September, 2020 | Manika Tomar
CEREBRAL PALSY FOR PROFESSIONALS
Cerebral Palsy is a group of neurological disorders that affects muscle coordination and body movement permanently.
At its core, Cerebral Palsy is a motor disorder that occurs in the womb or during infancy. It affects muscle control and tone, posture, balance, fine and gross motor skills, and oral motor functioning.
Signs and symptoms of Cerebral Palsy appear early during infancy. About 70% children with Cerebral Palsy get diagnosed within the first year as parents approach medical practitioners to get help for their baby. Remember also that the function of muscle groups can change over time, leading to changes in the symptoms associated with muscle coordination and body movement.
Recognising Cerebral Palsy
What causes Cerebral Palsy?
Cerebral Palsy is caused by damage or abnormal development of the cerebral cortex, the part of the brain that is responsible for directing muscle movement. Cerebral Palsy can be congenital (be caused during pregnancy or childbirth) or acquired.
- Congenital Cerebral Palsy: Most children are born with Cerebral Palsy, i.e. it is congenital. Causes of Congenital Cerebral Palsy are foetal or maternal infections, brain malformations due to genetic abnormalities, and brain injuries due to foetal stroke.
- Acquired Cerebral Palsy: A small proportion of children acquire Cerebral Palsy after birth. Causes of Acquired Cerebral Palsy are brain damage in the first few months or years after birth due to infections such as viral encephalitis or bacterial meningitis, poor blood flow to parts of the brain, or head injury from a fall, abuse, or car accident.
Types of brain damage observed in persons with Cerebral Palsy are:
- Periventricular leukomalacia: Damage or injury to the white matter of the brain that is responsible for transmitting signals inside the brain and to the rest of the body may result in neurodevelopmental injuries. This generally occurs in between 6.5 – 8.5 months during pregnancy.
- Cerebral dysgenesis: Conditions such as gene mutations, fevers, trauma and infections can disrupt the normal growth process of the brain. These can disrupt the normal transmission of brain signals and cause Cerebral Palsy.
- Intracranial haemorrhage: While still in the womb, some babies may suffer a foetal stroke due to blood clots in the placenta that block the blood flow to the brain. Such strokes cause internal bleeding in the brain that could cause Cerebral Palsy.
- Asphyxia: Poor supply of oxygen and breathing interruptions can cause a severe lack of oxygen to the brain. This is common in newborns for brief periods due to stressful labour or delivery. Such damage is known as hypoxic-ischemic encephalopathy and may cause Cerebral Palsy.
What are the signs and symptoms of Cerebral Palsy?
The age at which a child can be diagnosed with Cerebral Palsy depends on many factors:
- Severity: When children show severe symptoms like inability to control movement, it is usually easier to recognize it and make an early diagnosis.
- Type: Some types of Cerebral Palsy are easier to diagnose than others.
- Parental involvement: Parents’ watchfulness about attaining developmental milestones plays an important role in making an early diagnosis.
Children with Cerebral Palsy could have the following symptoms; however not all children who display these signs and symptoms have Cerebral Palsy:
- Difficulty in muscle coordination while performing voluntary movements
- Involuntary or uncontrollable movements because of muscle spasm
- Stiffness or floppiness in muscle tone
- Exaggerated reflexes (spasticity)
- Weakness of the arm or leg on one side
- Crouched gait (walk)
- Walking on tiptoes because of tightness in tendons
- Excessive drooling
- Gastro-oesophageal reflux
- Difficulty in swallowing or speaking
- Delayed motor skill development
- Difficulty with precise movement such as tying shoelaces
Most children with Cerebral Palsy are capable of walking, with approximately 30% using a wheelchair and 10% requiring an aid to walk. One in 5 people with Cerebral Palsy has difficulties in communication.
Intellectual Disability could accompany Cerebral Palsy in some children. Children with Cerebral Palsy could have impaired ability to handle objects along with abnormal physical perception and seizures. They may also experience hearing or vision loss, as well as issues in communication. Persons with Cerebral Palsy may suffer from chronic and acute pain, experienced most commonly in joints such as knees and ankles, hips, upper and lower back.
Children with Cerebral Palsy may display developmental delays, marked by slow progress in achieving developmental milestones such as learning to walk, sit or crawl. The child may fail to reach developmental milestones at the expected time. Educate your patients’ caregivers to look for developmental delays using Amrit’s Baby Milestone Tracker that redflags causes for concern in each age period.
