Cerebral Palsy

Cerebral Palsy

What is Cerebral Palsy?

Cerebral palsy (CP) is a physical disability that affects movement and posture. It is a permanent life-long condition, but generally does not worsen over time.

It is due to damage to the developing brain either during pregnancy or shortly after birth. Cerebral means ‘of the brain’ and palsy refers to ‘a lack of muscle control’. It’s an umbrella term that refers to a group of disorders affecting a person’s ability to move.

It affects body movement, muscle control, muscle coordination, muscle tone, reflex, posture and balance. People who have cerebral palsy may also have visual, learning, hearing, speech, epilepsy and intellectual impairments. There are around 34,000 people living with cerebral palsy in Australia – that’s 1 in 500 babies diagnosed with CP.

Symptoms

There are some signs that may indicate a child has cerebral palsy. Not all signs are visible at birth and may become more obvious as babies develop.

Babies

  • Low muscle tone (baby feels ‘floppy’ when picked up)
  • Unable to hold up his/her own head while lying on their stomach or in a supported sitting position
  • Muscle spasms or feeling stiff
  • Poor muscle control, reflexes and posture
  • Delayed development (can’t sit up or independently roll over by 6 months)
  • Feeding or swallowing difficulties
  • Prefers to use one side of their body

 

Toddlers/Children

Although the brain of toddlers/children with cerebral palsy remains injured, the injury does not get worse as they develop.

Depending on the level of severity of cerebral palsy, toddlers and children may experience difficulties with physical development such as:

  • not walking by 12-18 months
  • not speaking simple sentences by 24 months

If your child is not reaching these milestones or they display some of the signs of cerebral palsy, you may need to speak to your early childhood nurse, general practitioner or paediatrician.

In NSW, questions relating to developmental milestones are described in the Personal Health Record book (Blue Book) provided to families when their child is born.

Types & Severity

Cerebral palsy can affect a person’s posture, balance and ability to move, communicate, eat, sleep and learn. The parts of the body affected by cerebral palsy, the level of severity and combination of symptoms can differ for each person. For example, one person may have a weakness in one hand and find tasks like writing or tying shoelaces challenging. Another person may have little or no control over their movements or speech and require 24 hour assistance.

People with cerebral palsy may experience uncontrolled or unpredictable movements, muscles can be stiff, weak or tight and in some cases people have shaky movements or tremors. People with severe cerebral palsy may also have difficulties with swallowing, breathing, head and neck control, bladder and bowel control, eating and have dental and digestive problems.

Cerebral palsy can be described by the way it affects people’s movement, the part of the body affected and by how severe the affects are. The main types of cerebral pals

The main types of cerebral palsy are:

  • Quadriplegia (a form of bilateral cerebral palsy) where both arms and legs are affected. The muscle of the trunk, face and mouth are often also affected.
  • Diplegia (a form of bilateral cerebral palsy) where both legs are affected. The arms may be affected to a lesser extent.
  • Hemiplegia (a form of unilateral cerebral palsy) where one side of the body (one arm and one leg) is affected.

There are other classifications for severity. These are:

  • Spastic – 70-80% of individuals with cerebal palsy have motor cortex damage. This is the most common form of cerebral palsy where muscles feel stiff and tight.
  • Dyskinetic – 6% of individuals with cerebral palsy have Basal Ganglia damage which causes involuntary movements that are out of a person’s control.
  • Ataxic – 6% of individuals with cerebral palsy have cerebellum damage that causes shaky movements and affects balance as well as a sense of positioning in space.
  • Mixed type – where there is a combination of damage to the brain.

Causes

Cerebral palsy (CP) is a physical disability that affects movement and posture. It is a permanent life-long condition, but generally does not worsen over time. It is due to damage to the developing brain either during pregnancy or shortly after birth

For most people with cerebral palsy, the cause is unknown and there is no single cause.

Researchers have determined that only a very small percentage of cases of cerebral palsy are due to complications at birth (e.g. asphyxia or lack of oxygen).

Today, it is accepted that cerebral palsy usually arises from a series of causal pathways, i.e. a sequence of events that when combined can cause or accelerate injury to the developing brain.

For example: Although prematurity is the largest risk factor for cerebral palsy, it is the sequence of events (causal pathways) that led to the premature birth that may have caused the cerebral palsy, rather than the premature birth itself.

In 13 out of 14 cases of cerebral palsy in Australia, the brain injury leading to cerebral palsy occurs either in the uterus (while the mother is pregnant) or before 1 month of age.

Stroke is the most common cause in babies who acquire cerebral palsy after 1 month of age. The stroke may occur spontaneously or arise from surgical or heart complications.

 

Risk factors

Risk factors do not cause cerebral palsy. However, the presence of some risk factors may lead to an increased chance of a child being born with cerebral palsy. Some risk factors for cerebral palsy have been identified. These include:

  • premature birth (less than 37 weeks)
  • low birth weight (small for gestational age)
  • blood clotting problems (thrombophilia)
  • an inability of the placenta to provide the developing feotus with oxygen and nutrients
  • RH or A-B-O blood type incompatibility between mother and baby
  • infection of the mother with German measles or other viral diseases in early pregnancy
  • bacterial infection of the mother, foetus or baby that directly or indirectly attacks the infant’s central nervous system
  • prolonged loss of oxygen during the pregnancy or birthing process, or severe jaundice shortly after birth.

 

Who is at greatest risk?

The Australian Cerebral Palsy Register Report 2013 has identified four groups that, statistically, have a greater risk of cerebral palsy.

