presentation on cerebral palsy

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Cerebral palsy is a group of conditions that affect movement and posture. It's caused by damage that occurs to the developing brain, most often before birth.

Symptoms appear during infancy or preschool years and vary from very mild to serious. Children with cerebral palsy may have exaggerated reflexes. The arms, legs and trunk may appear floppy. Or they may have stiff muscles, known as spasticity. Symptoms also can include irregular posture, movements that can't be controlled, a walk that's not steady or some combination of these.

Cerebral palsy may make it hard to swallow. It also can cause eye muscle imbalance, in which the eyes don't focus on the same object. People with the condition might have reduced range of motion in their joints due to muscle stiffness.

The cause of cerebral palsy and its effect on function vary from person to person. Some people with cerebral palsy can walk while others need assistance. Some people have intellectual disabilities, but others do not. Epilepsy, blindness or deafness also might affect some people with cerebral palsy. There is no cure, but treatments can help improve function. The symptoms of cerebral palsy may vary during the child's development, but the condition doesn't get worse. The condition generally stays the same over time.

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Symptoms of cerebral palsy can vary greatly. In some people, cerebral palsy affects the whole body. In other people, symptoms might only affect one or two limbs or one side of the body. General symptoms include trouble with movement and coordination, speech and eating, development, and other issues.

Movement and coordination

Movement and coordination symptoms may include:

• Stiff muscles and exaggerated reflexes, known as spasticity. This is the most common movement condition related to cerebral palsy.
• Variations in muscle tone, such as being either too stiff or too floppy.
• Stiff muscles with regular reflexes, known as rigidity.
• Lack of balance and muscle coordination, known as ataxia.
• Jerky movements that can't be controlled, known as tremors.
• Slow, writhing movements.
• Favoring one side of the body, such as only reaching with one hand or dragging a leg while crawling.
• Trouble walking. People with cerebral palsy may walk on their toes or crouch down when they walk. They also may have a scissors-like walk with their knees crossing. Or they may have a wide gait or a walk that's not steady.
• Trouble with fine motor skills, such as buttoning clothes or picking up utensils.

Speech and eating

These symptoms related to speech and eating may occur:

• Delays in speech development.
• Trouble speaking.
• Trouble with sucking, chewing or eating.
• Drooling or trouble with swallowing.

Development

Some children with cerebral palsy have these symptoms related to development:

• Delays in reaching motor skills milestones, such as sitting up or crawling.
• Learning disabilities.
• Intellectual disabilities.
• Delayed growth, resulting in smaller size than would be expected.

Other symptoms

Damage to the brain can contribute to other neurological symptoms, such as:

• Seizures, which are symptoms of epilepsy. Children with cerebral palsy may be diagnosed with epilepsy.
• Trouble hearing.
• Trouble with vision and changes in eye movements.
• Pain or trouble feeling sensations such as touch.
• Bladder and bowel issues, including constipation and urinary incontinence.
• Mental health conditions, such as emotional conditions and behavior issues.

The brain condition causing cerebral palsy doesn't change with time. Symptoms usually don't worsen with age. However, as the child gets older, some symptoms might become more or less clear. And muscle shortening and muscle rigidity can worsen if not treated aggressively.

When to see a doctor

Contact your child's health care professional and get a prompt diagnosis if your child has symptoms of a movement condition. Also see a health professional if your child has delays in development.

See your child's health care professional if you have concerns about episodes of loss of awareness or of irregular bodily movements or posture. It's also important to contact your child's health care professional if your child has trouble swallowing, poor coordination, eye muscle imbalance or other developmental issues.

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Cerebral palsy is caused by irregular brain development or damage to the developing brain. This usually happens before a child is born, but it can occur at birth or in early infancy. Often the cause isn't known. Many factors can lead to changes in brain development. Some include:

• Gene changes that result in genetic conditions or differences in brain development.
• Maternal infections that affect an unborn baby.
• Stroke, which interrupts blood supply to the developing brain.
• Bleeding into the brain in the womb or as a newborn.
• Infant infections that cause swelling in or around the brain.
• Traumatic head injury to an infant, such as from a motor vehicle accident, fall or physical trauma.
• Lack of oxygen to the brain related to a hard labor or delivery, although this cause is less common than previously thought.

Risk factors

A number of factors are associated with an increased risk of cerebral palsy.

Maternal health

Certain infections or toxic exposures during pregnancy can significantly increase cerebral palsy risk to the baby. Inflammation triggered by infection or fever can damage the unborn baby's developing brain.

• Cytomegalovirus. This common virus causes flu-like symptoms. If a mother has her first active infection during pregnancy, it can lead to birth defects.
• German measles, known as rubella. This viral infection can be prevented with a vaccine.
• Herpes. This infection can be passed from mother to child during pregnancy, affecting the womb and placenta.
• Syphilis. This is a bacterial infection that's usually spread by sexual contact.
• Toxoplasmosis. This infection is caused by a parasite found in contaminated food, soil and the feces of infected cats.
• Zika virus infection. This infection is spread through mosquito bites and can affect the brain development of an unborn baby.
• Intrauterine infections. This includes infections of the placenta or fetal membranes.
• Exposure to toxins. One example is exposure to methyl mercury.
• Other conditions. Other conditions affecting the mother that can slightly increase the risk of cerebral palsy include thyroid conditions, preeclampsia or seizures.

Infant illness

Illnesses in a newborn baby that can greatly increase the risk of cerebral palsy include:

• Bacterial meningitis. This bacterial infection causes swelling in the membranes surrounding the brain and spinal cord.
• Viral encephalitis. This viral infection also causes swelling in the membranes surrounding the brain and spinal cord.
• Severe or untreated jaundice. Jaundice appears as a yellowing of the skin and eyes. The condition occurs when certain byproducts of "used" blood cells aren't filtered from the bloodstream.
• Bleeding into the brain. This condition is commonly caused by the baby having a stroke in the womb or in early infancy.

Factors of pregnancy and birth

The potential contribution from each is limited, but these pregnancy and birth factors may increase the risk of cerebral palsy risk:

• Low birth weight. Babies who weigh less than 5.5 pounds (2.5 kilograms) are at higher risk of developing cerebral palsy. This risk increases as birth weight drops.
• Multiple babies. Cerebral palsy risk increases with the number of babies sharing the uterus. The risk also can be related to the likelihood of premature birth and low birth weight. If one or more of the babies die, the survivors' risk of cerebral palsy increases.
• Premature birth. Babies born prematurely are at higher risk of cerebral palsy. The earlier a baby is born, the greater the cerebral palsy risk.
• Delivery complications. Events during labor and delivery may increase the risk of cerebral palsy.

Complications

Muscle weakness, muscle spasticity and trouble with coordination can contribute to complications in childhood or in adulthood, including:

• Contracture. Contracture is muscle tissue shortening due to severe muscle tightening. This can be the result of spasticity. Contracture can slow bone growth, cause bones to bend, and result in joint changes, dislocation or partial dislocation. These can include a dislocated hip, a curved spine or other bone changes.
• Malnutrition. Trouble with swallowing and feeding can make it hard to get enough nutrition, particularly for an infant. This can impair growth and weaken bones. Some children or adults need a feeding tube to get enough nutrition.
• Mental health conditions. People with cerebral palsy might have mental health conditions, such as depression. Social isolation and the challenges of coping with disabilities can contribute to depression. Behavior issues also can occur.
• Heart and lung disease. People with cerebral palsy may develop heart disease, lung disease and breathing conditions. Trouble swallowing can result in respiratory issues, such as aspiration pneumonia. Aspiration pneumonia happens when a child inhales food, drink, saliva or vomit into the lungs.
• Osteoarthritis. Pressure on joints or misalignment of joints from muscle spasticity may lead to this painful bone disease.
• Osteoporosis. Fractures due to low bone density can result from lack of mobility, poor nutrition and anti-seizure medicines.
• Other complications. These can include sleep conditions, chronic pain, skin breakdown, intestinal issues and issues with oral health.

Often cerebral palsy can't be prevented, but you can reduce risks. If you're pregnant or planning to become pregnant, take these steps to minimize pregnancy complications:

• Make sure you're vaccinated. Getting vaccinated against diseases such as rubella might prevent an infection. It's best to make sure you're fully vaccinated before getting pregnant.
• Take care of yourself. The healthier you are heading into a pregnancy, the less likely you'll be to develop an infection that results in cerebral palsy.
• Seek early and continuous prenatal care. See your health care professional regularly during pregnancy. Proper prenatal care can reduce health risks to you and your unborn baby. Seeing your health care professional regularly can help prevent premature birth, low birth weight and infections.
• Avoid alcohol, tobacco and illegal drugs. These have been linked to cerebral palsy risk.

Rarely, cerebral palsy can be caused by brain damage that occurs in childhood. Practice good general safety. Prevent head injuries by providing your child with a car seat, bicycle helmet, safety rails on the bed and appropriate supervision.

Cerebral palsy care at Mayo Clinic

• Paul S, et al. A review on recent advances of cerebral palsy. Oxidative Medicine and Cellular Longevity. 2022; doi:10.1155/2022/2622310.
• Ami TR. Allscripts EPSi. Mayo Clinic. June 1, 2023.
• Faccioli S, et al. Evidence-based management and motor rehabilitation of cerebral palsy children and adolescents: A systematic review. Frontiers in Neurology. 2023; doi:10.3389/fneur.2023.1171224.
• Morgan C, et al. Early intervention for children aged 0 to 2 years with or at high risk of cerebral palsy: International clinical practice guidelines based on systematic reviews. JAMA Pediatrics. 2021; doi:10.1001/jamapediatrics.2021.0878.
• Ferri FF. Cerebral palsy. In: Ferri's Clinical Advisor 2023. Elsevier; 2023. https://www.clinicalkey.com. Accessed June 12, 2023.
• Jankovic J, et al., eds. Cerebral palsy. In: Bradley and Daroff's Neurology in Clinical Practice. 8th ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed May 24, 2021.
• Cerebral palsy (CP). Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/cp/index.html. Accessed May 24, 2021.
• Cerebral palsy: Hope through research. National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Hope-Through-Research/Cerebral-Palsy-Hope-Through-Research. Accessed May 24, 2021.
• Cerebral palsy (CP). Merck Manual Professional Version. https://www.merckmanuals.com/professional/pediatrics/neurologic-disorders-in-children/cerebral-palsy-cp?query=cerebral%20palsy#. Accessed June 12, 2023.
• AskMayoExpert. Cerebral palsy. Mayo Clinic; 2020.
• Sorenson EJ (expert opinion). Mayo Clinic. June 16, 2021.
• OnabotulinumtoxinA injection. Facts & Comparisons eAnswers. https://fco.factsandcomparisons.com. Accessed June 20, 2023.
• Barkoudah E, et al. Cerebral palsy: Epidemiology, etiology, and prevention. https://www.uptodate.com/contents/search. Accessed June 1, 2021.
• FAQs: Tobacco, alcohol, drugs, and pregnancy. American College of Obstetricians and Gynecologists. https://www.acog.org/womens-health/faqs/tobacco-alcohol-drugs-and-pregnancy. Accessed June 1, 2021.
• Schwabe AL. Comprehensive care in cerebral palsy. Physical Medicine and Rehabilitation Clinics of North America. 2020; doi:10.1016/j.pmr.2019.09.012.

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Cerebral Palsy

What is cerebral palsy.

Cerebral palsy (CP) refers to a group of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination. CP is caused by damage to or abnormalities inside the developing brain that disrupt the brain's ability to control movement and maintain posture and balance. The term cerebral refers to the brain; palsy refers to the loss or impairment of motor function.

In some cases, the areas of the brain involved in muscle movement do not develop as expected during fetal growth. In others, the damage is a result of injury to the brain either before, during, or after birth. In either case, the damage is not reversible and the disabilities that result are permanent.

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

There is no cure for cerebral palsy, but supportive treatments, medications, and surgery can help many individuals improve their motor skills and ability to communicate with the world.

All people with CP have problems with movement and posture. The symptoms of CP differ in type and severity from one person to the next and may even change over time. Symptoms may vary greatly among individuals, depending on which parts of the brain have been injured. 

