Seizures and Cerebral Palsy

By Lee Vander Loop
CP Family Network Editor

As the parent of 4 grown children, one of whom has spastic quadrapalegia cerebral palsy, I feel like I’ve experienced my share of parental stress and fears of raising 4 children and dealing with the challenges of maintaining the best quality of life possible for my daughter with CP.

I’ve experienced the heart stopping moment of having my 3rd born not recognize me after a concussion and a multitude of other parental trials and worries, but nothing could prepare me for watching my daughter with cerebral palsy experience her first grand mal seizure also known as tonic-clonic seizures.

No training, literature, insight or experience can prepare you for the heart stopping, gut wrenching experience of watching your child suffer through a seizure. Whether it be the first seizure or 50th, they all feel like the first with the overwhelming sense of fear, helplessness and frustration that comes with the inability to stop your child’s suffering.

Not all children with cerebral palsy suffer from seizures, just as not all children who experience seizures or epilepsy have cerebral palsy. Additionally, although learning disabilities are common with children who experience seizures, not all children who suffer with seizures experience learning disabilities.

Depending on the severity of the trauma and cerebral injury, infants who suffer injury due to a birthing trauma may experience seizures immediately after birth. In the case of my daughter who suffered severe global cerebral insult as a result of neonatal asphyxia, she experienced 3 days of uncontrollable seizures immediately after birth.

What is a Seizure

Seizures differ, depending on which portion of the brain is involved. Nerve impulses are constantly being transmitted from brain cells and processed by neurotransmitters. Seizures occur as a result of abnormal and excessive discharges of nerve impulses originating from certain brain cells. Some of these excess impulses reach skeletal muscle fibers and trigger the violent contractions witnessed with a variety of seizures.

Groups of Seizures

Focal Seizures occur in only one part of the brain or one hemisphere. Generalized seizures occur in both hemispheres of the brain.

Atonic Seizures are characterized by sudden loss of muscle tone, particularly in the lower extremities, often resulting in falls which puts the individual at risk for head injury and other physical injuries.

Generalized Tonic-Clonic Seizures also known as generalized convulsions or grand mal seizures are commonly seen with cerebral palsy.

Tonic Seizures spread throughout the brain, and are normally followed by unconsciousness, twitching legs and arms, convulsive body movements, and loss of bladder control. A child may bite their tongue during such a seizure. The “tonic phase” of these seizures is characterized by sudden muscle contractions and rigidity (hypertonia/spasticity).

Clonic Seizures – Involves recurring and coordinated jerking movements involving both sides of the body as well as rhythmic contractions of the affected muscle groups and violent and extreme gross motor movements. I’ve had the misfortune of witnessing a tonic-clonic seizure with my daughter. She was literally vibrating across the bed with the convulsive gross motor involvement.

Complex Seizures – Involve involuntary but possibly coordinated movement such as lip smacking, chewing and abnormal oral motor activity. With my daughter I called these “birdie seizures”. The oral motor involvement she exhibited involved repeatedly opening and closing her mouth, bringing to mind a baby bird in a nest waiting for food.

Myoclonic Seizures – Characterized by sporadic jerking movements, usually involving both sides of the body, that may progress to violent gross motor convulsive movements.

Partial (focal) Seizures are confined to one part of the brain and may be simple or complex. Partial (focal) seizures result from electrical impulses from one part of the brain and are usually a motor or sensory seizure that is restricted to one side of the body. The individual remains conscious. However, if the seizure progresses to a more generalized seizure, a loss of consciousness will occur.

Petit mal (absence) Seizures – Also known as Absence Seizures with this type of seizure a child may appear to be “staring off into space”, and will be unresponsive to stimulation or their environment. I’ll never forget the “vacant stare” my daughter exhibited the first time I saw one of these seizures. It was obvious, even to me, that something was wrong. I had never witnessed such a seizure. These seizures don’t pose the same hazard some seizures do, but they can put a child at risk of aspiration if they occur while a child is eating.

