I Have Got 99 Problems, Cerebral Palsy Is just One” said Maysoon Zayid in TED Talk.
My name is Maysoon Zayid, and I am not drunk, but the doctor who delivered me was. He cut my mom six different times in six different directions, suffocating poor little me in the process. As a result, I have cerebral palsy, which means I shake all the time.
Look. It’s exhausting. I’m like Shakira, Shakira meets Muhammad Ali. CP is not genetic. It’s not a birth defect. You can’t catch it. No one put a curse on my mother’s uterus, and I didn’t get it because my parents are first cousins, which they are.It only happens from accidents, like what happened to me on my birth day.Now, I must warn you,I’m not inspirational. And I don’t want anyone in this room to feel bad for me, because at some point in your life, you have dreamt of being disabled.
Come on a journey with me. It’s Christmas Eve, you’re at the mall, you’re driving around in circles looking for parking, and what do you see?
Sixteen empty handicapped spaces. And you’re like, “God, can’t I just be a little disabled?” Also, I’ve got to tell you, I’ve got 99 problems, and palsy is just one.
HISTORY OF CEREBRAL PALSY
In the 1860s, an English surgeon named William Little wrote the first medical descriptions of a strange disorder that attacked children in the early years of life, causing spastic and stiff muscles in the legs and to a lesser degree, in the arms. These children had difficulty grasping objects, crawling and walking. Unlike most other diseases that affect the brain, this disease did not get worse as children grew older. On the other hand, their disabilities remained relatively the same.
The disorder, which was called Little’s disease for many years, is now known as spastic diplegia. It is one of a set of disorders that affect movement control and ]are grouped under the unifying term of “cerebral palsy.”
Because it appeared that many of Little’s patients had been born following preterm and complicated births, the doctor suggested that his illness was the result of oxygen deprivation during birth, damaging sensitive brain tissues that control movement. But in 1897, the famous psychiatrist Sigmund Freud did not agree. Noting that children with cerebral palsy often had other neurological problems such as mental retardation, visual disturbances, and seizures, Freud suggested that the disorder could have roots earlier in life, during the development of the brain in the womb. “Difficult births, in certain cases,” he wrote, “are only a symptom of deeper effects that influence the development of the fetus.”
Despite Freud’s observation, for many decades the belief that complications of childbirth caused most cases of cerebral palsy was general among physicians, families and even among medical researchers. In the 1980s, however, scientists funded by the National Institute of Neurological Disorders and Stroke (NINDS) analyzed extensive data from more than 35,000 newborns and their mothers and discovered that complications during birth and labor Labor accounted for just a fraction of babies born with cerebral palsy – probably less than 10 percent. In most cases, they could not find a single and obvious cause.
This finding challenged accepted medical theory about the cause of cerebral palsy. It also stimulated researchers to look for other factors before, during and after birth that was associated with the disorder.
Advances in imaging technology, such as magnetic resonance imaging (MRI), have given researchers a way to look inside the brains of babies and children with cerebral palsy and to discover unique structural malformations and areas of interest. Hurt. Basic science studies have identified mutations and genetic deletions associated with the abnormal development of the fetal brain. These findings offer provocative clues about what can go wrong during brain development to cause the abnormalities that lead to cerebral palsy.
Much of the new understanding of what causes cerebral palsy is the result of research spanning the past two decades that has been sponsored by the NINDS, the main sponsor of the federal government’s neurological research. These findings from the NINDS research have:
- Identified new causes and risk factors for cerebral palsy;
- Increased our understanding of how and why brain damage and critical stages of fetal development cause cerebral palsy;
- Improved surgical techniques to correct abnormalities in muscles and bones;
- Discovered new medications to control spastic and rigid muscles and developed more precise methods of administering them;
- Tested the effectiveness of the therapies used to treat cerebral palsy and to discover which method works best.
This comprehensive article describes what is cerebral palsy, cerebral palsy causes, cerebral palsy life expectancy, cerebral palsy signs, cerebral palsy symptoms, cerebral palsy treatments, how it could possibly be prevented and much more. Medical terms are defined in the glossary at the end of the article.
WHAT IS CEREBRAL PALSY?
Doctors use the term cerebral palsy to refer to any of a number of neurological disorders that appear in childhood or early childhood and that permanently affect body movement and muscle coordination but do not evolve, in other words, They do not get worse over time. The term brain refers to the two halves or hemispheres of the brain, in this case, the motor area of the outer layer of the brain (called the cerebral cortex), the part of the brain that directs muscle movement; Paralysis refers to the loss or deterioration of motor function.
Even when cerebral palsy affects muscle movement, it is not caused by problems in the muscles or nerves, but by abnormalities within the brain that interrupt the brain’s ability to control movement and posture.
In some cases of cerebral palsy, the cerebral motor cortex has not developed normally during fetal growth. In others, the damage is the result of a brain injury before, during or after birth. In any case, the damage is not repairable and the resulting incapacities are permanent.
Cerebral palsy in children exhibit a wide variety of symptoms, including:
- The lack of muscular coordination when performing voluntary movements (ataxia);
- Tense and rigid muscles and exaggerated reflexes (spasticity);
- Walk with one foot or drag one leg;
- Walking on tiptoe, a crouched gait, or walking “in scissors;”
- Variations in muscle tone, very rigid or very hypotonic;
- Excessive drooling or difficulty swallowing or talking;
- Shaking (trembling) or random involuntary movements; Y
- Difficulty with precise movements, such as writing or buttoning a shirt.
The symptoms of cerebral palsy differ in the type and severity of one person to another, and may even change in an individual over time. Some people with cerebral palsy also have other medical conditions, such as mental retardation, seizures, impaired vision or hearing, and abnormal physical sensations or perceptions.
Cerebral palsy does not always cause profound disabilities. While a child with severe cerebral palsy may be unable to walk and needs extensive and lifelong attention, another with mild cerebral palsy may be only somewhat clumsy and not require special assistance.
There is no cure for cerebral palsy, but supportive treatment, medications, and surgery can help many individuals improve their motor skills and the ability to communicate with the world.
HOW MANY PEOPLE SUFFER FROM CEREBRAL PALSY?
Christina’s Cerebral Palsy Story
The United Cerebral Palsy Foundation (UCP) estimates that about 800,000 children and adults in the United States live with one or more of the symptoms of cerebral palsy. According to the federal Centers for Disease Control and Prevention, every year about 10,000 babies born in the United States will get cerebral palsy.
Despite advances to prevent and treat certain causes of cerebral palsy, the percentage of infants who contract the condition has remained the same for the past 30 years. Improved care in neonatal intensive care units has resulted in higher survival rates for very low birth weight babies. Many of these babies will have developmental defects in their nervous systems or suffer brain damage that will cause the characteristic symptoms of cerebral palsy.
EARLY SIGNS OF CEREBRAL PALSY
From birth to age 5, children must reach certain motor indicators-known as developmental indicators-such as turning, sitting, standing and walking. Delays in reaching these motor indicators could be a sign of cerebral palsy. It is important to note that some children may present some of these signs even if they do not have cerebral palsy. The following are other signs of a possible cerebral palsy.
In babies from 3 to 6 months of age:
- The head falls backwards when they are lying on their backs and they are lifted.
- The muscles are rigid.
- The muscles are flaccid.
- The back and neck seem to stretch excessively when they are in arms.
- The legs become rigid and cross like scissors when they are lifted.
In babies older than 6 months of age:
- When they are lying down, they do not turn to either side to face up or face down.
- They can not put their hands together.
- They have difficulty putting their hands to their mouths.
- They try to reach things with one hand and have the other hand.
In babies older than 10 months of age:
- They crawl unevenly, pushing with one hand and one leg while dragging the opposite hand and leg.
- They move by jumping on the buttocks or knees, but do not crawl on the hands and knees.
