General

Infants are slow to start normal activities like sitting up, crawling, smiling or walking. They may favour one side when sitting up or maintain an abnormal posture. Their limbs may appear to be stiff and the child while growing up may seem excessively clumsy. While in some cases, the child may seem excessively floppy with flaccid, low toned muscles. Movements may be uncoordinated.

Eyes

42% of children suffering from CP have visual defects.

Musculoskeletal

Contractures may occur, especially in spastic CP. There may be dysarthria. The muscles are either hypertonic or hypotonic, or sometimes both. Bones are thin and weak, with the metaphyses appearing to be wide and ballooning while the diaphysis appear to be very narrow. Joint deformities may also occur. Stature is short due to improper bone development.

Neurological

Seizures, with or without epilepsy are common, occurring in about 28% of cases. 31-88% children suffer from speech defects due to hypertonia or hypotonia of muscles of the larynx, respiratory tree and oro-facial muscle defects. Children are both unable to articulate well, due to muscle abnormality as well as unable to learn the language in time due to mental impairment.

Psychiatrical

Mental impairment is present and the child has great difficulty in learning and performing simple activities like holding a pencil, catching a ball, etc in 23-56% of cases. This may lead to depression while growing up.

Systemic

Urinary and fecal incontinence may be present.

Complications

Complications are very rare since the disease is non progressive. However, some include:

• Breathing problems due to respiratory muscle involvement
• Persistent pain due to bone and joint deformities
• Severe seizures and epileptic fits
• Motor dysfunction leading to trauma
• Severe deformity

• Disability

  AIM: A population-based observational study design was used to describe the epidemiology of intellectual disability in cerebral palsy (CP) in terms of clinical and neuroimaging associations, and to report the impact of intellectual disability on utilization [ncbi.nlm.nih.gov]

  […] people with disabilities [ 17 ]. [doi.org]

  A person can have impairment without having a disability. Is Cerebral Palsy a disability? Sometimes. [cerebralpalsy.org]

  You may also qualify for free or reduced child care under the Americans With Disabilities Act (ADA) or educational assistance under the Individuals with Disabilities Act of 2004. [cerebralpalsyguidance.com]

  All disabled people are impaired, and all handicapped people are disabled, but a person can be impaired and not necessarily be disabled, and a person can be disabled without being handicapped.[160] The term "spastic" denotes the attribute of spasticity [en.wikipedia.org]

• Pain

  We review, briefly, what is known about chronic pain in CP and present what we need to know with respect to the neurobiology of pain and new developments in pain treatment research that might be applied to CP. [ncbi.nlm.nih.gov]

  The tools were intended to determine if a child had chronic pain (Body Diagram, Noncommunicating Children’s Pain Checklist-Revised [NCCPC-R], Pediatric Pain Questionnaire [PPQ]), track pain over time (Bath Adolescent Pain Questionnaire [BAPQ], Child Activity [doi.org]

• Epilepsy

  We describe the first clinical case with a 1.607 Mb duplication at 3q29 (chr3: 195,731,956-197,339,329), accompanied by severe intellectual disability, epilepsy, and cerebral palsy. [ncbi.nlm.nih.gov]

  A large proportion has some kind of cognitive impairment; the prevalence varies with the type of CP and especially increases when epilepsy is present. Epilepsy is present in 20 – 40%; it is most common among the hemi- and tetraplegics. [doi.org]

• Difficulty Walking

  They can also have difficulty speaking, poor reflexes, and walking abnormalities. Ataxic cerebral palsy Ataxic CP is the least common type of CP. [healthline.com]

  People with cerebral palsy may have difficulty walking. They may also have trouble with tasks such as writing or using scissors. Some have other medical conditions, including seizure disorders or mental impairment. [medlineplus.gov]

  The most common symptoms include: Seizures Stiffness of the arms and/or legs Difficulty walking Developmental delays Proper nutrition is highly important for children with cerebral palsy. [rileychildrens.org]

