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Cerebral Palsy Causes, Symptoms, and Long-Term Management

Cerebral palsy is the broad term for a neurological condition which affects muscle movement and balance and can affect the entire body. CP, as cerebral palsy is commonly known as, is due to brain damage or to abnormal brain development. The brain damage which causes CP can occur when the baby is still in the womb or during the delivery process; sometimes, CP-causing brain damage occurs shortly after birth. Cerebral palsy is considered congenital when a baby is born with it, but this does not mean that the condition is hereditary.

Researchers have divided cerebral palsy into nine general categories or forms:

• Spastic diplegia
• Spastic hemiplegia
• Spastic quadriplegia
• Athetoid dyskinetic cerebral palsy
• Choreoathetoid dyskinetic cerebral palsy
• Dystonic dyskinetic cerebral palsy
• Ataxic cerebral palsy
• Hypotonic cerebral palsy
• Mixed cerebral palsy

Eight of the forms have distinct symptoms which distinguish them from the others; as the name implies, mixed cerebral palsy is a combination of two or more forms.

Symptoms of Cerebral Palsy

Cerebral palsy has many symptoms, depending on the form the condition takes; symptoms range from mild to severe, depending on the extent and location of the brain damage or abnormality.

• Stiff muscles; too much muscle tone. Limbs may be held stiffly, bent and close to the body. Often arms and or legs are held in awkward, abnormal positions. Fingers may be clenched and hands held in abnormal positions. Movement is restricted or impossible. These symptoms are all characteristic of the three spastic forms of CP.

• “Floppy,” overly relaxed muscles. The patient may have a “rag doll” appearance. These symptoms are characteristic of hypotonic cerebral palsy.

• Combination of stiff and “floppy” muscles. This is most characteristic of mixed CP.

• Involuntary movements. This is most characteristic of the dyskinetic forms of CP. Children may exhibit slow, writhing movements.

• Difficulties with balance and depth perception. This is most characteristic of ataxic CP.

Conditions Associated with Cerebral Palsy

• Mental retardation. According to the National Institute of Neurological Disorders and Stroke, approximately two-thirds of people with CP have some degree of mental impairment; mental retardation in CP ranges from mild to severe. However, not all patients with CP are mentally retarded or learning disabled; some patients with CP have higher IQs than average and may be very intellectually gifted. Speech and communication problems, which can accompany CP, sometimes make it difficult to assess the person’s intelligence.

• Speech and communication difficulties. The speech of CP patients may be difficult to understand. Some CP patients have difficulty processing the spoken word or speaking with the correct syntax.

• Hearing difficulties and/or vision difficulties. These problems make communication even more difficult. Eyes which do not focus correctly may be a problem with CP; the condition can cause strabismus—cross eyes or lazy eye. Another (rarer) vision problem which can occur with CP is cortical blindness. The patient’s eyes are normal, but they are blind because the brain cannot process the visual information.

• Swallowing difficulties. Drooling. Swallowing difficulties may lead to malnutrition in CP patients. They may also cause aspiration—food is inhaled into the lungs because of choking; aspiration can lead to pneumonia.

• Difficulty with constipation or with bowel and bladder control.

• Seizures. Fifty percent of CP patients may have seizures. These range in severity from the convulsions of tonic-clonic seizures to mild, focal (partial) seizures—which may be noticeable only as temporary confusion, a temporary loss of attention, or mild muscle twitches.

• Scoliosis. Some patients with CP have or develop scoliosis—curvature of the spine which make walking even more difficult.

Possible Complications of Cerebral Palsy

• Contractures. Contractures occur when the stiff, spastic muscles pull too tightly on the bones and joints; the muscle cannot move and the bone and/or joint may become deformed from the pressure.

• Falls. Because of difficulty with movement and balance, CP patients who can walk may be prone to falling.

• Aspiration pneumonia and other respiratory problems because of swallowing difficulties and difficulty with diaphragmatic breathing. Such problems are especially likely for CP patients who are confined to a wheelchair.

• Malnutrition because of swallowing and chewing difficulties.

• Indigestion because of poor muscle motility. The food does not move in the esophagus and the rest of the digestion tract as it should.

