Definition of cerebral palsy
Cerebral palsy is a disabling condition that is dominated by central motor dysfunction. It is a syndrome resulting from non-progressive brain damage and developmental defects during fetal development in utero, pregnancy, birth or infancy. Cerebral palsy is a permanent condition, but sometimes its effects may become less severe. Cerebral palsy has become more common in recent years due to the increased survival of very low birth weight, immature (preterm) infants, with approximately 1 in 400 live births having cerebral palsy. Cerebral palsy is the most common cause of movement disorders in children.
How cerebral palsy is caused
The brain defects that cause cerebral palsy often occur before birth, at birth and one year after birth. The causes of cerebral palsy include
l. Maternal infections (e.g. rubella virus, hepatitis virus, cytomegalovirus) occurring early in the infant’s development.
2. Difficult and premature delivery, causing respiratory distress in the infant.
3. Cerebral hemorrhage (hematoma), which can occur in preterm and mature infants.
4.Intracranial hemorrhage, which can occur in preterm infants.
5.Fetal brain developmental malformations, which can occur for no apparent reason, and genetic disorders may occur even if the parents are completely healthy.
Types of cerebral palsy
There are various ways to classify cerebral palsy. One classification is based on the type of activity disorder caused, which is usually divided into 3 characteristic problems: spasticity, motor difficulties, and ataxia.
1. Spastic cerebral palsy
Spastic cerebral palsy is caused by damage or abnormal development of the cerebral cortex (brain cells) that control movement. Spastic cerebral palsy is a condition in which some muscles appear stiff and difficult to move, and is caused by defects or damage to the surface area of the brain (cortex) that controls voluntary movement. Spastic cerebral palsy is divided into 3 subtypes depending on the limb involved.
Spastic hemiplegia (also known as hemiplegic cerebral palsy) is the most common type of cerebral palsy and involves one upper and lower extremity. Most children can often learn to walk, but he usually has a limp and the affected limb cannot be used as flexibly as the normal side limb.
Spastic biplegia clearly involves both lower extremities and is commonly seen in premature infants. The legs are usually turned inward and crossed at the knee in a scissor-like fashion. Many children also have a crouching gait, which means that they walk with their knees flexed. Children with spastic diplegia can walk short distances, but may require a wheelchair for long distances or outings. Although rarely involving both upper extremities, these children have difficulty using both hands to grasp objects and often have strabismus.
The most severe type of cerebral palsy is spastic quadriplegia, which involves all of the upper and lower extremities. These children are usually less likely to walk or sit unaided and may also have learning difficulties, visual and sensory impairments, often with strabismus and epilepsy.
2. Dyskinetic cerebral palsy (motor difficulties)
Dyskinetic cerebral palsy occurs from abnormalities in the basal ganglia (a group of brain cells in the deep part of the brain). The basal ganglia allows movements to become organized and coordinated, so abnormalities in the basal ganglia can cause a variety of involuntary movement disorders (uncontrolled movements of the limbs and trunk) – tardive dyskinesia, chorea, or dystonia. Some children may have a mixed form, such as chorea-like tardive dyskinesia.
Hand-foot tardive dyskinesia refers to uncontrolled, slow, twisting movements of the limbs and trunk. Involuntary movement of the upper extremities, lower extremities and trunk, i.e., the child is unable to control the movement. Muscle tone fluctuates and the muscles change rapidly between flaccid and tense, but the joints can move with full range of motion. These involuntary reactive activities often result in difficulties with walking, balance, speech (called dysphonia), and swallowing (dysphagia). Some children have excessive involvement of the face or tongue muscles, causing tongue jerking and salivation, and children with tardive dyskinesia can barely stop moving because of poor hand control and impaired writing function. Tardive dyskinesia tends to increase when the child is agitated or frustrated, but can disappear during sleep.
Chorea is another type of involuntary movement with uncoordinated reflexes in the neck and upper extremities. Chorea also increases with excitement or fear and disappears during sleep. Many children have chorea-like tardive dyskinesia, a mixture of chorea and tardive dyskinesia.