  Each of them were having difficulty walking, with their knees starting to slope inwards. But a video of them walking in the exoskeleton suit showed noticeable improvements. [dailymail.co.uk]

• Underweight

  RESULTS: Poor nutritional status was common: 65% of children aged under 5 years were categorized as underweight, 54% as stunted, and 58% as wasted. [ncbi.nlm.nih.gov]

  The risk is highest in premature and underweight babies. [medbroadcast.com]

  José Bellver and Giulia Mariani, Impact of parental over- and underweight on the health of offspring, Fertility and Sterility, 10.1016/j.fertnstert.2019.02.128, (2019). [doi.org]

  If medical therapy is not successful or, despite optimal treatment of reflux, the child remains underweight, surgical procedures may be necessary. [medicalhomeportal.org]

• Failure to Thrive

  The individual had a history of failure to thrive, bowel and bladder incontinence, reduced bone mineral density (BMD) for age, and spinal deformity at the time exercise was initiated. [ncbi.nlm.nih.gov]

  […] to thrive Decreased ability to feel pain or identify items by touch Problems with bowel and bladder control Skin breakdown Low bone density and fractures Diagnosis and Treatment at UVA If you suspect that your child has CP, we will test your child’s [childrens.uvahealth.com]

  Other associated problems include: Eating, drinking and swallowing difficulties and poor nutrition: failure to thrive and malnourishment. Bladder problems: incontinence and infections are common. [patient.info]

  Definite hand preference before age 1 year: A "red flag" for possible hemiplegia Asymmetrical crawling or failure to crawl Growth disturbance, especially failure to thrive Increased reflexes: Indicating the presence of an upper motor neuron lesion; this [emedicine.medscape.com]

• Malocclusion

  We looked for a possible association between overall functional impairment and malocclusion in this population. [ncbi.nlm.nih.gov]

• Hearing Impairment

  Although the main focus is commonly the motor disorder, medical management also encompasses far wider issues including the management of multiple co-morbidities (e.g. epilepsy, visual and hearing impairment, gastro-oesophageal reflux and constipation, [discovery.ucl.ac.uk]

  Some children with CP also have coexisting conditions, such as vision and hearing impairment. These disorders are caused by brain damage and are not a direct result of one’s cerebral palsy. Cerebral palsy does not generally affect life expectancy. [cerebralpalsyguide.com]

  Because children with CP may have associated deficits of mental retardation, ophthalmologic and hearing impairments, speech and language disorders, and oral-motor dysfunction, screening for these conditions should be part of the initial assessment (Level [ncbi.nlm.nih.gov]

  For vision and hearing impairments, there was a lack of consistency in coding of impairments between authors and registries, as some authors used the term “some impairment.” [doi.org]

• Strabismus

  Strabismus and other visual defects may occur. Children with athetosis due to kernicterus commonly have nerve deafness and upward gaze paralysis. [merckmanuals.com]

  Vision problems: An ophthalmologist is consulted for children who have strabismus and visual problems. Medical therapy: This encompasses treatment for all medical problems whether related to CP or not. [emedicinehealth.com]

  • Although characterized by their motor dysfunction, children with cerebral palsy frequently have other associated impairments, which include language delay, seizures, strabismus, dysphagia, orthopedic deformities, and cognitive problems. • Advances [medlink.com]

• Esotropia

  Kolling, Best age for surgery for infantile esotropia, European Journal of Paediatric Neurology, 15, 3, (205), (2011). [doi.org]

• Muscle Spasticity

  RESULTS: Significant changes were observed in the children's gross motor function and muscle spasticity, as evidenced by the GMFM-88 total score, scores for each of its domains, the GMFM-66 percentile and the muscle tone (P CONCLUSION: The QOL of the [ncbi.nlm.nih.gov]

  Stiff muscles (hypertonia) are managed with oral medications, botulinum toxin (Botox) injections, and alcohol nerve blocks. We aim to minimize muscle spasticity and improve range of motion and mobility. [columbiadoctors.org]

