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Background |
Risk factors |
Causes |
Signs and symptoms |
Diagnosis |
Complications |
Treatment |
Integrative therapies |
Prevention |
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Bibliography
Cerebral Palsy
The term cerebral palsy, or CP, refers to a neurological disorder that appears in infancy or early childhood (most commonly under 37 weeks of age) and permanently affects body movement and muscle coordination but does not worsen over time.In CP, faulty development or damage to motor areas in the brain impair the body's ability to control movement and posture. This results in a number of chronic neurological disorders. CP is usually associated with events that occur before or during birth, but may be acquired during the first few months or years of life as the result of head trauma or infection.
The early signs of CP usually appear before a child reaches three years of age. The most common are ataxia (a lack of muscle coordination when performing voluntary movements), spasticity (stiff or tight muscles and exaggerated reflexes), walking with one foot or leg dragging, walking on the toes, a crouched or scissored gait, and muscle tone that is either too stiff or too floppy. A small number of children have cerebral palsy as the result of brain damage in the first few months or years of life, brain infections such as bacterial meningitis or viral encephalitis, or head injury from a motor vehicle accident, a fall, or child abuse.
Even though CP affects muscle movement, it is not caused by problems in the muscles or nerves. It is caused by abnormalities in parts of the brain that control muscle movements.
There is no cure for CP, but treatment can improve the lives of those who have it. Treatment includes medicines, braces, and physical, occupational, and speech therapy. Cerebral palsy is neither contagious nor inherited, nor is it progressive. The symptoms of cerebral palsy (CP) differ from person to person and change as children and their nervous systems mature. Some have other medical conditions, including seizure disorders or mental impairment.
Approximately one million people in the United States have CP. Improvements in prenatal, pediatric, and intensive care over the past 30 years have enabled more critically premature and frail babies to survive infancy. Many of these surviving children suffer developmental disorders and neurological damage.
Some persons with severe CP are completely disabled and require lifelong care, while others display only slight awkwardness and need no special assistance. Complications associated with CP include learning disabilities, gastrointestinal dysfunction, tooth decay (dental caries), sensory deficits, and seizures.
Background
The term cerebral palsy, or CP, refers to a neurological disorder that appears in infancy or early childhood (most commonly under 37 weeks of age) and permanently affects body movement and muscle coordination but does not worsen over time.In CP, faulty development or damage to motor areas in the brain impair the body's ability to control movement and posture. This results in a number of chronic neurological disorders. CP is usually associated with events that occur before or during birth, but may be acquired during the first few months or years of life as the result of head trauma or infection.
The early signs of CP usually appear before a child reaches three years of age. The most common are ataxia (a lack of muscle coordination when performing voluntary movements), spasticity (stiff or tight muscles and exaggerated reflexes), walking with one foot or leg dragging, walking on the toes, a crouched or scissored gait, and muscle tone that is either too stiff or too floppy. A small number of children have cerebral palsy as the result of brain damage in the first few months or years of life, brain infections such as bacterial meningitis or viral encephalitis, or head injury from a motor vehicle accident, a fall, or child abuse.
Even though CP affects muscle movement, it is not caused by problems in the muscles or nerves. It is caused by abnormalities in parts of the brain that control muscle movements.
There is no cure for CP, but treatment can improve the lives of those who have it. Treatment includes medicines, braces, and physical, occupational, and speech therapy. Cerebral palsy is neither contagious nor inherited, nor is it progressive. The symptoms of cerebral palsy (CP) differ from person to person and change as children and their nervous systems mature. Some have other medical conditions, including seizure disorders or mental impairment.
Approximately one million people in the United States have CP. Improvements in prenatal, pediatric, and intensive care over the past 30 years have enabled more critically premature and frail babies to survive infancy. Many of these surviving children suffer developmental disorders and neurological damage.
Some persons with severe CP are completely disabled and require lifelong care, while others display only slight awkwardness and need no special assistance. Complications associated with CP include learning disabilities, gastrointestinal dysfunction, tooth decay (dental caries), sensory deficits, and seizures.
Risk factors
Parental age: If the mother is over 40 years old, or younger than 20 years old, the risks for having a child with cerebral palsy (CP) increase. Also, if the father is younger than 20 years old, the incidence increases for having a child with CP.Parental ethnicity: Individuals with African-American descent have a higher rate of having children born with CP.
Pregnancy and birth complications: Infants at the highest risk for developing cerebral palsy are usually premature (born younger than 37 weeks), have a low birth weight (less than 5.7 pounds), do not cry within five minutes of delivery, are sustained on a ventilator for more than four weeks, or have a brain hemorrhage.
Complications during pregnancy, such as vaginal bleeding after the sixth month of pregnancy, proteinuria (protein in the urine), hyperthyroidism (high levels of thyroid hormone), hypertension (high blood pressure), exposure to viruses (such as herpes group B), Rh incompatibility, mental retardation, and seizures, can be risk factors for developing cerebral palsy (CP). Rh stands for rhesus factors found in the blood. All individuals either have, or do not have, the rhesus factor (or Rh antigen) on the surface of their red blood cells. There may be a prenatal danger to the fetus when a pregnant woman is Rh-negative and the biological father is Rh-positive. Tests are given to determine the Rh compatibility of the fetus and the mother before birth. Rh immunoglobulin (RhIg or Rhogam®) is a blood product given by injection to help the Rh negative mother by suppressing her ability to react to the Rh positive red cells. Reactions to the medication are generally minor, including soreness at the injection sight and sometimes a slight fever.
