In cerebral palsy, faulty development or damage to motor areas in the brain
impair the body's ability to control movement and posture. This results in a
number of chronic neurological disorders. Cerebral palsy is usually associated
with events that occur before or during birth, but may be acquired during the
first few months or years of life as the result of head trauma or infection.
Cerebral palsy is neither contagious nor inherited, nor is it progressive. The
symptoms of cerebral palsy (CP) differ from person to person and change as
children and their nervous systems mature.
Some persons with severe CP are completely disabled and require lifelong care,
while others display only slight awkwardness and need no special assistance.
Complications associated with CP include learning disabilities, gastrointestinal
dysfunction, tooth decay (dental caries), sensory deficits, and seizures.
Types:
Cerebral palsy (CP) is classified as spastic, athetoid, ataxic, or mixed. These
classifications reflect the type of movement disturbance displayed by the
patient.
Spastic CPstiff, permanently contracted muscles; 50% to 75% of cases
Athetoid CP (also called dyskinetic cerebral palsy)slow, uncontrolled, writhing
movements; 10% to 20% of cases
Ataxic CPpoor coordination, balance, and depth perception; 5% to 10% of cases
Mixed CPtwo or more types present; 10% of cases (percentage may be higher)
Incidence:
Approximately 1 million people in the United States have CP. Improvements in
prenatal, pediatric, and intensive care over the past 30 years have enabled more
critically premature and frail babies to survive infancy. Many of these
surviving children suffer developmental disorders and neurological damage.
Causes:
-Acquired
Approximately 10% to 20% of children with cerebral palsy acquire it after birth,
typically from brain damage sustained in the first few months or years of life.
In such cases, the disorder may result from brain infections like bacterial
meningitis or viral encephalitis, or from head trauma sustained from an
accident, fall, or inflicted injuries (e.g., shaken baby syndrome).
-Congenital
The cause or causes of congenital CPthe type that is present at birthoften are
unknown and many cases go undetected for months. Certain events during
pregnancy, labor, and delivery can damage motor centers in the developing brain
and cause cerebral palsy. However, birth complications account for only about
313% of congenital CP cases.
-Infections during pregnancy, such as German measles (rubella), can damage the
fetus's developing nervous system. Other potentially damaging infections include
cytomegalovirus and toxoplasmosis.
-Severe, untreated jaundice (hyperbilirubinemia) can damage brain cells in
newborns and infants.
-Deprivation of oxygen to the brain (asphyxia) or head trauma sustained during
labor and/or delivery can cause CP. Severe asphyxia for a lengthy period can
produce brain damage called hypoxic-ischemic encephalopathy, which causes many
infant deaths. Birth asphyxia is associated with spastic quadriplegia.
-Brain hemorrhage, or bleeding, can occur in the fetus during pregnancy or in
newborns around the time of birth, damaging fetal brain tissue and causing
neurological problems, including congenital CP. These hemorrhages are a type of
stroke that may be caused by broken, abnormal, or clogged blood vessels in or
leading to the brain, or by respiratory distress, a common breathing disorder in
premature infants.
Risk Factors:
Infants at the highest risk for developing cerebral palsy exhibit one or more of
these factors: premature; low birth weight (<5 lb 7 1/2 oz); do not cry within 5
minutes of delivery; sustained on a ventilator more than 4 weeks; brain
hemorrhage.
Other risk factors include the following:
-Complications in pregnant mother(vaginal bleeding after 6th month, proteinuria,
hyperthyroidism, high blood pressure, Rh incompatibility, mental retardation,
seizures)
-Breech birth(born feet or buttocks first)
-Labor and delivery complications (vascular or respiratory problems; may
indicate brain damage or abnormal brain development)
-Multiple births (twins, triplets, etc.; CP may be due to prematurity or
intrauterine growth retardation)
-Birth defects (malformation of spinal bones, hernia in groin area, abnormally
small jawbone, microcephaly)
-Newborn seizures
-Low Apgar score Infant heart rate, breathing, muscle tone, reflexes, and skin
color are each scored as 0 (low), 1 (intermediate), or 2 (normal) after
delivery. A total score of 7-10 at 5 minutes is considered normal; 4-6,
intermediate; and 0-3, low. Scores that remain low 10-20 minutes after delivery
indicate increased risk for CP.
Signs and Symptoms:
Symptoms of cerebral palsy can be as simple as having difficulty with fine motor
tasks like writing or using scissors, or as profound as being unable to maintain
balance or walk. Severely afflicted patients may have involuntary movements,
such as uncontrollable hand motions and drooling. Others suffer from associated
medical disorders, such as seizures and mental retardation.
