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Cerebral palsy doesn't always cause profound disabilities.
While one child with severe cerebral palsy might be unable to walk
and need extensive, lifelong care, another with mild cerebral palsy
might be only slightly awkward and require no special assistance.
Supportive treatments, medications, and surgery can help many
individuals improve their motor skills and ability to communicate
with the world.
There is no cure, but various forms of therapy
can help a person with the disorder to function and live more
effectively. 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. The
earliest proven intervention occurs during the infant's recovery in
the
neonatal intensive care unit
(NICU). Treatment may include one or more of the following:
physical therapy; occupational therapy; speech therapy; drugs to
control seizures, alleviate pain, or relax muscle spasms (e.g.
benzodiazepienes, baclofen and intrathecal phenol/baclofen);
hyperbaric oxygen; the use of
Botox
to relax contracting muscles; surgery to correct anatomical
abnormalities or release tight muscles; braces and other orthotic
devices; rolling walkers; and communication aids such as computers
with attached voice synthesizers. For instance, the use of a
standing frame can help reduce spasticity and improve
range of motion for people with CP who use wheelchairs.
Nevertheless, there is only some benefit from therapy. Treatment is
usually symptomatic and focuses on helping the person to develop as
many motor skills as possible or to learn how to compensate for the
lack of them. Non-speaking people with CP are often successful
availing themselves of
augmentative and alternative communication systems such as
Blissymbols.
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Interpersonal therapy
Physiotherapy programs are designed to encourage the patient to
build a strength base for improved gait and volitional movement,
together with stretching programs to limit contractures. Many
experts believe that life-long physiotherapy is crucial to maintain
muscle tone, bone structure, and prevent dislocation of the joints.
Occupational therapy helps adults and children maximise their
function, adapt to their limitations and live as independently as
possible
Speech therapy helps control the muscles of the mouth and jaw,
and helps improve communication. Just as CP can affect the way a
person moves their arms and legs, it can also affect the way they
move their mouth, face and head. This can make it hard for the
person to breathe; talk clearly; and bite, chew and swallow food.
Speech therapy often starts before a child begins school and
continues throughout the school years
Conductive education was developed in Hungary from 1945 based on
the work of
András Pető. It is a unified system of rehabilitation for people
with neurological disorders including cerebral palsy, Parkinson's
disease and multiple sclerosis, amongst other conditions. It is
theorised to improve mobility, self-esteem, stamina and independence
as well as daily living skills and social skills. The conductor is
the professional who delivers CE in partnership with parents and
children. Skills learned during CE should be applied
to everyday life and can help to
develop age-appropriate cognitive, social and emotional skills. It
is available at specialized centers.
Biofeedback is an
alternative therapy in which people with CP learn how to control
their affected muscles. Some people learn ways to reduce muscle
tension with this technique. Biofeedback does not help everyone with
CP.
Neuro-cognitive therapy It is based upon two
proven principles. (1) Neural Plasticity. The brain is capable of
altering its own structure and functioning to meet the demands of
any particular environment. Consequently if the child is provided
with an appropriate neurological environment, he will have the best
chance of making progress. (2) Learning can lead to development. As
early as the early 1900s, this was being proven by a psychologist
named
Lev Vygotsky. He proposed that children's learning is a social
activity, which is achieved by interaction with more skilled members
of society. There are many studies which provide evidence for this
claim. There are however, as yet no controlled studies on
neuro-cognitive therapy.
alternative therapy for people
with CP. The method is promoted by
The Institutes for the Achievement of Human Potential (IAHP), a
Philadelphia nonprofit, but has been criticized by the
American Academy of Pediatrics.[25]
The IAHP's methods have been endorsed by
Linus Pauling,[26]
as well as some parents of children treated with their methods
Massage therapy[30]
is designed to help relax tense muscles, strengthen muscles, and
keep joints flexible. More research is needed to determine the
health benefits of these therapies for people with CP.
Threshold electrical stimulation, which involves the
application of electrical stimulation at an intensity too low to
stimulate muscle contraction, is a controversial therapy.
Studies have not been able to demonstrate its effectiveness or any
significant improvement with its use.
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Surgery
Orthopedic surgery is often recommended when spasticity and
stiffness are severe enough to make walking and moving about
difficult or painful. For many people with cerebral palsy,
improving the appearance of how they walk - their gait - is also
important. A more upright gait with smoother transitions and
foot placements is the primary goal for many children and young
adults.
In the operating room, surgeons can lengthen muscles and
tendons that are proportionately too short. But first, they
have to determine the specific muscles responsible for the gait
abnormalities. Finding these muscles can be difficult.
It takes more than 30 major muscles working at the right time using
the right amount of force to walk two strides with a normal gait. A
problem with any of muscles can cause an abnormal gait.
In addition, because the body makes natural adjustments to
compensate for muscle imbalances, these adjustments could appear to
be the problem, instead of a compensation. In the past,
doctors relied on clinical examination, observation of the gait, and
the measurement of motion and spasticity to determine the muscles
involved. Now, doctors have a diagnostic technique known as
gait analysis.
