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The term motor impairment denotes difficulty with movements governed by the central nervous system. The most prominent cause of such impairment is cerebral palsy. One in four hundred babies gets affected and the cure is not possible, but the problems experienced can be conquered in many cases.
“Cerebral” denotes brain. “Palsy” implies a disorder of movement. CP refers to a group of non-progressive neuro-muscular problems of varying severity.
Cerebral palsy refers to a cluster of conditions that affect movement, balance and posture. Affected children have abnormalities in one or more parts of the brain that affect the ability to control muscles. Symptoms range from mild to severe but do not get worse as the child gets older. Most children can considerably improve their abilities with treatment.
Many children with cerebral palsy have other conditions comprising mental retardation, learning disabilities, seizures, abnormal physical sensations (difficulties with sense of touch), and troubles with vision, walking, hearing and speech and these desperately require thorough treatment.
Conditions associated with cerebral palsy:
- Mental retardation
- Breathing problems
- Learning Disabilities
- Bladder and bowel control problem
- Skeletal deformities
- Eating difficulties
- Dental problems
- Digestive problems
- Hearing and vision problems
Types of cerebral palsy:
Spastic cerebral palsy: Approximately 70 to 80 percent of affected individuals have the spastic type, in which muscles are rigid, making movement difficult. Spastic diplegia is a type of spastic cerebral palsy in which both legs are affected.
Affected children may have complexity walking because tight muscles in the hips and legs cause legs to turn inward and cross at the knees (called scissoring). In spastic hemiplegia, only one side of the body is affected, often with the arm more severely affected than the leg. Most severe is spastic quadriplegia, in which all four limbs, the trunk and face are affected. Children with spastic quadriplegia generally cannot walk. They often have mental retardation, difficulty speaking and seizures.
Athetoid or dyskinetic cerebral palsy: About 10 to 20 percent of affected individuals suffer from athetoid form, which affects the entire body. It is described by fluctuations in muscle tone (varying from too tight to too loose) and sometimes is associated with unrestrained movements (which can be slow and writhing or fast and jerky). Affected children often have trouble learning to organize their bodies well enough to sit and walk. Because muscles of the face and tongue can be affected, there also can be difficulties with sucking, swallowing and speech.
Ataxic cerebral palsy: About 5 to 10% of affected individuals have ataxic cerebral palsy. This type affects poise along with synchronization. Their walk may seem wobbly with feet far apart. They may also have difficulty with motions which need exact skill, for instance writing.
Causes of cerebral palsy:
Before Birth: Cerebral palsy is generally caused by factors that interrupt gradual development of the brain prior to birth. In some cases, hereditary defects may cause brain malformations and “miswiring” of nerve cell connections in the brain, bringing about cerebral palsy.
Inadequate oxygen reaching the fetus: This may take place when the placenta is not working appropriately or it gets separated from the wall of the uterus before delivery.
During Birth: As a result of prolonged labor, forceps delivery, cord around the neck causing inadequate supply of oxygen (asphyxia) and glucose to the developing brain of the baby. Researches reveal that birth complications, along with asphyxia, contribute to only 5 to 10 % of cases of cerebral palsy.
After Birth: Cerebral palsy may occur to an infant due to Meningitis, Encephalitis, Epilepsy, Jaundice or Accidents, and several other causes. Other cases are due to injuries to the developing brain, for instance a fetal stroke. But in several other cases, the actual reason of cerebral palsy in a child is still unknown.
Certain risk factors contribute to the development of cerebral palsy in babies. Nevertheless, most babies with one of these risk factors do not experience cerebral palsy. Risk factors for cerebral palsy are listed below:
Prematurity: Premature babies (those born before 37 completed weeks of pregnancy) weighing less than 3 1/3 pounds are between 20 and 80 times more susceptible to develop cerebral palsy than full-term babies. Majority of these little babies have to confront with bleeding in the brain and this can be really fatal as it may badly affect delicate brain tissue, or develop periventricular leukomalacia, damage of nerves surrounding fluid-filled cavities (ventricles) in the brain.
