Types of Cerebral Palsy
Spastic, Athetoid, and Ataxic.
The most common type of CP is spastic. A child with spastic CP can’t relax his/her muscles or his/her muscles may be stiff. Athetoid CP affects a child’s ability to control his/her muscles. This means that the arms or legs that are affected by athetoid Cerebral Palsy may flutter and move suddenly. A child with ataxic CP has problems with balance and coordination. A child with CP can have a mild case or a more severe case which depends on how much of the body is affected. If both arms and both legs are affected, a child might need to use a wheelchair. If only the legs are affected, a child might have to wear braces or walk with crutches. If the part of the brain that controls speech is affected, a child with CP might have trouble talking. Another child with Cerebral Palsy might not be able to speak at all.
Causes of Cerebral Palsy
No one knows for sure what causes cerebral palsy. For some babies, injuries to the brain can happen during or soon after birth and this sometimes causes CP. Small, premature babies (babies who are born many weeks before completion of 9 months in their mothers’ womb) or babies who need to be on a ventilator (a machine to help with breathing) for several weeks or more are most at risk for developing Cerebral Palsy. But for most children, the problem in the brain occurs before the baby is born, and we don’t know why.
Diagnosis of Cerebral Palsy
There is no actual test to figure out if a child has cerebral palsy. Doctors may order X–rays and blood tests to rule out other diseases of the brain and nervous system, but they must wait to see how a child develops in order to be sure, for proper management. A case of cerebral palsy can usually be diagnosed by the age of 18 months. Some children with CP won’t be able to sit up on their own by the age of 6 to 7 months or walk by 10 to 14 months, the way that most children without Cerebral Palsy can do. If a child has not done these things by a certain age, it can be an indication that he/she might have Cerebral Palsy. Doctors also look closely at problems with muscle tone, movement, and reflexes.
Managing Cerebral Palsy
It is difficult to differentiate between treatment and management, although most experienced physiotherapists in the field of cerebral palsy probably agree that periodic treatment sessions only are inadequate. The therapist must become involved with the parents, care staff and others and train them to physically manage the child appropriately throughout the day and night. However, this is not to say that specific, well–chosen treatment techniques performed by the skilled therapists are not an essential part of treatment as well. The aims of all management and handling techniques are:
- To promote the child’s assets and abilities, and, if possible, to stimulate normal patterns of movement.
- To prevent or reduce deformity.
- To discourage positions, movements and behaviors that make handling difficult, such as extending and thrusting backwards.
Lifting and CarryingThe adult should first decide how the child will be carried. He/she should approach the child from the front, explain what he/she is going to do and organize the child’s body (arms and legs especially) so both he/she and the child feel secure. He/she should then lift the child, keeping a straight back and a wide base of support, bending the knees, and holding the child as close to him/her as possible. Enough support should be provided so that the child is safe, but not so much that he/she is passive.
Methods of carrying the cerebral palsied child
- For fixed children.
- For extended of thrusting children. The adult’s hands may be under or in front of the child’s knees in either method of carrying.
- For children with tight hip adductors, hemiplegia and more able children. Note the position of the hemiplegic right arm, held by the adult in the extended position. For a left hemiplegia, carry on the left hip.
It is important that a cerebral palsied child experiences a variety of positions throughout the day. Most of the children, regardless of level of ability, will eventually be spending a good deal of the day in sitting. To counteract the detrimental effects of time spent in this flexed position, each child must also spend time in ‘Straight’ positions, either lying or standing, preferably both. Each of the positions discussed below is both posturally and functionally beneficial and detrimental, and it is up to the therapist to determine which ones suitably complement each other and are therefore appropriate.
In supine, many cerebral palsied children are completely unable to function, and in this position they may be most asymmetrical. If the supine position must be used, a pillow placed under the head and shoulders often promotes symmetry and the ability to get the hands together. In prone, the children are often more symmetrical, but they usually need to be raised off the floor, such as on a wedge, in order to use their hands and heads. A sandbag or strap placed across the child’s bottom may be needed to help the child maintain the position. Some children are very difficult to place in the prone position and do not tolerate it well. Others utilize the position to strengthen and improve their ability to extend and thrust, which should be discouraged. Side–lying is a position in which the child can be quite symmetrical, both hands are within his vision and are more likely to be used together. However, care must be taken that he/she does not fall partially into prone or supine lying, and therefore into a windswept deformity. Positions for sleeping can be difficult: children who have windswept hips tend to sleep in this position and often are woken by discomfort. A comfortable, non–detrimental position can only be found by trial and error. It may involve changing from supine to prone or side lying, or tilting the bed/mattress slightly to tip the child’s weight on to his/her relatively unweighted side. Leg gaiters, if tolerated, can help in maintaining a relatively symmetrical position.
