Cerebral palsy is a neurologic condition affecting the developing brain of an infant that results in impairments in movement, motor skills, muscle tone and coordination. Approximately 2 in 1,000 children are born with the condition.
CP may present in different ways, but abnormal muscle tone is a common characteristic. Muscle tone is what allows us to perform physical activities of daily living, such as sitting, standing, walking and running -- which require good muscle strength. In CP, many patients have very low muscle tone, which may affect their ability to hold themselves up, while others may have very rigid and contracted muscles, thereby preventing them from moving their limbs effectively.
CP can be a very wide-ranging condition. Some patients may exhibit little to no symptoms, and many patients retain a very sophisticated level of intellectual ability. However, other patients may experience difficulty with basic motor skills such as sitting, standing or walking; still others may have profound intellectual disabilities and need lifelong assistance with activities of daily living.
What Causes Cerebral Palsy?
CP is usually caused by a brain injury prior to, during or up to one year after birth. The condition is thought to occur when the developing brain is deprived of nutrient-rich blood and oxygen. In some instances, severe head trauma can cause CP as well. Other causes and risk factors may include premature birth (prior to 37 weeks), genetic causes, maternal health ( gestational diabetes/high blood pressure), maternal infections or drug use, stroke and brain infections around the time of birth.
How Can We Recognize Cerebral Palsy?
CP may present in different ways. Parents may notice their child missing or being severely delayed in reaching important developmental milestones. Other parents may notice their child is "floppy," meaning he or she has low and/or weak muscle tone. Other patients may be noted to have "spasticity," meaning extremely rigid and contracted muscles. Other common symptoms may include intellectual disabilities, involuntary movements and delays in speech, favoring only one side of the body (i.e. using only one arm and hand to crawl), difficulty eating and swallowing, difficulty standing, difficulty walking, toe-walking and having an abnormal gait.
How Is Cerebral Palsy Managed?
Unfortunately, CP is a condition that doesn't have a cure at this point. However, the condition can be quite manageable if patients, families, physicians and providers work together. It is important to remember that CP contains a wide variety of patients within its spectrum. There are patients who may not display the characteristic signs of the condition. In these patients, the condition may manifest itself with a mild, almost unnoticeable hardening or shortening of the muscles, or a very mild intellectual or gait disturbance.
Other patients may be completely immobile due to spasticity problems; however, they may retain above-average intelligence and intellectual capacities. Other patients may be completely non-verbal and non-communicative, with profound intellectual disabilities, as well as wheelchair-bound. It is, therefore, very important to tailor treatment for each individual patient, based on his or her physical and intellectual abilities and future goals.
The management of CP truly combines the efforts of multiple specialties, professionals and disciplines. Pediatric neurologists, physiatrists, neurosurgeons, orthopaedic surgeons and physical, occupational, speech and developmental therapists all form a multidisciplinary team to manage the various needs of patients with CP and ensure the best possible outcomes.
The team works together to manage the patient's various and individual needs, including administering medications to manage spasticity and concurrent neurologic issues such as seizures and epilepsy. They help to relieve patient muscle contractures with injections that relax rigid muscles and subsequently allow the patient more range of motion. Some patients may need braces to prevent worsening muscle and joint tightening. The braces can also help alleviate pain and improve the ability to walk.
Some CP patients need pumps placed in their spinal cord to help with spasticity, through a continuous, though regulated flow of muscle relaxer medication, or a procedure where nerve roots emerging from the lower spine, which are causing certain muscles to be spastic, are severed, thereby allowing the patient to have increased range of motion, as well as improvement in gait and walking.
Pediatric orthopaedic surgeons, such as our colleagues at Montefiore, play an instrumental role in helping to alleviate and relieve the muscle and tendon tightening, which often prevents the patient from standing or walking. Patients with mild cerebral palsy may have a single lower extremity deformity, which the orthopaedist can address through tendon lengthening. More involved CP patients often tend to have hip dislocations that may cause the patient pain and discomfort. For the caretaker, hip dislocations may make it more difficult to care for the patient.
The pediatric orthopaedic surgeon can offer many surgical and non-surgical options for treatment, ranging from muscle and tendon releases in young patients to prevent hip dislocations in the future, to osteotomies in older patients, where the surgeon reconstructs the bone in order to reduce symptoms of hip dislocation, improve the patient's quality of life and help facilitate the patient's care for the caretaker. Pediatric orthopaedic spine surgeons are also instrumental in correcting neuromuscular scoliosis, or large spine curvatures caused by abnormal brain impulses, which may cause discomfort for the patient, and occasionally breathing problems, as well as difficulty for the caretaker in sitting the patient up.
Therapists also play an important role in the care of CP patients. Speech and developmental therapists often help patients develop and enhance their verbal and intellectual function and capacities. In addition, patients are often referred to physical and occupational therapists for stretching, strengthening, range-of-motion exercises and gait training. These professionals can help some patients avoid the need for surgery by improving muscle tone and flexibility or by improving their gait. In practically all cases, patients are often referred to physical and occupational therapists post-operatively to enhance, improve and facilitate recovery.
What Is the Long-term Outlook?
Cerebral palsy is a life-altering condition, for both the patient and caretaker. However it does not have to be a major impediment. Although there is no cure, there are many management options, as well as a broad range of specialists who, truly, can help improve the quality of life for CP patients.
Norman Y. Otsuka, MSc, MD, FRCSC, FAAP, FACS, is Chief of Pediatric Orthopaedics at Montefiore and Professor of Orthopaedic Surgery and Clinical Pediatrics at Albert Einstein College of Medicine. He is a leading specialist in the areas of pediatric neuromuscular disorders, pediatric orthopaedic trauma and cerebral palsy.
Dmitry Vinnikov, PA-C, MSPAS, is a Physician Assistant, Pediatric Orthopaedic Surgery, at the Children's Hospital at Montefiore.