Studies have found that exposure to herpes group B viruses were found more often in babies who were later diagnosed with CP. In fact, the risk of cerebral palsy was nearly doubled with exposure to herpes group B viruses.
Breech birth is when the fetus is born with the feet or buttocks first. Manipulating the baby to prepare it for birth can result in complications such as CP. Fetal distress may occur in labor and delivery, including vascular (blood flow) or respiratory (breathing) problems, and may indicate brain damage or abnormal brain development.
Multiple births, such as having twins and triplets, may increase the incidence of CP. CP may be a result of prematurity (common in multiple births) or intrauterine growth retardation due to more fetuses in the womb.
Birth defects, such as malformation of spinal bones, hernia in groin area, abnormally small jawbone, seizures in the newborn, or microcephaly (small head), can result in developing CP.
Low Apgar score: The Apgar score is a simple and repeatable method to quickly and summarily assess the health of newborn children immediately after childbirth. Infant heart rate, breathing, muscle tone, reflexes, and skin color are each scored as 0 (low), 1 (intermediate), or 2 (normal) after delivery. A total score of seven to ten at five minutes is considered normal; four to six, intermediate; and zero to three, low. Scores that remain low 10-20 minutes after delivery indicate increased risk for CP.
Causes
Acquired cerebral palsy: Approximately 10-20% of children in the United States with cerebral palsy (CP) acquire the disorder after birth. Brain damage in the first few months or years of life, brain infections, such as bacterial meningitis or viral encephalitis, or head injury account for many of the cases of acquired cerebral palsy. In such cases, the disorder may result from brain infections like bacterial meningitis (inflammation of the lining of the brain caused by a bacteria), viral encephalitis (inflammation of the brain caused by a viral infection), head trauma sustained from an accident, fall, or inflicted injuries (such as shaken baby syndrome).Congenital cerebral palsy: CP that occurs at birth is often the result of specific events during pregnancy or around the time of birth. These events result in damage to the motor centers in the developing brain. Often times, however, congenital cerebral palsy may not be detected for months. However, birth complications account for only about 3-13% of congenital CP cases.
Infections during pregnancy: Viruses such as rubella (German measles) or herpes group B can infect the developing fetus in a pregnant woman and cause damage to the developing nervous system. Brain injury in the developing fetus may also be caused by other infections such as cytomegalovirus (herpesvirus type 5) and toxoplasmosis (a protozoal infection). Infections of the placental may also be associated with cerebral palsy.
Jaundice: If left untreated, severe jaundice can damage the brain. Jaundice is a condition produced when excess amounts of bilirubin circulating in the blood stream dissolve in the subcutaneous fat (the layer of fat just beneath the skin), causing a yellowish appearance of the skin and the whites of the eyes. With the exception of physiologic jaundice in the newborn (normal newborn jaundice in the first week of life), all other jaundice indicates overload or damage to the liver or inability to move bilirubin from the liver through the biliary tract to the gut. Jaundice in an infant, child, or an adult should always be evaluated by a doctor.
Newborn jaundice is common and, unless it is associated with an abnormal condition, it will clear without treatment. Gilbert's syndrome is another hereditary condition in which mild jaundice develops during times of stress. This condition, once recognized, requires no further treatment or evaluation. There are also other more rare hereditary causes of elevated bilirubin levels. All other jaundice is the result of an underlying disease, condition, or toxicity.
A yellow-to-orange color may be imparted to the skin by excessive intake of beta carotene, the orange pigment seen in carrots. Individuals who consume large quantities of carrots or carrot juice or take beta-carotene supplements may develop a distinctly yellow-orange cast to their skin. This condition is called hypercarotenemia or just carotenemia. Hypercarotenemia is easily distinguished from jaundice in that the sclera, or the white of the eyes, remains white, while people with true jaundice have a yellow sclera.
Rh incompatibility: When the mother's body produces immune cells called antibodies that destroy the fetus's blood cells, this may lead to a form of jaundice in the newborn.
Severe lack of oxygen: Hypoxic-ischemic encephalopathy is the name of a condition that occurs when the brain is deprived of oxygen for a prolonged period of time during labor and child delivery. Brain damage may occur. Birth complications, including asphyxia (lack of oxygen to the brain), account for approximately six percent of congenital cerebral palsy cases. Birth asphyxia is associated with spastic quadriplegia, the most commonly occurring form of CP.
Brain hemorrhage: Brain hemorrhage or bleeding may occur in the fetus during pregnancy or in newborns around the time of birth. Bleeding can damage fetal brain tissue and cause neurological problems, including congenital CP. These hemorrhages are a type of stroke that may be caused by broken, abnormal, or clogged blood vessels in or leading to the brain or by respiratory distress, a common breathing disorder in premature infants.
Signs and symptoms
Spastic cerebral palsy: Spastic cerebral palsy (CP) is the most common form, affecting approximately 70% of CP patients. This form is characterized by stiff and permanently contracted muscles. Spastic CP has a jerky, unpredictable effect on movement, causing difficulty in moving from position to position. Spastic cerebral palsy consists of subcategories, including diplegia (both arms of both legs are affected), hemiplegia (either the right arm and leg or left arm and leg are affected), quadriplegia (all arms and legs are affected), monoplegia (only one arm or leg affected), and triplegia (three arms or legs affected).Spastic diplegia: Spastic diplegia affects the legs more than the arms. The legs often turn in and cross at the knees. This causes a scissors gait, in which the hips are flexed, the knees nearly touch, the feet are flexed, and the ankles turn out from the leg, causing toe-walking. Learning disabilities and seizures are less common than in spastic hemiplegia.
