Cerebral Palsy

“A group of permanent disorders of the development of movement and posture causing activity limitation that are attributed to non-progressive disturbances of the foetal or infant brain”

Here I’ve mocked up a fake case history for the ‘typical’ cerebral palsy patient, which is how I remember the key features:

Charlie Babinski and his twin brother were born on the 2nd of November 2000 at 28 weeks gestation. He weighed 1499g, and his brother was a much bigger 2300g.

  • Babinski – often have persistent primitive reflexes
  • More common in multiple births
  • 2.11/1000 live births affected
  • Much higher incidence below 28 weeks
  • Much higher incidence below 1500g
  • Associated with IUGR, and CP patients usually small as their bones aren’t able to grow to their full potential

During the pregnancy, he’d suffered many infections, including toxoplasmosis and rubella. His mother had also been ill, and had very high blood pressure, for which she took ACE inhibitors. During the pregnancy she was involved in a plane crash, which she survived, but at the reassurance scan they noticed congenital abnormalities.

  • Antenatal causes of cerebral palsy:
    • infection
      • toxoplasmosis
      • rubella
    • maternal illness
    • teratogenic insult
    • abdominal trauma
    • plane – flight – DVT risk – coagulopathy
    • congenital malformations

At the time of his birth, he had got stuck during the delivery for several minutes, and suffered severe hypoxia as a result. He was then delivered forcefully with forceps and was very floppy when he was delivered. Because he was bright yellow, they did a scan and found he had significant intraventricular haemorrhage and periventricular leukomalacia.

  • Intrapartum/neonatal causes:
    • hypoxia
    • trauma
    • hyperbilirubinaemia – kernicterus
    • intraventricular haemorrhage
    • periventricular leukomalacia
  • children with CP may be hypo or hypertonic depending on the severity and location of the insult

Charlie is now a very happy child, and whizzes around at high speed in his four-wheeled electronic wheelchair. His eyesight isn’t very good and his joints are stiff so he regularly crashes into things. Sometimes these crashes trigger him to have a seizure, but his muscles are very short and stiff so he doesn’t move much when they occur, and he doesn’t ever talk about them. He gets very upset when his brother tip-toes past him with a pair of scissors and snips his homework into little pieces.

  • Mobilises with electronic wheelchair – Gross Motor Function Classification System (GMFCS)
    • level 4 impairment
  • Associated impairments:
    • emotional disturbances
    • poor vision
    • seizures
    • poor communication
  • Secondary motor impairments:
    • muscle shortening
    • arthritis
  • Tip-toes – toe walking seen in CP patients as they have very short calves
  • Scissors – ‘scissor legs’ seen due to shortened adductors
  • Learning difficulties

Charlie comes to see you for help. You decide to manage his condition in two stages; Temporarily, and Permanently.

Permanent management requires you to call the neurosurgeons, and in the meantime, you’d like to control his seizures, reduce his urinary incontinence and relax his stiff muscles. To do so you give him some oral medications and then tell him to take off his shoes and lie down on his front. You then give him a massage from his head, down his spine, to his toes, and insert a needle into his spine, which gets him all in a tizz.

  • Managment:
    • Temporary
      • Oral
        • Anticonvulsants
        • Antimuscarinics
        • Muscle relaxants
          • central – benzodiazepines
          • spinal – baclofen/tizamidine
          • peripheral – dantrolene
      • Intrathecal
        • baclofen
      • Orthotics
    • Permanent
      • Neurosurgery
      • Selective dorzal rhizotomy
      • Deep brain stimulation
      • Orthopaedic surgery

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: