What is Cerebral Palsy? \r\n
Doctors use the term cerebral palsy to refer to any one of a number of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination but aren''t progressive, in other words, they don''t get worse over time. The term cerebral refers to the two halves or hemispheres of the brain, in this case to the motor area of the brain''s outer layer (called the cerebral cortex), the part of the brain that directs muscle movement; palsy refers to the loss or impairment of motor function.
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Even though cerebral palsy affects muscle movement, it isn''t caused by problems in the muscles or nerves. It is caused by abnormalities inside the brain that disrupt the brain''s ability to control movement and posture.
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In some cases of cerebral palsy, the cerebral motor cortex hasn''t developed normally during fetal growth. In others, the damage is a result of injury to the brain either before, during, or after birth. In either case, the damage is not repairable and the disabilities that result are permanent.
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Children with cerebral palsy exhibit a wide variety of symptoms, including: \r\n
\r\n\r\n\r\n | \r\nLack of muscle coordination when performing voluntary movements ( ataxia ); | \r\n
\r\n\r\n | \r\nStiff or tight muscles and exaggerated reflexes ( spasticity ); | \r\n
\r\n\r\n | \r\nWalking with one foot or leg dragging; | \r\n
\r\n\r\n | \r\nWalking on the toes, a crouched gait, or a “scissored” gait; | \r\n
\r\n\r\n | \r\nVariations in muscle tone, either too stiff or too floppy; | \r\n
\r\n\r\n | \r\nExcessive drooling or difficulties swallowing or speaking; | \r\n
\r\n\r\n | \r\nShaking ( tremor ) or random involuntary movements; and | \r\n
\r\n\r\n | \r\nDifficulty with precise motions, such as writing or buttoning a shirt. | \r\n
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The symptoms of cerebral palsy differ in type and severity from one person to the next, and may even change in an individual over time. Some people with cerebral palsy also have other medical disorders, including mental retardation, seizures, impaired vision or hearing, and abnormal physical sensations or perceptions.
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Cerebral palsy doesn''t always cause profound disabilities. While one child with severe cerebral palsy might be unable to walk and need extensive, lifelong care, another with mild cerebral palsy might be only slightly awkward and require no special assistance.
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Cerebral palsy isn''t a disease. It isn''t contagious and it can''t be passed from one generation to the next. There is no cure for cerebral palsy, but supportive treatments, medications, and surgery can help many individuals improve their motor skills and ability to communicate with the world.
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What Are the Early Signs? \r\n
\r\n\r\n\r\n | \r\nThe early signs of cerebral palsy usually appear before a child reaches 3 years of age. | \r\n
\r\n\r\n | \r\nParents are often the first to suspect that their baby''s motor skills aren''t developing normally. | \r\n
\r\n\r\n | \r\nInfants with cerebral palsy frequently have developmental delay , in which they are slow to reach developmental milestones such as learning to roll over, sit, crawl, smile, or walk. | \r\n
\r\n\r\n | \r\nSome infants with cerebral palsy have abnormal muscle tone as infants. Decreased muscle tone ( hypotonia ) can make them appear relaxed, even floppy. Increased muscle tone ( hypertonia) can make them seem stiff or rigid. | \r\n
\r\n\r\n | \r\nIn some cases, an early period of hypotonia will progress to hypertonia after the first 2 to 3 months of life. | \r\n
\r\n\r\n | \r\nChildren with cerebral palsy may also have unusual posture or favor one side of the body when they move. | \r\n
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Parents who are concerned about their baby''s development for any reason should contact their pediatrician. A doctor can determine the difference between a normal lag in development and a delay that could indicate cerebral palsy.
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What Causes Cerebral Palsy? \r\n
\r\n\r\n\r\n | \r\nThe majority of children with cerebral palsy are born with it, although it may not be detected until months or years later. This is called congenital cerebral palsy . | \r\n
\r\n\r\n | \r\nIn the past, if doctors couldn''t identify another cause, they attributed most cases of congenital cerebral palsy to problems or complications during labor that caused asphyxia (a lack of oxygen) during birth. | \r\n
\r\n\r\n | \r\nHowever, extensive research by NINDS scientists and others has shown that few babies who experience asphyxia during birth grow up to have cerebral palsy or any other neurological disorder. Birth complications, including asphyxia, are now estimated to account for only 5 to 10 percent of the babies born with congenital cerebral palsy. | \r\n
\r\n\r\n | \r\nA small number of children have acquired cerebral palsy , which means the disorder begins after birth. In these cases, doctors can often pinpoint a specific reason for the problem, such as brain damage in the first few months or years of life, brain infections such as bacterial meningitis or viral encephalitis, or head injury from a motor vehicle accident, a fall, or child abuse. | \r\n
\r\n\r\n | \r\nWhat causes the remaining 90 to 95 percent? Research has given us a bigger and more accurate picture of the kinds of events that can happen during early fetal development, or just before, during, or after birth, that cause the particular types of brain damage that will result in congenital cerebral palsy. There are multiple reasons why cerebral palsy happens – as the result of genetic abnormalities, maternal infections or fevers, or fetal injury, for example. But in all cases the disorder is the result of four types of brain damage that cause its characteristic symptoms: | \r\n
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Damage to the white matter of the brain ( periventricular leukomalacia [PVL]). The white matter of the brain is responsible for transmitting signals inside the brain and to the rest of the body. PVL describes a type of damage that looks like tiny holes in the white matter of an infant''s brain. These gaps in brain tissue interfere with the normal transmission of signals. There are a number of events that can cause PVL, including maternal or fetal infection.