Infections during pregnancy: Certain infections in the mother can be responsible for brain damage and cause cerebral palsy. Cases of these infections consist rubella, cytomegalovirus (generally mild viral infection), herpes (viral infections that can cause genital sores), and toxoplasmosis (a usually mild parasitic infection). Maternal infections involving the placental membranes (chorioamnionitis) may encourage the proximity of cerebral palsy in full-term as well as preterm babies. A 2003 study at the University of California at San Francisco revealed that full-term babies were 4 times more vulnerable to have cerebral palsy provided they were exposed to chorioamnionitis in the mother’s womb.
Severe jaundice: Absence of proper treatment, elevated bilirubin levels can cause a risk of everlasting brain damage, causing athetoid cerebral palsy. Certain blood diseases, for example Rh disease, can result in serious jaundice and brain damage, leading to cerebral palsy. Rh disease is the result of an incompatibility between the blood of the mother and her fetus. It is generally prevented by giving an Rh-negative woman an injection of a blood product known as Rh immune globulin approximately the 28th week of pregnancy and again after the birth of an Rh-positive baby.
Blood clotting disorders (thrombophilias): The disorders that may heighten the risk of cerebral palsy in case of either mother or baby are listed below:
- Infection, seizure, thyroid, and/or other medical conditions in the mother
- Certain hereditary and genetic conditions
- Multiple births (twins, triplets)
Cerebral Palsy Symptoms
The indications of cerebral palsy are generally not obvious in early infancy but become more obvious as the child’s nervous system grows. Early signs are listed below:
Deferred milestones such as controlling head, rolling over, reaching with one hand, sitting without support, crawling, or walking
Persistence of “infantile” or “primitive” reflexes, which usually disappear 3-6 months following the birth. A child more than 6 months old reaches with only one hand while keeping the other in a fist.
A child ages above 10 months old crawling by pushing itself off with one hand and leg at the time of drawing the other hand and leg.
A child over 12 months unable to crawl or stand with support.
Exams and Tests
The doctor may recommend brain imaging tests, for example Magnetic Resonance Imaging (MRI), Computed Tomography (CT scan) or ultrasound. These tests sometimes can help recognize the cause of cerebral palsy. Ultrasound is often recommended in case of preterm babies who are thought to be at risk for cerebral palsy in order to help diagnose abnormalities of brain that are often related with cerebral palsy. In some children with cerebral palsy, especially those who are mildly affected, brain imaging tests display no abnormalities, suggesting that microscopically small areas of brain damage can cause symptoms. Electroencephalography (EEG) is crucial to analyze seizure disorders. A high index of thought is desired to identify non-convulsive or minimally convulsive seizures. This is undoubtedly a treatable cause of a CP-look-alike, which is not so difficult to treat if treated early. Electromyography (EMG) and nerve conduction studies (NCS) may be effective in differentiating CP from other muscle or nerve confusions. There is hardly any medical test that confirms the diagnosis of cerebral palsy. The diagnosis is made depending on the variety of information collected by the child’s health care giver or other advisors.
This information consists of a thorough medical interview regarding medical histories of the families of the parents, the mother’s medical conditions before and at the time of pregnancy, and a detailed history of the pregnancy, labor, delivery, and neonatal (newborn) period. Different kinds of blood and urine tests may be suggested if your child’s health care giver guesses that the child’s difficulties are the outcome of chemical, hormonal, or metabolic disorders. Detailed study of the child’s chromosomes, involving karyotype analysis and definite DNA testing, may be required to negate the possibility of a genetic syndrome.
Cerebral Palsy is certainly incurable. Various treatments are available to make children function at the highest possible level and with prompt and constant treatment; the disabilities related to cerebral palsy can be limited. Different therapies are now available but they should be carried out under the administration of a medical specialist or other associated expert. All of these therapies are not applicable to every person with cerebral palsy. The selection of the exact type of therapy should be made depending upon the need of the patient and what type of cerebral palsy he/she has. Whereas a certain treatment is applicable to a child it is not so for another. Therefore it is essential for the parents and the child’s care team to work together in order to select only those treatments that is beneficial to the child.
