Cerebral palsy refers to a group of conditions that involve difficulty moving and muscle stiffness (spasticity). It results from brain malformations that occur before birth as the brain is developing or from brain damage that occurs before, during, or shortly after birth.
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Causes of cerebral palsy include brain damage that can result from oxygen deprivation or from infections and brain malformations.
Symptoms range from barely noticeable clumsiness, to substantial difficulty moving one or more limbs, to paralysis and joints so stiff they cannot be moved at all.
Some children with cerebral palsy also have intellectual disability, behavioral problems, difficulty seeing or hearing, and/or seizure disorders.
The diagnosis is suspected when children are late learning to walk or developing other motor skills or when their muscles are stiff or weak.
There is no cure for cerebral palsy, but physical, occupational, and speech therapies and sometimes medications and/or surgery can help children achieve their highest potential.
Most children with cerebral palsy survive into adulthood.
Cerebral palsy (CP) occurs in about 2 of every 1,000 infants, especially premature infants who are less than 28 weeks gestation and infants who have a low birth weight.
Cerebral palsy is not a specific disease. Rather, it is a group of symptoms that results from malformations in, or damage to, the parts of the brain that control muscle movements (motor areas). Sometimes children who have cerebral palsy also have abnormalities of other parts of the brain. Brain damage that results in cerebral palsy may occur during pregnancy, during birth, after birth, or in early childhood. Once the brain damage has occurred, it does not get worse even though the symptoms may change as the child grows and matures. If muscle malfunction results from brain damage that occurs after 2 years of age, it is not considered cerebral palsy.
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Causes of Cerebral Palsy
Many different types of brain malformations and brain damage can cause cerebral palsy, and sometimes more than one cause is involved.
Problems that occur just before, during, and just after birth cause some cases. These problems include lack of oxygen during delivery, infections, and brain injuries.
During pregnancy, infections, such as rubella, toxoplasmosis, Zika virus infection, or cytomegalovirus infection, sometimes result in cerebral palsy. Sometimes the brain malformations that cause cerebral palsy result from genetic abnormalities.
Premature infants are particularly vulnerable, possibly in part because in a certain part of their brain, some of the blood vessels are thin and bleed easily. High levels of bilirubin in the blood can lead to a form of brain damage called chronic bilirubin encephalopathy (formerly known as kernicterus), which can cause cerebral palsy.
During the first 2 years of life, severe illness, such as inflammation of the tissues covering the brain (meningitis), a severe bloodstream infection (sepsis), injury, and severe dehydration, can damage the brain and result in cerebral palsy.
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Symptoms of Cerebral Palsy
Symptoms of cerebral palsy can range from clumsiness to severe spasticity that contorts the child's arms and legs, requiring mobility aids, such as braces, crutches, and wheelchairs. Because other parts of the brain may also be affected by the problem that caused the cerebral palsy, many children with cerebral palsy have other impairments and conditions, such as intellectual disability, behavioral problems, difficulty seeing or hearing, chronic pain, speech and language disorders, seizure disorders, dislocated hips, and drooling.
There are 4 main types of cerebral palsy:
Spastic
Dyskinetic (athetoid or dystonic)
Ataxic
Mixed
In all forms of cerebral palsy, speech may be hard to understand because the child has difficulty controlling the muscles involved in speech. Crossed, lazy, or wandering eyes (strabismus) and other vision problems may occur.
Spastic cerebral palsy
Spasticity is muscle stiffness that prevents normal movement.
Spastic cerebral palsy is the most common type and occurs in the majority of children with cerebral palsy.
In this type, the muscles are stiff (spastic) and weak. The stiffness may affect different parts of the body:
Both arms and both legs (quadriplegia)
The legs more than the arms (diplegia)
Sometimes only the arm and leg on one side (hemiplegia)
Rarely, only the legs and lower part of the body (paraplegia)
The affected arms and legs are poorly developed, as well as stiff and weak. Some children may walk in a criss-cross motion, where one leg swings over the other (scissoring gait), and some may walk on their toes.
