Cerebral palsy and spasticity

Overview

Cerebral palsy is a group of chronic disorders that damage areas of the brain controlling movement. The word "cerebral" refers to the brain and "palsy" is a condition that impairs control of movement and posture. These disorders usually appear in the first few years of life and don't worsen over time. Although children with severe cerebral palsy may have life-long disabilities, children with mild forms may manage very well on their own.

Cerebral palsy doesn't appear to be an inherited disease. There is not yet a cure, but treatments continue to improve through research. At UCSF Benioff Children's Hospital, we are at the forefront of research on cerebral palsy. Our neurologists are specially trained to treat the condition, using the latest imaging, technical equipment and therapies.

Types of cerebral palsy

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

• Spastic cerebral palsy. This type causes a child's muscles to be stiff and permanently contracted. The legs may turn in at the knees and walking is difficult. Your child also may have uncontrollable shaking or tremors on one side of the body. This form of cerebral palsy affects about 70 to 80 percent of patients.
• Athetoid (or dyskinetic) cerebral palsy. This type causes uncontrolled, slow, writhing of the hands, feet, arms, legs and facial muscles. Children with this condition may frown or drool. Movements may get worse during periods of stress and go away while your child sleeps. Speaking also may be difficult. This form affects about 10 to 20 percent of patients.
• Ataxic cerebral palsy. This type affects depth perception, balance and coordination. Your child may walk with his or her feet far apart and may have difficulty doing precise tasks such as picking up an object or slipping a button into a buttonhole. This form affects about 5 to 10 percent of patients.
• Mixed forms. Sometimes a child will experience multiple symptoms of the different forms of cerebral palsy mentioned above.

Risk factors for cerebral palsy

Some infants are at higher risk for developing cerebral palsy. Risk factors for developing the condition include:

• Breech birth. Babies who are born breech – meaning that they descend the birth canal feet first instead of head first – may have an increased chance of developing cerebral palsy.
• Complications during labor. Signs may occur during a woman's labor and delivery which indicate that a baby may have brain damage or development problems. This may signal a greater susceptibility to cerebral palsy later on in the baby's life.
• Physical birth defects. Babies born with problems such as hernia, a poorly formed spine, a very small jaw bone or microencephaly (a very small head) are at a higher risk for cerebral palsy.
• Low apgar score. The Apgar score, a way for doctors to evaluate a newborn's condition, is often lower for babies who show signs of cerebral palsy. The Apgar score looks at a baby's heart rate, reflexes, muscle tone, breathing and skin color. This test is conducted right after birth and several minutes later.
• Multiple births. Babies who are born as part of twins, triplets or other multiple births have an increased risk of cerebral palsy.
• Low birth weight or premature birth. Babies weighing less than 5 pounds, 7.5 ounces at birth or who are born less than 37 weeks into pregnancy are at greater risk for cerebral palsy.
• Seizures. Newborns who have seizures are at greater risk for cerebral palsy.

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

• Vaginal bleeding or severe proteinuria. Mothers with vaginal bleeding after the sixth month of pregnancy and severe proteinuria, which results in excess proteins in urine, have babies with a higher risk of developing cerebral palsy.
• Intellectual disability, seizures or hyperthyroidism. Mothers who have these conditions have a slightly increased chance of having a child with cerebral palsy.

Even if your child has one or more of these risk factors, it doesn't mean that he or she will develop cerebral palsy.

Signs & symptoms

Symptoms of cerebral palsy vary for each child. Symptoms may change over time, and may be affected by other medical conditions. Your child may experience the following:

• Difficulty with fine motor tasks, such as writing, buttoning shirts and using scissors.
• Earlier than usual development of hand preference, or the tendency to use either the right or left hand more often.
• Hypertonia or increased muscle tone. Your baby may seem rigid or stiff.
• Hypotonia or decreased muscle tone. Your baby may seem overly relaxed, flaccid or "floppy."
• Impaired motor development or developmental delay. Your baby may be slow to roll over, smile, sit, crawl or walk.
• Involuntary movements, such as uncontrollable writhing motion of the hands, or drooling.
• Retention of Moro reflex after age 6 months. The Moro reflex occurs when a baby is held on its back and tilted with the legs above the head. The baby usually extends its arms in what looks like an embrace.
• Trouble maintaining balance or walking.
• Unusual posture or a tendency to favor one side of the body.

Diagnosis

During your child's visit to the Child Neurology clinic at UCSF Benioff Children's Hospital, our doctors and other health professionals will evaluate your child. We will ask you about your child's medical history as well as your family medical history. If your child's pediatrician has provided medical records, we will review this information.

Be sure to tell your child's neurologist about medications your child is using, including over-the-counter medications, vitamins, nutritional supplements or herbal remedies.

Our doctors will check your child's motor skills and reflexes, and look for symptoms of cerebral palsy. We may conduct tests or procedures to rule out other conditions that could cause your child's movement problems.

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

• Computed tomography (CT) uses X-rays and a computer to create an image of your child's brain.
• Magnetic resonance imaging (MRI) produces images of your child's brain by using a magnetic field and radio waves instead of X-rays.
• Ultrasound forms a picture of your child's brain called a sonogram by bouncing harmless sound waves off the brain.
• An electroencephalogram (EEG) records electrical activity inside your child's brain.
• Intelligence tests may be used to see whether your child also has an intellectual disability.
• Vision or hearing tests may be ordered if your child's neurologist suspects that he/she is experiencing problems with these senses.

Treatment

Working with your child's primary care doctor, we will design a treatment plan tailored to your child's condition. Your child may need more than one kind of treatment or treatments that require several visits to UCSF Benioff Children's Hospitals. We also may refer your child to additional specialists or other medical professionals.

Because cerebral palsy can't be cured, treatment is an ongoing process focused on managing the disease's effects and improving your child's quality of life. Your child's neurologist will explain possible side effects and complications from the treatments your child will receive.

We may prescribe medications to control seizures and muscle spasms. Some medications, including the muscle relaxant called baclofen (Gablofen, Lioresal), can be administered intrathecally – directly into the spinal fluid. Intrathecal baclofen therapy can improve muscle spasms and stiffness but requires a procedure to implant a pump that delivers the medication.

For some patients, we may recommend surgery on the lower spinal cord. One procedure, called selective dorsal rhizotomy, can reduce spasticity in the legs by cutting some of the sensory nerves that are causing abnormal muscle tone.

Mechanical aids help some children, including special braces that can improve muscle balance. In addition, physical, speech and behavioral therapy may be elements of your child's treatment plan.

Feel free to ask us questions about your child's treatments. If your child is prescribed new medication, be sure it's taken exactly as instructed. It's also important to keep all follow-up appointments with our doctors and other medical staff.

Members of your child's care team may include:

• Doctors, such as a pediatrician, a pediatric neurologist (a specialist in the developing brain and nervous system), a pediatric physiatrist (a specialist in restoring or improving physical function), an orthopedic surgeon and a neurosurgeon (a specialist in surgery on the brain and nervous system)
• Nurses with special training in care for children with neurological disorders
• Physical therapists, whose exercise programs can help with improving movement and building strength
• Occupational therapists, who help your child develop skills for coping better at home and at school
• Speech pathologists, who help your child communicate better
• Psychologists, who help your child deal with the emotional and social effects of cerebral palsy
• Educators, who help your child overcome learning challenges associated with cerebral palsy
• Social workers, who help you and your child find educational programs and other services in your community