When the legs freeze – how does the symptom “Freezing of Gait” manifest itself?

Parkinson’s disease is a neurodegenerative disease that progresses very slowly. In the context of Parkinson’s disease, a number of symptoms may occur, ranging from tremors and motor symptoms to rigidity of certain body parts. One of the most common symptoms is the so-called freezing, in which the patient’s legs suddenly freeze, and they can no longer put one foot in front of the other. In this blog post, we show how this gait impairment can be positively affected through behavioral changes, regular practice, and exercise.

When the legs freeze – the motor symptom “Freezing of Gait”

If you are a person affected by it, you may already know: You walk around your home and want to turn into another room. Suddenly, however, nothing works at all. The steps become smaller and smaller, you finally come to a complete standstill and suddenly can’t move even an inch forward. Some patients also describe that although they are still able to take small steps in place, they still cannot move from the spot. A feeling of being frozen occurs. This state can last for different lengths of time – from a few minutes up to half an hour or even longer.

Most often, this symptom occurs when affected persons start walking (like a kind of start inhibition at the gait initiation), make turns, pass through narrow passages like doors, carry out dual tasks (like talking while walking), or try to reach a specific destination. In the literature, this symptom is called “Freezing of Gait (FOG)” and, along with postural instability, is one of the most noticeable signs of Parkinson’s disease.

Management of FOG through attention training and other exercises

Patients, therapists, and studies include and describe various exercises and methods to influence freezing of gait. These include directing your attention to your walking. Even if the symptom is not yet noticeable, you should consciously draw attention to your own steps. This can delay, or ideally even prevent, FOG.

If FOG has already set in, there are also measures and options to counteract freezing at the moment of immobility. There are also exercises that, if done regularly, can gradually reduce the frequency of freezing attacks.

Attention during walking

It all starts with introspection – perhaps the critical locations in the house are already known, or there are familiar paths where FOG tends to occur? Many patients also report certain times of day when FOG is more likely to occur, or they have been able to identify a correlation with their medication regimen. All of these things – once they are known – can improve FOG management and better prepare you for FOG each time.

If you feel that you are about to experience a freezing episode and may have difficulty walking, try to take larger and more rhythmic steps and try to lift your knees higher than normal. Especially when turning in a different direction, make sure that the steps are executed very specifically. By attentively and consciously setting each step, FOG can thus be reduced.

Regular gait training

Patients with Parkinson’s disease report – and there is also strong evidence in the literature – that gait training can positively influence FOG. We would like to present some of these suggestions and show you how you can use them to design your training and to improve your gait pattern.

Define a specific walking distance and try walking it in different ways:

• Variant 1: Take large steps forward and then backward.
• Variant 2: When walking, make sure the track is evenly spaced.
• Variant 3: Walk and raise knees high with each step.
• Variant 4: Take large sideways steps in both directions.

You can increase the influence of the exercises by also ensuring your arms move evenly while walking; that is, the arms swing back and forth in opposite directions – similar to two pendulums.

“Cueing”- giving a clear impulse

“Cueing” refers to an impulse that helps to stay in gait rhythm or to break free from the feeling of being “frozen in place.” This stimulus can’t be only auditory or visual, but also tactile. It can be set either by yourself or with the use of various tools.

Auditory cueing

Set an impulse in the above exercises by…

… counting along loudly & rhythmically.

… singing a rhythmic song.

Make use of various tools for auditory cueing. You can put on headphones and have the song or rhythm played to you. Try different methods and find out whether counting yourself or using headphones is more effective. Some patients even manage to overcome immobility by counting out loud.

Visual cueing

In addition to acoustic stimuli, there is also visual cueing, in which a visual stimulus is given. In practice, it looks like this:

Variant 1: Select and define distances on your walking route that you want to reach.

Variant 2: Depending on the possibility, lines can be marked on the floor with the help of adhesive tape, across which you want to step each time.

Variant 3: Another option is special adaptations you can put on your walking sticks that project a laser strip in front of your feet on the floor, across which you want to step. It is best to ask your therapist, who can help you obtain one.

Tactile cueing

Tactile cueing involves a touch stimulus in the form of a light rhythmic tap on the thighs while walking – this can positively influence the flow of movement. There are also devices that can be attached to the legs that prompt walking via a vibration pulse.

