Cerebral palsy

• Cerebral palsy:

  • Non-progressive, permanent neurological condition commonly affecting normal movement and posture
  • Most common cause of childhood motor impairment
  • Severity and type of symptoms vary significantly
• Aetiology:

  • Caused by damage to the developing brain which can occur while the baby is in utero, during birth or in the neonatal period
  • Often caused by hypoxia, haemorrhage or infection
  • Different areas of the brain being damaged correspond to different clinical features
• The aetiology of CP is multifactorial, often relating to the prenatal period and mechanisms of neonatal brain hypoxia.
• Antenatal risk factors:

  • Multiple gestation
  • Chorioamnionitis
  • Maternal TORCH infections (toxoplasmosis, rubella, CMV, and herpes simplex)
• Perinatal risk factors:

  • Prematurity (significant risk factor)
  • Low birth weight
  • Birth asphyxia
  • Neonatal sepsis
• Postnatal risk factors:

  • Meningitis
  • Severe hyperbilirubinaemia (neonatal jaundice)
• Other risk factors:

  • Any risk factors for prematurity are indirect risk factors
  • Low socioeconomic status
  • Male sex
• Cerebral palsy often presents with delayed motor milestones:

  • Not sitting by 8 months
  • Not walking by 18 months
  • Hand preference before 12 months
• Other clinical features of cerebral palsy may include:

  • Tone abnormalities (floppiness or stiffness)
  • Abnormal movements (e.g. asymmetrical movements, fidgety movements, lack of movement)
  • Feeding problems such as choking or dysphagia
  • Persistent toe walking
• As CP is a non-progressive condition there should be no regression in milestones. This is a red flag in any child and would suggest an alternative diagnosis.
• The clinical features of cerebral palsy depend on the area of the brain affected. Cerebral palsy can be classified based on which clinical features predominate in an individual. It is common for there to be a mixed picture of symptoms spanning different subtypes if there have been multiple areas of insult to the brain.
• Spastic cerebral palsy:

  • Most common type of CP
  • Characterised by velocity-dependent hypertonia (spasticity) and hyperreflexia
  • When a limb is moved quickly the muscle can suddenly increase in tone and stop further movement - spastic catch
• Dyskinetic cerebral palsy:

  • Involuntary, uncontrolled, recurring movements
  • Fluctuating muscle tone
  • Persistent primitive reflexes - sucking reflex, rooting reflex, moro (startle reflex)
• Ataxic cerebral palsy:

  • Characterised by loss of muscular coordination resulting in ataxia and tremor
  • Least common type of CP
  • Past pointing during finger to nose test
• Cerebral palsy can also be classified by which part of the body is most affected:

  • Monoplegic cerebral palsy affects one limb
  • Hemiplegic cerebral palsy affects one side of the body
  • Diplegic cerebral palsy is symmetrical, with the lower limbs more affected than the upper limbs
  • Quadriplegic cerebral palsy indicated all four limbs are severely affected.
• The difference between spasticity, dystonia and hypertonia can be confusing:

  • Hypertonia is the general term for increased resistance in the muscles.
  • Spasticity is velocity-dependent, meaning the faster you move a limb, the higher the tone you will feel.
  • Dystonia refers to abnormal postures which are worse on intention. An easy way to remember the difference between the two is that you feel spasticity but you can see dystonia.
• Conservative management:

  • Physiotherapy
  • Occupational therapy
  • Speech and language therapy
  • Dietician input
• Medical management:

  • Hyoscine hydrobromide or glycopyrronium bromide - excess drooling
  • Diazepam - pain
  • Baclofen (muscle relaxant)- Spasticity
  • Botulinum toxin type A injections - used if spasticity is severe
  • Hip displacement is very common in cerebral palsy - may need surgical intervention
• Although cerebral palsy is a non-progressive disease, complications can become apparent as a child grows up. Complications may include:

  • Problems with feeding and aspiration
  • Drooling
  • Constipation
  • Visual and hearing impairment
  • Epilepsy
  • Learning disability
  • Speech difficulty
  • Osteopenia and osteoporosis (especially if non-mobile)
  • Sleep disturbance