Cerebral Palsy

Cerebral Palsy
Roger Leo, MD
Agus Maharjana, MD
Definition
• a group of non-progressive disorders occurring in

young children in which disease of the brain causes
impairment of motor function (Haslam et al, 1955)
• Is a result of demage of the developing brain that

produce disorder of movement and posture that is
permanent but “not unchanging” (Mercer Rang
1990)
Definition (Rosenbaum, 2006)
• Describe a group of permanent disorders of the
development of movement and posture, causing activity
limitation, that are attribute to non progressive disturbance
that occur in the developing fetal or infant brain.
• The motor disorders of the cerebral palsy often
accompanying with sensation, perception, cognition,
communication and behaviour, by epilepsy and by secondary
musculoskeletal disorders.
Definition
Lesion immature brain (developing) :

nonprogrssive
Disorders musculoskeletal : progressive
* Static encephalopathy, progressive musculoskeletal

Definition
Lesion immature brain (developing) :

nonprogrssive
Disorders musculoskeletal : progressive
* Static encephalopathy, progressive musculoskeletal

Incidence
• Occurs in 1-5 in 1000 live births

• More common in advanced countries
• Advanced perinatal care increases survival of brain-
damaged children
• Care only slightly reduces incidence of CP
• More common in socioeconomically disadvantaged
Etiology
Prenatal Perinatal Postnatal
Congenital infections Prematurity Infections
meningitis
Torches : Low birth weight Encephalitis
Toxoplasmosis
Rubela Complicated delivery Head trauma
Cytomegalovirus (dystocia)
Herpes asphysia Cerebrovascular accident
Syphylis cerebral trauma cyanotic cong. heart disease
sickle cell anaemia
AIDS Infections vascular malformation
menigitis
Abuse drugs: herpes Cerebral anoxia
tobacco near drowning
alcohol Hyperbillirubinaemia aspiration asphyxia
marijuana Blood incomptabilities cardiac arrest
cocaine Other hemolytic disorder seizures
drugs
Hypoglycaemia Malnutrition
Cerebral malformation
Obstetric complication
pre eclampsia/eclampsia
abruptio placentae
placenta praevia
8
Classification
1. Movement
2. Anatomy
3. Function
Classification
Movement
Spastic (most Velocity-dependent increased muscle tone and hyperreflexia with
common) slow restricted movement due to simultaneous contraction of
agonist and antagonist. Most amenable to operative treatments.
Athetoid Characterized by constant succession of slow, writhing, involuntary

movements.
Ataxic Characterized by inability to coordinate muscle movements. Results
in unbalanced wide based gait.
Tremor Involuntary movement
Atonia No tone
Mixed Usually mixed spastic and athetoid features and involves the entire
body
Spastic Diplegia
Spastic Hemipeglia
Classification
Anatomic :
• Monoplegia
• Hemiplegia
• Paraplegia
• Diplegia
• Triplegia
• Total body involved
Classification
Gross Motor Function Classification Scale (GMFCS)

Level I Near normal gross motor function, independent
ambulator
Level II Walks independently, but with limitations
Level III Dependent ambulator
Level IV Minimal walking ability, uses adult assisted or
powered devices for community ambulation
Level V Nonambulator with global involvment, dependent
in all aspects of care
Classification
Pathogenesis
1. Weakness  UMN Lesion

2. Spasticiy  Due to lesion pyramidalis system
3. Muscle Contracture  Shortening muscle-
tendon unit, can’t keep up with the pace of
bone growth
4. Deformity  Result from unopposed muscle
contracture
Evaluation
History
• Clinical history
– Perinatal history
– Growth & development
– All medical treatment
• Functional status
– Patients nutritional status
– Respiratory function
– Sitting / standing posture
– Upper and lower extremities function
– Communication skills
– Acuity of hearing and vision
Evaluation
Physical Exam
• Muscular-skeletal exam
– Motion, tone, and strength
– Hamstring contracture's (lead to decreased lumbar
lordosis)
– Hip contractures (lead to excessive lumbar lordosis)
• Spine exam
– Look at flexibility of curve
– Spinal balance and shoulder height
– Pelvic obliquity
5 Pattern Gait Spastic Diplegic
• True equinuus
• Jump gait
• Apparent equinuus
• Crouch gait
• Asymetric gait
Other Gait
• Hemiplegic gait • Myophatic gait

• Extrapiramidal gait • Antalgic gait
• Ataxic gait • Scissor gait
• Chorea dancing gait • Waddling gait
• High Steppage gait
Cerebral palsy
Clinical Assessment
Hip Flexors
• Ilio-psoas
( the main and most powerful )
• Sartorius
• Tensor fascia lata
• Rectus femoris
• Adductors
Thomas Test
Staheli Test
Ely Test
Cerebral palsy
Hip Rotators
Internal Rotators External Rotators
• Gluteus Medius • Piriformis

anterior portion is the main
internal rotator • Gemilli
• Gluteus Minimus • Obturator internus
• Semitendinosis • Obturator externus
• Adductors
• Tensor fascia lata
Cerebral palsy
Hip
Adductors
Superficial layer
- Pectineus
- Adductor longus
- gracilis
Cerebral palsy
Hip
Adductors
Intermediate layer
- adductor brevis
Cerebral palsy
Hip Adductors
Deep layer
- adductor Magnus
Cerebral palsy
Clinical Assessment
Hip Adductors
Hip abduction / knees extended Hip abduction / knees flexed

