Category Archives: Types of Cerebral Palsy

Ataxic Cerebral Palsy

By The CP Family Network

Cerebral palsy is the umbrella term for brain damage. The neurological disorders that can result are many and varied.

  • Nonspastic extrapyramidal cerebral palsy includes dyskinetic cerebral palsy (subdivided into athetoid and dystonic forms) and ataxic cerebral palsy.
  • Ataxic cerebral palsy is the rarest type of cerebral palsy and involves the entire body.
  • Ataxic cerebral palsy describes a condition indicating weak muscle tone.
  • Dyskinetic cerebral palsy (also includes athoid, choreoathetoid and kystonic cerebral palsies). This type of cerebral palsy involves fluctuating muscle tone.  Abnormal body movements affect the trunk, hands, arms and legs.

Causes

Ataxic cerebral palsy may be caused by a birth injury or birthing trauma, environmental factors, or by genetic, muscle, or central nervous system disorders such as down syndrome, muscular dystrophy, cerebral palsy, Prader-Willi syndrome, myotonic dystrophy or Tay-Sachs disease. Some children may experience hypotonia. This neuromuscular disorder is also referred to as “floppy infant syndrome” or “infantile hypotonia.” Individuals with this diagnosis are said to be “hypotonic” and demonstrate “hypo-tonicity.”

Cerebral Cortex

Imagine the cerebral cortex as the brain’s switchboard. Since the cerebral cortex contains nearly 75% of all the neuron cell bodies in the nervous system, injury to this portion of the brain would result in a variety of neuromuscular disorders. The effects of various injuries to the cerebral cortex depend on the location and severity of the damage. Doctors often describe the type of cerebral palsy a child has based on which limbs are affected.

Functions of the Cerebral Cortex

  • Cells in the upper portions of the cerebral cortex motor areas send impulses to muscles in the legs and thighs.
  • Cells in the middle portions control muscles in the shoulders and arms.
  • In the lower portions of the cortex, motor areas activate muscles of the head, face and tongue. Therefore, any injury to the motor system or pathways may result in a loss of the ability to produce purposeful muscular movements. The resulting disability would be classified as a “neuromuscular” disorder.
  • The primary motor areas of the cerebral cortex lie in the frontal lobes of the brain, therefore frontal lobe damage can result in ataxic cerebral palsy as well as a large variety of neurological disorders. An injury to the motor system may result in loss of ability of purposeful muscular movements (movement disorders) and can impair use of the hands, arms, legs, head or eyes.
  • The frontal lobes are also responsible for behavior and emotional development, therefore trauma to this portion of the brain may impair perception and rationality, behavior, personality, language skills, attention span, motor skills, facial expressions and sexual behavior.

The names of the most common forms of cerebral palsy use terms to describe the location or number of affected limbs, combined with the words for weakened (paresis) or paralyzed (plegia).

  • Hemiparesis (hemi = half) indicates that only one side of the body is weakened.
  • Quadriplegia (quad = four) means all four limbs are paralyzed.

The effects of ataxic cerebral palsy can range from complete loss of a function to compromised and diminished function. It is possible to determine the location of a cerebral injury by determining what functions and abilities are absent or diminished.

In the field of research, scientists are looking at traumatic events in newborn babies’ brains, such as bleeding, epileptic seizures, and breathing and circulation problems, which can cause the abnormal release of chemicals that trigger the kind of damage that causes ataxic cerebral palsy.

Midbrain

Cerebral insult or injury to the parasympathetic or sympathetic portions of the midbrain can result in ataxic cerebral palsy since the midbrain plays a role in facilitating motor function and muscle tone.

Cerebellum

Damage to the cerebellum portion of the brain can result in ataxic cerebral palsy and hypotonia, since the cerebellum facilitates the controlling and coordinating of muscles and helps with sustaining posture.

