Understanding cerebral palsy
[ Dr. Amber Anand ]
Cerebral Palsy (CP) is an umbrella term for a group of disorders affecting body movement,
balance, and posture. Loosely translated, cerebral palsy means “brain paralysis”.
Cerebral palsy affects one in every five hundred children. It is a motor neurological
disorder that is non-progressive and usually appears very early in a child. It often
leads to slower than normal movements and trouble performing the more basic tasks.
Some children suffer primarily from motor development issues which makes it difficult
for them to exhibit normal motor actions like sitting down or putting their head
up. They suffer from cerebral palsy, a neurological condition that affects the motor
nerves. Children suffering from the condition usually have delayed head control,
learn to sit or stand up late or in some cases have trouble standing at all.
This condition is mostly caused due to an injury to the brain before, during or after
birth. Children suffering from this disease also exhibit some other conditions like
overall development delay, particularly delay in speaking. They can also have visual
impairment and hearing problems and in some cases neurological conditions like seizures
Common to all individuals with cerebral palsy is difficulty controlling and coordinating
muscles. This makes even very simple movements difficult.
Cerebral palsy may involve muscle stiffness (spasticity), poor muscle tone, uncontrolled
movements, and problems with posture, balance, coordination, walking, speech, swallowing,
and many other functions.
Mental retardation, seizures, breathing problems, learning disabilities, bladder
and bowel control problems, skeletal deformities, eating difficulties, dental problems,
digestive problems, and hearing and vision problems are often linked to cerebral
The severity of these problems varies widely, from very mild and subtle to very profound.
The magnitude of the problems may wax and wane over time.
However, the cause of the condition, the brain abnormality responsible for the cerebral
palsy, does not get worse over time. Nevertheless, the clinical picture may show
signs of deterioration as the individual ages.
Types of cerebral palsy are, as follows:
Spastic: Increased muscle tone is the defining characteristic of this type. The muscles
are stiff (spastic), and movements are jerky or awkward. This type is classified
by which part of the body is affected:
Spastic Hemiplegia: A child with spastic hemiplegia will typically have spasticity
(muscle stiffness) on one side of the body - usually just a hand and arm, but may
also involve a leg. The side that is affected may not develop properly. The child
may have speech problems. In the majority of cases intelligence is not affected.
Some children will have seizures.
Spastic Diplegia: The lower limbs are affected, and there is no or little upper body
spasticity. The child’s leg and hip muscles are tight. Legs cross at the knees, making
walking more difficult. The crossing of the legs when the child is upright is often
referred to as scissoring.
Spastic Quadriplegia: The child’s legs, arms, and body are affected. This is the
severest from of spastic cerebral palsy. Children with this kind of cerebral palsy
are more likely to have mental retardation. Walking and talking will be difficult.
Some children have seizures.
This is the most common type of CP, accounting for about 70% to 80% of cases.
Dyskinetic: This includes types that affect coordination of movements. There are
Athetoid: The person has uncontrolled movements that are slow and writhing. The movements
can affect any part of the body, including the face, mouth, and tongue. About 10%
to 20% of cerebral palsy cases are of this type.
Ataxic: This type affects balance and coordination. Depth perception is usually affected.
If the person can walk, the gait is probably unsteady. He or she has difficulty with
movements that are quick or require a great deal of control, such as writing. About
5% to 10% of cases of cerebral palsy are of this type.
Mixed: This is a mixture of different types of cerebral palsy. A common combination
is spastic and athetoid.
Many individuals with cerebral palsy have normal or above average intelligence. Their
ability to express their intelligence may be limited by difficulties in communicating.
All children with cerebral palsy, regardless of intelligence level, are able to improve
their abilities substantially with appropriate interventions. Most children with
cerebral palsy require significant medical and physical care, including physical,
occupational, and speech/swallowing therapy.
Despite advances in medical care, cerebral palsy remains a significant health problem.
