Cerebral palsy or syndrome (CP) is an umbrella term encompassing a group of non-progressive, non-contagious neurological disorders that cause physical disability in human development, specifically the human movement and posture.
The incidence in developed countries is approximately 2-2.5 per 1000 live births. Incidence has not declined over the last 60 years despite medical advances (such as electro-fetal monitoring) because these advances allow extremely low birth weight and premature babies to survive. Cerebral refers to the brain and palsy refers to disorder of movement. CP is caused by damage to the motor control centers of the young developing brain and can occur during pregnancy (about 75 percent), during childbirth (about 5 percent) or after birth (about 15 percent) up to about age three. Eighty percent of causes are unknown; for the small number where cause is known this can include infection, malnutrition, and/or head trauma in very early childhood. It is a non-progressive disorder; meaning the brain damage does not worsen, but secondary orthopedic deformities are common. There is no known cure for CP. Medical intervention is limited to the treatment and prevention of complications possible from CP's consequences. Overall, CP ranks among the most costly congenital conditions in the world to manage effectively.
CP is divided into four major classifications to describe the different movement impairments. These classifications reflect the area of brain damaged. The four major classifications are:
* Spastic
* Athetoid/Dyskinetic
* Ataxic
* Mixed
In 30 percent of all cases of CP, the spastic form is found along with one of the other types. There are a number of other minor types of CP, but these are the most common. Onset of arthritis and osteoporosis can occur much sooner in adults with CP. Further research is needed on adults with CP, as the current literature body is highly focused on the pediatric patient. CP's resultant motor disorder(s) are sometimes, though not always, accompanied by "disturbances of sensation, cognition, communication, perception, and/or behavior, and/or by a seizure disorder” (Rosenbaum et al, 2005).
Wednesday, April 25, 2007
Erb's Palsy, also known as Brachial Plexus Paralysis, is a condition which mainly due to birth trauma can affect 1 or all of the 5 primary nerves that supply the movement and feeling to an arm. The paralysis can be partial or complete; the damage to each nerve can range from bruising to tearing. Some babies recover on their own; however, some may require specialist intervention. A similar injury may be observed in adults following a traumatic fall on the side of the neck.
Signs & Symptoms
Erb's Palsy is usually the result of delivery in shoulder dystocia. Shoulder dystocia is an obstetric emergency (1% of vaginal births) defined by the impaction of the baby's anterior shoulder against the mother's symphysis pubis. It is more common after an assisted vaginal delivery such as with forceps, ventouse cap etc to deliver the baby. The maneuvers used to deliver the baby may increase the head-shoulder interval, stretching the ventral nerve roots of the cervical spine. In some cases it causes avulsions. The most common avulsion is at Erb's point - an area in the antereolateral neck (roughly corresponding to the roots C5 + 6) which damages the nerve roots of the brachial plexus supplying the ipsilateral upper limb & shoulder girdle. In some cases the C7 nerve root is also affected. This injury impairs function of some or all of the following nerves and the muscle groups they supply:
* Axillary - Abduction, flexion, and extension of shoulder (deltoid, teres minor)
* Dorsal scapular - Retractors/Elevators of Scapula (rhomboids, levator scapulae)
* Suprascapular - Abduction of shoulder (supraspinatus) and lateral rotation of humerus (infraspinatus)
* Subscapular nerves - (subscapularis, teres major)
* Musculocutaneous - Flexion of elbow, pronation of arm (Brachialis, Coracobrachialis, Biceps Brachii)
* Long thoracic - Protraction of scapula (serratus anterior)
* Radial - Extensors of arm and forearm (triceps and many other muscles)
* Lateral pectoral - (pectoralis major)
This injury results in lost or impaired function of muscles of the rotator cuff, flexors of the elbow, and lateral rotators of the humerus. This manifests itself as a flaccid paralysis know as the Waiter's tip deformity, so named because the affected limb hangs at the side with the hand pointing backwards as in a waiter expecting a tip. This deformity is characterized by:
* Limb hangs loosely by side (Loss of shoulder function)
* Extension of elbow (loss of arm flexors)
* Pronated forearm (Biceps non-functional)
* Hand in pinch grip position
Treatment
Neonatal / pediatric neurosurgery is often required for avulsion repair. Lesions may heal over time and function return. Physiotherapy is often required to regain muscle usage.
