Cerebral palsy is a disorder of movement and posture caused by a permanent and non-progressive cerebral lesion acquired early in brain development. It is often complicated by other neurological and learning difficulties. Although the brain lesion itself in cerebral palsy is non-progressive, the clinical picture changes as the child grows and develops. The underlying brain lesion may result from different insults occurring at various times in the developing brain.
In the neonatal period cerebral palsy may be suspected if a baby has difficulty sucking, irritability, convulsions, or an abnormal neurological examination. The diagnosis is usually made later in the first year when the following features emerge.
- Abnormalities of tone: Initially the tone may be reduced, but eventually spasticity develops.
- Delay in motor development: Such as marked head lag, delays in sitting and rolling over.
- Abnormal patterns of development: Movements are not only delayed, but also abnormal in quality.
- Persistence of primitive reflexes: Such as the Moro, grasp and asymmetric tonic neck reflex.
The diagnosis is made on clinical grounds, with repeated examinations often required to establish the diagnosis. Once made, a multidisciplinary assessment is needed to define the extent of the difficulties. An MRI scan is useful to demonstrate cerebral injury or malformations, delineating their extent and ruling out very rare progressive or treatable causes such as tumours.
Management of Cerebral Palsy
Most children with cerebral palsy have multiple difficulties and require a multidisciplinary input. This is provided by a Child Development Team, involving a paediatrician, physiotherapist, occupational therapist, speech and language therapist, health visitor and psychologist. They structure a coordinated programme of treatment to meet all the child’s needs, and ensure good liaison between professionals and parents.
Physiotherapists advise on handling and mobilization, and their role is crucial. The family must be taught how to handle the child in daily activities such as feeding, carrying, dressing and bathing in ways that limit the effects of abnormal muscle tone. They are also taught a series of exercises to prevent the development of deforming contractures. The physiotherapist may also provide a variety of aids, such as firm boots, lightweight splints and walking frames for the child when beginning to walk.
The role of the occupational therapist overlaps with that of the physiotherapist. The occupational therapist is trained to advise on equipment such as wheelchairs and seating, and on play materials and activities that best encourage the child’s hand function.
The speech and language therapist is involved on two accounts—feeding and language. In the early months advice may be required for feeding and swallowing difficulties. Later, a thorough assessment of the child’s developing speech and language is required and help given on all aspects of communication, including non-verbal systems when necessary.
The paediatrician’s key role is supportive, and involves liaison with other professionals, including school. In the long term the child needs to be monitored for developmental progress, medical problems, including epilepsy, development of contractures or joint dislocation, behavioural difficulties and nutritional status. Drugs, other than anticonvulsants for epilepsy, have a limited role in cerebral palsy. However, newer therapies include intramuscular botulinum toxin to relax hypertonic muscle groups and intrathecal baclofen via subcutaneous pump infusion for spasticity.
Even with adequate physiotherapy, orthopaedic deformities may develop as a result of long-standing muscle weakness or spasticity. Dislocation of the hip may occur as a result of spasticity in the thigh adductors and preschool children at risk require routine hip radiographs to ensure this is identified. Fixed equinus deformity of the ankle may develop as a result of calf muscle spasticity.
Undernutrition commonly occurs in children with cerebral palsy, and can reduce the child’s chances of achieving their physical and intellectual potential. Food must be given in a form appropriate to the child’s ability to chew and swallow. Energy-rich supplements and medical treatment for reflux may be required. A child who is unable to eat adequate amounts may need a gastrostomy to meet nutritional needs. Over time some children lose the ability to swallow safely, placing them at risk for aspiration. In this circumstance oral feeds must be discontinued.
Growing Up with Cerebral Palsy
The family has to cope with all the difficulties facing any family with a disabled child. However, cerebral palsy, if severe, places particularly heavy demands in terms of time and input. Everyday tasks such as dressing and bathing take time, and feeding, in particular, may take hours each day. The child also needs regular physiotherapy at home, and needs to attend appointments, both for medical follow-up and therapy. In view of this the family needs support, often beyond what family and friends can supply. Voluntary and social service agencies can provide babysitting, respite care and financial support.
Children with milder forms of cerebral palsy can cope at mainstream school, provided minor learning difficulties and physical access are addressed. Children with more severe cerebral palsy may need special schooling in a school for the physically or severely learning disabled, depending on the degree of their difficulties.
- Physiotherapy is needed to minimize the effects of spasticity and prevent contractures.
- Associated problems must be identified and managed.
- Any special educational needs must be met.
- The family needs adequate financial, practical and emotional support.
- The child’s integration into society should be maximized.