What follows is a fictitious dialogue between a doctor and an interviewer on Cerebral Palsy.This is based on the question concerned parents ask about their children with cerebral palsy. As always always consult a medical doctor before treating your child. The intention is raise awareness of Cerebral Palsy among parents and caregivers.
Doctor, will my child walk normally again?
“D’you call life a bad job? Never! We’ve had our ups and downs, we’ve had our struggles, we’ve always been poor, but it’s been worth it, ay, worth it a hundred times I say when I look round at my children.”
— W. Somerset Maugham
– by Dr. Easwar T.R
There are few things in our life that brings us such joy as a child. Children with their innocent pranks, the twinkle in their eyes so full of life, are enough to steal anybody’s heart.
Yet it is so sad so see so many children denied these simple childhood pleasures because of Cerebral Palsy. It is heart breaking to see the sense of helplessness in the eyes of these brave parents.
Variety of movement disorders can affect children both before and after birth that leaves their brain and nervous system permanently damaged. This results in poor and inappropriate control over their movements.
They are grouped and unfairly segregated by the society as ‘spastics’ . There is a general misconception that all these children are challenged intellectually and are ‘not normal’.
This belief is so prevalent that the child is shunned by his/her friends. The school also needs some convincing form the parents before they do admit these children as they are unaware of their demands and abilities.
So what is spasticity?
Spasticity means only inappropriate tightness of the muscles.
What causes spasticity?
This can be due to variety of causes; both before, during or after birth.
The basic factor is an interruption in the oxygen supply to the brain resulting in a permanent damage to the brain and the nervous system.
This could be due to infection when mother is pregnant, delayed labour, poor lung development in newborn child, prematurity, meningitis…. and a variety of other reasons.
It is not a genetic disorder or a hereditable one.
What happens because of this damage?
The damage causes poor brain control of the muscles. This results in very tight muscles and poor co-ordination.
As a result these children have great difficulty in performance of simple movement in a coordinated way.
You said the brain is permanently damaged; so, are all these children ‘intellectually challenged’.
Not at all.
Most of them have normal intelligence. The area of the brain commonly affected is the area which controls the muscle movement only. Most of these children can go to normal school and are just as intelligent as others.
However, there is a subset of these children where the initial injury is so bad that the intelligence, hand function and personal care is also affected. These children need special attention.
So, not all children are affected to the same degree?
Correct. As the initial injury to the nervous system can vary in severity the resulting movement disorder ranges from being mild and almost unnoticeable in public to a degree where child is permanently dependant on the caretaker even for eating and toileting.
It the more severe group that people associate with and mentally segregate.
So, is the disorder curable?
Since the damage to the brain is permanent, the disorder is not unfortunately curable.
However depending on the extent of involvement and problem, we can treat them so they can lead an independent and productive life. Earlier the treatment is started the better.
You said it is important to identify and start treatment early, how does a parent identify that the child needs medical attention?
Usually parents bring the children to the doctors because the child does not turn over, sit, stand or walk at the normal age of development. There may also be delayed speech development, poor toilet training and signs of hearing and vision impairment.
The child may also in addition walk on toes or may have a cross leg walking with frequent tripping and falls. In very mild afflictions the problem may be noticed only incidentally on routine check-up.
To identify it early you need to have a high index of suspicion. Some clues are there in birth history and childhood illnesses.
The paediatrician will note if the child is normal after delivery and has cried immediately after birth. Crying helps good intake and delivery of oxygen to the brain. A delayed labour and child passing stools before delivery are high risks as the child spends longer time without adequate oxygen to the brain.
How to proceed and whom to consult if the child has a problem?
In a country like India, the role of General practitioner is very important.
Due to lack of specialist facilities in rural areas, parents seek their advice first. Early referral to a specialist is important part of treatment and promises much better results.
No two patients have the same problem. Each has to assessed individually by a team of doctors and care given with close follow up.
The problem has to be dealt with by Paediatricians, Paediatric orthopaedic surgeons, Physiotherapists, Occupational and Speech therapists, Child psychologists, Social workers etc.
What are the common problems a child faces and how to comprehensively treat them?
Mainly it is a movement disorder with poor coordination of movements in upper and lower limbs. These results in disorders of gait and grasp function of hand. Many children also have associated posturing of hand and face. These are the most obvious external signs.
However there are other several more important but subtle problems which also need to be addressed for a comprehensive care of the child.
Depending on the extent of affection, they may also have drooling of saliva, speech difficulty, seizures, squinting of eye and vision problems, hearing problems, calcium loss from bone and weak bones, intellectual impairment and varying degrees of dependence on nursing care for ambulation and daily living.
Care involves appropriate nursing to maintain hygiene, prevention and management of pressure sores and varying degrees of assistance in personal care and nutrition.
Child has to be adequately exposed to sunlight as it helps keep calcium in the bones and keeps them strong. It is especially important in a child who is non-ambulant or one who is on long term anti-seizure medication.
What is role of you as a Paediatric Orthopaedic surgeon?
The orthopaedic surgeon is concerned with problems like standing, walking, sitting, hip problems, spinal deformity and problems hand function. After clinical assessment of the tight muscles, there are various non-surgical and surgical options available.
Ambulatory assistance can be given with splints, crutches and wheelchairs. Many people have a stigma associated with splints and calipers. Modern splints and supports are designed to provide the maximum comfort with a very good aesthetic appeal.
Botulinum injections in to the muscles with regular monitored physiotherapy are a very good choice for a young child with good ambulatory potential. It is given in a child between 3-6 years of age. The improvement has to be maintained with appropriate physiotherapy. The injection can be repeated afterwards if necessary.
For older children above 8 years of age surgical option may be considered after clinical assessment. Various surgical options are lengthening of the muscles, transferring the powerful tendons to a different area so that they pull in a different direction and bony surgery.
Even though the surgical option in commonly used for ambulatory children and children who may have a potential to ambulate, there are situations where a wheelchair bound or non-ambulant child may also require surgery.
Groin muscle tightness may cause difficulty in care of personal hygiene requiring surgery to allow spreading of lower limbs. These children are also at a high risk of hip dislocation due to inappropriate muscle pull and sometimes these can be very painful and interferes with sitting requiring surgery. Wheelchair bound children can also develop spinal deformity causing imbalance while sitting and require corrective surgery.
Even after the surgical procedures, physiotherapy and splinting has to be constantly followed up to prevent recurrence of the muscle tightness as child grows up. Splints need be monitored as child out grows them and they may need constant reworking to prevent sores.
As I said earlier this is only the orthopaedic management. We coordinate with a variety of health professional to ensure all round care.
Thank you , Doctor for answering my queries about Cerebral Palsy.
Dr. Easwar T.R DNB(Orth.), MNAMS
Consultant Paediatric Orthopaedic & Spine Surgeon
Ortho One Orthopaedic Speciality Centre, Coimbatore.
Phone : 0091-98407-24924
email : firstname.lastname@example.org
Join his online Paediatric Orthopaedic & Limb Deformity Community at http://facebook.com/Paedorth.India/
All Rights Reserved by Dr. Easwar T.R 2012. Unauthorized copying not allowed.