INFANT CEREBRAL PALSY: SYMPTOMS, TYPES, CAUSES - NEUROPSYCHOLOGY - 2025

The cerebral palsy is a group of neurological disorders that appear during fetal or child development and that will affect permanently to the movement of the body and muscle coordination, but will not increase its severity progressively (National Institute of Neurological Disorders and Stroke, 2016). It is estimated to be the most common cause of physical and cognitive disability at an early age (Muriel et al., 2014).

This type of pathology is caused by neurological abnormalities in the areas responsible for motor control. In most cases, individuals with cerebral palsy are born with it, although it may not be detected until a few months or years later.

Generally, when the child reaches three years of age, it is already possible to identify some signs: lack of muscular coordination in voluntary movements (ataxia); muscles with an unusually high tone and exaggerated reflexes (spasticity); walking using a single foot or dragging the legs, among others (National Institute of Neurological Disorders and Stroke, 2016).

Likewise, these motor alterations can also be accompanied by sensory, cognitive, communication, perception, behavioral deficits, epileptic seizures, etc. (Muriel et al., 2014).

There are a number of children who suffer this type of pathology as a result of suffering from brain damage during the first years of life, due to infections (bacterial meningitis or viral encephalitis) or head injuries; for example, a traumatic brain injury (TBI) (National Institute of Neurological Disorders and Stroke, 2016).

Prevalence

Cerebral palsy is the most frequent cause of motor disability in childhood (Simón-de las Heras and Mateos-Beato, 2007). In addition, the main cause of severe physical disability (Simón-de las Heras and Mateos-Beato, 2007) and cognitive disability in early ages (Muriel et al., 2014) is also treated.

The global prevalence of cerebral palsy is estimated at approximately 2-3 cases per 1,000 live births (Póo Argüelles, 2008; Robaina-Castellanos et al. 2007).

The United Cerebral Palsy Foundation (UCP) has estimated that approximately 800,000 children and adults in the United States live with one or more of the symptoms of cerebral palsy. According to the federal government's Center for Disease Control and Prevention, each year about 10,000 babies born in the United States will develop cerebral palsy (National Institute of Neurological Disorders and Stroke, 2010).

It is a pathology that occurs in a greater proportion in premature children or with low birth weight (<2,500g), the prevalence of these cases being 72.6% compared to 1.2% in children with a weight over 2,500g at the time of birth. (Muriel et al., 2014).

Approximately 94% of people with cerebral palsy acquired the disability in pregnancy or during childbirth. The remaining 6% cerebral palsy occurred during the first years of life (Confederation ASPACE, 2012).

On the other hand, half of people with cerebral palsy have a significant intellectual disability. 33% require assistance in their movements and the other 25% require auxiliary communication systems (Confederación ASPACE, 2012).

Definition

The concept of 'cerebral palsy' is used to encompass neurological sequelae of a broad nature that mainly affect the motor sphere (Camacho-Salas et al., 2007).

In the 1860s, an English surgeon named William Little wrote the first medical descriptions of a strange disorder that affected children in the early years of life, causing spastic and stiff muscles in the legs and to a lesser degree in the arms. (National Institute of Neurological Disorders and Stroke, 2010).

The disorder was called Little's disease for many years; it is now known as spastic diplegia. These are disorders that affect movement control and are grouped under the unifying term "cerebral palsy" (National Institute of Neurological Disorders and Stroke, 2010).

Cerebral palsy is a disability that is produced by a brain injury that occurs during the gestational period, childbirth or during the first years of life, in the stage of child development.

Normally, it will cause a physical disability that varies in its degree of affectation, but in addition, it may also appear accompanied by a sensory and / or intellectual disability (Confederación ASPACE, 2012).

