FREQUENTLY ASKED QUESTIONS
What is Cerebral (CP)?
Neural damage occurring during early fetal development has the most obvious effects on muscle control. Cerebral palsy is a condition characterized by motor dysfunction - uncoordinated muscle movement, or palsy. This motor dysfunction can be grouped descriptively into three types: spastic palsy (stiff movement), athetoid palsy (uncontrolled, involuntary movement), and ataxic palsy (loss of balance). Individuals with cerebral palsy often exhibit some combination of these motor problems.
Cerebral palsy typically involves injury to multiple sites in the cortex, and so it is not necessarily limited to motor dysfunction. Concurrent problems may include a loss of general balance, difficulty with speech and hearing, impaired vision, learning disabilities, and seizures. The dysfunctions associated with cerebral palsy are difficult to diagnose in newborn infants because a baby may exhibit apparent neurologic abnormalities very early in life, yet ultimately develop normally. Consequently, cerebral palsy is almost never diagnosed before children are 6 months to 1 year of age. Once detected, cerebral palsy can be managed with a physical therapy regime, and though it cannot cure the condition, physical therapy can teach individuals effective coping strategies. While these coping strategies may minimize the effects of cerebral palsy on an individual's life, the underlying condition neither regresses nor progress.
What Causes Cerebral Palsy?
During early brain development, neurons form at an astonishing rate --- about 250,000 neurons every minute during the peak phases. In fact, far more connections are formed in the brain of an infant than will be retained in adulthood. One advantage of this excess of neural growth is that the developing brain becomes tolerant of damage. A young brain has sufficient neural redundancy that injuries that would be catastrophic in an adult brain might have only a moderate effect on an infant.
Ironically, this tolerance for injury helps to explain why the pattern of trauma called cerebral palsy is found so predominantly in infants. Cerebral palsy is caused by sustained, chronic injury to the brain; though an infant's brain is damaged by this type of injury, an adult brain would be unlikely to survive such an insult.
Cerebral palsy is associated with several different types of injury that can affect a developing infant's brain. Indirect forms of injury include premature delivery and intrauterine infection, both resulting from maternal conditions (Grether, JK., Nelson, KB.). An infant's brain can also be injured directly from infection mediated by a class of molecules called cytokines and from anoxia. Karen Nelson and her colleagues at the National Institutes of Health have described the role of cytokines in fetal brain injury (Nelson, KB., Dambrosia, JM., Grether, JK, et al). Cerebral palsy is most often correlated with anoxic injury, damage to brain tissue that results from oxygen starvation. Neural tissues might be deprived of oxygen for several reasons; premature birth may cause bleeding into the infant's brain, awkward fetal positioning may block the baby's airways, small blood clots can cause strokes, and the baby's placenta can detach from the mother prematurely (in some cases because of infection and the production of cytokines). In each of these cases, cerebral palsy is most likely to result if the injury is repetitive or sustained and occurs before or during birth. Sudden, traumatic injury can also induce cerebral palsy, but these cases are rare.
Doctors in the United States have made aggressive, but unsuccessful, efforts to control the types of fetal injuries believed to result in cerebral palsy. These efforts have included very close monitoring of the fetus and its environment for abnormalities in heart rate, amniotic fluid composition, or fetal positioning. Any abnormality might prompt doctors to perform a caesarian section instead of a standard vaginal delivery. In fact, 20 to 25 percent of all deliveries in the United States are currently performed by caesarian section for this very reason, compared to just 5 percent of deliveries in, for example, Ireland. However, because cerebral palsy is the result of chronic injury to the brain before the time of delivery, caesarian section as a strategy for preventing cerebral palsy does not work. In point of fact, the frequency of cerebral palsy is approximately the same in United States as it is in Ireland, suggesting that new approaches to prevention of the condition are urgently needed.
New Research Techniques?
The types of chronic prenatal brain injury that lead to cerebral palsy are often subtle and difficult to detect. A whole host of identified maternal risk factors exist, for example hypertension and smoking, but many cases of cerebral palsy are not correlated with these risk factors. The medical community remains frustrated in its attempts to either predict or to reduce the incidence of cerebral palsy in newborns.
New research conducted by Dr. Frederick Kraus at the St. John's Mercy Medical Center in St. Louis suggests a better alternative for predicting, and eventually preventing, some of the causes of cerebral palsy. In the July 1999 issue of Human Pathology, (Kraus, Frederick T., Acheen, Viviana l.) Dr. Kraus and his colleagues report findings from their study of perinatal autopsies. They found that a significant number of infants who had tiny blood clots called thrombi in the fetal vessels of the placenta, also had such clots in their developing organs. The study showed that within the delicate tendrils of blood vessels supplying a fetus's brain, these thrombi caused infarct, or stroke, resulting in cerebral palsy.
Blood Screening for Pregnant Mothers?
During a recent interview, Dr. Kraus remarked that the placenta is "the baby's most important organ before and until it is born." He pointed out that traditionally, little attention is paid to the placenta as a source of insight into fetal development. Critics argue that since the placenta isn't accessible until after a baby is born, any problems placental analysis can reveal are historical. Nonetheless, Dr. Kraus's study shows that the placenta can reveal quite a lot about the conditions in which a fetus ultimately developed -- in particular, that blood clots in the placenta are highly predictive of blood clots in the fetal brain.