Gait analysis uses cameras that record how an individual
walks, force plates that detect when and where feet touch the
ground, a special recording technique that detects muscle activity
(known as electromyography), and a computer program that gathers and
analyzes the data to identify the problem muscles. Using gait
analysis, doctors can precisely locate which muscles would benefit
from surgery and how much improvement in gait can be expected.
The timing of orthopedic surgery has also changed in recent
years. Previously, orthopedic surgeons preferred to perform
all of the necessary surgeries a child needed at the same time,
usually between the ages of 7 and 10. Because of the length of
time spent in recovery, which was generally several months, doing
them all at once shortened the amount of time a child spent in bed.
Now most of the surgical procedures can be done on an outpatient
basis or with a short inpatient stay. Children usually return
to their normal lifestyle within a week.
Consequently, doctors think it is much better to stagger
surgeries and perform them at times appropriate to a child's age and
level of motor development. For example, spasticity in the
upper leg muscles (the adductors), which causes a "scissor pattern"
walk, is a major obstacle to normal gait. The optimal age to
correct this spasticity with adduction release surgery is 2 to 4
years of age. On the other hand, the best time to perform
surgery to lengthen the hamstrings or Achilles tendon is 7 to 8
years of age. If adduction release surgery is delayed so that
it can be performed at the same time as hamstring lengthening, the
child will have learned to compensate for spasticity in the
adductors. By the time the hamstring surgery is performed, the
child's abnormal gait pattern could be so ingrained that it might
not be easily corrected.
With shorter recovery times and new, less invasive surgical
techniques, doctors can schedule surgeries at times that take
advantage of a child's age and developmental abilities for the best
possible result.
Selective dorsal rhizotomy (SDR) is a surgical procedure
recommended only for cases of severe spasticity when all of the more
conservative treatments - physical therapy, oral medications, and
intrathecal baclofen -- have failed to reduce spasticity or chronic
pain. In the procedure, a surgeon locates and selectively
severs overactivated nerves at the base of the spinal column.
Because it reduces the amount of stimulation that reaches
muscles via the nerves, SDR is most commonly used to relax muscles
and decrease chronic pain in one or both of the lower or upper
limbs. It is also sometimes used to correct an overactive
bladder. Potential side effects include sensory loss,
numbness, or uncomfortable sensations in limb areas once supplied by
the severed nerve.
Even though the use of microsurgery techniques has refined
the practice of SDR surgery, there is still controversy about how
selective SDR actually is. Some doctors have concerns since it
is invasive and irreversible and may only achieve small improvements
in function. Although recent research has shown that combining
SDR with physical therapy reduces spasticity in some children,
particularly those with spastic diplegia, whether or not it improves
gait or function has still not been proven. Ongoing research
continues to look at this surgery's effectiveness.
Spinal cord stimulation was developed in the 1980s to treat
spinal cord injury and other neurological conditions involving motor
neurons. An implanted electrode selectively stimulates nerves
at the base of the spinal cord to inhibit and decrease nerve
activity. The effectiveness of spinal cord stimulation
for the treatment of cerebral palsy has yet to be proven in clinical
studies. It is considered a treatment alternative only when
other conservative or surgical treatments have been unsuccessful at
relaxing muscles or relieving pain.
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Other
Cooling high-risk full-term babies shortly after
birth may significantly reduce disability or death.[40]
Early nutritional support: In one
cohort study of 490
premature infants discharged from the NICU, the rate of growth
during hospital stay was related to neurological function at 18 and
22 months of age. The study found a
significant decrease in the
incidence of cerebral palsy in the group of premature infants
with the highest growth velocity. This study suggests that adequate
nutrition and growth play a protective role in the development of
cerebral palsy.[41]
Hyperbaric oxygen therapy (HBOT), in which pressurized
oxygen
is inhaled inside a
hyperbaric chamber, has been studied under the theory that
improving oxygen availability to damaged brain cells can reactivate
some of them to function normally. A 2007
systematic review concluded that the effect of HBOT is no
different from that of pressurized room air, and that some children
undergoing HBOT will experience
adverse events such as seizures and the need for ear pressure
equalization tubes; due to poor quality of data assessment the
review also concluded that estimates of the prevalence of adverse
events are uncertain
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Medication
Oral medications such as diazepam, baclofen, dantrolene
sodium, and tizanidine are usually used as the first line of
treatment to relax stiff, contracted, or overactive muscles.
These drugs are easy to use, except that dosages high enough to be
effective often have side effects, among them drowsiness, upset
stomach, high blood pressure, and possible liver damage with
long-term use. Oral medications are most appropriate for
children who need only mild reduction in muscle tone or who have
widespread spasticity.
Doctors also sometimes use alcohol "washes" -- injections
of alcohol into muscles -- to reduce spasticity. The
benefits last from a few months to 2 years or more, but the adverse
effects include a significant risk of pain or numbness, and the
procedure requires a high degree of skill to target the nerve.
