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Cerebral palsy

Cerebral palsy

Cerebral palsy (CP) is a group of disorders affecting the muscle tone, movement and motor skills, which is the ability to move in a coordinated and purposeful manner. CP is a common disorder existing before, during or after birth of children and into childhood up to 5 years of age. Signs of cerebral palsy usually appear before 18 months of age.

The exact causes of most cases of CP are unknown, but many are the result of problems during pregnancy in which the brain is either damaged or doesn’t develop normally. Brain damage in infancy or early childhood has also been linked to developing CP. A baby or toddler may suffer this damage due to bacterial meningitis, lead poisoning, being shaken as an infant or being in an automobile accident without the appropriate restraints. Cerebral palsy affects muscle control and coordination, making even simple movements, like standing still, difficult. CP can be associated with other health conditions like brain damage; vision, hearing and speech problems; and learning disabilities, urinary incontinence and seizures. Cerebral palsy does not get worse over time.

Signs of cerebral palsy

Children with CP can exhibit a wide range of symptoms that can be mild or severe. Some markers to look for in your child may include:

  • Lack of muscle coordination when engaged in voluntary movements – especially prevalent in ataxia types
  • Stiff muscles and exaggerated reflexes – found in spastic types
  • Walking with one foot or leg dragging
  • Variations in muscle tone, ranging from too stiff to too floppy
  • Excessive drooling or difficulties speaking, sucking or swallowing
  • Tremors, a muscle contraction
  • Difficulty engaging in precise motions like writing or buttoning a shirt

Any brain injury causing cerebral palsy does not change with time, meaning that these symptoms do not generally worsen as the child ages.

Diagnosing cerebral palsy

CP may be diagnosed early in a child’s life, if there was a premature birth or if the mother suffered the health issues previously mentioned. The child should be closely followed in these cases.

If your child was carried to term with no other obvious CP risk factors, it may be difficult to diagnose CP within the first year of your child’s life. Many times, a doctor is not able to make the appropriate diagnosis until there is a delay in normal developmental milestones such as the ability to reach for objects by 4 months or sitting up at 7 months.

Some other factors in diagnosing CP may include:

  • Abnormal muscle tone
  • Poorly coordinated movements
  • Persisting infant reflexes still present at an age where they should disappear

Sometimes, if the symptoms are mild, the diagnosis may not be made until your child is a toddler.

Treatment of cerebral palsy

Since the type and severity of cerebral palsy greatly vary from case to case, your child’s treatment will be based on their specific issues and conditions.

Treatment for children under 5 years of age:

  • The hospital provides orthotics to maintain optimal alignment of the upper and lower extremities as the child is growing. In some cases, the orthoses also help the child walk by providing stability. The hospital also provides assistive devices, such as walkers and Loftstrand crutches that help the child develop the ability to walk.
  • Children with spastic CP are managed by serial stretch casting and the judicious use of Botulinum toxin A, which is injected directly into the muscle in order to relax it and facilitate stretching by a therapist, with a cast or with an orthotic.

Between 5 and 7 years of age, it becomes evident which children with CP will be able to walk and which will require a wheelchair for mobility.

For children who don’t walk:

  • We have a seating team that develops a plan for a seating system that best meets the child’s needs. With such a prescription, families can contact a vendor in their own communities for the manufacture of the wheelchair.
  • This seating team will also evaluate existing seating systems and make recommendations for modifications to accommodate the growing child.

For children who can walk:

  • The gait pattern is frequently disrupted by muscle spasticity and contracture, skeletal malalignment and deficits of balance and motor control.
  • The gait pattern can be significantly improved by the proper use of therapy, orthotics and orthopaedic surgery.
  • Clinical decision making for these children is based on our understanding of the biomechanics of normal gait and the pathophysiology of gait disruption associated with CP. The central component to this approach is the use of quantitative motion/gait analysis, which utilizes computers and cameras to precisely measure how a child walks. With this information, the gait deviations can be identified, which leads to the selection of the appropriate treatment options. Quantitative gait analysis is also utilized to assess the outcome following an intervention such as surgery. Quantitative motion/gait analysis is performed at the motion analysis center.

Orthopaedic surgery

For the nonambulatory child, surgery is focused on the hips, the upper and lower extremities, and the spine.

  • Soft tissue and skeletal surgeries may be performed about the hips to prevent the development of painful dislocation that can occur due to muscle imbalance.
  • Soft tissue and skeletal surgeries are frequently utilized to correct foot and ankle alignment for these children in order to facilitate orthotic and shoe wear.
  • Children who are nonambulatory may develop scoliosis, which compromises sitting balance, and in severe cases, may be life threatening due to inhibition of heart and lung function. In these cases, correction of the spinal deformity by posterior fusion is performed.
  • Soft tissue and skeletal surgeries for the upper extremities are utilized to promote hygiene and in some cases, to improve function.

For children who can walk, surgery is primarily focused on the upper and lower extremities.

  • Soft tissue and skeletal surgeries may be performed about the hip, knee and ankle to improve range of motion and positioning of these joints.
  • Soft tissue and skeletal surgeries are frequently utilized to correct foot and ankle alignment in order to facilitate orthotic and shoe wear, as well as improve the loading pattern of the foot.
  • Skeletal surgery on the lower extremity may be necessary to correct common gait problems such as in-toeing or out-toeing.
  • Soft tissue and skeletal surgeries for the upper extremities are utilized to promote hygiene and in some cases, to improve function.

Tone management clinic

“Parents often note their child is not achieving normal developmental milestones such as smiling, sitting, crawling or walking,” describes David Westberry, M.D., pediatric orthopaedic surgeon at Shriners Hospitals for Children — Greenville. He says, “Babies with cerebral palsy can either have very little muscle control or be especially rigid and may sometimes favor one side of their body over the other.”

When a child has muscles that are rigid, otherwise known as spasticity, they have stiffness and movement difficulties. The Greenville Shriners Hospital knows that patients with spasticity need a wide-range of care and services in order to thrive. This is why the hospital’s tone management clinic offers a clinic setting where patients can be evaluated and treated, all in one location, by a team of specialists.

Shriners Hospitals for Children — Greenville’s tone management clinic is comprised of a multidisciplinary team consisting of five physicians with specialized training in pediatric orthopaedics, neurosurgery, neurology, physiatry and genetics. The physicians are supported by occupational therapists, physical therapists, social workers, registered nurses, physician assistants, nurse practitioners, motion analysis center representatives and an intrathecal Baclofen therapy specialist. The treatment plans that are developed in this very comprehensive clinic are individualized for each patient’s special needs. Examples of these plans of care can include recommendations for oral Baclofen, Baclofen trials to determine appropriateness of a Baclofen pump placement, Botulinum toxin A injections, orthopaedic surgery, stretch casting, and physical and occupational therapies.

Dr. Westberry says, “Each child’s mobility and subsequent quality of life can be improved through the coordination of their comprehensive care. One of the strongest arguments for traveling to a Shriners Hospitals for Children is that once there, the orthopaedic and rehabilitation services provided are comprehensive, negating the need for families to travel all over town to see specialist after specialist.”

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