Cerebral Palsy

Signs and Symptoms

Cerebral palsy is caused by the abnormal development of areas of the brain that control movement and posture or damage to those areas caused by head injury or disease, such as rubella, bacterial meningitis or viral encephalitis. Only 10 percent to 20 percent of cerebral palsy is acquired after birth. There are four general types of cerebral palsy:

• Spastic Cerebral Palsy -- This type causes muscles to be stiff and permanently contracted. Your child's legs may turn in at the knees. Walking is difficult. Your child also may have uncontrollable shaking or tremors on one side of the body. This form of cerebral palsy affects about 70 percent to 80 percent of patients.

• Athetoid, or Dyskinetic, Cerebral Palsy -- Characterized by uncontrolled, slow, writhing of the hands, feet, arms, legs or facial muscles. Children may frown or drool. Movements may get worse during periods of stress and go away while the child sleeps. Speaking also may be difficult. This form strikes about 10 percent to 20 percent of patients.

• Ataxic Cerebral Palsy -- This form affects depth perception, balance and coordination. Children may walk with their feet far apart and may have difficulty doing precise tasks such as picking up an object or slipping a button into a buttonhole. This form affects about 5 percent to 10 percent of patients.

• Mixed Forms -- Sometimes mixed forms of cerebral palsy occur when children have symptoms of more than one of the three forms listed above.

Infants who are at higher risk for developing cerebral palsy are those with the following conditions:

• Breech Birth -- This occurs when during birth, a baby begins to descend the birth canal feet first instead of head first.

• Complications During Labor -- Signs during labor and delivery that a baby may have brain damage or development problems may signal a greater susceptibility to cerebral palsy later on.

• Physical Birth Defects -- Babies born with problems such as hernia, a poorly formed spine, a very small jaw bone or microephaly (a very small head) are at a higher risk for cerebral palsy.

• Low Apgar Score -- The Apgar score, a way for doctors to evaluate a newborn's condition, is often lower for babies who will show signs of cerebral palsy. The Apgar score looks at signs such as the baby's heart rate, reflexes, muscle tone, breathing and skin color, both right after birth and several minutes later.

• Multiple Births -- Babies who are born as part of twins, triplets or other multiple births have an increased risk of cerebral palsy.

• Low Birth Weight or Premature Birth -- Babies weighing less than 5 pounds, 7.5 ounces at birth or who are born less than 37 weeks into pregnancy are at greater risk for cerebral palsy.

• Seizures -- Newborns who have seizures are at greater risk for having cerebral palsy.

Infants also have a higher risk for developing cerebral palsy if their mothers have the following conditions:

• Vaginal Bleeding or Severe Proteinuria -- Mothers with vaginal bleeding after the sixth month of pregnancy and severe proteinuria, which results in excess proteins in urine, have babies with a higher risk of having cerebral palsy.

• Mental Retardation, Seizures or Hyperthyroidism -- Mothers who have any of these conditions are slightly more likely to have a child with cerebral palsy.

Even if your child has one or more of these risk factors, it doesn't mean that your child will develop cerebral palsy. Many children don't develop the disease.

Symptoms

Signs and symptoms of cerebral palsy vary from child to child. They may change over time, and may be affected by other medical conditions. Symptoms may include:

• Difficulty with fine motor tasks, such as writing, buttoning shirts and using scissors.

• Hypotonia or decreased muscle tone. Your baby may seem overly relaxed, flaccid or "floppy."

• Impaired motor development or developmental delay. Your baby may be slow to roll over, smile, sit, crawl or walk.

• Trouble maintaining balance or walking.

• Hypertonia or increased muscle tone. Your baby may seem rigid or stiff.

• Involuntary movements, such as uncontrollable writhing motion of the hands, or drooling.

• Unusual posture or a tendency to favor one side of the body.

• Earlier than usual development of hand preference, or the tendency to use either the right or left hand more often.

