Cerebral palsy

Signs and symptoms of cerebral palsy can vary greatly from person to person. Cerebral palsy can affect the whole body, or it might be limited primarily to one or two limbs, or one side of the body. Generally, signs and symptoms include problems with movement and coordination, speech and eating, development, and other problems.

Movement and coordination

• Stiff muscles and exaggerated reflexes (spasticity), the most common movement disorder
• Variations in muscle tone, such as being either too stiff or too floppy
• Stiff muscles with normal reflexes (rigidity)
• Lack of balance and muscle coordination (ataxia)
• Tremors or jerky involuntary movements
• Slow, writhing movements
• Favoring one side of the body, such as only reaching with 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, a wide gait or an asymmetrical gait
• Difficulty with fine motor skills, such as buttoning clothes or picking up utensils

Speech and eating

• Delays in speech development
• Difficulty speaking
• Difficulty with sucking, chewing or eating
• Excessive drooling or problems with swallowing

Development

• Delays in reaching motor skills milestones, such as sitting up or crawling
• Learning difficulties
• Intellectual disabilities
• Delayed growth, resulting in smaller size than would be expected

Other problems

Damage to the brain can contribute to other neurological problems, such as:

• Seizures (epilepsy)
• Difficulty hearing
• Problems with vision and abnormal eye movements
• Abnormal touch or pain sensations
• Bladder and bowel problems, including constipation and urinary incontinence
• Mental health conditions, such as emotional disorders and behavioral problems

The brain disorder causing cerebral palsy doesn't change with time, so the symptoms usually don't worsen with age. However, as the child gets older, some symptoms might become more or less apparent. And muscle shortening and muscle rigidity can worsen if not treated aggressively.

When to see a doctor

It's important to get a prompt diagnosis for a movement disorder or delays in your child's development. See your child's doctor if you have concerns about episodes of loss of awareness of surroundings or of unusual bodily movements or muscle tone, impaired coordination, swallowing difficulties, eye muscle imbalance, or other developmental issues.

Cerebral palsy is caused by abnormal brain development or damage to the developing brain. This usually happens before a child is born, but it can occur at birth or in early infancy. In many cases, the cause isn't known. Many factors can lead to problems with brain development. Some include:

• Gene mutations that result in genetic disorders or differences in brain development
• Maternal infections that affect the developing fetus
• Fetal stroke, a disruption of blood supply to the developing brain
• Bleeding into the brain in the womb or as a newborn
• Infant infections that cause inflammation in or around the brain
• Traumatic head injury to an infant, such as from a motor vehicle accident, fall or physical abuse
• Lack of oxygen to the brain related to difficult labor or delivery, although birth-related asphyxia is much less commonly a cause than historically thought

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

Maternal health

Certain infections or toxic exposures during pregnancy can significantly increase cerebral palsy risk to the baby. Inflammation triggered by infection or fever can damage the unborn baby's developing brain.

• Cytomegalovirus. This common virus causes flu-like symptoms and can lead to birth defects if a mother has her first active infection during pregnancy.
• German measles (rubella). This viral infection can be prevented with a vaccine.
• Herpes. This infection can be passed from mother to child during pregnancy, affecting the womb and placenta.
• Syphilis. This is a sexually transmitted bacterial infection.
• Toxoplasmosis. This infection is caused by a parasite found in contaminated food, soil and the feces of infected cats.
• Zika virus infection. This infection is spread through mosquito bites and can affect fetal brain development.
• Intrauterine infections. This includes infections of the placenta or fetal membranes.
• Exposure to toxins. One example is exposure to methyl mercury.
• Other conditions. Other conditions affecting the mother that can slightly increase the risk of cerebral palsy include thyroid problems, preeclampsia or seizures.

Infant illness

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

• Bacterial meningitis. This bacterial infection causes inflammation in the membranes surrounding the brain and spinal cord.
• Viral encephalitis. This viral infection similarly causes inflammation in the membranes surrounding the brain and spinal cord.
• Severe or untreated jaundice. Jaundice appears as a yellowing of the skin. The condition occurs when certain byproducts of "used" blood cells aren't filtered from the bloodstream.
• Bleeding into the brain. This condition is commonly caused by the baby having a stroke in the womb or in early infancy.

Factors of pregnancy and birth

While the potential contribution from each is limited, additional pregnancy or birth factors associated with increased cerebral palsy risk include:

• Low birth weight. Babies who weigh less than 5.5 pounds (2.5 kilograms) are at higher risk of developing cerebral palsy. This risk increases as birth weight drops.
• Multiple babies. Cerebral palsy risk increases with the number of babies sharing the uterus. The risk also can be related to the likelihood of premature birth and low birth weight. If one or more of the babies die, the survivors' risk of cerebral palsy increases.
• Premature birth. Babies born prematurely are at higher risk of cerebral palsy. The earlier a baby is born, the greater the cerebral palsy risk.
• Delivery complications. Problems during labor and delivery may increase the risk of cerebral palsy.

