Cerebral palsy
Introduction
Cerebral palsy is a general term used by doctors to refer to a set of neurological conditions (conditions that affect the brain and nervous system) that affect a child's movement and coordination.
Cerebral palsy is caused by damage to the brain which normally occurs before, during, or soon after birth.
The symptoms of cerebral palsy vary from child to child. Some children will have problems walking, while others will be profoundly disabled and require life-long care.
It is estimated that 1 in every 500 children is born with cerebral palsy.
Children with cerebral palsy often have other related conditions. These include:
- epilepsy,
- learning difficulties,
- incontinence,
- impaired vision and/or hearing,
- difficulties speaker or understanding other people speak,
- delayed growth,
- curved spine (scoliosis), and
- drooling (unintentional loss of saliva from the mouth).
Cerebral palsy is not a progressive condition, meaning that it will not get worse as your child gets older. However, cerebral palsy can put a great deal of strain on the body which can cause problems in later life.
There is no cure for cerebral palsy, but there are a range of treatments that can help relieve symptoms and help increase a child's sense of independence and self-esteem.
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Symptoms
Initial symptoms
The symptoms of cerebral palsy will normally become apparent during the first three years of your child's life.
They may be slower in achieving important developmental goals, such as learning to crawl, walk or speak. Children with cerebral palsy also tend to have problems with their muscle tone (your unconscious ability to contract or relax muscles as needed).
Your child may have increased muscle tone which can make them appear stiff or rigid. This is known as hypertonia.
Alternatively, they may have a decreased muscle tone which makes them appear floppy. This is known as hypotonia.
In some cases, your child may experience an early period of hypotonia for the first two or three months of their live before progressing to hypertonia.
Children with cerebral palsy also tend to favour one side of the body over the other, which can make their posture appear unusual.
Types of cerebral palsy
There are several different common types of cerebral palsy, each of which has different symptoms. These are explained below.
Spastic hemiplageia
If your child has spastic hemiplageia, they will have muscle stiffness (spasticity) on one side of their body. This is normally limited to the hand and arm, but sometimes also affects their leg.
Spastic hemiplageia may also cause your child to develop an abnormal curvature of their spine (scoliosis). They may have problems speaking, but their intelligence should not be affected by the condition.
Some children with spastic hemiplageia will also experience epileptic seizures.
Spastic diplegia
In this type of cerebral palsy, your child will experience muscle stiffness in their legs. This may cause difficulty walking, and they may need aids such as leg braces or a walking frame.
Communication skills and intelligence should be unaffected.
Ataxic cerebral palsy
In this form of the condition your child's balance and depth perception will be affected (depth perception is the ability to judge where objects are in relation to your position).
They may appear clumsy and uncoordinated and have problems with activities that require precise movement, such as writing or tying a shoelace. They may also experience tremors in their hands (involuntary shaking), especially when they are trying to reach for an object.
Your child's communication skills and intelligence should be unaffected, though their speech may be erratic.
Athetoid or dyskinetic cerebral palsy
If your child has athetoid cerebral palsy (also referred to as dyskinetic cerebral palsy) they will experience both increased and decreased muscle tone. This means they frequently make apparently random and uncontrolled body movements. They will probably have problems with maintaining their posture.
Their speech will also be affected as they have difficulties controlling their tongue and vocal cords. Your child may also have problems with eating and drooling.
Intelligence is normally not affected in children with athetoid cerebral palsy.
Spastic quadriplegia
This is the most severe type of cerebral palsy, caused by extensive damage to the brain. Your child will have a high degree of stiffness in all their limbs, and may be unable to walk. Conversely, their neck muscles will be very lose and they may have problems supporting their head.
They will have difficulties in speaking, and the condition is also associated with a moderate to severe degree of learning difficulties.
Frequent epileptic seizures are common in children living with this condition.
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Causes
The cerebrum
Although cerebral palsy appears to be a condition involving the muscles, the cause of the condition is damage to the part of the brain that controls these muscles - the cerebrum.
The cerebrum is also responsible for other important brain functions such as communication skills, memory and ability to learn, which is why some children with cerebral palsy also have learning and communication difficulties.
Damage to the cerebrum can also cause problems with vision and hearing.
How does brain damage occur?
