Cerebral Palsy
Cerebral palsy (CP) is brain disorder that occur due to damage in developing fetal or infant brain and permanent affects body movements and muscle coordination. CP is caused by injury to the developing brain in preborn babies or early childhood and limit the daily life activities.
It was first described by William John Little in 1843 and was initially known as “Little disease”. He observed that spasticity happens due to brain injury during infancy, preterm birth, or birth asphyxia.
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Symptoms
Symptoms of CP is heterogenous means they vary person to person. One child may have mild brain injury affecting one part of the musculoskeletal system whereas, other child has severe brain injury may have various CP symptoms such as problem with movement, posture, coordination.
These difficulties affect daily activity such as walking, eating, or dressing. Some children also may also develop serious condition (comorbidities).
Injury in the child brain before, during and just after delivery affects nervous system (brain and spinal cord) and musculoskeletal system (muscle and bone) and develop symptoms such as:
Muscles become stiff, tight, or move involuntarily.
Difficulty maintaining normal body posture or balance.
Limited movement and difficulties in daily activities.
Problems with sensation (touch, vision, hearing) or difficulty interpreting sensory information.
Problems with thinking, learning, or memory.
Difficulties in speaking or expressing thoughts.
Problems with emotional or behavioral challenges.
Epilepsy (Seizures caused by abnormal electrical activity in the brain).
Problems such as joint deformities, muscle shortening, or bone abnormalities that develop over time.
Gastrointestinal disturbances
Sleep disorders
As the child grows, the symptoms of Cerebral Palsy may change and additional symptoms may appear. Muscle function and movement abilities may worsen over time, although the brain damage itself remains static and does not progress.
However, in some children, CP symptoms improve, easy to manage with therapy or disappear by around 2 years of age because the nervous system mature while the child grows.
Early signs of cerebral palsy
In 3–6 months old babies
The baby has difficulty holding the head steady.
Muscles feel tight or rigid.
The baby feels unusually loose or weak when held.
The baby bends the back backward frequently.
Legs may appear stiff or hard to move.
When the baby is lifted, the legs may cross like scissors, which is called scissoring.
More than 6 months old babies
The baby cannot roll from back to side or stomach, which normally develops around 4–6 months and the baby has difficulty controlling or coordinating arm and hand movements.
More than 10 months old Babies
Baby may crawl unevenly, drag one limb, and have difficulty standing, and many of these cases are associated with periventricular leukomalacia, a type of brain injury affecting movement control.
Causes
Cerebral palsy happens in children is because brain does not development properly and gets damage during early development process. These brain injury cause:
Damage to the brain’s white matter
Interruption of brain growth due to gene changes
Bleeding in the brain
Lack of oxygen (hypoxia)
Prenatal causes of Cerebral Palsy (before birth)
1. Infection and fever during pregnancy – Maternal infections can affect the developing fetal brain.
2. Metabolic disorders – Abnormality in the body’s chemical processes that may affect fetal brain development.
3. Intrauterine infection – Infection inside the uterus that can harm the fetus.
4. Chorioamnionitis – Infection of the fetal membranes (chorion and amnion) surrounding the baby.
5. Maternal ingestion of toxins – Exposure of the mother to harmful substances (drugs, chemicals, alcohol, etc.).
6. Preeclampsia – A pregnancy complication characterized by high blood pressure and organ stress, which can affect blood supply to the fetus.
7. Maternal trauma – Physical injury to the mother during pregnancy that may affect the fetus.
8. Exposure to methylmercury – Contact with toxic mercury compounds that can damage the fetal nervous system.
9. Genetic syndromes – Inherited genetic abnormalities affecting brain development.
10. Multiple pregnancies – Carrying twins or triplets, which increases the risk of complications.
11. Intrauterine Growth Restriction (IUGR) – The baby grows more slowly than normal in the uterus.
12. Fetal growth restriction – Poor fetal growth during pregnancy.
13. Placental abruption – The placenta separates from the uterus before birth, reducing oxygen supply to the fetus.
14. Failure of closure of the neural tube – A birth defect where the early nervous system does not close properly.
15. Schizencephaly – A rare brain malformation with abnormal clefts in the brain.
16. Chromosomal defects – Abnormalities in chromosomes that affect development.
17. Microcephaly – A condition where the baby’s head and brain are smaller than normal.
18. Rubella – A viral infection during pregnancy that can damage the developing fetus.
Perinatal cause of CP (around the time of birth delivery)
1. Obstructed labor – Labor in which the baby cannot pass through the birth canal normally, leading to prolonged delivery and possible oxygen deprivation.
2. Cord prolapses – The umbilical cord slips down before the baby during delivery, which can compress the cord and reduce oxygen supply to the baby.
