Introduction

Cerebral Palsy is a brain injury caused by a combination of events, before or after birth. Cerebral Palsy is an interesting brain injury, in that it is not caused by a single event. Often, the cause is unknown, but most people used to think it was often due to the lack of oxygen to a baby’s developing brain, but now scientists believe it is caused by a series of events. Cerebral means having to do with the brain, and palsy means weakness or problems with using the muscles. While no two brain injuries are alike, CP most often affects motor development. The severity of the brain injury involved in cerebral palsy varies greatly, based on the nature of the injury, which parts of the brain it most affects, and the overall severity of the brain injury. There are several risk factors that correlate to CP. While it cannot be said that these factors caused CP, there is an association with these risk factors and a child born with CP:
  • premature birth (less than 37 weeks)
  • low birth weight
  • blood clotting problems (thrombophilia)
  • an inability of the placenta to provide the developing fetus 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, fetus 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
  • neonatal stroke


While those with cerebral palsy always suffer from motor disabilities, there are secondary disabilities associated with CP as well. Some such disabilities include vision, hearing, or speech problems, seizures, and intellectual disabilities. Cerebral Palsy, however, does not progress over time. Each individual experiences CP differently, but it is not degenerative. A person does not directly die from the disease. The extent a person may suffer from the disease varies. Some are not all intellectually affected and can lead mostly independent lives, while others need constant care and are confined to a wheelchair. Like mentioned before, no two brain injuries are alike.
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__http://www.medicalindiatourism.com/blog/cerebral-palsy.html__

Facts about Cerebral Palsy

  • While there is slight evidence to suggest familial cerebral palsy, the genetic correlation is probably more due to children being born in the same type of environment (i.e., same womb) than actual genetic pre-dispositions. Cerebral Palsy is more common in males (57%) than females (43%).It is the most common motor disability in childhood.
    • In ninety percent of twins, in which one is affected by the disease, the other twin is not.
    • About one percent of people with cerebral palsy will also have a sibling with cerebral palsy.
  • CP occurs in approximately 2 in 1,000 live born infants.


Early Warning Signs of Cerebral Palsy

  • Baby begins crawling later than others its own age
  • Cannot keep head lifted
  • Relies on one side of its body more (hemiplegia)
  • Trouble swallowing
  • Seizures
  • Lack of balance and coordination
  • Increased or decreased muscle tone (hypotonia, hypertonia)
  • Muscle spasms
  • Fine motor control impairment as the child grows
  • Trouble with oral communication



Anatomy & Classes

Cerebral Palsy occurs due to damage to the cerebral cortex, the part of the brain that affects muscle movement. Depending on what part of the cerebral cortex is damaged, determines the type of Cerebral Palsy an individual has:

Spastic CP: In this type of CP, voluntary movement is very hard to control and less fluid. It is characterized by stiffness in the muscles and joints as well as jerky movements. Damage to the motor cortex and pyramidal tracts causes Spastic CP. Spastic cerebral palsy is caused by damage to the upper motor neurons in the pyramidal tracts, mainly the corticospinal tract. It originates in the cortex and terminates in the spinal cord on motor neurons.


Athetoid/dyskinetic CP: abnormal, involuntary movement. Hypertonia (unusually high muscle tone-stiffness and tension) and hypotonia (unusually low muscle tone- “floppiness” and low tension). Causes issues with posture, involuntary movements lead to trouble swallowing and drooling.
This type of CP is caused by damage to the basal ganglia and/or the cerebellum. Information is processed in the basal ganglia through two different pathways: the indirect and direct pathway. When the direct pathway is stimulated, the cortex is further excited resulting in a positive feedback loop. On the other hand, when the indirect pathway is stimulated, the cortex is inhibited resulting in a negative feedback loop. The basal ganglia functions to obtain a balance between these two pathways, exciting the proper one for the task at hand.


Ataxic CP: problems with balance and motor coordination-- caused by damage to the developing brain’s motor control centers. Struggle with precise movements such as writing and grasping small objects. Damage to the cerebellum (before during or after birth), essential for uninhibited motor function.
The cerebellum communicates to the nervous system through three large pathways called the cerebellar peduncles. These consist of the superior cerebellar peduncle, the middle cerebellar peduncle, and the inferior cerebellar peduncle.