Diagnosis

Many physicians are reluctant to make a diagnosis of cerebral palsy until a child is 18 to 24 months old. Many of the normal developmental milestones are based on motor functions:

  • Reaching for toys (3-4 months)
  • Sitting (6-7 months)
  • Walking (10-14 months).

Some of the most pronounced movement disorders associated with ataxic cerebral palsy may not be evident until a child is expected to achieve certain developmental milestones. Parents are often the first to suspect that their baby’s motor skills are not developing normally and should contact their physician with any concerns since they can help distinguish normal variation in development from a developmental disorder. Most children with cerebral palsy are diagnosed by 3 years of age. Early assessment and intervention is vital in helping a child with this disorder meet developmental milestones.

Symptoms of Ataxic Cerebral Palsy

Imagine trying to walk, talk, swallow or perform any number of physical or autonomic functions with reduced or absent muscle tone.

  • This rare type of cerebral palsy affects balance and depth perception. Children with ataxic cerebal palsy will often have poor balance and coordination and experience challenges with precise movements. For example, the person may reach too far or too close to touch objects and may also have poor hand control (intention tremor).
  • A child with this form of cerebral palsy may walk with the feet unusually far apart and experience hand control issues, whereby only one hand is able to reach for an object; and the other hand may shake with attempts to move it (intention tremor).
  • A child may not be able to write or use scissors and may experience difficulty with quick or precise movements, such as writing or buttoning a shirt.
  • A child may display difficulties with sucking, swallowing, oral motor skills, breathing, delayed gastric and intestinal motility, further putting a child at risk of reflux and GERD
  • Children may also experience poor gross motor control, as well as impaired balance and depth perception.
  • It can also present issues involving a child’s ability to walk, sit, maintain torso control or use upper and lower extremities.

The hypotonic state of muscle tone that may be accompanied with ataxic cerebral palsy is not the same as muscle weakness, although the two conditions can co-exist. Depending on the nature, severity and location of the neurological damage, hypotonia can affect the entire body or be limited to parts of the body. It has the potential to impact cardiac function and bladder control and may influence pulmonary function by inhibiting diaphragm and respiratory muscle tone.

Children with this disorder may or may not exhibit development disabilities or mental retardation. In moderate to severe cases, a child may be at increased risk of contractures, spinal scoliosis and other muscular skeletal disorders.

Movement Disorder Symptoms

Movement Disorders associated with ataxic cerebral palsy may include tremors or jerky uncoordinated movements, which can occur when trying to exhibit control over affected muscles.

Children with ataxia cerebral palsy, or ataxic CP, have a disturbed sense of balance and depth perception, characterized by tremors or shaky movements. Depending on the nature and severity of the underlying cerebral injury, each case affects a child differently and some have more than one form of cerebral palsy (mixed cerebral palsy).

Prognosis

Ataxic cerebral palsy does not always cause profound disabilities. While one child with severe ataxic cerebral palsy might be profoundly delayed or unable to walk and need extensive, lifelong therapy and care, another with mild cerebral palsy might be only slightly inconvenienced and require no special assistance. Therapy, supportive treatments, medications and surgery can help many individuals improve their motor skills and ability to communicate with the world.

Treatment

Although there is no cure for the underlying neurological injury, children with ataxic cerebral palsy can benefit greatly from a variety of interventions:

  • Physical, occupational and speech therapy offers the venue to strengthen diminished or hypotonic muscle groups, and in some cases can help the brain establish new and different pathways to help facilitate a specific motor function.
  • Early intervention and management of the consequences of ataxic cerebral palsy is crucial in early childhood development. Left unaddressed, the absence of life skills which children rely on for so many of life’s demands can lead to severe developmental delays, a diminished quality of life and a severely compromised level of independence. Not to mention the behavioral issues a child will surely exhibit as a result of frustrations due to their inabilities. Consult your doctor for use of these therapies with other neurological disorders.

