Cerebral Palsy (CP)

Cerebral palsy (CP) is the most common motor disability of childhood. CP is a group of disorders that affect muscle tone, posture, and movement as a result of damage to an infant's developing brain. Though the damage doesn't progress, the symptoms change over time with growth and development.

Children with CP often have one or more associated conditions, including learning disabilities, developmental delays, epilepsy, problems with vision or hearing, and challenges with speech and communication. They can also have other medical concerns, such as feeding and nutritional difficulties and respiratory issues.

The Children’s Rare Disease Collaborative (CRDC) is a Boston Children’s research effort that aims to identify, understand, and treat genetic causes of rare diseases. Learn about ongoing CRDC research on cerebral palsy.

There are several types of cerebral palsy. They are classified by the kind of motor function issues the child has:

• Spastic diplegia: spastic movements of the legs
• Spastic quadriplegia: spastic movements in all four limbs (both arms and legs)
• Spastic hemiplegia: spasticity that affects one half, or one side, of the body (such as the right arm and right leg)
• Athetoid: involuntary, uncontrolled, and purposeless movements
• Dystonia: sustained or repetitive muscle contractions that do not relax, causing twisted or fixed postures

It is sometimes helpful to think of dystonia as an "overflow" of movements due to abnormal signals from the brain's movement system. This differs from spasticity, which describes increased muscle tone, due to exaggerated stretch reflexes. Reflexes are normally suppressed by signals from the brain and spinal cord that allow us to move properly, and an inability to properly suppress reflexes results in spasticity.

It is not uncommon to have both spasticity and dystonia with CP, and it is often difficult to tell them apart because they both result in too much muscle tone.

Cerebral palsy symptoms can vary from child to child. Symptoms range from muscle weakness and poor motor control to muscle tightness (spasticity), to movement disorders (dyskinesias).

Children with CP may also have other symptoms including:

• Seizures
• Vision loss or trouble seeing
• Hearing loss or trouble hearing
• Speech problems
• Learning disabilities
• Behavioral problems
• Developmental delays
• Difficulty swallowing (dysphagia)
• Challenges with nutrition
• Respiratory problems
• Gastroesophageal reflux (GERD)
• Constipation
• Fragile bones

Infants with CP are often slow to reach developmental milestones, such as learning to roll over, sit, crawl, or walk. They may also have certain reflexes past the time these reflexes normally disappear (primitive reflexes). While CP doesn't progress or worsen over time, your child's symptoms may change with age.

There are many causes of CP, but all occur either during pregnancy, birth, or shortly after birth. Common causes include brain malformations, infection, or stroke. In a small number of cases, oxygen deprivation is the cause. In many cases, the cause is unknown.

Sometimes, CP occurs as a complication of another condition, like premature birth, low birth weight, or neurological trauma.

Clinicians typically diagnose CP when a child is 6 to 24 months old, since this is the time when they start missing developmental milestones such as walking and controlling hand and head movements.

The process of diagnosing CP begins with a thorough history and physical examination. During the initial exam, a neurologist or pediatrician obtains a complete history of the mother's pregnancy and the child's birth and infancy.

Next, your child may have a variety of tests, including:

• Neurologic examination to evaluate your child's reflexes and motor functions
• X-rays
• Electroencephalogram (EEG)
• Magnetic resonance imaging (MRI)
• Gait laboratory analysis to evaluate the walking pattern of the child
• Computerized tomography (CT) scans
• Genetic studies, which screen for conditions that tend to run in families
• Metabolic tests, which detect the absence or insufficiency of specific enzymes (for example, particular amino acids, vitamins, or carbohydrates) necessary to maintain normal body functions

Because CP affects children in different ways, your child's treatment plan will depend on several factors, including:

• Their age, overall health, and medical history
• The type of cerebral palsy they have
• The extent of symptoms
• Their tolerance for specific medications, procedures, or therapies
• The expected course of their cerebral palsy
• Your family's preferences for treatment

Cerebral palsy is a lifelong condition that has no cure, so treatments are focused on:

• Preventing or minimizing physical deformities
• Improving mobility and motion to the greatest possible extent
• Optimizing health
• Maximizing your child's ability to succeed at home, at school, and in the community

Medications to help manage cerebral palsy

While medication can't treat or cure CP itself, it can be helpful in managing certain symptoms. Medications include:

• Antispasmodics: reduces muscle spasms and relaxes tightness in the muscles
• Anticonvulsants: treats seizures in children who have them
• Anticholingerics: helps children who have rigidity and uncontrollable drooling
• Botulinum toxin injections: helps reduce muscle tightness

Your clinician will determine if medication is safe and recommended for you child.