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

• Lack of muscle coordination when performing voluntary movements (ataxia)
• Stiff or tight muscles and exaggerated reflexes (spasticity)
• Weakness in one or more arm or leg
• Walking on the toes, a crouched gait, or a “scissored” gait
• Variations in muscle tone, either too stiff or too floppy
• Shaking (tremor) or random involuntary movements
• Delays in reaching motor skill milestones
• Difficulty with precise movements such as writing or buttoning a shirt

Related conditions

• Intellectual disability—Approximately 30–50 percent of individuals with CP have an intellectual disability. 
• Seizure disorder—As many as half of all children with CP have one or more seizures. Children with both cerebral palsy and epilepsy are more likely to have intellectual disability.
• Delayed growth and development—Children with moderate to severe CP often lag behind in growth and development. The muscles and limbs affected by CP tend to be smaller.
• Spinal deformities and osteoarthritis—Scoliosis, kyphosis, and lordosis are associated with CP. Pressure on and misalignment of the joints may result in pain and a breakdown of cartilage in the joints and bone enlargement (osteoporosis). 
• Impaired vision—Many children with CP have strabismus, commonly called “cross eyes,” which left untreated can lead to poor vision and can interfere with the ability to judge distance. Some children with CP have difficulty understanding and organizing visual information. Other children may have poor vision or blindness in one or both eyes. 
• Hearing loss—Impaired hearing is more frequent among those with CP than in the general population. Some children have partial or complete hearing loss, particularly as the result of jaundice or lack of oxygen to the developing brain.
• Speech and language disorders—Speech and language disorders, such as difficulty forming words and speaking clearly, are present in more than 75 percent of people with CP. 
• Excessive drooling—Some individuals with CP drool because they do not have control of the muscles in the throat, mouth, and tongue. 
• Incontinence—A possible complication of CP is incontinence, caused by poor control of the bladder muscles. 
• Difficulty with sensations and perceptions—Some individuals with CP experience pain or have difficulty feeling simple sensations, such as touch.  
• Learning difficulties—Children with CP may have difficulty processing particular types of spatial and auditory information. 
• Infections and long-term illnesses—Many adults with CP have a higher risk of heart and lung disease, and pneumonia. 
• Contractures—Muscles can become painfully fixed into positions, called contractures, which can increase muscle spasticity and joint deformities in people with CP. 
• Malnutrition—Swallowing, sucking, or feeding problems can make it difficult for many individuals with CP, particularly infants, to get proper nutrition and gain or maintain weight. 
• Dental problems—Many children with CP are at risk of developing gum disease and cavities because of poor dental hygiene.  
• Inactivity—Many children with CP are unable to participate in sports and other activities at a level of intensity sufficient to develop and maintain strength and fitness. Inactive adults with CP often exhibit increased severity of disease and reduced overall health and well-being.
• Bone health—Bone mineral density is significantly lower in individuals with CP and puts individual at risk of bone fractures.
• Psychological issues—People with CP are at greater risk of developing anxiety, depression, and social and emotional issues.

What are the early signs?

Infants with CP frequently have developmental delays, in which they are slow in learning 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. 

Younger than 6 months of age:

• The head lags when you pick them up while they're lying on their back
• They feel stiff
• They feel floppy
• Their legs get stiff and cross or scissor when you pick them up

Older than 6 months of age:

• They don't roll over in either direction
• They cannot bring their hands together
• They have difficulty bringing their hands to their mouth
• They reach out with only one hand while keeping the other fisted

Older than 10 months of age

• They crawl in a lopsided manner, pushing off with one hand and leg while dragging the opposite hand and leg
• They cannot stand even while holding on to support

Who is more likely to get cerebral palsy?

Cerebral palsy is caused by abnormal development of part of the brain or by damage to parts of the brain that control movement. This damage can occur before, during, or shortly after birth. 

The majority of people have congenital cerebral palsy (they were born with it), although it may not be detected until months or years later. Possible causes of congenital CP include genetic abnormalities, congenital brain malformations, maternal infections or fevers, or fetal injury.

A small number of individuals 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.

The following types of brain damage may cause its characteristic symptoms:

• Damage to the white matter of the brain (periventricular leukomalacia, or PVL)—White matter is responsible for transmitting signals inside the brain and to the rest of the body. Damage from PVL creates tiny holes in the white matter of an infant's brain. Researchers have found that the developing fetal brain is vulnerable between 26 and 34 weeks of fetal development in the womb.
• Abnormal development of the brain (cerebral dysgenesis)—Any interruption of brain growth during fetal development can cause brain malformations. Mutations in the genes that control brain development during this early period can keep the brain from developing. Infections, fevers, trauma, or other conditions that cause unhealthy conditions in the womb also put an unborn baby's nervous system at risk.
• Bleeding in the brain (intracranial hemorrhage)—Bleeding inside the brain from blocked or broken blood vessels is commonly caused by fetal stroke. Babies can suffer a stroke while still in the womb because of blood clots in the placenta that block blood flow in the brain. Other types of fetal stroke are caused by malformed or weak blood vessels in the brain or by blood-clotting abnormalities. Maternal high blood pressure (hypertension) during pregnancy and infection has also been shown to increase the risk of fetal stroke.
• Severe lack of oxygen in the brain—Inadequate supply of oxygen to the brain (asphyxia) can occur in a baby during pregnancy or delivery and has been linked to some cases of CP.

There are medical conditions or events that can happen during pregnancy and delivery that may increase a baby's risk of being born with CP. These risks include:

• Low birthweight and premature birth—Premature babies (born less than 37 weeks into pregnancy) and babies weighing less than five pounds, eight ounces at birth have a much higher risk of developing cerebral palsy. Tiny babies born at very early gestational ages are especially at risk.
• Multiple births—Twins, triplets, and other multiple births—even those born at term—are linked to an increased risk of CP. The death of a baby's twin or triplet in the mother before birth further increases the risk.
• Infections during pregnancy—Toxoplasmosis, rubella (German measles), cytomegalovirus, Zika virus, and herpes can infect the womb and placenta. Inflammation triggered by the infection may then go on to damage the developing nervous system in an unborn baby. Maternal fever during pregnancy or delivery can also set off an inflammatory response.
• Exposure to toxic substances—Female parents who have been exposed to toxic substances during pregnancy, such as methyl mercury, are at a heightened risk of having a baby with CP.
• Female parents with thyroid abnormalities, intellectual disability, excess protein in the urine, or seizures—These conditions may lead to a baby with CP.

There are also medical conditions during labor and delivery, and immediately after delivery that act as warning signs for an increased risk of CP. However, most of these children will not develop CP. Warning signs include:

• Breech presentation—Babies with cerebral palsy are more likely to be in a breech position (feet first) instead of headfirst at the start of labor.
• Complicated labor and delivery—A baby who has vascular or respiratory problems during labor and delivery may already have brain damage.
• Small for gestational age—Babies born at a small size for their gestational age are at risk for CP.
• Jaundice—More than 50 percent of newborns develop a yellowing of the skin or whites of the eyes (jaundice) after birth when a substance normally found in bile builds up faster than the liver can break it down and pass it from the body. 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.

Can cerebral palsy be prevented?

Cerebral palsy related to genetic abnormalities cannot be prevented, but some risk factors for congenital cerebral palsy can be managed or avoided. For example, rubella (German measles) is preventable if female parents are vaccinated against the disease before becoming pregnant. Acquired cerebral palsy, often due to head injury, is preventable using common safety tactics, such as using car seats for infants and toddlers.

What are the different types of cerebral palsy?

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

There are four main types of CP:

• Spastic   cerebral palsy  is the most common. People have stiff muscles and awkward movements. Forms of spastic cerebral palsy include:   -Spastic hemiplegia/hemiparesis typically affects the arm and hand on one side of the body, but it can also include the leg. Children with spastic hemiplegia generally walk later and on tip-toe because of tight heel tendons. The arm and leg of the affected side are frequently shorter and thinner. Some children will develop scoliosis, an abnormal curvature of the spine.  Speech is delayed and, at best, may be competent, but intelligence is usually normal. -Spastic diplegia/diparesis involves muscle stiffness that is mainly in the legs and less severely affects the arms and face, although the hands may be clumsy. Tendon reflexes in the legs are hyperactive. Tightness in certain leg muscles makes the legs move like the arms of a scissor. Children may require a walker or leg braces. Intelligence and language skills are usually normal. -Spastic quadriplegia/quadriparesis is the most severe form of cerebral palsy and is often associated with moderate-to-severe intellectual disability. It is caused by widespread damage to the brain or significant brain malformations. Children will often have severe stiffness in their limbs but a floppy neck. They are rarely able to walk. Speaking is difficult. Seizures can be frequent and hard to control.
• Dyskinetic   cerebral palsy (also includes athetoid, choreoathetoid, and dystonic cerebral palsies) is characterized by slow and uncontrollable writhing or jerky movements of the hands, feet, arms, or legs. Hyperactivity in the muscles of the face and tongue makes some children grimace or drool. They find it difficult to sit straight or walk. Some children have problems hearing, controlling their breathing, and/or coordinating the muscle movements required for 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 a wide-based gait. They have difficulty with quick or precise movements, such as writing or buttoning a shirt, or a hard time controlling voluntary movement such as reaching for a book.
• Mixed types  of cerebral palsy refer to symptoms that don't correspond to 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.

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 a child's symptoms are mild, it can be difficult for a doctor to make a reliable diagnosis before the age of 4 or 5.

Doctors 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, age-appropriate motor control, hearing and vision, posture, and coordination, in order to rule out other disorders that could cause similar symptoms. 

Although symptoms may change over time, CP is not progressive. If a child is continuously losing motor skills, the problem more likely is a condition other than CP—such as a genetic or muscle disease, metabolism disorder, or tumors in the nervous system.

Lab tests can identify other conditions that may cause symptoms similar to those associated with CP.

Neuroimaging techniques can detect abnormalities that indicate a potentially treatable movement disorder. 

• Cranial ultrasound uses high-frequency sound waves to produce pictures of the brain. It is used for high-risk premature infants because it is the least intrusive of the imaging techniques.
• Magnetic resonance imaging (MRI) uses a computer, a magnetic field, and radio waves to create an anatomical picture of the brain's tissues and structures. MRI can show the location and type of damage, such as subtle changes in the white matter—the type of brain tissue that is damaged in CP.  MRI can also show characteristic brain abnormalities or malformations in metabolic disorders that can masquerade as CP.

Another test, an electroencephalogram, uses a series of electrodes that are either taped or temporarily pasted to the scalp to detect electrical activity in the brain. Changes in the normal electrical pattern may help to detect seizures.

Treating CP

Cerebral palsy can't be cured, but treatment will often improve a child's capabilities. Many children are able to manage their disabilities; the earlier treatment begins, the better chance children have of overcoming developmental disabilities.

There is no standard therapy that works for every person with CP. Referrals to specialists such as a child neurologist, developmental pediatrician, ophthalmologist, or otologist aid in a more accurate diagnosis and help doctors develop a specific treatment plan. Once the diagnosis is made, a team of health care professionals will work with the child and parents to identify specific impairments and needs, and then develop an appropriate plan to tackle the core disabilities that affect the child's quality of life.

• Physical therapy, usually in the first few years of life, is a cornerstone of CP treatment. Specific sets of exercises like stretching, resistive, or strength training programs and activities can maintain or improve muscle strength, balance, and motor skills, and prevent contractures. Special braces (orthotic devices) may be used to improve mobility and stretch spastic muscles.
• Occupational therapy focuses on optimizing upper body function, improving posture, and making the most of a child's mobility. Occupational therapists help individuals address new ways to meet everyday activities and routines at home, school, and in the community.
• Recreation therapy encourages participation in art and cultural programs, sports, and other events that help an individual expand physical and cognitive skills and abilities. Parents of children who participate in recreational therapies usually notice an improvement in their child's speech, self-esteem, and emotional well-being.
• Speech and language therapy can improve a child's ability to speak, help with swallowing disorders, and learn new ways to communicate, such as using sign language and/or special communication devices such as a computer with a voice synthesizer.
• Treatments for problems with eating and drooling are often necessary when children with CP have difficulty eating and drinking because they have little control over the muscles that move their mouth, jaw, and tongue.

Drug Treatments

• Oral medications such as diazepam, baclofen, dantrolene sodium, and tizanidine are usually used as the first line of treatment to relax stiff, contracted, or overactive muscles. Some drugs have side effects such as drowsiness, changes in blood pressure, and risk of liver damage that require continuous monitoring. Oral medications are most appropriate for children who need only mild reduction in muscle tone or who have widespread spasticity.
• Botulinum toxin (BT-A), injected locally into muscles, has become a standard treatment for overactive muscles in children with spastic CP. BT-A relaxes contracted muscles by keeping nerve cells from over-activating muscle. The relaxing effects last approximately three months. Side effects include pain upon injection and occasionally mild flu-like symptoms. BT-A injections are most effective when followed by physical therapy and splinting. BT-A injections work best for children who have some control over their motor movements and have a limited number of muscles to treat, none of which is fixed or rigid.
• Intrathecal baclofen therapy uses an implantable pump to deliver baclofen, a muscle relaxant, into the fluid surrounding the spinal cord. Baclofen decreases the excitability of nerve cells in the spinal cord, which then reduces muscle spasticity throughout the body. 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 individuals with chronic, severe stiffness or uncontrolled muscle movement throughout the body.
• Orthopedic surgery is often recommended when spasticity and stiffness are severe enough to make walking and moving about difficult or painful. Surgeons can lengthen muscles and tendons that are proportionately too short, which can improve mobility and lessen pain. Tendon surgery may help the symptoms for some children with CP but could also have negative long-term consequences. Orthopedic surgeries may be staggered at times appropriate to a child's age and level of motor development. Surgery can also correct or greatly improve spinal deformities.
• Surgery to cut nerves, or selective dorsal rhizotomy (SDR), is a surgical procedure recommended for cases of severe spasticity when all of the more conservative treatments haven't helped. A surgeon locates and selectively severs overactivated nerves at the base of the spinal column. SDR is most commonly used to relax muscles and decrease chronic pain in limbs. Potential side effects include sensory loss, numbness, or uncomfortable sensations.

Assistive devices

Assistive devices such devices such as computers, computer software, voice synthesizers, and picture books can greatly help some individuals with CP improve communications skills. Other devices make it easier for people with CP to adapt to activities of daily living.

• Orthotic devices help to compensate for muscle imbalance and increase independent mobility. 
• Braces and splints use external force to correct muscle abnormalities and improve function such as sitting or walking. Other orthotics help stretch muscles or the positioning of a joint. 
• Braces, wedges, special chairs, and other devices can help people sit more comfortably.
• Wheelchairs, rolling walkers, and powered scooters can help individuals who are not independently mobile. 
• Vision aids include glasses, magnifiers, and large-print books and computer typeface. Some individuals with CP may need surgery to correct vision problems. 
• Hearing aids and telephone amplifiers may help people hear more clearly.