Spastic hemiplegia: Individuals with spastic hemiplegia (hemiparesis) also may experience hemiparetic tremors or uncontrollable shaking of the limbs on one side of the body. Severe hemiparetic tremors can seriously impair movement. The arm is generally affected more than the leg. Learning disabilities, vision problems, seizures, and dysfunction of the muscles of the mouth and tongue are classic symptoms.
Spastic quadriplegia: Spastic quadriplegia involves all four limbs. There is dysfunction of the muscles of the mouth and tongue, seizures, medical complications, and increased risk for cognitive difficulties.
Ataxic cerebral palsy: Ataxic cerebral palsy is much less common that spastic, affecting approximately 5- 10% of CP patients. The main effect of this type is on the child's sense of depth perception and balance. This is often accompanied by poor coordination and children affected by ataxic cerebral palsy can display an abnormal gait when walking, as well as difficulty with precise movement. Another characteristic of ataxic cerebral palsy is the intention tremor. These tremors are initiated by a voluntary movement, such as reaching for a light switch, and become more severe as the individual gets closer to the objective.
Athetoid cerebral palsy: Athetoid or dyskinetic cerebral palsy affects about 10-20% of patients. Athetoid CP is characterized by athetosis (slow, uncontrolled, writhing movements of the hands, feet, arms, or legs). Patients also may have chorea (abrupt, irregular, jerky movements), choreoathetosis (a combination of athetosis and chorea), or dystonia (slow rhythmic movements with muscle tone abnormalities and abnormal postures).
Mixed cerebral palsy: Mixed cerebral palsy is a condition where two or more types of CP exist. This occurs in 10% of CP cases.
Speech: Just as patients have problems with muscle control in their arms and legs, they also have difficulties controlling their tongue, mouth, lips, jaw, and breath flow. As a result, they might have problems with speech. The most common speech problem is called dysarthria. This condition causes speech to be slow and slurred and, in some cases, hypernasal (too much air flow through the nose) or hyponasal (not enough air flow through the nose).
Drooling: There are a number of treatments available to combat the problem of drooling, including surgery, anticholinergics (drugs that reduce saliva flow), and biofeedback (helps allow patients to know when they are drooling).
Eating: Cerebral palsy can affect the muscle groups involved in the face and jaw, which can lead to difficulty eating. In severe cases, this can result in malnutrition and poor growth and development.
Incontinence: Incontinence is more commonly known as poor bladder control. This can take a number of forms, including enuresis or bed wetting, urination during physical activity, or a slow leak from the bladder.
Diagnosis
Typically, doctors diagnose cerebral palsy (CP) in infants by testing their motor skills and thoroughly analyzing their medical history. A medical history, diagnostic tests, and regular check-ups may be required to confirm the diagnosis of CP or to eliminate the possibility of other disorders.Unnaturally soft, relaxed, or floppy muscle tone is called hypotonia. Stiff or rigid muscle tone is called hypertonia. Some infants with CP have hypotonia in the first two or three months of life and then develop hypertonia. They also might develop an unusual posture or favor one side of the body.
A newborn held on its back and tilted so its legs are above its head will automatically respond with the Moro reflex, extending its arms in a gesture that resembles an embrace. This reflex usually disappears after about six months. Infants with cerebral palsy often retain it for an abnormally long period.
Signs of hand preference are also observed. When an object is held in front and to the side, infants usually do not display a tendency to use either the right or left hand. This is normal during the first 12 months of life. Infants with spastic hemiplegia, however, often develop hand preference early, indicating one side of their body is stronger than the other.
The doctor will look for other conditions that can be linked to CP, such as seizures, mental impairment, and vision or hearing problems.
Intelligence tests often are given to a child with CP to evaluate mental impairment, but the results can be misleading and there is a risk of underestimating intelligence. For instance, a child with movement, sensation, or speech problems associated with CP would have difficulty performing well on such tests.
Rule out other conditions: If motor skills decline over time, there may be genetic disease, muscle or metabolic disorder, or tumor in the nervous system, either coexistent or instead of CP. The doctor must rule out other disorders that cause movement problems (such as Huntington's disease), identify any coexisting disorder, and determine if the condition is changing.
Lab tests: A chromosome analysis may be performed to identify a genetic anomaly (such as in Down syndrome or Huntington's disease) when abnormalities in features or organ systems are present. Thyroid function tests may reveal low levels of thyroid hormone, which can produce several congenital defects and severe mental retardation. Hyperammonemia, or a high level of ammonia in the blood, may lead to central nervous system toxicity (including movement disorders). A deficiency in any of the enzymes involved in breaking down amino acids can cause hyperammonemia. This may be due to a liver disorder or a defect in metabolism.
