Cerebral Palsy

فرید ، مظهر نجدپزشکی دانشکده استادیار

ارتوپدی گروه

ETIOLOGY

• Cerebral palsy is a heterogeneous disorder of movement and posture that has a wide variety of presentations,…

Three distinctive features commonto all patients with cerebral palsy

• Some degree of motor impairment is present

• An insult to the developing brain has occurred

• A neurological deficit is present that is nonprogressive

The insult to the brain is believed to occur between the time of conception and age 2

years,

• By 8 years of age, most of the development of the immature brain is complete

• Although the neurological deficit is permanent and nonprogressive,

• the effect it can have on the patient is dynamic,

• and the orthopaedic aspects of cerebral palsy can change dramatically with growth and development

• Children with cerebral palsy constitute the largest group of pediatric patients with neuromuscular disorders in the United States.

The prevalence of cerebral palsy varies

• quality of prenatal care,• the socioeconomic condition• and the type of obstetrical and pediatric care

• In the United States, the occurrence is approximately two per 1000 live births

• Worldwide, the prevalence ranges from 0.6 to seven cases per 1000 live births.

• Injury to the developing brain can occur anytime from gestation to early childhood and typically is categorized as

• prenatal, perinatal, or postnatal

• Contrary to popular belief, fewer than 10% of injuries that result in cerebral palsy occur during the birth process

• with most occurring in the prenatal period.

prenatal period

risk factors inherent to the fetus genetic disorders

factors inherent to the mother seizure disorders, mental retardation previous pregnancy lossfactors inherent to the pregnancy itself Rh incompatibility, polyhydramnios, placental rupture, and drug or alcohol exposure. External factors, such as TORCH (toxoplasmosis, other agents, rubella, cytomegalovirus,

herpes simplex)

perinatal period

• Cerebral palsy in the perinatal period, from birth until a few days after birth, typically is associated with asphyxia or trauma that occurs during labor

perinatal period

• Oxytocin augmentation,• umbilical cord prolapse, • and breech presentation

perinatal period

• Nelson reported that only 10% of cases of cerebral palsy occur during this time period,

perinatal period

• Low-birth-weight infants « 1500 g are at dramatically increased risk of cerebral palsy, with an incidence of 60 per 1000 births compared with two per 1000 births in normal-weight infants

due to the fragility ofthe periventricular blood vessels,

postnatal period

• Hypoxic-ischemic encephalopathy, which is characterized by hypotonia, decreased movement, and seizures, is a common cause of cerebral palsy during the postnatal period

Meconium aspiration and persistent fetal circulation with true ischemia are the most common causes of hypoxicischemic

encephalopathy.

• Infections such as encephalitis and meningitis, most commonly caused by group B streptococcus and herpes, can lead to cerebral palsy during this period.

• Traumatic brain injury from accidents or child abuse also accounts for a significant number of cases

CLASSI FICA TION

• no universally accepted classification scheme.

Cerebral palsy can be classified by

• the clinical physiological picture,• the region of the body affected, • the neuroanatomical region• in relation to the time of birth,

Geographical Classification

Geographical Classification

Geographical Classification

Physiological Classification

• first trimester, the immature brain separates into the gross structures, including the cerebrum, cerebellum, and medulla

Physiological Classification

• Neurons begin to form in the second trimester, and the total number of neurons an individual eventually has are present at the end of this time frame

Physiological Classification

• Synaptic connections and myelination begin during the third trimester and continue through adolescence in a highly organized fashion

Physiological Classification

• pyramidal corticospinal tracts, spastic type

• extrapyramidal type, which affects the other regions of the developing brain.( athetoid, choreiform, ataxic, rigid, and hypotonic)

Spastic

• Spastic is the most common form of cerebral palsy, constituting approximately 80% of cases,

Spasticity

• Spasticity, or the velocity-dependent increase in muscle tone with passive stretch, is caused by an exaggeration of the normal muscle passive stretch reflex

• Joint contractures, subluxation, and degeneration are common in patients with spastic cerebral palsy.

Athetoid

• injury to the extrapyramidal tracts and is characterized by

dyskinetic, purposeless movements that may

be exacerbated by environmental stimulation.

• joint contractures are uncommon

• and the results of soft-tissue releases, in contrast to those seen in spastic cerebral

palsy, are unpredictable, and the procedures have a high complication rate

Choreiform

• Choreiform cerebral palsy is characterized by continual purposeless movements of the patient's wrists, fingers, toes, and ankles

Rigid

• Patients with rigid cerebral palsy are the most hypertonic of all cerebral palsy patients.

• These patients have a "cogwheel" or "lead pipe" muscle stiffness that often requires surgical release

Ataxic

• Ataxic cerebral palsy is very rare and probably is the most often misdiagnosed type.

• It is characterized by the disturbance of coordinated movement, most commonly walking, as a result of an injury to the developing cerebellum.

Hypotonic

• Hypotonic cerebral palsy is characterized by weakness in conjunction with low muscle tone and normal deep tendon reflexes

Mixed

• Many patients with cerebral palsy have features of more than one type and are referred to as having mixed cerebral palsy.

DIAGNOSIS

• History and physical examination are the primary tools in making the diagnosis of cerebral palsy

• Primitive reflex patterns of motor activity that are outgrown as part of the normal maturation process persist longer than normal and in some cases permanently in children with cerebral palsy

• Other, more mature motor patterns, which are essential for normal ambulation, may be

significantly delayed or never appear

Prognostic Factors

• sitting independently by 2 years a good predictor of independent ambulation.

• Half of children who can sit independently by 2 to 4 years old eventually walk

• if a child cannot sit independently by 4 years, it is unlikely he or she will ever walk without assistance.

• if a child has not learned to walk by age 8 years, it is unlikely he or she will ever walk at all.

ASSOCIATED CONDITIONS

• mental impairment or learning disability (40%);

• seizures (30%); • visual impairment (16% );• malnutrition and related conditions, such as

gastroesophageal reflux, obesity, and undernutrition (15% )

• hydrocephalus (14% )

• Education and communication are most important, followed by activities of daily living and mobility.

• Ambulation is ranked fourth

TREATMENT

• A multidisciplinary team approach-including physical, occupational, and speech therapy; orthotics; nutrition; social work; orthopaedics; and general pediatrics.

Nonoperative Treatment

• Medication, splinting and bracing, and physical therapy,

Medications

• The three most common agents are diazepam and baclofen, which act centrally,

(y-aminobutyric acid)

• and dantrolene, which acts at the level of skeletal muscle. (decreases muscle calcium ion release)

Physical therapy

• Is an essential component in the treatment of patients with cerebral palsy.

• Physical therapy typically is used as a primary treatment modality and in conjunction with other modalities, such as casting, bracing, medication, and surgery.

• The therapist plays a crucial role in all aspects of care.

Operative Treatment

• Operative treatment typically is indicated when contractures or deformities decrease function, cause pain, or interfere with activities of daily living

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