WHAT IS CEREBRAL PALSY?
Cerebral Palsy is a general term describing a group of permanent disorders of movement and posture caused by injury to the brain or a disturbance of brain development during the foetal, neonatal or early childhood period.
The brain injury or developmental disturbance that causes Cerebral Palsy is non-progressive.
This does not, however, mean that the clinical and functional condition remains unchanged throughout life.
As the child grows and enters adult life, muscle strength, spasticity or dystonia, mobility, gait, balance, upper-limb function, pain, fatigue and independence in everyday activities may change.
Cerebral Palsy is therefore a lifelong condition.
Medical follow-up, treatment and Rehabilitation are relevant to both children and adults.
RELATIONSHIP BETWEEN BRAIN INJURY AND THE NEUROLOGICAL PRESENTATION
The neurological and functional presentation depends on the timing of the injury to the developing brain, as well as on its location and extent.
For example, injury to the periventricular white matter, particularly in children born prematurely, is frequently associated with spastic Cerebral Palsy predominantly affecting the lower limbs.
Unilateral brain lesions may mainly cause motor difficulties on the opposite side of the body, while lesions involving the basal ganglia and thalamus are more commonly associated with dyskinetic forms, in which dystonia and involuntary movements may predominate.
Injury to, or developmental abnormalities of, the cerebellum may be associated with ataxia and disturbances of balance and coordination.
These associations are not absolute rules. The same anatomical lesion does not always produce the same clinical presentation, because the extent of the injury, the neural networks affected and the capacity of the developing brain to reorganise also play important roles.
HOW DOES CEREBRAL PALSY PRESENT?
The clinical presentation varies considerably from one person to another.
The motor disorder may predominantly affect one side of the body or both sides and can range from relatively minor difficulty with movement to severe limitation of mobility and independence.
TYPES OF CEREBRAL PALSY
According to the predominant type of motor disorder, Cerebral Palsy may be:
- Spastic, the most common form, accounting for approximately 80% of cases, with increased muscle tone and difficulty controlling movement.
- Dyskinetic, in which dystonia and involuntary movements predominate.
- Ataxic, with problems of balance and coordination.
- Mixed, when different motor patterns coexist.
The diagnosis, however, does not by itself describe what a patient with Cerebral Palsy can actually do.
What matters is functional ability, namely how the patient sits, stands, moves and walks; how they use their hands; how they communicate; how they eat and swallow; and the extent to which they can participate in everyday life.
HOW IS FUNCTIONAL ABILITY DESCRIBED?
International classification systems are used to describe a child’s functional ability clearly and consistently:
- The GMFCS describes gross motor function and mobility.
- The MACS describes how the hands are used in everyday activities.
- The CFCS describes the effectiveness of communication.
- The EDACS describes the safety and efficiency of eating and drinking.
These systems do not describe the child as a whole and do not, by themselves, determine what the child may ultimately achieve.
They do, however, provide a common language for describing functional ability and supporting therapeutic planning.
Progress is assessed using appropriate outcome measures and according to individualised therapeutic goals.
HOW IS CEREBRAL PALSY DIAGNOSED?
Cerebral Palsy is a clinical diagnosis. There is no single laboratory or imaging investigation that can confirm or exclude it.
Today, particularly in infants at high risk, Cerebral Palsy can be identified much earlier than in the past.
Neurological examination, systematic assessment of motor development and, when indicated, magnetic resonance imaging of the brain can, in combination, allow early identification of infants who have Cerebral Palsy or are at high risk of developing it.
Specialist assessment may include internationally recognised tools such as General Movements Assessment during the first months of life and the Hammersmith Infant Neurological Examination – HINE.
When there are clear indications, it is not appropriate simply to adopt a watch-and-wait approach and passively observe how the child’s condition develops.
Early recognition allows appropriate therapeutic intervention to begin early.
Because Cerebral Palsy results from a non-progressive injury to, or developmental disturbance of, the brain, loss of previously acquired skills, progressive neurological deterioration or other unexpected findings require reassessment of the diagnosis and investigation for another neurological disorder.
When the cause of Cerebral Palsy is unclear, or when findings on clinical examination or imaging do not fit the usual presentation, genetic testing and, in selected cases, metabolic investigations may be required to investigate the underlying cause and exclude other neurological disorders.
WHAT PROBLEMS MAY ACCOMPANY CEREBRAL PALSY?
Cerebral Palsy primarily affects movement and posture, but it may be accompanied by additional functional difficulties that vary considerably from one patient to another.