The number of people affected by cerebral palsy has increased over time. This may
be because more and more premature infants are surviving. In the United States, about
2 to 3 children per 1,000 have cerebral palsy. Cerebral palsy affects both sexes
and all ethnic and socioeconomic groups
Cerebral Palsy Causes
Cerebral palsy results from damage to certain parts of the developing brain. This
damage can occur early in pregnancy when the brain is just starting to form, during
the birth process as the child passes through the birth canal, or after birth in
the first few years of life.
In many cases, the exact cause of the brain damage is never known. At one time, problems
during birth, usually inadequate oxygen, were blamed for cerebral palsy. We now know
that fewer than 10% of cases of cerebral palsy begin during birth (perinatal). In
fact, current thinking is that at least 70% to 80% of cases of cerebral palsy begin
before birth (prenatal). Some cases begin after birth (postnatal). In all likelihood,
many cases of cerebral palsy are a result of a combination of prenatal, perinatal,
and postnatal factors.
Risk factors linked with cerebral palsy include infection, seizure disorder, thyroid
disorder, and/or other medical problems in the mother, birth defects, especially
those affecting the brain, spinal cord, head, face, lungs, or metabolism, Rh-factor
incompatibility, a difference in the blood between mother and fetus that can cause
brain damage in the fetus, certain hereditary and genetic conditions, complications
during labor and delivery, premature birth, low birth weight (especially if less
than 2 pounds at birth), severe jaundice after birth, multiple births (twins, triplets),
lack of oxygen (hypoxia) reaching the brain before, during, or after birth, brain
damage early in life, due to infection (such as meningitis), head injury, lack of
oxygen, or bleeding. [Dr. Anand is Consultant Physiotherapist, Healing Hands Physiotherapy
& Rehabilitation Center]
Cerebral Palsy Symptoms: The signs of cerebral palsy are usually not noticeable in
early infancy but become more obvious as the child’s nervous system matures. Early
signs include ‘delayed milestones such as controlling head, rolling over, reaching
with one hand, sitting without support, crawling, or walking; persistence of “infantile”
or “primitive reflexes,” which normally disappear 3 to 6 months after birth, developing
handedness before age 18 months (This indicates weakness or abnormal muscle tone
on one side, which may be an early sign of CP).
Problems and disabilities related to CP range from very mild to very severe. Their
severity is related to the severity of the brain damage. They may be very subtle,
noticeable only to medical professionals, or may be obvious to the parents and other
Abnormal muscle tone: Muscles may be very stiff (spastic) or unusually relaxed and
“floppy.” Limbs may be held in unusual or awkward positions. For example, spastic
leg muscles may cause legs to cross in a scissor-like position.
Abnormal movements: Movements may be unusually jerky or abrupt, or slow and writhing.
They may appear uncontrolled or without purpose.
Skeletal deformities: People who have cerebral palsy on only one side may have shortened
limbs on the affected side. If not corrected by surgery or a device, this can lead
to tilting of the pelvic bones and scoliosis (curvature of the spine).
Joint contractures: People with spastic cerebral palsy may develop severe stiffening
of the joints because of unequal pressures on the joints exerted by muscles of differing
tone or strength.
Mental retardation: Some, although not all, children with cerebral palsy are affected
by mental retardation. Generally, the more severe is the retardation, the more severe
is the disability overall.
Seizures: About one-third of people with cerebral palsy have seizures. Seizures may
appear early in life or years after the brain damage that causes cerebral palsy.
The physical signs of a seizure may be partly masked by the abnormal movements of
a person with cerebral palsy.
Speech problems: Speech is partly controlled by movements of muscles of the tongue,
mouth, and throat. Some individuals with cerebral palsy are unable to control these
muscles and thus cannot speak normally.
