What is Cerebral Palsy (CP)?
Cerebral Palsy is primarily a disorder affecting the movements and actions performed by various muscles of the body (motor disorder). Though described as non progressive the disability (due to the damage sustained at a time during early childhood) can progress.
How common is CP?
Most place the prevalence around 2 per1000 children. In India, no absolute figures are available, but estimated children affected (based on hospital records) are over 2.5 millions.
How do you recognize C.P.?
§ The hall mark of the condition is motor dysfunction, i.e. there is abnormal muscle tone, abnormal posture and movement
§ As the child grows, the movement disorder can appear worse because every effort to move is confronted by the force of gravity
§ The clinical expression of the child depends on the extent and area of brain damage, growth of the child, coexisting developmental problems
Why is it important to know about CP?
§ Ignorance about the problem often causes more problems for a person with C.P. than the condition itself.
§ Actually a child with C.P. is not hopeless
§ Half the children with C.P. have average or above average I.Q.
§ With timely help and proper guidance a vast majority can lead active, self supporting and long lives
Early diagnosis of CP
§ Lack of alertness
§ Increased abnormal movements, Fits
§ Feeding problems, drooling
§ Poor quality of sleep
§ Reduced head size or fall in its growth
§ Delayed social smile
§ Poor head control present at 3 months of age
§ Delayed appearance of developmental milestones
§ Constant fisting after 2 months of age
§ Increased tone, scissoring or assumption of equinus position of feet
§ Eye problems: roving eyes, no visual following, persistent squint
§ Lack of response to sound
Conditions that mimic CP
§ Birth defects-neural tube defects, vertebral instability etc.
§ Slowly progressive degenerative brain disorders e.g. metabolic disorders - amino aciduri as like glutaric acidemia type I, peroxisomal disorders, mitochondrial disorders
§ Neuromuscular disorders e.g. muscular dystrophies.
In all cases where the diagnosis is in doubt, further follow-up and diagnostic evaluation may be required.
Role of investigations
Diagnosis of CP is essentially clinical
ü Laboratory tests are not necessary to confirm diagnosis
ü Brain imaging studies including Ultrasound scan of brain, CT and MRI may be useful in elucidating the cause of cerebral palsy and suggesting a long term outcome.
ü Ultrasounds can head is easily available in most health centers and is useful to detect bleeding and periventricular leucomalacia in preterm babies.
ü CT and MRI - to detect / diagnose other diseases that may be confused with CP e.g. slow degenerations, birth defects etc.
Eye and hearing assessment
ü Always screen systematically for visual and auditory problems even if they may not be clinically apparent
Benefits of early intervention
ü Anatomical - Maintains soft tissue extensibility, optimises musculoskeletal growth and development
ü Physiological - Early visual and sensory inputs optimize movement, posture and balance
ü Developmental - Reinforces positive developmental patterns
ü Reduces cost of treatment, minimizes complications and mitigates need for adaptive equipment
Who does the CP management team consist of?
The CP management team consists of a Child neurologist, developmental pediatrician, physiotherapist, a child psychologist, orthopedic surgeon, speech therapist, occupational therapist and a social worker. The neurologist coordinates the functioning of the team and is primarily involved in diagnosis, assessing development and disability. Control of fits if any and determining the need for any interventions-medicines, surgery or otherwise.
How is CP managed?
The management of CP revolves around the management of associated conditions (like fits, mental subnormality, visual and hearing loss) prevent the progression of disability and rehabilitation.
Counseling: A physician should have an elementary idea of all the modalities required for holistic management.
Physiotherapy and motor training
Physiotherapy should be directed towards:
ü Specific training of actions such as sitting, standing, walking and stepping
ü Exercises designed to increase muscle strength
ü Prevention of contractures
ü Control of movement
Training in activities of daily living
Management of feeding difficulties
ü Usea shallow spoon, soft foods.
ü Place the food on the middle of tongue
ü Give small pieces of solid food
ü If needs help to keep mouth closed when chewing, apply pressure to jaw to keep it closed
ü Drooling can be minimized by improving swallowing, drugs not very effective
Early developmental stimulation
Basic principles are
ü Follow general principles of normal development
ü Attempt to break the primitive reflexes as they interfere with attainment of normal milestones
ü Children with mild CP do well in mainstream schools
ü Most children with moderate to severe cerebral palsy need to be educated in special schools.
ü Check for refractive error, advice eye exercises
ü Encourage child to speak. Guidance from speech therapist can help improve speech patterns
ü Management is same as for other children with fits
ü However,a larger proportion of children with CP may have refractory fits or require drug therapy for prolonged periods. Avoid phenobarbitone.
Counseling of the family
The doctor should emphasize that CP is:
ü Not a mental illness
ü Not necessarily associated with mental retardation
ü Not contagious
ü Not inherited (except in rare cases)
ü Not curable but treatment aims at minimizing disability to improve their quality of life.
Aim of the schools is not to admit them and segregate them from their family and peer groups but to provide an insight and train the parents and school teachers about the special needs of these children and their strength and weakness.
ü All CP children do not have low IQ and least 1/3rd have average 1Q
ü They are not a burden on the society and can contribute actively
Legislature – passed on 22nd December,1995 – disability bill for equal opportunities.
ü Equal opportunities, protection ofrights and full participation. As per this act the government and local authorities shall ensure that every child with disability has access to free and adequate education till the age of 18, integrate students with disabilities into normal schools, set up special school, for those in need of special education
ü Employment – posts are identified for disabled persons
ü The government shall within economic limits, undertake rehabilitation programs for persons with disabilities