CEREBRAL PALSY SYMPTOMS
Early signs of cerebral palsy usually appear before the child reaches 3 years of age. Parents are often the first to suspect that their baby’s motor skills are not developing normally. Babies with cerebral palsy often have developmental delays, in which they are slow to reach developmental milestones such as learning to roll over, sit, crawl, smile or walk. Some babies with cerebral palsy have abnormal muscle tone when they are babies. The decreased muscle tone (hypotonia) can make them appear relaxed, even hypotonic. Increased muscle tone (hypertonia) can make them appear stiff and rigid. In some cases, an early period of hypotonia will progress to hypertonia after the first 2 to 3 months of life. Children with cerebral palsy may also have an unusual posture or favor a side of the body when they move.
Parents concerned about the development of their baby for any reason should contact their pediatrician. A doctor can determine the difference between a normal developmental gap and a delay that could indicate cerebral palsy.
CEREBRAL PALSY CAUSES
Most 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. In the past, when doctors could not identify another cause, they attributed most cases of congenital cerebral palsy to problems or complications during labor that caused suffocation (a lack of oxygen) during birth. However, extensive research by NINDS scientists and others has shown that few babies who have asphyxia during birth grow up and have cerebral palsy or any other neurological disorder. It is now estimated that birth complications, including asphyxia, are responsible for only 5 to 10 percent of babies born with congenital cerebral palsy.
A small number of children have acquired cerebral palsy, which means that the disorder begins after birth. In these cases, doctors can often point to a specific reason for the problem, such as brain damage in the first months or years of life, brain infections such as bacterial meningitis or viral encephalitis, head injury due to a car accident, a fall, or child abuse.
What causes the remaining 90 to 95 percent? The research has given us a larger and more accurate picture of the types of episodes that can occur during early fetal development, or just before, during and after birth, that cause the particular types of brain damage that will cause congenital cerebral palsy. There are multiple reasons why cerebral palsy occurs, for example as a result of genetic abnormalities, infections or maternal fever, or fatal injuries. But in all cases the disorder is the result of four types of brain damage that cause their characteristic symptoms:
Damage to the white matter of the brain (periventricular leukomalacia [PVL, acronym in English]
The white matter of the brain is responsible for transmitting signals within the brain and to the rest of the body. PVL describes a type of damage that resembles small holes in the white matter of a baby’s brain. These gaps in brain tissue interfere with the normal transmission of signals. There are a number of episodes that can cause PVL, including maternal or fetal infection. 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 the periventricular white matter is particularly sensitive to aggression and injury.
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 prevent the brain from developing normally. Infections, fevers, trauma, or other diseases that cause unhealthy conditions in the uterus place the unborn baby’s nervous system at risk.
Cerebral hemorrhage (intracranial hemorrhage)
Intracranial hemorrhage describes bleeding inside the brain caused by blocked or broken blood vessels. A common cause of this type of damage is a fatal stroke. Some babies have a stroke while still in the womb due to 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 abnormalities in blood clotting. High maternal blood pressure (hypertension) is a common medical disorder during pregnancy that has been shown to cause a fatal stroke. It has also been shown that maternal infection, especially pelvic inflammatory disease, increases the risk of fatal stroke.
Brain damage caused by 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 by low oxygen supply, is common in babies due to the stress of labor and delivery. But even if a newborn’s blood is equipped to compensate for low oxygen levels in the short term, if the oxygen supply is interrupted or reduced for long periods, the baby can develop a type of brain damage called hypoxic-ischemic encephalopathy, that destroys brain motor cortex tissue and other areas of the brain. This type of damage can also be caused by very low maternal blood pressure, rupture of the uterus, detachment of the placenta or problems with the umbilical cord.
CEREBRAL PALSY RISK FACTORS
Just as there are particular types of brain damage that cause cerebral palsy, there are also certain diseases or events that can occur during pregnancy and childbirth that will increase the risk of a baby being born with cerebral palsy. Researchers have examined hundreds of pregnant women, followed them until birth, and monitored the early neurological development of their children to establish these risk factors. If a mother or her baby has any of these risk factors, it does not mean that cerebral palsy is unavoidable, but it increases the likelihood of the types of brain damage that cause it.
Low birth weight and premature birth
The risk of cerebral palsy is higher among babies who weigh less than 5½ pounds at birth or who are born at less than 37 weeks of pregnancy. The risk increases as the birth weight decreases or the weeks of gestation shorten. Intensive therapy for premature babies has dramatically improved over the past 30 years. Babies born very prematurely are surviving, but with medical problems that can put them at risk for cerebral palsy. Although babies of normal or greater weight are at a relatively low individual risk of having cerebral palsy, babies near term or term still account for half of the babies born with the disease.
The twins, triplets and other multiple births, even those born at term, are linked to an increased risk of having cerebral palsy. The death of the twin or triplet of a baby increases the risk more.
Infections during pregnancy
Infectious diseases caused by viruses, such as toxoplasmosis, rubella, cytomegalovirus, and herpes, can infect the uterus and the placenta. Currently, researchers think that maternal infection leads to high levels of immune system cells called cytokines that circulate in the brain and blood of the fetus. The cytokines respond to the infection triggering an inflammation, this can then continue to cause damage to the central nervous system of an unborn baby. Maternal fever during pregnancy or childbirth can also trigger this type of inflammatory response.
Rh incompatibility is a condition that develops when the mother’s Rh blood group (positive or negative) is different from the baby’s blood group. Because the blood cells of the baby and mother are mixed during pregnancy, if a mother is negative and her baby is positive, for example, the mother’s system will not tolerate the presence of Rh-positive red blood cells. Your body will begin to make antibodies that will attack and kill your baby’s blood cells. Rh incompatibility is routinely evaluated and treated in the United States, but the situation in other countries continues to make blood group incompatibility a risk factor for cerebral palsy.
Exposure to toxic substances
Mothers who have been exposed to toxic substances during pregnancy, such as methylmercury, are at higher risk of having a baby with cerebral palsy.
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.
There are also diseases during labor and delivery and immediately after delivery that acts as warning signs of increased risk of having cerebral palsy. Knowing these warning signs helps doctors maintain control over children at higher risk. However, parents should not be alarmed if their baby has one or more of these conditions at birth. Most of these children will not get cerebral palsy. The warning signs are:
Babies with cerebral palsy are more likely to be in a breech position (first the feet) instead of the head first at the start of labor.
Labor and delivery difficult
A baby who has vascular or respiratory problems during labor and delivery may already have suffered brain damage or abnormalities.
Small for gestational age
Babies born smaller than normal for their gestational age are at risk of having cerebral palsy due to factors that prevented them from growing naturally in the womb.
Apgar scores low.
The Apgar score is a numbered classification that reflects the status of a newborn. To determine an Apgar score, doctors periodically check the heart rate, breathing, muscle tone, reflexes, and color of the baby’s skin during the first few minutes after birth. Then they assign points; the higher the score, the more normal the baby’s condition will be. A low score at 10-20 minutes after delivery is often considered an important sign of potential problems such as cerebral palsy.
More than 50 percent of newborns develop jaundice after birth when bilirubin, a substance normally found in bile, accumulates more rapidly than what their livers can metabolize and take out of the body. Severe untreated jaundice can cause a neurological condition known as kernicterus, which kills brain cells and can cause deafness and cerebral palsy.
A baby who has seizures faces a higher risk of being diagnosed later in childhood with cerebral palsy.
CEREBRAL PALSY LIFE EXPECTANCY
Life Expectancy for People with HIE and Cerebral Palsy
The life expectancy of people with hypoxic-ischemic encephalopathy depends greatly on the degree to which they are affected and their access to treatments and therapies. For this reason, it is difficult to provide an “average” life for people with hypoxic-ischemic encephalopathy. Because many children with hypoxic-ischemic encephalopathy are also diagnosed with cerebral palsy, it may be more useful to review life expectancies for people with cerebral palsy.
People with very mild cerebral palsy usually live as long as their contemporaries. In general, life expectancy for a person with cerebral palsy depends on the extent to which they are affected:
- Life expectancy for patients with moderate cerebral palsy: For people with moderate cerebral palsy (defined as “walking without help”), life expectancy in women has been estimated between 70 and 80 years and in men among 66 and 76 years.
- Life expectancy for patients with severe cerebral palsy: For those who are more severely affected (paralysis defined as an inability to lift the head and who need to be fed by a tube), life expectancy has been estimated lower than before. for women as for men, according to the medical care they have received.