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http://www.medindia.net/patients/patientinfo/cerebral-palsy.htm

The motor cortex takes up three portions of the frontal lobe: the primary motor cortex, the premotor cortex, and the supplementary motor area. Stimulating each these areas of the motor cortex generates particular movements of different body parts. The motor cortex functions in initiating voluntary actions, coordinating order of movements, making decisions about the appropriate action and movements based on the context, and relaying specific commands to the proper sets of lower motor neurons.


The cerebellum is located at the back of the brain and functions to coordinate and regulate muscle activity. It accounts for 50% of the total neurons in the brain while only taking up a small portion of the brain. Through receiving information from the spinal cord, the sensory systems, and other parts of the brain, the cerebellum regulates motor movements. It functions to modify the information of the descending pathways, making movements more precise and adaptive. The cerebellum plays a role in cognitive functions, motor learning, maintenance of balance and posture and coordination of voluntary movements, as well as speech and emotions.

The basal ganglia is a group of nuclei that is located deep beneath the cerebral cortex. They play a significant role in refining action signals from the cortex in order to plan actions that are required to achieve a particular goal. They process information indirectly, receiving input from the cortex and returning it via the thalamus. Their primary goal is to facilitate the imperative movements while inhibiting the unnecessary movements.


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__https://www.gillettechildrens.org/blog/infographic-understanding-cerebral-palsy/__



Pathways



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__http://www.yhoccanban.com/2012/10/duong-di-bo-thap.html__

Diagnosis

Unfortunately, no single test can confirm cerebral palsy, so a diagnosis often takes some time. Diagnoses are usually made within the first two years of a child's life. A diagnosis usually begins with parents and doctors monitoring the early warning signs noted above. Doctors test reflexes, posture, and muscle tone as well as taking an MRI of the child's brain. Sometimes, CP is difficult to diagnose because a child may just be slower at developing than their average counterparts. But as time goes on, it usually more clear whether the child has CP, some other form of motor disorder, or is just on the lower end of the development spectrum. Often, a baby born with CP was born premature or the mother had some type of infection while pregnant, so the baby will be monitored closely from birth anyway; but in other babies, it is harder to diagnose. It is crucial, however, to get as early a diagnosis as possible so that therapy may be started on the child. An early diagnosis is also imperative for parents and baby alike so that the parents can mentally and emotionally prepare themselves and learn how to mentally prepare their child for a life with Cerebral Palsy.


Prognosis/Summary

While Cerebral Palsy can be an extremely debilitating disablement for some, others with CP go onto to live relatively normal lives, attending school, and maintaining relationships and careers. Many of the secondary effects of CP can be just as debilitating as the disability itself. Fortunately, Cerebral Palsy is not a degenerative disease, meaning it does not worsen over time. However, there is no cure for CP. There are, though, certain therapies (physical therapy, occupational therapy, speech therapy, etc) that have been shown to be beneficial to those suffering from Cerebral Palsy. There are also certain medications proven to reduce spasticity, the most common being baclofen, diazepam, and dantrolene. Many suffering from spastic CP choose to have a baclofen pump inserted into their lower abdomen, but the satisfaction of this pump varies from patient to patient. Many children with cerebral palsy also undergo surgeries throughout their life. Some surgeries involve lengthening tendons, and correcting spine curvatures. There are also surgeries for the secondary issues associated with CP, such as vision correction surgeries, and gastroenterology surgeries. Because no two cases of cerebral palsy warrant the same outcomes of the disease, it is imperative that the patient, with the guidance of their parents, seek out all necessary treatment for their particular needs. Many with Cerebral Palsy thrive just as well, if not more so, than people without Cerebral Palsy because of their will and determination to beat the odds against them.



