Understanding the Root of Cerebral Palsy: Uncovering Causes and Embracing Inclusivity

Cerebral palsy (CP)  is a group of non-progressive conditions occurring in children and adults. It is characterized by motor disability. Leading to impaired posture, movement, and coordination. CP occurs as a result of abnormal fetal brain development. It is a permanent condition associated with risk factors like low birth weight, and infection during pregnancy.1 This article aims to explore the causes and symptoms of CP, different diagnostic techniques, and management pathways. Read on to discover how to promote inclusivity amongst individuals living with cerebral palsy.  

Table of Contents

1. Introduction

   • Overview of Cerebral Palsy (CP)

   • Purpose of the Article

2. Causes of Cerebral Palsy

   • Pregnancy-Related Infections

   • Hypoxia (Lack of Oxygen)

   • Fetal Stroke

   • Perinatal Asphyxia

   • Premature or Preterm Birth

   • Brain Infections

   • Kernicterus

3. Clinical Manifestations of Cerebral Palsy

   • Muscle Spasticity and Motor Impairments

   • Dyskinesia and Dystonia

   • Coordination and Balance Problems (Ataxia)

   • Postural Reflex Issues

   • Muscle Weakness and Chronic Pain

   • Vision and Hearing Difficulties

   • Seizures and Epilepsy

   • Cognitive Impairments

4. Diagnosis of Cerebral Palsy

   • Physical Examination

   • Medical History Evaluation

   • Imaging Studies (MRI, CT Scans)

   • Developmental Monitoring

5. Management and Treatment of Cerebral Palsy

   • Medical Interventions

     • Muscle Stiffness Medications

     • Anti-seizure and Pain Management Drugs

   • Surgical Interventions

     • Selective Dorsal Rhizotomy (SDR)

     • Deep Brain Stimulation (DBS)

     • Orthopedic Surgeries

   • Speech and Language Therapy

   • Physical Therapy (PT)

6. Frequently Asked Questions (FAQs)

   • Life Expectancy of Individuals with Cerebral Palsy

   • Can People with Cerebral Palsy Give Birth?

   • Do Children with Cerebral Palsy Smile?

   • Can Folic Acid Prevent Cerebral Palsy?

7. Summary

   • Key Points on Causes and Management of Cerebral Palsy

8. References

   • Citations for Further Reading and Research

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What are cerebral palsy causes?

The major cause of CP is fetal brain damage, which can happen before, during, or after birth.

Pregnancy-related infections

Maternal infections during pregnancy have been associated with fetal brain insult. The immune system of the fetus responds to these infections through brain impairment, which leads to damage of the fetal white matter. The use of antibiotics to fight these infections during pregnancy is also likely to cause damage to the developing brain of the fetus.2 

Hypoxia (lack of oxygen) 

Cerebral palsy can result from oxygen deprivation (hypoxia) during embryonic brain development. Hypoxia can result from complications like oxidative stress, blood clots in the placenta, and detachment of the placenta from the uterus (a condition known as placenta abruption.3

Fetal stroke

Fetal stroke occurs when the supply of blood to the developing brain cuts off, due to blockage of blood vessels by blood clots. This results in injury in the brain which causes neurological and motor disabilities associated with cerebral palsy. It occurs between 14 gestational weeks of age to delivery.  One of the main causes of cerebral palsy is fetal stroke.4  

Perinatal asphyxia

Perinatal asphyxia also called birth asphyxia is a reduced oxygen or blood flow to the fetus during delivery. It can happen before, during, or after birth. Perinatal asphyxia leads to hypoxic ischemic encephalopathy and excess acid build up in the blood (acidosis).5 This condition interferes with the neurological development of the fetus leading to permanent brain injury, which results in the event of CP.6 

Placenta abruption, which is the separation of the placenta from the uterus, rupture of the uterine wall, and compression of the umbilical cord can all result in perinatal asphyxia.5

Premature or preterm birth 

Preterm babies are babies born before 37 weeks of gestation. A full-term pregnancy lasts from 37 weeks to 42 weeks. Babies who are born preterm may be at risk of serious health issues like cerebral palsy. Preterm babies are introduced into the extrauterine environment before they are prepared to adapt. This results in issues with the developing baby's brain, which is one of the primary causes of cerebral palsy. Premature birth is caused by abnormal pathological events like, Placental abruption, fetal growth restriction, gestational hypertension, and other complications. These complications can result in CP.7

Brain infections

CP can result from infections of the brain in early childhood, such as meningitis or encephalitis. These infections cause the inflammation of the brain membrane and spinal cord, leading to significant brain damage as well as damage to the part of the brain that control motor skills.8

Kernicterus

A serious complication of jaundice known as kernicterus results from an excess of unconjugated bilirubin in the baby's blood. Brain damage and neurodevelopmental toxicity are the results of bilirubin's deposition on the brain's basal ganglia once it passes the blood-brain barrier.9

What are the clinical manifestations of cerebral palsy?

