Cerebral palsy is a disorder of movement, muscle tone or posture that is caused by damage that occurs to the immature, developing brain, most often before birth.

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

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

Cerebral palsy’s effect on functional abilities varies greatly. Some affected people can walk while others can’t. Some people show normal or near-normal intellectual capacity, but others may have intellectual disabilities. Epilepsy, blindness or deafness also may be present.

Symptoms of Cerebral palsy

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

• Variations in muscle tone, such as being either too stiff or too floppy
• Stiff muscles and exaggerated reflexes (spasticity)
• Stiff muscles with normal reflexes (rigidity)
• Lack of muscle coordination (ataxia)
• Tremors or involuntary movements
• Slow, writhing movements (athetosis)
• Delays in reaching motor skills milestones, such as pushing up on arms, sitting up alone or crawling
• Favouring one side of the body, such as reaching with only one hand or dragging a leg while crawling
• Difficulty walking, such as walking on toes, a crouched gait, a scissors-like gait with knees crossing, a wide gait or an asymmetrical gait
• Excessive drooling or problems with swallowing
• A difficulty with sucking or eating
• Delays in speech development or difficulty speaking
• A difficulty with precise motions, such as picking up a crayon or spoon
• Seizures

The disability associated with cerebral palsy may be limited primarily to one limb or one side of the body, or it may affect the whole body. The brain disorder causing cerebral palsy doesn’t change with time, so the symptoms usually don’t worsen with age. However, muscle shortening and muscle rigidity may worsen if not treated aggressively.

Brain abnormalities associated with cerebral palsy also may contribute to other neurological problems. People with cerebral palsy may also have:

• A difficulty with vision and hearing
• Intellectual disabilities
• Seizures
• Abnormal touch or pain perceptions
• Oral diseases
• Mental health (psychiatric) conditions
• Urinary incontinence

When to see a doctor

It’s important to get a prompt diagnosis for any movement disorder or possible delays in your child’s development. See your child’s doctor if you have any questions or concerns about episodes of loss of awareness of surroundings or of abnormal bodily movements (also known as seizures), abnormal muscle tone, impaired coordination, swallowing difficulties, eye muscle imbalance, or other developmental issues.

Causes

Cerebral palsy is caused by an abnormality or disruption in brain development, usually before a child is born. In many cases, the exact trigger isn’t known. Factors that may lead to problems with brain development include:

• Mutations in genes that lead to abnormal brain development
• Maternal infections that affect the developing fetus
• Fetal stroke, a disruption of blood supply to the developing brain
• Infant infections that cause inflammation in or around the brain
• Traumatic head injury to an infant from a motor vehicle accident or fall
• Lack of oxygen to the brain (asphyxia) related to difficult labour or delivery, although birth-related asphyxia is much less commonly a cause than historically thought

Risk factors

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

Maternal health

Certain infections or health problems during pregnancy can significantly increase the cerebral palsy risk to the baby. Infections of particular concern include:

• German measles (rubella). Rubella is a viral infection that can cause serious birth defects. It can be prevented with a vaccine.
• Chickenpox (varicella). Chickenpox is a contagious viral infection that causes itching and rashes, and it can cause pregnancy complications. It too can be prevented with a vaccine.
• Cytomegalovirus. Cytomegalovirus is a common virus that causes flu-like symptoms and may lead to birth defects if a mother experiences her first active infection during pregnancy.
• Herpes. Herpes infection can be passed from mother to child during pregnancy, affecting the womb and placenta. Inflammation triggered by infection may then damage the unborn baby’s developing nervous system.
• Toxoplasmosis. Toxoplasmosis is an infection caused by a parasite found in contaminated food, soil and the faeces of infected cats.
• Syphilis. Syphilis is a sexually transmitted bacterial infection.
• Exposure to toxins. Exposure to toxins, such as methylmercury, can increase the risk of birth defects.
• Zika virus infection. Infants for whom maternal Zika infection causes microcephaly can develop cerebral palsy.
• Other conditions. Other conditions may increase the risk of cerebral palsy, such as thyroid problems, intellectual disabilities 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.

