Infantile cerebral palsy (ICP)

The disease is caused by injury to separate areas of the brain in acute and/or chronic effect of damaging factors on the central nervous system of a child during pregnancy, right around the time of birth or very early in life. “Cerebral” means the disorder is related to the brain, and “palsy” refers to a muscle problem or weakness.

It is important to understand that various muscular groups can be affected. The disease can vary in level of severity. The condition causes different types of motor disability, which can vary from clumsy walking to complete lack of movement. About one to three children out of every one thousand have cerebral palsy.

According ti infantile cerebral palsy classification developed by K. A. Semyonova in 1973, and International classification of diseases, edition X, 5 basic forms of ICP are as follows:

1. Spastic diplegia involves muscles of the upper and lower extremities of the human body, usually those of the legs. A child has trouble walking of various intensity. Those with spastic diplegia have variable involvement of upper extremity, from clumsy movement to severe movement restriction. A neurologist can find the first clinical signs at the age of 4–6 months as non-disappearance of neonatal reflexes and growth of muscle tone. Speech disturbances are seen in 80 % of cases as dysarthria (a motor speech disorder resulting from neurological injury of the motor component of the motor-speech system), dyslalia (difficulties in talking in normal hearing and preserved innervation of the speech system), etc. Intellectual impairment is observed in 30–50 % of cases. In timely and regular treatment, up to 20–25 % of children can walk and up to 40–50 % may use a walker and other forms of mobility assistance.

2. Hemiplegia is a condition that affects one side of the body. Depending on the intensity, clinical signs become evident when a child is some weeks or one year old. As a rule, parents notice an impact on child’s performance in upper limb activities, or by the age of one when a child starts dragging a leg while walking. Timely treatment makes favorable prognosis. Children walk more frequently whereas disability depends on movement restriction in the hand. Speech disturbances are found in 40 % of patients, impaired cognitive activity in 40 % of patients and cramps in 30 % of patients. This is the most favorable form when the child’s development can be predicted.

3. Double hemiplegia (tetraparesis) is the most severe form of cerebral palsy. Its clinical signs can be observed during the infancy. All limbs are affected. However, hands are damaged more severely as compared to legs. Intellectual impairment is found more than in 90 % of children, up to 50–75 % of children suffer from microcephalia, and 40 % of children have various damages of cranial nerves such as atrophy of the optic nerves and hearing disorder. These kids often have difficulty swallowing or chewing. It results in choking when taking food and increases the risk for chronic aspiration pneumonia (inflammation in the lungs caused by inhaling food) which is the most severe complication often leading to a child’s death. In spite of treatment, the children can rarely sit or stand. Even if the dynamics of motor development is positive, it is difficult for a child to socialize due to severe intellectual disturbances.

4. Hyperkinetic form of cerebral palsy is characterized by various involuntary movements in the hands, legs, face, and body, preventing from good posture and finely coordinated limb movement. Abnormal movements arise when the child is almost one year old. The movements can be both slow and abrupt. Up to 75 % of children can walk only when they are 5–6 years old. Up to 40–50 % of children have impaired hearing, increased salivation, difficult swallowing and articulation though impaired intelligence is rare. In hyperkinetic forms of cerebral palsy, the prognosis for development and social adaptation is favorable. Many children can study at schools and universities and work within their specialty.

5. Ataxic cerebral palsy affects coordinated movements. Balance and posture are involved. General muscle weakness (floppy infant) is observed. Some kids can walk though start doing it rather late. Walking gait is very wide and sometimes irregular. High rate of intellectual impairment and speech disorders (up to 90 % of cases) makes social adaptation of these children difficult. Ataxic cerebral palsy is believed to be attributed to many poorly diagnosed inherited diseases and syndromes.

6. Mixed cerebral palsy shares commonalities with two or more other recognized forms of cerebral palsy in a child. The prognosis depends on the intensity of motor, mental disorders and timely given treatment.
Symptoms of cerebral palsy and their intensity can vary during life though the substrate of brain damage is almost unchanged.
ICP is not a hereditary condition. It is not inherited genetically. However, risk factors that increase the chances of a child developing cerebral palsy can be inherited (for instance, familial coagulation failure resulting in risks in pregnancy).

