Cerebral palsy is a collection of motor disorders resulting from damage to the brain that occurs before, during, or after birth. The damage to the child’s brain affects the motor system, and as a result the child has poor coordination, poor balance, or abnormal movement patterns or a combination of these characteristics.

Cerebral palsy (CP) is a static disorder of the brain, not a progressive disorder. This means that the disorder or disease process will not get worse as time goes on. Nor are the motor disorders associated with cerebral palsy temporary. Therefore, a child who has temporary motor problems, or who has motor problems that get worse over time, does not have cerebral palsy. Children with cerebral palsy may have many other kinds of problems, including medical problems. Most of these problems are related to brain injury. They include epilepsy, mental retardation, learning disabilities, and/or attention deficit–hyperactivity disorder.

Congenital cerebral palsy (or cerebral palsy that exists from birth) is responsible for the largest proportion of cases of cerebral palsy. For a small percentage of children, injuries sustained during the birthing process or in early childhood may be considered the cause of cerebral palsy. When motor disorders appear after age 5, they are slightly different from the motor disorders of cerebral palsy and are usually diagnosed as they would be in an adult, as stroke or traumatic brain injury.

What Causes Cerebral Palsy

When cerebral palsy was first described in the 1880s, it was believed to be caused by lack of oxygen for the infant at birth. We now know that this is the cause in only a small minority, approximately 10 percent, of children with CP. The great majority of CP is caused by damage to the brain during foetal development, well before the birth process begins. Although the cause of this damage is usually not known (the medical term for “unknown cause” is idiopathic), we know from modern imaging techniques (computerised tomography and magnetic resonance imaging) that some cases of CP are caused by strokes or haemorrhaging in the brain in the late stages of foetal development. Others are caused by abnormal development of the brain in the early stages of foetal development (what is called a malformation or birth defect of the brain).

The brain damage that leads to CP can be caused by:

• Idiopathic (no known cause of damage to brain during pregnancy)—still the most common cause
• A viral infection during pregnancy, such as cytomegalovirus (CMV) or rubella
• Hydrocephalus, either before or after birth
• A blood clot in the foetus’ brain causing a stroke while in utero
• Bleeding into the brain: While in utero, this could be due to a bleeding disorder; after birth, this can be seen as a complication of extreme prematurity.
• Prolonged period of asphyxia (lack of oxygen) from, for example, abruptionplacenta, when the placenta tears away from the uterine wall during labour, cutting off the baby’s blood supply.
• Bacterial meningitis after birth
• Head trauma from shaken baby syndrome (child abuse) during the first year of life
• Lead poisoning during the first two years of life

Classification

Cerebral palsy is classified by the type of movement problem (spastic, athetoid, hypotonic, or mixed) and by the body parts involved (legs only, one arm and one leg, or all four limbs).

By type of movement

• Spastic: too much muscle tone
• Athetoid: no muscle control
• Hypotonic: decreased muscle tone (not enough tone)

Ataxic balance and coordination problems Mixed mixture of two or more of the above

By involved body parts

• Hemiplegia: one arm and one leg on the same side of the body
• Diplegia: predominantly both legs (arms also involved)
• Quadriplegia: all four extremities

Neurological problems

• Mental retardation
• Learning disabilities
• Attention deficit–hyperactivity
• disorder
• Seizure disorder (epilepsy)
• Visual impairment
• Swallowing difficulties
• Speech impairment (dysarthria)
• Hearing loss

Orthopaedic problems

• Scoliosis
• Hip dislocation
• Contractures of joints
• Discrepancy in leg length

Secondary effects

• Communication disorder
• Drooling
• Poor nutrition
• Depression
• Fragile bones and frequent fractures
• Cavities
• Constipation

Physiotherapy for adults and Children with CP

Physiotherapists play a key role in supporting children and adults with cerebral palsy. Physios usually become involved around the time of diagnosis. Their main aim will be to help children and adults with cerebral palsy to be as mobile and independent as possible. A physio can provide advice on managing the effects of the condition. This will include encouraging young people to become involved in their own development. Getting involved in this way will help the young person to meet challenges as they arise, in all areas of their lives. As the young person grows into adulthood, physios can continue to identify and help to solve problems. These problems might relate to maintaining mobility or getting involved in leisure activities or sports.

Physios are the third largest health profession after doctors and nurses. They work in the NHS, in private practice, for charities and in the work-place, through occupational health schemes.

Physical therapy is the rehabilitation of physical impairments by training and strengthening a patient’s large muscles – those in the arms, legs, and abdomen. The goal of physical therapy is to maximize functional control of the body, or increase gross motor function.

