Patients with Cerebral Palsy Paper

Cerebral palsy is a condition, considered as a set of disorders, which involves the brain and the nervous system tasks like hearing, locomotion, education, vision, and judgment. It is a compound expression that covers a set of non progressive and noncommunicable nervous conditions that result into bodily and or mental disabilities in human growth, primarily in the range of body parts that move (Miller & Browne, 2005). There are a number of diverse kinds of cerebral palsy. These include hypo tonic, kinetics, spastic, ataxic, and mixed. Cerebral palsy (CP) results from an injury or deformity of the brain. Most of the causes of CP take place as the infant develops in the womb. Though, the causes can happen at any time during the initial twenty-four months after the child is born, as the baby’s brain is still in the process of developing. Sometimes, cerebral palsy is caused when some parts of the body are damaged owing to short levels of oxygen in that part of the body.Patients with Cerebral Palsy Paper

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Developing infants are at a relatively elevated threat of developing cerebral palsy (Prasad, Verma, Srivastava, & Mishra, 2010). At the early stage, of a child develop several conditions can be the cause of Cerebral. These include and not limited to brain hemorrhage, brain diseases such as meningitis, encephalitis, herpes simplex infections, head hurt, diseases suffered by the mother during pregnancy, for example, rubella, and acute jaundice. In a few cases, the cause of CP palsy is never established. There is an ever-growing range of processes of management for signs of Cerebral Palsy and studies are underway to find more. The outcomes of Cerebral Palsy can be managed by a blend of methods, which comprise prescription, professional therapy, bodily and speech therapy, surgery, motorized aids and procedures.

The federal government and the state government both offer children with cerebral palsy help through a number of state and federal run programs. The aid range from Social Security and Medicaid to subsidized rent and loans with low-interest rates to afford the equipment and gadgets that aid the children. Managing cerebral palsy is a challenging task especially for families. The patience, especially children, need a number of services from surgeons, doctors, physical therapists, professional therapists, speech therapists, dentists and psychological well being counselors. Fortunately, the government at the two levels offers this (Farmer & Sabbagh, 2007).Patients with Cerebral Palsy Paper

Any cerebral palsy affected child is eligible for application of financial help. They can apply for Social Security benefits. If CP affects a person or a child prior to turning 22, he or she is eligible for Adult Child Social Security benefits. Under-18 children also are eligible for the supplemental Security Income benefits applicable at the local Social Security bureau. Under-18 children with cerebral palsy are admitted with ease to this federal-aid program, which is planned for individuals with permanent disabilities or are too old and weak for employment any longer. A number of ways exist through which the government offers support in Fairfax, VA (Calis, Olieman, Rieken, & Penning, 2007). For instance, the United Cerebral Palsy Community Resource Funds give emergency funds for living costs and technological requirements. The government offers low-interest, equipment loans, and there are state grants to aid spastic cerebral palsy patients acquire the needed medical appliances.

There are Temporary Disability Insurance programs for mothers who require taking time off from their job to take care for their baby. The Temporary Disability Insurance offers supplementary income from 50-60% of their standard income from for up to a year. Once a child reaches school-going age, the Individual Education Plan, based on the Individuals with Disabilities Act, offers children with a group of therapists and tutors, as well as the correct technological devices to make sure the child learn as much as it can. The government also provides patients with disability caused by Cerebral Palsy with housing aid vouchers and subsidized rent based on their earnings and verified requirement.Patients with Cerebral Palsy Paper

Cerebral Palsy Treatment

Treatment for cerebral palsy can be complex, addressing a wide range of individual symptoms and conditions.  As a result, doctors and medical specialists from multiple disciplines work together improving outcomes for children with CP.  Early intervention and treatment have the greatest positive impact. Sadly, a cure for cerebral palsy (C.P) is not yet available; nonetheless, various cerebral palsy treatments and therapies currently exist to enable individuals with this condition to reach their fullest cognitive, emotional and physical potential.

The purpose of treatment is to enhance the quality of life for each patient, creating rewarding outcomes for children with all types of cerebral palsy.  By improving overall health and reducing the incidence of complications, treatment reinforces independence and prepares CP patients to lead normal daily lives.

Cerebral palsy is a highly individualized disorder, impacting each patient in unique ways. Each patient’s cerebral palsy treatment largely depends on their own individual desires, based on the severity of their situation, as well as other pertinent factors. What to Know About Treatment

Physical symptoms are not the only concern for doctors and therapists committed to the needs of CP patients.  Social and emotional impacts must also be considered, calling for close collaboration between parents and various medical specialists.Patients with Cerebral Palsy Paper

Is the child content with his or her condition?  Is a particular treatment in the child’s best interest? Are therapy and treatment stressful or demanding, beyond expected benefits?

The type of treatments used depends on the patient’s:

Type of cerebral palsy
Location of movement problems
Level of disability
Co-occurring conditions

No two people receive the same treatment for cerebral palsy. Treatment encompasses short-term and management approaches to all the specific conditions that a child may face. This could involve medications, physical therapy, surgery and more.

Considerations Before Starting Treatment

The needs of a child with cerebral palsy aren’t solely based on correcting their physical disabilities. There are also social and emotional aspects of living a more fulfilling life. These aspects shouldn’t be ignored when considering treatment and therapy.

Many children are content with their disabilities. As a parent, it’s important to consider their feelings. Some treatments can be stressful and uncomfortable, and may not be in the best interest of the child. It’s important to discuss the physical and emotional impacts of all treatments with specialists and most importantly, the child.Patients with Cerebral Palsy Paper

Knowing the Specialists

Managing all aspects of a child’s unique diagnosis is essential for successful comprehensive treatment. Well-rounded treatment approaches require a team of multidisciplinary specialists, usually with a pediatrician at the center of the group.

Pediatricians are generalists who manage the treatment plan, recognize specific issues and recommend specialists who can treat those issues. Each specialist uses ongoing treatment and assessments to ensure that all areas of the child’s development are proceeding as normally as possible.

Types of specialists a child with cerebral palsy may require include:

Developmental pediatrician
Neurologist
Physical therapist
Occupational therapist
Surgeon
Behavioral therapist
Speech and language therapist
Ophthalmologist (eye specialist)
Otolaryngologists (ear, nose and throat specialist)Patients with Cerebral Palsy Paper
Physical Therapy

Physical therapy is typically the first, and most important, step toward treating cerebral palsy. It usually begins at a young age and is geared toward improving independent motor function. The types of physical therapies used for children depend on their specific movement problems and symptoms that coincide with cerebral palsy.

Physical therapy can improve:

Strength
Mobility
Posture
Balance
Flexibility

Before physical therapy begins, the therapist takes an assessment of the child’s motor capabilities. This helps determine the most appropriate measures for therapy. After evaluating the child, the therapist will prescribe strength training exercises, stretches and muscle relaxing techniques based on the child’s needs.Patients with Cerebral Palsy Paper

Exercise equipment includes weights, resistance bands, balance balls and machines to improve muscle tone. Hot and cold packs are often used to help relax and heal muscles.

Scoliosis (spinal curvature) and shortened achilles tendons are some specific movement and posture issues that are treated with physical therapy. Physical therapy is an important prevention measure, as these issues can get worse over time. Proper treatment of the above conditions can also improve the chance of a child walking independently.

