Cerebral Palsy

Cerebral palsy (CP) is a group of conditions that affects the parts of your brain that control your muscles. CP is the most common cause of movement problems in childhood. Four CP types to note, as categorized by the movement problem:
Spastic CP (most common, ~80%) : characterized by stiff muscles and/or awkward body movements.  Signs and symptoms include:
  • Tight muscles that do not stretch
  • Abnormal ambulation -- "scissor" walk, walks on toes, difficulty cross legs
  • Tight joints
  • Weak muscles or no movement in certain muscle groups
There are three subtypes of spastic CP: 
  1. Spastic diplegia. Stiffness focused mostly in the legs. Tight hips/legs cause difficult ambulation, often causing legs to "scissor" (legs turn inward and cross at knees). Often requires bracing or assistive devices for movement. 
  2. Spastic hemiplegia. Stiffness mainly affects one side of body. Affected side  is often thinner/shorter than unaffected side. Children are often late walkers and have abnormal gait patterns (walk on toes, etc).  Many will have scoliosis, seizures, and/or speech issues.
  3. Spastic quadriplegia. Stiffness affects arms/legs, torso, and face. 
Other kinds of CP include: 
  • Dyskinetic CP (athetoid CP, choreoathetoid CP, dystonic CP): muscle tone ranges from rigid stiffness to abnormal laxity. Often causes sudden, uncontrolled movements. Difficulty controlling hands, arms, feet and/or legs. Affected face/tongue muscles may cause excess drooling or frown-like appearance. Common speech issues.
  • Ataxic CP: Issues mainly around balance and coordination. Unsteady ambulators, +/- tremors with movements.
  • Mixed CP:  Child shows symptoms of more than one type of CP (most common = spastic-dyskinetic CP)

Assessment & Screening Tools

  • Review development milestones and growth chart
  • Full neuro exam (test reflexes, muscle tone, coordination)
  • Gait analysis
  • Anticipate MRIs, cranial ultrasounds, or CT scans
Scales:
  • Ashworth Scale-Modified & Original Scale for spasticity & tone
  • Comparison in Dev't between Typical Kids and CP
  • Early Diagnosis of CP - Primitive and Postural Reflexes
  • GMFCS Illustrations of 5 levels for gross motor classification
    -- kids 6 to 12 years
    -- teens 12 to 18 years  
  • Gross Motor Skills - Expected vs. Delayed/Deviant
Possible Labs:
  • Metabolic panel, including glucose, ammonia, lactate, blood gas, plasma amino acids and urine organic acids
  • TSH to r/o thyroid issues
  • Chromosomal analysis
Important to rule out:
  • Degenerative nervous disorders
  • Genetic diseases
  • Muscle disoders
  • Metabolism disorders
  • Nervous system tumors
  • Coagulation disorders
  • Acute injury
  • Intercranial neoplasms
  • Thyroid dysfunction
  • Urea cycle disorders
  • Tethered spinal cord
  • Ataxia disorders
Possible Imaging studies:
  • EEG to r/o seizures
  • MRI to ID and assess lesions
  • Head CT to r/o malformations, hemorrhrage, or periventricular leukomalacia
  • Spinal MRI to r/o  tethered spinal cord
POSSIBLE RISK FACTORS:
Prenatal
Maternal: thyroid disorder, mental retardation, seizure disorder, iodine deficiency, previous pregnancy loss, toxin exposure
Pregnancy: congenital malformations, infections,  polyhydramnos, thyroid hormone use, estrogen, or progesterone, severe maternal proteinuria or high blood pressure, third trimester bleeding, multiple gestations
Perinatal
prematurity (
Postpartum
infections, parenchymal or intraparenchymal hemorrhage, jaundice causing kernicterus, prolonged ventilation, hypoxic ischemic   encephalopathy (HIE)

Position Papers

  • Position paper on the use of botulinum toxin in cerebral palsy (Carr,  Cosgrove,  Gringras, &  Neville, 1998)

Articles

  • Enriched Environments and Motor Outcomes in Cerebral Palsy: Systematic Review and Meta-analysis (Morgan, Novak & Badawi, 2013)
  • Parents' actions, challenges, and needs while enabling participation of children with a physical disability: a scoping review (Piškur, Beurskens, Jongmans, Ketelaar, Norton , et al, 2012)
  • Clinical prognostic messages from a systematic review on cerebral palsy (Novak, Hines, Goldsmith & Barclay, 2012) 
  • The evidence-base for conceptual approaches and additional therapies targeting lower limb function in children with cerebral palsy: a systematic review using the ICF as a framework (Frank, Desloovere, De Cat, Feys, Molenaers, Calders, Vanderstraeten, Himpens & Van Broeck, 2012)
  • Does acute passive stretching increase muscle length in children with cerebral palsy? (Theis, Korff, Kairon & Mohagheghi, 2013)

Resources

  • Basics of Cerebral Palsy, by Learn Pediatrics
  • Cerebral palsy overview
  • NINDS Spasticity Information Page
  • Cerebral Palsy Guide
  • Cerebral Palsy: Hope Through Research (booklet)

Transitions to Adulthood
  • Centers for Independent Living Affliliate Directory
Organizations:
  • United Cerebral Palsy (UCP)
  • March of Dimes
  • Children's Neurobiological Solutions (CNS) Foundation
  • Cerebral Palsy International Research Foundation
  • Reaching for the Stars
  • Pathways Awareness
  • Easter Seals
  • Children's Hemiplegia and Stroke Assocn. (CHASA)
  • Pedal-with-Pete Foundation

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