Children with spastic quadriplegia are the most severely affected. They commonly have intellectual disability (sometimes severe) along with seizures and trouble swallowing. Children who have trouble swallowing may choke on secretions from the mouth and stomach and inhale (aspirate) them. Aspiration inflames the lungs, causing difficulty breathing. Repeated aspiration can permanently damage the lungs.
Many children with spastic diplegia have normal intelligence and are less likely to have seizures. Children with spastic quadriplegia may have severe intellectual disability.
Dyskinetic (athetoid or dystonic) cerebral palsy
Athetosis is involuntary writhing movements. Dystonias are involuntary muscle contractions.
Dyskinetic cerebral palsy is the second most common type and occurs in approximately 15% of children with cerebral palsy.
In this type the arms, legs, and body spontaneously move slowly and involuntarily. Movements may also be writhing, abrupt, and jerky. Strong emotion makes the movements worse, and sleep makes them disappear.
Difficulty articulating words clearly is common and is often severe. If the cause is chronic bilirubin encephalopathy, affected children are often deaf and have difficulty looking up.
Ataxic cerebral palsy
Ataxia is difficulty controlling and coordinating body movements, particularly walking.
Ataxic cerebral palsy is rare.
In this type, coordination is poor, and muscles are weak. Movements become shaky when children reach for an object (a type of tremor). Children have difficulty when they try to move rapidly or do things that require fine movements. They can walk unsteadily, with their legs widely spaced for balance.
Mixed cerebral palsy
In the mixed type, any of the above types, most often spastic and dyskinetic, are combined. This type occurs in many children with cerebral palsy.
Children with the mixed type may have severe intellectual disability.
Diagnosis of Cerebral Palsy
Imaging of the brain
Blood tests and sometimes tests of nerve and muscle function
Symptoms of cerebral palsy are not always visible at birth and may become more obvious as a baby grows. For example, as their baby grows, parents may notice delays in learning to walk and developing other motor skills (motor development); spasticity; or lack of coordination (see table Developmental Milestones From Birth to Age 12 Months). However, doctors can diagnose cerebral palsy before these symptoms are noticeable in children under 5 months of age. If a baby is born with a risk factor for cerebral palsy, such as prematurity or high levels of bilirubin in the blood, doctors do magnetic resonance imaging (MRI) of the baby's brain to look for abnormalities or damage. They also do neurologic and movement examinations. During these examinations, doctors pay special attention to the baby's movements, posture, and muscle tone. For example, some babies may not be able to sit up on their own at the typical age (around 7 months), and some have very relaxed, weak muscles, whereas others have stiff, tight muscles. The results of the MRI and the examinations can help doctors determine whether the baby has cerebral palsy. MRI and ultrasounds of the brain may be done to identify other problems with the brain.
Computed tomography (CT) scans and MRI may be done to identify problems with the brain in children 3 years old and older.
Doctors also ask questions about problems during the pregnancy or delivery and about the child's developmental progress. Such information may help identify a cause.
Although laboratory tests cannot identify cerebral palsy, a doctor may do blood tests to identify a cause and to look for other disorders.
If the cause is still not clear or if muscle problems seem to be getting worse or differ from those typically caused by cerebral palsy, doctors may recommend additional testing, such as electrical studies of nerves (nerve conduction studies) and muscles (electromyography) and genetic testing.
Treatment of Cerebral Palsy
Physical, occupational, and speech therapies
Braces
Botulinum toxin and other medications to reduce spasticity
Sometimes surgery
Cerebral palsy cannot be cured, and its problems are lifelong. However, symptoms of cerebral palsy can be managed and much can be done to improve a child's mobility and independence. The goal is to enable children to become as independent as they can be.
Physical therapy, occupational therapy, and braces may improve muscle control and walking, particularly when rehabilitation is started as early as possible. Speech therapy may make speech clearer and help with swallowing problems.
Occupational therapists can help some children learn ways to compensate for their muscle problems and thus do daily activities (such as bathing, eating, and dressing) for themselves. Or therapists may teach children to use devices that help them do these activities.
