CEREBRAL PALSY: Primary effects
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Abnormal muscle tone
Every muscle has a certain amount of tone — that is, a certain amount of strength and flexibility. Our muscles are usually strong enough for us to sit, stand and maintain posture. And they're usually flexible enough that we can make quick, smooth movements.
In people with normal muscle tone, the brain and spinal cord work together to send and receive accurate messages. In people who have cerebral palsy, the brain's messages are faulty.
- Some messages tell muscle groups to remain too tight, resulting in spasticity (also called hypertonia).
- Others tell muscles to remain too loose (hypotonia).
- Often, tone is mixed — the trunk of the body may show low tone while the arms and legs are spastic.
- When muscle tone fluctuates, the condition is called dystonia — a particularly complex form of cerebral palsy. Treatments for dystonia vary, depending on the types of movement each patient exhibits.
- Some brain damage results in athetosis, which causes slow, writhing movements.
In infants, one type of tone abnormality might be obvious immediately. Other tone problems can appear as a child's nervous system develops. A change in muscle tone doesn't mean the cerebral palsy is getting worse.
Without early intervention, however, abnormal tone can hinder movement, twist bones and harm internal organs. Interventions can include electrical stimulation, medication, physical therapy, sitting support orthoses, spasticity-reduction techniques and splints.
See: What treatments exist for people with cerebral palsy? -
Muscles that pull unevenly on the joints
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Abnormal reflexes
Cerebral palsy and other developmental disabilities often show up as abnormal reflexes. In most children, for example, the Babinski reflex and other primitive reflexes develop before birth and disappear within a year. In children with cerebral palsy, the reflexes persist — taking the place of more controlled responses that should develop.
Similarly, postural reflexes normally develop within the first year of life. When they don't, it's a sign of abnormal motor development. If there are concerns about your child's development, your primary-care physician can refer you to a pediatric neurologist or neurodevelopmental pediatrician.
See: A Pediatric Perspective July/August 2001, page 5 | What treatments exist for people with cerebral palsy?
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Balance and movement problems
Other primary effects include poor balance and trouble controlling movement. These effects aren't curable, and they may limit the effectiveness of other treatments. Physical therapy can help people make the most of their abilities. It also can reduce the effects of unbalanced muscles on the joints and bones. Some cases may require orthopaedic surgery.
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Developmental and motor delays
Like all children, kids with disabilities need opportunities to explore their environments. They need sensory experiences, and they need to learn cause and effect. Because children with disabilities often find mobility difficult, however, and because some disabilities impair sensory capabilities, exploring isn’t always easy. Accommodations help ensure that children with disabilities get adequate sensory stimulation and chances for discovery.Children learn when their play and interactions match their brain development. Children with developmental delays, therefore, often are more successful using simple toys that are easy to handle. For children who have trouble walking or using their arms, be sure to keep toys and books within reach. More severely involved children need more help. For example, you might need to help them hold a teddy bear or tap on a drum.
You also can help children expand their understanding by taking part in their activities. For example, paint or play games together, gently guiding their hands with yours. If an activity requires five steps, let the child perform as many as possible. You take care of the remaining ones. Even if children complete only one step, they’ll strengthen a skill and feel a sense of accomplishment.
In addition, you might look for toys children can activate using a switch or their voice. The Parent Advocacy Coalition for Educational Rights (PACER) Center (http://www.pacer.org/) has created a guide to purchasing toys appropriate for children with special needs. Call 952-838-9000 to request a free copy of the guide. You can also ask your child’s teachers or therapists for help selecting developmentally appropriate toys.
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CEREBRAL PALSY: Secondary effects
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Malformed bones and joints
The shape of a bone depends upon the forces that affect it — that is, on pressure from nearby muscles, joints, tendons and other tissues. If those forces are appropriate, the final shape of the bone will be correct. If the forces are distorted, the bone will be distorted.
People with spasticity can develop hip deformities, foot deformities and twisted bones. Children with low muscle tone can develop scoliosis as they grow. Orthopaedic surgery, therapy and braces can help prevent or repair these secondary effects.
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Inadequate muscle growth
Cerebral palsy inhibits muscle growth because such growth depends on the ability to stretch. Although bones grow during sleep, muscles grow only when they're stretched during activities.