In the past, doctors believed that the damage to the brain occurred during birth as a result of a chid being temporarily deprived of oxygen (asphyxia). Asphyxia can sometimes occur during a difficult or complicated birth.
However a major research project carried out in the 1980s showed that asphyxia was only responsible for an estimated 5-10% of cases of cerebral palsy.
The majority of cases occurred as a result of damage to the brain which happened before the child was born.
The adult brain is quite resilient and can recover from even quite serious damage. But the brains of children, especially during the first six months of development, are particularly vulnerable, and any damage that occurs during this time can have serious and life-long consequences.
Researchers believe that there are three ways the brain can be damaged before birth. These are discussed below.
Periventricular leukomalacia (PVL)
Periventricular leukomalacia (PVL) is a term that refers to damage of the white matter of the brain.This part of the brain is made up of many nerve fibres that are protected by a white fatty protein known as myelin; which is how it gets it name. The white matter of the brain is responsible for directing communication between the though-processing sections of the brain (known as grey matter) and the rest of the body.
It is thought the damage to the brain is caused by a reduction in the blood supply of the child. This reduced blood supply then deprives your child's brain of oxygen, damaging the brain cells. This damage has serious consequences in later life as the white matter of the brain is responsible for transmitting signals to the muscles.
PVL can be caused by:
- an infection caught by the mother, such as rubella or German Measles,
- the mother having abnormally low blood pressure,
- premature birth, especially if a child is born at six months of age or earlier, and
- the mother using cocaine during her pregnancy.
Abnormal development of the brain
Anything that changes or affects the normal development of the brain can lead to problems with the way it transmits information to the muscles and so cause cerebral palsy. The brain is particularly vulnerable during the first 20 weeks of a child's development.
The development of the brain can be affected by:
- mutations (alterations) in the genes that help the brain to develop,
- infection such as herpes, toxoplasmosis (an infection caused by a parasite) , and cytomegalovirus (a herpes-type virus which most people, but not all, have an immunity to), and
- trauma or injury to the unborn baby's head.
Intracranial haemorrhage
Intracranial haemorrhage is a term used to describe bleeding in the brain. This can be dangerous for two reasons. Firstly, the brain can be deprived of blood which can kill tissue. Secondly, the blood itself can damage brain tissue.
Intracranial haemorrhage normally occurs in unborn children as a result of them having a stroke. Strokes can be caused by:
- pre-existing weaknesses or abnormality in the child's blood vessels,
- the mother having high blood pressure (hypertension), and
- an infection during pregnancy - particularly pelvic inflammatory disease (an infection of the upper female reproductive system).
Damage after birth
There are a few cases of cerebral palsy which are caused by damage to the brain that occurs after birth.
The damage normally occurs during the first few months of a child's life, before the brain develops its ability to withstand and adapt to a moderate degree of damage.
Damage can be caused by an infection of the brain, such as meningitis, or as the result of a traumatic head injury.
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Diagnosis
If you are concerned about your child's development you should see your GP who will be able to refer you to a paediatrician (a doctor who specialises in the treatment of children).
The paediatrician will ask you about your child's history and their pattern of development. They will also study your child's reflexes, posture, motor skills and muscle tone.
Depending on your child's age, you may also be referred to an educational psychologist so your child's intellectual development can be assessed.
Testing
Further tests may be recommended to rule out other conditions that can cause similar symptoms to cerebral palsy, such as a tumour or muscular dystrophy (a genetic condition affecting the development of the muscles).
In some cases further testing will also be able to confirm a diagnosis of cerebral palsy. This is because the condition can cause changes to the structure of the brain which can be detected by the tests.
Some of the tests your child may require are listed below.
- Blood tests.
- Cranial ultrasound - this uses sound waves to build up a picture of your child's brain tissue.
- MRI scan - this test uses radio and magnetic waves to study the brain in more detail.
- CT scan - this test uses a series of X-rays which are then reassembled by a computer to create a detailed 3-D model of your child's brain.
While a confident diagnosis of cerebral palsy can usually be made when your child is two or three years old, the type and severity of your child's cerebral palsy may not be able to be assessed until they reach four or five years of age.
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Treatment
Your care team
If your child is diagnosed with cerebral palsy, they, and you, will be introduced to a team of many different health professionals who will be involved with helping you look after your child.