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

• Contracture. Contracture is muscle tissue shortening due to severe muscle tightening that can be the result of spasticity. Contracture can inhibit bone growth, cause bones to bend, and result in joint deformities, dislocation or partial dislocation. These can include hip dislocation, curvature of the spine (scoliosis) and other orthopedic deformities.
• Malnutrition. Swallowing or feeding problems can make it difficult for someone who has cerebral palsy, particularly an infant, to get enough nutrition. This can impair growth and weaken bones. Some children or adults need a feeding tube to get enough nutrition.
• Mental health conditions. People with cerebral palsy might have mental health conditions, such as depression. Social isolation and the challenges of coping with disabilities can contribute to depression. Behavioral problems can also occur.
• Heart and lung disease. People with cerebral palsy may develop heart disease, lung disease and breathing disorders. Problems with swallowing can result in respiratory problems, such as aspiration pneumonia.
• Osteoarthritis. Pressure on joints or abnormal alignment of joints from muscle spasticity may lead to the early onset of this painful degenerative bone disease.
• Osteoporosis. Fractures due to low bone density can result from several factors such as lack of mobility, inadequate nutrition and anti-epileptic drug use.
• Other complications. These can include sleep disorders, chronic pain, skin breakdown, intestinal problems and issues with oral health.

Most cases of cerebral palsy can't be prevented, but you can reduce 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. Getting vaccinated against diseases such as rubella, preferably before getting pregnant, might 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 results 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.
• Avoid alcohol, tobacco and illegal drugs. These have been linked to cerebral palsy risk.

Rarely, cerebral palsy can be caused by brain damage that occurs in childhood. Practice good general safety. Prevent head injuries by providing your child with a car seat, bicycle helmet, safety rails on the bed and appropriate supervision.

Signs and symptoms of cerebral palsy can become more apparent over time, so a diagnosis might not be made until a few months to a year after birth. In some cases where the signs and symptoms are mild, diagnosis may be delayed longer.

If your family doctor or pediatrician suspects your child has cerebral palsy, he or she will evaluate your child's signs and symptoms, monitor growth and development, review your child's medical history, and conduct a physical exam. Your doctor might refer you to specialists trained in treating children with brain and nervous system conditions, such as a pediatric neurologist, pediatric physical medicine and rehabilitation specialist, and child developmental specialist.

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

Brain scans

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

• MRI. An MRI uses radio waves and a magnetic field to produce detailed 3D or cross-sectional images of the brain. An MRI can often identify lesions or abnormalities in your child's brain. This test is painless, but it's noisy and can take up to an hour to complete. Your child will likely receive a sedative or light general anesthesia beforehand.
• Cranial ultrasound. This can be performed during infancy. A cranial ultrasound uses high-frequency sound waves to produce images of the brain. An ultrasound doesn't produce a detailed image, but it may be used because it's quick and it can provide a valuable preliminary assessment of the brain.

Electroencephalogram (EEG)

If your child is suspected of having seizures, an EEG can evaluate the condition further. Seizures can develop in a child with epilepsy. In an EEG test, a series of electrodes are attached to your child's scalp. The EEG records the electrical activity of your child's brain. It's common for there to be changes in normal brain wave patterns in epilepsy.

Laboratory tests

Tests of the blood, urine or skin might be used to screen for genetic or metabolic problems.

Additional tests

If your child is diagnosed with cerebral palsy, you'll likely be referred to specialists to test your child for other conditions often associated with the disorder. These tests can identify problems with:

• Vision
• Hearing
• Speech
• Intellect
• Development
• Movement
• Other medical conditions

The type of cerebral palsy is determined by the main movement disorder experienced, but several movement disorders can occur together. The most common type of cerebral palsy is spastic cerebral palsy, which includes stiff muscles and exaggerated reflexes. Other types of cerebral palsy include movement disorders involving poor balance and coordination (ataxic) and difficulty controlling voluntary muscles (dyskinetic).

After making the diagnosis of cerebral palsy, your doctor may use a rating scale tool, such as the Gross Motor Function Classification System, to determine function and severity of mobility, posture and balance. This information can help in selecting treatments.

Children and adults with cerebral palsy may require lifelong care with a medical care team. Besides a pediatrician or physical medicine and rehabilitation specialist (physiatrist) and possibly a pediatric neurologist to oversee your child's medical care, the team might include a variety of therapists and mental health specialists. These experts give special attention to needs and issues that are more common in people with cerebral palsy and can work together with your primary care provider. Together you can develop a treatment plan.

There is no cure for cerebral palsy. However, there are many treatments options that may help improve your child's daily functioning. Selecting care will depend on his or her specific symptoms and needs, and needs may change over time. Early intervention can improve outcomes.

Treatment options can include medications, therapies, surgical procedures and other treatments as needed.

Medications

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

• Muscle or nerve injections. To treat tightening of a specific muscle, your doctor might recommend injections of onabotulinumtoxinA (Botox), or another agent. The injections will need to be repeated about every three months.

  Side effects can include pain at the injection site and mild flu-like symptoms. Other more-serious side effects include difficulty breathing and swallowing.

• Oral muscle relaxants. Drugs such as baclofen, tizanidine (Zanaflex), diazepam (Valium) or dantrolene (Dantrium) are often used to relax muscles.

