Cerebral palsy is a disorder which is caused by damage to the developing brain, which affects the co-ordination of the tone of the muscles, muscular movement and/or posture. It mostly occurs during and before birth.

Symptoms

Depending on the severity of the disorder, the signs and symptoms may vary among children. The muscular coordination problems associated with cerebral palsy may include:

  • Variations in muscle tone, such as being either too stiff or too floppy
  • Stiff muscles and exaggerated reflexes (spasticity)
  • Stiff muscles with normal reflexes (rigidity)
  • Lack of muscle coordination (ataxia)
  • Tremors or involuntary movements
  • Slow, writhing movements (athetosis)
  • Delays in reaching motor skills milestones, such as pushing up on arms, sitting up alone or crawling
  • Favoring one side of the body, such as reaching with only one hand or dragging a leg while crawling
  • Difficulty walking, such as walking on toes, a crouched gait, a scissors-like gait with knees crossing, a wide gait or an asymmetrical gait
  • Problems with swallowing (excessive drooling)
  • Difficulty with sucking or eating
  • Delays in speech development or difficulty speaking
  • Seizures

 

Although the disabilities associated with cerebral palsy may be limited primarily to one limb or one side of the body, it may affect the whole body and, as the disorder does not change with time the symptoms do not get worse with aging. However, muscle shortening and muscle rigidity may worsen if not treated aggressively.

The damage to the brain may aggravate other neurologic problems and the victims may experience the following:

  • Difficulty with vision and hearing
  • Intellectual disabilities
  • Seizures
  • Abnormal touch or pain perceptions
  • Oral diseases
  • Mental health (psychiatric) conditions
  • Urinary incontinence due to the inability to control the bladder.

 

TYPES OF CEREBRAL PALSY

There are four main types of cerebral palsy. They are:

Spastic Cerebral Palsy

This is the most common type of CP. About 80% of people with CP are affected by Spastic CP.

People with spastic CP have increased muscle tone. This means their muscles are stiff and, as a result, their movements can be awkward. Spastic CP usually is described by what parts of the body are affected which include:

  • Spastic diplegia/diparesis: ―In this type of CP, muscle stiffness is mainly in the legs, with the arms less affected or not affected at all. People with spastic diplegia might have difficulty walking because tight hip and leg muscles cause their legs to pull together, turn inward, and cross at the knees (also known asscissoring).
  • Spastic hemiplegia/hemiparesis: ―This type of CP affects only one side of a person’s body; usually the arm is more affected than the leg.
  • Spastic quadriplegia/quadriparesis: ―Spastic quadriplegia is the most severe form of spastic CP and affects all four limbs, the trunk, and the face. People with spastic quadriparesis usually cannot walk and often have other developmental disabilities such as intellectual disability; seizures; or problems with vision, hearing, or speech.
Dyskinetic Cerebral Palsy (also includes athetoid, choreoathetoid, and dystonic cerebral palsies)

People with dyskinetic CP have problems controlling the movement of their hands, arms, feet, and legs, making it difficult to sit and walk. The movements are uncontrollable and can be slow and writhing or rapid and jerky. Sometimes the face and tongue are affected and the person has a hard time sucking, swallowing, and talking. A person with dyskinetic CP has muscle tone that can change (varying from too tight to too loose) not only from day to day, but even during a single day.

Ataxic Cerebral Palsy

People with ataxic CP have problems with balance and coordination. They might be unsteady when they walk. They might have a hard time with quick movements or movements that need a lot of control, like writing. They might have a hard time controlling their hands or arms when they reach for something.

Mixed Cerebral Palsy

Some people have symptoms of more than one type of CP. The most common type of mixed CP is spastic-dyskinetic CP.

