Cerebral Palsy

Cerebral palsy is condition, sometimes thought of as a group of disorders that can involve brain and nervous system functions such as movement, learning, hearing, seeing, and thinking.

The term cerebral palsy refers to any one of a number of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination but don't worsen over time. Even though cerebral palsy affects muscle movement, it isn't caused by problems in the muscles or nerves. It is caused by abnormalities in parts of the brain that control muscle movements. The majority of children with cerebral palsy are born with it, although it may not be detected until months or years later. The early signs of cerebral palsy usually appear before a child reaches 3 years of age.

A small number of children have cerebral palsy as the result of brain damage in the first few months or years of life, brain infections such as bacterial meningitis or viral encephalitis, or head injury from a motor vehicle accident, a fall, or child abuse.

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Types of Cerebral Palsy

There are several different types of cerebral palsy, including spastic, ataxic, athetoid/dyskinetic, hypotonic, and mixed.

Spastic

Spastic cerebral palsy is by far the most common type, occurring in 70% to 80% of all cases. Moreover, spastic CP accompanies one of the other types in 30% of all cases. People with this type are hypertonic and have a neuromuscular condition stemming from damage to the corticospinal tract or the motor cortex that affects the nervous system's ability to receive gamma amino butyric acid in the area(s) affected by the disability. Spastic CP is further classified by topography dependent on the region of the body affected; these include:

Spastic hemiplegia (one side being affected). Generally, injury to muscle-nerves controlled by the brain's left side will cause a right body deficit, and vice versa. Typically, people that have spastic hemiplegia are the most ambulatory, although they generally have dynamic equinus on the affected side and are primarily prescribed ankle-foot orthoses to prevent said equinus.

Spastic diplegia (the lower extremities are affected with little to no upper-body spasticity). The most common form of the spastic forms. Most people with spastic diplegia are fully ambulatory and have a scissors gait. Flexed knees and hips to varying degrees are common. Hip problems, dislocations, and in three-quarters of spastic diplegics, also strabismus (crossed eyes), can be present as well. In addition, these individuals are often nearsighted. The intelligence of a person with spastic diplegia is unaffected by the condition.

Spastic tetraplegia (all four limbs affected equally). People with spastic quadriplegia are the least likely to be able to walk, or if they can, to want to walk, because their muscles are too tight and it is too much effort to do so. Some children with quadriplegia also have hemiparetic tremors, an uncontrollable shaking that affects the limbs on one side of the body and impairs normal movement.

Occasionally, terms such as monoplegia, paraplegia, triplegia, and pentaplegia may also be used to refer to specific manifestations of the spasticity.

Ataxic

Ataxia (ICD-10G80.4) type symptoms can be caused by damage to the . The forms of ataxia are less common types of cerebral palsy, occurring in at most 10% of all cases. Some of these individuals have hypotonia and tremors. Motor skills such as writing, typing, or using scissors might be affected, as well as balance, especially while walking. It is common for individuals to have difficulty with visual and/or auditory processing.

Athetoid/Dyskinetic

Athetoid or dyskinetic is mixed muscle tone - People with athetoid CP have trouble holding themselves in an upright, steady position for sitting or walking, and often show involuntary motions. For some people with athetoid CP, it takes a lot of work and concentration to get their hand to a certain spot (like scratching their nose or reaching for a cup). Because of their mixed tone and trouble keeping a position, they may not be able to hold onto objects (such as a toothbrush or pencil). About one quarter of all people with CP have athetoid CP. The damage occurs to the extrapyramidal motor system and/or pyramidal tract and to the basal ganglia. It occurs in 10% to 20% percent of all cases. In newborn infants, high bilirubin levels in the blood, if left untreated, can lead to brain damage in certain areas (kernicterus). This may also lead to athetoid cerebral palsy.

Hypotonic

People with hypotonic CP appear limp and can move only a little or can't move at all.

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Symptoms

Symptoms of cerebral palsy can be very different between people with this group of disorders. Symptoms may:

  • Be very mild or very severe
  • Only involve one side of the body or both sides
  • Be more pronounced in either the arms or legs, or involve both the arms and legs

Symptoms are usually seen before a child is 2 years old, and sometimes begin as early as 3 months. Parents may notice that their child is delayed in reaching, and in developmental stages such as sitting, rolling, crawling, or walking.

There are several different types of cerebral palsy. Some people have a mixture of symptoms.

