Cerebral Palsy: Classification, Symptoms and Prevalence

Cerebral Palsy is a neurological disorder caused by brain injury or abnormal delayed development of the brain during prenatal, perinatal and postnatal stages. Children with Cerebral Palsy has orthopedic problem which is often accompanied by disturbance in Auditory, Visual,  Language, Speech, Cognition, Communication and Behavioural Developments; along with problems in sensation and perception; and musculoskeletal problems viz., spasticity, bone dislocation etc., that makes them disabled in various aspects of life. Cerebral Palsy can range from mild, moderate to severe.

Dr. William James Little, an orthopedic surgeon, was first person who documented spastic diplegia in the 19th Century and hence the type was named as Little’s Disease for years. Later, Sir William Osler, Father of Modern Medicine, coined the term Cerebral Palsy (CP).Cerebral palsy (CP) is one of the leading causes of disability in children having a prevalence rate of 2 to 2.5 per 1000 live births in United States (Winter et al., 2002). An important thing to note in this regard is that Cerebral palsy is basically a non-progressive condition that occurs due to damage to the developing brain. The problems of spasticity, movement, cognition, behavior and communication vary depending on the area of the brain that is affected.

Cerebral Palsy Classification

There are four main types of cerebral palsy depending on the Type of Neurological Dysfunction:

  • Spastic Cerebral Palsy (Pyramidal): In Spastic cerebral palsy, cortex is highly affected before and after first few days of birth. It can be diagnosed by jerky movements, muscle weakness, paralysis and joint stiffness that create a problem in voluntary movement. Sometime they cross their knees or make scissor-like movements with their legs. They have a problem in doing simple tasks.
  • Dyskinetic Cerebral Palsy (Extra Pyramidal): This can be again be divided into following types-
  1. Dystonia – Where slow movement of the torso, arm or leg with muscle stiffness and abnormal posture.
  2. Chorea-It is a repetitive, brief and irregular involuntary muscle movement in hand, feet, face, fingers and toes.
  3. Athetosis – It affects hands and feet, the term “athetoid” is derived from athetosis which mean sluggish and writhing movements.
  4. Choreoathetoid – This is a combination of chorea and athetosis.
  5. Ataxia – A rare type of cerebral palsy, ataxia include gait abnormality which create a loss of balance and coordination.
  6. Rigidity – Hypertonia muscle restricted movement.
  7. Dyskinesia – It refers to a category of movement disorder similar as chorea.

In Athetoid cerebral palsy, the basal ganglia or cerebellum is damaged due to lesion formations that occur during brain development within the first 18 months after birth. Itsdiagnosis is slow, and based on parental reports of uncontrolled movements of the extremities and trunk. In some cases, the face and tongue are also affected.

  • Ataxic Cerebral Palsy:Ataxia means ‘without order’ or ‘lack of coordination’. Ataxic cerebral palsy occurs due to damage in cerebellum. Diagnosis begins with the observation of slow motor development, abnormal muscle tone, and unusual posture in children, difficulty walking and performing fine motor activities, such as grasping objects and writing.
  • Mixed Cerebral Palsy: In Mixed cerebral palsy, the patient may experience complications which do not fit into one or other types of classification. The symptoms observed are commonly some from each of the types. Mental retardation is associated with mixed cerebral palsy. The most commontypes associated with mixed cerebral palsy are Spastic cerebral palsy and Athetoid cerebral palsy.

Classification based on Number and Distribution of Limb’s affected is as follows:

  • Monoplegia/Monoparesis is a kind of spasticity that occurs on one limb.
  • Hemiplegia/Hemiparesis which occur at one side of the body.
  • Quadriplegia– All four limbs are affected including torso and face. Spastic quadriplegic had a mental retardation with epilepsy.
  • Paraplegia/Paraparesis:Lower part of the body i.e., the lower limbsare affected.
  • Triplegia/Triparesis:Both lower limb and one upper are affected it can be both arm or leg or both leg or arm.
  • Double hemiplegia/Double hemiparesis:Four limbs are affected but either left or right side of the body is severely involved.
  • Tetraplegia: All four limbs are affected but one limb is less affected compared to the other three.
  • Pentaplegia/pentaparesis: Both upper and lower limbs are affected with neck and head paralysis.