Complementary and Alternative Therapies

Many children and adolescents with CP use some form of complementary or alternative medicine. 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. Such therapies include hyperbaric oxygen treatment, special clothing worn during resistance training, certain forms of electrical stimulation of muscles, and dietary supplements, such as herbal products. Most controlled clinical trials involving these therapies have been inconclusive or showed no benefit. Families of children with CP should discuss all therapies with their doctor.

Treatments for other conditions associated with cerebral palsy?

• Epilepsy—Many children with intellectual disability and CP also have epilepsy. Drugs are prescribed based on the type of seizures an individual experiences. Some people may need a combination of two or more drugs to achieve good seizure control.
• Incontinence—Medical treatments for incontinence include special exercises, biofeedback, prescription drugs, surgery, or surgically implanted devices to replace or aid muscles.
• Osteopenia—Children with CP who are unable to walk risk developing poor bone density (osteopenia), which makes them more likely to break bones. Vitamin D can help promote bone health. 
• Pain—Pain can be a problem for people with CP due to spastic muscles and the stress and strain on parts of the body that are compensating for muscle abnormalities. Some individuals may also have frequent and irregular painful muscle spasms. Drug treatments such as diazepam, gabapentin, botulinum toxin injections, and intrathecal baclofen have been shown to ease pain. Some people with CP use noninvasive and drug-free interventions such as distraction, relaxation training, biofeedback, and therapeutic massage to treat pain.

Special health challenges for adults with CP

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

• Premature aging—Most individuals 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 upon their bodies. Developmental delays due to CP keep some organ systems from developing to their full capacity and level of performance. As a consequence, organs such as the heart and lungs have to work harder and they age prematurely.
• Functional issues at work—The day-to-day challenges of the workplace are likely to increase as an employed individual with CP reaches middle age. However, some individuals 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. It appears to be related not so much to the severity of their disabilities, but to how well they cope with them. 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, overuse syndromes (also known as repetitive motion injuries), and arthritis. Fatigue is often a challenge because individuals with CP may use up to three to five times the amount of energy that able-bodied people use when they walk and move.
• Osteoarthritis and degenerative arthritis—Musculoskeletal abnormalities that may not produce discomfort during childhood can cause pain in adulthood. The challenged relationships between joint surfaces and excessive joint compression can lead to the early development of painful osteoarthritis and degenerative arthritis. Individuals with CP are also at risk for overuse syndromes and nerve entrapments.
• Pain—Individuals with CP may have pain that can be acute (usually comes on quickly and lasts a short while) or chronic, and is experienced most commonly in the hips, knees, ankles, and the upper and lower 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 causes pain.
• Sexual health—Although CP doesn't directly affect sex organs, skeletal and muscle issues can make sexual relations difficult and cause emotional concerns. It is 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 medical conditions, such as hypertension, incontinence, bladder dysfunction, and swallowing difficulties. Scoliosis is likely to progress after puberty. There is also a higher incidence of bone fractures, occurring most frequently during physical therapy sessions.

What are the latest updates on cerebral palsy?

The National Institute of Neurological Disorders and Stroke, ( NINDS ), a part of the National Institutes of Health ( NIH ), is the nation's leading funder of research on brain and nervous system disorders. 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 NINDS, 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, and a greater understanding of how and why brain damage during fetal development causes CP.  

• Genetic studies—Genetic abnormalities can be responsible for the brain abnormalities that cause CP. 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.
• Scientists are also scrutinizing events in newborn babies' brains, such as bleeding, epileptic 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—the most common cause of CP—is 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 on white matter development. Another NINDS-funded project involves the development of a novel mouse model and cell-based therapies for perinatal white matter injury. Inflammation in the brain can also cause white matter injury. Researchers are examining how inflammation leads to brain damage in infants.
• Stem cell therapy is being investigated as a treatment for CP. Stem cells are capable of becoming other cell types in the body. Scientists are hopeful that stem cells may be able to repair damaged nerves and brain tissues. Clinical studies in the U.S. are examining the safety and tolerability of umbilical cord blood stem cell infusion in children with CP.
• Neuroimaging and biomarkers—Researchers funded by NINDS and NICHD are using advanced neuroimaging and identifying other biomarkers from bloodwork to predict whether preterm 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 term or late preterm babies less than one month old with hypoxic-ischemia (HIE), a brain injury due to a severe decrease in the oxygen supply to the body, 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.

Additionally, NIH-funded scientists continue to look at new rehabilitative therapies to treat individuals with CP.

• Constraint-induced therapy (CIT) typically involves restraining the stronger limb in a cast and forcing the weaker arm to perform intensive activities every day 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 versus part-time splint restraint in improving upper body extremity skills in children with CP. Study findings will establish evidence-based practice standards to improve lifelong neuromotor capacity in individuals with CP.
• Functional electrical stimulation (FES)—The therapeutic use of low-level electrical current to stimulate and restore muscle movement is an effective way to target and strengthen spastic muscles. Researchers are evaluating how FES-assisted stationary cycling can improve lower extremity 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 will lead to an innovative clinical therapy aimed at improving locomotor function.
• Botulinum toxin (Botox), injected locally, has become a standard treatment in children with CP. Recent animal studies suggest Botox degrades bone but its skeletal consequences in humans is unknown. Other research shows a low intensity vibration treatment can improve bone structure in the lower extremity 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 its data-rich 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 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 carpal tunnel syndrome. Clinical research uses human volunteers to help researchers learn more about a disorder and perhaps find better ways to safely detect, treat, or prevent disease.

All types of volunteers 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 NIH Clinical Research Trials and You . Learn about clinical trials currently looking for people with cerebral palsy at Clinicaltrials.gov .

Where can I find more information about cerebral palsy? The following resources may help individuals, families, friends, and caregivers of people living with cerebral palsy: Cerebral Palsy Foundation Phone:  212-520-1686 Cerebral Palsy Research Network Children's Hemiplegia and Stroke Association Child Neurology Foundation Phone:  612-928-6325 Easter Seals Phone: 800-221-6827 ​​​​​ March of Dimes Phone:  888-663-4637 Eunice Kennedy Shriver   N ational Institute of Child Health and Human Development  (NICHD) Pathways.org Phone:  800-955-2445 United Cerebral Palsy (UCP) Phone:  202-776-0406 or 800-872-5827

What is Cerebral Palsy?

Types of cerebral palsy, early signs, screening and diagnosis, treatments and intervention services, causes and risk factors, if you’re concerned.

Cerebral palsy (CP) is a group of disorders that affect a person’s ability to move and maintain balance and posture. CP is the most common motor disability in childhood. Cerebral means having to do with the brain. Palsy means weakness or problems with using the muscles. CP is caused by abnormal brain development or damage to the developing brain that affects a person’s ability to control his or her muscles.

The symptoms of CP vary from person to person. A person with severe CP might need to use special equipment to be able to walk, or might not be able to walk at all and might need lifelong care. A person with mild CP, on the other hand, might walk a little awkwardly, but might not need any special help. CP does not get worse over time, though the exact symptoms can change over a person’s lifetime.

All people with CP have problems with movement and posture. Many also have related conditions such as intellectual disability ; seizures; problems with vision, hearing , or speech; changes in the spine (such as scoliosis ); or joint problems (such as contractures ).

Doctors classify CP according to the main type of movement disorder involved. Depending on which areas of the brain are affected, one or more of the following movement disorders can occur:

• Stiff muscles (spasticity)
• Uncontrollable movements (dyskinesia)
• Poor balance and coordination (ataxia)

There are four main types of CP:

Spastic Cerebral Palsy

The most common type of CP is spastic CP. Spastic CP affects about 80% of people with CP.

People with spastic CP have increased muscle tone. This means their muscles are stiff and, as a result, their movements can be awkward. Spastic CP usually is described by what parts of the body are affected:

• Spastic diplegia/diparesis―In this type of CP, muscle stiffness is mainly in the legs, with the arms less affected or not affected at all. People with spastic diplegia might have difficulty walking because tight hip and leg muscles cause their legs to pull together, turn inward, and cross at the knees (also known as scissoring ).
• Spastic hemiplegia/hemiparesis―This type of CP affects only one side of a person’s body; usually the arm is more affected than the leg.
• Spastic quadriplegia/quadriparesis―Spastic quadriplegia is the most severe form of spastic CP and affects all four limbs, the trunk, and the face. People with spastic quadriparesis usually cannot walk and often have other developmental disabilities such as intellectual disability; seizures; or problems with vision, hearing, or speech.

Dyskinetic Cerebral Palsy (also includes athetoid, choreoathetoid, and dystonic cerebral palsies)

People with dyskinetic CP have problems controlling the movement of their hands, arms, feet, and legs, making it difficult to sit and walk. The movements are uncontrollable and can be slow and writhing or rapid and jerky. Sometimes the face and tongue are affected and the person has a hard time sucking, swallowing, and talking. A person with dyskinetic CP has muscle tone that can change (varying from too tight to too loose) not only from day to day, but even during a single day.

Ataxic Cerebral Palsy

People with ataxic CP have problems with balance and coordination. They might be unsteady when they walk. They might have a hard time with quick movements or movements that need a lot of control, like writing. They might have a hard time controlling their hands or arms when they reach for something.

Mixed Cerebral Palsy

Some people have symptoms of more than one type of CP. The most common type of mixed CP is spastic-dyskinetic CP.

The signs of CP vary greatly because there are many different types and levels of disability. The main sign that a child might have CP is a delay reaching motor or movement milestones (such as rolling over, sitting, standing, or walking). Following are some other signs of possible CP. It is important to note that some children without CP also might have some of these signs.

In a Baby Younger Than 6 Months of Age

• His head lags when you pick him up while he’s lying on his back
• He feels stiff
• He feels floppy
• When held cradled in your arms, he seems to overextend his back and neck, constantly acting as if he is pushing away from you
• When you pick him up, his legs get stiff and they cross or scissor

In a Baby Older Than 6 Months of Age

• She doesn’t roll over in either direction
• She cannot bring her hands together
• She has difficulty bringing her hands to her mouth
• She reaches out with only one hand while keeping the other fisted

In a Baby Older Than 10 Months of Age

• He crawls in a lopsided manner, pushing off with one hand and leg while dragging the opposite hand and leg
• He scoots around on his buttocks or hops on his knees, but does not crawl on all fours

Tell your child’s doctor or nurse if you notice any of these signs. Learn more about developmental milestones that children should reach from birth to 5 years of age

Diagnosing CP at an early age is important to the well-being of children and their families. Diagnosing CP can take several steps:

Developmental Monitoring

Developmental monitoring (also called surveillance) means tracking a child’s growth and development over time. If any concerns about the child’s development are raised during monitoring, then a developmental screening test should be given as soon as possible.

Developmental Screening

During developmental screening a short test is given to see if the child has specific developmental delays, such as motor or movement delays. If the results of the screening test are cause for concern, then the doctor will make referrals for developmental and medical evaluations.

Developmental and Medical Evaluations

The goal of a developmental evaluation is to diagnose the specific type of disorder that affects a child.

Learn more about screening and diagnosis

There is no cure for CP, but treatment can improve the lives of those who have the condition. It is important to begin a treatment program as early as possible.

After a CP diagnosis is made, a team of health professionals works with the child and family to develop a plan to help the child reach his or her full potential. Common treatments include medicines; surgery; braces; and physical, occupational, and speech therapy. No single treatment is the best one for all children with CP. Before deciding on a treatment plan, it is important to talk with the child’s doctor to understand all the risks and benefits.

Visit the NINDS Cerebral Palsy Information Page to learn more about treatments for CP

Intervention Services

Both early intervention and school-aged services are available through our nation’s special education law—the Individuals with Disabilities Education Act (IDEA). Part C of IDEA deals with early intervention services (birth to 36 months of age), while Part B applies to services for school-aged children (3 to 22 years of age). Even if your child has not been diagnosed with CP, he or she may be eligible for IDEA services.

Learn more about IDEA Services

CP is caused by abnormal development of the brain or damage to the developing brain that affects a child’s ability to control his or her muscles. There are several possible causes of the abnormal development or damage. People used to think that CP was mainly caused by lack of oxygen during the birth process. Now, scientists think that this causes only a small number of CP cases.

The abnormal development of the brain or damage that leads to CP can happen before birth, during birth, within a month after birth, or during the first years of a child’s life, while the brain is still developing. CP related to abnormal development of the brain or damage that occurred before or during birth is called  congenital  CP. The majority of CP (85%–90%) is congenital. In many cases, the specific cause is not known. A small percentage of CP is caused by abnormal development of the brain or damage that occurs more than 28 days after birth. This is called  acquired  CP, and usually is associated with an infection (such as meningitis) or head injury.

Learn more about causes and risk factors for CP

If you think your child is not meeting movement milestones or might have CP, contact your doctor or nurse and share your concerns .

If you or your doctor is still concerned, ask for a referral to a specialist who can do a more in-depth evaluation of your child and assist in making a diagnosis.

At the same time, call your state’s public early childhood system to request a free evaluation to find out if your child qualifies for intervention services. This is sometimes called a Child Find evaluation. You do not need to wait for a doctor’s referral or a medical diagnosis to make this call.