Symptoms of spastic cerebral palsy, the most common type, include:

  • Muscles that are very tight and do not stretch. They may tighten up even more over time.
  • Abnormal walk (gait): arms tucked in toward the sides, knees crossed or touching, legs make "scissors" movements, walk on the toes
  • Joints are tight and do not open up all the way (called joint contracture)
  • Muscle weakness or loss of movement in a group of muscles (paralysis)
  • The symptoms may affect one arm or leg, one side of the body, both legs, or both arms and legs

The following symptoms may occur in other types of cerebral palsy:

  • Abnormal movements (twisting, jerking, or writhing) of the hands, feet, arms, or legs while awake, which gets worse during periods of stress
  • Tremors
  • Unsteady gait
  • Loss of coordination
  • Floppy muscles, especially at rest, and joints that move around too much

Other brain and nervous system symptoms:

  • Decreased intelligence or learning disabilities are common, but intelligence can be normal
  • Speech problems (dysarthria)
  • Hearing or vision problems
  • Seizures
  • Pain, especially in adults (can be difficult to manage)
  • Eating and digestive symptoms
  • Difficulty sucking or feeding in infants, or chewing and swallowing in older children and adults
  • Problems swallowing (at all ages)
  • Vomiting or constipation

Other symptoms:

  • Increased drooling
  • Slower than normal growth
  • Irregular breathing
  • Urinary incontinence

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Treatment

There is no cure for cerebral palsy. The goal of treatment is to help the person be as independent as possible.

Treatment requires a team approach, including:

Primary care doctor

Dentist (dental check-ups are recommended around every 6 months)

Social worker

Nurses

Occupational, physical, and speech therapists

Other specialists, including a neurologist, rehabilitation physician, pulmonologist, and gastroenterologist

Treatment is based on the person's symptoms and the need to prevent complications.

Self and home care include:

  • Getting enough food and nutrition
  • Keeping the home safe
  • Performing exercises recommended by the health care providers
  • Practicing proper bowel care (stool softeners, fluids, fiber, laxatives, regular bowel habits)
  • Protecting the joints from injury
  • Putting the child in regular schools is recommended, unless physical disabilities or mental development makes this impossible. Special education or schooling may help.

The following may help with communication and learning:

  • Glasses
  • Hearing aids
  • Muscle and bone braces
  • Walking aids
  • Wheelchairs
  • Physical therapy, occupational therapy, orthopedic help, or other treatments may also be needed to help with daily activities and care.

Medications may include:

  • Anticonvulsants to prevent or reduce the frequency of seizures
  • Botulinum toxin to help with spasticity and drooling
  • Muscle relaxants (baclofen) to reduce tremors and spasticity

Surgery may be needed in some cases to:

  • Control gastroesophageal reflux
  • Cut certain nerves from the spinal cord to help with pain and spasticity
  • Place feeding tubes
  • Release joint contractures

Stress and burnout among parents and other caregivers of cerebral palsy patients is common, and should be monitored.

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Causes

Cerebral palsy is caused by injuries or abnormalities of the brain. Most of these problems occur as the baby grows in the womb, but they can happen at any time during the first 2 years of life, while the baby's brain is still developing.

In some people with cerebral palsy, parts of the brain are injured due to low levels of oxygen (hypoxia) in the area. It is not known why this occurs.

Premature infants have a slightly higher risk of developing cerebral palsy. Cerebral palsy may also occur during early infancy as a result of several conditions, including:

  • Bleeding in the brain
  • Brain infections (encephalitis, meningitis, herpes simplex infections)
  • Head injury
  • Infections in the mother during pregnancy (rubella)
  • Severe jaundice

In some cases the cause of cerebral palsy is never determined.

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Diagnosis

A full neurological exam is critical. In older people, testing cognitive function is also important.

The following other tests may be performed:

  • Blood tests
  • CT scan of the head
  • Electroencephalogram (EEG)
  • Hearing screen
  • MRI of the head
  • Vision testing

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Prognosis

Cerebral palsy is a lifelong disorder. Long-term care may be required. The disorder does not affect expected length of life. The amount of disability varies.

Many adults are able to live in the community, either independently or with different levels of help. In severe cases, the person may need to be placed in an institution.

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Prevention

Getting the proper prenatal care may reduce the risk of some rare causes of cerebral palsy. However, dramatic improvements in care over the last 15 years have not reduced the rate of cerebral palsy. In most cases, the injury causing the disorder may not be preventable.

Pregnant mothers with certain medical conditions may need to be followed in a high-risk prenatal clinic.

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Complications

  • Bone thinning or osteoporosis
  • Bowel obstruction
  • Hip dislocation and arthritis in the hip joint
  • Injuries from falls
  • Joint contractures
  • Pneumonia caused by choking
  • Poor nutrition
  • Reduced communication skills (sometimes)
  • Reduced intellect (sometimes)
  • Scoliosis
  • Seizures (in about half of patients)
  • Social stigma

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Cerebral Palsy caused by birth injury

Although in some cases it can be difficult to determine the cause, early or late delivery, incorrect medication, or failure to use the appropriate birthing method account for the large majority of causes of Cerebral Palsy.

  • Forceps delivery
  • Vacuum extraction delivery
  • Exceptionally prolonged labor
  • Low levels of amniotic fluid
  • Twisted, compressed, or tangled umbilical cord
  • Macrosomia or a baby that is too big for its development
  • Placental abruption
  • Excessive bleeding

During delivery doctors will monitor the baby for any of these conditions. Fetal heart rate and pH are measured through the scalp in order to monitor the progression of delivery and anticipate any potential complications. Should any problems arise in delivery the doctor can order many alternative procedures such as an emergency C-section.

Unfortunately, more and more doctors are making the wrong decision and the moment of truth, and thousands of babies and their families must pay the price for these errors in judgment.

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