  Anti-cholinergic drugs to treat involuntary movements, drugs like diazepam to help with muscle spasticity, etc can be administered. Physical therapy is very useful in case of with muscle spasticity/flaccidity. [symptoma.com]

  Newman and Francis Degache, Walking-induced muscle fatigue impairs postural control in adolescents with unilateral spastic cerebral palsy, Research in Developmental Disabilities, 53-54, (11), (2016). Laura Kristine Brunton and Charles L. [doi.org]

  Complications Muscle weakness, muscle spasticity and coordination problems can contribute to a number of complications either during childhood or in adulthood, including: Contracture. [mayoclinic.org]

• Scissoring Gait

  The most common are a lack of muscle coordination when performing voluntary movements (ataxia); stiff or tight muscles and exaggerated reflexes (spasticity); walking with one foot or leg dragging; walking on the toes, a crouched gait, or a “scissored” [ninds.nih.gov]

  Physical indicators of spastic cerebral palsy include spastic paresis of multiple limbs and joint contractures, scissors gait, and persistence of primitive reflexes. [amboss.com]

  A scissors gait and toe walking are typical. In mild cases, impairment may occur only during certain activities (eg, running). [merckmanuals.com]

  The affected individuals have a wide, staggering gait, known as the scissors gait. Ataxic cerebral palsy In this type, instead of muscle rigidity and stiffness, hypotonia is present. Tremors are also found. [symptoma.com]

• Abnormal Behavior

  The findings were: (1) behavior (818 cases for analysis): 26% (95% CI: 24–28) had abnormal behavior (the rate and CI were from Parkes et al 22 because new CIs were unable to be calculated because only 1 study met inclusion criteria); (2) bladder and bowel [doi.org]

  Babies with abnormal organs or abnormal behaviors may also have CP. A variety of tests, such as an ultrasound test, can be used to diagnose these problems. [encyclopedia.com]

• Withdrawn

  Levels of requests were maintained for four weeks after therapy had been withdrawn. Sigafoos 1995 aimed to teach a boy to use three requests for objects in a multiple baseline design. [doi.org]

• Tremor

  […] development milestones – for example, not sitting by eight months or not walking by 18 months seeming too stiff or too floppy (hypotonia) weak arms or legs fidgety, jerky or clumsy movements random, uncontrolled movements muscle spasms shaking hands (tremors [web.archive.org]

  He had nystagmus and psychomotor delay since infancy and tremor with ataxia developing gradually. Brain MRI revealed demyelination over white matter of the cerebral hemispheres and posterior limbs of the internal capsules. [ncbi.nlm.nih.gov]

  (intention tremor), 5) staggering, wide based walking (ataxic gait), 6) tendency toward falling, 7) weak muscles (hypotonia), 8) slurred speech (ataxic dysarthria), and 9) abnormal eye movements (nystagmus). [neuroskills.com]

• Ataxia

  BACKGROUND: Ataxia-telangiectasia (A-T) is an autosomal recessive disease that consists of progressive cerebellar ataxia, variable immunodeficiency, sinopulmonary infections, oculocutaneous telangiectasia, radiosensitivity, early aging, and increased [ncbi.nlm.nih.gov]

  Cerebral palsy is a syndrome (not a specific disorder) that involves nonprogressive spasticity, ataxia, and/or involuntary movements. [merckmanuals.com]

  Ataxia is associated with cerebellar lesions. Ataxia is often combined with spastic diplegia. Most ataxic children can walk but some need walkers. [physio-pedia.com]

• Dystonia

  We rated the GRADE quality of the evidence as low.We found no difference in mean follow-up scores for change in dystonia as measured by the Barry Albright Dystonia Scale (BADS), which assesses eight body regions for dystonia on a 5-point scale (0 = none [ncbi.nlm.nih.gov]

• Cognitive Impairment

  This approach has been highly productive in regard of the establishment of spastic CP as a disorder that often involves cognitive difficulties and other impairments along with the motor impairments. [pure.au.dk]

