CEREBRAL PALSY TYPES

Cerebral Palsy (CP) is a disorder of movement and posture that appears during infancy or early childhood resulting from damage to the brain. Any non-progressive central nervous system (CNS) injury occurring during the first 2 (some say 5) years of life is considered to be CP.

Cerebral Palsy is a group of permanent, but not unchanging, disorders of movement and/or posture and of motor function, which are due to a non-progressive interference, lesion, or abnormality of the developing/immature brain

The brain damage occurs during one of the following periods: 

                                     1: Prenatal Period - Conception to the onset of labour. 

                                     2.  Perinatal Period - 28 weeks intrauterine to 7 days. 

                                     3.  Postnatal Period -First two (and some say five) years of                                             life.

After the age of 5 we speak of stroke or traumatic brain injury, not called as Cerebral Palsy.

Risk factors:     There are different risk factors for each stage . These can be broken down into Prenatal, Perinatal and Postnatal.                           

  Prenatal:

• Prematurity (Gestational age less than 36 weeks)
• Low Birth Weight (less than 2500 g), which could be due to poor nutritional status of the mother
• Maternal epilepsy
• Hyperthyroidism
• Infections (TORCH = Toxoplasmosis, Other (Syphilis, Varicella-Zoster, Parvovirus B19,) Rubella, Cytomegalovirus (CMV), Herpes Simplex Virus)
• Severe Toxemia, Eclampsia
• Drug Abuse
• Trauma
• Multiple Pregnancies
• Placental Insufficiency

Perinatal:

• Premature Rupture of Membranes
• Prolonged and Difficult Labour
• Vaginal Bleeding at the time of admission for labour
• Bradycardia

Postnatal (0-2 years):

• Central Nervous System infection (encephalitis,meningitis)
• Hypoxia
• Seizures
• Coagulopathies
• Neonatal Hyperbilirubinemia
• Head Trauma     

CLASSIFICATIONS:

             

                      Hemiplegic rigidity affecting one side only, although lesser impairment of the apparently uninvolved limb was frequently observed; Paraplegia affecting both legs more than the arms; and Generalised Rigidity

Anatomical classification are as follows:

Unilateral: One side of the body is affected.

Bilateral:Both sides of the body are affected

Spastic Cerebral Palsy: are used to distinguish between quadriplegia, diplegia and hemiplegia. Spastic Cerebral Palsy is either bilateral or unilateral.

Dyskinetic Cerebral Palsy and Ataxic Cerebral Palsy: always involve the whole body (bilateral). Spacticity Spasticity is defined as an increase in the physiological resistance of muscle to passive motion. It is part of the upper motor neuron syndrome characterized by hyperreflexia, clonus, extensor plantar responses and primitive reflexes. 

Spastic Cerebral Palsy is the most common form of Cerebral Palsy. Approximately 80% to 90% of children with Cerebral Palsy have Spastic Cerebral Palsy. Spastic Cerebral Palsy is characterized by at least two of the following symptoms, which may be unilateral (hemiplegia) or bilateral: Abnormal pattern of posture and/or movement Increased tone (not necessarily constantly) Pathological reflexes (hyper-reflexia or pyramidal signs e.g. Babinski response) 

Traditionally we recognized three types of spastic Cerebral Palsy: Hemiplegia, Diplegia and Quadriplegia. Hemiplegia (Unilateral): With hemiplegia, one side of the body is involved with the upper extremity generally more affected than the lower. Seizure disorders, visual field deficits, astereognosis, and proprioceptive loss are likely. Twenty percent of children with spastic Cerebral Palsy have hemiplegia. A focal traumatic, vascular, or infectious lesion is the cause in many cases. A unilateral brain infarct with posthemorrhagic porencephaly can be seen on Magnetic Resonance Imaging (MRI). 

 Diplegia (Bilateral): With diplegia, the lower extremities are severely involved and the arms are mildly involved. Intelligence usually is normal, and epilepsy is less common. 

Fifty per cent of children with Spastic Cerebral Palsy have diplegia. A history of prematurity is usual. Diplegia is becoming more common as more low- birth-weight babies survive. MRI reveals mild Periventricular Leukomalacia (PVL). 

Quadriplegia (Bilateral) With quadriplegia, all four limbs, the trunk and muscles that control the mouth, tongue and pharynx are involved. Thirty percent of children with Spastic Cerebral Palsy have quadriplegia. More serious involvement of lower extremities is common in premature babies. Some have perinatal hypoxic ischemic encephalopathy. MRI reveals Periventricular Leukomalacia (PVL). Dyskinetic CPAbnormal movements that occur when the child initiates movement are named Dyskinesias. Dysarthria, Dysphagia and drooling accompany the movement problem. Intellectual development is generally normal, however severe dysarthria makes communication difficult and leads the outsider to think that the child has intellectual impairment. Sensorineural hearing dysfunction also impairs communication. 

Dyskinetic Cerebral Palsy accounts for approximately 10% to 15 % of all cases of Cerebral Palsy. Hyperbilirubinemia or severe anoxia causes basal ganglia dysfunction and results in Dyskinetic Cerebral Palsy. Dyskinetic Cerebral Palsy is characterised by the following Symptoms: Abnormal pattern of posture and/or movement, and Involuntary, uncontrolled, recurring, occasionally stereotyped movements of affected body parts Dyskinetic Cerebral Palsy may be either: Dystonic Cerebral Palsy, dominated by both hypokinesia and hypertonia, or Choreoathetotic Cerebral Palsy, dominated by both hyperkinesia and hypotonia Ataxic CP Ataxia is loss of balance, coordination and fine motor control. 

Ataxic children cannot coordinate their movements. They are hypotonic during the first 2 years of life. Muscle tone becomes normal and ataxia becomes apparent toward the age of 2 to 3 years. Children who can walk have a wide-based gait and a mild intention tremor (Dysmetria). Dexterity and fine motor control is poor. Ataxia is associated with cerebellar lesions. Ataxia is often combined with spastic diplegia. Most ataxic children can walk but some need walkers. Ataxic Cerebral Palsy is characterized by the following symptoms: Abnormal pattern of posture and/or movement Lost of orderly muscular coordination, so that movements are performed with abnormal force, rhythm, and accuracy.

 Mixed Cp: Children with a mixed type of Cerebral Palsy commonly have mild spasticity, dystonia and/or athetoid movements. Ataxia may be a component of the motor dysfunction in children in this group. Ataxia and spasticity often occur together. Spastic Ataxic Diplegia is a common mixed type that often is associated with hydrocephalus.