Many specialists recommend starting physical therapy as early as possible to prevent future complications like conjectures—a shortening of muscles and tendons that can be painful and is common in spastic cerebral palsy. Strength training exercises are also helpful for children with kinetics cerebral palsy who have loose muscles and may experience atrophy.

Orthotics

Orthotics are devices used to train major muscle groups and are often a part of physical therapy. Splints, braces and casts may be used to assist children with high or low muscle tone. For example, children with scoliosis are often fitted with a plastic brace to correct curvature of the spine as they grow. These devices encourage mobility, balance and proper growth.Patients with Cerebral Palsy Paper

Occupational Therapy

Occupational therapy helps children with cerebral palsy improve fine motor skills. In general, physical therapy is used to improve gross motor function, but it doesn’t focus on fine motor function. People with cerebral palsy struggle with coordinating these skills for tasks such as grasping a spoon and bringing it to their mouth. But occupational therapists often work with physical and speech therapists to build a complete therapy plan.

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Occupational therapists evaluate a child’s needs by testing his or her fine motor skills, perception and oral motor skills. By observing how the child responds to touch and movements, the therapist can determine a treatment plan. The treatment plan typically involves positioning, reaching, grasping and releasing.

Occupational therapy can help with activities such as:

Writing
Picking up small objects
Fastening zippers
Opening jars
Using scissors

These skills are important for a child to develop the ability to be independent. Occupational therapy for children usually involves a form of play to keep them motivated.Patients with Cerebral Palsy Paper

Many children with cerebral palsy have sensory impairments that make movement difficult. Our senses help us recognize changes in temperature, feel pain and to be aware of the space around us. Senses, such as touch and balance, are important for motor skills like picking up objects and walking.

Other senses, such as preconception, allow people to know the location of their own body parts; being able to touch your finger to the tip of your nose is an example of the proprioceptive sense. Sensory impairments make it hard to develop movement skills, and occupational therapists help children work through these impairments.

Speech Therapy

Birth injuries can also affect the parts of the brain that control speech and the muscles that allow us to speak. Many children with CP have issues with speech due to their birth injury. Speech therapy can teach children how to pronounce certain words and communicate more effectively.

Speech therapists can diagnose speech issues and help improve language skills. They can also help with other skills, such as breathing and eating, because these issues involve the muscles in the mouth and face.Patients with Cerebral Palsy Paper

Speech therapy also tackles problems that affect a child’s ability to eat. Many children with CP struggle to maintain a healthy weight because it’s hard to chew or swallow food. Oral motor exercises can improve the ability to chew and swallow food effectively.

Speech therapists also work with other therapists. For example, a speech therapist and an occupational therapist can help children with drooling problems due to low muscle tone in the face and mouth.

Medications

People with cerebral palsy are often prescribed various medications to help manage their condition. Medications can help manage both movement issues and secondary conditions that develop due to cerebral palsy.  The types of medications to treat these conditions range from antidepressants for seizures to nerve blocks for plasticity. To prevent unnecessary side effects, doctors weigh the pros and cons of these medications before prescribing them.

Common conditions treated with medication include:

Seizures
Involuntary movement
Spasticity
Incontinence
Gastroesophageal (acid) re flux
Surgery

There are multiple surgical treatments that can help correct movement problems in children with cerebral palsy. However, parents should keep in mind that surgery isn’t right for every child with cerebral palsy.Patients with Cerebral Palsy Paper

Surgery is most commonly prescribed for those with spastic cerebral palsy because their increased muscle tone can be reduced to relieve restricted movement. For example, a child who walks on their toes due to high muscle tone in their legs can have those muscles or tendons lengthened, allowing for more normal walking.

A child may need one or several different types of treatment depending on how severe the symptoms are and what parts of the body are affected. The treatment differs from person to person, depending on each one’s specific needs. Although the initial damage of cerebral palsy in the brain cannot be reversed, earlier and aggressive treatments may help to improve function and adjustments for the young nervous system and musculoskeletal system.

Families may also work with their health care providers and, during the school years, school staff to develop individual care and treatment programs.

Common types of treatment for cerebral palsy include1,2:

Physical therapy and rehabilitation. A child with cerebral palsy usually starts these therapies in the first few years of life or soon after being diagnosed. Physical therapy is one of the most important parts of treatment. It involves exercises and activities that can maintain or improve muscle strength, balance, and movement. A physical therapist helps the child learn skills such as sitting, walking, or using a wheelchair. Other types of therapy include:
Occupational therapy. This type of therapy helps a child learn to do everyday activities such as dressing and going to school.
Recreational therapy. Participating in art programs, cultural activities, and sports can help improve a child’s physical and intellectual skills.
Speech and language therapy. A speech therapist can help a child learn to speak more clearly, help with swallowing problems, and teach new ways to communicate, such as by using sign language or a special communication device.Patients with Cerebral Palsy Paper
Orthotic devices. Braces, splints, and casts can be placed on the affected limbs and can improve movement and balance. Other devices that can help with movement and posture include wheelchairs, rolling walkers, and powered scooters.
Assistive devices and technologies. These include special computer-based communication machines, Velcro-fastened shoes, or crutches, which can help make daily life easier.
Medication. Certain medications can relax stiff or overactive muscles and reduce abnormal movement. They may be taken by mouth, injected into affected muscles, or infused into the fluid surrounding the spinal cord through a pump implanted near the spinal cord. For children who have cerebral palsy and epilepsy (seizures), standard epileptic medications should be considered, but these medications may also have negative effects on the developing brain.
Surgery. A child may need surgery if symptoms are severe. For instance, surgery can lengthen stiff, tightly contracted muscles. A surgeon can also place arms or legs in better positions or correct or improve an abnormally curved spine. Sometimes, if other treatments have not worked, a surgeon can cut certain nerves to treat abnormal, spastic movements. Before conducting surgery, it is important for a health care provider to assess the procedure’s benefits by carefully analyzing bio mechanics of the joints and muscles.

Not all therapies are appropriate for everyone with cerebral palsy. It is important for parents, patients, and health care providers to work together to come up with the best treatment plan for the patient.

Although the NICHD research portfolio includes work on cerebral palsy and rehabilitative therapies, the National Institute of Neurological Disorders and Stroke leads research on cerebral palsy at the NIH and offers comprehensive information on cerebral palsy and its treatment through its website.Patients with Cerebral Palsy Paper

Treating Cerebral Palsy is almost as complex as the condition is, and there’s no cookie-cutter approach because each individual is affected differently. Although the brain injury that causes Cerebral Palsy cannot be healed, the resulting physical impairment can be managed with a wide range of treatments and therapies. Although there is no universal protocol developed for all cases, a person’s form of Cerebral Palsy, extent of impairment, and severity level help to determine care.

What is the treatment for Cerebral Palsy?

While therapy and adaptive equipment are the primary treatment protocol for Cerebral Palsy, an individual may also require drug therapy and surgical interventions. Some families, with caution and physician guidance, turn to complementary and alternative medicine for additional assistance.

