Cerebral Palsy

What is Cerebral Palsy?

Cerebral palsy is a term used to describe a group of chronic conditions affecting body movements and muscle coordination. It is caused by damage to one or more specific areas of the brain, usually occurring during fetal development, or during infancy. It can also occur before, during or shortly following birth. "Cerebral" refers to the brain and "Palsy" to a disorder of movement or posture. If someone has cerebral palsy it means that because of an injury to their brain (cerebral) they are not able to use some of the muscles in their body in the normal way (palsy). Children with cerebral palsy may not be able to walk, talk, eat or play in the same ways as most other children. Cerebral palsy is neither progressive nor communicable. It is also not "curable" in the accepted sense, although education, therapy and applied technology can help persons with cerebral palsy lead productive lives. It is important to know that cerebral palsy is not a disease or illness. It isn't contagious and it doesn't get worse. Children who have cerebral palsy will have it all their lives.

Cerebral palsy is characterized by an inability to fully control motor function, particularly muscle control and coordination. Depending on which areas of the brain have been damaged, one or more of the following may occur:

muscle tightness or spasm

involuntary movement

disturbance in gait and mobility

abnormal sensation and perception

impairment of sight, hearing or speech

Types of cerebral palsy:

Cerebral palsy is a broad term which encompasses many different disorders of movement and posture. To describe particular types of movement disorders covered by the term, pediatricians, neurologists, and therapists use several classification systems and many labels. To understand different types of cerebral palsy more clearly, you must first understand what professionals mean by muscle tone.

Muscle tone refers to the amount of tension or resistance to movement in a muscle. Muscle tone is what enables us to keep our bodies in certain position or posture. Changes in muscle tone is what enables us to move. For example, to bend your arm to brush your teeth, you must shorten (increase the tone of) the biceps muscles on the front of your arm at the same time you are lengthening (reducing the tone of) the triceps muscles on the back of your arm. To complete a movement smoothly, the tone in all muscle groups involved must be balanced. The brain must send messages to each muscle group to actively change its resistance.

All children with cerebral palsy have damage to the area of the brain that controls muscle tone. As a result, they may have increased muscle tone, reduced muscle tone, or a combination of the two (fluctuating tone). Which parts of their bodies are affected by the abnormal muscle tone depends upon where the brain damage occurs.

There are three main types of cerebral palsy:

spastic (stiff and difficult movement)
athetoid (involuntary and uncontrolled movement)
ataxic (disturbed sense of balance and depth perception)

(There may be a combination of these types for any one person)

Spastic cerebral palsy is the most common type of cerebral palsy. It affects about 80 percent of all children with cerebral palsy. Children with this type of cerebral palsy have one or more tight muscle groups which limit movement. If muscle tone is too high or too tight, the term spastic is used to describe the type of cerebral palsy. Children with spastic cerebral palsy have stiff and jerky movements because their muscles are too tight. They often have a hard time moving from one position to another. They may also have a hard time holding and letting go of objects. If your child has spastic cerebral palsy, it is because he or she has damage to the part of the brain that controls voluntary movements.

Low muscle tone and poor coordination of movements is described as ataxic cerebral palsy. Children with ataxic cerebral palsy look very unsteady and shaky. This rare form of cerebral palsy affects the sense of balance and depth perception. Affected persons often have poor coordination and walk unsteadily with a wide based gait, placing their feet unusually far apart. They have a lot of shakiness, like a tremor you might have seen in a very old person, especially when they are trying to handle or hold a small object such as a pen. Because of the shaky movements and problems coordinating their muscles, children with ataxic cerebral palsy may take longer than other children to complete certain tasks such and writing a sentence. This form affects about 5-10 percent of the children diagnosed with cerebral palsy.

About 10 percent of children with cerebral palsy have the athetoid type. Athetoid cerebral palsy is caused by damage to the cerebellum or basal ganglia. These areas of the brain normally process the signals that enable smooth, coordinated movements as well as maintaining body posture. Damage to these areas may cause a child to develop involuntary, purposeless movements, especially in the face, arms, and trunk. These movements often interfere with speaking, feeding, reaching, grasping, and other skills requiring coordinated movements. For example, involuntary grimacing and tongue thrusting may lead to swallowing problems, drooling and slurred speech. The movements often increase during periods of emotional stress and disappear during sleep. In addition, children with athetoid cerebral palsy often have low muscle tone and have problems maintaining posture for sitting and walking.