A diagnosis of Parkinson’s disease and the symptoms that accompany it can often severely limit patients’ lives. However, proper exercises and a regular exercise routine can help regain confidence and self-determination in everyday life, thus improving quality of life.

Literature:

DGNR – Deutsche Gesellschaft für Neurorehabilitation e.V. (n.d.). 2017, from http://www.dgnr.de/

Ginis, P., Nackaerts, E., Nieuwboer, A., & Heremans, E. (2018). Cueing for people with Parkinson’s disease with freezing of gait: A narrative review of the state-of-theart and novel perspectives. Annals of Physical and Rehabilitation Medicine, 61(6), 407–413.

Gómez-González, J., Martín-Cashttps://doi.org/10.1016/j.rehab.2017.08.002as, P., & Cano-de-la-Cuerda, R. (2019). Effects of auditory cues on gait initiation and turning in patients with Parkinson’s disease. Neurología (English Edition), 34(6), 396–407.

Nieuwboer, A., Kwakkel, G., Rochester, L., Jones, D., van Wegen, E., Willems, A. M., Chavret, F., Hetherington, V., Baker, K., & Lim, I. (2007). Cueing training in the home improves gait-related mobility in Parkinson’s disease: The RESCUE trial. Journal of Neurology, Neurosurgery & Psychiatry, 78(2), 134–140.

After having a stroke, patients often experience impaired walking ability and can only walk in their own home. Approximately 70 % of those who retain the ability to walk cannot move at normal speed. Stroke survivors who want to restore their walking skills and increase their cardiovascular exercise can work with a robotic gait training system as part of their stroke rehabilitation.

Regaining their ability to walk is one of the most common goals for stroke survivors. Improved walking can impact their long-term survival after a stroke as well as improve many other areas of a patient’s health, including:

• Functional movement
• Independence
• Overall health and well-being

Having confidence in your actions improves quality of life after a stroke

Self-efficacy describes the confidence to master difficult situations independently.

Patients with strong self-efficacy achieve better progress in rehabilitation. They approach the changes in their circumstances objectively, positively, and calmly. This facilitates the interaction with family members, doctors, and therapists.

Read our blog article and learn how optimism and confidence can be cultivated. The goal is to regain control over your life and circumstances after a stroke.

Scientific studies on self-efficacy after a stroke

Patients with more self-confidence make much more progress during rehabilitation than those with low self-confidence. They approach the changes in their circumstances with a positive and calm mindset.

In addition to physical progress, there are potential beneficial effects on the patient’s mental health and quality of life.

In many cases, strokes are the result of high blood pressure. Good self-efficacy can lower blood pressure, even after a stroke has already happened.

How does self-confidence suffer after a stroke?

Daily life can be a challenge for stroke survivors. Even the simplest everyday tasks, such as getting washed and dressed, can be problematic or impossible due to paralysis. Trying without succeeding can lead to a lack of self-confidence over time.

Also, the other way around is possible: Patients may succeed with certain tasks, but still lack a sense of self-confidence. For example, a patient manages to walk several meters using a cane, but still thinks he or she is not quite ready yet to walk alone.

Both situations are an example of limited self-efficacy. Several studies have shown that certain measures can help to regain confidence after a stroke.

Setting goals to increase self-efficacy

“Only those who know the destination will find their way.” – Laozi

Goals help us to create a clear and positive idea of the future. They help us to determine what is needed in order to achieve what we desire. Having a clear plan in your mind can make it easier to handle difficulties on the path towards that goal.

It is important to keep your goals realistic when you want to improve self-confidence. Discuss with your therapist what the next realistic goal might look like. The goal should be very precisely defined and may only contain some aspects of a bigger task.

Example of a goal after a stroke:

Main goal

I can manage personal hygiene independently.

Subgoals

I can stand safely and freely.
I can brush my teeth independently.
I can go in and out of the shower safely.

The more realistic the goal, the higher the chance of achieving it. Every goal you achieve will improve your self-confidence. Talk to your family members and therapists about specific and realistic goals to make your daily life more independent.

Exchange and observation during rehabilitation

Every patient develops their own solution strategies for everyday challenges. Patients can exchange ideas, motivate each other and work towards goals together. Simply observing other patients with similar symptoms can help you find answers during your rehabilitation.

