WHAT IS CEREBRAL PALSY?

 "CAUSE AND TYPES" 

 OF  

 CEREBRAL PALSY 

MAIN CONTENTS:

1. What is Cerebral Palsy?

2. How does the brain work and its impact on cerebral palsy?

3. What are the symptoms of cerebral palsy and how it affects the body?

4. What are the causes of cerebral palsy?

5. What are the problems associated with cerebral palsy?

6. Complications in cerebral palsy.

7. Marked physical and sensory disorders in cerebral palsy

8. Classification of cerebral palsy according to problems.

9. Types of cerebral palsy

10. Frequent questions that parents ask the Therapist   

11. Conclusion

1. What is Cerebral Palsy? 

• Cerebral - brain

• Palsy - weakness, paralysis or loss of muscle control.

Cerebral palsy was first described by English physician "Sir Francis William Little [E] " in 1861, and was known as a “Little’s disease". Later the term cerebral palsy originated with Osler and Sigmund Freud, which occurs with stable encephalopathy of the brain.

Little thought that this condition was caused by neonatal asphyxia. Later, Sigmund Freud and other scientists challenged Little’s idea and proposed that a variety of insults during pregnancy could damage the developing brain.

Today, it is accepted that only approximately 10% of cases of CP can be attributed to neonatal asphyxia. The majority occur during the prenatal period, and in most of the cases, a specific cause cannot be identified.

DEFINITION:

• Cerebral palsy is a disorder in infancy or childhood involving movement, caused by non-progressive damage to the brain before or shortly after birth. Damage to the brain is permanent and cannot be cured, but its consequences can be minimized.

• Often associated with epilepsy, speech problems, vision compromise, and cognitive dysfunction. Movement and movement related disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication and behavioral problems.

• Cerebral palsy affects people in different ways as it can affect body movement, muscle control, muscle coordination, muscle tone, reflexes, posture and balance. Although cerebral palsy is a permanent life-long condition, some of these symptoms of cerebral palsy may improve or worsen over time.

• Cerebral palsy is the most devastating pathology in medicine. Cerebral palsy is actually a group neurological disorder and debility. It doesn't just affect one condition; it can cause varying amounts of deformity that can restrict activities, balance, and physical condition.

• The consequences of injury from a brain disorder can last a lifetime and cause severe physical deformity and cannot be cured, but the consequences of this deformity can be reduced by proper exercise therapy and rehabilitation services.

2. How does the brain work and its impact on cerebral palsy? 

Our brain contains billions of nerve cells that coordinate thoughts, feelings, behavior, activities, and sensations. It is complex system of nerves that connects your brain to the rest of the body, so communication can happen in split seconds. The brain has different regions and functions accordingly.

So when the particular area of the brain is affected, it also affects our actions. So in the case of cerebral palsy, the type of disorder is accompanied by an injury to a particular area of the brain during the process of the child's development. Therefore, a child’s motor functioning and intellectual abilities are highly dependent on the nature of a brain injury, where the damage occurs, and how severe it is.

A. CEREBRUM - It is the largest part of the brain. It is divided into two hemispheres or halves, which are called cerebral hemispheres. Regions within the cerebrum control muscle functions and also control speech, thought, emotion, reading, writing, and learning. The cerebrum consists of two cerebral hemispheres, an outer layer called the cortex (gray matter) and an inner layer (white matter). The cortex has four lobes, the frontal lobe, parietal lobe, temporal lobe, and occipital lobe.

a. Frontal Lobe - It controls thinking, planning, organizing, problem solving, short-term memory and body movements. It is important for managing voluntary body movements, expressive language, and high-level executive functions. Executive functions refer to a collection of cognitive skills, which include the ability to plan, organize, initiate, self-monitor, and control one's reactions to achieve a goal.

b. Parietal lobe – It brings together information from various senses, especially the spatial senses, and navigation. For example, it serves as a collaboration system regarding touch, balance and the visual system. It interprets sensory information such as taste, temperature and touch.

c. Occipital lobe - This combines that information with images from your eyes and stored in memory. It is associated with visual spatial processing, distance and depth perception, color determination, object and face recognition, and memory formation.

d. Temporal Lobe - It processes information from the senses to smell, taste and sound. They also play a role in memory storage. The main functions are auditory stimulation, memory and emotion. The temporal lobe contains the primary auditory complex. This is the first area responsible for interpreting information from the ear as sounds.

B. CEREBELLUM - The cerebellum receives information from sensory systems, the spinal cord, and other parts of the brain and then controls motor activities. The cerebellum coordinates voluntary movements such as body position, balance, coordination and speech, resulting in smooth functioning and balanced muscle activity.

C. BRAINSTEM - It serves as a relay center connecting the cerebrum and cerebellum to the spinal cord. It performs many automatic functions such as breathing, heart rate, body temperature, wake and sleep cycles, digestion, sneezing, coughing, vomiting and swallowing and plays an important role in controlling some involuntary actions of the body.

3. What are the symptoms of cerebral palsy and how it affects the body? 

a. Mobility Problems - Cerebral Palsy (CP) is a problem that affects muscle tone (muscle responsiveness), speed and motor skills (the precise movement of a specific muscle function). This hinders the body's ability to move in a coordinated and purposeful manner. It can also affect other body functions that involve motor skills and muscles, such as breathing, bladder and bowel control, eating and talking.

b. Pain problems - pain is often the result of disorders that are associated with cerebral palsy, e.g., contractures, abnormal bodily movements, dystonia, tightness of the skin, hip subluxation (partial dislocation of the hip) and scoliosis. This pain can affect a child's behavior, their ability to do things on their own and their social relationships. Children may avoid day-to-day activities that are important for independent living, such as attending school and social events.

