WHAT IS CEREBRAL PALSY?

Cerebral (derived from the brain) palsy (weakness) is a condition where there is a persistent disorder of movement and posture that is due to a non-progressive defect or damaged area in the immature (prenatal period through age 4 years) brain.

Cerebral palsy is not a disease entity but a clinical condition that fulfils the above criteria.

Cerebral palsy may be accompanied by but does not cause other types of brain dysfunction such as intellectual disability, epilepsy, hearing impairment or visual impairment.

Although cerebral palsy is not a progressive disorder, the clinical picture often changes as the child grows older.

 

HOW COMMON IS CEREBRAL PALSY?

The incidence of cerebral palsy in the Western World is between 1.5 to 2.5 per 1000 of the population. The incidence is probably higher in developing countries.

TYPES OF CEREBRAL PALSY

  • Spastic, where there is weakness of voluntary movement and increased muscle stiffness. Spasticity may manifest in the limbs on one side (hemiplegia), in all four limbs but more so in the legs (diplegia) or in all four limbs but more so in the arms(tetraplegia)

  • Dyskinetic, where involuntary movements interfere with attempts at voluntary movement. Involuntary movements may take the form of
    • athetosis: slow writhing movements involving the extremeties
    • chorea:sudden jerky movements of the limbs, head and trunk
    • dystonia:rotatory or thrusting movements of the head, neck & trunk
    • ballismus:flinging movements of the limbs

  • Ataxic, where there is poor coordination of movement and unsteady gait
  • Atonic, where there is generalized floppiness

  • Mixed types

CAUSES OF CEREBRAL PALSY

In the prenatal period

  • disordered brain development
  • brain infection
  • blood clot or bleeding in the brain

During labour & delivery

  • poor supply of oxygen to the brain
  • brain injury

In the newborn and early childhood period

  • severe jaundice
  • non-accidental injury/physical abuse
  • toxins e.g. lead
  • brain infection
  • blood clot or bleeding in the brain

HOW DOES CEREBRAL PALSY PRESENT?

  • Delay in motor development
  • Preference for use of one arm in the first year of life
  • Dragging one leg when walking
  • Poor growth of limbs on one side
  • Incidental finding on examination when a child presents with another neurological problem e.g. epileptic seizures

HOW IS CEREBRAL PALSY DIAGNOSED?

Taking  a thorough clinical history

Performing a complete physical examination

Doing appropriate laboratory tests such as blood tests and brain imaging

COMMON CONDITIONS THAT ACCOMPANY CEREBRAL PALSY

Squint ('cast eyes')

Hearing impairment

Intellectual disability

Epileptic seizures

SOME OTHER IMPORTANT FACTS

Children with dyskinetic cerebral palsy often have normal intelligence

Hearing assessment should always be performed in children with cerebral palsy who are also delayed in language development

Children with spastic tetraplegia often have problems with swallowing and run the risk of aspiration of foodstuff into the lungs

COMMON COMPLICATIONS OF CEREBRAL PALSY

Poor growth

Muscle, bone & joint: deformity of limbs; scoliosis (curvature of the spine); dislocation of hips

Digestive tract: constipation; gastro-esophageal reflux

Lungs: pneumonia

Skin: pressure ulcers

HOW IS CEREBRAL PALSY MANAGED?

The aim of treatment in cerebral palsy is to maximize mobility and prevent the development of fixed deformity. It is not only directed to the motor disability but also to the other types of brain disorder that may accompany it. Treatment will not result in a ‘cure’ since the brain defect or damage cannot be reversed.

Treatment involves a number of disciplines working together as a team. The team leader is usually the paediatrician who monitors growth, development, nutrition and immunization; gives anticipatory guidance and manages complications.

DISCIPLINES INVOLVED IN MANAGEMENT OF CEREBRAL PALSY

Early Intervention: a program of activities intended to stimulate the child to advance to the next expected level of development 

Physiotherapy: physical treatment such as stretching, splinting, and positioning to preserve and improve muscle function and prevent deformity

Occupational therapy: training in fine motor skills e.g. self-feeding, holding a pencil

Audiology: assessment of hearing ability; provision of hearing aids

Ophthalmology: assessment of visual function; correction of squint (‘cast eye’);

Nutritionist: advice about diet

Speech therapy: training in speech production; control of drooling; teaching of feeding techniques

Paediatric neurology: drugs to relieve spasticity; management of other disorders of brain function e.g. seizures

Orthopaedic surgery: tendon release; tendon transfer; surgery for scoliosis

Paediatric surgery: placement of a feeding tube in the stomach (gastrostomy)

Neurosurgery: Insertion of a reservoir containing a muscle relaxant drug (Baclofen) into the spinal fluid space or selective cutting of nerve roots entering the spinal cord (dorsal rhizotomy), for relief of spasticity

Physical medicine: Injection of Phenol into nerves and Botox into muscles to relieve spasticity

Social Worker: facilitation of day care services, health insurance, access to equipment for disabled persons & financial assistance

WHAT IS THE OUTLOOK FOR WALKING IN CHILDREN WITH CEREBRAL PALSY?

Children with cerebral palsy are very likely to walk independently if they develop head control before age 9 months and sit up without support before age 24 months.