CEREBRAL PALSY

MASTER: S
AGE: 4 Years (D.O.B. 14/10/2009)
SEX: Male
ADD: Thiruvatriyur, Chennai
INFORMANT: Mother (Reliability Good)

CHIEF COMPLAINTS:

Inability to use left upper limb and inability to walk,

Delayed developmental milestones,
Seizures since 2 years of age.
 Antenatal
1st TRIMESTER
Registered and immunized at a private hospital in Banglore.
Conceived spontaneously after 5yrs of 1st child birth
Folic acid supplements were taken.
No H/o fever, rash , lymphadenopathy ,arthralgia, no exposure to drugs and radiations.

2nd TRIMESTER
Quickening felt at 5 months;
TT - 2 doses were given; Iron and Calcium supplements were taken.
No h/o increase in blood sugars and blood pressure.
Anomaly scan was done and was said to be normal.
Had an emotional impact due to her husband’s heart attack.

3rd TRIMESTER
Fetal movements perceived; No h/o bleeding per vaginum.
Poor weight gain during pregnancy
Natal:
At 38 weeks, mother perceived decreased fetal movements for which she
was taken to hospital and was advised emergency caesarian section (breech
presentation),

Baby did not cry immediately after birth, required some tactile
stimulation and oxygen,
He had a Birth wt of 1.82 kg,was told to have had head circumference
smaller for age,without any obvious congenital malformation,
Passed urine and meconium within 48hours.

Neonatal:
Was in I.C.U. for 10 days, required oxygen support for 1 day
Tube feeds -- direct breast feeds.
No h/o Neonatal seizure, jaundice, fever and irritability.
Discharged on day 15 of life with weight of 2 kg.
 History Of Presenting Illness:
INABILITY TO USE LEFT UPPER LIMB AND BOTH LOWER LIMBS:
H/o fisting of upper limb; scissoring of lower limbs
Had difficulty in changing Diapers;
Mother gives a history of increased right hand usage since 5 months
UL: RT: He is able to feed himself with spilling
LT: he is not able to take objects from floor
RT: able to lift his hand above shoulder;
LT: not able to do so
LOWER LIMB:
Not Able to Stand/Walk but drags himself over his bottom.
C/o abnormal posturing of lower limbs
SEIZURE:
Duration: 2 years
Mother C/o multiple jerky movements of the body.
around 10 to 15 episodes per day,
each lasting for 2 to 3 sec,
without any postictal drowsiness or incontinence.
He is under anti-convulsant medication
 DEVELOPMENTAL HISTORY
DOMAINS EXPECTED ACHIEVED
GROSS MOTOR Hop or ride a tricycle, Not able to stand or
climb upstairs and walk
downstairs with one leg
FINE MOTOR Draws +, Reaches for objects
Copies or makes steps Feeds himself using
spoon with spilling
LANGUAGE Tell a story Interacts with mother by
cooing
SOCIAL Plays co-operatively in a Prefers mother and
group babbles
HEARING Listens and replies: Responds to mother and
Identifies basic colours turn towards sound
AND VISION He gets excited looking at
his mother
 H/O CRANIAL NERVES:

Able to follow light;

H/o abnormal eye position
No h/o deviation of angle of mouth;
No h/o facial asymmetry;
Responds to call;
No h/o regurgitation of foods;
Able to move his head from side to side,
No h/o deviation of tongue on protrusion.

H/O SENSORY SYSTEM:

Cries when he gets hurt while dragging over his bottom.
 H/O ANS:
Bowel control attained . bladder
control not attained
OTHER: No H/O trauma.
H/O COMPILCATIONS:
NO -previous surgery ,
-dental caries,,
-constipation; bed sores.
Hardening of skin in the left foot
 Past H/O:
Child was admitted at 1 ½ year of age, was diagnosed to have
pneumonia for which i.v. medications were given for 5 days.
Subsequently the condition of the child improved.

Immunization H/O:
Appropriately immunized for age as per EPI.
B.C.G. scar present.
Typhoid vaccine given other optional vaccines not given .
Last vaccination was given at 2 years of age.
 Dietary H/O:

Exclusively breast fed up to 6 months of age,

subsequently started on complementary feeds.
C/o difficulty in feeding semi-solids
Now He is not able to take solid foods.

24 - HR EXPECTED OBSERVED GAP

RECALL
PROTEIN 20g 20g -

CALORIE 1300kcals 1250kcals 50

Family H/O:

38 years 29 years

10 years 4 years

No h/o similar complaints in the family.

No H/O contact with a known case of TB; anyone in the family receiving
medicine from DOTS centre.