Therapists must deliberately select group size and the group members’ capabilities when arranging group therapy. Ideally, they are small groups of patients with comparable limitations.

Personal attitude in rehabilitation

Symptoms such as despondence, lack of motivation, loneliness, or depression are common long-term effects of a stroke. They may affect the patient’s attitude towards the condition and rehabilitation. A positive attitude can reduce physical and mental symptoms and make treatment more effective.

When having difficulties with motivation or finding the energy to do things, talking to your doctor, therapist or family members can be helpful. Sometimes, even just voicing the difficulties is beneficial.

Self-management programs following a stroke

The goal of self-management programs is to support patients in finding solutions for mastering everyday life challenges as independently as possible. Thus, these programs can boost the self-confidence of the patients. Therapists in both inpatient and outpatient settings can utilize self-management program techniques.

A core element of self-management programs is educating the patient concerning their condition and options for rehabilitation. Therapists enable self-help, and only provide enough support to allow the patient to find his or her own solutions.

Author: Hannes Aftenberger

Sources:

Positive Health Beliefs and Blood Pressure Reduction in the DESERVE Study, 2020

Self management programmes for quality of life in people with stroke, 2016

Self-efficacy and its influence on recovery of patients with stroke: a systematic review, 2011

Nedbal, A. (2011). Selbstmanagement nach Schlaganfall—Stark für den Alltag. physiopraxis, 2011; 9(4): 24-26.

Many patients with a neurological condition or injury may benefit from rehabilitation to improve their daily activities. Conditions that can benefit from rehabilitation include stroke, multiple sclerosis (MS), cerebral palsy, spinal cord injury (SCI), or traumatic brain injury (TBI).

A multidisciplinary rehabilitation team includes many skilled health professionals in different areas of expertise – all focused on helping patients get better.

What is a multidisciplinary team?

Like the saying “two heads are better than one,” a multidisciplinary team brings together several professionals from different areas of study. Their collective knowledge improves patient outcomes. For example, a nurse and a physical therapist have professional medical training in different disciplines. When they work together, they combine their distinct perspectives and expertise.

Combining different approaches during rehabilitation can lead to better results. Various disciplines promote each other. Additionally, every patient has different preferences and may prefer one discipline over the other.

Research has shown that stroke survivors who received care from a multidisciplinary team were more likely to live independently at home one year after the event.

Every team member has a role to play

Team members on a multidisciplinary neurorehabilitation team might include physicians; occupational, physical or speech therapists; nurses and behavioral health therapists.

• Physicians: Doctors on the team may specialize in physical medicine, rehabilitation, neurology or neurosurgery. Their extra training and experience contribute to treating a patient’s specific condition. In addition, physicians can manage care and recovery, recommend the course of treatment and prescribe medications.
• Physical, occupational and speech therapists: These therapists use physical and mental activities to help patients overcome their limitations and promote independence. While these different therapies often work together, they have their own areas of focus. For example, physical therapy focuses on reducing pain, building strength and increasing range of motion and functional mobility. Occupational therapy helps patients perform the activities of daily living, such as getting dressed or taking a shower. Speech language pathologists work to improve a patient’s ability to speak, eat and swallow. Speech therapy can especially help those affected by Aphasia.
• Nurses: Nurses regularly work with patients in many ways throughout rehabilitation. They play a major role in educating patients about their neurorehabilitation and health. Depending on the severity of a patient’s condition, a nurse may make regular visits to their home or provide 24/7 care. Some nurses act as care managers who help patients with ongoing care for a chronic condition.
• Behavioral health therapists: A neurological condition or injury can abruptly change a patient’s life. A behavioral health therapist can help patients cope with and work through those changes and help manage psychological problems that can arise after a brain injury. These professionals may be counselors, psychologists or psychiatrists.

Sources:

Rehabilitation for people with multiple sclerosis: an overview of Cochrane reviews (2019)

Psychological and emotional needs, assessment and support post-stroke: a multi-perspective qualitative study (2016)

Improving post-stroke recovery: The benefits of a multidisciplinary health care team (2015)

Benefits of occupational therapy in stroke rehabilitation (2014)

Life after a stroke is often different, both for patients and their families. After a stroke, many patients experience physical changes. They may not be able to feel or move one side of the body or have trouble with balance or coordination.

