Category Archives: Associated Conditions

Joint Contractures in Children with CP

By Drew Dillard

Joint contracture is the abnormal and essentially permanent shortening of a muscle resulting in the loss of normal joint movement. It is an especially prevalent condition in patients suffering from spastic cerebral palsy. Learn how to recognize joint contracture in your child and what treatment and therapy options are available to help alleviate the condition.

Definition

Normal muscles work in pairs. When one contracts, the other relaxes. This allows for conventional movement in the desired direction. In children with spastic CP, because brain-to-muscle communication is compromised, muscles have a tendency to work against each other, thus inhibiting effective movement. Over time, the pathological result of this muscular conflict (hypertonic spasticity) is a tightening or shortening of the joint. When muscle fibers are shortened (dystonia), the nearby joint can remain fixed in one position.  This, in part, is what causes the abnormal gait and postures seen in some spastic CP patients.

Hands, wrists, elbows, shoulders hips, feet, the back and even the jaw can be affected. Sometimes it affects only one or two joints, but in more extreme cases it can affect nearly every joint in the body. Untreated, it can lead to extreme pain and frequent bone fractures. Although spastic CP is not thought to be a progressive disorder, as brain damage does not get worse over time, spasticity in muscles can increase over time.

 

Symptoms and Diagnosis

In children with spastic CP, the process of growth often acts against them, making contractures more problematic. Symptoms may include a loss of motion in one or more extremity, joint inflammation, abnormal movements, disrupted growth (especially longitudinal growth) or an inability to stretch.  Discomfort is another symptom, as pain can result even without voluntary joint movement.

A healthcare professional skilled in joint mobilization will be able to test your child for indications of restricted structures within the joint. They might use a goniometer to measure the motion capabilities of a particular joint or use X-rays to reveal visible decreases in joint space, which could be an indication of a tight, contracted joint.

 

Prevention

As with anything, early detection is key. The best way to increase and maintain joint elasticity and prevent joint contracture is through joint mobilization and stretching. This can best be done with the guidance of a qualified physical or occupational therapist. Your child’s treatment regimen will depend on the severity of the condition and the child’s prior physical development. The sooner physical therapy is introduced into the child’s routine the better, because once joint contracture has taken place, it cannot be stretched or exercised away.

All physical therapy for cerebral palsy patients should include activities and education aimed at improving flexibility, strength, mobility and function. Cerebral palsy patients suffer from increased muscle tone (in the correct use of the term, muscle tone is an unconscious, low-level muscle contraction while the body is supposedly at rest). Tight muscles are the enemy of CP patients.

A physical therapist can also work with a client on “positioning” (placing the body in a specific position to attain long stretches) or suggest or provide adaptive equipment. A good physical therapist will teach the care-giver how to continue exercising, stretching and positioning at home.

Newer techniques, such as aquatic-based rehabilitation, have achieved impressive results in recent years. In addition to its restorative and detoxifying properties, water provides buoyancy that makes aerobic and anaerobic exercises easier and, in many cases, safer. Some of the documented benefits include improved neuromuscular responses, better muscle synchrony and improved range of motion in joints.

 

Treatment

If joint contraction has taken place, physical therapy and therapeutic massage will remain major parts of the treatment. Anything that increases mobility, joint elasticity and muscle strength can prevent the contraction from worsening, prevent additional contractions and provide pain relief.

Other treatments that may get introduced include: casts or splints, medication, nerve blocks and electrical stimulation and/or surgery.