Swallowing problems: Swallowing is a very complex function that requires precise
interaction of many groups of muscles. People with cerebral palsy who are unable
to control these muscles will have problems sucking, eating, drinking, and controlling
their saliva. They may drool. An even greater risk is aspiration, the inhalation
into the lungs of food or fluids from the mouth or nose. This can cause infection
or even suffocation.
Hearing loss: Partial hearing loss is not unusual in people with cerebral palsy.
The child may not respond to sounds or may have delayed speech.
Vision problems: Three-quarters of people with cerebral palsy have strabismus, which
is the turning in or out of one eye. This is due to weakness of the muscles that
control eye movement. These people are often nearsighted. If not corrected, strabismus
can lead to more severe vision problems over time.
Dental problems: People with cerebral palsy tend to have more cavities than usual.
This results from both defects in tooth enamel and difficulties brushing the teeth.
Bowel and bladder control problems: These are caused by lack of muscle control.
When to Seek
If a child was born prematurely, had a low birth weight, or was subject to certain
complications of pregnancy, labor, or delivery, he or she will be monitored carefully
over time for signs of CP. Any of the following warrant a visit to the child’s health
• The child has a seizure, • The child’s movements seem unusually jerky, abrupt,
uncoordinated, or slow and writhing,•The child’s muscles seem unusually tense or,
on the other hand, limp and “floppy.” The child does not blink in response to loud
noises by age 1 month, • The child does not turn his or her head toward a sound by
age 4 months, •The child does not reach out for a toy by age 4 months, • The child
does not sit up unsupported by age 7 months, •The child does not say words by age
12 months, • The child develops left- or right-handedness before age 12 months, •The
child has strabismus (one eye turned inward or outward), • The child does not walk
or walks with a stiff or abnormal gait, such as toe-walking.
These are only some of the most obvious examples of problems that may signal CP.
A parent should speak to the child’s health care professional about any problems
that suggest a lack of control of muscles or movements
Cerebral Palsy Diagnosis
If a child has problems that suggest cerebral palsy, he or she will undergo a very
thorough evaluation. There is no medical test that confirms the diagnosis of cerebral
palsy. The diagnosis is made on the basis of various types of information gathered
by the child’s health care professional and, in some cases, other consultants.
This information includes a detailed medical interview concerning medical history
of both the mother’s and father’s families, the mother’s medical problems before
and during pregnancy, and a detailed account of the pregnancy, labor, delivery, and
neonatal (newborn) period.
Parents will be asked to relate in detail the child’s medical problems and mental
and physical development.
Parents may be asked other questions as well. It is very important to answer all
questions as completely and honestly as possible, as the answers may help the child.
Lab studies: Various blood and urine tests may be ordered if your child’s health
care professional suspects that the child’s difficulties are due to chemical, hormonal,
or metabolic problems. Analysis of the child’s chromosomes, including karyotype analysis
and specific DNA testing, may be needed to rule out a genetic syndrome.
Imaging studies: These studies provide a picture of structures inside the body. Such
testing, when used on the brain or spinal cord, is often called neuroimaging. These
tests are not always necessary, but in many cases, they may help identify the cause
or extent of the cerebral palsy. They should be done as early as possible so that
appropriate treatment, if indicated, can be begun immediately. Many individuals with
mild cerebral palsy have no visible brain abnormalities.
Ultrasound: Ultrasound uses harmless sound waves to detect certain types of structural
and anatomic abnormalities. For instance, it can show hemorrhage (bleeding) in the
brain or damage caused by lack of oxygen to the brain. Ultrasound is often used on
newborns who cannot tolerate more rigorous tests such as CT scans or MRI.
CT scan of the brain: This scan is similar to an X-ray but shows greater detail and
gives a more three-dimensional image. It identifies malformations, hemorrhage, and
certain other abnormalities in infants more clearly than ultrasound.
MRI of the brain: This is the preferred test, since it defines brain structures and
abnormalities more clearly than any other method. Children who are unable to remain
still for at least 45 minutes may require a sedative to undergo this test.
