Cerebral palsy Essay Example

Osler also discussed the condition later on. Osler's book, The Cerebral Palsies of Childhood, became popular among doctors interested in paralysis caused by brain pathologies in children during the late 1800s. As a result, the term "Cerebral Palsy" started being used to describe children with cerebral-related palsies instead of other types such as orthopaedic, muscular, and spinal palsies. Examples of these other types include congenital hip dislocation, rheumatoid arthritis in juveniles, amputations, landmine injuries, muscular dystrophies, myopathies,inflammatory muscular diseases spina bifida,and spinal muscular atrophies,poliomyelitis,and spinal trauma(Bax ; Brown ,2004).

Freud's book Infantile Cerebral Paralysis, published in 1897, had a significant impact on physicians during that time. However, its widespread recognition in America did not occur until it was translated in 1968. The term cerebral palsy gained acceptance with the founding of The American Academy for Cerebral Palsy in 1947, now known as The American Academy for Cerebral Palsy and Developmental Medicine. In Trinidad and Tobago, The Cerebral Palsy Society became an established Non-Governmental Organization in 1993. Classified based on the affected area of the brain - the cerebrum - cerebral palsy's exact centers have yet to be fully localized but likely involve connections between the cortex and other brain regions like the cerebellum. Damage to motor control centers during brain development is responsible for causing cerebral palsy, which can occur during pregnancy (approximately 75 percent), childbirth (about 5 percent), or after birth (around 15 percent) until approximately age three.Cerebral palsy symptoms and signs can vary in severity, ranging from mild to severe in affected children. These manifestations can include ataxia, spasticity, asymmetrical walking with a dragging leg, variations in muscle tone, excessive drooling or difficulty with

swallowing, sucking or speaking, tremors, and difficulties with precise movements like writing or buttoning a shirt. Cerebral palsy is categorized into three types: 1.

Spastic cerebral palsy is the most common form of cerebral palsy. It is characterized by tight muscles and limited joint movement. This condition can affect different parts of the body and often makes walking or moving difficult. People with spastic hemiplegia have this condition on one side of their body, while those with affected legs but less affected arms are diagnosed with spastic diplegia.

If all four limbs are equally affected, it is referred to as 'spastic quadriplegia'. Individuals with athetoid cerebral palsy have involuntary movements due to rapid changes in muscle tone, which makes controlling their movements challenging. This can also affect speech clarity as it may be difficult to control the tongue, breathing, and vocal cords. Furthermore, these individuals often face hearing difficulties.

Ataxic cerebral palsy is characterized by difficulties with balance, spatial awareness, and body position judgement. It affects the entire body, causing unsteady walking, shaky hand movements, and irregular speech in individuals.

Mixed cerebral palsy is prevalent in children and involves a combination of symptoms from different types. This can include a mixture of tight and relaxed muscles, resulting in both stiffness and floppiness. Identifying the specific type of cerebral palsy can be difficult as individuals may have multiple combined types. It is important to note that no two people with cerebral palsy experience the exact same effects.

Cerebral palsy can manifest in various ways, with symptoms ranging from mild to severe. While some individuals may have barely noticeable symptoms, others require assistance in their daily activities. In 1954, the American

Academy for Cerebral Palsy proposed a classification system that encompassed different categories including physiological (motor), topographical, etiological, supplementary (related problems), neuroanatomical, functional capacity (severity), and therapeutic. This system aimed to provide a comprehensive understanding of cerebral palsy.

According to Bax and Brown 2004, CP can be classified based on the nature and topography of the motor disorder. The motor symptoms of CP can appear in various forms. The American Academy of Cerebral Palsy has proposed categories for CP, but there is no uniformity in nomenclature and classification. Over time, the classifications of CP's motor conditions have been modified, and some clinicians prefer certain classifications. Clinicians generally assess spasticity as it has a distinct hyperactive stretch reflex. In normal function, when the antagonist muscle contracts, it slightly stretches the muscle, stimulating the sensory endings in the neuromuscular spindles and causing appropriate muscle contraction.

Normal stretch reflexes are crucial for maintaining muscle tone and helping with posture. In the case of spasticity, the response to stretching is exaggerated. This hyperactivity can be observed during examinations, such as when an examiner rapidly extends the flexed forearm of a patient, which causes a reflex contraction in the biceps that is being stretched during the arm extension. Hyperactive stretch reflexes also cause knee extension when the patellar tendon is struck, as well as jerking movements of the foot in response to quick dorsiflexion. Spasticity often leads to abnormal postures, contractures, and mobility impairments (Mc.Donald, 1987). Topography typically refers to a specific anatomical region or body part.

