Child Cerebral Palsy – Causes, Symptoms, Treatment

Child Cerebral Palsy (CP) is a group of disorders that affect a person’s ability to move and maintain balance and posture. CP is the most common motor disability in childhood. Cerebral means having to do with the brain. Palsy means weakness or problems with using the muscles. CP is caused by abnormal brain development or damage to the developing brain that affects a person’s ability to control his or her muscles.

What is Cerebral Palsy?/Cerebral palsy refers to a group of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination Cerebral palsy (CP) is caused by damage to or abnormalities inside the developing brain that disrupt the brain’s ability to control movement and maintain posture and balance. The term cerebral refers to the brain; palsy refers to the loss or impairment of motor function.

Cerebral palsy affects the motor area of the brain’s outer layer (called the cerebral cortex), the part of the brain that directs muscle movement.

Types of Child Cerebral Palsy

The specific forms of cerebral palsy are determined by the extent, type, and location of a child’s abnormalities. Doctors classify CP according to the type of movement disorder involved — spastic (stiff muscles), athetoid (writhing movements), or ataxic (poor balance and coordination) — plus any additional symptoms, such as weakness (paresis) or paralysis (plegia). For example, hemiparesis (hemi = half) indicates that only one side of the body is weakened. Quadriplegia (quad = four) means all four limbs are affected.

Spastic cerebral palsy is the most common type of disorder. People have stiff muscles and awkward movements. Forms of spastic cerebral palsy include:

• Spastic hemiplegia/hemiparesis typically affects the arm and hand on one side of the body, but it can also include the leg. Children with spastic hemiplegia generally walk later and on tip-toe because of tight heel tendons. The arm and leg of the affected side are frequently shorter and thinner. Some children will develop an abnormal curvature of the spine (scoliosis). A child with spastic hemiplegia may also have seizures. The speech will be delayed and, at best, maybe competent, but intelligence is usually normal.
• Spastic diplegia/diparesis involves muscle stiffness that is predominantly in the legs and less severely affects the arms and face, although the hands may be clumsy. Tendon reflexes in the legs are hyperactive. Toes point up when the bottom of the foot is stimulated. Tightness in certain leg muscles makes the legs move like the arms of a scissor. Children may require a walker or leg braces. Intelligence and language skills are usually normal.
• Spastic quadriplegia/quadriparesis is the most severe form of cerebral palsy and is often associated with moderate-to-severe intellectual disability. It is caused by widespread damage to the brain or significant brain malformations. Children will often have severe stiffness in their limbs but a floppy neck. They are rarely able to walk. Speaking and being understood are difficult. Seizures can be frequent and hard to control.

Dyskinetic cerebral palsy (also includes athetoid, choreoathetoid, and dystonic cerebral palsies) is characterized by slow and uncontrollable writhing or jerky movements of the hands, feet, arms, or legs. Hyperactivity in the muscles of the face and tongue makes some children grimace or drool. They find it difficult to sit straight or walk. Some children have problems hearing, controlling their breathing, and/or coordinating the muscle movements required for speaking. Intelligence is rarely affected in these forms of cerebral palsy.

Ataxic cerebral palsy affects balance and depth perception. Children with ataxic CP will often have poor coordination and walk unsteadily with a wide-based gait. They have difficulty with quick or precise movements, such as writing or buttoning a shirt, or a hard time controlling voluntary movement such as reaching for a book.

Mixed types of cerebral palsy refer to symptoms that don’t correspond to any single type of CP but are a mix of types. For example, a child with mixed CP may have some muscles that are too tight and others that are too relaxed, creating a mix of stiffness and floppiness.

What other conditions are associated with cerebral palsy?

