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National Institute of Neurological Disorders and Stroke
Cerebral Palsy: Hope Through Research


Introduction

In the 1860s, an English surgeon named William Little wrote the first medical descriptions of
a puzzling disorder that struck children in the first years of life, causing stiff, spastic muscles
in their legs and, to a lesser degree, in their arms. These children had difficulty grasping
objects, crawling, and walking. Unlike most other diseases that affect the brain, this condition
didn’t get worse as the children grew older. Instead, their disabilities stayed relatively the
same.
The disorder, which was called Little's disease for many years, is now known as spastic
diplegia. It is one of a group of disorders that affect the control of movement and are gathered
under the umbrella term of “cerebral palsy.”
Because it seemed that many of Little’s patients were born following premature or
complicated deliveries, the doctor suggested their condition was the result of oxygen
deprivation during birth, which damaged sensitive brain tissues controlling movement. But in
1897, the famous psychiatrist Sigmund Freud disagreed. Noting that children with cerebral
palsy often had other neurological problems such as mental retardation, visual disturbances,
and seizures, Freud suggested that the disorder might have roots earlier in life, during the
brain's development in the womb. "Difficult birth, in certain cases," he wrote, "is merely a
symptom of deeper effects that influence the development of the fetus."
In spite of Freud’s observation, for many decades the belief that birth complications caused
most cases of cerebral palsy was widespread among physicians, families, and even medical
researchers. In the 1980s, however, scientists funded by the National Institute of
Neurological Disorders and Stroke (NINDS) analyzed extensive data from more than 35,000
newborns and their mothers, and discovered that complications during birth and labor
accounted for only a fraction of the infants born with cerebral palsy — probably less than 10
percent. In most cases, they could find no single, obvious cause.
This finding challenged the accepted medical theory about the cause of cerebral palsy. It also
stimulated researchers to search for other factors before, during, and after birth that were
associated with the disorder.
Advances in imaging technology, such as magnetic resonance imaging (MRI), have given
researchers a way to look into the brains of infants and children with cerebral palsy and
discover unique structural malformations and areas of damage. Basic science studies have
identified genetic mutations and deletions associated with the abnormal development of the
fetal brain. These discoveries offer provocative clues about what could be going wrong
during brain development to cause the abnormalities that lead to cerebral palsy.
Much of this new understanding about what causes cerebral palsy is the result of research
spanning the past two decades that has been sponsored by the NINDS, the federal
government’s leading supporter of neurological research. These findings from NINDS
research have:
• identified new causes and risk factors for cerebral palsy; • increased our understanding of how and why brain damage at critical stages of fetal • refined surgical techniques to correct abnormalities in muscle and bone; • discovered new drugs to control stiff and spastic muscles and developed more precise • tested the effectiveness of therapies used to treat cerebral palsy to discover which
This brochure describes what cerebral palsy is, its causes, its treatments, and how it might
possibly be prevented. Medical terms in italics are defined in the glossary at the back of the
booklet.
What is Cerebral Palsy?

Doctors use the term cerebral palsy to refer to any one of a number of neurological disorders
that appear in infancy or early childhood and permanently affect body movement and muscle
coordination but aren’t progressive, in other words, they don’t get worse over time. The term
cerebral refers to the two halves or hemispheres of the brain, in this case to the motor area of
the brain’s outer layer (called the cerebral cortex), the part of the brain that directs muscle
movement; palsy refers to the loss or impairment of motor function.
Even though cerebral palsy affects muscle movement, it isn’t caused by problems in the
muscles or nerves. It is caused by abnormalities inside the brain that disrupt the brain’s
ability to control movement and posture.
In some cases of cerebral palsy, the cerebral motor cortex hasn’t developed normally during
fetal growth. In others, the damage is a result of injury to the brain either before, during, or
after birth. In either case, the damage is not repairable and the disabilities that result are
permanent.
Children with cerebral palsy exhibit a wide variety of symptoms, including:
• lack of muscle coordination when performing voluntary movements (ataxia); • stiff or tight muscles and exaggerated reflexes (spasticity); • walking with one foot or leg dragging; • walking on the toes, a crouched gait, or a “scissored” gait; • variations in muscle tone, either too stiff or too floppy; • excessive drooling or difficulties swallowing or speaking; • shaking (tremor) or random involuntary movements; and • difficulty with precise motions, such as writing or buttoning a shirt. The symptoms of cerebral palsy differ in type and severity from one person to the next, and may even change in an individual over time. Some people with cerebral palsy also have other medical disorders, including mental retardation, seizures, impaired vision or hearing, and abnormal physical sensations or perceptions. Cerebral palsy doesn’t always cause profound disabilities. While one child with severe cerebral palsy might be unable to walk and need extensive, lifelong care, another with mild cerebral palsy might be only slightly awkward and require no special assistance. Cerebral palsy isn’t a disease. It isn’t contagious and it can’t be passed from one generation
to the next. There is no cure for cerebral palsy, but supportive treatments, medications, and
surgery can help many individuals improve their motor skills and ability to communicate with
the world.
How Many People Have Cerebral Palsy?

The United Cerebral Palsy (UCP) Foundation estimates that nearly 800,000 children and
adults in the United States are living with one or more of the symptoms of cerebral palsy.
According to the federal government’s Centers for Disease Control and Prevention, each year
about 10,000 babies born in the United States will develop cerebral palsy.
Despite advances in preventing and treating certain causes of cerebral palsy, the percentage of
babies who develop the condition has remained the same over the past 30 years. Improved
care in neonatal intensive-care units has resulted in higher survival rates for very low
birthweight babies. Many of these infants will have developmental defects in their nervous
systems or suffer brain damage that will cause the characteristic symptoms of cerebral palsy.
What Are the Early Signs?
The early signs of cerebral palsy usually appear before a child reaches 3 years of age. Parents
are often the first to suspect that their baby’s motor skills aren’t developing normally. Infants
with cerebral palsy frequently have developmental delay, in which they are slow to reach
developmental milestones such as learning to roll over, sit, crawl, smile, or walk. Some
infants with cerebral palsy have abnormal muscle tone as infants. Decreased muscle tone
(hypotonia) can make them appear relaxed, even floppy. Increased muscle tone (hypertonia)
can make them seem stiff or rigid. In some cases, an early period of hypotonia will progress to
hypertonia after the first 2 to 3 months of life. Children with cerebral palsy may also have
unusual posture or favor one side of the body when they move.
Parents who are concerned about their baby's development for any reason should contact their
pediatrician. A doctor can determine the difference between a normal lag in development and
a delay that could indicate cerebral palsy.
What Causes Cerebral Palsy?