  Dependent on the subgroup of CP, 25-80% have additional impairments. A large proportion has some kind of cognitive impairment; the prevalence varies with the type of CP and especially increases when epilepsy is present. [ncbi.nlm.nih.gov]

  Dependent on the subgroup of CP, 25 – 80% have additional impairments. A large proportion has some kind of cognitive impairment; the prevalence varies with the type of CP and especially increases when epilepsy is present. [doi.org]

• Dysarthria

  Children affected with athetoid cerebral palsy may be perceptive and intelligent; however, because of the involuntary movements and dysarthria, they are often unable to communicate by intelligible words or signs. [britannica.com]

  This study describes the use of a neuroplasticity-principled speech treatment approach (LSVT(®)LOUD) with children who have dysarthria secondary to cerebral palsy. [ncbi.nlm.nih.gov]

  Dysarthria occurs and is often severe. Ataxic syndromes occur in 5% of cases and result from involvement of the cerebellum or its pathways. [merckmanuals.com]

  Patients with non- spastic cerebral palsy present with dysarthria and abnormal involuntary movements (choreoathetoid, dystonic, or ataxic ) that worsen with stress. Seizure disorders and intellectual disability are associated with all types. [amboss.com]

  Dysarthria occurs and is often severe. Ataxic syndromes occur in < 5% of cases and result from involvement of the cerebellum or its pathways. [msdmanuals.com]

A definite test for cerebral palsy does not exist. Diagnosis is made based on the history and physical examination of the motor system [6]. A CT scan and an MRI may be performed to check for CNS abnormalities [5].

There is no cure for this disease. However, treatment helps improve the quality of life. Anti-convulsant drugs to prevent fits may be given. Anti-cholinergic drugs to treat involuntary movements, drugs like diazepam to help with muscle spasticity, etc can be administered [8].

Physical therapy is very useful in case of with muscle spasticity/flaccidity. Special exercises are performed by affected children that help improve motor coordination [10]. Speech therapy is undertaken to help the child to articulate better. It helps both in overcoming learning disabilities as well as speaking. Surgical intervention is needed to treat any bone or joint deformity, if present as well as muscle contractures.

Counselling is also a very important part if treatment as it helps the family understand how to support the affected child in the best way.

This disease is non progressive, so the symptoms do not worsen over time. With the right guidance and counselling, parents are able to help and support their child suffering from this disease.

Cerebral palsy occurs due to abnormalities in the developing brain. These abnormalities lie in the motor cortex hence the resulting motor dysfunction.

Structural defects

80% of CP are due to structural defects that occur in intrauterine life or due to hypoxia occurring during obstructed or difficult labor. These structural abnormalities occur mostly in the white matter and are of unknown cause.

Genetics

About 2% of cerebral palsy cases are due to genetic abnormalities which are either inherited (rare) or occur due to acquired mutations. No particular gene has been isolated as the sole culprit yet. However, it is believed that defects or deficiency in the enzyme glutamate carboxylase-1 may be involved. In inherited cases, the pattern of inheritance is autosomal recessive.

Causative factors

• Prematurity

Premature infants are at a much higher risk of developing CP. Around 40-50% infants born premature develop the disease. Out of these, 70-90% cases are due to abnormalities occurring in intrauterine life. In infants born before the 28th gestational week, chances of developing CP are as high as 11% [2].

• Birth weight

Infants with a low birth weight are more at risk [4]. Neonates having a birth weight of only 1-1.5 Kg, or less than 3.3 pounds, have a 6% chance of becoming a victim of cerebral palsy [1].

• Trauma

Trauma of the neonate, during or after labor and delivery may result in brain damage, either due to direct trauma, or due to other causes like hypoxia, exposure to toxins, etc. this may lead to CP.

• Rh-Incompatibility

Rh factor incompatibility between mother and her baby may result in excessive hemolysis leading to hypoxia and this brain injury.