• Retention of Moro reflex after age 6 months. The Moro reflex occurs when a baby is held on its back and tilted with the legs above the head. The baby usually extends its arms in what looks like an embrace.

Diagnosis

During your child's visit to the Child Neurology clinic, our doctors and other health professionals will evaluate your child to provide a precise diagnosis. Our staff will ask you about your child's medical history, as well as your family medical history. If your child's pediatrician has sent any medical records, we will review this information. Be sure to tell your child's neurologist about any medications your child is using, including over-the-counter medications, vitamins, nutritional supplements or herbal remedies. Our doctors will check your child's motor skills and reflexes, and look for symptoms of cerebral palsy. We also will rule out other conditions that might be causing the movement problems.

Your child may need one or more specialized procedures that test for cerebral palsy:

• Computed tomography (CT) uses X-rays and a computer to create an image of the brain.

• Magnetic resonance imaging (MRI) makes images of the brain using a magnetic field and radio waves instead of X-rays.

• Ultrasound forms a picture of the brain called a sonogram by bouncing harmless sound waves off the brain.

• An electroencephalogram (EEG) records electrical activity inside the brain.

• Intelligence tests may be used to see if your child also has mental impairment.

• Vision or hearing tests may be ordered if your child's neurologist suspects that problems with these senses are present.

Treatment

Your neurology team at UCSF Children's Hospital, along with your primary care physician, will design a treatment plan tailored to your child's medical condition, state of health and individual needs. Your child may need more than one kind of treatment, or treatment requiring several visits to UCSF. Your child also may be referred to additional doctors or other medical professionals.

Because cerebral palsy can't be cured, treatment involves an ongoing process to manage the disease's effects and improve your child's quality of life. Medications can be prescribed to control seizures and muscle spasms. Special braces may be recommended to improve muscle balance. Sometimes, surgery or mechanical aids are advised. Physical, speech and behavioral therapy may be part of the treatment program.

Your neurologist will explain any possible risks or complications from the treatments that your child will receive.

Don't be afraid to ask your doctors, nurses, or therapists about the treatments your child is receiving. If your child's treatment includes medication, be sure that he or she takes it exactly as the doctor has ordered. And make sure that your child keeps all of his or her follow-up appointments with our doctors and other medical staff.

The members of your child's medical team may include:

• Doctors such as a pediatrician, a pediatric neurologist who specializes in treating the brain and nervous system, a pediatric physiatrist who helps to restore normal physical functioning, an orthopedic surgeon who treats bones and muscles and a neurosurgeon who performs surgery to treat the brain and nervous system.

• Nurses who are specially trained to treat children with neurological disorders.

• Physical therapists whose exercise programs can help your child improve movement and build strength.

• Occupational therapists who help your child learn skills to cope better at home and at school.

• Speech pathologists who help your child communicate better.

• Psychologists who help your child deal with the emotional effects of cerebral palsy.

• Educators who help your child overcome educational challenges associated with cerebral palsy, such as learning disabilities.

• Social workers who help you and your child find educational programs and other services in your community.

Orthopedic Treatment

Orthopedic surgeons treat problems with bones, muscles, tendons, nerves or joints. Specific treatments for patients with cerebral palsy may consist of techniques such as physical therapy to decrease spasticity and improve function, orthopedic appliances such as braces to prevent deformity, and surgery to correct deformities.

Physical therapy may begin immediately after diagnosis to help your child learn skills like sitting, walking or using a wheelchair; improve muscle strength, balance and coordination; and prevent muscles from shortening. Stretching muscles may help prevent contraction. Physical therapy may involve activities like swimming and horseback riding to tone muscles.

Using braces, splints or casts may improve joint mobility and stability, prevent contraction and improve hand or leg function. Braces can compensate for muscle imbalance. If contraction is severe, surgery may lengthen affected muscles.

Surgery also may help if tightly contracted muscles cause stress to joints and lead to deformities or dislocations. Some children with cerebral palsy need surgery to correctly position their arms or legs.