Cerebral palsy

Cerebral palsy is a term used to describe a group of physical disability disorders caused by damage to particular areas of the brain that control a person’s movement and posture (cerebral refers to the brain and palsy refers to muscle weakness and uncontrolled body movements).

The primary symptoms of cerebral palsy can vary greatly between individuals, from mildly to severely disabling. Signs of cerebral palsy typically appear during infancy. In New Zealand, approximately 7,000 people are affected to some degree by cerebral palsy.

Causes

Cerebral palsy occurs as the result of damage to particular areas of the brain, which may be apparent with diagnostic tests such as MRI (magnetic resonance imaging) scans. The term cerebral palsy is used when this damage occurs early in life.

The damage that causes cerebral palsy may occur during foetal development, during childbirth, shortly after birth, or in early infancy. Cerebral palsy occurs in one in every 500 live births and affects males and females in equal numbers.

Damage to the foetal or infant brain can occur for a number of reasons:

• Insufficient oxygen reaching the baby during pregnancy (eg: problems with the placenta or umbilical cord)
• Insufficient oxygen reaching the baby during birth (eg: prolonged and/or difficult delivery)
• Maternal infection during pregnancy (eg: rubella (German measles), chickenpox, cytomegalovirus)
• Premature birth or low birth weight
• Blood group incompatibility between mother and baby
• Severe jaundice following birth.

Less commonly, the following can lead to damage to the brain and the development of cerebral palsy:

• Head injuries in early childhood
• Illnesses in early childhood (eg: meningitis)
• Genetic disorders.

Cerebral palsy does not become more severe with age but some difficulties may become more noticeable over time.

Types of cerebral palsy

There are four main types of cerebral palsy, each related to damage in different parts of the brain that affect aspects of movement and coordination.

Spastic cerebral palsy

This is the most common form of cerebral palsy and is characterised by stiffness and contractions (spasticity) of the muscles. The lower legs may turn in and cross at the ankle (scissor gait). Sometimes the long muscles on the back of the legs are so tightly contracted that the heels of the feet do not touch the ground and the child walks on tiptoe.

Athetoid (Dyskinetic) cerebral palsy

This type of cerebral palsy is characterised by slow, uncontrolled, writhing movements. Muscles are weak and change from being floppy to tense. Facial muscles may be affected causing distorted facial movements and drooling. Speech may be hard to understand because of difficulty with controlling the tongue, vocal cords, and breathing. Uncontrolled movements may increase during times of stress and may disappear when sleeping.

Ataxic cerebral palsy

This is the least common form of cerebral palsy, characterised by poor co-ordination of movement and poor muscle tone. The sense of balance and visual depth perception is affected and there is a lack of co-ordination when standing and/or walking. Movements may be shaky and a tremor may be present.

Mixed cerebral palsy

In this type of cerebral palsy various areas of the brain may be damaged, so the condition involves characteristics discussed above.

Symptoms

Early signs of cerebral palsy usually appear before the age of 18 months - the main symptoms are muscle weakness and a lack of muscle tone. A parent may notice that developmental milestones such as smiling and rolling over are delayed or not reached. As a child gets older, other symptoms may appear. These may include:

• Floppiness
• Muscle stiffness and/or spasms
• Slow, awkward, or jerky movements
• Involuntary movements
• Abnormal drooling
• Speech impairment
• Difficulty maintaining bladder and/or bowel control
• Hand tremors and the inability to identify objects by touch.

Often a child with cerebral palsy has normal intelligence. However, there may be mild or severe intellectual impairment in some children. Other difficulties and medical conditions occur more frequently in children with cerebral palsy. These include:

• Seizures
• Vision and/or hearing difficulties
• Difficulty with spatial perception
• Difficulties with chewing and swallowing
• Learning difficulties.

Treatment

A management plan aims to help the child achieve maximum potential in growth and development through the combined efforts of doctors, therapists, educationalists, parents and the child. Motivation is a key factor in how well any management plan will succeed. Emphasis is placed on the integration of games and play into the programme.

