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Cerebral palsy Content Supplied by NHS Choices
Introduction

Cerebral palsy is the general term for a number of neurological conditions that affect movement and co-ordination.

Neurological conditions are caused by problems in the brain and nervous system.

Specifically, cerebral palsy is caused by a problem in the parts of the brain responsible for controlling muscles. The condition can occur if the brain develops abnormally or is damaged before, during or shortly after birth.

Causes of cerebral palsy include:

  • an infection caught by the mother during pregnancy
  • a difficult or premature birth
  • bleeding in the baby's brain
  • changes (mutations) in the genes that affect the brain's development

Read more about the causes of cerebral palsy.

Symptoms of cerebral palsy

The symptoms of cerebral palsy normally become apparent during the first three years of a child's life.

The main symptoms are:

These symptoms can affect different areas of the body and vary in severity from person to person. Some people only have minor problems, whereas others are severely disabled.

Many people with cerebral palsy also have a number of associated problems, including:

Some people with the condition may have communication and learning difficulties, although intelligence is often unaffected.

Read more about the symptoms of cerebral palsy.

When to seek medical advice

A child with cerebral palsy may be slower in achieving important developmental goals, such as learning to crawl, walk or speak.

You should see your GP if you're concerned about your child's development. If necessary, they can refer you to a paediatrician (a doctor who specialises in the treatment of children), who can identify any problems.

Read more about diagnosing cerebral palsy.

How cerebral palsy is treated

There's no cure for cerebral palsy. However, there are numerous treatments available, which can treat many of its symptoms and help people with the condition to be as independent as possible.

These treatments include:

In some cases, surgery may also be needed.

Read more about treating cerebral palsy.

Outlook

Cerebral palsy isn't a progressive condition. This means the original problem in the brain doesn't get worse with age, and life expectancy is usually unaffected.

However, the physical and emotional strain of living with a long-term condition such as cerebral palsy can put a great deal of stress on the body, which can cause further problems in later life.

Read more about the complications of cerebral palsy.

Information about your child

If your child has cerebral palsy, your clinical team will pass information about him or her on to the National Congenital Anomaly and Rare Diseases Registration Service (NCARDRS).

This helps scientists look for better ways to prevent and treat this condition. You can opt out of the register at any time.

Find out more about the register.

Symptoms of cerebral palsy

The symptoms of cerebral palsy normally become apparent during the first three years of a child's life.

A child with cerebral palsy may be slower in achieving important developmental goals, such as learning to crawl, walk or talk.

Main symptoms

The main symptoms largely depend on the specific form of cerebral palsy a person has.

The four main types of cerebral palsy are:

  • spastic cerebral palsy - when the muscles are weak and stiff (hypertonia), especially if moving them rapidly
  • dyskinetic cerebral palsy - when muscle tone (the unconscious ability to contract or relax muscles) varies between stiffness and floppiness (hypotonia), causing random and uncontrolled body movements (choreoathetoid cerebral palsy), or involuntary spasms and postures (dystonic cerebral palsy)
  • ataxic cerebral palsy - when a person has balance and co-ordination problems, resulting in jerky and clumsy movements; they may also experience tremors (involuntary shaking) in their hands
  • mixed cerebral palsy - when a person has features of more than one of the types mentioned above

The symptoms of cerebral palsy differ in severity from person to person. Some people only have mild problems, while others are severely disabled.

The areas affected by cerebral palsy can also vary. Some cases only affect one side of the body, some affect primarily the legs, and some affect both the arms and legs.

Associated problems

People with cerebral palsy can also have a range of related conditions or problems, including:

When to seek medical advice

If you're concerned about your child's development, see your GP.

If necessary, they can refer you to a paediatrician (a doctor who specialises in the treatment of children), who can help identify the problem.

Read more about diagnosing cerebral palsy.

Causes of cerebral palsy

Cerebral palsy is caused by a problem in the parts of the brain responsible for controlling movement. It can occur if the brain is damaged in early life or develops abnormally, although the exact cause isn't always obvious.

Parts of the brain responsible for other important functions may also be affected, such as:

  • communication
  • hearing
  • vision
  • the ability to learn

This is why people with cerebral palsy can have various other problems which don't involve the muscles.

What causes the problems in the brain

In the past, doctors believed cerebral palsy was usually caused by brain damage sustained during birth - the direct result of being temporarily deprived of oxygen (asphyxiation). Asphyxiation can sometimes occur during a difficult or complicated birth.