Long sitting, with the knees slightly flexed or straight, is the position in which a normal baby learns to establish his/her bottom and legs as his/her base of support. The child first flexes his/her trunk right forward over his/her legs, and then gradually brings his/her trunk more upright as his/her legs, and then gradually brings his/her trunk more upright once his/her base becomes more established. It is not until the child is able to rotate his/her trunk and reach freely outside his/her stable base that he/she develops a straight back, and then a lumbar lordosis, in sitting. It is at this time that the child develops the ability to stand with support and may be starting to take his/her first step, signifying that his/her body has ‘Split in two’ one half anchoring, supporting and adjusting, while the other half counter–balancing and moving. The postural education that takes place in long sitting is obviously important. This is also a position in which the hamstrings and hip adductors can be stretched. If the child is unable to sit flat on the floor without his/her pelvis rotating posteriorly, he/she can be placed so that his/her bottom is slightly raised, such as on a very low stool, telephone book, or in sitting downhill on a wedge.
Some children choose to side–sit. If they do this more easily to one side than the other, there is probably a related problem of windswept hips, and the child should be encouraged to sit symmetrically, or on the other side for part of the time. More able children will sit cross–legged (tailor–sitting) readily, less able children find it difficult. It is for some a comfortable, acceptable alternative to long sitting. The only contra–indication might be a child whose legs ‘frog’ ( hips externally rotate and abduct) excessively, when the hips might be in danger of anterior dislocation.
W–sitting (between heels) has long been frowned upon by therapists. This is due to its possible reinforcement of the flexed, adducted and internally rotated position of the hips. It may contribute also to tibial torsion and foot deformity. However, for many cerebral palsied children it is an easily assumed and stable position for play, and such children must already have the necessary range of motion at the hip joints. Probably the major worry is when a child is placed into the position, or adopts it himself, but has great difficult getting out of it and is there for a prolonged period.
If the child sits on the floor for prolonged periods in a position felt to be detrimental and there is not an acceptable, floor–level alternative, it might be best to promote chair–sitting. For children able to sit on a chair–freely without falling, consideration must be given to
- The stability of the chair.
- Its height–the child’s feet should reach the floor, or a foot platform.
- The height of the work surface. If the child’s bottom tends to slide about, and he/she is otherwise stable, a mat placed under his/her bottom might be sufficient to anchor it.
Hip deformity is a common orthopedic problem in cerebral palsy. The correct formation of the acetabulum and femoral head and neck, which results in a stable hip, is apparently dependent upon early weight–bearing in a correct position.
Other benefits of standing include:
- Prevention of flexion deformity at the trunk, hips and knees and equinus deformity at the ankles.
- Development of weight–bearing surfaces of the feet.
- A child is often more able to use his/her head, arms and hands in standing than in other positions.
- Sensory feedback in standing is important both proprioceptively and perceptually.
- The child benefits socially from being at the same height as his/her standing peers.
- The cardiovascular, digestive, respiratory and excretory functions are stimulated.
- The child is very flexed and the main aim is to straighten him/her out.
- The child has developed severe deformities and the effect of gravity in upright standing only serves to pull him/her down into his/her deformities. In this care, the main aim is straightness and amelioration of deformity, with weight–bearing a secondary aim.
Positioning of Cerebral Palsied Child for Function
PositioningThe physiotherapist is often asked by other therapists and colleagues to advise on appropriate positioning for various functional activities. For example, improved exhalation and breath control for speech can often be obtained in prone lying or standing. A position in which the child can produce a reliable, repeatable response may be required for auditory, visual or psychological testing. Positioning for the optimal use of head and eyes may be needed educationally. With the increasing use of electronic aids for communication, play, and mobility, positioning for the most appropriate means of access to switches is a frequent and important consideration. Positions for dressing should encourage maximum participation from the child. The appropriate positions will vary from child to child and according to the activities required, but it is important to convey the idea that a variety of positions should be considered.
