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It is often not possible for medical professionals to give a reason why part of a baby’s brain has been injured or failed to develop.
Some possible causes are : The mother of the baby had an infection in the early part of the pregnancy.
The baby had a difficult to a premature birth, maybe they were unable to breathe properly.
There could have been some bleeding within the baby’s brain or perhaps, and this is very rare, the baby has a genetic disorder.
Cerebral Palsy ‘jumbles’ the messages between the brain and the muscles.
There are four type of cerebral palsy, depending on which messages are affected, called spastic, athetoid, ataxic and hypotonic. Many people with cerebral palsy have a combination of two or more types.
It is therefore complicated for a doctor to predict how a child with cerebral palsy will be affected later in life.
Cerebral palsy is not progressive, it does not become more severe as the child gets older, although some difficulties become more noticeable.
There is no cure for cerebral palsy. If children are positioned well from an early age and encouraged to play in a way that helps them to improve their posture and muscle control, they can be helped to develop and achieve more things for themselves.
Spastic Cerebral Palsy ‘Spastic’ means ‘stiff’ and this form of cerebral palsy stiffens the muscles and decreases the range of movements in the joints. This tightness is always there and means that someone with spastic cerebral palsy has to work harder to walk or move.
Athetoid Cerebral Palsy People with athetoid cerebral palsy make involuntary movements, because their muscles rapidly change from floppy to tense in a way they cannot control.
Their speech can be hard to understand because they have difficulty controlling their tongue, breathing and vocal cords. Hearing problems are also common.
Ataxic Cerebral Palsy People with ataxic cerebral palsy find it very difficult to balance or walk. They may have poor spatial awareness, which means it is difficult for them to judge their position relative to other things around them.
Ataxia affects the whole body. They may also have shaky hand movements and jerky speech.
Hypotonic Cerebral Palsy Hypotonic means low tone and this results in little or no muscle resistance to movement. It is difficult for a child to initiate movement and their limbs will feel floppy and heavy. They find it very hard to maintain an upright position against the pull of gravity.
It can be difficult to say what type of cerebral palsy a person has and they may have a combination of two or more types. The most important thing to remember is that no two people with cerebral palsy are the same.
Problems of Deformity and it’s Prevention A deformity is an abnormal joint position. To some extent, a child’s diagnosis and presenting symptoms, [for example, high or low muscle tone, preferred head position] will be good indicators of where potential problems may arise.
Many different factors contribute towards the development of deformity –these may take a long time to develop and become obvious. It is, therefore, important to be pro-active in anticipating potential problems and to take steps to prevent or decrease the impact of the contributory factors.
Whenever there is a tendency to adopt habitual postures of one part of the body or many parts, there is a danger of adaptive shortening of some soft tissues and lengthening of the others. In this way, joints may become stiff, leading to deformities which are very difficult to correct.
The least vulnerable children are those with athetoid types of cerebral palsy since these children are rarely still, but the high tone, low tone and rigid types may develop severe deformities if left untreated.
Causes of deformity may include :
Immobility – total or partial Immobility can result from many different causes, including high or low muscle tone, weakness, involuntary movements and spasms.
Other factors would include medication, sensory loss [mainly blindness], learning disabilities, poor nutritional status, recurrent chest infections. All these contribute to creating tired, lethargic children who prefer to be immobile.
High muscle tone [hypertonicity] Muscles with high tone pull the affected joints into abnormal positions. These occur in predicted patterns and, as a consequence, may cause joint contractures –in the arm, this could mean that the child or carers are unable to straighten the elbows, wrist, fingers, in the leg, high tone deformities lead to hip dislocation.
In some cases, Botox injections or surgical intervention may be required to alleviate muscle tension.
Low muscle tone [hypotonicity] Children with low muscle tone have difficulty moving out of the position in which they are placed as they have insufficient muscle tone to maintain a symmetrical upright position in sitting or assisted standing. Head control is often a major problem.
Common problems which can develop include :
rounded back [kyphosis],
curved backs [scoliosis], shortening or muscle groups around the hips and knees resulting in movement limitations / restrictions [i.e., it can be difficult to fully straighten the legs].
Abnormal reflex activity, including uncontrolled movement patterns and postures Some of these reflexes are present in all babies but are normally brought under control in the first few months of life. The repeated occurrence of the reflex produces movements in certain patterns [often caused by the child’s own efforts to move] and this can lead to muscle imbalance and deformity.
Examples include : Repeated extensor thrusts [opisthotonus] in the legs only leading to a fixed extensor posture.
Asymmetrical limb postures created by head turning [asymmetrical tonic neck reflex / ATNR] leading to limb deformities, scoliosis, torticollis and extensor postures.
Symmetrical limb postures created by flexion and extension of the cervical spine [symmetrical tonic neck reflex / STNR]
Asymmetry Any unequal distribution of muscle tone, growth of limbs, reflex activity or habitual postures in lying or sitting may lead to the development of reduced joint range and deformity.
Involuntary repetitive movements Repeated flexor or extensor spasms may give rise to tightness in the knee and / or hip joints.
Growth There are three main factors which cause or aggravate the development of deformity, as follows :
difference in leg length [ leg length discrepancy ]
growth spurts – unequal growth of bone and muscle, increase in height and, especially, increase in weight seem to bring on deformities.