MRI of the spinal cord: This may be necessary in children with spasticity of the
legs and worsening of bowel and bladder function, which suggest an abnormality of
the spinal cord. Such abnormalities may or may not be related to cerebral palsy.
Electroencephalography (EEG) is important in the diagnosis of seizure disorders.
A high index of suspicion is needed in order to detect non-convulsive or minimally
convulsive seizures. This is a potentially treatable cause of a CP-look-alike, which
is easier to treat when treated early.
Electromyography (EMG) and Nerve Conduction Studies (NCS) may be helpful in distinguishing
CP from other muscle or nerve disorders.
(Dr. Anand is Consultant, Physiotherapist Healing Hands Physiotherapy & Rehabilitation
Cerebral Palsy Treatment
There is no cure for cerebral palsy. With early and ongoing treatment, however, the
disabilities associated with cerebral palsy can be reduced. Many different therapies
are available, most under the supervision of a medical specialist or other allied
professional. Not all of these therapies are right for every person with cerebral
palsy. The therapy regimen for a specific individual with cerebral palsy should be
tailored to meet the needs of that individual. A treatment may work for one child
but not for another. The parents and the child’s care team work together to choose
only those treatments that offer some benefit to the child.
Cerebral Palsy Medical Treatment
While specific therapies help a child develop specific skills and abilities, the
overall goal of treatment is to help the individual with cerebral palsy reach his
or her greatest potential physically, mentally, and socially. This is accomplished
with a variety of different approaches managed by a team of professionals. Care for
people with cerebral palsy is complicated, requiring a number of different services
and specialists. In some areas, care is available through a single multidisciplinary
clinic that oversees all aspects of the child’s therapy.
Rehabilitation: A comprehensive rehabilitation program may include physiotherapy,
use of special equipment, and spasticity treatment. This program is often overseen
by a specialist in rehabilitation medicine.
· Physiotherapy involves stretching, physical exercises, and other activities that
develop muscle strength, flexibility, and control. The goal is to maximize function
and minimize disabling contractures. The focus is on developing specific skills such
as holding the head up, sitting unsupported, or walking. Braces, splints, and casts
may be used to help reach these goals.
· Special equipment that may be helpful to people with CP includes walkers, positioning
devices, customized wheelchairs, scooters, and tricycles.
· Spasticity may be treated by injections into the muscles or by medications. Reduction
of spasticity can improve range of motion, reduce deformity, improve response to
occupational and physical therapy, and delay the need for surgery.
The occupational therapist helps the individual learn physical skills he or she needs
to function and become as independent as possible in everyday life. Examples are
feeding, grooming, and dressing.
Speech / Language Therapy
This therapy helps the child overcome communication problems. Many children with
cerebral palsy have problems speaking because of poor tone or uncontrolled movements
in the muscles of the mouth and tongue. Speech therapy helps develop those muscles,
improving speech. Speech therapy also benefits children with hearing loss. Children
who cannot speak may be able to benefit from communication technologies such as a
computerized voice synthesizer.
Vision problems: An ophthalmologist is consulted for children who have strabismus
and visual problems.
This encompasses treatment for all medical problems whether related to CP or not.
Various specialists may be called upon to deal with specific problems.
· Seizures: Seizure disorders are common in people with cerebral palsy. These are
not always well controlled with medication. A specialist in conditions of the nervous
system (neurologist) may be consulted for help in selecting an appropriate regimen.
· Feeding and digestive problems: Individuals with cerebral palsy often have gastroesophageal
reflux or GERD (severe heartburn and related symptoms caused by regurgitation of
acid from the stomach) as well as swallowing and feeding problems. A team consisting
of a doctor who specializes in digestive diseases (gastroenterologist), a nutritionist,
and a feeding and swallowing therapist can assess nutritional status and treat problems.
Swallowing therapy helps the child eat and drink independently and helps prevent
aspiration. The child’s diet must be customized to accommodate limitations in swallowing.