 

CAUSES

In many cases, the exact trigger unknown but it is believed that the cause of cerebral palsy is linked to an alteration in the development of the brain usually before birth. Factors that may lead to problems with brain development include:

  • Mutationsin genes that lead to abnormal brain development
  • Maternal infectionsthat affect the developing fetus
  • Fetal stroke,a disruption of blood supply to the developing brain
  • Infant infectionsthat cause inflammation in or around the brain
  • Traumatic head injuryto an infant from a motor vehicle accident or fall which a pregnant woman may be involved in.
  • Lack of oxygento the brain (asphyxia) related to difficult labor or delivery, although birth-related asphyxia is much less commonly a cause than historically thought

 

Risk factors

Increased risk of cerebral palsy development is associated with some risk factors which may include:

Infant illness: because the body defense mechanisms of a new born are very low, they may be susceptible to the following disease conditions which can cause the development of cerebral palsy in them:

  • Bacterial meningitis.This bacterial infection causes inflammation in the membranes surrounding the brain and spinal cord.
  • Viral encephalitis.This viral infection similarly causes inflammation in the membranes surrounding the brain and spinal cord.
  • Severe or untreated jaundice. The condition occurs when certain byproducts of “used” blood cells aren’t removed by filtration from the bloodstream.

 

Maternal health: Certain infections or health problems during pregnancy can significantly increase cerebral palsy risk to the baby. Infections of particular concern include:

  • German measles (rubella).Rubella is a viral infection that can cause serious birth defects. It can be prevented with a vaccine.
  • Chickenpox (varicella).Chickenpox is a contagious viral infection that causes itching and rashes, and it can cause pregnancy complications. It too can be prevented with a vaccine.
  • Cytomegalovirus is a common virus that causes flu-like symptoms and may lead to birth defects if a mother experiences her first active infection during pregnancy.
  • Herpes infection can be passed from mother to child during pregnancy, affecting the womb and placenta. Inflammation triggered by infection may then damage the unborn baby’s developing nervous system.
  • Toxoplasmosis is an infection caused by a parasite found in contaminated food, soil and the feces of infected cats.
  • Syphilis is a sexually transmitted bacterial infection.
  • Exposure to toxins.Exposure to toxins, such as methyl mercury, can increase the risk of birth defects.
  • Zika virus infection.Infants for whom maternal Zika infection causes microcephaly can develop cerebral palsy.
  • Other conditions.Other conditions may increase the risk of cerebral palsy, such as thyroid problems, intellectual disabilities or seizures.

 

Other factors of pregnancy and birth

While the potential contribution from each is limited, additional pregnancy or birth factors associated with increased cerebral palsy risk include:

  • Breech births.Babies with cerebral palsy are more likely to be in a feet-first position (breech presentation) at the beginning of labor rather than headfirst.
  • Complicated labor and delivery.Babies who exhibit vascular or respiratory problems during labor and delivery may have existing brain damage or abnormalities.
  • Low birth weight.Babies who weigh less than 5.5 pounds (2.5 kilograms) are at higher risk of developing cerebral palsy. This risk increases as birth weight drops.
  • Multiple babies.Cerebral palsy risk increases with the number of babies sharing the uterus. If one or more of the babies die, the chance that the survivors may have cerebral palsy increases.
  • Premature birth.A normal pregnancy lasts 40 weeks. Babies born fewer than 37 weeks into the pregnancy are at higher risk of cerebral palsy. The earlier a baby is born, the greater the cerebral palsy risk.
  • Rh blood type incompatibility between mother and child.If a mother’s Rh blood type doesn’t match her baby’s, her immune system may not tolerate the developing baby’s blood type and her body may begin to produce antibodies to attack and kill her baby’s blood cells, which can cause brain damage.

DIAGNOSIS

Detecting cerebral palsy in children might be a difficult due to age factor. It will involve some physical examination that will require the expertise of a specialist in pediatric neurology.  Differential diagnosis may be done through blood tests to rule out infections:

Computer Tomographic Scan

Brain-imaging technologies can reveal areas of damage or abnormal development in the brain. These tests may include the following:

  • Magnetic resonance imaging (MRI).An MRI uses radio waves and a magnetic field to produce detailed 3-D or cross-sectional images of your child’s brain. An MRI can often identify any lesions or abnormalities in your child’s brain.

This test is painless, but it’s noisy and can take up to an hour to complete. Your child will likely receive a mild sedative beforehand. An MRI is usually the preferred imaging test.

  • Cranial ultrasound.This can be performed during infancy. A cranial ultrasound uses high-frequency sound waves to obtain images of the brain. An ultrasound doesn’t produce a detailed image, but it may be used because it’s quick and inexpensive, and it can provide a valuable preliminary assessment of the brain.