Visual tests: Imaging tests are helpful in diagnosing hydrocephalus (condition in which abnormal accumulation of cerebrospinal fluid causes pressure in the brain), structural abnormalities, and tumors. An electroencephalogram (EEG) traces electrical activity in the brain and can reveal patterns that suggest a seizure disorder. Computed tomography (CT scan) can show congenital (birth) malformations and hemorrhage (excessive bleeding) in infants. Magnetic resonance imaging (MRI) uses a magnetic field and radio waves to create pictures of the internal structures of the brain. This study is performed on older children. It defines abnormalities of white matter and motor cortex more clearly than other methods. Ultrasound uses the echoes of sound waves projected into the body to form a picture called a sonogram. It is often used in infants before the bones of the skull harden and close to detect cysts and abnormal structures in the brain.
Electromyography (EMG) and nerve conduction velocity (NCV) studies may be performed when a nerve or muscle disorder is suspected. These tests, which can be used in combination, are often referred to as EMG/NCV studies. NCV is administered before EMG and measures the speed at which nerves transmit electrical signals which can help diagnose CP. During NCV, electrodes are placed on the skin over a nerve that supplies a specific muscle or muscle group. A mild, brief electrical stimulus is delivered through the electrode and the response of the muscle is detected, amplified, and displayed. The strength of the signal is also measured. Neurological conditions can cause the NCV to slow down or to be slower on one side of the body. EMG measures nerve impulses within the muscles. Tiny electrodes are placed in the muscles in the arms and legs and the electronic responses are observed using an oscilloscope (an instrument that displays movement of an electric current). As muscles contract, they emit a weak electrical signal that can be detected, amplified, and tracked using the oscilloscope, providing information about how well the muscles are working.
Complications
Some individuals with cerebral palsy (CP) have other conditions, such as impaired intellectual development, seizures, failure to grow and thrive, and vision and sense of touch problems.Roughly one-third of patients with CP also have mild intellectual impairment or a decrease in intelligence. Another one-third are moderately or severely impaired and the remainder are intellectually normal. Mental impairment is most common in children with spastic quadriplegia.
As many as one-half of all patients with cerebral palsy have seizures in which uncontrolled bursts of electricity disrupt the brain's normal pattern of electrical activity. Seizures that recur without a direct trigger, such as a fever, are classified as epilepsy. Seizures generally are tonic-clonic or partial. Tonic-clonic seizures spread throughout the brain, typically causing the patient to cry out, followed by unconsciousness, twitching legs and arms, convulsive body movements, and loss of bladder control. Partial seizures are confined to one part of the brain and may be simple or complex. Simple partial seizures cause muscle twitching, chewing movement, and numbness or tingling. Complex partial seizures can produce hallucinations, staggering, random movement, and impaired consciousness or confusion.
Children with moderate-to-severe cerebral palsy, especially those with spastic quadriplegia, often experience failure to grow or thrive. Infants fail to gain weight normally, young children may be abnormally short, and teenagers may be short for their age and may have slow sexual development. These phenomena may be caused by a combination of poor nutrition and damage to the brain centers that control growth.
Some individuals, particularly those with spastic hemiplegia, have muscles and limbs that are smaller than normal. Limbs on the side of the body affected by CP may grow slower than those on the other side. Hands and feet are most severely affected. The affected foot in cases of hemiplegia usually is the smaller of the two, even in patients who walk, suggesting the size difference is due not to disuse but to a disrupted growth process. Limbs affected by CP in most instances do not reach normal physical size.
Vision and hearing problems are more common in people with cerebral palsy than in the general population. Differences in the left and right eye muscles often cause the eyes to be misaligned. This condition, called strabismus, causes double vision. In children, however, the brain often adapts by ignoring signals from one eye. Because strabismus can lead to poor vision and impaired depth perception, some physicians recommend corrective surgery.
Patients with hemiparesis may have hemianopia, a condition marked by impaired vision or blindness in half of the visual field in one or both eyes. A related condition, called homonymous hemianopia, causes impairment in the right or left half of the visual fields in both eyes.
Sensations of touch or pain may be impaired. An individual with stereognosis, for example, has difficulty perceiving or identifying the form and nature of an object placed in their hand using the sense of touch alone. A decrease in feeling may contribute to the difficulty in perception.
Hip dislocation, scoliosis (curvature of the spine), incontinence (inability to control the urine flow), constipation, dental caries (tooth decay), bronchitis (inflammation of the bronchial tubes), skin sores, and asthma are other complications commonly experienced by people with CP.
Treatment
A multidisciplinary team of healthcare professionals develops an individualized treatment plan based on the specific needs of each patient. The individuals with cerebral palsy (CP), families, teachers, and caregivers should be involved in all phases of planning, decision making, and treatment.Healthcare providers for children with CP usually include a pediatrician, pediatric neurologist, or pediatric physiatrist (doctor who specializes in physical medicine). A family doctor, neurologist, or physiatrist provides primary care for adults with CP.
Other specialists on the team may include orthopedist or orthopedic surgeon (to predict, diagnose, and treat associated muscle, tendon, and bone problems), a physical therapist (to design and supervise special exercise programs for improving movement and strength), speech and language pathologist (to diagnose and treat communication problems), occupational therapist (to help the patient learn life skills for home, school, and work), social worker (to help patients and their families obtain community assistance, education, and training programs), and a psychologist (to help address negative or destructive behaviors and guide the patient and the family through the stresses and demands presented by cerebral palsy).
The need for and types of therapy may also change over time. Adolescents with CP may need counseling to cope with emotional and psychological challenges. Physical therapy may be supplemented with special education, vocational training, recreation, and leisure programs. Adults may benefit from attendant care, special living accommodations, and transportation and employment assistance services, depending upon his or her intellectual and physical capabilities.