The Gracilis
Knee flexion / Hamstring
Contracture
• Hamstring Test / Holt’s Method
Popliteal Angle
Silverskiold test / Gastrosoleus
Contracture
Management
• Goal of Treatment :
1. Ambulation : community walker, household walker,

physiologic walker, non walker (Hoffer)
2. Communication : oral/verbal, non oral (sign,symbol,
electronic)
3. ADL : feeding, toileting, bathing, grooming, dressing
4. Mobility : independence, social integration,
employment (if possible)
Management
• Type of Treatment :
1. Physical Therapy
2. Orthotics
3. Control of Spasticity
4. Orthopaedic Surgery
Management acording to age, motor involvement,
assosiated handicap, social condition
(0 – 3) years : - physiotherapy
(4 – 6) years : - physiotherapy
- surgery with appropriate
indication
(7 – 8) years : - schooling, psychosocial
development
- some surgery
more 18 years : - orientation to work
- residence
- marriage (independent)
36
Management
• Non Operative
Physical therapy, bracing/orthotics, and medications for
spasticity
– Spasticity control
• Botox (botulinum - A toxin)
– competitive inhibitor of presynaptic cholinergic
receptor with a finite lifetime (usually last 2-3
months)
– used to maintain joint motion during rapid growth
when a child is too young for surgery
– often injected into gastocnemius
Management
• Baclofen
– reduces tone via unknown mechanism
» thought to act as GABA agonist
» intra-thecal administration is preferred
route to avoid cognitive impairment seen
with oral administration
Management
• Operative general
– surgery to improve function should be considered in a child >3 years old
with spasticity and voluntary muscle control
• multi-level soft tissue procedures
– indications
• perform early (< 5 years of age)
– techniques
• tenotomies for continuously active muscles (e.g. hip adductor)
• tendon lengthening for continuously active muscles (e.g. achilles
tendon or hamstring)
• tendon transfers for muscles firing out of phase (e.g. rectus tendon or
tibialis posterior)
– tendon transfers in the upper extremity show the best
improvement in function in patients with voluntary motor control
General Management
• Scoliosis : surgery indication
Curve 50-60%, worsening pelvic tilt
Curve I (double small curve thoracal, lumbal)
Curve II (large lumbal/TL)
• Hip Subluxation and/ Dislocation
Hip at risk : ABD < 25%. Uncovered femoral head <50%
Adductor tenotomy, release iliopsoas
• Hip Subluxation
head uncovered > 50%
femoral varus osteotomy
acetabular osteotomy (Dega, Chiari)
Management
• bony procedures (pelvis osteotomies, scoliosis surgery)
– indications
• done later in life ( > 5 years of age)
• rhizotomy
– neurosurgical resection of dorsal rootlets that do not show
a myographic or clinical response to stimulation
– indications
• ages 4 to 8, ambulatory spastic diplegia, and a stable
gait pattern that is limited by lower extremity spasticity
Prognosis
• Prognosis of walking (after 12 mo)

Walking prognosis test (score)
(after age 12 months) (Bleck,1975)
1) asymmetrical tonic neck reflex 1 point
2) Neck right reflex 1 point
3) Moro reflex 1 point
4) symmetrical tonic neck refle 1 point
5) Extensor thrust 1 point
6) Parachute reaction 1 point (if absent)
7) Foot placement reaction 1 point (if absent)
poor prognosis : score 2 or more

might walk : score 1 point
good prognosis : score 0 point
43
1. asymmetrical tonic neck reflex
44
2. Neck-righting reflex
45
3. Moro reflex
46
4. Symmetrical tonic neck reflex
47
5. Parachute reaction
48
6. Foot placement reaction
49
7. Extensor thrust
50
THANK YOU

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Cerebral Palsy

• a group of non-progressive disorders occurring in

• Is a result of demage of the developing brain that

Lesion immature brain (developing) :

* Static encephalopathy, progressive musculoskeletal

Lesion immature brain (developing) :

* Static encephalopathy, progressive musculoskeletal

• Occurs in 1-5 in 1000 live births

Athetoid Characterized by constant succession of slow, writhing, involuntary

Gross Motor Function Classification Scale (GMFCS)

1. Weakness  UMN Lesion

• Hemiplegic gait • Myophatic gait

• Gluteus Medius • Piriformis

Hip abduction / knees extended Hip abduction / knees flexed

1. Ambulation : community walker, household walker,

• Prognosis of walking (after 12 mo)

poor prognosis : score 2 or more

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