A lot of rehabilitation therapies focus on regaining physical abilities. However, a stroke also can cause a breakdown in cognitive skills.

What is stroke cognitive therapy?

Cognitive impairment frequently occurs in stroke survivors. Cognitive functions include mental skills, such as solving problems, remembering information and thinking clearly.

Fortunately, when a stroke damages the brain, the brain begins to heal itself. Neuroscientists refer to this feature as plasticity.

Plasticity means the brain can alter its structure and function. With regular, repeated brain stimulation, stroke patients can retrain their brains and possibly relearn abilities.

Cognitive therapy focuses on techniques that help improve a person’s thinking abilities. During cognitive rehabilitation, it’s common to work with a trained professional, such as an occupational therapist. There are many different methods and approaches for regaining cognitive function after stroke. The key is finding activities that you enjoy.

Brain exercises for stroke recovery

A big part of improving the brain’s cognitive function is putting it to work over and over again. Rehabilitation therapy with a professional is helpful. You can also do many easy activities at home to increase your brain function.

Play a board game or put together a puzzle

Playing games can help improve mental ability and memory loss after a stroke. For example, board games like Monopoly help with problem-solving and strategizing. Card games also help challenge memory and attention and train fine motor skills.

Jigsaw puzzles, brain teasers or word games, such as sudoku or crosswords, stimulate the brain by requiring abstract thinking.

Find online games on different devices

You can download many online brain games and apps to a laptop, phone or tablet. Some are specific for brain training. Using online games can help with both cognitive training and motor function movement.

Read and discuss

Reading or listening to a novel or short story can retrain the brain to pay attention and remember important details. You can also read out loud to practice your speech after a stroke. Try discussing or re-telling the story afterward to challenge your memory and practice critical thinking.

Listen to music

Listening to music is a helpful memory builder. Practice recalling information by singing or repeating the lyrics and verses in time to the beat. Music can be a fun, relaxing way to retrain the brain.

Do something creative, such as a craft

Research often links physical and mental improvement after a stroke. Using movement to stimulate your brain physically can also help your brain mentally. Hobbies like crafting (painting, drawing or making a paper sculpture) encourage problem-solving and abstract thinking. With crafting, you also need to plan what you want to do first, which is another thinking skill.

Sources:

The effect of early cognitive training and rehabilitation for patients with cognitive dysfunction in stroke (2021)

Recovering from stroke (2021)

Memory loss (2019)

Aerobic, resistance, and cognitive exercise training poststroke (2015)

Every year, between 250,000 and 500,000 people suffer a spinal cord injury. The causes are mostly motor vehicle accidents, falls, and sports accidents. Spinal cord injuries often affect young individuals.

A spinal cord injury is life-changing. This article explains what happens after an SCI, its consequences, and rehabilitation options.

What happens in an SCI?

The spinal cord is part of the central nervous system. It transmits information from the brain to the body. In simple terms – the brain issues a command, the spinal cord transmits and shapes that command, and the body carries it out.

A similar thing happens with stimuli: When someone touches our shoulder from behind, nerve fibers transmit this sensory information to the brain via the spinal cord. The brain issues the command “turn around.”

If the spinal cord is injured, transmitting nerves can no longer perform their functions. Signals between the brain and body may be transmitted only partially or not at all.

If motor nerve fibers are affected, the results are various forms of weakness or paralysis. If sensory fibers are affected, sensations like pain, pressure, or temperature are dulled or not felt at all.

Partial or complete spinal cord damage causes paraplegia or tetraplegia, depending on the affected body regions.

SCI: Location is key

The closer the damage to the spinal cord is to the head, the more extensive the consequences are for the patient.

Spinal cord injuries along the cervical spine are particularly catastrophic. Injuries at the first thoracic nerve and above (C1-T1) affect the arms, legs, and torso. Some patients with injuries to the uppermost cervical spinal cord (C1-C4) will depend on ventilation devices. Cervical spinal cord injuries result in tetraplegia (paralysis of arms, legs, and torso, or complete tetraplegia) or tetraparesis (weakness of the arms, legs, and torso, or incomplete tetraplegia).

