Cerebral palsyAbout one in 400 children born alive has cerebral palsy (CP). 40% of CP cases are related to a premature birth and can be caused my a number of foactors such as Infection in early pregnancy A difficult or premature birth Bleeding in the baby's brain Abnormal brain development in the baby(NHS 2012)CP can be thought as an 'umbrella' term that describes a disorder of posture or movement. It is caused by injury to the immature brain. This usually occurs during or shortly after birth(Gage 1991).The symptoms can range from mild to severe depending where the brain injury is, for example the motor cortex of the brain tends to be the most vulnerable or susceptible to brain injury during embryonic development.

CP can be classified into two categories, but in the interest of of patient respect and to maintain dignity, this should not be a method of labelling individuals as like many movment disorders, CP can be very distressing for the patient and parents.In the past there has been confusion and disagreement with regards to the pathophysiology , and this was related to a lack of a universally accepted classification system. In 1956 a classification was established and still used today(Gage 1991).

One classification is by the number of limbs that are affected. They are as follows, Quadriplegia, where all 4 limbs are affected equally. Diplegia, where all 4 limbs are affected however the legs are affected more severely than the arms. Hemiplegia, where one side of the body is affected. Triplegia, where 3 limbs are affected with the arms more severe. Monoplegia, where only one arm is affected, usually an arm.

Another way of classifying CP is by movment, for example, Spastic CP is the most common affecting the cerebral cortex accounts for 70% of patients. Symptoms include muscle imbalance with tightness and heavy resistance within the limbs. Athetoid CP affects the basal ganglia. 20% of patients experience athetoid CP and can experience speech difficulties as well as movment difficulties. Ataxic CP affects the brains major movment centre, the cerebellum. This accounts for 10% of CP cases.

In some cases it is possible to experience a combined condition, for example, Spastic quadriplegia is a very severe type where the patient may also experience learning difficulties.The photo below summarises movement disorder types.

As stated, CP is a movement disorder. Symptoms of CP depend on the type but all types will provide symptoms that involve tightness of muscles, problems with balance and in severe cases, speech problems and difficulties co-ordinating oral movements.

Spasticity is defined as increased stretch reflex determined by passive flexing and extending muscle groups across a joint(Gage 1991).This is a main factor when considering the gait in a patient with CP, as tightness and drawing of the muscles in the limbs make it very hard to achieve locomotion smoothly.This is described in more detail in the following page.

The 'normal' gaitThe gait cycle can be described as a series of events that occur during walking. Many muscles, joints, and neural pathways communicate with the brain to ensure that transportation of the body occurs safely and efficiently with minimal expenditure of energy.The gait cycle can be defined as the time interval between two successive occurrences of one of the repetitive events of walking(Whittle 2004).

In order to perform locomotion, the body must be able to achieve certain things, for example, each leg must be able to support the body weight without collapsing, balance must be maintained throughout the whole gait cycle and the swing leg must be able to achieve ground clearance and support the body one it makes ground contact.This all contributes to achieving locomotion.During locomotion, a complete gait cycle occurs once the heel of the foot makes ground contact and finishes when the same heel makes the same ground contact. There are two main phases during the gait cycle. They are the 'stance phase' and the 'swing' phase.

The above picture displays the gait cycle. Beginning from the left hand side we have heel strike of the left foot. The left foot then goes through the stance phase which includes foot flat,heel raise and toe off. Once toe off has been achieved, the foot and leg will then enter the swing phase. You can see circled above is the left foot achieving the swing phase and is about to heel strike, thus performing one full gait cycle. The stance phase occurs when the foot is in ground contact, where the swing phase occurs when there is no contact with the walking surface. The stance phase occurs for 60% of a whole gait cycle and the swing phase occurs for 40%.The picture below describes this.

We are now going to detail the significant events that occur in the foot during the gait cycle. This section has been broken down into 3 parts, (Initial contact/foot flat, Mid stance and Heel lift).

1. Initial contact

As we have already mentioned, initial contact and the gait cycle begins when the heel of the foot makes ground contact. At this point the ankle joint is at a 90 degree position, or a neutral position but with a slightly supinated fore foot. Newtons 3rd law of motion states that 'for every action, there is an opposite and equal reaction'. It is within this reference where plantar flexion of the ankle joint occurs. The heel will strike the surface with force, creating an opposite and equal reaction, plantarflexing the ankle and foot creating the loading response.

The picture to the left shows the human foot performing heel strike. Notice the neutral position of the ankle, prior to the plantarflexion created by the ground reaction force and the almost fully extended knee joint.In order to control the foot as it plantarflexes, the muscle tibialis anterior will contract eccentrically which de-accelerates the loading phase while the foot pronates, and while the tibia rotates internally to achieve planter grade position on the surface.The photo to the right shows the tibialis anterior muscle. When contracting concentrically its primary function is the dorsiflex and invert the foot, but when contracting eccentrically it provides a controlled movement of plantarflexion. See muscles contractures for more information on thedifferent types of contractures.

2. Mid stanceThe mid stance phase occurs between toe off on the opposite foot and heel life. The swing leg will pass at the time of mid stance and at this time the ankle position will change from plantarflexion to dorsiflexion as the tibia moves over the ankle joint.

This picture shows the mid stance phase of the gait cycle. Notice the ankle is now in a dorsiflexed position and the knee is fully extended.

