CEREBRAL PALSY
IN PRIMARY CARE
A.J. RUSH, MD
MARY FREE BED MEDICAL GROUP
616.780.7389
CONFLICTS OF INTEREST
• MARRIED TO SHANA RUSH, PHD, CCC-SLP
• I’LL BE MENTIONING PEDIATRIC NEUROPSYCHOLOGY, BUT
NOTHING OUTSIDE STANDARD OF CARE
• MEDTRONIC EDUCATIONAL CONSULTANT
• NOT GOING TO DISCUSS INTRATHECAL BACLOFEN PUMPS
• I’M GOING TO SAY: “IF THIS DOESN’T WORK THEN CALL
ME” ABOUT 6 TIMES
WHAT WE’RE NOT DOING TODAY
• MEMORIZING A BAZILLION GAIT
DEVIATIONS
• MEMORIZING SUBTYPES OF CP, EITHER
PATHOPHYSIOLOGIC (ATAXIC, SPASTIC,
ETC) OR ANATOMIC (DIPLEGIC, ETC)
• MAKING IT MYSTERIOUS
• LEAVING YOU FEELING LIKE YOU HAVE TO
GOALS
• EXPLAIN WHAT CP IS AND ISN’T, AND WHAT CAUSES
IT
• EXPLAIN SEVERITY GRADING FOR CP AND ITS
RELEVANCE TO GROWTH AND LIFESPAN
• TREAT SYMPTOMS OF HYPERTONIA IN SEQUENCE
• RANK GAIT DEVIATIONS BY IMPORTANCE
• BONUS: WORKUP/RX NONVERBAL PERSON IN PAIN
• BUT FIRST: MEMORIZE THE NEXT SLIDE…
GAIT
Weight Acceptance Single Leg Stance Swing Leg Advancement
Initial Loading Mid- Terminal Pre- Initial Mid- Terminal
Contact Response Stance Stance Swing Swing Swing Swing
Trunk Lean A/P
DEVIATION Pelvis
Lean L/R
Hikes
Lacks Forward Rotation
SYSTEMS Lacks Backward Rotation
Ipsilateral Drop
Contralateral Drop
OF PERRY Hip Flexion Limited
Flexion Excessive
Past Retract
& Knee Flexion Limited
Flexion Excessive
Wobbles
ESQUENAZ Hyperextends
Extensor Thrust
Valgus/Varus
I, CROSS- Ankle
Excessive Contralateral Flexion
Forefoot Contact
Foot Flat Contact
REFERENC Foot Slap
Excessive Plantarflexion
Excessive Dorsiflexion
ED &
Inversion/Eversion
Heel Off
No Heel Off
SIMPLIFIE
Drag
Contralateral Vault
Toes Inadequate Extension
D
Clawed/Hammered
DEFINITION & PREVALENCE
” A MOVEMENT DISORDER CAUSED BY A
NON-PROGRESSIVE INJURY TO AN
IMMATURE
• MAX BRAIN.”
AGE AT INJURY: 2-8 PROGRESSIVE
YEARS? • NOT A ‘GARBAGE CAN’ DX
• DEF’N OF “INJURY” IS • PREVALENCE IN CHILDREN
LOOSE
• CONGENITAL 2/1K
• PATHOLOGY CAN, • ALL 2.1-3.7/1K
HOWEVER, BE
• 500,000 AMERICANS
WHY IS DX NECESSARY? WHY NOT
CVA, ETC?
• RELATIVE FREQUENCY OF PATTERNS DRAMATICALLY
DIFFERENT THAN IN ADULTS BECAUSE OF IMMATURE
BRAIN ANATOMY
• INJURY IS NON-PROGRESSIVE BUT KIDS ARE PROGRESSIVE
• INFANTILE VS ADULT BONY ALIGNMENT
• TORSION
• JOINTS
• LINEAR GROWTH
• EASIER TO RE-LEARN THAN TO LEARN SKILLS
CLINICAL FEATURES &
ASSOCIATED ISSUES
• MOVEMENT COMMON, LATE • AUTISM: 7%
DISORDER IS RARE
• EPILEPSY: 20-
• SPASTIC: 70-80% • COGNITIVE 40%
• DYSKINETIC: IMPAIRMENT/
• SPEECH: ~75%
<10% LEARNING
DISORDER: ~2/3 • VISION
• ATAXIC: <10%
• HALF MILD, IMPAIRMENT:
• MIXED: 10-15% ~67%
HALF MOD-
• HYPOTONIC: SEVERE • CHRONIC PAIN:
EARLY IS
>25% OF ADULTS
ETIOLOGY
• PREMATURITY OR
CONGENITAL: 70%
• BIRTH TRAUMA: <5%
• TBI, INFECTIOUS,
TUMOR, ANOXIC BI,
ETC: 25%
Kidokoro, 2014
WHY DO EX-PREEMIES GET CP?