Movement between position
The everyday handling of a child will inevitably include movement from one position to another. This is an opportune time to promote some of his/her abilities without disrupting daily life.
The ability of the child to roll from supine to side–lying should depict his/her ability to shift weight from side to side. However, some children hyperextend their necks, arch their backs and flip themselves on to their sides, which serves only to strengthen their ability to totally extend, and should therefore be discouraged. When rolling to side–lying, the child should be encouraged to turn his/her head and tuck in his/her chin. Once the child has rolled to prone, an adult can encourage the child to turn his/her head and free his/her trapped arm by fixing his/her bottom with one hand and retracting his/her shoulder on the same side as his/her trapped arm with the other.
Lying to Sitting
Sitting positionWhen a cerebral palsied child is pulled from supine to sitting, two of his/her basic abilities should be encouraged:
- Fixing the bottom so that it does not slide, and
- Raising the head. However, many children either arch or round their backs and strongly adduct their legs. For these less able children, various means of promoting their abilities can be tried, including:
- Supporting the child proximally and protracting the shoulder as the child is lifted.
- Starting with the child’s head and shoulders raised by a pillow or something similar, so gravity has less effect.
- Starting from the sitting position and working gradually down to lying. Care must be taken that fixing the neck in hyperextension, poking the chin and hunching the shoulders are not mistaken for head control. An asymmetrical child will often anchor one side of his/her bottom better than the other, and will favor coming to sitting over one side only. When brought to sitting over the other side, being unable to anchor his/her bottom, he/she will spin around. For children who cannot be brought from supine to sitting without excessive effort or abnormal, asymmetrical activity, it is often best to roll them to side–lying prior to bringing them to sitting. For more able children, the adult might encourage the child to assist with lying to sitting by pulling him/her gently up with one arm and waiting for the other arm to be used spontaneously to lean on and push.
Sitting to standing
When a normal individual rises from sitting to standing, his/her base changes from the bottom/thighs/feet to just the feet. In order to keep from falling, he/she must bring the feet back and lean the trunk well forward (‘Nose over toes’) prior to rising. The cerebral palsied child often either fails to organize his/her feet and trunk correctly before attempting to rise and therefore pushes himself/herself over backward, or, in attempting to get his/her ‘Nose over his/her toes’, the child is unable to anchor his/her bottom and slides forward off the chair in a heap. Most children with cerebral palsy, if given assistance in organizing their bodies and given balance support (usually at the upper arms or shoulders), have some ability which can be a great help in the day–to–day management of the less able child, especially as he/she grows older and heavier, and should therefore be encouraged whenever practical.
Again, the cerebral palsied child’s common difficulty is bringing and maintaining his/her weight forward while he/she steps, and therefore the helper must assist the child to do this. It is probably best if the helper stands in front of the child facing him/her and supports him/her either at the hands (arm gaiters might be helpful), the upper arms, or shoulders depending on the child’s level of ability. The child should be encouraged to lean forward, not to pull. With the helper at the front, the child has less temptation to lean backward for support. For some small or heavy children it is often easier on the helper’s back if he stands behind the child. The important point is that the child is positioned so that his/her weight falls through or in front of his/her feet and not behind them. With a hemiplegic child, support should be given to the affected arm/hand in an attempt to increase the child’s awareness of it and to prevent the affected side of the body from lagging behind. In more able diplegic children, support at the hips only will reduce the child’s abnormal tendency to use his/her upper trunk for shifting his/her weight.
Surgery in Cerebral Palsy
Orthopedic Surgery in Cerebral Palsy
Orthopedic surgery in cerebral palsy has no effect on the central neurological problem, and can only affect the mechanics of movement dictated by it. It should not be viewed as an alternative to physiotherapy or as a final treatment after physiotherapy has failed, but should form part of the overall management of the child and be carried out when appropriate. General aims of surgery in cerebral palsy are to improve function, alleviate pain, improve cosmesis and/or ease of care and dressing. Any surgical procedure is disruptive and must not be undertaken lightly. There should be strong indications that a significant benefit will be achieved. The intermittent use of corrective plasters on children’s feet can often be very effective in maintaining the range of soft tissues, as well as providing a good base of support for improved sitting and standing activities. They can also delay the need for surgery, and give some indication as to the likely effectiveness of a proposed surgical procedure. For similar reasons long–leg cylinders applied with the knee in full extension can be useful.
