Cerebral palsy

DEFINITION

Cerebral palsy is a disorder of movement, muscle tone or posture that is caused by an insult to the immature, developing brain, most often before birth.

Signs and symptoms appear during infancy or preschool years. In general, cerebral palsy causes impaired movement associated with exaggerated reflexes, floppiness or rigidity of the limbs and trunk, abnormal posture, involuntary movements, unsteadiness of walking, or some combination of these.

People with cerebral palsy may have difficulty with swallowing and commonly have eye muscle imbalance. People with cerebral palsy may have reduced range of motion at various joints of their bodies due to muscle stiffness.

The effect of cerebral palsy on functional abilities varies greatly. Some people are able to walk while others aren't able to walk. Some people show normal to near normal intellectual function, but others may have intellectual disabilities. Epilepsy, blindness or deafness also may be present.

People with cerebral palsy often have underlying developmental brain abnormalities.

SYMPTOMS

Signs and symptoms can vary greatly. Movement and coordination problems associated with cerebral palsy may include:

Variations in muscle tone, such as being either too stiff or too floppy

Stiff muscles and exaggerated reflexes (spasticity)

Stiff muscles with normal reflexes (rigidity)

Lack of muscle coordination (ataxia)

Tremors or involuntary movements

Slow, writhing movements (athetosis)

Delays in reaching motor skills milestones, such as pushing up on arms, sitting up alone or crawling

Favoring one side of the body, such as reaching with only one hand or dragging a leg while crawling

Difficulty walking, such as walking on toes, a crouched gait, a scissors-like gait with knees crossing or a wide gait

Excessive drooling or problems with swallowing

Difficulty with sucking or eating

Delays in speech development or difficulty speaking

Difficulty with precise motions, such as picking up a crayon or spoon

The disability associated with cerebral palsy may be limited primarily to one limb or one side of the body, or it may affect the whole body. The brain disorder causing cerebral palsy doesn't change with time, so the symptoms usually don't worsen with age, although the shortening of muscles and muscle rigidity may worsen if not treated aggressively.

Other neurological problems

Brain abnormalities associated with cerebral palsy also may contribute to other neurological problems. People with cerebral palsy may also have:

Difficulty with vision and hearing

Intellectual disabilities

Seizures

Abnormal touch or pain perceptions

Oral diseases

Mental health (psychiatric) conditions

Urinary incontinence

When to see a doctor

It's important to get a prompt diagnosis for any movement disorder or possible delays in your child's development. See your child's doctor if you have any questions or concerns about muscle tone, muscle movement, coordination or other developmental issues.

CAUSES

Cerebral palsy is caused by an abnormality or disruption in brain development, usually before a child is born. In many cases, the exact trigger of this abnormality isn't known. Factors that may lead to problems with brain development include:

Random mutations in genes that control brain development.

Maternal infections that affect the developing fetus.

Fetal stroke, a disruption of blood supply to the developing brain.

Lack of oxygen to the brain (asphyxia) related to difficult labor or delivery. This is rarely a cause.

Infant infections that cause inflammation in or around the brain.

Traumatic head injury to an infant from a motor vehicle accident or fall.

RISK FACTORS

A number of factors are associated with an increased risk of cerebral palsy.

Maternal health

Certain infections or health problems during pregnancy can significantly increase the risk of giving birth to a baby with cerebral palsy. Infections of particular concern include:

German measles (rubella). Rubella is a viral infection that can cause serious birth defects. It can be prevented with a vaccine.

Chickenpox (varicella). Chickenpox is a contagious viral infection that causes itching and rashes, and it can cause pregnancy complications. It can be prevented with a vaccine.

Cytomegalovirus. Cytomegalovirus is a common virus that causes flu-like symptoms and may lead to birth defects if a mother experiences her first active infection during pregnancy.

Toxoplasmosis. Toxoplasmosis is a parasitic infection caused by a parasite found in contaminated food, soil and the feces of infected cats.

Syphilis. Syphilis is a sexually transmitted bacterial infection.

Exposure to toxins. Exposure to toxins, such as methyl mercury, can increase the risk of birth defects.

