cerebral palsy ,causes of cp , orthotics management of cp , gait patterns in cerebral palsy clinical features examination

1. CEREBRAL PALSY
ESHA MALIK
MPO I
DSMNRU

2. CEREBRAL PALSY (CP)
This is defined as a non-progressive neuro-musculardisorder of cerebral origin.
It includes a number of clinical disorders, mostly arising in childhood. The
essential features of all these disorders is a varying degree of upper motor
neurone type of limb paralysis (spasticity), together with difficulty in
coordination (ataxia) and purposeless movements (athetosis).
Essentials of orthopedics

3. https://cfns-ayu.com/services/cerebral-palsy/

4. AETIOPATHOLOGY

5. Birth anoxia and injuries are the commonest cause of CP in
developing countries. Causes can be divided into prenatal,
natal and postnatal.
Essentials of orthopedics

6. PRENATAL :
• 1 . Consanguineous
marriage.
• 2 . Drugs taken
during pregnancy.
• 3 . Maternal
infection
• 4 .Defective
development of
nervous system.
• 5 . Kernicterus
(damage to basal
nuclei )
• Fever during
pregnancy is a great
indication that
something is wrong.
Essentials of orthopedics maheshwari

7. PRENATAL :
• 1 . Consanguineous
marriage.
• 2 . Drugs taken
during pregnancy.
• 3 . Maternal
infection
• 4 .Defective
development of
nervous system.
• 5 . Kernicterus
(damage to basal
nuclei )
• Fever during
pregnancy is a great
indication that
something is wrong.
• 1 . Birth injury.
• 2 . Anoxaemia with
cerebral anoxia.
• 3 . Breech delivery.
• 4 . Big babies &
prolong labor.
• 5 . Cord around the
neck.
NATAL :
Essentials of orthopedics maheshwari

8. PRENATAL :
• 1 . Consanguineous
marriage.
• 2 . Drugs taken
during pregnancy.
• 3 . Maternal
infection
• 4 .Defective
development of
nervous system.
• 5 . Kernicterus
(damage to basal
nuclei )
• Fever during
pregnancy is a great
indication that
something is wrong.
NATAL :
• 1 . Birth injury.
• 2 . Anoxaemia with
cerebral anoxia.
• 3 . Breech delivery.
• 4 . Big babies &
prolong labor.
• 5 . Cord around the
neck.
POST NATAL :
• 1 . Infections
causing meningitis.
• 2 . Congenital
jaundice.
• 3 . Hydrocephalic
baby.
• 4 . Encephalitis
(inflammation of
brain )
• 5 . CVS i.e. Cerebro
- Vascular
Accidents.
• 6 . Head injury.
Essentials of orthopedics maheshwari

9. CLINICAL FEATURES

10. Presenting complaints: The clinical features vary according to the
severity of the lesion, the site of the neurological deficit and the
associated defects.
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11. Severity of lesion:
The lesion may be mild in 20 percent of cases: in which case the
child may remain ambulatory without any help and may never require
consultation
50 per cent of cases: the child requires help with ambulation. The usual
presentation is a child less than one year old, in whom the parents have
noticed a lack of control on the affected limb. There is a delay in the deve-
lopmental milestones such as sitting up, standing or walking.
30 per cent of cases : the involvement is severe, and the child is bed-
ridden.
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12. Pattern of involvement:
In 65 per cent of cases : The pyramidal tracts are involved and they present with
spasticity, exaggerated reflexes etc. One or all the limbs may be involved.
In 35 per cent of cases : extra-pyramidal symptoms such as ataxia, athetoid
movements, dystonia predominate.

13. https://teachmeanatomy.info/neuroanatomy/pathways/descending-tracts-motor/

14. Associated defects:
50 per cent : the patients are severely mentally retarded.
25 per cent : have moderate mental retardation.
25 per cent : have borderline mental retardation.
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15. CLINICAL EXAMINATION

