Cerebral Palsy

Definition

Cerebral Palsy (CP) is the term used to describe a group of conditions that affect the movement of muscles and the posture of the body. The term comes from the area of the brain affected, 'cerebral' refers to the brain (cerebrum) and 'palsy' is the disorder of movement or posture. It is estimated that one in 400 babies born in the UK has a type of cerebral palsy.

You may also hear terms such as hemiplegic or diplegic cerebral palsy. These refer to the parts of the body affected by cerebral palsy. Hemiplegia means one side of the body is affected, diplegia is where two limbs are affected, and monoplegia is where one limb is affected.

Cerebral palsy is an umbrella term to includes a whole range of severities and is individual in each child. Symptoms can include difficulties with walking, talking, eating or playing. More specifically:

  • Muscle tightness, or spasm, or floppy muscles
  • Involuntary movement of muscles
  • Difficulties with walking and mobility 
  • Abnormal sensations 
  • Impairment of sight, hearing or speech 
  • Seizures

Symptoms/causes

It is caused by abnormal development of, or damage to, the motor control centres of the brain. CP is caused by events before, during, or after birth. The area of the brain affected will dictate which muscles the brain cannot control or move and how severely these muscles are affected. It is non-progressive but is a lifelong condition.

 

Risk Factors

Risk factors will depend on the muscles and areas of the brain affected. Obviously, problems such as seizures or the muscles affecting breathing need to be quickly treated with medication and intervention to control them. Other risks can include delay in development, where a child may not hit age-appropriate goals, such as rolling, sitting and standing. At LOC, our multidisciplinary team monitors a child’s development to give appropriate help as needed. With children who are unable to sit and stand, it is important to monitor and control the posture of their limbs, joints and spine to prevent contractures, muscle tightening, or joint instability occurring.

Children who are starting to mobilise may be prone to falling over if muscles are weaker and/or tighter. If tight muscles are a part of a child’s cerebral palsy, they can be at risk of muscles tightening up, particularly during growth spurts.

Complications

Complications will depend on the severity of CP but can include breathing, swallowing and eating difficulties, and, in some cases, learning difficulties.

Other complications can include muscle and joint instability, muscle contractures (tightening), spinal problems, such as postural or structural scoliosis (a twist and rotation of the spine and/or muscles), and delay in development when compared to other children of the same age. As a child grows and mobilises, it is important to keep their muscles and joints aligned as near to 'normal' alignment as possible, to allow a stretch on the muscles, but also to protect the structure of the joint and muscles, i.e. to prevent the foot, ankle, knee, hip or spine from growing in an 'abnormal' position.

 

Tests and Diagnosis

Delays in reaching age-appropriate milestone developments in infants and children are usually the first symptoms of CP. Babies with more severe cases of CP are usually diagnosed earlier than others. Other signs will include favouring one hand over the other after 12-18 months of age.

No one test is diagnostic for CP, but certain factors increase the likelihood of CP. The Apgar score measures a baby's condition immediately after birth. Babies that have low Apgar scores are at increased risk for CP. Imaging of the brain using ultrasound, x rays, MRI, and/or CT scans may reveal a structural abnormality in the brain.

Orthotic Treatments

Depending on the area of the body and the severity of the CP, there are a large number of orthotic treatments that can help:

  • helmets to protect the head against falls following a seizure;
  • spinal jackets or spinal braces, which are used to maintain the alignment of the spine;
  • Lycra suits are dynamic orthoses that increase proprioception and allow natural muscle movement but guide weaker or abnormal movement with specifically placed panels that place pressure and direction on specific muscles. These garments can be gloves, socks or suits;
  • lower limb orthoses include AFOs (ankle foot orthoses) and SMOs (supra malleolar - or ankle foot orthoses), which aim to control the foot, ankle, knee and hip positions of a child through their walking cycle.
  • anti-contracture orthoses can be used to stretch out tight muscles at night such as KAFOs (knee ankle foot orthoses), gaitors (for arms or legs) and night AFOs.

Given the range of symptoms, and the matching range of possible orthotic treatments, it is essential that your clinician has the experience and clinical expertise to prescribe the correct treatment, and to fine-tune any orthotic fitted, so as to provide correction and protection to your child's bones, joints and muscles.