Ask Your Physician

Ask your child’s pediatrician what options are available to help your child avoid the possible consequences and complications that can result from ataxic cerebral palsy. If your child is not enrolled in an early intervention program, it’s NEVER too early. Many programs accept children under age 3. Most programs require a diagnosis, so if your child is diagnosed with ataxic cerebral palsy, get it in writing and ask your child’s physician to put you in contact with local and state service providers to begin the early intervention services and therapies your child can benefit from. Early assessment and services to address developmental issues are vital in allowing a child to reach their full potential.

Ask your child’s physician if your child would benefit from physical, occupation, speech or vision therapies, and request he write an order for services that he deems “medically necessary and appropriate.”

If a brain scan or MRI wasn’t done with the diagnosis, ask your child’s physician if a brain scan or MRI would be helpful to possibly better identify the cerebral injury and the possible long term consequences; proactive is always better then reactive. Many long-term crippling consequences of ataxic cerebral palsy can be minimized with diligence and the proper medications and therapies.

If your child has been prescribed medications, ask what follow up is needed with the medications; for example, lab work to monitor medication levels.

Resources

Floppy Infant Syndrome – http://www.ncbi.nlm.nih.gov/

Cerebral Palsy: Hope Through Research – http://www.ninds.nih.gov/disorders/cerebral_palsy/detail_cerebral_palsy.htm#154463104

Muscle Weakness (Hypotonia) – http://www.childrenshospital.org/az/Site1106/mainpageS1106P0.html

Athetoid Cerebral Palsy

By The CP Family Network

Cerebral Palsy is the umbrella term for brain damage. The neurological disorders that can result are many and varied.

To offer some insight into what it is to experience Athetoid Dyskinetic Cerebral Palsy and the associated movement disorders, consider an event that we’ve all experienced at some point in the twilight stages of sleep; just as we’re dozing off, our body twitches. Now imagine some extremity of your body, or your entire body, doing that when you’re awake, and not just once, but repetitively and there was nothing you could do to stop it!

 

Classifications

  • Quadriplegia – Affects all four limbs and the torso
  • Triplegia – Confined to three limbs ( Triplegia )
  • Hemiplegia – Affects only one side of the body
  • Diplegia –  Affects the lower extremeties and not the upper

Dyskinetic Cerebral Palsy (fluctuating tone), which also includes athetoid, choreoathetoid and dystonic cerebral palsies, is a neurological disorder resulting in a variety of movement disorders that include:

  • Involuntary writhing movements
  • Frequent, abrupt, jerky and involuntary gross motor movements
  • Possible head and torso involvement

Associated Movement Disorders are Known as:

  • Hyperkinetic (excessive)
  • Bradykinetic (reduced) activity
  • Spasticity refers to the inability of a muscle to relax
  • Athetosis refers to an inability to control the movement of a muscle

Children with athetoid cerebral palsy have trouble holding themselves in an upright, steady position for sitting or walking, and often show lots of movements of their face, arms and upper body that they don’t mean to make (random, involuntary movements). These movements are usually big.

For some children with athetoid cerebral palsy, it takes a considerable amount of work and concentration to get their hand to a certain spot (like to scratch their nose or reach for a cup). Individuals with this disorder may appear to be in constant motion and often have speech difficulties. Because of their mixed tone and trouble keeping a position, they may not be able to hold onto things (like a toothbrush, fork or pencil).

Involuntary Movements Classified As:

  • tremors
  • chorea
  • ballism
  • myoclonus
  • tics
  • dystonias

 

Causes

The effects of various cerebral injuries depend on the location and severity of the damage. Effects can range from complete loss of a function to compromised and diminished function. It is possible to determine the location of a cerebral injury by determining what functions and abilities are absent or diminished. Cerebral insult or injury to the parasympathetic or sympathetic portions of the midbrain can result in athetoid cerebral palsy since the mid brain plays a role in facilitating motor function and muscle tone.