Other 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:

• Breech births. Babies with cerebral palsy are more likely to be in a feet-first position (breech presentation) at the beginning of labour rather than headfirst.
• Complicated labour and delivery. Babies who exhibit vascular or respiratory problems during labour and delivery may have existing brain damage or abnormalities.
• 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 drop.
• Multiple babies. Cerebral palsy risk increases with the number of babies sharing the uterus. If one or more of the babies die, the chance that the survivors may have cerebral palsy increases.
• Premature birth. A normal pregnancy lasts 40 weeks. Babies born fewer than 37 weeks into the pregnancy are at higher risk of cerebral palsy. The earlier a baby is born, the greater the cerebral palsy risk.
• Rh blood type incompatibility between mother and child. If a mother’s Rh blood type doesn’t match her baby’s, her immune system may not tolerate the developing baby’s blood type and her body may begin to produce antibodies to attack and kill her baby’s blood cells, which can cause brain damage.

Complications

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

• Contracture. Contracture is muscle tissue shortening due to severe muscle tightening (spasticity). Contracture can inhibit bone growth, cause bones to bend, and result in joint deformities, dislocation or partial dislocation.
• Malnutrition. Swallowing or feeding problems can make it difficult for someone who has cerebral palsy, particularly an infant, to get enough nutrition. This may cause impaired growth and weaker bones. Some children may need a feeding tube for adequate nutrition.
• Mental health conditions. People with cerebral palsy may have mental health (psychiatric) conditions, such as depression. Social isolation and the challenges of coping with disabilities can contribute to depression.
• Lung disease. People with cerebral palsy may develop lung disease and breathing disorders.
• Neurological conditions. People with cerebral palsy may be more likely to develop movement disorders or worsened neurological symptoms over time.
• Osteoarthritis. Pressure on joints or abnormal alignment of joints from muscle spasticity may lead to the early onset of painful degenerative bone disease (osteoarthritis).
• Osteopenia. Fractures due to low bone density (osteopenia) can stem from several common factors such as lack of mobility, nutritional shortcomings and antiepileptic drug use.
• Eye muscle imbalance. This can affect visual fixation and tracking; an eye specialist should evaluate suspected imbalances.

Prevention

Most cases of cerebral palsy can’t be prevented, but you can lessen risks. If you’re pregnant or planning to become pregnant, you can take these steps to keep healthy and minimize pregnancy complications:

• Make sure you’re vaccinated. Vaccination against diseases such as rubella may prevent an infection that could cause fetal brain damage.
• Take care of yourself. The healthier you are heading into a pregnancy, the less likely you’ll be to develop an infection that may result in cerebral palsy.
• Seek early and continuous prenatal care. Regular visits to your doctor during your pregnancy are a good way to reduce health risks to you and your unborn baby. Seeing your doctor regularly can help prevent premature birth, low birth weight and infections.
• Practice good child safety. Prevent head injuries by providing your child with a car seat, bicycle helmet, safety rails on beds and appropriate supervision.

Diagnosis

If your family doctor or paediatrician suspects your child has cerebral palsy, he or she will evaluate your child’s signs and symptoms, review your child’s medical history, and conduct a physical evaluation. Your doctor may refer you to a specialist trained in treating children with brain and nervous system conditions (pediatric neurologist).

Your doctor will 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 may include the following:

• Magnetic resonance imaging (MRI). An MRI uses radio waves and a magnetic field to produce detailed 3-D or cross-sectional images of your child’s brain. An MRI can often identify any 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 mild sedative beforehand. An MRI is usually the preferred imaging test.
• Cranial ultrasound. This can be performed during infancy. A cranial ultrasound uses high-frequency sound waves to obtain images of the brain. An ultrasound doesn’t produce a detailed image, but it may be used because it’s quick and inexpensive, and it can provide a valuable preliminary assessment of the brain.

Electroencephalogram (EEG)

If your child has had seizures, your doctor may order an electroencephalogram (EEG) to determine if he or she has epilepsy, which often occurs in people with cerebral palsy. In an EEG test, a series of electrodes are affixed to your child’s scalp.

The EEG records the electrical activity of your child’s brain. If he or she has epilepsy, it’s common for there to be changes in normal brain wave patterns.

Laboratory tests

Laboratory tests may also screen for genetic or metabolic problems.