Constraint-induced movement therapy may help when the disorder does not affect all the limbs. For this therapy, the unaffected limb is restrained during waking hours, except during specific activities, so that children must do tasks with the affected limb. As a result, new pathways for nerve impulses may develop in the brain, enabling children to use the affected limb better.
Certain medications may help. When botulinum toxin is injected into muscles, the muscles are less able to pull unevenly on joints and less likely to become permanently shortened (called contractures). Botulinum toxin, the bacterial toxin that causes botulism, works by paralyzing the injected muscles. It is the same medication sold as Botox that is used to treat wrinkles.
Other medications used to lessen spasticity include baclofen, benzodiazepines (such as diazepam), tizanidine, and sometimes dantrolene, all taken by mouth. Some children with severe spasticity benefit from an implantable pump that provides a continuous infusion of Other medications used to lessen spasticity include baclofen, benzodiazepines (such as diazepam), tizanidine, and sometimes dantrolene, all taken by mouth. Some children with severe spasticity benefit from an implantable pump that provides a continuous infusion ofbaclofen into the fluid around the spinal cord.
Surgery may be done to cut or lengthen tendons of the stiff muscles that limit motion. Also, surgeons may connect tendons to a different part of the joint to balance the pull on the joint. Sometimes cutting certain nerve roots coming from the spinal cord (dorsal rhizotomy) reduces the spasticity and may help a few children, especially those who were born prematurely, as long as spasticity affects mainly the legs and mental function is good.
Many children with cerebral palsy grow normally and may attend regular schools if they do not have severe intellectual disabilities. Other children require extensive physical therapy, need special education, and are severely limited in activities of daily living, requiring some type of lifelong care and assistance. However, even severely affected children can benefit from education and training, which increase their independence and self-esteem. Many children's medical facilities are developing programs aimed at assisting children in their transition to adulthood, particularly in light of the reduced availability of support services for those with special needs.
Information and counseling are available to parents to help them understand their child's condition and potential and to assist with problems as they arise. Loving parental care combined with assistance from public and private agencies, such as community health agencies, health organizations such as United Cerebral Palsy, and vocational rehabilitation organizations, can help children reach their highest potential.
Prognosis for Cerebral Palsy
The prognosis usually depends on the type of cerebral palsy and on its severity. Most children with cerebral palsy survive into adulthood. Only the most severely affected—those incapable of any self-care or taking food by mouth—have a substantially shortened life expectancy.
With appropriate treatment and training, many children, especially those with spastic diplegia or hemiplegia, can lead a near-normal life.
Prevention of Cerebral Palsy
During pregnancy, if an infant is expected to be born very prematurely, pregnant people are given corticosteroids and magnesium sulfate. Corticosteroids help the infant's lungs mature while still in the mother's womb, which improves the supply of oxygen to the infant's developing brain. Magnesium helps protect the developing nerve cells in the infant's brain. Both medications may help prevent cerebral palsy in the newborn.
After birth, very premature newborns may be given caffeine. Caffeine stimulates the newborn's developing nervous system and, by increasing the newborn's rate of breathing, can help prevent damage to the brain because of a lack of oxygen. If the newborn lacked oxygen or blood flow to the brain and other organs before or during labor and delivery, the newborn is placed on a special cooling blanket for a few days to lower the body temperature. This treatment is known as therapeutic hypothermia. Therapeutic hypothermia helps lessen or prevent further injury to the newborn's brain.. Caffeine stimulates the newborn's developing nervous system and, by increasing the newborn's rate of breathing, can help prevent damage to the brain because of a lack of oxygen. If the newborn lacked oxygen or blood flow to the brain and other organs before or during labor and delivery, the newborn is placed on a special cooling blanket for a few days to lower the body temperature. This treatment is known as therapeutic hypothermia. Therapeutic hypothermia helps lessen or prevent further injury to the newborn's brain.
More Information
The following English-language resources may be useful. Please note that The Manual is not responsible for the content of these resources.
Miller, F and Bachrach, SJ: Cerebral palsy: A complete guide for caregiving, ed. 3. Baltimore, John Hopkins University Press, 2017.
