The infantile cerebral palsy (CP) is a group of neurological disorders that appear during fetal or child development and that will affect permanently to body movement and muscle coordination, but they will not increase its severity progressively (National Institute of Neurological Disorders and Stroke, 2016). It is estimated to be the most common cause of physical and cognitive impairment at early ages (Muriel et al., 2014).
This type of pathology is caused by neurological abnormalities in the areas responsible for motor control. In most cases, individuals with cerebral palsy are born with it, although it may not be detected until some months or years later.
Generally, when the child reaches the age of three, it is already possible to identify some signs: lack of muscle coordination in voluntary movements ( ataxia ); muscles with an unusually high tone and exaggerated reflexes ( spasticity ); walking with one foot or dragging the legs, among others (National Institute of Neurological Disorders and Stroke, 2016).
Also, these motor alterations can also be accompanied by sensory, cognitive, communication, perception, behavior, epileptic seizures, etc. (Muriel et al., 2014).
There are a number of children who suffer from this type of disease as a result of brain damage during the first years of life due to infections ( bacterial meningitis or viral encephalitis ) or a head injury such as head trauma ( TCE) (National Institute of Neurological Disorders and Stroke, 2016).
Prevalence of childhood cerebral palsy
Cerebral palsy is the most frequent cause of motor disability in childhood (Simón-de las Heras y Mateos-Beato, 2007). In addition, it is also the main cause of severe physical disability (Simón-de las Heras and Mateos-Beato, 2007) and cognitive impairment in the early ages of life (Muriel et al., 2014).
The global prevalence of cerebral palsy is estimated to be approximately 2-3 cases per 1,000 live births ( Roboina-Castellanos et al., 2007).
In Spain, statistical data have estimated that between 2 and 2.5 cases are cerebral palsy per thousand born. That is, in our country, 1 in 500 people. It is estimated that in total there may be about 120,000 people with cerebral palsy (Confederation ASPACE, 2012).
The United Cerebral Palsy Foundation (UCP) has estimated that approximately 800,000 children and adults in the United States coexist with one or more of the symptoms of cerebral palsy. According to the federal government’s Center for Disease Control and Prevention, about 10,000 babies born in the United States will contract cerebral palsy every year. (National Institute of Neurological Disorders and Stroke, 2010).
It is a pathology that occurs in a higher proportion in preterm or low birth weight (<2,500 g), with the prevalence of these cases being 72.6%, compared to 1.2% in children with a weight greater than 2,500 g at birth. (Muriel et al., 2014).
Approximately 94% of people with cerebral palsy acquired disability during gestation or during childbirth. The remaining 6% of cerebral palsy occurred during the first years of life (Confederation ASPACE, 2012).
On the other hand, half of the people with cerebral palsy present a significant intellectual disability. 33% require assistance in their travel and the other 25% require ancillary communication systems (Confederation ASPACE, 2012).
Definition and symptoms of childhood cerebral palsy
The concept of ‘cerebral palsy’ is used to encompass neurological sequelae of a broad nature that affect most of the motor sphere (Camacho-Salas et al., 2007).
In the 1860s, an English surgeon named William Little wrote the first medical descriptions of a strange disorder affecting children in the early years of life, causing spastic and stiff muscles in the legs and to a lesser extent in the arms (National Institute of Neurological Disorders and Stroke, 2010).
The disorder, called Little’s disease for many years, is now known as spastic diplegia . These are disorders that affect movement control and are grouped under the unifying term “cerebral palsy” (National Institute of Neurological Disorders and Stroke, 2010).
Cerebral palsy is a disability that is caused by a brain injury sustained during the gestational period, birth or during the first years of life, in the stage of child development. Normally, it will provoke a physical disability that varies in its degree of affectation, but in addition, it can also appear accompanied by a sensorial and / or intellectual disability (ASPACE Confederation, 2012).
Some of the signs and symptoms exhibited by children with cerebral palsy include (National Institute of Neurological Disorders and Stroke, 2010):
- Lack of muscle coordination when performing voluntary type movements (ataxia).
- The muscles are tense and rigid with exaggerated reflexes (spasticity).
- In many cases they walk with a single foot or by dragging one of the lower limbs.
- It is frequent to observe the march using the tip of one foot, squatting, or “marching in scissors”.
- Variations of muscle tone, from very rigid to flaccid or hypotonic.
- Difficulty swallowing or talking or excessive drooling.
- Presence of jolts, tremors, or involuntary movements at random.
- Difficulty executing precise movements, such as typing or buttoning a shirt.
In addition, injury or brain damage can affect other functions such as attention, perception, memory , language and reasoning. All this will depend on both the location, type, extent and timing of brain damage (ASPACE Confederation, 2012).
Numerous studies have demonstrated the presence of cognitive deficits in individuals with childhood cerebral palsy. These studies describe alterations in attention, visoperception, deficits in executive functioning and working memory, to a global and generalized impairment of cognitive abilities and intellectual function (Muriel et al., 2014).