Fever (febrile) Convulsions- Febrile seizures are convulsions brought on by a fever in infants and small children. During the seizure a child may lose consciousness accompanied by tremors or shaking. A majority of febrile seizures are harmless and there is no evidence to suggest that they cause brain damage. However, children who have experienced febrile seizures that are lengthy or that recur within 24 hours or children with cerebral palsy are at greater risk of developing epilepsy.
The National Institute of Neurological Disorders and Stroke (NINDS) provides a comprehensive online fact sheet on Febrile Seizures, provides a detailed and informative description of this type of seizure as well as information on diagnosis and treatment.

Simple Partial Seizures - Cause muscle twitching, chewing movement and numbness or tingling. Partial complex seizures- Are characterized by a brief loss of consciousness, behavioral, emotional symptoms, loss of memory and automatisms. Temporal lobe and frontal lobe seizures are often in this category.

Diagnosis

EEG – Your child’s neurologist will probably want to do an Electroencephalogram (EEG) if they suspect seizure activity. Although EEGs are often helpful in diagnosing some types of seizures, it may not detect all. EEG’s are typically performed in the hospital’s sleep clinic and involve placing electrodes on the child’s scalp

Brain Scans and MRI – The neurologist may order a CAT scan or Magnetic Resonance Imaging (MRI) to be performed. Although these studies don’t show the electrical impulses, they may show lesions or other possible suspected causes of seizure activity.

Video EEG – This study is usually performed overnight at a hospital’s sleep clinic. It involves a video camera and constant EEG monitoring though out the study. With the video and EEG combined, the physician can collate any suspected abnormal physical motor occurrences with the EEG, better identifying the seizure activity with the physical manifestations.

Document It

If you suspect your child may be experiencing seizures, keep a journal and document episodes or behaviors you suspect to be seizure related. If possible have some one video tape the episode. This will give your child’s pediatrician or neurologist insight into what you are witnessing, since it’s unlikely your child will experience a seizure during your 15-30 minutes visit with the physician.

In the case of documentation, note duration of the episode, did you child becomecyanotic (turn blue) or have blue lips which would indicate they weren’t breathing properly, what was your child doing at the time, note any abnormal behaviors your child may have exhibited that made you suspect the behavior as seizure activity.

If your child already has a diagnosis of seizure and you don’t feel that their current medication is managing their seizures effectively, again, keep a journal of any suspected break through seizure activity you may see. There are many medications and combinations of medications that can be used for seizure control. If the seizures are adversely impacting your child’s quality of life, don’t give up. Persevere and continue to question your child’s physicians until you find the right medication or combination of medications that offers a better level of control. In my daughter’s case, I was told, considering the severity of her cerebral injury, she would never be seizure free, and that she most likely experienced silent seizures even during sleep. After birth she was prescribed an anticonvulsant which seemed to do little to control the seizures. It just seemed to “zone her out.” This was not acceptable to me and I persisted with the neurologists until they changed her medication and we found a combination that proved effective, at least during her waking hours, without the side effects that she seemed to experience with her initial medication. I was amazed at her new level of awareness after the change. To this day that same combination of medications has continued to provide an optimum level of control. Never give up!

Treatments and Medications

• Protect a person from harm during a seizure. One of the complicated risks of seizures is that further damage can occur in the brain with severe seizures. The individual can also be hurt while falling or during spastic episodes resulting from grand mal seizures.
• Anticonvulsant medications are normally prescribed in the management of a seizure disorder. Tegretol, Phenobarbital, Dilantin, Klonopin, Valium and Topamax are several examples of medications that may be prescribed.
• Vagus Nerve Stimulation Therapy – This therapy is relatively new and involves a surgically implanted battery, with leads threaded under the skin and attached to the vagus nerve. Vagus Nerve Stimulation involves a device which sends short bursts of electrical energy into the brain via the vagus nerve.
• Ketogenic Diet – This form of therapy involves a diet high in fats and low in carbohydrates and makes the body burn fat for energy instead of glucose. This form of therapy has been proven effective in some children in the prevention of seizures.

