Nowadays, we see children with special health care needs. They have disabilities that are defined as abnormalities in body function or structure that interfere with the activities of normal daily life. Disabilities may be classified as acquired or congenital, and static (non-progressive) or progressive. An example of a static disability is cerebral palsy.
Cerebral palsy is a clinically descriptive term for a heterogeneous group of conditions typically classified according to the type, distribution, and severity of motor abnormality. Cerebral palsy describes a group of disorders of the development of movement, posture, and coordination. Cerebral means having to do with the brain, while palsy means weakness or problems with muscle use. The affected part of the brain is the motor area, and the outer layer is called the cerebral cortex. This part of the brain directs muscle movements. Some cases show that the cerebral motor cortex did not develop normally during fetal growth. In other instances, the damage is the result of brain injury either before, during or after birth. The brain damage is not repairable and the resulting disabilities are permanent.
The incidence of cerebral palsy is approximately 2 to 2.5 cases per 1,000 live births in developed countries. The Philippine Pediatric Society registry shows that there are 2,993 cases of unspecified cerebral palsy cases, 426 spastic quadriplegics, 59 spastic diplegics, 18 spastic diplegics, 15 dyskinetics, 10 ataxics, and 190 categorized under others but there may be more which have not been reported.
What symptoms do you see in children with cerebral palsy?
Poor muscle coordination, especially when performing voluntary movements (ataxia)
Rigid or tense muscles and exaggerated reflexes (spasticity)
Weakness in either one or both arm or leg
Walking on the toes, a crouched gait, or a scissored gait
Either too rigid or too flaccid variations in muscle tone
Excessive drooling or difficulty of swallowing or speaking
Shaking (tremor) or random involuntary movements
Delays in reaching motor skill milestone
Difficulty with precise movements (e.g. writing or buttoning a shirt)
Monitoring the developmental milestones of a baby/child during a well-child visit is important. The red flags or early warning signs that the individual may have cerebral palsy are as follows:
In a baby <6 months of age:
His head lags when you pick him up while he is lying on his back
He feels limp
His legs get stiff and they cross or scissor when you pick him up
In a baby >6 months of age:
He cannot roll over in either direction
He does not bring his hands together and has difficulty bringing them to his mouth
He reaches out with only one hand while keeping the other fisted
In a baby >10 months of age:
He crawls in an unbalanced way by pushing off with one hand and leg while dragging the opposite hand and leg
He cannot stand and holds onto a support
What causes cerebral palsy?
The type and severity of the cerebral palsy symptoms largely depend on the extent of the brain injury involved. Conditions that may cause cerebral palsy are:
- Prenatal disturbance of cell migration – In the developing fetus, cells differentiate and move into place in order to form the appropriate type of cell. Disrupting this process prevents the brain cells from migrating and developing properly, thus resulting in abnormal neurological conditions.
- Prenatal poor myelination of nerve cells – Myelin acts as the insulation to protect nerve cells. Inadequate myelination results in unprotected nerve cells leading to their damage.
- Perinatal brain cell death – Suffocation (asphyxia) or blood loss experienced during difficult deliveries or periods of fetal distress late in pregnancy necessitating an emergency birth may lead to the death of the brain cells.
- Postnatal non-functional or inappropriate synapses – Brain injury after birth can result in brain damage and cerebral palsy. Among the causes are brain infection, trauma, and asphyxia.
What are the risk factors for developing cerebral palsy?
Premature birth or low birth weight
Fetal distress, including problems with the placenta, umbilical cord, and amniotic fluid
Long and difficult labor during which asphyxiation can occur
Meningitis and other brain infections
Trauma after birth, including accidents that could lead to brain damage
What are the types of cerebral palsy?
- Spastic cerebral palsy – This is the most common type affecting more than 70% of cerebral palsy patients. Hypertonia (or increased muscle tone) and stiff tight muscles are seen in this type of patients.
- Spastic quadriplegia – This is the most severe type of spastic cerebral palsy. It is caused by significant brain damage and affects the entire body. Hypertonia in all four limbs is seen in these patients. They are unable to walk and cannot use their arms and hands effectively. They have difficulty swallowing, eating, and talking. Cognitive disabilities and seizures are observed in this group.
- Spastic diplegia – Less severe type affecting the legs primarily
- Spastic hemiplegia – Less severe type affecting the extremities of one side of the body
- Athetoid cerebral palsy – Also called dyskinetic or dystonic cerebral palsy, this makes up 10 to 20% of cerebral palsy cases. Patients show uncontrollable movements such as slow writhing of the body, jerky movements of the extremities, difficulty in holding the head up, and difficulty in swallowing and eating. The upper extremities and neck are more affected. There is less cognitive impairment but patients may struggle to eat and speak.
- Ataxic cerebral palsy – This affects around 5 to 10% of cases and is the least common type. Patients have difficulty coordinating voluntary movements, have problems with posture and balance, and struggles with cognitive function and language skills.
- Mixed type – This makes up 10% of cases, which is caused by injuries to the different brain areas. A combination of athetoid and spastic symptoms are the most common, manifesting as stiff muscles with involuntary movements.
Most cerebral palsy cases have paralysis and its severity varies among patients and can be grouped as:
- Monoplegia – affecting one limb or body part
- Diplegia/paraplegia – affecting two body parts, which are often the legs
- Hemiplegia – affecting all limbs on the right or left side of the body
- Double hemiplegia – affecting all four limbs
- Quadriplegia – affecting the whole body including the neck and trunk
Cerebral palsy is suspected when there is a delay in the child’s developmental milestones. A medical team involved in its treatment would include a pediatrician, neurologist, psychiatrist, orthopedic surgeon, physical therapist, occupational therapist, and a speech therapist. Diagnostic tests are done which include MRI (magnetic resonance imaging), CT (computed tomography) scan, EEG (electroencephalogram), and cranial ultrasound. Hearing and vision impairment, as well as cognitive function, are also assessed.
Presently, there is no cure for cerebral palsy. Treatment with medications and therapies lessen the gravity of the symptoms and allows the child to live the best life possible and to adjust to his disability. Treatment can help with managing pain symptoms, improving joint flexibility, increasing mobility, improving muscle definition and tone, managing secondary symptoms, and allowing for greater independence. It is appropriate to label cerebral palsy as a disorder rather than a disease due to the variability of the symptoms and factors causing it.