Although each medical specialist may have specific care goals related to their specialty and the individual’s unique condition, the overriding treatment goal for those with Cerebral Palsy is to:

Optimize mobility
Manage primary conditions
Control pain
Prevent and manage complications, associative conditions and co-mitigating factors
Maximize independence
Enhance social and peer interactions
Foster self-care
Optimize ability to communicate
Maximize learning potential
Provide quality of life
Conventional, complementary and alternative medicine

Conventional treatment methods involve systems, practices and products that have been researched, tested and approved by the medical community as acceptable forms of treatment. Complementary medicine differs from conventional as it has not yet been fully tested or approved, but may be under consideration. Complementary medicine, when used under doctor supervision, can be used as a complement to an existing treatment plan. Alternative medicine is a treatment method that is used to replace conventional medicine.Patients with Cerebral Palsy Paper

There are risks involved in using complementary or alternative forms of medicine so anyone considering a CAM should consult with their doctor before engaging in these forms of treatment.

What is a comprehensive treatment plan?

The child’s physical impairment is considered his or her primary condition. The primary physical impairment may involve challenges with muscle tone, reflexes, posture, balance, fine motor functioning, gross motor functioning and oral motor functioning. These conditions can, in turn, create secondary conditions that also require treatment. Management of the Cerebral Palsy is further complicated by co-mitigating factors not caused by the same brain injury that caused Cerebral Palsy, but that still exists in the child as a separate condition requiring simultaneous treatment.

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For example, the child’s Cerebral Palsy may cause a problem with facial muscle control and coordination. This would be considered a primary condition. Due to the lack in facial muscle control, the child may find it difficult to chew, swallow, or communicate, which are secondary conditions. In addition, a child may have an unrelated condition, such as asthma, which would be considered a co-mitigating factor.Patients with Cerebral Palsy Paper

Cerebral Palsy varies in type, location and severity of impairment. The child’s primary care physician, usually the pediatrician, will assess the child’s overall health to develop a comprehensive treatment plan to meet the unique needs of the child while taking into consideration the family dynamics. A comprehensive treatment plan is required to coordinate care of all conditions – primary, secondary, associative and co-mitigating conditions. Due to the variety of conditions that need to be addressed, a treatment plan usually involves a multidisciplinary team of medical specialists working closely with the child’s pediatrician to establish and accomplish care goals. Parents or legal guardians work closely with the multi-disciplinary team.

A comprehensive treatment plan takes the child’s abilities into consideration, as well as his or her sociology-economic situation and home care dynamics. Health insurance coverage is important and can be obtained through government sources, employer benefit programs, or private providers. Many avenues of government assistance, community support, and professional services are designed to assist in fulfillment of these needs, while the public education system is mandated by the government to accommodate a child’s special needs throughout his or her school-age years and transition to adulthood.

What Causes Cerebral Palsy?

Cerebral palsy is caused by traumatic injury to a developing brain, including the parts of the brain responsible for motor control, coordination and balance. Damage to different parts of the brain’s motor control centers causes different types of cerebral palsy. The level of disability depends on the severity and timing of the brain injury.

About 70 percent of cerebral palsy cases are caused by prenatal injuries
About 20 percent are caused by injuries during birth
About 10 percent are caused by injuries after birth Patients with Cerebral Palsy Paper
What Causes Brain Damage?

There are several incidents that can damage the developing brain. For example, an infection may inhibit the neurological development of neurons and synapses in the brain or trauma may occur during or after birth.

Things that can disrupt or hinder the healthy development of a child’s brain include:

Infections during pregnancy – Mothers can pass infections to the fetus during pregnancy. Prenatal infections are most dangerous in the first few weeks after conception. German measles (rubella) and cytomegalovirus (CMV) during pregnancy are known causes of cerebral palsy. These viruses cause the mother’s immune system to release proteins that not only attack the infection, but also cause inflammation in the baby’s brain that interferes with normal development. Mothers who eat raw or under cooked meat can increase the likelihood of getting an infection.
Severe untreated jaundice – When a newborn has a yellow color to their skin and/or eyes, it is known as jaundice. Jaundice is caused by excess bilirubin, a chemical pigment that is normally filtered out by the liver. It is normal for newborns to experience mild jaundice before their livers fully develop. However, severe jaundice left untreated can turn into a condition known as kernicterus. Kernicterus is characterized by buildup of an unsafe level of bilirubin, which is toxic to the brain
Asphyxiation – Asphyxiation is a lack of oxygen reaching the brain. It can cause severe brain damage to a baby during birth. Asphyxiation that occurs during labor or delivery may have been caused by medical malpractice or neglect. Early detachment of the placenta, a ruptured uterus during birth or the umbilical cord getting pinched in a way that restricts blood flow can cause oxygen deprivation. Choking on an object or a near-drowning experience can also cause asphyxiation that leads to cerebral palsy.Patients with Cerebral Palsy Paper
Brain injury during or shortly after birth – Blunt trauma to the infant or toddler brain can cause cerebral palsy.  Head injuries may occur during labor or delivery or within the first several years of life.
Brain hemorrhage before birth – A brain hemorrhage is abnormal bleeding of the brain caused by a ruptured blood vessel, which can cause serious damage to the motor control centers in the brain.
Infections after birth – Infections (such as meningitis) contracted by newborns can cause brain damage. Meningitis causes severe inflammation that can damage the motor control centers of the brain.
Genetic causes – There has been some speculation and research to suggest that a minute proportion of cerebral palsy cases are hereditary. This is still being studied, and the number of genetic cases of CP, if they exist, is likely negligible.
Determining the Cause of Your Child’s Condition

It usually takes up to 18 months to diagnose a child with cerebral palsy, but it could take longer for mild cases. Doctors may use computed tomography (CT) scans and magnetic resonance imaging (MRI) to take images of the child’s brain. These scans may reveal damage in key parts of the brain that give clues to the cause. However, it isn’t always possible to determine the cause of cerebral palsy.Patients with Cerebral Palsy Paper

Causes by Location of Brain Damage

The areas of the brain that control motor skills and movement are the motor cortex, pyramidal tract, cerebellum and the basal ganglia. All of these components relay the impulses from the brain to the nerves and muscles that control movement. Damage to any of these parts of the brain may cause cerebral palsy.

Spastic – Spastic cerebral palsy is caused by damage to the motor cortex. This causes exaggerated, jerky movements.
Athetoid/dyskinetic – Athetoid CP is caused by damage to the cerebellum and/or the basal ganglia. Damage to the cerebellum causes balance issues, while damage to the basal ganglia causes involuntary movements. Athetoid cerebral palsy involves damage to the basal ganglia, but some cases also involve damage to the cerebellum.
Ataxic – Damage strictly to the cerebellum causes ataxic cerebral palsy. This damage is responsible for issues with coordination and fine motor skills. Children with ataxic CP appear unbalanced.
Mixed – Those with a mixed condition have traits of several types of cerebral palsy caused by injuries to multiple motor control centers in the brain.

Parents are often disheartened to learn that there is no singular test that will accurately diagnose a child with Cerebral Palsy. Once a round of medical evaluations are initiated in order to form a diagnosis, parents prepare for a long and sometimes frustrating process that will, in time, provide answers about a child’s condition.

Diagnosis of Cerebral Palsy

Diagnosing Cerebral Palsy takes time. There is no test that confirms or rules out Cerebral Palsy.Patients with Cerebral Palsy Paper

In severe cases, the child may be diagnosed soon after birth, but for the majority, diagnosis can be made in the first two years.

