History

Fact Explanation
History of birth asphyxia, birth after fewer than 32 weeks’ gestation, birth weight of less than 5 lb, 8 oz (2,500 g), intrauterine growth retardation, intracranial hemorrhage, and trauma, bacterial meningitis, viral encephalitis, hyperbilirubinemia, motor vehicle collisions, falls, or child abuse [1] Because brain development continues during the first two years of life, cerebral palsy can result from brain injury occurring during the prenatal, perinatal, or postnatal periods. Seventy to 80 percent of cerebral palsy cases are acquired prenatally and from largely unknown causes. [1]
Poor motor development [2] Cerebral palsy is a non-progressive movement disorders that cause physical disability [2]
Early hand preference [1] Hand preference may occur before 12 months of age if spastic hemiplegia is present [1]
Fits [1] About one half of pediatric patients have seizures. [1]
Poor hearing [1] Growth problems are common, as well as neurologic abnormalities such as impaired vision or hearing [1]
Uncontrolled movements of the body [1] Athetoid cerebral palsy is characterised by slow, uncontrolled movements of the extremities and trunk. random and repetitive, uncontrolled movements known as chorea may also occur. Patients experience difficulty in maintaining posture and balance when sitting, standing, and walking due to these involuntary movements and fluctuations in muscle tone. Muscles of the face and tongue can be affected, causing involuntary facial grimaces, expressions, and drooling[1]
References
  1. KRIGGER KW. Cerebral palsy: an overview. Am Fam Physician [online] 2006 Jan 1, 73(1):91-100 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16417071
  2. KERR GRAHAM H., SELBER P.. Musculoskeletal aspects of cerebral palsy. [online] 2003 March, 85(2):157-166 [viewed 30 August 2014] Available from: doi:10.1302/0301-620X.85B2.14066

Examination

Fact Explanation
Muscle tone - spastic [1] Seventy to 80 percent of patients with cerebral palsy have spastic clinical features. People with this type of CP are hypertonic and have what is essentially a neuromuscular mobility impairment(rather than hypotonia or paralysis) stemming from an upper motor neuron lesion in the brain as well as the corticospinal tract or the motor cortex. If unilateral - hemiplegic Bilateral - quadriplegic [1]
Muscle tone - hypotonia [2] Ataxic cerebral palsy: Ataxia-type symptoms can be caused by damage to the cerebellum. Ataxia is a less common type of cerebral palsy, occurring between 5% and 10% of all cases. Some of these individuals have hypotonia [2]
Involuntary motions [2] Athetoid cerebral palsy or dyskinetic cerebral palsy is mixed muscle tone – both hypertonia and hypotonia mixed with involuntary motions [2]
Deep tendon reflexes [1] increased deep tendon reflexes in spastic type cerebral palsy [1]
Hand preference [1] Hand preference may occur before 12 months of age if spastic hemiplegia is present [1]
Infantile reflexes [1] Assessment of persistent infantile reflexes is important. In infants who do not have cerebral palsy, the Moro reflex is rarely present after six months of age [1]
Gait [1] characteristic scissors gait with toe-walking in spastic type cerebral palsy [1] wide-based gait in ataxic type cerebral palsy [1]
Chorea [1] Athetoid cerebral palsy is characterised by slow, uncontrolled movements of the extremities and trunk. random and repetitive, uncontrolled movements known as chorea may also occur. Muscles of the face and tongue can be affected, causing involuntary facial grimaces, expressions, and drooling[1]
References
  1. KRIGGER KW. Cerebral palsy: an overview. Am Fam Physician [online] 2006 Jan 1, 73(1):91-100 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16417071
  2. KERR GRAHAM H., SELBER P.. Musculoskeletal aspects of cerebral palsy. [online] 2003 March, 85(2):157-166 [viewed 30 August 2014] Available from: doi:10.1302/0301-620X.85B2.14066

Differential Diagnoses

Fact Explanation
Arginase deficiency [1] No neonatal onset; progressive spastic diplegia; subsequent dementia. Measurement of serum amino acids shows a dramatic increase in arginine concentrations; ammonia levels elevated (range: 85 to 170 mcg per dL [50 to 100 μmol per L]) [1]
Juvenile neuronal ceroid lipofuscinosis (i.e., VogtSpielmeyer disease) [1] Onset after five years of age; progressive loss of cognitive abilities; progressive extrapyramidal symptoms (e.g., rigidity, seizure, visual failure). Characteristic inclusion bodies in skin fibroblasts or blood lymphocytes. [1]
References
  1. KRIGGER KW. Cerebral palsy: an overview. Am Fam Physician [online] 2006 Jan 1, 73(1):91-100 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16417071