  • Males - Males are at greater risk of having cerebral palsy
  • Premature babies - Prematurity is associated with higher rates of cerebral palsy
  • Small babies - Low birth weight is associated with higher rates of cerebral palsy. This may be a result of prematurity or slow intrauterine growth. Around 42% of children with cerebral palsy had low birth weight, compared to just over 6% of the Australian population.
  • Twins, triplets and higher multiple births - 11% of children with cerebral palsy were from a multiple birth, whereas the rates of multiple births are only 1.7% in the Australian population.

 

Is cerebral palsy genetic/hereditary?

Familial cerebral palsy is uncommon, approximately 1% of people with cerebral palsy will have a sibling with the condition. It is even uncommon in twins – when one twin has cerebral palsy, 90% of co-twins will not have cerebral palsy.

However small these statistics, they are enough to suggest that there might be some genetic factors involved in cerebral palsy.

Researchers generally believe that a genetic disposition to certain characteristics, i.e. prematurity or heart problems, may start a chain of events (causal pathways) that can result in a child having cerebral palsy.

Diagnosis

Cerebral palsy is a complex disability and diagnosis is not always an easy process. Doctors may suspect cerebral palsy if a baby has slow motor development, has tight or floppy muscle tone, or displays unusual postures.

The period of time parents may have to wait before their child is given an official diagnosis of cerebral palsy can vary. Very premature babies are usually watched carefully and may have an early MRI scan (magnetic resonance imaging). However, most children with cerebral palsy are not born prematurely. Most are born at full term and it is not until they do not meet the usual infant milestones that any form of disability is considered. A MRI might show that they have an injury to the brain, but at that stage it is often too early to predict the impact.

The General Movements Assessment can be conducted from birth until 5 months of age. It is a strong predictor of cerebral palsy, particularly when certain changes to the brain are seen on an MRI. However, General Movements Assessment cannot predict the severity of cerebral palsy.

If a General Movements Assessment suggests that a baby is ‘at risk of cerebral palsy’, then intervention can start as early as possible.

 

How do doctors diagnose cerebral palsy?

They will pay special attention to the child’s movements – both their voluntary movements as well as their muscle tone.

Some children may have very relaxed, floppy muscles, while others have stiff, tight muscles.

Doctors will also look for any unusual postures or if the child favours one side over the other.

Scans such as MRI or CT may be ordered by the doctor.

One of the frustrations for parents is that sometimes a diagnosis can take a long time, with repeated tests and visits to specialists.

This may be because the child has a mild form of cerebral palsy, but it could also be because the doctor needs to make sure it is not another type of movement disorder that may be progressive (get worse over time).

 

What is the General Movements Assessment?

The General Movements Assessment is a non-invasive and cost-effective way to identify neurological issues which may lead to cerebral palsy and other developmental disabilities. The assessment can be completed from birth to 20 weeks of age (corrected for prematurity).

Infants have typical and distinct spontaneous “general movements” from before birth right through to 20 weeks post term. Infants whose general movements are absent or abnormal are at higher risk of neurological conditions, in particular cerebral palsy. The General Movements Assessment is used to identify absent or abnormal general movements and, depending on the type of general movements’ abnormality, can be highly predictive of cerebral palsy by about 3 months of post term age. Intervention can start very early, with potentially better outcomes, if an infant is diagnosed as at risk of cerebral palsy using the General Movements Assessment.

 

How is the assessment done?

General movements are assessed with the awake infant lying on their back while they are calm and alert. The infant should not have any toys or pacifiers and parents could be watching nearby but not interacting with their baby. The baby is videoed for 3-5 minutes and the assessment is scored from the video. In Australia, a growing number of allied health and medical personnel have been trained to observe and score General Movements Assessments.

 

Should my child have the General Movements Assessment?

A General Movements Assessment may give information on how your baby’s neurological system is developing if he/she is under 20 weeks post term age and there were medical concerns at birth (such as prematurity, lack of oxygen, stroke, or congenital heart disease). The assessment is not currently used as a screening tool for healthy babies.

Please speak to your medical practitioner or therapist if you have any concerns about your baby.

 

Who can do the assessment?

Some therapy staff at Cerebral Palsy Alliance are qualified to perform the General Movements Assessment. A growing number of tertiary hospitals across Australia also have staff who are able to use the assessment.

Videos taken by parents and others can be used by assessors. To take a video, the baby should be lying on their back, lightly dressed (no socks) and in a calm state. Do not interact with the baby. His/her spontaneous movement should be observed. Babies should not be sucking a dummy or playing with a toy. Film the baby quietly from above, making sure the baby’s hands and feet can be seen for 3-5 minutes. An assessor will need to know the baby’s date of birth, date of video and gestational age. The best age to take the video is 12-14 weeks after the baby’s due date.

Living with Cerebral Palsy

 

Sources:

  • Cans, C., Dolk, H., Platt, M. J., Colver, A., Prasauskiene, A., & Krageloh-Mann, I. (2007). Recommendations from the SCPE collaborative group for defining and classifying cerebral palsy. Developmental Medicine and Child Neurology, 49(Suppl 1), 9-24.
  • Krageloh-Mann, I., & Cans, C. (2009). Cerebral palsy update. Brain Development, 31(7), 537-544. doi: 10.1016/j.braindev.2009.03.009 See abstract
  • McIntyre, S., Morgan, C., Walker, K., & Novak, I. (2011). Cerebral palsy–don’t delay. Devolpmental Disability Research Reviews, 17(2), 114-129. doi: 10.1002/ddrr.1106 See abstract
  • Paneth, N. (2008). Establishing the diagnosis of cerebral palsy. Clinical Obstetrics and Gynecology, 51(4), 742-748. doi: 10.1097/GRF.0b013e318187081a See abstract

Susan Williams, mother of a young boy living with cerebral palsy, shares five of the benefits of toy libraries and where you can find one near you.