If the injury occurs between the second and twelfth thoracic nerves (T2-T12), the patient retains use of their arms and hands and has limited control of their torso. The legs are fully or partially paralyzed. This is called paraplegia (paralysis of the torso and legs, or complete paraplegia) or paraparesis (weakness of the torso and legs, or incomplete paraplegia).

If the spinal cord injury occurs along the lumbar spine (L1-L5), the patient retains limited control of the hips and legs. Some patients may be able to cover short distances using walking aids, even if the injury is severe or complete.

Injuries in the sacral area (S1-S5, between the pelvis and coccyx) reduce the function of hips, legs, ankles, and feet. However, these patients are usually able to walk and climb stairs independently, likely with some bracing and/or walking aids.

Consequences of a spinal cord injury

Any spinal cord injury is a major event with various consequences. In addition to paralysis, patients may also experience problems with autonomic functions such as digestion, defecation, circulation, temperature regulation, and sexual functions.

There is also a risk of additional complications such as spasticity, excessive reflexes, pressure sores or bedsores, increased risk of infection, and osteoporosis.

The social, financial, and psychological effects of living with a disability are often not discussed. The entire social network around the patient and the patient him- or herself must learn how to handle the new situation. Housing, transportation, leisure activities, and mobility are affected. Professional help can be invaluable support for getting used to a new life.

Sources:

De Gruyter, W. (2017). Pschyrembel. Klinisches Wörterbuch. 267. Auflage. Berlin / Boston

Gratzl O, Merlo A, Rückenmarksverletzungen, in: Siewert J R, Chirurgie, Springer Medizin Verlag Heidelberg; 2006. 203-204.

International Perspectives on Spinal Cord Injury, 2013

Wings for Life – Spinal cord research foundation

Every year, 15 million people in the world experience a stroke. Strokes involve damage to the brain or spinal cord, and the effects vary based on its location and severity.

No matter where the stroke occurs, it impacts the survivor’s physical fitness level. Stroke survivors are often physically inactive and spend a lot of time sedentary. In fact, heart and lung fitness is often cut in half as stroke survivors become less active. That inactivity can lead to lower energy levels, reduced aerobic capacity and higher triglyceride levels — a risk factor for future strokes.

Returning to previous activity levels can be challenging after a stroke. But working toward it is important to recovery, especially because good cardiovascular health is the best way to protect yourself from another stroke. Most rehabilitation programs focus on helping survivors regain lost function and mobility, such as the ability to walk and climb stairs, which allows for increased cardiovascular activity.

What you may feel after having a stroke

The muscles on the affected side of your body change after a stroke. You may find it difficult to do simple things, like raise one arm over your head. You may feel weak, sluggish or clumsy. Even something simple like getting out of bed in the morning may be difficult.

On the other hand, you may feel like you can jump right back into your old exercise routine, particularly if you were an active person beforehand. It’s important to take it easy. A stroke can affect your body in many ways; some that may not be immediately apparent. For example, walking short distances may now leave you out of breath when you used to run several miles a day.

Rehabilitation for stroke survivors

Many stroke survivors go straight from the hospital to a rehabilitation program, with the goal of re-establishing as much independence as possible.

Therapists work to improve the patients’ lower extremity strength and coordination. Gait rehabilitation is an essential component of recovery because it helps with a stroke survivor’s walking ability and speed. It also helps with balance and to reduce the risk of falls.

Using advanced technology, physical therapists can motivate stroke survivors to perform repetitive, rehabilitative movements by introducing fun, engaging therapies. Research has found that when someone enjoys an activity, he can temporarily forget about the long road to recovery.

But one area that’s missing from most rehabilitation plans for stroke survivors is cardiovascular exercise. A study found that the rehabilitation programs for heart attack survivors typically include aerobic activities, while those for stroke survivors don’t. The study suggested that people rehabilitating from a stroke can enhance their health and mobility by taking part in aerobic exercises.

Incorporating cardiovascular exercise into your routine

Cardiorespiratory training should be incorporated in the daily routine of stroke survivors. A walking program is a great way to start. You can work your way up to two or three walks a week, for 30 minutes or longer at a time. Find a friend to join you — exercise buddies make great accountability partners.

If walking without supervision is not advised, a personal trainer may be an option. Other great options are swimming or pool exercises that can be easier on your joints and muscles.