Other conditions. Other conditions may increase the risk of cerebral palsy, such as thyroid problems, intellectual disabilities or seizures.

Infant illness

Illnesses in a newborn baby that can greatly increase the risk of cerebral palsy include:

Bacterial meningitis. This is a bacterial infection that causes inflammation in the membranes that surround the brain and spinal cord.

Viral encephalitis. This viral infection causes inflammation in the membranes that surround the brain and spinal cord.

Severe or untreated jaundice. Jaundice is a condition that appears as a yellowing of the skin. Jaundice occurs when certain byproducts of "used" blood cells aren't filtered from the bloodstream.

Other factors of pregnancy and birth

Other factors of pregnancy or birth that are associated with an increased risk of cerebral palsy include:

Premature birth. A normal pregnancy lasts 40 weeks. Babies who are born fewer than 37 weeks into the pregnancy are at higher risk of cerebral palsy. The earlier the baby is born, the greater the risk of cerebral palsy.

Low birth weight. Babies who weigh less than 5.5 pounds (2.5 kilograms) are at higher risk of developing cerebral palsy. This risk increases as birth weight drops.

Breech births. Babies with cerebral palsy are more likely to be in a feet-first position (breech presentation) at the beginning of labor rather than in a headfirst position.

Multiple babies. The risk of cerebral palsy increases with the number of babies sharing the uterus. If one or more of the babies die, the chance that the survivors may have cerebral palsy increases.

COMPLICATIONS

Muscle weakness, muscle spasticity and coordination problems can contribute to a number of complications either during childhood or later during adulthood, including:

Contracture. Contracture is the shortening of muscle tissue due to severe tightening of the muscle (spasticity). Contracture can inhibit bone growth, cause bones to bend, and result in joint deformities, dislocation or partial dislocation.

Malnutrition. Swallowing or feeding problems can make it difficult for someone who has cerebral palsy, particularly an infant, to get enough nutrition. This may cause impaired growth and weaker bones. Your child may need a feeding tube for adequate nutrition.

Mental health conditions. People with cerebral palsy may have mental health (psychiatric) conditions, such as depression. Social isolation and the challenges of coping with disabilities can contribute to depression.

Lung disease. People with cerebral palsy may develop lung disease and breathing disorders.

Neurological conditions. People with cerebral palsy may be more likely to develop movement disorders or worsened neurological symptoms over time.

Osteoarthritis. Pressure on joints or abnormal alignment of joints from muscle spasticity may result in the early development of painful degenerative bone disease (osteoarthritis).

PREPARING FOR YOUR APPOINTMENT

If your child has cerebral palsy, how you learn about your child's condition may depend on the severity of the disabilities, when problems first appeared, and whether there were any risk factors during the pregnancy or delivery.

Well-baby visits

It's important to take your child to all regularly scheduled well-baby visits and annual appointments during childhood. These visits are an opportunity for your child's doctor to monitor your child's development in key areas, including:

Growth

Muscle tone

Muscle strength

Coordination

Posture

Age-appropriate motor skills

Sensory abilities, such as vision, hearing and touch

Your doctor may ask you several questions during appointments, including:

What concerns do you have about your child's growth or development?

How well does he or she eat?

How does your child respond to touch?

Do you observe any favoring of one side of the body?

Is your child reaching certain milestones in development, such as rolling over, pushing up, sitting up, crawling, walking or speaking?

Talking to your doctor about cerebral palsy

If your family doctor or pediatrician believes that your child exhibits signs of cerebral palsy, you may want to discuss the following questions:

What diagnostic tests will we need?

When will we know the results of the tests?

What specialists will we need to see?

How will we screen for disorders commonly associated with cerebral palsy?

How will you monitor my child's health and development?

Can you suggest educational materials and local support services regarding cerebral palsy?

Can my child be followed through a multidisciplinary program that addresses all of his or her needs on the same visit, such as a cerebral palsy clinic?

TESTS AND DIAGNOSIS

If your family doctor or pediatrician suspects that your child has cerebral palsy, he or she will evaluate your child's signs and symptoms, review your child's medical history, and conduct a physical evaluation. Your doctor may refer you to a doctor trained in treating children with brain and nervous system conditions (pediatric neurologist).