Children with severe swallowing problems require feeding through a tube.
· Breathing problems: People with cerebral palsy may have breathing problems because
the muscles that control expansion and contraction of the lungs are disabled. A specialist
in lung disorders (pulmonologist) should be consulted for management of the resulting
Many children with cerebral palsy, even those of average or above-average intelligence,
are challenged in cognitive processes such as thinking, learning, and memory. They
can benefit from the services of a specialist in learning disabilities.
· Such specialists can identify the child’s specific learning disabilities, direct
early interventions and preparation for school, and monitor his or her progress.
· Educational services for school-aged children are provided by the public school
system. The staff at the child’s school will work with the parents to develop an
Individualized Education Plan (IEP) for the child. This may include services besides
Navigating all of these different services can be difficult for parents. The child’s
health care professional can refer parents to a medical social worker who can help
them find and enroll in the services their child needs.
Cerebral Palsy Medications
The goal of drug therapy is to reduce the effects of cerebral palsy and prevent complications.
Medications are prescribed to reduce spasticity and abnormal movements and to prevent
Medications used to relieve spasticity and abnormal movements include the following:
· Dopaminergic drugs: Widely used in Parkinson’s disease, these drugs increase the
level of a brain chemical called dopamine. The effect is to decrease rigidity and
abnormal movements. Examples include levodopa/carbidopa (Sinemet) and trihexyphenidyl
· Muscle relaxants: These agents reduce spasticity by relaxing the muscle directly.
Examples include baclofen (Lioresal). This drug can be taken as a pill or be administered
automatically via an implantable pump.
· Benzodiazepines: These agents act on brain chemistry to relax muscles. The most
widely used of these agents is diazepam (Valium).
· Botulinum toxin type A: This substance is widely known as BOTOX®. When injected,
it causes a mild muscle paralysis and reduces contractions. In cerebral palsy, it
is used to decrease spasticity of muscles of the arms or legs, which improves range
of motion and overall mobility. This can be important in allowing a child to fit
into an orthotic (brace or splint) or even to be comfortably positioned in a wheelchair.
The effects of BOTOX® injections typically last 3 to 6 months. BOTOX® helps other
treatments work better, such as physical therapy or casting the limb. In some cases,
using BOTOX® can delay surgery or make surgery unnecessary. Some people have allergic-type
reactions to BOTOX® and must limit the number of injections or stop them altogether.
Medications used to relieve seizures include the following:
· Anticonvulsants: These agents stop seizure activity as rapidly as possible and
prevent seizure recurrence. There are many difference agents available; they vary
in their mechanism of action.
· Benzodiazepines: Agents such as diazepam often are used to stop seizures when they
are frequent or prolonged.
· Ketogenic diet: this is a special diet rich in fats that result in the production
of excess of ketones which, acting in the brain, can reduce the number of seizures.
(Dr. Anand is Consultant, Physiotherapist Healing Hands Physiotherapy & Rehabilitation
Cerebral Palsy Follow-up
The overall goal for ongoing care of individuals with CP is to help them reach their
full physical, mental, and emotional potential. Generally, this includes living as
much as possible in the mainstream of their society and culture. People with CP tend
to be happiest and most productive when they can go to school with, live with, and
work with their peers.
Children with CP require regular sessions with their physical, occupational, and
speech/language therapists, as well as frequent checkups with their medical and surgical
teams. The exact schedule of visits is determined by the severity of the child’s
condition and his or her response to treatment. A multidisciplinary CP clinic allows
for frequent and complete care with the minimum of inconvenience
Cerebral Palsy Prognosis
With proper therapy, many people with cerebral palsy can lead near-normal lives.
Even those with very severe disabilities can improve their condition significantly,
although they will never be able to live independently.