• Intellectual disability. Approximately 30 – 50 percent of individuals with CP will be intellectually impaired. Mental impairment is more common among those with spastic quadriplegia than in those with other types of cerebral palsy.
• Seizure disorder.  As many as half of all children with CP have one or more seizures. Children with both cerebral palsy and epilepsy are more likely to have intellectual disabilities.
• Delayed growth and development.  Children with moderate to severe CP, especially those with spastic quadriparesis, often lag behind in growth and development. In babies, this lag usually takes the form of too little weight gain. In young children, it can appear as abnormal shortness, and in teenagers, it may appear as a combination of shortness and lack of sexual development. The muscles and limbs affected by CP tend to be smaller than normal, especially in children with spastic hemiplegia, whose limbs on the affected side of the body may not grow as quickly or as long as those on the normal side.
• Spinal deformities and osteoarthritis. Deformities of the spine—curvature (scoliosis), humpback (kyphosis), and saddleback (lordosis) — are associated with CP. Spinal deformities can make sitting, standing, and walking difficult and cause chronic back pain. Pressure on and misalignment of the joints may result in osteoporosis (a breakdown of cartilage in the joints and bone enlargement).
• Impaired vision. Many children with CP have strabismus, commonly called “cross eyes,” which left untreated can lead to poor vision in one eye and can interfere with the ability to judge distance. Some children with CP have difficulty understanding and organizing visual information. Other children may have defective vision or blindness that blurs the normal field of vision in one or both eyes.
• Hearing loss. Impaired hearing is also more frequent among those with CP than in the general population.  Some children have partial or complete hearing loss, particularly as the result of jaundice or lack of oxygen to the developing brain.
• Speech and language disorders.  Speech and language disorders, such as difficulty forming words and speaking clearly, are present in more than a third of persons with CP. Poor speech impairs communication and is often interpreted as a sign of cognitive impairment, which can be very frustrating to children with CP, especially the majority who have average to above-average intelligence,
• Drooling.  Some individuals with CP drool because they have poor control of the muscles of the throat, mouth, and tongue.
• Incontinence.  A possible complication of CP is incontinence, caused by poor control of the muscles that keep the bladder closed.
• Abnormal sensations and perceptions.  Some individuals with CP experience pain or have difficulty feeling simple sensations, such as touch.
• Learning difficulties. Children with CP may have difficulty processing particular types of spatial and auditory information. Brain damage may affect the development of language and intellectual functioning.
• Infections and long-term illnesses. Many adults with CP have a higher risk of heart and lung disease, and pneumonia (often from inhaling bits of food into the lungs), than those without the disorder.
• Contractures.  Muscles can become painfully fixed into abnormal positions, called contractures, which can increase muscle spasticity and joint deformities in people with CP.
• Malnutrition. Swallowing, sucking, or feeding difficulties can make it difficult for many individuals with CP, particularly infants, to get proper nutrition and gain or maintain weight.
• Dental problems. Many children with CP are at risk of developing gum disease and cavities because of poor dental hygiene. Certain medications, such as seizure drugs, can exacerbate these problems.
• Inactivity. Childhood inactivity is magnified in children with CP due to impairment of the motor centers of the brain that produce and control voluntary movement. While children with CP may exhibit increased energy expenditure during activities of daily living, movement impairments make it difficult for them to participate in sports and other activities at a level of intensity sufficient to develop and maintain strength and fitness. Inactive adults with disabilities exhibit increased severity of disease and reduced overall health and well-being.

Causes of Child Cerebral Palsy

Cerebral palsy is caused by abnormal development of part of the brain or by damage to parts of the brain that control movement. This damage can occur before, during, or shortly after birth. The majority of children have congenital cerebral palsy CP (that is, they were born with it), although it may not be detected until months or years later. A small number of children have acquired cerebral palsy, which means the disorder begins after birth. Some causes of acquired cerebral palsy include brain damage in the first few months or years of life, brain infections such as bacterial meningitis or viral encephalitis, problems with blood flow to the brain, or head injury from a motor vehicle accident, a fall, or child abuse.

In many cases, the cause of cerebral palsy is unknown. Possible causes include genetic abnormalities, congenital brain malformations, maternal infections or fevers, or fetal injury, for example. The following types of brain damage may cause its characteristic symptoms:

Damage to the white matter of the brain (periventricular leukomalacia, or PVL). The white matter of the brain is responsible for transmitting signals inside the brain and to the rest of the body.  Damage from PVL looks like tiny holes in the white matter of an infant’s brain. These gaps in brain tissue interfere with the normal transmission of signals. Researchers have identified a period of selective vulnerability in the developing fetal brain, a period of time between 26 and 34 weeks of gestation, in which periventricular white matter is particularly sensitive to insults and injury.

Abnormal development of the brain (cerebral dysgenesis).  Any interruption of the normal process of brain growth during fetal development can cause brain malformations that interfere with the transmission of brain signals. Mutations in the genes that control brain development during this early period can keep the brain from developing normally. Infections, fevers, trauma, or other conditions that cause unhealthy conditions in the womb also put an unborn baby’s nervous system at risk.

Bleeding in the brain (intracranial hemorrhage).  Bleeding inside the brain from blocked or broken blood vessels is commonly caused by fetal stroke.   Some babies suffer a stroke while still in the womb because of blood clots in the placenta that block blood flow in the brain.  Other types of fetal stroke are caused by malformed or weak blood vessels in the brain or by blood-clotting abnormalities.  Maternal high blood pressure (hypertension) is a common medical disorder during pregnancy and is more common in babies with fetal stroke.  Maternal infection, especially pelvic inflammatory disease, has also been shown to increase the risk of fetal stroke.

Severe lack of oxygen in the brain.   Asphyxia, a lack of oxygen in the brain caused by an interruption in breathing or poor oxygen supply, is common for a brief period of time in babies due to the stress of labor and delivery.  If the supply of oxygen is cut off or reduced for lengthy periods, an infant can develop a type of brain damage called hypoxic-ischemic encephalopathy, which destroys tissue in the cerebral motor cortex and other areas of the brain.   This kind of damage can also be caused by severe maternal low blood pressure, rupture of the uterus, detachment of the placenta, or problems involving the umbilical cord, or severe trauma to the head during labor and delivery.

Common causes of cerebral palsy include:

• Bacterial and viral infections such as meningitis
• Bleeding in the brain (hemorrhaging)
• Head injuries sustained during birth or within the first few years of infancy
• Lack of oxygen to the brain before, during, or after birth (asphyxia)
• Mercury poisoning from fish
• Prenatal exposure to drugs and alcohol
• Toxoplasmosis from raw/undercooked meat

What are the risk factors?