Electroencephalogram (EEG)

This is mostly done for people with seizures. This test may be carried out to know if the child has epilepsy, which often occurs in people with cerebral palsy. In an EEG test, a series of electrodes are affixed to your child’s scalp.

The EEG records the electrical activity of your child’s brain. If he or she has epilepsy, it’s common for there to be changes in normal brain wave patterns.

Laboratory tests

Laboratory tests may also screen for genetic or metabolic problems.

Additional tests

If your child is diagnosed with cerebral palsy, you’ll likely be referred to specialists for assessments of other conditions often associated with the disorder. These tests may identify:

  • Vision impairment
  • Hearing impairment
  • Speech delays or impairments
  • Intellectual disabilities
  • Other developmental delays
  • Movement disorders

 

 

TREATMENT

Cerebral palsy requires long-term care with a medical care team which may include:

  • Pediatrician or physiatrist.A pediatrician oversees the treatment plan and medical care.
  • Pediatric neurologist.A doctor trained to diagnose and treat children with brain and nervous system (neurological) disorders may be involved in your child’s care.
  • Orthopedic surgeon.A doctor trained to treat muscle and bone disorders may be involved to diagnose and treat muscle conditions.
  • Physical therapist.A physical therapist may help your child improve strength and walking skills, and stretch muscles.
  • Occupational therapist.An occupational therapist can provide therapy to your child to develop daily skills and to learn to use adaptive products that help with daily activities.
  • Speech-language pathologist.A doctor trained to diagnose and treat speech and language disorders may work with your child if your child suffers from speech, swallowing or language difficulties.
  • Developmental therapist.A developmental therapist may provide therapy to help your child develop age-appropriate behaviors, social skills and interpersonal skills.
  • Mental health specialist.A mental health specialist, such as a psychologist or psychiatrist, may be involved in your child’s care. He or she may help you and your child learn to cope with your child’s disability.
  • Recreation therapist.Participation in art and cultural programs, sports, and other events that help children expand physical and cognitive skills and abilities. Parents of children often note improvements in a child’s speech, self-esteem and emotional well-being.
  • Social worker.A social worker may assist your family to find services and plan for care transitions.
  • Special education teacher.A special education teacher addresses learning disabilities, determines educational needs and identifies appropriate educational resources.

MEDICATIONS

There are some medications that can help reduce the stiffness of the muscles thereby improving their functionalities, treat pain and manage complications related to spasticity or other cerebral palsy symptoms.

It is especially crucial to discuss the efficacy and suitability of the drug for the client. Medication selection depends on whether the problem affects only certain muscles (isolated) or the whole body (generalized). Drug treatments may include the following:

  • Isolated spasticity.When spasticity is isolated to one muscle group, your doctor may recommend onabotulinumtoxinA (Botox) injections directly into the muscle, nerve or both. Botox injections may help to improve drooling. Your child will need injections about every three months.

Side effects may include pain, mild flu-like symptoms, bruising or severe weakness. Other more-serious side effects include difficulty breathing and swallowing.

  • Generalized spasticity.If the whole body is affected, oral muscle relaxants may relax stiff, contracted muscles. These drugs include diazepam (Valium), dantrolene (Dantrium) and baclofen (Gablofen).

Diazepam carries some dependency risk, so it’s not recommended for long-term use. Its side effects include drowsiness, weakness and drooling.

Dantrolene side effects include sleepiness, weakness, nausea and diarrhea.

Baclofen side effects include sleepiness, confusion and nausea. Note that baclofen may also be pumped directly into the spinal cord with a tube. The pump is surgically implanted under the skin of the abdomen.

Your child also may be prescribed medications to reduce drooling. Medications such as trihexyphenidyl, scopolamine or glycopyrrolate (Robinul, Robinul Forte) may be helpful, as can Botox injection into the salivary glands.

THERAPIES

A variety of nondrug therapies can help a person with cerebral palsy enhance functional abilities:

  • Physical therapy.Muscle training and exercises may help your child’s strength, flexibility, balance, motor development and mobility. You’ll also learn how to safely care for your child’s everyday needs at home, such as bathing and feeding your child.

For the first 1 to 2 years after birth, both physical and occupational therapists provide support with issues such as head and trunk control, rolling, and grasping. Later, both types of therapists are involved in wheelchair assessments.

