Cerebral palsy (CP) Theoretical Framework And Literature Review


Cerebral palsy (CP) is the one of the most common permanent motor disabilities seen in the childhood. Movement, posture and activity limitations are the motor disabilities caused by brain damage at prenatal, natal or postnatal terms of child. Motor disabilities can occur as a result of weakness of muscles, abnormal muscle tonus, orthopedic problems, abnormal reflex activities, insufficient trunk and head control . Additionally, children with CP often show other neurodevepmental disorders or impairments such as a sensational, perceptional, cognitional, communican and behavioral disorders.

During locomotion the upper body and lower extremity have different goals. The lower extremity’s aim is mobility and translation of body and, the upper body’s aim is to maintain the balance in response to the moving of lower extremity. Therefore trunk and head can be characterized as a stable system in dynamic equilibrium.

Trunk and head controls play a key role in executing daily living activities. Trunk control is important because inadequate trunk controls does not provide balance reactions and stable base of support for limbs and head which is necessary for the quality motion. In addition, trunk control takes part in controlled movement against gravity and body position for balance reaction and functions. Head control which starts to develop in the first four months of life, is a precondition for the development of locomotor skills and motor abilities such as grasping, sitting and reaching.

Because of the presence of many sensory systems in head, stabilization of the head during locomotor activities plays an important role due to the locomotion. The stabilized head position in space allows for the adjustment of sensory systems and trunk-head coordination for optimal functions. With the sudden movement of head, visual and vestibular receptors are stimulated and these receptors contribute motor and postural controls for activities. Furthermore, head movement is also important for visual control of task performance. Considering all these reasons, it is understood that providing head control is important to perform daily living activities.

Previous studies have demonstrated that head movements increase more in children with CP than in healthy children during inter-position transfers, lying down, sitting, at all stages of walking and even short and fast movements of the eye.Thus, increased frequency of antagonist activation, increased number of muscles recruited, increased sway and a tendency for rostral to caudal muscle recruitment are required to provide stability.

Inadequate trunk and head control which is resulting from fixation deficiencies, abnormal changes in muscle tone, inadequate reciprocal innervation and abnormal coordination also effect functioning of upper extremities. The movements of the upper extremity vary depending on the position in terms of speed and quality. Therefore, the development of head stability and control is considered as an one of the prerequisite for upper extremity functions and hand use. In summary, maintaining stability during dynamic equilibrium and stabilization in upright position is the primary task of the head and trunk during the movement of child.

Regarding these reasons, the aim of the study is to find the relationship between the movement of the head in the sagittal plane and the functions of the upper extremity in children with CP. The hypothesisof this study are following:

Hypothesis 0 (H0): There is no relationship between upper extremity functions and movement of the head in the sagittal plane in children with CP.

Hypothesis 1 (H1): There is a relationship between upper extremity functions and movement of the head in the sagittal plane in children with CP.

Cerebral palsy

Cerebral palsy | Theoretical Framework And Literature Review

The term CP was first used by William Little in the 1840s. Although many researchers have studied the definition of Cerebral palsy, it always have been a challenge define it. Recently, CP can be defined as an umbrella term that includes motor dysfunction and multiple comorbidities. CP occurs as a result of the brain damage in the prenatal, natal and postanal term and these insults can lead to hypoxic events, congenital brain malformations, and infections.

Furthermore, CP is a permanent condition; whatever it might be, neither resolves nor progresses and it is characterized by abnormal maturation of central nervous system, (spasticity and persistence of primitive reflexes), cognitive impairment and sensory impairments. All these factors act on abnormal muscle tone, muscle weakness, abnormal postural control, orthopedic problems, abnormal movement patterns and asymmetry

Epidemiology of Cerebral palsy

The studies to determine the prevalence of cerebral palsy demonstrated that rate of prevalence in Europe is between 1.51-2.2/1000, in the USA is between 1.7-2.0/1000 and in China to be 1,28-1,92/1000.

Etiology and Risk Factors of Cerebral palsy

The studies showed that cerebral palsy formation can not be defined exactly because CP is effected by multiple reasons and it is very diverse. Developing brain may be exposed to harmful factors in prenatal, natal or postanal term. These factors can be genetic, congenital or acquired such as inflammatory, infectious, anoxic, traumatic and metabolic.