As we have told earlier that there are different kinds of cerebral palsy therapy and treatment:
- Cerebral palsy physical therapy
- Cerebral palsy occupational therapy
- Cerebral palsy speech and language therapy
- Cerebral palsy medical treatment: Surgery
- Cerebral palsy medical treatment: Drug therapy
- Cerebral palsy sensory integration therapy
- Cerebral palsy adaptive equipment
The aim of Physiotherapy (PT) programs is to encourage the patient to build a strong base for improved way of walking and volitional movement, accompanied by stretching programs in order to limit contractures. Many specialists have a belief that constant physiotherapy is vital to sustain muscle tone, bone structure, and avert displacement of the joints.
Occupational therapy is useful in helping adults and children improve their function, become accustomed to their limitations and become as self-sufficient as possible.
Orthotic devices for example Ankle-Foot Orthoses (AFOs) are frequently prescribed to reduce gait irregularities. AFOs have been found to develop a number of measures of ambulation, including reducing the expenditure of energy and raising speed and length of stride.
Speech therapy is helpful in order to control the movements of the muscles of the mouth and jaw, and helps develop communication. Just as cerebral palsy can influence the way a person moves their arms and legs, it can also influence the manner they move their mouth, face and head. This may make it difficult for the person with cerebral palsy to breathe; talk clearly; and bite, chew and ingest food. Speech therapy often starts before a child goes to school and is generally carried on during the school years.
Hyperbaric oxygen therapy (HBOT): In this therapy a person with cerebral palsy inhales pressurized oxygen inside a hyperbaric chamber. It has been carried out in order to treat cerebral palsy under the hypothesis that improving the accessibility of oxygen to dented brain cells can reactivate some of them so that they can perform in the usual way. Its application for the treatment of cerebral palsy is not beyond controversy. According to 2007 systematic review the influence of HBOT on cerebral palsy is not radically different from that of pressurized room air, and that some children having treatment of HBOT will experience adverse effects like seizures and the requirement for ear pressure equalization tubes. Just because of the poor quality of data evaluation the review also concluded that estimations of the pervasiveness of adverse effects are in doubt.
Nutritional counseling may be effective while dietary requirements are not met due to the problems regarding having specific foods.
Both massage therapy and hatha yoga are useful to help relax stressed muscles, strengthen muscles, and keep joints supple enough. Hatha yoga breathing work outs are really useful to avoid lung infections. More research is required in order to decide the health advantages of these therapies for people suffering from cerebral palsy.
Surgery for people with CP generally includes one or a combination of the following:
Relaxing tight muscles and releasing fixed joints are frequently carried out on the hips, knees, hamstrings, and ankles. Rarely, this surgery may be applied to people experiencing rigidity of their elbows, wrists, hands, and fingers.
The introduction of a Baclofen Pump generally at the stage while a patient is a young adult. This is generally positioned in the left abdomen. Baclofen Pump is a special kind of pumping device, linked to the spinal cord, whereby it delivers some amount of Baclofen easing out incessant muscle flexion. Baclofen works as a muscle reliever and is frequently given PO to patients in order to help prevent the spastic effects.
Straightening unusual twists of the leg bones, i.e. femur (also called femoral anteversion or antetorsion) and tibia (tibial torsion). This is a secondary problem caused on account of generating abnormal forces on the bones by the spastic muscles, and often causes in toeing (pigeon-toed gait). The surgery is known as derotation osteotomy, in which the bone is cut and then placed in the exact position.
Operating nerves on the highly affected limbs by movements and tremors: This procedure, known as a rhizotomy, (“rhizo” means “root” and “tomy” denotes “a cutting of” from the Greek suffix ‘tomia’) decreases seizures and allows more suppleness and control of the damaged limbs and joints.
Botulinum Toxin A (Botox): This is injected into muscles that are either spastic or have experienced contractures in order to mitigate the disability and pain generated by the incongruously contracting muscle.
