Cerebral Palsy

What is cerebral palsy?

Cerebral palsy (CP) is a brain disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination. Cerebral palsy is caused by changes in the developing brain that disrupt its ability to control movement and maintain posture and balance. The term cerebral refers to the brain. Palsy refers to problems with movement.

Some cases of cerebral palsy happen when the areas of the brain involved in muscle movement don’t develop as expected in the womb. In others, the damage is a result of injury to the brain before, during, or after birth. 

The symptoms of cerebral palsy are caused by problems in the development of the brain that may include: 

• Damage to the brain’s white matter
• Interruption of brain growth caused by gene changes
• Bleeding in the brain
• A lack of oxygen 

CP is the leading cause of childhood disabilities in the U.S., but it doesn't always cause severe disabilities. Someone with mild CP may not need any assistance or may have slight problems, while a person with severe CP might need special equipment or lifelong care. Cerebral palsy isn't progressive, meaning it doesn't necessarily get worse over time. Some symptoms may even change or get better as the child gets older.

There’s no cure for cerebral palsy, but supportive treatments, medications, and surgery can help people improve their ability to move and communicate. 

Symptoms of cerebral palsy

The hallmark symptom of CP is problems with movement and posture. Symptoms and how serious they are vary person to person. 

Children with CP exhibit a wide variety of symptoms, including:

In addition to the symptoms listed above, people with cerebral palsy also often have:

People with CP are at higher risk of heart and lung disease and pneumonia. 

Early signs of cerebral palsy

Infants with CP frequently have developmental delays and may be slower to learn to roll over, sit, crawl, or walk. Decreased muscle tone (hypotonia) can make them appear relaxed, even floppy. Increased muscle tone (hypertonia) can make their bodies seem stiff or rigid. Children with CP may also have unusual posture or favor one side of the body when they reach, crawl, or move. 

Babies younger than 6 months may feel floppy or stiff and their legs may get stiff and cross or scissor when they are picked up. Adults may notice that their head lags when they are picked up from lying on their backs. 

For babies over 6 months of age, adults may notice they can’t roll over in either direction, bring their hands together or to their mouth, or they reach out with only one hand while the other stays in a fist. 

Older babies and toddlers over 10 months of age may crawl in a lopsided manner, pushing off with one hand or leg while dragging the other. They may not be able to stand even with support.

While these signs don’t always mean cerebral palsy, it’s important to speak with the child’s doctor if you notice any of these issues. If you notice any of these signs happening suddenly, call 911 because they could be signs of stroke.

Types of cerebral palsy

Doctors classify cerebral palsy according to the type of movement disorder involved: spastic (stiff muscles), athetoid/dyskinetic (writhing movements), or ataxic (poor balance and coordination). They also consider any additional symptoms, such weakness (paresis) or paralysis (plegia).

Spastic cerebral palsy is the most common.  There are three subtypes of spastic cerebral palsy:  

• People with spastic hemiplegia/hemiparesis typically have paralysis or weakness in the arm and hand on one side of the body. Sometimes the weakness or paralysis affects the leg, too. Children generally walk later and on tiptoe. The person’s arm and leg on the affected side are frequently shorter and thinner. This becomes more apparent as they get older. Some children will develop scoliosis. While speech is often delayed with this type of CP, intelligence is usually normal.
• People with spastic diplegia/diparesis have muscle stiffness mainly in the legs, but some stiffness in the arms and face is also possible. People often have tightness in the leg muscles that makes them move like the arms of a scissor, and children may need a walker or leg braces. Intelligence and language skills are usually normal for people with this type.
• Spastic quadriplegia/quadriparesis is the most severe form of cerebral palsy and is often accompanied by moderate-to-severe intellectual disability. Children will often have severe stiffness in their limbs but a floppy neck and are rarely able to walk. People with spastic quadriplegia/quadriparesis often have difficulty speaking and frequent seizures that don’t respond well to medications. 