There are some medical conditions or events that can happen during pregnancy and delivery that may increase a baby’s risk of being born with cerebral palsy. These risks include:

• Low birth weight and premature birth. Premature babies (born less than 37 weeks into pregnancy) and babies weighing less than 5 ½ pounds at birth have a much higher risk of developing cerebral palsy than full-term, heavier-weight babies.  Tiny babies born at very early gestational ages are especially at risk.
• Multiple births.  Twins, triplets, and other multiple births — even those born at term — are linked to an increased risk of cerebral palsy. The death of a baby’s twin or triplet further increases the risk.
• Infections during pregnancy.  Infections such as toxoplasmosis, rubella (German measles), cytomegalovirus, and herpes, can infect the womb and placenta. Inflammation triggered by infection may then go on to damage the developing nervous system in an unborn baby. Maternal fever during pregnancy or delivery can also set off this kind of inflammatory response.
• Blood type incompatibility between mother and child.   Rh incompatibility is a condition that develops when a mother’s Rh blood type (either positive or negative) is different from the blood type of her baby. The mother’s system doesn’t tolerate the baby’s different blood type and her body will begin to make antibodies that will attack and kill her baby’s blood cells, which can cause brain damage.
• Exposure to toxic substances.  Mothers who have been exposed to toxic substances during pregnancy, such as methyl mercury, are at a heightened risk of having a baby with cerebral palsy.
• Mothers with thyroid abnormalities, intellectual disability, excess protein in the urine, or seizures.  Mothers with any of these conditions are slightly more likely to have a child with CP. There are also medical conditions during labor and delivery, and immediately after delivery that act as warning signs for an increased risk of CP. However, most of these children will not develop CP. Warning signs include:
• Breech presentation.  Babies with cerebral palsy are more likely to be in a breech position (feet first) instead of head first at the beginning of labor. Babies who are unusually floppy as fetuses are more likely to be born in the breech position.
• Complicated labor and delivery.  A baby who has vascular or respiratory problems during labor and delivery may already have suffered brain damage or abnormalities.
• Small for gestational age.  Babies born smaller than normal for their gestational age are at risk for cerebral palsy because of factors that kept them from growing naturally in the womb.
• Low Apgar score.   The Apgar score is a numbered rating that reflects a newborn’s physical health. Doctors periodically score a baby’s heart rate, breathing, muscle tone, reflexes, and skin color during the first minutes after birth. A low score at 10-20 minutes after delivery is often considered an important sign of potential problems such as CP.
• Jaundice. More than 50 percent of newborns develop jaundice (yellowing of the skin or whites of the eyes) after birth when bilirubin, a substance normally found in bile, builds up faster than their livers can break it down and pass it from the body. Severe, untreated jaundice can kill brain cells and can cause deafness and CP.
• Seizures.  An infant who has seizures faces a higher risk of being diagnosed later in childhood with CP.

Symptoms of Child Cerebral Palsy

In some cases, the cerebral motor cortex hasn’t developed normally during fetal growth. In others, the damage is a result of injury to the brain either before, during, or after birth. In either case, the damage is not repairable and the disabilities that result are permanent.

Children with CP exhibit a wide variety of symptoms, including:

• lack of muscle coordination when performing voluntary movements (ataxia);
• stiff or tight muscles and exaggerated reflexes (spasticity);
• weakness in one or more arm or leg;
• walking on the toes, a crouched gait, or a “scissored” gait;
• variations in muscle tone, either too stiff or too floppy;
• excessive drooling or difficulties swallowing or speaking;
• shaking (tremor) or random involuntary movements;
• delays in reaching motor skill milestones; and
• difficulty with precise movements such as writing or buttoning a shirt.

The symptoms of CP differ in type and severity from one person to the next, and may even change in an individual over time. Symptoms may vary greatly among individuals, depending on which parts of the brain have been injured. All people with cerebral palsy have problems with movement and posture, and some also have some level of intellectual disability, seizures, and abnormal physical sensations or perceptions, as well as other medical disorders. People with CP also may have impaired vision or hearing, and language, and speech problems.

CP is the leading cause of childhood disabilities, but it doesn’t always cause profound disabilities.  While one child with severe CP might be unable to walk and need extensive, lifelong care, another child with mild CP might be only slightly awkward and require no special assistance. The disorder isn’t progressive, meaning it doesn’t get worse over time. However, as the child gets older, certain symptoms may become more or less evident.

A study by the Centers for Disease Control and Prevention shows the average prevalence of cerebral palsy is 3.3 children per 1,000 live births. There is no cure for cerebral palsy, but supportive treatments, medications, and surgery can help many individuals improve their motor skills and ability to communicate with the world.

What are the early signs?

The signs of cerebral palsy usually appear in the early months of life, although specific diagnoses may be delayed until age two years or later. Infants with CP frequently have developmental delays, in which they are slow to reach developmental milestones such as learning to roll over, sit, crawl, or walk. Some infants with CP have abnormal muscle tone. Decreased muscle tone (hypotonia) can make them appear relaxed, even floppy. Increased muscle tone (hypertonia) can make them seem stiff or rigid. In some cases, an early period of hypotonia will progress to hypertonia after the first 2 to 3 months of life. Children with CP may also have unusual posture or favor one side of the body when they reach, crawl, or move. It is important to note that some children without CP also might have some of these signs.

Physical Symptoms

• Contractures (shortening of muscles)
• Drooling
• Exaggerated or jerky reflexes
• Floppy muscle tone
• Gastrointestinal problems
• Incontinence
• Involuntary movements or tremors
• Lack of coordination and balance
• Problems swallowing or sucking
• Problems with movement on one side of the body
• Stiff muscles (spasticity)

Neurological Symptoms

• The buildup of cranial pressure due to fluid imbalance (hydrocephalus)
• Behavioral problems
• Delayed motor skill development
• Difficulty with speech and language (dysarthria)
• Sensory impairments
• Visual/hearing impairments

Parents and caregivers should monitor the timeline of their child’s developmental milestones, as babies with cerebral palsy may have developmental delays that go unnoticed.