Spastic CP is the most common type of cerebral palsy. It causes the muscles to
be stiff and permanently contracted. Spastic cerebral palsy is often
subclassified as one of five types that describe the affected limbs. The names
of these types combine a Latin prefix describing the number of affected limbs
(e.g., di- means two) with the term plegia or paresis, meaning paralyzed or
weak:
-Diplegiaeither both arms or both legs
-Hemiplegialimbs on only one side of the body
-Quadriplegiaall four limbs
-Monoplegiaone limb (extremely rare)
-Triplegiathree limbs (extremely rare)
-Spastic diplegia affects the legs more than the arms. The legs often turn in
and cross at the knees. This causes a scissors gait, in which the hips are
flexed, the knees nearly touch, the feet are flexed, and the ankles turn out
from the leg, causing toe-walking. Learning disabilities and seizures are less
common than in spastic hemiplegia.
Persons with spastic hemiplegia (hemiparesis) also may experience hemiparetic
tremors - uncontrollable shaking of the limbs on one side of the body. Severe
hemiparetic tremors can seriously impair movement. The arm is generally affected
more than the leg. Learning disabilities, vision problems, seizures, and
dysfunction of the muscles of the mouth and tongue are classic symptoms.
Spastic quadriplegia involves all four limbs. There is dysfunction of the
muscles of the mouth and tongue, seizures, medical complications, and increased
risk for cognitive difficulties.
Athetoid (or dyskinetic) cerebral palsy is characterized by slow, uncontrolled,
writhing movements of the hands, feet, arms, or legs (athetosis). Patients also
may have abrupt, irregular, jerky movements (chorea), a combination
(choreoathetosis), or slow rhythmic movements with muscle tone abnormalities and
abnormal postures (dystonia).
The muscles of the face and tongue may be affected, causing grimacing and/or
drooling. When the muscles that control speech are affected, the patient
experiences dysarthria (abnormal pronunciation of speech). Hearing loss is
commonly associated with this form of CP.
Ataxic cerebral palsy affects balance and depth perception. Persons with ataxic
CP have poor coordination and walk unsteadily, usually placing their feet far
apart. Many have trouble with quick or precise movements, like writing or
buttoning a shirt. Some also have intention tremor, in which a voluntary
movement, like reaching for an object, sets off trembling in the limb. The
tremor becomes more intense as the person nears the target object.
Mixed CP involves two or more types of cerebral palsy. While any mix of types
and subtypes can occur, the most common are athetodic-spastic-diplegic and
athetoid-spastic-hemiplegic; the least common is athetoid-ataxic. It is possible
to have a mix of all three (spastic-athetoid-ataxic).
Complications:
Some people with CP have associated disorders, such as impaired intellectual
development, seizures, failure to grow and thrive, and vision and sense of touch
problems.
Roughly a third of patients with CP also have mild intellectual impairment;
another third are moderately or severely impaired; and the remainder,
intellectually normal. Mental impairment is most common in children with spastic quadriplegia.
As many as half of all patients with cerebral palsy have seizures in which
uncontrolled bursts of electricity disrupt the brain's normal pattern of
electrical activity. Seizures that recur without a direct trigger, such as a
fever, are classified as epilepsy. Seizures generally are tonic-clonic or
partial.
Tonic-clonic seizures spread throughout the brain, typically causing the patient
to cry out, followed by unconsciousness, twitching legs and arms, convulsive
body movements, and loss of bladder control.
Partial seizures are confined to one part of the brain and may be simple or
complex. Simple partial seizures cause muscle twitching, chewing movement, and
numbness or tingling. Complex partial seizures can produce hallucinations;
staggering, random movement; and impaired consciousness or confusion.
Children with moderate-to-severe cerebral palsy, especially those with spastic
quadriplegia, often experience failure to grow or thriveinfants fail to gain
weight normally; young children may be abnormally short; and teenagers may be
short for their age and may have slow sexual development. These phenomena may be
caused by a combination of poor nutrition and damage to the brain centers that
control growth.
Some patients, particularly those with spastic hemiplegia, have muscles and
limbs that are smaller than normal. Limbs on the side of the body affected by CP
may grow slower than those on the other side. Hands and feet are most severely
affected. The affected foot in cases of hemiplegia usually is the smaller of the
two, even in patients who walk, suggesting the size difference is due not to
disuse but to a disrupted growth process.