These life expectancies were taken from a study carried out in 2008 in Child Development and Neurology Medicine. Click here to see the document that contains a detailed table with life expectancy for people with cerebral palsy. This takes into account age, sex, ability to move and feeding mechanism.
CEREBRAL PALSY PREVENTION
Cerebral palsy related to genetic abnormalities cannot be avoided, but some of the risk factors for congenital cerebral palsy can be controlled or avoided. For example, rubella can be avoided if women are vaccinated against the disease before becoming pregnant. Rh incompatibilities can also be controlled early in pregnancy. But there are still risk factors that cannot be controlled or avoided despite medical intervention.
For example, the use of electronic fetal monitoring machines to record the heartbeat of an unborn baby during labor, and the use of emergency cesarean section when there are significant signs of fetal distress has not diminished the number of babies born with cerebral palsy. Interventions to treat other prenatal causes of cerebral palsy, such as therapies to prevent prenatal stroke or antibiotics to cure intrauterine infections, are difficult to administer or have not yet been proven to decrease the risk of cerebral palsy in vulnerable infants.
Fortunately, acquired cerebral palsy, often due to a cranial injury, can be prevented by using common safety tactics, such as the use of car seats for infants and young children, and by making sure that young children wear helmets when riding a bicycle. In addition, common sense measures at home, such as closely monitoring babies and young children when they bathe, can reduce the risk of accidental injury.
Despite the best efforts of parents and doctors, children will still be born with cerebral palsy. Because in many cases the cause or causes of cerebral palsy are not completely known, little can currently be done to prevent it. As researchers learn more about the causes of cerebral palsy through basic and clinical research, doctors and parents will know more about how to prevent this disorder.
CEREBRAL PALSY TYPES
The specific forms of cerebral palsy are determined by the scope, type, and location of the child’s abnormalities. Doctors classify cerebral palsy according to the type of movement disorder involved: spastic (rigid muscles), athetoid (torsional movements), or ataxia (poor coordination and balance), plus any additional symptoms. Doctors will often describe the type of cerebral palsy a child has based on which members are affected. The names of the most common forms of cerebral palsy use terms in Latin to describe the location or number of affected limbs, combined with the words for debilitated (paresis) or paralyzed (plejía). For example, hemiparesis (hemi = medium) indicates that only one side of the body is weakened. Quadriplegia (quad = four) means that all members are paralyzed.
Hemiplegia / spastic hemiparesis
This type of cerebral palsy typically affects the arm and hand on one side of the body, but may also include the leg. Children with spastic hemiplegia will usually walk on toes later because of the tightness of the tendons at the ankles. The arm and leg on the affected side are often shorter and thinner. Some children will develop an abnormal curvature of the spine (scoliosis). Depending on the location of brain damage, a child with spastic hemiplegia may also have seizures. The language will be delayed and in an ideal situation will be competent, but intelligence is usually normal.
Spastic diplegia / diparesia
In this type of cerebral palsy, muscle rigidity is predominantly in the legs and affects the arms and face with less intensity, although the hands may be clumsy. The reflexes of the tendons are hyperactive, the toes point upwards. The tightness of certain muscles of the legs causes them to move like the arms of a scissor. Children with this type of cerebral palsy may need a walker or leg braces. Generally, intelligence and language skills are normal.
Quadriplegia / spastic quadriparesis
T0his is the most severe form of cerebral palsy, often associated with moderate to severe mental retardation. It is caused by widespread brain damage or significant brain malformations. Often children will have intense stiffness of the limbs but a flaccid neck. They will rarely be able to walk. Speaking and being understood is difficult. Seizures can be frequent and dfficult to control.
Cerebral dyskinetic paralysis (also includes athetosis, choreoathetosis, and dystonic cerebral palsies)
This type of cerebral palsy is characterized by uncontrolled twisting movements of the hands, feet, arms or legs. In some children, hyperactivity in the muscles of the face and tongue makes them gesticulate and drool. They find it difficult to sit upright or walk. Children may also have trouble coordinating the muscle movements needed to talk. Rarely is intelligence affected in these forms of cerebral palsy?
Ataxic cerebral palsy
This rare type of cerebral palsy affects balance and depth perception. Children often have poor coordination and walk unsteady with a wide gait, placing their feet unusually far apart. They have difficulty with fast or precise movements, such as writing or buttoning a shirt. They may also have intentional tremor, in which a voluntary movement such as taking a book is accompanied by a tremor that gets worse the closer the object’s hands are.
It is common for children to have symptoms that do not correspond to any type of cerebral palsy. Your symptoms are a mixture of types. For example, a child with mixed cerebral palsy may have some muscles that are very tight and others very relaxed, creating a mixture of stiffness and flaccidity.
WHAT CONDITIONS ARE ASSOCIATED WITH CEREBRAL PALSY?
Many individuals with cerebral palsy do not have additional medical disorders. However, because cerebral palsy involves the brain and that it controls so many functions of the body, cerebral palsy can also cause seizures, impaired intellectual development, and affect vision, hearing, and behavior. Facing these disabilities can be more challenging than facing the motor impairments of cerebral palsy.
These additional diseases are:
Two-thirds of individuals with cerebral palsy will have intellectual damage. Mental deterioration is more common among those with spastic quadriplegia than in those with other types of cerebral palsy, and children who have epilepsy and an electroencephalogram (EEG) or abnormal MRI are also more likely to have mental retardation.
Approximately half of the cerebral palsy in children have seizures. Seizures can take the classic form of tonic-clonic sizures as the less obvious focal (partial) seizures in which the only symptoms may be muscle tics or mental confusion.
Delay of growth and development
A syndrome called growth failure is common in children with moderate to severe cerebral palsy, especially those with spastic quadriparesis. Growth failure is a general term used by physicians to describe children who are lagging behind in growth and development. In babies, this delay usually takes the form of very little weight gain. In young children, it can appear as abnormal short stature, and in adolescents, it can appear as a combination of short stature and lack of sexual development.
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 the limbs on the affected side of the body may not grow as fast or as long as those on the normal side.
Deformities of the column
The deformities of the spine: curvature (scoliosis), hump (kyphosis), and back in the saddle (lordosis), are associated with cerebral palsy. Deformities of the spine can make sitting, standing, and walking difficult and cause chronic back pain.
Vision, hearing, and language impaired
A large number of cerebral palsy in children have strabismus, commonly called “squint,” in which the eyes are misaligned due to differences between the right and left eye muscles. In an adult, strabismus causes double vision. In children, the brain adapts to the condition by ignoring the signals of one of the misaligned eyes. If left 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.
Children with hemiparesis may have hemianopia, which is defective vision or blindness that clouds the normal field of vision in one eye. In the homonymous hemianopia, the damage affects the same part of the visual field in both eyes.
Hearing impairment is also more common among those with cerebral palsy compared to the general population. Speech and language disorders, such as difficulty in forming words and speaking clearly, are present in more than a third of those with cerebral palsy.
Some individuals with cerebral palsy are drooling because they have little control of the muscles of the neck, mouth, and tongue. Drooling can cause intense irritation of the skin. Because it is not socially acceptable, drooling can also isolate children from their peers.
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 wetting the bed, uncontrolled urination during physical activities, or slow loss of urine throughout the day.
Sensations and abnormal perception
Some children with cerebral palsy have difficulty feeling simple sensations, such as touch. They can have stereognosis, which makes it difficult to perceive and identify objects using only the sense of touch. For example, a child with stereognosis would have trouble closing his eyes and feeling the difference between a hard ball and a sponge ball placed in his hand.
CEREBRAL PALSY DIAGNOSIS
Early signs of cerebral palsy may be present from birth. Most cerebral palsy in children are diagnosed during the first 2 years of life. But if the child’s symptoms are mild, it can be difficult for the doctor to make a reliable diagnosis before 4 or 5 years of age. However, if a doctor suspects cerebral palsy, he or she will most likely schedule an appointment to observe the child and talk with parents about their child’s physical and behavioral development.
