CEREBRAL PALSY

Symptoms, Causes, Risk Factors, Tests and Diagnosis, Complications, Treatment & Drugs, Prevention and Coping & Support

Definition

"Cerebral palsy" is a general term that describes a group of disorders that appear during the first few years of life and affect a child's ability to coordinate body movements. These disorders are caused by damage to a child's brain early in the course of development. The damage can occur during fetal development, during the birth process or during the first few months after birth.

Cerebral palsy ranges from mild to severe. Physical signs of cerebral palsy include weakness and floppiness of muscles or spasticity and rigidity. In some cases, neurological disorders — such as mental retardation or seizures — also occur in children with cerebral palsy.

Cerebral palsy isn't curable. However, getting the right therapy for your child can make a big difference. Today, children with cerebral palsy benefit from a wide range of treatment options and innovations.

Symptoms

There are three major types of cerebral palsy:

• Spastic cerebral palsy. Most children with cerebral palsy have spastic cerebral palsy. This form of the condition causes muscles to stiffen, which makes movement difficult. It can affect both legs (spastic diplegia), or it can affect one side of the body (spastic hemiplegia). In the most severe cases, all four limbs and the trunk are affected (spastic quadriplegia) .

• Athetotic cerebral palsy. About one in five people with cerebral palsy have this form, which is also referred to as extrapyramidal cerebral palsy. It affects the entire body and often causes uncontrolled, slow movements.

• Ataxic cerebral palsy. This is the least common of the major types of cerebral palsy. It affects balance and coordination.

Some children have signs and symptoms of more than one type of cerebral palsy, which may be referred to as a mixed form of the condition.

In general, children with cerebral palsy exhibit a wide variety of signs and symptoms, ranging from mild to severe. Cerebral palsy symptoms don't worsen with age. They may include:

• Lack of muscle coordination when performing voluntary movements (ataxia)
  
• Stiff muscles and exaggerated reflexes (spasticity)
  
• Asymmetrical walking gait, with one foot or leg dragging
  
• Variations in muscle tone, from too stiff to too floppy
  
• Excessive drooling or difficulties swallowing, sucking or speaking
  
• Tremors
  
• Difficulty with precise motions, such as writing or buttoning a shirt

Some children with cerebral palsy have severe mental retardation, but others are extremely bright. Many need a wheelchair and extensive, lifelong care, but some require little or no special assistance.

Causes

Cerebral palsy results from an abnormality in or injury to the cerebrum — the largest area of the brain, which controls sensation and voluntary motor function. Although cerebral palsy affects movement, the underlying problem originates in the brain, not in the muscles themselves.

A small number of children with cerebral palsy acquire the disorder after birth. In these cases, doctors can sometimes pinpoint a specific reason for the neurological problem. For example, cerebral palsy can develop after an illness during early infancy, such as bacterial meningitis — an infection and inflammation of the membranes and fluid surrounding the brain and spinal cord. It can also be the result of a head injury.

However, doctors don't completely understand the cause of most cases of cerebral palsy, which are present at birth (congenital) . For many years, doctors and researchers believed that cerebral palsy was caused by a lack of oxygen during birth. Now they believe that only a small number of cases are caused by problems during labor and delivery.

Some possible causes

Doctors and researchers have now identified many possible causes of congenital cerebral palsy, including:

• Maternal infection during pregnancy, such as rubella or other viral infections
  
• Severe jaundice in newborns, which may be caused by infection, severe bruising or problems with red blood cells due to ABO or Rh incompatibility — two incompatibilities between the blood of the mother and her fetus
  
• Abnormal brain development before birth, resulting from genetic causes or metabolic disorders
  
• Disturbance to brain circulation before birth, caused by an artery spasm or blood clot, similar to a stroke in adults

Risk factors

Most children with cerebral palsy don't have any apparent problems during development in the womb and birth. But some factors may increase the risk of cerebral palsy:

• Babies that are premature or have a low birth weight
  
• Fetuses in a feet-first position (breech presentation) at the beginning of labor
  
• Complicated labor and delivery
  
• Maternal infection during pregnancy
  
• Health problems in the mother during pregnancy that impair normal blood circulation to the uterus and placenta

Meconium staining of amniotic fluid, caused by stool passed by the fetus in utero, also may indicate prenatal difficulties. However, most children with one or more of these risk factors don't develop cerebral palsy.