Children with cerebral palsy sometimes lack the balance, control and flexibility needed to perform activities that stretch their muscles. If a child can't run, for example, the muscles normally involved in running will tighten instead of grow. Shortened muscles contract, resulting in impaired abilities and, often, pain. Treatments include:
- Medications, such as botulinum toxin, oral or intrathecal baclofen, and phenol nerve blocks
- Physical therapy
- Splints, especially at night
- Stretching exercises
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CEREBRAL PALSY: Associated effects
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Attention span
Studies indicate that about 20 percent of children with cerebral palsy show signs of attention deficit hyperactivity disorder (ADHD) or attention deficit disorder (ADD). They are often easily distracted, overly active and impulsive. Children with ADHD or ADD may:
- Talk excessively
- Have trouble following directions
- Be restless
- Find taking turns difficult
- Have trouble playing quietly and organizing their activities
- Have difficulty with tasks — such as schoolwork — that require sustained concentration and mental effort
Often, attention issues become evident when children start school. If you notice such symptoms, consult your doctor, a developmental pediatrician or a psychologist. Medication can be helpful. Special-education individual family service plans (IFSPs) help meet the learning needs of newborns to 3-year-olds. Individual education plans (IEPs) help children with learning disabilities succeed in school. Consult your school district for more information.
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Breathing
People with cerebral palsy may have breathing problems. Symptoms include:
- Noisy breathing or snoring
- Irregular breathing patterns
- Congestion
- Coughing, wheezing or choking
- Frequent episodes of bronchitis or pneumonia
- Respiratory problems after eating or nursing
If you notice such symptoms, see a doctor promptly. Proper evaluation and treatment can address potentially serious problems, including apnea, lung disease and airway obstructions.
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Depression
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Hearing
Research shows that up to 20 percent of people who have cerebral palsy experience hearing loss and/or language problems as well. Typically, such hearing loss is sensorineural (involving the nerves that enable sense perception). Children with chronic ear infections might also have trouble hearing. Early identification and treatment of hearing impairments are important if children are to develop normal speech patterns. Be sure a doctor assesses the hearing of children who have cerebral palsy.
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Learning disabilities and mental retardation
About a quarter of people with cerebral palsy experience some degree of learning difficulties. The greater the brain damage, the greater the risk of cognitive problems. For example, about 50 percent of people with spastic quadriplegia have some mental retardation. Still, cerebral palsy can affect the entire body without harming intelligence.
If you need to assess the mental abilities of someone with cerebral palsy, be sure to involve a psychologist experienced in testing people who have disabilities. That's especially important if the person being tested is nonverbal, difficult to understand or unable to give consistent (verbal or nonverbal) responses. In such cases, psychologists measure abilities using nonverbal testing and developmental checklists. Testing young children is usually beneficial, because the tests create a benchmark for comparing the results of subsequent evaluations and monitoring a child's rate of learning.
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Nutrition
Sometimes, abnormal muscle tone affects the muscles responsible for chewing and swallowing. As a result, some people with cerebral palsy might find eating and drinking difficult or unpleasant. In addition, they might drool, be congested and experience dental problems.
Some people who have cerebral palsy have difficulty digesting food. Their esophagus, stomach, intestines and bowels may not work properly. Some people experience constipation. Others cope with gastro-esophageal reflux, in which stomach acid flows back into the esophagus.
Symptoms of eating or digestion concerns include:
- Difficulty eating or drinking
- A dislike of eating or drinking
- Lack of growth or weight gain in children
- More frequent illnesses than others of the same age
If you notice such symptoms, talk to your pediatrician or family physician. Therapy, medications and, occasionally, surgery can help.
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Seizures
Recurring seizures (epilepsy) are generally rare, occurring in about 1 percent of the general population. Recurring seizures are much more common, however, in people with spastic hemiplegia and spastic quadriplegia — 20 to 30 percent of people with those conditions experience seizures. In people with spastic diplegia and athetosis, on the other hand, seizures are no more common than they are among the general public.
There are many types of seizures. Some occur often; others occur rarely. Symptoms include:
- Staring spells
- Changes in alertness
- Changes in behavior
- Repetitive jerking of the body
If you notice such signs, discuss them with your doctor. Testing can help determine whether such episodes are seizures — and, if so, what type of seizures they are. Medication can control seizures in many people.
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Sense of touch
Some children with cerebral palsy also have a reduced or altered sense of touch, which can interfere with function. For example, children might have trouble holding a spoon if they can’t feel the spoon in their hands. Similarly, they might have difficulty walking, stepping on various textures, or tolerating splints, socks, braces and shoes.
Occupational and physical therapists can help determine the extent of a child’s sensation. They also can demonstrate ways of accommodating a reduced sense of touch. For example, they can teach children to:
- Look at their hand when attempting to use it
- Test temperatures with the less affected hand or foot
- Cover their hands and feet in cold temperatures
In addition, therapists can show patients and their families how to check braces and orthoses often, which helps prevent pressure sores and blisters.
