Cerebral palsy

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Contents 1 Cerebral Palsy 2 Introduction 3 Diagnostic work-up 4 Treatment of cerebral palsy 5 Cerebral Palsy Equipment

[edit] Cerebral Palsy

[edit] Introduction

Cerebral palsy is not a single disease entity, but should be labeled “cerebral palsy syndromes” as it consists of several similar syndromes with symptoms that differ somewhat from each other. There are at least four subcategories depending whether there is more spasticity, an ataxic gait, a dyskinetic gait problem (“athetoid”) or a mixed form (more details below). There is no clear cause of these syndromes. However, it is known that the vast majority of cases occur already in the womb (either caused through injuries to the fetus or inborn problems). Only about 5% of cases are from difficult births. The symptoms begin to express themselves by 2 years of age and are fully developed by the age of 5 years. From then on they do not get worse. About 0.2% of children are affected by one of these disabling conditions. However, among prematurely born children up to 15% are affected. In the following a brief description is given about the various types of cerebral palsy.

Spastic cerebral palsy syndrome The majority of cerebral palsy cases (more than 70%) are of this type. The affected legs and arms show a resistance when one attempts to passively move them. In a milder case the affected person may be able to walk with a limp, but when running is attempted, the muscles lock and spasticity makes it impossible for the person to move. There are physical findings such as hyperactive deep tendon reflexes. Neurologists tell us that the problem lies in damage of the upper motor neuron (the nerve connections from the brain to the spinal cord). Muscles are in spasm, but the affected person is almost unable to move the muscles actively and there is hardly any muscle power. The movements are also not coordinated. In mild cases there may be only one or two limbs affected, in severe cases all four limbs are affected (quadriplegia-like).

Ataxic cerebral palsy syndrome

This type is found in about 4 to 5% of cerebral palsy cases. It is caused by damage in the cerebellum or the pathways that connect from there to the spinal cord and muscles. This leads to unsteadiness in the gait with an ataxic gait. There is weakness of the muscles, a lack of muscle coordination and the person walks with a wide-based gait to stabilize the gait as much as possible. The muscle coordination gets worse with repetition or with fine motor movements. There is an intention tremor (more ataxia and shaking with concentrating on fine motor movements).

Athetoid (=dyskinetic) cerebral palsy syndrome

In this type the damage has occurred in the basal ganglia. This may have been from asphyxia (lack of oxygen) from a prolonged difficult delivery or from kernicterus as a result of too high a bilirubin level in the first weeks of life. About 20% of the cerebral palsy cases belong into this group. There are slow involuntary movements (athetoid movements) in the thigh and upper arm muscles, which get activated by emotional upsets or attempts to activate the muscles. In the forearms and hands and in the lower legs and feet there are jerky and abrupt movements (choreic movements). These children have problems with speech and are grimacing (involuntary face muscle movements). Often they are labeled as hysterical.

Mixed forms of cerebral palsy

Mixed types of cerebral palsy are common. They usually involve a combination of ataxia and athetosis.

[edit] Diagnostic work-up

As there are a variety of different, often rare conditions found that are termed cerebral palsy syndrome, it is important to try to zero in on what type of neurological abnormality is present in a particular patient. This involves a referral to a pediatrician and often to a pediatric neurologist. There may be special tests required such as metabolic blood tests to rule out some of the more rare conditions. In more complex cases this may require a short hospital stay in a children’s hospital where these special services are available. The majority of children cannot be accurately diagnosed until after the age of 2 years. With premature children who had a stroke or abnormalities in the periventricular system of the brain cranial ultrasonography will show the changes in the brain.

[edit] Treatment of cerebral palsy

A combination of several treatment modalities will give the best possible results. A pediatric orthopedic surgeon may need to help with gait problems in the case of joint contractures doing a release procedure, if spring-powered splints are not helping. Special braces may be required or walking devices. Physical therapy will often be helpful and occupational therapists can be useful as well. Some of the spastic muscles can be injected with Botox to decrease the pull on joints. Speech training and special schooling is required for many children with these conditions. Milder cases will be able to attend regular schools, while the more severe cases require a lot more support, special schooling or placement in a specialized home. There are many support organizations available. Here is an example that shows that many cerebral palsy children can be trained to ride a modified bike. This link will assist you in finding cerebral palsy support services.

[edit] Cerebral Palsy Equipment

Equipment In looking at children with cerebral palsy and assistive devices, the Gross Motor Function Classification System (GMFCS) is a good predictor of the amount of assistance required both in physical assistance and in assistive devices with children at higher levels requiring more devices or personal help, especially at levels IV and V.

Orthoses/Braces Orthoses (braces) are used for many children with cerebral palsy. They are used for hands, feet and for the trunk. Basically, there are two reasons for using them: positioning and enhancing function.

Ankle/Foot Orthoses (AFO) Orthoses for the foot and leg can be divided into four types. The first type controls the heel and foot position; these basically keep the feet from rolling over to the inside or to the outside and keep the ankle in the middle. These braces do not have a direct impact on keeping the foot down, for example in toe walking, nor do they have any impact on the knee. The two kinds are called supramalleolar (SMO) or submalleolar, also called UCBL (University of California at Berkeley Laboratory). Braces are generally named for the joints they cross; the malleolus is the name of the ankle bone on the inside and outside. Therefore, a supramalleolar brace or SMO goes just above the ankle, so it keeps the foot from rolling in or out but allows any movement that the child is able to do at the ankle up or down, (dorsiflexion or plantarflexion). The submalleolar then is below the ankle bone and helps keep good foot position in those who have a slight tendency to roll inward on the ankle.

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References: 1. Behrman: Nelson Textbook of Pediatrics, 17th ed. Copyright © 2004 Saunders Chapter 590: Movement Disorders.

• 2. Goetz: Textbook of Clinical Neurology, 2nd ed. Copyright © 2003 Saunders, Chapter 34 – Movement Disorders.
• 3. More info on cerebral palsy on the web.
• 4. Disaboom.com - Cerebral Palsy Information.