Mixed cerebral palsy:
About 10 percent of children with cerebral palsy have what is known a mixed-type cerebral palsy. These children have both the tight muscle tone of spastic cerebral palsy and the involuntary movements of athetoid cerebral palsy. This is because they have injuries to both the pyramidal and extrapyramidal areas of the brain. Usually the spasticity is more obvious at first, with involuntary movements increasing when the child is between nine months and three years old. The most common mixed form includes spasticity and athetoid movements, but other combinations are also possible.

History of cerebral palsy:

Cerebral palsy is not a new disorder. There have probably been children with cerebral palsy as long as there have been children. But the medical profession did not begin to study cerebral palsy as a distinct medical condition until 1861. In that year, an English orthopedic surgeon, Dr. William John Little, published the first paper describing the neurological problems of children with spastic diplegia. Spastic diplegia is still sometimes called Little's Disease. This was a disorder that struck children in the first years of life, characterized by stiff, spastic muscles in their arms and legs. These children had difficulty grasping objects, crawling, and walking. They did not show signs of improvement with age, nor did they become any worse.

The term cerebral palsy came into use in the late 1800's. Sir William Osler, a British medical doctor, is believed to have coined the term. Dr. Sigmund Freud, the Austrian neurologist better known for his work in psychiatry, published some of the earliest medical papers on cerebral palsy. In the early years, Dr. Little believed most cases of cerebral palsy were caused by obstetrical complications at birth. He suggested that children born with cerebral palsy were born following complicated deliveries, and that their condition was a result of lack of oxygen to the brain. He said this oxygen shortage damaged sensitive brain tissues controlling movement. But in the late 1800's, Freud disagreed. Noting that children with cerebral palsy often had other problems such as mental retardation, visual disturbances, and seizures, Freud suggested that the disorder might be caused earlier in life, during the brain's development in the womb.

Despite Freud's research on cerebral palsy, the belief that birth complications accounted for most cases was widespread among doctors, families, and even medical researchers. In the 1980's, scientists analyzed extensive data from a government study of more than 35,000 births. While they found that birth trauma was the cause of thousands of cerebral palsy cases, no cause could be found in the majority of cases. This has influenced researchers to explore other causes, and look at medical theories about cerebral palsy more closely.

Fortunately, in the past few decades, information on the many facets of cerebral palsy has significantly increased. Today, the medical community has great interest in studying cerebral palsy to determine its causes and the most effective ways to treat it. As knowledge and treatment techniques have expanded and improved, so too have the prospects of all children with cerebral palsy.

Can cerebral palsy be prevented?

Yes, cerebral palsy can be prevented. Several measures of prevention are increasingly possible today. Pregnant women are tested routinely for the Rh factor and, if Rh negative, they can be immunized within 72 hours after the birth and thereby prevent adverse consequences of blood incompatibility in a subsequent pregnancy. If the mother has not been immunized, the consequences of blood incompatibility in the newborn can be prevented by exchange transfusion in the baby. If the newborn baby has jaundice, this can be treated by photo therapy in the hospital nursery (baby is placed under lights). Failure to treat jaundice can result in severe brain damage. Other preventive programs are directed toward the prevention of prematurity, reducing exposure of pregnant women to infections, and reducing exposure to unnecessary X-rays. Also, measures are taken to control diabetes, anemia and other nutritional deficiencies. Cerebral palsy can also be prevented through optimal well being prior to conception, adequate prenatal care, and protecting infants from accidents or injury. More importantly, cerebral palsy can be prevented if the doctors and nurses caring for the expectant mother follow procedure and use good judgment when rendering care before, during, and after the delivery of a child.

Did a medical mistake cause your child's cerebral palsy?

As mentioned earlier, medical mistakes are the cause of thousands and thousands of cerebral palsy cases. Doctors and hospitals make mistakes during delivery, and it these mistakes that could be the cause of your child's cerebral palsy. The following are just a few of the mistakes made during delivery that have caused children to be born with cerebral palsy.