MOVEMENT, POSTURE AND GAIT
There may be muscle weakness, spasticity or dystonia, impaired control of voluntary movement, disturbances of balance and coordination, and difficulty maintaining a sitting or standing position, transferring and walking.
As the child grows, shortening of muscles and tendons, contractures and deformities of the limbs or spine may develop.
HIPS AND THE MUSCULOSKELETAL SYSTEM
Children with Cerebral Palsy are at increased risk of progressive hip displacement, particularly when motor function is more severely limited.
Hip displacement may initially progress without obvious symptoms.
For this reason, systematic hip surveillance is required, with clinical assessment and, according to the level of risk, radiological monitoring.
Radiological surveillance is based on a standardised anteroposterior pelvic radiograph and assessment of the Migration Percentage – MP.
The frequency of surveillance is determined mainly by age, GMFCS level, which describes gross motor function and mobility, and previous clinical and radiological findings.
Early recognition of hip displacement is particularly important because it allows intervention before pain, severe deformity and greater difficulty with sitting, walking and self-care develop.
BONE HEALTH
Children and adults with severe limitation of mobility may be at increased risk of reduced bone mineral density and fractures even after minor trauma.
The risk is greater when additional factors are present, such as feeding or swallowing difficulties, inadequate nutrition, low body weight, vitamin D deficiency, previous fracture or long-term use of certain antiepileptic medicines.
When such risk factors are present, nutrition, calcium and vitamin D intake, the ability to move and weight-bear through the lower limbs, and fracture history are assessed and, when indicated, further specialist laboratory and imaging investigations are undertaken.
UPPER LIMBS AND HANDS
Cerebral Palsy may affect grasp, fine motor control, coordination of both hands and activities such as eating, dressing, writing and using electronic devices.
SPEECH AND COMMUNICATION
Cerebral Palsy may affect the coordination of breathing with speech, phonation and articulation.
Difficulty speaking does not necessarily mean difficulty understanding or impairment of cognitive function.
When speech does not allow effective communication, Augmentative and Alternative Communication – AAC may be used, ranging from simple pictures and communication boards to advanced electronic systems.
SWALLOWING AND FEEDING
Difficulty controlling the muscles of the mouth, tongue and pharynx may cause problems with chewing and swallowing.
Coughing or choking during meals, prolonged mealtimes, inadequate food or fluid intake and recurrent respiratory infections may be signs of dysphagia.
Some patients may experience aspiration without an obvious cough.
Sialorrhoea, particularly when saliva passes posteriorly towards the pharynx, may also be associated with impaired swallowing and an increased risk of aspiration.
For this reason, when there are signs of swallowing impairment, specialist assessment is required.
RESPIRATORY HEALTH
Some people with Cerebral Palsy, particularly those with severe motor limitation, may be at increased risk of respiratory problems.
Dysphagia and aspiration, an ineffective cough and difficulty clearing bronchial secretions, reduced mobility and deformities of the chest or spine may compromise respiratory function.
Recurrent respiratory infections, difficulty clearing secretions or any change in respiratory status should be assessed promptly and managed within a comprehensive multidisciplinary approach.
BLADDER AND BOWEL
Cerebral Palsy may be associated with disorders of bladder and bowel function.
Urinary symptoms may include urgency, frequency, urinary incontinence, difficulty initiating or completing urination and, in some people, incomplete bladder emptying or urinary retention.
Constipation is also common and may be aggravated by reduced mobility, diet, inadequate fluid intake and certain medicines.
These problems should be recognised and treated because they can significantly affect comfort, sleep, independence and quality of everyday life.
HIGHER COGNITIVE FUNCTIONS, EMOTION AND BEHAVIOUR
Cerebral Palsy may be accompanied by difficulties with attention, memory, learning, information-processing speed and executive functions, although these are not present in everyone.
The severity of the motor disorder does not, by itself, determine cognitive ability.
Severe difficulties with movement or speech may lead to the child’s or adult’s true abilities being incorrectly underestimated.
Anxiety, low mood, irritability or difficulties with behaviour and social interaction may also occur.
OTHER PROBLEMS
Epilepsy, visual or hearing problems, pain, sleep disorders and nutritional or respiratory problems may also coexist.
THE CHILD WITH CEREBRAL PALSY
Early childhood is a period of considerable neuroplasticity, during which the developing brain has a particularly strong capacity to organise and reorganise its neural networks.
Modern early intervention is based on active and repeated practice of functional activities, with specific goals adapted to the child’s age, abilities and real needs.
The aim is not simply to “normalise” movement. The aim is for the child to be able to sit, stand, move, walk when this is achievable, use their hands, communicate, eat, play, learn and participate as fully as possible in everyday life.
