Spastic cerebral palsy

Cause

Spastic cerebral palsy is caused by malformation of or damage to the parts of the brain that control movement. What exactly makes some children susceptible to such brain damage is often unknown but it is believed that cerebral palsy may be the result of causal pathways, or chains of events that cause or increase the likelihood of brain injury. Most of the time, children are born with the brain damage resulting in spastic cerebral palsy, but a small percentage experience the damage shortly after birth following a stroke, head injury, or infection.

The following are types of brain damage that can result in spastic cerebral palsy:

• cerebral dysgenesis
• periventricular leukomalacia
• brain bleeds
• Hypoxic ischaemic encephalopathy

Risk factors

The following medical conditions are associated with increased likelihood of spastic cerebral palsy, as well as with other types of cerebral palsy:

• Preterm birth/low birthweight
• Multiple births
• Incompatible blood type between mother and fetus
• Exposure to toxins
• Complicated labor

Diagnosis

There is no single test to diagnose spastic cerebral palsy. It is typically diagnosed by age 2, though milder cases may go undetected for a longer time. A doctor will typically use a series of tests to assess developmental progress in growth, muscle control, coordination, vision, hearing, and posture. Continuous loss of motor skills likely indicates a condition other than spastic CP such as a genetic muscle disease Some metabolic disorders mimic spastic cerebral palsy and can be ruled out using a magnetic resonance imaging test (MRI).

Some tests to assess a child suspected to have spastic cerebral palsy are:

• Cranial ultrasound
• CT scan
• Magnetic resonance imaging

These tests are imaging techniques used to produce pictures of the brain and to examine them for areas of damage that indicate a diagnosis of spastic cerebral palsy. A child with a spastic CP diagnosis will likely be referred to screening for other conditions associated with spastic cerebral palsy such as epilepsy (seizure disorder), intellectual disability, and visual impairment.

Types

Scientific classifications

The types of spastic cerebral palsy are generally distinguished by the primary areas of the body that are affected.

• Spastic hemiplegia Hemiplegia is a type of cerebral palsy affecting one vertical half of the body (such as one arm and one leg). The affected side of the body is opposite the affected area of the brain in hemiplegia. For example, if the right side of the brain is damaged, the person will have weakness or paralysis on the left side of the body. People with hemiplegia typically favor an arm or hand and may keep the weaker hand in a fist. Typically, people that have spastic hemiplegia are the most ambulatory of all the forms, although they generally have dynamic equinus (a limping instability) on the affected side and are primarily prescribed ankle-foot orthoses to prevent said equinus.
• Spastic diplegia describes spastic CP in which muscle tightness predominantly occurs in the legs. The arms may be somewhat affected or not affected at all.
• Spastic monoplegia is one single limb being affected.
• Spastic triplegia is three limbs being affected.
• Spastic quadriplegia is all four limbs more or less equally affected. People with spastic quadriplegia are rarely able to ambulate without assistance and may not stand at all. Among the forms of spastic CP, quad CP is more likely to co-occur with seizures and mild to moderate intellectual disability.

In spastic cerebral palsy in children with low birth weights, 25% of children had hemiplegia, 37.5% had quadriplegia, and 37.5% had diplegia. No one person with a particular type of spastic CP presents in exactly the same way.

Treatment

There is no cure for spastic cerebral palsy and no way to reverse the initial brain injury. However, various treatments and assistive devices can help mitigate pain and allow those affected to have a higher quality of life. Different combinations of treatments are right for each individual and are determined by individuals and their care team.

Some common interventions are:

• Physical therapy: exercises to develop balance and strength and to learn skills such as walking, rolling, or driving a wheelchair.
• Occupational therapy: therapy to help an individual develop strategies to complete activities of daily living such as dressing, toileting, and bathing either independently or with a level of assistance that is safe and comfortable.
• Orthotics: braces and splints to improve posture and positioning (usually on legs or arms).
• Assistive devices: Wheelchairs, crutches, and walkers may help someone with spastic CP navigate safely. Different devices may be used in different settings or for longer distances. People with cerebral palsy may use up to 3–5 times the energy as those without when moving; thus, a device such as a wheelchair may reduce fatigue.
• Speech therapy: Therapy to help someone speak more clearly, swallow more safely, or use a communication device such as a DynaVox
• Medication: Certain medications can reduce stiffness from overactive muscles and decrease pain. Examples are botulinum toxin or baclofen, with the latter delivered orally or via an intrathecal pump.
• Surgery: In some cases, orthopedic and/or neurological surgeries are recommended when pain and stiffness interfere with participation in meaningful activities and other treatments are not effective.

Prognosis

Every case of spastic cerebral palsy is different. Some people with this type of CP can accomplish activities of daily living independently, while some need the assistance of a personal care aide for certain tasks, and others need 24-hour support. About 1/3 of people with cerebral palsy cannot walk, about 1/2 have intellectual disabilities, and 3/4 experience some level of chronic pain. There is limited research on adults with spastic CP. The brain injury causing CP does not progress or change, but the functional impact and thus, one's needs may change with age.

Some issues specific to adults with spastic and other forms of cerebral palsy are:

• Premature aging
• Fatigue
• Pain
• Arthritis
• Post impairment syndrome

Regardless of their particular expression of spastic cerebral palsy, affected individuals can lead fulfilling lives. Improved physical accessibility in society and increased social acceptance can increase community participation. Workforce participation of people with CP has almost doubled in the last four decades. Social inclusion and the presence or absence of policy to address discrimination, in addition to medical intervention, influences the outlook for people living with spastic cerebral palsy.