Some early warning signs:

In a Baby Younger Than 6 Months of Age

• His head lags when you pick him up while he’s lying on his back
• He feels stiff
• He feels floppy
• When you pick him up, his legs get stiff and they cross or scissor

In a Baby Older Than 6 Months of Age

• She doesn’t roll over in either direction
• She cannot bring her hands together
• She has difficulty bringing her hands to her mouth
• She reaches out with only one hand while keeping the other fisted

In a Baby Older Than 10 Months of Age

• He crawls in a lopsided manner, pushing off with one hand and leg while dragging the opposite hand and leg
• He cannot stand holding onto support

How is cerebral palsy diagnosed?

Most children with cerebral palsy are diagnosed during the first 2 years of life.  But if a child’s symptoms are mild, it can be difficult for a doctor to make a reliable diagnosis before the age of 4 or 5.

Doctors will order a series of tests to evaluate the child’s motor skills. During regular visits, the doctor will monitor the child’s development, growth, muscle tone, age-appropriate motor control, hearing and vision, posture, and coordination, in order to rule out other disorders that could cause similar symptoms. Although symptoms may change over time, CP is not progressive. If a child is continuously losing motor skills, the problem more likely is a condition other than CP—such as a genetic or muscle disease, metabolism disorder, or tumors in the nervous system.

Lab tests can identify other conditions that may cause symptoms similar to those associated with CP. Neuroimaging techniques that allow doctors to look into the brain (such as an MRI scan) can detect abnormalities that indicate a potentially treatable movement disorder. Neuroimaging methods include:

• Cranial ultrasound uses high-frequency sound waves to produce pictures of the brains of young babies. It is used for high-risk premature infants because it is the least intrusive of the imaging techniques, although it is not as successful as computed tomography or magnetic resonance imaging at capturing subtle changes in white matter—the type of brain tissue that is damaged in CP.
• Computed tomography (CT) uses x-rays to create images that show the structure of the brain and the areas of damage.
• Magnetic resonance imaging (MRI) uses a computer, a magnetic field, and radio waves to create an anatomical picture of the brain’s tissues and structures. MRI can show the location and type of damage and offers finer levels of details than CT.
• Electroencephalogram – uses a series of electrodes that are either taped or temporarily pasted to the scalp to detect electrical activity in the brain. Changes in the normal electrical pattern may help to identify epilepsy. Some metabolic disorders can masquerade as CP. Most of childhood metabolic disorders have characteristic brain abnormalities or malformations that will show up on an MRI.
• Cranial ultrasound – This must be performed during infancy. Cranial ultrasound is very useful in high-frequency sound waves to produce images of the brain. Ultrasound doesn’t produce a detailed image only, but it may be used because it’s a quick and inexpensive test or diagnosis, and it can provide a valuable preliminary assessment of the brain.
• Electroencephalogram (EEG) – If your child is suspected of having seizures, convulsion, an EEG can evaluate the condition further. Seizures can develop in a child with epilepsy and others associate problems. In an EEG test, a series of electrodes are placed or attached to your child’s scalp. The EEG records the electrical activity of your child’s brain and counts records. It’s most common for there to be changes in normal brain wave patterns in epilepsy.
• Cranial ultrasound – It uses high-frequency sound waves to produce pictures of the brains of young babies in most cases. It is used for high-risk infants because it is the least intrusive of the imaging techniques to find an abnormality, although it is not as successful as computed tomography (CT scan) or magnetic resonance imaging at capturing subtle changes in white matter—the type of brain tissue that is damaged in cerebral palsy.

Other types of disorders can also be mistaken for CP or can cause specific types of CP. For example, coagulation disorders (which prevent blood from clotting or lead to excessive clotting) can cause prenatal or perinatal strokes that damage the brain and produce symptoms characteristic of CP, most commonly hemiparetic CP. Referrals to specialists such as a child neurologist, developmental pediatrician, ophthalmologist, or otologist aid in a more accurate diagnosis and help doctors develop a specific treatment plan.

Treatment of Child Cerebral Palsy

Non-Pharmacological

Cerebral palsy can’t be cured, but treatment will often improve a child’s capabilities.  Many children go on to enjoy near-normal adult lives if their disabilities are properly managed. In general, the earlier treatment begins, the better chance children have of overcoming developmental disabilities or learning new ways to accomplish the tasks that challenge them.