However, a major research project carried out in the 1980s showed that in babies born at term, asphyxiation was responsible for less than 10% of cerebral palsy cases. Most were due to problems with the brain that developed before the child was born.

Researchers believe there are three main problems that can affect the brain before birth and cause cerebral palsy:

  • periventricular leukomalacia (PVL) - damage of the brain's white matter
  • abnormal development of the brain
  • intracranial haemorrhage and stroke

These are discussed below.

Periventricular leukomalacia (PVL)

PVL is also known as white matter damage (WMD) of prematurity.

The white matter part of the brain is made up of many nerve fibres, which are protected by a white fatty protein, known as myelin. White matter is responsible for directing communication between the movement and thought-processing sections of the brain (known as grey matter) and the rest of the body.

It's thought that the brain damage is caused by a reduction in the child's blood or oxygen supply, which damages the brain cells. This has serious consequences in later life, as the white matter is responsible for transmitting signals from the brain to the muscles.

It's not clear exactly why PVL occurs, but it's been linked to:

  • an infection caught by the mother
  • the mother having abnormally low blood pressure
  • premature birth, especially if a child is born at 32 weeks of pregnancy or earlier

Abnormal development of the brain

Anything that changes or affects the brain's normal structural development can lead to problems with the way it transmits information to the muscles. If this happens, a child can develop cerebral palsy.

Brain development can be affected by:

  • changes (mutations) in the genes that play a role in the brain's development
  • an infection caught by the mother
  • trauma or injury to the unborn baby's head

Stroke

Most strokes are caused by a blockage cutting off the blood supply to the brain (ischaemic stroke). However, strokes can also be caused by bleeding in or around the brain (haemorrhagic stroke). The result of both of these events is that brain tissue is damaged. This is the most common cause of hemiplegic cerebral palsy.

Intracranial haemorrhage is normally seen in babies born prematurely, although it sometimes occurs in unborn babies after they've had a stroke.

Factors that increase the risk of an unborn baby having a stroke include:

  • pre-existing weaknesses or abnormalities in the baby's blood vessels or the mother's placenta
  • high blood pressure in the mother
  • the mother having an infection during pregnancy - particularly pelvic inflammatory disease
  • twin pregnancy - where there is early loss of one twin during the pregnancy

Brain damage during or after birth

A few cases of cerebral palsy are caused by brain damage that occurs during or soon after birth.

Damage can be caused by:

Diagnosing cerebral palsy

If you're concerned about your child's development, see your GP. They can refer you to a paediatrician (a doctor specialising in treating children), if necessary.

The paediatrician will ask about your child's medical history and their development. They'll also study your child's reflexes, posture, movements and muscle tone.

Depending on your child's age, you may be referred to:

  • a physiotherapist - for a more formal assessment of your child's movements
  • an educational psychologist - so your child's intellectual development can be assessed

Tests and scans

More tests may be recommended to rule out other problems with similar symptoms to cerebral palsy. These can include:

  • a general delay in development
  • a specific medical condition - such as muscular dystrophy

In some cases, further testing can also confirm a diagnosis of cerebral palsy. This is because the condition can cause changes to the brain's structure, which can be detected by tests.

Tests your child may have include:

  • a magnetic resonance imaging (MRI) scan - which uses radio and magnetic waves to study the brain in more detail
  • an ultrasound scan - which uses sound waves to build up a picture of your child's brain tissue
  • a computerised tomography (CT) scan - which uses a series of X-rays that are then assembled by a computer to create a detailed 3D model of your child's brain
  • an electroencephalogram (EEG) - where small electrodes are placed on the scalp to monitor brain activity
  • an electromyogram (EMG) - where muscle activity and the function of the peripheral nerves (the network of nerves that run from your brain and spinal cord to other areas of the body) are tested
  • blood tests

When a baby needs special care in hospital after being born, it may be possible for a confident diagnosis of cerebral palsy to be made relatively quickly.

However, in many cases, a clear diagnosis is only possible after some months or years of screening. It may not be possible to determine the type and severity of your child's condition until they reach three to four years old.

Treating cerebral palsy

Although there's no cure for cerebral palsy, a range of treatments are available to help treat many of the symptoms.

