Cerebral Palsy Causes Classification and Treatment| Dr N Layyous

Cerebral Palsy: Causes, Classification and Treatment

Definition of Cerebral Palsy:

The Cerebral Palsy is a group of disorders or abnormality in movement, posture or coordination, caused by injury and damage to the motor control centers of the developing brain and can occur during pregnancy, childbirth or after birth up to approximately age of three.

According to the degree of the damage and the affected areas, some people are severely disabled while others have minor disruption.

Around 2000 babies from all social backgrounds and ethnic groups are diagnosed every year.

Cerebral Palsy may cause abnormal brain development for some people and can lead to results such as intellectual disabilities, blurred vision, seizures and many others serious problems.

Causes of Cerebral Palsy:

Cerebral Palsy (CP) was identified in 1860 by William Little, an English Surgeon, who referred the cause of the disorder mainly to the possibility of Asphyxia during Birth.

In 1897, Sigmund Freud, a Neurologist proved the contrary. He stated that Birth difficulties are only symptoms caused by other effects on the fetal development.

The researches, conducted during 1980 by the National Institute of Neurological Disorders (NINDS), submitted that few cases of CP are caused by the lack of Oxygen during Birth.

Most people think that CP is caused by difficulties during Labor and Birth, but its actually only less than 10% of CP that is due to Birth Asphyxia. As mentioned before, CP is a condition caused by injury and damage to the motor control centers of the developing brain, and can occur during pregnancy, childbirth or after birth up to about the age of three.

Actually, Antenatal Factors causing CP are found in 80% of the affected, including genetic problems… malformations of brain and maternal infections such as rubella or toxoplasmosis.

Premature delivery is an important cause for CP, around 40-50% of all children who develop CP were born prematurely.

Premature infants are vulnerable due to the incomplete development of their organs, increasing the risk of Hypoxic injury of the Brain. Low birth weight is a risk factor for CP, and premature infants usually have low birth weights < 2 kgs.

Multiple Birth infants (Twins, Triplets…) are more likely to be born early or have a low weight at birth than single birth infants.

Maternal infections, even infections that are not easily detected, may triple the risk of the child developing CP.

Infections cause the release of Cytokines, produced as part of inflammatory response. These chemicals are toxic to the brain.

In brief, CP is a result of the below:

• Antenatal or Prepartum causes of cerebral palsy:

1. Random mutations in genes controlling brain development.
2. Maternal infections ( toxoplasmosis, chicken pox, German measles….)
3. Infant's infections.
4. Fetal stroke (compromise in blood supply).
5. Exposure to radiation
6. Multiple gestations
7. Breech birth

• Intrapartum (during labor) causes of cerebral palsy:

1. Premature delivery
2. Birth trauma or asphyxia

• After birth causes of cerebral palsy

1. hyperbilirubinemia (jaundice).
2. Meningitis.
3. Lead poisoning.
4. Shaken baby syndrome
5. Choking on foreign objects such as toys, food, drowning or poisoning Unfortunately, in many cases doctors can’t give the parents a clear reason why the brain has been injured or failed to develop as it should, and there may be multiple or complex causes.

Signs and Symptoms of cerebral palsy:

The signs and Symptoms of CP are various and begin to appear directly after Birth.

They might affect one limb or one side of the body, as well as the whole body.

All types of CP are characterized by irregular muscle tone, reflexes, abnormal motor development and coordination.

1. Variation in muscle tone either too stiff or too floppy
2. Stiffness of the muscles and Hyperreflexia (spasticity)
3. Stiff muscles with normal reflexes ( rigidity)
4. Lack of muscle coordination (ataxia)
5. Tremors or involuntary movements
6. Slow and writhing movements (Athetosis)
7. Preferring to use one side of the body more than the other such as eating with only one hand or dragging a leg while crawling
8. Delays in reaching motor skills milestones, such as sitting up alone or crawling
9. Difficulty in walking, such as walking on toes, scissors like gait with knees or wide gate
10. Excessive drooling or difficulty swallowing, sucking, eating
11. Difficulty with drinking or eating
12. Delays in speech development or speaking
13. Difficulty with precise motions

Since the brain damage or injury is not progressive, the symptoms don’t usually worsen with age.

Classification of Cerebral Palsy:

A- Spastic :

• The most common type, occurring in 80% of all cases
• Characterized by hypertonic muscles
• Easy to manage by the person affected
• The spasticity will cause pain and stress from tightness leading to very early onset of arthritis and tendonitis
• Usually caused by damage of upper motor neuron, corticospinal tract or motor cortex

B- Ataxic :

• Caused by damage of the cerebellum
• Less common than spastic (10% of cases)
• Characterized by hypotonic and tremor
• Motor skills such as typing, writing, or using scissors for cutting might be affected
• Balance might be affected as well

C- Athetoid or Dyskinetic CP:

• mixed type characterized by both Hypotonia and Hypertonia combined with involuntary motions
• Trouble holding the body in an upright steady position like sitting or walking, It will take a lot of work and concentration to reach a certain spot using the hands (like scratching the nose or holding a pen
• The damage of brain in this type of CP is usually pyramidal, extra pyramidal tract or basal ganglia
• High level of Bilirubin in the blood of new-born babies is an important cause of this type of CP

Treatment of Cerebral Palsy:

There is no cure for Cerebral Palsy, but treatments and therapies may reduce its impact by providing new ways for communication. The treatment is a lifelong multidimensional process.

Children with CP do best when they get special help from an early age. In fact, the brain changes a lot at early ages, the ability to assess the extent of cerebral palsy at first is difficult, but most of the experts advice that babies should be assessed at age 9 to 12 months.

The brain up to age of eight years is not concrete in its development, it reorganizes and reroutes many signal paths that may have been affected. The earlier it is treated, the more successful it will be.

The treatments will include:

A- Medical Treatment of Cerebral Palsy

It mainly aims to lessen the spasticity of muscles and treat pain.

The selection of medication depends on whether the problem affects only certain muscles (isolated) or the whole body (generalized)

-Isolated spasticity: Local injection of Botox directly into the muscle (nerve or both) but might cause severe weakness as side effect.

-Generalized spasticity: Oral medications such as diazepam, Tizanidine, Baclofen which can be pumped directly to the spinal cord with a tube; the pump is surgically implanted under the skin of the abdomen.

B- Physical Therapy Treatment of cerebral palsy: -

Muscle training and exercises can help strength, flexibility, balance motor development and mobility of the muscles.

C- Occupational Therapy Treatment of Cerebral Palsy:-

It promotes the child’s independent participation in daily activities and routines at home/school.

D- Speech Therapy Treatment of Cerebral Palsy:-

IIt improves the ability to speak clearly or to communicate easily using communication devices.

E- Surgical Treatment of Cerebral Palsy: -

It helps loosen the tight muscles release fixed joints.

The insertion of Baclofen pump (Baclofen is a muscle relaxant) during the stage while a patient is a young adult, sends bits of baclofen alleviating continuous muscle flexion

Straightening abnormal twists of the leg bones, the surgery is called Derotation Osteotomy in which the bone is broken (cut) and then set in the correct alignment.

Choosing the muscles mostly affected in their movement and cutting their nerve supply and spasms, procedure called Rhizotomy.

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist