What is CP?

Types of Cerebral Palsy

Signs and symptoms

Early Signs

Screening and Diagnosis

Classification

Treatments

Causes and Risk Factors

Complications

Prevention

management

Cerebral palsy
Cerebral palsy is a group of disorders that affect movement and muscle tone or
posture. It's caused by damage that occurs to the immature, developing brain,
most often before birth.

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.

Signs and symptoms

Signs and symptoms appear during infancy or preschool years. In general,
cerebral palsy causes impaired movement associated with exaggerated reflexes,
floppiness or spasticity of the limbs and trunk, unusual posture, involuntary
movements, unsteady walking, or some combination of these.

People with cerebral palsy can have problems swallowing and commonly have
eye muscle imbalance, in which the eyes don't focus on the same object. They
also might have reduced range of motion at various joints of their bodies due to
muscle stiffness.

The cause of cerebral palsy and its effect on function vary greatly. Some people
with cerebral palsy can walk; others need assistance. Some people have
intellectual disabilities, but others do not. Epilepsy, blindness or deafness also
might be present. Cerebral palsy is a lifelong disorder. There is no cure, but
treatments can help improve function.

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.

The symptoms of CP vary from person to person. A person with severe CP might
need to use special equipment to be able to walk, or might not be able to walk at
all and might need lifelong care. A person with mild CP, on the other hand, might
walk a little awkwardly, but might not need any special help. CP does not get
worse over time, though the exact symptoms can change over a person’s lifetime.

All people with CP have problems with movement and posture. Many also have
related conditions such as intellectual disability; seizures; problems with vision,
hearing, or speech; changes in the spine (such as scoliosis); or joint problems
(such as contractures).

boy in blue wheelchair

Types of Cerebral Palsy

Doctors classify CP according to the main type of movement disorder involved.

Depending on which areas of the brain are affected, one or more of the following
movement disorders can occur:

Stiff muscles (spasticity)

Uncontrollable movements (dyskinesia)

Poor balance and coordination (ataxia)

There are four main types of CP:

Spastic Cerebral Palsy

The most common type of CP is spastic CP. Spastic CP affects about 80% of people
with CP.

People with spastic CP have increased muscle tone. This means their muscles are
stiff and, as a result, their movements can be awkward. Spastic CP usually is
described by what parts of the body are affected:

Spastic diplegia/diparesis―In this type of CP, muscle stiffness is mainly in the legs,
with the arms less affected or not affected at all. People with spastic diplegia
might have difficulty walking because tight hip and leg muscles cause their legs to
pull together, turn inward, and cross at the knees (also known as scissoring).

Spastic hemiplegia/hemiparesis―This type of CP affects only one side of a

person’s body; usually the arm is more affected than the leg.

Spastic quadriplegia/quadriparesis―Spastic quadriplegia is the most severe form

of spastic CP and affects all four limbs, the trunk, and the face. People with spastic
quadriparesis usually cannot walk and often have other developmental disabilities
such as intellectual disability; seizures; or problems with vision, hearing, or
speech.

Dyskinetic Cerebral Palsy (also includes athetoid, choreoathetoid, and dystonic

cerebral palsies)

People with dyskinetic CP have problems controlling the movement of their

hands, arms, feet, and legs, making it difficult to sit and walk. The movements are
uncontrollable and can be slow and writhing or rapid and jerky. Sometimes the
face and tongue are affected and the person has a hard time sucking, swallowing,
and talking. A person with dyskinetic CP has muscle tone that can change (varying
from too tight to too loose) not only from day to day, but even during a single
day.

Ataxic Cerebral Palsy

People with ataxic CP have problems with balance and coordination. They might
be unsteady when they walk. They might have a hard time with quick movements
or movements that need a lot of control, like writing. They might have a hard time
controlling their hands or arms when they reach for something.

Mixed Cerebral Palsy

Some people have symptoms of more than one type of CP. The most common
type of mixed CP is spastic-dyskinetic CP.

Early Signs
The signs of CP vary greatly because there are many different types and levels of
disability. The main sign that a child might have CP is a delay reaching motor or
movement milestones (such as rolling over, sitting, standing, or walking).
Following are some other signs of possible CP. It is important to note that some
children without CP also might have some of these 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 held cradled in your arms, he seems to overextend his back and neck,
constantly acting as if he is pushing away from you

When you pick him up, his legs get stiff and they cross or scissor

mother holding daughter

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 scoots around on his buttocks or hops on his knees, but does not crawl on all
fours

Tell your child’s doctor or nurse if you notice any of these signs. Learn more about
developmental milestones that children should reach from birth to 5 years of age

Screening and Diagnosis

Diagnosing CP at an early age is important to the well-being of children and their
families. Diagnosing CP can take several steps:

Developmental Monitoring

Developmental monitoring (also called surveillance) means tracking a child’s

growth and development over time. If any concerns about the child’s
development are raised during monitoring, then a developmental screening test
should be given as soon as possible.