  In some cases, baclofen is pumped into the spinal cord with a tube (intrathecal baclofen). The pump is surgically implanted under the skin of the abdomen.

• Medications to reduce drooling. One option is Botox injections into the salivary glands.

Talk to your doctor about benefits and risks and possible side effects of recommended medication options.

Therapies

A variety of therapies play an important role in treating cerebral palsy:

• Physical therapy. Muscle training and exercises can help your child's strength, flexibility, balance, motor development and mobility. You'll also learn how to safely care for your child's everyday needs at home, such as bathing and feeding your child. Your therapist can provide guidance on how you can continue muscle training and exercise at home between therapy visits.

  For the first 1 to 2 years after birth, both physical and occupational therapists work on issues such as head and trunk control, rolling, and grasping. Later, both types of therapists are involved in wheelchair assessments.

  Braces, splints or other supportive devices might be recommended for your child to help with function, such as improved walking, and stretching stiff muscles.

• Occupational therapy. Occupational therapists work to help your child gain independence in daily activities and routines at home and school and in the community. Adaptive equipment recommended for your child can include walkers, wide-based canes, standing and seating systems, or electric wheelchairs.
• Speech and language therapy. Speech-language pathologists can help improve your child's ability to speak clearly or to communicate using sign language. They can also teach the use of communication devices, such as a computer and voice synthesizer, if communication is difficult. Speech therapists can also address difficulties with eating and swallowing.
• Recreational therapy. Some children benefit from regular or adaptive recreational or competitive sports, such as therapeutic horseback riding or skiing. This type of therapy can help improve your child's motor skills, speech and emotional well-being. Both adults and children benefit from regular physical activity and exercise for general health and fitness.

Surgical 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 might need surgery on bones or joints to place their arms, spine, hips or legs in their correct positions. Surgical procedures can also lengthen muscles and lengthen or reposition tendons that are shortened by contractures. These corrections can lessen pain and improve mobility. The procedures can also make it easier to use a walker, braces or crutches.
• Cutting nerve fibers (selective dorsal rhizotomy). In some severe cases, when other treatments haven't helped, surgeons might cut the nerves serving specific spastic muscles in a procedure called selective dorsal rhizotomy. This relaxes the muscle in the legs and reduces pain, but can cause numbness.

Other treatments

As needed, medications and other treatments may be recommended for seizures, pain, osteoporosis, mental health conditions, and problems with sleep, oral health, feeding and nutrition, bladder incontinence, vision, or hearing.

Adults with cerebral palsy

As your child with cerebral palsy becomes an adult, his or her health care needs can change. In addition to general health screenings recommended for all adults, ongoing health care includes evaluation and treatment for conditions that are more common in adults with cerebral palsy. These can include:

• Vision and hearing problems
• Maintenance of muscle tone
• Seizure management
• Problems with pain and fatigue
• Dental issues
• Orthopedic problems, such as contractures, arthritis and osteoporosis
• Heart and lung disease
• Mental health issues, such as depression

Some children and adolescents with cerebral palsy use some form of complementary or alternative medicine. These are therapies that are unproved and have not been adopted into routine clinical practice. If you're considering a complementary or alternative medicine or therapy, talk with your doctor about potential risks and benefits.

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. At any age, your child's participation in social, educational, employment, recreational and other community activities can help them participate in society and have a positive effect on quality of life.
• Be an advocate for your child. You're 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 and your family cope with cerebral palsy and its effects. As a parent, you might 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 might also benefit from family support programs, school programs and counseling.
• Access services. Early intervention and special education services are available for children under 21 years of age through the Individuals with Disabilities Education Act. Services for adults with disabilities are also available. Talk with your health care team about how to access programs and services in your area.

Community resources and support for adults

In addition to addressing health needs, caring for your adult loved one with cerebral palsy may include planning for current and future lifestyle needs, such as:

• Guardianship
• Living arrangements
• Social and recreational participation
• Employment
• Financial support

If your child has cerebral palsy, how you learn about your child's condition can depend on the severity of the disabilities, when signs and symptoms started, and whether there were risk factors during pregnancy or delivery.

Here's some information to help you get ready for your child's appointment with his or her doctor.

What you can do

Before your appointment make a list of:

• Symptoms that concern you and when they began
• All medications, vitamins and other supplements your child takes, including doses
• Your child's medical history, including other conditions with which he or she has been diagnosed
• Information about your pregnancy and delivery, including any problems
• Questions to ask your doctor

Take a relative or friend with you, if possible, to help you remember the information you receive.

Questions to ask your doctor can include:

• What tests will my child need?
• When will we know the results of the tests?
• What specialists will we need to see?
• How will you monitor my child's health and development?
• Can you suggest educational materials and local support services regarding cerebral palsy?
• Can my child be followed through a multidisciplinary program that addresses all of his or her needs on the same visit, such as a cerebral palsy clinic?

Don't hesitate to ask other questions during your appointment.

What to expect from your doctor

Your doctor is likely to ask you questions, including:

• What concerns do you have about your child's growth or development?
• How well does your child eat?
• How does your child respond to touch?
• Do you observe 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?
• Did you have any problems during your pregnancy or delivery?