For those with milder symptoms, a diagnosis may not be rendered until the brain is fully developed at three to five years of age. For example, the average age of diagnosis for a child with spastic diplegia, a very common form of Cerebral Palsy, is 18 months.

This can be a difficult time for parents who suspect something might be different about their child. Often, parents are first to notice their child has missed one of the age-appropriate developmental milestones.

If a growth factor is delayed, parents may hope their child is just a slow starter who will “catch up.” While this may be the case, parents should inform the child’s doctor of concerns, nonetheless.

Confirming Cerebral Palsy can involve many steps. The first is monitoring for key indicators such as:

When does the child reach development milestones and growth chart standards for height and weight?
How do the child’s reflexes react?
Does it seem as if the child is able to focus on and hear his or her caregivers?
Does posture and movement seem abnormal?

Doctors will test reflexes, muscle tone, posture, coordination and other factors, all of which can develop over months or even years. Primary care physicians may want to consult medical specialists, or order tests such as MRIs, cranial ultrasounds, or CT scans to obtain an image of the brain. Even once a diagnosis of Cerebral Palsy is made, parents may wish to seek a second opinion to rule out misdiagnosis.Patients with Cerebral Palsy Paper

Why diagnosis is Important?

A diagnosis is important for many reasons:

To understand the child’s health status
To begin early intervention and treatment
To remove doubt and fear of not knowing
To find and secure benefits to offset the cost of raising a child with Cerebral Palsy

A variety of benefit programs are available to children with disability or impairment. To qualify for these programs, the child must have a formal diagnosis. Without a diagnosis, parents can fall into a limbo pattern.

Who’s on the diagnosis care team?

The process for diagnosing Cerebral Palsy usually begins with observations made by the child’s primary care physician, usually a pediatrician, and the child’s parents. There are some exceptions.

If a baby is born prematurely, or at a low birth weight, he or she is monitored closely in the neonatal intensive care unit of the hospital from time of birth. In extreme cases of child abuse, or shaken baby syndrome a pediatric neurologist called to the hospital’s emergency or NICU unit will diagnosis the child’s condition. In the majority of cases the child will attend regular well-baby visits where the pediatrician first uncovers signs of Cerebral Palsy during examination. In some cases, it is the parents who notice symptoms they relay to the child’s doctor during these visits.

Developmental delay, abnormal growth charts, impaired muscle tone, and abnormal reflexes are early indications of Cerebral Palsy. Because there is no test that definitely confirms or rules out Cerebral Palsy, other conditions must be excluded from the list of possible causes, and Cerebral Palsy must be fully considered. Other disorders and conditions can appear as Cerebral Palsy, and Cerebral Palsy is often accompanied by associated conditions that complicate the process of diagnosis.Patients with Cerebral Palsy Paper

What tests do they use?

Since there is no definitive test that can diagnose Cerebral Palsy, doctor’s may utilize one, or a combination, of the following to aid the diagnosis process:

Assessing reproductive health factors
Reviewing paternal health records
Reviewing pregnancy, labor and delivery records
Reviewing newborn screens conducted at birth
Considering APGAR score
Reviewing baby birth, medical, developmental and growth records
Performing a physical examination of baby
Performing additional screens (hearing, fatty acids, amino acids and hemoglobin)
Conducting micromanaging tests to determine if brain damage exists
Performing electroencephalography (EEG) or electrocardiography (EMG) to analyze nervous system function
Conducting lab tests (blood work, urinalysis or genetic testing)
Conducting evaluations (mobility, gait, speech, hearing, vision, feeding and digestion, cognitive and rehabilitation needs)

Historically, doctors have been overly cautious when diagnosing Cerebral Palsy and other developmental delays, in part due to the lack of a definitive testing mechanism, and because they felt test results may not be conclusive until the brain is fully developed somewhere between 3 to 5 years of age. Realizing that this was a crucial time for families to bond with their young child, and for the child to develop his or her personality, some conventional wisdom is under the assumption that a formal diagnosis may hamper a child’s development and potential for bonding. Others feared a misdiagnosis and wanted to wait until their diagnosis was conclusive.Patients with Cerebral Palsy Paper

For decades the protocol for diagnosing Cerebral Palsy involved observation over months to years, charting developing milestones and noting growth chart vulnerabilities. This can be an extremely trying time for parents who worry about their child’s condition, and have concerns about the need to provide therapy, deploy early intervention and procure adaptive equipment to manage their child’s potential, and minimize the resultant movement and coordination dysfunction. Some parents argue that bonding with their child is a given and that concern should not be cause for undue delay.

And, disappointingly, a small number of parents have expressed their doubts on whether their child’s diagnosis is delayed due to the statute of limitations on litigation should their child’s Cerebral Palsy have occurred due to medical malpractice or negligence. It is not unheard of to learn that some children are well beyond the brain’s developmental stage at the age of 8 or beyond and still without a formal diagnosis.

Concerned that the medical practitioners were being overly cautious to the extent of placing a child’s treatment progress at risk, The American Academy of Pediatrics on May 27, 2013 issued a clinical report titled, “Motor Delays: Early Identification and Evaluation” to help guide physicians through a 12-step process of diagnosis. The hope is that with a formal diagnosis, children were then able to qualify for early intervention, therapies, treatments and governmental assistance.

Signs and symptoms of Cerebral Palsy

Signs of Cerebral Palsy are different from symptoms of Cerebral Palsy.

Signs are clinically identifiable effects of brain injury or malformation that cause Cerebral Palsy. A doctor will discern signs of a health concern during the exam and testing.

Symptoms, on the other hand, are effects the child feels or expresses; symptoms are not necessarily visible.

Impairments resulting from Cerebral Palsy range in severity, usually in correlation with the degree of injury to the brain. Because Cerebral Palsy is a group of conditions, signs and symptoms vary from one individual to the next.

The primary effect of Cerebral Palsy is impairment of muscle tone, gross and fine motor functions, balance, control, coordination, reflexes, and posture. Oral motor dysfunction, such as swallowing and feeding difficulties, speech impairment, and poor facial muscle tone can also indicate Cerebral Palsy.Patients with Cerebral Palsy Paper

Associative conditions, such as sensory impairment, seizures, and learning disabilities that are not a result of the same brain injury, occur frequently with Cerebral Palsy. When present, these associative conditions may contribute to a clinical diagnosis of Cerebral Palsy.

Many signs and symptoms are not readily visible at birth, except in some severe cases, and may appear within the first three to five years of life as the brain and child develop.

In these instances, the most apparent early sign of Cerebral Palsy is developmental delay. Delays in reaching key growth milestones, such as rolling over, sitting, crawling and walking are cause for concern. Practitioners will also look for signs such as abnormal muscle tone, unusual posture, persistent infant reflexes, and early development of hand preference.

If the delivery was traumatic, or if significant risk factors were encountered during pregnancy or birth, doctors may suspect Cerebral Palsy immediately. In moderate to mild cases of Cerebral Palsy, parents are often first to notice if the child doesn’t appear to be developing on schedule. If parents do begin to suspect Cerebral Palsy, they will likely want to ask their physician to evaluate their child for Cerebral Palsy.

Most experts agree; the earlier a Cerebral Palsy diagnosis can be made, the better.

