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Life with
CEREBRAL PALSY

Cerebral palsy

Here you will find all the information to be more familliar with CP

Cerebral palsy (CP) is a common physical disability that is diagnosed during childhood. It is a group of neurological permanent disorders that are non-progressive.

Cerebral Palsy was first described in 1862 by the orthopaedic surgeon William Little. Today, the International Executive Committee defines cerebral palsy as:

“
a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing foetal or infant brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication and behaviour, by epilepsy, and by secondary musculoskeletal problems.” 1

The overall prevalence of CP is 2.11 per 1000 live births (95% CI 1.98–2.25) 2

 

The prevalence is highest in children weighing 1000 to 1499g at birth (59.18 per 1000 live births; 95% CI 43.38–73.95), and lowest in children weighing over 2500g at birth (1.33 per 1000 live births; 95% CI 1.19–1.49).2

Interestingly, a few years back, prevalence rates were used as outcome measures of obstetric practice and neonatal care, and it was expected that improvement in these areas would result in lower rates of cerebral palsy.3

As a result, interventions, such as electronic foetal monitoring and caesarean section, increased with time.3

There are many different types of CP, which vary in the parts of the body that are affected, the type of impairment and the severity of mobility limitations.

→Click to learn about the different types of CP

 

CP has a major impact on the child’s and caregiver’s quality of life.4 Caregivers are under a lot of pressure, and implications can affect their overall quality of life. With your help, caregivers and patients can overcome such challenges and improve their daily life. A better understanding of the emotional journey that caregivers go through may help you in finding solutions and/or recommendations to empower them.



References:

  1. Colver A et al. Cerebral palsy. Lancet. 2014;383:1240-49.
  2. Oskoui M et al. An update on the prevalence of cerebral palsy: a systematic review and meta-analysis. Dev Med Child Neurol. 2013;55(6):509-19.
  3. Reddihough DS and Collins KJ. The epidemiology and causes of cerebral palsy. Aust J Physiother. 2003;49(1):7-12.
  4. Eunson P. Aetiology and epidemiology of cerebral palsy. Symposium: Cerebral Palsy. Paediatrics and Child Health.2016;26:9:367-372.

Cerebral palsy (CP) can be diagnosed several months after birth, or even years later. Usually, CP is diagnosed before the age of three.

The diagnosis is essentially clinical. A systematic approach, focusing on maternal, obstetric and perinatal histories, a review of developmental milestones and a thorough neurological examination and observation of the child in various positions (supine, prone, sitting, standing, walking and running) is mandatory.

The symptoms are complex and vary depending on the types and degrees of motor impairment. You can read all about the degree of motor impairment in the following section

→Click to learn about the different types of CP


Some early signs of CP may include:1,2



Unfortunately, children with CP will most probably have multiple disabilities. 80% will have at least one associated disability, while 40% will have three or more.3

References:

  1. Colver A et al. Cerebral palsy. Lancet. 2014;383:1240-49.
  2. National Institute for Health and Care Excellence. Cerebral palsy in under 25s: assessment and management. Full Guideline. NG62. 2017. Available at:https://www.nice.org.uk/guidance/ng62/evidence/full-guideline-pdf-4357166226
  3. Cerebral Palsy. Critical elements of Care. Center of Children with Special Needs, Seattle Children’s Hospital. Seattle. WA, Fifth Edition. 2011; 4-9

Each child with cerebral palsy (CP) is unique, with varying abilities and disabilities. Nonetheless, severity can be generally classified according to the type of motor function impairment and the part of the body that is mostly affected.

Quadriplegia affects all 4 limbs (arms and legs), diplegia affects 2 limbs (typically both legs) and hemiplegia, or unilateral CP affects one arm and one leg on the same side of the body1.

The types of CP include:2,3,4,5,6

Motor symptoms of cerebral palsy can be divided depending on the location of the lesion and which motor tracts are affected (pyramidal or extrapyramidal).

The following illustration shows the motor syndromes associated with different types of CP.8

Motor syndromes of cerebral palsy



 

The severity of CP mobility limitations can also be categorized into 5 different levels, according to the Gross Motor Function Classification System (GMFCS).9 Each level clearly describes the child’s current physical abilities and whether equipment or mobility aids are or will be needed in the future.

GMFCS E & R between 6th and 12th birthday: Descriptors and illustrations

GMFCS E & R between 12th and 18th birthday: Descriptors and illustrations



It is important to recognize the diversity in CP cases and that every child with CP is unique, requiring personalised, tailored care.

 

References:

  1. Reddihough DS and Collins KJ. The epidemiology and causes of cerebral palsy. Aust J Physiother. 2003;49(1):7-12.
  2. Odding E,Disabil Rehabil 2006 28;28(4):183-91.
  3. Dahlseng MO,Dev Med Child Neurol 2012;54(10):938-44.
  4. Carnahan KD,BMC Musculoskeletal Disorders 2007;8:50.
  5. Andersen GL,Eur J Paediatr Neurol 2008;12(1):4-13.
  6. Sigurdardóttir S, Dev Med Child Neurol 2009;51:356–363.
  7. Prasad AN and Prasad C. Genetic evaluation of the floppy infant. Semin Fetal Neonatal Med. 2011;(16):99-108.
  8. Graham HK et al. Cerebral Palsy. Nat Rev Dis Primers. 2016;2:15082. doi: 10.1038/nrdp.2015.82
  9. Palisano R et al. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997;39(4):214-23.