Although range of motion is recovered in many children under one year in age, individuals who have not yet healed after this point will rarely gain full function in their arm and may develop arthritis.
Discovery
The renowned British obstetrician William Smellie is credited with the first medical description of an obstetric brachial plexus palsy. In his 1768 treatise on midwifery, he reported a case of transient bilateral arm paralysis in a newborn after difficult labour. In 1861, Guillaume Benjamin Amand Duchenne coined the term "obstetric palsy of the brachial plexus" after analyzing 4 infants with paralysis of identical muscles in the arm and shoulder. In 1875, Wilhelm Heinrich Erb concluded in his thesis on adult brachial plexus injuries that associated palsies of the deltoid, biceps and subscapularis are derived from a radicular lesion at the level of C5 and C6 rather than isolated peripheral nerve lesions
Signs & Symptoms
Erb's Palsy is usually the result of delivery in shoulder dystocia. Shoulder dystocia is an obstetric emergency (1% of vaginal births) defined by the impaction of the baby's anterior shoulder against the mother's symphysis pubis. It is more common after an assisted vaginal delivery such as with forceps, ventouse cap etc to deliver the baby. The maneuvers used to deliver the baby may increase the head-shoulder interval, stretching the ventral nerve roots of the cervical spine. In some cases it causes avulsions. The most common avulsion is at Erb's point - an area in the antereolateral neck (roughly corresponding to the roots C5 + 6) which damages the nerve roots of the brachial plexus supplying the ipsilateral upper limb & shoulder girdle. In some cases the C7 nerve root is also affected. This injury impairs function of some or all of the following nerves and the muscle groups they supply:
* Axillary - Abduction, flexion, and extension of shoulder (deltoid, teres minor)
* Dorsal scapular - Retractors/Elevators of Scapula (rhomboids, levator scapulae)
* Suprascapular - Abduction of shoulder (supraspinatus) and lateral rotation of humerus (infraspinatus)
* Subscapular nerves - (subscapularis, teres major)
* Musculocutaneous - Flexion of elbow, pronation of arm (Brachialis, Coracobrachialis, Biceps Brachii)
* Long thoracic - Protraction of scapula (serratus anterior)
* Radial - Extensors of arm and forearm (triceps and many other muscles)
* Lateral pectoral - (pectoralis major)
This injury results in lost or impaired function of muscles of the rotator cuff, flexors of the elbow, and lateral rotators of the humerus. This manifests itself as a flaccid paralysis know as the Waiter's tip deformity, so named because the affected limb hangs at the side with the hand pointing backwards as in a waiter expecting a tip. This deformity is characterized by:
* Limb hangs loosely by side (Loss of shoulder function)
* Extension of elbow (loss of arm flexors)
* Pronated forearm (Biceps non-functional)
* Hand in pinch grip position
Treatment
Neonatal / pediatric neurosurgery is often required for avulsion repair. Lesions may heal over time and function return. Physiotherapy is often required to regain muscle usage.
Although range of motion is recovered in many children under one year in age, individuals who have not yet healed after this point will rarely gain full function in their arm and may develop arthritis.
Discovery
The renowned British obstetrician William Smellie is credited with the first medical description of an obstetric brachial plexus palsy. In his 1768 treatise on midwifery, he reported a case of transient bilateral arm paralysis in a newborn after difficult labour. In 1861, Guillaume Benjamin Amand Duchenne coined the term "obstetric palsy of the brachial plexus" after analyzing 4 infants with paralysis of identical muscles in the arm and shoulder. In 1875, Wilhelm Heinrich Erb concluded in his thesis on adult brachial plexus injuries that associated palsies of the deltoid, biceps and subscapularis are derived from a radicular lesion at the level of C5 and C6 rather than isolated peripheral nerve lesions
Brachial Plexus Palsy.
Brachial plexus palsy. Edited by H. Kawai and H. Kawabata. Pp 333. Singapore: World Scientific, 2000. ISBN: 981-02-3139-3. $55.00.
This work, from four orthopaedic surgeons in Osaka, analyses the considerable clinical experience which they have acquired in the treatment of lesions of the brachial plexus. Japanese orthopaedic surgeons have made very great contributions to this field, especially in diagnosis by myelography and by neurophysiological investigation, and in treatment by nerve transfer. This depth of contribution is reflected in the strengths of this work.
