Cerebral Palsy and Epilepsy

Jennifer Li

Definition The definition of cerebral palsy (CP) has been highly controversial. In most cases, it is said to be a group of disorders affecting body movement and muscle coordination (8). It is also medically defined as a nonprogressive disorder of movement and/or posture, caused by a static lesion of the developing brain (2). Many arguments exist on whether the definition should exclude any condition presumed not to have been present before the age of 4 weeks (2).

Brief History Although the symptoms of cerebral palsy may have existed for as long as the history of mankind, it was not until 1861 when CP was first identified as a distinct medical condition, by an English orthopaedic surgeon - Dr. William John Little. Before the term cerebral palsy came into use in the late 1800's, it was referred to as spastic diplegia, or Little's Disease, as Dr. Little first described it as the neurological problems in children characterized by stiff, spastic muscles in their arms and legs (8). He had also noticed that the condition of these children did not improve with age, nor did it worsen. Little believed that the cause of cerebral palsy is the obstetrical complications at birth. He suggested that disturbances during a delivery may result in lack of oxygen to the baby's brain, which in turn could damage the sensitive brain tissues that are responsible for muscle control (8). However, his view was later challenged by Dr. Sigmund Freud, a well known Austrian neurologist. He quoted that "Difficult birth, in certain cases, is merely a symptom of deeper effects that influence the development of the fetus. (1)" He reasoned that, since the children with cerebral palsy also carried other problems such as mental retardation, visual disturbances, and seizures, the cause of it should be any damages during the brain's development in the womb (1). Nowadays, many families, doctors, and medical researchers still believe that birth complication was the number one reason for cerebral palsy. In the 1980s, extensive research involving 35,000 births indicated that only a small fraction - less than 10 percent - of the cases were caused by such complications (10). Fortunately, interests in finding alternative causes to cerebral palsy have spurred in the past few decades. In addition, biomedical research has brought great advancements to the diagnostic techniques used today, including brain imaging and modern gait analysis (1).

Prevalence

The recent prevalence of cerebral palsy is about 2 in 1000 babies (8). There are over 50,000 Canadians currently with cerebral palsy (8). In the U.S., about 10,000 babies develop cerebral palsy each year (9). The number of affected children and adults in the U.S. is approximately 500,000. This figure has risen slightly over the past 30 years, due to higher rates of survival of people with cerebral palsy through improved care (10).

Cause

In most cases, the cause of cerebral palsy is difficult to determine. Although large numbers of families and physicians question the possibilities of disturbance during a delivery, birth complications take the blame only 10% of the time. As a matter of fact, even the small premature infant has a better than 90 percent chance of not developing cerebral palsy (4). Conversely, some babies go through a straightforward pregnancy and delivery may be hit by CP "out of the blue(8). It has been settled that cerebral palsy comes from brain damage that can occur before, during, or shortly after birth. So the real issue is "How did the brain become damaged?" There are mainly two factors that contribute to this: 1) failure of the brain to develop properly, and 2) neurological damage to the child's developing brain (11). Generally speaking, the severity of CP symptoms depends on the type and timing of the injury. For instance, the longer an unborn child is deprived of oxygen, the greater extent of brain tissue damage occurs (11). A doctor should carefully review the child's medical history and conduct a variety of medical and neurological tests to determine the possible causes of cerebral palsy. Factors during pregnancy which may cause CP include (8):

Multiple births A damaged placenta which may interfere with fetal growth Infections Poor nutrition Exposure to toxic substance, including nicotine and alcohol Maternal diabetes, hyperthyroidism or high blood pressure Biochemical genetic disorders Chance malformations of the developing brain

Factors during labour which may cause CP include (8):

Premature delivery Abnormal positioning of the baby which makes delivery difficult Rupture of the amniotic membranes leading to fetal infection

CP can occur if a young child suffers brain damage due to (8):

Infection such as meningitis (Inflammation of the meninges of the brain and the spinal cord) Brain hemmorhages (bleeding) Head injury following falls, care accidents or abuse A lack of oxygen (asphyxia) due to accidents such as drowning Seizures

In addition, there are some high risk factors that suggest a possible onset of CP. For instance, small premature babies who does not cry in the first five minutes, who needs to be on a ventilator for over four weeks, and who has bleeding in his brain have the highest risk of developing cerebral palsy (4). Congenital malformations in systems such as the heart, kidneys, or spine could also indicate a high susceptibility to CP (4). Other risk factors include the following (11):

Mother 40 years or older

Mother 20 years or younger Father 20 years or younger African-American ethnicity. A first child or child born fifth or later in the family One of a pair of twins, especially if one twin dies Low birth weight, less than 3.5 pounds Premature infant, less than 37 weeks. Rh or ABO blood type incompatibility between mother and infant Infection of the mother with German measles or other virus in early pregnancy Attack by micro-organisms on the central nervous system of the infant.

It is important to clarify that risk factors are not the causes of cerebral palsy. They do not predict or imply the onset of the disorder. Their purpose is to alert the child's parents and physicians to be even more observant of the infant's development.