Although there is much variation in the clinical presentations of cerebral palsy, they usually include:

• Muscle tightness or increase in resistance to passive movement also known as spasticity

• Involuntary, writhing movement of some parts of the body (dyskinesia) and dystonia  

• Inadequate coordination and balance, resulting in erratic or uneven movements, this is also called ataxia

• Problem with postural reflexes leading to notable delay in sitting, walking, crawling, rolling, and standing

• Weakness in muscles causing trouble moving or keeping posture

• People with CP may have either muscle stiffness (hypertonia) or decreased muscle tone (hypotonia)

• Chronic pain occurs as a result of muscle stiffness, and tiredness due to the energy needed for movement 

• Vision and hearing difficulties can occasionally coexist with CP

• People with CP may experience bowel issue like constipation

• Some individuals with CP experience seizures or epilepsy, due to associated brain deformation

• Cognitive impairments involving learning and intellectual disabilities.10

How can cerebral palsy be diagnosed?

The diagnosis of CP involves a variety of processes to evaluate motor and sensory development, as well as identify any anomaly associated with reflexes and posture. It is very important to diagnose CP at its early stage in order to initiate interventions that can improve the development of the child. Diagnosing CP helps to rule out other conditions that mirror CP.10

Physical examination

As soon as the child enters the observation room, the examiner or the doctor will evaluate the child's gait. The physician assesses muscular tone, reflexes, posture, and coordination. The effectiveness of the examination can be impacted by the child's engagement, the examiner's expertise, and the assessment technique.11

Examination of medical history

A child's medical and surgical history plays a key role in the diagnosis of CP. Your doctor will collect information like, the surgical history of your child’s birth, perinatal information regarding whether your child was born full-term or preterm, gestational complications, other medical problems, and medication history.11

Imaging studies

Imaging tests like magnetic resonance imaging (MRI) or computed tomography (CT) scans are used to investigate brain anomalies. These tests identify regions of underdevelopment, or brain injury, particularly in the basal ganglia and motor cortex. Brain MRI has about 89% sensitivity in detecting disorders in the brain. This accounts for the higher diagnostic effectiveness of MRI than CT scans.10

Developmental monitoring

Developmental monitoring is an ongoing process that allows doctors to initiate early intervention even before a more elaborate diagnosis is made. It involves tracking the child's progress throughout time, participation in daily activities, and self-care routine.12

What are the possible treatments and management strategies of cerebral palsy?

The management of CP involves the collaboration of multi professionals, including,physiatrists, speech-language pathologists (SLPs), neurologists, and orthopedists.10 Although there is no cure for cerebral palsy, the quality of life of an individual can be significantly improved by early intervention and specialised therapy.

Medical Interventions

Medications

1. Botulinum toxin injections (known as Botox), baclofen, benzodiazepines, dantrolene, are used to manage muscle stiffness and spasticity associated with CP.10 

2. Stool softeners are administered to address constipation.10

3. Anti-inflammatory drugs are used to relieve the pains resulting from muscle stiffness.10 

4. Anti-seizure drugs are administered to individuals with epilepsy.10   

   
   

Surgical interventions

1. Selective dorsal rhizotomy (SDR)  surgery is carried out to reduce spasticity and improve gait.10 ,13  SDR is a permanent and non-reversible procedure. During this procedure, the nerves in the spine that are responsible for sending abnormal signals to the muscles are cut.14

2. Deep brain stimulation (DBS) is a neurosurgical technique done to improve mobility disorder in people with CP. It involves the implantation of electrodes and electrical stimulations at specific part of the brain responsible for movement.13 

3. Orthopedic surgeries are carried out to correct lower limb musculoskeletal disorders in CP. They include tendon lengthening, and tendon transfer.13 

Speech and language therapy

Individuals with cerebral palsy may experience difficulties with speech due to impaired muscle control in the mouth. Speech language pathologists (SLPSs) evaluate and improve communication skills of the patient, whether through traditional speech exercises or augmentative and alternative communication (AAC) systems like electronic devices or communication board.15

Physical therapy (PT)

PT programs are designed to help children with cerebral palsy achieve optimal motor function. Exercises focus on strengthening the muscles, improving gait, and maintaining balance.10

FAQs

What is the life expectancy of people with cerebral palsy?

• Life expectancy with cerebral palsy is influenced by the condition's severity and any comorbid conditions. As a result, the life expectancy of people with cerebral palsy is not predetermined. Patients with cerebral palsy often have the same life expectancy as those without the disorder.

Can people with cerebral palsy give birth?