However, some caution against making a diagnosis too early, and warn that other conditions need to be ruled out first. Because Cerebral Palsy is the result of brain injury, and because the brain continues to develop during the first years of life, early tests may not detect the condition. Later, however, the same test may, in fact, reveal the issue.Patients with Cerebral Palsy Paper

The earlier a diagnosis is made, the sooner a child can be enrolled in early intervention programs and treatment protocols. Early interventions and therapies have proven to help a child maximize their future potential. Early diagnosis also helps families qualify for government benefit programs to pay for such measures.

Classification preference changes based on the intended use

Professionals who specialize in the treatment of Cerebral Palsy approach the condition from a number of different vantage points. An orthopedic surgeon requires a definition of the limbs affected and the extent of impairment in order to prescribe treatment.

Neurosurgeons and neuroradiologists, on the other hand, are more concerned with the cause of the brain damage and descriptors for imposing white and gray matter so as to determine the type of brain injury or brain malformation. They are also concerned with diagnosing the extent and severity level of the child’s Cerebral Palsy.

At first, a parent may be concerned with the severity level classification – mild, moderate or severe – in order to better understand the seriousness of the child’s impairment or disability. When meeting with the child’s pediatrician or physical therapist, it is useful to understand the topographical distribution of the impairment – the limbs and the sides of the body affected by brain damage. It is also important to clarify whether the child has a plegia (paralysis) or paresis (weakened) condition.

Government agencies and school administrators may be more concerned with classification systems that coincide with their ability to qualify a child for special education supports and services. Only then can they plan and administer and allocate educational supports to the child.

Researchers are interested in utilizing a universally accepted classification system, such as the Gross Motor Function Classification System, or GMFCS, to increase consistency in studies worldwide and to expand the ability to build knowledge around prevalence, life expectancy, societal impact, prevention measures and educational awareness.Patients with Cerebral Palsy Paper

The move toward a universal classification system

For these reasons, many Cerebral Palsy classification systems are used today. Over the last 150 years, the definition of Cerebral Palsy has evolved and changed as new medical discoveries contributed to growing knowledge of the condition. Although a myriad of classifications – used differently and for many purposes – exists today, those involved in Cerebral Palsy research are working toward a universally accepted classification system.

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Because of the diversity of classification systems, parents may want to document different terms doctors use in Cerebral Palsy diagnosis. In addition, parents should also maintain home health records documenting associated impairments, anatomic and radiation findings, as well as causation and timing. MyChild™ has developed the Cerebral Palsy Diagnosis Checklist and the Cerebral Palsy Risk Factor Checklist for this purpose.

Pyramidal, or spastic Cerebral Palsy

The pyramidal tract consists of two groups of nerve fibers responsible for voluntary movements. They descend from the cortex into the brain stem. In essence, they are responsible for communicating the brain’s movement intent to the nerves in the spinal cord that will stimulate the event. Pyramidal Cerebral Palsy would indicate that the pyramidal tract is damaged or not functioning properly.

Extra pyramidal Cerebral Palsy indicates the injury is outside the tract in areas such as the basal ganglia, thalamus, and cerebellum. Pyramidal and extra pyramidal are key components to movement impairments.

Spastic implies increased muscle tone. Muscles continually contract, making limbs stiff, rigid, and resistant to flexing or relaxing. Reflexes can be exaggerated, while movements tend to be jerky and awkward. Often, the arms and legs are affected. The tongue, mouth, and pharynx can be affected, as well, impairing speech, eating, breathing, and swallowing.

Spastic Cerebral Palsy is hyper tonic and accounts for 70% to 80% of Cerebral Palsy cases. The injury to the brain occurs in the pyramidal tract and is referred to as upper motor neuron damage.

The stress on the body created by spastic can result in associated conditions such as hip dislocation, scoliosis, and limb deformities. One particular concern is contractual, the constant contracting of muscles that results in painful joint deformities.

Spastic Cerebral Palsy is often named in combination with a topographical method that describes which limbs are affected, such as spastic diplegia, spastic hemiparesis, and spastic quadriplegia.Patients with Cerebral Palsy Paper

Extra pyramidal, or non-spastic Cerebral Palsy

Non-spastic Cerebral Palsy is decreased and/or fluctuating muscle tone. Multiple forms of non-spastic Cerebral Palsy are each characterized by particular impairments; one of the main characteristics of non-spastic Cerebral Palsy is involuntary movement. Movement can be slow or fast, often repetitive, and sometimes rhythmic. Planned movements can exaggerate the effect – a condition known as intention tremors. Stress can also worsen the involuntary movements, whereas sleeping often eliminates them.

An injury in the brain outside the pyramidal tract causes non-spastic Cerebral Palsy. Due to the location of the injury, mental impairment and seizures are less likely. Non-spastic Cerebral Palsy lowers the likelihood of joint and limb deformities. The ability to speak may be impaired as a result of physical, not intellectual, impairment.

Non-spastic Cerebral Palsy is divided into two groups, ataxic and dyskinetic. Together they make up 20% of Cerebral Palsy cases. Broken down, dyskinetic makes up 15% of all Cerebral Palsy cases, and ataxic comprises 5%.

Ataxic/ataxia

Ataxic Cerebral Palsy affects coordinated movements. Balance and posture are involved. Walking gait is often very wide and sometimes irregular. Control of eye movements and depth perception can be impaired. Often, fine motor skills requiring coordination of the eyes and hands, such as writing, are difficult. Does not produce involuntary movements, but instead indicates impaired balance and coordination

Dyskinetic

Dyskinetic Cerebral Palsy is separated further into two different groups; athetoid and dystonic.

Athetoid Cerebral Palsy includes cases with involuntary movement, especially in the arms, legs, and hands.

Dystonia/Dystonic Cerebral Palsy encompasses cases that affect the trunk muscles more than the limbs and results in fixed, twisted posture.Patients with Cerebral Palsy Paper

Because non-spastic Cerebral Palsy is predominantly associated with involuntary movements, some may classify Cerebral Palsy by the specific movement dysfunction, such as:

Athetosis — slow, writhing movements that are often repetitive, sinuous, and rhythmic

Chorea — irregular movements that are not repetitive or rhythmic, and tend to be more jerky and shaky

Chorea — irregular movements that are not repetitive or rhythmic, and tend to be more jerky and shaky

Choreoathetoid — a combination of chorea and athetosis; movements are irregular, but twisting and curving

Dystonia — involuntary movements accompanied by an abnormal, sustained posture

Mixed

A child’s impairments can fall into both categories, spastic and non-spastic, referred to as mixed Cerebral Palsy. The most common form of mixed Cerebral Palsy involves some limbs affected by spasticity and others by athetosis.

 

Classification based on Gross Motor Function Classification System

Gross Motor Function Classification System, or GMFS, uses a five-level system that corresponds to the extent of ability and impairment limitation. A higher number indicates a higher degree of severity. Each level is determined by an age range and a set of activities the child can achieve on his or her own.

The GMFCS is a universal classification system applicable to all forms of Cerebral Palsy. Using GMFCS helps determine the surgeries, treatments, therapies, and assistive technology likely to result in the best outcome for a child. Additionally, the GMFCS is a powerful system for researchers; it improves data collection and analysis and hence result in better understanding and treatment of Cerebral Palsy.Patients with Cerebral Palsy Paper

The GMFCS addresses the goal set by organizations such as the World Health Organization, or WHO, and the Surveillance of Cerebral Palsy in Europe, or SCPE, which advocate for a universal classification system that focuses on what a child can accomplish, as opposed to the limitations imposed by his or her impairments.

