Cerebral Palsy

Cerebral palsy is the term for a group of brain disorders that affect muscles and body movement. The condition is caused by damage to parts of the brain that control muscle movement, balance, and posture. Signs and symptoms of cerebral palsy usually appear in infancy or early childhood and last throughout a person's life. In most cases, the symptoms do not get worse over time.

Cerebral palsy is the most common movement disorder in children, according to the Centers for Disease Control and Prevention.¹ The level and severity of disability caused by the condition differs from person to person. Some people with cerebral palsy may not be able to walk and need intensive, lifelong care, while others can walk and move with little or no help.²

There are several types of cerebral palsy, classified by the kind of movement affected, the body parts affected, and how severe the symptoms are. Some types involve intellectual and developmental disabilities (IDDs) as well as movement problems.²

• Spastic cerebral palsy. This type is the most common form of the disorder. People with spastic cerebral palsy have stiff muscles which cause jerky or repeated movements. There are different forms of spastic cerebral palsy, depending on the body parts affected. These forms are:
  • Spastic hemiplegia (pronounced hem-i-PLEE-jee-uh) or hemiparesis (pronounced hem-ee-puh-REE-sis). This type affects the arm, the hand, and sometimes the leg on only one side of the body. Children with this form may have delays in learning to talk, but intelligence is usually normal.
  • Spastic diplegia (pronounced dahy-PLEE-jee-uh) or diparesis (pronounced dahy-puh-REE-sis). People with this form mostly have muscle stiffness in the legs, while the arms and face are less severely affected. Intelligence and language skills are usually normal.
  • Spastic quadriplegia (pronounced kwod-ruh-PLEE-jee-uh)or quadriparesis (pronounced kwod-ruh-puh-REE-sis). This is the most severe form of cerebral palsy, involving severe stiffness of the arms and legs and a floppy, or weak, neck. People with spastic quadriplegia are usually unable to walk and often have trouble speaking. This form may involve moderate to severe IDD as well.
• Dyskinetic (pronounced dis-ki-NET-ik) cerebral palsy. This type involves slow and uncontrollable jerky movements of the hands, feet, arms, or legs. The face muscles and tongue may be overactive and cause some children to drool or make faces. People with this type often have trouble sitting straight or walking. People with dyskinetic cerebral palsy do not usually have intellectual problems.
• Ataxic (pronounced uh-TAK-sik) cerebral palsy. This form of the disorder affects balance and depth perception. People with ataxic cerebral palsy walk in an unsteady manner and have a hard time with quick or precise movements such as writing, buttoning a shirt, or reaching for a book.
• Mixed types. This kind of cerebral palsy includes symptoms that are a mix of the other types.

Even though the symptoms of cerebral palsy often differ from person to person, they can include¹:

• Ataxia (pronounced uh-TAK-see-uh), the loss of muscle coordination when making movements
• Spasticity (pronounced spa-STIS-i-tee), stiff or tight muscles; jerky, repeated movements; and stronger-than-normal reflexes (for example, the knee-jerk reflex)
• Weakness in arms or legs
• Walking on the toes
• Walking in a crouched position
• Muscle tone that is either too stiff or too floppy
• Drooling
• Trouble with swallowing or speaking
• Shaking (tremor) of arms, legs, hands, or feet
• Sudden, uncontrolled movements
• In infants and toddlers, delays in motor skills (such as sitting, crawling, walking)
• Trouble with precise movements such as writing or buttoning a shirt

It’s important to note that many of these symptoms result from problems with muscles and not from problems with cognition or thinking. For example, a person with cerebral palsy may have trouble speaking because he or she cannot control or move the muscles involved with speaking, not because of brain problems with language.

The symptoms of cerebral palsy vary in type, can range from mild to severe, and can change over time. Symptoms are different for each person, depending on the areas of the brain that have been affected. All people with cerebral palsy have movement and posture problems.¹

In addition to problems with muscle movement, symptoms occasionally include¹:

• Intellectual and developmental disabilities
• Seizures
• Feeling unusual physical sensations
• Vision problems
• Hearing problems

Although NICHD research portfolio includes work on cerebral palsy and rehabilitative therapies, the National Institute of Neurological Disorders and Stroke leads research on cerebral palsy at the NIH and offers comprehensive information on cerebral palsy through its website.

The signs of cerebral palsy usually appear in the first few months of life, but many children are not diagnosed until age 2 or later. In general, early signs of cerebral palsy include^1,2:

• Developmental delays. The child is slow to reach milestones such as rolling over, sitting, crawling, and walking. Developmental delays are the main clues that a child might have cerebral palsy.
• Abnormal muscle tone. Body parts are floppy or too stiff.
• Abnormal posture. The child might also use one side of the body more than the other when reaching, crawling, or moving.

Children without cerebral palsy may show some of these signs. If you notice any of these signs, you should talk to your child’s health care provider.