Marked pain in children with cerebral palsy can be clearly understood by observing the Childs expression through: 

• Crying during limb movement

• Strained facial expressions

• Activity restricted due to joints stiffness

• When trying to move and shifting the limbs

• Irritability due to indigestion and skin irritation

• Poor sleep and Fidgety movements

c. Communication problems - Cerebral palsy can affect a person's ability to coordinate the muscles around the mouth and tongue, which are essential for speech. Respiratory coordination required to support speech may also be affected, e.g. Some people can 'breathe' when they speak. Some children with cerebral palsy may not be able to produce any sounds, others may be able to produce sounds, but have difficulty controlling their movement that makes speech clear and understood by others. are capable of producing.

d. Abnormalities of the spine and hips – Abnormalities of the spine and hips are associated with cerebral palsy and can cause difficulty in sitting, standing and walking and can lead to chronic pain.  Children and adults who have severe physical disabilities or who affect both sides of the body are at higher risk of hip problems. People who use a wheelchair most of the time have a higher risk of hip problems than those who walk with or without assistive devices.

e. Bladder and bowel control problems - Continuity and constipation are the issues common to cerebral palsy. Bladder control is a problem in children with cerebral palsy. Children with intellectual disabilities and/or severe forms of cerebral palsy are most at risk. People with cerebral palsy can become constipated from lack of mobility and difficulty eating.

f. Eating and drinking problems – Cerebral palsy can affect the muscles that open, close the mouth, and move the lips and tongue. Some people with cerebral palsy may have difficulty chewing food and swallowing drinks – a condition known as dysphagia. Because cerebral palsy often affects finer motor skills, many people are unable to grasp plates using their hands, or to transfer food from a plate to their mouth. Others may suffer from gastro-esophageal reflux – where acid from the stomach rises up into the esophagus – which makes eating uncomfortable or painful.

g. Problems with saliva control - Because cerebral palsy can affect the muscles around the mouth, the baby has a loss of saliva also known as dribbling, drooling or sialorrhea.

h. Sleep problems - There are a number of factors associated with cerebral palsy including muscle spasms, muscle spasms, and other forms of muscle and bone pain, and a decreased ability to change body position during the night. Epilepsy is also known to cause sleep disturbances and is likely to lead to sleep disorders. Blindness or severe visual impairment can affect the timing and maintenance of sleep through the effects of melatonin secretion and their lack of light.

i. Epilepsy - When children have cerebral palsy and an intellectual disability, the incidence of epilepsy is higher whose symptoms can affect speech, intellectual functioning and physical functioning. Medication is the most effective intervention for epilepsy. Some medicines have side effects that cause drowsiness or irritability. Epilepsy and related medication can both affect a person's behavior and attention span.

j. Behavioral and emotional problems - those at greatest risk are those with an intellectual disability, epilepsy, severe pain or physical disability. Children with cerebral palsy may also have emotional problems such as difficulties with their peer group and strong emotional reactions to new challenges. Adolescents and adults with cerebral palsy may be at higher risk of depression and anxiety disorders.

k. Intellectual Disabilities and Learning Difficulties – Children with cerebral palsy may experience specific learning difficulties. These may include short attention span, motor planning difficulties (organization and sequencing of movement), perceptual difficulties and language difficulties.

l. Hearing Impaired - Cerebral palsy children can be affected by conductive hearing loss (CHL), sensori-neural hearing loss (SNHL), or a combination of the two (mixed hearing loss).

m. Visual Impaired - Visual impairment is common in children with cerebral palsy. Common visual conditions found in children with cerebral palsy include strabismus, cataracts, and refractive issues. Strabismus is a severely altered eye that makes it impossible for both eyes to work together.

n. Cognitive problems - Cognition is a person's ability to think matters using information from the brain. Because cerebral palsy is essentially caused by damage to the brain, the centers that transmit accurate information from multiple sources may be impaired. This means that a person with a brain injury may experience difficulty understanding or processing the information that he or she receives. When this happens, it is known as cognitive or intellectual impairment.

o. Perceptual difficulties - Perception is the understanding of information received from the senses. It enables children to learn about things and the surroundings such as moving around obstacles, understanding the shape and size of objects, and understanding how lines are connected to form letters. Children with perceptual difficulties have a harder time perceiving information they hear through their eyes and/or ears, which can affect many areas of learning.

p. Problems in reflexes – Absence of underdeveloped reflexes which are essential for position and defense of the body.

q. Involuntary muscle contraction - occurs when muscles that act or contract without conscious control, because of a loss of coordination between the brain and muscles.

4. What are the causes of cerebral palsy? 

Cerebral palsy is not a disease, but a disorder in the brain that results from trauma or diseases during pregnancy and after birth. The disorder in the brain does not progress, but the condition may worsen over time if proper medical and therapeutic intervention is not provided at the right time.

If therapy is delayed, more complications can be observed in the organs and body such as stiffness, shrinkage, loss of balance, progressive weakness of muscles and bones, loss of sensation, loss of appetite, digestive problems, stiffness etc.