Braces or splints may be recommended for your child. Some of these supports help with function, such as improved walking. Others may stretch stiff muscles to help prevent rigid muscles (contractures).

  • Occupational therapy.Using alternative strategies and adaptive equipment, occupational therapists work to promote your child’s independent participation in daily activities and routines in the home, the school and the community.

Adaptive equipment may include walkers, quadrupedal canes, seating systems or electric wheelchairs.

  • Speech and language therapy.Speech-language pathologists can help improve your child’s ability to speak clearly or to communicate using sign language.

Speech-language pathologists can also teach your child to use communication devices, such as a computer and voice synthesizer, if communication is difficult.

Another communication device may be a board covered with pictures of items and activities your child may see in daily life. Sentences can be constructed by pointing to the pictures.

Speech therapists may also address difficulties with muscles used in eating and swallowing.

  • Recreational therapy.Some children may benefit from recreational therapies, such as therapeutic horseback riding. This type of therapy can help improve your child’s motor skills, speech and emotional well-being.

Surgical or other procedures

Surgical procedure may be required to help release tightened muscles and reshape deformed bones by spasticity. These treatments include:

  • Orthopedic surgery.Children with severe contractures or deformities may need surgery on bones or joints to place their arms, hips or legs in their correct positions.

Surgical procedures can also lengthen muscles and tendons that are proportionally too short because of severe contractures. These corrections can lessen pain and improve mobility. The procedures may also make it easier to use a walker, braces or crutches.

  • Severing nerves.In some severe cases, when other treatments haven’t helped, surgeons may cut the nerves serving the spastic muscles in a procedure called selective dorsal rhizotomy. This relaxes the muscle and reduces pain, but can also cause numbness.

Complications

Complications can be as a result of weakness of the muscles, muscular spasticity and coordination problems. The complications may include:

  • This is the shortening of the muscle tissue as a result of severe muscle tightening (spasticity). It can inhibit bone growth, cause bones to bend, and result in joint deformities, dislocation or partial dislocation.
  • Swallowing or feeding problems can make it difficult for someone who has cerebral palsy, particularly an infant, to get enough nutrition. This may cause impaired growth and weaker bones. Some children may need a feeding tube for adequate nutrition.
  • Mental health conditions.People with cerebral palsy may have mental health (psychiatric) conditions, such as depression. Social isolation and the challenges of coping with disabilities can contribute to depression.
  • Lung disease.People with cerebral palsy may develop lung disease and breathing disorders.
  • Neurological conditions.People with cerebral palsy may be more likely to develop movement disorders or worsened neurological symptoms over time.
  • Pressure on joints or abnormal alignment of joints from muscle spasticity may lead to the early onset of painful degenerative bone disease (osteoarthritis).
  • Fractures due to low bone density (osteopenia) can stem from several common factors such as lack of mobility, nutritional shortcomings and antiepileptic drug use.
  • Eye muscle imbalance.This can affect visual fixation and tracking; an eye specialist should evaluate suspected imbalances.

SOURCES

  • American Association on Intellectual and Developmental Disabilities
    http://www.aaidd.org/content_100.cfm?navID=21
  • Honeycutt A, Dunlap L, Chen H, Homsi G. Economic costs associated with mental retardation, cerebral palsy, hearing loss, and vision impairment: United States, 2003. MMWR Morb mital Wkly Rep. 2004;53(3): 57-59.
    https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5303a4.htm
  • National Institute of Neurological Disorders and Stroke. Cerebral Palsy: Hope Through Research. NIH Publication Number 10-159, updated 5/6/10.
    http://www.ninds.nih.gov/disorders/cerebral_palsy/detail_cerebral_palsy.htm
  • CDC. (2012). Prevalence of autism spectrum disorders—Autism and Developmental Disabilities Monitoring Network, 14 sites, United States, 2008. MMWR Surveillance Summaries, 61(3), 1-19.
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  • Miller G. Clinical features and classification of cerebral palsy. http://www.uptodate.com/home. Accessed May 20, 2016.
  • Rubella: Make sure your child gets vaccinated. Centers for Disease Control and Prevention. http://www.cdc.gov/Features/Rubella/. Accessed June 2, 2016.