They can include:
- a paediatrician,
- a health visitor,
- a social worker,
- a physiotherapist (a therapist who helps people by improving their range of movement and coordination),
- a speech therapist,
- an occupational therapist (a therapist who helps people improve the skills and abilities that are needed for daily activities, such as washing or dressing) ,
- an incontinence advisor, and
- an educational psychologist (a psychologist who specialised in helping people with learning difficulties).
An individual care plan will be drawn up in order to address any needs or problems that your child has. The plan will be continually reassessed as your child gets older, and their needs and situation changes.
You and your child will also be assigned a keyworker, who will be the first point of contact between yourself and the various support services that are available. While your child is young, the keyworker will likely be a health visitor. As your child gets older, and their needs become more complex, it is likely that the keyworker will be a social worker.
There is no single treatment plan for a child with cerebral palsy. Instead there are a wide range of treatments, which are all designed to help your child achieve as much independence as possible. Some of these treatments are outlined below.
Physical therapy
Physical therapy is normally started as soon as your child has been diagnosed with cerebral palsy, and is one of the most important ways of helping your child to manage their condition.
There are two main goals in physical therapy. The first is to prevent the weakening of muscles that are not normally being used by your child. The second is to prevent muscles from getting stuck in a rigid position, which is known as contracture.
Contracture is a risk in children who have problems stretching their muscles because of muscle stiffness. If the muscles cannot stretch, they do not grow as fast as the bones, which can then lead to deformities, causing your child pain and discomfort.
The physiotherapist will teach your child a number of physical exercises that they can carry out every day in order to strengthen and stretch their muscles. Special arm or leg braces may also be used to help stretch their muscles.
Speech therapy
Speech therapy can help children with communication difficulties by teaching them a series of exercises which can improve their ability to speak clearly.
If their communication difficulties are severe, the therapist may be able to teach them an alternative method of communication such as sign language. Special equipment which helps your child communicate may also be available, such as a computer which is connected to a voice synthesizer.
Younger children can be given a device, similar to a laptop, which is covered with symbols of everyday objects and activities. The child then presses a combination of symbols in order to make themselves understood.
Occupational therapy
Occupational therapy is designed to improve your child's posture and to make the most of what mobility they already have. They will also be given advice on the best way for them to carry out day-to-day tasks that require a degree of physical dexterity, such as going to toilet or getting dressed.
Occupational therapy can be extremely useful in boosting your child's self-esteem and independence.
Medicines
If your child's muscles are particularly stiff and overactive it can cause them frustration and pain. If your child is experiencing these problems, they may require medication to help them relax their muscles.
The first type of medication your child may be prescribed is a muscle relaxant such as diazepam, which is usually taken in tablet form.
Side effects of diazepam include:
- drowsiness,
- slurred speech,
- constipation,
- nausea, and
- incontinence.
If muscle relaxants are not effective, an injection of botulinum toxin (BTA) may be given. BTA works by blocking the signals from the brain to the affected muscles.
The effects of the injection normally last for up to three months. The treatment is most effective when a programme of stretching and physical therapy follows the injections.
Another possible treatment option is known as intrathecal baclofen therapy. This involves surgically implanting a small pump on the outside of the body which is connected to the spinal cord. The pump then delivers regular doses of a medicine known as baclofen directly into the nervous system.
Baclofen works by blocking some of the nerve signals that cause muscle stiffness.
Feeding and drooling problems
Children who have problems controlling their mouth will often have problems swallowing food, as well as difficulty controlling their production of saliva. Both of these problems can be potentially serious and require treatment.
If your child has problems with swallowing their food (dysphagia), it means there is a risk that small pieces of food could enter their breathing tubes and then their lungs. This can damage the lungs and trigger an infection (pneumonia).
If your child's dysphagia is mild, it may be possible to teach them techniques to overcome the problem. A modified diet using soft foods may also be required. If the problem is more serious, a feeding tube may also be needed. The tube can be placed down their neck, or connected directly to their stomach during surgery.
If your child has drooling problems, the excessive saliva can irritate the skin around the mouth, chin and neck. It can also cause the top layer of skin to break down which can then lead to an infection.
There are a number of treatments which can help children control their drooling. Some of these treatments are listed below.
- Anticholinergic drugs - these medicines reduce the body's production of salvia.
- Surgery - this can be used to redirect the saliva gland so the saliva runs towards the back of the mouth rather than the front.
