Cerebral Palsy

We have selected the following expert medical opinion based on its clarity, reliability and accuracy. Credits: Sourced from the website OrthoInfo, reviewed by members of the Pediatric Orthopaedic Society of North America (POSNA) (see below). Please refer to your own medical practitioner for a final perspective, assessment or evaluation.

What is cerebral palsy?

Cerebral palsy (CP) is a disorder that affects a child's ability to control his or her muscles. It is caused by damage or abnormalities in the parts of the brain that are involved with movement and coordination. The spinal cord and muscles in a child with CP are structurally normal.

In most cases, cerebral palsy begins before a baby is born; however, CP can also begin at birth or during the first years of life. Early signs of CP include delays in meeting milestones, such as learning to roll over, sit, crawl, or walk.

Although there is no cure for CP, the disorder does not worsen as a child grows. Early treatment, such as physical therapy, medication, braces, and other assistive devices, can significantly help children improve their functional capabilities. 

Cause

In most children with CP, how the problems in the brain occur cannot be determined. Before birth, the brain of the unborn child is sensitive to damage from maternal infections and toxins, as well as exposure to drugs and alcohol. These factors may contribute to the development of CP. Lack of oxygen during birth has also been linked to the development of CP. After birth, infection (especially in low birth weight babies), lack of oxygen and head injury may be contributing factors. Premature babies are also at a greater risk for CP. 

Description

Cerebral palsy affects approximately 2 out of every 1,000 live births. The physical disabilities associated with CP can be mild, moderate, or severe, depending on which part and how much of the brain are involved. Some children can walk independently, while others need assistive devices, like crutches or walkers. Some children with CP require the use of wheelchairs for mobility. 

(Left) When this young child with CP walks, she must use her arms to maintain balance. (Right) Using a walker helps the child improve balance and stability.

Reproduced from Sussman MD: The orthopaedic management of cerebral palsy. Orthopaedic Knowledge Online Journal 2009; 7(4). Accessed January 2018. 

Classification of Cerebral Palsy

Doctors typically describe CP using three major classification systems.

These are:

• Physiologic
• Geographic
• Functional

Physiologic

There are four main types of cerebral palsy in the physiologic classification. Doctors can usually diagnose the specific type of CP when a child is about two years old.

• Spastic: The most common form of cerebral palsy is spastic CP, in which a child has increased muscle tone/tightness. A child's legs, arms, and back are stiff and contracted, which makes movement difficult.
• Athetoid: A child with athetoid CP has low muscle tone/looseness, which makes limbs weak and floppy. Athetoid CP causes uncontrolled and involuntary movements of the entire body. It may be difficult for a child to sit up straight or walk and speech can often be difficult to understand.
• Ataxic: This rare form of CP affects balance and depth perception. There is poor coordination, with a wide-based and clumsy gait. There is also difficulty with precise movements, such as using a pen or buttoning a shirt.
• Mixed: In mixed CP, there are symptoms of both spastic and athetoid CP. Some muscles are tight and others are loose. There is both stiffness and involuntary movements.

Geographic

Cerebral palsy can also be classified by the part of the body affected and how severe the effects are.

• Diplegic: Both legs are affected. Tight muscles in the hips and legs often cause the legs to turn inward and cross at the knees when walking, called "scissoring."
• Hemiplegic: One side of the body is affected. The arm is often more severely affected than the leg.
• Triplegic: Both legs and one arm are affected
• Quadriplegic or total body involvement: All four limbs and the trunk are affected. Independent walking may be difficult, or even not possible. In addition, the muscles of the mouth and tongue also may be affected, making swallowing and eating difficult.

Functional

The Gross Motor Functional Classification System is most commonly used to describe how independently a child with CP is able to function.

There are five functional levels:

1.  Able to walk without restrictions and is able to keep up with his or her peers.
2. Able to walk indoors and outdoors but is often unable to keep up with peers and will sometimes require leg braces.
3. Uses walking aids, such as crutches or a walker, for shorter distances and may use a wheelchair when traveling for long distances.
4.  Able to propel own wheelchair, usually nonambulatory.
5.  Unable to be independently mobile and support trunk.

Other Impairments Associated with CP

In addition to affecting muscles and motor skills, CP may cause a range of other impairments in some children.