The goal of physical therapy is to help individuals:

• develop coordination
• build strength
• improve balance
• maintain flexibility
• optimize physical functioning levels
• maximize independence

All treatment is designed to meet a child’s individual needs in a way that emphasises physical fitness, and minimises injuries and pain.

Additionally, a physical therapist provides positive reinforcement for a child by focusing on his or her capabilities, not limitations. The therapist will set goals for young patients, and work with them to meet predetermined benchmarks with confidence in a safe, supportive environment.

Therapy aids overall treatment goals such as:

• Overcoming physical limitations
• Expanding range of joint motion
• Building and maintaining muscle tone
• Increasing recreational capabilities
• Identifying alternate ways to perform everyday tasks
• Fostering independence
• Decreasing the likelihood of contractures, bone deformity
• Educating children and parents about adaptive equipment
• Providing sensory stimulation
• Increasing fitness
• Increasing flexibility
• Improving posture
• Improving gait
• Minimizing pain and discomfort

What are the benefits of physical therapy?

The benefit of physical therapy, for any patient that is experiencing physical limitations, is regaining – or developing – physical mobility.

By developing a comprehensive plan of treatment, a physical therapist can address limitations in a child’s mobility – and specifically address them. This is achieved through employing exercises that increase physical function, and using adaptive equipment such as wheelchairs, walkers, canes and orthotics to improve performance.

As a child’s physical abilities improve, the therapist can modify the equipment, or the overall course of therapy, to further advance a child’s treatment.

The largest benefit of therapy to the child with Cerebral Palsy is in treatment of problematic conditions when they occur, including:

• Muscle atrophy or tightening
• Loss in joint range of motion
• Muscle spasticity
• Pain in muscles and joints
• Joint inflammation
• Contractures (muscle rigidity)

The physiotherapy in ANRC Physiotherapy Clinic in Horsham and East Grinstead focuses on achieving optimal results and minimising unforeseen complications.

How is physical therapy performed?

Physical therapy is carried out by licensed physical therapists and physical therapy assistants, often by using means such as:

• • soft tissue mobilisation (kneading of the muscles)
  • joint mobilisation
  • specialised exercises
  • stretching
  • endurance exercises designed to meet therapeutic goals

Physical therapy is hands-on: a therapist, or an assistant, will guide the child through exercises.
Exercises often include the use of equipment, such as:

• • Weights
  • Exercise machines
  • Bands
  • Rollers
  • Balance balls
  • Heat and cold packs
  • Ultrasound technology

At some centres, sports or recreation like swimming, dancing and playing games such as throwing and catching a ball, may be used to help children develop muscles, balance, coordination and range of motion.

Swimming, because the child is almost entirely submerged in the water, will give children an opportunity to do exercises they cannot do otherwise; moving against the water, kicking and other beneficial exercises can be accomplished in a pool, sometimes in braces. These methods can provide children with an opportunity to play and have fun.

Adaptive equipment including braces, splints, walkers, orthotics, wheelchairs and even computers will be used in therapy; therapists will modify the equipment as needed. The therapist will also play an instructive role in this regard for children and parents, teaching them how to use the equipment

What happens during physical therapy?

There is no therapeutic template for Cerebral Palsy since there are many forms of Cerebral Palsy which affect each individual differently.

All physical therapy begins with a diagnosis – the child’s primary doctor will then refer the child to a physical therapist while providing specific treatment goals to accomplish.

At the start of physical therapy, a comprehensive medical history for the child will be obtained. Additionally, the therapist will conduct a series of tests, observations and measurements to assess the child’s body mechanics and function.

The examination may assess:

• • Gait
  • Range of joint motion
  • Physical strength
  • Flexibility
  • Balance
  • Endurance
  • Joint integrity
  • Posture
  • Neuromotor development
  • Sensory integration
  • Cognitive functioning
  • Reflexes
  • Breathing, respiration

The therapist then prepares a patient-centred plan of care that takes into account the child’s condition, and the child’s overall environment.

The physical therapist will also determine what orthotic equipment, adaptive equipment, or assistive technologies may be needed to help a child.

Orthotic equipment can include braces that stabilise the ankles, knees, legs, torso, upper arms, lower arms, elbows or hands. Adaptive equipment includes strollers, nets, walkers and wheelchairs. The therapist will teach the child – and his or her caregivers – how to operate the equipment, and will make modifications to accommodate a child’s condition.

Once the child’s plan of treatment is determined, therapists will set goals for a child’s progress, and work with the child to meet those benchmarks. This typically means the therapist and his or her assistants manipulate a child’s body while completing stretches, strength exercises or games with specific movements or purpose.

Often therapy includes instructions for exercises, stretches, posturing and balance to be performed while outside the therapy sessions; at home, school or work.