Risk factors can be divided into 3 subgroups according to the period the brain is damaged:

Prenatal risk factors

  • intrauterine infections
  • placental complication
  • multiple births
  • teratogenic exposures
  • maternal conditions Perinatal risk factors
  • infections
  • intracranial hemorrhage
  • hypoglycemia
  • seizures
  • hyperbilirubinemia
  • birth asphyxia Postnatal risk factors
  • toxic
  • infectious meningitis
  • encephalitis
  • trauma (23).

Prematurity is ( ≤ 34 weeks) the one of the most significant risk factor, although the presence of early high technology diagnostic procedures can prevent to CP. Alternatively, the risk factors which is most seen are prenatal injuries and low birth weight ( ≤1500 gr) with respect to gestatinonal age. Insufficient intrauterine growth, respiratory problems ( prolonged ventilation, pneumothorax, sepsis, hyponatremia, etc…) and genetic malformations can also lead to CP.

Classification of CP

For the evaluation of child with CP, classification of the type of CP is important to decide on an effective treatment plan and to set short and long term goals for the child. Moreover, the classification system explains the functional status and future prognosis of the child. Until recently, therapists have used more complicated classification system which included anatomical region of the brain lesion, clinical symptoms, time of damage, muscle tone and topographic involvement of extremities. For this reason, The Surveillance of Cerebral Palsy in Europe eliminated such complexity and introduced a new classification system. With this classification, cerebral palsy is divided into two groups as physiological and topographical

Physiological classification of spastic CP

In a physiological classification system, it is important to determine which region of a developing brain is affected. Different motor symptoms develop depending on the affected area. If the corticospinal tract (pyramidal) is affected; spastic type is observed. If the other tract, (extrapyramidal) is affected; athetoid, ataxic, and hypotonic CP occur .

Physiologic classification consists of the types of CP:

  • spastic,
  • dyskinetic (which includes dystonia and choreoathetosis),
  • ataxic
  • hypotonic
  • mixed

Topographic classification of spastic CP

Depending on the affected parts of the body, topographic classification of Cerebral palsy can be divided into 5 subtypes: Monoparetic, hemiparetic, triparetic, diparetic and tetraparetic Cerebral palsy.

In hemiparetic CP the same side of the body is affected. The upper extremities are involved rather than lower extremities. Children with hemiparetic CP have some impairments such as fine motor and grasping difficulties, stereognosis, two point discrimination and sensational problems.

Diparetic CP is emerged by low birth weight and prematurity. Generally, periventricular leukomalacia (PVL) causes ischemic brain injury which is one of the cause of diparetic Cerebral palsy. In this type, lower extremities are involved more than upper extremities. Children with diparetic Cerebral palsy have toe walking, seizures, nystagmus, stabilization problems, strabismus and scissoring of legs because of the adductor spasticity.

Tetraparetic CP is occurred as a result of an acute hypoxic intrapartum asphyxia but it is not the only reason to tetraparetic Cerebral palsy. Four limbs are affected and the upper part of the body is more severely affected than the lower part of the body. Furthermore, voluntary movement disorder is common due to the vasomotor changes of the extremities and most of these children have swallowing and aspiration problems.

Management of CP

A multidisciplinary treatment program plays an important role in achieving maximum independence of the children. Orthopedists, neurologists, physiatrists, physical therapists, occupational therapists, speech therapist and psychologist must be involved in a multidisciplinary team. In addition, while making a treatment plan neural plasticity, degree of brain damage, the welfare of the family and intervention’s aim must be considered by the therapist.

Many different methods are used in the treatment of cerebral palsy such as traditional physiotherapy, botulinum toxin injections, surgeries and medical treatments. The main goals of traditional physiotherapy are to increase muscle strength, joint movements, reduce muscle spasticity and pathological reflexes. Additionally, static and dynamic muscle stretching can be applied for the prevention of joint limitations.

Another method is a neurodevelopment treatment which is founded by Berta and Karl Bobath which is also known as Bobath Method. The main purpose of this method is to promote normal motor development and to prevent additional limitations and problems such as contracture, abnormal posture and reflexes.

In addition to physiotherapy, sensory integration and occupational therapy are essential for children with Cerebral palsy. Sensory integration therapy facilitates functional activities by using sensory networks and prevent sensory integration disorders such as sensory discrimination and impaired sensory modulation. In sensory integration therapy, the sensory network which includes visual, auditory and perceptual clues are used. Furthermore, combination of sensory integration and occupational therapy can improve the quality life of children by providing self-care activities. The quality of life is improved by changing the environment in which the child is located and adapting the vehicles to the child.

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