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Cerebral Palsy

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Overview

Cerebral palsy (CP) is an umbrella term for non-progressive, permanent disorders of movement and posture-limiting activity. It is caused by damage in the developing brain during the prenatal, neonatal, or early infant period where neuronal connections are still developing.

CP may also have associated disorders including communication, behaviour, sensation, perception, and cognition, excess saliva production, and feeding and swallowing difficulties.

Epilepsy is also associated with CP. 

Epidemiology

  • In the UK, the prevalence of CP is around 3.5 per 1000 live births
  • Incidence rates are higher in resource-poor countries

Causes

Classification

Spastic cerebral palsy

Spastic cerebral palsy makes up around 80% of cases.

It occurs due to upper motor neurone damage.

  • Patients have increased tone and reflexes
  • Subtypes include monoplegia, hemiplegia, diplegia, quadriplegia

Dyskinetic (athetoid) cerebral palsy

Dyskinetic (or athetoid) cerebral palsy is characterised by hyperkinesia, resulting in involuntary, recurring, unusual, fidgety movements.

It occurs due to damage to the basal ganglia and substantia nigra.

  • Subtypes include dystonia, chorea, and athetosis

Ataxic cerebral palsy

Ataxic cerebral palsy describes the loss of muscle coordination.

It occurs due to damage to the cerebellum.

  • Many patients have cerebellar signs 

Mixed cerebral palsy

Most patients with CP have a specific motor disorder that predominates. Mixed CP is the term used to describe scenarios where there is no clear dominant motor disorder. 

Presentation

Early features

Features of cerebral palsy include:

  • Motor features:
    • Tone abnormalities – hypotonia (floppiness), spasticity (stiffness), dystonia (fluctuating tone)
    • Abnormal motor development – late head control, rolling, and crawling
    • Feeding difficulties
    • Asymmetry, paucity of movement, unusual fidgety movements
  • Delayed motor milestones (corrected for gestational age):
    • Not sitting by 8 months
    • Not walking by 18 months
    • Early hand preference before 1 year

Many children with CP have associated non-motor problems such as:

  • Learning difficulties
  • Epilepsy
  • Hearing impairment
  • Strabismus

Referral

Overview

All children with suspected CP should be referred to a child development service for a multidisciplinary assessment to allow for early diagnosis and management.

An MRI of the brain may be considered to investigate the underlying cause in a patient with CP if the cause is not clear from their history (e.g. hypoxic-ischaemic encephalopathy).

Management

Overview

Children are managed under a multidisciplinary team which often includes paediatricians, physiotherapists, occupational therapists, speech and language therapists, dietetics, and psychologists.

Muscle-strengthening exercises, botulinum toxin A, intrathecal baclofen, orthopaedic surgery and dorsal rhizotomy may be considered for spasticity. 

Complications

  • Feeding difficulties, drooling, aspiration, and aspiration pneumonia
  • Vomiting, regurgitation, and gastro-oesophageal reflux
  • Osteopenia and osteoporosis – due to reduced mobility
  • Chronic constipation – around 3 in 5 people with CP
  • Incontinence – due to impaired bladder muscle motor control
  • Complications relating to perception:
    • Visual impairment (e.g. strabismus) – around 1 in 2 people with CP
    • Hearing impairment –in 10 people with CP
  • Behavioural complications such as difficulties with learning and communication
  • Pain
  • Impaired quality of life, impaired social interaction and participation

Prognosis

  • CP is permanent but although it is non-progressive, it can cause functional and neurological problems over time (such as unequal growth)
  • The severity of CP can range from mild spasticity in one arm and leg to all four limbs being affected with reduced life expectancy.

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