Common Symptoms Cerebral palsy is a movement disorder that involves poor muscle control such as difficulty in sucking, holding up the head, delay in rolling over, delay in walking or inability to walk, incoordination, muscle tightness, and muscle spasms6. Abnormal movements observed in patients with cerebral palsy could generally be divided into 6 types (6): 1) Spasticity. Tense, stiff, contracted muscles. 2) Ataxia. Poor sense of balance and impaired coordination. 3) Rigidity. Tense, stiff, contracted muscles that resist movement. This type of abnormal movement differs from spasticity based on other neurological findings. 4) Athetosis. Uncoordinated, writhing, or wormlike movements of the head, limbs, and eyes that occur without deliberate effort. 5) Dystonia. Unnatural and sustained postures of a body part, such as the hand, leg, or neck. 6) Tremor. Trembling or shaking. Many children with CP have a combination of the different symptoms, which may change from time to time. Some specific symptoms that could imply brain damage could sometimes be observed in an infant within the first few months after birth8:

Lethargy, or lack of alertness Irritability or fussiness Abnormal, high-pitched cry Trembling of the arms and legs Poor feeding abilities secondary to problems sucking and swallowing Low muscle tone Abnormal posture Seizures, staring spells, eye fluttering, body twitching Abnormal reflexes Muscle tone may change gradually from low tone to high tone; a baby may go from floppy to very stiff The child may hold his or her hand in tight fists There may be asymmetries of movement, that is, one side of the body may move more easily and freely than the other. The infant may feed poorly, with their tongue pushing food out of their mouth forcefully.

Cerebral palsy is sometimes associated with other conditions such as (8) (10):

Seizures Learning disabilities Hearing impairment Vision problems Growth problems Abnormal sensation and perception

Many children with cerebral palsy do not show clear signs of it right after birth, and symptoms may vary from child to child, with varying degree of severity. In addition, it's necessary to note that physical disabilities are not indications of the child's level of intelligence. Many people with CP have a normal life-expectancy.

Seizures In patients with cerebral palsy and seizures, disruptions of electrical charges in the brain can cause tonic-clonic seizures - where bursts of electricity spread throughout the brain and cause symptoms all over the body - or partial seizures - where disruption is confined to one part of the brain and symptoms are more specific (7). Many studies have been conducted regarding the prevalence of epilepsy in patients with cerebral palsy and mental retardation (MR). It was found that in children with CP alone, 10-32% developed epilepsy; and 10-29% developed epilepsy in children with only MR. However, up to 50% of children with both CP and MR developed epilepsy (5). The risk for epilepsy in these children with neurological handicaps remains elevated at least through the second decade of life (5). Some types of seizures are more likely than others to occur in those with cerebral palsy, these include infantile or juvenile spasms, or atonic or startle seizures (2). However, it is also possible for any other epileptic seizures to occur. Usually, when cerebral palsy and epilepsy are combined in a patient, intellectual stagnation or decline may arise (2). It is important to recognize in some children the seizure types are non-epileptic. For example, in sleeping infants with cerebral palsy, repetitive very brief tonic contractions may be described as 'sleep starts', which are nonepileptic. In such circumstances, no additional aggressive anti-epileptic therapy is required (3). Other facts:

Between 15 to 60 percent of patients with CP eventually develop seizures (7). In a study by Trevathan et al., 52% of patients with mental retardation and epilepsy also had CP, as opposed to 6% of those without (7). A study by Goulden et al., reported that the cumulative risk for epilepsy was 38% by age of 22 in patients with both cerebral palsy and mental retardation but that 39% of patients in their series no longer had active epilepsy (7). Epilepsy is 5 times more prevalent in hemiplegic CP patients with mental retardation than in those with normal intellect.

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References: 1. About Cerebral Palsy - Brief History of Cerebral Palsy; Retrieved on May 27, 2003, from 4MyChild;http://www.cerebralpalsy.org/history.htm 2. Engel, J., Jr and Pedley, T. A.; Epilepsy: A Comprehensive Textbook; Lippincott-Raven Publishers, Philadelphia, 1997. P. 2571-2573 3. Guerrini, Renzo; Aicardi, Jean; Andermann, Frederick; and Hallett, Mark; Epilepsy and Movement Disorders; Cambridge University Press, 2002. P. 353-357 4. Cerebral Palsy Program - What is this condition; Retrieved on May 28, 2003, from The Alfred I. Dupont Institute;http://gait.aidi.udel.edu/res695/homepage/pd_ortho/clinics/c_palsy/cpweb.htm 5. Kotagal, Prakash and Luders, Hans O.; The Epilepsies: Etiologies and Prevention; Academic Press: 1999, California; P. 5 6. Devinsky, Orrin; A Guide to Understanding and Living with Epilepsy; F. A. Davis Company: 1994, Philadelphia; P. 221-223 7. Aicardi, Jean; Epilepsy in Children (second edition); Lippincott-Raven Publishers: 1996, Philadelphia; P. 350-351 8. Cerebral Palsy Q&A; Retrieved on May 27, 2003, from Cerebral Palsy Canada; http://www.cerebralpalsycanada.com/Q&A.htm 9. About Cerebral Palsy; Retrieved on May 28, 2003, from National Center on Birth Defects and Developmental Disabilities;http://www.cdc.gov/ncbddd/dd/ddcp.htm 10. Cerebral Palsy; Retrieved on May 29, 2003, from Healthlink - Medical College of Wisconsin;http://healthlink.mcw.edu/article/931225858.html 11. Types of Cerebral Palsy; Retrieved on May 29, 2003, from Cerebral Palsy - Ask the Doctor; http://www.about-cerebral-palsy.org/definition/spastic-athetoid-ataxic.html