"If you could identify clotting cases early, based on the mother's medical history, you might be able to prevent cerebral palsy" Dr. Kraus said, "This requires screening mothers who are pregnant for coagulopathy (a blood clotting disorder). Right now, women with clotting disorders are normally not screened unless they have miscarriages because the testing is very expensive...If the link between thrombi and cerebral palsy can be established, then screening for coagulopathy becomes very important, and we could screen more affordably if we did it more often."
Hope for Prevention?
Studying placentas could provide the insight into cerebral palsy that the medical community has been looking for. He is now tracking a large group of live born infants whose placentas showed thrombi in the fetal circulation to determine what fraction of those infants ultimately develop cerebral palsy. If he finds a strong correlation between thrombi in the placenta and the development of cerebral palsy, Dr. Kraus's research may offer hope to a significant population of women at risk for coagulopathies that could threaten their children.
Still, much work remains to be done, and preventing fetal brain injuries that result from blood clots represents just one approach to a larger story. Placental abruption (early detachment of the placenta from the uterus), neonatal cytokines, and blood clotting factors also have the potential to injure the developing brain. But Dr. Kraus's study demonstrates that previously neglected sources of information such as a baby's placenta can provide invaluable insights into prevention of developmental injury, and may allow medicine to further unveil the shrouded mysteries of prenatal life.
How is Cerebral Palsy Managed?
Cerebral palsy can’t be cured, but treatment will often improve a child's capabilities. Many children go on to enjoy near-normal adult lives if their disabilities are properly managed. In general, the earlier treatment begins, the better chance children have of overcoming developmental disabilities or learning new ways to accomplish the tasks that challenge them.
There is no standard therapy that works for every individual with cerebral palsy. Once the diagnosis is made, and the type of cerebral palsy is determined, a team of health care professionals will work with a child and his or her parents to identify specific impairments and needs, and then develop an appropriate plan to tackle the core disabilities that affect the child’s quality of life.
A comprehensive management plan will pull in a combination of health professionals with expertise in the following:
physical therapy to improve walking and gait, stretch spastic muscles, and prevent deformities;
occupational therapy to develop compensating tactics for everyday activities such as dressing, going to school, and participating in day-to-day activities;
speech therapy to address swallowing disorders, speech impediments, and other obstacles to communication;
counseling and behavioral therapy to address emotional and psychological needs and help children cope emotionally with their disabilities;
drugs to control seizures, relax muscle spasms, and alleviate pain;
surgery to correct anatomical abnormalities or release tight muscles;
braces and other orthotic devices to compensate for muscle imbalance, improve posture and walking, and increase independent mobility;
mechanical aids such as wheelchairs and rolling walkers for individuals who are not independently mobile; and
communication aids such as computers, voice synthesizers, or symbol boards to allow severely impaired individuals to communicate with others.
Doctors use tests and evaluation scales to determine a child’s level of disability, and then make decisions about the types of treatments and the best timing and strategy for interventions. Early intervention programs typically provide all the required therapies within a single treatment center. Centers also focus on parents’ needs, often offering support groups, babysitting services, and respite care.
The members of the treatment team for a child with cerebral palsy will most likely include the following:
A physician, such as a pediatrician, pediatric neurologist, or pediatric physiatrist, who is trained to help developmentally disabled children. This doctor, who often acts as the leader of the treatment team, integrates the professional advice of all team members into a comprehensive treatment plan, makes sure the plan is implemented properly, and follows the child’s progress over a number of years.
An orthopedist, a surgeon who specializes in treating the bones, muscles, tendons, and other parts of the skeletal system. An orthopedist is often brought in to diagnose and treat muscle problems associated with cerebral palsy.
A physical therapist, who designs and puts into practice special exercise programs to improve strength and functional mobility.
An occupational therapist, who teaches the skills necessary for day-to-day living, school, and work.
A speech and language pathologist, who specializes in diagnosing and treating disabilities relating to difficulties with swallowing and communication.
A social worker, who helps individuals and their families locate community assistance and education programs.
A psychologist, who helps individuals and their families cope with the special stresses and demands of cerebral palsy. In some cases, psychologists may also oversee therapy to modify unhelpful or destructive behaviors.
An educator, who may play an especially important role when mental retardation or learning disabilities present a challenge to education.
Regardless of age or the types of therapy that are used, treatment doesn’t end when an individual with cerebral palsy leaves the treatment center. Most of the work is done at home. Members of the treatment team often act as coaches, giving parents and children techniques and strategies to practice at home. Studies have shown that family support and personal determination are two of the most important factors in helping individuals with cerebral palsy reach their long-term goals.
While mastering specific skills is an important focus of treatment on a day-to-day basis, the ultimate goal is to help children grow into adulthood with as much independence as possible.
As a child with cerebral palsy grows older, the need for therapy and the kinds of therapies required, as well as support services, will likely change. Counseling for emotional and psychological challenges may be needed at any age, but is often most critical during adolescence. Depending on their physical and intellectual abilities, adults may need help finding attendants to care for them, a place to live, a job, and a way to get to their place of employment.
Addressing the needs of parents and caregivers is also an important component of the treatment plan. The well-being of an individual with cerebral palsy depends upon the strength and well-being of his or her family. For parents to accept a child’s disabilities and come to grips with the extent of their care giving responsibilities will take time and support from health care professionals. Family-centered programs in hospitals and clinics and community-based organizations usually work together with families to help them make well-informed decisions about the services they need. They also coordinate services to get the most out of treatment.
A good program will encourage the open exchange of information, offer respectful and supportive care, encourage partnerships between parents and the health care professionals they work with, and acknowledge that although medical specialists may be the experts, its parents who know their children best.