Classification based on the Severity of Symptoms:

  • Mild:A child can move without assistance of escort and he/she can do his/herdaily living activities adequately.
  • Moderate:A child will need braces, medications, and adaptive equipment to accomplish daily activities.
  • Severe:A child will require an escort to do his/her regular activities

Symptoms of Cerebral Palsy

The symptoms of cerebral palsy can be varied depending on the area and severity of brain damage. The common symptoms include:

  • Differences in muscle tonei.e., either being too floopy or too stiff
  • Stiff Muscles having normal reflexes (Rigidity)
  • Tight muscles with exaggerated reflexes (spasticity)
  • Loss of muscle coordination (ataxia)
  • Delay in reaching motor development milestones, such as rolling over, taking head up while supporting on arms, ability to sit up alone, or ability to crawl.
  • Delay in speech development and/or difficulty in speaking.
  • Abnormal muscle tone, tremors or involuntary movements.
  • Excessive drooling and problems with swallowing, sucking or eating.
  • Difficulty in walking such as toe walking, a crouched posture and gait, a scissors-like gait where knees cross or a wide gait.
  • Neurological problems, such as seizures and intellectual disabilities

The symptoms can also be classified as per the types. They are:

Spastic Cerebral Palsy:

  • Awkward reflexes
  • Stiffness in one part of the body
  • Contractures (permanently tightened muscles or joints)
  • Abnormal gait
  • Exaggerated movements
  • Stiff, tight muscles (hypertonia)
  • Contractures
  • Abnormal reflexes
  • Abnormal gait
  • Crossed knees
  • Joints don’t extend fully
  • Walking on toes
  • Tight muscles in one part of the body

Dyskinetic Cerebral Palsy:

  • Involuntary movement
  • Tremors
  • Poor posture
  • Unsteadiness
  • Twisting of the torso
  • Slow, writhing movements
  • Abrupt movement

Ataxic Cerebral Palsy

  • Imprecise motor skills
  • Problem in walking
  • Gait abnormality
  • Poor coordination  in movements
  • Difficulty with recurrent movements, like clapping or writing
  • Scanning speech

Mixed Cerebral Palsy:

  • Involuntary movement
  • Excessive jerky movements
  • Abnormal reflexes
  • Improper posture
  • Tremors
  • Problem in coordination

Other associated problems observed are:-

  • Abnormal pain or touch perceptions
  • Physically impaired
  • Visual impairment
  • Hearing loss
  • Learning difficulty
  • Difficulty controlling their bladder(Urine and feces)
  • Oral diseases
  • Mental health conditions or psychiatric illness

Prevalence of Cerebral Palsy

Cerebral Palsy is found to be one of the most common childhood motor disabilities. A population-based study from around the world suggests that 1.5 to 4 per 1000 live births is affected by Cerebral Palsy. A 2008 report of ADDM CP concludes, Cerebral palsy is more common among boys compared to girls; black children are more affected than white; Hispanics and white children have an equal chance of having cerebral palsy; more than half of children having cerebral palsy can walk independently; and most of them have a co-occurring condition where 41% had a co-morbid epilepsy while 6.9% had Autism Spectrum Disorder.

According to WHO, approximately 10% of the world population has some or the other disability; in India it accounts for 3.8% of the population. Although, the incidence rate in India is 3 per 1000 live births; the actual data could be way more since it is a developing country and many cases are not reported.

The occurrence of cerebral palsy can depend on a variety of reason starting from the pre-birth, during birth to post birth stage. Certain genetic factors also influence the development of the disorder. Although there is no permanent cure, a number of different treatment methods, usually a combination of method helps in letting the child live a better life.

 

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