who can walk have a wide-based gait and a mild intention tremor (Dysmetria). Dexterity and fine motor control is poor. Ataxia is associated with cerebellar lesions. Ataxia is often combined with spastic diplegia. Most ataxic children can walk but some need walkers. Ataxic Cerebral Palsy is characterized by the following symptoms: Abnormal pattern of posture and/or movement Lost of orderly muscular coordination, so that movements are performed with abnormal force, rhythm, and accuracy Mixed CP Children with a mixed type of Cerebral Palsy commonly have mild spasticity, dystonia and/or athetoid movements. Ataxia may be a component of the motor dysfunction in children in this group. Ataxia and spasticity often occur together. Spastic Ataxic Diplegia is a common mixed type that often is associated with hydrocephalus. Khan Academy - Types of Cerebr… Cerebr… Khan Academy - Types of Cerebr… Cerebr… The Brain Here is some of the clinical terminology used when talking about Cerebral Palsy: https://www.physio-pedia.com/Cerebral_Palsy_Introduction#:~:text=Krista Eskay-,Definition,more improvement can be made. 6/10 08/11/2024, 12:54 Cerebral Palsy Introduction - Physiopedia Tonus Lesion Site Spastic Cortex Dyskinetic Basal Ganglia - Extrapyramidal System Hypotonic / Ataxic Cerebellum Mixed Diffuse Knowing where the damage could be located will not influence your interventions. Look at the following pictures of the brain to understand the relationship between the location of the damage and the symptoms. Problems Regularly Seen with Children with Cerebral Palsy This table highlights the problems that children with Cerebral Palsy experience in different areas. Neurological Musculoskeletal Associated Problems Muscle Weakness Contractures Epilepsy Abnormal Muscle Tone Deformities Visual Problems Balance Problems Hearing Loss Loss of Selective Control Speech and Communication Pathological Reflexes Feeding Difficulty & Failure to Loss of Sensation Thrive Swallowing Difficulty Respiratory Problems Incontinence Intellectual Impairment This image gives a nice pictorial overview of the problems experienced by children with CP. https://www.physio-pedia.com/Cerebral_Palsy_Introduction#:~:text=Krista Eskay-,Definition,more improvement can be made. 7/10 08/11/2024, 12:54 Cerebral Palsy Introduction - Physiopedia Associated Problems Cerebral palsy in itself can significantly impact upon the child. Many associated conditions also need to be managed. As a Health Care Professional, it is essential to also understand these associated conditions and think about how these might impact or influence your management strategies when working with the child. Diagnosis Cerebral palsy is one of the main causes of childhood disabilities, with many different signs, symptoms, and challenges. There is no one test to confirm if a child has cerebral palsy or something else. There is no blueprint of interventions for a child with cerebral palsy and each child is different and unique. Classification of gross motor, fine motor and communication will help medical professionals and the family to better understand the abilities of the child and what to focus on for interventions. The diagnosis of cerebral palsy is based on a clinical description. The diagnosis is not based on the result of a (biological) test or on imaging findings. Consequently, the diagnosis can be subject to some degree of variability. This means that two paediatricians may disagree on a diagnosis of CP for the same child. It is sometimes difficult for even professionals to differentiate between bilateral spastic cerebral palsy and Dyskinetic cerebral palsy. Ideally, a paediatrician or neurologist will give the diagnosis but some children with CP in developing countries have never seen a doctor. There are also many children in developing countries with CP who have seen many doctors previously but with no good explanation of the meaning and consequences of the diagnoses. Life Expectancy Mortality in CP is extremely variable. Life expectancy is normal in most diplegic and hemiplegic children who receive adequate medical care and have strong family support. Some severely affected quadriplegics die of malnutrition, infections or respiratory problems before reaching adolescence. In some very poor and poor resource areas children with cerebral palsy may not reach the age of 5 years. Interventions with Cerebral Palsy Outcomes in early childhood provide clinicians with development information about the children born extremely preterm (EP,