Cerebral Palsy: Classification

By: vaibhav mittal

introduction

• The term cerebral palsy was first used in 1843 by the English orthopedic surgeon William Little in a series of lectures entitled “Deformities of the Human Frame”

• It was known for many years as “Little’s disease”

introduction

• Cerebral palsy is a heterogeneous disorder of movement and posture that has a wide variety of presentations, ranging from mild motor disturbance to severe total body involvement.

Distinctive features

• There are three distinctive features common to all patients with cerebral palsy:

(1) some degree of motor impairment, versus autism;(2) an insult to the developing brain, making it different

from conditions that affect the mature brain in olderchildren and adults; and

(3) a neurological deficit that is nonprogressive, versusother motor diseases of childhood, such as the muscular dystrophies

Age

• The insult to the brain is believed to occur between the time of conception and age 2 years, at which time a significant amount of motor development has already occurred

• By 8 years of age, most of the development of the immature brain is complete, as is gait development, and an insult to the brain results in a more adult-type clinical picture and outcome.

ORTHOPAEDICS ASPECTS• Although the neurological deficit is permanent and

nonprogressive, the effect it can have on the patient is dynamic, and the orthopaedic aspects of cerebral palsy can change dramatically with growth and development

• Growth, along with altered muscle forces across joints, can lead to

(1)progressive loss of motion,(2)contracture, and eventually(3)joint subluxation or dislocation, resulting in(4)degeneration, that may require orthopaedic intervention

ETIOLOGY

• Injury to the developing brain can occur at any time from gestation to early childhood and typically is categorized as

1)Prenatal2)Perinatal3)Postnatal

• This includes risk factors inherent to the fetus (most commonly genetic disorders)

• Factors inherent to the mother (seizure disorders, mental retardation, and previous pregnancy loss)

• Factors inherent to the pregnancy itself (Rh incompatibility, polyhydramnios placental rupture, and drug or alcohol exposure).

• Trauma, head injury Infections Lack of oxygen Stroke in the young, Tumor, cyst

• External factors, such as TORCH syndrome (toxoplasmosis, other agents, rubella, cytomegalovirus, herpes simplex), also can lead to cerebral palsy in th prenatal period.

• Oxytocin augmentation, umbilical cord prolapse, and breech presentation all have been associated with an increased occurrence of cerebral palsy.

• Hypoxic-ischemic encephalopathy, which is characterized by hypotonia, decreased movement, and seizures, is a common cause of cerebral palsy during the postnatal period.

Classification

• Because of the wide variability in presentation and types of cerebral palsy, there is no universally accepted classification scheme

• Cerebral palsy can be classified by the(1) the region of the body affected.(2) the neuroanatomical region of the brain that was injured

It also can be classified(3) temporally in relation to the time of birth, as previouslyDescribed.

Hemiplegia In hemiplegia, one side of the body is involved, with the upper extremity usually more affected than the lower extremity. Patients with hemiplegia, approximately 30% of patients with cerebral palsy, typically have sensory changes in the affected extremities as well.

Hemiplegialimbs on only one side

Diplegia Diplegia is the most common anatomical type of cerebral palsy, constituting approximately 50% of all cases. Patients with diplegia have motor abnormalities in all four extremities, with the lower extremities more affected than the upper.The close proximity of the lower extremity tracts to the ventricles most likely explains the more frequent involvement of the lower extremities with periventricular lesions

Diplegia/ Paraplegia•both legs•both legs w/ slight

involvementelsewhere

This type of cerebral palsy is most common in premature infants

Intelligence usually is normal.

Most children with diplegia walk eventually, although walking is delayed usually until around age 4 years.

Quadriplegia In quadriplegia, all four extremities are equally involved, and many patients have significant cognitive deficiencies that make care more difficult

Head and neck control usually are present, which helps with communication, education, and seating.

Quadriplegia

Physiological Classification

Physiologically, cerebral palsy can be divided into a(1)spastic type, which affects the corticospinal (pyramidal) tracts,

and(2)an extrapyramidal type, which affects the other regions of the

developing brain• The extrapyramidal types of cerebral palsy include(1)athetoid (2)choreiform (3)ataxic (4)rigid (5)hypotonic

Physiological Classification

3 MAIN TYPES1. PYRAMIDAL

- originates from the motor areas of the cerebral cortex

2. EXTAPYRAMIDAL - basal ganglia and cerebellum

3. MIXED

Spastic CP• Increased muscle tone, tense and contracted muscles – Have stiff and jerky or awkward movements.– limbs are usually

underdeveloped– increased deep tendon

reflexes• most common form• 70-80% of all affected

Booth showed histologically that this altered muscle function leads to the deposition of type I collagen in the endomysium of the affected muscle, leading to thickening and fibrosis, the degree of which correlated to the severity of the spasticity. Joint contractures, subluxation, and degeneration are common in patients with spastic cerebral palsy.

Athetoid/ Dyskinetic CP• Fluctuating tone– involves abnormal involuntary

movements

– that disappear during sleep and increase with stress.

– Interferes with speaking, feeding, reaching, grabbing, and any other skills

– 20% of the CP cases,

Choreiform

Choreiform cerebral palsy is characterized by continual purposeless movements of the patient's wrists, fingers, toes, and ankles. This continuous movement can make bracing and sitting difficult.

Rigid Patients with rigid cerebral palsy are the most hypertonic of all cerebral palsy patients.

These patients have a “cogwheel” or “lead pipe” muscle stiffness that often requires surgical release.

Ataxic CP• Poor balance and lack of

coordination–Wide-based gait– Depth perception usually affected.– Tendency to fall and stumble– Inability to walk straight line.– Least common 5-10% of casesAtaxic cerebral palsy is very rare

As a result of an injury to the developing cerebellum.

It is important to distinguish true ataxia from

spasticity because with treatment many children

with ataxia are able to improve their gait

function without surgery.

MIXED CP

• A common combination is

spastic and athetoid

• Spastic muscle tone and involuntary movements.

• 25% of CP cases, fairly common

Thank you…..