CAUSE 1 - During pregnancy or before childbirth (Conception to the onset of labor)

a. Infection during pregnancy – Mothers can pass the infection to the fetus during pregnancy. Prenatal infection is most dangerous in the first few weeks after conception. German measles (rubella) and cytomegalovirus (CMV) are known causes of cerebral palsy during pregnancy. These viruses cause the mother's immune system to release proteins that not only attack the infection, but also cause inflammation in the baby's brain that interferes with normal development.

b. Asphyxia - Asphyxia is a lack of oxygen reaching the brain. It can cause serious brain damage to the baby during birth. Asphyxia that occurs during labor or delivery may be due to medical malpractice or neglect. Early detachment of the placenta, a ruptured uterus during birth or the placenta can compress in such a way that restricts blood flow to the fetus leading to a lack of oxygen.

c. Injury during labor – About 20% of cerebral palsy cases are caused by damage to the baby's brain (usually from lack of oxygen) that occurs during labor and delivery. When a brain injury occurs during childbirth, it is almost always triggered by a loss of oxygen to the baby's brain.

d. Not getting enough blood, oxygen, or other nutrients before or during birth.

e. Hereditary - Some problems passed down from parent to child (genetic condition) affect brain development.

f. Severe hypoglycemia, untreated jaundice, and severe neonatal infection in the neonatal period may be responsible for cerebral palsy.

g. Exposure of the mother's abdominal area to repeated X-ray radiation.

h. Multiple pregnancies – Babies born from multiple pregnancies are more likely to be born prematurely and have low birth weight, which can lead to breathing problems and reduced oxygen supply to the brain. A premature baby may also be at greater risk for infection and other complications that can result in cerebral palsy.

i. Rh incompatibility – blood type incompatibility – When a mother and her fetus have incompatible blood types, it can cause severe jaundice. Therefore, if blood type incompatibility is found, this issue should be addressed.

j. Drug abuse during pregnancy

k. Neonatal sepsis: This is a condition in which a newborn baby has an infection in his or her bloodstream. When a child has sepsis, his immune system responds to the infection by attacking his own tissues and organs. Sepsis can damage the brain by directly infecting the central nervous system, indirectly causing brain swelling (encephalitis), or causing a severe drop in blood flow to the brain (septic shock). Sepsis often leads to seizures, meningitis, ischemia, brain injury and cerebral palsy.

l. Newborn's first stool (Meconium Aspiration) - it is normal for a fetus or a newborn to pass meconium (first stool). If meconium is present in the mother's amniotic fluid during labor and delivery, it may indicate that the fetus is in distress. If meconium is there but is not expelled from the baby's airway and lungs soon after birth when the baby needs to breathe air, the meconium can block the baby's airway, preventing it from breathing , which can lead to lack of oxygen, brain damage and death.

m. Nutrient deficiencies in the mother – Nutritional deficiencies affect brain development in the prenatal period. Maternal malnutrition can also increase the risk of perinatal problems, including birth asphyxia, neurologic damage and is a major cause of cerebral palsy. Macronutrient malnutrition can lead to neuro-disability.

CAUSE 2 - After childbirth (natal) (o-7 days of child birth)

a. Prolonged pain during labor - If labor is prolonged, and the baby is already in the birth canal, the doctor may use tools such as forceps or a vacuum extractor to help expel the baby and Use can damage a child's skull, and with too much force, a head injury can occur. This can easily lead to brain damage that causes cerebral palsy.

b. Delayed birth cry (after 1 minute) - Most babies are breathing well or crying 1 minute after delivery. If the infant fails to establish adequate, sustained respiration after delivery, the infant is said to have failed to breathe well at birth. Hypoxia can occur in infants as a result of the failure to breathe well. As a result of hypoxia, there is a drop in heart rate, development of central cyanosis (ie, poor blood circulation and results in bluish discoloration of the skin) and the infant becomes hypotonic (floppy) and unresponsive. Most fetal hypoxia occurs during labor (i.e. intrapartum hypoxia).

c. Umbilical cord round the neck - The placenta gets stuck in the baby's neck during delivery – when an umbilical cord wraps around the baby's neck, the baby doesn't get the oxygen it needs for its brain to function. If the brain is unable to receive oxygen, brain cells can be damaged, resulting in loss of motor skills and motor skills, and cerebral palsy

d. Baby jaundice from birth – When severe jaundice goes untreated for too long, it can lead to a condition called kernicterus. Kernicterus is a type of brain damage that can damage brain cells as a result of high levels of bilirubin in the baby's blood.

e. Severe proteinuria or high blood pressure in the maternal

f. Hypoxia - This is brain injury from lack of oxygen to the brain, also commonly known as intrapartum asphyxia. The newborn's body can compensate for brief periods of decreased oxygen, but if asphyxia lasts long enough, brain tissue is destroyed.

g. Asphyxia - This can result from accidents and burns, knotted umbilical cord, multiple deliveries can cause asphyxia in the second or third baby.

h. Neonatal meningitis - usually associated with severe residual brain damage.

i. Birth complications - placental abruption, uterine rupture, or problems with the umbilical cord during birth can disrupt the oxygen supply to the baby and result in cerebral palsy.

j. TORCH infection - congenital (TORCH) infection (toxoplasmosis, rubella, cytomegalovirus, herpes virus, and other microorganisms HIV including hepatitis B, syphilis, and others) and affecting the infant's brain when Streptococcus B is transferred from mother to infant and can cause congenital motor impairment.

k. Perinatal ischemic stroke - Perinatal stroke is a cerebrovascular event that occurs before 28 days of fetal or neonatal life.

