Cerebral palsy (CP) is a movement disorder, muscle tone or posture that is caused by damage that occurs to the immature, developing brain, most often before birth. In general, CP causes impaired movement associated with abnormal reflexes, floppiness or rigidity of the limbs and trunk, abnormal posture, involuntary movements, unsteady walking, or some combination of these. Children may also have problems in their sensual organs, sensations and intellectual capability. CP prevalence is 2-3 per 1000 births.
Types of CP
CP has various types based on the involvement in the brain: Spastic, dyskinetic, ataxic.
1. Spastic CP: It is the most common form of CP. It constitutes 75% of all cases. In most of the patients, muscles are loose in the beginning, however spasticity develops gradually with stiffer muscles. Spastic CP is divided into three types: Hemiplegic, diplegic and total.
- Spastic hemiplegic CP: Most of the patients can ambulate spontaneously or with the help of rehabilitation in their ages between 1 and 2,5.
- Spastic diplegic CP: Although all four extremities are involved, legs are apparently more affected than arms. This is the most common type of spastic CP. Most of the patients can ambulate in their ages between 4 and 7.
- Spastic total involvement CP: Since most of the patients haven’t developed head control and sitting balance, it is functionally challenging for them to reach an ambulation level. Spasticity in these patients is generally accompanied with some dyskinesia.
2. Dyskinetic CP: This type constitutes %15 of all CP cases. It is frequently related to the birth asphyxia. It is characterized with involuntary movement patterns due to extrapyramidal system damage. These children are generally hypotonic at birth. Poor head and trunk control (Hypotony) make the maintenance of proper posture difficult. That hypotony lasts for a long time shows that involvement is severe.
Dyskinetic movement patterns characterized as dystonia (twisting and repetitive movements), chorea (dance-like irregular, unpredictable movements), athetosis (slow, stormy movements) and tremor emerge between the ages of 1 and 3. Oral-motor problems such as dysarthria, salivating, and swallowing difficulties are observed.
Dyskinetic CP is divided into two as dystonic and choreoathetotic: Dystonic CP is characterized with posture defect and unstable tonus. Tonus fluctuations defined as hypertonia exist. Since tonus can be easily stimulated and due to the fluctuations, voluntary movements are made with difficulty. Choreoathetotic type CP is characterized with hyperkinesia and hypotonia. Although there are fluctuations, tonus occurs less. In the distal extremities, more apparent and uncoordinated involuntary movements are distinctive. While involuntary movements decrease during the sleep, they increase with voluntary activities and it is affected by patient’s emotional situation. Its rehabilitation is harder as compared to other types.
3. Ataxic type CP: It is rarely seen. Balance and coordination disorders are prevalent. Due to the muscle coordination losses, rhythm, strength and sensitivity of movements deteriorated. In general, deep tendon reflexes (DTR) are normal. Hypotonia, nystagmus and tremor are frequent. Intellectual capability is normal.
4. Mixed type CP: Spasticity is accompanied by ataxia and/or dyskinetic findings.
Rehabilitation of CP
Most patients become independent and ambulatory in their daily life activities with the help of rehabilitation. Diplegic patients (whose legs are affected) becomes spastic after a loose period. Standing up and walking delay. Children who can gain sitting balance until their age of 2 may become ambulatory. Progress is slow in one fourth of tetraplegic children (whose arms and legs are affected), and these patients can become ambulatory and they can perform their daily life activities with slight limitations. In half of them, the progress is in a moderate level, and they cannot be fully independent. Nevertheless, they can reach an adequate level of functional capacity. Remaining one fourth of the patients experience heavy progress, and these children need a lifelong care.
Rehabilitation program for children with CP is arranged based on their age and functional conditions. Their rehabilitation includes:
- Physical therapy
- Occupational therapy
- Speech and swallowing therapy
- Private education
- Braces / Orthoses
- Medications
- Surgery
These therapies should be carried out by an interdisciplinary team in coordination with and under the leadership of a Physical Medicine and Rehabilitation physician.
One of the patient groups who benefit from rehabilitation robotics is CP.