3. Heel lift/propulsionHeel lift phase creates a transition from mid stance to propulsion and begins when the heel begins to lift from the surface caused by concentric actions of the gastrocnemius muscle. As the knee joint reaches peak extension the ankle will have reached peak dorsiflexion and begins to plantar flex late on in the mid stance. The tibia will then externally rotate as the foot supinates (this can be considered an opposite movement to when the foot makes initial contact). The toes will remain in ground contact, but will dorsiflex at the metatarsal phalangeal joints.

SummaryAbove are the main phases of the gait cycle. Each phase is paramount to achieving effective locomotion. There are also other joints and muscles involved in the gait cycle. Hip flexors such as illiopasoas and muscles that perform flexion and extension at the knee (quads and hammstrings) all play an important part in the gait cycle. The foot is a complex structure with many joints, bones, muscles and tendons that all need to work in order to achieve successful locomotion.

This picture shows the main joints that are involved in the foot during walking.

Pathological gait, cerebral palsyIn a child with Cerebral palsy (CP), the central control system is damaged. As previously explained, the lesion can be eitherspastic, athetoid orataxic In a patient who has purely spacticity, only the pyramidal system is damaged; in athetoid CP only the extrapyramidal system is involved while a mixed pattern can involve both systems.(gage 1991)

It must be remembered that CP involves damage to the central nervous system, and that the changes to length and structures of bones and muscles are all secondary to the CNS lesion. Damage to the central control system will produce some or all of the following features,1. Loss of selective muscle control2. Dependence on primitive reflex patterns for ambulation3. Abnormal muscle tone4. Relative imbalance between muscle agonists and antagonists across joints5. deficient equilibrium reactions(gage,1991)

As previously mentioned either some or all of the above features will be present in a patient with CP. Therefore the gait that a patient will present with will express more than one symptom as these symptoms do not occur on their own and will be accompanied by another abnormality.Compensatory mechanisms are then forced into action in order to help the patient deal with the abnormalities.A good example of this compensatory mechanism can involve the spaticity around the tricep surae muscle group. A decrease in muscle tone around the calf muscle can cause the foot to be constantly plantar flexed causing difficulties clearing the floor surface during the swing phase of gait. The patient may introduce hip hiking or hip circumduction in order to ensure ground clearance.

You can see here in the picture that the patient on the left side has a plantarflexed foot. He will most likely be using hip circumduction or hip hiking as a compensatory mechanism in order to ensure his foot clears the ground, and does not 'drag'.

The Scissor gait

The patient on the right side of the picture is displaying the scissor gait. This gait abnormality is found in the most commonly found in spastic cerebral palsy,usually found in spastic diplegic patients.This patient will present with symptoms including ridigity and flexion of the knee joint. What is very common in this type of gait is over-adduction or hyper-adduction at the hip joint. This is what causes the patient to walk with the knees close together. The contractures in the adductor muscles will pull the thigh region medially giving the scissor like appearance. Other contractures may force the patient to walk on their tip toesAdduction, flexion and internal rotation are the 3 most common and noticeable features of this type of gait, all of which contribute to the scissor gait.

Refer to the video below, for an example of the Scissor gait.

YouTube Video

The Ataxic gait

The ataxic gait is considered to be a very unstable and uncoordinated walking style that is assisted with fast involuntary movements of the upper body extremities. The gait will be very irregular and the person will be walking with a wide base of gait in attempt to provide stability. Tremors, typically seen inparkinson's diseasewill be present too, contributing to the instability of the gait.

This type of gait differs from other types as the patient may experience mental problems as well, with mental retardation often commonly found in this type of cerebral palsy.There has been debate regarding levels of ataxia. Arguments have been made that an extremely mild ataxic patient should be referred to as 'apraxic'. Children who are 'apraxic' do not experience the clinical signs such as the poor coordination or poor stability, however they are unable to correctly or safely perform other motor skills such as skipping.If motor limitations are minimal, and the impairment is so mild that orthopaedic care is unlikely, it is perhaps preferable to use the termapraxia rather than labeling the child as having cerebral palsy.(Gage 1991).Below is a video describing the ataxic gait, found in ataxic cerebral palsy.

YouTube Video

One thing is for sure, that is that each type of gait a patient with cerebral palsy experiences, will all have similar symptoms and features. There are however specific changes and clinical observations that will define which type of gait that person possesses.Certain features are common to all types of gait.As mentioned in thenormal gaitchapter, in order to achieve normal and effective locomotion, the following 4 points must be effective. Stability Sufficient foot clearance Effective swing phase Energy conservation.In cerebral palsy, these 4 points are all lost.

When looking a the sagittal plane, two very common contractures and features are excessive flexion of the knee joint and plantarflexion of the ankle joint. In most cases the knee will be flexed as a compensatory mechanism. This is due to rectus femoris being used to flex the hip which encourages the hammstrings to contract as an antagonistic, flexing the knee. Foot drop is common also due to the excessive plantar flexion of the the foot, however if the foot is excessively dorsiflexed, foot slap may occur.

Foot clearance tends to be a common problem. Even in normal gait, foot clearance is only around 2cm(Begg et al 2007).Therefore you can understand why a patient who has spastic paralysis will find it hard to achieve a sufficient swing phase in order to clear the ground. Also due to poor ankle control and poor dorsiflexion/plantar flexion this will also provide difficulties when in thepropulsion phase of gait.