Your doctor will also order a series of tests to make a diagnosis and rule out other possible causes.

Brain scans

Brain-imaging technologies can reveal areas of damage or abnormal development in the brain. These tests may include the following:

Magnetic resonance imaging (MRI). An MRI uses radio waves and a magnetic field to produce detailed 3-D or cross-sectional images of your child's brain. An MRI can often identify any lesions or abnormalities in your child's brain.

This test is painless, but it's noisy and can take up to an hour to complete. Your child will likely receive a mild sedative before the test. An MRI is usually the preferred imaging test.

Cranial ultrasound. This can be obtained during infancy. A cranial ultrasound uses high-frequency sound waves to obtain images of the brain. An ultrasound doesn't produce a detailed image, but it may be used because it's quick and inexpensive, and it can provide a valuable preliminary assessment of the brain.

Computerized tomography (CT) scan. A CT scan uses X-rays to obtain cross-sectional images of your child's brain. A CT scan may be used to identify abnormalities in your child's brain.

Scanning is painless and takes about 20 minutes. Because your child will need to be very still during the test, he or she will likely receive a mild sedative.

Electroencephalogram (EEG)

If your child has had seizures, your doctor may order an electroencephalogram (EEG) to determine if he or she has epilepsy, which often occurs in people with cerebral palsy. In an EEG test, a series of electrodes are affixed to your child's scalp.

The EEG records the electrical activity of your child's brain. If he or she has epilepsy, it's common for there to be changes in normal patterns of brain waves.

Laboratory tests

Your child's blood may need to be checked to rule out other conditions, such as blood-clotting disorders that can cause strokes, which may mimic cerebral palsy signs and symptoms. Laboratory tests may also screen for genetic or metabolic problems.

Additional tests

If your child is diagnosed with cerebral palsy, you'll likely be referred to specialists for assessments of other conditions that are often associated with the disorder. These tests may identify:

Vision impairment

Hearing impairment

Speech delays or impairments

Intellectual disabilities

Other developmental delays

Movement disorders

TREATMENTS AND DRUGS

Children and adults with cerebral palsy require long-term care with a medical care team. This team may include:

Pediatrician or physiatrist. A pediatrician oversees the treatment plan and medical care.

Pediatric neurologist. A doctor trained in diagnosing and treating children with brain and nervous system (neurological) disorders may be involved in your child's care.

Orthopedic surgeon. A doctor trained in treating muscle and bone disorders may be involved in diagnosing and treating muscle conditions.

Physical therapist. A physical therapist may help your child improve strength and walking skills, and stretch muscles.

Occupational therapist. An occupational therapist can provide therapy to your child to develop daily skills and to learn to use adaptive products that help with daily activities.

Speech-language pathologist. A doctor trained in diagnosing and treating speech and language disorders may work with your child if your child has difficulties with speech, swallowing or language.

Developmental therapist. A developmental therapist may provide therapy to help your child develop age-appropriate behaviors, social skills and interpersonal skills.

Mental health specialist. A mental health specialist, such as a psychologist or psychiatrist, may be involved in your child's care. He or she may help you and your child learn to cope with your child's disability.

Social worker. A social worker may be involved in assisting your family with finding services and planning for transitions in care.

Special education teacher. A special education teacher addresses learning disabilities, determines educational needs and identifies appropriate educational resources.

Medications

Medications that can lessen the tightness of muscles may be used to improve functional abilities, treat pain and manage complications related to spasticity or other cerebral palsy symptoms.

It's important to talk about the risk of drug treatments with your doctor and discuss whether medical treatment is appropriate for your child's needs. The selection of medications depends on whether the problem affects only certain muscles (isolated) or the whole body (generalized). Drug treatments may include the following:

Isolated spasticity. When spasticity is isolated to one muscle group, your doctor may recommend injections of onabotulinumtoxinA (Botox) directly into the muscle, nerve or both. Botox injections may help to improve drooling. Your child will need injections about every three months.

Side effects may include pain, bruising or severe weakness. Other more-serious side effects include difficulty breathing and swallowing.