- Intraoral devices - these are devices that are placed in the mouth and help encourage a better tongue position and regular swallowing.
- Biofeedback training - in this technique the child is taught to recognise when they are drooling and to swallow accordingly.
Orthopaedic Surgery
Surgery may be recommended if your child's cerebral palsy is causing them pain when they walk or move around. Surgery can also improve a child's posture and mobility skills, which in turn may help to improve their confidence and self-esteem
This type of surgery is known as orthopaedic surgery, and is designed to correct problems with bones and muscles.
During surgery, the surgeon will lengthen any muscles and tendons that are too short and are causing problems.
Surgical procedures are normally staggered over your child's life, taking into account their likely physical development. For example, the best time to correct problems with the upper muscles in a child's legs is when they are between 2-4 years of age, whereas the best time to correct problems with their hamstrings is when they are seven or eight years of age.
Due to advances in orthopaedic surgery, the recovery time from this type of surgery is relatively quick. Most children will be fully recovered a week after each surgical procedure.
Selective dorsal rhizotomy (SDR)
Selective dorsal rhizotomy (SDR) is a surgical procedure that is normally only recommended when other treatments for muscle stiffness and over-activity have been tried and failed.
During the operation, the surgeon will locate the nerves in the spinal column that are causing the muscle stiffness and then remove them.
Children who undergo surgery will require extensive physiotherapy, lasting between three to nine months, in order to 'relearn' basic motor skills such as walking.
This type of surgery has caused complications in some children, including:
- an unpleasant tingling sensation - much like 'pins and needles', in the part of the body that the removed nerves used to be connected to,
- constipation, and
- problems urinating.
Less common complications include:
- breathing difficulties, and
- lung infections.
You and your child (if they are able to understand the implications of surgery) should discuss both the potential benefits and risks of this procedure with your surgeon.
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Complications
Before the 1950's it was rare for children with cerebral palsy to survive into adulthood. Thankfully, due to advancements in treatment this is no longer the case. However, during the transition into adulthood, your child may face additional complications. Some of these complications are outlined below.
Post-impairment syndrome
Most adults with cerebral palsy experience what is known as post-impairment syndrome. This condition is the result of a combination of factors which are caused by the stresses that cerebral palsy places on the body. These factors may include:
- fatigue (people with cerebral palsy have to use five times as much energy to walk or move about then able-bodied people),
- muscle weakness,
- pain,
- arthritis (this is caused by the increased pressure that the condition puts on the bones and joints), and
- repetitive strain injury.
Further physiotherapy and equipment that can assist walking, such as a wheelchair or walking frame may help relive some of these symptoms.
Premature aging
Most adults living with cerebral palsy will experience premature aging by the time they reach 40 years of age. This is partly because of the strain that the condition puts on their body.
Many people will cerebral palsy do not have fully developed organs. This means that their organs often have to work harder than normal to compensate for the lack of development
Adults with cerebral palsy should therefore avoid activities that could further damage their organs such as smoking, drinking an excessive amount of alcohol and eating a high-fat diet.
Depression
Understandably, the day-to-day challenges of living with a chronic condition such as cerebral palsy can cause stress and anxiety which in turn can trigger conditions such as depression.
Cognitive behaviour therapy has been shown to be effective in both helping people fight their depression and cope better with their condition.
Cognitive behaviour therapy is based on the principle that the way we feel is partly dependent on the way we think about things. People who trained themselves to react differently to their condition - using relaxation techniques and maintaining a positive attitude - reported that the levels of pain, stress and depression experienced went down.
Making contact with other people living with cerebral palsy may also help. Scope, a charity for people with cerebral palsy, operates an Internet forum for people living with the condition. See the 'selected links' section for further information.
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Prevention
Most cases of cerebral palsy cannot be prevented even if the child receives the best possible care from their parents and doctors. However, it is possible to take steps to minimise the risk of complications during pregnancy and labour.
Following the recommendations on antenatal care is the best way to prevent complications.
In particular you should:
- ensure your vaccinations are up-to-date,
- attend all your antenatal appointments,
- avoid drinking alcohol and smoking, as this increases the chances of you having a premature birth - a risk factor for cerebral palsy,
- take regular exercise and eat a healthy diet - as this will boost your immune system which will reduce the risk of infection.
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