When to seek medical advice

If your baby seems to display weakness or paralysis in a limb or isn't developing motor skills at the expected times, talk to your family doctor or pediatrician. Every baby develops at his or her own pace, so there's no need to panic if your baby doesn't meet one of the monthly milestones described in a parenting book. But it's important to share any concerns about your baby's development with your doctor.

For example, children usually become right-handed or left-handed by age 2. Infants who appear right-handed or left-handed at younger ages may actually have impaired movement of one hand.

Tests and diagnosis

Early signs of cerebral palsy may be present from birth, but it's often difficult to make a definite diagnosis during the first six months. Cerebral palsy is generally diagnosed by age 1 or 2.

If your child shows some signs of cerebral palsy, your doctor will likely schedule an appointment to observe your child and to talk to you about your child's physical and behavioral development. In this evaluation, your doctor will check your child's reflexes, muscle tone and movements. Additional tests may rule out other disorders that can cause movement problems. Your doctor may have your child undergo one or more of these procedures:

• Computerized tomography (CT) scan. Images created with a CT scanner show the structure of your child's brain, as well as the presence and extent of any damage.

• Magnetic resonance imaging (MRI) scan. The cylinder-shaped MRI scanner uses no X-rays. Instead, a computer creates tissue-slice images of the brain from data generated by a powerful magnetic field and radio waves. These images can be viewed from any direction or plane.

• Other tests. Some children may need genetic or metabolic tests to help rule out other conditions.

You may be referred to a specialist to help determine if your child has cerebral palsy or some other condition. Your doctor may recommend a visit to a doctor with specialized training in the development of the brain and nervous system in children (pediatric neurologist) , a doctor who specializes in childhood development (developmental pediatrician) , or a doctor who specializes in physical medicine and rehabilitation (physiatrist) .

Complications

Besides difficulty with movement and posture, cerebral palsy may result in these health problems:

• Development of joint deformities or dislocation, if there's considerable spasticity
  
• Nutrition problems, if there are swallowing or feeding difficulties

Some children with cerebral palsy will have multiple handicaps and may require long term care. Some of the associated problems may include:

• Difficulty with vision, hearing and speech
  
• Dental problems
  
• Mental retardation
  
• Seizures
  
• Abnormal sensation or perception
  
• Urinary incontinence

Treatments and drugs

The brain abnormality or damage that underlies cerebral palsy doesn't worsen with time, but children with cerebral palsy often require long-term care. The type and amount of treatment depend on how many problems your child has and how severe they are.

The goal of cerebral palsy treatment is to help your child reach his or her maximum potential. Reaching this goal typically requires a multidisciplinary team of professionals, including physicians, therapists, psychologists, educators, nurses, special education teachers and social workers. These professionals work together to address issues of social and emotional development, communication, education, nutrition and mobility. Cerebral palsy treatments may include:

• Physical therapy. Physical therapists work to help your child reach his or her maximum potential for functional independence through a variety of approaches including exercise, mobility training, orthotics or braces, and use of other equipment. Muscle training and exercises may help your child's strength, flexibility, balance, motor development and mobility, as well as ease caregiving.

• Occupational therapy. Therapists in this field focus on the development of fine motor skills and self-care skills. Using exercises, facilitated practice, alternative strategies and adaptive equipment, they work to promote your child's independent participation in daily activities and routines in the home, school and community. They may also address difficulties with feeding and swallowing.

• Speech therapy. A speech therapist works with your child on both the receptive (understanding) part of speech and language as well as the expressive part (talking). Speech therapists help improve your child's ability to speak clearly or communicate using alternative means such as an augmentative communication device or sign language. Speech therapists may also help with difficulties related to feeding and swallowing.