• Physical therapy – usually begun in the first few years of life or soon after the diagnosis is made, is a cornerstone of CP treatment. Specific sets of exercises (such as resistive, or strength training programs) and activities can maintain or improve muscle strength, balance, and motor skills, and prevent contractures. Special braces (called orthotic devices) may be used to improve mobility and stretch spastic muscles.
• Occupational therapy – focuses on optimizing upper body function, improving posture, and making the most of a child’s mobility. Occupational therapists help individuals address new ways to meet everyday activities such as dressing, going to school, and participating in day-to-day activities.
• Recreation therapy – encourages participation in art and cultural programs, sports, and other events that help an individual expand physical and cognitive skills and abilities. Parents of children who participate in recreational therapies usually notice an improvement in their child’s speech, self-esteem, and emotional well-being.
• Speech and language therapy – can improve a child’s ability to speak, more clearly, help with swallowing disorders, and learn new ways to communicate—using sign language and/or special communication devices such as a computer with a voice synthesizer, or a special board covered with symbols of everyday objects and activities to which a child can point to indicate his or her wishes.
• Treatments for problems with eating and drooling – are often necessary when children with CP have difficulty eating and drinking because they have little control over the muscles that move their mouth, jaw, and tongue. They are also at risk for breathing food or fluid into the lungs, as well as for malnutrition, recurrent lung infections, and progressive lung disease.
• Assistive devices – Different kinds of equipment may be helpful for children with cerebral palsy. Leg braces can support their legs as they learn to walk. Arm braces can support arms or hands in a normal position. Other types of assistive devices include communication keyboards, special wheelchairs, and chairs to help with sitting.
• Alternative therapy – helps children focus on themselves as an individual and lets them overcome physical and mental obstacles. Alternative therapy includes hippotherapy, music therapy, aquatic therapy, acupuncture, and more.
• Functional electrical stimulation (FES) – It is the therapeutic use of low-level electrical current to stimulate muscle movement, posture, restore useful movements such as standing or stepping is the most effective way to target and strengthen spastic muscles. Researchers are evaluating how FES-assisted stationary cycling also improves physical conditioning with general lower extremity muscle strength adolescents age.
• Robotic therapy – It is applies controlled force to the leg during the swing phase of gait is may improve the efficacy of body weight-supported treadmill training in children with cerebral palsy. The results from this NICHD study will lead to an innovative clinical therapy aimed at improving locomotor function in children with CP.
• Stem cell therapy – It is being investigated as a treatment for cerebral palsy, but research is in the early stages and large-scale clinical trials are needed to learn if stem cell therapy is safe and effective in humans in near future. Stem cells are capable of becoming other types of cells in the body. Scientists are hopeful that stem cells may be able to repair damaged nerves, central nervous system, and brain tissues. Studies in the U.S. hopefully examining the safety and tolerability of umbilical cord blood stem cell infusion in children for cerebral palsy.
• Deep brain stimulation (DBS) – It has been used increasingly in those types of dyskinetic cerebral palsy. It is often used to decrease dystonia. Though it does decrease dystonia, hemiplagiain those  DCP, there is less benefit in quality of life and functionality compared to that seen in patients with primary (inherited) dystonia.

Stem cell therapy is being investigated as a treatment for cerebral palsy, but research is in the early stages and large-scale clinical trials are needed to learn if stem cell therapy is safe and effective in humans. Stem cells are capable of becoming other cell types in the body. Scientists are hopeful that stem cells may be able to repair damaged nerves and brain tissues. Studies in the U.S. are examining the safety and tolerability of umbilical cord blood stem cell infusion in children with CP.

Drug Treatments

Common classes of medications for children with cerebral palsy include

• Anticholinergics (neurotransmitter blockers)

• Anticonvulsants (suppress neurons that cause seizures)

• Antidepressants (relieve symptoms of depression)

• Anti-inflammatories (reduce pain and inflammation)

• Baclofen (muscle relaxer)

• Benzodiazepines (treats anxiety, seizures, and insomnia)

• Botox (treats spasticity)

• Muscle relaxants

• Nerve blocks

• Stool softeners

Medication may also be used to treat secondary disorders caused by cerebral palsy such as incontinence, acid reflux, behavioral disorders, and more.

• Oral medications such as diazepam, baclofen, dantrolene sodium, and tizanidine are usually used as the first line of treatment to relax stiff, contracted, or overactive muscles. Some drugs have some risky side effects such as drowsiness, changes in blood pressure, and risk of liver damage that require continuous monitoring. Oral medications are most appropriate for children who need an only mild reduction in muscle tone or who have widespread spasticity.
• Botulinum toxin (BT-A), injected locally, has become a standard treatment for overactive muscles in children with spastic movement disorders such as CP. BT-A relaxes contracted muscles by keeping nerve cells from over-activating muscle. The relaxing effect of a BT-A injection lasts approximately 3 months. Undesirable side effects are mild and short-lived, consisting of pain upon injection and occasionally mild flu-like symptoms. BT-A injections are most effective when followed by a stretching program including physical therapy and splinting. BT-A injections work best for children who have some control over their motor movements and have a limited number of muscles to treat, none of which is fixed or rigid.
• Intrathecal baclofen therapy uses an implantable pump to deliver baclofen, a muscle relaxant, into the fluid surrounding the spinal cord. Baclofen decreases the excitability of nerve cells in the spinal cord, which then reduces muscle spasticity throughout the body. The pump can be adjusted if muscle tone is worse at certain times of the day or night. The baclofen pump is most appropriate for individuals with chronic, severe stiffness or uncontrolled muscle movement throughout the body

Surgery

• Orthopedic surgery is often recommended when spasticity and stiffness are severe enough to make walking and moving about difficult or painful. For many people with CP, improving the appearance of how they walk – their gait – is also important. Surgeons can lengthen muscles and tendons that are proportionately too short, which can improve mobility and lessen pain. Tendon surgery may help the symptoms for some children with CP but could also have negative long-term consequences. Orthopedic surgeries may be staggered at times appropriate to a child’s age and level of motor development. Surgery can also correct or greatly improve spinal deformities in people with CP. Surgery may not be indicated for all gait abnormalities and the surgeon may request a quantitative gait analysis before surgery.
• Surgery to cut nerves.  Selective dorsal rhizotomy (SDR) is a surgical procedure recommended for cases of severe spasticity when all of the more conservative treatments – physical therapy, oral medications, and intrathecal baclofen — have failed to reduce spasticity or chronic pain. A surgeon locates and selectively severs overactivated nerves at the base of the spinal column. SDR is most commonly used to relax muscles and decrease chronic pain in one or both of the lower or upper limbs. It is also sometimes used to correct an overactive bladder. Potential side effects include sensory loss, numbness, or uncomfortable sensations in limb areas once supplied by the severed nerve.