Throughout, the style has admirable clarity. The opening chapter on anatomy includes a particularly good analysis of the variations of formation of the musculocutaneous nerve. The chapter describing the lesions of the spinal nerves contains important experimental observations about avulsion injury. That on clinical assessment is particularly good, although there might have been reference to the work of Jones and his colleagues who introduced intraoperative somatosensory recording in 1980. The account of the techniques of repair contains, as one might expect, an excellent analysis of intercostal transfer, discussing functional conversion and afferent reinnervation of the biceps muscle, and includes much valuable information on the remodelling of the patterns of muscle fibres. There are chapters on pain, which dispel the idea that Oriental people are immune to this complication of injury to the brachial plexus, and on reconstruction, which contains a critical analysis of the relative merits of muscle transfer and glenohumeral fusion.
Professor Shimada relates his experience of tumours of the brachial plexus with no less than 45 examples. His suggestion that nerves be repaired by graft after wide excision for malignant tumour may be open to debate. Professor Masatomi provides clear guidance on the approach to patients presenting with postirradiation plexopathy, which clarifies the indications for exploration when the diagnosis is in question. The difficulties of detecting endoneurial metastases are described. Professor Kawabata's chapter on repair in obstetric plexus palsy is particularly useful. His careful analysis points to the advantages of repair but also emphasises that rather poor results are obtained with repair of the lower root.
This work, from four orthopaedic surgeons in Osaka, analyses the considerable clinical experience which they have acquired in the treatment of lesions of the brachial plexus. Japanese orthopaedic surgeons have made very great contributions to this field, especially in diagnosis by myelography and by neurophysiological investigation, and in treatment by nerve transfer. This depth of contribution is reflected in the strengths of this work.
Throughout, the style has admirable clarity. The opening chapter on anatomy includes a particularly good analysis of the variations of formation of the musculocutaneous nerve. The chapter describing the lesions of the spinal nerves contains important experimental observations about avulsion injury. That on clinical assessment is particularly good, although there might have been reference to the work of Jones and his colleagues who introduced intraoperative somatosensory recording in 1980. The account of the techniques of repair contains, as one might expect, an excellent analysis of intercostal transfer, discussing functional conversion and afferent reinnervation of the biceps muscle, and includes much valuable information on the remodelling of the patterns of muscle fibres. There are chapters on pain, which dispel the idea that Oriental people are immune to this complication of injury to the brachial plexus, and on reconstruction, which contains a critical analysis of the relative merits of muscle transfer and glenohumeral fusion.
Professor Shimada relates his experience of tumours of the brachial plexus with no less than 45 examples. His suggestion that nerves be repaired by graft after wide excision for malignant tumour may be open to debate. Professor Masatomi provides clear guidance on the approach to patients presenting with postirradiation plexopathy, which clarifies the indications for exploration when the diagnosis is in question. The difficulties of detecting endoneurial metastases are described. Professor Kawabata's chapter on repair in obstetric plexus palsy is particularly useful. His careful analysis points to the advantages of repair but also emphasises that rather poor results are obtained with repair of the lower root.
Cerebral Palsy.
In the 1860s, an English surgeon named William Little wrote the first medical descriptions of a puzzling disorder that struck children in the first years of life, causing stiff, spastic muscles in their legs and, to a lesser degree, their arms. These children had difficulty grasping objects, crawling, and walking. They did not get better as they grew up nor did they become worse. Their condition, which was called Little's disease for many years, is known as spastic diplegia. It is just one of several disorders that affect control of movement and are grouped together under the term cerebral palsy.
Because it seems that many of these children were born following complicated deliveries, Little suggested their condition resulted from a lack of oxygen during birth. This oxygen shortage damaged sensitive brain tissues controlling movement, he proposed. But in 1897, the famous physician Sigmund Freud disagreed. Noting that children with cerebral palsy often had other problems such a mental retardation, visual disturbances, and seizures, Freud suggested that the disorder might sometimes have roots earlier in life, during the brain's development in the womb. "Difficult birth, in certain cases," he wrote, "is merely a symptom of deeper effects that influence the development of the fetus."