In CP classifications, the number and location of limbs affected are referred to. The distribution for Spastic CP can be Monoplegia, Hemiplegia, Diplegia (where the legs are

worse than the arms), Triplegia, and Tetra- or Quadraplegia (where all four limbs are equally affected), as the other motor disorders generally involve the entire body. Mono- and triplegia are rarely used, according to Bax and Brown (2004). In diplegia, only the two lower limbs are affected due to the meaning of "di" being two. Children with Diplegic CP exhibit slightly flexed and internally rotated hips, semi-flexed knees, extended plantar-flexed ankles, and the possibility of fixed contractures in all three joints (hip, knee, and ankle) depending on the extent of involvement and effectiveness of management. Some children have CP solely in their legs or with much more severe involvement in their legs than in their arms.

Children with diplegia face challenges in using their legs, which makes walking and running difficult for them. However, their upper bodies are typically unaffected, allowing them to maintain an upright posture and use their arms and hands effectively. Additionally, these children may exhibit certain postures in the upper limits, characterized by internally rotated shoulders, flexed elbows, wrists and fingers, and adducted/opposed thumbs. According to the European Cerebral Palsy Study (2003) and the Mutch and Ronald Study (1992), these postures do not usually appear until after the age of two but may not become fully apparent until three or four years old. Spasticity becomes more prominent as the child grows older, particularly towards the end of the first year and during the second year (Bax and Brown, 2004).

Hemiplegia refers to cerebral palsy affecting only one side of the child's body. "Hemi" signifies half, so either the right arm and leg or the left arm and leg are affected in these cases.

In

hemipligia, the arm is more affected than the leg, which makes walking appear relatively normal. The lack of fine movement is evident in the hand and toes. The characteristic postures are similar to diplegia, but only affect half of the body. Bony undergrowth of the affected limb occurs in the first two years of life and if not managed properly, it may lead to a tendo Achilles contracture. Most children with hemiplegia are able to walk, although there may be a delay in their onset of walking. Quadripligea refers to spasticity in all four limbs.

Quadriplegia refers to the condition in which a child displays cerebral palsy (CP) symptoms in all four of their limbs. This includes both their arms and legs. Typically, children with quadriplegic or tetraplegic CP have severe symptoms, often accompanied by seizures and significant cognitive impairment. These children experience little to no functional movement and are highly susceptible to developing contractures and deformities. For infants and young children who lack postural control and display limited or no ability to move, it can be challenging to differentiate between a profound motor disorder, a significant learning difficulty, or a combination of both. This difficulty arises because the motor signs of CP may be delayed or overshadowed by the secondary positional disorder resulting from their immobility (Fulford and Brown 1976, Brown 1985). The term Dystonic is now commonly used to describe the type of CP previously referred to as Extrapyramidal or Athetoid CP. Dystonic CP is characterized by abnormal and unpredictable involuntary movements.

An observer can notice that although reflexes are normal, performing simple motor acts may be challenging or impossible due to the interference of

uncontrollable involuntary movements (McDonald, 1987). Dystonic CP shows few signs in early infancy, except for possible variations in muscle tone. However, abnormal postures and movements start occurring in the second half of the first year. There are involuntary movements around the mouth, arms, and legs, and these become particularly noticeable when attempting fine or gross motor movements. In a recent interview with Mrs. Dianne Metivier, the President of the Cerebral Palsy Society of Trinidad and Tobago, she mentioned that Athethoid CP cases account for over 90% of reported cases in Trinidad and Tobago today. Nevertheless, these statistics may change due to the presence of numerous unreported cases in our country.

Ataxia is characterized by difficulty maintaining balance, which is usually not diagnosed until the child begins to walk. The child's feet are typically placed far apart and are slapped down when taking steps. While there are no involuntary movements, voluntary movements are affected throughout the body, often resulting in a gross intentional tremor in the arms and hands. Infants with Ataxic CP appear as floppy babies with reduced muscle tone, which is opposite to spasticity. According to Bax and Brown 2004, there are increased ranges of movement in all joints, including hip abduction, straight leg raising, popliteal angles, ankle dorsiflexion, and supination.

