Cerebral Palsy

Cerebral Palsy (CP) is a group of neurological disorders that permanently affects muscle coordination and body movement. Cerebral Palsy involves non-progressive damage and impairment of motor functions to the developing brain, traditionally considered so until the age of 2 years.

The motor disorder (i.e., muscle coordination and body movement) is caused by an injury or non-progressive malformation of the brain that occurs in the developing foetus (traditionally considered so until the age of 2 years) or during infancy. It affects muscle control and tone, posture, balance, fine and gross motor skills, and oral motor functioning. Persons with Cerebral Palsy may suffer from chronic and acute pain, experienced most commonly in joints such as knees and ankles, hips, upper and lower back.

Most children with Cerebral Palsy are capable of walking, with approximately 10% requiring an aid to walk, and 30% using a wheelchair. Further, 1 in 5 people with Cerebral Palsy have difficulties in communication.[1]

Recognising Cerebral Palsy
Types of Cerebal Palsy

Cerebral Palsy can be broadly classified into 3 categories based on the part of the body it affects, the type of movement it affects and the severity of the effects.

  • Spastic Cerebral Palsy: Have abnormal muscle tone. Body movements appear to be awkward and stiff. Different parts of the body may be affected by spastic Cerebral Palsy, for example, the hand and arm on one side of the body or stiffness in the leg muscles.
  • Dyskinetic Cerebral Palsy: Characterised by jerky, uncontrolled movements of the legs, feet, arms or hands or uncontrollable and slow writhing. It may also affect the face and tongue, so that the child has a hard time sucking, swallowing and talking.
  • Ataxic Cerebral Palsy: Affects the child’s perception of depth and his/her balance. As a result, children with Ataxia often display poor coordination and walk with a wide-based gait in an unsteady manner.

Some people display symptoms that do not correspond to any single aforementioned type of Cerebral Palsy. The most common type of Mixed Cerebral Palsy is spastic-dyskinetic, wherein children may have some muscles that are too tight, whilst others that are too relaxed.

What causes Cerebral Palsy?

Cerebral Palsy is caused by damage or abnormal development of the cerebral cortex, the part of the brain that is responsible for directing muscle movement. This may occur during pregnancy, childbirth or postpartum.  Cerebral Palsy can be congenital (from birth) or acquired.

  • Congenital Cerebral Palsy: Most of the children are born with Cerebral Palsy, i.e. it is congenital, even though it may not be diagnosed until many months or years later. Some of the causes of Congenital Cerebral Palsy include foetal or maternal infections, brain malformations due to genetic abnormalities and brain injuries due to fetal stroke.
  • Acquired Cerebral Palsy: A small proportion of children have acquired Cerebral Palsy after birth.  Causes of Acquired Cerebral Palsy include brain damage in the first few postpartum months or years due to infections such as viral encephalitis or bacterial meningitis, difficulties in the flow of blood to the brain, or head injury from a fall, abuse, or car accident.

Various types of brain damage has been observed in persons with Cerebral Palsy:[2]

  • Periventricular leukomalacia or PVL: Damage or injury to the white matter of the brain that is responsible for transmitting signals inside the brain and to the rest of the body may result in neuro-developmental injuries. This can hamper the normal transmission of signals in an infant and cause Cerebral Palsy. The period of pregnancy when the periventricular white matter is sensitive to injury has been identified by researchers as between 6.5 – 8.5 months.
  • Cerebral dysgenesis: During the developmental stage of the foetus, brain malformations that disrupt the normal transmission of brain signals, can cause Cerebral Palsy. Conditions such as gene mutations, fevers, trauma and infections can disrupt the normal growth process of the brain.
  • Intracranial hemorrhage: While still in the womb, some babies may suffer a foetal stroke due to blood clots in the placenta that block the blood flow in the brain. Foetal strokes may also occur as a result of weak or deformed blood vessels or due to blood-clotting abnormalities. Such strokes result in internal bleeding in the brain from impaired blood vessels that could cause Cerebral Palsy.
  • Asphyxia: Poor supply of oxygen and breathing interruptions can cause a severe lack of oxygen to the brain and is common in newborns for brief periods due to stressful labour or delivery.  If the infant brain is deprived of oxygen for prolonged periods of time, the cerebral motor and other parts of the brain may be damaged. Such damage is known as hypoxic-ischemic encephalopathy and may cause Cerebral Palsy.
What are the signs and symptoms of Cerebral Palsy?