The majority of children with cerebral palsy are born with it, although it may not be detected
until months or years later. This is called congenital cerebral palsy. In the past, if doctors
couldn’t identify another cause, they attributed most cases of congenital cerebral palsy to
problems or complications during labor that caused asphyxia (a lack of oxygen) during birth.
However, extensive research by NINDS scientists and others has shown that few babies who
experience asphyxia during birth grow up to have cerebral palsy or any other neurological
disorder. Birth complications, including asphyxia, are now estimated to account for only 5 to
10 percent of the babies born with congenital cerebral palsy.
A small number of children have acquired cerebral palsy, which means the disorder begins
after birth. In these cases, doctors can often pinpoint a specific reason for the problem, such
as brain damage in the first few months or years of life, brain infections such as bacterial
meningitis or viral encephalitis, or head injury from a motor vehicle accident, a fall, or child
abuse.
What causes the remaining 90 to 95 percent? Research has given us a bigger and more
accurate picture of the kinds of events that can happen during early fetal development, or just
before, during, or after birth, that cause the particular types of brain damage that will result in
congenital cerebral palsy. There are multiple reasons why cerebral palsy happens – as the
result of genetic abnormalities, maternal infections or fevers, or fetal injury, for example. But
in all cases the disorder is the result of four types of brain damage that cause its characteristic
symptoms:

Damage to the white matter of the brain (periventricular leukomalacia [PVL]). The white
matter of the brain is responsible for transmitting signals inside the brain and to the rest of the
body. PVL describes a type of damage that looks like tiny holes in the white matter of an
infant’s brain. These gaps in brain tissue interfere with the normal transmission of signals.
There are a number of events that can cause PVL, including maternal or fetal infection.
Researchers have also identified a period of selective vulnerability in the developing fetal
brain, a period of time between 26 and 34 weeks of gestation, in which periventricular white
matter is particularly sensitive to insults and injury.

Abnormal development of the brain (cerebral dysgenesis). Any interruption of the normal
process of brain growth during fetal development can cause brain malformations that interfere
with the transmission of brain signals. The fetal brain is particularly vulnerable during the
first 20 weeks of development. Mutations in the genes that control brain development during
this early period can keep the brain from developing normally. Infections, fevers, trauma, or
other conditions that cause unhealthy conditions in the womb also put an unborn baby’s
nervous system at risk.

Bleeding in the brain (intracranial hemorrhage). Intracranial hemorrhage describes
bleeding inside the brain caused by blocked or broken blood vessels. A common cause of this
kind of damage is fetal stroke. Some babies suffer a stroke while still in the womb because
of blood clots in the placenta that block blood flow. Other types of fetal stroke are caused by
malformed or weak blood vessels in the brain or by blood-clotting abnormalities. Maternal
high blood pressure (hypertension) is a common medical disorder during pregnancy that has
been known to cause fetal stroke. Maternal infection, especially pelvic inflammatory disease,
has also been shown to increase the risk of fetal stroke.

Brain damage caused by a lack of oxygen in the brain (hypoxic-ischemic encephalopathy
or intrapartum asphyxia). Asphyxia, a lack of oxygen in the brain caused by an interruption
in breathing or poor oxygen supply, is common in babies due to the stress of labor and
delivery. But even though a newborn’s blood is equipped to compensate for short-term low
levels of oxygen, if the supply of oxygen is cut off or reduced for lengthy periods, an infant
can develop a type of brain damage called hypoxic-ischemic encephalopathy, which destroys
tissue in the cerebral motor cortex and other areas of the brain. This kind of damage can also
be caused by severe maternal low blood pressure, rupture of the uterus, detachment of the
placenta, or problems involving the umbilical cord.
What are the Risk Factors?

Just as there are particular types of brain damage that cause cerebral palsy, there are also
certain medical conditions or events that can happen during pregnancy and delivery that will
increase a baby’s risk of being born with cerebral palsy. Research scientists have examined
thousands of expectant mothers, followed them through childbirth, and monitored their
children’s early neurological development to establish these risk factors. If a mother or her
baby has any of these risk factors, it doesn’t mean that cerebral palsy is inevitable, but it does
increase the chance for the kinds of brain damage that cause it.
Low birthweight and premature birth. The risk of cerebral palsy is higher among babies
who weigh less than 5 ½ pounds at birth or are born less than 37 weeks into pregnancy. The
risk increases as birthweight falls or weeks of gestation shorten. Intensive care for premature
infants has improved dramatically over the course of the past 30 years. Babies born
extremely early are surviving, but with medical problems that can put them at risk for cerebral
palsy. Although normal- or heavier-weight babies are at relatively low individual risk for
cerebral palsy, term or near-term babies still make up half of the infants born with the
condition.

Multiple births. Twins, triplets, and other multiple births -- even those born at term -- are
linked to an increased risk of cerebral palsy. The death of a baby’s twin or triplet further
increases the risk.

Infections during pregnancy. Infectious diseases caused by viruses, such as toxoplasmosis,
rubella (German measles), cytomegalovirus, and herpes, can infect the womb and placenta.
Researchers currently think that maternal infection leads to elevated levels of immune system
cells called cytokines that circulate in the brain and blood of the fetus. Cytokines respond to
infection by triggering inflammation. Inflammation may then go on to cause central nervous
system damage in an unborn baby. Maternal fever during pregnancy or delivery can also set
off this kind of inflammatory response.

Blood type incompatibility. Rh incompatibility is a condition that develops when a
mother’s Rh blood type (either positive or negative) is different from the blood type of her
baby. Because blood cells from the baby and mother mix during pregnancy, if a mother is
negative and her baby positive, for example, the mother’s system won’t tolerate the presence
of Rh-positive red blood cells. Her body will begin to make antibodies that will attack and
kill her baby’s blood cells. Rh incompatibility is routinely tested for and treated in the United
States , but conditions in other countries continue to keep blood type incompatibility a risk
factor for cerebral palsy.

Exposure to toxic substances. Mothers who have been exposed to toxic substances during
pregnancy, such as methyl mercury, are at a heightened risk of having a baby with cerebral
palsy.

Mothers with thyroid abnormalities, mental retardation, or seizures. Mothers with any
of these conditions are slightly more likely to have a child with cerebral palsy.
There are also medical conditions during labor and delivery, and immediately after delivery,
that act as warning signs for an increased risk of cerebral palsy. Knowing these warning signs
helps doctors keep a close eye on children who face a higher risk. However, parents
shouldn’t become too alarmed if their baby has one or more of these conditions at birth. Most
of these children will not develop cerebral palsy. Warning signs include:

Breech presentation. Babies with cerebral palsy are more likely to be in a breech position
(feet first) instead of head first at the beginning of labor.

Complicated labor and delivery. A baby who has vascular or respiratory problems during
labor and delivery may already have suffered brain damage or abnormalities.
Small for gestational age. Babies born smaller than normal for their gestational age are at
risk for cerebral palsy because of factors that kept them from growing naturally in the womb.

Low Apgar score. The Apgar score is a numbered rating that reflects a newborn's condition.
To determine an Apgar score, doctors periodically check a baby's heart rate, breathing, muscle
tone, reflexes, and skin color during the first minutes after birth. They then assign points; the
higher the score, the more normal a baby's condition. A low score at 10-20 minutes after
delivery is often considered an important sign of potential problems such as cerebral palsy.

Jaundice. More than 50 percent of newborns develop jaundice after birth when bilirubin, a
substance normally found in bile, builds up faster than their livers can break it down and pass
it from the body. Severe, untreated jaundice can cause a neurological condition known as
kernicterus, which kills brain cells and can cause deafness and cerebral palsy.

Seizures. An infant who has seizures faces a higher risk of being diagnosed later in
childhood with cerebral palsy.
Can Cerebral Palsy Be Prevented?