Other types of cerebral palsy (non-spastic), include:

• Dyskinetic cerebral palsy is characterized by slow and uncontrollable writhing or jerky movements of the hands, feet, arms, or legs. The muscles of the tongue and face may be overactive and make some children grimace or drool. It is difficult for children with dyskinetic cerebral palsy to sit straight or walk. Some have problems hearing, controlling their breathing, and speaking. Intelligence is rarely affected.
• Ataxic cerebral palsy affects balance and depth perception. Children with ataxic CP will often have poor coordination and walk unsteadily with their legs set wide. They have difficulty with quick or precise movements, such as writing or buttoning a shirt. It can be hard for people with ataxic cerebral palsy to control voluntary movement, such as reaching for something.
• Mixed cerebral palsy is when a person has symptoms that don't match any single type of CP but are a mix of types. For example, a child with mixed CP may have some muscles that are too tight and others that are too relaxed, creating a mix of stiffness and floppiness.

Who is more likely to get cerebral palsy?

Most people with CP have the condition at birth, although it may not be detected until months or years later. Possible causes of this type of CP include genetic changes, problems with the formation of the brain in the womb, infections or fevers in the pregnant parent, stroke, or injury before, during, or just after birth. 

A small number of people have acquired cerebral palsy, which means the disorder begins after birth. Some causes of acquired cerebral palsy include brain damage early in life, brain infections, problems with blood flow to the brain, or head injury. In many cases, the cause of cerebral palsy is unknown.

There are things that can happen during pregnancy that may increase a baby's risk of being born with CP. These risks include:

Low birthweight and premature birth

Premature babies and babies weighing less than five pounds, eight ounces at birth have a much higher risk of developing cerebral palsy. Tiny babies born very early are especially at risk.

Multiple births

Twins, triplets, and other multiple births—even those born at term—are statistically linked to an increased risk of CP. The death of a baby's twin or triplet in the womb before birth further increases the risk.

Infections during pregnancy

Toxoplasmosis, rubella (German measles), cytomegalovirus, Zika virus, and herpes can infect the womb and placenta. The infection triggers inflammation, which may then go on to damage the fetus’ developing nervous system. Fever for any reason during pregnancy or delivery can also set off an inflammatory response in the fetus.

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 CP.

Other risks

A mother with thyroid abnormalities, intellectual disability, excess protein in the urine, or seizures can increase the risk of the child having CP.

Factors affecting labor and delivery can act as warning signs for an increased risk of CP because they might be the first sign of something that happened before birth. It’s important to remember that most children born in these conditions won’t develop CP. Potential warning signs include:

• Breech presentation: Babies with cerebral palsy are more likely to be in a breech position (feetfirst) instead of headfirst at the start of labor.
• Complicated labor and delivery: A baby who has vascular or respiratory problems during labor and delivery might have brain damage and develop CP. These problems might have started well before delivery, but may not have been noticed because the baby had access to blood and oxygen through the umbilical cord and placenta in the womb. 
• Small for gestational age: Babies born at a small size for their gestational age are at risk for CP.
• Jaundice: More than half of newborns develop jaundice, which presents as a yellowing of the skin or whites of the eyes after birth. This happens when a substance normally found in bile builds up faster than the liver can break it down and pass it from the body. In rare cases, severe, prolonged, untreated jaundice can cause deafness and CP.
• Seizures: An infant who has seizures faces a higher risk of being diagnosed later in childhood with CP. This is typically a result of the same cause as the seizures.

Can cerebral palsy be prevented?

While cerebral palsy isn’t a genetic disorder, there are certain genetic factors that are thought to increase the risk of CP. Cerebral palsy related to these genetic abnormalities cannot be prevented, but some CP risk factors can be managed or avoided.

For example, rubella (German measles) is preventable if mothers get vaccinated against the disease before becoming pregnant. Acquired CP—which is often caused by head injury—is preventable using safety equipment, such as car seats and helmets.

How is cerebral palsy diagnosed and treated?

Diagnosing CP

Most children with cerebral palsy are diagnosed during the first two years of life. But if the child has mild symptoms, it may be difficult to make a diagnosis until later in childhood. 

