CEREBRAL PALSY

Robert J. Doman Jr.

Reprinted by permission of The NACD Foundation, Volume 1 No. 2, 1980
©NACD

THE PROBLEMS

The first problem faced by the parent of a hurt child is to discover just what it is that their child is, or has.
Whether the child's problem is discovered at birth, or a week, a month, or years after birth, or even if the
problem is created by some trauma such as an automobile accident during the teenage years, the
problem of discovering exactly what has happened is immense for most parents.

Most people are extremely ignorant in regards to hurt children. Their limited information usually comprises
a collection of "old wives tales," and a few details about a child belonging to some distant relative or
neighbor. As traumatic as the discovery that you have a hurt child is, the lack of information intensifies
that trauma all the more.

The family physician who helped you through your last case of the flu, or who correctly diagnosed your
neighbor's heart condition often disappoints you in regards to your hurt child. He frequently cannot even
tell you what is wrong with your child, let alone what to do about it. All too often his suggestion is to
institutionalize the child as soon as possible. Doctors commonly wish that the problem would simply go
away. Either at your doctor's recommendation, or because of our own need for information, you may
search further for answers by going to see a "specialist." The specialist usually takes the form of a
neurologist, neurosurgeon, orthopedist, or a psychiatrist. The visit with the specialist often is an even
more upsetting and frustrating experience than the visit with the family doctor, because the "specialist"
should know.

Why doesn't your doctor know? Why doesn't the specialist know? Quite frankly, they don't know because
almost no one knows! What is known about the brain today is extremely limited, and of what is known,
much of it has just been learned in the last twenty years.

Some diagnoses are relatively easy to make, such as Down Syndrome, with physical signs which can be
seen and chromosome tests which can be used for confirmation. Or to a lesser degree, cerebral palsy,
which is used to describe most children with obvious motor problems. But even with these problems, if
you ask the physician exactly where the problem is, or what is going to happen to the child, the answers
will probably be vague. Unfortunately however, of all the questions asked, the one which is generally
answered with the greatest frequency and confidence is the one about which the least is known. That is,
what is to become of my child, or what is the prognosis (outlook). Every hurt child is different and almost
every hurt child has a chance, if given the opportunity. If every doctor's response to the question of

creeping. within one child you may see many types of cerebral palsy. as opposed to mental. CEREBRAL PALSY Cerebral Palsy is a term applied to a group of individuals whose primary handicap is physical. or the child may exhibit different forms at various times during development. there is within the fields dealing with such children tremendous difference of opinion and controversy over the definitions and applications of specific terms. That is. and to verbalize or talk. In order to simplify the parent's task of acquiring some understanding of the various terms. during. as well as the areas of the body which are affected. and not that it is hopeless. it will be necessary to explore the vague and contradictory terminology applied to children with problems. Cerebral palsy may develop as the result of an injury to the central nervous system before. more hurt children would improve. . A thorough discussion of terms could easily comprise an entire volume in itself. In that a child may possess a variety of symptoms. exhibit problems which affect their ability to gain mobility (crawling. rather they are descriptions of the symptoms. I will endeavor to define each specific term as it relates to the general term of cerebral palsy. dressing). Within each group the level of severity varies. The primary classifications of cerebral palsy according to the location of involvement and in frequency of occurrence are:  Quadriplegia: Involvement of both arms and both legs. Of the many terms used to categorize children with problems. or the control of their muscle function. Except in very severe cases where an obvious injury has occurred (generally around the time of birth) a child may not be diagnosed until six to twenty-four months following birth. I wish only to give the parent some understanding of terms which may be applied to their child. a number of different symptomatic labels may be attached to each child. writing. and as it affects or relates to a child's functional abilities. prognosis is simply that he doesn't know. as it may be this long before the symptoms become obvious. as a group. walking). These children. SYMPTOMATIC DIAGNOSIS In order for the parent to begin to understand the nature of their child's problem. few are attempts to describe the source of the problem. or after birth. many. and some would have the opportunity for "normal" lives. and is outside the scope of this particular text. In addition to the problem of more than one term being applicable to an individual child. This large group is subdivided into lesser groups based primarily upon the specific way in which their muscles. many. is abnormal. There is also a great deal of overlap. to use their hands (eating.

