CEREBRAL PALSY

It is a non- progressive brain damage/injury or malformation occurring during a child’s brain

development. It affects movement, muscle tone and posture. Signs and symptoms appears during
infancy or pre-school years.

Classification of causes according to timing of brain insult

They can be classified as prenatal, perinatal and postnatal causes.

 Prenatal causes
- Maternal infections e.g. with cytomegalovirus, German measles etc.
- Multiple babies- risk increases with number of babies sharing the uterus.
- Congenital malformation of the fetus.
- Maternal exposure to toxin e.g. methyl mercury
- Maternal seizure disorder
- Thyroid hormone treatment of the mother
- Polyhyndramnios

 Perinatal causes
- Severe oxygen deprivation to the brain during birth
- Significant trauma/ injury to the head during labour
- Complications e.g. detachment of the placenta, uterine rapture, umbilical cord
detachment during birth.
- Premature labour and delivery
- Abnormal presentation e.g. breech
- Abnormal heart rate
- Post term pregnancies
 Post natal causes
- Infections e.g. Meningitis, Encephalitis
- Intracranial hemorrhage e.g. due to prematurity, trauma or vascular leukomalacia (in
premature infants)
- Hypoxia- ischemia e.g. from meconium aspiration
- Persisted hypertension of the newborn
- Kernicterus

Types of cerebral palsy

(1) Spastic cerebral palsy

It is the most common type. It is characterized by muscle stiffness and jerky movements.
Spasticity means increased muscle tone or hypertonia and this makes movement difficult or
impossible. The area of the brain injured in spastic cerebral palsy is the MOTOR CORTEX –
which plans and controls movement.

Clinical features

- Involuntary limb movements

- Continuous muscle spasms and contractures
- Abnormal scissor like movement
- Joint contractures
- Limited stretching
- Flexion of the elbow, wrist and fingers
- Poor control and coordination of muscle movement

Types of spastic cerebral palsy

 Spastic diplegia- muscle stiffness is in the legs

 Spastic hemiplegia- one sided stuffiness of the body
 Spastic quadriplegia- whole body / the four limbs are involved- there is loss of function
 Damage to the motor cortex – causes involuntary movements
 Spastic (pyramidal) cerebral palsy – muscular tension and mobility are impaired.

(2) Ataxic cerebral palsy

It is characterized by problems with balance and coordination. It results from damage to the
developing brain’s motor control centres. Movement control becomes hard. Brain injury happens
on the CEREBELLUM.

Clinical features

- Unsteady movements due to difficulty with balance

- Tremors especially when reaching for things
- Difficulties making quick movements
- Finger movement difficulties
- Slow eye movements
- Speech difficulties with breathy sound and monotone known as ‘scanning’ speech
- Hearing or visual problems in some cases.

(3) Athetoid cerebral palsy

It is also known as Dyskinetic cerebral palsy. It is a movement disorder resulting from brain
damage and characterized by abnormal involuntary movement and muscle tone fluctuations
i.e. between hypertonia and hypotonia. The injury in Athetoid CP is the BASAL GANGLIA
and / or CEREBELLUM.
Clinical features

 Dystonia – marked by
- Involuntary muscle contractions marked by writhing, slow and repetitive movements that
worsen when the child moves
- Abnormal awkward posture
- Alternating movements from slow and painful to fast and rapid
- Involuntary movements seen to increase with stress.

 Athetosis - marked by:

- Slow twitching and wriggling movements which get worse with movement
- Muscle tone fluctuation
- Grimacing and drooling from lack of facial muscle control
- Difficulties in eating and drinking
- Problems in grasping and holding

 Chorea – from Greek work meaning ‘dance’

Characterized by repetitive involuntary movement and affecting multiple parts of the body.

Types of Athetoid cerebral palsy

They include:

 Dystonia- slow rotational movement of the torso, arm or leg

 Chorea – sudden fingers/ toes involuntary movements
 Athetosis- sluggish/writhing movements in fingers and face
 Choreathetoid- A combination of chorea and Athetosis
 Ataxia- loss of balance and coordination
 Rigidity – High muscle tone (hypertonia)- causing restricted movements.
 Dyskinesia – involuntary movements

(4) Hypotonia cerebral palsy

It is characterized by floppy muscles and excessive flexibility. It is caused by damage to the
CEREBELLUM during birth. It causes issues with stability and developmental delays.

Clinical features

- Clumsiness
- Developmental delays
- Excessive muscle flexibility
- Difficulty chewing or swallowing
- Ligamentous laxity
- Poor hand/neck control
- Poor balance and stability

(5) Mixed cerebral palsy

It is a type of cerebral palsy that occurs when a child exhibits symptoms of more than one type of
cerebral palsy. Children with mixed type have damaged motor control centres in several parts of
the brain.

Clinical features

- Poor movement and balance

- Abnormal reflexes
- Exaggerated jerky movements
- Coordination issues
- Poor posture
- Tremors and shakiness
Diagnosis of cerebral palsy

 Medical history
 Complete physical examination
 Imaging tests e.g. MRI, CT scans, cranial ultrasound etc
 Electroencephalogram (EEG)- If there is presence of seizures
 Lab tests
 Additional tests e.g. Vision, hearing, speech, intellect, development, movement and other
medical condition.

Treatment

1. Medications
To lessen muscle tightness eg
 Muscle or nerve injections e.g. (Botox) or others
 Oral muscle relaxants
 Medications to reduce drooling

2. Therapies e.g.
(i) Occupational therapy

Management involves:-

- Assessment of the child’s needs

- Regular stretching exercises to decrease spasticity and prevent contractures
- Splinting, casting and bracing to maintain range of motion and flexibility
- Exercises for strengthening core muscles in the trunk and limbs to improve balance and
coordination
- Visual exercises to improve visual perception
- Sensory integration activities to improve sensory processing
- Joint strengthening by strengthening the muscles around them for more support and stability
e.g. heavy joint compression.
- Use of gentle developmental movements expected in every baby to help improve
neurological foundations of sensory-motor development.
- Referral to other professional for continued management e.g. hearing specialists, speech
therapists etc.

(ii) Physical therapy

For muscle training and exercises for strength, flexibility, balance, motor development
and mobility

(iii) Speech and language therapy

Helps improve the child’s ability to speak and communicate. They also help with sign
language as well.

(iv) Recreational therapy

Examples are:- competitive sports e.g. horseback riding and skiing. They improve motor
skills, speech and emotional well being

3. Surgical procedures
 Orthopaedic surgery – for children with severe bone contractures or deformities i.e. to
align their joints etc
 Selective dorsal Rhizotomy (cutting nerve fibres) i.e. the nerves that serve specific
spastic muscles. Aims at muscle relaxation in the legs and reducing pain. It can cause
numbness as a side effect.

4. Other treatments
Medications and treatment procedures for;-
  Seizures
 Pain
 Osteoporosis
 Mental health conditions
 Sleep/visual/hearing problems
 Oral health/feeding and nutrition problem
 Bladder incontinence among other problems

Prognosis

It depends on the severity of the cerebral palsy and concomitant medical complications.
Quadriplegic CP has a likelihood of epilepsy, extra pyramidal abnormalities and severe cognitive
impairment. With appropriate therapeutic services, patients may fully integrate academically and
socially.