• Behavior and emotional problems. The brain damage or brain malformations present in CP combined with the stress of dealing with physical disabilities can lead to behavioral and emotional problems for many CP patients.

• Delayed development and growth. Developmental delays (failing to reach for an object, sit up, crawl, stand, or walk at the age most babies do) are generally the first sign that an infant may have CP.

Causes of Cerebral Palsy

Throughout the entire nine months of pregnancy, the growing fetus is subject to many things which can affect its development. The brain is especially vulnerable during the first two trimesters. Brain damage can also occur from lack of oxygen during a difficult delivery; less than 10 percent of CP is caused by oxygen-deprivation during delivery. Sometimes CP is caused by infection, lack of oxygen, or head injury after birth.

Infections in either the mother or the unborn baby can cause the baby’s brain to be injured. Inflammatory pelvic disease in the mother is an especially high risk for the baby. The immune system fights infections by producing more cytokines (a type of immune cell); during the course of the infection fighting process, the cytokines produce inflammation. Although useful in fighting infection, inflammation can cause brain damage. Exposure to toxins can also put the unborn baby at risk for brain damage or brain malformations.

Premature babies are at especially high risk for developing brain damage after birth. Many preemies develop periventricular leukomalacias—lesions in the brain’s white matter. Periventricular leukomalacias inhibit circulation in the brain; the brain receives less oxygen and so the nervous system cannot communicate as well as it should with the muscles. Some 60 to 100 percent of babies with periventricular leukomalacias will develop CP.

Rh incompatibility is another risk factor for CP. In Rh incompatibility, the mother’s Rh blood type conflicts with the unborn baby’s Rh blood type. The mother’s body will develop antibodies against the baby’s blood and this can cause the baby’s brain to be damaged. Fortunately, testing for Rh incompatibility is a routine part of prenatal care in the U.S. Once detected, the condition can be treated and complications can be prevented.

Stroke in the unborn baby is another cause of CP, because strokes cause oxygen deprivation, leading to cell death and brain damage. Many people do not realize that babies can have strokes, but unborn babies are especially prone to the type of stroke which causes bleeding and they can also experience ischemic strokes—clots which block blood flow. High blood pressure or extremely low blood pressure in the mother can put the baby at high risk of stroke. Regular, quality prenatal care is vital for both the baby and the mother.

Women with mental retardation, gestational diabetes (diabetes which occurs only in pregnancy) or thyroid problems are also at greater risk for having a baby with CP. In addition, women with a seizure disorder are at high risk for having a baby with cerebral palsy. Being part of a multiple birth is also a risk factor for CP, as is low birthweight (even if the baby is full term).

Prognosis of Cerebral Palsy

The brain damage or brain malformations responsible for cerebral palsy do not grow worse with age, so the condition does not progress in this sense. With proper care, many CP patients live out a normal lifespan. However, the possible complications of CP can sometimes lead to life-threatening conditions, such as aspiration pneumonia or extreme malnutrition. The weak muscles of CP may grow weaker if the patient does not receive regular, appropriate physical therapy.

Treatment for Cerebral Palsy

Treatment for all forms of CP relies heavily on physical therapy. Physical therapy strengthens the muscles, prevents them from atrophying, and improves coordination. There are many forms of physical therapy used for CP. One controversial form, called conductive therapy or education, involves total immersion of the child in a regular, weekday education program aimed at improving the CP patient’s total quality of life.

Other newer therapies include hyperbaric oxygen therapy, suit therapy, and hippotherapy (horseback riding therapy). Alternative therapies such as massage or yoga also help some CP patients, but all therapies should only be done by a qualified, professional practitioner.

Medications are used to reduce spasticity and to control seizures when present. Medicine may also be used to deal with complications such as indigestion, poor appetite, acid reflux, constipation. Surgery is sometimes needed to correct bone deformities or scoliosis.

Sources

Ataxic Cerebral Palsy

There are nine forms of cerebral palsy—a condition in which brain abnormalities or damage interfere with the normal relaying of nerve messages from the brain to the nervous system. Ataxic cerebral palsy is one of the rarer forms of cerebral palsy (CP); fewer than one in ten people with CP have the ataxic form.

