Cerebral Palsy
Definition
Cerebral Palsy (CP) is a non-progressive brain injury causing neuromuscular imbalance and upper motor neuron disease, typically presenting before the age of 2.
Risk Factors
- Prematurity
- Anoxic birth trauma
- TORCH infections (toxoplasmosis, syphilis, rubella, cytomegalovirus, herpes)
- Other third-trimester disturbances or intrauterine issues
Classification
| Spastic |
Muscle imbalance and contractures, eventually causing bone deformity and arthrosis. Most common and treatable surgically. |
| Athetoid |
Dystonia and involuntary movements. |
| Ataxic |
Predominantly cerebellar symptoms. |
| Quadriplegia |
All limbs involved, low IQ, severe spasticity, unable to walk. |
| Diplegia |
Primarily lower limbs, possible normal intelligence, most able to walk. |
| Hemiparesis |
Unilateral involvement, most eventually able to walk. |
GMFCS - Gross Motor Function Classification System
| GMFCS 1 |
Walks, jumps, runs, climbs; minor balance/speed issues. |
| GMFCS 2 |
Walks with stair rail support; difficulty on uneven surfaces. |
| GMFCS 3 |
Walks with aid; self-propels wheelchair. |
| GMFCS 4 |
Occasional frame walking; primarily wheelchair-dependent. |
| GMFCS 5 |
Cannot support head independently; requires wheelchair assistance. |
Future Functional Estimation
Poor prognostic indicators include: - Retention of two or more primitive reflexes at 1 year (e.g., Moro and Parachute reflexes). - Inability to sit by 5 years or walk by 8 years.
Treatment Principles
- Multidisciplinary Approach: Includes PT and OT.
- Surgery: Generally deferred until after age 3, aiming to restore function and relieve pain.
- Treatment Ladder:
- MDT: Physio, OT for ADL support, speech therapy.
- Splinting/Serial Casting and Bracing.
- Medications:
- Baclofen: GABA receptor agonist for muscle relaxation.
- Botulinum Toxin (Botox): Temporary muscle relaxation.
| Dorsal Rhizotomy |
Cutting of dorsal rootlets (L1-S1) to reduce spasticity. |
| Soft Tissue Releases |
Includes tendon transfers, osteotomy, and fusion for structural corrections. |
Treatment of Commonly Affected Areas
Spine
- Deformity: Primarily scoliosis, sometimes kyphosis.
- Management: Posterior and long fusion including pelvis, anterior fusion if needed.
Hips
- Hip Subluxation/Dislocation: Common in non-ambulatory, GMFCS level 5 children.
- Management: Includes adductor tenotomy, iliopsoas release, VDRO, or Dega osteotomy based on age and migration percentage.
Feet
- Planovalgus/Equinovalgus Foot: Common in spastic diplegia, treated with calcaneal lengthening osteotomy and peroneus brevis lengthening.
- Equinovarus Foot: Common in spastic hemiparesis, managed with SPLAT transfer, TA/TP transfer, and Achilles lengthening if needed.
Knee
- Crouch Gait: Often due to hamstring contractures, managed through gait analysis, bracing, and hamstring release if necessary.
Upper Limb
- Shoulder Adduction/Internal Rotation: Often requires Botox or release if affecting ADLs.
- Hand and Wrist Deformities: Managed with OT, physio, tendon transfers, or fusion where needed.
Prognostic Indicators and Surgical Outcomes
Outcomes depend on flexibility, patient aims, pain, and severity of joint or skeletal arthrosis. Non-surgical management includes splints and orthoses, while surgical interventions aim to correct structural deformities to maximize function and comfort.