What Is Cerebral Palsy?
SOURCES USED: Pediatric Neurologic Physical Therapy Second Edition by Suzann K. Campbell and Teaching Motor Skills to Children with Cerebral Palsy and Similar Movement Disorders-A Guide for Parents and Professionals by Sieglinde Martin, M.S. P.T.
Cerebral Palsy may be the most common pediatric neurologic problem referred to physical therapists and, at the same time, may represent the least well-defined and the least understood. It is important to understand that the term CP is a description, not a specific diagnosis. CP is a disorder of movement and posture. It is caused by a brain injury that occurred before birth (prenatal), during birth (perinatal), or during the first few years after birth (postnatal). Prenatal factors could be hereditary or genetic conditions, viral, bacterial, or parasitic (toxoplasmosis) infections, fetal anoxia caused by hemorrhage from premature separation or malformation of the placenta, Rh incompatibility, metabolic disorders (such as maternal diabetes and toxemia), and development deficits which include maldevelopment of the brain, vascular, and skeletal structures.
Perinatal factors include rupture of brain blood vessels or compression of the brain during prolonged or difficult labor, and asphyxia caused by drug sedation, distress of labor, premature separation of the placenta, placenta previa, or related to prematurity.
Postnatal factors leading to CP include vascular accidents and intracranial hemorrhage, head trauma, brain infections, toxic conditions such as lead poisoning, anoxia from drowning or cardiac arrest, seizures, and tumors.
The injury hinders the brain’s ability to control the muscles of the body properly. The brain tells our muscles how to move and controls the tension (tone) of the muscles. Without the proper messages coming from the brain, infants with cerebral palsy have difficulty learning the basic motor skills such as crawling, sitting up, or walking.
How is Cerebral Palsy Diagnosed?
Since CP hinders a child’s development and usually causes problems that persist into adulthood, it is classified as a developmental disability. Even though the brain injury may be present at birth, it is often difficult for doctors to recognize it. For this reason, there may be a delay in diagnosis. CP generally is diagnosed during the first or second year after birth. But if a child’s symptoms are mild, it is sometimes difficult to make a diagnosis until the child is a few years older. A developmental evaluation can be performed by the primary care doctor or by a specialist. Specialists who do this type of evaluation include: Developmental pediatricians, neurologist, pediatric physiatrist or pediatric rehabilitation doctors. In addition to the developmental evaluation, additional tests can be done to look for a cause of CP. Specialists may suggest brain imaging tests, such as CT scans, MRIs, EEG, genetic testing, or metabolic testing.
How much a child’s development is affected by CP depends on the extent and location of the brain injury. A child may be mildly affected or have severe involvement that also affects parts of the brain causing seizure disorders, cognitive dysfunctions, and vision or hearing loss. Different parts of the brain influence our movements in different ways. The damage to the brain may affect some muscles more than others.
Classifications of CP based on the muscles affected:
1) Quadriplegia: this type of CP affects the muscles in the child’s whole body. The muscles of the trunk, arms, and legs do not work properly. Even the muscles of the face may be affected. This may cause feeding and speech problems in addition to gross and fine motor difficulties. Children with severe quadriplegia have difficulties with most activities of daily living.
2) Diplegia: this means that the legs are mainly affected. Often parents do not suspect a problem until their baby is 7 to 9 months old and fails to sit. Typically, children with diplegia gain the coordination and balance required for independent sitting more slowly and not as well as other infants. Standing and walking are affected most. Due to spastic (tight) leg muscles, children with diplegia tend to stand on their toes, turn their legs in (internally rotate), and push their knees together (adduction), sometimes called “scissoring”. Depending on the severity of the CP, some children with diplegia will be able to walk short distances with a walker or gait-trainer, while others may progress to walking independently indoors and then outdoors.
3) Hemiplegia: In hemiplegia, one side of the body is affected by CP. The arm is usually more affected than the leg. Frequently children with hemiplegia are able to compensate for the one-sided disability with their unaffected arm and leg. They may learn skills almost as quickly as children without CP until it is time to walk. Weakness, poor coordination, and spasticity of the affected leg may delay independent walking by a year or more. Depending on the severity of their hemiplegia, the children may have little or limited use of their affected hand.
Classifications of CP based on the location of Brain Injury:
1) Pyramidal (Spastic) Cerebral Palsy: this is the most common type of CP. About 80 percent of children with CP have spasticity. This means that they have muscles that are tight and limit movements. These children have involuntary movements caused by abnormal reflexes.
2) Extrapyramidal Cerebral Palsy: About 10 percent of children with CP have this type. They have abnormally low muscle tone and they have difficulty controlling their muscles. These children have involuntary movements which may include:
*Athetosis-the movements are slow and writhing
*Ataxia-the movements are unsteady, shaky, and lack coordination
*Dystonia-the movements are slow, rhythmic, and twisting, or
*Chorea-the movements are abrupt, quick, and jerky.
3) Mixed-Type Cerebral Palsy: About 10 percent of children with CP have both spastic muscles and involuntary movements characteristic of extrapyramidal CP.
How Does Pediatric Physical Therapy Help Children With Cerebral Palsy?
A Pediatric Physical Therapist will commonly use the Gross Motor Function Measure (GMFM) to evaluate change that occurs over time in the gross motor function of children with CP. A different tool, the Gross Motor Function Classification System (GMFCS) is used to classify the severity of mobility.
The GMFM tells a parent what their child can do at the time of testing. Retesting at regular intervals will show your child’s progress. After testing, the physical therapist can show you the items your child passed and other test items in oder of difficulty for children with CP. The next skills or goals your child will master will most likely be test items of similar difficulty your child has not yet passed.
The GMFCS divides children with CP into 5 different levels, according to their ability, and describes in general terms the gross motor progress of each level between birth and twelve years of age.
Pediatric physical therapists can help with the obstacles to motor development that are caused by the effects of CP. These obstacles typically are abnormal muscle tone, abnormal movement patterns, abnormal reflexes, lack of motor control and coordination, muscle weakness, and abnormal sensory awareness. Because of the concept of neuroplasticity (the capacity of the brain to adapt to, and supplement for a deficit), while the brain is still growing, changing, and forming new connections in the first and second year of life, it is possible that other cells may take over the work of the damaged cells in the brain. As brain growth subsides, neural plasticity decreases but the capacity for recovery continues to remain throughout a person’s life.
Physical therapists will provide strategies for motor learning while addressing the obstacles above and help a child work through more normal movement patterns in order to improve their gross motor skills. One treatment approach called NDT (Neurodevelopmental treatment) has been successful in providing physical therapy treatment of children with CP and similar movement disorders. It is important that therapy activities are helping the child improve with their daily motor tasks. Many parents want to know how long it will take their child to learn each new skill but this varies greatly from child to child. Some may learn a few skills rather quickly while others may require weeks or even months of daily practice. Just remember early intervention is best for the child!
SOURCES USED: Pediatric Neurologic Physical Therapy Second Edition by Suzann K. Campbell and Teaching Motor Skills to Children with Cerebral Palsy and Similar Movement Disorders-A Guide for Parents and Professionals by Sieglinde Martin, M.S. P.T.