Therapy options for cerebral palsy

Your child’s doctor may recommend one or more types of therapy to treat symptoms. These may include:

• Physical therapy (PT). PT can be very helpful in preventing muscle contractures by stretching your child's spastic muscles. Many children receive regular physical therapy to take part in stretches, strengthening exercises, and play activities that can help them improve their flexibility, endurance, and mobility. Physical therapy may be combined with orthotic devices like a brace or splint.
• Occupational therapy (OT). OT is very helpful in giving children with CP independence, confidence, and essential life skills. The occupational therapist will use exercises, games, and training to help your child develop better fine motor skills, improve hand-eye coordination, and master basic skills, such as getting dressed or bathing.
• Speech therapy. A speech therapist can work with your child to address concerns about communication, swallowing, and feeding. Speech therapy may include augmentative communication (using a computer system to help with communication) and feeding skill development, depending on the issue.

Nonsurgical treatments for cerebral palsy

Management of CP usually includes several nonsurgical aids, such as:

• Seating and positioning aids. These are used to help your child sit, lie, or stand and may include wheelchairs, walkers, and ergonomic chairs that promote correct posture.
• Orthotics. Orthotics are used to prevent deformity and to provide support or protection for your child’s limbs and torso. These devices can include braces and splints.
• Special eating or writing utensils. Forks, spoons, knives, pens, and pencils can be designed for kids with fine motor skill difficulties.
• Communication aids. Communication aids are used to help children who may have difficulty hearing, understanding, or communicating with others. These aids may include special picture books and posters, alphabet boards that can be used to spell out messages, and computers with adaptive programs and functions such as speech-recognition software.

Surgery for cerebral palsy

In some cases, surgery can be a helpful option for managing symptoms of cerebral palsy. These surgeries may include:

• Orthopedic surgery. Orthopedic surgeons treat CP symptoms that affect the skeleton and muscles, such as spasticity and muscle contractures. Surgery may be recommended if your child's muscle spasms cause problems with movement, balance, and coordination. Surgery can also help reduce spasticity in the legs by elongating or releasing the contracted muscles and tendons that are too short. Surgical procedures are also used to treat scoliosis, hip dislocations, and ankle and foot deformities.
• Neurosurgery. Some children with CP have pain and spasms severe enough to need neurosurgery. Procedures, including implant of a baclofen pump, can help control the pain and the spasms caused by CP. This is a small device placed under the skin of the belly to deliver the muscle relaxant baclofen directly into the spinal canal. Neurosurgeons may also perform selective dorsal rhizotomy or combined rhizotomy, operations that cut certain nerves in the spine to reduce spasticity and improve tone.

Although CP is a lifelong condition that can't be reversed, with proper medical and surgical treatment, children with cerebral palsy can lead rich, fulfilling lives.

Because cerebral palsy can refer to several different types of brain injury, it's important to seek treatment from experts from many different disciplines who understand:

• A child's symptoms of cerebral palsy might not match any given "textbook" example
• Cerebral palsy may affect many parts of a child's body
• How and why other medical conditions can occur alongside cerebral palsy
• The vital role of orthopedic support

The team of specialists in the Cerebral Palsy and Spasticity Center at Boston Children's Hospital provides evaluation and treatment for children with cerebral palsy and other neuromuscular conditions. We combine expertise in orthopedic surgery, complex care, neurology, and neurosurgery, among several other specialties, to improve the functional capabilities of more than 2,000 patients of all ages every year.