Other terms and languageThere are a number of other words you may here to describe CPThese include:Hypertonia- high muscle tone leading to stiffnessHypotonia- low muscle tone which leads to floppinessDystonia muscle tone fluctuates between floppy and stiffRigidity Sustained stiffness of limbsSpasm involuntary contraction of a muscleTremor rhythmic uncontrolled, repetitive movementsMinimal or mild CP Little obvious physical impairment but children experience poor coordination and clumsiness. This can be associated with learning difficulties.[4]- See more at: http://www.physio-pedia.com/QMU_Project_Group_5#sthash.nDnOP22L.dpuf

Signs and SymptomsReaching the expected developmental benchmarks of infancy and childhood sitting, rolling over, crawling, standing and walking are a matter of great joy for parents, but what if a childs developmental timetable seems delayed? There are many tell-tale signs that a child may have cerebral palsy, but those factors can be indicative of many conditions.

Signs and symptoms of cerebral palsySigns of cerebral palsy are different from symptoms of cerebral palsy.Signs are clinically identifiable effects of brain injury or malformation that cause cerebral palsy. A doctor will discern signs of a health concern during the exam and testing.Symptoms, on the other hand, are effects the child feels or expresses; symptoms are not necessarily visible.Impairments resulting from cerebral palsy range in severity, usually in correlation with the degree of injury to the brain. Because cerebral palsy is a group of conditions, signs and symptoms vary from one individual to the next.The primary effect of cerebral palsy is impairment of muscle tone, gross and fine motor functions, balance, control, coordination, reflexes, and posture. Oral motor dysfunction, such as swallowing and feeding difficulties, speech impairment, and poor facial muscle tone can also indicate cerebral palsy.Associative conditions, such as sensory impairment, seizures, and learning disabilities that are not a result of the same brain injury, occur frequently with cerebral palsy. When present, these associative conditions may contribute to a clinical diagnosis of cerebral palsy.Many signs and symptoms are not readily visible at birth, except in some severe cases, and may appear within the first three to five years of life as the brain and child develop.In these instances, the most apparant early sign of cerebral palsy is developmental delay. Delay in reaching key growth milestones, such as rolling over, sitting, crawling and walking are cause for concern. Practitioners will also look for signs such as abnormal muscle tone, unusual posture, persistent infant reflexes, and early development of hand preference.If the delivery was traumatic, or if significant risk factors were encountered during pregnancy or birth, doctors may suspect cerebral palsy immediately. In moderate to mild cases of cerebral palsy, parents are often first to notice if the child doesnt appear to be developing on schedule. If parents do begin to suspect cerebral palsy, they will likely want to ask their physician to evaluate their child for cerebral palsy.Most experts agree; the earlier a cerebral palsy diagnosis can be made, the better.However, some caution against making a diagnosis too early, and warn that other conditions need to be ruled out first. Because cerebral palsy is the result of brain injury, and because the brain continues to develop during the first years of life, early tests may not detect the condition. Later, however, the same test may, in fact, reveal the issue.The earlier a diagnosis is made the sooner a child can be enrolled in early intervention programs and treatment protocols. Early interventions and therapies have proven to help a child maximize their future potential. Early diagnosis also helps families qualify for government benefit programs to pay for such measures.

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Eight clinical signs of cerebral palsySince cerebral palsy is most often diagnosed in the first several years of life, when a child is too young to effectively communicate his or her symptoms, signs are the primary method of recognizing the likelihood of cerebral palsy.Cerebral palsy is a neurological condition which primarily causes orthopedic impairment. Cerebral palsy is caused by a brain injury or brain abnormality that interferes with the brain cells responsible for controlling muscle tone, strength, and coordination. As a child grows, these changes affect skeletal and joint development, which may lead to impairment and possibly deformities.The eight clinical signs include muscle tone, movement coordination and control, reflexes, posture, balance, gross motor function, fine motor function and oral motor function. These are detailed below.

Muscle toneThe most noticeable sign of cerebral palsy is impairment of muscle tone the ability of muscles to work together by maintaining proper resistance. Muscles coordinate with other muscles, oftentimes in pairs. As some muscles contract, others must relax. Even something as simple as sitting requires coordination of many muscles; some flexing while others relax. The brain injury or malformation that caused cerebral palsy impairs the ability of the central nervous system to coordinate muscle movement.Proper muscle tone allows limbs to bend and contract without difficulty, enabling an individual to sit, stand, and maintain posture without assistance. Improper muscle tone occurs when muscles do not coordinate together.When this happens, those muscles that work in pairs biceps and triceps, for example may both contract or relax at the same time, impeding movement and coordination. Trunk muscles might relax too much, making it difficult to maintain a tight core; this can result in impaired posture and an inability to sit or to move from a sitting to standing position.A child with cerebral palsy may demonstrate any combination of these signs. Different limbs may be affected by different impairments. The two most common signs of abnormal muscle tone are hypotonia and hypertonia, but tone can be defined in other ways as well: Hypotonia decreased muscle tone or tension (flaccid, relaxed, or floppy limbs) Hypertonia increased muscle tone or tension (stiff or rigid limbs) Dystonia fluctuating muscle tone or tension (too loose at times and too tight at others) Mixed the trunk of the body may be hypotonic while the arms and legs are hypertonic Muscle spasms sometimes painful, involuntary muscular contraction Fixed joints joints that are effectively fused together preventing proper motion Abnormal neck or truncal tone decreased hypotonic or increased hypertonic, depending on age and cerebral palsy type Clonus muscular spasms with regular contractions Ankle/foot clonus spasmodic abnormal movement of the foot Wrist clonus spasmodic movement of the hand