Physiotherapy/physical therapy

Physiotherapy and physical therapy can play an important role. Exercises and activities are designed to increase the function of those parts of the body that are not affected by cerebral palsy, and to maximise the function in parts that are affected. Use of braces and splints may also be recommended.

Occupational therapy

Occupational therapy helps with daily living needs. These include how to dress, hold a cup, clean teeth etc, and - as the person grows older - preparing them for education and employment.

Speech and language therapy

Where speech is affected, speech and language therapy aims to maximise communication skills. This therapy can also be useful if the person with cerebral palsy has difficulty swallowing.

Educational therapies

There are a number of different educational therapies that can be effective in the management of cerebral palsy. The younger the child when they start the therapy, the greater the long-term benefit of the treatment.

• Conductive education encompasses all aspects of learning such as motor skills, cognitive development, and social and emotional skills. The programme was developed specifically for children with movement disorders.
• Bobath aims to increase co-ordinated movement patterns.
• Feldenkrais is a form of education that uses gentle movement and directed attention to improve movement and enhance functioning.

Medications

Different medications can be useful in managing some symptoms of cerebral palsy. These include:

• Anticonvulsant medications to control seizures
• Muscle relaxant medications to ease the tension of contracted muscles
• Medications that help control urinary incontinence, tremors, and drooling

Botox injections, which work by blocking signals between the nerves and muscles, are also used to help relieve muscle spasms and stiffness in some children with cerebral palsy. The effects of the Botox injection last for three to six months, at which time the injection needs to be repeated for the benefits to be maintained.

Surgery

Where there are difficulties with severe muscle contractions, surgery involving a person’s tendons (the tissue that attach muscles to bone) may be an option. This can be done with the elbows, shoulders, back of the heel, and other areas of the body. Surgery may also be considered to correct bone abnormalities.

Where swallowing and eating is a problem, surgery to insert a feeding tube into the stomach may be required.

When other treatments have not been of benefit, surgery that involves cutting the nerves supplying the affected muscles (selective dorsal rhizotomy) may be recommended. This type of surgery relaxes the muscle and reduces pain.

Health complications and life expectancy

The muscle function and co-ordination problems associated with cerebral palsy can lead to health complications, including:

• Premature ageing
• Contracture (muscle tightening, which causes bones to bend and deformity of joints)
• Malnutrition (due to swallowing and feeding problems)
• Mental health conditions (eg: depression)
• Osteoarthritis
• Heart or lung disease.

Life expectancy for a person with cerebral palsy is related to the severity of the condition and the development of health complications.

In general, people with milder forms of cerebral palsy have life spans that approach those of the general population. People with severe forms of the condition are likely to have considerably reduced life expectancy.

However, due to earlier diagnosis and improved medical care, including the use of stomach feeding tubes for nutritional support, the life span of those severely affected by cerebral palsy has been increasing.

Support and information

The Cerebral Palsy Society provides support, information and advocacy.

Cerebral Palsy Society of New Zealand

Freephone: 0800 503 603
E-mail: [email protected]
Website: www.cerebralpalsy.org.nz

References

Abdel-Hamid, H.Z. (2018). Cerebral palsy (Web Page). Medscape Drugs and Diseases. New York, NY: WebMD LLC. http://emedicine.medscape.com/article/1179555-overview [Accessed: 07/05/20]
Cerebral Palsy Society of New Zealand (Date not stated). What is cerebral palsy (Web Page). Auckland: Cerebral Palsy Society of New Zealand (Inc). https://cerebralpalsy.org.nz/cerebral-palsy/what-is-cerebral-palsy/ [Accessed:07/05/20]Mayo Clinic (2019). Cerebral palsy (Web Page). Rochester, MN: Mayo Foundation for Medical Education and Research. [Accessed: 07/05/20]
O’Toole, M.T. (Ed.) (2017). Cerebral palsy. Mosby’s Dictionary of Medicine, Nursing & Health Professions (10th ed.). St Louis, MI: Elsevier.

Last Reviewed – June 2020

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