and in order of frequency are: SPASTIC The most common form of cerebral palsy is spastic cerebral palsy. In some cases. If a limb remains in a state of extreme tightening of the flexor muscle. and the fingers flex into a tight fist. curvature of the spine (which results from remaining in an upright position without the necessary development of the trunk muscles which would permit the child to support his spine). the opposing extensor muscles often become stretched and lose some of their functional ability.  Diplegia or Paraplegia: Involvement of both legs. while the spastic adductor muscles (inner thigh) of the legs draw the legs inward until they actually cross each other. many spastic children exhibit abnormal electrical activity in their brains with associated seizure activity. such as nystagmus (vibration of the eyes) or strabismus (lack of convergence the eyes' inability to work together in unison). In addition. usually both legs and one arm. causing a stretching of the extensor for extended periods of time. spastic children also suffer from some loss of mental ability. with the spastic fingers curled over it.  Triplegia: Involvement of three extremities. are also evident. Spastic involvement of the arms results in some degree of tightening of the flexor muscles. Spastic involvement of the legs generally results in some degree of "scissoring. The thumb generally is flexed to such a degree as to draw it against the palm of the hand. When a child with spasticity attempts to move the involved limb. Associated with the spastic child one often finds an exaggerated startle response to stimulation. The backs of the hands tend to come together. or if someone attempts to stretch an involved muscle. and failure to develop normal hip sockets because of his difficulty in achieving normal movement of his legs. so as to pull the elbows in toward the sides of the body." The spastic muscles of the legs tend to limit knee movement. In addition. The author would be remiss if he were not to mention the role of orthopedic surgery in the spastic child. pulling the leg away from the hip socket. the muscle responds with a strong contraction. This motion also tends to rotate the legs inward at the hips. and the hands and wrists toward the chin. particularly for .  Monoplegia: Involvement of only one limb. Hemiplegia: Involvement of one side of the body. In that the muscle flexion is centered in the flexor muscles. the flexor within the calf tends to pull the heel up which pushes the toes down and rotates the foot inward. The classifications of cerebral palsy according to syndrome. inefficient respiration. The term "spasticity" refers to the function of individual muscles within the child's body." in which the function of the limb is almost completely inhibited. Although orthopedic surgery is thought by many to be indicated in some spastic children. Various visual problems. or tightening. a condition develops which is known as a "contracture. the arm and leg on either the right or left side.

per se. drinking. if spastic adductor muscles are cut because they are causing the legs to scissor. when creeping on the hands and knees or walking. For every action. feet turn inward and toes turn up. the abnormal function decreases. will be lost and the legs will tend to spread. and speaking extremely difficult. adding to the overall problem by providing insufficient oxygen to the brain and increasing the chance for respiratory infections. whose progress is often extremely slow and difficult. and that surgery often presents not only a delay to rehabilitative therapy. but a complication often greater than the original problem. and hips. While the knees come together. which can be described as irregular. his efforts toward mobility are further complicated by an extremely poor sense of balance. For example. The athetoid who has gained the ability to walk often resembles the lurching. As with the spastic. bright child. causing the child to have difficulties trying to hold the body up straight. adductors. react in very abnormal fashion. an athetoid's attempts at such movements as the opening and closing of a hand are accompanied by overflow movements involving all the extremities. their later function of holding the legs directly under the body. The athetoid. heel cords. and writhing. TREMOR . when the child reaches the developmental age when the cut muscle should be doing its normal job. cheerful. a delightful. This uncontrolled movement increases with the child's effort to move with his level of excitement or with environmental stimulation. He is generally an extremely happy child. upon stimulation. Characteristically. assumes an "extensor thrust" position which is characterized by the arms being rapidly extended outward and back. that rehabilitation can often correct such problems without surgery. The neck flexes pulling the head back and to the side and the mouth opens and tongue protrudes. With relaxation. the athetoid's body flails rapidly and wildly. ATHETOSIS The athetoid child is one of the most perplexing children there is to work with. with the palms of the hands toward the floor and fingers over extended and spread. and the harder the child tries to correct an activity the more uncontrolled his movements become The abnormal motor function of the athetoid is in the form of excessive movement and uncontrolled movement. balance adjusting movement of someone trying to walk across the deck of a ship being tossed about in a storm. optimistic. hamstrings. With excessive stimulation. respiration is also irregular and shallow. If the orthopedist cuts a spastic muscle because it is producing an abnormal pull. that developmental movement of the limb will be lost or will be very abnormal. In addition to the athetoid's movement. although a bit hyper (increased) in tone. and with sleep. The athetoid child's muscles. disappears. there is a reaction. it is becoming less popular due to the understanding that the spastic child's problem is his brain and not his muscles. The involvement of the athetoid's mouth and throat make the activities of eating. unpredictable.

