Cerebral Palsy Diagnosis and Management: The state of the Art

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Craig Elice Date: 5/07/2010
Article title: Cerebral Palsy Diagnosis and Management: The state of the Art
Author(s): Murphy N> Such-Neibar T.
Journal: Curr Probl Pediatr ADosesch Health Care
Month, Year: May/ June 2003
Major topic: Definition of CP and classification of CP
Type of Article: Review article
Purpose: This article reviews all facets of CP
Overview: Cerebral Palsy is defined as abnormal movement and posture caused by a non-progressive lesion of the brain. It has a prevalence of 1 to 2.3 per 1000 live births and occurs in 1 of 20 live infants with extreme prematurity. However 7 of 10 CP children reach full term gestational term. CP is classified by limb involvement and quality of movement disorders as described by resting muscle tone and resistance felt to slow passive movement of limbs. Monoplegia involves a single limb; Diplegia affects mostly the lower extremities; Hemiplegia involves one side of the body with arms being affected more than the legs; Quadriplegia affects all 4 limbs. Movement is defined by Spasticity which represents 75% of affected children; Hypotonia which is rare and often leads to other types of CP: and Hyperrelexia and clonus which demonstrates increase in tone of muscles. The types combine both limb involvement and movement disorders. Spastic Quadriplegia CP is most disabling. Only 1/3 of affected children ever ambulate. Frequently have oral motor dysfunction leading to aspiration and other secondary medical complications Spastic Hemiplegia CP shows itself as asymmetric limb use by 6 months of age. Most often learn towalk by 2 years of age. Spastic Diplegia is most often associated with pre-term birth. Affects motor tone and control of lower extremeties yet learn to walk by 3 years of age. Extra-pyramidal CP develps distinct movement characteristics by 12-18 months of age. Often normal intelligence yet speech impairment is severe. Occurs due to Kernicturis (elevated bilirubin) and its affect onbasal ganglia and auditory nuclei. Risk factors: Uncertain in 50% of case. Documented risk factors include maternal MR, birth weight < 2KG, and fetal malformation. Death of one twin increases risk of CP in the surviving twin. Perinatal asphyxia is a factor in 8-10% of keds. Full term infants of normal birth weight may have cerebral malformation, prenatal strokes or infection. Cystic Periventricular leukomalacia (PVL) is the best independent predictor of CP. Diagnosis is difficult in early years of life but as child misses developmental milestones and primitive reflexes persist, it becomes clearer. The best predictor of pre-term infants is the presence of echodensities and cysts in the periventricular white matter regions of the brain. Therapeutic interventions include neurodevelopmental treatment which was not shown to be effective, Patterning which was used historically. It involves using exercises to improve neurological organization and slow ly build upon these milestones. Conductive education to educate children to control their bodies and overcome limitations. Not effective! Hyperbaric oxygen which did not work, and lastly, Forced use or Constrain Induced Movement which involves restraining the stronger unaffected side to favor the weaker extremity, This method has been shown to be effective. The authors describe interdisciplinary care incorporating multiple specialties and to focus on family centered care. Early intervention is criticalusing repetitive exercises to improve acquisition and expression of motor skills. Other items of interest include 90% of children show oral motor impairment and GI issues in 80-90%. Growht delays often occur as a result of malnutrition. Tube feedings lead to weight gain and in many cases improved immune competence, alertness and responsiveness Baclofen is an effective drug to reduce spasticity which decreases reflux, improves sleep. Other issues include compromised bladder function, constipation and drooling in 25-35% of patients. Spasticity Management: PT and OT facilitate range of motion exercises, strength, coordination, and functional activities. Botulinum toxins are injected into regions of spastic muscles to decrease spasiticity, with minimal side effects. Baclofen is the most common antispasticity drug used in children. Othopedic procedures include lengthening of chonically shortened muscles from spastic contractures. These procedures are usually delayed until after 5 years of age. Selective dorsal rhizotomy of sensory rootlets that are controlling muscle spasticity. This treatment is usually effective in higher functioning diplegic CP who have good strength, balance, and range of motions yet have limited function due to spasticity. Intrathecal Baclofin therapy is very effective as the medication is pumped directly into the spinal fluid. The life expectancy is related to the mobility and feeding skills of the patient. More severely disabled children reach 20 years of age before respiratory infections, seizure disorders and aspiration events lead to death. Higher functioning patients with CP with fewer compromised systems generally achieve a normal life expectancy.
Conclusion: General review article that classifies CP, and describes the different systems that can be affected and how it is currently treated
Assessment of article: Very long article probably representative of a broad description of CP .