Symptoms

Some of the signs and symptoms that children with cerebral palsy exhibit include (National Institute of Neurological Disorders and Stroke, 2010):

• Lack of muscle coordination when executing voluntary movements (ataxia).
• The muscles are tense and rigid with exaggerated reflexes (spasticity).
• On many occasions they walk using only one foot or dragging one of the lower limbs.
• It is common to observe gait using the tip of one foot, crouched, or "scissor gait."
• Variations in muscle tone, from very stiff to flaccid or hypotonic.
• Difficulty swallowing or speaking or excessive drooling.
• Presence of shaking, tremors, or random involuntary movements.
• Difficulty executing precise movements, such as writing or buttoning a shirt.

Cognitive deficits

Additionally, the brain injury (s) can affect other functions such as attention, perception, memory, language, and reasoning. All of this will depend on the location, type, extent and timing of the brain damage (ASPACE Confederation, 2012).

Numerous studies have shown the presence of cognitive deficits in individuals with infantile cerebral palsy. These studies describe alterations in attention, visual perception, deficits in executive functioning and working memory, up to a global and generalized impairment of cognitive abilities and intellectual function (Muriel et al., 2014).

Furthermore, the presence of these lesions will also interfere with the normal development of the central nervous system. Once the damage occurs, it will affect the process of brain development and maturation, and therefore, on child development (ASPACE Confederation, 2012).

Thus, children with neurodevelopmental disorders and deficits in the cognitive sphere, in turn, have a higher risk of presenting difficulties in the social sphere, behavioral problems, and there is also a greater risk of suffering from problems related to mental health (Muriel et al., 2014).

Types of cerebral palsy

Depending on when the brain damage occurs, cerebral palsy is classified into:

• Congenital: when the injury occurs in a prenatal stage.
• Natal or neonatal: when the injury occurs at birth and immediately after birth.
• Acquired or postneonatal: when the injury occurs after the first month of age.

In addition, it is also frequent to use a classification based on the type of motor disorder that predominates in the individual's clinical picture and based on the extent of the involvement (Póo Argüelles, 2008):

Spastic cerebral palsy

It is the most common type. Within this group we can distinguish several types:

• Tetraplegia (tetraparesis): patients present with involvement in all four limbs.
• Diplegia (dysresia): the affectation that patients present predominates in the lower extremities.
• Spastic hemiplegia: paresthesia occurs in one of the body halves, generally with greater involvement of the upper limb.
• Monoparesis: involvement of a single limb.

Dyskinetic cerebral palsy

It is a sudden fluctuation and change in muscle tone. In addition, it is characterized by the presence of involuntary movements and reflexes. Within this group we can distinguish several types:

• Choreoathetosic form: chorea, athetosis, tremor.
• Dystonic form: fluctuation of muscle tone.
• Mixed form: it is associated with the presence of increased muscle tone (spasticity).

Ataxic cerebral palsy

It is characterized by the presence of hypotonia, ataxia, dysmetria, or incoordination. Within this group we can distinguish several types:

• Ataxic diplegia: it is associated with spasticity of the lower limbs.
• Simple ataxia: presence of hypotonia that is associated with dysmetria, ataxia, or intentional tremor.
• Imbalance syndrome: characterized by the presence of an alteration of balance or incoordination.

Hypotonic cerebral palsy

It is characterized by the presence of a lowered muscle whole (hypotonia) accompanied by hyperreflexia.

Mixed cerebral palsy

It presents with associations between ataxia, simple dystonia, or dystonia with spasticity.

Apart from this classification, it is also possible to use a classification according to the affectation: mild, moderate, severe or profound, or according to the functional level that the motor affectation presents: levels from I to V, according to the Gross Motor Function Classiffication System (Póo Argüelles, 2008).

Mild cerebral palsy

It takes place when the individual does not present limitations for the execution of the activities of daily living, even if they present some type of physical affectation or alteration (Confederación ASPACE, 2012).

Moderate cerebral palsy

The individual presents difficulties to carry out daily activities and requires various assistance or support means (Confederación ASPACE, 2012).