This system is useful to parents and caretakers as a developmental guideline which takes into consideration the child’s motor impairment. It assigns a classification level (GMFCS Level 1 – 5). The parent is then able to understand motor impairment abilities over time, as the child progresses in age.

To best utilize the GMFCS, it is often combined with other classification systems that define the extent, location, and severity of impairment. It is also recommended to document upper extremity function and speech impairments.

Cerebral palsy (CP), defined as a group of non progressive disorders of movement and posture, is the most common cause of severe indispensability in children. Understanding its physio pathology is crucial to developing some protective strategies. Interruption of oxygen supply to the fetus or brain asphyxia was classically considered to be the main causal factor explaining later CP. However several ante-, peri-, and postnatal factors could be involved in the origins of CP syndromes. Congenital malformations are rarely identified. CP is most often the result of environmental factors, which might interact with genetic vulnerabilities, and could be severe enough to cause the destructive injuries visible with standard imaging (i.e., phonographic study or MRI), predominantly in the white matter in preterm infants and in the gray matter and the brain stem nuclei in full-term newborns. Moreover they act on an immature brain and could alter the remarkable series of developmental events. Biochemical key factors originating in cell death or cell process loss, observed in hypnotic-ischemic as well as inflammatory conditions, are excessive production of pro inflammatory cytokines, oxidative stress, maternal growth factor deprivation, extracellular matrix modifications, and excessive release of glutamate, triggering the exciton cascade. Only two strategies have succeeded in decreasing CP in 2-year-old children: hypothermia in full-term newborns with moderate neonatal encephalopathy and administration of magnesium sulfate to mothers in preterm labor.

The presentation of cerebral palsy can be global mental and physical dysfunction or isolated disturbances in gait, cognition, growth, or sensation. It is the most common childhood physical disability and affects 2 to 2.5 children per 1,000 born in the United States. The differential diagnosis of cerebral palsy includes metabolic and genetic disorders. The goals of treatment are to improve functionality and capabilities toward independence. Multispecialty treatment teams should be developed around the needs of each patient to provide continuously updated global treatment care plans. Complications of cerebral palsy include spasticity and contractures; feeding difficulties; drooling; communication difficulties; osteopenia; osteoporosis; fractures; pain; and functional gastrointestinal abnormalities contributing to bowel obstruction, vomiting, and constipation. Valid and reliable assessment tools to establish baseline functions and monitor developmental gains have contributed to an increasing body of evidenced-based recommendations for cerebral palsy. Many of the historical treatments for this ailment are being challenged, and several new treatment modalities are available. Adult morbidity and mortality from ischemic heart disease, cerebrovascular disease, cancer, and trauma are higher in patients with cerebral palsy than in the general population.

Cerebral palsy is characterized by motor impairment and can present with global physical and mental dysfunction. In 2001, the United Cerebral Palsy Foundation estimated that 764,000 children and adults in the United States carried the diagnosis of cerebral palsy. In addition, an estimated 8,000 babies and infants, plus 1,200 to 1,500 preschoolage children are diagnosed with cerebral palsy every year in the United States.1

Etiology

Cerebral palsy is a static neurologic condition resulting from brain injury that occurs before cerebral development is complete. Because brain development continues during the first two years of life, cerebral palsy can result from brain injury occurring during the prenatal, perinatal, or postnatal periods.1,2 Seventy to 80 percent of cerebral palsy cases are acquired prenatally and from largely unknown causes. Birth complications, including asphyxia, are currently estimated to account for about 6 percent of patients with congenital cerebral palsy.3 Neonatal risk factors for cerebral palsy include birth after fewer than 32 weeks gestation, birth weight of less than 5 lb, 8 oz (2,500 g), intrauterine growth retardation, intracranial hemorrhage, and trauma. In about 10 to 20 percent of patients, cerebral palsy is acquired postnatal, mainly because of brain damage from bacterial meningitis, viral encephalitis, hyperglycemia, motor vehicle collisions, falls, or child abuse.3

The Weinberg Family Cerebral Palsy Center at New York-Presbyterian/Morgan Stanley Children’s Hospital, the first of its kind on the East Coast, helps to:

Transition patients with cerebral palsy (CP) from pediatric to adult care
Provide education and training for the medical community to work with these patients
Deliver support to help maximize the potential of people with CP to lead productive lives at all ages

Medical advances in recent years are helping those with cerebral palsy live longer, more productive lives, with nearly 90 percent of CP patients reaching adulthood. This heartening progress brings new challenges to the medical community, however. Historically, doctors focusing on pediatric medicine have provided care to people with CP. But as these patients move through adolescence and into adulthood, they are faced with new and emerging health issues. While pediatric medicine is no longer their appropriate “medical home,” adult healthcare systems have not yet been able to provide the support they need. It is our goal to tackle this challenge head-on, exploring more fully the needs of this adult population and providing integrated health care to CP patients of all ages.Patients with Cerebral Palsy Paper

The Weinberg Cerebral Palsy Center offers a comprehensive, holistic approach to meet the healthcare needs of the growing adult CP population, with an emphasis on facilitating the often-difficult medical transition from adolescence into adulthood.

What is Cerebral Palsy?

Cerebral palsy is a general term to describe a group of conditions that start when there is damage to or abnormal development in certain areas of the brain. It is a lifelong condition that affects how the brain “talks” and coordinates the body’s muscles. This leads to uncoordinated movement and posturing of the body.

Causes

There are several reasons why a child would be born with cerebral palsy, some known and others unknown. The factors that increase your child’s risk include:

Prematurity
Blood clotting disorders
Very low birth weight
Viruses
Chemical or substance abuse during pregnancy
Infections
Bleeding in the brain
Trauma
Complications of labor and delivery

Cerebral palsy affects about two to three out of every 1,000 babies. It is more common in:

Boys than girls
Multiple births
African Americans, compared with other ethnicities Patients with Cerebral Palsy Paper
Symptoms of Cerebral Palsy

While there are specific symptoms of cerebral palsy, every child is different in how they experience them. Your child may experience muscle weakness, poor motor control, or shaking called spasticity. The following are the symptoms that are used to classify cerebral palsy:

Spastic diplegia (“di” means two): spastic movements of the arms or legs
Spastic quadriplegia (“quad” means four): spastic movement in all four limbs (arms and legs)
Spastic hemiplegia: spasticity affecting one half, or side, of the body (like the right arm and right leg)
Spastic double hemiplegia: spasticity in both sides of the body, but different amounts of shaking when comparing the right side to the left side
Athetoid (or dyskinectic): involuntary (unable to control) purposeless and rigid movements
Ataxic: affects balance, leading to an unsteady gait and motions that require fine coordination, such as writing
Treatment

Treatment for cerebral palsy is tailored for each patient’s needs, taking into account:

Your child’s age, overall health, and medical history
The extent of the disease
The type of cerebral palsy
Your child’s tolerance for specific medications, procedures, or therapies
Expectations for the course of the disease
Your opinions or preferences

Cerebral palsy is not a correctable illness, so most of the treatments will be focused on managing symptoms. At NewYork-Presbyterian/Morgan Stanley Children’s Hospital, an interdisciplinary team of healthcare providers offers your child both surgical and nonsurgical treatment options that may include:

Rehabilitation
Positioning aids (used to help your child sit, lie, or stand)
Braces and splints (used to prevent deformity and provide support or protection
Medications
Orthopedic surgeries targeting curvatures in the back, hip dislocations, ankle and foot deformities, and contracted muscles Patients with Cerebral Palsy Paper
Long-Term Outlook

Cerebral palsy is a lifetime condition. We customize a plan of care to maximize your child’s capabilities and potential while preventing and/or minimizing deformities.

