UNDERSTANDING CEREBRAL PALSY: WHAT EVERY PARENT AND CAREGIVER SHOULD KNOW

By Dr.Lynett Ongera & Margaret Makunja edited by Luke Lekishon

The word ‘cerebral’ refers to the two halves or hemispheres of the brain. ‘Palsy’ refers to paralysis that impairs body movement. Therefore, cerebral palsy (CP) can be defined as a group of non-progressive lifelong disorders that affect movement, posture, and muscle coordination. It is caused by abnormal brain development or damage usually occurring before birth, during birth, or in early childhood while the brain is still developing. Despite having no cure, early identification of CP and appropriate intervention can significantly improve a child’s functional abilities.

Cerebral palsy mainly affects motor functions such as walking, balance and control of muscles. A person suffering from CP is likely to have to poor coordination, impaired balance or unusual movement patterns. It is a non-progressive condition meaning that the brain injury does not get worse over time, however, symptoms may change as a person grows. CP may also affect intelligence, hearing, vision, sensation and speech. The symptoms vary from person to person.

Cerebral palsy is classified according to two factors, namely: movement (physiological) and limb involvement (topographical). According to movement, we have the following types of CP: Spasticity, Athetosis, Rigidity, Ataxia, Tremor, Mixed and Atonia. In Spasticity, the limb muscle is tight and contracts strongly (increased stretch reflex) with sudden attempted movement or stretching. Thus, when the person tries to perform a movement e.g. raising an arm, as soon as the arms begins to stretch, they contract reflexively. The result is jerky, uncoordinated movements.

In Athetosis, the limbs have involuntary, purposeless movements (the muscles are normal, not spastic), and purposeful movements are contorted. e.g. limbs thrashing about, spontaneous jerking motions, usually of the fingers or toes. The risk factors are jaundice and Rhesus factor incompatibility, which are now routinely diagnosed and treated, so the incidence has decreased. Most children in this category have normal intelligence, however, their learning may be affected due to a lack of muscle control. Rigidity is a severe form of spasticity – so much so that even the increased stretch reflexes are dampened. If an attempt is made to move the rigid limb, it gives way as if it were a lead pipe or a cogwheel. These children are usually quadriplegic.

Ataxia is characterised by difficulties in balance. The person walks as if intoxicated, and speech is frequently slurred. Such children walk with feet apart, trunk weaving, and arms held akimbo to maintain balance. The problem is presented in various activities that require body balance, e.g. beginning to sit and stand. They will often fall unlike others of the same age. They are clumsy in the use of their hands, for instance when feeding. Some problems which are normal for young children will last them a lifetime, e.g. walking in a straight line or being able to stand straight (attention). They will also have problems in fine motor skills which may affect their writing; this is a major obstacle in learning.

Tremor is the shakiness of the limb involved. Tremor might be noticed only when the child attempts to use the limb (intention tremor). Continuous tremor at rest is not common in children as is in adults with Parkinson’s disease of the brain. In Mixed CP, these children are quadriplegic and have both Spasticity and Athetosis. It results from damage to multiple brain areas, leading to a complex mix of movement difficulties, such as muscle rigidity alongside tremor or floppiness.

Atonia, meaning limp muscle tone and floppy is another type of CP that may be found in diagnoses. However, Atonia is non-existent in school children. The atonic diplegic infant usually evolves into Athetosis. According to limb involvement, CP can be classified as: Monoplegia (one limb is affected), Hemiplegia (upper and lower limb on the same side are affected), Paraplegia (lower limbs are affected), Diplegia (major involvement in the lower limbs and minor involvement in the upper limbs), Triplegia (three limbs are affected, usually one upper limb and both lower limbs), Quadriplegia (major involvement of all four limbs, also called Tetraplegia), Double hemiplegia (upper limbs are more involved than the lower limbs).

The causes of CP can be divided into three categories: prenatal causes, perinatal causes and postnatal causes. Prenatal causes are those that occur before birth. These are: inherited causes, gene changes that result in genetic conditions or differences in brain development, infections in the mother during pregnancy (rubella in the 1st trimester, herpes virus, toxoplasmosis, cytomegalic inclusion disease, Zika virus etc.), lack of oxygen to the foetal brain, foetal anoxia due to haemorrhage, placental separation, kinking or knotting of the umbilical cord, Rhesus incompatibility, maternal high blood pressure, poor maternal nutrition, maternal seizures, prematurity, metabolic disorders – diabetes and toxaemia of pregnancy, exposure to X-rays, exposure to toxins and other conditions affecting the mother that can slightly increase the risk of cerebral palsy include thyroid conditions, preeclampsia or seizures.

Perinatal causes are those that occur around childbirth. These include: birth injury (use of instruments such as forceps or vacuum), lack of oxygen (foetal asphyxia, anoxia or hypoxia), abnormal presentation/breech (face or feet first, traverse lie which makes for a difficult delivery), premature birth.

Postnatal causes are those that occur after childbirth. These include: head injuries (skull fractures, brain laceration and haemorrhages caused by accidents or child abuse), brain infections (such as encephalopathy i.e. meningitis, encephalitis, severe untreated jaundice and others such as malaria and tuberculosis that affect the brain), toxic chemicals (like lead and mercury poisoning and other poisonous chemicals such as herbicides and pesticides), high fevers due to infections (this is common with bottle-fed babies), brain haemorrhages or clots (these causes cut off the blood supply to the brain, leading to death of brain cells), lack of oxygen to the brain (cerebral anoxia), carbon monoxide poisoning, drowning and stoppage of the heart (cardiac arrest), brain tumours, stroke (which interrupts blood supply to the developing brain) and premature delivery (delivery in less than 37 weeks).

To manage cerebral palsy, one needs Special Needs Education and access to health professionals who can administer drug therapy among other interventions. At the Kenya Institute of Special Education (KISE), CP is managed in the following ways: assessment and referral for corrective surgery, registration with National Council for Persons with Disabilities (NCPWD), educational placement to special schools or regular schools depending on the nature and severity of the condition, physiotherapy, occupational therapy, play therapy and hydrotherapy at the assessment facility, guidance and counselling to parents and caregivers to offer support on care and management of children, supply of diapers issued by the NCPWD to deserving children, pre-school education for school-going children who can access the Model Inclusive Pre-school and training teachers in the department of Physical and Multiple Disabilities to serve learners with cerebral palsy.

Cerebral palsy can be a challenging disorder to manage but with the right interventions, it is possible for one to live a full life. Depending on the severity of the condition, one can be helped to be productive and even earn a living. Research and advancements in technology are doing much to help cope with this condition. Devices such as wheelchairs, scooters, seating aids, standing frames, walkers and braces have been developed to help those with CP function to the best of their abilities. With increased awareness and early interventions, we can help those with CP to have fulfilling lives.