CEREBRAL PALSY: Causes, Methods And Treatment
This is a disorder of movement and posture caused by a non-progressive lesion in the immature brain, leading to global dysfunction.
Lesions
In cerebral palsy, the lesion could be in either the brain or the upper cervical cord, and the lesion is static.
Classification
Cerebral palsy is classified based on various clinical types and based on the degree of severity.
Lesions in the Brain
In cerebral palsy, the lesions in the brain can occur in the following four areas:
- Cerebral cortex (spastic type)
- Midbrain (dyskinesia)
- Cerebellum (ataxic)
- Widespread brain involvement (rigidity and mixed).
Causes
In cerebral palsy, the causes are different in pre-natal, natal, postnatal and perinatal period.
Clinical Features
This depends on the location of lesions in the brain. Single muscle involvement is rare as in polio and entire portion of the body supplied by that area of brain is involved, the patients show delayed mile stones and primitive reflexes are usually preserved.
Other clinical features depend on the geographic distribution of cerebral palsy and the associated handicapping situations.
Orthopedic Deformities
The following are the common orthopedic deformities encountered in cerebral palsy.
Upper Limb
- Pronation contracture of the forearm.
- Flexion deformities of the wrist and fingers.
- Thumb in palm deformity.
- Swan neck deformity.
- Shoulder adduction and internal rotation deformity.
Lower Limb
- Adduction deformity (most common).
- Flexion and internal rotation deformity.
- Dysplastic and subluxated hip.
- Dislocated hip
- Pelvic obliquity.
- Scoliosis
- Kyphoscoliosis.
- Genu recurvatum
- Genu valgum
- Patella alta
- Subluxation or dislocation of patella.
- Knee flexion contracture-(most common).
- Equinus deformity
- Varus or valgus
- Talipes equinovarus
- Calcaneus deformity
- Talipes cavus
- Hallux valgus
Order of preference to improve the quality of life in cerebral palsy is as follows:
- Education and communication is the first priority
- Activities of daily life
- Mobility
- Ambulation
The role of orthopedic surgeon starts when the child is 12 months of age and seldom before.
Methods
- Motor age test
- Physiotherapy, occupational therapy, speech therapy, etc
- Use of braces to:
- Improve function
- Control unnecessary movements
- Prevent and correct deformities
- Drug therapy: The role of drug therapy is disappointing. Muscle relaxants, antiepileptic may have a role.
Treatment
Broad Principles of the treatment:
- To prevent deformities from developing.
- To assist returning of muscle power by graduated exercises.
- To reduce disability by appropriate appliance or by operations on joints and muscles.
Surgery:
- Not done till the child reaches five years of age.
- Indicated to correct deformity in an ambulatory patient and to make him or her socially more acceptable.
- Commonly indicated in spastic type of cerebral palsy.
Choice of Surgery
Operation on nervous system:
- Sympathectomy, rhizotomy (anterior or posterior).
Operation on muscles and tendons:
- Tenotomy, tendon lengthening and tendon transfers.
- Myotomy and muscle transposition.
Operation on bones and joints:
- Bone lengthening or bone shortening to equalize the limb lengths.
- Osteotomies to correct knock knee, and other bone deformities.
- Arthrodesis of wrist, hip, and foot to correct deformity, provide stability and to improve functions.