Treatment for cerebral palsy usually involves a team of health professionals with different areas of expertise. The team may include:

  • a paediatrician
  • a health visitor
  • a social worker
  • a physiotherapist - who helps with movement and co-ordination
  • an orthotist - who specialises in the use of devices (orthoses) to correct deformities and support weakened joints
  • a speech and language therapist
  • an occupational therapist - who helps with the skills and abilities needed for daily activities, such as washing or dressing
  • a teacher specialising in helping children with visual impairment
  • an educational psychologist - who specialises in helping people with learning difficulties
  • an orthopaedic surgeon - to monitor the hips, spine and sometimes for surgery
  • a neurologist
  • a neurosurgeon

The care team will help draw up an individual care plan to address any needs or problems your child has. The plan will be continually reassessed as your child gets older and their needs change.

You and your child will also be assigned a key worker, who will be the first point of contact between you and the various support services available. When your child is young, the key worker is likely to be a health visitor. As your child gets older and their needs become more complex, the key worker is likely to be a social worker.

There's no single treatment plan for a child with cerebral palsy. Instead, there are a wide range of treatments available, designed to improve your child's symptoms and let them be as independent as possible. Some of the main treatments are outlined below.

Physiotherapy

Physiotherapy is normally started when your child is diagnosed with cerebral palsy. It's one of the most important ways of helping your child manage their condition.

The main goals of physiotherapy are:

  • to encourage movement and improve capability - this may involve a walking aid or orthotics
  • to build on strength and to prevent the weakening of muscles that aren't normally used by your child
  • to prevent muscles shortening and losing their normal range of movement (known as a contracture)

There's a risk of contracture in children who have problems stretching their muscles as a result of muscle stiffness. If the muscles can't stretch, they don't grow as fast as the bones. This can lead to deformities, causing your child pain and discomfort.

A physiotherapist will teach your child a number of physical exercises to strengthen and stretch their muscles, which they can carry out every day. Special arm or leg braces (orthoses) may also be used to help stretch their muscles and improve their posture.

Speech therapy

Speech therapy can help children who have trouble communicating by allowing them to practise their speech with exercises, or teaching them an alternative method of communication, such as sign language or pictures.

Special equipment to help your child communicate may also be available, such as a computer connected to a voice synthesizer.

Younger children can be given a device similar to a laptop that's covered with symbols of everyday objects and activities. The child then presses a combination of symbols to communicate.

Occupational therapy

Occupational therapy involves a therapist identifying problems that your child may have carrying out everyday tasks.

They can advise your child on the best way to carry out tasks that require movement skills, such as going to the toilet or getting dressed.

Occupational therapy can be extremely useful in boosting your child's self-esteem and independence, especially as they get older.

Medications for muscle stiffness

If your child's muscles are particularly stiff, causing discomfort or preventing them from doing everyday tasks, medication to relax their muscles may be offered.

Diazepam

If fast and short-term treatment for muscle pain and stiffness is needed, diazepam can be recommended. This medication can be taken in liquid or tablet form.

Side effects of diazepam can include:

If diazepam doesn't work, there are other muscle relaxants that can be used, such as dantrolene or tizanidine. These have similar side effects to diazepam, although regular blood tests will be needed to check for more severe side effects, such as liver damage.

Baclofen

For longer-term treatment, baclofen may be recommended. Like diazepam, this can be taken in liquid or tablet form.

Side effects of baclofen can include:

In some cases, treatment with a baclofen pump may be recommended instead of tablets. This involves surgically implanting a small pump under the skin near the waist, which is connected through tubes to the spinal cord.

The pump delivers regular doses of baclofen directly into the fluid surrounding the spinal cord. This means it has fewer side effects than baclofen tablets and is better at reducing muscle stiffness.

Botulinum toxin

If your child has muscle stiffness affecting a specific muscle or group of muscles, injections of botulinum toxin can be offered.

The effects of botulinum toxin injections normally last between three and six months, but repeat injections can be given. The treatment is most effective when a programme of stretching and physiotherapy follows the injections.

In rare cases, botulinum toxin can cause serious side effects, such as swallowing difficulties. Your child's care team will explain how to recognise these problems and you'll be advised to go to the hospital immediately if they happen.

Medications for dyskinetic cerebral palsy

If your child has dyskinetic cerebral palsy, other medications may be trialled, such as:

  • trihexyphenidyl
  • gabapentin
  • clonidine

Read more about treating dystonia.

Treating feeding and drooling problems

Children who have problems controlling their head position and the movements of their mouth or tongue often find it difficult to swallow food and control their saliva production. Both of these can be potentially serious and require treatment.