or most often. They are difficult to treat and must be differentiated from conditions of the muscle such as some forms of muscular dystrophy. Ataxia is a condition characterized by loss of balance and poor coordination. CAUSE Children diagnosed as having cerebral palsy are children who have brain injury. FLACCIDITY. with greater power being exerted by the extensors. RIGIDITY Rigidity is generally associated with severity of involvement. Such children have difficulty gauging the amount of movement they are making with an extremity and may miss their intended amount of movement by overextending or underextending the part. this child is affected by an almost wave-like shaking that results from an alternate contraction of flexor and extensor muscles. trauma. Various associated complications are generally seen with these children ranging from severe respiratory problems to diminished vision and hearing. metabolic disturbance. is hampered by involuntary movement as is the athetoid. Injuries to their brains that have occurred before. The child with rigidity such that permits some controlled movement of an extremity has the further complication of involuntary movement of the opposite extremity (movement of the right arm results in a similar movement of the left). Rh incompatibility. as well as seizure disorder. impossible. resulting in a general lack of movement as opposed to inappropriate or involuntary movement. but of a different nature. resulting in an arched position with the back stiff and head and feet at the extremes of the arch. during. ATONIA. dangerous. ATAXIA Flaccidity and Atonia are fortunately relatively rare. hemorrhage. The child with rigidity is characterized by simultaneous and continuous contraction of both extensors and flexors. or anoxia (lack of . or after birth. but because the balance factors are inadequate. malnutrition. The location and size of injury determines the degree to which the injury produces dysorganization. so that the greater force which the child can exert. The tremor in such involved children is greatest in fine rather than gross activity. The direct cause of the dysfunction is the dysorganization of the brain which is itself caused by the brain injury. Such a child may have normal muscle strength and tone. The child with the form of cerebral palsy known as tremor. attempts at walking are difficult. Injury to the brain may result from a variety of causes. The injury to the brain indirectly is the cause of the lack of function within the children. the lesser the influence of the tremor. The limbs of the child with rigidity are virtually locked in full or over-extension. Prenatal injuries may be caused by maternal infections. As the name implies.

The location of the injury determines the form of the dysorganization.the brain! . Children with brain injury and resulting loss of motor function often go undiagnosed until many months following birth. or anoxia. The more connections between the brain cell bodies. and which either eliminate the possibility of a progressive disorder or indicate a course of medical treatment or intervention. the higher the level of function. TREATMENT All cerebral palsied children are brain injured. Symptomatic treatment attempts to lessen the symptoms. injury to the brain can be caused by infections. The problem with a rigid leg is a problem with the brain. all brain injured children are not cerebral palsied. the particular loss of function. a diagnosis based upon neurological studies which locate the injury. not reach the cause. mechanical injury. The injury to the brain which results in the symptoms which lead to a label of cerebral palsy is associated with injury to the motor centers of the brain. The problem with a spastic arm is a problem with the brain. A diagnosis of cerebral palsy is a symptomatic diagnosis which indicates brain injury. The cause of the dysorganization to the brain is not. Often the exact time or even cause of the injury is unknown. oxygen). Neither are injured cells repaired. however. With the child labeled as being cerebral palsied. STARTING POINT The time and cause of the injury to the brain are of limited significance. they represent the major causes. hemorrhage. or problems associated with pre or post mature deliveries. Following birth. however. Injuries caused during the birth process include anoxia. Brain cells that have died are not replaced. Although those causes listed are but some of the possible causes of an injury to the child's brain. treatment is directed toward organizing the brain (stimulating the growth of brain connections) . toxic substances. and thus. it is best if the family does not pursue the issue if the specifics are not readily available. trauma. and in that the time or cause has very little influence upon treatment. as with every other child lacking function because of neurological dysorganization. the problem often does not manifest itself until the child is functioning at the level of the injury. The more efficient the system. a child with a mid-brain injury would not necessarily have abnormal function until such time as he has developmentally reached that level. Through stimulation new connections grow between the healthy cells permitting those healthy parts of the brain to carry out the function of the injured or dead cells. Symptomatic treatment aimed solely at the limbs does not treat the cause of the problem . the more efficient the system. A working diagnosis however. Cerebral palsy is a symptomatic diagnosis which does not identify the problem. For example. Although the injury occurred at the time of birth. is indicated.

Reprinted from the Journal of The NACD Foundation (formerly The National Academy for Child Development http://www. and research.org/journal/cerebralpalsy. Not per week. requires the family's involvement. you can't give it to anyone else.as well as the answer lies within the BRAIN. Viewed as incurable. The problem . These children are generally treated symptomatically. neither can you get a "shot" that will make it go away.php . PROGNOSIS The outlook for brain-injured children with a symptomatic diagnosis is not good. virtually all of these children can improve. programming. The NACD Foundation is fortunate in being able to assist families of brain injured children in their efforts to help their children achieve their potential through individual evaluations.nacd. because of it's very intensity. and duration of appropriate stimuli. intensity. children with this fictitious disease have failed. Stimulation which treats the cause. But because historically. and some can achieve "normal" function." But given the opportunity (an hour of therapy twice a week is NOT an opportunity). You can't catch it. parent education. as a result of inappropriate treatment. Treatment which. per day! Hours of specific stimulation. There are very few "miracles. If you have it. Neurological organization is an ongoing process which can be accelerated by increasing the frequency. this fictitious disease is now viewed as an incurable disease. There is no such disease as cerebral palsy. Many hours per day are needed. Appropriate stimuli causes the growth of connections and a corresponding increase in function. not the symptom. these children have failed to show significant improvement. Historically. Opportunity for these children involves intensive treatment. Improvement in children with motor problems is often slow and difficult. these unfortunate children are often denied a real opportunity to improve.