The Child With Motor Weakness 2

The Child with Motor Weakness Neurology Module Pediatrics II

Cerebral Palsy - Objectives ► At

the end of this topic you should be able

to:  provide a clear definition of cerebral palsy;  discuss aetiological and risk factors associated with cerebral palsy;  explain the clinical features and associated impairments common to cerebral palsy;  demonstrate an understanding of diagnostic methods; 

The Floppy Baby ► J.M.,

17-month-old boy admitted because of cough

► Born

preterm at 7 months age of gestation by a repeat Caesarean section; BW=1.3 kg; Apgar score not known to mother but resuscitation was reportedly done. He developed sepsis and stayed in the NICU for a month.

► Discharged

with difficulty in feeding such

that he would often cough while sucking.

Case: J.M., 17 months old ►

He was never able to regard, hold head, roll over, use his hand purposively, babble or startle.

► He

had one episode of febrile seizure.

Case: J.M., 17 months old Pertinent Physical Examination Findings: ► Wt=5.95 kg(
HC=42cm(
►

Head lag on traction maneuver, slips through on vertical suspension, truncal hypotonia, loops over on horizontal suspension

►

Spastic limbs, limited movement of both lower extremities with +++ DTRs

Salient Points ► 17

months old, with developmental delay ► Preterm birth ► (+) Neonatal asphyxia ► (+) Infection ► (+) History of seizures ► Marked developmental delay ► Neurologic abnormalities - truncal hypotonia with spastic limbs, weakness of both lower extremities

QUESTION #1: Is there a neurologic disease? ►

Yes, as evidenced by the abnormal neurologic examination.

QUESTION #2: Where is the lesion? ► The

abnormalities in the tone (hypotonia) and movement (diplegia) point to the motor system.

► Weakness

can be due to lesions in the :

1. Central nervous system – Upper motor neuron (spasticity, hyperreflexia); may be accompanied by cerebral manifestations (seizures, cognition, language and sensory problems) 2. Peripheral nervous system – Lower motor neuron (decreased to absent reflexes, flaccid)

QUESTION #2: Where is the lesion? ►

J.M appears to have an upper motor lesion specifically the cerebral hemispheres.

QUESTION #3: What is the nature of the lesion? ► Disorders

of the motor system may be: 1. Acute - strokes/vascular metabolic disorders infection 2. Chronic - cerebral palsy (static) congenital CNS lesion degenerative disorders (progressive)

CEREBRAL PALSY ► Refers

to a group of disorders characterized by motor abnormalities (tone, posture or movement) which are neither progressive nor episodic.

► The

brain lesions are static and result from disorders of early brain development, usually insults in the perinatal period.

► They

are not progressive but the symptoms may change in time.

CEREBRAL PALSY ► Clinical

manifestations: 1. Delay in development – i.e. poor head control, delays in gross motor or fine motor development 2. Motor deficit – depending on the area of the brain involved and usually the risk factors present 3. Associated developmental disabilities – mental retardation, epilepsy, visual, hearing, speech and behavioral abnormalities

Types of Cerebral Palsy and the Major Causes Physiologic Spastic Athetoid Rigid Ataxic Tremor Atonic Mixed Unclassified

Topographic Monoplegia Paraplegia Hemiplegia Triplegia Quadriplegi a Diplegia Double hemiplegia

Etiologic Prenatal

Functional Class I –

(e.g., infection, metabolic, anoxia, toxic, genetic, infarction)

no limitation of activity

Class II –

Perinatal

slight to moderate limitation

(e.g., anoxia)

Class III –

Postnatal

moderate to great limitation

(e.g. toxins, trauma, infection)

Class IV – no useful

Topographic Classification

Diplegia

Hemiplegi a More Affected Less Affected

Quadriplegi a

Physiologic Classification

Hypotonic Cerebral Palsy

Physiologic Classification

Spastic Diplegic Cerebral Palsy

Diagnosis ► 1.

Thorough history, developmental assessment, physical and neurological examinations ► 2. Hearing and vision screening ► 3. EEG if with seizures ► 4. If no possible etiology or risk factors for CP, may do diagnostic tests as: Neuroimaging – CT/MRI Metabolic screening Chromosomal study

Differential Diagnosis 1. Motor delays from congenital structural lesions 2. Progressive disorders of the brain – white matter diseases 3. Muscle disorders- myopathies, dystrophies.

Management ►

Multidisciplinary 1. 2. 3. 4. 5. 6. 7. 8.

Pediatrician Neurologist Rehabilitation specialists Physical and occupational therapists Developmental psychologists Education specialists Orthopedic surgeons Social workers

Thank you!