3. Antepartum haemorrhage – Heavy bleeding from the mother before delivery, which may affect blood and oxygen supply to the foetus.
4. Metabolic acidosis – A condition in which excess acid accumulates in the baby’s blood, often due to lack of oxygen during labor.
5. Use of assisted reproductive technology (ART) – Techniques such as in vitro fertilization (IVF). These pregnancies sometimes have higher risks of complications like prematurity or multiple births.
6. Intrapartum hypoxia – Lack of oxygen to the baby during labor and delivery, which can damage brain cells.
Postnatal cause of CP (after birth)
1. Hypoglycaemia – Very low blood sugar in newborns, which can damage brain cells.
2. Jaundice – Yellowing of the skin and eyes due to high bilirubin levels. Severe cases may harm the brain.
3. Neonatal meningitis – Infection and inflammation of the membranes covering the brain and spinal cord in newborns.
4. Septicaemia – Severe bloodstream infection that can affect many organs including the brain.
5. Malaria – Malaria can affect the brain in severe cases.
6. Malaria with seizures – Severe malaria that causes seizures due to brain involvement.
7. Malaria with coma – A severe form called cerebral malaria where the child becomes unconscious.
8. Meningitis – Infection of the protective membranes of the brain and spinal cord.
9. Tuberculosis – A bacterial infection that can sometimes infect the brain (tuberculous meningitis).
10. Sickle cell disease – A genetic blood disorder that can cause strokes or brain injury.
11. HIV infection – Infection that can affect brain development and neurological function.
12. PVL (Periventricular Leukomalacia) – Damage to the white matter of the brain near the ventricles.
13. Congenital infections – Infections present at birth (for example toxoplasmosis or CMV).
14. Asphyxia – Lack of oxygen supply to the brain.
15. Hyperbilirubinemia – Very high bilirubin levels in newborns that may lead to brain damage (kernicterus).
16. Genetic causes – Inherited genetic mutations affecting brain development.
17. Neonatal stroke – Stroke occurring in a newborn that damages brain tissue.
Classification of Cerebral Palsy
There various types of classification such as
Classification based on the area of the body where muscle weakness or stiffness occurs. It shows whether one side of the body or multiple limbs are involved.
1. Quadriplegic CP
2. Hemiplegic CP
3. Diplegic CP
4. Monoplegic CP
Diplegic is the most common CP followed by hemiplegic and quadriplegic.
1. Quadriplegic CP
In quadriplegic CP, both hands and both legs are affected. In many codition, the hands are more severely affected than the legs.
This condition may occur because of serious brain problems such as:
Severe lack of oxygen before, during and after birth (acute hypoxic asphyxia)
Damage where brain tissue forms cyst-like spaces
Brain developmental abnormalities like Polymicrogyria and Schizencephaly. Polymicrogyria is abnormal development of the brain cortex with many small folds, and schizencephaly is abnormal clefts or splits in the brain.
Children with quadriplegic CP may show:
Very limited voluntary movement of arms and legs
Pseudobulbar signs – person suddenly starts to laugh or cry and can’t manage the reaction.
Accidental entry of food into the airways (aspiration)
Difficulty swallowing (dysphagia)
Optic atrophy – damage to the optic nerve affecting vision
Severe intellectual disability
2. Hemiplegic CP
In Hemiplegic CP, only one side if the body (either right or left leg and hand) is affected. In this condition, hands are more affected than the leg. The CP affected side shows increased muscle tone (spasticity) especially in flexor muscles, sensory abnormalities or reduced sensation on the affected side and seizures.
In affected leg, dorsiflexion (lifting the foot upward) and eversion (turning the foot outward) may be difficult. That can affect walking and balance.
3. Diplegic CP
In Diplegic cerebral palsy, both legs are mainly affected, while the arms are less affected. This type is commonly seen in premature babies. The most frequent brain abnormality associated with this condition is periventricular leukomalacia (PVL).
4. Monoplegic CP
In monoplegic Cerebral Palsy, only one limb is affected, usually one arm or one leg. It is the least common type of cerebral palsy and generally presents with mild symptoms.
Classification Based on location and severity of neurological symptoms.
1. Spasticity (stiff muscles)
spastic hemiplegia/hemiparesis
spastic diplegia/diparesis
Spastic quadriplegia/quadriparesis
2. Dyskinetic syndromes (writhing movements), and
3. Ataxia (poor balance and coordination)
4. Mixed CP
1. Spasticity
Spastic syndrome (spasticity) is most common and occurs when the areas of the brain and the nerve pathways that control movement are damaged. This damage cause muscles stiffness, tight, and difficult to control. This collagen buildup makes the muscles stiffer and less flexible, which affects the child’s motor abilities such as movement and coordination.
