Delayed milestones of development in a baby, such as a delay in sitting up or walking, may lead to a diagnosis of cerebral ataxia. For instance, most babies learn to walk by 12 to 14 months of age. If it is noticed that even at 20 months the baby cannot walk and other milestones of development are delayed, together with various other findings such as seizures and speech problems, cerebral palsy may need to be excluded.
What is Cerebral Palsy?
Cerebral palsy comprises disorders of posture, movement and muscle coordination that most commonly occur due to any cause that affects development of the brain while the baby is still in the uterus or within 2 years of birth. Even if it develops after birth, the condition may not be diagnosed till much later. The underlying brain disorder, affecting mainly the motor areas of the brain, is non-progressive in nature. This means that the disruption is in the areas of the brain that are responsible for muscle control and coordination and it does not get worse over time.
The motor impairment may produce symptoms such as lack of muscle coordination, delayed milestones of development, weakness, paralysis, abnormal limb movements, epilepsy, and speech problems. Mental retardation and learning disabilities are the other features that may be seen. Although cerebral palsy does not get progressively worse, it cannot be reversed or cured. Treatment aims at reducing disabilities as far as possible and preventing complications.
How does cerebral palsy occur?
Cerebral palsy occurs when areas of the brain which are responsible for balance, movement, and coordination do not develop properly or are damaged due to any cause. This may happen while brain development is taking place when the baby is still in the mother’s uterus or rarely due to brain damage occurring during or shortly after birth. Abnormalities may be present in one or more parts of the brain and the signs and symptoms will reflect the area of brain damage.
Causes of Cerebral Palsy
A definite cause may not always be found which can be held responsible for cerebral palsy. Often a number of factors may be involved. Any factor that interferes with normal brain development may lead to cerebral palsy.
Risk factors may include :
- Medical conditions in the mother, such as seizure disorder, infection, and thyroid problems.
- Genetic defects causing brain malformations and abnormality in brain cells and connecting nerve fibers.
- Certain hereditary conditions.
- Premature baby. Spastic diplegia may be related to preterm birth.
- Low birth weight.
- Multiple births, such as twins or triplets.
- Disorders affecting the baby while in the uterus.
- Neonatal encephalopathy.
- Kernicterus – a rare neurological condition that may occur in a newborn due to severe jaundice. The extremely high bilirubin in the blood may get deposited in the brain and lead to brain damage.
- Complications during labor and delivery.
- Perinatal factors, such as hypoxia (lack of oxygen), perinatal asphyxia, stroke, CNS infections.
- CNS trauma in early childhood, either following an accident or as a result of child abuse, such as inflicted trauma to the head or shaken baby syndrome.
- Intracranial hemorrhage, which may occur due to prematurity, trauma, or vascular malformations.
- Severe systemic disorders in early childhood, such as stroke, meningitis, lead poisoning, sepsis, malnutrition, and dehydration.
Types of Cerebral Palsy
The 3 major types of cerebral palsy are :
- Spastic cerebral palsy
- Athetoid cerebral palsy
- Ataxic cerebral palsy
Symptoms of more than one type of cerebral palsy may be present in a patient, such as spastic and athetoid together.
Spastic Cerebral Palsy
The majority of cases of cerebral palsy are of the spastic type which is characterized by increased muscle tone. There is spasticity or abnormal stiffness of the muscles which makes movement difficult. There are varying degrees of severity producing mild to severe types of deformities.
- In spastic diplegia, where both legs are affected, abnormally stiff muscles of the hips and legs result in a form of deformity known as scissoring. The legs turn inwards and cross at the knees, producing a type of walking known as scissored gait.
- In spastic hemiplegia, only one side of the body is affected.
- In double hemiplegia, both arms are more affected than the legs.
- In spastic quadriplegia, both legs and both arms, trunk, and face are affected. This is an extremely severe type of cerebral palsy since such patients are unable to walk at all. The condition may be further aggravated by mental retardation, seizures, and speech difficulties.
Athetoid Cerebral Palsy
In this type of cerebral palsy, also known as dyskinetic cerebral palsy, there may be involuntary and uncontrolled writhing or jerky movements. It usually affects the whole body and the muscle tone may vary from stiff to flaccid, thus making it difficult to sit or walk. Such children may face difficulties in sucking, swallowing, or speaking when muscles of the face, mouth, and tongue are affected.
Ataxic Cerebral Palsy
Here, balance, coordination, and depth perception are mainly affected, which may cause the patient to walk in an unsteady manner with feet apart. Problem with fine coordination may make tasks such as writing difficult.
Signs and Symptoms of Cerebral Palsy
The symptoms may be mild to severe. In cases with very minor brain damage, the symptoms may not be recognizable to the untrained eye.
- Delayed milestones of development, such as keeping the head straight, sitting up without support, crawling, standing up, and walking.
- Muscles may be stiff or flaccid to varying degrees.
- Unsteadiness in walking.
- Scissor gait.
- Uncontrolled abnormal movements.
- Abnormal touch or pain sensations.
- Deformities such as shortened limbs on the affected side.
- Stiffening of the joints.
- Learning disability – some children have normal intelligence.
- Mild to severe mental retardation.
- Speech, vision, and hearing problems.
- Difficulty in bladder and bowel control.
- Difficulty in swallowing.
Diagnosis of Cerebral Palsy
There is no definite test to diagnose cerebral palsy. The history, physical and neurological examination, and various tests may suggest the diagnosis. Special importance should be given to noting the developmental milestones.
Tests may include :
- Blood tests.
- Urine tests.
- Chromosomal analysis – to rule out a genetic syndrome.
- Neuroimaging studies – to evaluate brain damage. These may include cranial ultrasonography, CT scan and MRI of the brain.
- Electroencephalography (EEG) – to diagnose seizure disorders.
- Electromyography (EMG).
- Nerve conduction studies (NCS).
Treatment of Cerebral Palsy
Although there is no cure for cerebral palsy, treatment can help to reduce disabilities and prevent complications. Treatment for each child has to be tailor-made to suit that particular patient. Treatment options may include :
Physical therapy may help with sitting, holding the head up, walking and to prevent deformities. This may be done by developing muscle strength and control by means of physical exercises, and by the use of splints and braces.
Occupational therapy may help to develop physical skills so that the person can be independent as far as possible in day to day activities.
Speech therapy may help with speech and swallowing difficulties.
Counseling and Behavioral Therapy
This may help to cope emotionally and psychologically.
- To reduce spasticity and abnormal movements. These may include dopaminergic drugs such as levodopa and trihexyphenidyl, muscle relaxants such as baclofen, benzodiazepines, and Botulinum toxin type A.
- Drugs to control seizures, such as benzodiazepines and anticonvulsants.
- Treatment of other conditions associated with cerebral palsy, such as pain and incontinence.
Surgery may include :
- Selective dorsal rhizotomy (SDR) involves cutting a few specific nerves at their roots at the base of the spinal column. This procedure may help in sitting up, standing, and walking by reducing muscle stiffness in case of severe spasticity where other treatments have failed.
- Implantation of a baclofen pump in the abdominal wall will provide a continuous dose of baclofen and thus help in muscle relaxation.
- Stereotactic surgery is done to that part of the brain which is associated with muscle tone and movement.
- Reconstructive surgery can help to correct spasticity and deformities.
- Mechanical aids such as walkers and wheelchairs.
- Communication aids such as voice synthesizers and computers.
Complications of Cerebral Palsy
- Contractures due to muscle spasticity.
- Premature aging.
- Post-impairment syndrome – there is tiredness, weakness, and pain due to excessive strain on the body to function in day to day life.