Conductive Education (CE): It was first modeled in Hungary from 1945 depending on the work of András Pető. It is a combined system of treatment and psychoanalysis of people with neurological disorders along with cerebral palsy, Parkinson’s disease and multiple sclerosis, among other conditions. It is theorised in order to develop mobility, self-respect, strength and independence as well as everyday living skills and social skills. It is conducted by the expert who delivers conductive education in collaboration with parents and children. Skills acquired during conductive education should be applied to everyday life and can help develop cognitive, social and emotional skills considering age. There are some specialized centers that offer such education.
Neuro-cognitive therapy: It is based upon two established guidelines.
(1) Neural Plasticity. The brain is able to modify its own structure and execution to meet the demands of any particular environment. As a result if the child is endowed with an apt neurological environment, he will have the best possibility of achieving improvement.
(2) Learning can lead to development. As early as the early 1900s, this was being verified by a psychologist named Lev Vygotsky. He proposed that children’s learning is a social activity, which is attained by interaction with more skilled members of society. There are several studies, which offer confirmation for this claim. There are though, as yet no controlled studies on neuro-cognitive therapy.
Patterning is an alternative therapy for people with CP. This controversial process is endorsed by The Institutes for the Achievement of Human Potential (IAHP), a Philadelphia nonprofit. But this therapy has not been approved by the American Academy of Pediatrics. The IAHP’s methods have been supported by Linus Pauling, as well as some parents of children treated with their methods.
Cord Blood Therapy: According to a report published in Science Daily, the compound of sugar-alcohol, termed as mannitol, developed the therapeutic efficiency of human umbilical cord blood cells introduced into neonatal rat models with cerebral palsy. The study carried out by the University of South Florida reveals that the mannitol opened the blood-brain obstruction by provisionally contracting the rigid endothelial cells that constitute the barrier.
It has also been revealed that intravenously-introduced Human Umbilical Cord Blood (HUCB) may therapeutically be beneficial to the people with cerebral palsy. But this will be possible only if the blood cells can surpass the blood-brain barrier to reach the spot of the injury. It’s true that mannitol can’t enhance the survival of HUCB grafts but the elevation of the trophic factors HUCB along with mannitol can bring about drastic functional improvement.
It is undoubtedly a revolution in the field of medicine as well as neurology as it facilitates cell therapy in order to treat neonatal injury of brain and potentially cerebral palsy.
Can cerebral palsy be prevented?
In several cases, the origin of cerebral palsy is not identified. In those cases nothing that can be done to prevent it. However, some causes of cerebral palsy can be prevented by eliminating or controlling certain risk factors.
Rh disease and congenital rubella syndrome used to be common causes of cerebral palsy. Now Rh disease generally can be prevented when an Rh-negative pregnant woman receives proper care. Women can be examined for immunity to rubella ahead of pregnancy and vaccinated if they are not immune. A woman can help decline her risk of premature birth when she seeks early (preferably starting with a preconception visit) and regular prenatal care and stays away from cigarettes, alcohol and illicit drugs.
Babies with serious jaundice can be treated with special lights (phototherapy) and blood transfusions (exchange transfusions), when indicated. Head injuries in babies and young children can frequently be averted while riding with babies in car seats. Properly place your baby in the back seat of the car and young children should put on helmets at the time of riding bicycles. Routine vaccination of babies (with the Hib vaccine) prevents several cases of meningitis, another cause of brain damage in the early months.
Extend your support
Even today disabled people face discrimination and difficulties imposed by society in every sphere of their lives. Rather than enforcing an independent attitude in them society’s attitude is quite disappointing as they are pathetically forced into dependence.
It’s time to realize that children with cerebral palsy should be treated with more care and affection- they are very much a crucial part of our society and not the aliens. They have every right to live a joyous life; they have complete liberty to sing, clap, dance, giggle, smile, talk, draw, dance, learn, stand up, explore, and thus taste everything that life offers. Therefore a thorough knowledge of cerebral palsy is imperative in order to generate a positive attitude toward people with cerebral palsy.