The child's reflexes are rapid and swinging, leading to delayed development in posture (rolling/sitting/standing) and difficulty in walking. They may also have disrupted hand skills, resulting in difficulties judging speed, distance, and strength. This can resemble dyspraxia as it affects the motor learning cerebellum. In Trinidad and Tobago, this is the second most common form of cerebral palsy (CP). The severity of mobility-related motor

disorders can be classified using the Gross Motor Classification System (GMFCS), which consists of five classifications:

1. Level 1: Limited higher gross motor skills such as running, jumping, and hopping.
2. Level 2: The child can walk without assistance but with limitations outside their home.
3. Level 3: The child walks with aid but still faces restrictions indoors and outdoors.
4. Level 4: The child can move independently but with some limitations; they may rely on a wheelchair.
5. Level 5: Severe limitations on independent movement even with aids.

In addition to GMFCS, Rusk (1977) introduced a classification system based on the child's ability to perform essential self-help behaviors necessary for daily living and communication. These classifications include:

1. Mild: The individual possesses satisfactory self-help abilities for everyday personal needs, can walk unaided, and does not require medical intervention for speech issues.

Moderate. The individual has inadequate self-help skills and may require special equipment for walking. Speech may also be impaired. Treatment of various types is necessary.

Severe.

Even with treatment and the use of adaptive equipment, the prognosis remains poor for developing self-help skills, ambulation, and functional speech. This is still used today. Cerebral Palsy can be caused by illness during pregnancy, premature delivery, accidents, lead poisoning, infections during infancy and early childhood (such as meningitis or encephalitis), child abuse, or other factors. Other causes can include premature birth, RH or A-B-O blood type incompatibility between parents, infection of the mother with German measles or other viral diseases in early pregnancy, and microorganisms that attack the newborn's central nervous system. Lack of good prenatal care can also be a factor. Acquired cerebral palsy is a less common type that is usually caused by head injury, often resulting from motor vehicle

accidents, falls, or child abuse (CPSTT, 2006). The majority of children with cerebral palsy are born with it, although it may not be detected until months or years later.

Congenital cerebral palsy, as stated by McDonald (1987), can occur when normal development is disrupted due to factors that affect the biochemistry of development or the supply of nutrients and oxygen. One of the main causes is a lack of oxygen or poor blood flow to the fetus or newborn brain, which can be caused by various factors such as premature separation of the placenta, difficult birth positions, prolonged or abrupt labor, or interference with the umbilical cord. However, extensive research conducted by the National Institute of Neurological Disorders and Stroke (NINDS) in 2008 and other scientists has shown that only a few babies who experience asphyxia during birth develop cerebral palsy or other neurological disorders. Birth complications, including asphyxia, are now estimated to only account for 5 to 10 percent of babies born with congenital cerebral palsy. During the perinatal phase (delivery risk factors), the mother's body undergoes changes to expel the fetus.

The contractions of uterine muscles push the baby down through the birth canal, a journey often described as the most dangerous any person will ever make (Mc Donald, 1987). This can sometimes cause trauma or sudden pressure changes that lead to bleeding in the brain and subsequent brain damage. Other factors during this time include prolonged rupture of the amniotic membranes, which can result in fetal infection if it lasts for more than 24 hours, a slow fetal heart rate indicating distress during labor, pain relief medications given to the mother that can depress

the baby's breathing, and abnormal presentations such as breech, face, or transverse lie positions which can make delivery difficult. In cases like these, medical intervention during childbirth may sometimes cause brain damage. In Trinidad, forceps-assisted deliveries have been associated with cerebral palsy. Improper use of forceps or applying excessive pressure to the baby's head (commonly in the area related to coordination) can result in brain damage. In Trinidad, close monitoring of pregnant women is crucial, particularly those who may have a difficult birth or whose babies may experience oxygen deprivation or poor blood flow.

Children who have experienced a period of normal development before being affected by brain damage in the postnatal period have a more mature nervous system than newborns (MC Donald, 1987). Approximately 10 to 20 percent of children with cerebral palsy develop the disorder after birth, while many other cases are caused by incidents during pregnancy or birth. Cerebral palsy acquired after birth is a result of brain damage during the first few months or years of life. Infections such as bacterial meningitis, viral encephalitis, or jaundice, as well as head injuries from accidents, falls, or abuse, are common causes of brain damage during this postnatal period (CPSTT, 2006).

