Diagnosis: Cerebral Palsy

Cerebral palsy (CP) is a neurological disorder, predominantly a spastic disorder of the nervous and muscular systems. It is characterized by impairment of the nervous and muscular systems in the areas of muscle tone, muscle strength, coordination, and the execution of movement.

It is a disorder of the motor system caused by insufficient or absent oxygen supply to brain cells during the development of motor functions. Brain cells are the most sensitive cells in the body to lack of oxygen.

There are several causes that can lead to oxygen deprivation of brain cells: maternal bleeding during pregnancy, serious injuries during pregnancy, infections, complications with the umbilical cord, complicated or poorly managed labor, complications during birth, and head injuries in early childhood. Most often, cerebral palsy occurs during childbirth. It affects approximately 3 out of 1,000 live-born children. Prematurely born infants are most commonly affected.

The most prominent symptom of CP is paralysis. The extent of damage to brain cells and motor centers depends on how long the brain was deprived of oxygen. The longer the period without vital oxygen, the more extensive the paralysis.

Disorders associated with CP may occur during pregnancy (prenatal), during birth (perinatal), or shortly after birth (postnatal), due to immaturity of the brain and the entire central nervous system.

CP may also develop in prematurely born infants because their central nervous system is still immature and underdeveloped at the time of birth.

CP is incurable; its typical feature is varying degrees of motor impairment. However, it is not a hereditary disease. This means that a mother (or father) with CP can have a completely healthy child.

CP manifests through changes in muscle tone. Some children with cerebral palsy show abnormal muscle tone already as newborns — hypotonia (reduced muscle tone — excessive looseness - the infant lies limp and cannot activate muscle activity, or only with great effort). Hypertension, on the other hand, is increased muscle tone - the child is stiff and less flexible. In some cases, hypotonia changes into hypertonia during the first months of life. Disorders of coordination, involuntary movements, or a combination of these may also appear.

DMO is divided into three forms:

Spastic form of CP
Non‑spastic form of CP
Ataxic form of CP
Combined form – the most common is a combination of the spastic form and the dyskinetic form

Spastic form

This is the most common form and affects 70–80% of people with cerebral palsy. It is characterized by permanently increased muscle tone, which restricts or even prevents movement in the affected areas. According to the number of limbs involved, it is divided into:

Diparetic form – affects the whole body – the upper limbs less than the lower limbs
Hemiparetic form (spastic hemiparesis) – manifests as paralysis of both limbs on either the right or the left side
Triparetic form – usually affects both legs and one arm, or the opposite combination
Quadruparetic form – a more severe type of the above forms, affecting the head, trunk, and all upper and lower limbs

Spasticity also causes joint stiffness. A typical presentation is as follows: the legs at the hips are flexed, angled, and turned inward. The elbow, wrist, and knee tend to stiff flexion. The forearm is bent, and the thumb is turned inward. The ankle and foot are in the so‑called tiptoe position (pes equinovarus). Curvature of the spine also occurs.

Non‑spastic form (10–20% of patients)

This form involves damage to the basal ganglia. It manifests as a pathologically rapid and uncontrollable alternating of muscle tension and relaxation in the affected areas. Typical symptoms include athetosis (sudden, uncontrollable, writhing movements) and chorea (small, involuntary, jerky movements). This category also includes the hypotonic form of CP, which presents with reduced muscle tone of the trunk and limbs. It is typical in infancy and later develops into one of the spastic forms or, most commonly, into dyskinetic forms. In rare cases, the patient remains permanently hypotonic.

Ataxic form of CP

This form results from damage to the cerebellum (5–10% of patients). In this form, the perception of balance and sensitivity is impaired, causing poor coordination of movements. Walking is unsteady, and the feet are placed widely apart — referred to as a “drunken gait.” These patients may also suffer from intention tremor, meaning trembling that appears during voluntary, purposeful movements.

Associated conditions

Motor impairment is the dominant symptom, but other difficulties are often present as well.

Intellectual disability or autism may accompany CP. However, this does not mean that a person with CP always has an intellectual impairment — society sometimes mistakenly assumes this.

Cerebral palsy also affects other areas such as speech, perception, and emotionality. Changes in sensory perception may appear even if the child does not have a sensory impairment. Children may have difficulties with visual‑motor coordination or controlling their own movements.

Problems also appear in the area of concentration; children tire easily. Their memory is fragmented and inconsistent. Speech development may be delayed or undeveloped. Dysarthria is typical — a speech disorder accompanied by impaired breathing, voice production, voice modulation, and resonance. Oromotor function — mobility of speech organs — is impaired and causes articulation difficulties of varying severity.

Epilepsy accompanies CP in 35–55% of children. CP does not arise from epilepsy, but because of brain damage, the brain is more prone to developing epilepsy. The likelihood of abnormal neuronal activity increases, which leads to seizures. Children with hemiplegia or quadriplegia are most susceptible. A seizure may last from a few seconds to several minutes.

Diagnosis

The full clinical picture of CP develops only after several months. Right after birth, diagnosing CP is difficult. It is essential to monitor the child's development dynamically over time. However, suspicion of a risk of CP can be raised within the first weeks of life based on a detailed neurological examination and assessment of psychomotor development, positional tests, brain ultrasonography, and other imaging methods such as CT or MRI of the brain.

Therapy

CP is a non‑progressive disease, but it is not an unchanging impairment; it is a condition of the developing brain with damage in multiple areas. Prevention of CP is not possible. Early identification and early initiation of therapy are essential – especially rehabilitation, which has an important and crucial importance. Early rehabilitation, particularly within the first year of life, can improve the quality of life of children with CP as well as their families. Overall motor development is slower than in a healthy child. Individual motor milestones appear later.

The basis of therapy is a comprehensive and regular therapeutic program prescribed by a rehabilitation physician. This therapy is tailored individually to the needs of the child, taking into account overall skills, abilities, the child’s general health, as well as the need for regeneration, which is often a neglected factor.

Basic rehabilitation exercises include the Vojta method, the Bobath concept, the Therasuit method, the Fay method, the Rood method, and orofacial stimulation.

Supporting methods include kinesiotaping, oxygen therapy, basal stimulation, SCENAR therapy, Snoezelen, animal‑assisted therapies such as hippotherapy, dolphin therapy and canistherapy, as well as music therapy, art therapy, occupational therapy, spa treatment, etc.

Patients with CP often undergo surgical treatment aimed at releasing stiff and non‑functional muscles and tendons, repairing damaged joints, or correcting scoliosis. These surgeries help improve function, but the reason for the operation can also be pain relief.

Medication treatment includes addressing symptoms and associated conditions – treatment of epilepsy, reduction of spasticity and muscle‑relaxing drugs, stool‑softening medications, laxatives, antacids (medication for the prevention of gastric ulcers), sleep medications, etc.

Cerebral Palsy

General