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Cerebral palsy (CP)

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Cerebral palsy (CP) is a nonprogressive lesion of the brain that occurs prior to the age of two and results in a disorder of posture and voluntary movement. It may also impair speech, vision, hearing, and perceptual function[1].


Contents

Incidence and Prevalence

Nearly 800,000 children and adults in the United States have one or more symptoms of CP. Each year about 10,000 babies in the United States will develop cerebral palsy[2].


Causes

Cerebral palsy is generally caused by hypoxia, or lack of oxygen to the brain, and can develop at three different stages of life: while in the womb (prenatal or congenital), during birth, or after birth up to two years of age (postnatal or acquired).

  • Prenatal (Congenital)
Cerebral palsy can be caused by genetic disorders, congential malformations of the brain, intracranial hemorrhage, and infections while in the womb. Risk factors include mothers with rubella, herpes, or with thyroid abnormalities, or those who are exposed to toxic substances while pregnant [2].
  • Birth
Babies are more likely to develop CP if they are born prematurely, they present as a breech birth, or in the case of multiple births[3].
  • Postnatal (Acquired)
Cerebral palsy can also develop after a baby is born. Erythroblastosis, encephalitis, or a head injury can result in CP[3].


Pathophysiology

Cerebral palsy is a permanent but static lesion in the cerebral motor cortex of the brain. This means that the disorder will always be present but will not get worse. CP is an injury to the upper motor neurons, which decreases the brain signals sent to the spinal cord. This affects muscle control, decreases the number of effective motor units, and produces abnormal muscle control and weakness. It can also increase the excitability of the gamma and alpha neurons, which causes spasticity[4].


Types of CP

  • Spastic CP comprises approximately 65% of all cases of cerebral palsy. It is generally a corticospinal system lesion in the cerebral motor cortex, which results in stiff and difficult movement.
  • Athetoid CP accounts for about 20% of cerebral palsy cases. The brain injury usually occurs in the extrapyramidal system in the basal ganglia. This results in uncoordinated movements.
  • Ataxic CP is caused by a cerebellar or brain stem lesion and is about 5% of cases. This is characterized by disturbed balance and shaky hands.

About 10% of cases are classified as “other,” with mixed symptoms resulting from multiple brain lesions, or rare movement disorders such as tremors, rigidity, or atonia[3].


Levels of Involvement

Levels of CP
Levels of CP

There are different levels of involvement on cerebral palsy, which are determined by the location of the lesion as well as its size or extent.

  • Monoplegia occurs when only one limb is affected. This type of CP is rare.
  • Hemiplegia accounts for 35-50% of CP cases. This is when both limbs on the same side of the body are affected.
  • Paraplegia or diplegia occurs when both lower limbs are affected and accounts for 10-20% of cerebral palsy cases.
  • Triplegia is rare. Three limbs are affected in this case.
  • Quadriplegia or tetraplegia occurs when there is involvement with all four limbs. It is the most severe type of cerebral palsy and accounts for 15-20% of cases[3].


Signs and Symptoms

Normal developmental milestones for babies. Failure to achieve these can be a sign of cerebral palsy.
Normal developmental milestones for babies. Failure to achieve these can be a sign of cerebral palsy.

Cerebral palsy is not clinically obvious in the first few months of life. CP can be suspected when infants fail to achieve normal developmental milestones, when abnormal muscle tone is present, or when primitive reflexes linger longer than they should. Clinical manifestations may include:

  • Paralysis or paresis (weakness) of voluntary movement patterns
  • Increased muscle tone or tight muscles (spasticity)
  • Lack of muscle coordination
  • Scissors or crouch gait
  • Cognitive impairments[2][3].

Treatment

Because there are so many types and levels of cerebral palsy, treatment plans are individualized to the patient. Some people with CP may not require any treatment at all, while some may require different kinds of treatment to allay their symptoms. Treatment options include:

Pharmacological treatment

In order to reduce spasticity, Botulinum-A toxin injections can be administered directly to the spastic muscles. Skeletal muscle relaxants such as baclofen, diazepam, and dantrolene can be administered orally or intrathecally to help reduce muscular tone and spasticity[3].

Physical therapy and occupational therapy

Physical therapy is commonly needed to improve gait and to stretch muscles to prevent contractures, or deformities. Additionally, occupational therapy is used to develop motor skills used for everyday activities, such as eating, bathing, and going to school[2].

Surgical management

Children with CP often develop contractures, or deformities, of their arms and legs due to spasticity and tight muscles. Surgery can be performed to release tight muscle groups and correct the contractures, including tendon lengthening (commonly of the Achilles tendon and hamstrings tendons), tendon transfer (commonly of the tibialis posterior and flexor carpi ulnaris), and arthodesis (joint fusion, commonly done in the three posterior foot joints). Additionally, a selective dorsal rhizotomy can be performed for severe spasticity cases[3].

Orthotic treatment

People with cerebral palsy often have difficulty walking due to decreased motor control. Orthoses can be used to improve stability and alignment, provide corrective forces to assist in walking, and provide rigid support. Orthoses can also be used for non-ambulatory patients for positioning to prevent the development of contractures. Commonly used orthoses for patients with CP include:

  • Supramalleolear orthoses (SMOs)
  • Ankle-foot orthoses (AFOs), including solid-ankle AFOs and floor-reaction AFOs
  • Knee-ankle-foot orthoses (KAFOs)
  • Hip-knee-ankle-foot orthoses (HKAFOs)
  • Parapodiums or standing frames
  • Hip abduction orthoses
  • Wrist-hand orthoses (WHOs)

Additionally, cerebral palsy can require the use of a wheelchair, walker, or crutches for stability.


Prognosis

Many children with mild to moderate cerebral palsy go on to have near-normal lifespans. There is an increased mortality rate under the age of four and over the age of 50 compared to people who do not have CP[1]. However, they are more likely to have comorbidities, including hypertension, incontinence, scoliosis, bone fractures, and vision and hearing problems [1]. Those with severe cerebral palsy often have shortened lifespans due to increased stress on the body causing premature aging. With proper treatment, people with CP can have a high quality of life.


References

  1. 1.0 1.1 1.2 Goodman CC, Boissonnault WG, Fuller KS. Pathology: Implications for the Physical Therapist, 3rd ed. Philadelphia: Saunders Company; 2009.
  2. 2.0 2.1 2.2 2.3 National Institute of Neurological Disorders and Stroke. Cerebral Palsy: Hope Through Research, 2010. Available at: http://www.ninds.nih.gov/disorders/cerebral_palsy/detail_cerebral_palsy.htm#154443104. Retrieved November 30, 2011.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Salter RB. Textbook of Disorders and Injuries to the Musculoskeletal System, 3rd ed. Baltimore: Lippincott Williams & Wilkins; 1999.
  4. Koman LA, Smith BP, Shilt JS. Cerebral Palsy. The Lancet 2004;363;1619-1631.


External Links

United Cerebral Palsy