Types of Cerebral Palsy
Cerebral Palsy can be classified into 3 types based on the part(s) of the body affected, the type of movement affected and the severity of its effects:
- Spastic Cerebral Palsy: Characterised by abnormal muscle tone. Body movements are awkward and stiff. Typically, certain parts of the body may be affected by spastic Cerebral Palsy, for example, the hand and arm on one side of the body, or the leg muscles on both sides etc.
- Dyskinetic Cerebral Palsy: Characterised by jerky, uncontrolled movement of the legs, feet, arms or hands, or slow, uncontrollable writhing. It may also affect the face and tongue, so that the child finds sucking, swallowing and talking difficult.
- Ataxic Cerebral Palsy: Characterised by poor perception of depth and balance. As a result, children with Ataxia display poor coordination and walk with a wide-based gait in an unsteady manner.
Some people display symptoms that of more than one type of Cerebral Palsy. The most common type of mixed Cerebral Palsy is Spastic-Dyskinetic in which some muscles may be too tight, while others are too relaxed.
Assessment of Cerebral Palsy
Why carry out an assessment of a person with Cerebral Palsy?
Early detection and intervention is extremely important. It helps to ensure that children with Cerebral Palsy function better and are successfully integrated into society. Early diagnosis means that developmental, educational, and vocational services as well as plans for treatment of congenital malformations and other medical conditions can be made in time.
An important reason to carry out an assessment of a child is to ‘grade’ the level of disability that s/he experiences. This has implications for whether the person will get a Disability Certificate.
What is a Disability Certificate?
Disability Certificate is a government certification of the nature and extent of the disability that a person has. It is the basic document that any Indian requires in order to avail government facilities, benefits, entitlements and concessions.
Persons with Cerebral Palsy are eligible to apply for a disability certificate if:
- S/he has minimum 40% of locomotor disability
- S/he has minimum of 35% mental disability if Intellectual Disability is present.
State/ District Government Hospitals have Medical Boards which are the certifying authority to issue a Disability Certificate. Click this link to the relevant information on Amrit’s website.
How is Cerebral Palsy diagnosed?
All aspects of the motor function of the child are looked into: both at rest and while walking. Although Cerebral Palsy is not a progressive disorder, there is physical impairments and functional mobility that change with growth.
Systems to classify Cerebral Palsy
Cerebral Palsy is classified into 5 levels through the use of two systems. The Gross Motor Function Classification System (GMFCS) looks at gross motor skills of lower extremity and spine and the Manual Ability Classification System looks at the fine motor skills of upper extremity.
- The Gross Motor Function Classification System
- GMFCS is used to evaluate persons with Cerebral Palsy. It is based on self-initiated movement, with an emphasis on sitting, transfers, and mobility. The classification system is based on the need for hand-held mobility devices (such as walkers, crutches, or canes) or wheeled mobility, and to a much lesser extent, quality of movement.
- Movement between levels becomes moslty stagnant after the age of 5 years. So if a child is 6 years old and at level IV, then s/he is likely to need an assistive device throughout their lives.
- A person with Cerebral Palsy may have other limitations such as visual impairment, speech impairment, epilepsy, locomotor disability, intellectual disability etc.
GMFCS looks at physical impairments of lower extremity and spine to arrive the impact of Cerebral Palsy on gross motor skills. They are assessed separately and a final disability is calculated using the combining formula: a+b(90-a)/90 where a=higher value and b=lower value. Total permanent impairment is calculated from 100%.
Manual Ability Classification System (MACS)
- The Manual Ability Classification System (MACS) describes how children with Cerebral Palsy (CP) use their hands to handle objects in daily activities. MACS describes five levels. The levels are based on the children’s self-initiated ability to handle objects and their need for assistance or adaptation to perform manual activities in everyday life.
- MACS spans the entire spectrum of functional limitations found among children with Cerebral Palsy and covers all sub-diagnoses.
- Knowing a child’s MACS level helps parents, teachers and other to understand how independently can a child function and to assess if there is a need for external support
- It is based on the use of both hand in activities, not an assessment of each hand separately.
- Assessment of MACS is done by looking at the activity of upper extremity i.e hands and arms. Muscle strength, range of motions of hands and arms along with performance in coordinated activities like buttoning, wearing clothes without external help, picking an object up and putting it down without any help are looked at.