The term ataxic comes ataxia, a medical term referring to loss of muscle coordination, particularly in the limb. Ataxic cerebral palsy is less disabling than some of the other forms of cerebral palsy,but the symptoms have a significant impact on patients’ lives.

Distinct Symptoms of Ataxic Cerebral Palsy

Depth perception and balance are affected by ataxic cerebral palsy. People with ataxic CP have difficulty with coordination; some must walk by planting their feet an unusual distance apart. Quick movements are difficult. So are activities which require precision movements, such as putting a coin in a slot.

Some people with ataxic cerebral palsy experience a symptom called an intention tremor. This means that when they are deliberately reaching for something their hand or hands begin to tremble. The tremble worsens the nearer they come to the object they are reaching for.

Ataxic cerebral palsy can cause mental retardation, but generally intelligence is unaffected by this form of CP. All forms of CP can sometimes affect vision and/or hearing.

Causes of Ataxic Cerebral Palsy

Like the other, less rare forms of CP, ataxic cerebral palsy is caused by abnormal brain development or by brain damage. Infections in either the mother or the unborn baby and exposure to toxins can cause the fetal brain to not develop properly. During the first two trimesters, the fetal brain is particularly vulnerable to developing abnormally.

Ataxic cerebral palsy may be caused by lesions (holes) in the brain’s white matter; these are called periventricular leukomalacias. Damage to the white matter affects the entire body because this part of the brain sends signals to the entire nervous system, as well as signals within the brain. The brain’s white matter is especially vulnerable during the third trimester.

Bleeding in the unborn baby’s brain can lead to brain damage. Bleeding in the brain is generally caused by strokes. Most fetal strokes are the type which causes bleeding; they may be due to mal-formed or weak brain blood vessels. Occasionally blood clots form in the placenta, causing ischemic strokes by obstructing the baby’s circulation.

When a mother has high blood pressure her unborn baby is at greater risk of stroke. High blood pressure during pregnancy is common, since the growing baby is putting extra stress on the woman’s system. Blood pressure should be carefully checked during pregnancy to assure a healthy outcome for both mother and child. Infections in the mother are yet another cause of stroke in the unborn baby; inflammatory pelvic disease is especially risky for the fetus.

The womb and the placenta may be infected by maternal viral infections. During an infection the body produces more cytokines (a type of immune cell) which in turn produce inflammation. Inflammation fights infection, but it may damage the fetal brain.

Fetal brain damage also occurs if the brain is deprived of oxygen for any length of time. When cerebral palsy was originally described in the 1800s, it was thought that oxygen deprivation during a difficult delivery caused most incidents of the disorder. Today, scientists believe that fewer than ten percent of cerebral palsy cases are due to oxygen deprivation during delivery. Oxygen deprivation can happen at any time during the pregnancy; babies are more likely to be harmed by it when in the womb. Tearing or rupturing of the uterus can cause oxygen deprivation, so can damage to the placenta or umbilical cord. Lack of oxygen is also caused when the mother’s blood pressure drops too low.

Possible Complications from Ataxic Cerebral Palsy

In ataxic cerebral palsy there is a risk that some muscles will not get sufficient use, causing atrophy and possible contractures (rigid muscles that can cause the attached bone to be deformed). However, the risk of contractures is much less than in the spastic forms of CP.

Malnutrition can also be a problem with ataxic cerebral palsy, since the patient may have difficulty feeding him or herself. In addition, coordinating chewing and swallowing sometimes is difficult.

Age of Diagnosis

Although in some forms of CP, the baby show symptoms at birth, ataxic cerebral palsy is usually diagnosed later. Developmental delays and awkward movements generally cause parents to suspect a problem when the child is between three and eighteen months old. Regular visits to the pediatrician are especially important for children under three years old, so that any developmental problems may be treated early.

Treatments for Ataxic Cerebral Palsy

Physical therapy is the gold standard of treatment for all forms of cerebral palsy. It can help people with ataxic cerebral palsy develop better balance and reflexes. It also helps prevent unused muscles from atrophying (growing weak and shrinking).

An alternative form of physical therapy called conductive therapy or conductive education has been successfully used by some CP patients. Conductive therapy can improve the fine motor skills as well as the gross motor skills, thus it may be especially suited to people with ataxic cerebral palsy. Conductive education is done in a group setting using songs and games to encourage the children. While standard physical therapy is sometimes given only two or three times a week, conductive education is done for several hours five days a week.