Physical therapy: It is important for physical therapy to begin soon after a diagnosis of CP is made. A physical therapist specializes in improving the development of the large muscles of the body, such as those in the legs, arms, and abdomen (called gross motor skills). Physical therapists help children with CP learn better ways to move and balance. They may help children with CP learn to walk, use a wheelchair, stand by themselves, or go up and down stairs safely. Physical therapists will also work on skills such as running, kicking and throwing, or learning to ride a bike. Physical therapy usually begins in the first few years of life, or soon after the diagnosis of cerebral palsy is made. These therapists use specific sets of exercises to work toward the prevention of musculoskeletal complications. An example of this is preventing the weakening or deterioration of muscles that can develop with lack of use. Also, physical therapy will help avoid contractures, in which muscles become fixed in a rigid, abnormal position. Physical therapy will help prevent musculoskeletal problems, as well as help the child perform common everyday activities.
Occupational therapy: An occupational therapist specializes in improving the development of the small muscles of the body, such as the hands, feet, face, fingers and toes. These therapists also teach daily living skills, such as dressing and eating, as well as make sure children are properly positioned in wheelchairs. They may teach the child better or easier ways to write, draw, cut with scissors, brush their teeth, dress, and feed themselves. Occupational therapists will also help the child find the right special equipment to make everyday life a little easier.
Speech and language therapist: A speech and language therapist helps develop better control of the jaw and mouth muscles, which can improve speech and language skills and eating abilities. They also help develop creative communication methods for those who can not speak. A speech and language therapist will work with the child on communication skills. This means talking, using sign language, or using a communication aid. Children who are able to talk may work with a speech therapist on making their speech clearer, or on building their language skills by learning new words, learning to speak in sentences, or improving their listening skills. Children who can not talk may learn sign language or how to use special equipment, such as a computer that actually talks for the individual.
Surgery: Surgery is not always necessary for children with CP, but it is sometimes recommended to improve muscle development, correct contractures, and reduce spasticity in the legs. Before selecting any surgical procedure, the doctor will thoroughly discusses the risks involved, long-term effects, and postoperative follow-up. Second opinions are generally recommended and speaking with other parents whose children have had the same surgical procedure may be helpful.
Children with cerebral palsy often walk on their toes. This may indicate a tight heel cord. When other treatments for this fail, such as splints and braces, surgery may help correct it by lengthening the tendon. This surgery may help improve the child's ability to walk, improve balance, and prevent further deformity. Surgery is also available to relieve spasticity in the legs and hips of children. This surgery involves identifying sensory nerve fibers behind the spinal cord and then selectively cutting those nerve fibers thereby reducing spasticity. Research on this surgery is still being conducted. The adductors are muscle groups that bring the legs together. If a child's doctor determines that the adductors are causing deformities or problems with walking, they may suggest a surgical procedure to cut the tendon, which can release muscle contractures and improve mobility.
Drug therapy: Doctors may prescribe drugs to prevent or control seizures associated with CP such as carbamazepine (Tegretol®), phenytoin (Dilantin®), and valproic acid (Depakene® or Depakote®). Drug therapy can also help reduce spasticity associated with cerebral palsy and may include the use of diazepam (Valium®, a benzodiazepine), baclofen (Liorisal®, a muscle relaxant), and dantrolene (Dantrium®, a muscle relaxant). If surgery is not recommended, these drugs can help reduce spasticity for short periods. However, their long term value is still being researched. Side effects include drowsiness and fatigue (excessive tiredness). Although drug therapy may not completely correct complications associated with cerebral palsy, evidence does show that it helps manage problems such as seizures and spasticity. Anticholinergic drugs may be prescribed to control the abnormal movements associated with athetoid cerebral palsy. These drugs inhibit the effects of acetylcholine, a chemical in brain cells that triggers muscle contraction. The most commonly prescribed anticholinergic drugs are trihexyphenidyl (Artane®) and benztropine (Cogentin®). Side effects associated with anticholinergic drugs include dry mouth, constipation, agitation, and dysuria (painful urination).
Botulinum toxin, or BOTOX®, is injected directly into muscle. BOTOX® blocks acetylcholine and alleviates muscle spasm for three to six months. Botulinum toxin may produce muscle weakness. In some cases, physicians may try to reduce spasticity or correct a developing contracture by injecting phenol into a muscle. This weakens the muscle and gives physicians and therapists a chance to stretch and lengthen the muscle with therapy, bracing, or casts. If the contracture is treated early enough, the need for surgery may be avoided.
Sensory integration therapy: Another approach to help children with CP achieve their optimal level of functioning is sensory integration therapy (SIT). SIT helps to overcome problems experienced by many young children in absorbing and processing sensory information. Encouraging these abilities ultimately improves balance and steady movement. Therapies include stimulating touch sensations and pressures on different parts of the body.
Adaptive equipment: Special equipment is also available for children with CP. Wheelchairs, walkers, and braces may help children with CP to perform daily tasks.
A wheelchair is sometimes used when a child cannot walk. This will allow the child to move from one place to another. Many children with cerebral palsy can use their arms to roll the wheels of their wheelchair themselves and can move around without much difficulty at all. There are also wheelchairs available that are motorized. This type of wheelchair has a motor that moves the wheels for the child. There may be a joystick on one arm rest that the child can operate on his or her own.
