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Mild Cerebral Palsy

By Helen Harrison

This discussion is interesting for a number of reasons. First of all, I am reminded that many preemies who have a primary diagnosis of spasticity also have areas of hypotonicity. With my son, his hypotonicity is in his face, mouth and throat muscles which cause him to gag when eating ( except for when it's chocolate -- then he does fine). Otherwise he is predominantly hypertonic. It is my understanding that many preemies have a mixed pattern of motor dysfunction, that is, they have hypotonia mixed with hypertonia.

Which gets us to the definition of CP. I am currently working with an international research project to compare school-age outcome data on preemies from around the world. To compare data, you must be working with similar definitions of certain problems -- like CP. Well, as far as I can see there is no standard definition for CP, and whether or not a child is "diagnosed" with CP has more to do with the person doing the evaluating than with any objective standards. On this project, anonymous case histories are being circulated among the physicians to see how similarly they make this diagnosis. My feeling from the results so far is that the diagnoses are not at all similar.

I have often been contacted by parents whose children were dismissed from follow-up clinics as "normal" only to be diagnosed (at the very same time) as having CP by a private pediatrician or neurologist. Or vice versa -- the pediatrician says everything's normal and the follow-up clinic diagnoses CP. The point I'm getting at here is that the diagnosis of CP is highly subjective.

Many of our kids have motor problems that look a lot like CP but are never called that. Things like toe-walking, coming to standing (on toes) before being able to maintain equilibrium when sitting, rolling over precociously from stomach to back (but not the other way), precocious ability to hold the head up in the prone position (but head lag when the baby is pulled up from his or her back). These can all be signs of spasticity (CP). Many of the behavioral peculiarities we have noted in our babies can also be signs of CP --excessive irritability, often with a high-pitched cry; sleeping difficulties; tendency to dislike the bath -- arching the back rigidly as soon as the feet touch the side of the tub; feeding problems-- poor suck, frequent spitting up, difficulties coordinating sucking and swallowing; jittery or jumpy behavior, easily startled; stiffness when handled. Any baby with two or more of these attributes, particularly in combination with premature birth, is at risk for CP. (Bennett FC.Cerebral palsy: The why and how of early diagnosis. Consultant. June 1984) This doesn't mean that all, or even most, of our children with these attributes will be labelled as having CP. But in my view, it means something similar is going on with them and with the kids who ARE labelled as having CP. I personally feel it is more useful to think of children with these difficulties as being at varying stages on a continuum of motor problems rather than dividing them into (probably phony) categories of "CP" or "no CP."

Some children with tone problems are eventually diagnosed with "transient dystonia." That means they have abnormal tone in the first year of life which gradually becomes less noticeable, and does not (usually) result in a CP diagnosis. These children do, however, go on to have higher rates of learning and behavior problems and minor motor problems such as clumsiness than do children who always have normal tone. Some physicians feel that this constellation of problems is probably caused by an underlying "brain trauma." (Not all brain trauma results from bleeds or can be seen in scans.)

Whether PT fixes or ameliorates any of these problems is the big question. I think the evidence strongly suggests that it doesn't, and that many kids "recover" from transient dystonia without therapy. (The syndrome and its natural resolution was described long before physical therapy came into vogue.) But I urge each of you who is interested to read the articles on PT for yourself, discuss them with your pediatrician and come to your own conclusions.

References:

Rothberg et al. Six year follow-up of early physiotherapy intervention in very low birth weight infants. Pediatrics. 1991; 88:547-552.

Palmer et al. The effects of physical therapy on cerebral palsy:  A controlled trial in infants with spastic diplegia. New England Journal of Medicine.1988; 318:803-8.


Helen Harrison is the well known author of The Premature Baby Book, often referred to as the "Bible of Prematurity" by older preemie parents. These observations are excerted with permission from posts to the prematurity parents support internet mailing lists on prematurity: Preemie-child and Preemie-L.
 


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