Orthopedic conditions of ICP are developed when a child is growing and progress when the load to the skeleton is increasing. Disturbed muscle coordination, spasticity in paretic muscles, disturbed normal blood circulation in the affected muscles result in the growth failure of the affected limbs, development of abnormal posture and further skeletal deformities in a growing child. Spinal curvature, dislocation of the hips, joint contractures are typical problems of patients with cerebral palsy. Skeletal and joint deformities are often accompanied by pains making the motor activity impossible. It is desirable to prevent orthopedic complications using physical therapy, orthopedic aids, physiotherapy, massages, physical loads and orthotics (restoration of the form and functions of the affected segments using special technical aids such as orthesis). Developed skeletal malformations can be removed only surgically. The locomotor apparatus dynamics in a growing patient is controlled using an annual X-ray control of joints, predominantly hip joints, as they are more prone to dislocations and dystrophic processes. In the presence of secondary skeletal deformities, the program of rehabilitation treatment is reviewed considering the existing pathology. Thus, load on joints is restricted in case of dysplasia or dystrophic changes whereas load on bones is restricted in case of osteoporosis.

Equinus foot position is the most frequent abnormality of the lower limbs. Equinus foot position is an excessive plantar flexion due to flexor hypertension which may result in a contracture (a condition when a limb can’t be completely flexed or unflexed in one or several joints). According to statistical data, some spastic forms of various intensity are met in 85.5 % of patients with ICP. Approaches to treatment of spasticity in ICP depend on what muscular groups or body segments are affected by spasticity and on its intensity.

In case of contractures and locomotor deformities, orthopedic surgery is used. The treatment is aimed at removal of the occurred deformities and restoring a range of motions in the joints. However, contracture will soon recur if no adequate physical management of the static and hyperkinetic syndromes is provided.

We can’t remove the existing injury to the nervous system. However, aid can still be provided to the sick baby. An infant’s brain is able to compensate the acquired damage. But for this, it is extremely important to make a diagnosis right during this period. Under proper conditions, the function of damaged cells is undertaken by healthy cells. A child’s brain possesses plasticity. In case of adequate rehabilitation, even children with severe diseases can display good or sometimes astonishing results.

• Robotic mechanotherapy: locomotor therapy (Locomat), suits (Atlas, Phaethon, Adele, etc.)

• Physiotherapy: electric therapy, magnetotherapy, laser therapy, light therapy, heat and hydrotherapeutic procedures, health resort treatment

• Acupuncture, supporting simulation

• Occupational therapy develops skills necessary in everyday life (dressing, hygienic procedures, etc.)

• Speech therapy eliminates problems associated with swallowing and speech problems

• Orthopedic supplies (braces, splints) to prevent formation of pathologic postures and contractures

• Selection of mechanical aids (wheel chairs, walkers)

• Neurotrophic therapy with peptide drugs to mobilize the internal resources of a child

• Symptomatic drug therapy to normalize muscle tone, treatment of epilepsy, management of behavioral disturbances

• Surgeries: to manage deformities in the joints, bones and ligaments

• Neurosurgeries to eliminate spasticity

All children, even children with a similar form of ICP, are different as related to motor skills, mental development and adaptive capabilities. For instance, some children require a wheel chair to move, whereas others are only slightly instable while walking. Thus, it is necessary to develop an individual-tailored rehabilitation treatment which is the best for your child.

Your child must be seen by a team of doctors (neurologist, orthopedist, physical therapist, physiotherapist, speech therapist, psychologist). If a child suffers from epilepsy or epileptic EEG, an epileptologist must participate in the program development.

Movement therapy (kinesiotherapy) means adapted and slowly increasing force actions developed for every patient considering his/her case history, age-related, physiological and other peculiarities and other concurrent diseases. Slow learning correct (simple and complex) movements promotes their consolidation at the neuroreflectory level and restoration of trophism (nutrition) and metabolism in the musculoskeletal system. Kinesiotherapy can be active (exercise therapy, position treatment, game therapy, labor therapy, art therapy, sports when a patient moves in his own) and passive (massage and mechanical treatment i.e. treatment using physical exercises and special appliances).