This type of cerebral palsy was once common as a result of blood type incompatibility, but is now rarely seen. Athetoid cerebral palsy affects about 10% of children diagnosed with a form of Cerebral Palsy.

 

Diagnosis

Many physicians are reluctant to make a diagnosis of Cerebral Palsy until a child is 18 to 24 months old. Many of the normal developmental milestones are based on motor functions such as:

  • Reaching for toys (3-4 months)
  • Sitting (6-7 months)
  • Walking (10-14 months)

Some of the most pronounced movement disorders associated with athetoid cerebral palsy may not be evident until a child is expected to achieve certain developmental milestones. Parents are often the first to suspect that their baby’s motor skills are not developing normally and should contact their physician with any concerns, since they can help distinguish normal variation in development from a developmental disorder. Most children with cerebral palsy are diagnosed by 3 years of age. Early assessment and intervention are vital in helping a child with this disorder, to meet developmental milestones.

 

Complications

Many children may be only mildly inconvenienced with the related movement disorders and neuromuscular involvement, while others may face years of therapies, medications and possibly surgeries to manage and reduce the consequences of athetoid cerebral palsy.

Some may be at increased risk for muscular skeletal complications such as contractures and scoliosis due to poor torso control in addition to compromised oral motor function resulting in speech and feeding challenges.

Many individuals with cerebral palsy have no additional medical disorder. However, depending on the nature of the cerebral injury, children with athetoid cerebral palsy may or may not exhibit developmental delays or learning disabilities. Many may have learning challenges due to the distraction the neuromuscular disorder causes, and the impact it would have on a child’s ability to focus and retain information. Some may additionally experience seizures, impaired intellectual development, oral motor skill dysfunction, vision and hearing impairment. Coping with these disabilities may be even more of a challenge than coping with the motor impairments of athetoid cerebral palsy.

 

Treatment

Medications can be prescribed to administer orally or via a feeding tube that can help reduce spasticity and the severity of the related movement disorders. They include: baclofen, diazepam or others your physician may consider beneficial. Additionally, therapy, supportive treatments and surgery may be necessary and can help many individuals improve their motor skills and ability to function and communicate with the world. Early childhood intervention programs are vital in identifying, addressing and managing the developmental and neuromuscular issues that some children may experience with this disorder. Untreated, a child with moderate to severe athetoid cerebral palsy can suffer severe developmental delays and be at risk for crippling neuromuscular conditions.

 

Source

National Institute of Neurological Disorders and Stroke NINDS – Athetoid Dyskinetic Cerebral Palsy.

March of Dimes – marchofdimes.com – Athetoid Cerebral Palsy.

 

Spastic Diplegia – Overview and Considerations for Children

Spastic diplegia is a form of cerebral palsy that primarily affects the legs, hips, and pelvis. Arms can also be affected, but to a lesser degree. Considered a less severe form of cerebral palsy, children born with spastic diplegia usually have average to slightly below average intelligence and language skills. Most also learn to walk, although it may come late, but usually by age 8.

People with this form of cerebral palsy will have a distinct scissoring gait, in which the legs cross over each other in a stiff, scissoring pattern.

Causes of Spastic Diplegia

Overall, the most common cause of spastic diplegia is periventricular leukomalacia, more commonly known as neonatal asphyxia, a sudden shortage of oxygen delivered through the umbilical cord, combined with premature birth. The presence of certain maternal infections during pregnancy can also lead to spastic diplegia, since such infections can have similar effects to infant hypoxia. This lack of oxygen damages areas of the brain associated with movement.

Diagnosis

Since the disorder is frequently associated with birth trauma before, during, or shortly after delivery or prematurity, an infant can be assessed at birth as high risk. The type or severity of cerebral palsy may not be known for some months or even years depending on extent of the brain damage.