To determine if a child has CP, the doctor will order a series of tests to evaluate the child's motor skills. During regular visits, the doctor will monitor the child's development, growth, muscle tone, motor control, hearing and vision, posture, and coordination. This regular monitoring can help identify signs that may indicate CP and rule out other disorders that could cause similar symptoms. Lab tests can help identify other conditions that may cause symptoms similar to CP.

Ultrasound may be used to produce pictures of the brain in high-risk premature infants because it is the least intrusive of the imaging techniques. MRI (magnetic resonance imaging), which creates a picture of the brain's tissues and structures, can show the location and type of damage, including subtle changes in the white matter—the type of brain tissue that is damaged in CP.  MRI can also show brain changes in metabolic disorders that can look like CP. An electroencephalogram (EEG) can detect electrical activity in the brain. Changes in the normal electrical pattern may help to detect seizures. Learn more about neurological diagnostic tests and procedures. 

Although symptoms may change over time, CP isn’t progressive. If the child continuously loses motor skills, the problem is likely not CP. Progressive loss of movement skills may be caused by a genetic or muscle disease, metabolism disorder, or tumors in the nervous system. Brain imaging techniques can detect problems seen in potentially treatable movement disorders. 

Treating CP

Cerebral palsy can't be cured, but treatment can help improve the child’s abilities. There is no standard therapy that works for every person with CP. Many people with CP are able to manage their symptoms. The earlier treatment begins, the better chance children have of overcoming developmental disabilities.

Once a diagnosis of cerebral palsy is made, a team of healthcare professionals will work with the child and parents to identify specific impairments and needs. In collaboration with the family and caregivers, the team will develop an appropriate plan to tackle the core disabilities that affect the child's quality of life.

Physical, speech, and occupational therapy

Physical therapy, usually in the first few years of life, is an important part of CP treatment. Stretching, resistance, and strength training programs and activities can maintain or improve muscle strength, balance, and movement skills—and prevent contractures (chronic muscle shortening). 

Speech and language therapy can improve a child's ability to speak and help with swallowing disorders. It can help people learn new ways to communicate, such as using sign language or special communication devices (like a computer with a voice synthesizer). Speech and language therapists can also help with problems with eating and swallowing. 

Occupational therapy focuses on improving function and making the most of a child's mobility. Occupational therapists help people address new ways to do activities and manage everyday routines at home, school, and in the community. 

Recreational therapy can also be helpful. It encourages participation in art and cultural programs, sports, and other activities that help the person build their physical and cognitive skills and abilities.

Drug treatments

Several drug treatments are approved to help manage symptoms in people with cerebral palsy. Medicines that can relax stiff muscles in people with CP include diazepam, baclofen, dantrolene sodium, and tizanidine.  These medicines work best in children who need only mild reduction in muscle tone or who have muscle stiffness all over the body. They may also ease pain in people with cerebral palsy. 

Botulinum toxin (commonly known as Botox), injected directly into the muscles is often used in children with spastic CP. The symptom relief lasts approximately three months after the injection, which is most effective when accompanied by physical therapy and using splints. 

Intrathecal baclofen therapy uses an implantable pump to deliver baclofen, a muscle relaxant, into the fluid surrounding the spinal cord. The pump can be adjusted if muscle tone is worse at certain times of the day or night. The baclofen pump is most appropriate for people with chronic, severe stiffness or uncontrolled muscle movement throughout the body.

Surgery

In some cases, people with cerebral palsy can have surgery to help with their symptoms. Surgery is often recommended when spasticity and stiffness are severe enough to make walking difficult or painful. Surgeons can lengthen muscles and tendons, which can improve mobility and lessen pain.

Tendon surgery may help some children with CP but could also have negative long-term consequences. Surgeries can be staggered over time based on the child's age and development. Surgery can also correct or greatly improve spinal deformities.

Assistive devices

Assistive devices—such as computer software, voice synthesizers, and picture books—can help people with CP improve communications skills. Mobility devices—including orthotics, braces and splits, special chairs, walkers, and wheelchairs—can help people with CP move around more easily and sit more comfortably. 