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Speech and language
Some people who have cerebral palsy have trouble communicating. If their muscle control is poor, they might have trouble speaking clearly. If they have language-processing issues, they might have trouble expressing themselves and understanding others. Speech and language therapy helps many children learn to talk. Augmentative communication devices can help some people communicate more easily.
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Vision
Studies have found that 40 to 75 percent of children with cerebral palsy also have vision-related problems. Some have blurry vision or a smaller-than-usual field of vision. Others have trouble with visual motor control and visual perception.
Brain damage or imbalanced muscles in the eye can affect the optic nerve and cause abnormal vision. Some children with cerebral palsy develop retina disorders, optic nerve problems and cortical visual impairment. With cortical visual impairment, the eye is normal. The damage occurs in the part of the brain that interprets what is seen. Many people with cortical visual impairment have some sight, but interpreting what is seen may be difficult — even if the eyes work properly.
Some children develop oculomotor problems, which affect depth perception. Oculomotor conditions include:
- Esotropia or esophoria (eye turns in, toward the nose)
- Exotropia or exophoria (eye turns out, toward the ears)
- Hypertropia or hyperphoria (eye turns up)
- Hypotropia or hypophoria (eye turns down)
- Strabismus (a muscle imbalance that interferes with vision)
- Amblyopia (“lazy eye”)
Other vision problems include nearsightedness, farsightedness and astigmatism. Identifying abnormalities early and treating them with glasses, an eye patch or surgery will help protect a child's vision. If left untreated, the brain can “turn off” the image in one eye.
Such conditions usually respond at least partially to treatment. If your child has cerebral palsy, consult an optometrist or ophthalmologist regularly. Some eye conditions respond well to glasses, patching, vision therapy, or surgery. In addition, glasses often enhance learning by enabling children to better observe and absorb situations.
Visual motor control Children with cerebral palsy commonly experience difficulties with visual motor control and perception.
Visual motor control is the ability to use visual information and motor skills to perform intentional movements. Drawing, writing and cutting are examples of visual motor skills. Some children lack sufficient muscle control to guide their movements; others have trouble processing what they see. Many children with cerebral palsy use so much energy and concentration for gross motor skills — such as sitting up or reaching accurately — that relatively little remains for visual tasks.
Children with weak visual motor control know what they want to do, but can’t control their movements enough to do it. If they can’t successfully complete what they attempt, they tend to stop trying. As a result, they often avoid pastimes such as putting together puzzles, coloring, cutting with scissors, building models and performing other fine mechanical tasks. At school, they might have trouble copying lines, shapes, letters and numbers. They also might find it difficult to place letters on a line.
Unfortunately, avoiding such activities can hamper development. Such children might not learn appropriate visual motor, visual perceptual, and fine-motor skills, and they might not acquire normal gripping and pinching strength. Early detection of difficulties, followed by occupational therapy, can help. Activities that develop visual motor skills include:
- Copying designs, including letters and numbers
- Completing mazes
- Coloring within lines
- Writing on lines
- Cutting along lines with scissors
- Playing Pick-Up Sticks, jacks and similar games
- Playing with puzzles
Visual perception
Visual perception is the ability to recognize, recall, discriminate and make meaning of what we see. It’s related to other abilities, including:
- Attention (focusing on relevant stimuli)
- Memory (recognizing or recalling information learned previously)
- Sensory integration (using two or more senses at the same time)
- Problem-solving
- Concept formation (the ability to respond in a specific way to a class of stimuli)
- Simultaneous processing (noting and understanding different attributes of a stimulus at one time)
Children with developmental delays or learning disorders often have difficulty with such processes. Similarly, some children with cerebral palsy have difficulty recognizing symbols. For example, they might recognize letters and numbers later than other children their age do. They also might struggle with eye/hand coordination.
Visual perception isn’t a matter of how well people see — instead, it’s related to how the brain interprets what they see. For example, some children find it difficult to copy information from a blackboard to the paper on their desk. They don’t have trouble seeing the blackboard. They have trouble processing the information.
When visual-perception problems interfere with learning, it’s important to compensate. Helpful strategies include:
- Using a word processor
- Demonstrating knowledge by speaking instead of writing
- Assigning fewer lessons that require writing
- Using paper with margins
- Placing a strip showing letters and numbers on a child’s desk
Such methods keep the focus on academics, rather than on the act of making letters.
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