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Cerebral Palsy

Basics

  • Group of clinical syndromes causing motor and postural dysfunction due to static lesions in developing brain.
  • Motor impairment with activity limitation required for diagnosis.
  • Classified by movement disorder type and severity.

Epidemiology

  • Incidence: 1.5 to 3 per 1,000 live births.
  • Incidence higher with lower gestational age and birth weight:
  • 146/1,000 for GA 22-27 weeks
  • 62/1,000 for GA 28-31 weeks
  • 7/1,000 for GA 32-36 weeks
  • 1/1,000 for GA ≥37 weeks

Etiology and Pathophysiology

  • Multifactorial: prenatal, perinatal, postnatal brain injury or lesion.
  • Inflammatory mediators (cytokines, free radicals) contribute.
  • Spastic CP most common, linked to prematurity, periventricular leukomalacia, or germinal matrix hemorrhage.
  • Genetic associations with thrombophilic, cytokine, and apolipoprotein E gene polymorphisms reported.

Risk Factors

  • Prenatal: congenital anomalies, multiple gestation, in utero stroke, infections (CMV, varicella), IUGR, chorioamnionitis, maternal health conditions.
  • Perinatal: prematurity, low birth weight, hypoxia/asphyxia, intracranial hemorrhage, neonatal seizures/stroke, hyperbilirubinemia.
  • Postnatal: traumatic brain injury, stroke, meningitis, encephalitis, asphyxia, progressive hydrocephalus.

Prevention

  • Antenatal corticosteroids
  • Magnesium sulfate for neuroprotection in preterm delivery
  • Therapeutic hypothermia in term infants with intrapartum hypoxia

Commonly Associated Conditions

  • Seizures
  • Intellectual and speech/language impairment
  • Behavioral problems
  • Hearing and visual impairments
  • Feeding/swallowing dysfunction (may require gastrostomy)
  • Poor dentition, drooling
  • GI: constipation, vomiting, GERD
  • Growth abnormalities
  • Osteopenia
  • Incontinence
  • Orthopedic deformities: contractures, hip subluxation/dislocation, scoliosis

Diagnosis

  • Early diagnosis guidelines include:
  • Neuroimaging
  • Prechtl General Movements Assessment (GMA) before 5 months
  • Hammersmith Infant Neurologic Examination (HINE) 3-12 months
  • Clinical diagnosis: delayed milestones, abnormal tone/reflexes, no regression, no alternative diagnoses.

History

  • Prenatal, perinatal, postnatal risk factors.
  • Neurobehavioral signs: poor feeding, vomiting, irritability.
  • Motor milestone timing, asymmetry, abnormal spontaneous movements.
  • No regression of skills.

Physical Exam

  • Tone abnormalities: spasticity, dystonia, hypotonia, ataxia.
  • Trunk/head control often poor.
  • Reflexes: persistence of primitive reflexes, brisk deep tendon reflexes, clonus.
  • Motor function reduced; contractures; gait abnormalities (scissoring, toe-walking).
  • Classification:
  • Spastic: hemiplegic, diplegic, quadriplegic
  • Dystonia: hypertonia + reduced movement
  • Choreoathetosis
  • Ataxia
  • MACS used for upper extremity function.

Differential Diagnosis

  • Congenital hypotonia
  • Brachial plexus injury
  • Familial spastic paraplegia
  • Dopa-responsive dystonia
  • Muscular dystrophies
  • Metabolic and mitochondrial disorders
  • Genetic syndromes (e.g., Rett)

Diagnostic Tests

  • Labs to exclude other etiologies.
  • Genetic/metabolic testing if atypical.
  • Neuroimaging (MRI preferred) for brain malformations, infarctions, hemorrhages, leukomalacia, ventricular changes.
  • EEG only if seizures suspected.

Treatment

  • Symptom control and maximizing function.
  • Early intervention 0-3 years.
  • Physical, occupational, speech therapy.
  • Orthotic devices: ankle-foot orthosis, spinal bracing.
  • Augmentative communication.
  • Medications:
  • Diazepam (GABA-A agonist): short-term spasticity control.
  • Botulinum toxin A: injected for focal spasticity; lasts 12-16 weeks.
  • Baclofen (GABA-B agonist): oral or intrathecal; beware withdrawal.
  • Surgery:
  • Dorsal root rhizotomy (selective dorsal rootlet cutting)
  • Orthopedic surgery for deformities and scoliosis
  • Gastrostomy if feeding issues severe.

Complementary Therapies

  • Hippotherapy (therapeutic horse riding)
  • Aquatherapy

Prognosis

  • Lifespan reduced with higher functional impairment and intellectual disability.

Clinical Pearls

  • CP is a nonprogressive disorder with static brain lesions.
  • No regression of motor skills.
  • Multidisciplinary care improves outcomes.