Assistive devices

Assistive devices such devices as computers, computer software, voice synthesizers, and picture books can greatly help some individuals with CP improve communications skills. Other devices around the home or workplace make it easier for people with CP to adapt to activities of daily living.

Orthotic devices help to compensate for muscle imbalance and increase independent mobility. Braces and splints use external force to correct muscle abnormalities and improve function such as sitting or walking. Other orthotics help stretch muscles or the positioning of a joint. Braces, wedges, special chairs, and other devices can help people sit more comfortably and make it easier to perform daily functions. Wheelchairs, rolling walkers, and powered scooters can help individuals who are not independently mobile. Vision aids include glasses, magnifiers, and large-print books and computer typeface. Some individuals with CP may need surgery to correct vision problems. Hearing aids and telephone amplifiers may help people hear more clearly.

Complementary and Alternative Therapies

Many children and adolescents with CP use some form of complementary or alternative medicine. Controlled clinical trials involving some of the therapies have been inconclusive or showed no benefit and the therapies have not been accepted in mainstream clinical practice. Although there are anecdotal reports of some benefit in some children with CP, these therapies have not been approved by the U.S. Food and Drug Administration for the treatment of CP. Such therapies include hyperbaric oxygen therapy, special clothing worn during resistance exercise training, certain forms of electrical stimulation, assisting children in completing certain motions several times a day, and specialized learning strategies. Also, dietary supplements, including herbal products, may interact with other products or medications a child with CP may be taking or have unwanted side effects on their own. Families of children with CP should discuss all therapies with their doctor.

Cerebral palsy surgery may be recommended to:

• Correct fixed joints and tendons
• Correct foot deformities
• Correct muscle contractures
• Correct spinal curvatures (scoliosis)
• Improve posture
• Improve balance and coordination
• Prevent hip dislocation
• Prevent spinal deformities
• Reduce tremors
• Relieve pain
• Relieve stiff muscles
• Treat co-occurring conditions

Assistive Devices

Specialized assistive devices can help individuals with cerebral palsy that experienced issues with communication, hearing, and vision.

Types of assistive devices include:

• Cochlear implants
• Electronic communication boards
• Eye-tracking devices
• Typing aids
• Writing aids

Mobility Aids

Children with mobility limitations may benefit from assistive technology that can be adjusted to their individual needs. Mobility aids aim to help children with cerebral palsy move freely and can greatly improve their quality of life and independence.

Types of mobility aids include:

• Canes
• Crutches
• Lifts
• Power scooters
• Orthotic devices
• Standers
• Walkers
• Walking sticks
• Wheelchairs

Are there treatments for other conditions associated with cerebral palsy?

• Epilepsy. Many children with intellectual disability and CP also have epilepsy. In general, drugs are prescribed based on the type of seizures an individual experiences, since no one drug controls all types. Some individuals may need a combination of two or more drugs to achieve good seizure control.
• Incontinence. Medical treatments for incontinence include special exercises, biofeedback, prescription drugs, surgery, or surgically implanted devices to replace or aid muscles.
• Osteopenia. Children with CP who are unable to walk risk developing poor bone density (osteopenia), which makes them more likely to break bones. In a study of older Americans funded by the National Institutes of Health (NIH), a family of drugs called bisphosphonates, which has been approved by the FDA to treat mineral loss in elderly patients, also appeared to increase bone mineral density Doctors may choose to selectively prescribe the drug off-label to children to prevent osteopenia.
• Pain. Pain can be a problem for people with CP due to spastic muscles and the stress and strain on parts of the body that are compensating for muscle abnormalities. Some individuals may also have frequent and irregular muscle spasms that can’t be predicted or medicated in advance. Diazepam can reduce the pain associated with muscle spasms and gabapentin has been used successfully to decrease the severity and frequency of painful spasms. Botulinum toxin injections have also been shown to decrease spasticity and pain. Intrathecal baclofen has shown good results in reducing pain. Some children and adults have been able to decrease pain by using noninvasive and drug-free interventions such as distraction, relaxation training, biofeedback, and therapeutic massage.

Do adults with cerebral palsy face special health challenges?