Vojta method is used when an instructor presses on certain points of a patient’s body when the patient occupies a certain position activating certain muscles engaged in movement. Vojta treatment can be used in infants. It is most effective during the first year of life. It is not contraindicated in children with epilepsy.

Bobath therapy is based on the neurodevelopment approach to management of motor disturbances. Bobath therapy suppresses abnormal movements and postures; facilitates natural and physiological movements and maintains posture; ensures stimulation necessary to better sense one’s body position through space.

Kozyavkin method rests upon the manual correction of the spinal column aimed at the restoration of normal mobility of vertebral joints. Specialized methods of muscle relaxation are used simultaneously to that. Biomechanical correction of the spine and large joints is used in combination with reflex therapy, exercise therapy, massage, rhythmic gymnastics and mechanotherapy.

The method of dynamic proprioceptive correction by Professor K. A. Semyonova The method is based on the combined position therapy and active kinesiotherapy using therapeutic suits. Adele and Graviton suits are represented by a system of elastic retainers facilitating correct movements and inhibiting incorrect ones. More modern Phaeton suits act like frames using compressed air which is filled in according to every patients’ needs.

Korvit Plantar Pressure Simulator is based on the method of proprioceptive stimulation. The Korvit system consists of a pair of plastic boots connected to the power supply and pulse mode generator. The plantar surface of a patient’s foot undergoes mechanical stimulation. The principles of walking and running are simulated.

Position treatment is a passive fixation of a patient’s body parts in positions that are close to physiological ones using special tools such as positioning, pillows, splints, braces, plaster splints, tapes, orthopedic footwear. Passive fixation of a body part is preceded by massage using relaxing techniques.

To achieve a global change in posture of a patient with severe muscular weakness, a special equipment is used such as standing frames, Gross simulator, Spider simulator. They are used to preserve a vertical or suspended position with a decreased load to the locomotor system when the support, step motions, coordination, etc. are trained with an instructor’s help.

Mechanotherapy Nowadays, the major part of equipment for mechanotherapy is functioning on the basis of the principle of neurofeedback. A patient uses some (active) simulators to make movements by applying physical efforts. The load degree is determined by a number of factors such as mass of the weight attached, bar position of the weight, angle at which the pendulum is suspended, frequency of oscillations and exercise duration (MOTOmed multifunctional training system, KOBS multifunctional platform, Nirvana virtual reality interactive system). Other (passive) simulators use a motor aid for movement. This aid decreases physical load on a patient (PowerPlate vibroplatform, Locomat rehabilitation complex for locomotor load).

It should be noted that a mechanotherapeutic device is not capable of exact reproduction of a wide variety of human motor functions no matter how perfect the device is. Device-based exercises are strictly normalized. They are accomplished following a prescheduled scheme with a definite speed, amplitude and load. Thus, mechanotherapy is always auxiliary to exercise therapy which is initially characterized by a greater freedom of choosing between the rate, form and direction of movements. However, when combined with mechanotherapy, exercise therapy is more effective as compared with exercise regime alone.

Choosing an individual rehabilitation program, it is necessary to remember that the principal aim of restorative treatment of a child with cerebral palsy consists in adequate social adaptation when not only the motor function, but also communicative skills are developed, a child is integrated into society, gets education and profession. That’s why restorative activities of a patient with ICP must include methods of social and pedagogical rehabilitation.

• Occupational therapy develops skills necessary in everyday life (unassisted dressing, hygienic procedures, etc.)

• Speech therapy eliminates problems associated with swallowing and speech problems

• Ergotherapy is a selection of rehabilitation equipment (wheel chairs, walkers, canes)

• Art therapy and sports rehabilitation keep motivated in treatment and social integration

Conductive pedagogics (Peto method) is predominantly based on educational model of intervention and combines both pedagogical and rehabilitation purposes within the same program. This concept assists children with motor disturbances in acquiring the ability to function in the society compensating for motor deficiency with plasticity in the central nervous system.

Equine therapy, canis therapy, dolphin therapy. Animals participate in the rehabilitation of children with cerebral palsy. The method is a combination of movement therapy and positive emotions.

O. V. Bykova

Doctor of Med. Sc., Principal Researcher of the Centre for Applied Research in Pediatric Psychoneurology

of Moscow Health Department