The signs and symptoms of Cerebral Palsy appear early on during infancy even though specific diagnosis may be delayed until the child is two years old or later. Children with Cerebral Palsy often display developmental delays, marked by slow progress in achieving developmental milestones such as learning to walk, sit or crawl.

The signs and symptoms of Cerebral Palsy can vary from one child to the next. Even in one individual, the symptoms may even change over time. Cerebral Palsy may also result in a certain level of Intellectual Disability among some people.  Children with Cerebral Palsy may exhibit an impaired ability to handle objects during everyday activities, along with abnormal physical perception and seizures.  In addition, persons with Cerebral Palsy may experience hearing or vision loss, as well as issues in communication.

Further, persons with Cerebral Palsy display a wide variety of symptoms including:

  • Difficulty in muscle coordination while performing voluntary movements
  • Involuntary or uncontrollable movements because of muscle spasm
  • Stiffness or floppiness in muscle tone
  • Exaggerated reflexes (spasticity)
  • Weakness of the arm or leg on one side
  • Crouched gait
  • Walking on tiptoes because of tightness in tendons
  • Excessive drooling
  • Gastro-oesophageal reflux
  • Difficulty in swallowing or speaking
  • Delayed motor skill development
  • Difficulty with precise movement such as tying shoelaces

However, it should be noted that not all children who display these signs and symptoms have Cerebral Palsy.

Diagnosing Cerebral Palsy
How is Cerebral Palsy diagnosed?

Cerebral Palsy is mostly diagnosed in children during the first 2 years of their life. However, in certain situations where a child exhibits mild symptoms of Cerebral Palsy, it may not be easy for a doctor to reach a reliable diagnosis before the age of 4 – 5 years.

Techniques that enable doctors to study the brain including neuro-imaging methods such as magnetic resonance imaging (MRI), cranial ultrasound, computed tomography (CT) scan, electro-myogram (EMG) and electro-encephalogram (EEG), can be used to diagnose Cerebral Palsy.

Unfortunately, there is no single test available to confirm Cerebral Palsy definitively. Lab tests can recognise other disorders that cause similar symptoms to those related to Cerebral Palsy. Even though the symptoms can change over a period of time, Cerebral Palsy is non-progressive in nature.  Doctors may require regular visits and a series of tests to monitor and evaluate the child’s development and motor skills. This would also help the doctor to rule out other conditions that result in symptoms similar to Cerebral Palsy.

Whom should I approach for diagnosis?

It is recommended to seek expert consultation from:

  • Development Paediatrician
  • Ophthalmologist
  • Child Neurologist
  • Otologist
  • Educational Psychologist
What should I do post-diagnosis?

A diagnosis of Cerebral Palsy in a child can be overwhelming. You may find it helpful to hear from other parents – for example, through Parent Support Groups. Learning from their experiences can be a reassuring way to adapt to the diagnosis.

Once Cerebral Palsy is diagnosed and the type is determined, health care professionals can design an appropriate treatment plan to enhance and sustain the capabilities of a child with Cerebral Palsy. A customised treatment plan to tackle the fundamental issues that affect the child’s quality of life is important. Therapeutic options such as physical therapy, occupational therapy, recreational therapy and language and speech therapy are recommended for children with Cerebral Palsy.

Oral medications such as diazepam, baclofen, dantrolene sodium, and tizanidine are often used as the first line of treatment to help relax contracted, overactive or stiff muscles.[3]

In case stiffness and spasticity are severe enough to stifle mobility or make it painful to move, an orthopedic surgery may be recommended. Orthopedic surgeries may also be undertaken to improve the gait or the appearance of how persons with Cerebral Palsy walk.

