Understanding Cerebral Palsy (CP)

Cerebral Palsy (CP) is a disorder of movement and posture due to an insult/damage to the developing brain.

CP is a static and non-progressive disorder.

CP occurs in 1-2 of every 2000 babies born and is 10 times more frequent in babies who are born premature as well as babies of low birth weight.

Cause of CP

CP occurs due to insult / damage to developing brain –

• In-utero, while the baby is still in the womb
• During the process of labor / delivery
• Ex-utero, after the baby is born
• In children under the age of 5.

The majority of children with CP have an unknown cause.

10-15% occurs due to insult / damage during birth as well as lack of blood circulation / supply to the brain before, during or after birth.

Premature babies are at higher risk of developing CP, and this might be due to immaturity of the vascular system as well as lack of sufficient oxygen to the developing brain.

Brain damage can also occur due to:

• High blood bilirubin levels (seen in newborn babies with severe neonatal jaundice) which results in kernicterus as well as brain damage.
• Serious infections in the first year of life (such as encephalitis, meningitis, sepsis, trauma and severe dehydration)

Signs and Symptoms

Signs and symptoms usually develop before the age of 2 years and in severe cases as early as 3 months.

The signs and symptoms of CP are variable, ranging from mild to moderate motor as well as cognitive disability. This often leads to deformity as well as the child being wheelchair bound or even bed-ridden.

CP is classified into 4 types:

1. Spastic type (65% of all CP cases), muscles have increased tone and are weak. The involvements of the muscles are further divided into:
   • Quadriplegia (both hands and feet)
   • Diplegia (both feet)
   • Hemiplegia (one side affected only)
2. Dyskinetic type (Choreoathetoid, 10% of all CP cases), muscles of the arms, hands, feet and all spontaneous movements are slow and impaired. They are involuntary and clumsy. These can involve both gross as well as fine movements and these tend to be worse during periods of anxiety as well as emotion. These movements however disappear during sleep.
3. Attaxic type, (5% of all CP cases), consists of involuntary, uncontrollable and uncoordinated movements resulting in broad based gait and impaired fine motor movements as well as dyscordination.
4. Mixed type (20% of all CP cases), consists of a mixture of 2 of the above types and the most common combination is one of mixed spastic dyskinetic CP.

   CP children can also have other problems which are often encountered:

   • Cognitive impairment
   • Seizures / Epilepsy
   • Feeding disorder
   • Disordered breathing
   • Speech disorder
   • Visual impairment
   • Auditory impairment

Diagnosis

Delayed development as well as persistence of primitive reflexes is usually the first clues to a diagnosis.

Certain abnormal postures as well as movements are also suggestive such as muscle tremors and increased tone as well as arching of back and scissoring of lower limbs.

Investigations that are usually done for CP children:

• MRI or CT scan brain to look for structural anomalies and insult/damage to brain.
• Hearing assessment
• Visual assessment
• EEG if there are seizures

Treatment

There is no cure for CP and it is a lifelong disorder.

However rehabilitation is still possible so as to maximize the full potential of the child with CP.

The aim of therapy is for the child to be as independent as possible.

Therapy depends on the type of CP and may include:

• Occupational therapy
• Orthotics
• Visual aids
• Hearing aids
• Special needs school
• Anti-spasmodic
• Orthopaedic surgeon
• Speech therapy

For children with mild CP, majority of them attend mainstream schooling. The rest requires lifelong physical therapy as well as occupational and cognitive therapy.

Those with severe deformity might require orthopaedic intervention for joint deformity.

Other surgeries might be performed for feeding incardination as well as severe gastrosophageal reflux?s.

Prognosis

This depends on the type of CP as well as level of severity.

Favorable signs are head control by 9 months, roll over from front to back by 18 months, sitting independently before 24 months and crawling by 30 months. Those with the above milestones have a higher chance of independently walking.

The full intellectual potential of a child born with CP will often not be known until the child starts school. CP children are more likely to have some learning disability.

The ability to live independently varies widely depending on the severity of each case. Some children with CP will require personal assistant services for all activities of daily living while others can lead semi-independent lives, needing support only for certain activities. Still others can live in complete independence. The need for personal assistance often changes with increasing age and associated functional deterioration.