Patients with ataxic cerebral palsy may also need medications for problems that develop from their condition, but generally the need for medicine in this form of cerebral palsy is not as great as in the spastic forms.

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Congenital Cerebral Palsy

Cerebral palsy (CP) is a disorder which originates in the brain and interferes with movement. Cerebral refers to the brain; palsy refers to the difficulty with movement. Ninety to ninety-five percent of cerebral palsy cases are congenital cerebral palsy; congenital means that a disorder was present at birth.

The remaining five percent or so of CP cases are acquired CP, meaning that they were acquired after birth as a result of infection, head trauma, or some other cause of brain damage. Congenital cerebral palsy occurs when the baby’s brain does not develop normally in the womb or when brain damage has occurred during development.

Causes of Congenital Cerebral Palsy

There are many causes of congenital cerebral palsy, some of which are not completely understood. Genetic abnormalities sometimes cause brain malformation, but the majority of congenital CP cases result from brain damage due to fetal stroke, or fetal or maternal infection. Good prenatal care can lower the risk of these conditions, but it cannot entirely prevent them.

Diseases such as rubella which cause birth defects can be prevented if the mother is vaccinated before getting pregnant. Rh incompatibility (conflict between the fetus’ blood type and the mother’s blood type) can cause brain damage if left untreated. Rh incompatibility is routinely monitored for in the U.S. Early treatment of Rh incompatibility protects the unborn baby from any harmful effects from the disorder.

Avoiding toxins can help prevent birth defects, including cerebral palsy. The unborn baby’s brain is most subject to damage from toxins during the first two trimesters of pregnancy, but damage can also occur in the final trimester.

Controlling the mother’s blood pressure can help prevent strokes in the unborn baby. Both high blood pressure and extremely low blood pressure in the mother can cause a fetal stroke. Strokes in unborn babies are generally the type which causes bleeding; intracranial hemorrhage (bleeding in the brain) can cause permanent brain damage. Sometimes unborn babies suffer ischemic strokes—strokes caused by blood clots which block blood flow.

Obstructed blood flow or bleeding in the brain are both conditions which can lead to CP, because they interfere with oxygen flow in the brain. Oxygen is vital to the all of the brain’s functions, including the functioning and production of neurotransmitters—the brain’s chemical messengers. Neurotransmitters relay messages from brain to the nervous system; these messages are necessary for muscle movement.

When a mother has inflammatory pelvic disease, her unborn child can be at higher risk of stroke. Trying to be infection-free before pregnancy can lower this risk, but it cannot always prevent problems. Other causes of congenital cerebral palsy are also not completely preventable. Intrauterine infections (infections in the baby while in the womb) are difficult to treat and newer methods of delivering antibiotics may not work as effectively as hoped.

At one time doctors believed that asphyxia (lack of oxygen) during a prolonged or difficult delivery was the cause of most cases of congenital cerebral palsy, but studies done during the 1980s proved that this was not the case. Less than 10 percent of congenital CP is caused by asphyxia during delivery. Lack of oxygen while the baby is still in the uterus is more likely to cause CP, because it is more prolonged than what occurs during labor. Accidents such as rupture of the uterus, problems with the umbilical cord, or detachment of the placenta can cause severe lack of oxygen in the unborn baby and lead to CP.

Symptoms of Congenital Cerebral Palsy

The symptoms of congenital cerebral palsy depend on the part of the brain affected and on the amount of damage done. Symptoms include:

  • Stiff muscles and difficulty moving. Muscles may be so tight (spastic) that they draw up the limbs. These symptoms appear mainly in the three spastic forms of CP and in mixed CP.
    • Loose, overly-relaxed, “floppy” muscles. This type of problem occurs in hypotonic cerebral palsy and in mixed CP.
    • Writhing, involuntary movements. Most common in dyskinetic CP.
    • Difficulty speaking. Difficulty understanding language.
    • Difficulty swallowing.
    • Mental retardation. Approximately half of CP patients have some form of mental impairment; others may be of normal intelligence or intellectually gifted. Because of communication difficulties, it is sometimes difficult to assess the IQ of CP patients.
    • Seizures

Conditions Associated with Cerebral Palsy

Problems such as vision difficulties, hearing difficulties, and difficulties with nutrition are sometimes associated with congenital cerebral palsy. A common problem for CP patients is the condition popularly called crossed eyes; the muscles controlling eye movement are weak, making focusing difficult.

