Cerebral palsy Cerebral palsy Cerebral Palsy: Aetiology, Cerebral Palsy: Aetiology, � Definitions and Definitions and prevalence prevalence Associated Problems and Associated Problems and Management Management g � Risk factors and Risk factors and aetiology aetiology ti l ti l Lecture for FRACP candidates Lecture for FRACP candidates � Associated problems Associated problems July 2010 July 2010 � Management options Management options What is cerebral palsy? What is cerebral palsy? Definition (Bax 1964) Definition (Bax 1964) Cerebral palsy is Cerebral palsy is a disorder of a disorder of movement and movement and posture due to a posture due to a t t d d t t defect or lesion defect or lesion of the immature of the immature brain brain Cerebral palsy Cerebral palsy – – an umbrella an umbrella New definition of cerebral palsy New definition of cerebral palsy term term All children are All children are Cerebral palsy describes a group of Cerebral palsy describes a group of different different developmental disorders of movement and developmental disorders of movement and posture, causing activity restriction or posture, causing activity restriction or The associated The associated disability, that are attributed to disturbances disability, that are attributed to disturbances p p problems may be problems may be y y occurring in the fetal or infant brain. The occurring in the fetal or infant brain. The more significant than more significant than motor impairment may be accompanied by a motor impairment may be accompanied by a the motor disorder the motor disorder seizure disorder and by impairment of seizure disorder and by impairment of Permanent, non Permanent, non- - sensation, cognition, communication and/or sensation, cognition, communication and/or progressive but not progressive but not behaviour behaviour unchanging unchanging (Rosenbaum 2007) (Rosenbaum 2007) 1
Storm’s words Storm’s words Classification systems Classification systems Nature of Nature of movement disorder movement disorder eg spasticity, eg spasticity, dystonia, ataxia dystonia, ataxia dystonia ataxia dystonia ataxia Distribution eg Distribution eg diplegia, diplegia, quadriplegia quadriplegia Severity Severity Why does classification matter? Why does classification matter? Type of motor disorder Type of motor disorder Descriptors for parents Descriptors for parents � Spasticity Spasticity Type of treatment needed Type of treatment needed � Dyskinesia Dyskinesia Prognosis Prognosis � Athetosis Associated problems Associated problems Athetosis Information for service Information for service � Dystonia Dystonia providers providers � Ataxia Ataxia Research studies – Research studies – drawing together similar drawing together similar � Hypotonia Hypotonia groups groups � Mixed Mixed Distribution Distribution Severity Severity � Quadriplegia Quadriplegia � Mild Mild � arms arms � walks independently walks independently � legs � Moderate legs Moderate � trunk trunk � walks with sticks / walks with sticks / frame frame � head and neck head and neck � Severe Severe � Diplegia Diplegia � wheelchair dependent wheelchair dependent � Hemiplegia Hemiplegia 2
Classification of severity Classification of severity The GMFCS The GMFCS Level 1 Level 1 – – walk without walk without Gross Motor Gross Motor restrictions restrictions Function Function Level 2 Level 2 – – walk walk independently but more independently but more Classification Classification Classification Classification limitations limitations limitations limitations Level 3 – Level 3 – need mobility need mobility System (The System (The devices eg frames devices eg frames “GMFCS”) “GMFCS”) Level 4 – Level 4 – sit on a regular sit on a regular chair, but use wheelchair chair, but use wheelchair Level 5 Level 5 – – no means of no means of independent mobility independent mobility Measuring motor progress Measuring motor progress The Growth Motor Curves The Growth Motor Curves The The Growth Growth Motor Motor Curves Curves 3
What causes cerebral palsy? What causes cerebral palsy? Case history of Lisa Case history of Lisa PMH PMH At 8 years At 8 years – Pregnancy and birth Pregnancy and birth – Presented to RCH Presented to RCH normal normal – Falling more Falling more – Crawled 10 months Crawled 10 months – Motor problems had Motor problems had – Sat 12 months Sat 12 months deteriorated deteriorated At 24 months At 24 months – Diagnosis of spastic Diagnosis of spastic diplegia diplegia History History Changing views Changing views Little Little: : poor poor obstetric obstetric care care associated associated with with 1960’s 1960 ’s: : mechanism mechanism for for the the prevention prevention of of birth asphyxia birth asphyxia responsible responsible for for most most cases cases kernicterus kernicterus Freud Freud Freud: Freud: adverse adverse adverse adverse fetal fetal fetal fetal events events events events early early early early in in in in 1970 1970 s: increased 1970 1970’s ’s: increased increased resources increased resources resources for resources for for obstetric for obstetric obstetric obstetric development development may may cause cause both both birth birth and and neonatal neonatal care, care, for for example, example, increased increased complications and complications and spasticity spasticity Caesarean Caesarean Section Section rate rate and and use use of of electronic electronic fetal fetal monitoring monitoring Results of changes in Results of changes in Prevalence of cerebral palsy Prevalence of cerebral palsy practice practice 2 per thousand 2 per thousand No major change No major change live births live births in cerebral in cerebral in cerebral in cerebral 130 new cases in Victoria 130 new cases in Victoria palsy rates palsy rates each year each year 4
Rates of CP, neonatal deaths and Rates of CP, neonatal deaths and Gender Gender stillbirth rates stillbirth rates Cerebral palsy, neonatal death and � Males are over Males are over stillbirth rates Victoria, 1973 - 1999 14 represented in all represented in all p 12 Stillbirths s Rate per 1000 birth 10 Neonatal deaths Cerebral palsy 8 case series of case series of 6 4 2 cerebral palsy cerebral palsy 0 1973 1976 1979 1982 1985 1988 1991 1994 1997 Year of birth Why do premature infants Why do premature infants Risk factors and causes: Risk factors and causes: challenges challenges develop cerebral palsy? develop cerebral palsy? 1. Are they damaged 1. Are they damaged before birth and then before birth and then survive with good survive with good neonatal care? neonatal care? neonatal care? neonatal care? Many risk factors, for example, prematurity, but few Many risk factors, for example, prematurity, but few 2. Do they develop 2. Do they develop definite causes definite causes – Rates 25 Rates 25- -30 x higher in infants weighing less than 1500 g 30 x higher in infants weighing less than 1500 g complications of complications of – Babies who weigh <2500g account for 1/3 of children with Babies who weigh <2500g account for 1/3 of children with prematurity such as prematurity such as cerebral palsy cerebral palsy IVH? IVH? Causal pathways – Causal pathways – a series of factors leading to the a series of factors leading to the damaging event damaging event When does cerebral palsy When does cerebral palsy Prenatal events Prenatal events occur? occur? � Prenatal (75%) Prenatal (75%) � Antenatally Antenatally 75% 75% � Brain malformations Brain malformations � Perinatal Perinatal 10 10 - - 15% 15% eg cortical dysplasias eg cortical dysplasias � Postnatal � Postnatal Postnatal10% Postnatal10% 10% 10% � Intrauterine infections Intrauterine infections eg CMV eg CMV � The cause remains unknown in a substantial The cause remains unknown in a substantial proportion of cases, and is therefore attributed to proportion of cases, and is therefore attributed to antenatal events antenatal events 5
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