  • Casts or Splints. Casts or splints can hold a body part in place in an effort to stretch the soft tissues surrounding an affected joint and keep it in a more functional position. They need to be examined and changed regularly to reassess joint position and avoid skin breakdown.
  • Medications. Baclofen infusion, a relatively new procedure, involves inserting a pump into the abdomen that distributes baclofen (a muscle relaxant) to muscles, thus temporarily reducing spasticity. Another relatively new treatment involves botox (a muscle paralyzer) injections into overly tightened muscles. In successful cases, the botox was able to weaken the group of muscles and reduce spasticity for periods of up to 4 months.
  • Nerve Blocks and Electrical Stimulation. Because the root problem in spasticity is muscles not working in tandem as they should, in some cases, opposing muscles can be alternately blocked (anesthetically numbed) while others are electrically stimulated. This treatment is usually combined with casting.
  • Surgery. When a contracture is unresponsive to other treatments, it may become necessary for an orthopedic surgeon to surgically lengthen or release certain tendons or muscles to improve range of motion.

The treatment for spastic cerebral palsy can vary greatly depending on the condition and prior development of your child. Assembling and consulting with a treatment team, including physical therapist, pediatrician, physiatrist, neurologist and orthopedic surgeon will aid in the decision making process. Started early, a well-managed and determined therapy regimen can prevent joint contracture from ever occurring.

 

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Failure to Thrive May Indicate Cerebral Palsy

By Stacey Bucklin
CP Family Network Editor

Children grow more quickly in their first few years than they do at almost any other time in their lives. However, some children lag behind and fail to gain weight or grow as quickly as their peers. Failure to thrive is a term used to describe children whose current weight or rate of weight gain falls significantly below that of other children their age. Many factors can contribute to failure to thrive, but it is often one of the first warning signs of cerebral palsy.

Causes

Failure to thrive may be due to medical factors such as disease or disability (organic failure to thrive) or environmental factors such as abuse or neglect (non-organic failure to thrive). Here, we’ll focus on organic failure to thrive and its links to cerebral palsy and other disabilities. Organic failure to thrive occurs when a child is unable to take in, maintain or use the calories required to gain weight and grow normally due to medical reasons.

Medical causes of failure to thrive include:

  • Brain injury or damage to the central nervous system
  • Cerebral palsy
  • Complications due to low birth weight (especially common in multiple births)
  • Chromosomal conditions including Down syndrome and Turner syndrome
  • Organ problems
  • Heart or lung (cardiopulmonary) problems
  • Anemia or other blood disorders
  • Growth hormone deficiency or other hormone deficiencies
  • Metabolic disorders
  • Conditions involving the gastrointestinal system, including gastroesophageal reflux disease (GERD)
  • Chronic infections

Cerebral palsy can cause changes to a child’s brain and body that make it difficult for them to obtain nourishment and grow at a normal rate. Children with CP may have difficulty swallowing their food or feeding themselves, making it hard for them to consume enough calories. They may also experience loss of muscle mass due to inadequate exercise. Some children with cerebral palsy have damage to the parts of the brain that control growth and development.

Symptoms

Although there are many causes of failure to thrive, the symptoms are often the same. If you notice your child is experiencing any of the following symptoms, seek the advice of your child’s doctor. It is important to diagnose failure to thrive early so that corrective actions can be taken as soon as possible.

Symptoms of failure to thrive include:

  • Weight, height and head circumference do not correspond with standard growth charts
  • Weight is lower than 3rd percentile or 20% below the ideal weight for their height – Most babies double their birth weight by 4 months and triple it by age 1, but kids with failure to thrive often don’t meet those milestones.
  • Growth may have slowed or stopped after a previously established growth curve
  • Delays in rolling over, sitting, standing and walking
  • Underdeveloped mental and social skills
  • Delayed puberty in adolescents
  • Poor feeding due to lack of interest or trouble receiving nutrition
  • Constipation
  • Excessive crying
  • Excessive sleepiness (lethargy)
  • Irritability

Diagnosis

Although failure to thrive is not difficult to diagnose, determining the underlying cause can be harder. Your child’s doctor will perform a physical exam and compare your child’s height and weight to the normal ranges for children of the same age and gender. Your pediatrician will discuss your child’s medical and dietary history with you, and may involve a dietician to assess your child’s nutritional requirements.

Sometimes, a fairly simple change in your child’s food intake can significantly improve his or her growth rate. However, your doctor may decide to perform additional tests such as the Denver Developmental Screening Test, a test specifically designed to reveal developmental delays.