Movement coordination and controlThe impairment of muscle tone affects a childs limbs and body in different ways, although all children with cerebral palsy will likely feel some effect on muscle control and coordination. Different muscle control impairments can combine to cause limbs to be perpetually extended, contracted, constantly moving in rhythmic patterns or jerking spastically.Some signs will be more apparent when the child is under stress. Some may be task related, such as reaching for an object. Sometimes signs will seem to disappear when the child is asleep and muscles are relaxed.It is common for a child to experience different types of impaired muscle control in opposite limbs. Coordination and control can likewise be affected differently in each limb.The impairment of coordination and control fall under the following types: Spastic movements hypertonic movements where the muscles are too tight resulting in muscle spasms, scissoring of the legs, clonus, contracture, fixed joints, and over-flexed limbs Athetoid or dyskinetic movements fluctuating muscle tone causing uncontrolled, sometimes slow, writhing movements which can worsen with stress Ataxic movements- poor coordination and balance making tasks such as writing, brushing teeth, buttoning shirts, tying shoes, and putting keys into slots difficult Mixed movements a mixture of movement impairments, most commonly a combination of spastic and athetoid types, affecting different limbs Gait disturbances control impairments affecting the way a child walksGait disturbances include: In-toeing toes angle or rotate inward Out-toeing- toes angle or rotate outward Limping- more weight is placed on one foot than the other, causing a dipping, or wavy stride Toe walking the weight is unevenly placed on the toes Propulsive gait a child walks hunched over in a stiff posture with the head and shoulders bent forward Spastic and scissor gait- the hips flex slightly making it look like the child is crouching while knees and thighs slide past one another like scissors Spastic gait one leg drags due to muscle spasticity Steppage gait toes drag because the foot drags Waddling gait- duck-like walking pattern that can appear later in life

ReflexReflexes are involuntary movements the body makes in response to a stimulus. Certain primitive reflexes are present at or shortly after birth, but disappear at predictable stages of development as the child grows. Specific reflexes that do not fade away or those that dont develop as the child grows can be a sign of cerebral palsy.Certain abnormal reflexes may also indicate cerebral palsy. Hyperreflexia are excessive reflex responses that cause twitching and spasticity. Underdeveloped or lacking postural and protective reflexes are warning signs for abnormal development, including cerebral palsy.Abnormal primitive reflexes may not function properly in children with cerebral palsy, or they may not disappear at specific points in development as they do with children with no impairment. Common primitive reflexes that may improperly function or persist include, but are not limited to:Common primitive reflexes that may improperly function or persist include, but are not limited to: Asymmetrical tonic reflex when the head turns, the legs on the same side will extend, and the opposite limbs contract like in a fencing pose. Asymmetrical tonic reflex should disappear around six months of age. Symmetrical tonic neck reflex the infant assumes a crawling position when the head is extended. Symmetrical tonic neck reflex should disappear between eight and 11 months. Spinal gallant reflexes when the infant lies on its stomach, the hips will turn towards the side of the body that is touched. Spinal gallant reflexes should disappear between three and nine months. Tonic labyrinthine reflex when the head is tilted back, the back arches, the legs straighten, and the arms bend. Tonic labyrinthine reflex should disappear by three-and-a-half years of age. Palmer grasp reflex when stimulating the palm the hand flexes in a grasping motion. Palmer grasp reflex should disappear around four to six months. Placing reflex when an infant is held upright and the back of a foot touches the surface, the legs will flex. Placing reflex should disappear by five months. Moro (startle) reflex when the infant is tilted so his or her legs are above their head, the arms will extend. Moro reflex should disappear by six months.Early hand preference can also indicate possible impairments. A child normally develops hand preference in his or her second year. As this is a wide timeframe and rough average, development of hand preference, especially if it is early preference, is cause for concern. Various sources state that early hand preference falls between six-18 months.

PostureCerebral palsy affects posture and balance. Signs may appear as an infant begins to sit up and learn to move about. Typically, posture is expected to be symmetrical. For example, a baby in a sitting position would normally have both legs in front. When bent, they become mirror images of one another.Asymmetrical posture means the right and left limbs will not mirror one another. The hip-joints are one area where this is often prominent in instances of cerebral palsy. One leg will bend inward at the hip, and the other will bend outward.Much like reflexes, postural responses are expected reactions when putting a baby in certain positions. They typically appear as the baby develops. Impairment may be a possibility if the responses do not develop, or if they are asymmetric.Much like reflexes, postural responses are expected reactions when putting a baby in certain positions. They typically appear as the baby develops. Impairment may be a possibility if the responses do not develop, or if they are asymmetric.Common postural responses are: Traction Landau reflex when the infant is supported in a lying position, pushing the head down will cause the legs to drop, and lifting the head will cause them to rise. This response appears around four or five months of age. Parachute response when the infant is positioned with his or her head towards the ground, the infant should instinctively reach as if bracing for impact. This response appears around eight to 10 months of age. Head righting when an infant is swayed back and forth, his or her head will remain straight. This response appears around four months of age. Trunk righting when a sitting infant is quickly pushed to the side, the infant will resist the force and use opposite hand and arm to brace against impact. This response appears around eight months of age.