ALL THAT EMBRYOLOGY IS FINALLY GOOD
FOR SOMETHING
[Link]
@[Link]
RISK FACTORS FOR CONGENITAL
CP
• LOW BIRTH WEIGHT • MULTIPLE BIRTHS: 5X RISK
• <1500G: 59.5/1K • ONLY PARTIALLY DUE TO
• 1500-2500G: 6.2/1K INCREASED RISK OF LOW
BIRTH WEIGHT OR
• >2500G: 1.1/1K PREMATURITY
• PREMATURITY • IVF: 1.6X RISK
• 28-31 WEEKS: 35.0-79.5/1K • AT LEAST MOSTLY DUE TO
• 32-36 WEEKS: 6.1/1K INCREASED RISK OF LOW
• ≥37 WEEKS: 1.1-1.7/1K BIRTH WEIGHT OR
PREMATURITY
GMFCS-ER:
GROSS MOTOR FUNCTION
CLASSIFICATION SYSTEM (EXTENDED & REVISED)
I. WALKS WITHOUT LIMITATIONS
II. WALKS WITH LIMITATIONS
III. WALKS USING A HAND-HELD MOBILITY
DEVICE
IV. SELF-MOBILITY WITH LIMITATIONS; MAY USE
POWERED MOBILITY
V. TRANSPORTED IN A MANUAL WHEELCHAIR
NT: ORAL FEEDS
TF: FEEDING TUBE
Median Height & Weight by GMFCS
70 CDC
I
65
260 II
60 III
IV
55 210 V
CDC
50
I
45 160 II
III
40 IV
110 V
35
V-GT
30
60
25
20 10
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
GMFCS I GROWTH CHARTS
3 STRATA OF MOVEMENT
DISORDER SX
1. SYMPTOMATIC
• PAIN
• SKIN BREAKDOWN
• PERCEPTION OF DISFIGUREMENT
2. PASSIVE
• POSITIONING
• DIFFICULTY COOPERATING WITH
CAREGIVERS
3. ACTIVE
PRACTICAL ORTHOTIC TREATMENT OF
HIGH TONE FEET IN NON-AMBULATORY
CHILDREN
1. TYPES OF AFOS
2. SCHOOL OR OUTPATIENT PT/OT CAN BE VERY HELPFUL
[Link]/dafo-guide
3. IF THE 1ST THING YOU TRY DOESN’T WORK THEN CALL
ME
PRACTICAL PHARMACOLOGIC
TREATMENT OF HYPERKINETIC
MOVEMENT DISORDERS
1. IDENTIFY TARGET SYMPTOM FROM 2 SLIDES BACK
2. ARGUE WITH THE PARENTS WHO WANT YOU TO MAKE
THEIR KID WALK DESPITE THEIR DIFFICULTY CHANGING
HIS DIAPER
3. BACLOFEN DOSING MADE SIMPLE
A. START 0.1MG/KG PO QPM
B. TITRATE TO EFFECT AS RAPIDLY AS TOLERATED TO “MAX” OF
0.3MG/KG TID AS LIMITED BY SEDATION
4. IF THAT DOESN’T WORK THEN DON’T WEAN IT ANY
FASTER THAN YOU STARTED IT AND CALL ME
3 TASKS OF GAIT
#1 STABLE BASE OF SUPPORT
#2 LIMB ADVANCEMENT
#3 LIMB CLEARANCE
• FOOT > ANKLE > VladiMens
KNEE > HIP…
• WEIGHT VS
STABILITY VS
CONVENIENCE VS Doris Fanny
COSMESIS
• CONTEXT COUNTS
Tasks of Gait Goals of Gait
# Stable base of = Don’t fall down or
1 support get hurt
# Limb = Body goes forward
2 advancement
# Limb clearance = Don’t waste energy
3 on the ground
#1 STABLE BASE OF SUPPORT
Charisse Living with Cerebral Palsy
#2 LIMB ADVANCEMENT
Walk With Yani
#3 LIMB CLEARANCE
kerrymallini
PRACTICAL APPROACH TO
ORTHOTIC PRESCRIPTION FOR
AMBULATORY CHILDREN
1. WATCH CHILD WALK. ARE THEY (1)
UNSTABLE, (2) POOR FORWARD
MOMENTUM, OR (3) DRAGGING FOOT?
