Cerebral palsy

Cerebral palsy is a group of disorders of movement and posture. Cerebral refers to the two hemispheres of the brain, and palsy refers to impaired movement. People who have cerebral palsy may have other disabilities as well, such as mental impairment, learning disabilities or seizure disorders. Vision, hearing and speech problems may also be present. About 5,000 infants and children are diagnosed with cerebral palsy in the United States each year.


Causes/associated factors
Cerebral palsy is caused by damage to the brain that affects the ability to control body movement and posture.
When the brain damage occurs before birth or during delivery, it's known as congenital cerebral palsy. Possible causes may include:

infections during pregnancy, such as rubella (German measles), cytomegalovirus (a viral infection) or toxoplasmosis (a parasitic infection)
Rh disease (an incompatibility between the blood proteins of the mother and baby), which can lead to jaundice (an accumulation of bile pigments, which can damage brain cells)
lack of oxygen to the brain before or during birth
Vaginal bleeding during pregnancy and breech birth (when the baby is born feet first) may increase the risk of congenital cerebral palsy.

When the brain damage occurs after birth or during the first months or years of life, it's known as acquired cerebral palsy. Possible causes may include:

an infection in or around the brain (such as meningitis)
a head injury from a fall, motor vehicle accident or child abuse
bleeding in the brain, often due to premature birth (especially if birth weight is less than 3 1/2 pounds)

Signs/symptoms
Signs of cerebral palsy usually appear before age 3. Often, developmental milestones such as rolling over, sitting, crawling and walking are delayed. Other symptoms may range from mild to severe, including:
difficulty with fine motor tasks
difficulty maintaining balance or walking
weakness in the arms or legs
standing or walking on tiptoes
excessive drooling or difficulty swallowing
speech difficulties
Although symptoms may change over time, they generally don't get worse. Children who have mild cerebral palsy may even improve with age. In fact, about half of these children outgrow their symptoms by age 7.


Types of cerebral palsy
Cerebral palsy is classified by category, depending on how movement is affected.
Spastic: The most common form of cerebral palsy. With spastic cerebral palsy, the affected muscles are stiff and permanently contracted, which makes movement difficult. Spastic cerebral palsy may affect both legs, one side of the body or, in its most severe form, the muscles of both the arms and legs. Tremors or uncontrollable shaking may be present in the affected arms or legs as well.

Athetoid (also called dyskinetic): Characterized by uncontrolled, slow, writhing movements of the hands, feet, arms or legs. The face and tongue muscles may also be affected, causing facial grimacing, drooling and difficulty with speech and sucking.

Ataxic: The rarest form of cerebral palsy, occurring in only 5 to 10 percent of cases. Balance and coordination are affected, which impairs walking and fine motor skills (such as writing).

Mixed: Characterized by symptoms of more than one of the forms described above. The most common combination is spastic and athetoid.

Diagnosis
Cerebral palsy is usually diagnosed before age 2, sometimes as early as age 6 months. The doctor will review the child's medical history and observe the way he or she moves, noting muscle tone, reflexes and posture.
Diagnostic tests may include imaging techniques such as computed tomography (CT scan) or magnetic resonance imaging (MRI). These tests can provide pictures of the brain's tissues and structures, which may help the doctor determine a possible cause for cerebral palsy.

Ultrasound (an imaging technique that uses sound waves to form a picture) may be used as another diagnostic tool, particularly for premature infants at high risk for bleeding in the brain.

Additional testing may be done to identify conditions that often accompany cerebral palsy, such as seizure disorders, mental impairment, and vision or hearing problems.


Treatment
There is no cure for cerebral palsy. Instead, treatment focuses on therapies to relieve specific symptoms and help the child reach his or her maximum potential.
Treatment involves a team of health care professionals led by a doctor, usually a pediatrician. The team may include a physical or occupational therapist, speech pathologist, social worker and psychologist. Depending on the child's symptoms, other doctors may be involved as well, such as a specialist in physical medicine, rehabilitation or orthopedic surgery. The most successful treatment plans include parents and other caregivers who can help plan, make decisions and carry out treatments.

Physical therapy, which often begins soon after diagnosis, can help a child improve muscle strength and prevent contractures (shortening of the muscles that limits joint movement).

Devices such as braces, splints and casts are often used along with physical therapy to help prevent contractures and improve muscle function. Some children need walkers or other devices to stand upright and walk. Children who are unable to walk may need mechanical aids such as a motorized wheelchair or scooter.

If contractures are severe, surgery may be recommended to lengthen the affected muscles.

Medications such as diazepam, baclofen and dantrolene may be prescribed for short-term relief of muscle spasticity. They can be taken orally, but injecting the medication directly into the muscle has proven to be more beneficial because the effect lasts longer with fewer side effects. In some cases, botulinum toxin (Botox) injections into the muscle may be used to decrease muscle spasticity. When moderate to severe spasticity affects all four limbs, the medication baclofen may be continuously delivered through a pump that's inserted under the skin.

For children who are affected by spasticity in both legs, a surgical procedure known as dorsal rhizotomy may improve the ability to sit, walk and stand. With this procedure, which is usually done between ages 2 and 6, the nerve fibers that cause the spasticity are cut.

Medications such as benztropine (Cogentin) may be used to reduce uncontrolled movements in athetoid cerebral palsy.


Complications
About half of all children who have cerebral palsy also have seizures, which are caused by uncontrolled bursts of electrical activity in the brain. Severity may range from muscle twitching to convulsive body movements followed by loss of consciousness. Medication can help control seizures.
People who have cerebral palsy may have poor control of the muscles in the throat, mouth and tongue. This increases the risk of nutritional problems, especially if swallowing is affected. Excessive drooling can lead to skin irritation, breakdown and infections.

Bladder control may be affected as well, which may result in bedwetting or slow leakage of urine. This can lead to skin breakdown and infections.

When cerebral palsy is accompanied by other disabilities, such as severe mental impairment, a child may live as few as ten years due to complications from pneumonia and other infections.


Pregnancy-specific information
Pregnant women are not at risk for developing cerebral palsy since it's an early childhood disorder.

Senior-specific information
Again, cerebral palsy is an early childhood disorder. Growing older is not a risk factor for this condition.

Prevention
Some causes of cerebral palsy are unknown and, therefore, can't be avoided. However, several causes of cerebral palsy may be preventable. Keep these considerations in mind:
Receive good prenatal care throughout your pregnancy, including testing for your Rh factor. If your baby's blood type is not compatible with yours, steps can be taken to prevent your baby from developing Rh disease.

If you're considering pregnancy and haven't had rubella (German measles) or are unsure if you've had it, ask your doctor about testing for immunity. If you're not immune, your doctor will recommend a rubella vaccination. Note: Pregnancy should be avoided for at least three months after the vaccination.

Minimize the risk factors for premature labor. Don't smoke or drink while you're pregnant, eat a healthful diet (including taking recommended dietary supplements), gain an adequate amount of weight, and follow any recommended activity limitations.

To help your child avoid a head injury, always use child safety seats in cars. Provide close adult supervision at all times to decrease the risk of falls and other injuries.