Doctors diagnose cerebral palsy by evaluating a child’s motor skills and observing their medical history carefully and painstakingly. In addition to looking for the most characteristic symptoms – slow development, abnormal muscle tone, and unusual posture – the doctor should also rule out other disorders that can cause similar symptoms. Most importantly, a doctor must determine that the child’s condition is not getting worse. Although the symptoms may change over time, cerebral palsy by definition does not evolve. If the child continually loses motor skills, the problem is likely to begin elsewhere – such as a genetic or muscular disease, a metabolic disorder, or tumors in the nervous system. A complete medical history, special diagnostic tests, and, in some cases, repeated tests can help confirm that other disorders are not the problem.
Additional tests are often used to rule out other movement disorders that may cause the same symptoms as cerebral palsy. Neuroimaging techniques that allow doctors to look inside the brain (such as an MRI) can detect abnormalities that indicate a potentially treatable movement disorder. If it is cerebral palsy, the MRI can also show the doctor the location and type of brain damage.
Methods with neuroimaging include:
- Cranial ultrasound. This test is used for high-risk premature babies because it is the least invasive of imaging techniques, although it is not as successful as the two methods described below to capture the subtle changes in white matter – the type of brain tissue that is damaged in cerebral palsy.
- Computed tomography (CT). This technique creates images that show the structure of the brain and areas of damage.
- Magnetic resonance imaging (MRI). This test uses a computer, a magnetic field, and radio waves to create an anatomical image of the tissues and structures of the brain. Doctors prefer MRI images because they offer better levels of detail.
In rare cases, metabolic disorders can be masked as cerebral palsy and some children will require more tests to rule them out. Most metabolic disorders of childhood have abnormalities or characteristic brain malformations that will appear in an MRI.
Other types of disorders can be confused with 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 often the cause of hemiplegic cerebral palsy, a doctor may find it necessary to perform diagnostic tests in children with this type 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.
To confirm a diagnosis of cerebral palsy, a doctor can refer a child to other doctors with specialized knowledge and training, such as a child neurologist, developmental pediatrician, ophthalmologist (eye doctor), or otologist (ear doctor). Additional observations help the doctor make a more accurate diagnosis and begin to develop a specific treatment plan.
HOW IS CEREBRAL PALSY HANDLES?
Cerebral palsy cannot be cured, but often the treatment will improve the child’s abilities. Many children progress to enjoy almost normal lives as adults if their disabilities are adequately controlled. In general, the sooner treatment begins, the better the children’s chances of overcoming developmental disabilities or of learning new ways to complete tasks that involve a challenge for them.
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 medical professionals will work with a child and their parents to identify specific impairments and needs, and then develop an appropriate plan to address the essential disabilities that affect the quality of the child’s life.
A comprehensive management plan will include a combination of health care professionals experienced in the following:
Physiotherapy to improve gait and the way to do it, stretch the spastic muscles and prevent deformities;
Occupational therapy to develop compensation techniques for everyday activities such as dressing, going to school and participating in daily activities;
Speech therapy to address swallowing disorders, language difficulties, and other communication obstacles;
Behavioral therapy and counseling
Behavioral therapy and counseling to address emotional and psychological needs and help children emotionally cope with their disabilities;
Medications to control seizures, relax muscle spasms, and relieve pain;
Surgery to correct anatomical abnormalities or release tight muscles;
Appliances and other orthotic devices
Appliances and other orthotic devices to compensate for muscle imbalance, improve posture and walking, and increase independent mobility;
Mechanical assistance such as wheelchairs and wheeled walkers for individuals who are not independently mobile; Y
Communication aids such as computers, speech synthesizers, or symbols boards to allow severely damaged individuals to communicate with others.
Doctors use tests and assessment 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 necessary therapies within a single treatment center. The centers also focus on the needs of parents, often offering support groups, child care services, and respite care.
Members of the treatment team for a child with cerebral palsy will most likely include the following:
A doctor, such as a pediatrician, a pediatric neurologist, or a pediatric physiatrist, trained to help children with developmental disabilities. This physician, who often acts as a leader of the treatment team, integrates the professional advice of all team members into a comprehensive plan, ensures that the plan is properly implemented, and tracks the child’s evolution over a number of years.
A traumatologist, a surgeon who specializes in the treatment of bones, muscles, tendons, and other parts of the skeletal system. Often the orthopedic surgeon comes to diagnose and treat muscle problems associated with cerebral palsy.
A physiotherapist, who designs and puts into practice special exercise programs to improve strength and functional mobility.
An occupational therapist, who teaches the skills necessary for daily life, school and work.
A speech and language pathologist, who specializes in diagnosing and treating disabilities related to swallowing and communication difficulties.
A social worker, who helps individuals and their families locate community assistance and educational programs.
A psychologist, who helps individuals and their families cope with the stress and special demands of cerebral palsy. In some cases, psychologists can also supervise the therapy to modify useless or destructive behaviors.
An educator, who can play an especially important role when mental retardation or learning disabilities present an educational challenge.
Regardless of age or the types of therapy used, treatment does not end when an individual with cerebral palsy leaves the treatment center. The majority of the work is done at home. Often members of the treatment team 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 achieve their long-term goals.
Although learning specific skills is an important focus of day-to-day treatment, the ultimate goal is to help children reach adulthood as independently as possible.
As a child with cerebral palsy grows, it is likely that the need for therapy and the types of therapy needed will change, as will support services. Counseling for emotional and psychological challenges may be necessary at any age but is generally essential during adolescence. Depending on their physical and intellectual abilities, adults may need help finding people to care for them, a place to live, a job, and a way to move to their place of employment.
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 on the strength and well-being of their family. That parents accept a child’s disabilities and are willing to accept the scope of their responsibilities as caregivers will take time and support from medical professionals. Family-centered programs in hospitals and clinics and community-based organizations usually work in conjunction with families to help them make informed decisions about the services they need. They also coordinate services to get the most out of the treatment.
A good program will encourage an open exchange of information, offer respectful attention and support, encourage partnerships between parents and the medical professionals with whom they work, and recognize that although medical specialists may be the experts, it is parents who know best their children.
CEREBRAL PALSY TREATMENT
Is there any treatment for cerebral palsy?
Physical therapy, usually begun in the first years of life or shortly after the diagnosis is made, is the mainstay of the treatment of cerebral palsy. Physiotherapy programs use specific groups of exercises and activities to work towards two important goals: to avoid weakening or deterioration of unused muscles (atrophy due to disuse), and to prevent the muscles from being fixed in a rigid and abnormal position (contracture).
Often resistance exercise programs (also called strength training) and other types of exercises are used to increase muscle performance, especially in children and adolescents with mild cerebral palsy. Daily fighting with exercises keeps muscles that are not normally used mobile and active and less likely to wear out. Exercise also reduces the risk of contracture, one of the most common and serious complications of cerebral palsy.
Children who grow normally stretch their muscles and tendons when they run, walk and move in their daily activities. This ensures that your muscles grow at the same speed as your bones. But in children with cerebral palsy, spasticity prevents the muscles from stretching. As a result, your muscles do not grow fast enough to keep up with the growing bones. The resulting muscle contracture can delay the functional gains made. Physical therapy alone or in combination with special devices (called orthotic devices) helps prevent contracture by stretching the spastic muscles.
This type of therapy focuses on optimizing trunk functions, improving posture, and taking better advantage of the child’s mobility. An occupational therapist helps the child learn the basic activities of daily life, such as eating, dressing, and using the bathroom alone. The promotion of this type of independence increases self-confidence and self-esteem and helps reduce demands on parents and caregivers.
Recreational therapies, such as therapeutic rides (also called hippotherapy), are sometimes used on mildly damaged children to improve their motor skills. Parents of children participating in recreational therapy generally notice an improvement in the child’s language, self-esteem, and emotional well-being.
Controversial physical therapies
“Establishing patterns” is physiotherapy based on the principle that children with cerebral palsy must learn 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 the ability to walk. Some experts and organizations, including the American Academy of Pediatrics, have expressed great reservations about the approach to establishing patterns because studies have not documented their value.
Experts have similar reservations about the Bobath technique (also called “neurodevelopmental treatment”), named after a team of husbands who pioneered the approach in England. In this form of physiotherapy, instructors inhibit abnormal movement patterns and encourage more normal movements.
