All baby brains have the potential to recover to some extent and some may be cured completely. (Baby Brains Can Recover – Pediatric Neuroplasticity) What about the child who does not recover completely? Common wisdom is that once the diagnosis of cerebral palsy is determined, the child will have it for life. It is incurable. Very few people think there is hope for later recovery in an older child. (What Does Your Doctor Believe?) I believe the potential for further recovery is underestimated in most children with mild to moderate severity cerebral palsy.
I first noticed later recovery of function in a child with the diagnosis of cerebral palsy because of a hospital expansion. At the time, I was a Neonatologist at The Hospital for Sick Children in Toronto, Canada. I also worked in the Neonatal Follow Up Clinic, monitoring the growth and development of high-risk survivors from the NICU. The hospital was in the midst of building a new patient care wing and as a result, my office was temporarily relocated to space in an abandoned ward of the old hospital. The Clinic suddenly had spacious offices and examining rooms and most importantly, a long, wide, empty hallway.
One day, during my examination of a young boy with mild left sided hemiplegia, his mother told me that he was playing soccer in a local league. I was surprised that he was on the team, but I assumed it was an all-inclusive team, that accepted anyone of the right age who wanted to play. I was wrong. She explained that there had been a series of tryouts and he had made it through to the end and was now on the team. I was confused and did not understand how he could run well enough to play competitive soccer. His mother said, “Let me show you”. We went out into the deserted hallway and he ran up and down the length of it with a normal running gait. He performed perfect turns, at speed, on both legs, even though his left leg was affected by cerebral palsy. It was one of the most surprising demonstrations that I had ever seen. He had a classic hemiplegia gait and I had been so sure that he would run awkwardly! I needed the demonstration to prove that the mother was telling the truth. Her son could run well, but walked with an abnormal pattern. This might be described by some as my error of arrogance, thinking that I knew better than the mother, but I prefer to think of it as an error of omission. If I had examined the full range of his skills, I would have seen him run well.
Since that first humbling experience, I have tried to examine each child’s higher order motor skills. When it was impossible to do, I have asked the parents about these skills and believed their answers. In my experience, most children diagnosed with a mild to moderate severity hemiplegia have a slow and clumsy walking pattern. However, by the age of 4 to 6 years, many have learned to run much better than they are able to walk. When running, the movements are smoother and faster. Even pivot turns, which require weight bearing on either leg, may be possible. At first, the affected arm is held stiffly, but after the child runs a fair distance, the affected arm will start to swing with a normal, reciprocal movement. The walk is abnormal. The run is near normal.
There is a deceptively simple explanation for the child’s ability to run better than he can walk. The human brain matures over 18 to 21 years with gradual acquisition of new brain systems. These new systems provide additional brain “real estate” for the child to use for motor function. This process is called Developmental Neuroplasticity. The next big player in motor control is the cerebellum. The cerebellum normally contributes to our ability to perform rapid sequenced movements, as in running. The cerebellum is one of the later developing areas of brain, usually becoming active between 4 and 6 years of age and it is rarely damaged in the perinatal period. This boy’s early walking pattern, the pattern we see first, is a habit learned with a damaged, immature brain. His walk is a lower order movement learned during the 2 to 3 year time period when his injured brain was recovering from the initial brain injury. The higher order skill of running, learned at an older age, is a better indicator of the child’s ultimate brain function. This higher order skill was learned after the brain had time to recover as much as possible from the original damage and after the brain had matured to the point that the child had a new, undamaged brain system, the cerebellar system, to help him run.
It takes more time to accurately assess the true state of the child’s brain. More time interviewing the parents, asking about their child’s best performance. More time and space is needed for a complete examination. Empty hallways are a luxury denied most physicians. The search for best possible performance has taken me to many unexpected forums. I have seen older children and teenagers with a clear diagnosis of mild to moderate cerebral palsy who are able to skateboard, ride bikes, roller-blade, play varsity basketball, golf with a 3 handicap, play tennis, win higher order belts in martial arts, and even dance at a professional level. In spite of these excellent higher order motor skills, they still walk with a spastic gait and are labelled with the diagnosis of cerebral palsy. Obviously, these children have capable motor systems. Do we focus on the walk, which is abnormal and consistent with a diagnosis of cerebral palsy or do we look at skills that are at a competitive level and call them better than normal? If a child with spastic cerebral palsy can do 3 to 4 reciprocal heel-toe steps in therapy, they have sufficient neurological recovery to learn to walk normally. (Moving From Deep Water Jogging to Land) If a child can run with co-ordination and balance, they can learn to walk with a similar skill level. In all these cases, it is the early learned habit that stands in the way of improvement, not permanent brain damage. Habits are hard to change, but they can be changed.
Baby Brains Recover, but Habit Hides It