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Nakhieeran Nallasamy 
Azreen Onny 
Nirmalatiban Parthiban (The Expert)
• Abnormality of movement and posture, 
causing activity limitation attributed to non-progressive 
disturbances that occurred in the 
developing fetal or infant brain 
• Most common cause of motor impairment in 
children – 2 per 1000 live births 
• CP term - Brain injuries up to 2 years of age 
• <2 - Acquired brain injury as diagnosis 
• Underlying cause is static - resulting motor 
disorder may evolve -> deterioration
• Motor disorders accompanied by: 
– Cognition 
– Communication 
– Perception 
– Sensation 
– Behaviour & seizure disorder 
– Secondary MSK problems 
• Diagnosis: 
– Distribution of the motor disorder 
– Movement type 
– Cause 
– Any associated impairment
Spastic CP 
• Damage to upper motor neurone 
(pyramidal/corticospinal tract) pathway 
• Limb tone is persistently increased (spastic) a/w: 
• Brisk deep tendon reflexes 
• Extensor plantar responses 
• Spastic tone – velocity dependent -> dynamic 
catch 
• May suddenly yield under pressure - ‘clasp knife’
• Limb involvement – unilateral or bilateral 
(asymmetrical signs) 
• Spasticity – present early; can even be seen in 
the neonatal period 
• Sometimes -> initial hypotonia, esp. head & 
trunk 
• THREE main types of spastic CP: 
– Hemiplegia 
– Quadriplegia 
– Diplegia
 Hemiplegia 
• Unilateral involvement of arm and leg (Arm>Leg; Face 
spared) 
• Often present at 4-12 months with: 
– Fisting of the affected hand 
– Flexed arm; Pronated forearm 
– Asymmetric reaching or hand function 
– Subsequently -> tip-toe walk (toe-heel gait) 
• Initially flaccid & hypotonic, but increased tone 
becomes the predominant sign 
• In some, caused by neonatal stroke; strokes -> 
hemianopia
 Quadriplegia 
• All four limbs; often severe 
• Trunk – opisothonus, poor head control, low central 
tone 
• Severe CP a/w seizures, microcephaly and moderate 
or severe intellectual impairment 
 Diplegia 
• All four limbs (Leg>Arm) -> Hand function normal 
• Motor difficulties in arms -> functional use of hands 
• Walking is abnormal 
• a/w preterm birth due to periventricular brain 
damage
Dyskinetic CP 
• Damage to the basal 
ganglia 
1. Chorea 
2. Athetosis 
3. Dystonia
Chorea 
Definition 
• “Dance-like” irregular, involuntary, brief and abrupt 
movements 
Features 
• Mild: Fidgety, clumsy 
• Severe: Wild, violent movements with large 
amplitude (“Ballism”) 
• Speech, movement and swallowing disturbances
Athetosis 
Definition 
• Slow writhing movements occurring more distally 
(Fanning of fingers) 
Features 
• Fluctuations of muscle tones 
• Activities using hand and feet disturbed 
• Muscles of face and tongue may be affected 
(grimacing, drooling, speech, breathing, swallowing 
problem) 
• Worsen when moving and emotional stress
Dystonia 
Definition 
• Simultaneous contraction of agonist 
and antagonist muscles of the trunk 
and proximal muscles 
• “Twisting” appearance 
• 2 types: Focal and generalised 
Features 
• Repetitive and sustained movements 
• Awkward postures 
• Rapid or slow movements (painful) 
• Speech and swallowing difficulties 
(generalised) 
• Increase when tired, anxious, tense 
or emotional 
Sensory tricks 
Specific movements or 
sensations which may 
suppress the unwanted 
movements 
 Example; 
= Touching face or chin 
with hand or finger
Choreoathetoid CP 
Definition 
• Chorea + Athetosis 
• Abnormal, uncontrollable, writhing movements of 
arms and legs 
Features 
• Variable muscle tone (common: hypotonia) 
• Activated by stress, laughing or attempt to move
Ataxic (Hypotonic) CP 
• Due to acquired brain injury (cerebellum and the 
connections) 
Features 
• Ipsilateral and symmetrical 
• Early trunk and limb hypotonia 
• Poor balance 
• Delayed motor development 
• Incoordination 
• Intention tremor 
• Ataxia
Cerebral palsy
Cerebral Palsy Management 
Multidisciplinary approach 
Child development services 
Pediatrician 
-Investigation, diagnosis 
-Continuing medical 
management 
-Coordinating input from 
other agencies 
Physiotherapist 
-Balance and mobility 
(aids- motorised 
wheelchair/frame) 
-Postural maintenance 
-Prevention of joint 
contractures 
Speech and language 
therapist 
-Augmentation and 
alternative communication 
(Makaton sign) 
Occupational therapist 
-Activities of daily living 
(ADL)- feeding, washing, 
toileting , seating 
Psychologist 
-Cognitive testing 
-Behavior management 
-Education advice 
Specialist health 
visitor/Social worker 
- Helps coordinate MDT 
-Advocate for child and 
family
Clinical 
Multidisciplinary approach 
Rehabilitation 
Physiatrist 
-Rehabilitation medicine 
specialist 
-Management (sialorrhea, 
insomnia) 
Orthopedic surgeon 
-Correct structural deformities 
-Spasticity (tenotomy, a 
tendon-lengthening 
procedure) 
Neurologist and 
neurosurgeons 
-Treatment patients with 