If your child has problems swallowing their food (dysphagia), there's a risk that small pieces of food could enter their lungs. This can damage the lungs and cause an infection (pneumonia). If feeding and swallowing are difficult, it may also be hard to get proper nutrition.

If your child's dysphagia is mild, it may be possible for a speech and language therapist to teach them techniques to deal with it. A diet of soft foods may also be advised.

If the problem is more serious, a feeding tube may be needed. This can be placed into their stomach, either through their nose and throat (nasogastric tube) or directly through their abdominal wall (gastrostomy tube).

If your child has drooling problems, the excess saliva can irritate the skin around the mouth, chin and neck. This will increase the risk of these areas becoming infected.

A number of treatments can help children control their drooling, including:

  • anticholinergic medication - given as a tablet or skin patch, which reduces the body's production of saliva
  • botulinum toxin injections into the salivary glands (although this is only a temporary solution)
  • surgery to redirect the saliva gland - so the saliva runs towards the back of the mouth, rather than the front
  • devices placed in the mouth to encourage a better tongue position and regular swallowing
  • biofeedback training - where a child is taught to recognise when they're drooling and to swallow accordingly

Read more about treating dysphagia.

Surgery

Orthopaedic surgery may sometimes be used to correct problems with bones and joints. This may be recommended if your child's cerebral palsy is causing them pain when they move. It can also improve their posture and movement, as well as their confidence and self-esteem.

Orthopaedic surgery may involve either:

  • soft tissue surgery - such as tendon release or muscle lengthening
  • bone surgery - such as treating hip dislocation

If the two are combined, it's known as multilevel surgery.

However, it can take a while for your child to experience the full benefits of orthopaedic surgery, and a long course of physiotherapy may be needed after the operation. For example, if your child has surgery to improve their ability to walk, it may take up to two years for the full effects of the treatment to be achieved.

Surgery can also be used to treat other problems, including curvature of the spine (scoliosis) and urinary incontinence. See treating scoliosis and surgery for urinary incontinence for more information.

Your child will be routinely monitored and may need regular hip and spine X-rays to check for any problems that need to be corrected with surgery.

Selective dorsal rhizotomy (SDR)

Selective dorsal rhizotomy (SDR) is a surgical procedure that can help children with severe muscle spasticity in their legs to improve their walking. It's usually only recommended if scans have shown damage to the brain's white matter (periventricular leukomalacia) and other treatments for muscle stiffness have failed.

The operation involves cutting some of the nerves in the lower spinal column, which can help relieve leg stiffness.

However, extensive physiotherapy lasting several months will be needed after the operation, to help your child "relearn" how to control their leg muscles.

As with all types of surgery, the SDR procedure also carries the risk of complications, including:

  • temporary difficulty emptying the bladder (urinary retention)
  • scoliosis (abnormal twisting and curvature of the spine)
  • a change in the way their legs feel

You and your child (if they're able to understand the implications of surgery) should discuss the potential benefits and risks with your surgeon.

For more information about SDR, see the guidelines from the National Institute for Health and Care Excellence (NICE) on selective dorsal rhizotomy for spasticity in cerebral palsy. This operation is not currently available on the NHS.


Complications of cerebral palsy

The problem in the brain that causes cerebral palsy doesn't get worse with age. However, as a person with the condition grows, physical and emotional problems can develop.

Physical problems

Many adults with cerebral palsy develop further physical problems (such as osteoarthritis) as a result of their condition, which can cause pain, fatigue and weakness.

These problems are largely caused by the bone and muscle abnormalities associated with cerebral palsy, which can place a lot of physical stress on the body. As a result, a person with the condition can use up much more energy carrying out everyday tasks than someone who doesn't.

Further physiotherapy and mobility equipment, such as a wheelchair or walking frame, may help to relieve some of the physical problems that can develop later on as a result of cerebral palsy.

Depression

The daily challenges of living with cerebral palsy can be difficult to cope with emotionally, and adults with the condition are at an increased risk of developing depression.

You should see your GP or care team if you think you may be depressed. There are several treatments that can help, such as cognitive behavioural therapy (CBT).

Talking to other people living with cerebral palsy may also help. Scope, a charity for people with cerebral palsy, runs an internet forum for people with the condition.

Scope also has more detailed information about ageing and cerebral palsy (including life expectancy).

 
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