Complications of Congenital Cerebral Palsy

Nutrition difficulties occur when the patient cannot chew or swallow efficiently, making it difficult to obtain enough calories. Patients who experience involuntary movements need more calories because of the energy expended. Difficulty controlling bowel and bladder function can also be a problem for CP patients.

Spastic forms of CP can lead to muscle contractures; the muscles become so tight that they pull the bones or joints out of place. Ankle equinus, a condition in which the patient must walk on the toes is a common problem with CP. Foot drop, in which the person has difficulty raising the front of the foot is another common problem in congenital CP problem.

Age of Diagnosis

Most cases of congenital cerebral palsy are diagnosed before the child is three years old. Developmental delays are usually the first clues that the baby may have cerebral palsy. Symptoms such as overly stiff or overly relaxed muscles may not be apparent until some months after birth.

Treatments for Congenital Cerebral Palsy

The standard treatment for all forms of congenital cerebral palsy is physical therapy. Physical therapy strengthens weak muscles and helps prevent muscle contractures; many CP patients make substantial progress with physical therapy and become able to do a range of activities they would not have been able to have done without this extra help.

Medications are used to relax spastic muscles. Anti-seizure medicines are used to control seizures. Other medications are used to prevent or control other problems associated with CP, such as bowel problems.

Surgery may be needed to correct contractures or joint problems such ankle equinus. Braces can also help prevent or correct some joint problems. Other forms of orthopedic supports can make life easier for CP patients.

Sources

“Cerebral Palsy: Hope Through Research” National Institute of Neurological Disorders and Stroke. Retrieved March 27, 2009 from the World Wide Web:https://www.ninds.nih.gov/Disorders/All-Disorders/Cerebral-Palsy-Information-Page

“Cerebral Palsy” March of Dimes. Retrieved March 28, 2009 from the World Wide Web:https://www.marchofdimes.org/complications/cerebral-palsy.aspx

“Cerebral Palsy” MayoClinic.com Retrieved March 27, 2009 from the World Wide Web:http://www.mayoclinic.com/health/cerebral-palsy?DS00302

Hypotonic Cerebral Palsy

Cerebral palsy (CP) is used as a blanket term to cover nine forms of muscle and movement difficulties caused by brain damage or malformations in the brain structure. The disabilities caused by CP range from so mild that they are hardly noticeable to severe. Hypotonic cerebral palsy is a form of the disorder marked by floppy (overly relaxed) muscles; hypotonic CP is rarer than the spastic forms of the disorder.

Hypotonia means less muscle tone. It can be caused by several factors: cerebral palsy, muscular dystrophy, Down’s syndrome, myotonic dystrophy, Tav-Sachs disease, and Prader-Willi syndrome. Hypotonic cerebral palsy is hypotonia which is caused by brain damage or brain malformation; it is generally congenital (present at birth), but an injury shortly after birth can also cause it.

Distinct Symptoms of Hypotonic Cerebral Palsy

People with hypotonic cerebral palsy have noticeably “floppy” muscles and no control of their head. The arms and legs hang down like a “rag doll.” Joints may be lax. Reflexes may be poor, and walking is usually difficult.

The condition causes posture problems and may cause breathing and swallowing difficulties. Speech may also be difficult, although intelligence is usually unaffected.

Causes of Hypotonic Cerebral Palsy

Like other categories of CP, hypotonic cerebral palsy is caused by brain damage or by abnormal brain development. The location and extent of the brain damage or malformation determines the kind of impairment produced. Hypotonia is generally associated with damage to the cerebellum—the part of the brain which controls coordination and balance. The unborn baby’s brain is particularly vulnerable to damage caused by toxins or infections during the first five months of development.

When the mother has an infection it can be damaging to her unborn child. Infections of any sort cause the levels of cytokines (a type of immune cell) to rise; this produces inflammation. Inflammation is a normal part of the infection fighting process; however, inflammation can cause brain damage to the fetus.