Generalized spasticity. If the whole body is affected, oral muscle relaxants may relax stiff, contracted muscles. These drugs include diazepam (Valium), dantrolene (Dantrium) and baclofen (Gablofen).

There is some risk of dependency with diazepam, so it's not recommended for long-term use. Its side effects include drowsiness, weakness and drooling.

Side effects of dantrolene include sleepiness, nausea and or diarrhea.

Side effects of baclofen include sleepiness, confusion and nausea. Baclofen may also be pumped directly into the spinal cord with a tube. The pump is surgically implanted under the skin of the abdomen.

Your child also may be prescribed medications to reduce drooling. Medications such as trihexyphenidyl, scopolamine (Scopace) or glycopyrrolate (Robinul, Robinul Forte) may be helpful.

Therapies

A variety of nondrug therapies can help a person with cerebral palsy to enhance functional abilities. These include the following:

Physical therapy. Muscle training and exercises may help your child's strength, flexibility, balance, motor development and mobility. You will also learn how to safely care for your child's everyday needs at home, such as bathing and feeding your child.

Braces or splints may be recommended for your child. Some of these supports are used to help with function, such as improved walking. Others may stretch stiff muscles to help prevent rigid muscles (contractures).

Occupational therapy. Using alternative strategies and adaptive equipment, occupational therapists work to promote your child's independent participation in daily activities and routines in the home, the school and the community.

Adaptive equipment may include walkers, quadrupedal canes, seating systems or electric wheelchairs.

Speech and language therapy. Speech-language pathologists can help improve your child's ability to speak clearly or to communicate using sign language.

Speech-language pathologists can also teach your child to use communication devices, such as a computer and voice synthesizer, if communication is difficult.

Another communication device may be a board covered with pictures of items and activities your child may see in daily life. Sentences can be constructed by pointing to the pictures.

Speech therapists may also address difficulties with muscles used in eating and swallowing.

Recreational therapy. Some children may benefit from recreational therapies, such as therapeutic horseback riding. This type of therapy can help improve your child's motor skills, speech and emotional well-being.

Surgical or other procedures

Surgery may be needed to lessen muscle tightness or correct bone abnormalities caused by spasticity. These treatments include:

Orthopedic surgery. Children with severe contractures or deformities may need surgery on bones or joints to place their arms, hips or legs in their correct positions.

Surgical procedures can also lengthen muscles and tendons that are proportionally too short because of severe contractures. These corrections can lessen pain and improve mobility. These procedures may also make it easier to use a walker, braces or crutches.

Severing nerves. In some severe cases, when other treatments haven't helped, surgeons may cut the nerves serving the spastic muscles in a procedure called selective dorsal rhizotomy. This relaxes the muscle and reduces pain, but can also cause numbness.

LIFESTYLE AND HOME REMEDIES

Most cases of cerebral palsy can't be prevented, but you can lessen risks. If you're pregnant or planning to become pregnant, you can take these steps to keep healthy and minimize pregnancy complications:

Make sure you're vaccinated. Vaccination against diseases such as rubella may prevent an infection that could cause fetal brain damage.

Take care of yourself. The healthier you are heading into a pregnancy, the less likely you'll be to develop an infection that may result in cerebral palsy.

Seek early and continuous prenatal care. Regular visits to your doctor during your pregnancy are a good way to reduce health risks to you and your unborn baby. Seeing your doctor regularly can help prevent premature birth, low birth weight and infections.

Practice good child safety. Prevent head injuries by providing your child with a car seat, bicycle helmet, safety rails on beds and appropriate supervision.

COPING AND SUPPORT

When a child is diagnosed with a disabling condition, the whole family faces new challenges. Here are a few tips for caring for your child and yourself:

Foster your child's independence. Encourage any effort at independence, no matter how small. Just because you can do something faster or more easily doesn't mean you should.

Be an advocate for your child. You are an important part of your child's health care team. Don't be afraid to speak out on your child's behalf or to ask tough questions of your physicians, therapists and teachers.

Find support. A circle of support can make a big difference in helping you cope with cerebral palsy and its effects. As a parent, you may feel grief and guilt over your child's disability.

Your doctor can help you locate support groups, organizations and counseling services in your community. Your child may benefit from family support programs, school programs and counseling