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Cerebral Palsy Explained


What is Cerebral Palsy?

Historically, the term "Cerebral Palsy" has been used to describe a loosely connected group of neurological problems resulting from prenatal (before birth) and perinatal (typically considered to be the time frame of 20-28 weeks gestation, before birth, and 7-28 days after birth) brain damage.

Cerebral Palsy typically appears before the age of 3 years due to non-progressive damage to the brain. It is sometimes referred to as "Little's Disease." It can develop before, during, or shortly following birth. In this context, "cerebral" refers to the brain and "palsy" refers to lack of appropriate control over the muscle structures and muscle weakness.

 

What are the different types of Cerebral Palsy?

The primary categories of Cerebral Palsy include:

  • Spastic Paralysis: This disorder is marked by a spastic (involving sustained contraction of muscles) paralysis of all four limbs (but typically more marked in the legs). It is the most common and most noticeable feature of Cerebral Palsy and is found in approximately 70% of CP patients. It is caused by damage to the motor cortex or to the white motor fibers which lead from the motor cortex to the spinal cord. The motor cortex and the related white fibers initiate voluntary control of the various muscle groups. The damage results in lesions referred to typically as upper motor neuron lesions. The flexor muscles predominate in this setting and thus all the joints tend to be held in a characteristic hyperflexed (bent) position which makes movement difficult. Ultimately, these patients have difficulty walking, loss of dexterous movements, and speech impairments (dysarthria) due to difficulty in moving the structures of the jaw and mouth.
  • Athetoid: Athetoid movements consist of periodic involuntary writhing and twisting movements generally involving the whole body (trunk, limbs, head, and face). These athetoid movements are found in approximately 20% of CP patients.
  • Ataxia: Ataxic difficulties include extremely poor depth perception, coordination difficulties, and balance difficulties. For example, in clinical testing the patient may not be able to place the tip of the finger on the end of the nose, nor may the patient be capable of rubbing the heel up and down the opposite shin. Ataxic difficulties are found in approximately 10% of CP patients.
  • Spastic Paralysis with Athetosis: The difficult and awkward movements associated with Spastic Paralysis (characteristic hyperflexed position) is combined with the involuntary athethoid movements. Athetosis and Ataxia present together far less often.
  • Epileptic: A substantial portion of CP patients present with characteristic epilepsy. Of this group, approximately 25% experience epileptiform seizures.
  • Mental Retardation: A significant number of CP patients have normal or relatively normal intelligence. When mental retardation is present, it is usually associated with patients who have epileptiform seizures or Spastic Paralysis with Athetosis. 

In summary, the general signs of Cerebral Palsy include:

  • Hyperflexed (bent) position of joints
  • Difficult, stiff, or awkward movements
  • Involuntary writhing and twisting movements
  • Poor depth perception, balance, and coordination difficulties
  • Muscle spasm or tightness
  • Twitching
  • Poor muscle control
  • Seizures, including epileptiform seizures
  • Impairments of speech, hearing and/or sight
  • Mental retardation.

 

What causes Cerebral Palsy?

The causes of Cerebral Palsy are often misunderstood even by lawyers professing expertise in the area.

The most common cause of brain damage resulting in Cerebral Palsy is from intrauterine infections. An additional cause is rhesus incompatibility where, for example, maternal antibodies cause hemolytic anemia (a breakdown of the oxygen carrying hemoglobin) and the excess bilirubin (formed from the breakdown of hemoglobin) damages the brain cells. This problem is now less common since the Rh factor incompatibility can be identified early on and preventative measures can be taken. For example, when there is present an Rh negative mother and an Rh positive father, the mother can be prescribed an anti-rhesus gammaglobulin immediately following delivery of the baby. Other preventative measures can also be taken throughout the course of the pregnancy.

Trauma is also a cause of Cerebral Palsy. The trauma usually involves the cerebrum (the primary portion of the brain), the cerebellum (the "little" brain, dealing with equilibrium, and corresponding to the description as "Little's Disease"), the basal ganglia, or the pyramidal tracts (which are nerve transmitters, resembling cables, which transmit impulses corresponding to movement of muscles).