Movement and posture disorders result from defect or lesion of the immature brain. Nevertheless, the exact causes of cerebral palsy may remain unknown in a large number of cases.1

It is helpful to classify the known causes according to the timing of the brain insult, whether prenatal, perinatal or postnatal.1

It is also helpful to categorise the causes of CP into three broad groups, related to the effect seen on the brain.2

  • Brain damage
  • Brain malformation
  • Disorders of brain function

Prenatal causes:

Prenatal causes are responsible for approximately 75% of all cases of cerebral palsy.1

In the absence of clear evidence, prenatal causes are assumed to be the cause of cerebral palsy.3-5

However, it is usually impossible to determine the reason and the exact timing of the damaging event.1

Perinatal causes:

Perinatal causes happen during pregnancy.1

Known causes are:1

  • Vascular events, demonstrated by brain imaging (for example, middle cerebral artery occlusion)
  • Asphyxia (accounts for between 6% and 8% of cerebral palsy cases)
  • Maternal infections during the first and second trimesters of pregnancy (rubella, cytomegalovirus, toxoplasmosis)

Less common causes are:1

  • Metabolic disorders
  • Maternal ingestion of toxins
  • Rare genetic syndromes.

The type of cerebral palsy also depends on the gestation period. Interference in brain development during the first trimester is associated with cerebral malformations, such as schizencephaly, a rare birth defect characterised by abnormal clefts lined with grey matter.6

Interference during the second trimester is associated with periventricular white matter damage.6

Interference during the third trimester is associated with cortical and deep grey matter damage.6

Postnatal causes:

Postnatal causes are responsible for 10 to 18% of cerebral palsy cases.1,4,7

Infections, such as meningitis and injuries, are responsible for most cases of post-neonatally acquired cerebral palsy in developed countries.1

Meningitis, septicaemia and other conditions, such as malaria, remain extremely important causes of cerebral palsy.1

The introduction of new vaccines against meningitis will hopefully decrease the number of children with infections and subsequent neurological sequelae.1

Accidental injuries, such as motor vehicle accidents and near-drowning episodes, as well as non-accidental injuries, may result in cerebral palsy.1

Other causes include apparent life-threatening events, cerebrovascular accidents and surgery for congenital malformations.1

There are also certain risk factors that are associated with cerebral palsy, such as:

Maternal factors before pregnancy (delayed onset of menstruation, irregular menstruation, long intermenstrual intervals)

Medical conditions (intellectual disability, seizures, thyroid disease)

Other factors:

  • Premature birth, which is associated with half of all cases of cerebral palsy8
  • Severe jaundice, which is an established cause of dyskinetic cerebral palsy6
  • Iodine deficiency6

References:

  1. Reddihough DS and Collins KJ. The epidemiology and causes of cerebral palsy. Aust J Physiother. 2003;49(1):7-12.
  2. Eunson P. Aetiology and epidemiology of cerebral palsy. Symposium: Cerebral Palsy. Paediatrics and Child Health.2016;26:9:367-372.
  3. Gaffney G et al. Cerebral palsy and neonatal encephalopathy. Arch Dis Child Fetal Neonatal Ed. 1994;70(3):F195-200.
  4. Holm VA. The causes of cerebral palsy. A contemporary perspective. JAMA. 1982;247(10):1473-7.
  5. Palmer L. Antenatal antecedents of moderate and severe cerebral palsy. Paediatr Perinat Epidemiol. 1995;9(2):171-84.
  6. Colver A et al. Cerebral palsy. Lancet. 2014;383:1240-49.
  7. Pharoah PO et al. Acquired cerebral palsy. Arch Dis Child. 1989;64(7):1013-6.
  8. Rouse DJ and Gibbins KJ. Magnesium sulfate for cerebral palsy prevention. Semin Perinatol. 2013;37(6):414-6.

Thanks to a growing body of research, the epidemiology and aetiology of cerebral palsy is now better understood. MRI scanning has helped in understanding the interference that happens in brain development in utero. Nevertheless, on-going and future research, especially in brain plasticity, are key to better understanding the causes and to improving treatment of the disorder.1,2

Possible prevention techniques that can effectively decrease the burden of the disease are:

  • Antenatal Magnesium Sulfate (MgSO4), which has been demonstrated to help in preventing cerebral palsy in prematurely delivered neonates.1
  • Improved nutrition, infection control, and accident prevention should especially help in reducing the prevalence of post-neonatal cerebral palsy.2

Helping individuals with cerebral palsy to feel more included in the society is another key development area. New technologies directed both to the individual, such as voice synthesisers, and to the environment, such as intelligent household appliances, help in improving their quality of life.2

Understanding the detailed causes and complications of cerebral palsy is essential for a better diagnosis and treatment. However, understanding the emotional journey of caregivers before, during and after diagnosis is also essential for the overall wellbeing of the family.

→Take a look at our next section, “The Journey”

Furthermore, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) recently published updated nutritional guidelines that are relevant for children with CP, Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Neurological Impairment (2017). The authors state that nutritional assessment and nutritional interventions in neurologically impaired children are a challenge for physicians but should be part of the child’s comprehensive care and rehabilitation.3

→We invite you to go through our section dedicated to nutrition

References:

  1. Rouse DJ and Gibbins KJ. Magnesium sulfate for cerebral palsy prevention. Semin Perinatol. 2013;37(6):414-6.
  2. Colver A et al. Cerebral palsy. Lancet. 2014;383:1240-49.
  3. Romano C et al. European Society for Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Neurological Impairment. J Pediatr Gastroenterol Nutr. 2017;65(2):242-264.
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