Cerebral Palsy

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Risk Factors

Infants at the highest risk for developing cerebral palsy exhibit one or more of these factors: premature; low birth weight (<5 lb 7 1/2 oz); do not cry within 5 minutes of delivery; sustained on a ventilator more than 4 weeks; brain hemorrhage.

Other risk factors include the following:

• Complications in pregnant mother (e.g., vaginal bleeding after 6th month, proteinuria, hyperthyroidism, high blood pressure, Rh incompatibility, mental retardation, seizures)

• Breech birth (born feet or buttocks first)

• Labor and delivery complications (vascular or respiratory problems; may indicate brain damage or abnormal brain development)

• Multiple births (e.g., twins, triplets; CP may be due to prematurity or intrauterine growth retardation)

• Birth defects (e.g., malformation of spinal bones, hernia in groin area, abnormally small jawbone, microcephaly)

• Newborn seizures

• Low Apgar score—Infant heart rate, breathing, muscle tone, reflexes, and skin color are each scored as 0 (low), 1 (intermediate), or 2 (normal) after delivery. A total score of 7-10 at 5 minutes is considered normal; 4-6, intermediate; and 0-3, low. Scores that remain low 10-20 minutes after delivery indicate increased risk for CP.

Signs and Symptoms

Symptoms of cerebral palsy can be as simple as having difficulty with fine motor tasks like writing or using scissors, or as profound as being unable to maintain balance or walk. Severely afflicted patients may have involuntary movements, such as uncontrollable hand motions and drooling. Others suffer from associated medical disorders, such as seizures and mental retardation.

Spastic CP is the most common type of cerebral palsy. It causes the muscles to be stiff and permanently contracted. Spastic cerebral palsy is often subclassified as one of five types that describe the affected limbs. The names of these types combine a Latin prefix describing the number of affected limbs (e.g., di- means two) with the term plegia or paresis, meaning paralyzed or weak:

• Diplegia–either both arms or both legs
• Hemiplegia–limbs on only one side of the body
• Quadriplegia–all four limbs
• Monoplegia–one limb (extremely rare)
• Triplegia–three limbs (extremely rare)

Spastic diplegia affects the legs more than the arms. The legs often turn in and cross at the knees. This causes a scissors gait, in which the hips are flexed, the knees nearly touch, the feet are flexed, and the ankles turn out from the leg, causing toe-walking. Learning disabilities and seizures are less common than in spastic hemiplegia.

Persons with spastic hemiplegia (hemiparesis) also may experience hemiparetic tremors—uncontrollable shaking of the limbs on one side of the body. Severe hemiparetic tremors can seriously impair movement. The arm is generally affected more than the leg. Learning disabilities, vision problems, seizures, and dysfunction of the muscles of the mouth and tongue are classic symptoms.

Spastic quadriplegia involves all four limbs. There is dysfunction of the muscles of the mouth and tongue, seizures, medical complications, and increased risk for cognitive difficulties.

Athetoid (or dyskinetic) cerebral palsy is characterized by slow, uncontrolled, writhing movements of the hands, feet, arms, or legs (athetosis). Patients also may have abrupt, irregular, jerky movements (chorea), a combination (choreoathetosis), or slow rhythmic movements with muscle tone abnormalities and abnormal postures (dystonia).

The muscles of the face and tongue may be affected, causing grimacing and/or drooling. When the muscles that control speech are affected, the patient experiences dysarthria (abnormal pronunciation of speech). Hearing loss is commonly associated with this form of CP.

Ataxic cerebral palsy affects balance and depth perception. Persons with ataxic CP have poor coordination and walk unsteadily, usually placing their feet far apart. Many have trouble with quick or precise movements, like writing or buttoning a shirt. Some also have intention tremor, in which a voluntary movement, like reaching for an object, sets off trembling in the limb. The tremor becomes more intense as the person nears the target object.

Mixed CP involves two or more types of cerebral palsy. While any mix of types and subtypes can occur, the most common are athetodic-spastic-diplegic and athetoid-spastic-hemiplegic; the least common is athetoid-ataxic. It is possible to have a mix of all three (spastic-athetoid-ataxic).

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