Despite Freud's observation, the belief that birth complications cause most cases of cerebral palsy was widespread among physicians, families, and even medical researchers until very recently. In the 1980s, however, scientists analyzed extensive data from a government study of more than 35,000 births and were surprised to discover that such complications account for only a fraction of cases -- probably less than 10 percent. In most cases of cerebral palsy, no cause could be found. These findings from the National Institute of Neurological Disorders and Stroke (NINDS) perinatal study have profoundly altered medical theories about cerebral palsy and have spurred today's researchers to explore alternative causes.
At the same time, biomedical research has also led to significant changes in understanding, diagnosing, and treating persons with cerebral palsy. Identification of infants with cerebral palsy very early in life gives youngsters the best opportunity for developing to their full capacity. Biomedical research has led to improved diagnostic techniques -- such as advanced brain imaging and modern gait analysis -- that are making this easier. Certain conditions known to cause cerebral palsy, such as rubella (German measles) and jaundice, can now be prevented or treated. Physical, psychological, and behavioral therapy that assist with such skills as movement and speech and foster social and emotional development can help children who have cerebral palsy to achieve and succeed. Medications, surgery, and braces can often improve nerve and muscle coordination, help treat associated medical problems, and either prevent or correct deformities.
What Is Cerebral Palsy?
Cerebral palsy is an umbrella-like term used to describe a group of chronic disorders impairing control of movement that appear in the first few years of life and generally do not worsen over time. The term cerebral refers to the brain's two halves, or hemispheres, and palsy describes any disorder that impairs control of body movement. Thus, these disorders are not caused by problems in the muscles or nerves. Instead, faulty development or damage to motor areas in the brain disrupts the brain's ability to adequately control movement and posture.
Symptoms of cerebral palsy lie along a spectrum of varying severity. An individual with cerebral palsy may have difficulty with fine motor tasks, such as writing or cutting with scissors; experience trouble with maintaining balance and walking; or be affected by involuntary movements, such as uncontrollable writhing motion of the hands or drooling. The symptoms differ from one person to the next, and may even change over time in the individual. Some people with cerebral palsy are also affected by other medical disorders, including seizures or mental impairment. Contrary to common belief, however, cerebral palsy does not always cause profound handicap. While a child with severe cerebral palsy might be unable to walk and need extensive, lifelong care, a child with mild cerebral palsy might only be slightly awkward and require no special assistance. Cerebral palsy is not contagious nor is it usually inherited from one generation to the next. At this time, it cannot be cured, although scientific research continues to seek improved treatments and methods of prevention.
How Many People Have This Disorder?
The United Cerebral Palsy Associations estimate that more then 500,000 Americans have cerebral palsy. Despite advances in preventing and treating certain causes of cerebral palsy, the number of children and adults it affects has remained essentially unchanged or perhaps risen slightly over the past 30 years. This is partly because more critically premature and frail infants are surviving through improved intensive care. Unfortunately, many of these infants have developmental problems of the nervous system or suffer neurological damage. Research is under way to improve care for these infants, as in ongoing studies of technology to alleviate troubled breathing and trials of drugs to prevent bleeding in the brain before or soon after birth.
What Are the Different Forms of Cerebral Palsy?
Spastic diplegia is only one of several disorders called cerebral palsy. Today doctors classify cerebral palsy into four broad categories -- spastic, anthetoid, ataxic, and mixed forms -- according to the type of movement disturbance.
* Spastic cerebral palsy: In this form of cerebral palsy, which affects 70 to 80 percent of patients, the muscles are stiffly and permanently contracted. Doctors will often describe which type of spastic cerebral palsy a patient has based on which limbs are affected. The name given to these types combine a Latin description of affected limbs with the term "plegia" or "paresis," meaning paralyzed or weak.
When both legs are affected by spasticity, they may turn in and cross at the knees. This abnormal leg posture, called scissoring, can interfere with walking.
Individuals with spastic hemiparesis may also experience hemiparetic tremors, in which uncontrollable shaking affects the limbs on one side of the body. If these tremors are severe, they can seriously impair movement.
* Athetoid, or dyskinetic, cerebral palsy: This form of cerebral palsy is characterized by uncontrolled, slow, writhing movements. These abnormal movements usually affect the hands, feet, arms, or legs and, in some cases, the muscles of the face or tongue, causing grimacing or drooling. The movements often increase during periods of emotional stress and disappear during sleep. Patients may also have problems coordinating the muscle movements needed for speech, a condition known as dysarthria. Athetoid cerebral palsy affects about 10 to 20 percent of patients.
