Cerebral palsy is static encephalopathy where the fixed and non-progressive brain lesion results in motor impairment.
Cerebral palsy can be defined as non-progressive lesions of the central nervous system that interfere with the control of one or more limbs by paresis, involuntary movements, or incoordination and that sensory, emotional or psychological disturbance may exist as well.
Cerebral palsy is classified by the neuropathic type of motor dysfunction and by the anatomic region of involvement.
The neuropathic types are spastic cerebral palsy, athetoid cerebral palsy, ataxic cerebral palsy, and hypotonic cerebral palsy.
The anatomic patterns are quadriplegic cerebral palsy, diplegic cerebral palsy, hemiplegic cerebral palsy, double hemiplegia, and triplegia.
The exact cause of cerebral palsy is not known.
In most cases risk factors can be detected; however, in 30% of patients, no risk factors can be identified.
Prenatal risk factors – Maternal infection like TORCHES infection; fetal exposure to drug-like cocaine, heroin and marijuana, and alcohol; congenital malformation of the brain; rhesus blood group incompatibility resulting in kernicterus; maternal health problems like infections, renal failure, epilepsy, mental retardation, hyperthyroidism, severe toxemia, incompetent cervix and third trimester bleeding; allele of apolipoprotein E gene on chromosome 19; irradiation of mother during the 1st three months of pregnancy; and abnormally low fetal biophysical profile score (antenatal hypoxia).
Perinatal risk factors – Anoxia (a tight nuchal cord, placenta abruption); hypoxia (Oxytocin augmentation, cord prolapse, breech delivery); multiple births; complication of multiple births; abnormalities of blood flow to the brain; trauma; kernicterus; vaginal bleeding at the time of admission; premature rupture of membrane; chorionitis; sepsis in the neonatal period in low birth weight infant; bronchopulmonary dysplasia and prolonged ventilation in a preterm infant; and open heart surgery for severe congenital heart disease.
Postnatal risk factors – Head trauma; a vascular accident in the brain; CNS infection; kernicterus; hypoxia or anoxia from such causes as near-drowning, suffocation, cardiac arrest, and other problems.
Cerebral palsy is a very vibrant disease with a variable presentation. Some cerebral palsies so trivial that no opinion may be sought until the child is several years old and others are so severe that spasticity may be present at birth.
The usually presenting complaints are developmental delay, motor delay, speech disturbance, and associated problems like seizure disorders.
On examination, there will be abnormal posture, the persistence of primitive reflex, exaggerated knee jerk, ankle clonus, spasticity of muscles, and plantar extensor after 2 years of age, aid in the diagnosis of cerebral palsy.
Intelligence, speech, vision, hearing assessment, balance assessment, gait assessment, rotational profiles of lower limb assessment are needed.
More than investigations multi-disciplinary assessment is needed to make the diagnosis of cerebral palsy.
The multi-disciplinary team includes a developmental pediatrician, pediatric neurologist, pediatric orthopedic surgeon, physiotherapist and, orthotics specialist.
Once the diagnosis of cerebral palsy is suspected, then blood investigation, MRI brain, and skeletal survey are done.
In an ambulant child, gait analysis is an important tool in the assessment and planning of the treatment.
Principles of cerebral palsy treatment –
The common aim of treatment is to achieve the maximum function of which the child may be capable.
No cerebral palsied child can become completely normal, but without correct treatment and guidance, many may fail to achieve what might otherwise be possible and some may be handicapped by lack of experience or by the development of deformity that need not have occurred.
The gradual development of the nervous system and growth of the child and his intellect is an important factor. The aid, direction, and teaching offered by physiotherapeutic measures, supplemented by parental care, channels the developing abilities to the achievement of maximum function.
The amount of treatment that is required and whether it should be as an in-patient or out-patient will depend on the individual circumstances and requirements.
Each child needs a regime of treatment that is appropriate to his age, intelligence, and type and extent of disability.
Management of spastic, rigid, and ataxic children is much more rewarding than the treatment of athetosis.
Up to 6 years of age, the mainstay of the treatment is non-surgical with antispastic medication, physiotherapy, braces, and hip surveillance.
After 8 years of age, surgical interventions are preferred and surgical dosing is variable to each and every child.
The cerebral palsy child needs long term regular follow up.
Each child will behave differently, so variable anticipation will be present.