Many people are unaware of the devastating effect the mother’s infection may have on the unborn baby; they are also unaware that unborn babies may have strokes. Most people think of stokes as being a risk for the elderly, but not for newborn babies. Unfortunately, unborn babies can have strokes which cause brain damage.

Most strokes suffered by unborn babies are the type which cause bleeding. Poorly formed or weak blood vessels in the fetal brain are frequently responsible for this type of stroke.

Unborn babies may also have ischemic strokes—strokes caused by clots which block circulation and prevent oxygen from traveling to a part of the brain. Brain cells die if this blockage continues for any length of time. Blood clots in the placenta sometimes cause the fetus to have a stroke.

Decades ago, doctors thought that most cases of cerebral palsy were caused by oxygen deprivation during delivery, but it now known that lack of oxygen when the baby is still in the womb is a greater risk, than lack of oxygen during delivery. Damage to the umbilical cord or rupture of the uterus can also cause lack of oxygen.

In addition, the risk of stroke in the fetus increases if the mother has an infection or high blood pressure. Inflammatory pelvic disease is especially likely to cause a fetal stroke. Monitoring the mother’s blood pressure is a vital part of prenatal care, since too high or too low of blood pressure can cause serious problems for both the mother and child.

Possible Complications of Hypotonic Cerebral Palsy

The swallowing difficulties caused by hypotonic CP can lead to malnutrition. All forms of CP can lead to falls. Patients with hypotonic cerebral palsy are not as prone to contractures (a stiffened muscle deforms the bone by pulling on it) as people with the spastic form of CP; however, hypotonic cerebral palsy can contribute to joint problems.

Sometimes the brain damage which causes CP can also cause other problems, such as vision problems and hearing problems.

Age at Diagnosis

Hypotonic cerebral palsy is usually easily recognized early in the baby’s life. Babies with this condition have little muscle tone; their limbs are “floppy” and limp. They cannot hold their heads up.

If hypotonic cerebral palsy is suspected, imaging tests and ECGS will be used to confirm the diagnosis.

Treatment of Hypotonic Cerebral Palsy

Hypotonic cerebral palsy is treated primarily with physical therapy to strengthen the muscles, help the posture, and prevent future problems. Therapy can also help speech problems, swallowing problems, and breathing problems. A new, somewhat controversial therapy approach called conductive therapy or conductive education is helping some CP patients.

Conductive therapy is done in a group setting. Songs and games are used to keep the children interested. Unlike regular physical therapy, which may only be done every other day, conductive therapy is conducted five days per week. The sessions integrate learning life skills and academic skills, along with the physical exercises; conductive therapy is a total education program. It may benefit some hypotonic cerebral palsy patients.

Sometimes medications may be used for complications that may accompany hypotonic cerebral palsy. Surgery may be used to help joint problems or to correct bone deformities.

Sources

1. “Ankle Equinus: in CP” Wheeless’ Textbook of Orthopaedics. Retrieved March 29, 2009 from the World Wide Web: http://www.wheelessonline.com/ortho/ankle_equinus_in_cp 2. Banta, John V. “Cerebral Palsy, Myelodysplasia, Hydrosyringomylia, Rett Syndrome, and Muscular Dystrophies” in Spinal Deformities: the comprehensive text. Ronald L. Dewald, ed. New York: Thieme, 2003. 3. “Cerebral Palsy: Hope Through Research” National Institute of Neurological Disorders and Stroke. Retrieved March 27, 2009 from the World Wide Web 4. “Cerebral Palsy” March of Dimes. Retrieved March 28, 2009 from the World Wide Web:https://www.marchofdimes.org/complications/cerebral-palsy.aspx 5. “Cerebral Palsy” MayoClinic.com Retrieved March 27, 2009 from the World Wide Web:http://www.mayoclinic.com/health/cerebral-palsy?DS00302 6. “Hypotonia” National Institutes of Health. Retrieved April 3, 2009 from the World Wide Web 7. “Foot drop” The Mayo Clinic. Retrieved March 30, 2009 from the World Wide Web: https://www.mayoclinic.org/diseases-conditions/foot-drop/symptoms-causes/syc-20372628

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