Cerebral palsy related to genetic abnormalities is not preventable, but a few of the risk factors
for congenital cerebral palsy can be managed or avoided. For example, rubella, or German
measles, is preventable if women are vaccinated against the disease before becoming
pregnant. Rh incompatibilities can also be managed early in pregnancy. But there are still
risk factors that can’t be controlled or avoided in spite of medical intervention.
For example, the use of electronic fetal monitoring machines to keep track of an unborn
baby’s heartbeat during labor, and the use of emergency cesarean section surgery when there
are significant signs of fetal distress, haven’t lowered the numbers of babies born with
cerebral palsy. Interventions to treat other prenatal causes of cerebral palsy, such as therapies
to prevent prenatal stroke or antibiotics to cure intrauterine infections, are either difficult to
administer or haven’t yet been proven to lower the risk of cerebral palsy in vulnerable
infants.
Fortunately, acquired cerebral palsy, often due to head injury, is preventable using common
safety tactics, such as using car seats for infants and toddlers, and making sure young children
wear helmets when they ride bicycles. In addition, common sense measures around the
household, such as supervising babies and young children closely when they bathe, can
reduce the risk of accidental injury.
Despite the best efforts of parents and physicians, however, children will still be born with
cerebral palsy. Since in many cases the cause or causes of cerebral palsy aren’t fully known,
little can currently be done to prevent it. As investigators learn more about the causes of
cerebral palsy through basic and clinical research, doctors and parents will know more about
how to prevent this disorder.
What Are the Different Forms?

The specific forms of cerebral palsy are determined by the extent, type, and location of a
child’s abnormalities. Doctors classify cerebral palsy according to the type of movement
disorder involved -- spastic (stiff muscles), athetoid (writhing movements), or ataxic (poor
balance and coordination) -- plus any additional symptoms. Doctors will often describe the
type of cerebral palsy a child has based on which limbs are affected. The names of the most
common forms of cerebral palsy use Latin terms to describe the location or number of
affected limbs, combined with the words for weakened (paresis) or paralyzed (plegia). For
example, hemiparesis (hemi = half) indicates that only one side of the body is weakened.
Quadriplegia (quad = four) means all four limbs are paralyzed.

Spastic hemiplegia/hemiparesis. This type of cerebral palsy typically affects the arm and
hand on one side of the body, but it can also include the leg. Children with spastic hemiplegia
generally walk later and on tip-toe because of tight heel tendons. The arm and leg of the
affected side are frequently shorter and thinner. Some children will develop an abnormal
curvature of the spine (scoliosis). Depending on the location of the brain damage, a child
with spastic hemiplegia may also have seizures. Speech will be delayed and, at best, may be
competent, but intelligence is usually normal.

Spastic diplegia/diparesis. In this type of cerebral palsy, muscle stiffness is predominantly
in the legs and less severely affects the arms and face, although the hands may be clumsy.
Tendon reflexes are hyperactive. Toes point up. Tightness in certain leg muscles makes the
legs move like the arms of a scissor. Children with this kind of cerebral palsy may require a
walker or leg braces. Intelligence and language skills are usually normal.

Spastic quadriplegia/quadriparesis. This is the most severe form of cerebral palsy, often
associated with moderate-to-severe mental retardation. It is caused by widespread damage to
the brain or significant brain malformations. Children will often have severe stiffness in their
limbs but a floppy neck. They are rarely able to walk. Speaking and being understood are
difficult. Seizures can be frequent and hard to control.

Dyskinetic cerebral palsy (also includes athetoid, choreoathetoid, and dystonic cerebral
palsies). This type of cerebral palsy is characterized by slow and uncontrollable writhing
movements of the hands, feet, arms, or legs. In some children, hyperactivity in the muscles of
the face and tongue makes them grimace or drool. They find it difficult to sit straight or
walk. Children may also have problems coordinating the muscle movements required for
speaking. Intelligence is rarely affected in these forms of cerebral palsy.

Ataxic cerebral palsy. This rare type of cerebral palsy affects balance and depth perception.
Children will often have poor coordination and walk unsteadily with a wide-based gait,
placing their feet unusually far apart. They have difficulty with quick or precise movements,
such as writing or buttoning a shirt. They may also have intention tremor, in which a
voluntary movement, such as reaching for a book, is accompanied by trembling that gets
worse the closer their hand gets to the object.

Mixed types. It is common for children to have symptoms that don’t correspond to any
single type of cerebral palsy. Their symptoms are a mix of types. For example, a child with
mixed cerebral palsy may have some muscles that are too tight and others that are too relaxed,
creating a mix of stiffness and floppiness.
What Other Conditions Are Associated With Cerebral Palsy?

Many individuals with cerebral palsy have no additional medical disorders. However, because
cerebral palsy involves the brain and the brain controls so many of the body’s functions,
cerebral palsy can also cause seizures, impair intellectual development, and affect vision,
hearing, and behavior. Coping with these disabilities may be even more of a challenge than
coping with the motor impairments of cerebral palsy.
These additional medical conditions include:

Mental retardation. Two-thirds of individuals with cerebral palsy will be intellectually
impaired. Mental impairment is more common among those with spastic quadriplegia than in
those with other types of cerebral palsy, and children who have epilepsy and an abnormal
electroencephalogram (EEG) or MRI are also more likely to have mental retardation.

Seizure disorder. As many as half of all children with cerebral palsy have seizures.
Seizures can take the form of the classic convulsions of tonic-clonic seizures or the less
obvious focal (partial) seizures, in which the only symptoms may be muscle twitches or
mental confusion.

Delayed growth and development. A syndrome called failure to thrive is common in
children with moderate-to-severe cerebral palsy, especially those with spastic quadriparesis.
Failure to thrive is a general term doctors use to describe children who lag behind in growth
and development. In babies this lag usually takes the form of too little weight gain. In young
children it can appear as abnormal shortness, and in teenagers it may appear as a combination
of shortness and lack of sexual development.
In addition, the muscles and limbs affected by cerebral palsy tend to be smaller than normal.
This is especially noticeable in children with spastic hemiplegia because limbs on the affected
side of the body may not grow as quickly or as long as those on the normal side.

Spinal deformities. Deformities of the spine -- curvature (scoliosis), humpback (kyphosis),
and saddle back (lordosis) -- are associated with cerebral palsy. Spinal deformities can make
sitting, standing, and walking difficult and cause chronic back pain.

Impaired vision, hearing, or speech. A large number of children with cerebral palsy have
strabismus, commonly called “cross eyes,” in which the eyes are misaligned because of
differences between the left and right eye muscles. In an adult, strabismus causes double
vision. In children, the brain adapts to the condition by ignoring signals from one of the
misaligned eyes. Untreated, this can lead to poor vision in one eye and can interfere with the
ability to judge distance. In some cases, doctors will recommend surgery to realign the
muscles.
Children with hemiparesis may have hemianopia, which is defective vision or blindness that
blurs the normal field of vision in one eye. In homonymous hemianopia, the impairment
affects the same part of the visual field in both eyes.
Impaired hearing is also more frequent among those with cerebral palsy than in the general
population. Speech and language disorders, such as difficulty forming words and speaking
clearly, are present in more than a third of those with cerebral palsy.

Drooling. Some individuals with cerebral palsy drool because they have poor control of the
muscles of the throat, mouth, and tongue. Drooling can cause severe skin irritation. Because
it is socially unacceptable, drooling may also isolate children from their peers.

Incontinence. A common complication of cerebral palsy is incontinence, caused by poor
control of the muscles that keep the bladder closed. Incontinence can take the form of bed-
wetting, uncontrolled urination during physical activities, or slow leaking of urine throughout
the day.
Abnormal sensations and perceptions. Some children with cerebral palsy have difficulty
feeling simple sensations, such as touch. They may have stereognosia, which makes it
difficult to perceive and identify objects using only the sense of touch. A child with
stereognosia, for example, would have trouble closing his eyes and sensing the difference
between a hard ball or a sponge ball placed in his hand.
How Does a Doctor Diagnose Cerebral Palsy?