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Researchers have also identified a period of selective vulnerability in the developing fetal brain, a period of time between 26 and 34 weeks of gestation , in which periventricular white matter is particularly sensitive to insults and injury.
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Abnormal development of the brain ( cerebral dysgenesis ). Any interruption of the normal process of brain growth during fetal development can cause brain malformations that interfere with the transmission of brain signals. The fetal brain is particularly vulnerable during the first 20 weeks of development. Mutations in the genes that control brain development during this early period can keep the brain from developing normally. Infections, fevers, trauma, or other conditions that cause unhealthy conditions in the womb also put an unborn baby''s nervous system at risk.
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Bleeding in the brain ( intracranial hemorrhage ). Intracranial hemorrhage describes bleeding inside the brain caused by blocked or broken blood vessels. A common cause of this kind of damage is fetal stroke. Some babies suffer a stroke while still in the womb because of blood clots in the placenta that block blood flow. Other types of fetal stroke are caused by malformed or weak blood vessels in the brain or by blood-clotting abnormalities. Maternal high blood pressure (hypertension ) is a common medical disorder during pregnancy that has been known to cause fetal stroke. Maternal infection, especially pelvic inflammatory disease , has also been shown to increase the risk of fetal stroke.
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Brain damage caused by a lack of oxygen in the brain ( hypoxic-ischemic encephalopathy or intrapartum asphyxia ). Asphyxia, a lack of oxygen in the brain caused by an interruption in breathing or poor oxygen supply, is common in babies due to the stress of labor and delivery. But even though a newborn''s blood is equipped to compensate for short-term low levels of oxygen, if the supply of oxygen is cut off or reduced for lengthy periods, an infant can develop a type of brain damage called hypoxic-ischemic encephalopathy, which destroys tissue in the cerebral motor cortex and other areas of the brain. This kind of damage can also be caused by severe maternal low blood pressure, rupture of the uterus, detachment of the placenta, or problems involving the umbilical cord. \r\n
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What are the Risk Factors?\r\n
If a mother or her baby has any of these risk factors during pregnancy, it doesn''t mean that cerebral palsy is inevitable, but it does increase the chance for the kinds of brain damage that cause it.
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Low birthweight and premature birth . The risk of cerebral palsy is higher among babies who weigh less than 5 ˝ pounds at birth or are born less than 37 weeks into pregnancy. The risk increases as birthweight falls or weeks of gestation shorten. Intensive care for premature infants has improved dramatically over the course of the past 30 years. Babies born extremely early are surviving, but with medical problems that can put them at risk for cerebral palsy. Although normal- or heavier-weight babies are at relatively low individual risk for cerebral palsy, term or near-term babies still make up half of the infants born with the condition.
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Multiple births. Twins, triplets, and other multiple births -- even those born at term -- are linked to an increased risk of cerebral palsy. The death of a baby''s twin or triplet further increases the risk.
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Infections during pregnancy. Infectious diseases caused by viruses, such as toxoplasmosis, rubella (German measles), cytomegalovirus, and herpes, can infect the womb and placenta.
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Blood type incompatibility. Rh incompatibility is a condition that develops when a mother''s Rh blood type (either positive or negative) is different from the blood type of her baby. Because blood cells from the baby and mother mix during pregnancy, if a mother is negative and her baby positive, for example, the mother''s system won''t tolerate the presence of Rh-positive red blood cells. Her body will begin to make antibodies that will attack and kill her baby''s blood cells. Rh incompatibility is routinely tested for and treated in the United States , but conditions in other countries continue to keep blood type incompatibility a risk factor for cerebral palsy.
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Mothers with thyroid abnormalities, mental retardation, or seizures. Mothers with any of these conditions are slightly more likely to have a child with cerebral palsy.
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There are also medical conditions during labor and delivery, and immediately after delivery, that act as warning signs for an increased risk of cerebral palsy. Knowing these warning signs helps doctors keep a close eye on children who face a higher risk. However, parents shouldn''t become too alarmed if their baby has one or more of these conditions at birth. Most of these children will not develop cerebral palsy. Warning signs include:
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Breech presentation. Babies with cerebral palsy are more likely to be in a breech position (feet first) instead of head first at the beginning of labor.
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Complicated labor and delivery. A baby who has vascular or respiratory problems during labor and delivery may already have suffered brain damage or abnormalities.
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Small for gestational age. Babies born smaller than normal for their gestational age are at risk for cerebral palsy because of factors that kept them from growing naturally in the womb
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Low Apgar score . The Apgar score is a numbered rating that reflects a newborn''s condition. To determine an Apgar score, doctors periodically check a baby''s heart rate, breathing, muscle tone, reflexes, and skin color during the first minutes after birth. They then assign points; the higher the score, the more normal a baby''s condition. A low score at 10-20 minutes after delivery is often considered an important sign of potential problems such as cerebral palsy.
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Jaundice . More than 50 percent of newborns develop jaundice after birth when bilirubin , a substance normally found in bile, builds up faster than their livers can break it down and pass it from the body. Severe, untreated jaundice can cause a neurological condition known as kernicterus, which kills brain cells and can cause deafness and cerebral palsy.
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Seizures. An infant who has seizures faces a higher risk of being diagnosed later in childhood with cerebral palsy. \r\n
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Can Cerebral Palsy Be Prevented?
