Introduction

Cerebral Palsy is not a diagnosis but an "encompassing term" covering numerous clinical presentations. It refers to permanent mobility and postural problems that limit activities and are caused by non-progressive defects in the developing foetal or infant brain. Sensory, perceptual, and cognitive problems frequently accompany cerebral palsy movement abnormalities.¹

Definition

The Centres for Disease Control and Prevention define cerebral palsy as a group of conditions that impair an individual's mobility, posture, and balance.² The clinical signs, which are caused by a lesion to the developing brain, are permanent and nonprogressive, but they may vary over time.

Movement disorders associated with cerebral palsy are spasticity, dyskinesia, ataxia, or mixed/other.³ Spasticity is the most frequent movement problem, affecting 80% of children with cerebral palsy. Movement abnormalities in cerebral palsy can cause secondary problems such as hip pain or dislocation, balance issues, hand dysfunction, and equinus deformity (ankle joint locks in such a way that it restricts the upward movement of the foot).

Symptoms

Everybody who has Cerebral Palsy struggles with posture and mobility.⁴ The kind and intensity of CP symptoms vary from person to person and might even alter over time. Depending on the areas of the brain that have been damaged, each person may experience very different symptoms.

Early signs of CP^5,6

• Early dominance of the hands
• Delayed achieving motor milestones
• Enduring rudimentary reflexes
• Scissored legs below 6 months
• Floppiness
• Stiffness
• Comorbidities present in CP children
• Pain
• Intellectual impairment
• Gait Disorders
• Hip displacement
• Speech issues
• Epilepsy
• Incontinence
• Behavioural disorders
• Sleeping problems
• Hearing impairment
• A visual impairment
• Cognitive limitation
• Thyroid disorders
• G.I. difficulties

Epidemiology

CP prevalence is typically stated as 2-3 per 1000 live births in both developed and developing nations, for a variety of reasons.⁷ The prevalence of cerebral palsy among term children is one per 1000 live births. Furthermore, projections for moderately preterm children (32-36 weeks' gestation) are 6-10 times higher, while prevalence is 10 times higher for extremely preterm children (less than 32 weeks' gestation). CP rates for live births are lower for babies weighing less than 1000 g as compared to those weighing 1000-1499 g. This odd impact is produced by the large number of babies who do not live long enough to acquire cerebral palsy and it disappears when predicting prevalence for neonatal survival.

Etiological factors

The causes of cerebral palsy are numerous and varied: congenital, hereditary, inflammatory, infectious, anoxic, traumatic, and metabolic conditions. Prenatal, natal, or postnatal damage to the developing brain is possible.⁸  More than thirty per cent of children have no documented aetiology or risk factors, yet some risk factors have been linked to CP on many occasions.^{9, 10, 11} It can be challenging to identify the precise origin of cerebral palsy in all cases, as the condition can arise from multiple aetiologies and manifest at any point from preconception to infancy.^{9, 11, 12} Recognised causes can be categorised as prenatal, perinatal, or postnatal based on when the brain injury occurred.

Prenatal causes of cerebral palsy

Congenital brain abnormalities, including defects in cortical development, are among the major recognised causes of cerebral palsy. According to current theories, most cases are caused by intrauterine development issues, congenital abnormalities, asphyxia that occurs at any gestational age, and preterm birth. Even though it was once believed to be a primary cause of cerebral palsy, intrapartum asphyxia only occurs in 10–20% of cases.

Periventricular leukomalacia (PVL), periventricular haemorrhage, and cerebral infarction are the most prevalent prenatal or neonatal aetiologies in low birth weight infants; in infants of normal birth weight, hypoxic-ischemic encephalopathy is the most common cause.¹³ One risk factor for CP development is periventricular leukomalacia (PVL), which affects 60–100% of individuals. Congenital abnormalities and cerebral palsy are generally significantly linked.^{13, 14}

Other vascular events shown by brain imaging, such as middle cerebral artery occlusion, are known prenatal causes of cerebral palsy. Long-term neurodevelopmental disabilities are known to be caused by maternal TORCH (toxoplasmosis, rubella, cytomegalovirus, and herpes simplex) infections during the first and second trimesters of pregnancy. It is believed that over 5% of CP cases in industrialised nations can be attributed to TORCH infections.¹⁵

Ingestion of poisons by the mothers, uncommon genetic abnormalities, and metabolic diseases are among the less frequent causes of cerebral palsy.¹⁶