Early signs of cerebral palsy may be present from birth. Most children with cerebral palsy are
diagnosed during the first 2 years of life. But if a child’s symptoms are mild, it can be
difficult for a doctor to make a reliable diagnosis before the age of 4 or 5. Nevertheless, if a
doctor suspects cerebral palsy, he or she will most likely schedule an appointment to observe
the child and talk to the parents about their child’s physical and behavioral development.
Doctors diagnose cerebral palsy by evaluating a child’s motor skills and taking a careful and
thorough look at their medical history. In addition to checking for the most characteristic
symptoms -- slow development, abnormal muscle tone, and unusual posture -- a doctor also
has to rule out other disorders that could cause similar symptoms. Most important, a doctor
has to determine that the child's condition is not getting worse. Although symptoms may
change over time, cerebral palsy by definition is not progressive. If a child is continuously
losing motor skills, the problem more likely begins elsewhere – such as a genetic or muscle
disease, metabolism disorder, or tumors in the nervous system. A comprehensive medical
history, special diagnostic tests, and, in some cases, repeated check-ups can help confirm that
other disorders are not at fault.
Additional tests are often used to rule out other movement disorders that could cause the same
symptoms as cerebral palsy. Neuroimaging techniques that allow doctors to look into the
brain (such as an MRI scan) can detect abnormalities that indicate a potentially treatable
movement disorder. If it is cerebral palsy, an MRI scan can also show a doctor the location
and type of brain damage.
Neuroimaging methods include:
• Cranial ultrasound. This test is used for high-risk premature infants because it is the
least intrusive of the imaging techniques, although it is not as successful as the two methods described below at capturing subtle changes in white matter – the type of brain tissue that is damaged in cerebral palsy. • Computed tomography (CT) scan. This technique creates images that show the
structure of the brain and the areas of damage. • Magnetic resonance imaging (MRI) scan. This test uses a computer, a magnetic
field, and radio waves to create an anatomical picture of the brain's tissues and structures. Doctors prefer MRI imaging because it offers finer levels of detail. On rare occasions, metabolic disorders can masquerade as cerebral palsy and some children will require additional tests to rule them out. Most of the childhood metabolic disorders have characteristic brain abnormalities or malformations that will show up in an MRI. Other types of disorders can also be mistaken for cerebral palsy. For example, coagulation disorders (which prevent blood from clotting) can cause prenatal or perinatal strokes that damage the brain and cause symptoms characteristic of cerebral palsy. Because stroke is so often the cause of hemiplegic cerebral palsy, a doctor may find it necessary to perform diagnostic testing on children with this kind of cerebral palsy to rule out the presence of a coagulation disorder. If left undiagnosed, coagulation disorders can cause additional strokes
and more extensive brain damage.
To confirm a diagnosis of cerebral palsy, a doctor may refer a child to additional doctors with
specialized knowledge and training, such as a child neurologist, developmental pediatrician,
ophthalmologist (eye doctor), or otologist (ear doctor). Additional observations help a doctor
make a more accurate diagnosis and begin to develop a specific plan for treatment.
How is Cerebral Palsy Managed?

Cerebral palsy can’t be cured, but treatment will often improve a child's capabilities. Many
children go on to enjoy near-normal adult lives if their disabilities are properly managed. In
general, the earlier treatment begins, the better chance children have of overcoming
developmental disabilities or learning new ways to accomplish the tasks that challenge them.
There is no standard therapy that works for every individual with cerebral palsy. Once the
diagnosis is made, and the type of cerebral palsy is determined, a team of health care
professionals will work with a child and his or her parents to identify specific impairments
and needs, and then develop an appropriate plan to tackle the core disabilities that affect the
child’s quality of life.
A comprehensive management plan will pull in a combination of health professionals with
expertise in the following:

physical therapy to improve walking and gait, stretch spastic muscles, and prevent
deformities;

occupational therapy to develop compensating tactics for everyday activities such as
dressing, going to school, and participating in day-to-day activities;

speech therapy to address swallowing disorders, speech impediments, and other obstacles to
communication;

counseling and behavioral therapy to address emotional and psychological needs and help
children cope emotionally with their disabilities;

drugs to control seizures, relax muscle spasms, and alleviate pain;

surgery to correct anatomical abnormalities or release tight muscles;

braces and other orthotic devices to compensate for muscle imbalance, improve posture and
walking, and increase independent mobility;

mechanical aids such as wheelchairs and rolling walkers for individuals who are not
independently mobile; and

communication aids such as computers, voice synthesizers, or symbol boards to allow
severely impaired individuals to communicate with others.
Doctors use tests and evaluation scales to determine a child’s level of disability, and then
make decisions about the types of treatments and the best timing and strategy for
interventions. Early intervention programs typically provide all the required therapies within
a single treatment center. Centers also focus on parents’ needs, often offering support groups,
babysitting services, and respite care.
The members of the treatment team for a child with cerebral palsy will most likely include the
following:
A physician, such as a pediatrician, pediatric neurologist, or pediatric physiatrist, who is
trained to help developmentally disabled children. This doctor, who often acts as the leader of
the treatment team, integrates the professional advice of all team members into a
comprehensive treatment plan, makes sure the plan is implemented properly, and follows the
child’s progress over a number of years.
An orthopedist, a surgeon who specializes in treating the bones, muscles, tendons, and other
parts of the skeletal system. An orthopedist is often brought in to diagnose and treat muscle
problems associated with cerebral palsy.
A physical therapist, who designs and puts into practice special exercise programs to
improve strength and functional mobility.
An occupational therapist, who teaches the skills necessary for day-to-day living, school,
and work.
A speech and language pathologist, who specializes in diagnosing and treating disabilities
relating to difficulties with swallowing and communication.
A social worker, who helps individuals and their families locate community assistance and
education programs.
A psychologist, who helps individuals and their families cope with the special stresses and
demands of cerebral palsy. In some cases, psychologists may also oversee therapy to modify
unhelpful or destructive behaviors.
An educator, who may play an especially important role when mental retardation or learning
disabilities present a challenge to education.
Regardless of age or the types of therapy that are used, treatment doesn’t end when an
individual with cerebral palsy leaves the treatment center. Most of the work is done at home.
Members of the treatment team often act as coaches, giving parents and children techniques
and strategies to practice at home. Studies have shown that family support and personal
determination are two of the most important factors in helping individuals with cerebral palsy
reach their long-term goals.
While mastering specific skills is an important focus of treatment on a day-to-day basis, the
ultimate goal is to help children grow into adulthood with as much independence as possible.
As a child with cerebral palsy grows older, the need for therapy and the kinds of therapies
required, as well as support services, will likely change. Counseling for emotional and
psychological challenges may be needed at any age, but is often most critical during
adolescence. Depending on their physical and intellectual abilities, adults may need help
finding attendants to care for them, a place to live, a job, and a way to get to their place of
employment.
Addressing the needs of parents and caregivers is also an important component of the
treatment plan. The well-being of an individual with cerebral palsy depends upon the strength
and well-being of his or her family. For parents to accept a child’s disabilities and come to
grips with the extent of their caregiving responsibilities will take time and support from health
care professionals. Family-centered programs in hospitals and clinics and community-based
organizations usually work together with families to help them make well-informed decisions
about the services they need. They also coordinate services to get the most out of treatment.
A good program will encourage the open exchange of information, offer respectful and
supportive care, encourage partnerships between parents and the health care professionals
they work with, and acknowledge that although medical specialists may be the experts, it’s
parents who know their children best.
What Specific Treatments Are Available?