* Ataxic cerebral palsy: This rare form affects balance and coordination. Affected persons may walk unsteadily with a wide-based gait, placing their feet unusually far apart, and experience difficulty when attempting quick or precise movements, such as writing or buttoning a shirt. They may also have intention tremor. In this form of tremor, beginning a voluntary movement, such as reaching for a book, causes a trembling that affects the body part being used. The tremor worsens as the individual gets nearer to the desired object. The ataxic form affects an estimated 5 to 10 percent of cerebral palsy patients.
* Mixed forms: It is common for patients to have symptoms of more than one form of cerebral palsy mentioned above. The most common combination includes spasticity and athetoid movements but other combinations are possible.
What Other Medical Disorders Are Associated with Cerebral Palsy?
Many individuals who have cerebral palsy have no associated medical disorders. However, disorders that involve the brain and impair its motor function can also cause seizures and impair an individual's intellectual development, attentiveness to the outside world, activity and behavior, and vision and hearing. Medical disorders associated with cerebral palsy include:
* Mental impairment. About one-third of children who have cerebral palsy are mildly intellectually impaired, one-third are moderately or severely impaired, and the remaining third are intellectually normal. Mental impairment is more commonly seen in children with spastic quadriplegia.
* Seizures or epilepsy. As many as half of all children with cerebral palsy have seizures. During a seizure, the normal, orderly pattern of electrical activity in the brain is disrupted by uncontrolled bursts of electricity. When seizures recur without a direct trigger, such as fever, the condition is called epilepsy. In the person who has cerebral palsy and epilepsy, this disruption may be spread throughout the brain and cause varied symptoms all over the body -- as in tonic-clonic seizures -- or may be confined to just one part of the brain and cause more specific symptoms -- as in partial seizures.
Tonic-clonic seizures generally cause patients to cry out and are followed by loss of consciousness, twitching of both legs and arms, convulsive body movements, and loss of bladder control.
Partial seizures are classified as simple or complex. In simple partial seizures, the individual has localized symptoms, such as muscle twitches, numbness, or tingling. In complex partial seizures, the individual may hallucinate, stagger, perform automatic and purposeless movements, or experience impaired consciousness or confusion.
* Growth problems. A syndrome called failure to "thrive" is common in children with moderate-to-severe cerebral palsy, especially those with spastic quadriparesis. Failure to thrive is a general term physicians use to describe children who seem to lag behind in growth and development despite having enough food. In babies, the lag usually takes the form of too little weight gain; in young children, it can appear as abnormal shortness; in teenagers, it may appear as a combination of shortness and lack of sexual development. Failure to thrive probably has several causes, including, in particular, poor nutrition and damage to the brain centers controlling growth and development.
In addition, the muscles and limbs affected by cerebral palsy tend to be smaller than normal. This is especially noticeable in some patients with spastic hemiplegia, because limbs on the affected side of the body may not grow as quickly or as large as those on the normal side. This condition usually affects the hand and foot most severely. Since the involved foot in hemiplegia is often smaller than the unaffected foot even among patients who walk, this size difference is probably not due to lack of use. Scientists believe the problem is more likely to result from disruption of the complex process responsible for normal body growth.
* Impaired vision or hearing. A large number of children with cerebral palsy have strabismus, a condition in which the eyes are not aligned because of differences in the left and right eye muscles. In an adult, this condition causes double vision. In children, however, the brain often adapts to the condition by ignoring signals from one of the misaligned eyes. Untreated, this can lead to very poor vision in one eye and can interfere with certain visual skills, such as judging distance. In some cases, physicians may recommend surgery to correct strabismus.
Children with hemiparesis may have hemianopia, which is defective vision or blindness that impairs the normal field of vision. For example, when hemianopia affects the right field of vision, a child looking straight ahead might have perfect vision except on the far right. In homonymous hemianopia, the impairment affects the same part of the visual field of both eyes.
Impaired hearing is also more frequent among those with cerebral palsy than in the general population.
