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Cerebral Palsy Subtypes
Cerebral Palsy is categorized based on the type of motor abnormalities, which often correlates to the location of the injury in the brain. Even though CP can be diagnosed at an early age, it is not usually classified with the below subtypes until 18-24 months of age. Classification of these subtypes has evolved over many years, as we continue to learn about the disease. There are many overlaps of symptoms within each type, so you might notice that different types have similar characteristics. This can make diagnosis of CP tricky, which is why there is not just one test to rule in the diagnosis.
Spastic Cerebral Palsy
Spastic CP is the most commonly diagnosed subtype of CP, with 70-80% of individuals with this form. This category is very extensive with many different subtypes, so the characteristics can vary from patient to patient. Most often, those with spastic CP have muscles that look and feel stiff and jerky, which results from increased muscle tone. Increased muscle tone can make movements difficult or impossible for these patients, which could leave them highly impaired. In spastic CP, the injured part of the brain sends messages to the muscles incorrectly. When the body is stressed, or trying to create voluntary movements, this rigid feel can actually get worse. Spastic CP can, of course, affect the arms and legs, but it can also affect speech, since there are muscles in the tongue and face that allow us to speak and form words. Thus, eating and drinking may also be impacted, which can lead to decreased growth. Over time, patients with spastic CP can experience intense pain due to constant overactivity and changes in the bone to muscle connection as the body grows. In order to diagnose this subtype, the healthcare provider will assess which muscles are affected, how badly they are affected, and if the patient can control their muscles voluntarily. They will also feel for stiffness when moving arms and legs and can measure the degree of motion which they move. The healthcare provider might also ask the patient to perform certain activities, like sit down and stand up, to evaluate the ability to perform voluntary functions.
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Dyskinetic Cerebral Palsy
This subtype affects just 6% of individuals diagnosed with CP and can often have more than one form of involuntary movement. The area of the brain which is injured in dyskinetic CP patients, is the area of the brain that usually interprets messages from the ‘movement center’ of the brain and the spinal cord. It’s only job is to regulate voluntary movements. Since this area is injured, it is unable to regulate voluntary movements, which leads to unpredictable motions. Sometimes, we can even see dyskinetic characteristics in patients who also have spastic CP. Dyskinetic movements are also considered involuntary, much like spastic CP, but they are especially seen when the patient tries to make movements. Involuntary movements can also get worse when the patient is anxious, tired, or emotional. This can happen because the same place in the brain that is supposed to regulate movements, should also regulate mood and emotions.
There are three different kinds of movements under the dyskinetic subtype. The first is dystonia, which is exhibited by twisting and repetitive movements. Dystonia can affect one part of the body (focal) or can affect the entire body (generalized). Additionally, certain types of dystonia can affect only one half of the body, whether it’s side to side, or top to bottom. Focal dystonia may only happen when the patient is trying to perform a particular task, like standing on one foot. Generalized dystonia, however, can affect much of the body, which can also impair speech, eating, and drinking.
The second is athetosis, which are slow, continuous, involuntary, writhing movements which are visible at rest, but worse with attempts to move. These patients are typically only completely still when they are fully relaxed, so the movements will stop when they are asleep.
The last kind of movement is called chorea, which are dance-like, irregular and unpredictable movements. Mild chorea can make patients simply appear clumsy or fidgety, while more severe forms can make patients look wild and violent – even though they don’t mean to be. Chorea type movements will generally get better while the patient is sleeping.
Ataxic Cerebral Palsy
This is the least common form of CP, and means ‘without order.’ These movements are often seen as clumsy, imprecise, or unstable; they are not smooth and may look jerky. The incoordination gets worse when the individual is trying to perform a voluntary task, and can cause total lack of muscle control in arms and legs. In ataxic CP patients, the area of the brain that is in charge of balance is injured, and thus, cannot maintain balance and depth perception well. This results in general instability, shaky movements, difficulty maintaining balance, and impaired depth perception. Ataxia can leave individuals highly dependent only because they are at a high risk for injury. Ataxic CP has been shown to improve over time.
Mixed or Atonic Cerebral Palsy
This subtype of CP is not well known, so there is much research still being done. From what we do know, however, it maintains that these are infants who have no tone or are called ‘floppy’ when they are supposed to be learning how to sit and crawl. Generally, they will go on to develop spastic, dyskinetic, and/or ataxic characteristics of CP. These patients are severely ill and rarely learn how to stand or walk. There are no specific characteristics that define this subtype, since it seems to be a mixture of all the types listed above.
Not a Simple Diagnosis
It is clear that diagnosing cerebral palsy is not black and white. There are many evaluations and assessments that can go into it. While trying to classify which type of CP a patient might have, we can also use terms to describe which parts of the body are most affected. Diplegia refers to impairment of both legs. The arms may be affected as well, but to a lesser degree. Hemiplegia refers to only one side of the body being affected. Finally, quadriplegia is when all four limbs are affected, as well as the face and mouth. We can also measure severity of each subtype by using classification systems that measure gross motor skills, fine motor skills, and communication skills. It may take many doctors visits to get all the answers and a clear diagnosis, but once this is done, proper management and treatments can be performed.
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