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\r\n\r\n\r\n | \r\nCerebral palsy related to genetic abnormalities is not preventable, but a few of the risk factors for congenital cerebral palsy can be managed or avoided. | \r\n
\r\n\r\n | \r\nFor example, rubella, or German measles, is preventable if women are vaccinated against the disease before becoming pregnant. | \r\n
\r\n\r\n | \r\nRh incompatibilities can also be managed early in pregnancy | \r\n
\r\n\r\n | \r\nBut there are still risk factors that can''t be controlled or avoided in spite of medical intervention. | \r\n
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What Are the Different Forms?
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\r\n\r\n\r\n | \r\nThe specific forms of cerebral palsy are determined by the extent, type, and location of a child’s abnormalities. | \r\n
\r\n\r\n | \r\nDoctors classify cerebral palsy according to the type of movement disorder involved -- spastic (stiff muscles), athetoid (writhing movements), or ataxic (poor balance and coordination) -- plus any additional symptoms. | \r\n
\r\n\r\n | \r\nDoctors will often describe the type of cerebral palsy a child has based on which limbs are affected. The names of the most common forms of cerebral palsy use Latin terms to describe the location or number of affected limb, combined with the words for weakened (paresis) or paralyzed (plegia). For example, hemiparesis (hemi = half) indicates that only one side of the body is weakened. Quadriplegia (quad = four) means all four limbs are paralyzed. | \r\n
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Spastic hemiplegia/hemiparesis . This type of cerebral palsy typically affects the arm and hand on one side of the body, but it can also include the leg. Children with spastic hemiplegia generally walk later and on tip-toe because of tight heel tendons. The arm and leg of the affected side are frequently shorter and thinner. Some children will develop an abnormal curvature of the spine ( scoliosis ). Depending on the location of the brain damage, a child with spastic hemiplegia may also have seizures. Speech will be delayed.
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Spastic diplegia/diparesis. In this type of cerebral palsy, muscle stiffness is predominantly in the legs and less severely affects the arms and face, although the hands may be clumsy. Tendon reflexes are hyperactive. Toes point up. Tightness in certain leg muscles makes the legs move like the arms of a scissor. Children with this kind of cerebral palsy may require a walker or leg braces. Intelligence and language skills are usually normal.
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Spastic quadriplegia/quadriparesis . This is the most severe form of cerebral palsy, often associated with moderate-to-severe mental retardation. It is caused by widespread damage to the brain or significant brain malformations. Children will often have severe stiffness in their limbs but a floppy neck. They are rarely able to walk. Speaking and being understood are difficult. Seizures can be frequent and hard to control.
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Dyskinetic cerebral palsy (also includes athetoid, choreoathetoid , and dystonic cerebral palsies). This type of cerebral palsy is characterized by slow and uncontrollable writhing movements of the hands, feet, arms, or legs. In some children, hyperactivity in the muscles of the face and tongue makes them grimace or drool. They find it difficult to sit straight or walk. Children may also have problems coordinating the muscle movements required for speaking. Intelligence is rarely affected in these forms of cerebral palsy.
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Ataxic cerebral palsy. This rare type of cerebral palsy affects balance and depth perception. Children will often have poor coordination and walk unsteadily with a wide-based gait, placing their feet unusually far apart. They have difficulty with quick or precise movements, such as writing or buttoning a shirt. They may also have intention tremor, in which a voluntary movement, such as reaching for a book, is accompanied by trembling that gets worse the closer their hand gets to the object.
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Mixed types. It is common for children to have symptoms that don''t correspond to any single type of cerebral palsy. Their symptoms are a mix of types. For example, a child with mixed cerebral palsy may have some muscles that are too tight and others that are too relaxed, creating a mix of stiffness and floppiness
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What Other Conditions Are Associated With Cerebral Palsy?\r\n
Many individuals with cerebral palsy have no additional medical disorders. However, because cerebral palsy involves the brain and the brain controls so many of the body''s functions, cerebral palsy can also cause seizures, impair intellectual development, and affect vision, hearing, and behavior. Coping with these disabilities may be even more of a challenge than coping with the motor impairments of cerebral palsy.
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These additional medical conditions include:
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Mental retardation. Two-thirds of individuals with cerebral palsy will be intellectually impaired. Mental impairment is more common among those with spastic quadriplegia than in those with other types of cerebral palsy, and children who have epilepsy and an abnormal electroencephalogram (EEG) or MRI are also more likely to have mental retardation.
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Seizure disorder. As many as half of all children with cerebral palsy have seizures. Seizures can take the form of the classic convulsions of tonic-clonic seizures or the less obvious focal ( partial) seizures , in which the only symptoms may be muscle twitches or mental confusion.
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Delayed growth and development. A syndrome called failure to thrive is common in children with moderate-to-severe cerebral palsy, especially those with spastic quadriparesis. Failure to thrive is a general term doctors use to describe children who lag behind in growth and development. In babies this lag usually takes the form of too little weight gain. In young children it can appear as abnormal shortness, and in teenagers it may appear as a combination of shortness and lack of sexual development.
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In addition, the muscles and limbs affected by cerebral palsy tend to be smaller than normal. This is especially noticeable in children with spastic hemiplegia because limbs on the affected side of the body may not grow as quickly or as long as those on the normal side.
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Spinal deformities. Deformities of the spine -- curvature (scoliosis), humpback ( kyphosis ), and saddle back ( lordosis ) -- are associated with cerebral palsy. Spinal deformities can make sitting, standing, and walking difficult and cause chronic back pain.
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Impaired vision, hearing, or speech. A large number of children with cerebral palsy have strabismus , commonly called “cross eyes,” in which the eyes are misaligned because of differences between the left and right eye muscles. In an adult, strabismus causes double vision. In children, the brain adapts to the condition by ignoring signals from one of the misaligned eyes. Untreated, this can lead to poor vision in one eye and can interfere with the ability to judge distance. In some cases, doctors will recommend surgery to realign the muscles.