* Abnormal sensation and perception. Some children with cerebral palsy have impaired ability to feel simple sensations like touch and pain. They may also have stereognosia, or difficulty perceiving and identifying objects using the sense of touch. A child with stereognosia, for example, would have trouble identifying a hard ball, sponge, or other objects placed in his hand without looking at the object.
Because it seems that many of these children were born following complicated deliveries, Little suggested their condition resulted from a lack of oxygen during birth. This oxygen shortage damaged sensitive brain tissues controlling movement, he proposed. But in 1897, the famous physician Sigmund Freud disagreed. Noting that children with cerebral palsy often had other problems such a mental retardation, visual disturbances, and seizures, Freud suggested that the disorder might sometimes have roots earlier in life, during the brain's development in the womb. "Difficult birth, in certain cases," he wrote, "is merely a symptom of deeper effects that influence the development of the fetus."
Despite Freud's observation, the belief that birth complications cause most cases of cerebral palsy was widespread among physicians, families, and even medical researchers until very recently. In the 1980s, however, scientists analyzed extensive data from a government study of more than 35,000 births and were surprised to discover that such complications account for only a fraction of cases -- probably less than 10 percent. In most cases of cerebral palsy, no cause could be found. These findings from the National Institute of Neurological Disorders and Stroke (NINDS) perinatal study have profoundly altered medical theories about cerebral palsy and have spurred today's researchers to explore alternative causes.
At the same time, biomedical research has also led to significant changes in understanding, diagnosing, and treating persons with cerebral palsy. Identification of infants with cerebral palsy very early in life gives youngsters the best opportunity for developing to their full capacity. Biomedical research has led to improved diagnostic techniques -- such as advanced brain imaging and modern gait analysis -- that are making this easier. Certain conditions known to cause cerebral palsy, such as rubella (German measles) and jaundice, can now be prevented or treated. Physical, psychological, and behavioral therapy that assist with such skills as movement and speech and foster social and emotional development can help children who have cerebral palsy to achieve and succeed. Medications, surgery, and braces can often improve nerve and muscle coordination, help treat associated medical problems, and either prevent or correct deformities.
What Is Cerebral Palsy?
Cerebral palsy is an umbrella-like term used to describe a group of chronic disorders impairing control of movement that appear in the first few years of life and generally do not worsen over time. The term cerebral refers to the brain's two halves, or hemispheres, and palsy describes any disorder that impairs control of body movement. Thus, these disorders are not caused by problems in the muscles or nerves. Instead, faulty development or damage to motor areas in the brain disrupts the brain's ability to adequately control movement and posture.
Symptoms of cerebral palsy lie along a spectrum of varying severity. An individual with cerebral palsy may have difficulty with fine motor tasks, such as writing or cutting with scissors; experience trouble with maintaining balance and walking; or be affected by involuntary movements, such as uncontrollable writhing motion of the hands or drooling. The symptoms differ from one person to the next, and may even change over time in the individual. Some people with cerebral palsy are also affected by other medical disorders, including seizures or mental impairment. Contrary to common belief, however, cerebral palsy does not always cause profound handicap. While a child with severe cerebral palsy might be unable to walk and need extensive, lifelong care, a child with mild cerebral palsy might only be slightly awkward and require no special assistance. Cerebral palsy is not contagious nor is it usually inherited from one generation to the next. At this time, it cannot be cured, although scientific research continues to seek improved treatments and methods of prevention.
How Many People Have This Disorder?
The United Cerebral Palsy Associations estimate that more then 500,000 Americans have cerebral palsy. Despite advances in preventing and treating certain causes of cerebral palsy, the number of children and adults it affects has remained essentially unchanged or perhaps risen slightly over the past 30 years. This is partly because more critically premature and frail infants are surviving through improved intensive care. Unfortunately, many of these infants have developmental problems of the nervous system or suffer neurological damage. Research is under way to improve care for these infants, as in ongoing studies of technology to alleviate troubled breathing and trials of drugs to prevent bleeding in the brain before or soon after birth.
What Are the Different Forms of Cerebral Palsy?
Spastic diplegia is only one of several disorders called cerebral palsy. Today doctors classify cerebral palsy into four broad categories -- spastic, anthetoid, ataxic, and mixed forms -- according to the type of movement disturbance.