BalanceThe impairment of gross motor function can affect a childs ability to balance. Signs become recognizable as a child learns to sit, rise from a sitting position, and begins crawling or walking. Infants need to use their hands often as they learn these skills. They develop the strength, coordination, and balance to accomplish the task when mastering it without the use of their hands.A childs inability to sit without support can be a sign of cerebral palsy. The Gross Motor Function Classification System, or GMFCS, a five-level system commonly used to classify function levels, uses balance while sitting as part of its severity level system.Signs to look for when a child sits include: Requiring both hands for support Having difficulty balancing when not using hands for support Unable to sit without using hands for supportOther signs to look for include, but are not limited to: Swaying when standing Unsteady when walking Difficulty making quick movements Needing hands for activities that require balance Walking with abnormal gaitBalance is often the same whether a childs eyes are open or closed. Balance impairment is most often associated with ataxic, and to a lesser degree, spastic cerebral palsy.

Gross motor functionAs a child develops, signs of impaired or delayed gross motor function may be noticeable. The ability to make large, coordinating movements using multiple limbs and muscle groups is considered gross motor function.Gross motor function may be impaired by abnormal muscle tone, especially hypertonia or hypotonia.For example, hypertonic limbs can be too tight, or inflexible, to allow proper flexion and movement; whereas hypotonic limbs may be too loose to properly support a childs movements.As a babys brain and body develop, they are expected to reach developmental milestones. Reaching the milestone later than expected, or reaching it but with low quality of movement (such as favoring one side while crawling), are possible signs of cerebral palsy. Impaired gross motor functions limited capability of accomplishing common physical skills such as walking, running, jumping, and maintaining balance. Delayed gross motor functions physical skills developed later than expected; often used in conjunction with developmental milestones for predictable stages of development.Significant milestones of gross motor function include: Rolling Sitting up Crawling Standing Walking BalancingThese should be monitored to note when the baby reaches the milestone, and the quality of movement.

Fine motor functionExecuting precise movements defines the category of fine motor function. Fine motor control encompasses many activities that are learned, and involve a combination of both mental (planning and reasoning) and physical (coordination and sensation) skills to master.Impaired or delayed fine motor skills are an indicator of possible cerebral palsy. Intention tremors, where a task becomes more difficult as it gets closer to completion, is one such sign.Examples of fine motor function development are: Grasping small objects Holding objects between thumb and forefinger Setting objects down gently Using crayons Turning pages in a book

Oral motor functionDifficulty in using the lips, tongue, and jaw indicate impaired oral motor function; this is a sign that may be present in up to 90% of preschool-aged children diagnosed with cerebral palsy. Signs of oral motor function impairment include, but are not limited to difficulty with: Speaking Swallowing Feeding/chewing DroolingSpeech requires proper intellectual and physical development. Cerebral palsy impairs the physical aspects of speaking by improperly controlling the muscles required to speak. Oral motor impairment can affect: Breathing the lungs, and specifically the muscles controlling inhalation and exhalation necessary for proper speech patterns. The diaphragm and abdominal muscles are important for proper air flow and posture. Articulating muscles controlling the face, throat, mouth, tongue, jaw, and palate all must work together to form the proper shape necessary for pronunciation of words and syllables. Voicing vocal cords are controlled by muscles that essentially stretch the vocal folds between two regions of cartilage.Apraxia, an inability of the brain to effectively transmit proper signals to the muscles used in speaking, is one type of speech impairment common to cerebral palsy. It is divided into two types: Verbal apraxia affects the articulation muscles, especially regarding the specific sequence of movements needed to carry out proper pronunciation. It is common in children with hypotonia. Oral apraxia affects the ability to make nonspeaking movements of the mouth, but is not related solely to speaking. Example of oral apraxia would be the inability to lick the lips, or inflate the cheeks.Dysarthria is another speech impairment common to cerebral palsy. Like apraxia it is a neurological impairment, as opposed to a muscular condition. It is often found in cerebral palsy that result in hypertonia and hypotonia. Dysarthria is broken into the following subgroups: Ataxic dysarthria slow, erratic, inarticulate speech caused by poor breathing and muscular coordination Flaccid dysarthria nasal, whiny, breathy speech caused by the inability of the vocal chords to open and close properly. There may be difficulty with consonants. Spastic dysarthria slow, strenuous, monotone speech and difficulty with consonants Mixed dysarthria all three may be present.Drooling is another sign of cerebral palsy that results from muscles in the face and mouth not being able to properly control coordination. Some specific factors which can contribute to drooling are impairments in: Swallowing Closing the mouth Positioning the teeth Inability to move saliva to back of mouth Tongue thrustingFeeding difficulties can be present with cerebral palsy. They typically manifest as decreased ability to chew and swallow, and may also involve choking, coughing, gagging, and vomiting.12-Step Processfor Diagnosing Cerebral PalsyParents that suspect a child has cerebral palsy likely wish that a one-step, quick test would confirm that diagnosis. That, however, is not how physicians make a determination regarding cerebral palsy. Getting to a diagnosis is a multi-step, complex process of tests, evaluations, and eliminations that in the end, rule everything else out. Understanding the diagnosis process can be a source of comfort for parents anxious about the process.