In tension disorders, the muscles may suddenly stiffen due to severe contractions. The muscle stiffness may last for a few seconds or minutes. When the face is involved, it can appear strange; neck involvement can appear bowed. If the dystonia lasts for several minutes, the child will appear twisted and bowed, and will remain in this position until the dystonic spasm disappears.
3. Ataxic Cerebral Palsy
Children with ataxic cerebral palsy are the least common type of cerebral palsy and have difficulty maintaining balance and coordinating hand movements. These children are unstable and may fall frequently. There may be both jittery hand movements – tremors – and unclear, unsteady speech. Ataxic cerebral palsy is the result of a defect or damage to the cerebellum at the base of the brain.
4.Mixed cerebral palsy
In mixed cerebral palsy, spastic type combined with ataxic type or spastic type combined with tardive dyskinesia is common.
What are the physical signs of cerebral palsy?
Each child with cerebral palsy is affected differently in terms of balance control, movement, and posture. Some children have fairly minimal deficits or limping, while others have difficulty crawling, walking, speaking, eating, or using their hands. Some children may require support to sit up. The most severely affected children have severe disabilities and require care from others. We can only identify a child with cerebral palsy if the child shows delays in motor development, sitting and standing posture and balance. Spastic hemiplegia and diplegia are hardly noticeable until the child is 2 years old. However, the upper and lower extremities seem to have stiffness earlier, yet it is difficult to diagnose at this age. In addition to difficulty moving the upper and lower extremities, children with cerebral palsy can have many other impairments or medical problems, including convulsive seizures, epilepsy, difficulty swallowing or controlling facial expressions, salivation, speech impairment, hearing impairment, vision problems or inability to interpret visual images in the brain (cortical visual impairment), and unaffected or severely involved intelligence. Many children have normal abilities but have specific learning difficulties related to visual and motor deficits. Many children with cerebral palsy also present with weaknesses in touch, pain perception, proprioception, and commonly incontinence and bedwetting. Thus without proper support and advice, children with cerebral palsy can also have psychological and social problems. However, with early and correct diagnosis and treatment then these problems can be avoided or mitigated.
The importance of creating the ability for the child to walk normally
Encouraging children with cerebral palsy to walk as normally as possible is one of the main goals of rehabilitation. Because children with cerebral palsy must compensate for the effects of spasticity, they may walk using abnormal gait patterns such as hyperflexion of the hips and knees – a crouching gait. This gait causes shortening of the affected muscles and progressive stiffening of the joints, which eventually progresses to bony deformities. As the child grows, without proper treatment, the situation becomes worse because the bones grow faster than the muscles, which leads to differences in the length of the lower limbs, muscles and tendons. The muscles in children need to be in a state of stretch and relaxation in order to grow, which is why the affected limbs and muscles are shorter than normal. The spasm of the triceps calf muscle causes the affected child to walk with a pointed foot and not be able to place the heel on the ground properly. This position of the foot makes their toes feel like they are stepping on uneven ground and they will waddle and fall. If the affected muscles are left untreated, eventually the muscles become permanently contracted and shortened, leaving the limb in an abnormal position, limiting joint movement and leading to early wear and tear of bones and joints, deformities, and even hip dislocation. Contractures are one of the most common complications of cerebral palsy, and hip dislocations are common in children with lower extremity spasticity. However, early intervention can greatly reduce the risk of this damage.
Treatment recommendations for cerebral palsy
The treatment of cerebral palsy is a matter of common inquiry, and there is no gold standard approach to date. However, with comprehensive evaluation, early and effective rehabilitation by medical professionals and parents, many secondary problems can be minimized and each child can reach their maximum potential.
Early and aggressive treatment can enable many children to achieve full independence, but this requires clear treatment goals and the development of an individualized treatment plan. The main issue that needs to be addressed early in spastic cerebral palsy is how to release the spasticity, and all accompanying other medical problems should be treated as well as possible. In addition to family counselors, social support, and the combined efforts of doctors and therapists are needed. As parents, they should be closely involved in the development of their child’s treatment plan and in making decisions, and they play a very important role in the daily treatment and motor training.