Where to call for a free evaluation from the state depends on your child’s age:

• If your child is not yet 3 years old, contact your local early intervention system. You can find the right contact information for your state by calling the Early Childhood Technical Assistance Center (ECTA) at 919-962-2001 or visit the Early Childhood Technical Assistance Center .
• If your child is 3 years of age or older, contact your local public school system. Even if your child is not yet old enough for kindergarten or enrolled in a public school, call your local elementary school or board of education and ask to speak with someone who can help you have your child evaluated. If you’re not sure who to contact, you can call the Early Childhood Technical Assistance Center (ECTA) at 919-962-2001 or visit the Early Childhood Technical Assistance Center .

Learn more about early intervention

American Academy of Pediatrics Healthy Children / Cerebral Palsy http://www.healthychildren.org/English/health-issues/conditions/developmental-disabilities/pages/Cerebral-Palsy.aspx

American Association on Intellectual and Developmental Disabilities https://aaidd.org/home

Honeycutt A, Dunlap L, Chen H, Homsi G. Economic costs associated with mental retardation, cerebral palsy, hearing loss, and vision impairment: United States, 2003. MMWR Morb mital Wkly Rep. 2004;53(3): 57-59. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5303a4.htm

Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. Council on Children With Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Pediatrics, July 2006. http://pediatrics.aappublications.org/content/118/1/405.full.pdf [PDF – 930 KB]

March of Dimes. Cerebral Palsy. http://www.marchofdimes.org/baby/cerebral-palsy.aspx

My Child Without Limits http://www.mychildwithoutlimits.org/?page=home

National Institute of Neurological Disorders and Stroke. Cerebral Palsy: Hope Through Research. NIH Publication Number 10-159, updated 5/6/10. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Hope-Through-Research/Cerebral-Palsy-Hope-Through-Research

Pellegrino, Louis. Cerebral Palsy, in Batshaw ML, Pellegrino L, Roizen NJ (eds.), Children with Disabilities, 6th Edition, Baltimore, MD, Paul H Brookes Publishing Company, 2007, pp 387-408.

UCP http://www.ucp.org

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Cerebral Palsy (CP)

• Symptoms and Signs |
• Diagnosis |
• Treatment |
• Prognosis |
• Key Points |
• More Information |

Cerebral palsy (CP) is a group of conditions that causes nonprogressive spasticity, ataxia, or involuntary movements; it is not a specific disorder or single condition.

CP occurs in 2 to 3/1000 live births. The highest prevalence, 111.8/1000 live births, occurs in preterm infants 1 ).

1. Wimalasundera N, Stevenson VL : Cerebral palsy.  Pract Neurol 16(3):184–194, 2016. doi: 10.1136/practneurol-2015-001184

Etiology of Cerebral Palsy

Etiology of cerebral palsy is multifactorial, and a specific cause is sometimes hard to establish. Prematurity , in utero disorders, neonatal encephalopathy, and kernicterus often contribute. Perinatal factors (eg, perinatal asphyxia, stroke , central nervous system [CNS] infections ) probably cause 15 to 20% of cases.

Examples of types of CP are

Spastic diplegia after preterm birth

Spastic quadriparesis after perinatal asphyxia

Athetoid and dystonic forms after perinatal asphyxia or kernicterus

CNS trauma or a severe systemic disorder (eg, stroke, meningitis, sepsis, dehydration) during early childhood (before 2 years of age) may also cause CP.

Symptoms and Signs of Cerebral Palsy

Before a specific type develops, symptoms include lagging motor development and often persistent infantile reflex patterns, hyperreflexia, and altered muscle tone.

Types of cerebral palsy

CP is categorized mainly as one of the following, depending on which parts of the CNS are malformed or damaged ( 1 , 2 ):

Spastic CP is the most common type and occurs in > 80% of cases ( 2 ). Spasticity is a state of resistance to passive range of motion; resistance increases with increasing speed of that motion. It is due to upper motor neuron involvement and may mildly or severely affect motor function. Spastic CP may cause hemiplegia, quadriplegia, diplegia, or paraplegia. Usually, deep tendon reflexes in affected limbs are increased, muscles are hypertonic, and voluntary movements are weak and poorly coordinated. Joint contractures develop, and joints may become misaligned. A scissors gait and toe walking are typical. In mild cases, impairment may occur only during certain activities (eg, running). Corticobulbar impairment of oral, lingual, and palatal movement, with consequent dysarthria or dysphagia, commonly occurs with quadriplegia.

Athetoid CP or dyskinetic CP is the second most common type. It occurs in about 15% of cases and results from basal ganglia involvement. Athetoid or dyskinetic CP is defined by slow, writhing, involuntary movements of the proximal extremities and trunk (athetoid movements), often activated by attempts at voluntary movement or by excitement. Abrupt, jerky, distal (choreic) movements may also occur. Movements increase with emotional tension and disappear during sleep. Dysarthria occurs and is often severe.

Ataxic CP is rare and results from involvement of the cerebellum or its pathways. Weakness, incoordination, and intention tremor cause unsteadiness, a wide-based gait, and difficulty with rapid or fine movements.

Mixed CP is common—most often with spasticity and athetosis.

A tool called the  Gross Motor Function Classification System–Expanded and Revised (GMFCS–E&R) can be used to describe the gross motor function of children with CP. The system categorizes gross motor function into 5 different groups. It provides a description of current motor function that helps identify current and future needs for mobility aids.

Findings associated with cerebral palsy

About 25% of patients, most often those with spasticity, have other manifestations. Strabismus and other visual defects may occur. Children with athetosis due to kernicterus commonly have nerve deafness and upward gaze paralysis.

Many children with spastic hemiplegia or diplegia have normal intelligence; children with spastic quadriplegia or mixed CP may have severe intellectual disability .

Symptoms and signs references

2. Monbaliu E, Himmelmann K, Lin JP, et al : Clinical presentation and management of dyskinetic cerebral palsy.  Lancet Neurol 16(9):741–749, 2017. doi: 10.1016/S1474-4422(17)30252-1

Diagnosis of Cerebral Palsy

Sometimes testing to exclude hereditary metabolic or neurologic disorders

If CP is suspected, identifying the underlying disorder is important. History may suggest a cause. A brain MRI can detect abnormalities in most cases.

CP can rarely be confirmed during early infancy, and the specific type often cannot be characterized until 2 years of age. High-risk children (eg, those with evidence of asphyxia, stroke, periventricular abnormalities seen on cranial ultrasonography in preterm infants, jaundice, meningitis, neonatal seizures, hypertonia, hypotonia, or reflex suppression) should be followed closely.

Differential diagnosis

CP should be differentiated from progressive hereditary neurologic disorders and disorders requiring surgical or other specific neurologic treatments.

Ataxic CP is particularly hard to distinguish, and in many children with persistent ataxia, a progressive cerebellar degenerative disorder is ultimately identified as the cause.

Athetosis, self-mutilation, and hyperuricemia in boys indicate Lesch-Nyhan syndrome .

Cutaneous or ocular abnormalities may indicate tuberous sclerosis complex , neurofibromatosis , ataxia-telangiectasia , von Hippel–Lindau disease , or Sturge-Weber syndrome .

Infantile spinal muscular atrophy, muscular dystrophies, and neuromuscular junction disorders associated with hypotonia and hyporeflexia usually lack signs of cerebral disease.

Adrenoleukodystrophy begins later in childhood, but other leukodystrophies begin earlier and may be mistaken for CP at first.

Identification of a cause

When history and/or brain MRI does not clearly identify a cause, laboratory tests should be done to exclude certain progressive storage disorders that involve the motor system (eg, Tay-Sachs disease , metachromatic leukodystrophy , mucopolysaccharidoses ) and metabolic disorders (eg, organic or amino acid metabolism disorders ).

Other progressive disorders (eg, infantile neuroaxonal dystrophy) may be suggested by nerve conduction studies and electromyography. These and many other brain disorders that cause CP (and other manifestations) are being increasingly identified with genetic testing (eg, microarray analysis, CP spectrum disorders gene panel, whole exome sequencing analysis), which may be done to check for a specific disorder or to screen for many disorders.

Treatment of Cerebral Palsy

Physical and occupational therapy

Braces, constraint therapy, medications, or surgery to treat spasticity

Botulinum toxin injections

Intrathecal baclofen

Assistive devices

Physical therapy and occupational therapy for stretching, strengthening, and facilitating good movement patterns are usually used first and are continued. Bracing, constraint therapy, and medications may be added.

Botulinum toxin may be injected into muscles to decrease their uneven pull at joints and to prevent fixed contractures.

Orthopedic surgery (eg, muscle-tendon release or transfer) may help reduce restricted joint motion or misalignment. Selective dorsal rhizotomy, done by neurosurgeons, may help a few children if spasticity affects primarily the legs and if cognitive abilities are good.

When intellectual limitations are not severe, children may attend mainstream classes and take part in adapted exercise programs and even competition. Speech training or other forms of facilitated communication may be needed to enhance interactions.

Some severely affected children can benefit from training in activities of daily living (eg, washing, dressing, feeding), which increases their independence and self-esteem and greatly reduces the burden for family members or other caregivers. Assistive devices may increase mobility and communication, help maintain range of motion, and help with activities of daily living. Some children require varying degrees of lifelong supervision and assistance.

Many children's facilities are establishing transition programs for patients as they become adults and have fewer supports to help with special needs.

Parents of a child with chronic limitations need assistance and guidance in understanding the child’s status and potential and in dealing with their own feelings of guilt, anger, denial, and sadness (see Effects on the family ). These children reach their maximal potential only with stable, consistent parental care and the assistance of public and private agencies (eg, community health agencies, vocational rehabilitation organizations, lay health organizations such as United Cerebral Palsy ).

Prognosis for Cerebral Palsy

Most children survive to adulthood. Severe limitations in sucking and swallowing, which may require feeding by gastrostomy tube, decrease life expectancy.

The goal is for children to develop maximal independence within the limits of their motor and associated deficits. With appropriate management, many children, especially those with spastic diplegia or hemiplegia, can lead near-normal lives.

Cerebral palsy (CP) is a group of conditions (not a specific disorder) that involve nonprogressive spasticity, ataxia, and/or involuntary movements.

Etiology is often multifactorial and sometimes unclear but involves prenatal and perinatal factors that are associated with central nervous system (CNS) malformation or damage (eg, genetic and in utero disorders, prematurity, kernicterus, perinatal asphyxia, stroke, CNS infections).

Intellectual disability and other neurologic manifestations (eg, strabismus, deafness) are not part of CP but may be present depending on the cause.

Symptoms manifest before 2 years of age; later onset of similar symptoms suggests another neurologic disorder.

Do brain MRI and, if needed, testing for hereditary metabolic and neurologic disorders.

More Information

The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

CanChild: Gross Motor Function Classification System–Expanded and Revised (GMFCS–E&R) : A tool for describing the gross motor function of children with CP (available in many languages)

United Cerebral Palsy: Provides information about therapy, early intervention programs, and support services for people who have cerebral palsy and other disabilities

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Cerebral Palsy Disorder

Cerebral palsy disorder presentation, free google slides theme and powerpoint template.

Cerebral Palsy is a condition that affects the part of the brain that controls the person’s ability to move and balance. That is why people who suffer from it often need aid for moving, doing tasks or taking care of themselves. This is a very complicated condition that appears from a very young age, often in babies less than a year old. Use this medical template for health professionals and speak about this illness in a professional way

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Types and Presentations of Cerebral Palsy

In last month’s blog about cerebral palsy (CP) , I talked about the neurological condition and what can be improved by working with a physical therapist. This week, I am going to delve deeper into the condition and explain why some kids with CP are so different from one another.

Cerebral palsy has many classification systems. Medical professionals use these systems to understand and manage a child’s symptoms and help plan their treatment.

As stated previously, cerebral palsy describes a brain lesion that occurred in utero or around the time of birth.   Much like a brain injury, CP can be classified based on severity level, location of lesion, body part affected, change in motor control, and how gross motor function is affected.

Classification of CP Based on Level of Severity:

This is a common method of categorizing children with CP, used by doctors and parents alike, though it provides relatively little information. Parents and doctors use this classification system as a simplified communication tool to describe the exact level of impairment.

• Mild: Having mild CP means a child can move independently and without assistance from people or equipment. He can complete his daily activities without any limitations.
• Moderate: A child with moderate cerebral palsy will need braces, medical interventions, and adaptive equipment to do functional things, such as walking and keeping up with peers.
• Severe: A child who will require a wheelchair and who will need quite a bit of assistance to accomplish daily activities is said to have severe CP. Often times, severe cases have multiple equipment needs, and simple things such as eating or sitting alone can be a challenge.
• No CP: Some children display cerebral palsy signs though the brain injury occurred after the time of birth, and therefore is classified under traumatic brain injury or encephalopathy.

Classification Based on Topographical Distribution (Body Part Affected):

When trying to plan treatment protocol for a child newly diagnosed with CP, many therapist and pediatricians like to know which body parts are affected and how they are affected. Is one limb weakened (paresis) or paralyzed (plegia)? How many limbs are affected that way?