The process of diagnosisThe process for diagnosing cerebral palsy involves monitoring the childs development and watching for possible signs of impairment. If a baby is born prematurely, or at a low birth weight, he or she is monitored closely in the neonatal intensive care unit of the hospital. If the infant attends regular well-baby visits, during examination of the child the pediatrician may be first to notice signs of cerebral palsy. In some cases, it is the parents who notice symptoms they relay to the childs doctor.Parents are often disheartened to learn that there is no singular test that will definitively diagnose a child with cerebral palsy. Once a round of medical evaluations are initiated in order to form a diagnosis, parents prepare for a long and sometimes frustrating process that will, in time, provide answers about a childs condition.The diagnosis process can seem intimidating. Understanding the diagnosis process can be a source of comfort for parents anxious about the process.The 12-Step Diagnostic Process entails the following steps: Step 1: Parental Observation Step 2: Clinical Observations Step 3: Motor Skill Development Analysis Step 4: Medical History Review Step 5: Documenting Associative Conditions, Co-Mitigating Factors, and Ruling-Out Other Conditions Step 6: Obtaining Test Results Step 7: Diagnosis Step 8: Obtaining a Second Opinion Step 9: Determining Cause Step 10: Care Team Assembly Step 11: Care Plan Creation Step 12: Embracing a Life with Cerebral PalsyThese steps are detailed below.

Step 1: Parental ObservationsOutside severe cases, which are often diagnosed at or within days of birth, parents may question noticeable signs. The primary indicators parents will notice are developmental delay and impaired muscle tone.Developmental delay occurs when a child does not develop specific skills within the predicted time period. Parents might notice the child is not reaching for toys at three or four months, sitting up by six or seven months or walking at 12-14 months. In some cases, the child might appear to develop motor skills ahead of schedule. Rolling over is a significant milestone, but when rolling occurs too early, it can be a sign of abnormal reflexes. It can also indicate spasticity. Demonstrating hand preference before 12 months is also an indicator of possible cerebral palsy.Muscle tone is another indicator. Normally, muscles contract when a limb is flexed and relax when the limb is extended. Muscles that are very tight, or inappropriately relaxed, can be a sign of cerebral palsy, which directly affects muscle tone and posture. Tremors are also a sign.Additionally, parents may notice the child seems stiff, has problems swallowing, does not appear to hear or has eyes that do not seem to focus. The child may experience gastrointestinal problems, such as vomiting, constipation, or bowel obstruction. Some children demonstrate impaired oral-motor function with signs of vomiting, aspiration pneumonia, failure to thrive, drooling or communication difficulties. One half of children with cerebral palsy experience seizure activity. Any of these signs, or others, should be discussed with the childs primary care physician, preferably during well-baby visits.

Step 2: Clinical ObservationsParent observations are an important part of a doctors evaluation. Pediatricians use parental input as a basis for further examination. They will explore signs parents notice and gauge the possibility of impairment. Well-baby visits are designed for clinical documentation of developmental milestones. Height, weight, reflex, and age-appropriate behavior are part of developmental surveillance recommended by the American Academy of Pediatrics for infants at the ages of nine months, 18 months, and 30-months of age. When surveillance of a child spurs concern, the Academy recommends standardized developmental screening tool assessment and early return visits.In addition, doctors will look for the persistence of primitive reflexes that, in typical development, appear and disappear in a predictable order during infancy. The tonic reflex (when the babys head is turned to the side, the baby will extend the arm on the side the head is facing, while flexing the other arm) appears around four months and then fades away. It is not a strong reflex, yet in children with cerebral palsy the tonic reflex does not always fade, and sometimes continues to grow stronger, even dominating a childs motor skills. Doctors examine the childs supine position (retraction of the head, neck and shoulders); prone position (protective head turns, arm flexor spasticity, and extensor spasticity of legs); and upright posture (extensor spasticity of legs, reflexes, and protective arm extension).Many other reflexes develop, then disappear over time. Doctors test and document the childs development. The information recorded in these records is then used to confirm or rule out cerebral palsy or other conditions.

Step 3: Motor Skill Development AnalysisThe cause of cerebral palsy is either brain injury or brain malformation occurring during fetal development, birth, or after birth while the brain is still developing. The brain damage occurs in parts of the brain that affect motor control. It does not progress, which differentiates cerebral palsy from similar conditions. Motor skill development analysis is used at various intervals to gauge key developmental milestones. The following are essential in determining the extent, location, and severity of cerebral palsy:In the case of cerebral palsy, developmental motor delay is a key indicator. The pediatrician will be evaluating: Muscle tone Movement coordination and control Reflex irregularity Posture Balance Fine motor function Gross motor function Oromotor functionThe evaluation of motor skills may help establish the type(s) of impairment and degree of severity. This is essential in determining the cause or source of impairment. The severity of impairment also may be necessary in qualifying for benefits and support services.

Step 4: Medical History ReviewEliminating other possibilities is a crucial factor in diagnosis of cerebral palsy. Both parents medical histories are important to this process. By reviewing medical history of parents, doctors can look for possible genetic, progressive, or degenerative nervous system disorders. Economic status and social habits may also be reviewed.Doctors will also want to know about the childs prenatal history, as well as any complications during labor and delivery.