Failure of the normal specific bony structural changes of the hip – these normally occur during growth but do not do so due to spasticity and non-weight bearing.
Normal Gross Motor Development & the Impact of Cerebral Palsy :
Supine Lying The supine position allows the child’s head to be supported so that they can see and watch nearby activities or their own arms and legs. The child has to move against gravity, which is an important beginning for learning muscle coordination.
As the child moves their arms and legs, their body is shifted from side to side, which helps develop the balance responses of the body. The movement skills learned in the supine position help to lay the foundation for the development of more advanced motor skills.
The child optimally positioned with their head in midline and their chin slightly ticked. Their shoulders should be down and their arms should be forward with their hands towards the middle of the body. The child’s body should be straight, with their hips and knees bent.
Be careful that the child’s arms and legs are not positioned away from the middle of the body, lying flat against the ground, [frogged position] – this is a tendency for children who tend to have hypotonic muscles.
With children who have hypertonic muscles, make sure that the head is not arched back, with shoulders and arms pushed back against the ground [retracted] and with the hips and legs straight or crossed.
Prone Lying Prone is an important developmental position. Head control develops as the head is lifted and turned. When the child begins to push up on their arms and lean on their elbows and hands, the child is beginning to develop the muscles of their shoulders and arms. The more a child lifts their head and the higher the child pushes up with their arms, the more the muscles of their back are developed, [spinal extension]. The child also shifts body weight towards the hips, beginning the development of their hip muscles.
As the child learns to shift weight to lean on one arm whilst reaching with the other, the child learns to isolate motor control of their arms and hands. These movement skills provide a foundation for the development of more advanced motor skills.
To promote the development of these skills, the child optimally should be positioned with their head up, in line and with the chin slightly ticked. Their arms should be out from under their body, with their elbows directly under or slightly in front of their shoulders. Hands should be facing forward with palms down. The child’s body should be straight with hops straight an flat, and the legs should be together.
Make sure that the child’s arms and legs are not positioned away from the body in a frogged position [this could occur with hypotonia] or that the arms and legs are not bent or trapped underneath the body[this could occur with hypertonia].
If a child persistently remains in either of these positions, they will have difficulty coordinating their body movements, changing their position or interacting with their environment.
Sitting Sitting is important for the child because, when upright, they can develop head control and see their surroundings. In sitting, a child learns to hold and balance their body upright against gravity and they begin to develop control of their hip muscles.
Initially, a child uses their arms to support their body and this helps to increase arm strength. As the child is able to use their hip, abdominal and back muscles to remain upright, the arms and hands are free to reach and play. As a child reaches outwards for toys, they learn to shift their body weight whilst maintaining balance. They also learn to change position.
When sitting on the floor, the child’s head should be upright, in line with the body and chin tucked. Their body should be upright and straight, with their hips bent to 90 degrees and legs out in front.
When in a chair, the legs would be bent to 90 degrees at the hips and knees with the feet supported and flat. The child’s shoulders should be down with arms forward ready to engage in an activity.
Children should not be allowed to ‘W-sit’ as this does not allow them to develop balancing skills. Prolonged ‘W-sitting’ can affect the ligaments in the hips and knees and can shorten the muscles that pass behind the knees.
When positioning children with floppy, hypotonic muscles, be careful that their legs are not too far apart as they will not develop balancing skills.
For children who have tight, hypertonic muscles, the knees must be started, [possibly using a pommel, cushion or knee blocks] to ensure equal weight bearing through both hips.
In chair sitting, both high and low tone children may sit back on their tailbone with their back curved or rounded, [kyphotic] instead of straight. When the child sits in this rounded position, [sacral sitting], their shoulders and head are reclined which limits development of upper limbs and fine motor control. This should be discouraged through careful moving and handling and appropriate positioning aids.
In high tone children, their upper body and hand skills may be hampered by the tendency to hold their arms up and out to the side with the elbows bent, [high guard]. The increased tightness in the muscles between the shoulder blades an make it impossible to reach forward and bring hands together in front of the body.
Kneeling Standing Standing is important in the child’s development and some children need help to achieve this. In standing the child experiences the feeling of weight bearing and they can begin to strengthen / develop leg, hip and body muscles.
Standing position increases the child’s awareness of their environment and, when appropriately supported, allows optimum arm function.
Walking Transitions Positioning A 24 hour approach to symmetrical, aligned posture should always be the aim. Allowing a child to stay in a twisted or flexed position, although they may appear to be comfortable, will probably lead to deformities of the hips and / or spine.
Positioning of the Head – postural effects
Asymmetrical Tonic Neck reflex [ATNR] This can have a profound effect on the posture of the body, particularly in lying, and in those children who do not have control of their head movement. This can potentially lead to hip dislocation and muscle contractures in the arms and the legs.
Symmetrical Tonic Neck reflex [STNR] This reflex occurs most noticeably in sitting and does not have the same potential for deformity, but can affect the functional abilities of the child.
If the head flops forward the upper limbs flex and the lower limbs extend. If the head flops backwards, the upper limbs extend and the lower limbs flex.
A child who has poor head control will, therefore, experience sudden movements in the arms or legs over which they have no control.
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