Investigations - for Diagnosis

Fact Explanation
Neuroimaging with CT or MRI [1] Neuroimaging with CT or MRI is warranted when the cause of a person's cerebral palsy has not been established. The CT or MRI is also capable of revealing treatable conditions, such as hydrocephalus, porencephaly, arteriovenous malformation, subdural hematomas and hygromas [1]
References
  1. KRIGGER KW. Cerebral palsy: an overview. Am Fam Physician [online] 2006 Jan 1, 73(1):91-100 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16417071

Investigations - Fitness for Management

Fact Explanation
Assessment of vision [1] neurologic abnormalities such as impaired vision or hearing are common. Visual defects occur in 25 to 39 percent of adult patients. Children may present with strabismus (oculomotor defects) or hemianopia. [1]
Assessment of hearing and language [1] Eight to 18 percent of adults with cerebral palsy have hearing problems. the hearing loss is sensorineural. Children with CP often have speech problems. This happens because the muscles that are used in producing speech (in the tongue, throat, lungs, etc.) are impacted by the CP, a giving rise to dysarthria. [1]
References
  1. KRIGGER KW. Cerebral palsy: an overview. Am Fam Physician [online] 2006 Jan 1, 73(1):91-100 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16417071

Investigations - Followup

Fact Explanation
Growth parameters - weight , height [1] Growth abnormalities are common among patients with cerebral palsy [1]
X ray - limbs , vertebrae [1] Markedly reduced bone mass in nonambulatory adults and children Can cause osteopenia, osteoporosis, fracture, scoliosis [1]
References
  1. KRIGGER KW. Cerebral palsy: an overview. Am Fam Physician [online] 2006 Jan 1, 73(1):91-100 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16417071

Investigations - Screening/Staging

Fact Explanation
Sensation and perception [1] Some children have impaired sensations to touch and pain with or without astereognosis [1]
References
  1. KRIGGER KW. Cerebral palsy: an overview. Am Fam Physician [online] 2006 Jan 1, 73(1):91-100 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16417071

Management - General Measures

Fact Explanation
Assessment instruments [1] Several assessment instruments are available to quantify and monitor developmental milestones and skills and to assess the quality of life of patients and their caregivers. Readily available and useful assessment instruments include the Child Health Questionnaire, the Wong-Baker FACES Pain Rating Scale, and the Gross Motor Function Classification System for Cerebral Palsy. Functional scales such as the Gross Motor Function Classification System for Cerebral Palsy standardize self-initiated movements and measure change in gross motor function over time, and this particular scale is widely accepted and easy to administer in the primary care office [1]
Psychological support [1] Cognitive impairment is present in two thirds of patients with cerebral palsy. Neurosis and psychosis also can occur. Encourage functionality and independence with living accommodations, transportation, exercise, mechanical aids, or employment opportunities. Provide counseling for emotional and psychological challenges. Support groups for care givers [1]
References
  1. KRIGGER KW. Cerebral palsy: an overview. Am Fam Physician [online] 2006 Jan 1, 73(1):91-100 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16417071

Management - Specific Treatments

Fact Explanation
Management of complications - Gastrointestinal problems (e.g., vomiting, constipation, or bowel obstruction) [1] Caused by delayed gastric emptying, abnormal autonomic control of gastrointestinal mobility, immobilization, inadequate oral intake, and prolonged colonic transit. Use stool softeners with narcotic pain medications. Perform bowel hygiene. Increase fluids and fiber with or without laxatives [1]
Management of complications - Impaired oral-motor functions [1] Can cause hypoxemia, temporomandibular joint contractures, vomiting, and aspiration pneumonia associated with gastroesophageal reflux, poor nutrition, failure to thrive, drooling, and communication difficulties. For feeding difficulties, use special diets, positioning, new feeding techniques, gastrostomy, or nasogastric tube feeding. Medications, surgery, and biofeedback have been used to control drooling. Speech therapy and the use of computer voice synthesizers can help impaired communication. [1]
Management of complications - Spasticity and contractures [1] Spasticity prevents the stretching of muscles and tendons. Consequently, they do not grow at the same rate as lengthening bones, forming contractures and difficulty with ambulation and fine- or gross-motor movements. Pain is created by hip dislocations, repetitive use syndromes, and degenerative joint disease. Prevent with physical therapy with or without orthotic devices. Treat with drugs, surgery, or cerebral stimulation. Assess clinical condition by physical examination and radiographic studies. Ask or use instruments to qualify and monitor pain. Adequately treat the pain. Botulinum toxin (Botox) is a formulation of botulinum toxin type A, derived from the bacterium Clostridium botulinum. This bacterium produces a protein that blocks the release of acetylcholine and relaxes muscles. Baclofen - to reduce spasticity [1]
Management of complications - Urinary incontinence [1] Caused by impaired control of bladder muscles. Special exercises Biofeedback Prescription medications Surgery Surgically implanted devices to replace or aid muscles Specially designed undergarments [1]
References
  1. KRIGGER KW. Cerebral palsy: an overview. Am Fam Physician [online] 2006 Jan 1, 73(1):91-100 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16417071