Birth trauma associated with a long and hard delivery process can certainly cause Cerebral Palsy, but it actually occurs far less often than previously thought. Similarly, neonatal asphyxia (the baby is blue when delivered, appears not to be breathing, and is difficult to resuscitate) can cause Cerebral Palsy, but again occurs less frequently than previously thought. The fetus, as well as the newborn, are very resistant to hypoxic (lack of oxygen) damage and, thus, it is thought in many cases that the brain damage was already present before the labor began. Ultrasound studies performed in the first week of life will demonstrate damage to the white fiber bundles in the region of the cerebral ventricles (known as periventricular leukomalacia). Typically, over a period of 2-3 weeks, these damaged white fiber bundles are replaced by small fluid-containing cysts. If these periventricular cysts, which take approximately 3 weeks to develop subsequent to the insult to the brain, are present soon after birth, it is more likely than not the original damage occurred, at least, 2-3 weeks earlier.

Though the fetus and newborn are very resistant to hypoxic (lack of oxygen) damage, such a lack of oxygen may certainly cause Cerebral Palsy. Oxygen supply to the fetus can be disrupted and thus result in brain damage for a number of reasons including, but not limited to: compression of the umbilical cord during the birth process; separation of the placenta prematurely from the wall of the uterus; mechanical trauma (inappropriate or excessive use of vacuum extraction); unusual birth position of the baby (breech or butt first rather than head first); placenta previa (the placenta is implanted in the lower portion of the uterus); trauma related to the disproportionate size of the fetal head when compared to the pelvis of the mother (thus increasing the likelihood of the fetus becoming stuck in the birth canal); prolapse of the umbilical cord (the umbilical cord is delivered prior to the fetus); a build-up of acid in the blood level of the fetus related to lack of oxygen measured by a decrease in the blood pH, also called acidosis, and frequently linked to babies with brain damage; and, very importantly, fetal distress including, but not limited to, meconium (fecal) staining (which represents the first intestinal discharge of the fetus and which does occur during times of distress when, for example, the fetus is stuck in the birth canal), bradycardia (the heartbeat is too slow), tachycardia (the heartbeat is too fast), cardiac arrhythmia (the heartbeat is irregular and thus abnormal). All of the foregoing possible complications are reasons for a Cesarean Section (C-Section) to be performed. It is often the failure of the physician to perform the Cesarean Section when indicated which results in otherwise preventable brain damage.

In summary, the issues we typically examine closely include:

  • Intrauterine infection which was undiagnosed
  • Rhesus (Rh factor) incompatibility for which preventative measures were not taken
  • Neonatal asphyxia
  • The presence of periventricular leukomalacia and/or periventricular cysts
  • Failure to identify an obstetric condition present in the mother which can lead to complications
  • Failure to identify and interpret properly changes in the fetus during the prenatal and perinatal time frames
  • Failure to identify and interpret properly changes in the condition of the mother during the prenatal and perinatal time frames
  • Failure to recognize birth trauma and/or creation of unnecessary mechanical trauma (by improper use of vacuum extraction or forceps)
  • Failure to recognize the labor process was too long or too short (including the failure to deliver the baby by Cesarean Section within a reasonable time after the membranes had ruptured, i.e. the water broke)
  • Failure to properly identify fetal distress as present on the Fetal Monitor strips
  • Failure to recognize the need for Cesarean Section so as to prevent fetal distress and ultimately brain damage.

 

DIAGNOSIS AND INTERVENTION:

Recognizing the signs and symptoms mentioned earlier can lead to earlier intervention. Commencing physical therapy within the first year, if possible, will make the adjustment in dealing with Cerebral Palsy easier for you and your child. However, the typical features of Cerebral Palsy may not become obvious until your child's second year of life. This is the typical time frame in which the brain assumes more control physically over the body. Prior to this time, you may simply think your child's muscle tone to be more flaccid than expected. If your child has difficulty crawling, walking, or holding his or her head upright, this may be an indicator. Abnormalities become more visible and noticeable when your child reaches the second year.

As noted, ultrasound studies in the neonatal time frame where suspicion is present can reveal periventricular leukomalacia and thus identify those children who are likely to develop Cerebral Palsy. Where periventricular leukomalacia is identified, it can also provide an indicator as to the severity of Cerebral Palsy. Physical therapy should be commenced as soon as practicable to reduce long-term deficits. Similarly, as soon as practicable, speech therapy and other modes, such as specific play therapy, should be initiated.

 

DEVELOPMENTAL TIME FRAMES FOR YOUR BABY:

Normal development by 3 months:

  • Actively move arms and legs
  • Visually track objects that move
  • Hold up his/her head when lying on stomach
  • Smile in response to familiar faces or when talked to.