Side Effects

Every medication involves side effects. Some children may tolerate one medication but another child may experience intolerance or contradictions with the same medication. In my daughter’s case, I was in a position where I had to decide what side effects were acceptable and which weren’t. With the initial anticonvulsant, my daughter seemed unresponsive to her environment and “disconnected” from the world. That was not acceptable to me, but the new medication offered its array of side effects also. I remember researching the new medication in my boss’s Physician’s Desk Reference (PDR) and calling up the neurologist almost frantic!

Our neurologist was exceptional, and we communicated with ease. When I told him of my research in the PDR and my concerns (I think I heard a slight groan) he patiently explained to me that yes, the side effects and contradictions I was reading were cause for concern but the PDR had to list every incident of contradiction so the ratio seemed out of proportion. In most cases, the incidents were more a rarity then the norm. He assured me of the safety of the new medication and told me what would constitute severe side effects or contradictions that would warrant intervention. I thanked him for his time and for taking my call. My baby was a part of my world for the first time and was showing a new level of awareness. That went far in outweighing the unavoidable side effects and possible contradictions that came with the new medication. This isn’t meant to discourage a parent’s research, just the opposite. Educate yourself on all medications. That’s the only way you make an INFORMED DECISION.

There is much research being conducted and many clinical trials occurring in the field of neurology and seizure management. Many individuals are living seizure free as a result of the advances made in Neurologic medicine.

Questions to Ask Physician

• You may have a thousand questions in your head about your child’s possible seizures, medications, or management, but you won’t think of half of them during your appointment with your child’s physician or neurologist. Write them down as you think of them!
• Ask your physician what side effects to expect with any medication and what contradictions you need to be aware of and what to do in the case of a serious adverse side effect.
• Should your child take the medication with or without food? Make your child’s neurologist aware of any other medications your child may be on, whether it’s seizure-related medication or not.
• Make sure you’re aware of any blood work or lab work that needs to be done and the frequency. Many anticonvulsants require blood work to monitor the levels of the medication in the blood and to monitor possible kidney and liver function in relation to the medication.
• Some children experience seizures that may be triggered by different environmental or dietary factors. Ask your physician if there are any environmental factors or dietary issues that you need to be aware of.

Visual Issues in Children with Cerebral Palsy

By John Lehman

Studies have indicated that as many as 75% of children suffering from cerebral palsy have vision impairments of some kind. Sense of sight is an important part of a child’s development, and for children affected by cerebral palsy, detecting vision issues early is critical. Any information you can arm yourself with brings you closer to providing your child with a happy, functional life as he or she grows older. Below, we have identified several vision disorders in children with cerebral palsy and options to treat them.

Types of Vision Disorders

There are many different vision disorders that can result from cerebral palsy, although many share similar forms of corrective treatment.

Cortical Visual Impairment (CVI)

Perhaps the most common condition associated with cerebral palsy. Also called Cerebral Visual Impairment. CVI is categorized as more of a brain dysfunction rather than a direct problem with the eyes. Those suffering from CVI may experience symptoms such as frequent visual fatigue, abnormal responses to light, unusual eye movement, as well asother issues.

Acuity Loss

Acuity loss generally refers to blurred vision. The most common types of acuity loss are nearsightedness and farsightedness, both of which are typically treated by prescribing glasses or contact lenses.

Field Loss

This refers to a group of dysfunctions in the eye’s field of vision. Types of field loss include:

• Central Loss – Visual impairment in the center of the field of vision.
• Hemianopia – Visual impairment on either the upper-lefthand, upper-righthand, lower-lefthand or lower-righthand side of the field of vision.
• Island of vision – Most vision is missing, save for some isolated spots in various places.
• Peripheral loss – The sides of a person’s vision are missing. This is similar to tunnel vision.
• Scotomas – A reversal of “island of vision.” Vision is mostly clear, save for some isolated spots in various places.

Amblyopia

This condition is common amongst children with or without cerebral palsy alike. This condition is also called “lazy eye.” The eyes have difficulty processing depth of field and one eye will have poorer vision than the other.

