Cerebral palsy

Cerebral palsy - Chronic

 

Definition  

A disorder of movement and posture control caused by a nonprogressive lesion or injury in the developing brain

 

Initial Evaluation of Associated Conditions  

 

Suspected seizure disorder  

* Electroencephalogram: In adults with a new onset seizure, an EEG showing epileptiform activity (spikes or sharp waves) is considered significantly abnormal and is predictive of seizure recurrence.

 

Medical History  

* Prematurity of fetus

* Intrauterine hypoxia AND/OR birth asphyxia

* Chorioamnionitis

* Low birth weight infant

* Fetal growth restriction

* Thromboembolic stroke

* Intracranial hemorrhage

* Birth trauma

* Parity finding

* Corticosteroid use

* Bacterial meningitis

* Viral encephalitis

* Child abuse

* Head trauma

* Hyperbilirubinemia

* Fetus or neonate affected by maternal infection

* Intrauterine toxin exposure

 

Findings  

* Motor dysfunction

* Developmental delay

* Poor muscle tone

* Muscular hypertonicity

* Spasticity

* Abnormal reflex

* Abnormal gait

* Hemiplegia

* Diplegia

* Quadriplegia

* Dyskinesia

* Impaired cognition

* Dysphagia - Chronic

* Hand preference - finding

* Abnormal posture

* Undernourished

* Asymmetric muscle tone

* Difficulty swallowing

* Hearing loss

 

Tests  

 

Suspected and known cerebral palsy  

* Magnetic resonance imaging of brain and brain stem: Brain MRI is preferred to CT because of the higher yield in suggesting the etiology and timing of the brain insult leading to cerebral palsy .

* CT of head: CT is less sensitive than MRI in suggesting the etiology and timing of the brain insult leading to cerebral palsy but may detect surgically treatable conditions in a small percentage of patients .

 

Suspected blood coagulation disorder in hemiplegic cerebral palsy  

* Blood coagulation panel: Coagulation studies should be considered in children with hemiplegic CP because of the high incidence of unexplained cerebral infarction .

 

Suspected metabolic disease underlying or mimicking cerebral palsy  

* Metabolic screening test: Metabolic testing should be considered if a specific structural abnormality is not identified, the history or physical exam is atypical, or a brain malformation is present .

 

Differential Diagnosis  

* Glutaric aciduria, type 1

* Niemann-Pick disease, type C

* Lesch-Nyhan syndrome

* Pelizaeus-Merzbacher disease

* Rett's disorder

* Arginase deficiency

* Juvenile neuronal ceroid lipofuscinosis

* Metachromatic leukodystrophy, juvenile type

* Hereditary spastic paraplegia

* Ataxia-telangiectasia syndrome

* Diurnal dystonia

* Mitochondrial cytopathy

 

Treatment  

 

Drug Therapy  

 

Generalized spasticity and athetosis in cerebral palsy  

 

DIAZEPAM  

Adults: 2 to 10 mg orally 3 to 4 times daily

Pediatrics: 0.12 to 0.8 mg/kg/day orally in divided doses

 

BACLOFEN

Adults: 5 mg orally 3 times daily; may increase dosage by 15 mg/day increments every 3 days (maximum 80 mg/day in 3 to 4 divided doses)

Pediatrics (2 to 7 years): 10 to 15 mg/day orally in 2 to 3 divided doses; may increase by 5 to 15 mg/day increments every 3 days (maximum 40 mg/day in 3 to 4 divided doses)

Pediatric (?8 years): 10 to 15 mg/day orally in 2 to 3 divided doses; may increase by 5 to 15 mg/day increments every 3 days (maximum 60 mg/day in 3 to 4 divided doses)

 

TIZANIDINE HYDROCHLORIDE

Adults: Initially, 4 mg/day orally and gradually increase in 2 to 4 mg increments on an individual basis over 2 to 4 weeks; maintenance, 8 mg orally every 6 to 8 hr (maximum 36 mg/day)

 

 

Cerebral palsy with limb spasticity  

 

ONABOTULINUMTOXINA

 

 

Procedural Therapy  

 

* Physical therapy procedure: Physical therapy is an integral part of the management of spastic cerebral palsy to help decrease or prevent deformity, promote function, and alleviate pain .

 

* Occupational therapy: Occupational therapy often is beneficial and may be useful individuals with dysphagia secondary to oromotor deficits .

* Speech therapy: Speech therapy is indicated for children with cerebral palsy who have speech and language disorders .

* Provision of assistive equipment: Assistive devices may help persons with cerebral palsy overcome physical and communication limitations .

 

* Orthotic procedure: Orthotic devices often are used to alter the unopposed, deforming forces or increased muscle activity associated with spastic cerebral palsy .

* Surgical procedure: Soft tissue or bony surgery may be used to alter the unopposed, deforming forces or increased muscle activity associated with spastic cerebral palsy .

 

* Enteral feeding: Enteral feeding may be necessary in undernourished children with feeding problems and swallowing dysfunction, however evidence supporting its benefits is lacking and many complications have been reported .