Cerebral palsy

Cerebral palsy is a disorder of movement, muscle tone or posture that is caused by injury or abnormal development in the immature 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 or rigidity of the limbs and trunk, abnormal posture, involuntary movements, unsteadiness of walking, or some combination of these. The effect of cerebral palsy on functional abilities varies greatly.

People with cerebral palsy often have other conditions related to developmental brain abnormalities, such as intellectual disabilities, vision and hearing problems, or seizures. A broad spectrum of treatments may help minimize the effect of cerebral palsy and improve a person's functional abilities.


Symptoms

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

* Variations in muscle tone — 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 difficulty 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 injury 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 may also contribute to other neurological problems. People with cerebral palsy may also have:

* Difficulty with vision and hearing
* Intellectual disabilities or mental retardation
* Seizures
* Abnormal touch or pain perceptions
* Dental problems
* 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
* Infant infections that cause inflammation in or around the brain
* Traumatic head injury to an infant from a motor vehicle accident, fall or child abuse

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), a viral infection that can be prevented with a vaccine
* Chickenpox (varicella), a viral infection that can be prevented with a vaccine and can emerge later in life as shingles
* Cytomegalovirus, a very common virus that causes flu-like symptoms and may lead to birth defects if a mother experiences her first active infection during pregnancy
* Toxoplasmosis, a parasitic infection caused by a parasite found in soil and the feces of infected cats
* Syphilis, a sexually transmitted bacterial infection
* Exposure to toxins, such as methyl mercury
* Other conditions that may increase the risk of cerebral palsy, such as thyroid problems, mental retardation or seizures

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

* Bacterial meningitis, a bacterial infection that causes inflammation in the membranes that surround the brain and spinal cord
* Viral encephalitis, a viral infection that causes inflammation of the brain
* Severe or untreated jaundice, a condition that appears as a yellowing of the skin and that 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 falls.
* Breech births. Babies who have 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:

* 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.
* Depression. Social isolation and the challenges of coping with disabilities can contribute to depression.
* Premature aging. People with cerebral palsy often experience medical conditions in middle age that are more commonly associated with older age. Such premature aging can result from significant stress on the body and poorly developed heart, lungs or other organs that may not function at a typical capacity.
* Post-impairment syndrome. This condition is characterized by pain, fatigue and weakness resulting from stresses on the body, movements to compensate for disabilities and the significant exertion of energy needed for everyday functions.
* 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

How you learn about your child's condition — if your child has cerebral palsy — may depend on how severe the disabilities are, when problems first appear, and whether there were any significant 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 — vision, hearing and touch

Questions you should be prepared to answer during regular checkups might include the following:

* 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?


Tests and diagnosis

If your family doctor or pediatrician suspects that your child has cerebral palsy, he or she will 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) uses radio waves and a magnetic field to produce detailed 3-D or cross-sectional images of the brain. This test is painless, but it is noisy and can take up to an hour to complete. Your child will likely receive a mild sedative. An MRI is usually the preferred imaging test.
* 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. The ultrasound device is placed over the soft spot (fontanel) on the top of a baby's head.
* Computerized tomography (CT) is a specialized X-ray technology that can produce cross-sectional views of the 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.

Lab tests
Your child's blood may need to be checked to rule out other conditions — such as blood-clotting disorders that can cause strokes — that may mimic cerebral palsy signs and symptoms. Lab 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 or mental retardation
* Other developmental delays

Treatments and drugs

Children and adults with cerebral palsy will require some degree of long term care with a medical care team. This team may include:

* Pediatrician or physiatrist, who oversees the treatment plan and medical care
* Pediatric neurologist, who specializes in the diagnosis and treatment of neurological disorders in children
* Orthopedist, who treats muscle and bone disorders
* Occupational therapist, who specializes in therapy to develop everyday skills and to use adaptive products that help with everyday activities
* Developmental therapist, who specializes in therapy to help your child develop age-appropriate behaviors, social skills and interpersonal skills
* Mental health provider, such as a psychologist or psychiatrist
* Social worker, who assists the family with accessing services and planning for transitions in care
* Special education teacher, who 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. 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. Severe weakness is a possible side effect. There also is some evidence of more-serious side effects, including difficulty breathing and swallowing.
* Generalized spasticity. If the whole body is affected, oral muscle relaxants may relax stiff, contracted muscles. These drugs include diazepam (Diazepam Intensol, Valium), tizanidine (Zanaflex), dantrolene (Dantrium), and baclofen. 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 tizanidine include sleepiness, weakness, low blood pressure and liver damage. Side effects of dantrolene and baclofen include sleepiness. Baclofen may also be pumped directly into the spinal cord with a tube. The pump is surgically implanted under the skin of the abdomen.

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. 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 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.
* Speech therapy. Speech therapists help improve your child's ability to speak clearly or to communicate using sign language. They can also teach your child to use special communication devices — such as a board covered with pictures of everyday items and activities. Sentences can be constructed by pointing to the pictures. Speech therapists may also address difficulties with muscles used in eating and swallowing.

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 and 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, improve mobility, and 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. This relaxes the muscle and reduces pain, but can also cause numbness.


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.


Prevention

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.