Physical and Occupational Therapy
Physical therapy (using movement therapy, manipulation, postural placement, plaster immobilization, bracing, etc.) is an essential part of treatment for children with cerebral palsy. Physical therapy helps the child learn how to control muscles and maintain balance, and helps the parents learn to assist the child to move and live as independently as possible. Sometimes it is recommended to stretch the muscles in specific ways to help promote muscle growth, and to use specific movement therapy to help the child improve muscle strength and maintain or improve joint mobility. Exercise therapy can help strengthen muscles, improve endurance, avoid muscle weakness in disused muscles, and reduce the development of fixed contractures. Occupational therapy can improve fine motor control of the small muscles that children use for eating, dressing, writing, etc. Treatment can also be provided with specific orthopedic supports and aids for the lower extremities and feet. Orthopedic supports and aids can help reduce the development of the deformity by pulling on the spastic muscles to inhibit spasticity. Serial cast immobilization can be used for early contractures, with cast changes every few days or weeks to continually increase muscle distraction, followed by short-term application of the cast to maintain distraction. Plaster immobilization may also assist in weight bearing. Plaster immobilization is recommended prior to brace treatment to reduce muscle tone and maintain the joint in a better position. Ankle casts are most effective and can also be used for knee, elbow and wrist treatment.
Medication
Reducing muscle spasm early in the spasm can slow the progression to permanent damage. The most commonly used muscle relaxants are baclofen and dantrolene. Dantrolene can be administered orally and acts on the muscle by interfering with the muscle contraction struts. Because dantrolene enters the bloodstream, it can cause a systemic reaction, resulting in general weakness and flaccidity, especially at the start of treatment. Because dantrolene can affect the liver, liver function needs to be checked every few months. Baclofen acts on the spinal cord to relax the muscles by reducing spinal signals sent. This can reduce stiffness and involuntary spasms. Baclofen is available in tablet form and can be taken orally, but can cause side effects such as fatigue and drowsiness. These often occur at the start of treatment or with large dose increases. Therefore, small doses of baclofen are given for treatment and the dose is gradually increased as the child tolerates it. Baclofen can also be injected directly into the cerebrospinal fluid near the spinal cord (i.e. intrathecally), bringing it close to the site of action. This means that fewer doses can be used and systemic side effects can be reduced. Under anesthesia, a micropump is placed under the skin in the abdomen, and the micropump can be continuously injected with the drug, potentially improving spasticity. It is important to carefully choose the right method as needed, as intrathecal injections are difficult to accept and are not as promptly stopped as oral medications, which require lifelong use. Diazepam can be used as a treatment for muscle spasms but causes sedation, and sedation is only recommended when the spastic state prevents sleep.
Surgical procedures
Surgery in children with cerebral palsy is an effective adjunct to rehabilitation and is only recommended when muscle contractures produce permanent stiffness and skeletal deformities. surgery is usually reserved for the correction of hip problems in children under 5 years of age, while surgery is recommended for older children with muscle contracture formation and bone and joint deformities.
Orthopedic surgery requires precise identification of the causative muscle, but this is not an easy task. This is not an easy task, since several muscles are usually involved in joint movements (e.g. running). The age requirement for surgery is also very strict: too early and the condition may recur due to the growth of the child; too late and the fixed contracture may develop and then the contracture will be more difficult to correct. Another surgical technique is selective spinal neurectomy, which involves cutting the specific spinal nerve that causes the spasticity. In addition, the child is kept in the hospital for several weeks after surgery and requires intensive rehabilitation for 12 months.
Nerve block therapy
Nerve block therapy involves the injection of an anesthetic, such as ethanol or phenol, into the motor nerve that controls the muscles, thereby destroying the central messaging axon and blocking the transmission of information, with the external myelin sheath of the nerve intact and usually regenerating after 6-18 months. This is a very useful technique for nerves that can only carry motor signals to control muscles, however most nerves that carry both motor and sensory signals are not suitable for this type of treatment.