Approximately 25% of children with cerebral palsy have mild involvement with few
or no limitations in walking, self-care, and other activities. Approximately half
are moderately impaired to the extent that complete independence is unlikely but
function is satisfactory. Only 25% are so severely disabled that they require extensive
care and are unable to walk.
Of the 75% of children with cerebral palsy who are eventually able to walk, many
rely on assistive equipment. The ability to sit unsupported may be a good predictor
of whether a child will walk. Many children who can sit unsupported by age 2 years
eventually will be able to walk, while those who cannot sit unsupported by age 4
years probably will not walk. These children will use wheelchairs to move around.
The likelihood of medical complications of cerebral palsy is related to the severity
of the condition. Generally, the more severe the CP, the more likely are related
conditions such as seizures and mental retardation. Individuals with quadriplegia
are much more likely than those with diplegia or hemiplegia to have these related
· Seizure disorders occur in about one third of people with cerebral palsy.
· Mental retardation occurs in about 30% to 50% of people with cerebral palsy. Standardized
tests that evaluate primarily verbal skills may underestimate a child’s intelligence
· Obesity is a common problem in children who are confined to a wheelchair or are
unable to move freely.
Life expectancy in people with cerebral palsy also is related to the severity of
their condition. People with milder forms of cerebral palsy have the same life expectancy
as the general population. Those with severe forms of cerebral palsy typically have
a shorter life span, especially if they have many medical complications.
With the advances in medical care and the awareness that children with cerebral palsy
merit aggressive treatment of any acute condition that is treatable, the average
life expectancy has increased. As a result, it is not unusual to see adults, even
those with severe forms of cerebral palsy, reaching 50 and even the 60 years of age.
Adults with cerebral palsy are likely dependent on others for activities of daily
living and in need of continuous support. The parents may be no longer alive or with
limitations in the ability of providing support. Unfortunately, at the present time
there are very few medical services that are oriented to treat adults with cerebral
palsy. Historically, cerebral palsy has been a condition of children; however, at
the present time there is a sizable and growing number of adults with cerebral palsy.
In addition, there are few internists or general practitioners with expertise in
CP. Just recently a few academic adult hospitals offer formal training positions
in the area of developmental disabilities. These adults with cerebral palsy need
strong advocacy to guarantee the services they need.
Some studies have found that abnormalities of muscle tone or movement in the first
several weeks or months after birth may gradually improve over the first years of
life. In one study, almost 50% of very young infants thought to have cerebral palsy
and 66% of those thought to have spastic diplegia “outgrew” these signs of cerebral
palsy by age 7 years. Many children do not manifest full motor signs that are suggestive
of cerebral palsy until aged 1 to 2 years. Thus, some propose that the diagnosis
of cerebral palsy should be deferred until the child is aged 2 years.
Support Groups and Counseling
Clearly, children with cerebral palsy may have very substantial problems, but almost
all have the potential to learn, achieve, succeed, and create a happy life for themselves.
This cannot happen without effort, and they need the help of their families. Having
a child with cerebral palsy brings many challenges. It is understandable, then, that
parents and siblings of a child with cerebral palsy may have significant stress.
A parent may feel guilt, anger, anxiety, and/or hopelessness. The parent may feel
alone and uncertain about what he or she should do.
Before parents can help themselves or their child, they need to develop appropriate
expectations and get organized. Only then can parents learn practical ways to cope
with the child’s problems and put these methods into practice. But making changes
is not always easy. Sometimes it helps to have someone to talk to. This is the purpose
of support groups. Support groups consist of people in similar situations. They come
together to help each other and to help themselves. Support groups provide reassurance,
motivation, and inspiration. They help parents see that their situation is not unique
and not hopeless, and that gives them power. Support groups also provide practical
tips on coping with cerebral palsy and navigating the medical, educational, and social
systems that parents will rely on for help for themselves and their child. Being
in a cerebral palsy support group is recommended by most mental health professionals
(Dr. Anand is Consultant, Physiotherapist Healing Hands Physiotherapy & Rehabilitation