seizures 
-Treat hydrocephalus, 
spasticity 
Geneticists 
-To rule out other disorders 
-Evaluate for genetic syndrome 
(dysmorphic features, multiple 
organ abnormalities) 
Gastroenterologist, nutritionist 
-manage feeding/swallowing 
difficulties, GERD, asses 
nutritional status 
Pulmonologists 
-Bronchopulmanory dysplasia 
Recurrent aspiration 
Pediatricians
Management of abnormal movements 
Target : spasticity, dystonia, myoclonus 
Baclofen 
-Orally or intrathecally 
to treat spasticity 
-gamma aminobutyric 
acid- to activate GABA 
Anticonvulsants 
(benzodiapenes, 
diazepam)- to treat 
myoclonus 
Phenol intramuscular 
neurolysis 
-Large muscles 
-Limited to nerves with motor 
innervation as it may result in 
sensory dysasthesia 
-To block nerve conduction 
Botulinum toxin 
-Treat for spasticity 
-Should be considered lower 
extremities 
-Allow range of motions 
-Blocks the release of 
acetylcholine
Intrathecal baclofen pump 
insertion 
-Placed in anterior abdominal wall 
and connects to a 
catheter to subarachnoid of spinal 
cord 
-Allows more local inhibition and 
fewer adverse effects than oral 
baclofen 
Selective dorsal rhizotomy 
-To treat for spaticity 
-Surgical ablation of sensory nerve roots. 
-It decreases spasticity by decreasing 
reflexive motor neuron activation 
-Targets nerves that do not receive gamma 
aminobutryic acid – cause of overfiring – 
hypotonia 
Stereotactic basal ganglia 
-May improve rigidity, tremor 
Orthopedic surgical team 
-Scoliosis and hip dislocation are common require 
surgery 
-Tendon lengthening-spastic muscle imbalance 
-Osteotomy to realign limbs-femoral neck, tibia 
-Reconstructive surgeries to release contractures, 
stabilize joints
THANK YOU!!!

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Cerebral palsy

  • 1. Nakhieeran Nallasamy Azreen Onny Nirmalatiban Parthiban (The Expert)
  • 2. • Abnormality of movement and posture, causing activity limitation attributed to non-progressive disturbances that occurred in the developing fetal or infant brain • Most common cause of motor impairment in children – 2 per 1000 live births • CP term - Brain injuries up to 2 years of age • <2 - Acquired brain injury as diagnosis • Underlying cause is static - resulting motor disorder may evolve -> deterioration
  • 3. • Motor disorders accompanied by: – Cognition – Communication – Perception – Sensation – Behaviour & seizure disorder – Secondary MSK problems • Diagnosis: – Distribution of the motor disorder – Movement type – Cause – Any associated impairment
  • 4. Spastic CP • Damage to upper motor neurone (pyramidal/corticospinal tract) pathway • Limb tone is persistently increased (spastic) a/w: • Brisk deep tendon reflexes • Extensor plantar responses • Spastic tone – velocity dependent -> dynamic catch • May suddenly yield under pressure - ‘clasp knife’
  • 5. • Limb involvement – unilateral or bilateral (asymmetrical signs) • Spasticity – present early; can even be seen in the neonatal period • Sometimes -> initial hypotonia, esp. head & trunk • THREE main types of spastic CP: – Hemiplegia – Quadriplegia – Diplegia
  • 6.  Hemiplegia • Unilateral involvement of arm and leg (Arm>Leg; Face spared) • Often present at 4-12 months with: – Fisting of the affected hand – Flexed arm; Pronated forearm – Asymmetric reaching or hand function – Subsequently -> tip-toe walk (toe-heel gait) • Initially flaccid & hypotonic, but increased tone becomes the predominant sign • In some, caused by neonatal stroke; strokes -> hemianopia
  • 7.  Quadriplegia • All four limbs; often severe • Trunk – opisothonus, poor head control, low central tone • Severe CP a/w seizures, microcephaly and moderate or severe intellectual impairment  Diplegia • All four limbs (Leg>Arm) -> Hand function normal • Motor difficulties in arms -> functional use of hands • Walking is abnormal • a/w preterm birth due to periventricular brain damage
  • 8. Dyskinetic CP • Damage to the basal ganglia 1. Chorea 2. Athetosis 3. Dystonia
  • 9. Chorea Definition • “Dance-like” irregular, involuntary, brief and abrupt movements Features • Mild: Fidgety, clumsy • Severe: Wild, violent movements with large amplitude (“Ballism”) • Speech, movement and swallowing disturbances
  • 10. Athetosis Definition • Slow writhing movements occurring more distally (Fanning of fingers) Features • Fluctuations of muscle tones • Activities using hand and feet disturbed • Muscles of face and tongue may be affected (grimacing, drooling, speech, breathing, swallowing problem) • Worsen when moving and emotional stress
  • 11. Dystonia Definition • Simultaneous contraction of agonist and antagonist muscles of the trunk and proximal muscles • “Twisting” appearance • 2 types: Focal and generalised Features • Repetitive and sustained movements • Awkward postures • Rapid or slow movements (painful) • Speech and swallowing difficulties (generalised) • Increase when tired, anxious, tense or emotional Sensory tricks Specific movements or sensations which may suppress the unwanted movements  Example; = Touching face or chin with hand or finger