* Spastic cerebral palsy: In this form of cerebral palsy, which affects 70 to 80 percent of patients, the muscles are stiffly and permanently contracted. Doctors will often describe which type of spastic cerebral palsy a patient has based on which limbs are affected. The name given to these types combine a Latin description of affected limbs with the term "plegia" or "paresis," meaning paralyzed or weak.
When both legs are affected by spasticity, they may turn in and cross at the knees. This abnormal leg posture, called scissoring, can interfere with walking.
Individuals with spastic hemiparesis may also experience hemiparetic tremors, in which uncontrollable shaking affects the limbs on one side of the body. If these tremors are severe, they can seriously impair movement.
* Athetoid, or dyskinetic, cerebral palsy: This form of cerebral palsy is characterized by uncontrolled, slow, writhing movements. These abnormal movements usually affect the hands, feet, arms, or legs and, in some cases, the muscles of the face or tongue, causing grimacing or drooling. The movements often increase during periods of emotional stress and disappear during sleep. Patients may also have problems coordinating the muscle movements needed for speech, a condition known as dysarthria. Athetoid cerebral palsy affects about 10 to 20 percent of patients.
* Ataxic cerebral palsy: This rare form affects balance and coordination. Affected persons may walk unsteadily with a wide-based gait, placing their feet unusually far apart, and experience difficulty when attempting quick or precise movements, such as writing or buttoning a shirt. They may also have intention tremor. In this form of tremor, beginning a voluntary movement, such as reaching for a book, causes a trembling that affects the body part being used. The tremor worsens as the individual gets nearer to the desired object. The ataxic form affects an estimated 5 to 10 percent of cerebral palsy patients.
* Mixed forms: It is common for patients to have symptoms of more than one form of cerebral palsy mentioned above. The most common combination includes spasticity and athetoid movements but other combinations are possible.
What Other Medical Disorders Are Associated with Cerebral Palsy?
Many individuals who have cerebral palsy have no associated medical disorders. However, disorders that involve the brain and impair its motor function can also cause seizures and impair an individual's intellectual development, attentiveness to the outside world, activity and behavior, and vision and hearing. Medical disorders associated with cerebral palsy include:
* Mental impairment. About one-third of children who have cerebral palsy are mildly intellectually impaired, one-third are moderately or severely impaired, and the remaining third are intellectually normal. Mental impairment is more commonly seen in children with spastic quadriplegia.
* Seizures or epilepsy. As many as half of all children with cerebral palsy have seizures. During a seizure, the normal, orderly pattern of electrical activity in the brain is disrupted by uncontrolled bursts of electricity. When seizures recur without a direct trigger, such as fever, the condition is called epilepsy. In the person who has cerebral palsy and epilepsy, this disruption may be spread throughout the brain and cause varied symptoms all over the body -- as in tonic-clonic seizures -- or may be confined to just one part of the brain and cause more specific symptoms -- as in partial seizures.
Tonic-clonic seizures generally cause patients to cry out and are followed by loss of consciousness, twitching of both legs and arms, convulsive body movements, and loss of bladder control.
Partial seizures are classified as simple or complex. In simple partial seizures, the individual has localized symptoms, such as muscle twitches, numbness, or tingling. In complex partial seizures, the individual may hallucinate, stagger, perform automatic and purposeless movements, or experience impaired consciousness or confusion.
* Growth problems. A syndrome called failure to "thrive" is common in children with moderate-to-severe cerebral palsy, especially those with spastic quadriparesis. Failure to thrive is a general term physicians use to describe children who seem to lag behind in growth and development despite having enough food. In babies, the lag usually takes the form of too little weight gain; in young children, it can appear as abnormal shortness; in teenagers, it may appear as a combination of shortness and lack of sexual development. Failure to thrive probably has several causes, including, in particular, poor nutrition and damage to the brain centers controlling growth and development.
In addition, the muscles and limbs affected by cerebral palsy tend to be smaller than normal. This is especially noticeable in some patients with spastic hemiplegia, because limbs on the affected side of the body may not grow as quickly or as large as those on the normal side. This condition usually affects the hand and foot most severely. Since the involved foot in hemiplegia is often smaller than the unaffected foot even among patients who walk, this size difference is probably not due to lack of use. Scientists believe the problem is more likely to result from disruption of the complex process responsible for normal body growth.