Detection of Vision Issues

It’s very important to detect visual impairment in your child as early in their development as possible. As a parent, it’s very likely you will notice the signs before your doctor diagnoses a vision disorder at a routine check up. Common signs include frequent rubbing of eyes, difficulty tracking objects, consistent red eyes and other eye problems. If you suspect your child is developing vision issues, consult your child’s doctor or an optometrist as soon as possible.

Treatment Options

Thankfully, most of the vision problems related to cerebral palsy are very treatable and the procedures are not much different than treating common vision issues. Prescriptions for glasses with corrective lenses or contact lenses are common treatments for many of the vision issues children with cerebral palsy will face.

Children with cerebral palsy who have also been diagnosed with CVI usually face a more involved and routine treatment plan. At an earlier age, some doctors recommend vision stimulation therapies to ensure the best possible development of your child’s visual skills. If your child’s visual skills have not advanced very far before they reach age 10, it may be necessary to begin training your child to use non-visual ways of communication, reading and writing. These could include using text-to-speech software or Braille. Your child’s doctor or optometrist should be able to recommend a program based on your child’s specific needs.

Further Reading

Cerebral Visual Impairment – SSC

Vision Problems – WebMD

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Psychotherapy for Children Diagnosed with 
Cerebral Palsy

By Drew Dillard

View similar stories.

The causes of cerebral palsy (CP) are both many and unknown, and no two people diagnosed with CP endure identical situations. However, at one point or another, nearly all people with cerebral palsy will face emotional and psychological challenges regarding the limitations CP has placed upon them. Let’s explore the types of psychotherapy available and how they might benefit your child.

Psychotherapy

Psychotherapy is a general term referring to therapeutic interaction or treatment contracted between a trained professional and a patient in an effort to improve that person’s sense of well-being, coping skills, communication skills and general disposition in the navigation of life’s challenges. It is different from therapeutic disciplines such as physical, speech & language, music & dance, occupational and play therapy, but is an important part of the overall care plan for your CP child.

Behavioral Therapy

Behavioral therapy uses psychological techniques that encourage the mastery of tasks. It is rooted in the belief that responses to emotional challenges and negative behaviors are learned and can therefore ne changed through therapy. Children do not yet possess the cognitive ability to process all that goes on with their thoughts and emotions, much less the ability to clearly communicate them. Psychotherapists are trained in identifying troubling situations, helping that child explore the thoughts, emotions and beliefs surrounding that situation, then helping the them acquire skills that will allow them to respond in a more effective and beneficial manner.

The activities used in behavioral therapy vary greatly depending on the abilities of the child and the problem behavior being addressed. Activities can be designed to teach completing tasks, managing emotions, resolving conflicts, delaying gratification and any number of other basic life skills. Behavioral therapy can help alleviate depression, mood swings, sadness, loss, anger and frustration by allowing previous negative outcomes to be replaced with a more positive perspective.

Counseling or Talk Therapy

As they get older, children with cerebral palsy will likely feel ostracized by peers, isolated from friendships, embarrassed by body image and/or frustrated with treatment goals. This may be a good time to introduce them to “counseling” or “talk therapy,” where they can talk about the things that are bothering them and learn to put them in perspective. It differs from behavioral therapy in that the goals are more along the lines of learning to accept and embrace one’s individuality rather than of raw behavior modification.

Even the most “normal” young person faces daily psychological and emotional challenges. Your hopes for your child at this age won’t differ much from that of any other parent. You want your child to cultivate a healthy attitude toward his or her challenges and to acquire the basic tools that will carry them into adulthood.  Many adolescents and teens see therapists to help process these complicated years. The right therapist can work wonders.

Social and Group Therapy

Individuals with physical or cognitive limitations often face real, and sometimes self-imposed, challenges in building relationships. Difficulties in communicating, fitting in or feeling accepted can lead to delays in social, emotional and even physical development.

Social therapy, introduced in the late 1970’s, helps children learn and embrace strategies that will help them develop friendships as they grow older by participating in group therapeutic settings. This decreases their sense of loneliness, isolation and stress. Social therapy focuses on the health and welfare of the individual as an integral part of a group dynamic. This relational approach helps children integrate into society and understand their role within.

