Cerebral Palsy (CP) Treatment in the Republic of Cuba

Cerebral Palsy (CP) is a group of neurological disorders that affect a person’s interaction with their environment, particularly their movement, muscle tone, and posture. This condition is the result of disturbances in the brain during development or damage to the brain during birth or shortly after. CP can have a profound impact on a person’s mobility and independence, however, despite the challenges it poses, many individuals with CP lead fulfilling lives, achieving personal goals and overcoming obstacles with the right support systems in place.

CP exists in various forms, each affecting people differently in terms of their physical capabilities and the degree of assistance they might require. The condition can affect one or multiple areas of the body, leading to a wide range of experiences from person to person. Due to its diverse nature, CP often requires individualized approaches to care and daily management, tailored to each person’s specific needs.

Though CP is a lifelong condition, it is not progressive, meaning it does not worsen with time, but the symptoms can vary in severity. Some individuals may experience mild impairments, while others may be more severely affected and require assistance for mobility or daily activities.

Key Characteristics of Cerebral Palsy

Cerebral Palsy (CP) encompasses a broad range of physical challenges that manifest differently depending on the severity and type of CP, but they often result in difficulties performing everyday activities and engaging in certain physical tasks.

Spasticity or Hypotonia:

• Spasticity, characterized by muscle stiffness, can make movements jerky, limit flexibility, and restrict a person’s range of motion. On the other end of the spectrum, hypotonia refers to reduced muscle tone, resulting in floppiness or weakness in the muscles. This can affect the person’s ability to maintain posture or hold their body upright.

Spasticity Dyskinesia:

• Dyskinesia refers to uncontrolled and often erratic movements, which may occur as twisting, writhing, or sudden jerking motions. These movements are involuntary, meaning the individual has little or no control over them.

Ataxia:

• Ataxia involves difficulties with balance, coordination, and depth perception. People with ataxic CP may have unsteady, shaky movements and struggle to maintain stability while walking or standing.

Difficulty with Fine Motor Skills:

• Fine motor skills involve small, precise movements, typically involving the hands and fingers. Individuals with CP may have trouble performing tasks like writing, buttoning clothes, using utensils, or manipulating small objects.

Speech and Swallowing Difficulties (in more severe cases):

• In more severe cases of CP, speech and swallowing can be affected due to impaired control over the muscles in the face, mouth, and throat.

Seizures (Epilepsy):

• Some individuals with CP also experience epilepsy, a condition marked by recurrent seizures. These can range from mild, brief episodes to more severe, prolonged seizures.

Cognitive and Learning Disabilities:

• Some individuals with CP may have intellectual disabilities or learning difficulties, although this is not true for everyone with the condition. These can range from mild to severe and may affect problem-solving, attention, memory, or understanding complex information.

Sensory Impairments:

• CP can affect the senses for some individuals, leading to visual or hearing impairments.

Pain and Discomfort:

• Muscle tightness, joint stiffness, and abnormal postures can lead to chronic pain or discomfort, especially in cases where movement is limited which can cause strain on muscles and joints leading to orthopedic issues such as joint contractures (permanent shortening of a muscle or joint), hip dislocations, or scoliosis (curvature of the spine).

Bladder and Bowel Control Issues:

• Some individuals with CP experience difficulties with bladder and bowel control due to poor muscle coordination in the pelvic region. This may result in conditions such as urinary incontinence, constipation, or difficulty controlling bowel movements.

Difficulty with Growth and Nutrition:

• Feeding difficulties, coupled with issues like dysphagia (swallowing difficulties), can lead to challenges with nutrition and growth. Children with CP may have trouble gaining weight or growing at the same rate as their peers, requiring careful nutritional management or feeding assistance.

Sleep Disorders:

• Sleep disturbances are common in individuals with CP, often due to discomfort, seizures, or difficulties with positioning during sleep.

Levels of Cerebral Palsy

CP is often classified into levels based on the severity of motor impairments and how these impairments affect an individual’s mobility and ability to function independently.

• Level 1: Individuals with level 1 are largely independent and can participate in most daily activities without restrictions. However, there may be difficulties with speed, balance, or coordination.

• Level 2: Individuals with Level 2 can walk in most settings, including indoors and outdoors, and can climb stairs with the use of a railing for support but may have difficulty walking on uneven surfaces or long distances. Balance, speed and coordination are more affected than in Level 1.

• Level 3: Individuals at this level can walk with the use of a mobility aid such as a walker or crutches. They may be able to navigate indoor settings without assistance but typically need a wheelchair or other mobility device for longer distances or when navigating uneven surfaces or stairs. Daily activities may require assistance, especially outside the home.