* Impaired vision or hearing. A large number of children with cerebral palsy have strabismus, a condition in which the eyes are not aligned because of differences in the left and right eye muscles. In an adult, this condition causes double vision. In children, however, the brain often adapts to the condition by ignoring signals from one of the misaligned eyes. Untreated, this can lead to very poor vision in one eye and can interfere with certain visual skills, such as judging distance. In some cases, physicians may recommend surgery to correct strabismus.
Children with hemiparesis may have hemianopia, which is defective vision or blindness that impairs the normal field of vision. For example, when hemianopia affects the right field of vision, a child looking straight ahead might have perfect vision except on the far right. In homonymous hemianopia, the impairment affects the same part of the visual field of both eyes.
Impaired hearing is also more frequent among those with cerebral palsy than in the general population.
* Abnormal sensation and perception. Some children with cerebral palsy have impaired ability to feel simple sensations like touch and pain. They may also have stereognosia, or difficulty perceiving and identifying objects using the sense of touch. A child with stereognosia, for example, would have trouble identifying a hard ball, sponge, or other objects placed in his hand without looking at the object.
Celebral Palsy.
Brain infections, like meningitis, are the most common cause of celebral palsy among Filipinos. Cerebral palsy is movement and posture disorder acquired usually at birth or in childhood.
According to the Cerebral Palsied Association of the Phlippines (CPAP), a non-government organization, apart from brain infection - which is the leading cause of celebral palsy in the contry, acquired celebral palsy can be caused by head injury when a child is between two months and five years old.
Head injury can be sustained from a fall, child abuse or vehicular mishap.
When acquired cerebral palsy comes after the child turns two years of age, one of its common manifestations or symptoms is mental retardation.
The incidence of celebral palsy throughout the world has been widely studied. In a major study in Sweeden between 1954 and 1970, there was a decrease of 2.3 to 1.4 incidence rate per 1,000 live births.
In the 1970's the palsy incidence increased. Between 1979 and 1982 more children were born prematurely with resulting disabilities.
Similar results were found in other industrialized nations. The worldwide incidence rate in 1979 was reported to range from 1 to 5.9 per 1,000 live births.
In the US it is 2 per 1,000 live births. In the Philippines CPAP said a conservative estimate would be 3.5 per 1,000 live births.
According to Philippine Cerebral Palsy Inc., a non-stock and non-profit organization, celebral palsy is caused by injury to the brain before, during or shortly after birth.
During birth, problems such as the baby not getting enough oxygen, or difficult delivery may also cause injury to the child's brain.
Problems after birth may likewise happen when a baby is prematurely delivered and his body is not ready to live outside the mother's womb.
Even babies born in normal delivery, however, may develop infection or bleeding in their brain, ultimately injuring it as it develop after birth.
Experts advise parents to be aware of important growth and developmental landmarks in the lives of their children, so they will know what to expect in normal child development and growth.
Once familiar with the stages of growth and development, parents will be able to recognize any deviation from or slowness in child's development and maturation process.
There are cerebral palsy symptoms to watch out for in newborn infants, including poor head control after the three months of age, stiff or rigid arms or legs, pushing away or arching the back (floppy or limp posture), inability to sit up without support after eight months, and when the child only uses one side of the body or arms to crawl.
Some behavioral problems may also appear such as extreme irritability, failure to smile by three months, feeding difficulties, persistent gagging or choking when fed after six months of age especially if the tongue pushes the food out of the mouth.
Unfortunately, cerlebral palsy is incurable. It is also considered a non-progressive condition so the damage done to the brain is set for life.
The degree of palsy from a minor condition to a severe physical and mental disability no longer permits parents to think of "normalcy" for their afflicted children.
CPAP noted that within the limits of the disability, the child will adapt and accomplish whatever is possible.
A child whose legs are severely affected may not win a race but such individuals can compete at their own level.
Most often, the child with cerebral will become an adult who uses his or abilities to gain independence and achieve realistic goals.
CPAP, in its statement, noted that studies demonstrated that at least 50 percent of people with the condition have some degree of mental retardation although most may be only mildly retarded.
Even severely disabled persons with cerebral palsy (and there are many) have escaped damage to that part of the brain involved with intelligence .
A careful assessment and evaluation by professional team will be crucial in determining to what extent the child is or is not retarded.
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