When diagnosing cerebral palsy, doctors focus on two main areas: the child's medical history and their motor skills. In addition to assessing for delayed development, abnormal muscle tone, and unusual posture, physicians can perform various medical tests like Magnetic Resonance Imaging (MRI) to identify abnormal areas near the bones, Computed Topographies to reveal underdeveloped brain areas or abnormal cysts, and ultrasounds to examine images of the infant's brain. These tests can aid in determining the

cause of the child's problems and ruling out other disorders (CPSTT, 2006).

Doctors also utilize a range of assessments, such as reflex tests, hand preference tests, electroencephalograms (EEG’s), intelligence tests, and vision tests, to identify signs of seizure disorders in individuals. Furthermore, there are associated problems and disorders that can occur alongside cerebral palsy. These conditions are more prevalent in children with CP. Most of these complications are neurological in nature, affecting the specific area of the brain that controls muscle movement and coordination. One common associated condition is intellectual impairment, which affects approximately 65% of individuals with cerebral palsy in the United States. Among this group, about one-third have mild impairment, while the other two-thirds experience moderate to severe impairment.

35 percent of individuals with cerebral palsy will have normal or above-average intelligence. Cerebral palsy affects all sensory modalities, including vision and hearing. Visual disorders such as oculomotor defects and central processing problems are common in individuals with CP. Poor oropharyngeal motor control and poor airway alignment increase the risk of sensorineural hearing loss and conductive loss, as well as middle ear infections. Some individuals with CP have diminished tactile sensitivity, while others are hypersensitive to tactile stimulation. People with cerebral palsy are more likely to have vision impairments, including strabismus, which affects the muscles of the left and right eye.

Strabismus, commonly known as crossed eyes, can cause misalignment and double vision. In children, the brain may adapt by ignoring signals from one eye. Studies have revealed that approximately 65 percent to 70 percent of children with cerebral palsy experience strabismus. If left untreated, it can result in severe vision impairment in one eye and hinder

certain visual abilities, such as depth perception. Physicians may suggest surgical intervention as a solution for correcting strabismus.

Children with severe CP may have communication problems, specifically with unintelligible speech caused by the neuromuscular disorder affecting their speech mechanism. While some children may be able to use communication aids, those with poor upper extremity control find it impossible to use computers or language boards. Additionally, the mother-infant relationship can be compromised due to the initial difficulty in taking care of a child with CP. The child's dependence on others can interfere with the development of a positive self-concept and diminish their self-esteem, especially considering the extent of care needed for activities such as dressing, toileting, and feeding. Furthermore, educational difficulties arise based on the extent of retardation. Some children with CP face limited achievements, struggling with tasks such as handling writing instruments like pencils and pens. However, it is important to note that some children with CP successfully overcome these challenges and pursue careers as lawyers and doctors.

Seizure Disorders- Recurrent convulsions are congenital malformations of the brain and damage to the brain following hemorrhage or lack of oxygen (Baird, 1972). Children with CP may have grand mal, petit mal and psychomotor disorders.

Physical Disabilities- Children with CP most of the times have orthopedic problems, such as clubfoot and congenital deformities of the spine. It is important to note that these problems are not due to CP but the restricted movement associated with CP eventually contributes to restricted joint motion in the upper and lower extremities.

References

1. Treating Cerebral Palsy for Clinicians by Clinicians. National Institute of Neurological Disorders and Stroke, 2007. http://www. ninds. nih. gov/disorders/cerebral_palsy/detail_cerebral_palsy.

Origins

of Cerebral Palsy website can be found at http://www.originsofcerebralpalsy.com/.

For more information, visit Scope Response website at http://213.52.233/.

138/downloads/factsheets/word/introcp. doc Scrutton D., DAmiano D., Mayston M, 2004.

Management of the Motor Disorders of Children with Cerebral Palsy 2nd Edition.

http://articles.directorym.com/Cerebral_Palsy_Trinidad_CO-r800084-Trinidad_CO.html The Mayo Clinic. http://www.mayoclinic.com

Mayo Clinic

The Nemours Foundation

Wikipedia, The Free Encyclopaedia

Visit the website wikipedia.org/wiki/Cerebral palsy for more information.