Abnormal development by 3 months (which may indicate CP):

In general terms, your baby may experience problems indicated by:

  • The sucking reflex
  • Inability to hold his/her head up while lying on stomach
  • Legs and arms are unusually stiff or unusually floppy
  • One or both hands are kept in the "fist" position the majority of the time and it is difficult to open the hand(s)

Normal development by 6 months:

In general terms, your baby should be able to:

  • Roll from back to stomach and stomach to back without difficulty
  • Sit with support
  • Turn in the direction of sounds
  • Pass objects and toys from hand to hand using each hand relatively equally
  • Put objects and toys in mouth
  • Coo.

Abnormal development by 6 months (which may indicate CP):

In general terms, your baby may experience problems indicated by:

  • Rolls over only by extending back and legs (appears to be bridging or arching)
  • Cannot sit even with support
  • Eyes are crossed
  • Legs are crossed and/or difficult to get apart
  • Uses only one hand and does not switch objects and toys from hand to hand
  • One hand is typically fisted
  • Does not make cooing sounds
  • Typically turns head only to one side.

Normal development by 9 months:

  • Sit unsupported
  • Typically say a few words (momma, dada, etc.)
  • Know his/her name and respond to it
  • Drink from a Sippy cup
  • Get in and out of the sitting position.

Abnormal development by 9 months (which may indicate CP):

In general terms, your baby may experience problems indicated by:

  • Still not sitting or has just begun sitting unsupported
  • Rounds the back forward while sitting or arches the back
  • Has fine motor control difficulty with the hands (difficult to pick up and manipulate objects)
  • "Army" crawls (pulls with just one side of the body)
  • Cannot support weight on legs
  • Has difficulty with even thin liquids and gags frequently
  • Has trouble with head and trunk control
  • Toes are pointed continually.

Normal development by 12 months:

In general terms, your baby should be able to: 

  • Pull to a standing position and walk around furniture
  • May take a few independent steps
  • Speak more words
  • Has fine motor control and is able to pick up objects and toys with the thumb and first finger.

Abnormal development by 12 months (which may indicate CP):

In general terms, your baby may experience problems indicated by:

  • Still cannot pull to a stand or has significant trouble trying to do so
  • Walks on toes continually
  • Still has undeveloped grasping in one or both hands with no pincer grasp
  • Grasps objects with all the fingers and the palm or still cannot grasp objects or toys.

Normal development by 15 months:

In general terms, your baby should be able to:

  • Stand without support
  • Most babies are walking without support at this time
  • Can feed himself/herself
  • Use typically 4-5 words.

Abnormal development by 15 months (which may indicate CP):

In general terms, your baby may experience problems indicated by:

  • Still not standing independently
  • Continually stands or walks on toes and has difficulty bringing the toes and feet to the ground, or cannot do so at all
  • Cannot sit properly or sits to one side.

**If any of the above-identified abnormal symptoms persist, you should have your baby evaluated by a pediatric neurologist.

If you have questions, please call us toll free at 1-800-393-8686. You may also e-mail us at info@FloridaTrialLawyer.com or use our "Contact Us" form. We will be pleased to answer your questions and to provide you with immediate feedback concerning your potential birth-related injury claim.

 

SUPPORT GROUPS AND LINKS:
  • American Academy for Cerebral Palsy and Developmental Medicine: www.aacpdm.org
  • Cerebral Palsy Disability Information and Frequently Asked Questions: www.netathon.org/Pages/disability.html
  • Children's Hemiplegia and Stroke Association - CHASA is a non-profit corporation which offers support and information for families of children who have hemiplegia, hemiparesis, or childhood stroke: www.hemikids.org
  • Exceptional Parent Magazine - Articles, resource guides, links to disability web sites, info about disability associations: www.eparent.com
  • KidPower - a support and informational site for families living with cerebral palsy and other disabilities: www.kid-power.com
  • National Information Center for Children and Youth with Disabilities (NICHCY) - Information on disabilities and disability-related issues: www.nichcy.org
  • TASH - Advocacy association of people with disabilities, their family members, advocates and people who work in the field: www.tash.org
  • United Cerebral Palsy Association - Website of the National UCPA Organization: www.ucpa.org

 

 

 

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Riley Allen Law
429 S. Keller Rd. Ste 300
Orlando, FL 32810
Phone 800-393-8686
 

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