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Cerebral palsy (CP) is a childhood condition in which there is a motor disability (palsy) caused by a static, nonprogressive lesion in the brain (cerebral). The causative event has to occur in early childhood, usually defined as less than 2 years of age. Children with CP have a condition that is stable and nonprogressive; therefore, they are in most ways normal children with special needs. Understanding the medical and anatomic problems in individuals with CP is important; however, always keeping in mind the greater long-term goal, which is similar to that for all normal children, is important as well. The goal for these children, their families, medical care, education, and society at large is for them to grow and develop to their maximum capabilities so that they may succeed as contributing members of society. This goal is especially important to keep in perspective during the more anatomically detailed concerns discussed in the remainder of this text.

Cerebral palsy (CP) is a static lesion occurring in the immature brain that leaves children with a permanent motor impairment. The lesion may occur as a developmental defect, such as lissencephaly; as an infarction, such as a middle cerebral artery occlusion in a neonate; or as trauma during or after delivery. Because brain pathology in all these etiologies is static, it is considered CP. Many minor static lesions leave no motor impairment and do not cause CP. Many pathologies, such as Rett syndrome, are progressive in childhood, but then become static at or after adolescence. These conditions are not part of the CP group, but after they become static, they have problems very similar to those of CP from the motor perspective. Other problems, such as progressive encephalopathy, have very different considerations from the motor perspective.

Children with cerebral palsy (CP) have a large variety of motor impairments, all of which are secondary to the encephalopathy. These impairments, which directly emanate from the encephalopathy and the disability that results, are well recognized as specific problems; however, the pathophysiology connecting the encephalopathy to the impairment and the disability is not well defined. The treatment goal of children with CP is to allow them to function in their environment, ideally the larger society, to the best of their abilities. These children continue to have CP, and the changes made by the medical treatment are directed at decreasing these disabilities by altering the secondary impairments. To alter the impairments in ways that decrease the disability requires that the interaction of different impairments in a given individual must be well understood. An understanding of the neurologic control of motor activity is required to place a construct around these impairments.

Almost all children with cerebral palsy (CP) will receive therapy and go to school. Most of the therapy has to be orderesd by physicians as part of the medical treatment of the CP. Because education is a universal experience in the lives of these children, it behooves the physicians treating the motor impairments to have some understanding of the educational system. These children often receive therapy as early as in the neonatal intensive care nursery. This early therapy is provided in a medically-based construct. As the children get older, especially over age 3 years, the main intervention shifts to the educational system, and much of this therapy also shifts into the education milieu. As these children enter grade school, except for periods of acute medical treatment, education is predominant with therapy occurring within this context. During the children’s growth and development, the therapists provide the best bridge between the education and medical systems. The final physical and emotional function and independence of these children depends on intervention by both the medical and educational systems; therefore, the bridging effect provided by the therapists is an important aspect. In addition to the standard therapy treatment in education, there are many treatment modalities that are promoted as beneficial for CP treatment. Some of these modalities may start as an alternative medicine approach, such as hippotherapy, but then develop acceptance within traditional medicine.

Durable medical equipment is the category of devices that are prescribed to ameliorate the disabilities from the motor impairments. Each of these devices, such as orthotics to assist with limb positioning or a seating system to assist with sitting, has very specific indications and contraindications. For physicians who care for children’s motor impairments, many more prescriptions are written for durable medical equipment than for drugs. Because each durable medical equipment device has its own indications, contraindications, and risks, after a physician examination, a careful consideration of the risk-benefit ratio should be performed before a prescription is written. Many of these durable medical devices are very expensive, often ranging from $1,000 for an orthotic to more than $20,000 for a very sophisticated power wheelchair. It is the responsibility of the physician writing the prescription to understand the specific benefit the device is expected to provide and to know its contraindications and possible risks. It is the responsibility of both physicians and the durable medical equipment suppliers to inform patients and caretakers of the side effects and risks of the device. This process is exactly the same as used when physicians prescribe a drug, in which they are expected to understand the indications and contraindications of using specific drugs in specific patients whom they have examined.

Treatment of the motor effects on ambulatory ability are the most common musculoskeletal problems that the orthopaedist has to address when treating children with cerebral palsy (CP). There are only a minority of patients whose motor function is so limited that ambulation is of no concern. From children with the most mild effects of hemiplegia to children with quadriplegia who are just able to do standing transfers, lower extremity function for mobility is usually a major concern of parents. The first task in the orthopaedic treatment plan is to individually identify how significant the gait impairment is to a child’s whole disability. The second task is to determine if treatment of the impairment is likely to improve this child’s function. The final goal is to explain the treatment plan to the parents and children and to inform them of the specific functional gains that can be expected and the associated risks. Normal human gait is one of the most complex functions of the human body, and gait is clearly the most complex impairment treated by pediatric orthopaedists. To understand and develop a specific treatment plan for children with gait impairments due to CP, orthopaedists have to have a good understanding of normal gait, understand measurement techniques used to evaluate gait, and be able to evaluate pathologic gait.

In the 1960s and early 1970s, pediatric therapists for CP appeared distinct from therapists who trained on poliomyelitis cases and from there quickly developed a cadre of therapists who practiced neurodevelopmental therapy (NDT). Neurodevelopmental treatment has gone through a long evolution over the years. Time has forced it to become more eclectic and become one of the most commonly used intervention strategies for children from infancy through adulthood with CP.1 Since the conception of NDT by Dr. Karl and Mrs. Berta Bobath in the 1940s, the scientific community’s understanding of the brain and the conceptual framework of NDT has evolved. As our understanding of how the brain inspires and controls movement evolves, so does the theory of NDT into what is currently accepted as the Dynamic Systems Theory. In this way NDT is a “living concept.”2 It adapts and grows as knowledge of the brain’s function is revealed.

In past years, several clinical myths existed about what one should never provide to patients with CP, such as “no plastic for spastics” when prescribing orthoses or “never strengthen spasticity.” Recent research has provided evidence to dispel these myths and bring a new level of awareness of how children with CP can be helped. It has always been known that increased tone is not the only or even the most significant impairment of CP, but that there is poor recruitment of muscle unit activity and inconsistent maintenance of maximum efforts. Research that investigates muscle strengthening has contributed to this understanding.

The impairments of motor control and tone in and of themselves can present a balance problem to patients, or there can even be further impairments of the vestibular and sensory system, which affect balance and equilibrium, thus creating an even more complicated picture.

An area that has received a great deal of press and a great deal of anecdotal experience is the role of electrical stimulation in CP. A review of the literature is very confusing, and there is great inconsistency from one medical center to the next as to what they are referring. Dr. L.J. Michaud probably has the most lucid discussion of electrical stimulation in CP.22