Improving Function and Quality of Life for Patients with Cerebral Palsy

While there is currently no cure for cerebral palsy, several treatment options are available to help improve function and quality of life for CP patients, and the continuous advancement of these treatment options will be the model for CP transitional care. The effects of CP and associated disorders can be greatly alleviated by treatment from a variety of healthcare providers, including medical specialists, educators, psychologists, physical therapists, occupational therapists, speech therapists, and social workers. Through the integrated coordination of care among these many providers, patients and their families will benefit from enhanced communication and support.

Providers and Services

Faculty members in the Weinberg Family Cerebral Palsy Center include those with specialties in orthopaedics, cardiology, dentistry, neurology, endocrinology, gastroenterology, liver and kidney disorders, dermatology, obstetrics and gynecology, pediatrics, developmental medicine, pulmonology, kinesiology and movement disorders, genetics, regenerative medicine, urology, nutrition, and psychology and mental illness.Patients with Cerebral Palsy Paper

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The Weinberg Family Cerebral Palsy Center offers a comprehensive range of healthcare services to satisfy the specific medical needs of each and every one of our patients. These services include orthopaedic and physical therapy evaluations, Botox treatment, occupational therapy, surgical procedures, orthotic and prosthetic interventions, rehabilitation services, and wheelchair clinics, among others. Additional support comes from highly trained speech and language pathologists, social workers, and educators, who provide reliable support, information, and resources for patients and families. Whether providing routine or problem-related assistance, the Center’s services are designed to provide patients with the highest level of care.

People living with cerebral palsy, carers and researchers have joined forces to create an Australian-first kit helping general practitioners better understand and support patients living with the developmental disability.

The Murdoch Children’s Research Institute’s (MCRI) Neurodisability and Rehabilitation Group developed the CP for GPs resource after recognising that many GPs felt inadequately trained and resourced to help people with cerebral palsy maintain optimum health and function.

Lead by MCRI’s Professor Dinah Reddihough, the kit comprises 16 fact sheets covering many facets of cerebral palsy care. She said while cerebral palsy was primarily a disorder of movement and posture, there were a range of associated impairments including visual, hearing, communication and cognitive difficulties.

“There seemed to be very little information available about cerebral palsy specifically for GPs, yet the expectation on these practitioners is great and their time is limited,”

“Therefore we felt that strategies needed to be put in place to assist them in the care of both children and adults with cerebral palsy and the associated complex conditions.”

One in 500 Australian babies is diagnosed with cerebral palsy, making it the most common childhood physical disability. The permanent condition results from damage to or dysfunction of the developing brain. Common symptoms includes clumsiness, involuntary muscle movements, drooling, slurred or no speech and stiffness or paralysis.

While children with cerebral palsy are typically cared for by a multidisciplinary team of medical, nursing and allied health professionals, most families rely on their paediatrician to oversee their child’s care and provide information on various health issues associated with cerebral palsy management.Patients with Cerebral Palsy Paper

But for adults with cerebral palsy, there is no equivalent medical specialist and expertise is hard to find. Natasha Street, who has cerebral palsy, said that once she left the care of her paediatrician, there was no appropriate medical specialist for her to see. By her mid-20s she had been referred to a gerontologist. Natasha, who contributed to the CP for GP kit, believes this leaves GPs in a central position to provide care, source expertise and work with allied health professionals to better assist patients with cerebral palsy.

The Tasmanian social worker said things like specialised physiotherapy programs and pain management can make an enormous difference to quality of life.

“When you get into the adult setting you have to go all over the place to find what you need and it is a nightmare. I am doing everything I can to get the right information, but it is disconnected and difficult to find and I feel that the support isn’t there for me or my GP,” Natasha said.

“GPs are like the one-stop-shop, but they are very busy and don’t necessarily know how to help. I hope these fact sheets will give them what they need to help us reach our full potential.”

Natasha said she helped develop the CP for GPs resource because she wanted to contribute her knowledge and experience to help others unable to speak up for themselves.

“The rate of CP hasn’t gone down, but we are living longer and we want to get more out of life,” she said.

“I don’t want to sit in a corner like a pot plant. I want to be at work and participating in the community. If we really want people with disability participating in society, then we need to look at it holistically and our GPs are a part of that.”

The CP for GP fact sheets, which are available for download, cover issues including definition and causes of cerebral palsy, pain management, sleep, communication, early detection and diagnosis, mental health, navigating the NDIS and getting older with the condition.Patients with Cerebral Palsy Paper

The Royal Australian College of General Practitioners is also using the resource, which was funded by an Avant quality improvement grant, as the basis for online learning activities for their members.

Cerebral palsy (CP) is a term which encompasses a diverse range of nonprogressive motor, sensory, and neurological disorders with different degrees of impairment. The diversity of clinical spectrum extends from mild monoplegia with normal intelligence to severe quadriplegia with mental retardation. The genesis of this disorder is multifactorial, but the inciting event is the injury to the developing brain. Known factors include perinatal hypoxia, infection, trauma, congenital abnormalities, and genetic influences. Diagnosis of this disorder is essentially clinical, but advanced imaging modalities such as magnetic resonance imaging reveals periventricular changes in majority of the patients.[1] Patients with CP often have to be bought to the operation theater for certain surgical procedures, namely, orthopedic procedures, dental extractions or restorations, gastrostomy and antireflux procedures, imaging, and other procedures pertaining to the specialties of neurosurgery, ophthalmology, and ENT. Thus, these patients have to be administered anesthesia and anesthesia providers should be well-versed with the etiology, pathophysiology, and management of these patients for smooth and safe conduct of anesthetic course.Patients with Cerebral Palsy Paper

Preoperative assessment of these patients should be meticulous and exhaustive and preferably involve multidisciplinary evaluation. Communication and cognitive problems may pose difficulties in eliciting history and physical evaluation. However, since feelings and emotions is present in these patients, gentle, and sympathetic approach goes a long way in establishing the rapport of the attending anesthesiologist with the patients and the parents. Preoperative assessment includes eliciting the history of seizures (focal/generalized), visual/auditory impairment. Respiratory abnormalities such as chronic lung disease, aspiration, swallowing impairment, esophageal dysmotility, or scoliosis may coexist which necessitates physiotherapy, bronchodilators, and antibiotics for optimization. Gastrointestinal disorders such as decreased lower esophageal sphincter tone predispose to aspiration. Tongue thrusting and inadequate head movement contribute to difficult airway management. Poor feeding contributes to malnutrition, anemia, dehydration, and electrolyte imbalance. Nasogastric or gastrostomy tubes might have been in position for feeding these patients which needs to be taken care of during surgical procedure. These patients have muscle contractures and are prone to dislocations and decubitus ulcers. Deformities increase the complexities of intravenous access, invasive monitoring, and regional anesthesia. Thus, meticulous preoperative plans for the same should be clearly formulated beforehand. Latex allergies may be present, so the history of same needs to be taken and documented. Concurrent medications for seizures, spasticity, reflux, constipation, and depression should be enquired about and their anesthetic interactions should be considered. Anticonvulsant medications effect enzymatic functions, cause blood dyscrasias, and may cause over sedation. Antispasticity medications such as baclofen, botulinum, benzodiazepines, tizanidine, or vigabatrine are often prescribed which needs to be ascertained. Their overdosage or intravascular administration may cause respiratory muscle paralysis. In addition, ataxia, lethargy, bradycardia, hypotension, delayed arousal from anesthesia, or seizures may occur.[2]