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Impaired hearing is also more frequent among those with cerebral palsy than in the general population. Speech and language disorders, such as difficulty forming words and speaking clearly, are present in more than a third of those with cerebral palsy.
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Drooling. Some individuals with cerebral palsy drool because they have poor control of the muscles of the throat, mouth, and tongue. Drooling can cause severe skin irritation. Because it is socially unacceptable, drooling may also isolate children from their peers.
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Incontinence. A common complication of cerebral palsy is incontinence, caused by poor control of the muscles that keep the bladder closed. Incontinence can take the form of bed-wetting, uncontrolled urination during physical activities, or slow leaking of urine throughout the day.
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Abnormal sensations and perceptions. Some children with cerebral palsy have difficulty feeling simple sensations, such as touch. They may have stereognosia , which makes it difficult to perceive and identify objects using only the sense of touch. A child with stereognosia, for example, would have trouble closing his eyes and sensing the difference between a hard ball or a sponge ball placed in his hand.
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How Does a Doctor Diagnose Cerebral Palsy?
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Early signs of cerebral palsy may be present from birth. Most children with cerebral palsy are diagnosed during the first 2 years of life. But if a child''s symptoms are mild, it can be difficult for a doctor to make a reliable diagnosis before the age of 4 or 5.
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Doctors diagnose cerebral palsy by evaluating a child''s motor skills and taking a careful and thorough look at their medical history. In addition to checking for the most characteristic symptoms -- slow development, abnormal muscle tone, and unusual posture -- a doctor also has to rule out other disorders that could cause similar symptoms. Most important, a doctor has to determine that the child''s condition is not getting worse. Although symptoms may change over time, cerebral palsy by definition is not progressive. If a child is continuously losing motor skills, the problem more likely begins elsewhere – such as a genetic or muscle disease, metabolism disorder, or tumors in the nervous system. A comprehensive medical history, special diagnostic tests, and, in some cases, repeated check-ups can help confirm that other disorders are not at fault.
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Additional tests are often used to rule out other movement disorders that could cause the same symptoms as cerebral palsy. Neuroimaging techniques that allow doctors to look into the brain (such as an MRI scan) can detect abnormalities that indicate a potentially treatable movement disorder. If it is cerebral palsy, an MRI scan can also show a doctor the location and type of brain damage
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Neuroimaging methods include:
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\r\n\r\n\r\n | \r\nCranial ultrasound. This test is used for high-risk premature infants because it is the least intrusive of the imaging techniques, although it is not as successful as the two methods described below at capturing subtle changes in white matter – the type of brain tissue that is damaged in cerebral palsy. | \r\n
\r\n\r\n | \r\nComputed tomography (CT) scan. This technique creates images that show the structure of the brain and the areas of damage. | \r\n
\r\n\r\n | \r\nMagnetic resonance imaging (MRI) scan . This test uses a computer, a magnetic field, and radio waves to create an anatomical picture of the brain''s tissues and structures. Doctors prefer MRI imaging because it offers finer levels of detail | \r\n
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On rare occasions, metabolic disorders can masquerade as cerebral palsy and some children will require additional tests to rule them out. Most of the childhood metabolic disorders have characteristic brain abnormalities or malformations that will show up in an MRI.
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Other types of disorders can also be mistaken for cerebral palsy. For example, coagulation disorders (which prevent blood from clotting) can cause prenatal or perinatal strokes that damage the brain and cause symptoms characteristic of cerebral palsy. Because stroke is so often the cause of hemiplegic cerebral palsy, a doctor may find it necessary to perform diagnostic testing on children with this kind of cerebral palsy to rule out the presence of a coagulation disorder. If left undiagnosed, coagulation disorders can cause additional strokes and more extensive brain damage.
\r\nTo confirm a diagnosis of cerebral palsy, a doctor may refer a child to additional doctors with specialized knowledge and training, such as a child neurologist. Additional observations help a doctor make a more accurate diagnosis and begin to develop a specific plan for treatment.
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How is Cerebral Palsy Managed?\r\n
Cerebral palsy can''t be cured, but treatment will often improve a child''s capabilities. Many children go on to enjoy near-normal adult lives if their disabilities are properly managed. In general, the earlier treatment begins, the better chance children have of overcoming developmental disabilities or learning new ways to accomplish the tasks that challenge them.
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There is no standard therapy that works for every individual with cerebral palsy. Once the diagnosis is made, and the type of cerebral palsy is determined, a team of health care professionals will work with a child and his or her parents to identify specific impairments and needs, and then develop an appropriate plan to tackle the core disabilities that affect the child''s quality of life.
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A comprehensive management plan will pull in a combination of health professionals with expertise in the following:
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physical therapy to improve walking and gait, stretch spastic muscles, and prevent deformities;
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occupational therapy to develop compensating tactics for everyday activities such as dressing, going to school, and participating in day-to-day activities;
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speech therapy to address swallowing disorders, speech impediments, and other obstacles to communication;
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counseling and behavioral therapy to address emotional and psychological needs and help children cope emotionally with their disabilities;
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drugs to control seizures, relax muscle spasms, and alleviate pain;
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surgery to correct anatomical abnormalities or release tight muscles;
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braces and other orthotic devices to compensate for muscle imbalance, improve posture and walking, and increase independent mobility;
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mechanical aids such as wheelchairs and rolling walkers for individuals who are not independently mobile; and
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communication aids such as computers, voice synthesizers, or symbol boards to allow severely impaired individuals to communicate with others.