* leaving the child in the birth canal too long causing a lack of oxygen to the brain

* failure to recognize and treat seizures following delivery

* failure to detect a prolapsed cord (the umbilical cord can wrap around the child's neck, cutting off oxygen to the brain)

* excessive use of vacuum extraction

* improper use of forceps

* failure to perform a cesarean section in the presence of fetal distress

* not responding to changes in the fetal heart rate

* failure to plan a c-section (a large birth weight infant could compromise a normal spontaneous vaginal delivery)

* failure to respond to the mothers changing conditions, such as high blood pressure or toxemia

* failure to timely diagnose and treat jaundice

* failure to timely diagnose and treat meningitis

The doctors and nurses caring for the expectant mother and unborn child are responsible for providing safe and effective care before, during, and after birth. When procedure is not followed, and the standard of care is broken, permanent brain damage to the unborn child can occur. So how can you tell if a medical mistake occurred during the birth of your child? The following are indicators that a medical mistake may have caused your child's cerebral palsy:

1. emergency delivery with forceps, vacuum extraction, or cesarean section.

2. your child required resuscitation (CPR) after birth.

3. following delivery, your child was transferred to a different hospital, or spent time in the NICU (neonatal intensive care unit).

4. your child had seizures immediately after birth, or within the first 3-4 days of life.

5. your child required special testing after birth, such as an MRI, or brain scan.

6. your child required oxygen to facilitate breathing after birth.

7. a specialist was called to care for your newborn.

How is Cerebral Palsy Diagnosed?

When an infant or child has brain damage, a variety of symptoms can lead doctors and parents to suspect that something is wrong. In the first few months of life, an infant with brain damage may demonstrate some or all of the following symptoms:
Lethargy, or lack of alertness
Irritability or fussiness
Abnormal, high-pitched cry
Trembling of the arms and legs
Poor feeding abilities secondary to problems sucking and swallowing
Low muscle tone
Abnormal posture, such as the child favoring one side of their body
Seizures, staring spells, eye fluttering, body twitching
Abnormal reflexes
During the first six months of life, other signs of brain injury may also appear in an infants muscle tone and posture. These signs include:

Muscle tone may change gradually from low tone to high tone; a baby may go from floppy to very stiff
The child may hold his or her hand in tight fists
There may be asymmetries of movement, that is, one side of the body may move more easily and freely than the other side
The infant may feed poorly, with their tongue pushing food out of their mouth forcefully
Once a baby with brain damage reaches six months of age, it usually becomes quite apparent that he or she is picking up movement skills slower than normal. Infants with cerebral palsy are more often slow to reach certain developmental milestones, such as rolling over, sitting up, crawling, walking and talking. Parents are more likely to notice these developmental delays and abnormal behaviors, especially if this is not their first child. Sometimes when they express their concerns to their physicians, their child is immediately diagnosed as having cerebral palsy. More often, however, medical professionals hesitate to use the term "cerebral palsy"at first. Instead, they may use broader terms such as:

Developmental delay, which means that a child is slower than normal to develop movement skills such as rolling over and sitting up

Neuromotor dysfunction, or delay in the maturation of the nervous system

Motor disability, indicating a long term movement problem

Central nervous system dysfunction, which is a general term to indicate the brain's improper functioning

Static encephalopathy, meaning abnormal brain function that is not getting worse

So why do doctors frequently delay making a final diagnosis and prognosis when a child may have cerebral palsy? Part of the answer lies in the plasticity of a child's central nervous system, or it's ability to recover completely or partially after an injury occurs. The brains of very young children have a much greater capacity to repair themselves than do adult brains. If a brain injury occurs early, the undamaged areas of a child's brain can sometimes take over some of the functions of the damaged areas. Although the child may have some motor impairment, he or she can often make great progress in other motor skills.

Another reason doctors may delay a diagnosis of cerebral palsy is that a child's nervous system organizes over time. Damage to the brain may affect your child's motor abilities differently. For example, tone can go from low to high or vise versa, or involuntary movements can become more obvious. Generally, however, a child's motor symptoms stabilize by two to three years of age. After this age, tone is probably not going to change dramatically.

So what does all of this mean? It means that cerebral palsy is not diagnosed over night. Since the extent of your child's problems will probably not be clear for some time, his or her symptoms need to be monitored by an interdisciplinary team. This is a group of professionals with specialties in different areas. These health care professionals gather information on the child's accomplishments and make comparisons over the months and years of the child's life. They will keep you up to date on your child's current needs and problems, as well as the medical reasons for these problems, if known. When diagnosing cerebral palsy, the interdisciplinary team must first conduct an assessment, or evaluation of the child's strengths and needs in all areas. As your child grows older, additional assessments may be necessary.

