Cerebral palsy (CP) is a childhood condition in which there is a motor disability (palsy) caused by a static, nonprogressive lesion or injury of the immaturein the brain (cerebral). The causative event has to occur in early childhood, usually defined as lessthan 2 years of age. Children with CP have a condition that is stable and nonprogressive; therefore, they are in most ways normal children with special need.(miller)
EPIDEMIOLOGY AND ETIOLOGY
Cerebral palsy is the leading cause of childhood disability. The reported incidence varies but is approximately 2-3 per 1000 live births. Nelson and Ellenberg found a prevalence rate of 5.2 per 1000 neonatal survivors at 12 months of age but reported resolution in up to half of these children by age 7 years. More recent studies report an overall prevalence rate of 1.5-2.0 per 1000 live births.1
As noted previously, there are many causes of CP may occur during the prenatal, perinatal, or postnatal period, and knowing the exact etiology is not very important for a physician managing the motor impairments. The etiology may be important when considering whether a child is following an expected course of maturation and development. Also, parents find the etiology important because it is part of coming to terms with the larger question of why the CP happened. Many etiologies can be separated into a time period as to when these insults occurred. MilleR and molnar
CLASSIFICATION AND PROGNOSES MOTOR DISORDER
Prognosis of movement abilities can be made in the second to third year of life and is strongly related to the kind and localization of the motor disorder and the mental status of the child. There are three main types of motor syndromes: spastic paresis, ataxic paresis, and dyskinetic paresis.
Spastic paresis is characterized by a posture and movement dependent tone regulation disorder. The clinical symptoms are the loss or absence of tone in lying, and increase in tone in sitting, standing, walking, or running, depending on the degree of involvement. Spastic paresis is the most common motor disorder (83%).
In patients with ataxic paresis, impairments of equilibrium and coordination are dominant. There are hypermetric movements in the extremities, and tremor and titubations can be present. Only 4% of children with CP have a mainly ataxic paresis, often with some signs of spasticity in the legs. The time course of obtaining walking ability is delayed in comparison with spastic paresis, but most children achieve walking ability, at least with a walking aid.
Dyskinetic paresis can be divided into the hyperkinetic (athetoid) type, characterized by involuntary movements, most pronounced in the face and extremities, which are present even at rest, and the dystonic type, characterized by slow powerful contractions of agonist and antagonist of movement simultaneous, locally or with total body involvement. In time, a hyperkinetic type of movement can change into a dystonic type, and combinations are also possible. The development of head and trunk balance is delayed. Some children achieve walking ability even at the age of 10 years. Dyskinetic paresis is seen in 12% of children with CP.
For the proper treatment of children with CP, the classification of the kind of motor disorder is crucial. The surgical and orthotic management in children with dyskinetic or ataxic paresis is completely different from that of children with spastic paresis. Because the spastic paresis is the most common motor syndrome, this article will focus on that motor disorder linked by orthosis prescription.
The motor disorder can also be classified in regard to the localization: hemiplegia is defined as a unilateral involvement (33%); diplegia as a bilateral involvement, in which only the lower extremities are involved or the lower extremities are more involved than the upper extremities (44%); quadriplegia (or tetraplegia) is defined as a bilateral involvement, in which the upper extremities are equal or more involved than the lower extremities (6%). This classification is unambiguous and easy to use in clinical practice. [Classifications using the presence of muscle impairment of the upper extremities (paraparesis if no involvement of the upper extremities, diplegia with involvement of the upper extremities) or bulbar involvement (diplegia without bulbar involvement, quadriplegia with bulbar involvement) can cause confusion. These signs can be present only slightly, so it is difficult in clinical practice to set limits for the classification paraparesis, diplegia, and quadriplegia.] According to this classification, the functional prognosis of independent walking ability (with or without walking aids) can be set: 100% of the hemiplegic children, 85% of the diplegic children, based on the ability to put weight on the hands while prone at 18 months and a short sit at the age of 24 months, and none of the quadriplegic children will achieve independent walking ability in adulthood. The Gross Motor Function Classification System (GMFCS) is an instrument for early classification the severity of the motor disorder.
The mainstay of treatment of spasticity is through the application of modalities. Primarily, this has been through therapeutic exercise. Regular and daily range of motion can help prevent or delay contractures and can reduce the severity of increased muscle tone for several hours. Therapeutic exercise includes a variety of treatment techniques that are used to decrease or inhibit tone. Casting and splinting can improve range of motion. Casting for 2 or 3 weeks can decrease tone and improve range of motion for 3 to 4 months.
Response of the drugs is often unpredictable, and occasionally the side effects preclude long-term use. The most commonly used antispasticity medications are benzodiapines, dantrolene, baclofen, clonidine. Spasticity has also been treated with phenol intramuscular neurolysis and botulinum A toxin (Botox) intramuscular blocks, which reduce spasticity for 3 to 6 months. Several neurosurgical procedures have been recommended for tone management.
Orthoses are prescribed to provide support, limit motion, improve function, and delay or prevent deformity. The specific goals are to prevent contracture, provide optimal joint alignment, provide selective motion, protect weak muscles, control abnormal tone and related deviations, enhance function, and protect tissues postoperatively.
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