Children with Mild Cerebral Palsy

Mild forms of cerebral palsy are often more difficult to detect and diagnose. Sometimes this leads to missed opportunities to introduce early-intervention corrective treatments, including those of a psychological nature. Undiagnosed abnormalities are often more emotionally troubling than diagnosed ones. If a child’s family and doctors don’t know what’s going on, it can be frustrating and confusing for the child.

A child that only exhibits minor physical impediments, such as issues of balance and coordination, may be completely normal in every other way. This can easily affect the child’s self-esteem. Also, children with minor physical or intellectual limitations are actually more likely to be teased and bullied for it than a child with an overt disability. Likewise, recent studies have shown that children with even minor learning disabilities benefit as much from treating the emotional component of the condition as with remediation of the learning disability itself.

It Takes a Village

It is important that parents and caregivers remain fully involved in the child’s therapies, especially with pre-teens. Caregivers need to understand and practice the positive behavior modifications learned in therapy to be able to recognize attention disorders, identify stressors, prevent meltdowns and minimize triggers all in an effort to reinforce a child’s progress.

Parents, caregivers and children with CP can all benefit from the positive interactions achieved with psychotherapy to compassionately, respectfully and appropriately interact with each other in a stable, secure and happy environment.

Resources

4therapy.com

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Electrical Muscle Stimulation Treatments for 
Cerebral Palsy

By John Lehman

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Electrical Muscle Stimulation (EMS) refers to a group of treatments that make use of electrical current to stimulate nerve endings, with the aim of reverting damage to the patient’s nervous system. Children suffering from cerebral palsy often have issues with movement and muscle spasticity, and EMS has proven to be effective at treating these issues, improving their overall quality of life. Combined with physical therapy, research has shown that EMS can increase walking speed, reduce muscle spasticity and improve overall motor function.

Types of Electrical Muscle Stimulation

EMS can be broken down into two main categories:

• Neuromuscular Electrical Stimulation (NMES) – Also known as Therapeutic Electrical Stimulation (TES) or Functional Electrical Stimulation (FES). This form of the treatment is usually provided by a medical practitioner. Unlike Threshold Electrical Stimulation, NMES uses a higher voltage in shorter increments, with the aim of stimulating muscles to contract.
• Threshold Electrical Stimulation – This treatment differentiates itself from NMES, as it does not induce muscle contractions. Instead, a lower voltage is used over a long period of time. Patients can purchase devices for this treatment without a prescription and use it at home, typically while sleeping.

How EMS Works

Whether treating cerebral palsy or other motor dysfunctions, EMS follows the same procedure. First, electrodes are placed on the skin near muscles that have atrophy or are weaker than their counterparts. These electrodes are attached to a small electric generator, operated by patient (or in this case, the parent), or by a medical practitioner.

As mentioned before, Threshold Electrical Stimulation is usually performed at home, with the parent sending minor amounts of electric current through the electrodes over the course of several hours. With NMES, the patient is subjected to a slightly higher level of current, which coerces the muscle to contract. In either case, the electric current is mild and should not cause any pain or discomfort for your child.

How Effective is EMS?

Although doctors can usually agree on the benefits of EMS, many find that the therapy is unnecessary or unreliable since it does not produce permanent results. EMS typically needs to be conducted over a long period of time, as a single session of EMS will only temporarily improve motor function in the patient. Marked improvement is usually seen after the patient has undergone treatment between one to three months, with 2-hour sessions every day. Any prolonged breaks from the treatment may result in your child’s spasticity returning to an abnormal state. Because of this, many patients undergo the treatment throughout their life.

Although research is promising regarding the use of EMS for cerebral palsy patients, most research suggests that it is supplementary to standard treatments. Typically, EMS is combined with exercise or some other form of physical activity, depending on the child’s muscle condition. Some studies suggest that EMS alone can be used to treat smaller muscle groups, such as forearms or wrists. For larger muscle groups, such as leg muscles, EMS would be combined with another form of physical therapy.

Nevertheless, research is ongoing as to whether EMS can stand alone as an effective treatment for cerebral palsy and issues with motor skills. Ask your child’s doctor about EMS and whether it could help your child’s spasticity.

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