Cardiovascular training with robotic rehabilitation devices

Cyclic sports that activate several large muscle groups are ideal for cardiovascular training. Good examples are cycling, walking, hiking, handcycling or swimming.

For neurologic patients, many forms of exercise are limited or not possible at all, especially in the early rehabilitation phase. Robotic devices can help. Therapy devices support the patient to perform movements such as cycling. In the early rehabilitation phase, it is the goal to activate the cardiovascular system and gradually reintroduce the joints and muscles to various forms of movement. The exercise has not to be perfect yet!

Sources:

Interventions for reducing sedentary behaviour in people with stroke, 2021

Are Aerobic Programs Similar in Design to Cardiac Rehabilitation Beneficial for Survivors of Stroke? A Systematic Review and Meta‐Analysis, 2019

Stroke Patients Motivation Influence on the Effectiveness of Occupational Therapy, 2018

High-Intensity Interval Training After Stroke: An Opportunity to Promote Functional Recovery, Cardiovascular Health, and Neuroplasticity, 2018

Physical fitness training for stroke patients, 2016

Physical Activity and Exercise After Stroke, 2014

Following a stroke, frequent overlooking of items or failure to react when addressed or touched on one side can be early symptoms of neglect. Affected patients no longer perceive one side of their body and environment correctly. More commonly the left side is affected.

Neglect – Reduced perception following a stroke

Neglect patients do not react to stimuli on one side of their body or their environment. For example, when eating, food on one side of the plate remains untouched. When putting on makeup or shaving, one side is missed, or when spoken to from the affected side, individuals will not react.

Patients suffering from neglect do not realize that their perception is limited. Stimuli from the environment are sent to the brain, but the brain fails to process this information correctly.

The brain controls the body crosswise: The right hemisphere controls the left side of the body, and the left hemisphere coordinates the right side of the body. Typically, neglect occurs following damage to the right half of the brain.

Neglect – What can I do to help?

A stroke is a new, challenging situation – for the entire family. A neglect can worsen the situation by the fact that those affected do not notice that they are missing or neglecting things.

In everyday life, relatives can support the independence and motivate those affected to be active. In the case of a neglect, it can be helpful to stimulate the affected side of the body, for example by handing the person objects, sitting or addressing that person from the neglected side.

A neglect can also make communication and interaction difficult. Affected individuals sometimes react inappropriately to conversations or situations and have difficulty maintaining eye contact. This can affect social life.

In day-to-day life, the family should encourage the patient to complete more and more tasks independently and to exercise. Understanding and interacting with the patient can improve the patient’s condition. Furthermore, family members should support rehabilitation exercises in coordination with the treating therapist. Where appropriate, family and patients can join self-help groups, either together or separately.

Robotic rehabilitation for neglect

A 2021 study showed that robotic hand training can have a positive impact on neglect after a stroke.

The advantage of robotic rehabilitation equipment is that it allows for passive, active or assistive movement of the affected part of the body with a high number of repetitions. Whereas therapists typically had to provide continuous movement of the hand of a stroke patient, this task can now be carried out by technology under supervision of the therapist.

Movement stimulates neuroplasticity. The brain starts to form new connections to compensate for damaged areas. This can help reduce the impact of neglect.

Technology also allows for objective assessments in neglect therapy. The “wiping” exercise using Myro can quantify the extent of a neglect. Deficits can then be addressed specifically, and progress can be monitored.

Author: Michaela Partel

Sources:

Leitlinien für Diagnostik und Therapie in der Neurologie. Rehabilitation bei Störungen der Raumkognition, 2017

Neglect und assoziierte Störungen, 2018

Passive limb movements improve visual Neglect, 2001

The effects of robot-assisted left-hand training on hemispatial Neglect in older patients with chronic stroke: A pilot and randomized controlled trial, 2021

Effects of contralesional robot-assisted hand training in patients with unilateral spatial Neglect following stroke: a case series study, 2014

Infantile cerebral palsy (ICP) describes a malformation of or damage to the brain during infancy up to the age of 2 years. As the malformation or damage can affect various areas of the brain, ICP has a wide range of symptoms. It usually results in multiple disabilities. ICP occurs in 2 to 3 of 1,000 live births.

What causes ICP?

A variety of factors can cause cerebral palsy. Only in about half of all cases can an actual cause be established. About 20% of ICP cases have their origin in immediate peri- or postnatal events.