Vision and hearing problems are more common in people with cerebral palsy than
in the general population. Differences in the left and right eye muscles often
cause the eyes to be misaligned. This condition, called strabismus, causes
double vision; in children, however, the brain often adapts by ignoring signals
from one eye. Because strabismus can lead to poor vision and impaired depth
perception, some physicians recommend corrective surgery.
Patients with hemiparesis may have hemianopia, a condition marked by impaired
vision or blindness in half of the visual field in one or both eyes. A related
condition, called homonymous hemianopia, causes impairment in the right or left
half of the visual fields in both eyes.
Sensations of touch or pain may be impaired. A patient with stereognosis, for
example, has difficulty perceiving or identifying the form and nature of an
object placed in their hand using the sense of touch alone.
Hip dislocation, curvature of the spine (scoliosis), incontinence, constipation,
tooth decay (dental caries), bronchitis, skin sores, and asthma are other
complications commonly experienced by people with CP
Diagnosis:
Typically, doctors diagnose cerebral palsy (CP) in infants by testing their
motor skills and thoroughly analyzing their medical history. A medical history,
diagnostic tests, and regular check-ups may be required to confirm the diagnosis
of CP or to eliminate the possibility of other disorders.
Unnaturally soft, relaxed, or floppy muscle tone is called hypotonia; muscle
tone that is stiff or rigid is called hypertonia. Some infants with CP have
hypotonia in the first 2 or 3 months of life and then develop hypertonia. They
also might develop an unusual posture or favor one side of the body.
A newborn held on its back and tilted so its legs are above its head will
automatically respond with the Moro reflex, extending its arms in a gesture that
resembles an embrace. This reflex usually disappears after about 6 months.
Infants with cerebral palsy often retain it for an abnormally long period.
Signs of hand preference are also observed. When an object is held in front and
to the side, infants usually do not display a tendency to use either the right
or left hand. This is normal during the first 12 months of life. Infants with
spastic hemiplegia, however, often develop hand preference early, indicating one
side of their body is stronger than the other.
The physician will look for other conditions that can be linked to CP, such as
seizures, mental impairment, and vision or hearing problems.
Intelligence tests often are administered to a child with CP to evaluate mental
impairment, but the results can be misleading and there is a risk of
underestimating intelligence. For instance, a child with movement, sensation, or
speech problems associated with CP would have difficulty performing well on such tests.
If motor skills decline over time there may be genetic disease, muscle or
metabolic disorder, or tumor in the nervous system, either coexistent or instead
of CP. The physician must rule out other disorders that cause movement problems,
identify any coexisting disorder, and determine if the condition is changing.
An electroencephalogram (EEG) traces electrical activity in the brain and can
reveal patterns that suggest a seizure disorder.
Electromyography (EMG) and nerve conduction velocity (NCV) studies may be
performed when a nerve or muscle disorder is suspected. These tests, which can
be used in combination, are often referred to as EMG/NCV studies. NCV is
administered before EMG and measures the speed at which nerves transmit
electrical signals.
During NCV, electrodes are placed on the skin over a nerve that supplies a
specific muscle or muscle group. A mild, brief electrical stimulus is delivered
through the electrode and the response of the muscle is detected, amplified, and
displayed. The strength of the signal is also measured. Neurological conditions
can cause the NCV to slow down or to be slower on one side of the body.
EMG measures nerve impulses within the muscles. Tiny electrodes are placed in
the muscles in the arms and legs and the electronic responses are observed using
an instrument that displays movement of an electric current (oscilloscope). As
muscles contract, they emit a weak electrical signal that can be detected,
amplified, and tracked, providing information about how well the muscles are
working.
Lab tests:
Chromosome analysis may be performed to identify a genetic anomaly (e.g., Down
syndrome) when abnormalities in features or organ systems are present.
Thyroid function tests may reveal low levels of thyroid hormone, which can
produce several congenital defects and severe mental retardation.
A high level of ammonia in the blood (hyperammonemia) is toxic to the central
nervous system (i.e., brain and spinal cord). A deficiency in any of the enzymes
involved in breaking down amino acids can cause hyperammonemia. This may be due
to a liver disorder or a defect in metabolism.
Imaging tests:
Imaging tests are helpful in diagnosing hydrocephalus, structural abnormalities,
and tumors. This information can help the physician assess the child's long-term
prognosis.
Magnetic resonance imaging (MRI scan) uses a magnetic field and radio waves to
create pictures of the internal structures of the brain. This study is performed
on older children. It defines abnormalities of white matter and motor cortex
more clearly than other methods.