Physical therapy, usually begun in the first few years of life or soon after the diagnosis is
made, is a cornerstone of cerebral palsy treatment. Physical therapy programs use specific sets
of exercises and activities to work toward two important goals: preventing weakening or
deterioration in the muscles that aren’t being used (disuse atrophy), and keeping muscles from
becoming fixed in a rigid, abnormal position (contracture).
Resistive exercise programs (also called strength training) and other types of exercise are
often used to increase muscle performance, especially in children and adolescents with mild
cerebral palsy. Daily bouts of exercise keep muscles that aren’t normally used moving and
active and less prone to wasting away. Exercise also reduces the risk of contracture, one of
the most common and serious complications of cerebral palsy.
Normally growing children stretch their muscles and tendons as they run, walk, and move
through their daily activities. This insures that their muscles grow at the same rate as their
bones. But in children with cerebral palsy, spasticity prevents muscles from stretching. As a
result, their muscles don’t grow fast enough to keep up with their lengthening bones. The
muscle contracture that results can set back the gains in function they’ve made. Physical
therapy alone or in combination with special braces (called orthotic devices) helps prevent
contracture by stretching spastic muscles.

Occupational therapy. This kind of therapy focuses on optimizing upper body function,
improving posture, and making the most of a child’s mobility. An occupational therapist
helps a child master the basic activities of daily living, such as eating, dressing, and using the
bathroom alone. Fostering this kind of independence boosts self-reliance and self-esteem, and
also helps reduce demands on parents and caregivers.

Recreational therapies. Recreational therapies, such as therapeutic horseback riding (also
called hippotherapy), are sometimes used with mildly impaired children to improve gross
motor skills. Parents of children who participate in recreational therapies usually notice an
improvement in their child’s speech, self-esteem, and emotional well-being.

Controversial physical therapies. "Patterning" is a physical therapy based on the principle
that children with cerebral palsy should be taught motor skills in the same sequence in which
they develop in normal children. In this controversial approach, the therapist begins by
teaching a child elementary movements such as crawling -- regardless of age – before moving
on to walking skills. Some experts and organizations, including the American Academy of
Pediatrics, have expressed strong reservations about the patterning approach because studies
have not documented its value.
Experts have similar reservations about the Bobath technique (which is also called
“neurodevelopmental treatment”), named for a husband and wife team who pioneered the
approach in England . In this form of physical therapy, instructors inhibit abnormal patterns
of movement and encourage more normal movements.
The Bobath technique has had a widespread influence on the core physical therapies of
cerebral palsy treatment, but there is no evidence that the technique improves motor control.
The American Academy of Cerebral Palsy and Developmental Medicine reviewed studies that
measured the impact of neurodevelopmental treatment and concluded that there was no strong
evidence supporting its effectiveness for children with cerebral palsy.
Conductive education, developed in Hungary in the 1940s, is another physical therapy that at
one time appeared to hold promise. Conductive education instructors attempt to improve a
child’s motor abilities by combining rhythmic activities, such as singing and clapping, with
physical maneuvers on special equipment. The therapy, however, has not been able to
produce consistent or significant improvements in study groups.

Speech and language therapy. About 20 percent of children with cerebral palsy are unable
to produce intelligible speech. They also experience challenges in other areas of
communication, such as hand gestures and facial expressions, and they have difficulty
participating in the basic give and take of a normal conversation. These challenges will last
throughout their lives.
Speech and language therapists (also known as speech therapists or speech-language
pathologists) observe, diagnose, and treat the communication disorders associated with
cerebral palsy. They use a program of exercises to teach children how to overcome specific
communication difficulties.
For example, if a child has difficulty saying words that begin with "b," the therapist may
suggest daily practice with a list of "b" words, increasing their difficulty as each list is
mastered. Other kinds of exercises help children master the social skills involved in
communicating by teaching them to keep their head up, maintain eye contact, and repeat
themselves when they are misunderstood.
Speech therapists can also help children with severe disabilities learn how to use special
communication devices, such as a computer with a voice synthesizer, or a special board
covered with symbols of everyday objects and activities to which a child can point to indicate
his or her wishes.
Speech interventions often use a child’s family members and friends to reinforce the lessons
learned in a therapeutic setting. This kind of indirect therapy encourages people who are in
close daily contact with a child to create opportunities for him or her to use their new skills in
conversation.

Treatments for problems with eating and drooling are often necessary when children with
cerebral palsy have difficulty eating and drinking because they have little control over the
muscles that move their mouth, jaw, and tongue. They are also at risk for breathing food or
fluid into the lungs. Some children develop gastroesophageal reflux disease (GERD,
commonly called heartburn) in which a weak diaphragm can’t keep stomach acids from
spilling into the esophagus. The irritation of the acid can cause bleeding and pain.
Individuals with cerebral palsy are also at risk for malnutrition, recurrent lung infections, and
progressive lung disease. The individuals most at risk for these problems are those with
spastic quadriplegia.
Initially, children should be evaluated for their swallowing ability, which is usually done with
a modified barium swallow study. Recommendations regarding diet modifications will be
derived from the results of this study.
In severe cases where swallowing problems are causing malnutrition, a doctor may
recommend tube feeding, in which a tube delivers food and nutrients down the throat and into
the stomach, or gastrostomy, in which a surgical opening allows a tube to be placed directly
into the stomach.
Although numerous treatments for drooling have been tested over the years, there is no one
treatment that helps reliably. Anticholinergic drugs – such as glycopyrolate -- can reduce the
flow of saliva but may cause unpleasant side effects, such as dry mouth, constipation, and
urinary retention. Surgery, while sometimes effective, carries the risk of complications.
Some children benefit from biofeedback techniques that help them recognize more quickly
when their mouths fall open and they begin to drool. Intraoral devices (devices that fit into
the mouth) that encourage better tongue positioning and swallowing are still being evaluated,
but appear to reduce drooling for some children.
Drug Treatments

Oral medications such as diazepam, baclofen, dantrolene sodium, and tizanidine are usually
used as the first line of treatment to relax stiff, contracted, or overactive muscles. These drugs
are easy to use, except that dosages high enough to be effective often have side effects, among
them drowsiness, upset stomach, high blood pressure, and possible liver damage with long-
term use. Oral medications are most appropriate for children who need only mild reduction in
muscle tone or who have widespread spasticity.
Doctors also sometimes use alcohol “washes” -- injections of alcohol into muscles -- to
reduce spasticity. The benefits last from a few months to 2 years or more, but the adverse
effects include a significant risk of pain or numbness, and the procedure requires a high
degree of skill to target the nerve.
The availability of new and more precise methods to deliver antispasmodic medications is
moving treatment for spasticity toward chemodenervation, in which injected drugs are used to
target and relax muscles.

Botulinum toxin (BT-A), injected locally, has become a standard treatment for overactive
muscles in children with spastic movement disorders such as cerebral palsy. BT-A relaxes
contracted muscles by keeping nerve cells from over-activating muscle. Although BT-A is
not approved by the Food and Drug Administration (FDA) for treating cerebral palsy, since
the 1990s doctors have been using it off-label to relax spastic muscles. A number of studies
have shown that it reduces spasticity and increases the range of motion of the muscles it
targets.
The relaxing effect of a BT-A injection lasts approximately 3 months. Undesirable side
effects are mild and short-lived, consisting of pain upon injection and occasionally mild flu-
like symptoms. BT-A injections are most effective when followed by a stretching program
including physical therapy and splinting. BT-A injections work best for children who have
some control over their motor movements and have a limited number of muscles to treat, none
of which is fixed or rigid.
Because BT-A does not have FDA approval to treat spasticity in children, parents and
caregivers should make sure that the doctor giving the injection is trained in the procedure and
has experience using it in children.

