What is Cerebral Palsy?
Cerebral - of the brain, Palsy: lack of muscle control
Cerebral palsy is an umbrella term that refers to a group of non-progressive brain injury or malformation disorders that affect a person's ability to move.
It happens due to damage to the developing brain either during pregnancy or soon after birth.
Children with cerebral palsy may also have visual, hearing, speech, learning, epilepsy and intellectual problems.
Types of Cerebral Palsy
- Spastic Cerebral Palsy (fig 1)
- Dyskinetic Cerebral Palsy
- Dystonic (fig 2)
- Choreoathetoid Cerebral Palsy (fig 3)
- Mixed Cerebral Palsy
Areas involved (fig 4)
- Monoplegia: affects one limb, usually an arm
- Hemiplegia: affects one side of the body including arm, leg, and trunk
- Diplegia: affects either both the legs or both the arms
- Quadriplegia: affects all four limbs
Cerebral palsy happens because of problem in brain development while baby is growing inside the mother's womb, or because of brain damage during birth or soon after birth.
Problems before birth include:
- reduction in the baby's blood or oxygen supply
- an infection caught by mother such nas cytomegalovirus, rubella, chickenpox or toxoplasmosis
- an injury to the unborn baby's head
- Genetic disorders such as Down's syndrome, Rett's syndrome
Problems during or after birth include:
- Asphyxia: lack of oxygen to the brain during a difficult birth
- an infection of the brain such as meningitis
- a serious head injury during forceps/suction delivery or after birth due to external trauma
- choking or nearly drowning, causing lack of oxygen to the brain
- a very low blood sugar level
- a stroke: sudden blockage of blood flow to the brain
Some pregnancies or births are at high risk of such brain damage. These include:
- Prematurity (birth before the 37th week of pregnancy): babies born at 32 weeks or earlier are at a high risk since the fetus has not grown completely
- a low birth weight
- a twin or multiple pregnancy
- the mother being 35 years of age or older
- the mother having unusually low blood pressure or high blood pressure
- Bacterial and viral infections
- Prenatal exposure to drugs and alcohol, stress, heavy metals including mercury poisoning from fish
- Stiff or floppy posture
- Excessive lethargy/poor cry or irritability/ high pitched cry
- Poor head control
- Weak suck
- Tongue thrust
- Feeding difficulties
Common physical symptoms
- Delayed milestones (fig 6)
- Stiff musclesor floppy body (fig 7)
- Fidgety, jerky or clumsy movements
- Weak arms or legs
- Difficulty in walking (fig 8)
- Bad posture (fig 9)
- Deformities (fig 10)
- Poor vision (fig 11)
- Poor hearing (fig 12)
- Poor speech
- Swallowing difficulty
- Poor cognition (fig 13)
- Abnormal behavior (fig 14)
- Maximize independence (fig 15)
- Prevent deformities (fig 16)
- Maximize communication(fig 17)
- Social & peer interaction (fig 18)
Currently there is no cure for cerebral palsy. Treatments available help in minimizing the symptoms, preventing future complications, and maximizing functional independence.
A multidisciplinary approach is being followed to achieve the above goals. This includes:
- Occupational therapy
- Speech therapy
- Treatments for feeding problems
- Treatments for drooling
Physiotherapy is one of the most important treatments for cerebral palsy.
Physiotherapy helps toincrease strength of weak muscles, encourage movement, lengthen the tight muscles, prevent contractures of muscles, alleviate pain, thereby enhancing mobility and maximizing independence. Physiotherapists use techniques such as NDT, Bobath, Rood's approach, stretching, gait training, selection of appropriate aids and orthosis to achieve the above goals. also
Occupational therapy as the name suggests identification of the problems that a child faces in day to day tasks and to addresses them so as to make the child enable to carry out complex movements involved in daily tasks such as bathing, dressing, transferring to the toilet, etc. Also, parents and caregivers are educated for possible modifications which can be done to assist the child in a functional activity. Thus occupational therapy helps boosting children's and parents' self esteem and confidence, which in turn helps the children to become independent with their daily activities.
Speech and swallowing therapy
Children with cerebral palsy may have difficulty in speech and language development, and many a times experience difficulty with facial epressions and hand gestures. Speech therapy thus aims at improving oral motor skills, speech and language skills. Children who cannot speak, are taught sign language, or how to use special equipment like computer/tablet for communication through pictures, etc. A speech therapist also provides guidance regarding hearing aids if hearing deficit is the cause of delayed speech.