THE ADULT WITH CEREBRAL PALSY
Cerebral Palsy does not cease to exist when a child reaches adulthood.
Medical follow-up and Rehabilitation should continue after the transition to adulthood, with adjustment to each patient’s functional needs and goals.
Although the original brain injury does not progress, over the years there may be pain, fatigue, reduced endurance, increasing difficulty walking or loss of functional abilities that were previously possible.
Any significant new change should be investigated and not automatically attributed to Cerebral Palsy or ageing.
In adults, Rehabilitation aims to maintain or improve mobility, strength, endurance and independence, manage pain and disorders of muscle tone, and support participation in family, social and working life.
WHAT ARE HYPERTONIA, SPASTICITY AND DYSTONIA?
In Cerebral Palsy, the brain’s control of movement and muscle tone is disturbed.
Muscle tone is the normal resting tension within muscles and contributes to maintaining posture and readiness for movement.
Hypertonia is a pathological increase in muscle tone, expressed as increased resistance when a part of the body is moved passively.
Spasticity and dystonia are two different disorders frequently encountered in Cerebral Palsy.
Spasticity is a form of hypertonia, whereas dystonia is a movement disorder and is not always characterised by increased muscle tone.
Spasticity is the most common form of hypertonia in Cerebral Palsy. During passive movement of a limb, resistance is increased and becomes greater as the speed of movement increases.
Dystonia is a movement disorder characterised by sustained or intermittent muscle contractions causing involuntary, often repetitive movements, abnormal postures, or both. It is frequently triggered or aggravated by voluntary effort.
Muscle tone in dystonia may vary and is not always increased. When muscle contractions are sustained, dystonic hypertonia with rigid postures may occur.
Dystonia is characteristic of dyskinetic Cerebral Palsy but may also coexist with the spastic form.
In simple terms, in spasticity, increased muscle tone is a key feature and resistance increases as the limb is moved more rapidly. In dystonia, involuntary and often fluctuating movements or postures predominate, while muscle tone may increase and decrease.
HOW IS SPASTICITY MANAGED?
The presence of spasticity does not, by itself, constitute an indication for therapeutic intervention.
The need for treatment is determined by whether spasticity causes pain, restricts movement or function, makes care more difficult or contributes to the development of contractures and deformities.
In some people, a degree of increased muscle tone may assist standing or transfers. Excessive reduction of tone may therefore worsen function.
Spasticity is always assessed in relation to the patient’s functional ability and specific therapeutic goals.
Management may, according to individual needs, include physiotherapy, appropriate positioning and mobilisation, the use of suitable aids and orthoses, specialised aquatic therapy in the Hydrotherapy Pool and medication.
In selected patients with focal spasticity, botulinum toxin type A may be injected into selected muscles as part of the overall Rehabilitation programme.
In patients with severe generalised spasticity that continues to cause significant functional problems despite conservative treatment, continuous intrathecal baclofen delivered through an implanted pump may be considered at a specialist centre.
In carefully selected patients with significant spasticity of the lower limbs, Selective Dorsal Rhizotomy – SDR may also be considered following specialist multidisciplinary assessment and with a structured postoperative Rehabilitation programme.
HOW IS DYSTONIA MANAGED?
Dystonia must be recognised and assessed separately from spasticity, because the two disorders are not always managed in the same way.
The need for treatment depends on the extent to which dystonia affects movement, posture, sitting and sleep, causes pain or makes care and everyday function more difficult.
Management is individualised and may include Rehabilitation, medication and, in selected cases, botulinum toxin type A injections into selected muscles as part of the overall Rehabilitation programme.
In severe dystonia that remains painful and functionally limiting despite appropriate treatment, assessment at a specialist centre may be required for other interventions, such as treatment with an implanted baclofen pump or, in carefully selected patients, Deep Brain Stimulation – DBS.
HOW DO WE MANAGE CEREBRAL PALSY AT ANAPLASI?
At ANAPLASI, the Multidisciplinary Rehabilitation Team assesses neurological and functional status and develops an individual Rehabilitation programme for each child or adult.
Assessment focuses on the child’s or adult’s actual abilities in everyday life and on the factors that most significantly limit function.
Specific and measurable therapeutic goals are established and progress is reassessed systematically.
Information, education and guidance are also provided to the child or adult, according to age and ability, and to the family, on the Rehabilitation process and the safe management of functional difficulties and needs that may change with growth and age.
MOVEMENT, POSTURE AND GAIT
Physiotherapy focuses on active movement, muscle strengthening, balance, trunk control, transfers, standing and walking.
