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Cerebral Palsy

Questions

what is Cerebral Palsy?

Cerebral Palsy is the group of permanent disorders affecting the development of movement and causing a limitation of activity. Cerebral palsy is the most common cause of childhood disability. Cerebral palsy is the outcome of non-progressive disturbances that manifest in a developing fetus or infant brain. The degree and impairment of functional capabilities vary depending on etiology.

Types: Cerebral palsy is characterized by the type of tone abnormality and distribution of motor abnormalities. The subtypes of cerebral palsy are: -

Spastic diplegic: The patient has spasticity and motor difficulties affecting legs more than the arms.                                                                                                                                                       

Spastic hemiplegic: The patient has spasticity and motor difficulties affecting one side of the body, arms affected more than the legs.

Spactic quadriplegic: The patient has spasticity and motor difficulties affecting all the extremities.                                                                                                                                                                  

Dyskinetic/ hyperkinetic: The patient has involuntary excessive movements, characterized as a combination of rapid dance like contractions of muscles and slow writhing movements.                                      

Dystonic: The patient has involuntary sustained muscle contractions causing twisted and repetitive movements.                                                                                                                                                   

Ataxic: The patient has unsteadiness and incoordination; they are often hypotonic.

Symptoms of Cerebral Palsy

  1. Micro- or Macrocephaly
  2. Excessive Irritability
  3. Hyper-or Hypotonia
  4. Spasticity
  5. Dystonia
  6. Muscle Weakness
  7. Abnormal or Absent postural reflexes
  8. Incoordination
  9. Hyperreflexia

Causes of Cerebral Palsy

Abnormal development or damage to fetal or Infant's brain causes cerebral palsy. The brain Injury causing CP is non progressive (static) and can occur in prenatal, perinatal and postnatal periods. The etiology in an individual patient is often multifactorial: 

Prenatal cause:                                                                                                                                                                                    

·         Congenital brain malformation                                                                                                                                

·         Intrauterine infections        

·         Intrauterine stroke                                                                                                                                                               

·         Chromosomal abnormalities                                                                                                                         

Perinatal cause:                                                                                                               

·         Hypoxic ischemic insults                                                                                                                                                           

·         Central nervous system (CNS) infections                                                                                                                                   

·         Stroke                                                                                                                                                                                                   

·         Kernicterus                                                                                                                                                                 

Postnatal causes;                                                                                                                                                          

·         Accidental and non-accidental trauma                                                                                                                                        

·         CNS infections                                                                                                                                                                                    

·         Stroke                                                                                                                                                                       

·         Anoxic insults.                                                                                                                           

                 Prematurity is a significant risk factor for cerebral palsy. Other risk factors associated with cerebral palsy are multiple gestation, intrauterine growth restriction, maternal substance abuse, preeclampsia, abnormal placental pathology, perinatal hypoglycemia and genetic susceptibility.

Diagnosis of Cerebral Palsy

Taking patients clinical history and physical examination, combined with neuroimaging and   standardized development assessments are used to make a diagnosis of cerebral palsy. MRI is the preferred imaging modality as MRI has higher diagnostic yield than CT. For early detection of cerebral palsy, standardized developmental assessments along with neuroimaging should be done.                                                                                                                     

The General Movement Assessment (GM) observes the quality of spontaneous movement in infants while lying supine. Cramped synchronized general movements and the absence of fidgety movements between 9 to 20 months predict cerebral palsy.                                                                                                    

The Hammersmith Infant Neurological Exam (HINE) is a standardized neurological assessment that can be administered between the ages of 2 to 24 months. It consists of 37 items and is divided into 3 sections: physical examination, documentation of motor development and evaluation of behavior state. The HINE has 90% sensitivity for cerebral palsy. An EEG should be obtained in patients suspected of having seizures. 

Treatment of Cerebral Palsy

Treatment of cerebral palsy takes an interprofessional approach. The treatment includes physicians, therapists, behavioral health specialist, social workers and educational specialists. Interventions should focus on maximizing the quality of life and decreasing disability burden. Oral and injectable like botulinum toxin is used to treat tone abnormalities. Medications used for spasticity mainly include benzodiazepine. Dystonia is often treated with gabapentin, carbidopa- levodopa. In this section we will discuss the aspects of physical therapy in treating cerebral palsy.                                                                                                                         There are many benefits of physical therapy, from improving mobility to preventing future issues such as contractures and joint dislocations by keeping the body strong and flexible. Some therapeutic approaches to cerebral palsy are:

Constraint Induced Movement Therapy: CIMT is used predominantly in individuals with hemiplegic cerebral palsy to improve the use of affected upper limb.

 • Passive stretching: It is the manual application of spastic muscles to relieve soft tissue tightness. Manual stretching may increase range of movements, reduce spasticity, or improve walking efficiency in children with spasticity.                                     

The types of stretching include                                                     

  1. Fast / quick

  2. Prolonged                   

  3.Maintained                                                                                                                                                                     

Fast/quick stretching: stretch for facilitation. Produce a short-lived contraction of the agonist muscle and short-lived inhibition of the antagonist muscle which facilitates a muscle contraction.                                                                             

Prolonged stretching: use of stretch to normalize the tone and maintain soft tissue length. Passive stretching may be achieved through a number of methods which include: 

Manual stretching: Prolonged manual stretch may be applied manually, using the effect of body weight and gravity or mechanically, using machines or splints                                                                                                   

Weight bearing: weight bearing has been reported to reduce the contracture in the lower limb through the use of Tilt-tables and standing frames through a prolonged stretch.                                                                 

Splinting: splints and casts are external devices, designed to apply, distribute or remove forces to or from the body in a controlled manner.                                                                                                                                     

Serial casting: serial casting is a common technique that is used and most effective in managing spasticity related contractures. It provides increased range if joint motion.

• Functional exercise: Training programs on static bicycles or treadmill have shown to be beneficial for gait and gross motor development but have not shown any effect on spasticity.                                                                       

• Electrical stimulation: The goal of electrical stimulation is to increase the muscle strength and motor functions. Electrical stimulation is provided by Transcutaneous Electrical Nerve Stimulation (TENS) Unit which is portable, invasive and can be used in home settings. Neuromuscular Electrical Stimulation (NMES) involves application of transcutaneous electrical currents that result in contractions. NMES has been postulated to increase the muscle strength by increasing the cross- sectional area of the muscle and by increased recruitment of type 2 muscle fibers. Functional Electrical Stimulation refers to application of electrical stimulation during a given task or activity when a specific muscle is expected to be contracting.