Intrathecal baclofen therapy uses an implantable pump to deliver baclofen, a muscle
relaxant, into the fluid surrounding the spinal cord. Baclofen works by decreasing the
excitability of nerve cells in the spinal cord, which then reduces muscle spasticity throughout
the body. Because it is delivered directly into the nervous system, the intrathecal dose of
baclofen can be as low as one one-hundredth of the oral dose. Studies have shown it reduces
spasticity and pain and improves sleep.
The pump is the size of a hockey puck and is implanted in the abdomen. It contains a
refillable reservoir connected to an alarm that beeps when the reservoir is low. The pump is
programmable with an electronic telemetry wand. The program can be adjusted if muscle
tone is worse at certain times of the day or night.
The baclofen pump carries a small but significant risk of serious complications if it fails or is
programmed incorrectly, if the catheter becomes twisted or kinked, or if the insertion site
becomes infected. Undesirable, but infrequent, side effects include overrelaxation of the
muscles, sleepiness, headache, nausea, vomiting, dizziness, and constipation.
As a muscle-relaxing therapy, the baclofen pump is most appropriate for individuals with
chronic, severe stiffness or uncontrolled muscle movement throughout the body. Doctors
have successfully implanted the pump in children as young as 3 years of age.
Surgery

Orthopedic surgery is often recommended when spasticity and stiffness are severe enough to
make walking and moving about difficult or painful. For many people with cerebral palsy,
improving the appearance of how they walk – their gait – is also important. A more upright
gait with smoother transitions and foot placements is the primary goal for many children and
young adults.
In the operating room, surgeons can lengthen muscles and tendons that are proportionately too
short. But first, they have to determine the specific muscles responsible for the gait
abnormalities. Finding these muscles can be difficult. It takes more than 30 major muscles
working at the right time using the right amount of force to walk two strides with a normal
gait. A problem with any of those muscles can cause an abnormal gait.
In addition, because the body makes natural adjustments to compensate for muscle
imbalances, these adjustments could appear to be the problem, instead of a compensation. In
the past, doctors relied on clinical examination, observation of the gait, and the measurement
of motion and spasticity to determine the muscles involved. Now, doctors have a diagnostic
technique known as gait analysis.
Gait analysis uses cameras that record how an individual walks, force plates that detect when
and where feet touch the ground, a special recording technique that detects muscle activity
(known as electromyography), and a computer program that gathers and analyzes the data to
identify the problem muscles. Using gait analysis, doctors can precisely locate which muscles
would benefit from surgery and how much improvement in gait can be expected.
The timing of orthopedic surgery has also changed in recent years. Previously, orthopedic
surgeons preferred to perform all of the necessary surgeries a child needed at the same time,
usually between the ages of 7 and 10. Because of the length of time spent in recovery, which
was generally several months, doing them all at once shortened the amount of time a child
spent in bed. Now most of the surgical procedures can be done on an outpatient basis or with
a short inpatient stay. Children usually return to their normal lifestyle within a week.
Consequently, doctors think it is much better to stagger surgeries and perform them at times
appropriate to a child’s age and level of motor development. For example, spasticity in the
upper leg muscles (the adductors), which causes a “scissor pattern” walk, is a major obstacle
to normal gait. The optimal age to correct this spasticity with adduction release surgery is 2
to 4 years of age. On the other hand, the best time to perform surgery to lengthen the
hamstrings or Achilles tendon is 7 to 8 years of age. If adduction release surgery is delayed
so that it can be performed at the same time as hamstring lengthening, the child will have
learned to compensate for spasticity in the adductors. By the time the hamstring surgery is
performed, the child’s abnormal gait pattern could be so ingrained that it might not be easily
corrected.
With shorter recovery times and new, less invasive surgical techniques, doctors can schedule
surgeries at times that take advantage of a child’s age and developmental abilities for the best
possible result.

Selective dorsal rhizotomy (SDR) is a surgical procedure recommended only for cases of
severe spasticity when all of the more conservative treatments – physical therapy, oral
medications, and intrathecal baclofen -- have failed to reduce spasticity or chronic pain. In
the procedure, a surgeon locates and selectively severs overactivated nerves at the base of the
spinal column.
Because it reduces the amount of stimulation that reaches muscles via the nerves, SDR is
most commonly used to relax muscles and decrease chronic pain in one or both of the lower
or upper limbs. It is also sometimes used to correct an overactive bladder. Potential side
effects include sensory loss, numbness, or uncomfortable sensations in limb areas once
supplied by the severed nerve.
Even though the use of microsurgery techniques has refined the practice of SDR surgery,
there is still controversy about how selective SDR actually is. Some doctors have concerns
since it is invasive and irreversible and may only achieve small improvements in function.
Although recent research has shown that combining SDR with physical therapy reduces
spasticity in some children, particularly those with spastic diplegia, whether or not it improves
gait or function has still not been proven. Ongoing research continues to look at this surgery's
effectiveness.

Spinal cord stimulation was developed in the 1980s to treat spinal cord injury and other
neurological conditions involving motor neurons. An implanted electrode selectively
stimulates nerves at the base of the spinal cord to inhibit and decrease nerve activity. The
effectiveness of spinal cord stimulation for the treatment of cerebral palsy has yet to be
proven in clinical studies. It is considered a treatment alternative only when other
conservative or surgical treatments have been unsuccessful at relaxing muscles or relieving
pain.
Orthotic Devices

Orthotic devices – such as braces and splints – use external force to correct muscle
abnormalities. The technology of orthotics has advanced over the past 30 years from metal
rods that hooked up to bulky orthopedic shoes, to appliances that are individually molded
from high-temperature plastics for a precise fit. Ankle-foot orthoses are frequently
prescribed for children with spastic diplegia to prevent muscle contracture and to improve
gait. Splints are also used to correct spasticity in the hand muscles.
Assistive Technology

Devices that help individuals move about more easily and communicate successfully at home,
at school, or in the workplace can help a child or adult with cerebral palsy overcome physical
and communication limitations. There are a number of devices that help individuals stand
straight and walk, such as postural support or seating systems, open-front walkers,
quadrupedal canes (lightweight metal canes with four feet), and gait poles. Electric
wheelchairs let more severely impaired adults and children move about successfully.
The computer is probably the most dramatic example of a communication device that can
make a big difference in the lives of people with cerebral palsy. Equipped with a computer
and voice synthesizer, a child or adult with cerebral palsy can communicate successfully with
others. For example, a child who is unable to speak or write but can make head movements
may be able to control a computer using a special light pointer that attaches to a headband.
Alternative Therapies

Therapeutic (subthreshold) electrical stimulation, also called neuromuscular electrical
stimulation (NES), pulses electricity into the motor nerves to stimulate contraction in selective
muscle groups. Many studies have demonstrated that NES appears to increase range of
motion and muscular strength.

Threshold electrical stimulation, which involves the application of electrical stimulation at
an intensity too low to stimulate muscle contraction, is a controversial therapy. Studies have
not been able to demonstrate its effectiveness or any significant improvement with its use.