Because spastic diplegic cerebral palsy is primarily associated with movement of the legs, a diagnosis frequently comes when a child starts showing signs of not meeting developmental milestones for walking. This occurs usually between the ages of 18 months and three years.

Before this time, an infant’s legs may seem stiff, or may start out unusually floppy and gradually stiffen. The cause of this stiffness or floppiness is muscle tone, which has to do with the ability of muscle groups to lengthen and contract to produce movement. Too much muscle tone is called hypertonia, and too little is called hypotonia.

Some spastic diplegic cerebral palsy is so mild that people with the disorder report only minor problems with balance and gait.

Treatments for Spastic Diplegia

Treatment for spastic diplegia focuses on physical therapy to strengthen and retain range of motion; braces or other devices to direct bone development; and surgery, for older children, to lengthen muscles and ease muscle contractures. Massage can begin in infancy to help relax stiff muscles. Medications, such as intrathecal baclofen, are also available to help relax muscles and ease pain associated with contractures. For more information about treatments for spastic cerebral palsy, visit Cerebral Palsy Family Network.

Surgical Considerations

Orthopedic surgery is often recommended when spasticity and stiffness are severe enough to make walking and moving difficult or painful, and to smooth an awkward gait.

Before surgery occurs, doctors must determine which among the 30 major muscles involved in walking are causing the problem. Doctors today use a computerized diagnostic technique known as gait analysis to guide them in making surgical decisions. Gait analysis uses cameras that record how an individual walks, force plates that detect how the feet land, a test called electromyography that records muscle activity, and a computer program that gathers and analyzes the data. Using this information, doctors can precisely locate which muscles would benefit from surgery and how much improvement in gait can be expected.

According to the National Institute of Neurological Disorders and Stroke, the timing of orthopedic surgery is now based on the child’s age and motor development. For example, spasticity in the upper leg muscles (the adductors), which causes the “scissor pattern” walk, is a major obstacle to normal gait. The optimal age to correct this spasticity with adduction release surgery is between 2 and 4 years of age. However, the best time to perform surgery to lengthen the hamstrings or Achilles tendon is between 7 and 8 years of age. Today, most of these surgical procedures can be done on an outpatient basis or with a short inpatient stay. Children usually return to their normal activities within a week.

Selective dorsal rhizotomy (SDR) is a surgical procedure recommended only for cases of severe spasticity when all other standard treatments have failed to reduce spasticity or chronic pain. In the procedure, a surgeon locates and selectively severs nerves at the base of the spinal column.

The Child with Spastic Diplegia

According to Living with Cerebral Palsy, children with spastic diplegia may:

  • Crawl using a commando-type movement (pulling themselves around by their forearms with legs dragging behind), or may skip crawling altogether.
  • Prefer sitting in a W position between 1 and 3 years of age. Therapists may recommend other positions, such as sitting cross-legged, and child-size chairs, to help develop good sitting postures and avoid hip and gait problems.
  • Need a program to promote standing postures, if, by age 2 ½ the child is not pulling to a stand. This may include ankle-foot braces (AFOs) and prone type standers. Regularly standing an hour or two a day can improve balance, and stimulate the normal development of bones and joints in the legs. Standing programs are only recommended for children with severe involvement.
  • Require ankle braces to prevent toe-walking or rolling in of the feet. These can be low profile braces that can be hidden by clothes or shoes. Long leg braces and knee braces are almost never needed for children with diplegia.
  • Need regular hip exams and x-rays at age 2 for spastic hip disease, which can lead to hip dislocation. This condition can cause arthritis and pain as the child grows. The process of gradual dislocation is called subluxation of the hip.
  • Need to concentrate on regular physical therapy between the ages of 4 and 6, and then switch the focus to cognitive issues when the child starts school. For a child with mild diplegia, replacing therapy with other physical activities, such as swimming, dance class, karate, or horseback riding, is a good idea because the child’s interest will keep her active in developing her motor skills.
  • Be able to walk only short distances.

 

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