In conclusion, cerebral palsy is diagnosed by a complete examination of your child's current health status. Doctors will test your child's motor skills and look carefully at his or her medical history. They will also look for slow development, abnormal muscle tone, and unusual posture. When diagnosing cerebral palsy, doctors must rule out other disorders that can cause abnormal movements. Cerebral palsy does not get worse, in other words, it is not progressive. Based on this fact, doctors must make the determination that your child's condition is not progressively getting worse. Doctors will also use a number of different specialized tests in diagnosing cerebral palsy. For example, the doctor may order a CT (computed tomography). This is an imaging of the brain that can determine underdeveloped areas of brain tissue. The doctor may also order an MRI (magnetic resonance imaging). This test also generates a picture of the brain to determine areas that may be damaged. In addition to these imaging tests, intelligence testing is also used. This helps to determine if a child is behind from a mental standpoint. In addition to diagnosing cerebral palsy through a complete and thorough examination of the child's abnormalities and behaviors, a review of the mother's pregnancy, labor and delivery and care received is also conducted.

Treatments Available for Cerebral Palsy:
Following your child's interdisciplinary assessment, the professionals providing care for your child will develop recommendations for his or her treatment. Many treatments are available to help a child function at the highest level possible. Although many treatments are available, we will touch upon a few of the most basic approaches used today to help a child achieve their optimal level of functioning.

Since no two children are affected by cerebral palsy in exactly the same way, individual treatment programs vary widely. But because all children with cerebral palsy have movement problems, you can expect that an important component of your child's treatment will be a therapeutic exercise program. Depending on your child's needs, a physical therapist, an occupational therapist, and a speech-language pathologist will work with your child to help him or her improve posture and movement.

Physical Therapy: A physical therapist specializes in improving the development of the large muscles of the body, such as those in the legs, arms and abdomen (gross motor skills). Physical therapists help children learn better ways to move and balance. They may help children with cerebral palsy learn to walk, use a wheelchair, stand by themselves, or go up and down stairs safely. Physical therapists will also work on fun skills such as running, kicking and throwing, or learning to ride a bike. Physical therapy usually begins in the first few years of life, or soon after the diagnosis of cerebral palsy is made. These therapists use specific sets of exercises to work toward the prevention of musculoskeletal complications. An example of this is preventing the weakening or deterioration of muscles that can develop with lack of use. Also, physical therapy will help avoid contractures, in which muscles become fixed in a rigid, abnormal position. Physical therapy will help prevent muskuloskeletal problems, as well as helping your child perform common everyday activities.

Occupational Therapy: An occupational therapist specializes in improving the development of the small muscles of the body, such as the hands, feet, face, fingers and toes. These therapists also teach daily living skills such as dressing and eating, as well as making sure children are properly positioned in wheelchairs. They may teach your child better or easier ways to write, draw, cut with scissors, brush their teeth, dress, and feed themselves. Occupational therapists will also help your child find the right special equipment to make everyday jobs a little easier.

Speech / Language Therapist: A speech and language therapist helps develop better control of the jaw and mouth muscles, which can improve speech and language skills and eating abilities. They also help develop creative communication methods for those who can not speak. A speech and language therapist will work with your child on communication skills. This means talking, using sign language, or using a communication aid. Children who are able to talk may work with a speech therapist on making their speech clearer, or on building their language skills by learning new words, learning to speak in sentences, or improving their listening skills. Children who can not talk may learn sign language, or how to use special equipment such as a computer that actually talks for you.

At first, your child will likely see his or her therapist quite often, sometimes at least twice a week. As your child grows, he or she may need a less intensive program. The therapists will probably expect you to work on the child's movement skills at home, and will train you in special exercises and handling techniques. Because the time commitment to a therapy program is tremendous, it is wise for both parents, or other caretakers, to be involved. In general, it is considered very early intervention if a baby begins therapy before six months of age. Most infants are not referred until later in the first year or sometime in the second year of life. Of course, the age at which your child is referred will depend to some extent on how quickly the physicians diagnose cerebral palsy, or other problems requiring therapy. Researchers are still studying the long term benefits therapy can offer. But it is generally agreed that children who receive good treatment not only have fewer movement limitations, but also have better postures, better muscle development, and better abilities in toileting, feeding, and dressing themselves. Furthermore, therapy programs enrich children's lives by enabling them to explore and experience activities that they might not otherwise be able to do independently.