2. THEIR PT WILL HAVE SPECIFIC REQUEST.
ASK THEM HOW IT WILL HELP.
3. IF THEIR 1ST SUGGESTION DOESN’T SEEM
TO RESOLVE THE MOST FUNDAMENTAL
TIMELINE OF
SURVEILLANCE/INTERVENTIONS
FOR PCPS
• ASAP MULTIDISCIPLINARY
• PT/OT/SLP CLINIC
• CONSIDER • NEUROPSYCHOLOGICAL
AUDIOLOGY/VISION EVALUATION
• AT 1 YEAR, 48% OF HEALTHY • CONCERNS: ASAP
EX-29 WEEK PREEMIES HAVE
CORTICAL VISION • ROUTINE: AFTER 2ND HALF
ABNORMALITIES OF KINDERGARTEN
• SPECIALIST REFERRAL: • DON’T FORGET TWINS &
EITHER PM&R OR ≤34 WEEK PREEMIES
PROGNOSIS & LIFE EXPECTANCY
• IF REALLY STRICTLY DX’D THEN MILDEST 20% ‘OUTGROW’ IT IN
GRADESCHOOL
• REALLY REALLY STRICTLY
• NEUROPLASTICITY?
• GMFCS I & II: NORMAL
• GMFCS III & IV: 3X RISK OF DEATH
• GMFCS V: 60% SURVIVAL AT 19 YEARS
• ≥4 MAJOR NEURO DX: IF SURVIVE TO AGE 4 THEN 50% SURVIVE TO AGE
18
• GT: 9X RISK OF DEATH
ECONOMIC IMPACT
• MEDICAID 2005
• CP & INTELLECTUAL DISABILITY: $43,338
• CP: $16,721
• TYPICALLY DEVELOPING: $1,674
• CDC ESTIMATED IN 2003 LIFETIME COST PER
PERSON WITH CP IS NEARLY $1 MILLION
• COMBINED LIFETIME COSTS FOR PEOPLE WITH CP
BORN IN 2000: $11.5 BILLION
BONUS: WORKUP & RX
NONVERBAL PERSON IN PAIN
• TIMELINE IS ESSENCE OF HX
• SPASMS PAIN OR VICE VERSA?
• FULL PE (YOU’D BE SURPRISED)
• DENTAL EXAM >20% DENTAL ABSCESS
• CBC, CMP, CRP, AMYLASE, LIPASE, ABDOMINAL/PELVIC
US, CONSIDER SKELETAL SURVEY
• GABAPENTIN 10MG/KG DIV TID, INCREASE AS
RAPIDLY AS NEEDED/TOLERATED TO 50MG/KG DIV TID
TAKE HOME
• DX EXISTS BECAUSE KIDS • HYPERTONIA SX
AREN’T SMALL ADULTS • SYMPTOMATIC: PAIN, ETC
• NON-CP PER SE PROBLEMS • PASSIVE: POSITIONING, ETC
• VISION • ACTIVE: MOVING
• COGNITION • GAIT
• SPEECH • BASE OF SUPPORT: STABILITY
• PAIN ESPECIALLY AS ADULTS • LIMB ADVANCEMENT:
• [Link]/ FORWARD
ARTICLES/ • LIMB CLEARANCE: EFFICIENCY
[Link] • 616.780.7389