Above: Blue Galaxy Hinged AFOs

Above: Blue Galaxy Hinged AFOs

OSKAR Clinic

In recognition of this, we have set up a specialist clinic within LOC called OSKAR. This stands for The Optimal Kinematic Alignment approach to Rehabilitation and is an orthotic method of treating children with lower limb neuromuscular conditions. It was originally developed by Elaine Owen MBE MSc SRP MCSP, a world-renowned physiotherapist.

In the OSKAR clinic, we dedicate even more time to the initial consultation and utilise our video vector Gait Lab facility. This gives us highly accurate information about the forces that are exerted on a body during the gait cycle. It allows us to prescribe and fit more accurate and objectively measured orthotics.

 

Further information

We also have strong links with specialist neuro clinicians: Farshideh Bondarenko at Birkdale, Helen Miles at Milestones, and paediatric physiotherapist Kiki von Eisenhart Goodwin at Kiki's Clinic and Hannah Spink at Bumble Bee Physio. We also work with case managers, such as NeuroHealth.

Having a multidisciplinary team approach is the best way to ensure the best possible outcome of treatment. If you want to bring along your therapist to our clinic please feel free. If that proves not to be possible, we will happily discuss your treatment with them.

There are a number of charities offering information, help and support to CP sufferers. These are perhaps the best known:

  • Cerebral Palsy UK
  • Scope
Above: Emily with her bespoke AFO and SMO

Above: Emily with her bespoke AFO and SMO

FAQs:

An AFO is an Ankle Foot Orthosis which as the name would suggest encompasses the ankle and foot. The objective is to control the position and movement of the ankle. AFOs are used to support weak limbs; they can also be used to immobilise the ankle and lower leg to correct foot drop. When set up correctly they can also have a great influence on the knee and hip joints. They are the most commonly used Orthoses.

The length of time that one needs to wear an AFO very much depends on the condition being treated. If it is a long-term condition like cerebral palsy or post-polio syndrome it is likely to be years as the condition cannot be cured. Your orthotist will advise you.

A patient’s comfort in their AFO is vital for compliance with the prescribed wearing regime.

So there are a number of steps the orthotist should take to ensure a comfortable fit: the patient’s heel should fit fully into the heel cup without excess space, the contours of the plantar surface of the AFO should match the patient’s foot, for children there needs to be up to half an inch growth room in the toe shelf length. At LOC we use our Gait Laboratories at our Kingston and Manchester clinics to fine-tune our bespoke orthotics.

A GRAFO is used to control instabilities in the lower limb by maintaining proper alignment of limbs and controlling their motion. It reaches around to the front of the knee extending down to the ankle. It works by altering a patient’s limb presentation to displace load and impact as well as offering further control to the knee.

The cost of an AFO is dependent on the type of AFO that has been prescribed and the material that it has been made with. Carbon fibre will be more expensive than metal or plastic for example. LOC’s bespoke AFOs cost can be found on our Orthotic Prices page.

The ability to drive while wearing an AFO is dependent on the condition being treated and the orthosis that has been prescribed. If wearing a hinged AFO, for example, you will be able to drive, but if wearing a knee brace, you won’t. Your orthotist will advise you.

The most flexible type of AFO is a Dynamic Ankle Foot Orthosis (DAFO).  It is thin and provides flexible support to the foot and ankle.

Both normal AFOs and DAFOs improve static balance (eg: while standing). Research among MS sufferers suggests that DAFOs aided balance while walking more than AFOs.

The simple answer is: yes they can. However one has to be sensible and look for wide-fitting trousers/jeans preferably of light and thin material.

Typically an AFO is stiff and rigid whereas a DAFO is thin, flexible and wraps around the patient’s entire foot. A DAFO provides support but also allows some range of normal movement.

A Supra Malleolar Orthosis SMO gets its name from the part of the body it encompasses. Thus an SMO supports the leg just above the ankle bone or malleoli. It allows dorsiflexion and plantar flexion(toes up and toes down) but eliminates mediolateral movement.

It typically takes a few weeks but is slightly dependent on the chosen materials and current availability.

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