A walker is a piece of equipment usually made out of light metal. It most often will have four legs that are adjustable in height. Some children with cerebral palsy can walk, but have poor balance and may fall. They may use a walker to help them balance and get around without the use of a wheelchair.
Because of the fine motor problems often associated with cerebral palsy, children may have a hard time using utensils for eating. Special handles or grips are available for children who have trouble holding onto small objects, such as a fork or spoon. Eating utensils that are specially designed for children with fine motor problems also exist. They may be curved or bent and are usually designed to fit the child's needs. Special grips and handles are also used on pencils and pens to make them easier for the child to hold and use.
Communication aids, including computers, books, posters, and alphabet boards, are available for children who are hard to understand or who have difficulty talking with others.
Psychotherapy: Behavioral therapy can complement physical therapy, employing psychological techniques that encourage the mastery of tasks that promote muscular and motor development. Praise, positive reinforcement, and small rewards can encourage a child to learn to use weak limbs, overcome speech deficits, and stop negative behaviors like hair pulling and biting. Medications for psychiatric symptoms may also be used, including antidepressants (such as fluoxetine or Prozac® and sertraline or Zoloft®) and antipsychotic medications (such as quetiapine or Seroquel®).
Support Groups: To meet the challenges of cerebral palsy, patients, families, and caregivers need help and support. There are many government-supported and private volunteer groups that provide information about prevention, diagnosis, and treatment, as well as clinical and support services.
Integrative therapies
The integrative therapies listed below have been reported useful in movement disorders in general. Although the use of these therapies has not been studied in cerebral palsy, the use in movement disorders suggests their use in cerebral palsy may improve symptoms associated with the condition.Good scientific evidence:
5-HTP: Cerebral ataxia results from the failure of part of the brain to regulate body posture and limb movements. 5-HTP has been observed to have benefits in some people who have difficulty standing or walking because of cerebral ataxia. Some research shows that 5-HTP may allow individuals with unsteady movements to stand alone without assistance, walk without aid, or improve coordination. Other research shows no benefit. Further research is needed before a conclusion can be drawn. 5-HTP may interact with other mood altering medications such as antidepressants and anti-anxiety drugs.
Music therapy: Music therapy has been reported to improve symptoms in people with Parkinson's disease. Modest improvement were seen in symptoms including motor coordination, speech intelligibility and vocal intensity, bradykinesia (slow movement), emotional functions, activities of daily living, and quality of life.
Omega-3 fatty acids: Omega-3 fatty acids are essential fatty acids found in cold water fish (including salmon, herring, and tuna) and other marine life (such as krill and algae). Omega-3 fatty acids can also be found in certain plants and nuts, including purslane and walnuts. An investigational drug for the symptomatic treatment of the neurological condition Huntington's disease (HD) is ethyl-EPA (Miraxion®), a pharmaceutical drug based on a component of omega-3 fatty acids called eicosapentaenoic acid (EPA). Miraxion® seems to help decrease the chorea (involuntary movements) that can be debilitating in individuals with HD. Omega-3 fatty acid supplements (including fish oils) may cause an increase in bleeding in sensitive individuals, including those taking blood thinning drugs such as warfarin (Coumadin®) or those with bleeding disorders. More research should be performed for the use of Miraxion® in other neurological disorders.
Unclear or conflicting scientific evidence:
Acupressure, Shiatsu: The practice of applying finger pressure to specific acupoints (energy points) throughout the body has been used in China since 2000 B.C. Shiatsu technique involves finger pressure at acupoints and along body meridians (energy lines). It can incorporate palm pressure, stretching, massaging, and other manual techniques. Shiatsu practitioners commonly treat musculoskeletal and psychological conditions, including neck/shoulder and lower back problems, arthritis, depression, and anxiety. Preliminary clinical evidence from one small study with individuals with facial spasm reports improvement when using Shiatsu acupressure. Further research is needed.
Acupuncture: Acupuncture has been reported to help relieve symptoms of some neurological disorders including cerebral palsy, hemiplegia (full or partial paralysis of one side of the body due to disease, trauma, or stroke), Parkinson's disease (characterized by fine muscle coordination and tremors), spinal cord injury, Tourette's syndrome (characterized by "tics"), and trigeminal neuralgia. One study found that parents were impressed with acupuncture therapy on functional well-being in Huntington's disease in children. There is insufficient evidence available from well-designed studies for using acupuncture in neurological disorders such as Tourette's syndrome. More trials need to be performed.
Alexander technique: The Alexander technique is an educational program that teaches movement patterns and postures, with an aim to improve coordination and balance, reduce tension, relieve pain, alleviate fatigue, improve various medical conditions, and promote well-being. Preliminary research suggests that Alexander technique instruction may improve fine and gross movements and reduce depression in patients with Parkinson's disease. Well-designed human trials are necessary.
Arginine: Arginine, or L-arginine, is considered a semi-essential amino acid, because although it is normally synthesized in sufficient amounts by the body, supplementation is sometimes required. Adrenoleukodystrophy (ALD) is a rare inherited metabolic disorder characterized by the loss of fatty coverings (myelin sheaths) on nerve fibers in the brain and progressive destruction of the adrenal gland. ALD is inherited as an x-linked genetic trait that results in dementia and adrenal failure. Injections of arginine have been proposed to help manage this disorder, although most study results are inconclusive. Further research is needed to evaluate the use of arginine in ALD and other neurological conditions.