If the more conservative therapies and treatments fail to relieve a child with Cerebral Palsy from chronic pain and severe spasticity, selective dorsal rhizotomy, a surgical procedure that involves cutting the nerves is recommended.

Living with Cerebral Palsy
Cerebral Palsy in childhood

Given the right support, a child with Cerebral Palsy can learn to lead a fulfilling life and make a valuable contribution to society. As a parent of a child with Cerebral Palsy, you play an important role in helping your child reach his/her full potential. There are a number of interventions you can make at home, but you may also need to seek out professional advice and specialist support.

What is the importance of early childhood intervention for a child diagnosed with Cerebral Palsy?

Early detection and intervention is extremely important. It helps to ensure that children with Cerebral Palsy function better and are successfully integrated into society. As Cerebral Palsy may also be the consequence of a genetic disorder, the parents can seek genetic counseling.  Early diagnosis also means that plans for treatment of congenital malformations, and other medical conditions, along with developmental, educational, and vocational services can be made in time. Early intervention consists of a program of therapies, exercises and activities, designed to specifically help your child. These can be carried out at home, as well as through specialist interventions.

What kind of care can I provide at home?

The best place for your child to grow is in his/her own home surrounded by family, where he/she can be nurtured with appropriate and non-judgmental stimulation. As a parent of a child with Cerebral Palsy, you play an important role in helping your child reach their full potential. You and your child will have many accomplishments.

What interventions are made for a child diagnosed with Cerebral Palsy?

Different kinds of therapy can help children with Cerebral Palsy to achieve their maximum potential in growth and development. As soon as it is diagnosed, a child can begin therapy for movement, and other areas that need help, such as learning, speech, hearing, and social and emotional development. Depending on his/her symptoms, a person may need any of the following:

  • Surgery: Muscle and tendons that are too short can be corrected through lengthening. Surgery can also be used to correct curvature of the spine (scoliosis) and urinary incontinence.
  • Medication: Medication can be used if muscles are particularly stiff, cause your child discomfort, and prevent him/her from performing everyday tasks. Medicines can also be given to control muscle spasticity, seizures and other abnormal movements.
  • Physical Therapy: This involves a set of special exercises aimed at increasing and improving the child’s movement and strength. It also helps prevent the weakening of muscles not normally used by your child.
  • Mechanical Aids: Orthotic braces can help to stretch muscles and improve their function, by holding bones in certain positions. Other aids include computers equipped with special input devices, and speech synthesizers to help the child communicate.
  • Occupational Therapy: The therapist first identifies the problems that your child may face in carrying out everyday tasks, and helps him/her develop the fine motor skills needed to accomplish these. Occupational therapy also helps to boost your child’s self-esteem and independence.
  • Speech Therapy: Speech therapists will teach your child a series of exercises that can help him/her to speak clearly. In case the speech difficulty is severe, the therapist can also teach your child an alternative method of communication, such as sign language.
  • Counselling: The counsellor (social worker or psychologist) will work with your child and family to help cope with the child’s condition and access the required services.
  • Other Support: Sometimes, coping with the emotional and practical aspects of Cerebral Palsy can be overwhelming for caregivers. It can be helpful to meet with a social worker or counsellor to talk about thoughts or concerns. Joining a Cerebral Palsy support group is also an alternative. In support groups, patients and their family members get together to share what they have learned about Cerebral Palsy. It is important to remember that in order to provide care to another, you must first take care of yourself.

Should I enrol my child in a special education program?

Your child has a legal right to education. These laws also protect your rights as a parent to be fully informed about or to challenge educational decisions concerning your child.

Whether to send your child to a mainstream or special school is a personal decision, based on your child’s special education needs and your personal preferences.

Whatever you decide, it is important to be involved with your child’s education. If your child is in a mainstream school, he or she may need an adapted curriculum and may sometimes be required to attend special classes.