  • 12. Choreoathetoid CP Definition • Chorea + Athetosis • Abnormal, uncontrollable, writhing movements of arms and legs Features • Variable muscle tone (common: hypotonia) • Activated by stress, laughing or attempt to move
  • 13. Ataxic (Hypotonic) CP • Due to acquired brain injury (cerebellum and the connections) Features • Ipsilateral and symmetrical • Early trunk and limb hypotonia • Poor balance • Delayed motor development • Incoordination • Intention tremor • Ataxia
  • 15. Cerebral Palsy Management Multidisciplinary approach Child development services Pediatrician -Investigation, diagnosis -Continuing medical management -Coordinating input from other agencies Physiotherapist -Balance and mobility (aids- motorised wheelchair/frame) -Postural maintenance -Prevention of joint contractures Speech and language therapist -Augmentation and alternative communication (Makaton sign) Occupational therapist -Activities of daily living (ADL)- feeding, washing, toileting , seating Psychologist -Cognitive testing -Behavior management -Education advice Specialist health visitor/Social worker - Helps coordinate MDT -Advocate for child and family
  • 16. Clinical Multidisciplinary approach Rehabilitation Physiatrist -Rehabilitation medicine specialist -Management (sialorrhea, insomnia) Orthopedic surgeon -Correct structural deformities -Spasticity (tenotomy, a tendon-lengthening procedure) Neurologist and neurosurgeons -Treatment patients with seizures -Treat hydrocephalus, spasticity Geneticists -To rule out other disorders -Evaluate for genetic syndrome (dysmorphic features, multiple organ abnormalities) Gastroenterologist, nutritionist -manage feeding/swallowing difficulties, GERD, asses nutritional status Pulmonologists -Bronchopulmanory dysplasia Recurrent aspiration Pediatricians
  • 17. Management of abnormal movements Target : spasticity, dystonia, myoclonus Baclofen -Orally or intrathecally to treat spasticity -gamma aminobutyric acid- to activate GABA Anticonvulsants (benzodiapenes, diazepam)- to treat myoclonus Phenol intramuscular neurolysis -Large muscles -Limited to nerves with motor innervation as it may result in sensory dysasthesia -To block nerve conduction Botulinum toxin -Treat for spasticity -Should be considered lower extremities -Allow range of motions -Blocks the release of acetylcholine
  • 18. Intrathecal baclofen pump insertion -Placed in anterior abdominal wall and connects to a catheter to subarachnoid of spinal cord -Allows more local inhibition and fewer adverse effects than oral baclofen Selective dorsal rhizotomy -To treat for spaticity -Surgical ablation of sensory nerve roots. -It decreases spasticity by decreasing reflexive motor neuron activation -Targets nerves that do not receive gamma aminobutryic acid – cause of overfiring – hypotonia Stereotactic basal ganglia -May improve rigidity, tremor Orthopedic surgical team -Scoliosis and hip dislocation are common require surgery -Tendon lengthening-spastic muscle imbalance -Osteotomy to realign limbs-femoral neck, tibia -Reconstructive surgeries to release contractures, stabilize joints

Editor's Notes

  1. Chorea: Irregular, sudden and brief non repetitive movements Athetosis: Slow writhing movements occurring more distally such as fanning of fingers Dystonia: Simultaneous contraction of agonist and antagonist muscles of the trunk and proximal muscles giving a twisting appearance
  2. Worsen in attempts to move, anxiety and stress, subside during sleep May occur with athetosis (choreoathethosis) and dystonia
  3. Athetosis: worsens when trying to move Fluctuation: Problem when trying to concentrate at one task. Eg: Scratching nose (hypertonia and hypotonia)
  4. Focal: only occur when person doing a particular movement or task. One (cervical) Generalised: Affects both legs and at least one arm OR trunk in combination with at least one arm or leg
  5. Related to bilirubin encephalopathy: Kernicterus
  6. Dx can only be made after the child’s brain fully developed (3-5 years old) History: birth hx, family hx, newborn screen at birth, APGAR score, baby gwth records Neuroleptics: Typical neuroleptics: Haloperidol, fluphenazine Atypical neuroleptics: Risperidone, olanzapine, clozapine, quetiapine
  7. 4%- 5% only : especially fine motor and gait Moro reflex and romberg test : Persistent and exacerbation of reflex (normal: lost after 6 months old). Romberg: significant: focal/localized cerebellar dysfunction CT, MRI (infarctions, brain malformations)
  8. Include other specialties : Ophthalmologist – visual deficits audiologists- hearing deficits, Endocrinologists- precocious puberty
  9. To reduce neuronal excitability