The Bobath technique has had an extended influence on the physiotherapies essential for the treatment of cerebral palsy, 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 not much evidence to support its efficacy in children with cerebral palsy.
Conductive education, developed in Hungary in the 1940s, is another physiotherapy that once seemed promising. Conductive education instructors try to improve the child’s motor skills by combining rhythmic activities, such as singing and clapping, with physical maneuvers on special equipment. However, the therapy has not been able to produce uniform or significant improvements in the study groups.
Speech and language therapy
About 20 percent of children with cerebral palsy are unable to produce intelligible language. They also experience challenges in other areas of communication, such as hand gestures and facial expressions, and have difficulty participating in the basic exchange of a normal conversation. These challenges will last all their lives.
Speech and language therapists (also known as speech therapists or speech and language pathologists) observe, diagnose and treat the communication disorders associated with cerebral palsy. They use an exercise program to teach children to cope with specific communication difficulties.
For example, if a child has difficulty saying words that begin with “b,” the therapist may suggest a daily practice with a list of words with “b,” increasing their difficulty as they learn each list. Other types of exercises help children learn the social skills involved in communication by teaching them to hold their heads up, maintain eye contact, and repeat when they have not been understood.
Language therapists can also help children with severe disabilities learn to use special communication devices, such as a computer with a speech synthesizer, or a special blackboard covered with symbols of everyday objects and activities to which the child or Girl can point to indicate your wishes.
Speech interventions often use the child’s family and friends to reinforce lessons learned in the therapeutic setting. This type of indirect therapy encourages people who are in close daily contact with a child to create opportunities to use their new skills in conversation.
Treatments for problems with food and drooling are often necessary when children with cerebral palsy have difficulty eating and drinking because they have little control of the muscles that move their mouths, jaws, and tongues. They also have a risk of sucking food or fluid into the lungs. Some children get gastroesophageal reflux disease (GERD, commonly called acidity) in which a weak diaphragm cannot prevent stomach acids from spilling into the esophagus. Acid irritation can cause hemorrhage and pain.
Individuals with cerebral palsy are also at risk of malnutrition, recurrent lung infections, and progressive lung disease. The individuals with more risk of having these problems are those with spastic quadriplegia.
Initially, children should be evaluated for their ability to swallow, which is usually done with a modified barium swallow study. Recommendations on dietary modifications will derive from the results of this study.
In severe cases where swallowing problems cause malnutrition, a physician may recommend a feeding tube, through which food and nutrients are administered down the throat and into the stomach, or a gastrostomy, in which a surgical hole allows a tube to be placed directly in the stomach.
Although numerous treatments for drooling have been tried for years, there is no treatment that is reliable. Anticholinergic medications – such as glycopyrrolate – can reduce the flow of saliva but can cause unpleasant side effects, such as dry mouth, constipation, and urinary retention. Surgery, although sometimes effective, presents the risk of complications. Some children benefit from biofeedback techniques that help them recognize more quickly when their mouths open and begin to drool. Intraoral devices (devices that are placed inside the mouth) that encourage a better position of the tongue and swallowing are still being evaluated, but they seem to reduce drooling in some children.
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 medications are easy to use, except that dosages high enough to be effective often have side effects, including drowsiness, upset stomach, high blood pressure, and possible liver damage with prolonged use. Oral medications are very suitable for children who only need a slight reduction in muscle tone or who have generalized spasticity.
Sometimes doctors use “washes” with alcohol, which are injections of alcohol into the muscles, to reduce spasticity. The benefits last from a few months to 2 years or more, but side effects include a significant risk of pain or numbness, and the procedure requires a high degree of ability to attack the nerve.
The availability of new and more precise methods for administering antispasmodic drugs is moving the treatment of spasticity towards chemodenervation, in which the injected drugs are used to attack and relax the muscles.
Botulinum toxin (BT-A), injected locally, has become a standard treatment for hyperactive muscles in children with spastic movement disorders such as cerebral palsy. The BT-A relaxes the contracted muscles preventing the nerve cells from overacting the muscle. Although BT-A is not approved by the Food and Drug Administration (FDA) for the treatment of cerebral palsy since the 1990s doctors have used it outside of the approved indication to relax spastic muscles. A number of studies have shown that it reduces spasticity and increases the range of motion of the target muscles.
The relaxing effect of the BT-A injection lasts approximately 3 months. The unwanted side effects are mild, last for a short time, and consist of pain from the injection and occasionally flu-like symptoms. BT-A injections are most effective when followed by a stretching program that includes physiotherapy and splinting. BT-A injections work best in 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.
Because BT-A does not have FDA approval to treat spasticity in children, parents and caregivers must ensure that the doctor administering the injection is trained in the procedure and has experience using it in children.
Intrathecal baclofen therapy uses an implantable pump to deliver baclofen, a muscle relaxant, into the fluid that surrounds the spinal cord. Baclofen works by decreasing the excitability of nerve cells in the spinal cord, which in turn reduces muscle spasticity throughout the body. Because it is administered directly into the nervous system, the dose of intrathecal baclofen can be as low as one-hundredth of the oral dose. Studies have shown that it reduces spasticity and pain and improves sleep.
The pump is the size of a hockey puck and is implanted in the abdomen. It contains a refillable reservoir connected to an alarm that sounds when the reservoir is low. The pump is programmable with an electronic telemetric wand. The program can be adjusted if muscle tone worsens at certain times of day or night.
The baclofen pump has a small but significant risk of serious complications if it fails or is incorrectly programmed, if the catheter is twisted or bent, or if the site of the insert becomes infected. Undesirable but infrequent side effects are muscle over relaxation, drowsiness, headache, nausea, vomiting, dizziness and constipation.
As a muscle-relaxing therapy, the baclofen pump is best suited for individuals with intense chronic stiffness or uncontrolled muscle movements throughout the body. Doctors have successfully implanted the pump in children as young as 3 years old.
Orthopedic surgery is often recommended when the spasticity and stiffness are so severe that they make it difficult or painful to walk and move. For many people with cerebral palsy, it is also important to improve the way they walk. A more upright walk with transitions and softer foot placement is the main goal of many children and young adults.
In the operating room, surgeons can stretch muscles and tendons that are proportionally very short. But first, they must determine the specific muscles responsible for gait abnormalities. Finding these muscles can be difficult. Take more than 30 major muscles working at the right time using the right amount of strength to walk two strides with a normal gait. A problem with any of those muscles can cause an abnormal gait.
In addition, because the body makes natural adjustments to compensate for muscle imbalances, these adjustments could be a problem, rather than compensation. In the past, doctors relied on clinical examination, gait observation, and measurement of movement and spasticity to determine the muscles involved. Now, doctors have a diagnostic technique known as gait analysis.
Gait analysis uses cameras that record how an individual walks, plates of force to detect when and where to touch the floor, a special recording technique that detects muscle activity (known as electromyography), and a computer program that collects and analyze data to identify the problem muscles. Using gait analysis, doctors can pinpoint which muscles would benefit from surgery and how much gait improvement can be expected.
The coordination of orthopedic surgery has also changed in recent years. Previously, orthopedic surgeons preferred to perform all the operations that a child needed at the same time, usually between 7 and 10 years. Due to the period of time spent in recovery, which was usually several months, doing them all at the same time shortening the amount of time the child spent in bed. Now, most of the surgical procedures can be done on an outpatient basis or with a brief hospital stay. Children usually return to their normal lifestyle in a week.
Therefore, doctors think it is much better to stagger operations and perform them at times appropriate to the child’s age and level of motor development. For example, spasticity in the muscles of the thigh (the adductors), which cause walking “in scissors,” 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 ligaments of the hamstrings or Achilles tendon is from 7 to 8 years of age.
If the adduction release surgery is delayed to be done at the same time as the lengthening of the hamstring, the child will have learned to compensate for his spasticity in the adductors. By the time the operation of the hamstring is performed, the child’s abnormal gait pattern will be so ingrained that correction will not be so easy.