Chiropractic: Chiropractic is a healthcare discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system) and how this relationship affects the preservation and restoration of health. Although there is not enough reliable scientific evidence to conclude the effects of chiropractic techniques in the management of Parkinson's disease, anecdotal reports suggest a positive impact on fine muscle coordination in some individuals. More clinical research is necessary.
Coenzyme Q10: Coenzyme Q10, or CoQ10, is produced by the human body and is necessary for the basic functioning of cells. There is promising evidence from one case control study and two case series to support the use of CoQ10 in the treatment of symptoms associated with the neurological condition Friedrich's ataxia. These studies are lacking in sample sizes. A future randomized controlled trial with a substantial number of participants is necessary for proper evaluation of efficacy of CoQ10 in Friedrich's ataxia. Further research using CoQ10 for neurological conditions is necessary.
Ginseng: A clinical study found that patients with neurological disorders may improve when taking Asian ginseng (Panax ginseng). This supports research findings that report that Panax ginseng improves cognitive function. However, more research is needed in this area.
L-carnitine: Although used traditionally for support of neurological conditions, one poorly designed preliminary clinical study reported that L-acetyl-carnitine (carnitine or L-carnitine) possesses neither efficacy nor toxicity towards patients with Huntington disease. Further trials are required to determine if L-carnitine is beneficial in individuals with neurological disorders.
Melatonin: Melatonin is a naturally occurring hormone that helps regulate the sleep/wake cycles (circadian rhythm). Melatonin has been reported useful in neurological conditions including Parkinson's disease, periodic limb movement disorder, and tardive dyskinesia. The use of melatonin in these conditions, however, is not supported by rigorous scientific testing. Better-designed research is needed to determine if melatonin is beneficial in individuals with neurological disorders.
Moxibustion: Moxibustion uses the principle of heat to stimulate circulation and break up congestion or stagnation of blood and chi (energy). One small study reported treatment of trigeminal neuralgia with cupping to have a significant therapeutic effect. However, there is insufficient available evidence and more clinical studies are needed in this area
Reiki: Reiki is a system of lying on of the hands that originated in as a Buddhist practice approximately 2,500 years ago. One randomized trial suggests that Reiki may have an effect on autonomic nervous system functions such as heart rate, blood pressure, or breathing activity, important in neurological disorders that may damage autonomic function. Large, well-designed studies are needed before conclusions can be drawn.
Safflower: Friedreich's ataxia is a genetic neurodegenerative disease. In one clinical trial, safflower (Carthamus tinctoria) decreased deterioration caused by Friedreich's ataxia. More high-quality studies with larger sample sizes are needed to establish safflower's effect on neurological conditions.
Taurine: Taurine may affect cellular hyperexcitability by increasing membrane conductivity to potassium and chloride ions, possibly by altering intracellular (within the cell) availability of calcium. Results from a single non-randomized trial suggest that taurine supplementation may result in improvements in myotonic (slow relaxation after contraction of muscles) complaints. Well designed clinical trials are needed.
TENS: Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Electrodes are temporarily attached with paste in various patterns, depending on the specific condition and treatment goals. Several studies have reported benefits of TENS therapy in patients with trigyminal neuralgia (facial pain). However, these trials have been small without clear descriptions of design or results. A small clinical study also found TENS effective in decreasing symptoms associated with spinal cord injury. Therefore, additional research is needed before a firm conclusion can be drawn in the area of neurological disorders.
Vitamin B6: Vitamin B6 (pyridoxine) is required for the synthesis of the neurotransmitters serotonin and norepinephrine and for myelin formation. Pyridoxine deficiency in adults principally affects the peripheral nerves, skin, mucous membranes, and the blood cell system. In children, the central nervous system (CNS) is also affected. Major sources of vitamin B6 include: cereal grains, legumes, vegetables (carrots, spinach, peas), potatoes, milk, cheese, eggs, fish, liver, meat, and flour. Some prescription drugs called neuroleptics, which are used in psychiatric conditions, may cause movement disorders as an unwanted side effect. Vitamin B6 has been studied for the treatment of acute neuroleptic-induced akathisia (NIA, a neuromuscular disorder characterized by a feeling of "inner restlessness" or a constant urge to be moving) in schizophrenic and schizoaffective disorder patients. Preliminary results indicate that high doses of vitamin B6 may be useful additions to the available treatments for NIA, perhaps due to its combined effects on various neurotransmitter systems. Further research is needed to confirm these results.
Vitamin E: Vitamin E has been studied in the management of tardive dyskinesia, and has been reported to significantly improve abnormal involuntary movements, although the results of existing studies are not conclusive enough to form a clear recommendation. Vitamin E may be more effective in higher doses and in people who have had tardive dyskinesia for less than five years.
Other supplements used in movement disorders that have unclear or conflicting scientific evidence include ashwagandha root (Withania somniferum), dehydroepiandosterone (DHEA), dong quai root (Angelica sinensis), homeopathic dilutions of belladonna (Belladonna atropa), choline, psychotherapy, selenium, and yohimbe bark (Pausinystalia yohimbe).