16. https://www.osmosis.org/learn/Developmental_milestones:_Clinical_practice

17. https://www.osmosis.org/learn/Developmental_milestones:_Clinical_practice

18. • On examination, there may be weakness of muscles, the distribution of which is variable.
This leads to marked muscle imbalance, resulting in deformities. The joints are stiff
because of spasticity; hence when a steady pressure is applied, the muscle relaxes and
the deformity is partially corrected.
• As the pressure is released, the spasm returns immediately. The tendon reflexes are
exaggerated, and clonus may be present.
• The patient exhibits a lack of voluntary control when asked to hold an object. As the
patient tries to move a single group of muscles, other groups contract at the same time
(athetoid movements). Mental deficiency may be present. There may also be defective
vision and impaired hearing.
Essentials of orthopedics maheshwari

19. CLINICAL SIGNS :
Depend on site of neurological deficit & associated defect .
1 . Delayed milestones .
2 . Head circumference is small (normal is 34 –36cm at birth)
3 . Sucking reflex absent .
4 . Drooling of saliva .
5 . Normal environmental response is absent .
6 . Abnormal reflexes.
Essentials of orthopedics maheshwari

20. TREATMENT
• Principles of treatment: The aim of treatment is to maintain and develop whatever
physical and mental capabilities the child has. It consists of: (i) orthopaedic treatment.
(ii) speech and occupational therapy.
(iii) Orthotics treatment.
Essentials of orthopedics maheshwari

21. CEREBRAL PALSY: CLASSIFICATION
• Physiologic
• Topographic
• Etiologic
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22. https://www.osmosis.org/learn/Developmental_milestones:_Clinical_practice

23. 1.SPASTICITY:
When pressure is released spasm immediately returns .Generally shows synergy i.e. when
patient try to do one movement another happens automatically .
Spasm & muscle imbalance leads to fixed deformity later .
Essentials of orthopedics maheshwari

24. 2 . ATHETOID :
2nd frequently diagnosed type . Main damage is in basal nuclei .
Fluctuating tone & dystonic involuntary movements .
Generally does not get any contractures or deformities as both the muscle groups are
equally strong .
Not fitted with any orthosis as there are chances of some injury due to involuntary movements .
Essentials of orthopedics maheshwari

25. Least diagnosed type showing in coordination of movements &
equilibrium & poor sense of balance.
3 . ATAXIA :
Shows all above or some features together .
4 . MIXED :
Complete paralysis of muscles .
5 . FLACCID :
Essentials of orthopedics maheshwari

26. Cerebral Palsy: Topographic
Monoplegia Paraplegia Hemiplegia
Triplegia Quadriplegia
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27. Monoplegic
Monoplegia is paralysis
limited to a single limb—
usually an arm.
Occasionally, the paralysis is
even further limited, to just a
single muscle.
https://www.healthline.com/health/monoplegia#:~:text=Monoplegia%20is%20paralysis

28. • Paraplegic
Paraplegia is a type
of paralysis that affects
your ability to move the
lower half of your body.
https://www.healthline.com/health/monoplegia#:~:text=Monoplegia%20is%20paralysis

29. • Hemiplegic
one side of body is
involved.
https://www.sciencedirect.com/book/9780323483230/atlas-of-orthoses-and-assistive-devices

30. • Triplegic
Three limbs involved .
https://www.healthline.com/healttriplegia#:~:text=Monoplegia%20is%20paralysis

31. •
Quadriplegic
All four limbs are involved
.
https://www.sciencedirect.com/book/9780323483230/atlas-of-orthoses-and-assistive-devices

32. Mainly two patterns of deformities are seen in LE .
1 . EXTERNALLY ROTATED DEFORMITIES ( ERD )
Also called as EXTENSION PATTERN
2 . INTERNALLY ROTATED DEFORMITIES (IRD )
Also called as FLEXION PATTERN
Clevanal certified clinic

33. ERD
• Femur externally rotated .
• Knee hyper extended .
• Tibia externally rotated
• Heel or calcaneus goes into varus .
• Foot is supinated .
• Forefoot is adducted .
• Benefitted with articulated AFO .
IRD
• Femur internally rotated .
• Knee flexed & move into valgus
position .
• Tibia internally rotated
• Heel or calcaneus goes into valgus
.
• Foot is pronated .
• Forefoot is abducted .
• Benefitted with solid ankle AFO .
https://www.sciencedirect.com/book/9780323483230/atlas-of-orthoses-and-assistive-devices