Depending on individual needs, orthoses, mobility aids, specialised standing and gait exercises and specialised aquatic therapy in the Hydrotherapy Pool may be used.
ROBOTIC EXOSKELETON AND GAIT RETRAINING
In appropriately selected patients, a robotic exoskeleton may be used for standing, weight transfer and controlled, repetitive gait training.
The level of assistance is adjusted according to the patient’s strength and motor control, enabling the greatest possible degree of active participation.
Robotic technology is an adjunct and does not replace active therapeutic exercise.
UPPER LIMBS AND HAND FUNCTION
Occupational therapy focuses on grasp, fine motor control, coordination of both hands and, above all, the ability to use the hand in real-life activities.
In children with unilateral involvement, when indicated, intensive training of the more affected upper limb may be applied, with temporary restriction of the use of the less affected hand, or intensive training in the coordinated use of both hands.
ROBOTIC UPPER-LIMB TRAINING AND ROBOTIC GLOVE
At ANAPLASI, a robotic glove may also be used in combination with functional and interactive exercises, bimanual training and visual feedback.
Using a specialised system, movement of the less affected hand can trigger corresponding movement of the more affected hand, allowing synchronised bimanual training.
MANAGEMENT OF SPASTICITY
At ANAPLASI, spasticity management forms part of the overall Rehabilitation programme and is always linked to specific functional goals.
In selected patients with focal spasticity, botulinum toxin type A may be injected under electromyographic guidance, allowing treatment to be directed precisely to the selected muscles.
Depending on individual needs and therapeutic goals, treatment is followed by physiotherapy, occupational therapy and, when indicated, the use of appropriate aids and orthoses.
At the same time, factors that may increase muscle tone are investigated, including pain, constipation, urological problems, infections or inappropriate positioning.
SPEECH AND COMMUNICATION
Speech and language assessment and intervention include coordination of breathing with speech, phonation, articulation and the ability to communicate functionally.
When speech does not allow effective communication, appropriate Augmentative and Alternative Communication systems are selected.
SWALLOWING AND NUTRITION
When swallowing is impaired, specialist assessment and treatment are provided.
At the ANAPLASI Dysphagia Unit, when clinically indicated, Flexible Endoscopic Evaluation of Swallowing – FEES is performed.
The examination uses a thin, flexible endoscope introduced through the nose, allowing direct assessment of swallowing function, secretion management and airway protection.
This enables assessment of the safety and efficiency of swallowing, and the findings are used to guide the individualised planning of treatment, feeding and hydration.
When required, dietetic assessment and follow-up are also provided to support adequate and safe nutrition and hydration as far as possible.
MANAGEMENT OF SIALORRHOEA (DROOLING)
Sialorrhoea is common in Cerebral Palsy and is usually caused by difficulty controlling and swallowing saliva rather than by excessive saliva production.
It may be anterior, when saliva escapes from the mouth, or posterior, when saliva passes towards the pharynx and may increase the risk of aspiration and respiratory complications.
Management is individualised following assessment of swallowing, oromotor control, posture and factors that may aggravate the problem, such as gastro-oesophageal reflux, certain medicines and problems within the oral cavity.
Depending on severity and the patient’s needs, treatment may include therapeutic interventions to improve oromotor control and swallowing, medication to reduce saliva production and, in selected patients, botulinum toxin type A injections into the salivary glands, usually under ultrasound guidance.
Botulinum toxin injections into the salivary glands require careful patient selection and close monitoring because, in rare cases, they may cause or worsen difficulties with chewing or swallowing and increase the risk of aspiration.
In severe cases that do not respond adequately to conservative treatment and medication, specialist assessment for surgical management may be required. The choice of procedure is individualised according to the type of sialorrhoea and the safety of swallowing.
RESPIRATORY PHYSIOTHERAPY
For inpatients, respiratory physiotherapy is provided from the time of admission, with the aim of maintaining and improving respiratory function, promoting better lung expansion and facilitating the mobilisation and clearance of bronchial secretions.
BLADDER AND BOWEL CARE
When bladder or bowel problems are present, symptoms and factors that may aggravate them are assessed systematically.
Depending on the clinical presentation, assessment of bladder function may include evaluation of urination and the post-void residual urine volume and, when there are specific indications, urodynamic testing.
Urodynamic testing allows objective assessment of how the bladder stores and empties urine, as well as the pressures generated during these phases.
It is not required in every person with Cerebral Palsy, but is used when symptoms or findings suggest significant lower urinary tract dysfunction.
Bowel function, particularly constipation, is also assessed and managed with an individualised programme that may include modification of diet and fluid intake, a bowel-emptying programme and, when required, appropriate medication.