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Doctors use tests and evaluation scales to determine a child''s level of disability, and then make decisions about the types of treatments and the best timing and strategy for interventions. Early intervention programs typically provide all the required therapies within a single treatment center. Centers also focus on parents'' needs, often offering support groups, babysitting services, and respite care .
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The members of the treatment team for a child with cerebral palsy will most likely include the following:
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A physician , such as a pediatrician, pediatric neurologist, who is trained to help developmentally disabled children. This doctor, who often acts as the leader of the treatment team, integrates the professional advice of all team members into a comprehensive treatment plan, makes sure the plan is implemented properly, and follows the child''s progress over a number of years.
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An orthopedist , a surgeon who specializes in treating the bones, muscles, tendons, and other parts of the skeletal system. An orthopedist is often brought in to diagnose and treat muscle problems associated with cerebral palsy.
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A physical therapist , who designs and puts into practice special exercise programs to improve strength and functional mobility.
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An occupational therapist, who teaches the skills necessary for day-to-day living, school, and work.
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A speech and language pathologist, who specializes in diagnosing and treating disabilities relating to difficulties with swallowing and communication.
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A social worker, who helps individuals and their families locate community assistance and education programs.
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A psychologist, who helps individuals and their families cope with the special stresses and demands of cerebral palsy. In some cases, psychologists may also oversee therapy to modify unhelpful or destructive behaviors.
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A special educator, who may play an especially important role when mental retardation or learning disabilities present a challenge to education.
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Regardless of age or the types of therapy that are used, treatment doesn''t end when an individual with cerebral palsy leaves the treatment center. Most of the work is done at home. Members of the treatment team often act as coaches, giving parents and children techniques and strategies to practice at home. Studies have shown that family support and personal determination are two of the most important factors in helping individuals with cerebral palsy reach their long-term goals.
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While mastering specific skills is an important focus of treatment on a day-to-day basis, the ultimate goal is to help children grow into adulthood with as much independence as possible.
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As a child with cerebral palsy grows older, the need for therapy and the kinds of therapies required, as well as support services, will likely change. Counseling for emotional and psychological challenges may be needed at any age, but is often most critical during adolescence. Depending on their physical and intellectual abilities, adults may need help finding attendants to care for them, a place to live, a job, and a way to get to their place of employment.
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Addressing the needs of parents and caregivers is also an important component of the treatment plan. The well-being of an individual with cerebral palsy depends upon the strength and well-being of his or her family. For parents to accept a child''s disabilities and come to grips with the extent of their care giving responsibilities will take time and support from health care professionals. Family-centered programs in hospitals and clinics and community-based organizations usually work together with families to help them make well-informed decisions about the services they need. They also coordinate services to get the most out of treatment.
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A good program will encourage the open exchange of information, offer respectful and supportive care, encourage partnerships between parents and the health care professionals they work with, and acknowledge that although medical specialists may be the experts, it''s parents who know their children best.
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What Specific Treatments Are Available?
Physical therapy , usually begun in the first few years of life or soon after the diagnosis is made, is a cornerstone of cerebral palsy treatment. Physical therapy programs use specific sets of exercises and activities to work toward two important goals: preventing weakening or deterioration in the muscles that aren''t being used ( disuse atrophy ), and keeping muscles from becoming fixed in a rigid, abnormal position ( contracture ).
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Resistive exercise programs (also called strength training) and other types of exercise are often used to increase muscle performance, especially in children and adolescents with mild cerebral palsy. Daily bouts of exercise keep muscles that aren''t normally used moving and active and less prone to wasting away. Exercise also reduces the risk of contracture, one of the most common and serious complications of cerebral palsy.
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Normally growing children stretch their muscles and tendons as they run, walk, and move through their daily activities. This insures that their muscles grow at the same rate as their bones. But in children with cerebral palsy, spasticity prevents muscles from stretching. As a result, their muscles don''t grow fast enough to keep up with their lengthening bones. The muscle contracture that results can set back the gains in function they''ve made. Physical therapy alone or in combination with special braces (called orthotic devices ) helps prevent contracture by stretching spastic muscles.
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Occupational therapy. This kind of therapy focuses on optimizing upper body function, improving posture, and making the most of a child''s mobility. An occupational therapist helps a child master the basic activities of daily living, such as eating, dressing, and using the bathroom alone. Fostering this kind of independence boosts self-reliance and self-esteem, and also helps reduce demands on parents and caregivers.
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Recreational therapies. Recreational therapies, such as therapeutic horseback riding (also called hippotherapy), are sometimes used with mildly impaired children to improve gross motor skills. Parents of children who participate in recreational therapies usually notice an improvement in their child''s speech, self-esteem, and emotional well-being.
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Controversial physical therapies. "Patterning" is a physical therapy based on the principle that children with cerebral palsy should be taught motor skills in the same sequence in which they develop in normal children. In this controversial approach, the therapist begins by teaching a child elementary movements such as crawling -- regardless of age – before moving on to walking skills. Some experts and organizations, including the American Academy of Pediatrics, have expressed strong reservations about the patterning approach because studies have not documented its value
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Experts have similar reservations about the Bobath technique (which is also called “neurodevelopmental treatment”), named for a husband and wife team who pioneered the approach in England . In this form of physical therapy, instructors inhibit abnormal patterns of movement and encourage more normal movements.
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The Bobath technique has had a widespread influence on the core physical therapies of cerebral palsy treatment, but there is no evidence that the technique improves motor control. The American Academy of Cerebral Palsy and Developmental Medicine reviewed studies that measured the impact of neurodevelopmental treatment and concluded that there was no strong evidence supporting its effectiveness for children with cerebral palsy.