These include:

• Mental impairment (such as intellectual disability or learning disability)
• Seizures
• Vision difficulties
• Shortened limbs
• Curvature of the spine (scoliosis)
• Dental problems
• Complete or partial hearing loss
• Problems with joints (contractures, hip forced out of socket)

Doctor Examination

Medical History and Physical Examination

Give the doctor your child's complete medical history. This may help to rule out other disorders that can cause movement problems, such as genetic or muscle diseases, metabolism disorders, and tumors of the nervous system.

Your doctor will evaluate your child's muscle tone and reflexes, and may want to watch your child walk, crawl, sit, and lie down.

If your child is less than one year old, your doctor may need to wait a few months before confirming the diagnosis of cerebral palsy in order to see whether your child develops specific problems with movement.

During the physical examination, your doctor also may check for other conditions linked to CP, such as mental impairment, seizures, and vision problems. 

Tests

There is no specific blood test or imaging study that can make the diagnosis of cerebral palsy.

However, your doctor may order a magnetic resonance imaging (MRI) scan of your child's brain. This test can show damage or abnormalities in the brain. 

Treatment

Individuals who have cerebral palsy often need help from their families and medical specialists throughout their lives. Many types of healthcare professionals are involved in treating those with CP.

Depending upon the type of CP your child has, as well as any additional impairments, the medical treatment team may include:

• Orthopaedic surgeons to treat problems with bones, muscles, tendons, nerves or joints
• Physical therapists to improve movement and strength
• Occupational therapists to teach daily living skills, such as eating and dressing
• Speech and language specialists to treat communication problems
• Social workers to help locate community assistance and education programs
• Psychologists to help patients and families cope with stress
• Behavioral therapists to foster social and emotional development
• Other medical specialists such as eye doctors, neurologists, and nutritionists

Nonsurgical Treatment

Physical therapy

Physical therapy may be recommended shortly after the diagnosis is made in order to help your child learn skills such as sitting, walking, or using a wheelchair. It also may help improve muscle strength, balance, and coordination, as well as prevent muscles from becoming too tight. Physical therapy may involve fun activities to tone muscles, like swimming and horseback riding. 

(Left) A physical therapist teaches a child with CP to use walking sticks. (Right) A young child with CP learns how to use a harness walker.

Reproduced from Sussman MD: The orthopaedic management of cerebral palsy. Orthopaedic Knowledge Online Journal 2009; 7(4). Accessed January 2018. 

Braces, splints, and casts

Using braces, splints, or casts may improve range of motion in joints and joint stability, prevent contracture, and improve hand or leg function. Braces can compensate for muscle imbalance.

Botox

This drug can be injected into spastic muscles to loosen them. It is especially helpful for children younger than 5 years old, and when used in combination with casting.

Medication

Some medications (such as oral diazepam and baclofen) can control or prevent seizures or muscle spasms, ease muscle stiffness, or reduce abnormal movements.

Surgical Treatment

If contractures are severe, surgery to lengthen affected muscles can improve a child's ability to move and walk. This surgery may also help if tightly contracted muscles cause stress to joints and lead to deformities or dislocations.

Some children with CP need surgery to correctly position their arms or legs, or to correct curvature of the spine (scoliosis).

Severe spasticity and muscle stiffness may be helped with an intrathecal baclofen pump. In this procedure, a small pump is surgically implanted under the skin to deliver doses of a muscle relaxant.

If other treatments cannot effectively manage severe spasticity, your doctor may recommend selective dorsal rhizotomy. During this surgery of the spine, specific nerves that control spastic muscles are cut to help the muscles relax, as well as to relieve associated pain. This particular type of surgery is done infrequently. 

Coping Strategies

Parents of children with cerebral palsy or other disabilities often feel guilt and/or grief about their child's condition.

Some tips to help parents cope:

• Learn all you can about CP. You may want to join a family support group or get help from professionals. Stay informed about new treatments and technologies.
• Work with professionals at your child's school to develop an individualized plan that meets his or her needs and abilities.
• Love and encourage your child. Family support and personal determination are important factors in achieving long-term goals. Go places and have fun. Be patient, and keep hoping for improvement.
• Get help from family and friends. Caring for a child with CP is hard work. Teach others how to do it so you can take breaks. 

About the source

POSNA

The Pediatric Orthopaedic Society of North America (POSNA) is a group of board eligible/board certified orthopaedic surgeons who have specialized training in the care of children's musculoskeletal health. 

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