With shorter recovery periods and new and less invasive surgical techniques, doctors can schedule surgeries at times that take advantage of the child’s age and developmental skills to get the best result.
Selective dorsal rhizotomy (SDR) is a surgical procedure recommended only for cases of severe spasticity when all more conservative treatments – physiotherapy, oral medications, and intrathecal baclofen – have failed to reduce spasticity or chronic pain. In the procedure, a surgeon selectively locates and sections the overactivated nerves at the base of the spinal column.
Because it reduces the amount of stimulation that reaches the muscles through the nerves, SDR is most commonly used to relax muscles and decrease chronic pain in one or both upper or lower limbs. Sometimes it is also used to correct an overactive bladder. Potential side effects are a sensory loss, numbness, or uncomfortable sensations in the areas of the limbs that were once supplied by the severed nerve.
Even though the use of microsurgery techniques has improved the practice of RDS surgery, there is still controversy about how selective it really is. Some doctors worry because it is invasive and irreversible and can only achieve small improvements in function. Although recent research has shown that combining SDR with physiotherapy reduces spasticity in some children, particularly those with spastic diplegia, it has not yet been shown whether it improves gait or function. Ongoing research continues to study the effectiveness of this surgery.
Spinal cord stimulation was developed in the 1980s to treat spinal cord injuries and other neurological conditions involving motor neurons. An implanted electrode selectively stimulates the nerves at the base of the spinal cord to inhibit and decrease nerve activity. The efficacy of spinal cord stimulation for the treatment of cerebral palsy has yet to be proven in clinical studies. It is considered an alternative treatment only when other conservative or surgical treatments have not been successful in relaxing muscles or relieving pain.
Orthotic devices – such as appliances and splints – use external force to correct muscle abnormalities. Orthotic technology has advanced in the last 30 years from metal bars that were hooked to bulky orthopedic shoes, to devices that are individually molded from high-temperature plastics to achieve a precise fit. Orthosis for the foot-ankle is often indicated for children with spastic diplegia to prevent muscle contracture and improve gait. Splints are also used to correct spasticity in the muscles of the hand.
Devices that help individuals move more easily and communicate successfully at home, at school, or in the workplace can help the child or adult with cerebral palsy cope with physical and communication limitations. There are a number of devices that help individuals stand upright and walk, such as postural support or seating systems, front-opening walkers, quadruped canes (very light metal poles with four legs), and walking poles. Electric wheelchairs allow the most severely damaged adults and children to move successfully.
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 speech 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 illuminated pointer that attaches to a headband.
Therapeutic electrical stimulation (subthreshold), also called electrical neuromuscular stimulation (NES), pulses electricity to the motor nerves to stimulate contraction in selected muscle groups. Many studies have shown that NES seems to increase range of motion and muscle strength.
Threshold electrical stimulation, which involves the application of electrical stimulation at too low an intensity to stimulate muscle contraction, is a controversial therapy. Studies have not been able to demonstrate their efficacy or any significant improvement with their use.
Hyperbaric oxygenation therapy
Some children have cerebral palsy as a result of brain damage from oxygen deprivation. Proponents of hyperbaric oxygenation therapy believe that brain tissues around the damaged area can “wake up” by forcing high concentrations of oxygen into the body under more pressure than atmospheric pressure.
A recent study compared a group of children who did not receive hyperbaric treatment with a group that received 40 treatments in 8 weeks. In each measurement of function (gross motor, cognitive, communication, and memory) at the end of 2 months of treatment and after 3 months of follow-up, the two groups had identical results. There is no added benefit with hyperbaric oxygenation therapy.
ARE THERE TREATMENTS FOR OTHER CONDITIONS ASSOCIATED WITH CEREBRAL PALSY?
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 medications are generally effective in controlling seizures, their use is hampered by undesirable and harmful side effects.
The treatment of epilepsy has advanced significantly with the development of new drugs that have fewer side effects. These medications are felbamate, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine, topiramate, vigabatrin, and zonisamide.
In general, medications are prescribed based on the type of seizures an individual has since no medication controls all types. Some individuals may need a combination of two or more medications to achieve good seizure control.
Medical treatments for incontinence include special exercises, biofeedback, prescription medications, surgery, or surgically implanted devices to replace or help the muscles. Specially designed absorbent underwear can also be used to protect against accidental loss.
Children with cerebral palsy who are unable to walk risk having a low bone density (osteopenia), which makes them more likely to break bones. In a study of elderly Americans sponsored 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 icrease bone mineral density. Doctors may choose the selective indication of the medication outside of the approved indication in children to prevent osteopenia.
Pain can be a problem for people with cerebral palsy due to spastic muscles and stress and tension on parts of the body that are compensating for muscle abnormalities. Some individuals may also have frequent and irregular muscle spasms that cannot be predicted or medicated in advance.
Doctors often prescribe diazepam to reduce the pain associated with muscle spasms, but it is not known exactly how the medication works to interfere with painful signals. The drug gabapentin has been used successfully to decrease the intensity and frequency of painful spasms. It has also been shown that BT-A injections decrease spasticity and pain and that they are most commonly administered under anesthesia to avoid the pain associated with injections. Intrathecal baclofen has shown good results in reducing pain, but its administration is invasive, time intensive and expensive.
Someave been able to reduce pain using non-invasive interventions and without medications such as distraction, training t relax, biofeedback and therapeutic massage.
WHAT WORK CHALLENGES WILL ADULTS WITH CEREBRAL PALSY HAVE?
Before the mid-twentieth century, few children with cerebral palsy survived into adulthood. Now, due to improvements in medical care, rehabilitation and assisted technologies, 65 to 90 percent of children with cerebral palsy live to adulthood. This increase in life expectancy is often accompanied by an increase in medical and functional problems, some of which relatively begin at an early age, including the following:
Premature old age
Most individuals with cerebral palsy will experience some form of premature aging when they reach their 40th birthday due to the added stress and strain that the disease puts on their bodies. The developmental delays that often accompany cerebral palsy prevent some organs from developing to their maximum capacity and level of performance. As a result, organic systems such as the cardiovascular (heart, veins, and arteries) and the pulmonary system have to work harder and age prematurely.
Functional topics at work
It is likely that the daily challenges of the workplace increase as an individual employed with cerebral palsy reach middle age. Some individuals will be able to continue to work with accommodations such as a tight work schedule, support team, or frequent rest periods. For others, early retirement will be necessary.
Mental health issues are also a concern as someone with cerebral palsy grows. The rate of depression is three to four times higher in people with disabilities such as cerebral palsy. It seems to be related not so much to the severity of their disabilities as to how well they face them. They have a significant impact on mental health the amount of emotional support a person has, the success they have to face disappointment and stress, and whether or not they have an optimistic perspective on the future.
Most adults with cerebral palsy experience what is called post-deterioration syndrome, a combination of pain, fatigue, and weakness due to muscle abnormalities, bone deformities, overuse syndromes (sometimes also called repetitive motion injuries), and arthritis. Fatigue is often a challenge since individuals with cerebral palsy use three to five times the amount of energy that people physically trained when they walk and move.
Osteoarthritis and degenerative arthritis
Musculoskeletal abnormalities that may not cause discomfort during childhood can cause pain in adulthood. For example, abnormal relationships between joint surfaces and excessive joint compression can lead to the early development of painful osteoarthritis and degenerative arthritis. Individuals with cerebral palsy also have limited strength and restricted movement patterns, which puts them at risk for overuse and nerve entrapment syndromes.
Issues related to pain often go unnoticed by healthcare providers because individuals with cerebral palsy may not be able to describe the extent and location of their pain. The pain can be acute or chronic and is most commonly felt in the hips, knees, ankles, and upper and lower back. Individuals with spastic cerebral palsy have a greater number of painful sites and worse pain than those with other types of cerebral palsy. The best treatment for pain due to musculoskeletal abnormalities is preventive – correct skeletal and muscular abnormalities early to avoid the progressive accumulation of stress and tension that causes pain. Dislocated hips, which can particularly cause pain, can be surgically repaired. If properly controlled, pain does not need to be a chronic condition.