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Conductive education, developed in Hungary in the 1940s, is another physical therapy that at one time appeared to hold promise. Conductive education instructors attempt to improve a child''s motor abilities by combining rhythmic activities, such as singing and clapping, with physical maneuvers on special equipment. The therapy, however, has not been able to produce consistent or significant improvements in study groups.
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Speech and language therapy. About 20 percent of children with cerebral palsy are unable to produce intelligible speech. They also experience challenges in other areas of communication, such as hand gestures and facial expressions, and they have difficulty participating in the basic give and take of a normal conversation. These challenges will last throughout their lives.
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Speech and language therapists (also known as speech therapists or speech-language pathologists) observe, diagnose, and treat the communication disorders associated with cerebral palsy. They use a program of exercises to teach children how to overcome specific communication difficulties.
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For example, if a child has difficulty saying words that begin with "b," the therapist may suggest daily practice with a list of "b" words, increasing their difficulty as each list is mastered. Other kinds of exercises help children master the social skills involved in communicating by teaching them to keep their head up, maintain eye contact, and repeat themselves when they are misunderstood.
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Speech therapists can also help children with severe disabilities learn how to use special communication devices, such as a computer with a voice synthesizer, or a special board covered with symbols of everyday objects and activities to which a child can point to indicate his or her wishes.
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Speech interventions often use a child''s family members and friends to reinforce the lessons learned in a therapeutic setting. This kind of indirect therapy encourages people who are in close daily contact with a child to create opportunities for him or her to use their new skills in conversation.
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Treatments for problems with eating and drooling are often necessary when children with cerebral palsy have difficulty eating and drinking because they have little control over the muscles that move their mouth, jaw, and tongue. They are also at risk for breathing food or fluid into the lungs. Some children develop gastroesophageal reflux disease (GERD, commonly called heartburn) in which a weak diaphragm can''t keep stomach acids from spilling into the esophagus. The irritation of the acid can cause bleeding and pain.
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Individuals with cerebral palsy are also at risk for malnutrition, recurrent lung infections, and progressive lung disease. The individuals most at risk for these problems are those with spastic quadriplegia.
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In severe cases where swallowing problems are causing malnutrition, a doctor may recommend tube feeding, in which a tube delivers food and nutrients down the throat and into the stomach, or gastrostomy , in which a surgical opening allows a tube to be placed directly into the stomach.
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Drug Treatments
Oral medications such as diazepam, baclofen, dantrolene sodium, and tizanidine are usually used as the first line of treatment to relax stiff, contracted, or overactive muscles. These drugs are easy to use, except that dosages high enough to be effective often have side effects, among them drowsiness, upset stomach, high blood pressure, and possible liver damage with long-term use. Oral medications are most appropriate for children who need only mild reduction in muscle tone or who have widespread spasticity.\r\n
Botulinum toxin (BT-A) , injected locally, has become a standard treatment for overactive muscles in children with spastic movement disorders such as cerebral palsy. BT-A relaxes contracted muscles by keeping nerve cells from over-activating muscle.
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The relaxing effect of a BT-A injection lasts approximately 3 months. Undesirable side effects are mild and short-lived, consisting of pain upon injection and occasionally mild flu-like symptoms. BT-A injections are most effective when followed by a stretching program including physical therapy and splinting. BT-A injections work best for children who have some control over their motor movements and have a limited number of muscles to treat, none of which is fixed or rigid.
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Orthopedic surgery is often recommended when spasticity and stiffness are severe enough to make walking and moving about difficult or painful. For many people with cerebral palsy, improving the appearance of how they walk – their gait – is also important. A more upright gait with smoother transitions and foot placements is the primary goal for many children and young adults.
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In the operating room, surgeons can lengthen muscles and tendons that are proportionately too short. But first, they have to determine the specific muscles responsible for the gait abnormalities. Finding these muscles can be difficult. It takes more than 30 major muscles working at the right time using the right amount of force to walk two strides with a normal gait. A problem with any of those muscles can cause an abnormal gait.
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The timing of orthopedic surgery has also changed in recent years. Previously, orthopedic surgeons preferred to perform all of the necessary surgeries a child needed at the same time, usually between the ages of 7 and 10. Because of the length of time spent in recovery, which was generally several months, doing them all at once shortened the amount of time a child spent in bed. Now most of the surgical procedures can be done on an outpatient basis or with a short inpatient stay. Children usually return to their normal lifestyle within a week
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Consequently, doctors think it is much better to stagger surgeries and perform them at times appropriate to a child''s age and level of motor development. For example, spasticity in the upper leg muscles (the adductors), which causes a “scissor pattern” walk, is a major obstacle to normal gait. The optimal age to correct this spasticity with adduction release surgery is 2 to 4 years of age. On the other hand, the best time to perform surgery to lengthen the hamstrings or Achilles tendon is 7 to 8 years of age. If adduction release surgery is delayed so that it can be performed at the same time as hamstring lengthening, the child will have learned to compensate for spasticity in the adductors. By the time the hamstring surgery is performed, the child''s abnormal gait pattern could be so ingrained that it might not be easily corrected.
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Orthotic Devices\r\n
Orthotic devices – such as braces and splints – use external force to correct muscle abnormalities. The technology of orthotics has advanced over the past 30 years from metal rods that hooked up to bulky orthopedic shoes, to appliances that are individually molded from high-temperature plastics for a precise fit. Ankle-foot orthoses are frequently prescribed for children with spastic diplegia to prevent muscle contracture and to improve gait. Splints are also used to correct spasticity in the hand muscles.
