Managing cerebral palsy

- [Voiceover] So this little boy here has been diagnosed with cerebral palsy, and we want to look at how we might go about managing this condition. Now you might have noticed there that I said that we want to manage it, I didn’t say anything about curing his cerebral palsy, and that’s because cerebral palsy is a lifelong disorder. The damage that has occurred in the movement centers of the brain and caused cerebral palsy, it’s permanent. We don’t really have a way of undoing or totally fixing this damage. So we can’t really cure or even completely treat cerebral palsy. So instead what we want to do is focus on reducing or managing the problems that someone with cerebral palsy experiences. So in order for us to figure out what we might need to do, let’s start off by checking out this spectrum here that shows us the range of movement impairments that someone with cerebral palsy can experience. Now, people with cerebral palsy don’t just have movement impairments, and we’ll talk more about some of the other problems that can arise shortly. But for now I just want to focus in on this one aspect of cerebral palsy. So the spectrum here is pretty wide, right? So at the mild end of our spectrum we’ve got a kid here who seems to be able to walk and run around without much assistance. And then on the severe end of our spectrum we’ve got a kid here in a wheelchair who needs a lot of assistance to get around. So these are kind of the two extreme ends of the spectrum of movement impairments that we can see in someone with cerebral palsy. So someone with cerebral palsy can fall kind of anywhere along this wide spectrum, and where they fall, well that depends on the kind of brain damage that they have and how bad that damage is. So when we look at this spectrum you can probably imagine that someone over here on the spectrum is gonna have very different needs than someone over here on the spectrum. So what we need to do to manage this person’s cerebral palsy well, it might look a little different compared to what we need to do to manage this person’s cerebral palsy. So considering the diversity of movement impairments that different people with cerebral palsy can have, well you can imagine how diverse managing cerebral palsy can be between these different people cause we need to individualize our management plans to make sure that we’re addressing the strengths and the limitations that each person with cerebral palsy has. So let’s check out some of the tools that we have to manage cerebral palsy. So if we start off on the mild end of our spectrum here, what might we see over here? Well for someone on the mild end of our spectrum if they have spastic cerebral palsy, so the most common type of cerebral palsy, where the affected muscles are really stiff, well they might have a bit of this muscle stiffness. And you might remember that this stiffness occurs because the muscles are actually too active. They’re getting too many messages from the neurons that control them, and that’s what makes them really stiff. So one thing that we can do to help reduce this muscle stiffness, is we can try to intervene here with medications that block some of those extra signals going from the neurons to the muscles. So one of these medications that we often use for just this purpose in someone with cerebral palsy is actually botox. The same botox that you’ve probably seen on late night tv commercials about getting rid of wrinkles on your face. So it’s actually interesting how botox works. It’s actually a neurotoxin, it relaxes muscles. So in the case of those wrinkles in the tv commercials, botox relaxes the muscles that cause the wrinkles. And so for cerebral palsy it does a really similar thing. It actually does the exact same thing. It makes the stiff muscles in spastic cerebral palsy less stiff, but there’s a bit of a catch. Botox doesn’t really like to travel very far, so it needs to be injected straight into the muscles that we want to make less stuff. So we do our little botox injection and then the toxin, what it does is it actually prevents the neurons from being able to talk to and stimulate the muscles, and it does this by blocking the release of a chemical called acetylcholine from these neurons. And it’s the acetylcholine that the neurons are sending to the muscles to stimulate them and make them active. So when botox this acetylcholine message from even reaching the muscles, the muscles aren’t able to be so active anymore, and this helps reduce that muscle stiffness. Now, spastic cerebral palsy isn’t the only type of cerebral palsy that we can manage by using medications. So for dyskinetic cerebral palsy, where the main problem is too much movement, the problem again is that the muscles are just too active. But this time we don’t manage the problem by using medications at the site of the muscle like we did with spastic cerebral palsy. Instead we manage the problem by using medications that work on the control center, the brain. So whereas before we used botox injections in specific spastic muscles that we knew to be really stiff, with dyskinetic cerebral palsy we kind of have to tone down the activity of all of the muscles, the