Other medical conditions
Adults have higher than normal rates of other medical conditions secondary to their cerebral palsy, such as hypertension, incontinence, bladder dysfunction, and difficulty swallowing. It is likely that the curvature of the spine (scoliosis) evolves after puberty when the bones have matured to their final shape and size. People with cerebral palsy also have a higher incidence of bone fractures, which occur more frequently during physiotherapy sessions. A combination of mouth breathing, poor hygiene, and tooth enamel abnormalities increases the risk of tooth decay and periodontal disease. Twenty-five to 39 percent of adults with cerebral palsy have visual problems; eight to 18 percent have hearing problems.
Due to their unique medical situations, adults with cerebral palsy benefit from regular visits to their doctor and continuous assessments of their physical condition. It is important to evaluate physical complaints to make sure they are not the result of underlying conditions. For example, adults with cerebral palsy are likely to experience fatigue, but fatigue may also be due to undiagnosed medical problems that can be treated and reversed.
Because many individuals with cerebral palsy live longer than their primary caregiver, the issue of long-term care and support must be considered and planned.
WHAT RESEARCH IS BEING DONE REGARDING TREATMENT AND DIAGNOSIS OF CEREBRAL PALSY?
Researchers in many fields of medicine and health are using their experience to help improve the treatment and diagnosis of cerebral palsy. Much of their work is sponsored by the NINDS, the National Institute of Child Health and Human Development (NICHD), other agencies within the federal government, non-profit groups such as the United Cerebral Palsy Research and Educational Foundation, and other private institutions.
The last hope for curing cerebral palsy is based on prevention. In order to prevent cerebral palsy, however, scientists must understand the development of the normal fetal brain in order to understand what happens when a baby’s brain develops abnormally.
Between the conception and the birth of a baby, a cell divides to form a group of cells, and then hundreds, millions and finally billions of cells. Some of these cells specialize to become neurons and then specialize more toward particular types of neurons that travel to the right place in the brain (a process scientists call neuronal migration). Once they are in the right place, they establish connections with the other neurons. This is how the brain develops and becomes able to communicate with the rest of the body, by overlapping neural circuits composed of billions of interconnected and interdependent neurons.
Many scientists now think that a significant number of children develop cerebral palsy due to setbacks at the beginning of brain development. They are examining how neurons specialize and form the right connections, and are looking for ways to prevent the factors that disrupt the normal processes of brain development.
Genetic defects are sometimes responsible for the malformations and abnormalities of the brain that cause cerebral palsy. Scientists sponsored by the NINDS are looking for the genes responsible for these abnormalities by obtaining DNA samples from people with cerebral palsy and their families and using genetic evaluation techniques to discover links between individual genes and specific types of abnormalities – mainly those associated with migration abnormal neuronal
Scientists are examining episodes in the brains of newborn babies, such as hemorrhages, epileptic seizures, and respiratory and circulatory problems, which can cause the abnormal release of chemicals that triggers the type of damage that cerebral palsy causes. For example, research has shown that hemorrhage in the brain triggers dangerously high amounts of a brain substance called glutamate. Although glutamate is necessary for the brain to help neurons communicate, too much glutamate overexcites and kills neurons. Scientists are watching glutamate closely to see how its release damages brain tissue. By learning how brain substances that are normally useful become dangerously toxic, scientists will have opportunities to develop new drugs to block their harmful effects.
Scientists sponsored by the NINDS are also investigating whether substances in the brain that protect neurons from damage, called neurotrophins, could be used to prevent brain damage as a result of a stroke or oxygen deprivation. Understanding how these neuroprotective substances act would allow scientists to develop synthetic neurotrophins that could be administered immediately after injury to prevent neuronal death and damage.
The relationship between uterine infections during pregnancy and the risk of cerebral palsy continues to be studied by researchers sponsored by the NIH. There is evidence that uterine infections trigger inflammation and the production of immune system cells called cytokines, which can pass into the brain of an unborn baby and disrupt normal development. By understanding what cytokines do in the fetal brain and the type of damage these immune system cells cause, researchers have the potential to develop drugs that can be given to mothers with uterine infections to prevent brain damage in their children. Born.
Approximately 10 percent of newborns are born prematurely, and of those babies, more than 10 percent will have brain injuries that will lead to cerebral palsy and other disabilities of cerebral origin. A particular type of brain white matter damage, called periventricular leukomalacia (PVL), is the predominant form of brain injury in premature babies. NINDS-sponsored researchers studying PVL are looking for new strategies to prevent this type of harm by developing safe and non-toxic therapies administered to mothers at risk to protect their unborn babies.
Although congenital cerebral palsy is a disease present at birth, it may take one or two years before the disabilities are noticed. Researchers have shown that the earlier rehabilitation treatment begins, the better the outcome for children with cerebral palsy. But early diagnosis is hampered by the lack of diagnostic techniques to identify brain damage or abnormalities in babies.
Research sponsored by the NINDS is using imaging techniques, devices that measure electrical activity in the brain, and neurobehavioral tests to predict which premature babies will get cerebral palsy. If these evaluation techniques are successful, doctors will be able to identify babies at risk of having cerebral palsy before they are born.
Non-invasive methods to record the brain activity of unborn babies and to identify those with brain damage or abnormalities would also be a valuable addition to the set of diagnostic tools. Another study sponsored by the NINDS focuses on the development of fetal magnetoencephalography (fmeg) – a technology that would allow doctors to look for abnormalities in fetal brain activity.
Epidemiological studies – studies that look at the distribution and causes of disease among people – help scientists understand the risk factors and outcomes of particular medical conditions and diseases. Researchers have established that premature birth (when a baby is born before 32 weeks of gestation) is the greatest risk factor for cerebral palsy. Therefore, the increase in the rate of premature births in the United States places more babies at risk.
An extensive long-term study sponsored by the NIH is following a group of more than 400 mothers and their babies born between 24 and 31 weeks of gestation. He is looking for relationships between premature birth, maternal uterine infection, fetal exposure to infection, and neurological and health outcomes in the short and long term. Researchers hope to discover environmental or lifestyle factors, or particular characteristics of mothers, that can protect premature babies from neurological disabilities.
While this research offers hope to prevent cerebral palsy in the future, ongoing research to improve treatment illuminates the prognosis for those who must face the challenges of cerebral palsy today. An important thrust of such research is the evaluation of treatments already in use so that doctors and parents have valid information to help them choose the best therapy. A good example of this effort is an ongoing study sponsored by the NINDS that promises to shed new information on which patients are most likely to benefit from selective dorsal rhizotomy, a surgical technique that is increasingly being used to reduce spasticity (see Surgery).
Similarly, although physiotherapy programs are used almost universally to rehabilitate children with cerebral palsy, there are no definitive studies that indicate which techniques work best. For example, restraint-induced therapy (CIT) is a type of physiotherapy that has been used successfully with adult stroke survivors and individuals with traumatic brain injury and who remain with a weak or disabled arm on one side of the brain. Body. The therapy involves holding the stronger arm in a cast and forcing the weaker arm to perform 6 hours of intensive “conditioning” activities every day for the course of 3 weeks. Researchers who conducted clinical studies on adult stroke survivors noted the potential of the ILC to strengthen the weakened arms of children with cerebral palsy.
In a randomized, controlled study with cerebral palsy sponsored by the NIH, the researchers placed one group of children in conventional physical therapy and another group in 21 consecutive days of CIT. The researchers looked for evidence of improvement in movement and function of the incapacitated arm if the improvement lasted after the end of treatment, and if it was associated with significant gains in other areas, such as trunk control, mobility, communication, and self-help skills.
Children who received CIT exceeded children who received conventional physiotherapy in all measures of success, including how well they could move their arms after therapy and their ability to do new tasks during the study and then at home with their families. Six months later they still had better control of their arm. The results of this study are the first to prove the benefits of physiotherapy. Additional research to determine the optimal duration and intensity of the ILC will allow physicians to add this therapy to the cerebral palsy treatment toolbox.