34. Gait Patterns & Common Deformities

35. SPASTIC HEMIPLEGIA / UNILATERAL CP
Type 1 – weak or paralysed/silent dorsiflexors (=
dropfoot)
Type 2 – type 1 + triceps surae contracture
Type 3 – type 2 + hamstrings and/or Rectus Femoris
spasticity
Type 4 – type 3 + spastic hip flexors and adductors

37. Type 1 Hemiplegia
• In Type 1 hemiplegia there is a `drop foot' which is noted most clearly in the
swing phase of gait due to the inability to selectively control the ankle
dorsiflexors during this part of the gait cycle. There is no calf contracture and
therefore during stance phase, ankle dorsiflexion is relatively normal.
• The only management maybe needed is a leaf spring or hinged ankle foot
orthosis (AFO). Spasticity management and contracture surgery are clearly not
required.

38. Type 1

39. Orthotic Management for Type 1

40. Type 2 Hemiplegia
• Type 2 hemiplegia is by far the most common type in clinical practice. True
equinus is noted in the stance phase of gait because of the spasticity
and/or contracture of the gastroc-soleus muscles. There are two sub-
categories to type 2 hemiplegic gait patterns, which are:
• Equinus plus neutral knee and extended hip.
• Equinus plus recurvatum knee and extended hip.

41. Orthotic Management for Type 2
• If the knee is fully extended or in recurvatum, then a hinged
AFO with an appropriate plantar flexion stop is the most
appropriate choice of orthosis.
• A plantarflexion stop or posterior stop in an AFO is designed
to substitute for inadequate strength of the ankle dorsiflexors
during swing phase of gait. This stop is effective by limiting the
plantarflexion range of motion of the talocrural joint.

42. Type 3 hemiplegia
Type 3 hemiplegia is characterized by gastroc-
soleus spasticity or contracture, impaired ankle
dorsiflexion in swing and a flexed, `stiff€
knee gait'
as the result of hamstring/quadriceps co-
contraction. At a later stage, management may
comprise muscle-tendon lengthening for gastroc-
soleus contracture.

43. Orthotic Management
A solid or hinged AFO may also be helpful; the choice
should be according to the integrity of the plantar-flexion,
knee-extension couple'.

44. Type 4 Hemiplegia
• In Type 4 hemiplegia there is much more marked proximal involvement
and the pattern is similar to that seen in spastic diplegia. However,
because involvement is unilateral, there will be marked asymmetry,
including pelvic retraction. In the sagittal plane, there is equinus, a
flexed stiff€
knee, a flexed hip and an anterior pelvic tilt.
• In the coronal plane, there is hip adduction and in the transverse
plane, internal rotation.

45. Orthotic Management
• Management is similar to Type 2 and Type 3
hemiplegia, with respect to the distal problems.
• However, there is a high incidence of hip
subluxation and careful radiographic
examination of the hip is important.

47. Common Postural/Gait Patterns Bilateral
Spastic Cerebral Palsy
.
• Torsional deformities of the long bones and foot deformities are frequently found
in bilateral spastic CP, in association with musculo-tendinous contractures.
These are collectively referred to as `lever arm disease‘.
• The most common bony problems are medial femoral torsion, lateral tibial
torsion, midfoot breaching, with foot valgus and abduction. Rotational
osteotomies and foot stabilization surgery are often required, in association with
spasticity and contracture management.

48. lever arm disease :There is an out-toed stance and
gait pattern because of midfoot breaching and lateral
tibial torsion. The right image is a sagittal view
demonstrating a crouch gait pattern. When the bony
lever (the foot) is both bent and maldirected, the
already weakened gastroc-soleus is unable to
control the progression of the tibia over the planted
foot and a crouch gait results.

49. Type 1. True Equinus
Classification of Gait Patterns in Cerebral Palsy
Jump to:navigation, search Original Editor - Roelie Wolting Top Contributors - Michelle Lee, Laura Ritchie, Kim Jackson, Vidya Acharya, Evan Thomas, Naomi O'Reilly,
WikiSysop, Aminat Abolade and Aya Alhindi
• When the younger child with bilateral cerebral palsy begins to walk with or without
assistance, calf spasticity is frequently dominant resulting in a `true equinus' gait with the
ankle in plantar flexion throughout stance and the hips and knees extended.
• The patient can stand with the foot flat and the knee in recurvatum. The equinus is real
but hidden.
• A few children with bilateral cerebral palsy remain with a true equinus pattern throughout
childhood and, if they develop flexed contracture, may eventually benefit from isolated
gastrocnemius lengthening.
• The persistence of this pattern is unusual and seen in only a small minority of children
with bilateral CP.
• Orthotic management: solid or hinged AFO.