Socioeconomic H/O:

E+ O+ I= 14
Lower middle class III of Modified Kuppuswamy Scale.
 Summary:
4 year old child 2nd born to non consanguineous parents
with significant antepartum and peripartum problems,
DELAYED DEVELOPMENTAL MILESTONES with right handedness
since 5 months of age,
with Lt Eye Squint,
Seizure and on antiepileptic medication,
I would like to think in terms of a Chronic Non Progressive Motor Disorder,
probably CEREBRAL PALSY.
 GENERAL EXAMINATION
Child is sitting comfortably in the mother’s lap, is cheerful, has paucity of
movements on the left upper and both lower limbs.
Drooling of saliva present.

No Pallor
No Icterus
No Cyanosis
No Clubbing
No Generalised Lymphadenopathy
No Edema.
PARAMETERS OBSERVED EXPECTED % IMPRESSION

Normal
LENGTH 99 100 99 As per McLaren’s
classification

WEIGHT 13 16 81.5 Normal

As per IAP classification

HC 45 50 <3rd percentile Microcephaly

MAC 14.5 - - Normal

 VITALS:
PULSE:
Rate: 94/min,
Rhythm: regular,
Volume: normal,
No specific character
No radio-radial delay, radio-femoral dealy
Peripheral pulses well felt.

R.R.: 24/min, Thoracoabdominal

B.P.: 100/60mm hg in Right Upper limb, Supine position

C.F.T.: < 3 sec

Temperature: 990F
 Head To Toe Examination:

Head size appears to be smaller for age.

No dysmorphic facies
No conjunctival/corneal xerosis,bitot spot
Squint of the left eye present
No dental carries, swollen gums, cheilosis, angular stomatitis.
No skin ulcers, injury marks or healing skin lesions
No involuntary movements seen
No spinal deformity
Equinus deformity of foot noted more on left side than right
Callosities present on the dorsum of foot more on left side than right
No Neurocutaneous markers.
 SYSTEMIC EXAMINATION - CNS
HIGHER MENTAL FUNCTION:

Higher mental function of the child could not be checked, but the child
is comfortable with the mother, gets irritated when approached by
outsiders. Child uses his right hand for all activities and not the left
hand.
Consciousness could not be checked
Oriented to parents but not to time and place
Memory – Can’t be checked
Irritable when approached by strangers
Speech - Babbles
 CRANIAL NERVE EXAMINATION

1st Nerve : could not be checked

2nd Nerve: Visual acuity - could not be checked but able to recognize
mother
Light Reflex present

3rd, 4th & 6th Nerve: doll’s eye movement present in both sides.
5th Nerve: Conjunctival reflex +, Pain sensation over the face
ellicitable

7th Nerve: No forehead wrinkling while crying

No deviation of angle of mouth
8th Nerve: He is able to respond to sound,and his name
when called upon.
Hearing distraction test present

9th, 10th Nerve: uvula is central,

Gag reflex present.

11th Nerve: able to shrug his shoulder against gravity, move

his head from side to side

12th Nerve: No fasciculations,wasting of tongue noted.

No deviation of tongue noted on protrusion.
 MOTOR SYSTEM EXAMINATION:
POSTURE: Both upper limb is in flexion at the elbow joint with hand open;
Both lower limbs are in partial flexion at the hip and knee joint:
Equinus deformity - both ankles.

BULK Rt Lt

Midarm 15 cm 15 cm

Forearm 13 cm 13 cm

Thigh 24 cm 24 cm

Leg 16 cm 16 cm
TONE:
Hypertonia in Lt upper limb and both lower limbs
Spastic type
 POWER Rt Lt
Shoulder Joint
Flexion 4/5 3/5
Extension 4/5 3/5
Abduction 4/5 3/5
Adduction 4/5 3/5

Elbow Joint
Flexion 4/5 3/5
Extension 4/5 3/5

Wrist Joint
Flexion 3/5 3/5
Extension 3/5 3/5
 Hip Joint
Flexion 3/5 3/5
Extension 3/5 3/5
Abduction 3/5 3/5
Adduction 3/5 3/5

Knee Joint
Flexion 3/5 3/5
Extension 3/5 3/5

Ankle Joint
Dorsiflexion 3/5(restricted) not able to check
Plantarflexion 3/5(restricted) not able to check
Inversion & Eversion not able to check not able to check
REFLEXES Rt Lt

Biceps Brisk Brisk

Triceps Brisk Brisk
Supinator Brisk Brisk
Knee EXAGGERATED EXAGGERATED
Ankle ELICITED ELICITED

Superficial reflexes: Rt Lt
Conjunctival Present Present
Abdominal Present Present
Cremasteric Present Present
Plantar Extension Extension

Primitive reflex:
Palmomental Reflex present
 Sensory System Examination:

Complete systemic examination could not be done but response to touch and
pain sensation could be elicited.

Cerebellar Signs:

No hypotonia, pendular knee jerk,

No Past pointing while reaching out for objects

Meningeal Signs:
No neck stiffness

Spine:
Spine appears normal
 OTHER SYSTEMS

R.S:
B/L air entry present,
normal bronchovesicular breath sound heard, no added sound.

