Cerebral Palsy

Based on the affected part of the brain, cerebral palsy is of four types:

1. Spastic cerebral palsy
2. Dyskinetic cerebral palsy
3. Ataxic cerebral palsy
4. Hypotonic cerebral palsy

Most people experience a combination of the above types. Also, the effects of different types become apparent as the child grows and begins to perform basic functions such as walking.

The symptoms of cerebral palsy are different in different individuals. In some cases, it may affect the whole body, while in others, it may be limited to a limb or two. General symptoms are:

• Problems with movement and coordination
• Stiff muscles and exaggerated reflexes, known as spasticity
• Variations in muscle tone - stiffness or floppiness
• Rigid muscles with normal reflexes
• Lack of balance and muscle coordination, known as ataxia
• Tremors or jerky involuntary movements
• Difficulty walking, such as a scissors-like gait with knees crossing, walking on toes, a crouched gait, a wide gait or an asymmetrical gait.
• Slow, writhing movements
• Favouring one side of the body, for example, only reaching with a single hand or dragging a leg while crawling
• Difficulty with fine motor skills, for example, buttoning clothes or picking up utensils.
• Speech and eating-related issues
• Delays in speech development
• Difficulty speaking
• Difficulty with chewing, eating or sucking
• Excessive drooling or problems with swallowing
• Developmental issues
• Delays in reaching motor skills milestones, like sitting or crawling
• Intellectual disabilities
• Learning difficulties
• Delayed growth, causing smaller size than would be expected
• Other problems
• Seizures (epilepsy)
• Abnormal pain sensations
• Bladder and bowel problems like urinary incontinence
• Constipation
• Abnormal touch sensations
• Difficulty hearing
• Problems with vision and abnormal eye movements
• Mental health problems like emotional and behavioural problems

Cerebral palsy does not improve with age but rather worsens. However, with growing age, some symptoms become less apparent. On the other hand, muscle rigidity and shortening can worsen if not treated on time.

Cerebral palsy develops due to abnormal brain development, injury, or damage to a developing brain. The damage usually occurs when the baby is not born but may also occur at the time of birth or early infancy. The main cause of the disorder is not known. However, some factors that may contribute include:

• Gene mutations: These result in genetic anomalies or differences in brain development.
• Maternal infections: Many infections the pregnant mother suffers may be transmitted to the developing foetus and cause damage to the brain. This damage may develop cerebral palsy.
• Foetal stroke: This condition causes an obstruction of blood supply to the developing brain that damages it.
• Bleeding into the brain: Sometimes, an internal haemorrhage in the womb or in a newborn baby damages the brain and leads to cerebral palsy.
• Infant infections: Some infections occurring in infants may cause inflammation in or around the brain, thereby damaging it.
• A traumatic head injury: Traumatic injuries to an infant, such as from a fall or physical abuse, or a motor vehicle accident, may lead to the development of cerebral palsy.
• Lack of oxygen to the brain may occur during difficult labour or delivery. However, this is a lot less common nowadays.

The symptoms of cerebral palsy take time to develop and may not be apparent until a few months to a year after birth. Hence, it takes time for the condition to be diagnosed. Diagnosis may be delayed due to mild signs and symptoms in some cases.

If the paediatrician suspects cerebral palsy, they may evaluate the child's symptoms and monitor their growth and development. Further, they review the child's medical history and conduct a physical examination. Finally, they may refer to a specialist, such as paediatric physical medicine and rehabilitation specialist, paediatric neurologist, and child developmental specialist if indicated.

They may also advise some tests to confirm the diagnosis and to rule out other causes of the symptoms. Some scans include:

• Imaging of the brain such as MRI, cranial ultrasound, and EEG.
• Laboratory tests such as genetic and metabolism testing
• Additional tests to assess issues with vision, hearing, speech, intellect, development, growth and movement.

Patients with cerebral palsy require lifelong care with a medical care team. The medical team comprises a paediatrician, neurologist, physical medicine and rehabilitation specialist, and mental health specialist.

It is imperative to understand that there is no cure for cerebral palsy. However, treatment can help improve the quality of life. Different treatment modalities help children perform daily activities with ease and include therapies, medications, surgical procedures, and other necessary treatments.

Cerebral palsy can contribute to numerous muscle and coordination complications during childhood and adulthood, which include:

• Contracture: Contracture is the shortening of muscle tissue due to severe muscle tightening. This occurs due to spasticity. This may lead to the inhibition of bone growth, bone bending, joint deformities, and complete or partial dislocation of bones.
• Malnutrition: Malnutrition may occur due to swallowing difficulties, especially in infants. People with cerebral palsy often fail to receive adequate nutrition, which further impairs muscle and bone growth. A feeding tube may be needed in some severe cases to facilitate feeding.
• Mental health conditions: Individuals with cerebral palsy may experience anxiety and depression. In addition, social isolation and difficulty in coping with disabilities can also contribute to depression and cause behavioural issues.
•  Heart and lung disease: Individuals with cerebral palsy may develop breathing, heart, and lung disorders, in addition to problems with swallowing that may lead to respiratory problems, like aspiration pneumonia.
• Osteoarthritis: Increased pressure on the joints or abnormal alignment of joints with an increase in age and weight may lead to the early onset of osteoarthritis.
• Osteoporosis: Bone fractures are common due to reduced bone density. Other contributing factors include inadequate nutrition, mobility, and anti-epileptic drug use.
• Other complications: Some other associated complications include sleep disorders, skin and intestinal problems, chronic pain, and issues with oral health.

Numerous risk factors are associated with cerebral palsy. These include:

• Maternal health: If pregnant women are infected, they may transmit the disease or medicines to the foetus that may damage the brain.
• Viral infections
• Cytomegalovirus
• German measles (rubella)
• Herpes
• Syphilis
• Toxoplasmosis
• Zika virus infection
• Intrauterine infections
• Exposure to toxins such as methylmercury.
• Other conditions: Other conditions such as thyroid, seizures, and preeclampsia may lead to cerebral palsy.
• Infant illness
• Bacterial meningitis
• Viral encephalitis
• Severe or untreated jaundice
• Bleeding into the brain
• Factors of pregnancy and birth
• Low birth weight
• Multiple babies: Having multiple children at once can increase the risk of cerebral palsy. It also adds to the risk of premature birth and preterm low birth weight. In addition, if one of the babies dies, the survivor's risk of cerebral palsy increases.
• Premature birth in babies carries a higher risk of developing cerebral palsy.
• Delivery complications increase the risk of the foetus developing cerebral palsy.

Reviewed by Dr. Mukesh Kumar, Associate Director and Head (Parkinson's Disease Unit), Neurosciences, Neurology on 23-Jan-2023.