Some age-specific signs may include:

• Infants younger than 6 months of age^1,2:
  • Cannot hold up their head when picked up from lying on their back
  • May feel stiff or floppy
  • When picked up, their legs get stiff or cross
  • When held, they may overextend their back and neck, constantly acting as though they are pushing away from you
• Infants older than 6 months of age^1,2:
• Cannot roll over
  • Cannot bring their hands to their mouth
  • Have a hard time bringing their hands together
  • Reach out with only one hand while holding the other in a fist
• Infants older than 10 months of age^1,2:
  • Crawl in a lopsided way, pushing with one hand and leg while dragging the opposite hand and leg
  • Scoot around on their buttocks or hop on their knees but do not crawl on all fours
  • Cannot stand even when holding onto support

Children without cerebral palsy may show some of these signs. If you notice any of these signs, you should talk to your child’s health care provider.

Cerebral palsy is caused by damage or abnormal development in the parts of the brain that control movement. These events can happen before, during, or shortly after birth or in the first few years of life, when the brain is still developing. In many cases the exact cause of cerebral palsy is not known.^1,2

The majority of children with cerebral palsy were born with the condition, a situation called congenital cerebral palsy.

Causes of cerebral palsy that occur before birth include^1,2:

• Damage to the white matter of the brain. The brain’s white matter sends signals throughout the brain and the rest of the body. Damage to white matter can disrupt the signals between the brain and the body that control movement. The white matter in the fetus’s brain is more sensitive to injury between 26 weeks and 34 weeks of pregnancy, but damage can happen at any time during pregnancy.
• Abnormal brain development. Disruptions in the normal growth process of the brain can cause abnormalities. These abnormalities affect the transmission of brain signals. Infections, fever, trauma, or gene changes (mutations) can cause the brain to develop abnormally.
• Bleeding in the brain. A fetus can have a stroke, which is a common cause of brain bleeding. Strokes occur when blood vessels in the brain become blocked or broken, leading to brain damage. Conditions including blood clotting problems, abnormally formed blood vessels, heart defects, and sickle cell disease can also cause bleeding in the brain.
• Lack of oxygen in the brain. The brain can become damaged if it does not get enough oxygen for a long time. Very low blood pressure in the mother, a torn uterus, detachment of the placenta, problems with the umbilical cord, or severe trauma to the infant’s head during labor and delivery can prevent oxygen from getting to the brain.

A small number of children have what is called acquired cerebral palsy, which means the disorder begins more than 28 days after birth. Causes of acquired cerebral palsy may include^1,2:

• Brain damage in the first few months or years of life
• Infections, such as meningitis or encephalitis
• Problems with blood flow to the brain due to stroke, blood clotting problems, abnormal blood vessels, a heart defect that was present at birth, or sickle cell disease
• Head injury from a car accident, a fall, or child abuse

Some events or medical problems during pregnancy can increase the risk of congenital cerebral palsy. These risk factors include^1,2:

• Low birth weight or preterm birth. Infants born preterm (defined as before 37 weeks of pregnancy) and infants who weigh less than 5.5 pounds at birth are at greater risk of cerebral palsy than are early term (defined as 37 weeks to 38 weeks of pregnancy) and full-term (defined as 39 weeks to 40 weeks of pregnancy) infants and those who are heavier at birth. The earlier the birth and the lower the infant’s birthweight, the greater the risk.
• Multiple gestations. Twins, triplets, and other multiple births are at higher risk of cerebral palsy. The risk is also greater for an infant whose twin or triplet dies before or shortly after birth.
• Infertility treatments. Infants born from pregnancies resulting from the use of certain infertility treatments are at higher risk for cerebral palsy than are infants born from pregnancies not related to infertility treatments. Much of this increased risk may be due to the fact that infertility treatments are more likely to result in preterm delivery and multiple gestations.
• Infections during pregnancy. Toxoplasmosis, rubella (German measles), cytomegalovirus, and herpes can infect the womb and placenta, leading to brain damage in the fetus.
• Fever during pregnancy. Sometimes fever in the mother during pregnancy or delivery can lead to brain damage in the fetus, resulting in cerebral palsy.
• Blood factor between mother and fetus does not match. Those who have a certain protein found on red blood cells—abbreviated Rh—are Rh positive; those who do not have the protein are Rh negative. If a mother’s Rh factor is different from that of the fetus, her immune system may attack the blood cells of the fetus, including blood cells in the brain, which can lead to brain damage.
• Exposure to toxic chemicals. If a mother is exposed to a toxic substance, such as high levels of methyl mercury (found in some thermometers and in some seafood), during pregnancy the fetus is at higher risk of cerebral palsy.
• Maternal medical conditions:
  • Abnormal thyroid function
  • Intellectual and developmental disability
  • Too much protein in the urine
  • Seizures
• Complicated labor and delivery. Infant heart or breathing problems during labor and delivery and immediately after birth increase the risk of cerebral palsy.
• Jaundice (pronounced JAWN-dis). Jaundice, which causes an infant’s skin, eyes, and mouth to turn a yellowish color, can be a sign that the liver is not working normally. Jaundice occurs when a substance called bilirubin (pronounced BIL-uh-roo-bin) builds up faster than the liver can clear it from the body. This condition is common and is usually not serious. However, in cases of severe, untreated jaundice, the excess bilirubin can damage the brain and cause cerebral palsy.
• Seizures. Infants who have seizures are more likely to be diagnosed with cerebral palsy later in childhood.

