Cerebral Palsy and Associated Conditions: Symptoms Beyond Movement Issues

Cerebral palsy (CP) is the most common motor disability, caused by injury to the developing brain. It is defined as permanent movement and posture disorder due to non-progressive disturbances in the fetal or infant brain.

The symptoms of CP vary widely depending on the type and severity, ranging from mild muscle stiffness to severe spasticity, impaired motor function and difficulty with balance and coordination. In addition to motor challenges, individuals with CP may also experience cognitive, sensory and communication difficulties.

 

Sensory Impairments

In cerebral palsy sensory impairments are often overlooked but recognizing them is crucial as they significantly impact the functional use of affected extremities. Sensory loss did not always correspond to the motor deficit for example spastic diparesis CP shows abnormal tactile spatial discrimination with normal upper extremity motor function.

Common Sensory Deficits in CP include:

• Two-point discrimination - ability to distinguish between two points of contact on the skin as separate stimuli.
• Proprioception - it is the sense of body position and movement in space, even without visual input.
• Stereognosis - ability to recognize objects by touch alone, without visual input.

 

Visual Impairments

Strabismus is most commonly reported. It is a condition where the eyes do not align properly, often described as "crossed eyes."

Example: One eye might turn inward (esotropia) or outward (exotropia), leading to issues with depth perception and binocular vision.

Other disorders include:

• Retinopathy of prematurity which is abnormal blood vessel development in the retina, typically occurring in premature infants. Risk factors include prematurity and low birth weight, often exacerbated by oxygen therapy.
• Cortical visual impairment where the brain has difficulty processing visual information, despite normal eye structure. Common in CP cases involving hypoxic-ischemic encephalopathy (HIE).
• Homonymous hemianopsia i.e. loss of vision on the same side in both eyes, typically due to brain injury. It is common in children with hemiparesis, as both conditions result from damage to one hemisphere of the brain.

Relationship Between Visual Disorders and CP Severity (GMFCS Scale)

The Gross Motor Function Classification System (GMFCS) grades CP severity from I (mild) to V (severe), with visual impairments varying by level:

Hearing Impairments

Hearing impairments are less common in CP compared to visual or sensory deficits but can still significantly impact communication and learning. Sensorineural hearing loss (SNHL), the most common type in CP, occurs due to damage to the inner ear or auditory nerve.

Common Causes of Sensorineural Hearing Loss in CP:

1. Congenital Infection

TORCH is an acronym for a group of infections that can be transmitted from mother to fetus during pregnancy. These infections often lead to sensory and neurological damage, including hearing loss.

• Toxoplasmosis
• Rubella
• Cytomegalovirus
• Herpes

2. Bacterial Meningitis

It is a serious infection of the protective membranes covering the brain and spinal cord. The infection and resultant inflammation can damage the cochlea, auditory nerve, and brain regions involved in hearing.

Meningitis is a leading cause of acquired SNHL in children with CP.

3. Ototoxic Drugs

Certain medications can be toxic to the auditory system, especially in neonates and infants with compromised health. Children with CP often require intensive medical care, including treatments with ototoxic drugs, increasing their risk of hearing loss.

Examples of Ototoxic Drugs:

• Aminoglycoside antibiotics (e.g., gentamicin)
• Loop diuretics (e.g., furosemide)
• Chemotherapy agents (e.g., cisplatin)

Cognitive Impairments

Greater severity of neuromuscular impairment increases the risk of cognitive deficits. Some patients with severe motor impairments (e.g., athetosis from basal ganglia lesions) may have normal intelligence. Cognitive assessments are challenging due to motor and communication difficulties, leading to:

• Possible underestimation in patients with severe impairments.
• Possible overestimation in socially responsive patients.

 

Emotional and Behavioral Problems

Children with cerebral palsy are prone to emotional and behavioral issues. 

Mental health specialist referrals should be considered for evaluation and treatment. Common issues  includes:

• Attention deficit disorder
• Passivity and immaturity
• Anger and sadness
• Impulsivity and emotional lability
• Low self-esteem and anxiety

Specific Behavioral Problems:

• Dependency
• Being headstrong
• Hyperactivity

Common social and emotional challenges includes:

• Peer relationship difficulties 
• Hyperactivity 
• Emotional issues 
• Reduced sociable and leadership behaviors. 

Epilepsy or Seizure

Epilepsy is a frequent comorbidity in children with CP, with seizures resulting from brain damage that also causes the motor and sensory impairments characteristic of CP. The occurrence and frequency of seizures depend on the severity and type of CP, as well as the underlying brain abnormalities.

 

Oromotor Impairments in CP:

It is associated with more severe forms of CP and can lead to feeding difficulties along with increased risk of aspiration. Common issues include:

• Weak suction
• Poor coordination of swallowing
• Tongue thrusting
• Tonic bite reflex

Other Oromotor Issues:

• Difficulty controlling oral secretions and drooling.
• May negatively affect social interactions.
• Dental health issues like dental malocclusion and challenges with oral hygiene is seen, along with increased risk of periodontal disease.

Speech disorders are most common in children with spastic quadriparesis or athetosis. They range from mild articulation disorders to anarthria.

Growth and Nutrition Challanges in  Cerebral Palsy:

Children with CP presents with contractures and scoliosis making it difficult to measure stature. Other than this nutritional challenges are also faced, factors increasing malnutrition risk in CP:

• Poor oromotor skills
• Gastroesophageal reflux

Risk for overfeeding and obesity is also seen in CP. Children with more severe form have lower energy expenditure and higher body fat, making them at risk for overfeeding with energy-dense enteral feeds.

 

Urinary Continence Development

Children with CP often experience delays in achieving urinary continence due to a combination of neurological and physical factors. Factors influencing urinary incontinence are:

• Severe motor impairments (e.g. quadripersis) can hinder bladder control.
• Cognitive difficulties can affect recognition of the need to void or the ability to communicate this need effectively.

While urinary incontinence is the most common problem, children with CP may also experience:

• Frequency - needing to urinate more than usual.
• Urgency - a sudden, strong need to urinate.
• Hesitancy = difficulty starting urination.
• Urinary retention - inability to empty bladder completely.

 

Respiratory Problems

Children with CP face a heightened risk of respiratory issues due to:

1. Impaired respiratory muscle control: Difficulty in coordinating breathing muscles.
2. Ineffective cough: Challenges in clearing mucus and secretions from the airway.
3. Aspiration risks which results from impaired swallowing reflex, gastroesophageal reflux and seizure activity.

Consequences of Increased Airway Secretions:

• Wheezing
• Atelectasis
• Recurrent aspiration pneumonia
• Restrictive lung disease
• Bronchiectasis

Decreased Bone Mineral Density

Children with moderate to severe CP, especially nonambulatory ones, are prone to low bone mineral density. By age 10, most nonambulatory children develop osteopenia.

Contributing Factors:

• Neurologic Impairment Severity: More significant impairments correlate with lower BMD.
• Feeding Difficulties: Poor nutritional intake and associated challenges.
• Anticonvulsant Use: Certain medications can negatively affect bone density.
• Low Body Fat: Lower triceps skinfold and reduced fat stores, which may contribute to weaker bones.