CAUSE 3 - After childbirth - Postnatal (0 to 2 years)

a. Central nervous system infections (encephalitis, meningitis) - meningitis or viral encephalitis in children causes inflammation of the membranes surrounding the spinal cord, which can lead to cerebral palsy.

b. Premature birth – A birth is considered to be premature or before conception, when it occurs before the 37th week of pregnancy. When babies are born too early, their normal brain development is disrupted, and they are more likely to have problems later in life. A variety of brain injuries result from disrupting brain development.

c. Epilepsy - It is the most commonly caused by any kind of injury to the brain. However, there is often no clear indication as to what exactly causes seizures. Some of the main causes of epilepsy are: low oxygen during birth, major injuries during birth, brain tumors, genetic conditions resulting from brain injuries, infections such as meningitis or encephalitis, stroke or any other brain damage abnormal levels of substances, such as sodium or blood sugar.

d. Head trauma - Cerebral palsy is caused by traumatic injury to a developing brain, which includes the parts of the brain responsible for motor control, coordination, and balance. Damage to different parts of the brain's motor control centers causes different types of cerebral palsy. Infection of the brain, e.g., early-stage meningitis or encephalitis. Injuries to the brain, for example, head injuries due to a motor vehicle accident or a fall from a height during pregnancy or in the newborn.

e. Neonatal jaundice (neonatal hyperbilirubinemia) – Jaundice occurs when bilirubin accumulates in the baby's body. Bilirubin is a yellow-brown substance found in bile, which is made after the body breaks down old red blood cells. Newborns produce more red blood cells than adults, resulting in a higher turnover of blood cells, leading to jaundice. When severe jaundice goes untreated for too long, it can lead to a condition called kernicterus. Kernicterus is a type of brain damage that can damage brain cells as a result of high levels of bilirubin in the baby's blood.

f. Low birth weight - At birth, the baby's weight is low. Babies weighing less than 2.5 kg are at a higher risk of developing cerebral palsy. An underweight baby may have trouble eating, gaining weight, and fighting off infections. Some low birth weight babies can also have long term health problems in unborn babies.

g. Breech birth – which is when your baby's buttocks or legs protrude first. Breech presentation may require the use of forceps or vacuum extraction. When used incorrectly (or with too much force), these devices can compress a child's skull and brain, causing permanent brain damage or deformity.

h. Rh incompatibility – this occurs when a mother's blood Rh type is incompatible with her baby's blood Rh type

i. Infection after birth - infection (such as meningitis) is a disease acquired by newborns that can lead to brain damage. Meningitis causes severe inflammation that can damage the motor control centers of the brain.

j. post-date pregnancy or prolongation pregnancy - which extends the duration of the standard gestation period (37–42 weeks). In later cases of pregnancy, the baby may become more developed and larger in the womb resulting in difficulty in delivery and an increased risk for birth trauma, brain hemorrhage, hypoxic ischemic encephalopathy, seizures and other forms of brain damage. Which is the cause of cerebral palsy in the child.

5. What are the problems associated with cerebral palsy? 

1. PHYSICAL SIGNS

• Poor head and neck control after 3 months of age

• Tightness of limbs

• Can't sit without support after 8 months

• Using only one side of the body

• Scissoring pattern of legs

• Sensory loss (hearing, vision)

• After 6 months of age, persistent tongue thrusting

• Unsteady walk

2. BEHAVIORAL SIGNS

• excessive irritability or crying

• having difficulty feeding

• lack of interest in playing

• excessive sleepiness and getting tired easily

3. ASSOCIATED PROBLEMS

• Intellectual impairment

• Epilepsy

• Visual problems

• Deafness

• Speech and communication problems

• Difficulty swallowing

• Feeding difficulties and failure to thrive

• Respiratory system problems

• Incontinence

4. MUSCULOSKELETAL PROBLEMS - Pertaining to the muscles and the skeleton 

• Contraction of muscle joints

• Physical deformity

• Loss of selective motor control

• Abnormal bone growth

• Poor balance

• Muscle contraction

5. NEUROLOGICAL PROBLEMS

• Muscle weakness

• Abnormal muscle tone

• Balance problem

• Loss of selective control

• Pathological reflex

• Loss of sensation

6. Complications in cerebral palsy 

Muscle weakness, muscle twitches and coordination problems can contribute to a number of complications, either during childhood or adulthood. These children may have additional problems, including:

• Delay in physical and mental development
• Abnormal muscle tone
• Vision, hearing and speech problems
• Learning disabilities and behavior problems
• Intellectual, language and learning disabilities
• Bowel and bladder problems
• Bone abnormalities
• Muscle contraction
• Malnutrition
• Physical development retardation
• Mental health condition
• Heart and lung disease
• Osteopenia - fractures due to low bone density
• Mental retardation
• Abnormal muscle reaction

7. Marked physical and sensory disorders in cerebral palsy 

a. Hypotonic - Newborns with hypotonic do not have strong arms and legs. It is also called floppy muscle. The muscles are loose and they have weak strength to hold the body in a strong manner.

b. Hypertonia - a condition characterized by too much muscle tone where the arms or legs are stiff and difficult to move or increased tightness of muscle tone.

c. Choriform - continuous purposeless physical movement.

