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Cerebral palsy

Cerebral palsy is defined as a group of non-progressive but often changeable motoric damages caused by lesion in central nervous system in early stages of development (Kuban and Leviton, 1994). Even though the lesion stays non-progressive, resulting damage, inabilities, and handicaps can be progressive.  
CP frequency is determined by Phelps number.
 The cause of many CP cases remains unknown. Most frequent factor is low birth weight, asphyxia, neonatal infection, instrumental birth, and antepartum haemorrhage.

Generally we can divide CP causes into two groups:   

  1. Brain development malformations
  2. Brain development damages


Primary damages are those which are an imminent or direct result of a lesion.
Secondary damages are developed in systems or organs through a period of time because of one or more primary damages, and can become as dangerous as primary damages.  

Neurological problems connected to CP include:

  • Convulsions and epilepsy
  • Problems in behaviour
  • Mental retardation
  • Sight problems
  • Problems learning
  • Loss of hearing
  • Attention deficits and hyperactivity
  • Speech problems
  • Hydrocephalus
  • Problems with pushing
  • Secondary consequences of CP include:  
  • Growth disorder
  • Sleeping problems
  • Nutrition disorders
  • Upper breathing pathways obstruction
  • Aspiration pneumonia
  • Communication disorders
  • Gastroaesophageal reflux
  • Teeth decomposition and gum diseases
  • Frequent fractures
  • Hernias
  • Constipation
  • Drooling
  • Problems with urination control
  • Orthopedic problems include:
  • Scoliosis
  • Hip dislocation
  • Joint contractures
  • Leg length imbalance


CEREBRAL PALSY TYPES:

In clinical practice, we use a simple CP division which includes three basic types: spastic , extrapyramidal and mixed. More than two thirds of children have spastic type of CP, and about quarter of children have mixed pyramidal and extrapyramidal symptoms.  

Spastic types of cerebral palsy include:

Spastic quadriplegia (all four limbs are involved) – type of CP usually accompanied by microcephalus, mental retardation, and epilepsy. It includes strong spasticity. Upper limbs show flexor-adductor-pronation spasticity type, and lower show inner rotation with enhanced extensor and adductor tone.  
Spastic diplegia – type of CP with greater spasticity in lower limbs, while spasticity in upper limbs can be discreet. Mental deficit and convulsions are present, but less frequently than in spastic quadriplegia.
Spastic hemiplegia is the most common type of cerebral palsy. One-sided spasticity is present, and only one side of the body is affected. Usually around half of these children have epileptic crises.
Spastic paraplegia involves only lower extremities, monoplegia affects a single extremity, and triplegia affects three extremities.
Spastic cerebral palsy presents itself with the resistance to passive movements – resistance while stretching. Normal muscles work in pairs – one muscle group contracts while the other relaxes in order to perform the desired movement. Spastic muscles are active simultaneously and block the normal movement. This is called contraction.

Extrapyramidal types of cerebral palsy - characterized by unwilling movements, as a result of damage in extrapyramidal motoric system (basal ganglion, cerebellum). These disorders manifest themselves as athetosis, choreoathetosis, distonic types, congenital cerebral ataxia. Clinical image of extrapyramidal cerebral palsy evolves gradually and slowly.  

Mixed types of cerebral palsy present a combination of spasticity and extrapyramidal phenomenology.

TREATMENT
Treatment guidelines include: inhibition of abnormal posture reflex activity in order to reduce hypertoning in spastic and athetosic children, facilitation of normal posture position and movement based on normal muscle tone, enhancing of posture reflex tone and regulation of reciprocal muscle function.

According to Stamer, 2000 modern NDT approach has several important concepts:

  • The child is evaluated as a unique person living in a specific family with specific needs. The child's current and future life is taken into consideration in planning the goal of the treatment, which is to enhance functional abilities.
  • Therapist uses the knowledge on normal development to understand the different ways of development present in CP children. This will help to understand why CP children cannot perform certain things. CP children do not have normal development markings. Normal development scales can be used in determining the problem, but they will never be used as a measure of treatment's success.
  • Treatment must be an active process since the movement disability is being treated. Motoric skills require integration of many physical systems. Child's problems with certain movements are identified and their influence on child's functioning is observed.
  • Treatment is teamwork. No doctor or family member can see all possible damages, functional limitations, or inabilities by himself/herself.

The concept of treating CP children was developed by Vojta simultaneously with Bobath, but they differ. Bobath inhibits pathological activities in order to develop normal movements and positions. Vojta's therapeutical concept is as follows: „With the help of reflex locomotor based treatment, certain abilities (such as walking, posture, etc) shouldn't be trained but we must awaken and enable a congenital mororic ontogenetic programme in the central nervous system.“
There are other therapeutical approaches. The latest one is TAMO (Tscharnuter Akademie for Movement Organisation). Instead of learning every individual movement and storing it, we can learn general rules of coordination which can then be applied in several movement skills.

There are three therapy approaches:

Mechanic treatment – based on muscle strength, joint mobility, gravity, mass, and posture stability.
Neurological treatment – based on different neurology aspects

  • p e r i p h e r a l -  uses exteroception and proprioception to ease or inhibit muscle action
  • c e n t r a l – based on changing the disorder, if not structurally then at least in function of damaged central nervous system.
  • e d u c a t i o n a l – intervention becomes more of an education than a treatment.

Elements of truth can be found in every technique. None of them are „the one“. Every therapeutic relation has two sides: patient with his or her needs, and therapist with his or her skills. This means that finding the right therapy for its child must include the child's needs, therapist's skills, social, cultural, geographical and financial factors (Bruce Gans). What is widely accepted is the importance of early therapy.  
Other than physical therapy we administer working therapy, speech therapy, hearing therapy, sight therapy, orthopedic surgery, medicament therapy of muscle relaxation, and anticonvulsive therapy.  
One of the modern drugs has in itself botulinum toxin (BotoX), and is administered into the muscle to reduce spasticity.
Today we have special kindergartens for CP children (Montessori) which also have a good effect on skill development and successful everyday activity and this leads to better life quality and socialization of the child. 

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