Other tests used to assess failure to thrive include:

  • Hemoglobin electrophoresis to check for conditions such as sickle cell anemia
  • Complete blood count (CBC)
  • X-rays to determine bone age and condition
  • Electrolyte balance
  • Hormone studies, including thyroid function tests
  • Urinalysis

Treatment

Treating a child that has failed to thrive depends on the cause of the delayed growth and development. When medical conditions are responsible for the delay, treating the underlying condition is of the utmost importance. This may involve physical therapy, occupational therapy, corrective surgery, special diets or other medical interventions.

The primary goal of treatment is to make sure the child receives sufficient calories and any other support necessary to grow at a healthy rate. Adjusting your child’s diet to ensure their nutritional needs are met should always be done in consultation with your pediatrician.

 

Resources:

U.S. National Library of Medicine

Kids Health

Nationwide Children’s

 

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Visual Issues in Children with Cerebral Palsy

Studies have indicated that as many as 75% of children suffering from cerebral palsy have vision impairments of some kind. Sense of sight is an important part of a child’s development, and for children affected by cerebral palsy, detecting vision issues early is critical. Any information you can arm yourself with brings you closer to providing your child with a happy, functional life as he or she grows older. Below, we have identified several vision disorders in children with cerebral palsy and options to treat them.

Types of Vision Disorders

There are many different vision disorders that can result from cerebral palsy, although many share similar forms of corrective treatment.

Cortical Visual Impairment (CVI) Perhaps the most common condition associated with cerebral palsy. Also called Cerebral Visual Impairment. CVI is categorized as more of a brain dysfunction rather than a direct problem with the eyes. Those suffering from CVI may experience symptoms such as frequent visual fatigue, abnormal responses to light, unusual eye movement, as well as other issues.

Acuity Loss
Acuity loss generally refers to blurred vision. The most common types of acuity loss are nearsightedness and farsightedness, both of which are typically treated by prescribing glasses or contact lenses.

Field Loss
This refers to a group of dysfunctions in the eye’s field of vision. Types of field loss include:

  • Central Loss – Visual impairment in the center of the field of vision.
  • Hemianopia – Visual impairment on either the upper-lefthand, upper-righthand, lower-lefthand or lower-righthand side of the field of vision.
  • Island of vision – Most vision is missing, save for some isolated spots in various places.
  • Peripheral loss – The sides of a person’s vision are missing. This is similar to tunnel vision.
  • Scotomas – A reversal of “island of vision.” Vision is mostly clear, save for some isolated spots in various places.

Amblyopia
This condition is common amongst children with or without cerebral palsy alike. This condition is also called “lazy eye.” The eyes have difficulty processing depth of field and one eye will have poorer vision than the other.

Detection of Vision Issues

It’s very important to detect visual impairment in your child as early in their development as possible. As a parent, it’s very likely you will notice the signs before your doctor diagnoses a vision disorder at a routine check up. Common signs include frequent rubbing of eyes, difficulty tracking objects, consistent red eyes and other eye problems. If you suspect your child is developing vision issues, consult your child’s doctor or an optometrist as soon as possible.

Treatment Options

Thankfully, most of the vision problems related to cerebral palsy are very treatable and the procedures are not much different than treating common vision issues. Prescriptions for glasses with corrective lenses or contact lenses are common treatments for many of the vision issues children with cerebral palsy will face.

Children with cerebral palsy who have also been diagnosed with CVI usually face a more involved and routine treatment plan. At an earlier age, some doctors recommend vision stimulation therapies to ensure the best possible development of your child’s visual skills. If your child’s visual skills have not advanced very far before they reach age 10, it may be necessary to begin training your child to use non-visual ways of communication, reading and writing. These could include using text-to-speech software or Braille. Your child’s doctor or optometrist should be able to recommend a program based on your child’s specific needs.

Further Reading

Cerebral Visual Impairment – SSC

Vision Problems – WebMD

 

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