Developmental Screening

During developmental screening a short test is given to see if the child has specific
developmental delays, such as motor or movement delays. If the results of the
screening test are cause for concern, then the doctor will make referrals for
developmental and medical evaluations.

Developmental and Medical Evaluations

The goal of a developmental evaluation is to diagnose the specific type of disorder

that affects a child.

Treatments and Intervention Services

There is no cure for CP, but treatment can improve the lives of those who have
the condition. It is important to begin a treatment program as early as possible.

After a CP diagnosis is made, a team of health professionals works with the child
and family to develop a plan to help the child reach his or her full potential.
Common treatments include medicines; surgery; braces; and physical,
occupational, and pushing off with one hand and leg while dragging the opposite
hand and leg

He scoots around on his buttocks or hops on his knees, but does not crawl on all
fours
Tell your child’s doctor or nurse if you notice any of these signs. Learn more about
developmental milestones that children should reach from birth to 5 years of age

Screening and Diagnosis

Diagnosing CP at an early age is important to the well-being of children and their

families. Diagnosing CP can take several steps:

Developmental Monitoring

Developmental monitoring (also called surveillance) means tracking a child’s

growth and development over time. If any concerns about the child’s
development are raised during monitoring, then a developmental screening test
should be given as soon as possible.

Developmental Screening

During developmental screening a short test is given to see if the child has specific
developmental delays, such as motor or movement delays. If the results of the
screening test are cause for concern, then the doctor will make referrals for
developmental and medical evaluations.

Developmental and Medical Evaluations

The goal of a developmental evaluation is to diagnose the specific type of disorder

that affects a child.

Diagnosis
The diagnosis of cerebral palsy has historically rested on the person's history and
physical examination and is generally assessed at a young age. A general
movements assessment, which involves measuring movements that occur
spontaneously among those less than four months of age, appears most
accurate.Children who are more severely affected are more likely to be noticed
and diagnosed earlier. Abnormal muscle tone, delayed motor development and
persistence of primitive reflexes are the main early symptoms of CP.Symptoms
and diagnosis typically occur by the age of two, although depending on factors
like malformations and congenital issues, persons with milder forms of cerebral
palsy may be over the age of five, if not in adulthood, when finally diagnosed.
Cognitive assessments and medical observations are also useful to help confirm a
diagnosis. Additionally, evaluations of the child's mobility, speech and language,
hearing, vision, gait, feeding and digestion are also useful to determine the extent
of the disorder. Early diagnosis and intervention are seen as being a key part of
managing cerebral palsy. Machine learning algorithms facilitate automatic early
diagnosis, with methods such as deep neural network[86] and geometric feature
fusion producing high accuracy in predicting cerebral palsy from short videos. It is
a developmental disability.

Once a person is diagnosed with cerebral palsy, further diagnostic tests are
optional. Neuroimaging with CT or MRI is warranted when the cause of a person's
cerebral palsy has not been established. An MRI is preferred over CT, due to
diagnostic yield and safety. When abnormal, the neuroimaging study can suggest
the timing of the initial damage. The CT or MRI is also capable of revealing
treatable conditions, such as hydrocephalus, porencephaly, arteriovenous
malformation, subdural hematomas and hygromas, and a vermian tumour (which
a few studies suggest are present 5–22% of the time). Furthermore, an abnormal
neuroimaging study indicates a high likelihood of associated conditions, such as
epilepsy and intellectual disability.There is a small risk associated with sedating
children to facilitate a clear MRI.
The age when CP is diagnosed is important, but medical professionals disagree
over the best age to make the diagnosis.[81] The earlier CP is diagnosed correctly,
the better the opportunities are to provide the child with physical and educational
help, but there might be a greater chance of confusing CP with another problem,
especially if the child is 18 months of age or younger.[81] Infants may have
temporary problems with muscle tone or control that can be confused with CP,
which is permanent.[81] A metabolism disorder or tumors in the nervous system
may appear to be CP; metabolic disorders, in particular, can produce brain
problems that look like CP on an MRI.[1] Disorders that deteriorate the white
matter in the brain and problems that cause spasms and weakness in the legs,
may be mistaken for CP if they first appear early in life.However, these disorders
get worse over time, and CP does not[81] (although it may change in character).
[1] In infancy it may not be possible to tell the difference between them.In the
UK, not being able to sit independently by the age of 8 months is regarded as a
clinical sign for further monitoring. Fragile X syndrome (a cause of autism and
intellectual disability) and general intellectual disability must also be ruled out.
Cerebral palsy specialist John McLaughlin recommends waiting until the child is 36
months of age before making a diagnosis because, by that age, motor capacity is
easier to assess.

