CEREBRAL PALSY CLINIC

Cerebral Palsy is a condition in which a child has difficulty in sitting, standing or walking due to damage to the child’s brain. The brain is the organ which controls all movements of the body. So if a part of the brain is damaged, the muscles whose movements are controlled by the damaged part become weak and tight which leads to the difficulties in movements.

1. The problems include:

  • 2. Weakness
  • 3. Movement disorder (spasticty/ dystonia/ ataxia)
  • 4. Sensory disturbances
  • 5. Lack of coordination and balance

What are the types of Cerebral Palsy?

Cerebral Palsy can be classified into different types depending on the type of movement abnormality:

  • 1. Spastic Cerebral Palsy: This is the commonest type in which the muscles are spastic (tight), fail to relax and therefore interfere with movement. It occurs due to damage to a part of the brain called cerebrum.
  • Dyskinetic Cerebral Palsy: This is a type of cerebral palsy characterized by muscle contractions which are involuntary (not under the child’s control) resulting in abnormal movements and postures. It occurs due to damage to a part of the brain called basal ganglia. Dykinetic Cerebral Palsy can further be classified as dystonic or athetoid
  • Ataxic Cerebral Palsy: This is type of Cerebral Palsy in which there is a lack of balance leading to frequent falls. It occurs due to damage to a part of the brain called cerebellum
  • Mixed Cerebral Palsy: Mixed Cerebral Palsy is a type of Cerebral Palsy in which more that one of the above types of movement disorders are seen. Here is the brain damage is usually more extensive.

Cerebral Palsy is also classified according to the body part affected:

  • Monoplegic: Single limb affected, extremely rare
  • Hemiplegic: One half of the body is affected and upper limb is affected more than the lower limb
  • Diplegic: Lower limbs are more affected than the upper limbs
  • Quadriplegic: Both upper and lower limbs are affected. This is the most severe type

Cerebral Palsy is also classified according to the severity of involvement. This classification is called the GMFCS (Gross Motor Function Classification System)

  • Level 1: Children walk without limitations and can run and jump, but speed and coordination are reduced.
  • Level 2: Walk without aids indoors and with assistive mobility devices such as crutches, walkers, and/or orthotics.
  • Level 3: Walk indoors and outdoors with assistive mobility devices such as crutches, walkers, and/or orthotics.
  • Level 4: Rely on a wheelchair for most mobility. Children may have a very limited ability to take steps but are not functionally ambulatory.
  • Level 5: No independent mobility and unable to maintain an upright trunk without support.

What causes Cerebral Palsy?

Cerebral Palsy may be caused by:

Prenatal causes (causes before birth): Brain may fail to develop normally. This may occur due to genetic causes, certain infections during pregnancy, hypertension during pregnancy, exposure to radiation or harmful drugs during pregnancy. Perinatal causes (causes around birth): Complications during child delivery can lead to cerebral palsy by leading to inadequate supply of oxygen to the brain. This is more prone to occur in premature deliveries, low birth weight deliveries, twin pregnancies, meconium aspiration, cord around the neck, prolonged labour, etc. Contrary to popular belief, recent studies show that only 10 to 15% of cases of cerebral palsy occur due to complications during child birth. Postnatal causes (causes after birth): Brain damage due to causes such as severe infection, meningitis, drowning, electric shock, etc in first 2 years of life can lead to cerebral palsy

What are the orthopaedic problems in cerebral palsy?

Muscles in a child with cerebral palsy are tight. This tightness maybe:

  • 1. Spasticity: muscle tight but can be stretched out with sustained slow force
  • 2. Joint contractures: Untreated spasticity will lead to contracture where the tightness cannot be stretched out.

This is most likely to occur at the ankle, knee, hip, elbow and wrist.

In addition, children with cerebral palsy are at risk for developing hip subluxation (movement of the head of the thigh bone out of the hip socket) and dislocation. This is most likely to occur in children that are not walking independently (GMFCS levels III, IV and V). Regular monitoring and surveillance with hip X-rays is important.

Spinal deformity (scoliosis) is another common problem and regular evaluation is necessary to detect occurrence of this complication

In addition to disorder of movement and posture, what other problems may occur in a child with cerebral palsy?