50. https://cpresource.org/topic/gait-development-movement-
analysis/gait-patterns-cerebral-palsy-fact-sheet

51. Type 2. Jump Gait (With or Without Stiff Knee)
Classification of Gait Patterns in Cerebral Palsy
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Original Editor - Roelie Wolting Top Contributors - Michelle Lee, Laura Ritchie, Kim Jackson, Vidya Acharya, Evan Thomas, Naomi O'Reilly, WikiSysop, Aminat Abolade and Aya Alhindi
• The jump gait pattern is very commonly seen in children with diplegia, who have more proximal
involvement, with spasticity of the hamstrings and hip flexors in addition to calf spasticity.
• The ankle is in equinus, the knee and hip are in flexion, there is an anterior pelvic tilt and an
increased lumbar lordosis.
• There is often a stiff knee because of rectus femoris activity in the swing phase of gait.
• In younger children, this pattern can be managed effectively by botulinum toxin type A injections
to the gastrocnemius and hamstrings and the provision of an AFO.
• In older children musculotendinous lengthening of the gastrocnemius, hamstrings and iliopsoas
may be indicated with transfer of the rectus femoris to semi-tendinosus for co-contraction at the
knee.

52. https://cpresource.org/topic/gait-development-movement-
analysis/gait-patterns-cerebral-palsy-fact-sheet

53. Type 3. Apparent Equinus (With or Without Stiff Knee)
Classification of Gait Patterns in Cerebral Palsy Jump to:navigation, search
Original Editor - Roelie Wolting Top Contributors - Michelle Lee, Laura Ritchie, Kim Jackson, Vidya Acharya, Evan Thomas, Naomi O'Reilly, WikiSysop, Aminat Abolade and Aya Alhindi
• As the child gets older and heavier, a number of changes may occur which may render the calf
muscle and the plantar flexion–knee extension less competent. Equinus may gradually
decrease as hip and knee flexion increase.
• There is frequently a stage of `apparent equinus' where the child is still noted to be walking on
the toes and simple observational gait analysis may mistakenly conclude that the equinus is
real when it is in fact apparent.
• Sagittal plane kinematics will show that the ankle has a normal range of dorsiflexion but the hip
and knee are in excessive flexion throughout the stance phase of gait..
• Orthotic management: ground reaction (Saltiel) AFO, solid AFO or hinged AFO according to the
integrity of the plantar flexion–knee extension.

54. Classification of Gait Patterns in Cerebral Palsy Jump to:navigation, search
Original Editor - Roelie Wolting Top Contributors - Michelle Lee, Laura Ritchie, Kim Jackson, Vidya Acharya, Evan Thomas, Naomi O'Reilly,
WikiSysop, Aminat Abolade and Aya Alhindi

55. Type 4. Crouch gait (With or Without Stiff Knee Gait)
Classification of Gait Patterns in Cerebral Palsy Jump to:navigation, search Original Editor - Roelie Wolting Top Contributors - Michelle Lee, Laura Ritchie, Kim Jackson, Vidya Acharya, Evan Thomas, Naomi O'Reilly,WikiSysop, Aminat
Abolade and Aya Alhindi
• Crouch gait is defined as excessive dorsiflexion or calcaneus at the ankle in combination with
excessive flexion at the knee and hip.
• This pattern is part of the natural history of gait disorder in children with more severe diplegia
and in the majority of children with spastic quadriplegia.
• Regrettably, the commonest cause of crouch gait in children with spastic diplegia is isolated
lengthening of the heel cord in the younger child.
• Once the heel cord has been lengthened, if the spasticity/contracture of the hamstrings and
iliopsoas has not been recognized and is not managed adequately, there will be a rapid
increase in hip and knee flexion..
• Orthotic management: long-term use of a ground reaction (Saltiel) AFO until the integrity of the
plantar flexionknee extension couple is clearly re-established.

56. https://www.flintrehab.com/crouch-gait-cerebral-palsy/

57. Classification of Gait Patterns in Bilateral Spastic
Cerebral Palsy