d. Ballismus - the rarest body gait and function disorder, involves random movements in large, rapid patterns focused on the entire limb.

e. Dystonia - is a slow movement with a slow movement (sudden body movements and stressful movements) element, which may be localized in one limb or involve the whole body. Over time, the speed varies greatly, and the pattern can be completely reversed, such as going from full extension external rotation to full flexion and internal rotation in upper extremity.

f. Athetosis - there are large movements of the more proximal joints, often with an extensor pattern.

g. Chorea - involves jerky physical movements, most commonly including the digits, and has varying degrees of range of motion.

h. Tremor - a rhythmic physical activity of small magnitude that usually involves small joints, is not a common feature in children with CP.

i. Mixed problems - characteristics of more than one type of physical and sensory problem. 

j. Involuntary reflex – This is a condition where an automatic muscle response to a stimulus response is disturbed.

k. Vestibular response - the vestibular system is a sensory system that fails to provide a sense of balance and spatial orientation leading to the coordination of body movements with balance.

l. Limited range of motion - This limits the full range of motion of the joints of the body due to the tightness of the muscles.

m. Proprioception problems - this is the inability to sense the position and location of the body and its parts and the tactile system, changes in body position, and body movements.

n. Abnormal muscle Tone – It results in, inability to respond to or withstand an external force, stretch or change in direction. This makes the child unable to respond quickly to an external force through balance responses, protective responses.

o. Praxis problems - a reduction in motor planning in physical activity in which the body is unable to produce an appropriate motor response to the activities.

p. Decreased coordination - both static and dynamic methods result in a loss of balance in the body's balance.

8. Classification of cerebral palsy according to problems 

a. Classification by Severity Level

• Mild - mild cerebral palsy means a child can move without assistance; His or her daily activities are not limited.

• Moderate – Moderate cerebral palsy means that a child will need an assistive device, light therapy interventions and adaptive devices to reduce mild stiffness in the limbs that are “calipers” to carry out daily activities.

• Severe – Severe cerebral palsy means that a child will require a serious medical and therapy intervention and have significant challenges carrying out daily activities.

b. Classification according to the distribution of limbs affected

Cerebral palsy is also classified on the basis of which part of the body or arms and legs are affected. On the basis of the affected parts, it is mainly classified into five parts –

• Monoplegia - means only one limb is affected.

• Hemiplegia – In this one side/part of the human body, both arms and legs are affected on the same side

• Diplegia – Mostly both the legs are affected in this, but sometimes its effect is visible in the hand also.

• Paraplegia – Under this both the legs of the person are affected.

• Quadriplegia – Under this, both the hands and both the legs i.e. the whole part of the body is affected.

c. Classification based on motor function

Brain injury that causes cerebral palsy that affects motor function, which affects the maintaining the ability to control the body. Spastic and non-spastic into two main groups are included. Each has many variations and a mixture of both types is possible.

• Spastic cerebral palsy is characterized by increased muscle tone.

• Non-spastic cerebral palsy will exhibit decreased or fluctuating muscle tone.

The motor function classification describes the area of the brain injury affecting a child's body. Using motor function allows parents, doctors, and therapists to describe a specific, yet comprehensive, symptom of a child, which helps doctors choose the treatment with the best chance for success.

d. Classification based on muscle tone

Muscle tone is defined as the tension in the muscles when the muscle is at rest. It is a muscle response to an external force, such as a stretch or a change in direction. Appropriate muscle tone enables our body to respond to stretch faster.

• Hypertonia/hypertonic - increased muscle tone, often resulting in very stiff limbs. Hypertonia associated with spastic cerebral palsy

• Hypotonia/hypotonic - decreased muscle tone, often resulting in muscle loose, floppy limbs. Hypotonia is associated with non-spastic cerebral palsy and they have a weak strength to keep their bodies strong.

9. Types of cerebral palsy 

A. SPASTIC CEREBRAL PALSY 

B. DYSKINETIC CEREBRAL PALSY

• DYSTONIA
• ATHETOID
• CHOREA

C. HYPOTONIC CEREBRAL PALSY

D. ATAXIC CEREBRAL PALSY

E. MIXED CEREBRAL PALSY

A. SPASTIC CEREBRAL PALSY 

Spastic cerebral palsy is the most common form 80–90% of cerebral palsy. The muscles of these children are stiff and rigid. These can be in the upper part of the body, the lower part, or both. They can be on one or both sides of the body.

Because their muscles are tight and stiff, children with spastic cerebral palsy do not move easily. Their movements may seem jerky. Often, the muscles do not do what the child wants them to do. Spastic cerebral palsy can be mild or severe. It also depends on how much the brain is involved. For example, a child with mild spastic cerebral palsy may have stiffness in only one hand. Children with severe Spastic cerebral palsy, however, may not be able to move certain muscles.

a. What causes Spasticity paralysis?

In cerebral palsy, convulsions occur before, during or after birth due to damage to the motor cortex of the brain. This part of the brain is considered the supreme command center for control of body movements. The Motor Cortex is the area of the cerebral cortex that is involved in the planning, control, and execution of voluntary movements. Classically, the motor cortex is a region of the frontal lobe, located in the posterior anterior gyrus, anterior to the central sulcus.

