Pediatric Orthopaedics

Cerebral Palsy

Cerebral palsy is a neurological disorder that occurs in infants or in early childhood which affects body movements, balance, posture, and muscle coordination. It is the result of damage to one or more brain parts that controls muscle movements. The commonly observed signs include mental retardation, lack of muscle coordination (ataxia), stiff muscles, walking with one foot or dragging legs while walking, and walking on toes. Cerebral palsy is caused due to fetal brain injuries or infections at birth or pregnancy, severe jaundice during birth, infections of the brain such as bacterial meningitis or viral encephalitis, or head injury following an accident, fall, or child abuse. Birth injuries can also lead to cerebral palsy in some cases.

Premature babies born with low birth weight are at a greater risk of developing cerebral palsy.

The three types of cerebral palsy are:

• Spastic cerebral palsy – It involves muscle stiffness causing difficult jerky movements.
• Athetoid cerebral palsy – It causes slow uncontrolled movements.
• Ataxic cerebral palsy – It causes disturbed sense of balance and coordination.

The early signs and symptoms of cerebral palsy include:

• Delayed development of activities such as head control, roll-over, sitting, crawling and walking in infants.
  
  
• Infantile reflexes such as sucking reflex and startle reflex, which otherwise disappears within 3-6 months, may persist for long time.

• Muscles may become very stiff or unusually relaxed. Body movements may be jerky or abrupt, or slow and uncontrolled.
  
  
• Joints may become very stiff because of differing levels of pressure exerted on them by muscle of different tones.
  
  
• Seizures may occur in early years with some cases of cerebral palsy.
  
  
• Speech may not be clear in some individuals as they are unable to control the muscles of the tongue, mouth and throat which help in speech.
  
  
• Drooling of saliva and difficulty in swallowing may be seen.
  
  
• Child may not react to sound or may have a delayed speech.
  
  
•  Dental cavities may occur more commonly because of defective tooth enamel and difficulty in maintaining good hygiene.

• Bowel and/or bladder control may be difficult because of lack of muscle control.

If any of the above mentioned symptoms are present in your child, then a thorough medical evaluation by your physician is necessary. The diagnosis is made based on the information gathered from the family medical history and any problems that occurred during pregnancy and labor. Some of the tests your doctor may order include:

•  Laboratory studies: Blood and urine tests are conducted to check for any hormonal and metabolic conditions. DNA testing and chromosome analysis may be done to rule out genetic disorders.
  
  
• Imaging techniques: These tests help to detect the cause and extent of cerebral palsy.
  
  
• Ultrasound of the brain is done to detect any abnormality such as bleeding or brain damage.
• Computed tomography (CT) scan of the brain clearly reveals any abnormalities.
• Magnetic resonance imaging (MRI) of the brain helps to define the internal structure of the brain more clearly than other methods.
• Imaging of the spinal cord with MRI is suggested in children with spastic leg muscles and lack of bladder and bowel control.



• Other tests performed include
  
  
• Electroencephalography (EEG): This test is done to detect the types of seizures.
  
  
• Electromyography (EMG) and Nerve Conduction Studies (NCS): These tests help to rule out other nerve and muscle disorders.

• Physical therapy (PT) involves stretching exercises, and other activities that can develop flexibility and strengthen the muscles. PT helps to develop skills such as holding the head up, sitting unsupported, or walking. Use of braces, splints, and casts are recommended.
  
  
• Special equipments such as walkers, positioning devices, wheelchairs help to improve function in children with cerebral palsy.
  
  
• Occupational therapy (OT) helps teach physical skills needed to function independently in life such as eating, dressing, and teeth brushing,.
  
  
• Speech/language therapy helps the child to improve speech and overcome problems of communication.
  
  
• Drug therapy is recommended to reduce the effects of cerebral palsy and prevent complications. Medicines such as dopamine, muscle relaxants, and anti-convulsants are prescribed to reduce spastic movements and prevent seizures.

Surgical treatment for cerebral palsy includes:

• Dorsal Rhizotomy: In this procedure, a few nerves are cut at the roots where they divide from the spinal cord. This is performed to reduce spasticity and improve the mucscle movements.
  
  
• Implantation of a baclofen pump: A muscle relaxant drug—baclofen, helps to reduce spasticity. A tiny pump is placed in the abdominal wall to give a continuous dose to the spastic muscles of the limbs.
  
  
• Severe spasticity can be treated with surgical procedure known as Tenotomy which is a tendon lengthening procedure.

Some of the causes of cerebral palsy which include pre-term birth, low birth weight, infections and head injuries can be prevented.

• Prenatal care and regular checks help to maintain a healthy pregnancy and avoid preterm labor.
  
  
• Avoid smoking, alcohol consumption, and medicines during pregnancy as these can increase the risk of premature delivery.
  
  
• Immunization against rubella (measles) during pregnancy protects you from the disease and the risk of cerebral palsy in your child.
  
  
• Vaccination against measles and meningitis prevents you from the disease and the risk of cerebral palsy in your child.