Objectives
1- Define CP.
2- List its causes and types.
3- Describe the most common types.
4- Perform management.
Definition
It is a central permanent non- progressive motor disorder.
It is the most common form of chronic motor disability with a
prevalence of 3.5/1000.
Associated features: epilepsy and abnormalities of speech,
vision, hearing, and intellectual function.
Term (static encephalopathy)
Etiology
- Prenatal: (e.g. anomalies, infection, metabolic, anoxia,
toxic, genetic, infarction).
- Perinatal: (e.g. Asphyxia, jaundice)
- Postnatal: (toxin, trauma, infection)
In 80%, antenatal factors causing abnormal brain development.
Fewer than 10% of children with CP had evidence of birth
asphyxia.
Classifications
Physiologic:
- Spastic
- Athetoid
- Mixed
- Rigid
- Tremor
- Atonic
- Ataxic
Topographic:
- Monoplegia
- Hemiplegia
- Quadriplegia
- Diplegia/ Paraplagia
- Triplegia
- Double hemiplegia
Functional:
- Class 1: no limitation of activity.
- Class 2: slight to moderate limitation
- Class 3: moderate to great limitation
- Class 4: no useful physical activity.
Spastic Hemiplegia
Decreased spontaneous movements on one side, The arm is
often more involved than the leg.
hand preference at a very early age.
Walking is usually delayed, and a circumductive gait is
apparent.
Examination:
- growth arrest.
- upper motor n. signs.
- an equinovarus deformity
of the foot .
1/3 seizure; 25 MI.
CT scan or MRI: atrophic
contralateral cerebral hemisphere.
Spastic Hemiplegia
Spastic Diplegia
Bilateral spasticity of the legs.
Due to damage of white matter, mainly in preterms.
The 1st indication is:
- at crawling (commando crawl).
- application of a diaper is difficult
Examination:
- upper motor n. signs.
- scissoring posture.
- delayed Walking, equinovarus,
tiptoe walking, Disuse atrophy.
Intellectual development is
excellent, and the likelihood
of seizures is minimal.
periventricular leukomalacia.
Spastic Para/
The prevalence of CP is increased among
preterm infants, because of intracerebral
hemorrhage and periventricular
leukomalacia (PVL).
Spastic Quadriplegia
It is the most severe form of CP.
Marked motor impairment of all extremities .
high association with mental retardation, seizures, & speech & visual
abnormalities .
Swallowing difficulties are common as a result of supranuclear bulbar
palsies, often leading to aspiration pneumonia.
MRI: severe PVL and multicystic cortical encephalomalacia.
Children with spastic quadriparesis often have evidence of athetosis
and may be classified as having mixed CP.
Athetoid CP (choreoathetoid or
extrapyramidal)
- Most likely to be associated with kernicterus & birth asphyxia.
- Affected infants are characteristically hypotonic with poor
head control and marked head lag
- Increased tone with rigidity
and dystonia with athetosis over
several years.
- upper motor neuron
signs are not present.
- seizures are uncommon,
and intellect is preserved
in many patients.
Athetoid
DIAGNOSIS
Exclude a progressive disorder of the CNS, including
degenerative diseases, metabolic disorders, spinal cord
tumor, or muscular dystrophy.
An MRI scan of the brain is indicated to determine the
location and extent of structural lesions or associated
congenital malformations.
Genetic evaluation: in patients with congenital
malformations (chromosomes) or evidence of metabolic
disorders.
Tests of hearing and visual function
TREATMENT
Multidisciplinary team
Spastic diplegia: adaptive equipment, such as walkers and
standing frames, adductor tenotomy may be needed.
Tight heel cord may be treated surgically by tenotomy of the
Achilles tendon.
Quadriplegia: wheelchairs, special practice devices.
Lower urinary tract dysfunction
Several drugs have been used to treat spasticity
Objectives
1- Define MR.
2- What are the grades and causes of MR?
3- Evaluate the child with MR.
Definition
It is significant sub-average general intellectual function with
deficits in adaptive behavior,
manifested during the
developmental period (before age 18 years).
Significant sub-average intellectual functioning (an IQ score of
less than 70).
Mental age/ chronological age x 100
Mental age: many tests, e.g. Wechler test, Stanford- Binet
Adaptive behaviors include 3 broad sets of skills: conceptual,
social, and practical.
Global developmental delay: limitations have not yet
resulted in a formal diagnosis of intellectual disability;
Classification
Depending on I Q level:
Mild Mental Retardation: 52- 70.
Moderate Mental Retardation: 37- 51.
Severe Mental Retardation: 20- 36.
Profound Mental Retardation: below 20.
Severity Unspecified
Depending on levels of support required: intermittent,
limited, extensive, or pervasive.
ETIOLOGY
2.5% of the population, 85% mild MR.
Mild MR is a consequence of both biological and socioeconomic
(poverty, undernutrition) factors, it is strongly related to
environmental factors.
The most common biologic causes include genetic syndromes with
minor congenital anomalies, prematurity, intrauterine exposure to
drugs of abuse, and sex chromosomal abnormalities.
Severe MR is more linked to severe biologic causes:
- chromosomal : Down syndrome, fragile X syndrome.
- abnormaly developing brain: lissencephaly.
-inborn errors of metabolism/ neurodegenerative disorders:
mucopolysaccharidoses.
- others: congenital infections, HIE, IVH, PVL, fetal alcohol
syndrome), trauma, meningitis, & hypothyroidism.
CLINICAL MANIFESTATIONS
It is usually presented with either
- Dysmorphisms.
- Associated problems (e.g. seizures, cerebral palsy).
- Developmental delay.
Developmental delay:
-Early infancy: lack of visual or auditory responsiveness, feeding
difficulties, & unusual muscle tone (hypo- or hypertonia) or posture.
- Between 6 and 18 mo: motor delay.
- After 18 mo: language delay and behavior problems. delays in fine
motor skills: cutting, coloring, drawing, .
- School age (>5 yr): Academic underachievement, behavior
difficulties.
Neuroimaging, metabolic, and
electroencephalography (EEG)
chromosomal
study,
and
TREATMENT
Mental retardation is not treatable.
Many associated impairments are amenable to intervention.
Education is the single most important step involved
in the treatment, more appropriate classroom setting is chose if
intervention is needed, mental age here is used.
The behavioral/emotional disorders are the primary cause for outof-home placements.