The Child With Motor Weakness

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;  recognize the various methods of effectively managing cerebral palsy.

The Child with a Motor Weakness  C.R.,2 yrs. Old, F, referred

to neuropdevelopmental clinic because of delay in walking  Born by CS, term, BW 1.5 kg, had respiratory distress and resuscitated  Frerquent Cough a & fever , 2 hospitalizations.

 Described as quiet, passive  Able to hold head up and steady at 6

months, rolled over at 8 months; sat alone 1 yr.  Able to take steps at 1 ½ yrs.  Vocalized at 6-8 months  Socialized with mother at 6 months and other siblings at 1 ½ yrs.

P.E / N.E. Temp= 37.3’C; PR=95/min; RR=31/min; HC=48 cm; Wt = 9.2 kg; Ht=75 cm. No skin lesions, no dysmorphisms Awake, alert, responds to sounds and simple commands Follows moving objects in all directions, Pupils 2 mm equally reactive to light

Neuro exam  No facial asymmetry; with drooling  Moves all extrwemities, the left more than

the right  Spastic Rt UE and Rt LE; left extremities=normal tone.  Deep tendon reflexes: Rt ++++; Lt ++  BaBINSKI + Rt.

Salient Points       

2 yr. old F Asphyxia in the newborn period Delayed motor development Delayed language development Rt hemiparesis Hyperreflexia (Rt) Babinski (Rt)000

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 (spasticity) and movement ( hemiparesis) 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? 

C.R appears to have an upper motor lesion specifically the cerebral hemispheres.

Spasticity is the opposite with hyperextension of the limbs as in this patient

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 Quadriplegia Diplegia Double hemiplegia

Etiologic Prenatal

Functional Class I –

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

no limitation of activity

Perinatal

Class III –

(e.g., anoxia)

Postnatal (e.g. toxins, trauma, infection)

Class II – slight to moderate limitation moderate to great limitation

Class IV – no useful physical activity

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!