• Monoplegia/monoparesis – Only one limb is affected.
• Diplegia/diparesis – When the legs and the lower body are more affected than the arms
• Hemiplegia/hemiparesis – The arm and leg on one side of the body are affected.
• Paraplegia/paraparesis – Only the legs are affected.
• Triplegia/triparesis – When 3 limbs are affected, or 2 limbs and the face
• Double hemiplegia/double hemiparesis – All four limbs are affected, but one side of the body is more affected than the other.
• Tetraplegia/tetraparesis – All 4 limbs are affected, but three limbs are more affected than the fourth.
• Quadriplegia/quadriparesis – All four limbs are impacted.
• Pentaplegia/pentaparesis – All four limbs involved, as well as the neck and head.

Classification Based on Motor Control:

What is motor control? It is the body’s ability to voluntarily control limb and joint motion.  Muscles are controlled by the nervous system and abnormal contractions (too much or too little) often occur with brain lesions. Cerebral palsy is often a complex condition. It is possible to have variable muscle tone or a mixture of motor control presentations.

Spastic CP – indicates increased muscle tone, the most common type of cerebral palsy. Non-Spastic Cerebral Palsy – characterized by low muscle tone or fluctuating muscle tone, or involuntary movements.

When muscle tone is affected, the movements and power needed to move the joints are often affected as well.

Hypertonia/hypertonic – describes increased muscle tone and is often associated with spastic cerebral palsy.  The child may present with stiff limbs, muscles that seem tight, or decreased ability to open his hands or straighten a limb. Hypotonia/Hypotonic – often used to describe low muscle tone, and can be seen in diagnoses outside of CP. A child’s limbs or trunk may seem hard to control and “floppy.”

Some children’s cerebral palsy can actually be mixed in presentation, where some limbs are affected by spasticity and others are non-spastic.

Classification Based on the Gross Motor Function Classification System (GMFCS):

The last system of categorizing CP is a five-level system that describes the severity of impairment and limitations a child experiences with the condition.  Higher numbers mean a child is able to achieve less activities on his own.

GMFCS Level I – the individual walks without limitations GMFCS Level II – walks with some limitations, including long distances, running, jumping, and balancing.  They may need devices when first learning to walk, up to age 4, and may need wheeled mobility when travelling long community distances. GMFCS Level III – walks with an adaptive device.  Assistance is needed to walk indoors and wheeled mobility needed outdoors.  The individual can sit independently or with some external support. GMFCS Level IV – the child is independent with powered mobility (motorized wheelchair) though need support when sitting. He may be unable to push himself in manual wheelchair. GMFCS Level V – the individual shows significantly limited head and trunk control. Much of his mobility will need assistive technology or physical assistance.

A more expansive copy of the GMFCS system can be viewed here.

Why so many classification systems?

Most cerebral palsy specialists, health professionals, and parents will need guidance and direction when approaching a child with cerebral palsy. Knowing whether or not a child has low or high tone will determine equipment needs. Knowing the severity level will help physicians plan out need for future treatments and care options.  Understanding whether a child has spastic or non-spastic CP will help tell neurologists and neurosurgeons which part of the nervous system is affected. Having a better grasp on the type and location of lesion will help the medical team prepare for long term associated conditions of cerebral palsy, such as hip dislocation, scoliosis, joint contractures, or seizures.   It is important for therapists to know whether a child with CP has difficulties with muscle tone, muscle control, hand-eye coordination, balance, stiffness, or muscle strength.

The Gross Motor Function Classification System (GMFCS) is used by researchers and clinicians alike and is applicable to all types of cerebral palsy. While other classification systems describe what a child is limited by, the GMFCS places more emphasis on what a child can accomplish. Therefore, parents can use this system to understand how their children will progress over time.

Classification is very important in the treatment of the young child with cerebral palsy, and multiple classification systems help therapists and specialists create individualized plan of care for those children and families impacted by the condition.

Reference: Types and Forms of Cerebral Palsy. MyChildTM at The Cerebral Palsy Organization website. Available from: http://cerebralpalsy.org/about-cerebral-palsy/types/; 2014 [accessed 18 March 2014]

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Clinical Examination of Children with Cerebral Palsy

Kailash sarathy.

Department of Paediatric Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India

Chintan Doshi

Alaric aroojis.

Cerebral palsy (CP), a heterogeneous disorder of movement and posture, is one of the most important causes of disability affecting children. With a wide variability in the clinical presentation and a paucity of reliable diagnostic tests, decision-making in CP is fraught with difficulties and challenges. The plethora of musculoskeletal manifestations includes poor muscle function, spasticity, rigidity, muscle weakness, poor selective motor control, soft-tissue and joint contractures, torsional malalignments, and lever arm dysfunctions. Children with CP are at a high risk of further worsening and progression of these musculoskeletal abnormalities with the natural course of the disease. A comprehensive assessment that includes a combination of detailed medical history, functional assessment, clinical examination, analysis of gait, and radiological assessment is required to provide a favorable treatment outcome in these children. A close surveillance is essential so as to identify risk factors for the development and progression of musculoskeletal problems so that early interventions can be carried out to circumvent them. This review article is to highlight the importance of clinical examination in the assessment of children with CP.

Introduction

Cerebral palsy (CP) is defined as a qualitative motor disorder of movement and posture appearing before the age of 3 years, due to non-progressive damage of the brain, occurring before growth of the nervous system is complete. 1 The effect of the nonprogressive damage may however contribute to a misunderstanding of the secondary musculoskeletal pathology, which is not static but is most definitely progressive. 2 The presentation of patients with CP is highly variable, ranging from those with mild neurological deficit to those with severe involvement. The diagnostic matrix to be followed in case of CP includes a detailed history, gait analysis, physical examination of lower limbs, examination of upper extremities and spine, and additional tests for appropriate clinical evaluation. The above diagnostic matrix is an important pillar for decision-making in CP [ Figure 1 ].

Diagnostic flowchart in cerebral palsy

Search criteria

The authors identified the relevant articles using a protocol based on searching Cochrane Database of Systematic Reviews (1993–2017; www.cochrane.org ); Google Scholar; MEDLINE (1956–2016); and PubMed. Searches were also supplemented by hand searching. Interventions and keywords for investigation were identified using (1) contributing authors’ knowledge of the field; (2) internationally recognized CP websites such as the American Academy of Cerebral Palsy and Developmental Medicine ( www.aacpdm.org ); and (3) the top twenty hits in Google using the search terms “cerebral palsy” and “Clinical Examination” as an indicator of popular subject matter. The full search strategy is available from the authors on request.

The most important aspect in the initial clinical evaluation of a child with CP is the medical and surgical history of the child. The history includes information regarding the birth, developmental milestones, other associated medical problems, surgical history, ongoing medications, and physiotherapy treatment.

The birth history includes important details about antenatal problems, perinatal history including whether child was preterm, full term, or post-term, and whether there were other associated factors leading to hypoxic injury to the brain such as prolonged labor, meconium aspiration. etc. Treatment of a child in the neonatal Intensive Care Unit after delivery is an important pointer in history. An immature or preterm infant with periventricular leukomalacia typically presents with spastic diplegia, whereas a child with periventricular hemorrhage is more likely to present with hemiplegia. 3 A full-term child with watershed ischemia may present with quadriparesis and that with focal ischemia may present with hemiparesis.

History of developmental milestones is important, as it signifies the stages of physical development as the child becomes more mature. The current functional activity level of the child provides a good insight for treatment, future prognosis, capacity, and goal setting. The earlier the child attains standing balance, the better is the outcome with respect to hip deformities. It is also important to acquire previous history of associated medical illness, physiotherapy records, and previous surgical records to accurately assess present deformities and compensations. Present functional ability at home, school, and in community as well as other functional skills such as walking, running, and stair climbing also affect treatment plans and outcome analysis.

Clinical Examination

Physical examination, especially in children with CP, has limitations and benefits. The information collected during physical examination is based on static responses, whereas functional activities, such as walking, are dynamic. The independence of gait analysis and physical examination measures supports the notion that each provides information that is important in the delineation of problems of children with CP. 4 The method of assessment, the skill of the examiner, and the participation of the child can all affect the usefulness of the examination.

Gait analysis

Gait analysis is commonly ignored in the examination of children with CP and is sometimes performed last in the examination sequence. However, gait analysis is most important as it indicates relative functional deviations rather than static physical examination. The first and most important part in the examination of a child with CP is observing the gait when the child walks into the consultation room. Gait analysis can be done with different techniques such as observational gait analysis, videographic gait analysis, and instrumented 3D gait analysis. 5 , 6 , 7 Observational gait analysis is performed by observing the gait cycle in both sagittal and coronal planes and observing joint angles at different stages of gait cycle at different levels. Videographic gait analysis is performed by observing gait in slow-motion video and analyzing the movements of different joints in both coronal and sagittal planes. The most comprehensive gait analysis is performed by instrumented 3D gait analysis with the use of reflective markers in a gait laboratory. However, 3D gait analysis requires a setup with a lot of infrastructure expenditure, and often sufficient findings can be obtained by observation and slow-motion videographic gait analysis on a day-to-day basis.

Gait patterns in cerebral palsy

Depending on the involvement of spasticity or contracture of different muscles, there are different patterns of gait observed in children with CP. Gait pattern variations related to topographical type of CP are best seen in contrast between unilateral spastic CP and bilateral spastic CP. 8

In spastic hemiplegia, there is more involvement distally and therefore true equinus is the basis of common patterns. Winters et al. described four gait patterns in spastic hemiplegics based on sagittal kinematics. 9

• Type 1 hemiplegia gait – Drop foot type

Type II hemiplegic gait. (a): Anteroposterior view showing right-sided hemiplegia with ankle equinus in stance. (b): Lateral view showing right-sided hemiplegia with ankle equinus in stance

• Type 3 hemiplegia gait – Stiff knee gait
• Type 4 hemiplegia gait – In sagittal plane, the ankle is in equinus, knee in flexion, hip in flexion and anterior pelvic tilt is present. In coronal plane, there is hip adduction and internal rotation.

Gait patterns in spastic diplegia

In spastic diplegia, there is more proximal involvement and therefore apparent equinus and crouch gait are seen commonly. 10 There are four common patterns of gait in spastic diplegia as described by Rodda et al. 11

• Type 1 – True equinus

Type II diplegic gait. (a): Anteroposterior view showing jump gait with bilateral hip and knee flexion and ankle equinus. (b): Lateral view showing jump gait with bilateral hip and knee flexion and ankle equinus

• Type 3 – Apparent equinus

Type IV diplegic gait. (a): Anteroposterior view showing crouch gait with bilateral hip and knee flexion and ankle dorsiflexion. (b): Lateral view showing crouch gait with bilateral hip and knee flexion and ankle dorsiflexion

Physical Assessment

A standard, detailed physical examination is crucial in assessing children with movement disorders, especially CP. The four primary reasons for the need to classify CP include (1) to provide a detailed description that can delineate the nature of the problem and its severity, (2) to provide predictions of both current and future service needs for an individual, (3) to provide comparison so that groups of patients with CP at one institution can be compared with those at another, and (4) to evaluate change so that one individual with CP can be evaluated at various times and change can be documented. 12

In CP, the Gross Motor Function Classification System, developed by Palisano et al. , 13 has been in use for over two decades. It is a five-level clinical classification system that describes the gross motor function of people with CP on the basis of self-initiated movement abilities. The purpose of this system is to classify the child's present gross motor function in a systematic and reliable manner and serves as a useful matrix for identification of where a child is at a specific point in time in relation to its age and gross motor function. Distinctions between levels are based on functional abilities; the need for walkers, crutches, wheelchairs, or canes/walking sticks; and to a much lesser extent, the actual quality of movement. The various levels that are described include:

• Level I – The child can walk indoors and outdoors and climb stairs without using hands for support and can perform usual activities such as running and jumping but has decreased speed, balance, and coordination
• Level II – The child can climb stairs with a railing but has difficulty with uneven surfaces, inclines, or in crowds and has minimal ability to run or jump
• Level III – The child walks with assistive mobility devices indoors and outdoors on level surfaces, able to climb stairs using a railing, and may propel a manual wheelchair but needs assistance for long distances or uneven surfaces
• Level IV – Here, the walking ability is severely limited even with assistive devices such as wheelchairs most of the time and may propel own power wheelchair, standing transfers, with or without assistance
• Level V – The child has physical impairments that restrict voluntary control of movements, has very poor head, neck, and trunk control, has impairment in all areas of motor function, and cannot sit or stand independently, even with adaptive equipment.

The physical examination itself can be categorized into the following:

Functional mobility assessment

Over the years, various simple categorical scales have been developed for the assessment of functional ability and functional mobility of children with CP. These scales were designed to be responsive to change and can be used to document the serial attainment of mobility and functional abilities, the deterioration or improvement in these skills after intervention, or other changes consequent on growth and development. The Functional Mobility Scale (FMS) had been described by Graham et al. 14 to classify the extent of mobility in children, taking into account the range of assistive devices a child might use for mobility. The scale is useful in documenting change over time following interventions such as orthopedic surgery or selective dorsal rhizotomy and was found to be highly sensitive to detect changes after operative intervention. 15

The FMS rates walking ability at three specific distances such as 5, 50, and 500 m and is further graded from 1 to 6 depending on the level of mobility. The scoring represents the child's mobility in the home, at school, and in the community setting. The walking ability of the child is rated at each of the three distances according to the need for assistive devices such as crutches, walkers, or wheelchairs.

The rating is from 1 to 6 which is described as follows:

1 – The child mostly uses a wheelchair but may stand for transfers and does some stepping supported by a caretaker or with the help of a walker; 2 – The child uses a walker or frame to ambulate; 3 – The child independently walks but with the help of crutches; 4 – The child walks independently but with the help of sticks (one or two); 5 – The child walks independently only on leveled surfaces; 6 – The child walks independently on all surfaces; C – The child crawls for mobility at home (5 m); N – Not applicable (e.g., the child does not complete 500 m).

