Cerebral Palsy

A congenital disorder of movement, muscle tone or posture. Cerebral palsy is due to abnormal brain development, often before birth. Cerebral palsy is a neurological condition caused by brain damage and it is the most common motor and movement disability of childhood. Cerebral palsy causes range of disabilities, from mild to severe.    

Causes of cerebral palsy

Brain damage is the cause of CP but there are many different things that can trigger damage. For this reason, the exact cause of cerebral palsy can't always be determined. Possibilities include:-

• Poor brain development in the womb.
  
• Maternal infections or medical conditions.
• Disruption of blood flow to the developing brain.
• Genetic conditions.
• Ingestion of toxins and drugs during pregnancy.
• Damage to the head or skull during delivery.
• Complications related to premature delivery.

Types of cerebral palsy

There are four types of cerebral palsy:

 1.  Spastic cerebral palsy

           Spastic cerebral palsy accounts for 75 percent of all cases. It causes increased muscle tone, known as spasticity and causes:

• Delayed developmental milestones for moving.
• Abnormal movements.
• Movement inhibition.
• Stiff and spastic muscles.
• Difficulties controlling muscle movement.
• Difficulties moving from one position to another.

 2. Dyskinetic cerebral palsy

      Dyskinetic cerebral palsy is the second the second most common type of CP. Symptoms include:

• Dystonia, repetitive and twisting motions.
• Athetosis, writhing movements.
• Chorea, unpredictable movements.
• Poor posture.
• Painful movements.
• Difficulty swallowing or talking.

3.  Ataxic cerebral palsy

    Ataxic cerebral palsy is the least common. It causes poor balance, limited coordination, tremors, and shaky moements that are difficult to control.

4. Mixed cerebral palsy

   Mixed cerebral palsy causes symptoms characteristic of two or three of the other types. Spastic-dyskinetic cerebral palsy is the most common type of mixed CP.

Signs of cerebral palsy

Some signs of cerebral palsy in an infant or toddler are:

• Delays in movements and motor skills, such as holding head up, rolling over, sitting, crawling, and walking.
• Body parts that are too stiff or floppy.
• Favoring one side of the body.
• Scooting on the bottom instead of crawling.
• Inability to stand, even with support.

Management of cerebral palsy

 A variety of treatment options can improve symptoms and quality can improve symptoms and quality of life for babies and children. Many interventions can be started immediately after diagnosis is given.

Medical management

Various medications help control spastic movements, seizures, relieve pain, and manage other symptoms and related conditions:

• Baclofen or other muscle relaxants.
  
• Diazepam.
• Anticonvulsants.
• Anticholinergics.
  
• Antacids.
  
• Stool softeners/laxatives.
• Sleep aids.

Activities daily living and cerebral palsy

 When children are born, they are dependent on their caregivers for most of their ADL's (activitiesof daily living). Gradually but slowly, children become more independent. At a certain age, most children become more independent. At a certain age, most children having motivation to do things by themselves and enjoy the feeling of achievement. A big part of a caregiver's role is to help the child to gain independence.

Being able to perform ADL's effectively and independently demand skills in multiple areas:

•  Gross motor: eg. in order to stay sitting or squatting while using toilet, lift up a leg to put on trousers.
• Fine motor: eg. in order to undo in a zipper, hold a spoon and bringing it to the mouth without spilling the food.
• Visual
• Cognitive
• Sensorial
• Communication skills, etc.

Children with cerebral palsy who are affected in many areas may have difficulty in performing some or all ADL's eg. impaired hand function, which affects 50% of children living with cerebral palsy, will have an impact of child's performance in upper limb activities.

Some children will be able to become more or less independent with appropriate training and possible modifications to the environment or the activity, while others with severe impairments may always need consistent care. Even for children who will always need help, parents can be trained and supported to allow children to participate where they can ADL's. ADL's are very important moments in daily life of a child and caregivers should also be trained and encouraged to use these moments:

Help the child participate to the best of their ability/potential

• eg. If the child can only use one arm, they should do as much as possible with that arm, even if the caregiver needs to finish the work afterward. The caregivers shouldn't rush to do it for the child only because it's quicker.
  

Try to develop new skills

• Starting from the point where the child currently is, we can continue to work on new skills.

Engage in communication / cognitive / play activities with the child

• eg. Today we are going to put on sweater because it is chilly outside. Do you like it when it is chilly? And my sweater, which color is it? Now show mw your right arm so I can help you to put swear on.

Give the child options:

• Do you prefer this sweater or this other one? Even if a child needs a lot of physical help, developing a sense of autonomy, being able to make decisions and make choices, feeling that they have some control over their lives, is crucial for well-being and psychological growth.

Create bond between the child and the caregiver

• Use ADL's to spend time looking at the child's eyes, smiling, showing love and affection towards the child.

Activities of Daily living = Therapy / Development time

• Caregivers should be shown how to utilize the time engaging in ADL's to incorporate development skills and activities that the child needs to work on. This way it will be more likely that caregivers will remember and will find the to do them. 

Physiotherapy and ADL's

Performance in ADL's depends greatly on the ability to sustain a posture and control the movement of the different segments of the body. Physiotherapists can help caregivers understand the child's patterns of movement and posture to help finds ways where function can be optimized e.g. in order to be able to use arms and hands in the most effective way, including being able to look at them, requires a good position of the head, shoulders and trunk should be attained, with support if needed.

Caring for a child with cerebral palsy can have a great impact on the quality of life and wellness of caregivers, particularly in relation to the physical strain of handling and positioning a child or an adult with poor posture and movement control on a daily basis. Physiotherapists can help caregivers to understand better ways of handling their child while performing self care routines, in ways that are safer and more comfortable for both the child and caregiver. They can also train caregivers on ways to protect their own physical health.

Set up daily home care goals

Being at home is often to most comforting place a child with CP can be. It's also an ideal place for children learn and grow while feeling accepted and the best place to help them get acquainted with daily plans and activities. To get started, you'll need to think of what your daily goals are. Regardless of what your ultimate goals are, it's a good idea to make a list of things you want to accomplish. An example goal list may include:

• Promoting self- independence.
• Practicing daily living activities.
• Social interaction.
• Learning
  
• Healthy meals scheduled in advance
• Practice daily physical therapy
• Practicing grooming and hygiene skills

Guiding force behind

Dr Rajesh Gautam (PT)

Reference

1. ÖHRVALL A, ELIASSON AC, LÖWING K, Ödman P, KRUMLINDE‐SUNDHOLM LE. Self‐care and mobility skills in children with cerebral palsy, related to their manual ability and gross motor function classifications.

2. Developmental Medicine & Child Neurology. 2010 Nov 1;52(11):1048-55.
Geere JL, Gona J, Omondi FO, Kifalu MK, Newton CR, Hartley S. Caring for children with physical disability in Kenya: potential links between caregiving and carers' physical health. Child: care, health, and development. 2013 May 1;39(3):381-92.
  

3. Y Source. Bladder and Bowel Control in Children with Cerebral Palsy. Available at https://www.yourtherapysource.com/blog1/2016/08/01/bladder-bowel-control-children-cerebral-palsy/ (Last Accessed 2 Sep 2016).