Medical Treatment: There are two major medical treatments that help children with cerebral palsy achieve their optimal level of functioning.

1) Surgery: Surgery is not always necessary, but it is sometimes recommended to improve muscle development, correct contractures, and reduce spasticity in the legs. Before selecting any surgical procedure, make sure the doctor thoroughly discusses the risks involved, long-term effects and postoperative follow-up. Also, always get a second opinion and speak with other parents whose children have had the same surgical procedure.

Children with cerebral palsy often walk on their toes. This may indicate a tight heel cord. When other treatments for this fail, such as splints and braces, surgery may help correct it by lengthening the tendon. This surgery may help improve the child's ability to walk, improve balance, and prevent further deformity. Surgery is also available to relieve spacticity in the legs and hips of children. This surgery involves identifying sensory nerve fibers being the spinal cord, and then selectively cutting those nerve fibers therefor reducing spacticity. Research on this surgery is still being conducted. The adductors are muscle groups that bring the legs together. If a child's physician determines that the adductors are causing deformities or problems with walking, he or she may suggest a surgical procedure to cut the tendon, which can release muscle contractures and improve mobility. Again, surgery may not always be necessary, but in many instances it can help your child achieve his or her optimal level of functioning.

2) Drug Therapy: Your child's doctor may prescribe drugs to prevent or control seizures associated with cerebral palsy. These drugs are very effective in preventing seizures in many children. Because there are different types of seizures, different drugs may be prescribed because no one drug prevents or controls all types of seizures. Such drugs may include Tegretol, Dilantin and Phenobarbital. Drug therapy can also help reduce spacticity associated with cerebral palsy. These drugs include Diazepam, Baclofen, and Dantrolene. If surgery is contradicted, these drugs can help reduce spacticity for short periods, however, their long term value is still being researched. Although drug therapy may not completely correct complications associated with cerebral palsy, evidence does show that it helps manage problems such as seizures and spactisity. Consult with a physician to find out if drug therapy is appropriate for your child.

One other approach to help children with cerebral palsy achieve their optimal level of functioning is Sensory Integration Therapy. This therapy helps to overcome problems experienced by many young children in absorbing and processing sensory information. Encouraging these abilities ultimately improves balance and steady movement. Therapies include stimulating touch sensations and pressures on different parts of the body. With the use of certain items, such as Styrofoam chips, water, or textured toys, this therapy will also motivate children to learn sequences of movements.

Special equipment is also available for children with cerebral palsy. Because of the muscle problems children with cerebral palsy have, your child's doctor or therapist may recommend them using some special equipment to help them get around or do everyday activities.

A Wheelchair is sometimes used when a child cannot walk. This will allow the child to move from one place to another. Many children with cerebral palsy can use their arms to roll the wheels of their wheelchair themselves, and can move around without much difficulty at all. There are also wheelchairs available that are motorized. This type of wheelchair has a motor that moves the wheels for the child. There may be a joystick on one arm rest that the child can operate on his or her own.

A Walker is a piece of equipment usually made out of light metal. It most often will have four legs that are adjustable in height. Some children with cerebral palsy can walk, but have poor balance and fall a lot. They use a walker to help them balance and get around without the use of a wheelchair. You may also see a walker with wheels on it, as well as a basket to put some of the child's belongs in.

Because of the fine motor problems often associated with cerebral palsy, children may have a hard time using utensils for eating. Special handles or grips are available for children who have trouble holding onto small objects, such as a fork or spoon. You may also find eating utensils that are specially designed for children with fine motor problems. They may be curved or bent, and are usually designed to fit the child's needs. Special grips and handles are also used on pencils and pens to make them easier for the child to hold and use.

Communication Aids are available for children who are hard to understand, or who have difficulty talking with others. A communication aid might be a book or poster with pictures that show things the child might want, or an alphabet board that the person can use to spell out their message. There are also computers that are used as communication aids that actually talk for the child.

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What research is being done?
National research programs are being vigorously pursued to prevent cerebral palsy and to improve the quality of life for persons with cerebral palsy. The two organizations with major research programs are the United Cerebral Palsy Research and Educational Foundation in the private sector and the National Institutes of Health in the Government sector.