Some people with cerebral palsy may need glasses, surgery to correct vision problems, or hearing aids for hearing issues.

Complementary and alternative therapies

Many children and adolescents with CP use some form of complementary or alternative medicine, which may include dietary supplements, oxygen treatment, or other approaches. Although there are anecdotal reports of some benefit in some children with CP, alternative therapies have not been approved by the U.S. Food and Drug Administration (FDA) for the treatment of CP. Families of children with CP should discuss all therapies and supplements with their doctor.

Special health challenges for adults with CP

Although CP diagnosis and treatment often focuses on children and adolescents, adults with CP can develop unique health challenges that may increase in severity with age. Some children and adolescents with CP also face these challenges:

Premature aging

Most people with CP experience some form of premature aging by the time they reach their 40s because of the extra stress and strain the disease puts on their bodies. Developmental delays due to CP keep some organ systems from reaching their full capacity and performance. As a result, organs such as the heart and lungs have to work harder and age prematurely.

Functional issues at work

The day-to-day challenges of the workplace are likely to increase as an employed person with CP reaches middle age. Some people are able to continue working with accommodations.

Depression

The rate of depression is three to four times higher in people with disabilities such as cerebral palsy than the general population. The amount of emotional support someone has and how successful they are at coping have a significant impact on mental health.

Post-impairment syndrome

This syndrome is marked by a combination of pain, fatigue, and weakness due to muscle abnormalities, bone deformities, repetitive motion injuries, and arthritis. Fatigue is often a challenge because people with CP may use up to five times the amount of energy that other people use when they walk and move.

Osteoarthritis

Musculoskeletal abnormalities that may not produce discomfort during childhood can start to cause pain in adulthood and may lead to the development of osteoarthritis.

Pain

People with CP may have pain that can be acute (usually comes on quickly and lasts a short while) or chronic. They usually experience pain in the hips, knees, ankles, and back. Preventive treatment aimed at correcting skeletal and muscle problems early in life may help to avoid the progressive accumulation of stress and strain that contributes to pain.

Sexual problems

Although CP doesn't directly affect sex organs, skeletal and muscle issues can make sexual relations difficult and cause emotional concerns. It’s important to note that adolescents and adults with CP have sex drives and can have an active sexual life.

Other medical conditions

Adults with CP have higher rates of some medical conditions—including hypertension, incontinence, bladder dysfunction, and swallowing difficulties.

What are the latest updates on cerebral palsy?

NINDS, a part of the National Institutes of Health (NIH), is the nation's leading funder of research on brain and nervous system disorders, including disorders such as CP. Another NIH agency, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), also conducts and supports research on cerebral palsy. 

Much of what we now know about CP came from research sponsored by NIH, including: 

• The identification of new causes and risk factors for cerebral palsy
• The discovery of drugs to control stiff and spastic muscles and more precise methods to deliver them
• Refined surgical techniques to correct abnormalities in muscle and bone
• A greater understanding of how and why brain damage during fetal development causes CP

Genetic studies

In ongoing studies, NINDS-funded researchers are collecting DNA samples from people with CP and their families and using genetic screening techniques to discover linkages between individual genes and specific types of abnormality—primarily those associated with neural circuit wiring in early brain development. Identifying genetic causes of CP may help with diagnosis and lead to earlier, more effective treatments.

Neurochemicals

Scientists are also seeking to understand events in newborn babies' brains—such as bleeding, seizures, and circulation problems—which can cause the abnormal release of neurochemicals that triggers brain damage. For example, research has shown that bleeding in the brain unleashes dangerously high amounts of glutamate, a neurochemical that helps neurons communicate. 

However, too much glutamate overexcites and kills neurons. By learning how brain chemicals become dangerously toxic, scientists will have opportunities to develop new drugs to block their harmful effects.

Periventricular white matter damage

Periventricular white matter damage is the most common cause of CP. It’s characterized by death of the white matter around the fluid-filled ventricles in the brain. NINDS-sponsored researchers are examining the role the brain chemicals play in white matter development. 