• Vision and hearing aids. Depending on how severely your child's eyes are affected, he or she may need eyeglasses or surgery to correct a condition, such as cross-eye or other inability of the eyes to focus together properly (strabismus) . Hearing aids may help correct any hearing problems.

• Orthotics. A variety of orthotics or "braces" or "splints" may be recommended for your child. These may be used on your child's legs, arms or trunk. Some of these supports are used to help with function, such as improved walking. The purpose of others is for additional stretching or optimal positioning of a joint. You'll need to pay careful attention to your child's skin under the orthotics to make sure that the skin isn't becoming irritated. Just like your child needs new shoes as they grow, they may also need new orthotics over time. Your rehabilitation team can help you decide which type of orthotic is most useful at what time of your child's life.

• Medications. These may include muscle relaxants to ease muscle spasticity and anticonvulsants to reduce seizures. Injections of botulinum toxin (Botox) directly into spastic muscles also may be helpful.

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  Surgery. Children with severe contractures or deformities may need surgery on tendons, bones or joints to place their arms and legs in their correct positions. This can make it easier to use a walker, braces or crutches. Children with severe spasticity who haven't responded to oral medications may also benefit from surgical procedures.

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  One option is dorsal rhizotomy, a procedure in which surgeons identify and cut a portion of the spinal sensory roots that provide input to spastic leg muscles. Another option is intrathecal baclofen. In this procedure, an intraspinal catheter is placed and connected to a reservoir under the skin of the abdomen. This mechanism continuously pumps small amounts of an antispastic medication called baclofen into the fluid around the spinal cord.

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  These surgeries require careful screening and an expert team of health professionals, including pediatric neurosurgeons, orthopedic surgeons, pediatric neurologists, pediatric physiatrists and physical therapists.

• Assistive technology. A range of devices and gadgets can help with communication, mobility and daily tasks. Assistive technology includes such small things as rails, grab bars, magnifiers, and Velcro grips attached to forks and pens to make them easier to grasp. It also includes more expensive, high-tech tools, such as customized wheelchairs, voice communication devices, computer software programs, and positioning equipment that puts a child in the correct posture to sit or stand with other kids or family members. These devices and gadgets for school and home can make a big difference in the lives of children with cerebral palsy.

Prevention

For more than a century, doctors have hoped that by somehow improving labor and birth practices, they could reduce the incidence of cerebral palsy. But these rates have remained fairly constant, despite increased prenatal care, electronic fetal monitoring, prenatal ultrasound and increased use of Caesarean section delivery over the past 25 years.

Fewer babies now develop cerebral palsy as a consequence of birth injury. However, larger numbers of extremely premature babies survive, and some will develop cerebral palsy.

Most cases of cerebral palsy can't be prevented, despite the best efforts of parents and doctors. But, if you're pregnant, you can take these steps to keep healthy to minimize the possibility of pregnancy complications:

• Make sure you're immunized. Immunization against diseases such as rubella may prevent an infection that could cause fetal brain damage.
  
• Take care of yourself. The healthier you are heading into a pregnancy, the less likely you'll be to develop an infection that may result in cerebral palsy.
  
• Seek early and continuous prenatal care. Regular visits to your doctor during your pregnancy are a good way to reduce health risks to you and your unborn baby. Seeing your doctor regularly can help prevent premature birth, low birth weight and infections.

Coping and support

When a child is diagnosed with a disability, it forces the whole family to face a range of new challenges. Here are a few tips for caring for yourself and your child:

• Foster your child's independence. Encourage any effort at independence, no matter how small. Just because you can do something faster and quicker doesn't mean you should.

• Be an advocate for your child. You are an important part of your child's health care team. Don't be afraid to speak out on your child's behalf or to ask tough questions of your physicians, therapists and teachers.

• Find support. A circle of support can make a big difference in helping you cope with cerebral palsy and its effects. As a parent, you may feel grief and guilt over your child's disability. Your doctor can help you locate support groups, organizations and counseling services in your community. Your child may benefit from family support programs, school programs and counseling.