Classification
CP is classified by the types of motor impairment of the limbs or organs, and by
restrictions to the activities an affected person may perform.The Gross Motor
Function Classification System-Expanded and Revised and the Manual Ability
Classification System are used to describe mobility and manual dexterity in people
with cerebral palsy, and recently the Communication Function Classification
System, and the Eating and Drinking Ability Classification System have been
proposed to describe those functions. There are three main CP classifications by
motor impairment: spastic, ataxic, and dyskinetic. Additionally, there is a mixed
type that shows a combination of features of the other types. These classifications
reflect the areas of the brain that are damaged.
Cerebral palsy is also classified according to the topographic distribution of
muscle spasticity.This method classifies children as diplegic, (bilateral involvement
with leg involvement greater than arm involvement), hemiplegic (unilateral
involvement), or quadriplegic (bilateral involvement with arm involvement equal
to or greater than leg involvement).

Spastic

Spastic cerebral palsy is the type of cerebral palsy characterized by spasticity or

high muscle tone often resulting in stiff, jerky movements. Itself an umbrella term
encompassing spastic hemiplegia, spastic diplegia, spastic quadriplegia and –
where solely one limb or one specific area of the body is affected – spastic
monoplegia. Spastic cerebral palsy affects the motor cortex of the brain, a specific
portion of the cerebral cortex responsible for the planning and completion of
voluntary movement.[96] Spastic CP is the most common type of overall cerebral
palsy, representing about 80% of cases.

Botulinum toxin is effective in decreasing spasticity.[7] It can help increase range

of motion which could help mitigate CPs effects on the growing bones of children.
[7] There may be an improvement in motor functions in the children and ability to
walk. however, the main benefit derived from botulinum toxin A comes from its
ability to reduce muscle tone and spasticity and thus prevent or delay the
development of fixed muscle contractures.

Ataxic

Ataxic cerebral palsy is observed in approximately 5–10% of all cases of cerebral

palsy, making it the least frequent form of cerebral palsy.Ataxic cerebral palsy is
caused by damage to cerebellar structures. Because of the damage to the
cerebellum, which is essential for coordinating muscle movements and balance,
patients with ataxic cerebral palsy experience problems in coordination,
specifically in their arms, legs, and trunk. Ataxic cerebral palsy is known to
decrease muscle tone.The most common manifestation of ataxic cerebral palsy is
intention (action) tremor, which is especially apparent when carrying out precise
movements, such as tying shoe laces or writing with a pencil. This symptom gets
progressively worse as the movement persists, making the hand shake. As the
hand gets closer to accomplishing the intended task, the trembling intensifies,
which makes it even more difficult to complete.

Dyskinetic

Dyskinetic cerebral palsy (sometimes abbreviated DCP) is primarily associated

with damage to the basal ganglia and the substantia nigra in the form of lesions
that occur during brain development due to bilirubin encephalopathy and
hypoxic-ischemic brain injury.[102] DCP is characterized by both hypertonia and
hypotonia, due to the affected individual's inability to control muscle tone.

Clinical diagnosis of DCP typically occurs within 18 months of birth and is primarily
based upon motor function and neuroimaging techniques.

Dyskinetic cerebral palsy is an extrapyramidal form of cerebral palsy.

Dyskinetic cerebral palsy can be divided into two different groups;

choreoathetosis and dystonia.[94] Choreo-athetotic CP is characterized by
involuntary movements, whereas dystonic CP is characterized by slow, strong
contractions, which may occur locally or encompass the whole body.

Mixed

Mixed cerebral palsy has symptoms of dyskinetic, ataxic and spastic CP appearing
simultaneously, each to varying degrees, and both with and without symptoms of
each. Mixed CP is the most difficult to treat as it is extremely heterogeneous and
sometimes unpredictable in its symptoms and development over the lifespan.
Treatments and Intervention Services

There is no cure for CP, but treatment can improve the lives of those who have
the condition. It is important to begin a treatment program as early as possible.