2. Dyskinetic CP
In Dyskinetic CP, children have involuntary and uncontrolled movements. There is slow writhing movements (athetosis) or jerky movements of the hands, feet, arms, and legs.
Muscles of the face and tongue may be overactive, which can cause grimacing (unusual facial expressions) and drooling. Children may have difficulty sitting upright or walking because they cannot control their muscle movements properly.
Some children may also have problems with hearing, breathing control and speech. Intelligence is usually normal, meaning cognitive ability is often not affected.
This type is also called choreoathetoid CP, where CP child has rapid, irregular, dance like muscle movements and slow writhing movements that leads to excess involuntary movements.
3. Ataxia
Ataxic accounts for 5-10% of CP and mainly affects balance and coordination. In this condition, children face difficulties in judging distance and maintaining body stability. Children often walk with their legs spread wide to maintain balance. They have difficulty in performing precise tasks, such as writing, buttoning a shirt, difficulty controlling voluntary movements, such as reaching or picking up objects.
Children with ataxic CP are often hypotonic, meaning their muscles have low tone and appear loose or floppy.
4. Mixed cerebral palsy
Mixed cerebral palsy occurs when a child shows symptoms of more than one type of cerebral palsy at the same time.
GMFCS, MACS, CFCS and EDACS
Evaluating the severity of motor disorders helps to understand how well the affected limb function, and how effective treatments and therapies might be. There are four system are used for this purpose which include:
- GMFCS – Gross Motor Function Classification System
- MACS – Manual Ability Classification System
- CFCS – Communication Function Classification System
- EDACS – Eating and Drinking Ability Classification System
1. GMFCS – Gross Motor Function Classification System
It determines how CP patients can sit, stand and walk.
GMFCS level 1
The child can walk without any assistive devices. Motor abilities are mostly normal, but some limitations may appear depending on age, such as difficulty with running or jumping.
GMFCS level 2
The child can walk independently, but there are limitations in speed, balance, and endurance. Walking long distances may be difficult, and the child may need assistive devices (handheld or wheeled) for longer distances.
GMFCS Level 3
The child can walk indoors using handheld mobility devices (such as walkers or crutches). Supervision is needed for stair climbing. For long distances, the child usually requires a wheelchair or wheeled mobility aid.
GMFCS level 4
The child has limited self-mobility. They can sit with support, but moving independently is very difficult. Transportation usually requires a manual or powered wheelchair.
GMFCS level 5
The child is dependent on others for mobility in all settings. They have difficulty maintaining posture against gravity (antigravity posture). Wheelchair use is necessary for transportation.
2. MACS – Manual Ability Classification System
MACS is used to evaluate how well children with cerebral palsy use their hands and arms in daily activities.
MACS level I
The child can handle objects easily and independently. There may be minor limitations in accuracy, but these do not affect daily activities.
MACS level II
The child can handle objects but with reduced speed and quality. The child may use alternative methods to perform tasks. However, the child can still complete daily activities independently.
MACS A child in MACS IV
The child can perform only simple activities, and even these require considerable effort. They usually need continuous assistance from caregivers. Specially adapted equipment may also be required to perform activities.
MACS V
Individuals in MACS V are dependent.
3. CFCS – Communication Function Classification System
It measures how effectively a person sends and receives messages with others.
CFCS level I
The person can communicate effectively and at a normal pace. They can send and receive information with both familiar and unfamiliar people
CFCS level II
Communication is slower than normal. The person can still communicate successfully with others.
CFCS level III
Communication is effective mainly with familiar people.
CFCS level IV
Communication with familiar people is inconsistent. The person may sometimes have difficulty expressing or understanding messages.
CFCS level V
The person cannot communicate effectively or consistently, even with familiar or unfamiliar people.
4. EDACS – Eating and Drinking Ability Classification System
It assesses how safely and efficiently a person can eat and drink.
EDACS level I
Children with CP can eat and drink safely and independently. They may have minor difficulty with very hard foods, but overall swallowing is safe.
EDACS In level II
Children with CP can eat and drink safely, but the speed of eating is slower. Sometimes coughing or choking may occur, especially if food is given too quickly.
EDACS In level III
CHildren have moderate difficulty swallowing. They usually cannot eat hard foods and require soft, mashed, or pureed food to eat safely.
EDACS IV
Significant swallowing problems are present.
Eating and drinking are not completely safe, and careful supervision or assistance is required.
EDACS V
The person cannot eat or drink safely by mouth. Tube feeding is usually required to provide nutrition.
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