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Assistive Technology
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Devices that help individuals move about more easily and communicate successfully at home, at school, or in the workplace can help a child or adult with cerebral palsy overcome physical and communication limitations. There are a number of devices that help individuals stand straight and walk, such as postural support or seating systems, open-front walkers, quadrupedal canes (lightweight metal canes with four feet), and gait poles. Electric wheelchairs let more severely impaired adults and children move about successfully.
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The computer is probably the most dramatic example of a communication device that can make a big difference in the lives of people with cerebral palsy. Equipped with a computer and voice synthesizer, a child or adult with cerebral palsy can communicate successfully with others. For example, a child who is unable to speak or write but can make head movements may be able to control a computer using a special light pointer that attaches to a headband
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Are There Treatments for Other Conditions Associated with Cerebral Palsy? \r\n
Epilepsy. Twenty to 40 percent of children with mental retardation and cerebral palsy also have epilepsy. Doctors usually prescribe medications to control seizures. The classic medications for this purpose are phenobarbital, phenytoin, carbamazepine, and valproate. Although these drugs generally are effective in controlling seizures, their use is hampered by harmful or unpleasant side effects.
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Treatment for epilepsy has advanced significantly with the development of new medications that have fewer side effects. These drugs include lamotrigine, levetiracetam, oxcarbazepine, topiramate, vigabatrin, and zonisamide.
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In general, drugs are prescribed based on the type of seizures an individual experiences, since no one drug controls all types. Some individuals may need a combination of two or more drugs to achieve good seizure control.
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Incontinence . Medical treatments for incontinence include special exercises, biofeedback, prescription drugs, surgery, or surgically implanted devices to replace or aid muscles. Specially designed absorbent undergarments can also be used to protect against accidental leaks.
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Osteopenia . Children with cerebral palsy who aren''t able to walk risk developing poor bone density (osteopenia), which makes them more likely to break bones. In a study of older Americans funded by the National Institutes of Health (NIH), a family of drugs called bisphosphonates , which was recently approved by the FDA to treat mineral loss in elderly patients, also appeared to increase bone mineral density. Doctors may choose to selectively prescribe the drug off-label to children to prevent osteopenia.
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Pain. Pain can be a problem for people with cerebral palsy due to spastic muscles and the stress and strain on parts of the body that are compensating for muscle abnormalities. Some individuals may also have frequent and irregular muscle spasms that can''t be predicted or medicated in advance.
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Doctors often prescribe diazepam to reduce the pain associated with muscle spasms, but it''s not known exactly how the drug works to interfere with pain signals. The drug gabapentin has been used successfully to decrease the severity and frequency of painful spasms. BT-A injections have also been shown to decrease spasticity and pain, and are commonly given under anesthesia to avoid the pain associated with the injections.
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Glossary
acquired cerebral palsy — cerebral palsy that occurs as a result of injury to the brain after birth or during early childhood.
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Apgar score — a numbered scoring system doctors use to assess a baby''s physical state at the time of birth.
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anticholinergic drugs — a family of drugs that inhibit parasympathetic neural activity by blocking the neurotransmitter acetylcholine.
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asphyxia — a lack of oxygen due to trouble with breathing or poor oxygen supply in the air.
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ataxia (ataxic) — the loss of muscle control.
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athetoid — making slow, sinuous, involuntary, writhing movements, especially with the hands.
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bilirubin — a bile pigment produced by the liver of the human body as a byproduct of digestion.
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bisphosphonates — a family of drugs that strengthen bones and reduce the risk of bone fracture in elderly adults.
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botulinum toxin — a drug commonly used to relax spastic muscles; it blocks the release of acetylcholine, a neurotransmitter that energizes muscle tissue.
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cerebral — relating to the two hemispheres of the human brain.
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cerebral dysgenesis — defective brain development.
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chemodenervation — a treatment that relaxes spastic muscles by interrupting nerve impulse pathways via a drug, such as botulinum toxin, which prevents communication between neurons and muscle tissue.
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choreoathetoid — a condition characterized by aimless muscle movements and involuntary motions.
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computed tomography (CT) scan — an imaging technique that uses X-rays and a computer to create a picture of the brain''s tissues and structures.
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congenital cerebral palsy — cerebral palsy that is present at birth from causes that have occurred during fetal development.
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contracture — a condition in which muscles become fixed in a rigid, abnormal position, which causes distortion or deformity.
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cytokines — messenger cells that play a role in the inflammatory response to infection.
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developmental delay — behind schedule in reaching the milestones of early childhood development.
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disuse atrophy — muscle wasting caused by the inability to flex and exercise muscles.
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dyskinetic — the impairment of the ability to perform voluntary movements, which results in awkward or incomplete movements.
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dystonia (dystonic) a condition of abnormal muscle tone.
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electroencephalogram (EEG) — a technique for recording the pattern of electrical currents inside the brain.
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electromyography — a special recording technique that detects muscle activity.
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failure to thrive — a condition characterized by a lag in physical growth and development.
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focal (partial) seizure — a brief and temporary alteration in movement, sensation, or autonomic nerve function caused by abnormal electrical activity in a localized area of the brain.
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gait analysis — a technique that uses cameras, force plates, electromyography, and computer analysis to objectively measure an individual''s pattern of walking.
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gastroesophageal reflux disease (GERD) — also known as heartburn, which happens when stomach acids back up into the esophagus.
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gastrostomy — a surgical procedure that creates an artificial opening in the stomach for the insertion of a feeding tube.
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gestation — the period of fetal development from the time of conception until birth.