Hyperbaric oxygen therapy. Some children have cerebral palsy as the result of brain
damage from oxygen deprivation. Proponents of hyperbaric oxygen therapy propose that the
brain tissue surrounding the damaged area can be “awakened” by forcing high concentrations
of oxygen into the body under greater than atmospheric pressure.
A recent study compared a group of children who received no hyperbaric treatment to a group
that received 40 treatments over 8 weeks. On every measure of function (gross motor,
cognitive, communication, and memory) at the end of 2 months of treatment and after a
further 3 months of follow up, the two groups were identical in outcome. There was no added
benefit from hyperbaric oxygen therapy.
Are There Treatments for Other Conditions Associated with Cerebral Palsy?

Epilepsy. Twenty to 40 percent of children with mental retardation and cerebral palsy also
have epilepsy. Doctors usually prescribe medications to control seizures. The classic
medications for this purpose are phenobarbital, phenytoin, carbamazepine, and valproate.
Although these drugs generally are effective in controlling seizures, their use is hampered by
harmful or unpleasant side effects.
Treatment for epilepsy has advanced significantly with the development of new medications
that have fewer side effects. These drugs include felbamate, gabapentin, lamotrigine,
levetiracetam, oxcarbazepine, tiagabine, topiramate, vigabatrin, and zonisamide.
In general, drugs are prescribed based on the type of seizures an individual experiences, since
no one drug controls all types. Some individuals may need a combination of two or more
drugs to achieve good seizure control.

Incontinence. Medical treatments for incontinence include special exercises, biofeedback,
prescription drugs, surgery, or surgically implanted devices to replace or aid muscles.
Specially designed absorbent undergarments can also be used to protect against accidental
leaks.

Osteopenia. Children with cerebral palsy who aren’t able to walk risk developing poor bone
density (osteopenia), which makes them more likely to break bones. In a study of older
Americans funded by the National Institutes of Health (NIH), a family of drugs called
bisphosphonates, which was recently approved by the FDA to treat mineral loss in elderly
patients, also appeared to increase bone mineral density. Doctors may choose to selectively
prescribe the drug off-label to children to prevent osteopenia.

Pain. Pain can be a problem for people with cerebral palsy due to spastic muscles and the
stress and strain on parts of the body that are compensating for muscle abnormalities. Some
individuals may also have frequent and irregular muscle spasms that can’t be predicted or
medicated in advance.
Doctors often prescribe diazepam to reduce the pain associated with muscle spasms, but it’s
not known exactly how the drug works to interfere with pain signals. The drug gabapentin
has been used successfully to decrease the severity and frequency of painful spasms. BT-A
injections have also been shown to decrease spasticity and pain, and are commonly given
under anesthesia to avoid the pain associated with the injections. Intrathecal baclofen has
shown good results in reducing pain, but its delivery is invasive, time intensive, and
expensive.
Some children and adults have been able to decrease pain by using noninvasive and drug-free
interventions such as distraction, relaxation training, biofeedback, and therapeutic massage.
Do Adults with Cerebral Palsy Face Special Health Challenges?

Before the mid-twentieth century, few children with cerebral palsy survived to adulthood.
Now, because of improvements in medical care, rehabilitation, and assistive technologies, 65
to 90 percent of children with cerebral palsy live into their adult years. This increase in life
expectancy is often accompanied by a rise in medical and functional problems – some of them
beginning at a relatively early age – including the following:
Premature aging. The majority of individuals with cerebral palsy will experience some form
of premature aging by the time they reach their 40s because of the extra stress and strain the
disease puts upon their bodies. The developmental delays that often accompany cerebral
palsy keep some organ systems from developing to their full capacity and level of
performance. As a consequence, organ systems such as the cardiovascular system (the heart,
veins, and arteries) and pulmonary system (lungs) have to work harder and they age
prematurely.

Functional issues at work. The day-to-day challenges of the workplace are likely to increase
as an employed individual with cerebral palsy reaches middle age. Some individuals will be
able to continue working with accommodations such as an adjusted work schedule, assistive
equipment, or frequent rest periods. Early retirement may be necessary for others.

Depression. Mental health issues can also be of concern as someone with cerebral palsy
grows older. The rate of depression is three to four times higher in people with disabilities
such as cerebral palsy. It appears to be related not so much to the severity of their disabilities,
but to how well they cope with them. The amount of emotional support someone has, how
successful they are at coping with disappointment and stress, and whether or not they have an
optimistic outlook about the future all have a significant impact on mental health.

Post-impairment syndrome. Most adults with cerebral palsy experience what is called post-
impairment syndrome, a combination of pain, fatigue, and weakness due to muscle
abnormalities, bone deformities, overuse syndromes (sometimes also called repetitive motion
injuries), and arthritis. Fatigue is often a challenge, since individuals with cerebral palsy use
three to five times the amount of energy that able-bodied people use when they walk and
move about.

Osteoarthritis and degenerative arthritis. Musculoskeletal abnormalities that may not
produce discomfort during childhood can cause pain in adulthood. For example, the abnormal
relationships between joint surfaces and excessive joint compression can lead to the early
development of painful osteoarthritis and degenerative arthritis. Individuals with cerebral
palsy also have limited strength and restricted patterns of movement, which puts them at risk
for overuse syndromes and nerve entrapments.

Pain. Issues related to pain often go unrecognized by health care providers since individuals
with cerebral palsy may not be able to describe the extent or location of their pain. Pain can
be acute or chronic, and is experienced most commonly in the hips, knees, ankles, and the
upper and lower back. Individuals with spastic cerebral palsy have an increased number of
painful sites and worse pain than those with other types of cerebral palsy. The best treatment
for pain due to musculoskeletal abnormalities is preventive – correcting skeletal and muscle
abnormalities early in life to avoid the progressive accumulation of stress and strain that
causes pain. Dislocated hips, which are particularly likely to cause pain, can be surgically
repaired. If it is managed properly, pain does not have to become a chronic condition.

Other medical conditions. Adults have higher than normal rates of other medical conditions
secondary to their cerebral palsy, such as hypertension, incontinence, bladder dysfunction,
and swallowing difficulties. Curvature of the spine (scoliosis) is likely to progress after
puberty, when bones have matured into their final shape and size. People with cerebral palsy
also have a higher incidence of bone fractures, occurring most frequently during physical
therapy sessions. A combination of mouth breathing, poor hygiene, and abnormalities in
tooth enamel increase the risk of cavities and periodontal disease. Twenty-five percent to 39
percent of adults with cerebral palsy have vision problems; eight to 18 percent have hearing
problems.
Because of their unique medical situations, adults with cerebral palsy benefit from regular
visits to their doctor and ongoing evaluation of their physical status. It is important to
evaluate physical complaints to make sure they are not the result of underlying conditions.
For example, adults with cerebral palsy are likely to experience fatigue, but fatigue can also
be due to undiagnosed medical problems that could be treated and reversed.
Because many individuals with cerebral palsy outlive their primary caregiver, the issue of
long-term care and support should be taken into account and planned for.
What Research Is Being Done?

