Cerebral Palsy

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Cerebral palsy (CP)\: Non-progressive, permanent neurological condition a
cause of childhood motor impairment. A
Cause\: Damage to the developing brain (hypoxia, haemorrhage, infection) during prenatal, perinatal, or neonatal periods.
Risk factors\:
Antenatal\: Multiple gestation, chorioamnionitis, maternal TORCH infections.
Perinatal\: Prematurity, low birth weight, birth asphyxia, neonatal sepsis.
Postnatal\: Meningitis, severe hyperbilirubinaemia.
Other\: Low socioeconomic status, more common in boys.
Clinical features\: Delayed motor milestones (not sitting by 8 months, not walking by 18 months, hand preference before 12
months), tone abnormalities, abnormal movements, feeding problems, persistent toe walking.
Types\:
Spastic CP\: Velocity-dependent hypertonia and hyperre
Dyskinetic CP\: Involuntary, uncontrolled movements; divided into dystonic (abnormal posturing) and choreoathetotic
(chorea and athetosis).
Ataxic CP\: Loss of muscular coordination, ataxia, and tremor.
Limb involvement\: Monoplegic (one limb), hemiplegic (one side of the body), diplegic (symmetrical, lower limbs more
a
Investigations\: Clinical diagnosis, MRI brain may show damage in white matter, deep grey matter, and basal ganglia, useful
in excluding other diagnoses.
Management\: Multidisciplinary approach.
Conservative\: Physiotherapy, occupational therapy, speech and language therapy, dietician input.
Medical\: Hyoscine hydrobromide or glycopyrronium bromide (drooling), diazepam (pain), baclofen (hypertonia), botulinum
toxin type A injections (spasticity).
Surgical\: Interventions for hip displacement if needed.
Complications\: Feeding problems, drooling, constipation, visual and hearing impairment, epilepsy, learning disability,
speech di
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Introduction

Cerebral palsy, also known as CP, is a non-progressive, permanent neurological condition commonly a
movement and posture.
1
It is the most prevalent cause of childhood motor impairment, with the UK incidence rate at around 1 in 400 births.
1
The severity and type of symptoms vary signiAetiology
Cerebral palsy is caused by damage to the developing brain which can occur while the baby is in utero, during birth or in
the neonatal period. Often, this is caused by hypoxia, haemorrhage or infection.
Di

Risk factors

The aetiology of CP is multifactorial, often relating to the prenatal period and mechanisms of neonatal brain hypoxia.
2
Signi
Antenatal risk factors include\:
3
Multiple gestation
Chorioamnionitis
Maternal TORCH infections (toxoplasmosis, rubella, CMV, and herpes simplex)
Perinatal risk factors include\:
3
Prematurity (signi
Low birth weight
Birth asphyxia
Neonatal sepsis
Postnatal risk factors include\:
3
Meningitis
Severe hyperbilirubinaemia (neonatal jaundice)
Other risk factors include\:
3,4
Any risk factors for prematurity are indirect risk factors
Low socioeconomic status
CP is more common in boys than girls at around 1\:1.3