Children with CP, despite having a similar diagnosis, vary in their abilities and level of functioning within and across different environmental contexts such as home, school, or a community setting. 16 Capacity (what a child can do in standardized, controlled environment) may or may not be the same as performance (what a child actually does in his/her daily environment). The FMS is a performance measure and it is important to rate what the child actually does at the time of assessment and not what they can do or used to be able to do. The FMS has been found to be a reliable tool that can be used by clinicians to assess mobility in children with CP. 17

Muscle tone assessment

Tone can be defined as resistance to passive stretch at the relaxed state of muscle activity. It is difficult and cumbersome to assess the tone in CP children, as this can be influenced by apprehension and excitement in the child and the position in which the child is assessed. Hypertonia in a CP child can be due to spasticity, dystonia, rigidity, or a combination of the above features. First, the muscle contracture at rest is assessed by manual palpation of the muscle in testing. Second, the limb is moved slowly through its passive range and later at various speeds or velocity and catch or the resistance to passive motion is assessed. The spasticity assessment is commonly done using the Modified Ashworth scale 18 , 19 , 20 and the Tardieu scale. 21

Modified Ashworth scale

The Modified Ashworth scale, which is used to grade the amount of spasticity, is one of the commonly performed tests as it does not need any equipment and can be performed quickly, easily, and in a day-care clinic. The test is performed manually to determine the resistance of muscle to passive stretching. This was initially described as a measure of spasticity but depends on the speed at which the test is performed. In the original article, it was suggested that the movement of the limb segments should be performed through the full range of movement enough to be a test of spasticity during walking [ Table 1 ].

ROM=Range of motion

Due to the potential shortcomings of this test regarding reliability and chances of error in measurements, assessments of spasticity using this scale should be interpreted with caution. 19 , 20

Tardieu scale

This is a scale for measuring spasticity that takes into account the resistance to passive movement at both slow and fast speeds. As this test is simple and relatively easy to perform and recorded as an angle measure, it can be easily correlated with gait analysis, if required. The various parameters include the following:

• V1 – Velocity to stretch as slow as possible
• V2 – Velocity to stretch with the speed of limb segment falling with gravity
• V3 – Velocity to stretch as fast as possible (> natural drop)

Tardieu scale. (a): Clinical photograph showing Tardieu score at the ankle (R1). (b): Clinical photograph showing Tardieu score at the ankle (R2)

• R2 – Full range of motion (ROM) achieved when muscle is at rest and tested at V1 velocity [ Figure 5b ].

A large difference between R1 and R2 in outer and middle ROM indicates a larger dynamic component and a small difference between R1 and R2 in middle and inner ROM indicates a predominant fixed contracture.

The Tardieu scale has an excellent intra- and inter-rater reliability when assessed at the elbow and ankle joints of children with CP, with no difference noted between visual and goniometric measurements. 22 Training is associated with a highly significant improvement in reliability.

Although we use these scales routinely during the assessment of the CP children, they have some disadvantages because they are not standardized, stimulus is not well controlled, and they lack reliability and validity for all the muscle groups. They offer only qualitative and subjective information in measuring spasticity. 23

Analysis of range of motion and joint contractures

Assessing the muscle length and joint contractures is an integral part of the physical examination. 24 The muscle length is indirectly measured by assessing the ROM of the joint through which the muscle acts. These have to be undertaken with appropriate precautions and standardization, as abnormally false results and errors commonly arise due to faulty technique of examination. Reliability studies suggest that the standard error of measurement of passive joint range is of the order of 5°. 25 Although it is difficult to differentiate static and dynamic deformities in nonanesthetized child, a comprehensive static examination gives a good insight on the type of contracture and in planning the management of the same. 26

Hip deformity is one of the common presenting abnormalities in CP. Although the hips per se are normal at birth, late displacements occur due to abnormal balance, loss of selective motor control, and tone abnormalities. Thus, hip screening is an essential part of examination of a CP child, 27 especially in non-walkers and late walkers. The components of hip examination include the following:

Clinical photograph showing measurement of hip flexion deformity by the Thomas test

Clinical photograph showing Staheli prone extension test

On comparing the above tests, the Thomas’ test showed the best results in normal population whereas the Staheli's test was shown to have accurate results in children with CP. 32

The next part of assessment is to measure the amount of adductor contracture. With the patient in supine position, passive abduction of the hip is performed with the knee in extension and with the knee in 90° flexion (Phelp's Test) [Figure ​ [Figure8a 8a and ​ andb]. b ]. If abduction improves on knee flexion, the primary pathology lies in the medial hamstring muscles and gracilis. If both the measurements are the same, the prime pathology is in the adductor muscles.

Phelp's test. (a): Clinical photograph showing passive hip abduction with knees in extension. (b): Clinical photograph showing improved hip abduction with knee flexion

It has been proposed that, with a significant hip flexion contracture in combination with combined hip abduction of <80°, there is an increased risk of hip subluxation and chronic hip pain in the near future. 33

The commonly presenting deformity in knee is that of flexion contracture, which is more pronounced in a nonambulatory child. The first step in assessment is to differentiate true joint contracture from contracture due to muscle spasticity or tightness.

Clinical photograph showing knee flexion deformity

Popliteal angle test for hamstring contracture. (a): Clinical photograph showing unilateral popliteal angle. (b): Clinical photograph showing bilateral popliteal angle. Difference between the two measurements is the “hamstring shift”

In ambulatory children, a crouch gait develops as a part of the natural course of the disease, especially in diplegic children, in which there is a failure of plantar flexion–knee extension couple. 36 While contemplating crouch correction, other abnormalities such as lever arm dysfunction due to torsional malalignments, planovalgus feet, and muscle imbalance have to be kept in mind to provide overall improvement in the outcome. 37

Assessment of rectus femoris spasticity using Duncan-Ely's/Prone Rectus test [ Figure 11 ] is essential, as this in conjunction with hamstring contracture can result in a stiff knee gait pattern, which necessitates a different approach to management.

Clinical photograph showing prone rectus test. Note the pelvic rise on knee flexion indicating spasticity of the rectus femoris

Ankle and foot

The most common deformities seen in CP include equino-varus and plano-valgus. Assessment of equinus (gastro-soleus spasticity/contracture) is done by passive dorsiflexion of ankle with knee in extension and then with knee joint in 90° flexion (Silverskiold test) [Figure 12a and ​ andb]. b ]. A difference of 20°–30° shows a spastic gastrocnemius component.

Silverskiold test. (a): Clinical photograph showing degree of ankle equinus with knee in extension. (b): Clinical photograph showing correction of ankle equinus with knee flexion indicating predominantly gastrocnemius contracture

Muscle strength analysis and selective motor control

Assessment of muscle strength and selective motor control is an integral part of the examination protocol of children with CP. As muscle strength is directly proportional to motor function, strength evaluation is necessary for providing optimal functional outcomes. Muscle strength analysis is also required to assess the appropriateness for surgical interventions.

The Medical Research Council (MRC) grading for muscle strength assessment has been in use for decades. 38 The main disadvantage of this grading system is that it neither considers the ROM for which a movement can be performed nor defines the strength of resistance against which a movement can be performed. The MRC grading system consists of six grades (scale of 0–5) in relation to the maximum range expected for that muscle [ Table 2 ].

Medical Research Council grading of muscle power

In children with CP, who have poor comprehension and in whom isolated muscle testing is cumbersome, manual muscle testing using Kendall scale is used. 39 It is a 10-point scale which provides a simpler way to assess muscle strength or muscle imbalance [ Table 3 ]. However, it relies heavily on the examiner's judgment and experience, the amount of force generated, and the accuracy of patient positioning. It is subjective and prone to have a significant examiner bias. Studies have shown that clinically small but significant differences in strength may not be detected by this method. However, under strict evaluation protocols, this method was still found to be useful. 40 For children who are under the age of 5, and who cannot follow complex directions for maximal force production, the manual muscle testing method, as well as any other method of strength assessment, is still a vague screening tool. In recent studies, use of a handheld dynamometer has been shown to provide more reliable results in assessing muscle strength, especially the isometric strength. 41

Kendall Scale

Selective motor control

In children with CP, the reduced ability to control and isolate movements provides great hindrance in muscle strength assessment. The typical scale for muscle group selectivity is given as follows:

• Grade 0 – No ability/only patterned movement observed
• Grade 1 – Partial ability/partially isolated movements
• Grade 2 – Complete ability/completely isolated movements.

To assess the overactivity of tibialis anterior muscle (varus/supination), confusion test is used. Here, due to loss of selective motor control, resistance to hip flexion causes the overactive tibialis anterior muscle to act and there is dorsiflexion at the ankle and forefoot supination.

Recently, a newer assessment scheme has been put forth, the Selective Control Assessment of Lower Extremities, which gives a comprehensive scheme for the motor function assessment. 42

Torsional profile and concept of lever arm dysfunction

“Lever arm dysfunction” is a term originally coined by Gage in 1991 43 to describe the particular orthopedic deformities that arise in an ambulatory child with CP. Lever arm dysfunction describes a general class of bone modeling, remodeling, and or traumatic deformities that include hip subluxation, torsional deformities of long bones, and/or foot deformities. Since muscles and ground reaction forces (GRFs) must act on skeletal levers to produce locomotion, abnormalities of these lever arm systems greatly interfere with the child's ability to walk.

In CP, the muscles and the GRFs are neither appropriate nor adequate because of contractures, poor selective motor control, and abnormality of the bony lever arms due to bony malalignments. Among the malalignments, excessive femoral anteversion (FAV) and tibial torsion are the two commonly described conditions in literature. 44 Excessive FAV and coxavalga can produce intoeing gait and hip instability. 45

The Craig's test/Trochanteric prominence test [ Figure 13 ] has been used for the assessment of FAV. With the patient in prone position and knee at 90° flexion, the angle between the vertical line and long axis of the leg at the greatest prominence of the greater trochanter palpated laterally measures the amount of FAV. In recent studies, it has been found that trochanteric prominence test in combination with hip internal rotation X-rays is a better predictor of FAV and neck-shaft angle as compared with computed tomography. 46

Clinical photograph showing Craig test to measure femoral anteversion

Tibial torsion malalignment can be assessed clinically by the following:

Clinical photograph showing Thigh Foot Angle test to measure tibial torsion

• Bi-malleolar axis method – With the knee in full extension, the leg is rotated to align the femur bi-condylar axis horizontally. The angle between the horizontal and bimalleolar axis measures the tibial torsion 47
• Second toe test – With the patient in prone position, the leg is rotated so that the 2 nd toe points vertically down. Now with the thigh held and knee flexed, the angle between the vertical line and the leg axis gives the measure of tibial torsion.

Standing balance and equilibrium

To conclude the physical examination, assessment of posture, trunk balance, and position of the pelvis and lower extremities in standing position (static) and during walking (dynamic) in both planes gives overall information regarding motor control and compensatory mechanisms. Children with CP tend to have delayed and reduced posterior equilibrium responses. A comprehensive analysis of equilibrium in all planes should be done before planning for any modality of treatment.

Upper-limb Examination

The upper extremity examination includes an assessment of tone, ROM of joints, strength of muscles, and assessment of upper-limb functions. Assessment of tone is by the Ashworth scale similar to that for lower extremity muscles. ROM is assessed at each of the joints at shoulder, elbow, forearm, wrist, and hand.

Assessment of upper-limb function

The Manual Ability Classification System describes how children with CP use their hands to manipulate relevant and appropriate objects for activity of daily living, classifying them into five levels 48 [ Table 4 ]. Other assessment scales for upper-limb evaluation are Assisting Hand Assessment score, Quality of Upper Extremity Skills Test (QUEST), Melbourne Assessment of Unilateral Upper limb Function, and Shriners Hospital Upper Extremity Evaluation.

Manual Ability Classification System scoring system

Spine Examination

Spine deformities are a common presentation in CP. They present in varied patterns – scoliosis, kyphosis, lordosis, pelvic obliquity, and a combination of these. Scoliosis is the most common spinal deformity in patients with CP. 49 The incidence of scoliosis increases with increasing severity of the disease. The classic curve pattern is a long C-shaped curve that is often kyphoscoliotic or lordoscoliotic. The curve progression is gradual; however, it can become rapid with onset of puberty, deteriorating neurological function, or spending prolonged time in wheelchair. Scoliosis developing at a younger age (<15 years of age) has a higher risk for progression, and progression can be seen even after skeletal maturity in severely affected children. 50 Nonoperative management of spinal deformity can be achieved by sitting modifications and bracing. However, nonoperative management does not halt the progression of deformity. Surgical management depends on factors such as patient's age, functional capabilities, curve pattern, and other comorbidities.

Conclusions

A detailed bi-annual examination of all children with CP is essential. The frequency of examinations should be more if the child is nonambulant, has deterioration on subsequent examination, or undergoes any surgical management. Although strict guidelines have not been established for a streamlined physical assessment of children with CP, a comprehensive clinical examination using the described diagnostic matrix should be undertaken by every clinician before contemplating the management of these children.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

SYSTEMATIC REVIEW article

Diagnosis and therapies for patients with cerebral palsy over the past 30 years: a bibliometric analysis.