After a CP diagnosis is made, a team of health professionals works with the child
and family to develop a plan to help the child reach his or her full potential.
Common treatments include medicines; surgery; braces; and physical,
occupational, and speech therapy. No single treatment is the best one for all
children with CP. Before deciding on a treatment plan, it is important to talk with
the child’s doctor to understand all the risks and benefits.

Intervention Services
Both early intervention and school-aged services are available through our
nation’s special education law—the Individuals with Disabilities Education Act
(IDEA). Part C of IDEA deals with early intervention services (birth through 36
months of age), while Part B applies to services for school-aged children (3
through 21 years of age). Even if your child has not been diagnosed with CP, he or
she may be eligible for IDEA services.

Causes and Risk Factors

CP is caused by abnormal development of the brain or damage to the developing
brain that affects a child’s ability to control his or her muscles. There are several
possible causes of the abnormal development or damage. People used to think
that CP was mainly caused by lack of oxygen during the birth process. Now,
scientists think that this causes only a small number of CP cases.

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

The abnormal development of the brain or damage that leads to CP can happen
before birth, during birth, within a month after birth, or during the first years of a
child’s life, while the brain is still developing. CP related to abnormal development
of the brain or damage that occurred before or during birth is called congenital
CP. The majority of CP (85%–90%) is congenital. In many cases, the specific cause
is not known. A small percentage of CP is caused by abnormal development of the
brain or damage that occurs more than 28 days after birth. This is called acquired
CP, and usually is associated with an infection (such as meningitis) or head injury.

Risk factors
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 increase.

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.

Complications
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.

Prevention
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.

management
the approach to CP management has shifted away from narrow attempts to fix
individual physical problems – such as spasticity in a particular limb – to making
such treatments part of a larger goal of maximizing the person's independence
and community engagement.[118]: 886  However, the evidence base for the
effectiveness of intervention programs reflecting the philosophy of independence
has not yet caught up: effective interventions for body structures and functions
have a strong evidence base, but evidence is lacking for effective interventions
targeted toward participation, environment, or personal factors.[118] There is
also no good evidence to show that an intervention that is effective at the body-
specific level will result in an improvement at the activity level or vice versa.[118]
Although such cross-over benefit might happen, not enough high-quality studies
have been done to demonstrate it.[118]

Because cerebral palsy has "varying severity and complexity" across the lifespan,
[91] it can be considered a collection of conditions for management purposes.[82]
A multidisciplinary approach for cerebral palsy management is recommended,[91]
focusing on "maximising individual function, choice and independence" in line
with the International Classification of Functioning, Disability and Health's goals.
[84] The team may include a paediatrician, a health visitor, a social worker, a
physiotherapist, an orthotist, a speech and language therapist, an occupational
therapist, a teacher specialising in helping children with visual impairment, an
educational psychologist, an orthopaedic surgeon, a neurologist and a
neurosurgeon.[119]

Various forms of therapy are available to people living with cerebral palsy as well
as caregivers and parents. Treatment may include one or more of the following:
physical therapy; occupational therapy; speech therapy; water therapy; drugs to
control seizures, alleviate pain, or relax muscle spasms (e.g. benzodiazepines);
surgery to correct anatomical abnormalities or release tight muscles; braces and
other orthotic devices; rolling walkers; and communication aids such as
computers with attached voice synthesisers.[citation needed] A Cochrane review
published in 2004 found a trend toward the benefit of speech and language
therapy for children with cerebral palsy but noted the need for high-quality
research.[120] A 2013 systematic review found that many of the therapies used
to treat CP have no good evidence base; the treatments with the best evidence
are medications (anticonvulsants, botulinum toxin, bisphosphonates, diazepam),
therapy (bimanual training, casting, constraint-induced movement therapy,
context-focused therapy, fitness training, goal-directed training, hip surveillance,
home programmes, occupational therapy after botulinum toxin, pressure care)
and surgery. There is also research on whether the sleeping position might
improve hip migration, but there are not yet high-quality evidence studies to
support that theory.[121] Research papers also call for an agreed consensus on
outcome measures which will allow researchers to cross-reference research. Also,
the terminology used to describe orthoses[122] needs to be standardised to
ensure studies can be reproduced and readily compared and evaluated. Surgical
intervention in CP children mainly includes orthopaedic surgery and neurosurgery
(selective dorsal rhizotomy).[17][118]
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