Cerebral palsy (CP) is a spectrum of permanent disorders of movement, posture and muscle tone, causing activity limitation, that are attributed to non-progressive disturbances that occurred during fetal brain development. According to predominant motor syndrome, CP can be clinically classified into spastic hemiplegia, spastic diplegia, spastic quadriplegia, and dyskinetic or extrapyramidal. The neuromotor disturbances often include disturbances in perception, sensation, communication, cognition, and behaviour, by secondary musculoskeletal problems and by epilepsy. The main risk factors for CP are prematurity and low birth weights. Other responsible risk factors could be multiple gestations, neonatal seizures, sepsis, hypoxic-ischemic encephalopathy, congenital brain malformations, and maternal disorders of clotting. Postnatal CP can also occur due to meningitis, traumatic brain injury, and near-drowning.
The early and accurate diagnosis of CP is primarily based on a combination of findings from clinical history, neuroimaging, and standardized neurological and motor assessment tools and interpreted by medical personnels with specific training and experience. The most predictive tools for detection of CP in the infant ≤5 months of age are MRI, Hammersmith Infant Neurological Examination, and Prechtl Qualitative Assessment of general movements. Along with MRI and Hammersmith Infant Neurological Examination, developmental assessment of young children is done to detect CP in the infant ≥6 months of age.
Early signs of CP in a baby of 3-6 months of age are feeling stiff and floppy, head falls back when picked up while lying on back, seems to overextend back and neck when cradled in someone’s arms etc. Babies older than 6 months show the signs, such as not rolling over in either direction, not bringing hands together, and having difficulty bringing hands to the mouth etc. A baby who is older than 10 months old may exhibit uneven crawling, pushing off with one hand and leg while trailing the other, scooting about on their buttocks, or hopping on their knees, but not all fours.
Spasticity, dyskinesia, hypotonia, and ataxia are the most common symptoms of the neurologic impairment of the motor system in children with CP. A crucial clinical feature of CP is the persistence of fundamental motor patterns or rudimentary reflexes past the predicted age. Among all clinical phenotype, spastic diplegia is the most common in children and occurs due to the immature oligodendroglia between 20 and 34 weeks of gestation. In this condition, both the thalamocortical and motor corticospinal pathways are affected. Other phenotypes are, spastic quadriplegia, associated with cognitive deficit, visual impairment and significant functional limitations and spastic hemiplegia, most commonly reported in infants born at term and most cases are due to in utero or perinatal stroke. Extrapyramidal CP, comprises dystonic, choreoathetonic or dyskinetic clinical phenotype, is associated with seizures, cognitive deficit, behavioural problems, sleep disturbances, visual impairment or hearing impairment.
The four functional classifications to standardize the assessment and therapy of an individual are gross motor function classification system (GMFCS), manual ability classification system (MACS), communication function classification system (CFCS), and eating and drinking ability classification system (EDACS). GMFCS is generally used to explain gross motor function, particularly the ability to walk, for children from 2-18 years of age. MACS are used to describe the typical use of upper extremities and both hands for children from 4-18 year of age. CFCS is used to express the ability of patients with CP for daily routine communication. EDACS is used to represent the eating and drinking behaviour for children of 3 years of age or older. MRI scan of CP patients shows abnormal findings, such as brain malformations due to utero stroke or white matter loss. The most common neuropathologic finding observed on neuroimaging is periventricular leukomalacia.
The optimal model for the medical treatment of children and people with CP throughout their lifespan is a multidisciplinary team approach, which also addresses the support system and psychological requirements. This multidisciplinary team involves members such as audiologist, medical social worker, nursing, nutritionist, occupational therapist, pediatric neurologist, pediatric gastroenterologist, pediatric orthopaedic surgeon, pediatric pulmonologist, pediatric surgeon, paediatrician, physiatrist, physiotherapist, psychologist, and speech language therapist.
Children with CP have many associated medical conditions which require proper medical care. The medical associated medical conditions include seizure, restrictive lung disease, refractive vision errors, hearing impairment, speech and language impairment, sleep disturbances, depression, cognitive deficit, learning difficulties, ADHD, migraine, delayed puberty, bladder incontinence etc.
The level of arousal of the child at the time and the amount of time that has passed since the triggering event that caused spasticity affect the degree or severity of spasticity in children with CP. Multiple factors may be under consideration in decision to treat spasticity. These include acute or chronic nature of spasticity, age of the child at the time of intervention, cognitive and emotional maturity of the child, distribution of spasticity, functional impact of reducing spasticity, growth potential etc. different treatment interventions have been used to treat spasticity in children with CP. They include pharmacologic intervention such as baclofen, botulinum toxin IM injection, valium and clonazepam oral and non pharmacologic interventions such as physiotherapy, occupational therapy, etc. Orthopaedic surgical interventions may be required to the children with CP who develop multiple secondary, often progressive, musculoskeletal conditions. Physiotherapy has been shown to prevent or reduce joint contractures and improve muscle strength, joint range of movement, and local muscular endurance in children with CP. An adaptive bungee trampoline program has been shown to improve lower limb muscle strength. Treadmill training intervention aims at improving balance and lower extremity symmetry. As it is time and labor intensive, robotic gait training has been shown to reduce this burden associated with treadmill training. Occupational therapy is an integral component demonstrating its long-term effects on promoting improvement in fine motor functionality. Orthoses, assistive technology, adaptive equipment devices are used to boost child’s functional abilities and facilitate activities of daily living. Other interventions may include neurodevelopmental training, acupuncture, sensory integration, electrical stimulation, suit therapy, hippotherapy, video game therapy, music therapy, and stem cell therapy. Most children with CP grow up to be adults with early intervention, adequate medical treatment, and continued support services; the overall survival rate for all children with CP up to the age of 20 is 90%.
Reference:
Patel, Dilip R.; Neelakantan, Mekala; Pandher, Karan; Merrick, Joav (2020). Cerebral palsy in children: a clinical overview. Translational Pediatrics, 9(S1), S125–S135. doi:10.21037/tp.2020.01.01
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