• Cerebral palsy has no effect on fertility. There is no conclusive evidence that women with cerebral palsy are at an increased risk for additional birth issues, such as miscarriages, abnormalities, or pregnancy-induced hypertension, despite having a higher incidence of caesarean deliveries.

Do children with cerebral palsy smile?

• These developmental milestones are missed by some children who have cerebral palsy. If they are unable to regulate their facial muscles, they may not smile at all or smile later. The child may be slower to follow and recognize faces and things because they may have difficulty coordinating the muscles in their neck and eyes.

Can folic acid prevent cerebral palsy?

• According to studies, regular doses of folic acid lowers the chance of preterm birth by 70%, which is a major cause of cerebral palsy. It is recommended that pregnant women adhere to a prenatal vitamin program.

Summary 

Cerebral palsy is a group of non-progressive disease which occurs due to damage to the brain. It is  characterized by motor disabilities, and neurodegenerative issues. It affects children during delivery, before delivery or after delivery. CP is caused by a combination of many factors like infection during pregnancy, low birth weight, preterm birth, fetal stroke, etc. There is no permanent treatment for CP. But the motor disabilities and other associated clinical manifestations can be improved by a team of multidisciplinary health professionals including physiatrists, speech-language pathologists (SLPs), neurologists, and orthopedists.

References 

1. Patel DR, Neelakantan M, Pandher K, Merrick J. Cerebral palsy in children: a clinical overview. Transl Pediatr; 9(Suppl 1):S125–35. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082248/.

2.  Miller JE, Pedersen LH, Streja E, Bech BH, Yeargin-Allsopp M, Braun KVN, et al. Maternal Infections during Pregnancy and Cerebral Palsy: A Population-based Cohort Study. Paediatric and perinatal epidemiology [Internet]. 2013; 27(6):542. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4997608/.

3. Fatemi A, Wilson MA, Johnston MV. Hypoxic Ischemic Encephalopathy in the Term Infant. Clin Perinatol [Internet]. 2009; 36(4):835–vii. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2849741/.

4. Fetal Stroke and Hypoxic-Ischemic Encephalopathy (HIE). ABC Law Centers: Birth Injury Lawyers [Internet]. Available from: https://www.abclawcenters.com/practice-areas/prenatal-birth-injuries/fetus-or-newborn-medical-problems/fetal-stroke/.

5. Gillam-Krakauer M, Gowen Jr CW. Birth Asphyxia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. Available from: http://www.ncbi.nlm.nih.gov/books/NBK430782/.

6. Zhang S, Li B, Zhang X, Zhu C, Wang X. Birth Asphyxia Is Associated With Increased Risk of Cerebral Palsy: A Meta-Analysis. Front Neurol [Internet]. 2020; 11:704. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7381116/.

7. Trønnes H, Wilcox AJ, Lie RT, Markestad T, Moster D. Risk of cerebral palsy in relation to pregnancy disorders and preterm birth: a national cohort study. Develop Med Child Neuro [Internet]. 2014; 56(8):779–85. Available from: https://onlinelibrary.wiley.com/doi/10.1111/dmcn.12430.

8. Alliance (UK) NG. Causes of cerebral palsy. In: Cerebral palsy in under 25s: assessment and management [Internet]. National Institute for Health and Care Excellence (NICE); 2017. Available from: https://www.ncbi.nlm.nih.gov/books/NBK533241/.

9. Rose J, Vassar R. Movement disorders due to bilirubin toxicity. Semin Fetal Neonatal Med [Internet]. 2015; 20(1):20–5. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388741/.

10. Hallman-Cooper JL, Rocha Cabrero F. Cerebral Palsy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. Available from: http://www.ncbi.nlm.nih.gov/books/NBK538147/.

11. Sarathy K, Doshi C, Aroojis A. Clinical Examination of Children with Cerebral Palsy. Indian J Orthop [Internet]. 2019; 53(1):35–44. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6394192/.

12. CanChild [Internet]. Available from: https://www.canchild.ca/en/resources/294-monitoring-development-of-children-with-cerebral-palsy-the-on-track-study-protocol-of-a-longitudinal-study-of-development-and-services.

13. Chin EM, Gwynn HE, Robinson S, Hoon AH. Principles of Medical and Surgical Treatment of Cerebral Palsy. Neurol Clin [Internet]. 2020; 38(2):397–416. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7158771/.

14. Wang KK, Munger ME, Chen BP-J, Novacheck TF. Selective dorsal rhizotomy in ambulant children with cerebral palsy. J Child Orthop [Internet]. 2018; 12(5):413–27. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6169562/.

15. Pennington L, Goldbart J, Marshall J. Speech and language therapy to improve the communication skills of children with cerebral palsy. Cochrane Database Syst Rev [Internet]. 2004; 2004(2):CD003466. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8407241/.