Clinical features

Cerebral palsy often presents with delayed motor milestones\:
2
Not sitting by 8 months
Not walking by 18 months
Hand preference before 12 months
Importantly, these milestones must be corrected for gestational age (prematurity is a signi
palsy).
For more information, see the Geeky Medics guide to developmental milestones.
Other clinical features of cerebral palsy may include\:
2
Tone abnormalities (
Abnormal movements (e.g. asymmetrical movements,
Feeding problems such as choking or dysphagia
Persistent toe walking
As CP is a non-progressive condition there should be no regression in milestones. This is a red
suggest an alternative diagnosis.
Types of cerebral palsyThe clinical features of cerebral palsy depend on the area of the brain a
which clinical features predominate in an individual. It is common for there to be a mixed picture of symptoms spanning
di
Spastic cerebral palsy
Spastic cerebral palsy is characterised by velocity-dependent hypertonia (spasticity) and hyperre
common type of CP. 5
In this type of CP, when a limb is moved quickly the muscle can suddenly increase in tone and stop
further movement (a spastic catch).
Dyskinetic cerebral palsy
Dyskinetic cerebral palsy is characterised by involuntary, uncontrolled, recurring movements,
persistent primitive re
5
Dyskinetic CP is divided into two subtypes\:
Dystonic CP\: abnormal posturing and hypertonia
Choreoathetotic CP\: chorea and athetosis
Ataxic cerebral palsy
Ataxic cerebral palsy is characterised by loss of muscular coordination resulting in ataxia and tremor. It is the least
common type of cerebral palsy, and this group of patients is likely to contain other progressive genetic conditions which
cause ataxia. A patient with ataxic CP may point past your
5
Classi
Cerebral palsy can also be classi
6
Monoplegic cerebral palsy a
Hemiplegic cerebral palsy a
Diplegic cerebral palsy is symmetrical, with the lower limbs more a
Quadriplegic cerebral palsy indicated all four limbs are severely a
However, this classi
functional grading systems such as the Gross Motor Function Classi
The Bimanual Fine Motor Function (BFMF) for upper limb function.
5
Hypertonia, spasticity and dystonia
The di
Hypertonia is the general term for increased resistance in the muscles.
Spasticity is velocity-dependent, meaning the faster you move a limb, the higher the tone you will feel.
Dystonia refers to abnormal postures which are worse on intention. An easy way to remember the di
between the two is that you feel spasticity but you can see dystonia.
For more information, see the Geeky Medics OSCE guides to neurological examination.

Investigations

Cerebral palsy is a clinical diagnosis, and there are no de
3
An MRI brain may be requested for a child presenting with possible CP. 3
matter and the basal ganglia.
7
This may show damage in white matter, deep grey
Neuroimaging will not usually change management unless an alternative cause of symptoms is found. It can be useful in
excluding other dimultiple sclerosis).Management
The management of cerebral palsy will vary depending on the type and severity of the condition, as well as managing any
complications that arise. A multidisciplinary approach is crucial in managing the many di
condition.
Conservative management
Conservative management of cerebral palsy includes\:
Physiotherapy\: important in helping to assess and improve function and mobility, as well as preventing muscle
contractures and pain.
Occupational therapy\: enables patients to perform everyday activities and modify homes to be more accessible.
Speech and language therapy\: can help patients with communication and swallowing di
Dietician input\: address feeding problems and assess nutritional status. Some patients with dysphagia may require PEG
feeding.
Medical management
Medical management of cerebral palsy is aimed at managing symptoms and may include\:
7,8
Hyoscine hydrobromide or glycopyrronium bromide\: excess drooling
Diazepam\: pain
Baclofen\: hypertonia
Botulinum toxin type A injections\: used if spasticity is severely a
Surgical management
Hip displacement is very common in people with cerebral palsy. Surgical intervention may be required in some cases.
8

Complications

Although cerebral palsy is a non-progressive disease, complications can become apparent as a child grows up.
Complications may include\:
2
Problems with feeding and aspiration
Drooling
Constipation
Visual and hearing impairment
Epilepsy
Learning disability
Speech di
Osteopenia and osteoporosis (especially if non-mobile)
Sleep disturbance

References

SCOPE. C e r e b r a l p a l s y ( C P ) . Published in 2022. Available from\: [LINK]
NICE CKS. C e r e b r a l p a l s y . Published in 2019. Available from\: [LINK]
BMJ Best Practice. C e r e b r a l p a l s y . Available from\: [LINK]
J L Hutton, K Hemming and UKCP collaboration. L i f e e x p e c t a n c y o f c h i l d r e n w i t h c e r e b r a l p a l s y . Published in 2006.
Available from\: [LINK]
European Commission. C P a n d C P s u b t y p e s . Available from\: [LINK]
Trishla Foundation. C e r e b r a l P a l s y T y p e s – S p a s t i c , D y s k i n e t i c , A t a x i c , from\: [LINK]
M i x e d C e r e b r a l P a l s y . Published in 2017. AvailableNICE. C e r e b r a l p a l s y i n u n d e r 2 5 s \: a s s e s s m e n t a n d m a n a g e m e n t . Published in 2017. NICE. S p a s t i c i t y i n u n d e r 1 9 s \: m a n a g e m e n t . Published in 2012. Available from\: [LINK]
Available from\: [LINK]

Reviewer

Consultant Paediatric Neurologist

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Contents

Introduction
Aetiology
Risk factors
Clinical features
Source\: geekymedics.com