• 1 Department of Outpatient, Hangzhou Children's Hospital, Hangzhou Normal University, Hangzhou, Zhejiang, China
• 2 Department of Radiology, Zhejiang Hospital of Integrated Traditional Chinese and Western Medicine, Hangzhou, Zhejiang, China
• 3 Department of Neurosurgery, Zhejiang Hospital of Integrated Traditional Chinese and Western Medicine, Hangzhou, Zhejiang, China
• 4 Department of Neurosurgery, People's Hospital of Haimen District, Nantong, Jiangsu, China
• 5 Department of Neurosurgery, Hangzhou Children's Hospital, Hangzhou Normal University, Hangzhou, Zhejiang, China

Background: Currently, the incidence of cerebral palsy is high in newborns. However, the current methods for diagnosing and treating patients with cerebral palsy are complex and poorly targeted. Moreover, these studies lack the support of bibliometric analysis results.

Objective: Our study focused on a bibliometric analysis of published papers on the diagnosis and treatment of patients with cerebral palsy. This study identified the primary authors, institutions, and countries involved in analyzing the status and trends of research on the diagnosis and treatment of patients with cerebral palsy. Additionally, the study also involved screening pathways related to cerebral palsy.

Methods: The PubMed database was searched for publications on the diagnosis and treatment of patients with cerebral palsy between 1990 and 2023. R v4.2.2 and VOSviewer v1.6.18 software tools were utilized to perform bibliometric analysis and visualization.

Results: There were 1,965 publications on cerebral palsy diagnosis and 5,418 articles on the qualified treatment strategies, and the annual number of publications also increased. The United States dominated in this field of research. Gregory Y.H. Lip and Patrizio Lancellotti published the most number of papers. The Cleveland Clinic published the most number of papers in the field. According to the analysis of the co-occurrence of keywords, we found that the main research directions were age, sex, disease diagnosis, and treatment. Newly emerging research has focused mainly on heart failure, which is related to valvular heart disease.

Conclusion: The findings presented in this study offer valuable insights into ongoing research and potential future directions pertaining to cerebral palsy. These insights can assist researchers in identifying suitable collaborators and enhancing their investigations aimed at identifying the underlying molecular mechanisms associated with cerebral palsy, encompassing its etiology, preventive measures, and therapeutic interventions.

Introduction

Cerebral palsy (CP) is not a clear, separate disease classification but rather an umbrella term that includes miscellaneous signs and symptoms that change with age. Cerebral palsy is diagnosed primarily through motor function and posture disorders and typically develops in early childhood and persists throughout life. These disorders are not progressive but change with age ( 1 , 2 ). Motor dysfunction is a fundamental manifestation of cerebral palsy and frequently co-occurs with additional impairments encompassing sensory, perceptual, cognitive, communicative, and behavioral disorders; epilepsy; and secondary musculoskeletal complications ( 3 ). Cerebral palsy occurs in 2–3 infants out of 1,000 live births ( 4 ). There are multiple causes of brain damage that affect movement, posture, and balance. Motor disorders associated with cerebral palsy can be classified as spasms, motor disorders, ataxia, or mixed/other disorders ( 5 ). The symptoms of cerebral palsy include movement disorders, hip dislocations, balance difficulties, and hand dysfunction. In cases of cerebral palsy without a clear cause, magnetic resonance imaging may help diagnose brain damage when there is no clinical diagnosis. Once cerebral palsy is diagnosed, instruments such as the hair motor function classification system can be used to assess its severity and treatment response. The treatment of motor disorders associated with cerebral palsy includes intramuscular botulinum toxin A, medications, selective dorsal rhizotomy, and physiotherapy could be used to treat a wide range of muscle disorders. Patients with cerebral palsy often experience problems that are not related to movement and that need to be addressed in adulthood; these problems include cognitive impairment, seizures, pressure sores, osteoporosis, behavioral or emotional problems, and speech and hearing impairment ( 6 ).

The visual analysis software used for literature analysis included R v4.2.2 and VOSviewer, which play important roles in analyzing the current state of scientific research, detecting disciplinary frontiers, and selecting research directions. Bibliometrics can provide us with information on the most influential factors (including countries, institutions, and authors) in the field we want to study through relevant publications. In a manner, this approach could provide researchers with potentially favorable directions for their research. Currently, there is no research summarizing the treatment and diagnosis of cerebral palsy.

The identification of the relationships between the molecular and pathological levels of pathways and between the diagnosis and therapies used in patients with cerebral palsy can provide a basis for understanding the pathogenesis of cerebral palsy to some extent. However, there have been few bibliometric studies on the diagnosis/therapies of patients with cerebral palsy. Based on our bibliometric analysis, we generated data on cerebral palsy to provide insights for researchers who seek to discover new topics and directions.

Materials and methods

Data selection.

We screened the PubMed database for the period from 1 January 1990 to 20 January 2023 to identify publications related to the diagnosis and treatment of patients with cerebral palsy. We considered only English-language publications. The title and abstract were reviewed and screened by two independent reviewers (Lili Jiang and Song Zhang), and disagreements were resolved.

Data analysis and visualization

Key information (e.g., title, author, country/region, institution, keywords, and the year of publication) was derived from our included articles that met the inclusion criteria. The above variables were processed and visualized using Python v3.10.8, R v4.2.2, and VOSviewer v1.6.18.

VOSviewer was applied to perform the network analysis of the authors and frequent keywords. The minimum number of occurrences of a keyword was seven, which was the parameter of VOSviewer. A country collaboration map and various chart drawings based on the bibliometrix R package were constructed.

Pathway enrichment analysis

We downloaded canonical pathway gene sets based on the Reactome pathway database from the GSEA database ( 7 ). The pathway enrichment analysis of the GSE183021 ( 8 ) dataset was performed using the GSVA R package ( 9 ). The differential gene expression analysis of pathway scores was performed based on the limma R package ( 10 ).

General information

A total of 7,383 publications were identified from PubMed. Of these, 1,965 publications were based on diagnosis, and 5,418 publications were based own treatment. We created two boxplots ( Figure 1 ) to represent the number and ratio of annual publications over the last 33 years, which indicated the development trend of related research in this field. This field continues to attract the attention and interest of researchers, as evidenced by the growing number of publications. Research on the promotion of different diseases has shown differences in the associations between diagnosis and treatment.

Figure 1 . The number of annual publications relating to research on the diagnosis and treatment of cerebral palsy from 1990 to 2023. (A) The number of studies related to cerebral palsy diagnosis from 1990 to 2023. (B) The number of studies related to cerebral palsy treatment from 1990 to 2023. (C) A comparison of the annual journal publications related to cerebral palsy diagnosis and treatment.

Compared to diagnostic research, the treatment of cerebral palsy received more attention from 1990 to 2023. In summary, our results showed that the diagnosis and treatment of patients with cerebral palsy have gained widespread attention.

Distribution of authors

The top 10 authors were involved in more than 10 papers on the diagnosis and treatment of patients with cerebral palsy, most of which were published in Europe and Australia ( Tables 1 , 2 ). The bar chart shows that most of the studies originated from the United States and were mainly single-country studies ( Figure 2 ). The author collaboration network visualization ( Figure 3 ) was performed on VOSviewer.

Table 1 . The top 10 authors published articles on the diagnosis of cerebral palsy.

Table 2 . The top 10 authors published articles on the therapy for cerebral palsy.

Figure 2 . Boxplot of countries engaged in research on the diagnosis (A) and treatment (B) of cerebral palsy.

Figure 3 . The network of authors who contributed to the research on the diagnosis (A) and treatment (B) of cerebral palsy. In the network, author contributions are reflected by node size. The connection strength is reflected by the thickness of the line.

Distribution of countries/territories and institutions

The top 10 institutions had over 937 ( Figure 4A ) and 1,105 ( Figure 4B ) articles on the diagnosis and treatment of patients with cerebral palsy, respectively. According to the country collaboration map, we found that the research was mostly distributed in Europe and was closely related to many regions ( Figure 5 ).

Figure 4 . The treemap of institutions engaged in research on the diagnosis (A) and treatment (B) of cerebral palsy.

Figure 5 . A country collaboration map of the research on the diagnosis (A) and treatment (B) of cerebral palsy.

Analysis of keywords and research direction analysis

The results of keyword analysis not only help us understand the topic of the article but also help us understand the hot spots in a research area. The top 20 keywords with the highest frequency are listed in Tables 3 , 4 . As shown in Figure 6 , we used VOSviewer to display the network of keywords.

Table 3 . The top 20 keywords for the diagnosis of cerebral palsy.

Table 4 . The top 20 keywords related to therapy for cerebral palsy.

Figure 6 . The network visualization of keywords related to the diagnosis (A) and treatment (B) of cerebral palsy. A keyword's weight is represented by the size of its circle. The distance between two circles indicates the relatedness between the two circles. Shorter distances are associated with stronger relatedness. The different colors of the circles represent the cluster classes.

The heat map did not reveal relatively important results in the field of diagnosis, but, during treatment, we found that the individual may be more important in the clinical treatment of cerebral palsy ( Figure 7 ).

Figure 7 . Thematic map of the research on the diagnosis (A) and treatment (B) of cerebral palsy. In the thematic map, the horizontal axis represents the centrality and the vertical axis represents the density. Motor themes: these themes are important and well-developed. Niche themes: these themes are very specialized/niche themes that are well-developed but are not important for the current field. Emerging or declining themes: these themes are not well-developed, may just emerge, or may soon disappear. Basic themes: these themes are very important to the field and have not achieved good development.

We downloaded the Reactome pathway dataset, subjected it to enrichment analysis to obtain the fractional matrix of the pathways, and conducted differential analysis to obtain the differential heatmap of cerebral palsy-related pathways ( Figure 8 ).

Figure 8 . Pathway enrichment analysis of the expression matrix in cerebral palsy patients.

We identified 3,089 pathways enriched in cerebral palsy, including 56 upregulated pathways (logFC > 0, P < 0.01) and 10 downregulated pathways (logFC < 0, P < 0.01).

In relation to publishing patterns, our analysis reveals a steady upward trajectory in the number of publications pertaining to this domain since 1990. This trend suggests that both fields will continue to garner significant interest from researchers in the coming years. Moreover, the authors' collaborative network analysis offers a valuable tool for researchers to foster collaborative associations, as it enables the identification of influential research groups and potential partners.

Most of the authors listed in Tables 1 , 2 are located in Europe/Australia, and the relationships between European scholars are much closer than those between scholars in other regions. As shown in Figure 2 , many authors have made contributions to this field, but their cooperation needs to be strengthened. Figure 4 shows that most well-published institutions are located in the United States. For the current research, the active cooperation and exchange of ideas between researchers/research institutions in various countries will be beneficial to the development of this field.

Study hotspots

We have not mined important research directions from the diagnosis section, but we have found that the basic themes for the diagnosis section are similar to the motor themes for the treatment section. The basic criteria for diagnoses included studies on humans (1,653), female (1,047), male (944), child, preschool (623), infant (515), infant or newborn (445) factors; retrospective studies (307); information on risk factor (200); pregnancy (176); and follow-up studies (133).

The motor themes for the treatment included studies on humans (4,474), child (2,790), female (2,641), male (2,483), child, preschools (1,614), adolescent (1,537), treatment outcome (1,160), adult (687), retrospective studies (591), and cerebral palsy/complications (514). However, to some extent, these results do not explain some of the details, thus we combined them with keyword analysis.

Research has shown that cerebral palsy or “high risk of cerebral palsy” can be accurately predicted before the corrected age of 6 months, and detecting cerebral palsy before the corrected age, including magnetic resonance imaging (MRI), has the best predictive effectiveness, with a sensitivity of 86–89% ( 11 ).

Magnetic resonance imaging (MRI) can help assess the duration of brain damage during the development of cerebral palsy (CP) ( 12 ). MRI can also be used to assess white matter damage in premature infants and is therefore more common in the field of cerebral palsy diagnosis ( 13 ).

Therefore, the development of MRI technology and the discovery of cerebral palsy monitoring indicators have become increasingly important. In the biological and molecular research fields, finding more accurate monitoring indicators is particularly important ( 14 , 15 ).

The keywords used for the treatment of cerebral palsy include muscle spasticity and physical therapy modifications. The treatment of cerebral palsy (CP) includes physical therapy and complementary therapies to various standard clinical treatments ( 16 ).

The prenatal diagnosis of cerebral palsy relies on routine ultrasound examinations, which mainly detect congenital malformations and other diseases, but there is currently no specific method for treating cerebral palsy ( 17 ). Research ( 18 ) has summarized the risk factors for cerebral palsy, such as chorioamnionitis, maternal infection, neurotropic virus infection, any virus from Herpes Group B for hemiplegia, and infection of the mother with cytomegalovirus during the first trimester.

Therefore, in the absence of significant progress in imaging, biochemistry, and other related research fields, the discovery of key genes and therapeutic targets in genetics for cerebral palsy will promote the development of methods for diagnosing and treating cerebral palsy.

Future frontiers

Due to the extensive screening of diagnosis and treatment, we observed a relatively significant clinical situation. Imaging is used for the diagnosis of cerebral palsy, while physical therapy and some auxiliary treatments are used for the clinical treatment of cerebral palsy. At the molecular level, research on cerebral palsy

is relatively scarce. Currently, relatively few studies on neurons, muscle contractures, and genes exist; these studies have not been fully examined through bibliometric analysis of the literature. Research on the underlying mechanism of cerebral palsy is not particularly abundant, but, in combination with other research studies on diseases and a small amount of basic research, we speculate that research on the molecular mechanisms will provide evidence for the diagnosis and treatment of cerebral palsy to some extent.