Computed tomography (CT scan) can show congenital malformations, hemorrhage, and
periventricular leukomalacia in infants.
Ultrasound uses the echoes of sound waves projected into the body to form a
picture called a sonogram. It is often used in infants before the bones of the
skull harden and close to detect cysts and abnormal structures in the brain
Treatment:
A multidisciplinary team of health care professionals develops an individualized
treatment plan based on the patient's needs and problems. It is imperative to
involve patients, families, teachers, and caregivers in all phases of planning,
decision making, and treatment.
A pediatrician, pediatric neurologist, or pediatric physiatrist (physician who
specializes in physical medicine) provides primary care for children with CP. A
family doctor, neurologist, or physiatrist provides primary care for adults with
CP.
The primary care provider gathers input from the health care team, synthesizes
the information into a comprehensive treatment plan, and follows the patient's
progress.
Other specialists on the team may include:
Orthopedist or orthopedic surgeon to predict, diagnose, and treat associated
muscle, tendon, and bone problems
Physical therapist to design and supervise special exercise programs for
improving movement and strength
Speech and language pathologist to diagnose and treat communication problems
Occupational therapist to help the patient learn life skills for home, school,
and work
Social worker to help patients and their families obtain community assistance,
education, and training programs
Psychologist to help address negative or destructive behaviors, and guide the
patient and his/her family through the stresses and demands presented by
cerebral palsy
The need for and types of therapy change over time. Adolescents with CP may need
counseling to cope with emotional and psychological challenges. Physical therapy
may be supplemented with special education, vocational training, recreation, and
leisure programs.
Adults may benefit from attendant care, special living accommodations, and
transportation and employment assistance services, depending upon his or her
intellectual and physical capabilities.
Physical Therapy:
It is important for physical therapy to begin soon after diagnosis is made.
Daily range of motion exercises help prevent muscles from growing weak and
atrophied or rigidly fixed from contracture.
Normally, muscles and tendons stretch and grow at the same rate as bones.
Spasticity can prevent stretching, and muscle growth may not keep up with bone
growth. The muscles can become fixed in stiff, abnormal positions. Physical
therapy, often in combination with special braces, helps prevent contracture by
stretching spastic muscles. It also can improve a child's motor development.
To prepare a child for school, the focus of therapy gradually shifts toward
activities associated with daily living and communication. Exercises are
designed to improve the child's ability to sit, move independently, and perform
tasks such as dressing, writing, and using the bathroom.
Orthotics can help control limb position, and walkers can help some patients
walk. Mastering such skills reduces demands on caregivers and helps the child
obtain some degree of self-reliance, which helps build self-esteem.
Mechanical Aids:
A variety
of devices and mechanical aids can help patients with cerebral palsy overcome
physical limitations. These range from simple Velcro shoe straps to motorized
wheelchairs and computerized communication devices.
Computers can transform the lives of cerebral palsy patients. Fitted with a
light pointer attached to a headband and a voice synthesizer, they can give a
child unable to speak or write the power of communication using nothing but
simple head movements.
Casting and splinting for 2-3 months can improve range of motion (ROM) of a
joint and decrease muscle tone for 3-4 months
Treating Complications
Incontinence, caused by faulty control over the bladder muscles, can be treated
with exercises, biofeedback, prescription drugs, surgery, or surgically
implanted devices that replace or aid muscles.
Drooling, caused by poor functioning of the muscles of the throat, mouth, and
tongue, can be difficult to control. Anticholinergic drugs reduce the flow of
saliva but may produce side effects like mouth dryness and poor digestion.
Surgery sometimes helps, but also can worsen swallowing problems. Biofeedback
has been proven helpful in patients who are intellectually unimpaired and
motivated.
Eating and swallowing problems may require the caregiver to prepare food in a
semisolid fashion, such as strained vegetables and fruits. Physical therapy can
support and promote proper positioning while eating or drinking, or help extend
the neck away from the body to reduce the risk of choking.
Severe swallowing problems may necessitate the use of a tube to deliver food
down the throat and into the stomach. Gastrostomy, which involves making a
surgical opening in the abdomen that allows tube-feeding directly into the
stomach, is sometimes necessary
Prevention
The best prescription for having a healthy baby is to have regular prenatal care
and good nutrition, and to avoid smoking, alcohol consumption, and drug abuse.
Other forms of prevention include:
Prevent head injuries by using child safety seats in automobiles and helmets
when riding bicycles, skateboards, etc. Supervise young children closely during
bathing and swimming. Prevent child abuse. Keep poisons out of reach.