Perinatal causes of cerebral palsy

Cerebral palsy cannot be linked to the acute intrapartum phase unless certain conditions are met. These conditions include antepartum haemorrhage, obstructed labour, and cord prolapse, which might endanger the foetus and cause hypoxia.^{17, 18} These include early onset of severe or moderate neonatal encephalopathy in infants of >34 weeks gestation, metabolic acidosis in the umbilical cord, foetal scalp, or very early neonatal blood samples.¹⁸

Children with cerebral palsy who have experienced neonatal encephalopathy in the past are more likely to have displayed intrapartum hypoxia symptoms, such as amniotic fluid stained with meconium.¹⁹  Cerebral palsy may result from severe low blood sugar levels, untreated jaundice, or a severe neonatal infection during the newborn period.¹⁶

Postnatal causes of cerebral palsy

In industrialised nations, postnatally acquired cerebral palsy is primarily caused by infections and traumas. Many children's cases of meningitis and its associated neurological aftereffects have decreased due to the introduction of new vaccinations. Non-accidental injuries and accidents, including car crashes and near-drowning incidents, cause cerebral palsy. 

Cerebrovascular accidents, incidents that appeared to be life-threatening, and the aftermath of congenital deformity surgery are other causes of postnatally acquired cerebral palsy. In developing nations, meningitis, septicaemia, malaria, and other illnesses are among the leading causes of cerebral palsy.¹⁶

Cerebral palsy is linked to disorders affecting mothers. These include thyroid disease, intellectual disability, seizures, maternal thrombophilia, and previous reproductive loss.^{20, 21, 22} There is also a correlation between CP and a sibling's experience of cerebral palsy.²⁰ Low birthweight, low gestational weeks, and birth traumas are common in teenage pregnancies.

One of the risk factors for CP is maternal age (> 35).¹⁵ There is also noted a considerable increase in adolescent pregnancies and considerably younger moms of children with CP. Mothers of CP infants experienced protracted labour, low birth weight, and low gestational weeks.

Diagnosis and treatment

Cerebral palsy is primarily diagnosed clinically, although if the patient's symptoms are not clearly explained, magnetic resonance imaging (MRI) can be useful in confirming brain injury.³ Once cerebral palsy is identified, its severity and response to therapy can be assessed using a tool like the Gross Motor Function Classification System.

Intramuscular Onabotulinumtoxin A, systemic and intrathecal muscle relaxants, selective dorsal rhizotomy, and physical and occupational therapy are among the treatments used for the movement impairments linked to cerebral palsy.

Cerebral palsy patients may also have non-movement-related issues that require ongoing care well into adulthood. These issues include cognitive impairment, seizures, pressure ulcers, osteoporosis, emotional or behavioural issues, and difficulties with speech and hearing.

Various approaches used in the management of cerebral palsy

Physiotherapy

Physiotherapy has made significant contributions in the realm of cerebral palsy. Muscle stretching, joint range of motion exercises, low resistance repetitive exercises, progressive resistance training, functional strength training, balance training, plyometrics, and constraint-induced movement therapy are a few techniques used to achieve this goal.²³

Speech therapy

Speech and swallowing are challenging for CP youngsters due to their aberrant tone and decreased muscular function. Speech treatment for such illnesses can help improve oral motor abilities, disarticulation issues, and communication skills.²⁴

Robot-assisted devices

Robotics is a revolutionary technology that uses a computerised control system to aid in motor learning and brain reorganisation, improving upper and lower limb performance.²⁵ Because functional movements are more beneficial than typical movement patterns, gait therapy has been shown to improve lower limb function. Traditional gait rehabilitation has been replaced with robot-assisted gait training due to advancements in technology. 

Summary

A brain injury is the cause of cerebral palsy (CP), a neurodevelopmental disorder marked by impairments in muscle tone, mobility, and motor skills.²⁶ Although suggestive signs and symptoms may be present at a younger age, the clinical aspects of this entity change over time, and the specific CP syndrome may only be recognised at 3-5 years of age. In addition to diagnosing and treating co-morbidities (such as epilepsy, cognitive, vision, hearing, and growth and gastrointestinal disorders), the management entails neurological rehabilitation (addressing abnormalities in muscle tone and developing physical and occupational therapies). As a result, the management is multidisciplinary and consists of the treating physician collaborating with a group of orthopaedic, psychological, social, and rehabilitative care.