Cerebral palsy-clinical presentation

during neonatal period
1. babies IDed if at risk
early features
1. infancy
  1. abnormal limb &/or trunk posture & tone
  2. delayed developmental milestones
  3. +/-slowing of head growth
2. feeding difficulties w/
  1. oromotor incoordination
  2. slow feeding
  3. gagging
  4. vomiting
3. abnormal gait once walking achieved
4. asymmetric hand function before 12 months old
persistence of primitive reflexes (pathological)
1. normal role of primitive reflexes
  1. aid appearance of normal patterns of movement
  2. to disappear for motor development to progress
diagnosis
1. by clinical exam w/ attn to
  1. posture & pattern of tone in limbs & trunk
  2. hand function
  3. gait
3 main clinical subtypes
1. spastic
  1. damage to upper motor neurone pathway
    1. pyramidal/corticospinal tract
  2. persistently increased limb tone (spasticity)
    1. velocity dependent spastic tone
      1. the faster muscle stretched, the greater resistance it'll have
        -> dynamic catch
        characteristic of spasticity
    2. clasp knife
      1. increased limb tone suddenly gives way under Pa
  3. brisk deep tendon reflexes
  4. extensor plantor responses (upgoing)
  5. unilat or bilat limb involvement
  6. early presentation
    1. even as neonate
  7. 3 main types
    1. hemiplegia
      1. unilat arm & leg involvement
        arm > leg affected
      2. face spared
      3. present @ 4-12 months old
        fisting of affected hand
        a flexed arm
        asymmetric reaching/hand funcn
        subseq tiptoe walk
        toe-heel gait on affected side
      4. initially affected limbs flaccid & hypotonic
        increased tone then emerges as dominant sign
      5. past med hx
        normal
        unremarkable birth hx
        neontal stroke
        can be the cause
      6. hemianopia
        ipsilat side as affected limbs
        due to larger brain lesions (strokes)
    2. quadriplegia
      1. all 4 limbs affected
        often severely
      2. truncal involvement
        tendency to opisothonus (extensor posturing)
        poor head control
        low central tone
      3. more severe CP
      4. assoc
        microcephaly
        seizures
        moderate/severe intellectual impairment
      5. hx of perinatal hypoxic-ischaemic encephalopathy
    3. diplegia
      1. all 4 limbs
        legs>arms affected
        relatively normal hand funcn
        arm motor difficulties most visible on using hands
      2. abnormal walking
      3. assoc
        preterm birth
        periventricular brain damage
2. dyskinetic
  1. movements
    1. involuntary
    2. uncontrolled
    3. stereotyped (sometimes)
    4. more evident w/ active movement or stress
  2. variable muscle tone
  3. primitive motor reflex patterns predominate
  4. description
    1. chorea
      1. irreg, sudden & brief non-repetitive movements
    2. athetosis
      1. slow writhing movements occurring distally
        e.g. fanning of fingers
    3. dystonia
      1. simultaneous contracn of agonist & antag truncal & prox mm
        twisting appearance
  5. relatively unimpaired intellect
  6. presentation
    1. infancy
      1. floppiness
      2. poor trunk control
      3. delayed motor development
      4. abnormal movements can show only toward end of 1st year of life
  7. pathology
    1. damage/dysfunction
      1. basal ganglia
      2. extrapyramidal pathways
  8. cause
    1. kernicterus (hyperbilirubinaemia)
      1. commonest cause in past
      2. due to Rh disease of newborn
    2. hypoxic-ischaemic encephalopathy @ term
      1. current commonest cause
3. ataxic (hypotonic)
  1. cause
    1. genetically determined
    2. acquired brain injury to cerebellum or its connections
      1. signs ipsilat to lesion
        but rel symmetrical
  2. early trunk & limb hypotonia
  3. poor balance
  4. delayed motor developments
  5. features appearing later
    1. incoordinate movements
    2. intention tremor
    3. ataxic gait
description of functional ability
1. Gross Motor Function Classification
  1. Level I
    1. walks w/o limitations
  2. Level II
    1. walks w/ limitations
  3. Level III
    1. walks using a handheld mobility device
  4. Level IV
    1. self-mobility w/ limitations; may use self-powered mobility
  5. Level V
    1. transported in a manual wheelchair

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Cerebral palsy-clinical presentation

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	Created by v.djabatey almost 11 years ago