• Level 4: Individuals with Level 4 have severely limited self-mobility and rely primarily on wheelchairs or other assistive devices for moving around. Walking is possible only with extensive support. Daily activities such as dressing, feeding, and personal care require significant help.

• Level 5: Individuals with Level 5 are the most severely affected and are completely dependent on others for mobility. They have little or no voluntary control of movement and may be unable to sit or stand independently without extensive support. Extensive help is needed for all activities of daily living, including personal care, mobility, and communication.

Diagnosis of Cerebral Palsy

The treatment process begins with a comprehensive medical history review and a thorough physical examination to identify treatable causes of the impairment with the primary focus on improving movement, motor skills, muscle tone, reflexes, and posture.

Assessing a patient with CP before initiating treatment is crucial in developing a personalized treatment plan, identifying comorbidities and complications and maximizing independence and improving quality of life.

Additionally, attention is given to the patient’s cognitive abilities, motor sphincter control, the presence of seizures, and any vision, hearing, or speech problems.

Furthermore, surgical options may be suggested for patients who can walk with or without help in order to improve movement and alignment in the legs, ankles, feet, and hips, to increase autonomous motor function, and to enhance gait and range of motion.

• Review of medical history

• Review of family history

• Consultation with medical professionals including neurologist, psychologist and psychiatrist

• Past medical interventions

• Physical examination

• Neurological assessment

• Musculoskeletal examination

• Functional abilities

• Cognitive and behavioral assessment

• Sensory assessment including vision, hearing and speech abilities

• Nutritional and growth assessment

• Seizure activity

• Laboratory investigations and clinic analysis

• In-depth clinical evaluations

• Meeting with family or legal guardian

Treatment of Cerebral Palsy:

While there is no cure for CP, various treatments can help manage symptoms and improve quality of life. In Cuba, treatment involves a comprehensive approach that combines medical, neurological, and physical rehabilitation. Patients receive care from a multidisciplinary team that includes physiatrists, neurologists, psychologists, nutritionists, podiatrists, and speech therapists. 

• Botulinum toxin (Botox) therapy: Botox is a form of medical treatment used to reduce muscle spasticity and stiffness by temporarily paralyzing overactive muscles by blocking the nerve signals that cause muscle contractions, allowing the muscles to relax and lengthen.

• Physical Therapy: Intensive physiotherapy, consisting of 38 sessions of strengthening exercises, aims to improve motor skills, normalize postural control, overcome persistent impairments, facilitate normal movement patterns, and readapt balance and gait. This program may also include swimming exercises to enhance cardiovascular function, muscle strength, and tone.

• Occupational Therapy: Rehabilitative treatment focuses on helping individuals perform daily life activities and their ability to carry out tasks, such as dressing, eating, and personal hygiene, independently and efficiently. The primary goal of this therapy is to develop fine motor skills, improve hand-eye coordination, and adapt to physical limitations.

• Speech Therapy: This type of therapy assists with speech, language, and swallowing difficulties. Beyond enhancing communication skills, speech therapy also focuses on strengthening and improving control of facial and oral muscles.

• Neurological rehabilitation: Focused on enhancing cognitive, emotional, and psychosocial aspects, the primary aim is to improve information processing, memory, attention and concentration, planning and prioritizing, and visual perception.

• Pressotherapy: This is a therapeutic technique that involves the use of controlled air pressure to stimulate the lymphatic and circulatory systems. This treatment aims to reduce muscle stiffness, improve blood flow, alleviate pain and decrease swelling, thereby enhancing overall comfort and mobility.

• Ozone therapy: Ozone therapy for cerebral palsy patients involves the administration of ozone gas to enhance oxygen delivery to tissues, reduce inflammation, and promote healing. The therapy aims to improve cellular metabolism and boost the body’s natural antioxidant defenses. By increasing oxygen levels in the blood, ozone therapy may support better overall function and well-being.

• Magnetic bed therapy: This therapy involves using a bed embedded with magnets to create a magnetic field to improve circulation, reduce inflammation, and alleviate pain. The therapy aims to enhance muscle relaxation, reduce spasticity, and promote overall physical well-being by influencing the body’s natural magnetic fields.

• Functional Electrical Stimulation (FES): FES is particularly beneficial in improving gait patterns, hand function, and overall mobility. This form of therapy uses low-level electrical currents to activate specific muscles to improve motor function and strength and hence enhance movement control, reduce spasticity, and promote muscle re-education.

• Orthopedic surgery: For CP patients who can walk with or without help orthopedic surgery may be performed to correct musculoskeletal abnormalities and improve mobility, posture, and overall function. This type of surgery may involve lengthening or releasing tight muscles and tendons, realigning bones and joints, or stabilizing joints to reduce pain and improve movement.