Additional tests

If your child is diagnosed with cerebral palsy, you’ll likely be referred to specialists for assessments of other conditions often associated with the disorder. These tests may identify:

• Vision impairment
• Hearing impairment
• Speech delays or impairments
• Intellectual disabilities
• Other developmental delays
• Movement disorders

Treatment

Children and adults with cerebral palsy require long-term care with a medical care team. This team may include:

• Paediatrician or physiatrist. A paediatrician oversees the treatment plan and medical care.
• Pediatric neurologist. A doctor trained to diagnose and treat children with brain and nervous system (neurological) disorders may be involved in your child’s care.
• Orthopaedic surgeon. A doctor trained to treat muscle and bone disorders may be involved to diagnose and treat muscle conditions.
• Physical therapist. A physical therapist may help your child improve strength and walking skills, and stretch muscles.
• Occupational therapist. An occupational therapist can provide therapy to your child to develop daily skills and to learn to use adaptive products that help with daily activities.
• Speech-language pathologist. A doctor trained to diagnose and treat speech and language disorders may work with your child if your child suffers from speech, swallowing or language difficulties.
• Developmental therapist. A developmental therapist may provide therapy to help your child develop age-appropriate behaviours, social skills and interpersonal skills.
• Mental health specialist. A mental health specialist, such as a psychologist or psychiatrist, may be involved in your child’s care. He or she may help you and your child learn to cope with your child’s disability.
• Recreation therapist. Participation in art and cultural programs, sports, and other events that help children expand physical and cognitive skills and abilities. Parents of children often note improvements in a child’s speech, self-esteem and emotional well-being.
• Social worker. A social worker may assist your family to find services and plan for care transitions.
• Special education teacher. A special education teacher addresses learning disabilities determines educational needs and identifies appropriate educational resources.

Medications

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

It’s important to talk about drug treatment risks with your doctor and discuss whether medical treatment is appropriate for your child’s needs. Medication selection depends on whether the problem affects only certain muscles (isolated) or the whole body (generalized). Drug treatments may include the following:

• Isolated spasticity. When spasticity is isolated to one muscle group, your doctor may recommend onabotulinumtoxinA (Botox) injections directly into the muscle, nerve or both. Botox injections may help to improve drooling. Your child will need injections about every three months. Side effects may include pain, mild flu-like symptoms, bruising or severe weakness. Other more serious side effects include difficulty breathing and swallowing.
• Generalized spasticity. If the whole body is affected, oral muscle relaxants may relax stiff, contracted muscles. These drugs include diazepam (Valium), dantrolene (Dantrium) and baclofen (Gablofen). Diazepam carries some dependency risk, so it’s not recommended for long-term use. Its side effects include drowsiness, weakness and drooling. Dantrolene side effects include sleepiness, weakness, nausea and diarrhoea. Baclofen side effects include sleepiness, confusion and nausea. Note that baclofen may also be pumped directly into the spinal cord with a tube. The pump is surgically implanted under the skin of the abdomen.

Your child also may be prescribed medications to reduce drooling. Medications such as trihexyphenidyl, scopolamine or glycopyrrolate (Robinul, Robinul Forte) may be helpful, as can Botox injection into the salivary glands.

Therapies

A variety of nondrug therapies can help a person with cerebral palsy enhance functional abilities:

• Physical therapy. Muscle training and exercises may 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. For the first 1 to 2 years after birth, both physical and occupational therapists provide support with issues such as head and trunk control, rolling, and grasping. Later, both types of therapists are involved in wheelchair assessments. Braces or splints may be recommended for your child. Some of these supports help with function, such as improved walking. Others may stretch stiff muscles to help prevent rigid muscles (contractures).
• Occupational therapy. Using alternative strategies and adaptive equipment, occupational therapists work to promote your child’s independent participation in daily activities and routines in the home, the school and the community. Adaptive equipment may include walkers, quadrupedal canes, 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. Speech-language pathologists can also teach your child to use communication devices, such as a computer and voice synthesizer if communication is difficult. Another communication device may be a board covered with pictures of items and activities your child may see in daily life. Sentences can be constructed by pointing to the pictures. Speech therapists may also address difficulties with muscles used in eating and swallowing.
• Recreational therapy. Some children may benefit from recreational therapies, such as therapeutic horseback riding. This type of therapy can help improve your child’s motor skills, speech and emotional well-being.

Surgical or other procedures

Surgery may be needed to lessen muscle tightness or correct bone abnormalities caused by spasticity. These treatments include:

• Orthopaedic surgery. Children with severe contractures or deformities may need surgery on bones or joints to place their arms, hips or legs in their correct positions. Surgical procedures can also lengthen muscles and tendons that are proportionally too short because of severe contractures. These corrections can lessen pain and improve mobility. The procedures may also make it easier to use a walker, braces or crutches.
• Severing nerves. In some severe cases, when other treatments haven’t helped, surgeons may cut the nerves serving the spastic muscles in a procedure called selective dorsal rhizotomy. This relaxes the muscle and reduces pain, but can also cause numbness.

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