Glossary of Terms

  • Cerebellum: the part of the brain that works to coordinate and regulate muscle activity
  • Motor Cortex: part of the cerebrum that generates motor movements
  • Basal Ganglia: a cluster of nuclei located in the cerebrum that refine action signals from the cortex to plan a particular motion
  • Spastic Cerebral Palsy: a type of CP that is characterized by stiffness in the muscles and joints and jerky movements
  • Athetoid/dyskinetic Cerebral Palsy: a type of CP that is characterized by abnormal, involuntary movement
  • Ataxic Cerebral Palsy: a type of CP characterized by balance and motor coordination issues
  • Descending Pathways: a nerve pathway that goes down the spinal cord and allows the brain to control movement of the body below the head
  • Ascending Pathways: a nerve pathway that go upward from the spinal cord toward the brain carrying sensory information from the body to the brain
  • Corticospinal Pathway: the primary descending pathway that carries motor commands that underlie voluntary movement
  • Diplegia: paralysis in either the arms or legs but not both
  • Hemiplegia: paralysis on one half of the body
  • Quadriplegia: paralysis of all four limbs


Quiz

1) Match the type of Cerebral Palsy to its definition
Spastic CP, Ataxic CP, Athetoid/dyskinetic CP
A. characterized by balance and motor coordination issues

B. characterized by abnormal, involuntary movement

C. characterized by stiffness in the muscles and joints and jerky movements

2) What type of paralysis affects only the legs or arms but not both?

3) True or False: CP is degenerative.

4) What part of the brain coordinates muscle activity?

5) True or False: While there are many causes of CP, it is usually fairly simple to pinpoint the cause for an individual born with CP.

6) Damage to the cerebellum most often results in what type of CP?

7) True or False: Damage to the basal ganglia most often results in Athetoid/dyskinetic CP.

8) Essay: A six month old child presents with difficulty lifting his head and troubles with grasping while nursing. He was born at 36 weeks premature with no other obvious signs of CP. What needs to be done in order to be given a diagnosis and/or rule out Cerebral Palsy? Be sure to include other warning signs to look for, medical history, approximately how long it will take to find a diagnosis, steps the doctor and parents must perform to make a complete diagnosis, and give a prognosis/treatment for the patient.

9) Short answer: What is the most common type of CP?

10) Essay: Why is every case of cerebral palsy different for each patient?

11) Essay: Describe the different symptoms related to each class of CP.


12) Explain three ways that someone may be at risk for Cerebral Palsy.







Answers: 1) Spastic-C, Ataxic-A, Athetoid/dyskinetic-B 2) Diplegia 3) False 4) Cerebellum 5) False 6) Ataxic 7) True
8) The doctor should perform reflex tests because even if a baby is not muscularly developed yet, his reflexes should still be intact. Vision, auditory and any secondary issues associated with CP should be tested as well as getting an MRI of the brain. Sometimes, the MRI will be obvious, and one can make a diagnosis of CP right there, but other times it is less obvious and monitoring must continue for up to two years. Medical history of the mother's pregnancy should be reviewed carefully, seeing if there was anything that could have been missed like a trip out of the country where an infectious disease could have been picked up. The parents' job in presenting a diagnosis is crucial because they are the ones around the child the most. Seeing how their child interacts with other babies its own age and the differences among them can lead to more answers. If their child is unusually sensitive or unhappy, it could be because their joints are in pain due to CP as well. With an adequate diagnosis and continued monitoring, the child should begin therapies tailored to his specific needs i.e. speech therapy, occupational therapy, physical therapy, corrective surgeries, chiropractic care, eye-glass fittings, etc. Based on the type of CP he has and the way he presents with it, his doctors and parents will determine the path he will take as he gets older, but most often he will still be able to attend school, maintain relationships, and live a relatively normal life, even if he is not fully independent.
9) Spastic
10) It depends on the severity of the individual's brain injury. The symptoms that develop depend on how severe the injury is, sometimes they are hardly noticeable. The damage to the brain may affect other aspects of brain function as well, resulting in symptoms of other issues. It’s also due to the timing of the injury to the developing brain.
11) Spastic CP: stiff muscles (spaticity), associated with damage to or developmental differences in the cerebral cortex. Athetoid/dyskinetic CP: Uncontrollable movements (dyskinesia), associated with damage to the basal ganglia. Hypertonia and hypotonia. Ataxic CP: poor balance and coordination (ataxia) associated with damage to the cerebellum. Mixed: a combination of two or more types associated with damage to multiple areas of the brain.
12) Lack of oxygen to a baby’s developing brain; Premature infants are very vulnerable to CP; Severe illness during the first years of life



Suggested Readings

  • Our Fractured Wholeness by Diana Ventura (2010)






References








Dedication

Thanks to Sarah Hall, for allowing us the opportunity to see the intimate details of a life with spastic, quadriplegic Cerebral Palsy, and overcoming them one step at a time.