Investigators from many fields of medicine and health are using their expertise to help
improve the treatment and diagnosis of cerebral palsy. Much of their work is supported
through the NINDS, the National Institute of Child Health and Human Development
(NICHD), other agencies within the federal government, nonprofit groups such as the United
Cerebral Palsy Research and Educational Foundation, and other private institutions.
The ultimate hope for curing cerebral palsy rests with prevention. In order to prevent cerebral
palsy, however, scientists have to understand normal fetal brain development so that they can
understand what happens when a baby’s brain develops abnormally.
Between conception and the birth of a baby, one cell divides to form a handful of cells, and
then hundreds, millions, and, eventually, billions of cells. Some of these cells specialize to
become brain cells, and then specialize even further into particular types of neurons that travel
to their appropriate place in the brain (a process that scientists call neuronal migration). Once
they are in the right place, they establish connections with other brain cells. This is how the
brain develops and becomes able to communicate with the rest of the body -- through
overlapping neural circuits made up of billions of interconnected and interdependent neurons.
Many scientists now think that a significant number of children develop cerebral palsy
because of mishaps early in brain development. They are examining how brain cells
specialize and form the right connections, and they are looking for ways to prevent the factors
that disrupt the normal processes of brain development.

Genetic defects are sometimes responsible for the brain malformations and abnormalities that
cause cerebral palsy. Scientists funded by the NINDS are searching for the genes responsible
for these abnormalities by collecting DNA samples from people with cerebral palsy and their
families and using genetic screening techniques to discover linkages between individual genes
and specific types of abnormality – primarily those associated with abnormal neuronal
migration.
Scientists are scrutinizing events in newborn babies’ brains, such as bleeding, epileptic
seizures, and breathing and circulation problems, which can cause the abnormal release of
chemicals that trigger the kind of damage that causes cerebral palsy. For example, research
has shown that bleeding in the brain unleashes dangerously high amounts of a brain chemical
called glutamate. Although glutamate is necessary in the brain to help neurons communicate,
too much glutamate overexcites and kills neurons. Scientists are now looking closely at
glutamate to detect how its release harms brain tissue. By learning how brain chemicals that
are normally helpful become dangerously toxic, scientists will have opportunities to develop
new drugs to block their harmful effects.
Scientists funded by the NINDS are also investigating whether substances in the brain that
protect neurons from damage, called neurotrophins, could be used to prevent brain damage
as a result of stroke or oxygen deprivation. Understanding how these neuroprotective
substances act would allow scientists to develop synthetic neurotrophins that could be given
immediately after injury to prevent neuron death and damage.
The relationship between uterine infections during pregnancy and the risk of cerebral palsy
continues to be studied by researchers funded by the NIH. There is evidence that uterine
infections trigger inflammation and the production of immune system cells called cytokines,
which can pass into an unborn baby’s brain and interrupt normal development. By
understanding what cytokines do in the fetal brain and the type of damage these immune
system cells cause, researchers have the potential to develop medications that could be given
to mothers with uterine infections to prevent brain damage in their unborn children.
Approximately 10 percent of newborns are born prematurely, and of those babies, more than
10 percent will have brain injuries that will lead to cerebral palsy and other brain-based
disabilities. A particular type of damage to the white matter of the brain, called
periventricular leukomalacia (PVL), is the predominant form of brain injury in premature
infants. NINDS-sponsored researchers studying PVL are looking for new strategies to
prevent this kind of damage by developing safe, nontoxic therapies delivered to at-risk
mothers to protect their unborn babies.
Although congenital cerebral palsy is a condition that is present at birth, a year or two can
pass before any disabilities are noticed. Researchers have shown that the earlier rehabilitative
treatment begins, the better the outcome for children with cerebral palsy. But an early
diagnosis is hampered by the lack of diagnostic techniques to identify brain damage or
abnormalities in infants.
Research funded by the NINDS is using imaging techniques, devices that measure electrical
activity in the brain, and neurobehavioral tests to predict those preterm infants who will
develop cerebral palsy. If these screening techniques are successful, doctors will be able to
identify infants at risk for cerebral palsy before they are born.
Noninvasive methods to record the brain activity of unborn babies in the womb and to
identify those with brain damage or abnormalities would also be a valuable addition to the
diagnostic tool kit. Another NINDS-funded study focuses on the development of fetal
magnetoencephalography (fMEG) – a technology that would allow doctors to look for
abnormalities in fetal brain activity.
Epidemiological studies – studies that look at the distribution and causes of disease among
people -- help scientists understand risk factors and outcomes for particular diseases and
medical conditions. Researchers have established that preterm birth (when a baby is born
before 32 weeks’ gestation) is the highest risk factor for cerebral palsy. Consequently, the
increasing rate of premature births in the United States puts more babies at risk. A large,
long-term study funded by the NIH is following a group of more than 400 mothers and their
infants born between 24 and 31 weeks’ gestation. They are looking for relationships between
preterm birth, maternal uterine infection, fetal exposure to infection, and short-term and long-
term health and neurological outcomes. The researchers are hoping to discover environmental
or lifestyle factors, or particular characteristics of mothers, which might protect preterm
babies from neurological disabilities.
While this research offers hope for preventing cerebral palsy in the future, ongoing research to
improve treatment brightens the outlook for those who must face the challenges of cerebral
palsy today. An important thrust of such research is the evaluation of treatments already in
use so that physicians and parents have valid information to help them choose the best
therapy. A good example of this effort is an ongoing NINDS-supported study that promises to
yield new information about which patients are most likely to benefit from selective dorsal
rhizotomy, a surgical technique that is increasingly being used to reduce spasticity (see
Surgery).
Similarly, although physical therapy programs are used almost universally to rehabilitate
children with cerebral palsy, there are no definitive studies to indicate which techniques work
best. For example, constraint-induced therapy (CIT) is a type of physical therapy that has
been used successfully with adult stroke survivors and individuals who have traumatic brain
injury and are left with a weak or disabled arm on one side of the body. The therapy involves
restraining the stronger arm in a cast and forcing the weaker arm to perform 6 hours of
intensive “shaping” activities every day over the course of 3 weeks. The researchers who
conducted the clinical trials in adult stroke survivors realized CIT’s potential for
strengthening children’s arms weakened by cerebral palsy.
In a randomized, controlled study of children with cerebral palsy funded by the NIH,
researchers put one group of children through conventional physical therapy and another
group through 21 consecutive days of CIT. Researchers looked for evidence of improvement
in the movement and function of the disabled arm, whether the improvement lasted after the
end of treatment, and if it was associated with significant gains in other areas, such as trunk
control, mobility, communication, and self-help skills.
Children receiving CIT outperformed the children receiving conventional physical therapy
across all measures of success, including how well they could move their arms after therapy
and their ability to do new tasks during the study and then at home with their families. Six
months later they still had better control of their arm. The results from this study are the first
to prove the benefits of a physical therapy. Additional research to determine the optimal
length and intensity of CIT will allow doctors to add this therapy to the cerebral palsy
treatment toolbox.
Studies have shown that functional electrical stimulation is an effective way to target and
strengthen spastic muscles, but the method of delivering the electrical pulses requires
expensive, bulky devices implanted by a surgeon, or skin surface stimulation applied by a
trained therapist. NINDS-funded researchers have developed a high-tech method that does
away with the bulky apparatus and lead wires by using a hypodermic needle to inject
microscopic wireless devices into specific muscles or nerves. The devices are powered by a
telemetry wand that can direct the number and strength of their pulses by remote control. The
device has been used to activate and strengthen muscles in the hand, shoulder, and ankle in
people with cerebral palsy as well as in stroke survivors.
As researchers continue to explore new treatments for cerebral palsy and to expand our
knowledge of brain development, we can expect significant improvements in the care of
children with cerebral palsy and many other disorders that strike in early life.
Zdroj: http://www.ninds.nih.gov/disorders/cerebral_palsy/detail_cerebral_palsy.htm#154383104

Source: http://www.rizikovedeti.sk/public/files/anglicky7.pdf