Child with cerebral palsy may have following additional problems:

  • Mental retardation
  • Epilepsy
  • Learning difficulties
  • Hearing impairment
  • Vision impairment
  • Swallowing difficulty
  • Severe nutritional deficiencies (severe deficiencies of Vitamin D and Vitamin C can also lead to significant weakening of bone and fractures)
  • Constipation
  • Recurrent respiratory infections

In addition to disorder of movement and posture, what other problems may occur in a child with cerebral palsy?

Child with cerebral palsy may have following additional problems:

  • Mental retardation
  • Epilepsy
  • Learning difficulties
  • Hearing impairment
  • Vision impairment
  • Swallowing difficulty
  • Severe nutritional deficiencies (severe deficiencies of Vitamin D and Vitamin C can also lead to significant weakening of bone and fractures)
  • Constipation
  • Recurrent respiratory infections

What is the treatment of Cerebral Palsy?

Treatment of a child with cerebral palsy requires an team approach a experts of different specialities need to coordinate and design a rational, customised and integrated treatment strategy for each child:

  • Pediatrician
  • Neurologist
  • Developmental Pediatrician
  • Physiotherapist
  • Occupational Therapist
  • Orthopaedic surgeon
  • Neurosurgeon
  • Speech Therapist
  • Special Educator
  • Ophthalmogist
  • ENT surgeon
  • Gastroenterologist

What treatment modalities are available for the movement disorder in cerebral palsy?

Treatment modalities available for improving ambulation potential of a child with cerebral palsy include:

Physiotherapy: Techniques including Neuro-Develomental Therapy (NDT), Conductive Education, Constraint Induced Movement Therapy (CIMT) and goal directed therapies are employed to optimize walking and hand function in a child with cerebral palsy

Splints and Orthoses: Orthoses like Ankle Foot Orthoses (AFOs), Hip abduction brace, and upper limb splints are commonly used to prevent joint deformities in children with Cerebral Palsy

Oral medications: Medications like Baclofen, Tizanidine, Diazepam and Trihexyphenidyl are used to decrease muscle tightness in children with cerebral palsy

What is Injection Botulinum Toxin and how does it help to decrease muscle tightness in cerebral palsy?

Botulinum Toxin is a neurotoxin produced by bacteria called Clostridium Botulinum. When injected in a tight muscle it acts at the junction of nerve and muscle and blocks the release of a substance called Acetyl Choline. Acetyl Choline is essential to make a muscle tight. Blockage of it’s release helps to relax the muscle tightness.

Is Botulinum Toxin safe?

If given by experts trained in using Botulinum Toxin, and given in recommended dosages, it is very safe. Allergy is extremely rare but has been reported. Other extremely rare complications reported include breathing difficulties. The authors in their 12 years experience of using Botulinum Toxin have not encountered these complications.

What are the advantages of Botulinum Toxin?

Botulinum Toxin by decreasing the muscle tightness removes the brakes hampering movement and thereby facilitates the job of your physiotherapist. The therapist can then focus on improving muscle balance, coordination, core strength which then synergistically improves the walking ability of the child. Here it should be absolutely emphasized that physiotherapy after Botulinum Toxin is absolutely mandatory and improvements in function will be noted after a sufficient period if rehabilitation.

What are the disadvantages of Botulinum Toxin?

The major disadvantage of Botulinum Toxin is that effect of the injection wears of after a period of about 6 months due to sprouting of new nerve terminals. If this results in functional impairment the injection may need to be repeated after a period of one year.

What is the procedure for injecting Botulinum Toxin?

Botulinum Toxin needs to be injected accurately into the tight muscles. To make sure that the toxin is being injected accurately into the tight muscle, the injection is often given Ultrasound guided or Nerve stimulator guided. The injection is given under anaesthesia. For this, the child needs a daycare admission. After the injection, a plaster cast is applied. The cast is removed after a period of two weeks after which physiotherapy and appropriate splintage is re-instituted.

What is the ideal age for Botulinum Toxin?

Botulinum Toxin is generally given between the ages of 2 and 6 years. Beyond the age of 6 years, generally the muscle spasticity evolves into fixed joint contractures which will not benefit with Botulinum Toxin and need surgical release.