Treat jaundice in newborns with phototherapy. Exposing jaundiced babies to
special blue lights that break down bile pigments and prevent them from building
up and causing brain damage. In rare cases, a blood transfusion may be
necessary.
Identify potential Rh incompatibility in expectant mothers. Incompatible Rh
factor usually is not problematic with first pregnancies, as the mother's body
typically produces the unwanted antibodies only after delivery. A special serum
given after each delivery can prevent the production of antibodies.
If antibodies develop during a first pregnancy, or if antibody production is not
prevented, the developing baby is monitored closely. If necessary, a transfusion
may be given to the infant in the womb or an exchange transfusion may be given
after birth, removing and replacing a large volume of the infant's blood.
Be vaccinated against German measles (rubella) before becoming pregnant.
Alternative Therapies
Adults with CP may benefit from alternative therapies such as acupuncture,
massage, osteopathy, and homeopathy.
Support Groups:
To meet the challenges of cerebral palsy, patients, families, and caregivers
need help and support. There are many government-supported and private voluntary
groups that provide information about prevention, diagnosis, and treatment, as
well as clinical and support services.
Prognosis:
Most people with cerebral palsy experience a normal life span. Those with severe
forms of CP may have a reduced life span. As people with cerebral palsy age,
they may experience long-term effects of chronic physical impairment, such as
the following:
-Increase in spasms
-Increase in shortening of muscles (contractures)
-Joint problems (e.g., pain, loss of flexibility)
-Tight muscles
-Increase in back pain
-Emergence of incontinence
-Increase in incontinence
-Reduced energy levels
-Factors that contribute to these effects include:
-Poor wheelchair seating and posture
-Spinal deformities
-Weight gain
-Severe learning disability
-Discontinuance of physical therapy
-Walking when it is increasingly difficult
-Inappropriate orthopaedic surgery
-Physical exhaustion from inadequate rest or recovery from illness or injury can
lead to an overall decline in physical and mental function. Ways to maintain
physical function include the following:
-Appropriate wheelchair seating and posture
-Assume various positions out of the wheelchair
-Use a wheelchair when fatigued and when walking is difficult
-Regular and appropriate exercise, including stretching exercises and exercises
to maintain flexibility in joints
-Maintain ideal weight
-Have regular medical check-ups
-Avoid sustained mental stress
-Carefully consider proposed surgery
-Plan for appropriate rehabilitation after surgery
-What isthe role of? physical therapy?
-Pediatric physical therapy is a specialty that deals with the wide variety of
diagnoses that may affect your child's overall development from 0 to 18 years of
age. ----Depending on the age, disability, and setting, the role of the
pediatric physical therapist differs greatly. However, the primary role that the
pediatric therapist assumes is to be an advocate for you and your child.
Pediatric physical therapists help to ensure that your child's physical
performance in every day activities is at its best. Therapists rely on the
implementation of their expert knowledge of the neurological, musculoskeletal,
cardiopulmonary, and integumentary (skin) systems to help your child in any one
of the following ways:
Achieve age-appropriate developmental milestones (e.g., crawl, sit, stand, walk)
Better participate in age-appropriate gross motor or school activities with
peers
Improve range of motion, strength, mobility, posture, balance, endurance for
independent function
Improve your child's ability to independently negotiate his or her environment
(home, school, job, community)
Actively participate and contribute to the society at large
Treating your child includes examining, evaluating, and assessing the areas in
which your child may have difficulty functioning and then incorporating
activities to address these areas. After examining your child, the therapist
will make an evaluation of his findings using any combination of standardized
tests, observations, and/or clinical expertise.
Once an assessment has been reached, your therapist will discuss his findings
with you and educate you on your child's needs; educating caregivers (and your
child when possible) on the nature or extent of injury, disability, and the
prognosis is an essential component of pediatric physical therapy and helps to
keep the caregiver involved and informed of the child's progress. You will also
review the plan of care with your therapist, which will entail a discussion of
the number of visits, frequency, duration of physical therapy, prognosis, and
home activities you must do with your child to help him excel in his areas of
difficulty.
Together, you will then create an individualized program specific to your
child's goals and/or the family's goals. Activities in the form of play are
provided to help your child be better motivated to reach his goals. Your role as
a caregiver and your compliance with your child's home program are extremely
important for a successful plan of care.
However, please keep in mind that your needs are just as important as your
child's needs. In many instances, your pediatric therapist can advocate your
needs to the appropriate agencies, which may help to provide you with assistance.
posted by Fairouz El-sherif & Mohamed rizk
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