Preoperative investigations include full blood counts, renal parameters, electrolytes, Chest X-ray, and electrocardiography. Grouping and cross matching of blood and products should be done before major surgeries. Standard guidelines for fasting should be advised to avoid inadvertent dehydration.Patients with Cerebral Palsy Paper

Intraoperative management should be unhurried and meticulous. Sedative premedications should be administered by titrating them against their unpredictable responses and general state of the patients. Antacids and antireflux medications are necessary. Anticholinergics reduce secretions but can also increase the risk of thickening of pulmonary secretions. EMLA cream administration beforehand decreases the distress and pain associated with venipuncture. Standard noninvasive monitoring should be instituted. Intravenous access might require expert assistance and ultrasound guidance. For induction propofol is desirable, especially in patients with reactive airways. Theoretically, resistance to nondepolarizing muscle relaxants can be expected due to upregulation of acetylcholine receptors with reduced duration of action. Succinylcholine can be expected to increase the potassium levels; however, it is not seen clinically.[3] Pooled secretions in the oropharynx might impair mask ventilation and the glottis view during laryngoscopy. Thus, frequent suctioning may be necessary. Coexisting scoliosis can also complicate airway management. Endotracheal intubation using appropriate sized tubes (based on weight) should be accomplished bearing in mind that majority of the patients are small for age. Rapid sequence induction in patients with florid gastroesophageal reflux can be considered on the individual case basis. Postintubation, positioning of the patient, may pose difficulty due to contractures and spasticity. Tendency for decubitus ulcers requires careful padding of the pressure points to prevent them. Increased sensitivity to narcotics has been observed.[4] Tramadol lowers the threshold for seizure generation and hence is avoided. Other epileptogenic drugs such as ketamine, methohexitone, etomidate, and pethidine should be avoided. Minimum alveolar concentration of inhalational agents is lowered for these patients. A further reduction occurs due to chronic intake of anticonvulsants. Hence, they should be titrated accordingly or better still, bispectral index monitoring may be employed to avoid excessive depth of anesthesia.[5] Neuromuscular monitoring is useful as patients may have altered responses to muscle relaxants.

Hypothermia is a common and serious concern in these individuals. This occurs due to altered thermoregulatory responses because of hypothalamic dysfunction, lack of insulation with muscles/fat, and malnourishment. Serious adverse effects of perioperative hypothermia include wound infection, prolonged hospitalization, physical discomfort, increased blood requirement for transfusion, cardiac arrhythmias, and delayed awakening from anesthesia. Temperature monitoring is therefore to be done very stringently. Measures to conserve temperature should include warming of intravenous and irrigating fluids plus warming blankets or forced air warmers. Furthermore, warm humidified gases can be used to preserve body heat.

Regional anesthesia techniques are strongly recommended for intraoperative as well as postoperative pain relief. Regional techniques however require higher degree of technical skills as scoliosis; muscle contractures and the uncooperative patients make performance of the same, demanding. Opioids in regional techniques should be used with caution as they can accumulate, cause nausea and vomiting, and respiratory depression.

Postoperative care should also be individualized according to the preoperative condition of these patients. Emergence may be delayed. Irritability on arousal is common. This may be compounded further due to reduced communication and cognitive skills of the patients. Parental presence can be helpful in these situations. Drooling can be a cause of postoperative aspiration requiring frequent suctioning and airway protection. Preoperative anticonvulsants should be restarted as early as possible to maintain the therapeutic plasma levels. In patients who are kept nil orally or are vomiting, intravenous formulations may be necessary. Children with CP are prone to constipation. Oral, intravenous, and epidural opioids may compound this problem.Patients with Cerebral Palsy Paper

Therefore, attention to normal bowel habits for that child and the prescription of laxatives, supplemented by enemas, may be necessary.[2] Chest physiotherapy is required in patients with poor cough, secretions, and chest infections. Tracheostomy or elective ventilation may be rarely required in some patients.

Postoperative pain management is compounded by the fact that these patients have limited communication skills and poor levels of intellect. Subjective indicators such as facial grimacing, groaning, moaning, or altered sleep patterns may be difficult to interpret. It is advisable to plan the postoperative analgesic regimen on a continuous basis. Multimodal analgesia regimens using nonsteroidal anti-inflammatory drugs, paracetamol, and local anesthetics should be customized according to the patient profile. Opioids should be used very cautiously and with vigilance to detect episodes of oversedation and respiratory depression. An important aspect in orthopedic postoperative patients is the development of compartment syndrome. Decreased communication skills and use of postoperative analgesia techniques can delay the diagnosis of this event. The use of splitting plaster casts and limb elevation can reduce this risk. Additional postoperative issues which might be encountered are poor wound healing due to nutritional deficiencies. The incidence of decubitus ulcers is also high in these patients who remain nonambulatory in the postoperative period due to musculoskeletal contractures.

To conclude, CP is a group of nonprogressive disorder with varying degrees of motor, sensory, and behavioral impairment. Anesthesia for these patients should be customized to suit their specialized pathophysiology. Thorough understanding of their pathophysiology and drug interactions can guide the attending anesthesiologist to formulate the best possible anesthetic regimen and meticulous perioperative planning for a better outcome.

Cerebral palsy is the most commonly-diagnosed physical disability in children. Decades ago, many infants and toddlers with cerebral palsy were not expected to achieve a normal life expectancy. But modern treatment advances mean more adults with cerebral palsy are living longer lives, and those with less severe forms can expect the same lifespan as people without cerebral palsy.Patients with Cerebral Palsy Paper

As people with cerebral palsy age, both their symptoms and the care they need can change significantly from what they experienced in childhood. In addition to contending with the physical, medical and potential cognitive aspects of their disease, an adult with cerebral palsy must also face the same age-related health risks as any adult, including cardiovascular disease, obesity, diabetes, osteoporosis, frailty and fracture risk.

These “normal challenges of aging” can grow much worse much faster in people with cerebral palsy, making preventive care a top priority for these patients, along with primary symptom management.

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Adults living with cerebral palsy need individualized, multidisciplinary care that grows with them. Michigan Medicine is home to one of only a few dedicated adult cerebral palsy clinics in the country. The clinic focuses on managing the symptoms of cerebral palsy while helping patients navigate the manageable, often preventable health challenges all of us face as we grow older.  We also discuss life issues such as independence and accessibility, and manage equipment and medication needs.  We also offer injections, intrathecal baclofen, and access to surgeons skilled in treating individuals with cerebral palsy.Patients with Cerebral Palsy Paper