• Due to Damage to the Motor Cortex result in poor coordination of voluntary movement and cause muscle spastic and result in poor relaying of signals to other parts of the brain to control movement of limbs

• Due to Damage to the Pyramidal Tracts the motor cortex fails to send proper signal and information that is essential for sight, touch and movement 

• The damage to the brain is due to infection and prenatal brain haemorrhage

• Traumatic injury to the immature brain after birth

• Lack of oxygen to the brain during birth

b. The most common symptoms of Spastic cerebral palsy are:

Stiff, tight muscles on one or both sides of the body (hypertonia)

• Unable to extend your joints full range of motion
• Limited joint mobility
• Unusual gait pattern
• Tight leg with scissor pattern
• Joints don't fully extend 
• walking on tip toes
• Stiffness in limbs
• Poor postural reflexes
• Abnormal reflex action
• Other co-presenting problems may also present themselves, such as hearing and vision impairment, but these are not directly related to cerebral palsy; They are caused by an early birth injury.

c. Effect of spasticity on the upper limbs (arms and hands)

If spasticity affects one or both arms, it can lead to:

• Elbow flexed
• Wrist flexed
• Fingers clenched

d. Impact on the lower limbs

If spasticity affects one or both legs, it can lead to:

• Legs raised when lying down or body leans forward when standing due to which the legs are pulled together like scissors
• Change in a person's body posture while standing
• Tightness in the foot muscles causes the toes to point down, and the heel to the ground
• The toe is pulled upwards and backwards towards the shin
• Flat feet – Flat feet occur when the foot has very few arches or no arches. In cerebral palsy children, flat feet develop due to decreased muscle tone.
• Clubfoot - Clubfoot occurs when the foot turns inward, often to the point that the bottom of the foot is facing down or up.
• Walking on the toes – Cerebral palsy can cause severe contraction of the Achilles tendon, which can cause the child to walk on the toes or balls.

e. Muscle group stiffness seen in Spastic cerebral palsy

• Hip Adductor Muscles - The hip adductors are the muscles of your inner thigh, which support balance and alignment. These stabilizing muscles are used to engage the hips and thighs or move them toward the midline of your body. Their primary action is to bring and join the thighs together; They also aid in rotation and flexion of the thigh.

• Hamstring muscles – The hamstring muscles are included in the back of the thigh. The hamstring muscles are responsible for the movement of your hip and knee, which helps in walking, sitting, flexing the knees and flexing the hip.

• Quadriceps Muscles - The quadriceps are a group of four muscles located on the front of your thigh. These four muscles work together to help you stand, walk, run and move around with ease. They also keep your knee cap (patella bone) stable.

• The calf muscles - the calf muscles in the back of the legs are responsible for plantar movement of the foot and ankle. During walking, running or jumping, the calf muscle pulls the heel up to allow forward movement.

B. DYSKINETIC CEREBRAL PALSY

Dyskinetic forms of cerebral palsy have unstable limb movement that is involuntary (outside their control). These involuntary limb movements are especially noticeable when a person attempts to perform some activity.

i. What causes Dyskinesia?

Dyskinetic cerebral palsy results from an injury to the brain we call the basal ganglia. Different forms of dyskinesia (Dystonia, Athetosis and Chorea) result from injury to slightly different structures within the basal ganglia. The basal ganglia are like the brain's switchboard for interpreting messages between the activity center and the spinal cord – it is responsible for controlling voluntary activity. Other important non-motor related functions also occur through the connections of the basal ganglia with other areas of the brain, such as controlling emotion, mood, and behavior.

ii. Types of Dyskinetic activity:

a. Dystonia - involuntary and repetitive movements of the limbs

Dystonia is characterized by involuntary muscle contractions that result from slow twisting or repetitive movements or abnormal sustained postures, triggered by attempts to move the limbs.

iii.Symptoms of Dystonia include:

• repetitive and continuous activity
• strange limb movements
• activity that is rapid or slow and is often painful
• involuntary movements triggered by attempts at controlled movements
• activity may increase pain

b. ATHETIOD - slow, involuntary movements of the limbs due to involuntary contraction of muscles

Athetoid cerebral palsy is a type of cerebral palsy characterized by athetosis, or uncontrolled movement. This lack of control usually leads a person with Athetoid cerebral palsy to make erratic movements, especially when the person is in motion. Fluctuating muscle tone is experienced in Athetoid cerebral palsy. For people with this condition, their muscles may be tighter or looser than usual.

i. Symptoms of Athetosis include:

• Slow and involuntary muscle activity
• Unwanted activity may be small or large, rapid, irregularly repetitive, random or jerky
• Fluctuations in involuntary and uncontrollable activity sometimes affecting the whole body
• The muscles of the face and tongue may also be affected.
• Can affect a person's ability to control lip and tongue movement, breathing, and laryngitis
• Experiencing difficulties with eating and drinking
• Difficulty holding an object due to fluctuations in muscle tone

ii. Main causes of Athetoid cerebral palsy

• Hypoxic-ischemic brain injury - This injury is a form of cerebral hypoxia, in which oxygen cannot reach the cells in the brain. Lesions in the putamen and thalamus due to this type of brain injury are the primary cause of Athetoid and can occur at birth and shortly thereafter. Lesions that arise after this period are usually the result of brain injury or infection. The cerebral cortex and white matter are often relative sparing, so intelligence is often normal.