In addition, the presence of these lesions will also interfere with the normal development of the Central Nervous System. Once the damage occurs, it will have repercussions on the process of brain development and maturation, and therefore on child development (Confederation ASPACE, 2012).
Thus, children with neurodevelopmental disorders and deficits in the cognitive sphere, in turn, present a higher risk of social difficulties, behavioral problems and, in addition, there is an increased risk of problems related to mental health ( Muriel et al., 2014).
Types of Cerebral Palsy
Depending on when brain damage occurs, cerebral palsy is classified as:
- Congenital: when the lesion occurs in a prenatal stage.
- Natal or neonatal: when the injury occurs at the time of birth and in an immediate time after birth.
- Acquired or postneonatal: when the injury occurs after the first month of age.
In addition, it is also common to use a classification based on the type of motor disorder that predominates in the clinical picture presented by the individual and according to the extent of the affectation that is described in the work of Póo Argüelles (2008):
Spastic cerebral palsy
It is the most frequent type. Within this group we can distinguish several types:
- Tetraplegia (tetraparesis) : patients have an affection in the four extremities.
- Diphysiology (dysparesis) : the involvement of patients predominates in the lower limbs.
- Spastic hemiplegia : paresthesia occurs in one of the body halves, usually with a greater involvement of the upper extremity.
- Monoparesis : involvement of a single limb.
It is a fluctuation and sudden change in muscle tone. In addition, it is characterized by the presence of involuntary movements and reflexes. Within this group we can distinguish several types:
- Choreoathetosis : chorea, athetosis, tremor.
- Dystonic form : fluctuation of muscle tone.
- Mixed form: is associated with the presence of elevated muscle tone (spasticity).
It is characterized by the presence of hypotonia, ataxia, dysmetria or incoordination. Within this group we can distinguish several types:
- Ataxic diplegia : is associated with spasticity of the lower limbs.
- Simple ataxia: presence of hypotonia that is associated with dysmetria, ataxia, or intentional tremor.
- Imbalance Syndrome: characterized by the presence of an imbalance of balance or incoordination.
Hypotonic Cerebral Palsy
It is characterized by the presence of a descending muscular whole (hypotonia) accompanied by hyperreflexia .
It presents with associations between ataxia, simple dystonia or dystonia with spasticity.
Apart from this classification, it is also possible to use a classification according to the affectation: mild, moderate, severe or profound, or according to the functional level that presents the motor affectation: levels from I to V, according to the Gross Motor Function Clasiffication System (Poo Argüelles, 2008).
Mild Cerebral Palsy
It takes place when the individual does not present limitations to the execution of the activities of the daily life, although it presents some type of affectation or physical alteration (Confederation ASPACE, 2012).
Moderate cerebral palsy
The individual presents difficulties to carry out the daily activities and requires means of support or diverse supports (Confederation ASPACE, 2012).
Severe cerebral palsy
Supports and adaptations are required for practically all activities of daily living (Confederation ASPACE, 2012).
Causes of Cerebral Palsy
Most children with cerebral palsy are born with it, although it may not be detected until months or years later. As there are particular types of brain damage that cause cerebral palsy, there are also certain illnesses or events that may occur during pregnancy and childbirth that will increase the risk of a baby being born with cerebral palsy (National Institute of Neurological Disorders and Stroke , 2010).
In a summarized and structured way, Póo Argüelles (2008) shows the most prevalent cerebral palsy risk factors divided according to the moment of occurrence:
Prenatal Factors (Póo Argüelles, 2008)
- Maternal factors: disorders of coagulation; autoimmune diseases; HTA, intrauterine infections; occurrence of trauma; thyroid dysfunction.
- Placental disorders: maternal thrombosis; fetal thrombosis; chronic vascular changes; infections.
- Fetal Factors: multiple gestation, intrauterine growth retardation, polyhydramnios, hydrops fetalis or malformations.
They can be: prematurity, low birth weight; maternal fever during childbirth, CNS or systemic infection; presence of sustained hyperglycemia; presence of hyperbilirubinemia; intracranial hemorrhage; hypoxic-ischemic encephalopathy; trauma or heart surgery (Póo Argüelles, 2008).
They can be: infections of the type meningitis or encephalitis; head trauma; seizure status; cardiorespiratory arrest; intoxication or severe dehydration (Póo Argüelles, 2008).
All these risk factors will lead to various mechanisms that will damage the child’s brain: white matter damage; abnormal development of the brain and nervous system in general; cerebral haemorrhage; cerebral hypoxia-ischemia, etc. (National Institute of Neurological Disorders and Stroke, 2010).
These lesional mechanisms will cause the symptoms detailed above in function of the area to which it is restricted, the extent and severity of the event.
Thus, when a cerebral palsy affects muscle movement and coordination, it is not caused by problems or alterations in muscles or nerves, but by abnormalities within the brain that disrupt the brain’s ability to control movement and posture.