The physiotherapist should provide input regarding pros and cons of surgery. Pre–operatively he/she should assess range of motion, both passively and in functional positions, strength of relevant muscle groups, and functional ability. Pre and post–operative management must be well planned and the parents must be prepared. Consideration must be given to positioning of the child postoperatively while in plaster, both while sleeping and for daily activities. If special splints, boots, orthoses, or seating will be needed post–operatively, they should be ordered and obtained at the appropriate time. There are generally two difficult periods of time post–operatively: immediately post–surgery when the child may be in pain and discomfort, and following removal of immobilization casts, when the limbs often spasm painfully. Mobilisation of the joints must be carried out gradually and carefully. Treatment will also aim to improve postural ability, maintain joint range, strengthen appropriate muscle groups, and support unstable joints.
OrthoticsMany cerebral palsied children require special footwear which will support unstable ankles, or correct, or maintain, deformity. The position of the feet in sitting and standing has a great influence on the position and ability of the rest of the body, and it is important that appropriate footwear is provided. Leather footwear will eventually deform to the feet and must be replaced as necessary . The addition of a heel–retaining strap will help to keep the heel well back in the boot. Support or correction of hind foot varus of valgus can be accomplished by using an inside or outside iron with a T–strap, or by using a polypropylene ankle–foot orthosis (AFO), which provides more intimate support and is less likely to deform. Some deformities make getting boots on difficult and periodic use of corrective casting can be helpful.
Sitting is a position in which many children will spend a good deal of the time and appropriate support is important. Ideally, a number of seats should be available for one child. Seating should not be viewed as something separate from treatment, but should reinforce and reflect the child’s ability. A seat should be changed not only when the child physically outgrows it, but also when his/her level of ability changes. The therapist must, therefore, be involved in prescribing the type and amount of support required. As an example, a very disorganized and/or deformed child should have a seat which will intimately support him/her, such as a moulded seat or even a hammock seat. Modular or ply–and–padding seating systems are usually appropriate for more able children who are able to be easily placed in sitting but require full support in order to function effectively. In assessing seating needs, the relative height of floors, seats and working surfaces are important.
Various devices provide support in standing, they either support in an upright, vertical position, or are inclined forward or backward to varying degrees.
Prone crawlers and sit–on trucks
Some prone crawlers support only the child’s trunk in prone and leave the head, arms and legs free for weight–bearing, propulsion and play. They are often more effective if the support can be angled down at the back to prevent the child from falling forward onto his/her nose and to aid purchase between the knees and the floor. Other prone crawlers leave only the head and arms free and support the rest of the body in one horizontal plane with the legs held in abduction. Many of the sit–on toys on wheels which are propelled by the feet are useful for some cerebral palsied children.
Walking AidsThere is a range of walking aids for various levels of ability. The child who, if given support at the shoulders or upper trunk, can support some of his/her weight against gravity and step might be able to use a Cheyne nursery walker. Rollators and push toys are suitable for children with more trunk control, and more able children may be able to progress to sticks, some will progress from quadripods to tripods to canes. For some, Canadian crutches with loose arm bands are more suitable.
Although the position in a buggy is not ideal, it is usually safe and easy for the parent to use. For children who extend and have difficulty anchoring their bottoms, a Cheyne insert which introduces additional hip flexion is often effective. With older and larger children, wheelchairs with appropriate support can be posturally effective and easier to push over rough ground than buggies. However, the hammock effect of the seat can aggravate problems of asymmetry and instability and should be removed by the use of a shaped cushion or a cushion on top of a flat baseboard. For children requiring total, intimate support, a moulded seat or a shapeable matrix seat can be made to fit into a wheelchair.
It is becoming evident that provision of powered mobility early on has dramatic benefits in terms of motivation, and socialization. With new technology, a variety of switches is being developed to allow access to powered chairs. Before switches are investigated for a particular child, it is essential that correct positioning and support are first provided.