It is possible that an unborn child’s brain develops incorrectly or suffers damage during pregnancy or before birth (intrauterine, prenatal). An infection of the mother, damage to the unborn child caused by alcohol and/or drug use, various medications, thrombosis of the unborn child, carbon monoxide poisoning or insufficient oxygen supply can cause prenatal ICP.

The brain can also suffer damage during birth (peripartum). A birth is a strenuous process for both mother and child. Disruption of blood circulation or birth trauma may cause cerebral palsy.

Damage occurring after birth (postpartum) is usually caused by infection of the newborn, thrombosis, or enterotoxins (toxins produced by micro-organisms). Babies born prematurely are particularly at risk. Bacteria and toxins can cause “poisoning” in newborns’ immature intestines, which may spread to the brain via the bloodstream and cause damage.

If the damage to the brain occurs within the first two years of life, the condition is known as infantile cerebral palsy. The main causes include severe illness, such as meningitis (inflammation of brain membranes), sepsis (blood poisoning), or injuries such as traumatic brain injuries or severe dehydration (insufficient fluid intake).

How is ICP diagnosed?

ICP is often difficult to diagnose in newborns. Usually, delayed development is observed over time. These children acquire motor functions later than their peers or not at all.

They may exhibit reduced coordination, suffer from spasticity (muscle stiffness, cramps), have impaired vision or hearing, and/or demonstrate reduced ability to speak. Recurring epileptic episodes are also possible.

To determine the cause of such symptoms, an MRI (magnetic resonance imaging) of the brain is performed. If no clear diagnosis is possible, nerve and muscle function tests can be helpful. A careful look at the medical history can narrow down possible causes.

What are the symptoms of ICP?

Symptoms of ICP can range from mere clumsiness to severe physical disabilities. Not only may areas of the brain controlling motor function be affected, patients may also exhibit behavioral disorders, impaired vision/hearing, and/or reduced intellectual capacity. They may also suffer from epileptic seizures. If facial muscles are affected, the ability to speak may also be reduced.

Impairment of motor function caused by ICP is categorized into four main groups:

Spasticity – stiffness and weakness of muscles

There are different forms of spasticity. It can predominantly affect one extremity (spastic monoparesis), one half of the body (spastic hemiplegia), both legs (spastic diplegia), or all extremities (spastic tetraplegia). Muscle tone in the torso is often reduced (hypotonic).

Spasticity affects about 80% of children with ICP, making it the most common ICP symptom.

Dyskinesia – interruption of motion sequences

Children suffering from dyskinesia struggle to coordinate their movements. Involuntary, writhing (secondary) movements occur. These movements can be convoluted, abrupt or jerky. Emotions may exacerbate dyskinesia. These involuntary movements disappear when the child is asleep.

As facial muscles may also be affected, speech problems may occur.

Ataxia – difficulties with coordination of movements

Ataxia is an impairment of muscle movement coordination caused by damage to the cerebellum. Muscles are often weaker, movements can be trembling (tremor), and rapid motion sequences and fine motor functions are difficult to execute. The patient’s gait is wobbly and insecure.

Mixed-forms of ICP

Patients usually suffer from a mixed form of spastic and dyskinetic ICP. In mixed forms, additional limitations such as reduced intelligence or behavioral abnormalities are much more common.

With all forms of ICP, movements and muscle tone changes may cause secondary damage. Common are deformities of the feet and the legs, especially hip subluxation. Spinal scoliosis is also possible. One-sided load-bearing when sitting or lying can cause open areas of skin (decubitus ulcers) and reduced bone strength (osteoporosis).

What is the prognosis for ICP?

There is no complete cure for ICP. The prognosis very much depends on the severity of the damage. If the limitations are minor to moderate, life expectancy is almost identical to the norm.

As parents, you can help your child achieve their full potential. It is important to experience as much “normal” daily life as possible. Every activity promotes the individual resources of the child and allows for a childhood beyond the condition.

Author: Saskia Wibner

Sources:

Cerebral Palsy: An Overview, 2020

Overview of Four Functional Classification Systems Commonly Used in Cerebral Palsy, 2017

An update on the prevalence of cerebral palsy: a systematic review and meta-analysis, 2013