Historical or theoretical uses lacking sufficient evidence:
Integrative therapies used in movement disorders, such as cerebral palsy, that have historical or theoretical uses but lack sufficient clinical evidence include: aloe (Aloe vera), arabinoxylan, aromatherapy, art therapy, asparagus (Asparagus officinalis), arnica (Arnica montana), bacopa (Bacopa monnieri), bitter orange (Citrus aurantium), black cohosh (Actaea racemosa), cat's claw (Uncaria tomentosa), chelation therapy (EDTA), chondroitin sulfate, cordyceps (Cordyceps sinensis), devil's claw (Harpagophytum procumbens), horse chestnut (Aesculus hippocastanatum), kava kava (Piper methysticum), kudzu (Pueraria lobota), hypnosis, magnet therapy, lycopene, massage, muira puama (Ptychopetalum olacoides), omega-3 fatty acids, prayer, qi gong, relaxation, St. John's wort (Hypericum perforatum), and valerian (Valeriana sp.).
Prevention
Adequate prenatal care during pregnancy, labor, delivery, and immediately after the delivery of the infant is essential. Healthcare professionals recommend that individuals see their doctor regularly, take prenatal vitamins as prescribed, stop smoking, and eat healthy foods including more fresh fruits and vegetables. Failure to perform the necessary tests and accurately interpret the results of these tests may cause injury to the developing brain. Improper use of medications, unrecognized fetal distress, untreated infections, excessive use of abortion, and the failure to perform a timely cesarean section may result in damage to the motor centers in the brain.Preventing head injuries by using child safety seats in automobiles and helmets when riding bicycles and skateboards is important. Supervision of young children closely during bathing and swimming helps prevent injury.
Vaccination against German measles (rubella) is recommended before becoming pregnant.
Physical exhaustion from inadequate rest or recovery from illness or injury can lead to an overall decline in physical and mental function. Ways to maintain physical function include appropriate wheelchair seating and posture, assumption of various positions out of the wheelchair, and use of a wheelchair when fatigued and when walking is difficult. Also, regular and appropriate exercise, including stretching exercises and exercises to maintain flexibility in joints, is recommended.
Maintaining ideal weight is important. It may be best to avoid refined foods such as white breads, pastas, and sugar. Doughnuts, pastries, bread, candy, soft drinks, and foods with high sugar content may all contribute to weight gain that may worsen symptoms of movement disorders.
Food can be cut into small pieces, softened, or pureed to ease swallowing and prevent choking. While some foods may require the addition of thickeners, other foods may need to be thinned. Dairy products, in particular, tend to increase the secretion of mucus, which in turn increases the risk of choking.
Author information
Natural Standard is an international research collaboration that aggregates and synthesizes data on complementary and alternative therapies. Using a comprehensive methodology and reproducible grading scales, information is created that is evidence-based, consensus-based, and peer-reviewed, tapping into the collective expertise of a multidisciplinary Editorial Board. The mission of this collaboration is to provide objective, reliable information that aids clinicians, patients, and healthcare institutions to make more informed and safer therapeutic decisions. Natural Standard is widely recognized as one of the worlds premier sources of information in this area.Bibliography
Cerebral Palsy Information. www.cerebralpalsyinfo.org. Accessed May 19, 2007.
Cerebral Palsy Source. www.cerebralpalsysource.com. Accessed May 19, 2007.
Kenney C, Simpson R, Hunter C, et al. Short-term and long-term safety of deep brain stimulation in the treatment of movement disorders. J Neurosurg. 2007;106(4):621-5. View Abstract.
The Movement Disorder Society. www.movementdisorders.org. Accessed May 19, 2007.
National Association of Neurological Disorders and Stroke. www.ninds.nih.gov. Accessed May 19, 2007.
National Student Speech Language Hearing Association. www.asha.org. Accessed May 3, 2007.
Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com. Copyright © 2007. Accessed May 19, 2007.
United Cerebral Palsy. www.ucp.org. Accessed May 19, 2007.
Worldwide Education and Awareness for Movement Disorders. www.wemove.org. Accessed May 19, 2007.
Related Terms
Adaptive equipment, anticholinergics, antigen, Apgar score, asphyxia, ataxia, ataxic cerebral palsy, athetoid cerebral palsy, athetosis, bilirubin, breech birth, bronchitis, carotenemia, chorea, choreoathetosis, computed tomography, CP, CT, cytomegalovirus, dental caries, diplegia, Down syndrome, dysarthria, dyskinetic, EEG, electroencephalogram, electromyography, EMG, encephalitis, epilepsy, fetal distress syndrome, fetus, German measles, Gilbert's syndrome, hemianopia, hemiparesis, hemiplegia, hemorrhage, herpes type B, Huntington's disease, hydrocephaly, hyperammonemia, hypercarotenemia, hypertension, hyperthyroidism, hypertonia, hypotonia, incontinence, jaundice, magnetic resonance imaging, meningitis, microcephaly, movement disorder, MRI, NCV, nerve conduction velocity, neurological disorder, occupational therapy, pediatric neurologist, pediatrician, physiatrist, physical therapy, placental, pregnancy, premature, proteinuria, psychotherapy, respiratory, Rh factor, rhesus factor, rubella, seizure, sensory integration therapy, shaken baby syndrome, spastic cerebral palsy, spastic diplegia, spastic hemiplegia, spastic quadriplegia, spasticity, speech therapy, stereognosis, tonic-clonic seizure, toxoplasmosis, ultrasound, vascular, walker, wheelchair.
Natural Standard Bottom Line Monograph, Copyright © 2009 (www.naturalstandard.com). Commercial distribution prohibited. This monograph is intendedfor informational purposes only, and should not be interpreted as specific medical advice. You should consult with a qualified healthcare provider before making decisions about therapies and/or health conditions.
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