Step 5: Documenting Associative Conditions, Co-Mitigating Factors and Ruling-Out Other ConditionsBecause there is no test that definitely confirms or rules out cerebral palsy, there is always a chance other conditions must be excluded from a list of possibilities, and cerebral palsy must be fully considered. Other disorders and conditions can appear as cerebral palsy, and cerebral palsy is often accompanied by associated conditions that complicate the process of diagnosis.The medical examination process can involve multiple doctors, tests, and appointments. During this time doctors will rule out other similar conditions such as: Degenerative nervous disorders Genetic diseases Muscle diseases Metabolism disorders Nervous system tumors Coagulation disorders Other injuries or disorders which delay early development, some of which can be outgrownThe brain injury or malformation that caused cerebral palsy is non-progressive. Many nervous system disorders do progress. They may start with minor symptoms, but over time, the symptoms continue to worsen or multiply. If the childs condition is showing signs of progression, these signs will help doctors rule out a cerebral palsy diagnosis. Like many aspects of diagnosing cerebral palsy, this requires observation over time.

Step 6: Obtaining Test ResultsMany screens, tests and medical specialists are part of the process of diagnosis. Every state mandates newborn screens at the time of birth. The tests performed vary by state, but may yield some early results.Infants who test positive for a developmental delay may be referred to medical specialists for further evaluations. The pediatrician will document all surveillance, screening, evaluation, and referral activities in the childs health record. It is suggested that parents request a written copy of all test results and advice rendered, as well as any other information presented at various visits to the the doctors office. These documents become valuable when speaking with the multitude of practitioners that may be required in the childs future care. Having the documents on hand will save money and allow parents to be informed and efficient.Common tests that involve neurologists or neuroradiologists, include neuroimaging, such as cranial ultrasound, computed tomography scan (CT Scan), and magnetic resonance imaging scans (MRIs). These tests allow neurologists to actually see the brain. Various disorders, injuries, and conditions yield different results. These can be used to rule out cerebral palsy. Or, if cerebral palsy is eventually diagnosed, they can provide doctors an exact picture of the injury to the brain. Blood tests may be ordered to check chemistry, plasma and chromosome levels. Seizure activity will be monitored.Medical specialists are brought in to test hearing, vision, and perception, as well as cognitive, behavioral, and physical development. A child may be sent to an orthopedic surgeon to ascertain delay in motor development, record persistence of primitive reflexes, examine for dislocated hips, and check on abnormal postural reactions.A genetic specialist may look for hereditary components.The lengthy and detailed process can help rule out or confirm cerebral palsy, while also providing a broader assessment of the childs abilities.

Step 7: DiagnosisThe months or years it takes to confirm a cerebral palsy diagnosis does not lessen the impact of the news. It can be an emotional moment for parents.Many issues that surround the diagnosis of cerebral palsy do not have anything to do with the medical tests and observations necessary to confirm the condition. For example, parents may initially shy away from the news, especially if they were fostering hope that their child would outgrow the condition. The diagnosis may bring a mixture of fear, guilt, or apprehension. Some parents wonder if the cause of the childs impairment is somehow their fault, or whether they did something wrong. Others may be relieved that their child has a physical impairment, but is expected to live a full, long life.Doctors, likewise, may not want to deliver a cerebral palsy diagnosis until they are fully certain. A major fear is that a diagnosis of cerebral palsy will interfere with bonding between parents and child. Doctors do not want to misdiagnose the condition and cause undue stress.Doctors and parents are aware that early diagnosis can lead to early intervention options. Some treatment protocols have proven more effective when provided early. A formal diagnosis is required to obtain government benefits that help a family mitigate the financial burden as expenses for ongoing testing and medical care pile up.Debate exists over the best time to diagnose cerebral palsy. Issues surrounding the timeliness of diagnosis focus on three areas: Early diagnosis Early diagnosis can lead to early intervention, treatments, therapies, funding and benefit programs. It can result in misdiagnosis. Delayed diagnosis A delay in diagnosis can allow time for the family to bond before the condition is known. It allows time to observe developmental milestones; rule out other conditions; and confidently confirm cerebral palsy. Misdiagnosis Misdiagnosis can occur if signs are not properly monitored, tested, and confirmed. Or, when other conditions arent ruled out properly. The diagnosis of cerebral palsy may be correct, but the severity, extent, or co-mitigating factors may be improperly diagnosed.

Step 8: Obtaining a Second OpinionParents may seek a second opinion to confirm the diagnosis of cerebral palsy and to rule out the possibility of misdiagnosis. A diagnosis of cerebral palsy is enough to warrant a second opinion. Additional factors that might increase the need for a second opinion include: When surgery is presented as a treatment option When there are many possible treatment options When the proposed treatment is unsatisfactory for any reason When no treatment is presented When parents just feel they require another opinionThe current doctor should not be offended if parents ask for a referral for a second opinion by explaining that this is a complicated and important issue for the family. Those who feel uncomfortable asking one provider for a referral may ask another trusted family doctor, or their health insurance provider network. The costs and procedure for seeking a second opinion vary depending on the health care provider, and parents should therefore discuss the intention of seeking a second opinion with their health insurance provider to fully ascertain whether it will be covered under the insurance plan.Second opinions can assist with outstanding questions; remove any doubts; provide a second opinion on treatment options; and allow for a more informed, educated decision on appropriate treatment when moving forward.