Children with cerebral palsy may also suffer from chewing and swallowing difficulties due to weakness of masticatory (chewing) muscles and pharyngeal (swallowing) muscles. Difficulty in swallowing can be life threatening since it can cause severe choking or food entering the wind pipe causing difficulty in breathing, or it can cause aspirational pneumonia of the lungs resulting in long term ailments and malnutrition. Thus a speech therapist teaches children and caregivers swallowing techniques, appropriate positioning and oromotor exercises, makes dietary changes as in the consistency of food (soft/liquid/mashed), etc. In more severe cases, a feeding tube has to be inserted into the stomach through the nose or directly into the stomach through the skin of the abdomen by a trained gastroenterologist.
Medications are given to children with cerebral palsy to mange their difficult to manage symptoms such as seizures, spasticity, dystonia, pain, drooling, etc which come in the way of child's development and the therapy. Parents have to get a consultation from a pediatric neurologist or pediatrician for medical assitance.
Following are few examples of common symptoms and medications advised:
- Seizures: carbamazepine, phenytoin, valproate, valproic acid, gabapentin, lamotrigine, levetiracetam, topiramate, etc.
- Spasticity: baclofen, clonazepam, dantrolene, diazepam, etc.
- Dystonia: levodopa, procyclidine hydrochloride, diazepam, lorazepam, clonazepam
- Pain: acetaminophen, ibuprofen
- Drooling: Glycopyrrolate
- Constipation: Dulcolax, magnesium hydroxide, lactulose
- Behavioral problems: medications for ADHD,
Children with cerebral palsy may develop contractures of muscles resulting in limited joint range, joint and bony deformities such as scoliosis, dislocation of hip, etc which need corrective surgery like tendon release, corrective osteotomy. These surgeries are performed by pediatric orthopedic surgeons.
The treatment options that are currently available help the patients in managing the symptoms to some extent, but they do not repair the underlying brain damage. Therefore developing a standard therapeutic approach is a need of the hour. Scientists and researchers worldwide are now considering stem cell therapy as a potential treatment option for patients suffering from cerebral palsy.
How stem cell therapy works in cerebral palsy
Till very recently, it was believed that brain damage during birth is irreversible .However, now with emerging research; we understand that it is possible to repair the damaged brain tissue using cell therapy.
Stem cells obtained from various sources can be used for stem cell therapy. Our approach, at NeuroGen BSI makes use of autologous bone marrow derived mononuclear cells (BMMNCs) for transplantation. The transplanted stem cells have the ability to migrate to the area of the damaged tissue in the brain and home in those affected areas to help repair the damage. They release several trophic factors that decrease the process of damage in those areas and also differentiate into several cell types of the nervous system such as oligodendrocytes, glial cells and other cells of the nervous system. The main mechanisms that help tissue repair and regeneration include:-
- Prevention of cell death in neuronal population
- Establishment of new blood vessels
- Cell multiplication and integration
- Establishment of new neuronal maps in the brain in order to learn new functions.
These mechanisms repair and regenerate the damaged tissue, restoring activity in the affected area, which translates into clinical improvements .This plays a great role in improving the overall quality of life. Also autologous BMMNCs do not show any adverse side effects and they do not face any immune rejection. Also, they are obtained from the same patient and thus are free of the ethical issues surrounding the use of stem cells.
With our comprehensive approach and our aim to guide and support our patients through thick and thin, we have successfully treated over 276 patients with cerebral palsy. The patients who had reached a plateau stage, after stem cell therapy have shown colossal improvements in their symptoms. Most of the symptoms that are seen in cerebral palsy are oromotor/speech, balance, trunk activity, upper limb activity, lower limb activity, muscle tone and ambulation. Together, they affect activities of day to day life.
Graph demonstrating improvements after stem cell therapy in cerebral palsy.
We analysed the effect of stem cell therapy in 267 patients diagnosed with cerebral palsy. Changes in common symptoms like oromotor/speech, balance, trunk activity, upper limb activity, lower limb activity, muscle tone, ambulation and Activities of Daily Living were recorded on follow up. The improvements were graded as no change, mild improvements, moderate improvements and significant improvements. Analysis revealed that out of 267 patients, Overall 91.01% patients showed symptomatic improvements. 8.98% of patients showed no improvements in any of the symptoms. Mild improvements were observed in 29.96% of patients, moderate in 41.19% of patients, whereas, 19.85% of patients showed significant improvements. We observed that patients who continued regular exercise program at home under supervision of professional therapists showed significant improvements. Patients who did not follow regular rehabilitation showed mild improvements. Therefore, in our experience stem cell therapy should be followed by regular rehabilitation under supervision of a therapist.