• Others

Other causes include obstructed labor, complications during delivery, exposure to radiation, teratogens, lead poisoning, severe infections during pregnancy, severe jaundice, meningitis, etc.

Race

Black infants and children are at a higher risk of developing cerebral palsy than white infants. This may be attributed to a low level of maternal health care and low socioeconomic status in most black countries [7].

Age

Incidence is much higher in preterm than term infants. Majority of the cases occur at birth, however, some preterm infants may develop CP between 3-5 years of age [3].

Sex

Cerebral palsy is much more common in males.

Incidence

Studies reveal that 2.1 to 4 out of every 1,000 individuals in the United States suffer from Cerebral Palsy. It is estimated than more than 764,000 people suffer from Cerebral Palsy currently in the US. Around 8,000-10,000 children are likely to develop this disease every year.

Cerebral palsy occurs due to structural or genetic defects leading to abnormalities in the white matter of the motor cortex which results in motor dysfunction [2]. The type of palsy present is classified according to the degree and type of motor impairment present.

Spastic cerebral palsy

This is by far the most common type of cerebral palsy accounting for around 70% of cases. It presents with stiff or spastic muscles. Lower limbs are mostly involved, resulting in diplegia or just single leg paralysis. Upper limbs may also be involved, along with the leg of that side resulting in hemiplegia. In severe cases, both arms and legs may be spastic, making the patient quadriplegic. The affected individuals have a wide, staggering gait, known as the scissors gait.

Ataxic cerebral palsy

In this type, instead of muscle rigidity and stiffness, hypotonia is present. Tremors are also found. Visual and auditory functioning is commonly disturbed. Since in this type, the abnormality lies mainly in the cerebellum, patients present with movement and balance discoordination, unstable gait, writing and speech disabilities. It occurs in 5-10% of cases.

Dyskinetic or athetoid cerebral palsy

10% of cases of CP are of this type. In this type, the defect occurs in the pyramidal or extra pyramidal tracts and the basal ganglia may also be involved. Affected individuals have both hypertonia and hypotonia resulting in complete inability of fine motor movements. They are unable to maintain their posture or complete simple movements such as holding or touching a certain object.

Mixed cerebral palsy

This is the most rare type and is a heterogeneous combination of all three subtypes: Spastic, ataxic and athetoid cerebral palsies. Diagnosis is exceedingly difficult as symptoms vary greatly.

• Early treatment with magnesium sulphate in high risk preterm infants may prove to be beneficial in preventing cerebral palsy.
• Full term babies that are at high risk may be protected from disabilities by cooling them immediately after birth.
• Maintaining a healthy nutritional diet during pregnancy.
• Managing maternal hypertension and/or diabetes.
• Managing anemia.
• Avoiding alcohol intake and smoking during pregnancy.
• Avoiding exposure to harmful radiation, chemicals and intake of illegal drugs.

Cerebral palsy (CP) is a group of motor defects that result in movement disabilities along with other symptoms. The word cerebral denotes an abnormality in the cerebrum of the brain and the word palsy refers to weakness or paralysis of a group of muscles.

So due to an abnormality in the part of the brain that controls motor activity of the body, movement disorders occur. Patients with this condition suffer from immobility or difficulty in walking with an uneven gait, uncoordinated and disjointed movements, involuntary, spastic motions as well as speech and visual defects. Mental impairment and low IQs may be present.

Cerebral palsy mostly occurs at birth, but in some cases, it may develop in children between 3-5 years of age. The disease is non progressive, but unfortunately, it does not have a cure.

Definition

Cerebral palsy is a group of motor defects that are due to structural abnormalities in the brain occurring either before birth, or after birth up to around 5 years of age.

Cause

It is due to structural abnormalities in the part of the brain that controls movements and coordination.

Signs and symptoms

Affected children are short with weak bones, stiff, rigid or extremely floppy muscles, limb paralysis, speech defects, visual defects, seizures and mental impairment.

Treatment

There is no cure but treatment can be started to improve quality of life. It includes counselling, medication, physical therapy, and sometimes surgery.

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