Severe cerebral palsy

Supports and adaptations are required for practically all activities of daily living (ASPACE Confederation, 2012).

Causes

Most children with cerebral palsy are born with it, although it may not be detected until months or years later. Just as there are particular types of brain damage that cause cerebral palsy, there are also certain diseases or events that can take place during pregnancy and delivery that will increase the risk of a baby being born with cerebral palsy (National Institute of Neurological Disorders and Stroke, 2010).

In a summarized and structured way, Póo Argüelles (2008) shows the most prevalent risk factors for cerebral palsy divided according to the time of occurrence:

Prenatal factors

• Maternal factors: coagulation disorders; autoimmune diseases; HT, intrauterine infections; occurrence of trauma; thyroid dysfunctions.
• Alterations of the placenta: maternal thrombosis; fetal thrombosis; chronic vascular changes; infections.
• Fetal factors: multiple gestation, intrauterine growth retardation, polhydramnios, hydrops fetalis or malformations.

Perinatal factors

They can be: prematurity, low birth weight, maternal fever during childbirth, infection of the central or systemic nervous system, presence of sustained hyperglycemia, presence of hyperbilirubinemia, intracranial hemorrhage, hypo-hypoxic-ischemic encephalopathy, trauma or cardiac surgeries (Póo Argüelles, 2008).

Postnatal factors

They can be: infections such as meningitis or encephalitis, head trauma, seizure status, cardio-respiratory arrest, intoxication or severe dehydration (Póo Argüelles, 2008).

All these risk factors will give rise to various mechanisms that will damage the child's brain: damage to white matter, abnormal development of the brain and the nervous system in general, cerebral hemorrhage, cerebral hypoxia-ischemia, etc. (National Institute of Neurological Disorders and Stroke, 2010).

These injury mechanisms will cause the symptoms detailed above depending on the area to which it is restricted, the extent and severity of the event.

Thus, when cerebral palsy affects muscle movement and coordination, it is not caused by problems or alterations in the muscles or nerves, but by abnormalities within the brain that interrupt the brain's ability to control movement and posture.

In some cases of cerebral palsy, the cerebral motor cortex has not developed normally during fetal growth. In others, the damage is the result of brain injury before, during, or after birth. In any case, the damage is not repairable and the resulting disabilities are permanent (National Institute of Neurological Disorders and Stroke, 2010).

Consequences

Cerebral palsy is considered a very heterogeneous clinical pathology. Individuals who suffer from it may present various neurological syndromes (motor, cerebellar, convulsive, etc.) and also may present other syndromes that are not directly related to the central nervous system (digestive, ostemioarticular, etc.), as a result of the presence of various secondary alterations (Robania-Castellanos et al., 2007).

The consequences of cerebral palsy differ in type and severity, and can even change in an individual over time (National Institute of Neurological Disorders and Stroke, 2010).

Thus, some people will present a generalized bodily involvement, while others will only present some difficulties or deficiencies in walking, speaking or using the limbs.

Therefore, some people will live with hardly any manifestations of the pathology, while others will find themselves in a situation of full dependence and, therefore, will require the support of third parties to carry out most of the tasks (Confederación ASPACE, 2012).

In addition to the motor disorders detailed in the definition and symptoms section, people with cerebral palsy also have other medical disorders, such as mental retardation, seizures, impaired vision or hearing, and abnormal physical sensations or perceptions (National Institute of Neurological Disorders and Stroke, 2010).

In this way, many of the people with cerebral palsy may present, to a greater extent, any of the following conditions (Confederación ASPACE, 2012):

• Intellectual disability: this condition can occur in approximately half of the cases of individuals with cerebral palsy. On many occasions it is associated with a verb-spatial discordance.
• Epileptic seizures: it is estimated that between 25% and 30% of cases may present generalized or partial seizures.
• Vision impairment: the most common condition is strabismus in 50% of cases.
• Hearing disorders: in approximately 10-15% of cases, people with infantile cerebral palsy may present some type of hearing deficit.