The positive changes that we record in our patients are not just restricted to their symptomatic improvements, but also bring about a constructive change in their brain metabolism as observed in their PET-CT scans.
Intrathecal autologous stem cell therapy is safe, feasible and effective treatment strategy for children with cerebral palsy. This repairs the underlying brain damage which can also be objectively seen on PET CT scan of brain along with improvement in functional and achievement of milestones in children. Stem cell therapy along with standard treatment augments the development and improves the quality of life of these children.
Can my child get better?
Cerebral Palsy refers to a permanent condition and problems related to this condition remain throughout the lifetime, however, these children can cope up with the condition as they grow. Various treatments available often bring out improvement in the condition, though it is not a cure.
Can my child's condition deteriorate after stem cell therapy?
No.Your child's condition will not deteriorate further unless there are any underlying factors such as any illness or infection which may cause the child's progress to come to stand still.
Why do the muscles become tight or why deformities happen?
Stiffness in the muscles is due to spasticity, contractures or both. It is difficult to distinguish between spasticity and shortening and during growth spurts the child's bones will grow more rapidly than muscles, which lead to tightening and activities like walking or standing makes it more apparent. Treatment for spasticity and shortening is different.
Can emotional stress hinder my child's progress?
Yes it can, especially when the child is pushed or forced to achieve a skill, they may react by becoming stubborn or may refuse to cooperate, and this may certainly be a reason for lack of progress but which actually does not mean that the child's condition is deteriorating. But if the child loses previously acquired skills, then it is important that you should discuss it with your therapist or doctor.
Will my child learn how to walk independently?
Every child with cerebral palsy is different from each other, and so it is not possible to come to a conclusion. Unless the child has been observed over time by the peadrician and therapist. As a parents you are always curious and worried about your child's walking. However children with mild cerebral palsy can learn to walk independently, children with moderate cerebral palsy may walk with a stick or walker and children with severe cerebral palsy are generally wheelchair.
Will my child learn how to talk?
Yes and no. Children with cerebral palsy may not have any difficulties to talk ,while few may have controlling the movement s around the mouth or delay in developing learning skills. Children with cerebral palsy will need help from a speech therapist to learn how to use alternative methods of communication or develop speech.
Can my child be independent?
The aim of all the treatment is to encourage these children to learn to be as independent as possible. As parents it is always important for you to encourage your child to do as much as possible. Children with mild cerebral palsy may not have any problems achieving independence but the ones with severe cerebral palsy may require assistance from others throughout their lives.
Can my child develop behavior problem?
Some children with cerebral may have behavioral problems, which can be difficult to manage. They may also be frustrated, due to inability to move, talk. Clinical psychologists play an important role in addressing behavioral issues and help develop and motivate and encourage child to feel good about them and be happy.
Can my child lead a normal expectancy?
Most children with cerebral palsy are healthy and lead a normal life. Children with severe brain damage associated conditions such as epilepsy may be a risk of reduced life expectancy.
Will my next child also have cerebral palsy?
It is extremely unlikely for your second child to have cerebral palsy. Please ask your doctor to guide you about genetic counseling and future care in pregnancies.
1. Ashrut Yadav
Master Ashrut Yadav, a 5 years old male child is a known case of Diplegic Cerebral Palsy. Ashrut's chief complaints were drooling, unclear speech, difficulty in standing and walking without support, poor hand functions of left arm, affected coordination, poor sitting and standing balance, Improper Gait, tightness in arms and legs, poor cognition, etc. Like every parent Mr. and Mrs. Yadav consulted many doctors from different parts of India, from big to small hospitals, and also tried homeopathy. But no one said that there can be any improvement. Everyone said nothing can be done, shattering all their hopes each time. Ashrut used to go for physiotherapy but not on regular basis. "In a local function we met a family having a child like Ashrut, they told us about NeuroGen Brain and Spine Institute in Mumbai, we immediately started our search. I went through their website, spoke to Dr.Nandini Gokulchandran on phone about my child's case and decided to take Ashrut to NeuroGen for Stem Cell Therapy."- says Mr.Yadav.