• Premature aging. The majority of individuals with CP will experience some form of premature aging by the time they reach their 40s because of the extra stress and strain the disease puts upon their bodies. The developmental delays that often accompany CP keep some organ systems from developing to their full capacity and level of performance. As a consequence, organ systems such as the cardiovascular system (the heart, veins, and arteries) and pulmonary system (lungs) have to work harder and they age prematurely.
• Functional issues at work.  The day-to-day challenges of the workplace are likely to increase as an employed individual with CP reaches middle age.  Some individuals will be able to continue working with accommodations such as an adjusted work schedule, assistive equipment, or frequent rest periods.
• Depression.  Mental health issues can also be of concern as someone with cerebral palsy grows older.  The rate of depression is three to four times higher in people with disabilities such as cerebral palsy.  It appears to be related not so much to the severity of their disabilities, but to how well they cope with them.  The amount of emotional support someone has, how successful they are at coping with disappointment and stress, and whether or not they have an optimistic outlook about the future all have a significant impact on mental health.
• Post-impairment syndrome.  This syndrome is marked by a combination of pain, fatigue, and weakness due to muscle abnormalities, bone deformities, overuse syndromes (sometimes also called repetitive motion injuries), and arthritis.   Fatigue is often a challenge, since individuals with CP may use up to three to five times the amount of energy that able-bodied people use when they walk and move about.
• Osteoarthritis and degenerative arthritis.  Musculoskeletal abnormalities that may not produce discomfort during childhood can cause pain in adulthood.  For example, the abnormal relationships between joint surfaces and excessive joint compression can lead to the early development of painful osteoarthritis and degenerative arthritis.  Individuals with CP also may have limited strength and restricted patterns of movement, which puts them at risk for overuse syndromes and nerve entrapments.
• Pain. Individuals with CP may have pain that can be acute (usually comes on quickly and lasts a short while) or chronic and is experienced most commonly in the hips, knees, ankles, and the upper and lower back. Individuals with spastic CP may have an increased number of painful sites and worse pain than those with other types of cerebral palsy. Preventive treatment aimed at correcting skeletal and muscle abnormalities early in life may help to avoid the progressive accumulation of stress and strain that causes pain. Dislocated hips, which are particularly likely to cause pain, can be surgically repaired.
• Other medical conditions. Adults have higher than normal rates of other medical conditions secondary to their cerebral palsy, such as hypertension, incontinence, bladder dysfunction, and swallowing difficulties. Scoliosis is likely to progress after puberty when bones have matured into their final shape and size. People with CP also have a higher incidence of bone fractures, occurring most frequently during physical therapy sessions.

What research is being done?

The National Institute of Neurological Disorders and Stroke, (NINDS), a part of the National Institutes of Health (NIH), is the nation’s leading funder of basic, clinical, and translational research on brain and nervous system disorders.  Another NIH agency, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), also conducts and supports research on cerebral palsy.

Much of what we now know about CP came from research sponsored by the NINDS, including the identification of new causes and risk factors for cerebral palsy, the discovery of drugs to control stiff and spastic muscles and more precise methods to deliver them, refined surgical techniques to correct abnormalities in muscle and bone, and a greater understanding of how and why brain damage at critical stages of fetal development causes CP.

Many scientists think that a significant number of children develop CP because of mishaps early in

brain development. They are examining how neurons (nerve cells) in the brain specialize and form the right connections with other brain cells, and they are looking for ways to prevent the factors that disrupt the normal processes of brain development.

Genetic defects are sometimes responsible for the brain malformations and abnormalities that cause cerebral palsy.  Scientists are searching for the genes responsible for these abnormalities by collecting DNA samples from people with cerebral palsy and their families and using genetic screening techniques to discover linkages between individual genes and specific types of abnormality – primarily those associated with the process in the developing brain in which neurons migrate from where they are born to where they settle into neural circuits (called neural migration).

Scientists are scrutinizing events in newborn babies’ brains, such as bleeding, epileptic seizures, and breathing and circulation problems, which can cause the

abnormal release of chemicals that triggers the kind of damage that causes cerebral palsy.  For example, research has shown that bleeding in the brain unleashes dangerously high amounts of glutamate, a chemical that helps neurons communicate.  However, too much glutamate overexcites and kills neurons.  By learning how brain chemicals that are normally helpful become dangerously toxic, scientists will have opportunities to develop new drugs to block their harmful effects.

Researchers are using

imaging techniques and neurobehavioral tests to predict those preterm infants who will develop cerebral palsy. If these screening techniques are successful, doctors will be able to identify infants at risk for cerebral palsy before they are born.

Periventricular

white matter damage—the most common cause of CP—is characterized by the death of the white matter around the fluid-filled ventricles in the brain. The periventricular area contains nerve fibers that carry messages from the brain to the body’s muscles. NINDS-sponsored researchers are hoping to develop preventative strategies for white matter damage. For example, researchers are examining the role brain chemicals play on white matter development in the brain. Another NINDS-funded project involves the development of a novel mouse model and cell-based therapies for perinatal white matter injury.  Researchers funded by NINDS are studying a chemical found naturally in the body, called erythropoietin to see if it decreases the risk of CP in prematurely born infants.

NIH-funded scientists continue to look at new therapies and novel ways to use existing options to treat individuals with CP, including:

Constraint-induced therapy (CIT) is a promising therapy for CP. CIT typically involves restraining the stronger limb (such as the “good” arm in a person who has been affected by a stroke on one side of the body) in a cast and forcing the weaker arm to perform intensive activities every day over a period of weeks.  A clinical study sponsored by the NICHD is examining the use of different dosage levels of daily training using either full-time cast immobilization vs. part-time splint restraint in improving upper body extremity skills in children with weakness on both sides of their body. Study findings will establish evidence-based practice standards to improve lifelong neuromotor capacity in individuals with CP.