Studies have shown that functional electrical stimulation is an effective way to attack and strengthen spastic muscles, but the method of administering electrical pulses requires bulky and expensive devices implanted by a surgeon or stimulation of the surface of the skin by from a trained therapist. Researchers sponsored by the NINDS have developed a high-tech method that removes the bulging device and electrodes, using a hypodermic needle to inject microscopic wireless devices into specific muscles or nerves. The devices are guided by a telemetric rod that can direct the number and strength of their pulses by remote control. The device has been used to activate and strengthen the muscles of the hand, shoulder, and ankle in people with cerebral palsy as well as in stroke survivors.
As researchers continue to explore new treatments for cerebral palsy and expand our knowledge of brain development, we can expect significant improvements in the care of children with cerebral palsy and many other disorders that attack early in life.
- Gait analysis – a technique that uses cameras, force plates, electromyography, and computerized analysis to objectively measure an individual’s gait pattern.
- Suffocation – a lack of oxygen due to difficulty in breathing or little oxygen supply in the air.
- Intrapartum asphyxia – the reduction or total suspension of circulating oxygen in the baby’s brain during labor and delivery.
- Ataxia (ataxic) – the loss of muscle control.
- Respite care – rest or relief of care obligations.
- Athetoid – make slow, sinuous, involuntary and torsional movements, especially with your hands.
- Atrophy due to disuse – muscle wasting caused by the inability to flex and exercise muscles.
- Baclofen intrathecal – baclofen that is injected into the cerebrospinal fluid of the spinal cord to reduce spasticity.
- Bisphosphonates – a family of medications that strengthens bones and reduces the risk of bone fracture in the elderly.
- Bilirubin – a bile pigment produced by the liver of the human body as a byproduct of digestion.
- Cerebral – related to the two hemispheres of the human brain.
- Kyphosis – an outer curvature similar to a hump of the upper column.
- Cytokines – messenger cells that play a role in the inflammatory response to infection.
- Contracture – a condition in which the muscles become fixed in an abnormal, rigid position, causing distortion or deformity.
- Focal (partial) seizure – a temporary and brief alteration in movement, sensation, or autonomic nerve function caused by abnormal electrical activity in a localized area of the brain.
- Tonic-clonic seizure – a type of seizure that causes loss of consciousness, generalized seizures, loss of bladder control, and tongue bite followed by confusion and lethargy when seizures end.
- Choreoathetosis – a condition characterized by muscle movements without meaning and involuntary gestures.
- Quadriplegia – paralysis of the arms and legs.
- Spastic quadriplegia (or quadriparesis) – a form of cerebral palsy in which all limbs are paralyzed or weak equally.
- Spastic diplegia (or diparesis) – a form of cerebral palsy in which spasticity affects both legs, but the arms are relatively or completely respected.
- Dyskinetic – impairment of the ability to perform voluntary movements, resulting in awkward or incomplete movements.
- Cerebral dysgenesis – defective brain development.
- Orthotic devices – special devices, such as splints or appliances, used to treat postural problems involving muscles, ligaments, or bones.
- Dystonia (dystonic) – an abnormal muscle tone condition.
- Electroencephalogram (EEG) – a technique to record the pattern of electrical currents within the brain.
- Electromyography – a special recording technique that detects muscle activity.
- Hypoxic-ischemic encephalopathy – brain damage caused by low blood flow or insufficient oxygen supply to the brain.
- Gastroesophageal reflux disease (GERD) – also known as heartburn, occurs when stomach acids regurgitate into the esophagus.
- Pelvic inflammatory disease (PID, sometimes also 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. The symptoms of PID are fever, vaginal discharge with a foul odor, abdominal pain, and pain during intercourse, and vaginal bleeding. Many different organisms can cause PID, but most cases are associated with gonorrhea and chlamydia.
- Nervous entrapment – repeated or prolonged pressure on the root of a nerve or peripheral nerve.
- Scoliosis – a disease of the spine in which it twists or curves to one side of the body.
- Spasticity (or spasticity) – describes stiff muscles and clumsy movements.
- Stereognosis – difficulty perceiving and identifying objects using the sense of touch.
- Strabismus – misalignment of the eyes, also known as squint.
- Failure to thrive – a condition characterized by a delay in physical growth and development.
- Gastrostomy – a surgical procedure that creates an artificial hole in the stomach to insert a feeding tube.
- Gestation – the period of fetal development from the moment of conception until birth.
- Hemianopia – defective vision or blindness that affects half the normal field of vision.
- Hemiparesis – a paralysis that affects only one side of the body.
- Spastic hemiplegia (or hemiparesis) – a form of cerebral palsy in which spasticity affects an arm and leg on one side of the body.
- Intracranial hemorrhage – bleeding in the brain.
- Hypertonia – increased muscle tone.
- Hypotonia – decreased muscle tone.
- Homonym – This has the same description, name, or term.
- Jaundice – a blood disorder caused by the abnormal buildup of bilirubin in the bloodstream.
- Magnetic resonance imaging (MRI) – an imaging technique that uses radio waves, magnetic fields, and computerized analysis to create an image of body tissues and structures.
- Rh incompatibility – a blood disease in which antibodies from the blood of a pregnant woman attack the fetal blood cells and damage the supply of oxygen and nutrients to an unborn baby.
- Intrauterine infection – infection of the uterus, ovaries, or fallopian tubes (see pelvic inflammatory disease for a more detailed explanation).
- Kernicterus – a neurological syndrome caused by the deposition of bilirubin in brain tissues. Kernicterus develops in extremely jaundiced infants, especially those with severe Rh incompatibility. Periventricular leukomalacia (PVL) – “peri” means close; “Ventricular” refers to the ventricles or spaces with the fluid of the brain, and “leucomalacia” refers to the softening of the white matter of the brain. PVL is a condition in which the cells that make up the white matter die near the ventricles. Under a microscope, the tissue looks soft and spongy.
- Lordosis – an increased inner curvature of the lower column.
- Anticholinergic drugs – a family of drugs that inhibits parasympathetic neural activity by blocking the neurotransmitter acetylcholine.
- Medications out of the approved indication – prescription drugs to treat conditions other than those for which they were approved by the Food and Drug Administration.
- Neuronal migration – the process within the developing brain in which neurons migrate from where they are born to where they are established as neural circuits. Neuronal migration, which occurs as early as the second month of gestation, is controlled in the brain by guides and chemical signals.
- Neuroprotector – describes substances that protect cells of the nervous system from damage or death.
- Neurotrophins – a family of molecules that stimulate the survival of nervous system cells.
- Osteopenia – reduced density and mass of the bones.
- Paralysis – paralysis, or lack of control over voluntary movements.
- Acquired cerebral palsy – cerebral palsy that occurs as a result of a brain injury after birth or during early childhood. Congenital cerebral palsy – cerebral palsy that is present at birth due to causes that have occurred during fetal development.
- Paresia or -plejía – 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. Placenta – an organ that unites the mother with her unborn baby and provides nutrition and sustenance.
- Apgar score – a numbered scoring system that doctors use to assess the physical state of a baby at birth.
- Chemodenervation – a treatment that relaxes the spastic muscles by interrupting nerve impulse pathways through a medication, such as botulinum toxin, which prevents communication between neurons and muscle tissue.
- Developmental delay – delay in achieving early childhood development milestones.
- Selective dorsal rhizotomy – a surgical procedure in which selected nerves are sectioned to reduce spasticity of the legs.
- Rubella – a viral infection that can damage the nervous system of an unborn baby if the mother contracts the disease during pregnancy.
- Overuse syndrome (also called repetitive strain injury) – a condition in which repetitive movements or forced posture cause muscle and nerve damage, which results in discomfort or persistent pain in the muscles, tendons, and other soft tissues. This can happen in different parts of the body, but more likely to happen in the arms, legs or hands.
- Post-deterioration syndrome – a combination of pain, fatigue, and weakness due to muscle abnormalities, bone deformities, overuse syndromes or arthritis.
- Tremor – an involuntary shaking or shaking.
- Computed tomography (CT) – an imaging technique that uses x-rays and a computer to create an image of brain tissues and structures.
- Botulinum toxin – a medication commonly used to relax spastic muscles; blocks the release of acetylcholine, a neurotransmitter that energizes muscle tissue.
- Ultrasound – a technique that bounces waves are