The aim is safe and effective bladder and bowel function, prevention of complications and the greatest possible independence in everyday life.
HIGHER COGNITIVE FUNCTIONS, EMOTION AND BEHAVIOUR
When required, neuropsychological assessment evaluates attention, memory, learning, information-processing speed and executive functions – such as planning, organisation, cognitive flexibility and problem-solving – as well as other cognitive abilities.
This assessment helps determine the patient’s true cognitive abilities without confusing them with limitations caused by difficulties in movement, speech or communication.
When necessary, emotional state, behaviour and social interaction are also assessed, taking into account factors such as pain, sleep disturbance, communication difficulties and reduced independence.
Based on the findings, interventions may be designed to improve higher cognitive functions, together with psychological support for the child or adult and support for the family.
DIGITAL COGNITIVE REHABILITATION SYSTEM RehaCom
At ANAPLASI, when indicated, the cognitive Rehabilitation programme is supported by the specialised digital cognitive Rehabilitation system RehaCom.
Specially designed exercises are used to train functions such as attention, memory, information-processing speed, executive functions and visuospatial abilities.
The level of difficulty is adjusted to each patient’s needs and performance, allowing individualised and systematic training and monitoring of progress.
RehaCom is used as part of the overall Rehabilitation programme and does not replace neuropsychological assessment and individualised therapeutic intervention.
INDEPENDENCE IN EVERYDAY LIFE
Improvement in an isolated movement has real value when that improvement can be used in everyday life.
For this reason, Rehabilitation includes, according to individual needs, training in mobility and transfers, eating, dressing and self-care, using the toilet, writing and using electronic devices, and moving around the home and in the community.
When required, appropriate walking aids, wheelchairs, seating systems, orthoses and other assistive technologies are selected.
CREATIVE ACTIVITIES, SPORT AND SOCIAL PARTICIPATION
At ANAPLASI, creative activities, sport and social participation complement the Rehabilitation programme and are adapted to each patient’s abilities, interests and therapeutic goals.
Activities include painting, arts and crafts, cooking, group games, music and theatre activities, sport, as well as participation in cultural and social activities both within and outside ANAPLASI.
These activities provide opportunities for active participation, social interaction, taking initiative and using the patient’s functional abilities in everyday life.
CARE OF THE PATIENT WITH SEVERE FUNCTIONAL LIMITATION
In people with severe motor limitation, particular importance is placed on appropriate positioning, systematic changes of position, skin protection, safe transfers and prevention of complications associated with prolonged immobility.
In the Inpatient Rehabilitation Unit at ANAPLASI, advanced therapeutic beds are used, allowing controlled and programmed changes of position, alternating lateral rotation, specialised pressure management, a full-chair position and, where indicated, gradual progression towards a more upright position.
These functions contribute to both the prevention and management of pressure ulcers.
The beds also provide percussion and vibration functions which, when clinically indicated, may form part of the patient’s respiratory care.
These features are used as part of the overall medical, nursing and therapeutic management and do not replace active mobilisation or the structured Rehabilitation programme.
In patients with a high level of physical dependence, electrically powered patient hoists may also be used for safer transfers from the bed to the wheelchair and to treatment areas.
SEXUAL FUNCTION AND REHABILITATION
During adolescence and adult life, Cerebral Palsy may affect sexual life through motor limitations, spasticity or dystonia, pain, fatigue, bladder and bowel disorders, communication difficulties and psychological or social factors.
When a relevant problem is present and the person wishes to address it, sexual rehabilitation may include individualised assessment, management of factors affecting sexual function, practical guidance, counselling and psychological support and, where required, specialist medical treatment.
The patient’s partner may also be involved where this is helpful and the patient wishes them to participate.
HOW IS REHABILITATION PROVIDED?
Rehabilitation may be provided through Inpatient Rehabilitation, Day Rehabilitation or Rehabilitation at Home, according to age, functional status, the severity of the problems and the needs of the child or adult.
WHAT IS THE AIM OF THE REHABILITATION PROGRAMMES?
At ANAPLASI, Rehabilitation is not limited to reducing spasticity, increasing muscle strength or improving isolated movements.
For the child, the aim is to develop their true potential as fully as possible, acquire new skills and participate actively in family, school and social life.
For the adult, the aim is to maintain or improve functional ability, address problems that emerge over time and preserve the greatest possible independence.
At ANAPLASI, effective Rehabilitation brings together movement, higher cognitive functions, communication and emotional well-being to promote functional ability, independence and active participation in everyday, family, school, social and working life.