Some risk factors for acquired cerebral palsy are²:

• Infancy. Infants are at greater risk than older children for an event that causes brain damage.
• Preterm or low birthweight. Children born preterm or at a low birthweight have a higher risk for acquired cerebral palsy.
• Not getting certain vaccinations. Childhood vaccinations can prevent brain infections that can cause cerebral palsy.
• Injury. Not taking certain safety precautions for infants or lack of adult supervision can lead to injury that can cause cerebral palsy.

Most children with cerebral palsy are diagnosed during their first 2 years of life. But if symptoms are mild, a healthcare provider may not be able to make a diagnosis before the age of 4 or 5.^1,2

During regular well-baby and well-child visits, a child’s healthcare provider will examine^1,2:

• Growth and development
• Muscle tone
• Control of movement
• Hearing and vision
• Posture
• Coordination and balance

If a health care provider finds signs of cerebral palsy during an examination, he or she may then use one or more brain scanning methods to look for damage in the brain. These methods may include^1,2:

• Ultrasound. This method is used most commonly in high-risk preterm infants to take pictures of the brain. Ultrasound is not as good as other methods at taking images of the brain, but it is the safest way to look at the brains of preterm infants.
• Computed tomography (CT). CT uses X-rays to take pictures of the brain and can show areas that are damaged.
• Magnetic resonance imaging (MRI). MRI uses a computer, a magnetic field, and radio waves to create an image of the brain. It can show the location and type of damage in better detail than CT.
• Electroencephalogram (EEG). If a child has had seizures, a health care provider may order this test to rule out another disorder such as epilepsy. Small disks called electrodes are placed on the scalp to measure the brain’s activity.

If a health care provider thinks that your child has cerebral palsy, he or she may then refer the child to specialists such as a pediatric neurologist (doctor who specializes in the brain and nervous system), a developmental pediatrician (doctor who specializes in child development), an ophthalmologist (eye doctor), or an otologist (hearing doctor), depending on the specific symptoms. These health care providers can help give a more accurate diagnosis and create a treatment plan.^1,2

A child may need one or several different types of treatment depending on how severe the symptoms are and what parts of the body are affected. The treatment differs from person to person, depending on each one’s specific needs. Although the initial damage of cerebral palsy in the brain cannot be reversed, earlier and aggressive treatments may help to improve function and adjustments for the young nervous system and musculoskeletal system.

Families may also work with their health care providers and, during the school years, school staff to develop individual care and treatment programs.

Common types of treatment for cerebral palsy include^1,2:

• Physical therapy and rehabilitation. A child with cerebral palsy usually starts these therapies in the first few years of life or soon after being diagnosed. Physical therapy is one of the most important parts of treatment. It involves exercises and activities that can maintain or improve muscle strength, balance, and movement. A physical therapist helps the child learn skills such as sitting, walking, or using a wheelchair. Other types of therapy include:
  • Occupational therapy. This type of therapy helps a child learn to do everyday activities such as dressing and going to school.
  • Recreational therapy. Participating in art programs, cultural activities, and sports can help improve a child’s physical and intellectual skills.
  • Speech and language therapy. A speech therapist can help a child learn to speak more clearly, help with swallowing problems, and teach new ways to communicate, such as by using sign language or a special communication device.
• Orthotic devices. Braces, splints, and casts can be placed on the affected limbs and can improve movement and balance. Other devices that can help with movement and posture include wheelchairs, rolling walkers, and powered scooters.
• Assistive devices and technologies. These include special computer-based communication machines, Velcro-fastened shoes, or crutches, which can help make daily life easier.
• Medication. Certain medications can relax stiff or overactive muscles and reduce abnormal movement. They may be taken by mouth, injected into affected muscles, or infused into the fluid surrounding the spinal cord through a pump implanted near the spinal cord. For children who have cerebral palsy and epilepsy (seizures), standard epileptic medications should be considered, but these medications may also have negative effects on the developing brain.
• Surgery. A child may need surgery if symptoms are severe. For instance, surgery can lengthen stiff, tightly contracted muscles. A surgeon can also place arms or legs in better positions or correct or improve an abnormally curved spine. Sometimes, if other treatments have not worked, a surgeon can cut certain nerves to treat abnormal, spastic movements. Before conducting surgery, it is important for a health care provider to assess the procedure’s benefits by carefully analyzing biomechanics of the joints and muscles.

Not all therapies are appropriate for everyone with cerebral palsy. It is important for parents, patients, and health care providers to work together to come up with the best treatment plan for the patient.

Although NICHD research portfolio includes work on cerebral palsy and rehabilitative therapies, the National Institute of Neurological Disorders and Stroke leads research on cerebral palsy at the NIH and offers comprehensive information on cerebral palsy and its treatment through its website.