In addition, from these physical or intellectual conditions, other difficulties or manifestations may also appear (Confederación ASPACE, 2012):

• Behavioral: aggressive or self-injurious behavior, apathy (passivity, lack of initiative, fear of the outside world or inhibition) or stereotype (atypical and repetitive habits).
• Cognitive: among the most frequent are the lack of concentration and / or attention.
• Language: there are difficulties in the ability to speak due to the involvement of the muscles that control the mouth, tongue, palate and the oral cavity in general.
• Emotional: increase in the prevalence of psychological and emotional disorders such as mood disorders (depression), anxiety, affective immaturity, among others.
• Social: motor disorder can in many cases cause a poor adaptation to the social environment, producing isolation or social stigmatization.
• Learning: many people may have an intellectual disability or specific learning needs, although it does not have to be correlated with a lower IQ than normal.

Diagnosis

Most cases of children with cerebral palsy are diagnosed during the first two years of life. However, if the symptoms are mild, it can complicate the diagnosis, being delayed until 4 or 5 years of age.

When a specialist suspects the presence of cerebral palsy by a specialist, various exploratory interventions will most likely be performed (National Institute of Neurological Disorders and Stroke, 2010).

Specialists diagnose cerebral palsy by evaluating motor skills, identifying the most characteristic symptoms. Furthermore, it must be determined that it is not a degenerative state.

A complete medical history, special diagnostic tests, and in some cases repeat check-ups, can help confirm that other disorders are not the problem (National Institute of Neurological Disorders and Stroke, 2010).

In many cases, additional tests are used to rule out another type of disorder. The most used with brain imaging (MRI), cranial ultrasound, or computed tomography (National Institute of Neurological Disorders and Stroke, 2010).

Treatment

Currently there is no curative treatment for cerebral palsy, but various therapeutic strategies can be implemented so that the person can maintain their quality of life.

Treatments can be used that improve their movements, that stimulate intellectual development or that allow the development of an efficient level of communication, therefore stimulating social relationships (Confederación ASPACE, 2012).

There are several fundamental pillars in therapeutic intervention with cases of cerebral palsy: early care, physical therapy, speech therapy, psychopedagogy, neuropsychological rehabilitation, psychotherapy and social intervention (Confederación ASPACE, 2012).

In general, the best therapeutic intervention is one that starts early and therefore offers more and better opportunities for capacity development or learning.

Treatment therefore may include: physical and occupational therapy; language therapy; medications to control epileptic symptoms or muscle spasms and pain; surgery to correct various anatomical alterations; the use of orthopedic adaptations (wheelchairs, walkers, communication aids), etc. (National Institute of Neurological Disorders and Stroke, 2016).

References

1. ASPACE. (2012). ASPACE Confederation. Obtained from Cerebral Palsy: aspace.org
2. Camacho-Salas, A., Pallás-Alonso, C., de la Cruz-Bértolo, J., Simón-de las Heras, R., & Mateos-Beato, F. (2007). Cerebral palsy: concept and population-based records. Rev neurol, 45 (8), 503-508.
3. Muriel, V., García-Molína, A., Aparicio-López, C., Enseñat, A., & Roig-Rovira, T. (2014). Cognitive stimulation in children with cerebral palsy. Rev neurol, 59 (10), 443-448.
4. NIH. (2010). Cerebral Palsy. Obtained from the National Institute of Neurological Disorders and Stroke: espanol.ninds.nih.gov
5. NIH. (2016). Cerebral Palsy. Obtained from the National Institute of Neurological Disorders and Stroke: ninds.nih.gov
6. Póo Argüelles, P. (2008). Child brain paralysis. Spanish Association of Pediatrics.
7. Robania-Castellanos, G., Riesgo-Rodríguez, S., & Robania-Castellanos, M. (2007). Definition and classification of cerebral palsy: Is a problem already solved? Rev Neurol, 45 (2), 110-117.