C.V.S.:
S1/S2 heard, no murmur .

P/A:
Soft, no organomegaly
bowel sounds present.
 FINAL DIAGNOSIS:
Spastic Triplegia,
secondary to antenatal and perinatal insult,
Grade 4 functional Disability,
Microcephaly,
seizure disorder,
Global developmental delay,
Left eye squint/Malalignment,
with Equinus deformity,
without any evidence of protein energy malnutrition/ micronutrient deficiency.
 CEREBRAL PALSY
Cerebral Palsy is a static encephalopathy.
It is defined as a Non-progressive disorder of posture and
movement.
Often assosciated with epilepsy and abnormalities of speech,
vision and intellect resulting from a defect or lesion of the
developing brain.

It consist of: a. motor handicap.

b. non-motor handicap (≥ 1).
INVESTIGATIONS
CT
MRI
(preferred modality)

Considering DD’s:

a. urine for metabolic

screening.
b. chromosomal analysis.
TREATMENT
 COMPREHENSIVE
ONGOING
MULTIDISCIPLINARY
NEURO-
REHABILITATION
PROGRAMME
 TEAM MANAGEMENT

Pediatric neurologist.
Physiotherapist.
Occupational therapist.
CEREBRAL Orthopedic/Neuro surgeon.
PALSY Speech therapist
Social workers.
Nutritionist.
MEDICATIONS
Anti-convulsants:
Valproate
Carbemezapine,
Phenytoin,
Phenobarbitone

Anti-spastic drugs:
Baclofen,
Dantrolene sodium,
Benzodiazepines.

Anti-reflux drugs:
Metaclopromide,
Lansoprazole.
OVERVIEW
The incidence of cerebral palsy has remained virtually
unchanged over the past 40
years at approximately 2.5 per 1000 live births
 ETIOLOGY
• Prenatal
Brain malformations
In utero stroke
Congenital cytomegalovirus infection
• Perinatal
Hypoxic ischemic encephalopathy
Viral encephalitis
Meningitis
• Postnatal
Accidental head trauma
Anoxic insult
Child abuse
Prematurity
 DIAGNOSIS
•cerebral palsy remains a clinical diagnosis, and represents a
continuing role for the ‘‘art’’ of medicine.
The essential findings include:
• Delayed motor milestones
• Abnormal muscle tone
• Hyperreflexia
• Absence of regression or evidence of a more specific
diagnosis.
•These clinical findings should be present to the degree that
the child appears unlikely to ‘‘outgrow’’ these findings.
 TYPES OF CP
•Spastic
Hemiplegia (unilateral involvement)
Diplegia (disporprotionate lower extremity
involvement)
Quadriplegia (total body involvement)
•Dyskinetic
Choreoathetoid
Dystonic
•Hypotonic
•Mixed
 PRESENTING HISTORY
Describe child’s problems in terms
of:

Reasons for current admission

 motor and non-motor complications

Developmental milestones in correct

sequence

Treatment received

Social issues
 IMPORTANT POINTS IN HISTORY:
PREGNANCY: Prematurity,
Maternal diseases (uncontrolled
diabetes, maternal hypertension,
poor weight gain).
Fever, rash, lymphadenopathy.
Drugs or exposure to radiation

DELIVERY: Emergency C/S.

Syntocinon usage
Prolonged rupture of membrane.
Prolonged 2nd stage of labour.

AFTER BIRTH: Prematurity signs/ small size baby

Delayed weak cry, delayed poor
sucking, Hyperbilirubinemia,
neonatal seizures, RDS, Trauma,
meningitis
 RISK FACTORS FOR CP:
Family history of CP,

Malpresentation(breech)

Low socioeconomic status,

Choroiamniotis,

Persistent LOW APGAR SCORE at 20 minutes

Prolonged second stage of labour.

 EXAMINATION
Head circumference.
 Eyes for squint and nystagmus.
 Anthropometry.
 Tone - active and passive methods.
 - 180 degrees.
 Demonstrate hyperreflexia
 Look for persistance of primitive reflexes
Look for dysmorphic features/neuro-cutaneous markers for other
causes
 GROSS MOTOR FUNCTIONAL
CLASSIFICATION SYSTEM
LEVEL FUNCTION

I Ambulatory in all settings

II Walks without aides but

has limitations in community settings

III Walks with aides

IV Mobility requires wheelchair

V Dependent for mobility

 HOW TO PRESENT
For instance;

A patient whose all 4 limbs are affected and found to be spastic

with squint, microcehaly on examination and history revealed
difficult labor and treatment for respiratory distress.

Would Be Classifed As:

Spastic quadriplegic CP due to birth asphyxia and possible

microcephaly, Mental Retardation, squint and aspiration
pneumonia.
THE END