Step 9: Determining CauseBrain injury or brain malformation is the root cause of cerebral palsy. There are three types of brain injury and a form of brain malformation: Periventricular leukomalacia (PVL) damage to the white matter of the brain tissue Intracranial hemorrhage (IVH) brain hemorrhage Hypoxic-ischemic encephalopathy (HIE) or intrapartum asphyxia lack of oxygen to the brain (asphyxia) Cerebral dysgenesis brain malformation or abnormal brain developmentThe Academy of Pediatrics recommends that parents attempt to discern what caused the brain damage and at what point in the developmental process the damage occurred. According to the Academy, cause of brain damage can be identified in approximately 25% of all cases. Identifying the root cause will provide the following benefits: Greater understanding of the childs impairment Identify whether there is recurrent risk in future pregnancies or family planning Identify specific medical treatments Identify therapeutic intervention programs Identify early intervention education programs Identify government assistance, community resources, benefit programs, and funding sources Further research for prevention and cures

Step 10: Care Team AssemblyOne of the most important components of parenting a child with cerebral palsy is the responsibility of assembling the proper doctors, therapists, educators, and organizations to provide the best care, treatment, and support for the child. The goal is to assemble resources that will help the child succeed.A care team can evolve over time and is subject to immediate and long-term needs of the child. The team consists of professionals from different specialties, such as: Caregivers daycare, respite, personal assistants, and guide dogs Support organizations MyChild, cerebral palsy organizations, community support groups, disability organizations, counseling services, friends, and family Educators school administrators, teachers, speech therapists, and special education support staff Lawyers lawyers concentrating in estate planning, disability rights, birth injury, family law, SSI, school rights, medical malpractice, and more Government agencies government agencies (federal, state and local) offering benefits, education programs, information resources, disability guidance, health care options, advocacy, and research Tax and financial planners accountants and financial planners that advise in special needs tax advantages, financial planning, wills and trusts, and planning for future expensesMany health care professionals may assist throughout the childs life. Some will only be seen for specific needs such as diagnosis, whereas others may oversee the childs overall treatment plan well into adulthood. Medical professionals often utilized in the diagnosis process include: Pediatricians care for children from birth through early adulthood Neurologists specialize in the nervous system of children, particularly neurological disorders and diagnosing the brain injury or malformation that caused the childs cerebral palsy Ophthalmologists focus on the eyes and visual pathways Orthopedic surgeons specialize in motor development disorders, bones, joints, ligaments, tendons, and muscles. Otologists study the ear, its diseases, and disorders Neonatologists medical professionals who typically work in the neonatal intensive care units (NICU) who specialize in the care of newborn infants, in particular the ill or premature babies Geneticists study genetics and heredity disordersHowever, depending on the childs signs and symptoms or the treatment protocol required, the following practitioners may also become involved in the childs treatment plan at some point in the childs life span: Audiologist Behavioral Therapist Counselors and Social Workers Dentists/Orthodontists Developmental Behavioral Specialists Developmental Pediatrician ENT/Otorhinolangologist Geneticists Neonatologists Neurologists Neuroradiologists Nutritionists Obstetrics Gynecologists Occupational Therapist Ophthalmologists Orthopedist/Orthopedic Surgeons Orthotist Otologists Pediatrician Physical Therapists Psychologist Rehabilitation Medicine Specialist Researchers Speech and Language Pathologists UrologistsA leader is essential to the success of the care team. Ideally, this would be the childs primary care physician who coordinates with the other health professionals. Oftentimes doctors work in isolation, unaware of the treatments and therapies others may be utilizing. This can be counterproductive. A leader can ensure all professionals involved in treating the child are aware of each others concerns, treatment goals, and progress. This allows the care team to work together and optimize the childs treatment.Sometimes doctors are unable or unwilling to take on the responsibility of being a childs care team leader. In this case a parent or guardian is best suited to fill the role. Even if a doctor does assume the lead, the parent or guardian should maintain care plan documentation and save important documentation related to the childs care. These documents can then be easily reviewed by others considering the childs care.Medical records are essential to the care plan and coordinating the care team. Parents can request copies of their childs medical records. Occasionally, parents may be asked to pay a fee to obtain the records, but if this cannot be afforded, doctors or hospital staff may have ways of assisting.

Step 11: Care Plan CreationA care plan tracks a childs treatment, including tests, diagnosis, and treatments received. This allows parents to share information between members of the care team. The care plan is a diary of events, a scrapbook of medical records, a game plan for future treatment goals, and a collection of test results. It is a history of the childs care and progress.The care plan is more, though. Establishing and maintaining a care plan allows easy, efficient access to valuable information. Keeping receipts organized helps in obtaining tax benefits. Medical records and test results may be required in an application for benefits and funding. Planning treatment protocols can help parents plan for financial needs, while wills and trusts provide for future care of the child in the event the parent can no longer support the child. Maintaining insurance records helps when paying bills; organized records provide peace-of-mind. Habits lead to efficiency, and sharing thoughts, feelings and hopes can be inspiring when reviewing progress years later.The care plan will continue to benefit the child, and those who will care for them, throughout the childs life.

Step 12: Embracing a Life with Cerebral PalsyRaising a child who has cerebral palsy creates fresh challenges for the whole family. Research indicates a household with a special needs child is more prone to depression, suicide, financial strain, relationship challenges, divorce, and bankruptcy. Others will boast that it can bring relationships together with purpose.Embracing a life with cerebral palsy requires planning, organization, perspective, adaptation, and inspiration. For parents, a review of their childs care plan provides a chronology of choices theyve made, steps theyve taken, learning theyve experienced, and a glimpse at their hopes and dreams for tomorrow; a true source of pride and accomplishment. Many learn how to embrace a life with cerebral palsy somewhere inside the journey itself.