You should try and enrol your child in classes with other children of the same age. Think of ways you can stimulate your child’s thinking skills without making tasks too difficult. Remember, it is okay for your child to sometimes fail. Keeping the child’s positive image of himself/herself alive is essential, and will help him/her to succeed in life.

Cerebral Palsy in adolescence

Adolescents with Cerebral Palsy have the same needs as everyone else. Cerebral Palsy is a non-progressive condition, but due to its neurological nature, adolescents may find it difficult to apply skills from one situation to another. The adolescents must be taught appropriate inputs, such as how to adapt their movement and understand and control their growing adult body. This will enable them to continue developing skills throughout adult life.

You can help your child develop healthy relationships by teaching appropriate social skills and behaviour. Peer acceptance and self-esteem are affected by how well your adolescent child addresses these issues. You may also want to start planning your child’s future work and living arrangements.

Here are some tips:

  • As your child enters puberty, teach them proper grooming and hygiene.
  • Encourage your child to take part in school and community activities. Teens almost always graduate from high school. Provide opportunities for your child to form healthy friendships. This is critical for your child’s happiness and sense of belonging.
  • Be aware of the social difficulties and vulnerabilities your child faces. Start early to increase your child’s confidence in their own abilities, independence, social and daily living skills.
  • Create an inspiring and positive atmosphere so that your child enjoys learning.
  • Help them to improve bodily control and mobility by increasing the range of movement and flexibility in joints.
  • Learn important techniques, such as moving in and out of wheelchair, using ankles when standing and walking, etc.
Cerebral Palsy in adulthood

Many adults with Cerebral Palsy function well in society. They often have regular jobs and take part in community activities. Some might need assistance in caring for themselves. As parents, you should encourage his/her interests, such as in art, theatre, music or literature.

Many people who have Cerebral Palsy live independently as adults or in group homes/apartments with support services. But most group homes and community centres require a basic level of self-sufficiency, such as being able to eat, dress, and bathe independently. Occupational therapists can assist in these transitions.

An adult with Cerebral Palsy benefits greatly from working outside the home and having social activities. Unfortunately, prejudice against persons with Cerebral Palsy often bars them from the mainstream workplaces. Employers often make assumptions about what a person with challenges can and cannot do, when in reality they have a wide range of abilities. Vocational training helps many young adults learn how to work in many settings, such as stores, restaurants, and hotels. Day-to-day challenges are likely to increase as an adult with Cerebral Palsy ages, with some individuals being able to continue working by adjusting work schedules, using assistive equipment, or resting more frequently.

As people with Cerebral Palsy grow older, they face a new set of challenges including conditions such as depression and hypertension. It is important that both caregivers and providers be aware of the increased chance of these conditions, and screen appropriately and regularly for them.

For more information, visit the section on Persons with Challenges.

Frequently Asked Questions
Q: Is Cerebral Palsy treatable?

There is no cure for Cerebral Palsy, but interventions, including treatment, therapy, special equipment, and, in some cases, surgery can help children with Cerebral Palsy.

Q: Is Cerebral Palsy life-threatening?

With the exception of a few cases of severe Cerebral Palsy, most children with the condition are expected to live well into adulthood.

Q: What are other related conditions that a child with Cerebral Palsy is likely to have?

Some conditions that accompany Cerebral Palsy are seizures, problems with vision, hearing or speech, changes in the spine, joint problems or Intellectual Disability. Because of the Cerebral Palsy, they may also have hypertension, incontinence, bladder dysfunction and difficulty in swallowing.

Q: Does a person with Cerebral Palsy suffer from depression?

Persons with Cerebral Palsy are three to four times more likely to have depression. The level of emotional support, and how one copes with the stress can both have a significant impact on his/her mental health.

Acknowledgement and References

We would like to extend our sincere gratitude to Dr. Sudha Sreedharan who reviewed this content and whose suggestions and guidance proved immensely valuable.

The following references were used to compile the above information:

[1] http://yourcpf.org/what-is-cp/

[2] http://yourcpf.org/cause-and-timing/

[3] http://yourcpf.org/what-is-cp/