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What is the most common cause of motor impairment in children?
Cerebral palsy
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What is cerebral palsy?
Disorder of motor function due to a NON PROGRESSIVE (static) lesion of the developing brain
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How do the symptoms compare to the lesion?
Although the lesion is non-progressive, the symptoms EVOLVE as the nervous system develops
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What are the 2 areas of motor function that CP affects?
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What are the other problems that children with CP suffer from?
- Learning difficulties
- Epilepsy
- Squints
- Visual impairment from errors of refraction and cortical damage
- Hearing impairment
- SAL problems – hearing loss, oro-motor incoordination, LD
- Behaviour problems
- Feeding
- Joint contractures, hip subluxation, scoliosis
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What are the DEVELOPMENTAL problems in CP – think of the 4 domains
- Fine motor and vision: visual impairment due to refractive error and cortical damage
- Hearing, speech, language
- Behavioural, emotional
- Gross motor – spasticity
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What are the problems with eyes in CP?
- Refractive error
- Cortical damage – affecting vision
- Squints
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What are the musculoskeletal problems in CP apart from spasticity?
Joint contracture
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What is a joint contracture?
- High resistance to passive stretch of a muscle
- Resulting from fibrosis of the tissue supporting the muscles or joints
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How do you divide the causes of CP? And what % each?
- Antenatal: 80%
- Intrapartum: 10%
- Postnatal: 10%
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What are the antenatal causes of CP?
- Vascular occlusion
- Cortical migration disorder
- Structural maldevelopment of the brain during gestation
- Congenital infections: rubella, CMV, toxoplasmosis
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What is the main intrapartum cause of CP?
Birth asphyxia – Hypoxic Ischaemic injury
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What are the post natal causes of CP?
- Preterm birth: HIE, PVL from ischaemia / intraventricular haemorrhage
- Hyperbilirubinaemia (kernicterus in basal ganglia – choreoathetoid CP)
- Hypoglycaemia
- Head injury
- Intracranial infection: meningitis, encephalitis
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What are the early features of CP?
- Abnormal limb tone/posture
- Delayed motor milestones
- Slowing of head growth
- Feeding difficulties – oromotor incoordination (slow feeding, gagging, vomiting)
- Abnormal gait
- Asymmetric hand function before 12 months of age
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What happens to primitive reflexes in normal babies and in CP?
- Normally – need to disappear for motor development to progress
- CP – may persist and become obligatory
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How is the diagnosis of CP made?
- Pattern of tone in limbs and trunk
- Posture
- Hand function
- Gait
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What are the 3 main clinical types of CP?
- Spastic
- Ataxic hypotonic
- Dyskinetic
- Mixed
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Where is the damage in spastic cerebral palsy?
UMN (corticospinal tract)
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What are the features of spastic CP?
- Spasticity: increased limb tone (clasp knife fashion)
- Brisk deep tendon reflexes
- Extensor plantar responses
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What are the 3 types of spastic CP?
- Hemiplegia: unilateral involvement of arm and leg (arm>leg), face spared
- Quadriplegia
- Diplegia
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If an infant has fisting of the hand, a flexed arm and pronated foream, asymmetric reaching and tiptoe walk what type of CP is that?
Spastic hemiplegic
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What may happen initially to the tone in the arms in spastic CP?
Hypotonia and flaccid then becomes spastic later
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What can spastic hemiplegia sometimes be caused by?
Neonatal stroke
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What are the features of quadriplegia CP?
- All 4 limbs affected
- Arms > legs
- Trunk: extensor posturing
- Poor head control
- Low central tone
- Scissoring of the legs – due to excessive adduction
- Pronated forearms
- Fisted hands
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What may there have been a history of in quadriplegic spastic CP?
HIE after birth
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What else is quadriplegic spastic CP associated with?
- Seizures
- Microcephaly
- Low IQ
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What is deplegia?
- Both legs affected – walking is abnormal
- Arms may be affected to certain degree
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What are the 4 features of ataxic hypotonic CP?
- Trunk and limb hypotonia
- Poor balance
- Delayed motor development
- Uncoordinated movements
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Where is the brain damage in ataxic hypotonic CP?
Cerebellum – so remember all cerebellar signs eg incoordination, intention tremor, ataxic gait
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what is dyskinetic CP due to? – where is damage?
- Basal ganglia or extra pyramidal pathways
- Eg in kernicterus
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What is the clinical presentation of dyskinetic CP?
- Delayed motor development
- Abnormal INVOLUNTARY movements appear later:
- Chorea- abrupt, jerky movements
- Athetosis – slow writhing continuous movements
- Dystonia – sustained abnormal postures
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What is the management of CP?
- MDT!
- Community paediatrician
- Physio
- OT
- Dietician
- Community nurse
- SALT
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What must be done for parents?
Accurate diagnosis and prognosis
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How can increased tone be treated?
- Physiotherapy
- Muscle relaxants – diazepam, baclofen
- Botulinum toxin injections to specific muscle groups
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What gastro problem do CP children get?
Reflux
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What is common presentation to hospital in a child with CP?
Chest infection as they are less mobile, and less able to clear secretions
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