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hemianopia — defective vision or blindness that impairs half of the normal field of vision.
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hemiparesis — paralysis affecting only one side of the body.
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homonymous — having the same description, name, or term.
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hypertonia — increased muscle tone.
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hypotonia — decreased muscle tone.
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hypoxic-ischemic encephalopathy — brain damage caused by poor blood flow or insufficient oxygen supply to the brain.
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intracranial hemorrhage — bleeding in the brain.
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intrapartum asphyxia — the reduction or total stoppage of oxygen circulating in a baby''s brain during labor and delivery.
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intrathecal baclofen — baclofen that is injected into the cerebrospinal fluid of the spinal cord to reduce spasticity.
intrauterine infection — infection of the uterus, ovaries, or fallopian tubes (see pelvic inflammatory disease for a more detailed explanation).
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jaundice — a blood disorder caused by the abnormal buildup of bilirubin in the bloodstream.
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kernicterus — a neurological syndrome caused by deposition of bilirubin into brain tissues. Kernicterus develops in extremely jaundiced infants, especially those with severe Rh incompatibility.
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kyphosis — a humpback-like outward curvature of the upper spine.
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lordosis — an increased inward curvature of the lower spine.
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magnetic resonance imaging (MRI) — an imaging technique that uses radio waves, magnetic fields, and computer analysis to create a picture of body tissues and structures.
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nerve entrapment — repeated or prolonged pressure on a nerve root or peripheral nerve.
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neuronal migration — the process in the developing brain in which neurons migrate from where they are born to where they settle into neural circuits. Neuronal migration, which occurs as early as the second month of gestation, is controlled in the brain by chemical guides and signals.
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neuroprotective — describes substances that protect nervous system cells from damage or death.
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neurotrophins — a family of molecules that encourage survival of nervous system cells.
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off-label drugs — drugs prescribed to treat conditions other than those that have been approved by the Food and Drug Administration.
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orthotic devices — special devices, such as splints or braces, used to treat posture problems involving the muscles, ligaments, or bones.
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osteopenia — reduced density and mass of the bones.
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overuse syndrome (also called repetitive strain injury) — a condition in which repetitive movements or constrained posture cause nerve and muscle damage, which results in discomfort or persistent pain in muscles, tendons, and other soft tissues. This can happen in various parts of the body, but is most likely to happen in the arms, legs, or hands.
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palsy — paralysis, or the lack of control over voluntary movement.
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-paresis or -plegia — weakness or paralysis. In cerebral palsy, these terms are typically combined with other phrases that describe the distribution of paralysis and weakness; for example, quadriplegia means paralysis of all four limbs.
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pelvic inflammatory disease ( PID , also sometimes called pelvic infection or intrauterine infection ) — an infection of the upper genital tract (the uterus, ovaries, and fallopian tubes) caused by sexually transmitted infectious microorganisms. Symptoms of PID include fever, foul-smelling vaginal discharge, abdominal pain and pain during intercourse, and vaginal bleeding. Many different organisms can cause PID, but most cases are associated with gonorrhea and chlamydia.
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periventricular leukomalacia (PVL) — “peri" means near; "ventricular" refers to the ventricles or fluid spaces of the brain; and "leukomalacia" refers to softening of the white matter of the brain. PVL is a condition in which the cells that make up white matter die near the ventricles. Under a microscope, the tissue looks soft and sponge-like.
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placenta — an organ that joins a mother with her unborn baby and provides nourishment and sustenance.
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post-impairment syndrome — a combination of pain, fatigue, and weakness due to muscle abnormalities, bone deformities, overuse syndromes, or arthritis.
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quadriplegia — paralysis of both the arms and legs.
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respite care — rest or relief from caretaking obligations.
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Rh incompatibility — a blood condition in which antibodies in a pregnant woman''s blood attack fetal blood cells and impair an unborn baby''s supply of oxygen and nutrients.
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rubella — (also known as German measles) a viral infection that can damage the nervous system of an unborn baby if a mother contracts the disease during pregnancy.
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scoliosis — a disease of the spine in which the spinal column tilts or curves to one side of the body.
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selective dorsal rhizotomy — a surgical procedure in which selected nerves are severed to reduce spasticity in the legs.
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selective vulnerability — a term that describes why some neurons are more vulnerable than others to particular diseases or conditions. For example, motor neurons are selectively vulnerable to the loss or reduction in levels of the neurotransmitter dopamine, which results in the weakness and paralysis of amyotrophic lateral sclerosis (ALS, commonly called Lou Gehrig''s disease).
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spastic (or spasticity ) — describes stiff muscles and awkward movements.
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spastic diplegia (or diparesis ) — a form of cerebral palsy in which spasticity affects both legs, but the arms are relatively or completely spared.
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spastic hemiplegia (or hemiparesis ) — a form of cerebral palsy in which spasticity affects an arm and leg on one side of the body.
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spastic quadriplegia (or quadriparesis ) — a form of cerebral palsy in which all four limbs are paralyzed or weakened equally.
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stereognosia — difficulty perceiving and identifying objects using the sense of touch.
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strabismus — misalignment of the eyes, also known as cross eyes.
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telemetry wand — a hand-held device that acts as a remote control, directing the dosing level of a drug via a pump implanted beneath the skin.
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tonic-clonic seizure — a type of seizure that results in loss of consciousness, generalized convulsions, loss of bladder control, and tongue biting followed by confusion and lethargy when the convulsions end.
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tremor — an involuntary trembling or quivering.
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ultrasound — a technique that bounces sound waves off tissue and bone and uses the pattern of echoes to form an image, called a sonogram.
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