The “Activation of the Ap 1 Family of Transcription Factors” was the most significantly differentially expressed pathway. A previous study showed that gene mutations in AP-1-related transcription factor complexes can affect brain development ( 19 ).

The “Akt Phosphorylates Targets in the Cytosol” represents the presence of phosphorylated Akt in the cytoplasm. Studies have shown that the phosphoinositide 3-kinase (PI3K)-protein kinase B (Akt) signaling pathway enhances neurogenesis ( 20 ). Our study showed that Akt phosphorylation was downregulated in patients with NAFLD compared to healthy individuals ( Figure 8 ).

This study examined a comprehensive collection of 7,383 publications spanning from 1990 to 2023 that specifically address valvular diagnosis and therapies in patients with cerebral palsy. The objective of this research is to identify the countries, institutions, and authors that have had significant impacts on this field. Furthermore, our investigation focuses on specific topics to discern prevailing research patterns. Additionally, we employed GSVA R package to explore common pathways associated with cerebral palsy. Although cerebral palsy is a congenital disease, clinical detection has been less common but should be the focus of future research. Although the molecular mechanisms involved have not been the focus of current research, these mechanisms will provide a basis for the drug treatment to some extent.

Data availability statement

The original contributions presented in the study are included in the article/ Supplementary material , further inquiries can be directed to the corresponding author.

Author contributions

LJ: Project administration, Writing – original draft. WY: Writing – original draft. HC: Data curation, Writing – review & editing. HS: Data curation, Writing – review & editing. SZ: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This study was supported by Hangzhou, Zhejiang Province, Biomedical and Health Industry Development Support Science and Technology Special Project (2023WJC326).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fneur.2024.1354311/full#supplementary-material

Figure S1. A flowchart of literature identification and selection.

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Keywords: cerebral palsy, bibliometric analysis, visual analysis, diagnosis, therapy

Citation: Jiang L, Yang W, Chen H, Song H and Zhang S (2024) Diagnosis and therapies for patients with cerebral palsy over the past 30 years: a bibliometric analysis. Front. Neurol. 15:1354311. doi: 10.3389/fneur.2024.1354311

Received: 12 December 2023; Accepted: 20 March 2024; Published: 17 April 2024.

Reviewed by:

Copyright © 2024 Jiang, Yang, Chen, Song and Zhang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Song Zhang, zhsg1049@163.com

† These authors have contributed equally to this work and share first authorship

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Cerebral Palsy

Mar 31, 2019

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Cerebral Palsy. A presentation by Shalonda Thomas, Chairun Combs, Alan Kauffman, Anthony Nanfito, Robert Scott, and Kathryn Buckles. Presentation Outline. Introduction (Shalonda) Challenges (Chairun) Brainstorm Activity (Alan) Classroom Adaptations (Anthony)

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Cerebral Palsy A presentation by Shalonda Thomas, Chairun Combs, Alan Kauffman, Anthony Nanfito, Robert Scott, and Kathryn Buckles

Presentation Outline • Introduction (Shalonda) • Challenges (Chairun) • Brainstorm Activity (Alan) • Classroom Adaptations (Anthony) • Curriculum Modifications (Robert) • Instructional Strategies (Kathryn) • References

Introduction to Cerebral Palsy Shalonda Thomas

Cerebral Palsy (CP) • Cerebral Palsy (CP) is a disorder that affects muscle tone, movement, and motor skills. • CP is usually caused by brain damage that occurs before or during a child's birth, or during the first 3 to 5 years of a childs' life. • The brain damage that leads to cerebral palsy can also lead to other health issues, including vision, hearing, speech problems and learning disabilities. • About 500,000 living in the US that have this condition.

Types of CP • Spastic cerebral palsy - causes stiffness and movement difficulties. • Athetoid cerebral palsy - leads to involuntary and uncontrolled movements. • Ataxic cerebral palsy - causes a disturbed sense of balance and depth perception.

Causes of CP • The exact cause of CP is unknown although many are the result of problems during pregnancy in which the brain is either damages or does not develop normally. • This damage can be caused by infections, maternal health problems or a genetic disorder. • Premature babies have a higher risk of CP

Diagnosis of CP • CP may be diagnosed very early in an infant known to be at risk. • Doctors usually follow these kids from birth so that they can identify and address any developmental delays. • Difficult to diagnose this disorder in the first year of life. • Doctors aren't able to diagnose CP until they see a delay in normal developmental milestones (reaching for toys or sitting up).

Challenges Chairun Combs

Fine Motor Coordination • Does the student have difficulty keeping their hand or paper steady when writing or taking notes? • Can the student create a piece of artwork in the allowed amount of time?

Gross Motor and Motor Planning Skills • Does the student have difficulty with movement or postural control that may affect their ability when sitting or moving around the classroom? • Does the student have motor planning issues that keep them from going about tasks even if they know what they want to do?

Communication And Language • Does the student have difficulty understanding written and spoken language? • Does the student have difficulty expressing themselves in written or spoken terms? Can they find the right words to describe something?

Attention Span • Does the student have a short attention span? Are they able to concentrate as long as their peers? • Are the expectations as to what the student should achieve in class realistic?

Perception • Does the student have difficulty interpreting information from their senses such as judging the size of objects, distinguishing different sounds or looking at diagrams?

Brainstorm Activity Alan Kauffman

Classroom Adaptations Anthony Nanfito

Classroom Adaptations • Physical Environment • Making the classroom wheel-chair accessible • Clean floor; free of rugs or elevated surfaces • Maintain unobstructed aisles and means of egress • Provide an accessible classroom desk or portable wheelchair desk • Adapting lab equipment • Providing grips to lab equipment • Adapting lab station so it is wheel-chair accessible • Using parents as a resource: what adaptations have been made at home for the child?

Classroom Adaptations • Physical Environment (cont’d.) • Assistive technology • Enlarged keyboard or voice activated computer program • Writing and/or grip aides • Positioning the student near the front of the room to accommodate vision or hearing impairment • Social Environment

Curriculum Modifications Robert Scott

Curriculum Modifications • Be aware of the students symptoms (consult the students IEP) • Make appropriate accommodations during lesson planning • Students may need special accommodations for test taking

Instructional Strategies Kathryn Buckles

Instructional Strategies • Teachers, Parents, and Therapist should design an Individualized Education Plan that would best accommodate the student with CP • Teachers should maintain open communication with the student’s family to encourage carry over to home programs, including the student • Educators should demonstrate a great deal of emotional support and patience and UTILIZE EFFECTIVE TEACHING STRATEGIES

Depending on the student’s obstacles the following may be helpful: • Individualized help • Determine students learning preference and ability to help make all lessons accessible to students with CP • Differentiated, direct, or indirect instruction • May have to provide alternative assessments for student with CP • Modify hands on lessons so that CP students can participate • Research and use assistive technology in your classroom, see what would best support your student with CP • Use of technology in the classroom • Provide additional handouts • Use literacy strategies • Audio • teacher reads aloud

Videos • The Family Center on Technology and Disability: Assistive Technology in Action Video Series • Sam: http://youtu.be/YayaN9vwipU • Elle: http://youtu.be/R8VuA8yVBv8

References • Early School Years Fact Pact. Cerebral Palsy Alliance. http://www.cerebralpalsy.org.au/__data/assets/pdf_file/0020/4709/early_school_years_fact_pack.pdf • About Cerebral Palsy. MyChild Cerebral Palsy Foundation. http://cerebralpalsy.org/about-cerebral-palsy/ • Cerebral Palsy in the Classroom. Teach-Nology.com http://www.teach-nology.com/teachers/special_ed/disabilities/cp/ • How to Help Students with Cerebral Palsy. Suite 101. http://suite101.com/article/how-to-help-students-with-cerebral-palsy-a149277 • Accommodating Students with Cerebral Palsy. Job Accommodation Network, U.S. Department of Labor: Office of Disability Employment Policy. • The IRIS Center. http://iriscenter.com/ • The Family Center on Technology and Disability. http://www.fctd.info/

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Cerebral palsy

Cerebral Palsy. Was first described by William Little in 1862.Then it was known as Little disease.The term Cerebral palsy originated with Freud.DefinitionIn all cases the following must be trueCerebral palsy is the result of a brain lesion. Therefore, the spinal cord and muscles are structur

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Cerebral Palsy. Cerebral palsy results from damage to the structures of the cerebral cortex, cerebellum, and spinal cord. It is characterized by atypical muscle tone and poor coordination among muscle groups which results in postural abnormalities and structural deformities. Cerebral Palsy.

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CEREBRAL PALSY

CEREBRAL PALSY. Dr. Maninder S. Dhaliwal. Define. Is defined as a : Persistent but not unchanging Disorder of movement, tone and posture Due to non-progressive defect/lesion Of immature brain ( fetal life, infancy, childhood) ( immature brain cut off take as 5 yrs –AAP).

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Cerebral Palsy. By Robin Hill Mrs. Rooney/Ms. Scheetz B-11 Multi-Media Research Project. What is Cerebral Palsy?. Cerebral palsy is a condition that affects the brain’s ability to control the muscles. This happens before or during birth, or sometimes during the early years of life.

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Cerebral Palsy . Betsy Schirmer SPED 735 University of Kansas. What Is Cerebral Palsy?. Cerebral palsy (CP) is a disorder that affects muscle tone, movement, and motor skills. It hinders the ability to move in a coordinated and purposeful way.

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Cerebral Palsy. Hannah Bauer &amp; Caydense Debnam.

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Cerebral Palsy. Trey Sutter Matthew Leitzen. Definition. Cerebral Palsy is a condition, sometimes thought of as a group of disorders that can involve brain and nervous system functions such as movement, learning, hearing, seeing, and thinking.

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Cerebral Palsy . Rebecca Roy REH 277 Douglas Dunlap Fall 2009. “To be yourself in a world that is constantly trying to make you something else is the greatest accomplishment.” Ralph Waldo Emerson. Outline . What is it? Population Prevalence &amp; Course Diagnostic Criteria

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Cerebral Palsy. Meagan Ricks. What is it?. Cerebral Palsy is a group of disorders which can affect the brain and nervous system. Oftentimes, this can result in delays and disabilities with movement, hearing, seeing, thinking, and learning.

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Cerebral Palsy. By: Alexxis and Georgia (:. What is Cerebral Palsy?. Cerebral Palsy is a term used to describe a group of chronic conditions affecting body movements and muscle coordination. Characteristics. Loss of muscle control Clumsy walking Lack of balance Shaking of the body

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Cerebral Palsy. Nadia Lozano Rocio Martin Selene Mireles Deborah Obilana Erin Trainer. What is Cerebral Palsy?. Group of problems that affect body movement and posture Related to brain injury/ brain growth Causes uncontrollable reflex movements Causes muscle tightness

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Cerebral Palsy. By Bryce &amp; Henare. What is Cerebral Palsy?. Cerebral palsy is one of the neurological disorders It appears in baby’s or early childhood It forever affects body movement and muscle coordination. It doesn’t get worse over time. ..Symptoms of Cerebral Palsy.

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Cerebral Palsy . by Kayla. We are all human beings. Whether we look different or not. Go Hard or Go Home!!!!. Whether you like it or not we're all different. Kid. Or Adult. What causes Cerebral Palsy.

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Cerebral Palsy. Lewis, pp. 1716-1724. Etiology/Pathophysiology. Non-progressive neuromuscular disorder Caused by perinatal trauma/hemorrhage or anoxia to areas of brain or prenatal brain abnormalities

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CEREBRAL PALSY. CEREBRAL PALSY. Chronic disability of central nervous system origin characterised by aberrant control of movement of posture, appearing early in life and not the result of progressive neurological disease. Spastic: Upper motor neurone lesion.

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Cerebral Palsy. Matondo Mpongo March 6,2013 Psychology (Honors) 4th. Common Name : Cerebral Palsy (CP). Causes. Caused by damage to or abnormal development of the motor control centers of the brain

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Cerebral Palsy. By: Shaina King. Cerebral Palsy the damage caused to the brain before or during birth, at infancy, or during the early toddler years. Cerebral Palsy is a misconnection in the brain that that causes a child not to be able to control his or her muscles. What is Cerebral Palsy?.

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Cerebral Palsy. Judian Williams March 6, 2013 3rd Period. A.K.A. “Static Motor Encephalopathy&quot;. Causes of Cerebral Palsy. The exact cause is unknown but it is believed that C.P occurs during pregnancy when the brain gets damaged or is underdeveloped. Who does C.P affect?.

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Cerebral Palsy. Don’t get too spaced out, but, it’s time for a warm-up activity. Today, we are studying cerebral palsy. Partner up with one other student and, for 4-minutes, brainstorm facts you know about cerebral palsy. HOOAH!!!.

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Cerebral Palsy. Cause unknown but may be due to birth injury or abnormal brain development It is present at birth Symptoms include: Spastic quadriplegia Head Rolling Grimacing Difficulty with speech and swallowing NORMAL INTELLIGENCE!.

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Cerebral Palsy. Joe Conte and Sarah Lupo. Video. http://www.dailymotion.com/video/x68kwh_cerebral-palsy-wwwbrainpalsycom_shortfilms. What is Cerebral Palsy?. A group of permanent disabling symptoms resulting from damage to the motor control areas of the brain

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