In some cases of cerebral palsy, the cerebral motor cortex has not developed normally during fetal growth. In others, the damage is the result of a brain injury before, during, or after birth. In any case, the damage is not repairable and the resulting disabilities are permanent ( National Institute of Neurological Disorders and Stroke, 2010).
Cerebral palsy is considered a very heterogeneous clinical pathology. The individuals who suffer from it may present with a variety of neurological syndromes (motor, cerebellar, convulsive, etc.) and may present other syndromes that are not directly related to the central nervous system (digestive, osteoarticular, etc.) resulting from the presence of several secondary alterations (Robania-Castellanos et al., 2007).
The consequences of cerebral palsy differ in type and severity from one person to another, and may even change in an individual over time (National Institute of Neurological Disorders and Stroke, 2010).
Thus, some individuals will present generalized bodily affection, while others will only present some difficulties or deficiencies for gait, speech or use of the extremities. Therefore, some people will live without presenting only manifestations of the pathology, while others will be in a situation of full dependence and therefore, will require the support of third persons for the accomplishment of the majority of the tasks (Confederation ASPACE, 2012).
In addition to motor disorders detailed in the section on definition and symptoms, people with cerebral palsy also have other medical conditions , such as mental retardation, convulsions, impaired vision or hearing, and abnormal physical sensations or perceptions (National Institute of Neurological Disorders and Stroke , 2010).
In this way, many people with cerebral palsy may present, to a greater extent, one of the following conditions (Confederation ASPACE, 2012):
- Intellectual disability: This condition can occur in about half of the cases of individuals with cerebral palsy. In many cases, it is associated with a verb-spatial discordance.
- Epileptic seizures: it is estimated that between 25% and 30% of cases generalized or partial epileptic seizures may occur.
- Vision impairment: The most common involvement is strabismus in 50% of cases.
- Hearing disorders: approximately 10-15% of the cases people with PC may present some kind of auditory deficit.
In addition, of these physical or intellectual conditions, other difficulties or manifestations may also appear (Confederation ASPACE, 2012):
- Behavioral : aggressive or self-injurious behavior, abulia (passivity, lack of initiative, fear of the outside world or inhibition) or stereotype (atypical and repetitive habits).
- Cognitive : among the most frequent are lack of concentration and / or attention.
- Language : difficulties of the speech capacity due to the affection of the muscles that control the mouth, the tongue, the palate and
- the buccal cavity in general.
- Emotional : increased prevalence of psychological and emotional disorders such as mood disorders (depression), anxiety, affective immaturity, among others.
- Social : motor disorder can in many cases lead to poor adaptation to the social environment, resulting in social isolation or stigmatization .
- Learning : Many people may have an intellectual disability or specific learning needs, although it does not have to correlate with an IQ that is lower than normal.
Most cases of children with cerebral palsy are diagnosed during the first two years of life. However, if the symptoms are mild, it can complicate the diagnosis, becoming delayed until the 4 or 5 years of age.
When there is suspicion of the presence of a PC by a specialist, it is most likely that several exploratory interventions will be performed (National Institute of Neurological Disorders and Stroke, 2010).
Specialists diagnose cerebral palsy by assessing motor skills by identifying the most characteristic symptoms. In addition, it must be determined that it is not a degenerative state. A complete medical history, special diagnostic tests, and, in some cases, repeated checks may help confirm that other disorders are not the problem National Institute of Neurological Disorders and Stroke, 2010).
In many cases, additional tests are used to rule out another type of disorder. The most used are those with brain imaging (MRI), cranial ultrasound, or computed tomography (National Institute of Neurological Disorders and Stroke, 2010).
Currently, there is no curative treatment for cerebral palsy. But different therapeutic strategies can be put in place so that the person can maintain their quality of life . Treatment can be used to improve their movements, to stimulate intellectual development or to develop an efficient level of communication and thus to stimulate social relations (Confederation ASPACE, 2012).
There are several fundamental pillars in the therapeutic intervention with cases of cerebral palsy: early care, physiotherapy, speech therapy, psychopedagogy, neuropsychological rehabilitation , psychotherapy and social intervention (ASPACE Confederation, 2012).
In general, the best therapeutic intervention is the one that starts early and therefore offers more and better opportunities for capacity development or learning.
Treatment may therefore include: physical and occupational therapy; language therapy; medications for the control of epileptic symptoms or of muscle spasms and pain; surgery to correct various anatomical alterations or the use of orthopedic adaptations (wheelchairs, walkers, communication aids, etc.) (National Institute of Neurological Disorders and Stroke, 2016).
The suffering of a cerebral palsy can have important repercussions on the quality of life of the individuals who suffer it, especially in the case of the child population, since it will greatly limit many later learning.
Precise diagnosis and early therapeutic intervention are essential to achieve the best possible adaptations to the underlying deficits.