• Bilirubin encephalopathy - also known as kernicterus, is an accumulation of bilirubin in the gray matter of the central nervous system. The main accumulation targets of hyperbilirubinemia are the basal ganglia, the ocular movement nucleus, and the acoustic nuclei of the brainstem. Several factors are involved in the pathogenesis of bilirubin encephalopathy, including the transport of bilirubin across the blood–brain barrier and to neurons.

c. CHOREA - Irregular, unpredictable movements of the limbs

The word  Chorea is derived from the Greek word 'dance'. Chorea is characterized by involuntary movements that are small, sudden, irregular and unpredictable. People with mild chorea may appear fidgety or clumsy, while those with more severe choreiform movements may display wild, violent movements that are large in amplitude (ballismus). Movements can affect various body parts and interfere with movement, speech, and swallowing.

Chorea may be worsened by attempts at anxiety or tension. Movements are reduced during sleep. Choriotome movements may accompany athetosis and when this occurs, they are known as choreoathetosis.

C. WHAT IS HYPOTONIC (ATONIC) CEREBRAL PALSY?

Atonic cerebral palsy, also known as hypotonic cerebral palsy or Ataxic-hypotonic cerebral palsy, is a rare form of the disorder that affects various muscle groups and activity. It can also have accompanying conditions, such as seizures and vision impairment.

Hypotonic CP is a form of cerebral palsy that causes hypotonia, also known as low muscle tone. It also loosens up your baby's muscles and these "floppy" muscles can make everyday activity tiring as well as difficult. This causes many children with Hypotonic cerebral palsy to reach physical and mental delayed developmental (crawling, standing, etc.) more slowly than their peers.

Hypotonic cerebral palsy is caused by either abnormal brain development or brain damage. Especially for this type, damage is often found in the cerebellum. Infections, blood clots, stroke, lack of oxygen and difficulties during the breathing process can lead to cerebral palsy.

i. What are the symptoms of Hypotonic cerebral palsy?

• Decreased sensory processing in which the vestibular, proprioceptive and tactile systems fail to alert the brain of changes in body position. 
• Poor head and neck control
• Decreased praxis or motor planning in which the body is unable to produce an appropriate motor response to activities
• There is a lack of balance in the body, both static and dynamic.
• Decreased coordination of upper and lower body movements
• Delayed physical skills
• shortness of breath
• Loosening of ligaments and joints
• Poor balance
• Impaired physical mobility
• Exhaustion
• Difficulty sitting/standing
• Hyperactivity of joints

ii. What are the causes of Hypotonic cerebral palsy?

• Abnormal brain development or brain damage. The damage is often found in the cerebellum.
• Infections, blood clots, stroke, lack of oxygen and difficulties during the delivery process can lead to cerebral palsy.
• Hypoxic ischemic encephalopathy – This is a type of brain abnormality that occurs when the brain does not receive enough oxygen or blood flow in a timely manner. Hypoxic means not enough oxygen; Ischemic means not enough blood flow; and Encephalopathy means brain disorder.

D. WHAT IS ATAXIC CEREBRAL PALSY

Ataxic cerebral palsy occurs in 6% of people with cerebral palsy and is the result of damage to the cerebellum.

Like all other forms of cerebral palsy, ataxic cerebral palsy is a developmental disorder that affects the precise movement (motor function) of a specific function of the muscle. Ataxic cerebral palsy is characterized by problems with balance and coordination.

These issues are due to damage to the motor control centers of the developing brain. Children with ataxic cerebral palsy have a hard time controlling their movements. They are unstable and struggle with precise movements, such as writing and holding small objects. Ataxic cerebral palsy can affect the hands, feet, eyes and even the ability to speak.

Risk factors for ataxic cerebral palsy are events that increase the chances of a child developing the condition. Mothers who had poor maternal health have a higher risk of having a child with ataxic cerebral palsy.

i. Signs and symptoms of ataxic cerebral palsy: The primary symptoms of ataxic cerebral palsy are problems with balance and coordination of motor skills.

• To apply precocious motor skills
• Trouble walking and balance
• Problems with handling anything

ii. Developmental signs of ataxic cerebral palsy child include:

• Legs spread too far while walking
• Trouble shaking hands
• Unsteady gait
• Problems handling objects
• Difficulty repeating tasks
• Difficulty speaking
• Slow eye movement

E. WHAT IS MIXED CEREBRAL PALSY?

Mixed cerebral palsy is a developmental disorder caused by brain damage that occurs before or shortly after birth. Those diagnosed with Mixed cerebral palsy have damage to motor control centers in several parts of the brain. Children who exhibit one or more types of cerebral palsy that exhibit movement problems are classified as mixed Cerebral Palsy.

Cerebral palsy is the result of damage to the developing brain or malformations in the brain. Injuries to different motor control centers give rise to different types of cerebral palsy. In Mixed cerebral palsy, several parts of the motor control centers may be damaged, leading to movement problems seen in different types of cerebral palsy.

i. Children with this condition may have problems with mobility, including:

• Spasticity (sudden, convulsive movements),
• Involuntary movement,
• Imbalance and
• Lack of coordination

ii. Common signs and symptoms of Mixed cerebral palsy are:

• Abnormal reflexes
• Jerky movement
• Problems with coordination
• Abnormal physical growth
• Body stiffness
• Abnormally stiff muscles
• Unusual gait
• Inability to physically roll over on stomach and back
• Using only one hand when reaching for objects
• Inability to support the head

iii. Causes and risk factors of Mixed cerebral palsy

• Damage to the motor cortex - The motor cortex is one of the most important components of the motor control centers of the brain. Body movements and gestures begin as signals from the motor cortex that are related to other parts of the brain that control motor control. These signals are then carried to the nerves in the muscles. Damage to the motor cortex causes tension in the muscles, joints, and tendons.