Another NINDS-funded project involves the development of a novel mouse model and cell-based therapies for white matter injury before birth. Inflammation in the brain can also cause white matter injury. 

Stem cell therapy

Stem cell therapy is being investigated as a treatment for CP. Stem cells are special because they can become other types of cells. Scientists are hopeful that stem cells may be able to repair damaged nerves and brain tissues. 

Neuroimaging and biomarkers

Researchers funded by NINDS and NICHD are using advanced neuroimaging and identifying other biomarkers (biological signs of disease that can be found and measured) to predict whether infants will develop CP. Researchers are also developing wireless neuroimaging systems to map and decode brain function in children with CP. These new imaging methods may enable earlier diagnosis and more personalized treatment.

Systemic hypothermia

The controlled medical cooling of the body's core temperature may protect the brain and decrease the rate of death and disability from brain injuries. Previous studies have shown that hypothermia is effective in treating neurologic symptoms in full-term or late preterm babies less than one month old with hypoxic ischemic encephalopathy (HIE).

HIE is a brain injury caused by a lack of oxygen supply, which can cause CP. NICHD-funded researchers are studying different cooling treatments to improve the chance of survival and neurodevelopment outcomes in infants with HIE.

New rehabilitative therapies

NIH-funded scientists continue to look at new rehabilitative therapies to treat people with CP.

Constraint-induced therapy (CIT) typically involves restraining the stronger limb in a cast and forcing the weaker arm to perform intensive activities over a period of weeks. An NICHD-funded clinical study is examining the use of different levels of daily training using either full-time cast immobilization or part-time splint restraint in improving arm and hand dexterity and skills in children with CP. Study findings will establish evidence-based practice standards to improve lifelong capacity in people with CP.

Functional electrical stimulation (FES) is the use of low-level electrical current to stimulate and restore muscle movement and is an effective way to target and strengthen spastic muscles. Researchers are evaluating how FES-assisted stationary cycling can improve leg muscle strength in adolescents. Robotic therapy that applies controlled force to the leg during walking may improve the efficacy of treadmill training in children with CP. The results from this NICHD study may lead to an innovative clinical therapy aimed at improving locomotor function.

Botulinum toxin, injected locally, has become a standard treatment in children with CP. However, recent research in animals suggests it can be harmful to bone tissue. Other research shows a low intensity vibration treatment can improve bone structure in leg bones of children with CP. In a novel clinical study being conducted by NICHD, researchers are determining the effect of Botox treatment in conjunction with a daily vibration treatment on bone mass and bone structure in children with spastic CP.

The Cerebral Palsy Research Network (CPRN) is a multi-institution collaboration that was created during an NIH workshop that examined the goals of research and current gaps in cerebral palsy studies. Participating clinicians use this patient registry to build powerful multicenter studies that can more rapidly find practice variations and develop quality improvement initiatives. CPRN enables groundbreaking clinical research on CP and the study of long-term outcomes from the many interventions that children go through after their initial diagnosis of CP.

For more information on research about cerebral palsy, check NIH RePORTER, a searchable database of current and past research projects supported by NIH and other federal agencies. RePORTER also includes links to publications and resources from these projects. 

For research articles and summaries on cerebral palsy, search PubMed, which contains citations from medical journals and other sites.

How can I or my loved one help improve care for people with cerebral palsy?

Consider participating in a clinical trial so clinicians and scientists can learn more about cerebral palsy. Clinical research with human participants helps researchers learn more about a disorder and perhaps find better ways to safely detect, treat, or prevent disease.

All types of participants are needed—those who are healthy or may have an illness or disease—of all different ages, sexes, races, and ethnicities to ensure that study results apply to as many people as possible, and that treatments will be safe and effective for everyone who will use them.

For information about participating in clinical research visit the NINDS Clinical Trials site and NIH Clinical Research Trials and You. Learn about clinical trials currently looking for people with cerebral palsy at ClinicalTrials.gov, a searchable database of current and past clinical studies and research results.