Functional electrical stimulation (FES)—the therapeutic use of low-level electrical current to stimulate muscle movement and restore useful movements such as standing or stepping—is an effective way to target and strengthen spastic muscles. Researchers are evaluating how FES-assisted stationary cycling can improve physical conditioning and general lower extremity muscle strength in adolescents.

Robotic therapy that applies controlled force to the leg during the swing phase of gait is may improve the efficacy of body weight-supported treadmill training in children with CP. The results from this NICHD study will lead to an innovative clinical therapy aimed at improving locomotor function in children with CP.

Botulinum toxin (Botox), injected locally, has become a standard treatment in children with spastic movement disorders such as CP. Recent animal studies suggest Botox degrades bone but there are no studies of its skeletal consequences in humans. Other research shows a low-intensity vibration treatment can improve bone structure in the lower extremity leg bones of children with CP. In a novel clinical study being conducted by NICHD, researchers are determining the effect of Botox treatment in conjunction with a daily vibration treatment on bone mass and bone structure in children with spastic CP.

Systemic hypothermia—the controlled medical cooling of the body’s core temperature—appears to protect the brain and decrease the rate of death and disability from certain disorders and brain injuries. Previous studies have shown that hypothermia is effective in treating neurologic symptoms in term or late preterm babies less than the one-month old that is attributed to hypoxic-ischemia (HIE, brain injury due to a severe decrease in the oxygen supply to the body), which can cause quadriplegic CP, with or without movement disorder. In an effort to determine the most effective cooling strategies, NICHD-funded researchers are studying different cooling treatments to improve the chance of survival and neurodevelopment outcomes 18-22 months post-treatment in infants with neurologic symptoms attributed to HIE. Other researchers are examining if combined therapy using hypothermia and recombinant erythropoietin (a hormone that promotes the growth of new red blood cells and increases oxygen levels in the blood) is more effective than either therapy alone in treating neurodevelopmental handicaps in an animal model involving a lack of oxygen before, during, or just after birth.

Preventing CP

In many cases, the cause or causes of congenital CP aren’t fully known, which means that currently little can be done to prevent it. CP related to genetics is not preventable. However, there are actions people can take before and during pregnancy, as well as after birth that might help reduce the risk of developmental problems, including CP.

Taking steps to help ensure a healthy pregnancy can help prevent developmental problems, including CP. Acquired CP often is related to an infection or injury, and some of these cases can be prevented.

Before Pregnancy

• Be as healthy as possible before pregnancy. Make sure that any infections in the mother are treated and health conditions are in control, ideally before pregnancy occurs.
• Get vaccinated for certain diseases (such as chickenpox and rubella) that could harm a developing baby. It is important to have many of these vaccinations before becoming pregnant.
• If assistive reproductive technology (ART) infertility treatments are used to get pregnant, consider ways to reduce the chance of a multiple pregnancy (twins, triplets, or more), such as transferring only one embryo at a time.

During Pregnancy

• Learn how to have a healthy pregnancy.
• Get early and regular prenatal care, both for your health and for that of your developing baby.
• Wash your hands often with soap and water to help reduce the risk of infections that might harm your developing baby.
• Contact your health care provider if you get sick, have a fever, or have other signs of infection during pregnancy.
• A flu shot is your best protection against serious illness from the flu. A flu shot can protect pregnant women and their unborn babies, both before and after birth. Flu shots have not been shown to cause harm to pregnant women or their babies.
• If there is a difference in the blood type or Rh incompatibility between mother and baby it can cause Jaundice and kernicterus. Women should know their blood type and talk to their doctor about ways to prevent problems. Doctors can treat the mother with Rh immune globulin (“Rhogam”) when she is 28 weeks pregnant and again shortly after giving birth to prevent kernicterus from occurring.
• Talk to your doctor about ways to prevent problems if you are at risk for preterm delivery. Research has shown that taking magnesium sulfate before anticipated early preterm birth reduces the risk of CP among surviving infants. ^{(rx,rx,rx,rx)}

After the Baby is Born

• Learn how to help keep your baby healthy and safe after birth.
• Any baby can get jaundice. Severe jaundice that is not treated can cause brain damage, called kernicterus. Kernicterus is a cause of CP that potentially can be prevented. Your baby should be checked for jaundice in the hospital and again within 48 hours after leaving the hospital. Ask your doctor or nurse about a jaundice bilirubin test. In addition, steps can be taken to prevent kernicterus that is caused by Rh blood type incompatibility between the mother and baby.
• Make sure your child is vaccinated against infections that can cause meningitis and encephalitis, including Haemophilus influenzae type B (HiB vaccine) and Streptococcus pneumoniae (pneumococcal vaccine).
• Take steps to prevent injuries:
  • Buckle your child in the car using an infant or child car seat, booster seat, or seat belt (according to the child’s height, weight, and age).
  • Make living areas safer for children by using window guards to keep young children from falling out of open windows and using safety gates at the top and bottom of stairs.
  • Make sure the surface on your child’s playground is made of a shock-absorbing material, such as hardwood mulch or sand.
  • Carefully watch young children at all times around bathtubs, swimming or wading pools, and natural bodies of water. Adults watching kids near water should avoid distracting activities like using a computer or handheld device, reading, or talking on the phone.
  • Make sure your child wears a helmet for activities like riding a bike.
  • Never hit, throw, shake, or hurt a child.

Cerebral Palsy Frequently Asked Questions

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