Ashrut came to NeuroGen in August 2015, where he underwent Stem Cell Therapy along with a customized rehabilitation program which aimed at increasing the strength of affected areas, improving dissociations, posture, balance, walking, grip, cognition, and increasing overall stamina of the patient. Mr. and Mrs. Yadav found new hope with NeuroGen's Stem Cell Therapy and were motivated and positive for their child after going back home and they continued with his rehabilitation.
There were tremendous improvements seen in Ashrut's condition on follow up in December 2015:
- Attention had improved; he paid attention towards things that interested him.
- Cognition had improved, started identifying few colors, alphabet 'A'.
- Memory became better.
- Lying, sitting and standing posture had improved.
- Crawling was better. Weight shifts had improved in walking.
- Neck holding had improved.
- Sitting static balance had improved from fair to good.
- Standing static balance had improved from fair to good.
- Walking static balance had improved.
- Holding objects with his hands, fisting his hand and opening had improved compared to earlier.
- Walking pattern had improved and knees were straight now.
- Foot movement had improved from poor to fair.
- He was able to assist mother in grooming, upper body and lower body dressing.
- Sitting was better than before (more erect). Sitting in 'W' psoture was lesser.
- Standing posture was better.
- Kneeling had improved.
- He tried to pick up objects from floor.
- Tightness had reduced (lower limb more than upper limb).
- Balance had improved. Had started walking independently without support.
- Drooling had reduced.
- He could drink water by using both hands better than before.
- He could eat with spoon better than before.
- Handwriting had improved. Earlier, he used to scribble, now he could write better than before.
- Floor to bed transfer was better. He could climb up on bed with support now.
Life of this cute child Ashrut yadav has changed after Stem Cell Therapy. The child can play a little better; can understand better, he can enjoy his childhood a little better today. His parents decided to give Stem Cell Therapy to Ashrut for the second time in March 2016 and are hoping for their son to attain near normalcy. "After consulting many doctors and hospitals my search finally ended at NeuroGen BSI where we got great positive results. Today we are more positive, motivated and very well guided in our path to help our child recover. I would suggest all parents like us should at least go to NeuroGen BSI (Mumbai) once." - concludes Ashrut's Father.
2 Diyan Jain
Master Diyan Jain, 5 year old boy from Vijayawada is a known case of Cerebral Palsy (Diplegic). " Our major concern for Diyan were his delayed milestones, thanks to our family and their support, we did not let the reality affect us and started looking for various treatment options. In April 2016 Diyan's Physiotherapist asked Mr. & Mrs. Jain to check Stem Cell Therapy at NeuroGen Brain & Spine Institute, Mumbai. Diyan's parents found new hope for development of their son. In the urge of not delaying the treatment further they decided to undergo stem cell therapy for Diyan in May 2016.
Diyan's complaints according to his parents were inability to transfer from one place to another, stooped sitting, tightness in legs, thighs, calves, difficulty in crawling, inability to stand and walk independently, difficulty in gripping objects, cognition and problem solving not age appropriate, inappropriate eye hand coordination.
At NeuroGen, Diyan underwent Stem Cell Treatment followed by intensive neurorehabilitation which included physiotherapy, occupational therapy, cognitive and behavioral therapy, special education which aimed at reducing spasticity and tightness, improving movement control, gross and fine activities, problem solving, etc.
Following were the improvements seen in Diyan's condition six months post Stem Cell Therapy
- He could sit in erect manner now.
- Sitting posture had improved.
- His balance as well as reaching out for things had improved.
- He could walk with one hand support. Earlier he couldn't do it.
- He could now do side walking minimum 5 steps each side with 2 hands held.
- Higher mental functions had improved. He could now follow more commands at a time.
- Grip in left hand had improved and tightness had reduced.
- Walking pattern had improved.
- He had started taking bath by himself and brushing by himself.
- Overall tightness of the body had improved.
Diyan had now started going to school. "Our experience at NeuroGen BSI was good, we are satisfied with the guidance we got, the doctors and the entire support staff are very helpful. Stem cell therapy has given that push in Diyan's progress and a hope in our minds that he will soon start living an independent life. Looking at Diyan getting so much love from everyone who meets him is very motivational for us" - concludes Mr.Gautam Jain, Diyan's father.