The availability of new and more precise methods to deliver
antispasmodic medications is moving treatment for spasticity toward
chemodenervation, in which injected drugs are used to target and
relax muscles
Botulinum toxin (BT-A), injected locally, has become a
standard treatment for overactive muscles in children with spastic
movement disorders such as cerebral palsy. BT-A relaxes
contracted muscles by keeping nerve cells from over-activating
muscle. Although BT-A is not approved by the Food and Drug
Administration (FDA) for treating cerebral palsy, since the 1990s
doctors have been using it off-label to relax spastic muscles.
A number of studies have shown that it reduces spasticity and
increases the range of motion of the muscles it targets. The
relaxing effect of a BT-A injection lasts approximately 3 months.
Undesirable side effects are mild and short-lived, consisting of
pain upon injection and occasionally mild flu-like symptoms.
BT-A injections are most effective when followed by a stretching
program including physical therapy and splinting.
BT-A injections work best for children who have some control over
their motor movements and have a limited number of muscles to treat,
none of which is fixed or rigid.
Because BT-A does not have FDA approval to treat spasticity
in children, parents and caregivers should make sure that the doctor
giving the injection is trained in the procedure and has experience
using it in children
Intrathecal baclofen therapy uses an implantable pump to
deliver baclofen, a muscle relaxant, into the fluid surrounding the
spinal cord. Baclofen works by decreasing the excitability of
nerve cells in the spinal cord, which then reduces muscle spasticity
throughout the body. Because it is delivered directly into the
nervous system, the intrathecal dose of baclofen can be as low as
one one-hundredth of the oral dose. Studies have shown it
reduces spasticity and pain and improves sleep.
The pump is the size of a hockey puck and is implanted in
the abdomen. It contains a refillable reservoir connected to
an alarm that beeps when the reservoir is low. The pump is
programmable with an electronic telemetry wand. The program
can be adjusted if muscle tone is worse at certain times of the day
or night.
The baclofen pump carries a small but significant risk of
serious complications if it fails or is programmed incorrectly, if
the catheter becomes twisted or kinked, or if the insertion site
becomes infected. Undesirable, but infrequent, side effects
include overrelaxation of the muscles, sleepiness, headache, nausea,
vomiting, dizziness, and constipation.
As a muscle-relaxing therapy, the baclofen pump is most
appropriate for individuals with chronic, severe stiffness or
uncontrolled muscle movement throughout the body. Doctors have
successfully implanted the pump in children as young as 3 years of
age.
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Are There Treatments for Other Conditions Associated with
Cerebral Palsy?
Epilepsy. Twenty to 40 percent of children with
mental retardation and cerebral palsy also have epilepsy.
Doctors usually prescribe medications to control seizures. The
classic medications for this purpose are phenobarbital, phenytoin,
carbamazepine, and valproate. Although these drugs generally
are effective in controlling seizures, their use is hampered by
harmful or unpleasant side effects.
Treatment for epilepsy has advanced significantly with the
development of new medications that have fewer side effects.
These drugs include felbamate, gabapentin, lamotrigine,
levetiracetam, oxcarbazepine, tiagabine, topiramate, vigabatrin, and
zonisamide.
In general, drugs are prescribed based on the type of
seizures an individual experiences, since no one drug controls all
types. Some individuals may need a combination of two or more drugs
to achieve good seizure control.
Incontinence. Medical treatments for incontinence
include special exercises, biofeedback, prescription drugs, surgery,
or surgically implanted devices to replace or aid muscles. Specially
designed absorbent undergarments can also be used to protect against
accidental leaks.
Osteopenia. Children with cerebral palsy who aren't
able to walk risk developing poor bone density (osteopenia), which
makes them more likely to break bones. In a study of older
Americans funded by the National Institutes of Health (NIH), a
family of drugs called bisphosphonates, which was recently approved
by the FDA to treat mineral loss in elderly patients, also appeared
to increase bone mineral density. Doctors may choose to
selectively prescribe the drug off-label to children to prevent
osteopenia.
Pain. Pain can be a problem for people with
cerebral palsy due to spastic muscles and the stress and strain on
parts of the body that are compensating for muscle abnormalities.
Some individuals may also have frequent and irregular muscle spasms
that can't be predicted or medicated in advance.
Doctors often prescribe diazepam to reduce the pain
associated with muscle spasms, but it's not known exactly how the
drug works to interfere with pain signals. The drug gabapentin
has been used successfully to decrease the severity and frequency of
painful spasms. BT-A injections have also been shown to
decrease spasticity and pain, and are commonly given under
anesthesia to avoid the pain associated with the injections.
Intrathecal baclofen has shown good results in reducing pain, but
its delivery is invasive, time intensive, and expensive.
Some children and adults have been able to decrease pain by
using noninvasive and drug-free interventions such as distraction,
relaxation training, biofeedback, and therapeutic massage finance
researchers
Source
http://www.ninds.nih.gov/disorders/cerebral_palsy/detail_cerebral_palsy.htm
Brand-new treatment for children with cerebral palsy
How to Treat Cerebral Palsy
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