By Dr. Pranathi Gutta
What is Cerebral Palsy ?
Cerebral Palsy is a condition that effects muscle control and movement. Is a non progressive condition due to a one time injury to the developing brain, before, during or after birth? The condition will not get worse, although the effects of CP may change over time.
How many people have CP?
It is difficult to estimate exactly how many people have CP. With increasing improvements in the care of the newborns it is estimated that 3:1000 babies and 1:3 premature babies are affected. According to WHO 15-20% of the disabled and challenged children in India have CP.
What causes CP?
The brain development starts in early pregnancy and continues until about 3 years of age. As a result any injury to the brain interferes with messaging from and to the brain and the body.
During Pregnancy any condition which tends to produce low birth weight will increase the likelihood of CP.During delivery and shortly thereafter, lack of Oxygen or sugar to the brain, head injury, infections, bleeding or clotting in the brain may produce CP.
Diagnosis of CP
A child with CP will probably be delayed in reaching milestones, such as sitting, walking or talking. A baby may feel unusually stiff or floppy.
A diagnosis of CP is given only after a child’s progress is observed over a period of time and other conditions are ruled out. MRI of the brain is usually undertaken. Blood tests to rule out other conditions might be undertaken.
Types of Cerebral Palsy
Depending on which part of the brain is injured, these children may have various difficulties. CP takes many forms, but there are 3 main types. People will have a mixture of these. The effects may vary from person to person.
Spastic CP
Spasticity means the muscle tone is tight and stiff, which will limit movement. As the muscles are tight, the spasticity can be painful. Spasticity can affect different parts of the body. Hemiplegia, Monoplegia, Diplopia, Trilegiant, and Quadriplegia.
Dyskinetic CP
Sometimes called athetoid, choreo-athetoid or dystonic Cerebral Palsy. Dyskinetic CP causes uncontrolled, involuntary, sustained or intermittent muscle contractions. It may be difficult to maintain an upright position. It may be difficult to control the tongue, vocal chords and breathing. This may affect speech.
Ataxic CP
Ataxia is an inability to activate the correct pattern of muscles during movement. This affects balance and spatial awareness. Most people can walk but will be unsteady with shaky movements. It can also affect the speech.
Mixed CP
Many children will have a mix of types.
Cerebral Palsy: Associated conditions
The injury to the brain that caused CP can also cause a number of other associated conditions. Children may or may not have associated conditions.
Epilepsy: affects up to a third of children with CP.
Hearing impairment: in up to 8% of children
Visual impairment: in up to 60 % of children with CP
Swallowing and eating difficulties.
Sleep difficulties.
Toilet problems.
Learning and Behavioral issues: affect 1in 4 children with CP
Management and supports
CP is not a curable condition and the word management is used more often than treatment.
There is much that can be done to lessen the effects of CP and help children with CP to lead independent lives. It is easy to be overwhelmed by the number of professionals involved and different management and therapy options.
Therapy
A lifestyle that involves regular exercise and proper nutrition (high fibre and protein rich diet) is very important including those with disabilities.
Physical therapy: Aims to help people achieve their potential for physical independence and mobility. It includes exercises, correct positioning and teaching alternate ways of movement like walkers, bracing etc
Occupational Therapy: designs purposeful activities to increase independence through fine motor skills. OTs help children to use adaptive equipment such as feeding, seating etc.
Speech and Language Therapy: Aims at improving communication.
Orthotics, Casts and Splints:
Most children will be prescribed Orthotics, casts or splints to supplement their therapy programs. These should be custom made to help provide stability, keep joints in position and help stretch muscles.
Medications
Medications fmay be prescribed for conditions associated with CP such as Seizures. Sometimes drugs may be prescribed for severe spasticity, or painful spasms.
Spasticity can be temporarily reduced by nerve blocking injections.
Botulinum Toxin (Botox) can be injected into a spastic muscle group. This can reduce tone for several months, during which time physical therapy should continue.
Surgery
Orthopedic and soft tissue surgery can help to counter the effects of spasticity on the hips, legs and spine. Surgery can lengthen or transfer tendons, enabling the child to move more easily. When the child has finished growing, bone surgery may help reposition and stabilize bones.
Neurosurgery involves surgery on the nerve roots in the spine, which control muscle tone.
Educational supports
Many children with CP will also have some type of learning difficulty. Assessment by a psychologist and the support of special educators can reduce the effects of a learning difficulty. These should be instituted as early as possible, even before starting school.
Most children should have an integrated education enabling them to mix with peers. They should all have an individualized education plan, which assesses the child performance, sets goals and specifies which supports are needed. The amount of support offered varies widely between school boards and individual schools in India. A good partnership between parents and educators will help children achieve their goals. A child with mild CP may need minor program adjustments, like for example if his hand control is poor a little more time to write an exam. Other children may require considerable support.
Attitudes:
It is very hurtful to have someone pat you on the head if you are sitting in a wheel chair or walk away if they cannot understand what you are saying, Prejudice and teasing can be very damaging. Children who are overprotected may also be prevented from being independent.
People with CP often site discriminatory attitudes and barriers as a greater challenge than any physical or cognitive difficulty they may have. The barriers that individuals with CP may face are often created by others. For instance someone with CP may wish to enter a building that has no wheel chair entrance, the barrier in this case is the building itself not the person using wheel chair.
Public education and policy initiatives need to be developed to be more inclusive. It is difficult to lead an independent life if public buildings, washroom and transportation facilities are not accessible.
The Author is Consultant Paediatric Neurologist, KIMS Hospitals, Sec-bad