• Damage to the pyramidal tracts - The pyramidal tracts are the pathways that travel from the motor cortex to the nerves in the spine. Damage to the pyramidal tract has a similar effect on the damaged motor cortex, as signals from the motor cortex cannot travel through the pyramidal tracts. Therefore, this type of brain injury also causes the movement problems seen with Spastic cerebral palsy.

• Damage to the Basal Ganglia - The basal ganglia are a group of several types of neurons in the center of the brain. The basal ganglia process signals from the motor cortex before being sent to the brainstem. Athetoid cerebral palsy is caused by damage to the basal ganglia, which help control voluntary movements and cognition. Children with Athetoid CP tend to have issues with high and low muscle tone.

• Damage to the Cerebellum – The role of the cerebellum in motor function is to maintain balance and coordination of movement. Children with damage to the cerebellum have problems with posture, walking and fine motor skills. Some children with Athetoid cerebral palsy also have damage to the cerebellum. Children can develop Ataxic cerebral palsy, if only part of the brain is damaged by the cerebellum.

10. Frequent questions that parents ask the Therapist   

a. Will my child get better?  

Certainly, there is no cure for Cerebral Palsy, but a child's quality of life can improve with: proper therapeutic intervention and rehabilitation. Therapy includes physiotherapy, occupational therapy, and speech therapy, special education, aids and appliances support to help child get around and communicate with others. Treatment may involve surgical intervention to correct deformities.

b. Will my child’s condition deteriorate? 

Deterioration of child’s condition depends upon the type and severity of the problems. Cerebral palsy cases with only locomotors problem can lead a quality independent life with proper therapy care and rehabilitation and join normal mainstream of life.

The success rate varies when we talk about cerebral palsy with physical as well as severity of mental retardation or we can say mixed cerebral palsy. Physical recovery also affects in different conditions such as malnutrition, convulsions, poor immune system etc. Children with physical and mental disorders have poor response to environmental factors such as parental recognition, identification of objects, food, spatial relationships, unwanted reflexes, convulsions, vision problems, breathing system problems, bowel and bladder problems, persistent fever and illness etc.

These conditions therefore impede healing in a sustained manner, leading to slow brain and physical development. 

c. Will my child learn to walk? 

The child ability to walk depends upon the type, condition and severity of cerebral palsy. The type of cerebral palsy with ataxic, spasticity, mild hypotonic and athetoid can achieve walking pattern with continued therapy effort. But in cases with severe mental retardation and multiple disability can hamper walking pattern due to lack and inability of respond to various stimulus and intervention as their brain is devoid of responces

  

d. Will my child have a normal life expectancy? 

When we talk about the improvement and life expectancy of cerebral palsy, we find that prognosis expected outcome of the cerebral palsy is classified into two types. 

• One is cerebral palsy with physical deformity and the 

• Other is cerebral palsy with physical deformity and mental retardation (mixed cerebral palsy).

Where there is cerebral palsy with physical disorders, the success factor is very high and a normal life can be lived only if the intervention of therapy is appropriate according to the condition of the pathology. Children affected by ataxic cerebral palsy improve much more rapidly than in spastic, athetoid, and hypotonic cases. The success rate also depends on age factors. Children who begin therapy within one year of age begin to find success and can join the general mainstream.

The success rate varies when we talk about cerebral palsy with physical as well as intellectual ability and severity of mental retardation. Physical recovery also affects different cases such as malnutrition, convulsions, poor immune system etc. Children with physical and mental disorders have poor response to environmental factors such as parental recognition, identification of objects, food, spatial relationships, unwanted reflexes, convulsions, vision problems, breathing system problems, bowel and bladder problems, persistent fever and illness etc.

These conditions therefore impede healing in a sustained manner, leading to slow brain and physical development. 

Proper therapy process not only brings about physical improvement, but also other physiological improvements such as blood circulation, improves skin and appearance, good sleep, strengthens functional abilities, relieves stiffness, visual ability and recognition, feeling of hunger , feeling proper bowel and bladder functions, responding to sound and moreover responding. Love, acceptance and working with facts are the keys to healthy growth and physical development for children with cerebral palsy.

Therapy is equivalent to oxygen in the treatment of cerebral palsy. This is why physiotherapy and occupational therapy is indeed a great treatment involving art and science and one can certainly imagine the improvement when done in a technical manner.

10. Conclusion 

Cerebral Palsy is a diverse group characterized by delayed body function, disorders and neurological that is non-progressive. Although the clinical picture may change as the brain matures. There is a need to know the associated signs and symptoms. Diagnosis and thorough testing is needed to know the exact problem in a child affected by cerebral palsy.

Cerebral palsy children require a complex health care team for identification, assessment, therapy intervention and follow-up with these children that gives them the best quality of life they can have.

Early physiotherapy and occupational therapy interventions provide an opportunity for the child to practice functional activities, body positions and develop proper gait pattern. By practicing meaningful and effective skills in a variety of environments, the child will have the opportunity to acquire skills that encourage them to be more independent with the activity of daily living and to increase their level of participation in society.

Therefore, effective therapy plan for children with cerebral palsy focuses on promoting functional independence and preventing further muscle weakness by applying needful exercises according the condition.