Development of the Child with Cerebral Palsy

Introduction

The knowledge of the normal development is essential to compare the atypical development of the CP children, at all stages but even more in early stages were the imparments are not so clear. http://www.cdc.gov/ncbddd/actearly/milestones/index.html

Depending on the type of the Cerebral Palsy and Neurodevelopment Disorders, we will observe different patterns including positions and movements and different impairments.

The symptoms and function of each person with Cerebral Palsy varies. Cerebral Palsy is non-progressive so does not get worse over time, but the exact symptoms and function can change over a person's lifetime. From Birth to 5 years of age, a child should reach specific movement goals or developmental milestones - e.g. rolling, sitting up, standing, and walking which are often delayed or absent in the child with Cerebral Palsy.

Lets examine the development related to each type of Cerebral Palsy. Different body systems can influence the development milestones in children with Cerebral Palsy.

Musculoskeletal System:

Bony structures deformities or impairments are secondary due to:

• Impact of gravity on a body that has poor alignment and moves abnormally
• Abnormal muscle contraction during growth
• Lack of variety of movements and strategies e.g. weight-bearing postures.
  

Neuromuscular System;

In relation to Spasticity and Muscle Fibre, the literature supports the notion that, although spasticity is multifactorial and neural in origin, significant structural alterations in muscle also occur. An understanding of the specific changes that occur in the muscle and extracellular matrix may facilitate the development of new conservative or surgical therapies for this problem. ( see Annexe 1)

Sensory and Perceptual System;

In many children with Cerebral Palsy vision is compromised in relation to postural control and movement, proprioceptive, tactile and vestibular functioning, which creates pathologic patterns and strategies to move and orient the body in space.

Respiratory System:

Many children with Cerebral Palsy have difficulty to maintain respiration while at the same time supporting posture and movement. Infants breathe primarily with the diaphragm which sits high in the thoracic ribcage, with each inspiration, it contracts, pushing down on the abdominal contents. In the infant, the abdominal muscles are not yet working to oppose this force of the diaphragm, and the belly expands. This is called belly breathing. In addition the ribcage is elevated and the ribs horizontally positioned, making the ribcage a fairly rigid structure. This is why the ribcage remains elevated and the spine in flexion in many children with Cerebral Palsy. They have difficulty to expand the rib cage for air exchange and difficulties in exhalation of air to control the speech. The abdominal muscles fail to be used posturally to support lower trunk stability in children with Cerebral Palsy.

Associated Conditions:

Other impairments that CP child develop are skin and digestión problems, motivation, nutrition and growth, déficit of attention, learning difficulties…

Typical Postures and Movement Strategies

This information is based on clinical observation and clinical reasoning from the evaluation and assessment of the impairments, and describes the atypical features for children with spasticity, athetosis, hypotonia and ataxic cerebral palsy.

The child adopts pathologic pattern in the attempt to see or play:

• Head is sustained with asymmetrical hyper-extension, cervical spine is not elongated, not able to move in the 3 planes (frontal, sagittal, transverse) so often develops tightness in extensors and the loss of ROM in the upper cervical spine into flexion.
• No chin tuck.
• Minimal upper to mid-thoracic extension
• Shoulders in extension and Internal/Medial Rotation
• Ribcage elevated with Scapulae Elevated and Abducted
• Forced Thoracic Extension with no elongation of Cervical or Thoracic Vertebrae in 3 Planes
• Forearm remain in pronation
• Wrist in Flexion and Ulnar Deviation, Finger Flexion and Thumb in Adduction

Note: This pattern will correspond to a child with normal development at 1 month, but babies developing normally change this position by controlling the head within 3 planes; Extension, Flexion, Lateral Flexion and Rotation while pushing the surface against gravity.

• No binocular vision. The eyes are not independence from the movement of the head (like a normal child at 3months) so perception of the environment is difficult.
• The jaw remains open (extension) and the tongue retracted, coordination between them is severely compromised, due to these poor alignment of oral structures they will have difficulties in feeding and sound production.
• Quadriplegic kids have extremely difficult using upper extremities, such as reaching out, grasp and release.
  

Quadriplegia:
Lower Limb Observation: |- | valign="top" | Neuromuscular System: Child try to lift the head, so recruits excessive extension of mid-thorax with poor synergy between extensors and rotators cuff of the shoulders (Supraespinous, Infraspinous, Teres minor, Subscapularis: SITS), pectoralis, rhomboids and serratus anterior. This create a specific musculoskeletal feature. With the time and the effort of the kid to upright the head, pectoralis and latissimus dorsi contract bringing more and more the shoulder in extension and internal rotation. In consequence the biceps brachialis is unable to do an eccentric contraction, because the elbow cannot create a base of support in the epitroclea against the gravity and align with shoulder so this create the elbow flexion. The forearm pronators and hand flexors are not fully lengthened.	Neuromuscular System: Erectors of the lumbar spine and abdominal rectucs muscles are easy to recruit because there are superficial. In fact this two muscle and the pectoralis are the ones to bring the centre of mass forward to maintain the sitting position.  Impossibility to rotate or dissociate upper and lower extremities due to the difficulty to recruit multifidus, exterior and interior abdominal oblique’s muscles. Huge contraction of hip flexor muscles, internal rotators, adductors pulling hip into dislocation or malformation of hip joint.  Tightening of hamstrings pull pelvis in posterior tilt. The antagonist muscles; external rotators muscles (gluteus maximus, medius and rotators) cannot co-contract in synergy because of loss of alignment of pelvis and hips. So the muscles are not in the correct anatomical position to contract correct. Nevertheless the flexors, hamstrings and adductors have longer lever arm that enable them to contract more than their antagonist.
Musculoskeletal Feature: The quadriplegic kid is able to extend the lumbar spine more than the thoracic and cervical spine, Hips in flexion, grater trocanter in anterior torsion and lumbar lordosis. Legs in internal rotation and feet in pronation, hindfoot in eversion, plantar flexion and forefoot in adduction.  Scissor Pattern