What orthopaedic surgeries are performed in Cerebral Palsy? Orthopaedic surgeries performed in a child with Cerebral Palsy may include:

Soft Tissue releases: These surgeries are performed in the presence of muscle contractures which lead to deformities and difficulty in walking. These surgeries need to be done by an expert after lot of deliberation as inappropriate and excess release of muscle can lead to muscle weakening. Soft tissue releases are often performed around the ankle (tight heel cords), knee (tight hamstrings), hips (tight adductor muscles, psoas muscle)

Soft tissue balancing: Occasionally surgery is needed to balance muscle forces across a joint wherein one group of muscles is stronger and overpowering another muscle thereby creating a deformity. For example, this type of surgery is needed in the foot where the foot is turing inwards due to stonger inner muscle. It is also needed in presence of weak muscles around the wrist.

Bony surgery: This type of surgery is needed for long standing muscle tightness which tends to deform the bones. It’s commonly needed for flatfoot deformity and for twisting deformities of thigh and leg bones.

Surgery for the hip: The hip joint is at risk for dislocation in children with cerebral palsy due to abnormal tightness in muscles around the hip. This is especially true for severely affected children who are severely affected and bed-ridden. This complication needs to be looked for by doing periodic Xrays. Hip dislocation needs to be treated since it can be painful, can interfere with sitting balance and can lead to difficulty maintain hygiene of private parts. Hip dislocation can be prevented by doing muscle release if muscles are tight. Once dislocation occurs more extensive surgery consisting of muscle as well as bony surgery is needed.

Surgery for crouch: Crouch is a situation in cerebral palsy in which the children walk with excessively bent knees. This deformity occurs in adolescents and older children. A specialized form of bony surgery is needed to correct this deformity Surgery for spine: Spinal deformities occur in severely affected children with cerebral palsy and need surgery in cases where the deformity is causing breathing difficulties and difficulties in sitting.

What are the special features of the Pinnacle Orthocentre CP clinic?

At the Pinnacle Orthocentre CP clinic, different experts dealing with movement and posture disturbances in Cerebral Palsy evaluate the child jointly and after due deliberation evolve a Common Treatment Programme which will address all the movements issues. The team consists of a Pediatric Orthopaedic Surgeon (who advises on need for Injection Botulinum Toxin and Surgery), Physiotherapist (who designs an exercise and therapy programme) and Orthotist (who designs and manufactures splints after discussion with rest of the team)

Can Cerebral Palsy be completely cured?

In the end, we need to emphasise that irrespective of what several proponents of alternative medicine may claim, there is no known cure for Cerebral palsy. The brain damage is irreversible and permanent, and all scientifically proven treatment modalities aim to optimize the function of a child with cerebral palsy and thereby improve quality of life.

There are many “magic remedies” being marketed today which claim to cure a child with cerebral palsy. Parents are cautioned to thoroughly check the scientific validity of these treatment modalities before embarking on them.

Proponents of Stem Cells therapy are widely proclaiming it to be a panacea in the treatment of Cerebral Palsy. However an unbiased review of scientific studies shows that though stem cells show promise of a new avenue of CP treatment, currently available evidence shows that there is still some way to go before it can be validated as a safe and effective treatment for Cerebral Palsy. The Indian Academy has released a statement to that effect (http://www.iacp.co.in/statement.html) and the 2017 guidelines for Stem Cells Research issued by the Indian Council for Medical Research (ICMR) (http://icmr.nic.in/guidelines/Guidelines_for_stem_cell_research_2017.pdf) clearly states that apart for certain hematological diseases like blood cancer, stem cell therapy cannot be offered as a therapeutic modality for treatment of other diseases including cerebral palsy.

In conclusion, for the benefit of the child, the entire comprising the parent with battery of experts have to design a comprehensive treatment strategy aimed at solving all problem areas. Perseverance and hard work are the key to successful outcome.

Dr Sandeep Vaidya
Director, Division of Children’s Orthopaedics
Pinnacle Orthocentre Hospital, Thane
drsandeepvaidya@pinnacleorthocentre.com