whole system. We can’t just treat one area or one muscle group like we can with spastic cerebral palsy. So to have this global full body effect we use a medication called an anticholinergic. So this helps reduce those extra movements that someone with dyskinetic cerebral palsy experiences. Because remember, acetylcholine is one of the chemicals that’s required to make movements of our muscles. And an anticholinergic is going to reduce the activity of acetylcholine at all places in your body, right? Anticholinergic; so less movement. Now you might remember that there’s also a third type of cerebral palsy. Ataxic cerebral palsy, where the person is really shaky and unstable on their feet. Now, with this type of cerebral palsy we don’t really have a medication that can help with the shakiness or the instability, but it’s not uncommon for people with ataxic cerebral palsy to also have spastic cerebral palsy, or dyskinetic cerebral palsy. So sometimes people with ataxic cerebral palsy may also be on some of these medications to help with their spasticity or their dyskinesia. So as we move down our severity spectrum here we often need to add a few more things to our management plan. So while we’re on the topic of medications, one problem that can arise is that this spasticity, this muscle stiffness, can often be worse or more widespread in someone who’s further down our severity spectrum here. So when this is the case sometimes botox isn’t enough to deal with their spasticity. Remember, with botox we need to inject it straight into that muscle that’s effected, because botox does not like to travel very far. But if we have too many effected muscles that’s a lot of botox injections. So when spasticity is too widespread to be managed by botox alone, we need something else that can act in a more widespread kind of way. So we actually have a medication called baclofen that comes in and blocks the activity of the neurons in the brain that are ultimately responsible for that increased muscle activity that causes stiffness. So we can induce some global muscle relaxation with this medication. Now, as we’ve moved down our spectrum here you can see that crutches or maybe wheelchairs might be needed to help the person with cerebral palsy get around, because some parts of the body might be too stiff or maybe too shaky for them to get around without some extra support. And one thing that we need to look out for when this is the case is we need to make sure that any muscles that aren’t being used as much as they normally would, we don’t want those muscles getting too weak, or stuck or twisted in abnormal positions. Because when this is left over time it can lead to joint dislocations that can cause muscle, tendon, or bone damage that might require surgery later on to fix. So an important part of managing cerebral palsy, and this is true across our whole spectrum here and across the different types of cerebral palsy, is making sure that those effected muscles are used and stretched as much as possible to try to prevent damage from disuse or abnormal positions later on. And actually, most people with cerebral palsy, regardless of where they fall on the spectrum, will attend regular physiotherapy to keep their muscles as healthy as possible. So if we head down to the far end of our spectrum here this is where we might see the need for surgery to correct for problems that can occur when the muscles are very stiff and joints like the hip can become damaged from the legs being in abnormal positions that put strain on the joint. Sometimes surgery is also used to try to lengthen those muscles and tendons that have been shortened because the muscles are so stiff and contracted. So at the end of this spectrum there are some other problems that can crop up that might also need to be managed. So sometimes the muscles in the mouth and the throat, that are really important for eating and swallowing, well these muscles can also become really stiff and this can make it really hard for the person to eat normally, so they might need a feeding tube to make sure that they’re getting all of the nutrients that they need. They might also have trouble closing their mouth properly, and controlling their saliva because the facial muscles can become really stiff. So drooling may become a problem that needs to be managed with medications like botox injections into the effected muscles. And remember, right now we’re talking about people that are a bit further down our spectrum here. This isn’t what happens for everyone with cerebral palsy. And remember that cerebral palsy is ultimately caused by damage to movement centers in the brain. So sometimes this damage can lead to other disorders like epilepsy, which is where the person has recurrent seizures. And this is actually really common in people with cerebral palsy. About half of people with cerebral palsy also have epilepsy. So we would need to manage other disorders like epilepsy with its own medications. So for epilepsy these medications are called anticonvulsants. So these are some of the ways that we can work to manage cerebral palsy, and management will sort of be tailored to where a person might be on this spectrum.