Cerebral Palsy (CP)
Cerebral palsy (CP) is caused by damage or abnormalities in the part of the brain that controls movement. It is considered a motor disorder, meaning that it’s characterized by unusual or involuntary movements. Cerebral palsy also often causes musculoskeletal conditions that manifest in joint and bone deformities. Additionally, many people with cerebral palsy have issues such as epilepsy, cognitive impairments, and problems with vision or hearing. Cerebral palsy is the most common motor disability in childhood, affecting one in 323 children (1). A large number of diagnoses are caused by preventable birth injuries and medical malpractice.
- What is cerebral palsy (CP)?
- Types of CP
- Classifying CP
- Signs and symptoms
- Conditions associated with cerebral palsy
- Treatment and therapy
- Do you have a cerebral palsy case?
What is cerebral palsy?
Cerebral palsy (CP) is a group of non-progressive motor conditions that cause physical disability. CP is caused by damage to the motor control centers of the developing brain, which can occur before a baby is born, during childbirth, or after birth up to age five (2). ‘Cerebral’ refers to the cerebrum, which is the affected area of the brain (although the disorder may involve other parts of the brain, such as the cerebellum), and ‘palsy’ refers to a disorder of movement (3).
The effects of cerebral palsy can vary dramatically from one individual to the next. Some have only minor impairments and are totally independent; others struggle greatly with the tasks of daily life and require extensive assistance and 24-hour care.
Currently, cerebral palsy has no cure, but there are a variety of treatments and therapies that can alleviate certain symptoms and improve function.
How do you pronounce cerebral palsy?
Types of cerebral palsy
Although there are many different ways of describing or categorizing the way cerebral palsy affects an individual (this will be discussed more in the next section), people often divide it into the following four subtypes:
- Spastic cerebral palsy
- Ataxic cerebral palsy
- Athetoid/dyskinetic cerebral palsy
- Mixed cerebral palsy
Spastic cerebral palsy
Spastic cerebral palsy is by far the most common type of cerebral palsy, comprising roughly 80% of all cases (4). Children with spastic cerebral palsy have lesions in the upper motor neurons of the central nervous system (5). This damage leads to hypertonia (extreme muscle tension) in the muscles that receive signals from damaged portions of the brain (4). Hypertonia can cause involuntary muscle contractions, spasms, and secondary pain and/or stress (5). Additional side effects of spastic cerebral palsy include joint deformities (6), scoliosis (7), hip dislocation (8), and more.
Ataxic cerebral palsy
Ataxic cerebral palsy is the least common type, occurring in roughly 5-10% of all CP cases. It is caused by damage to the cerebellum (9), and affects controlled movements and fine motor skills. This includes balance and coordination (particularly while walking) and precise movements such as writing (10). In young children, hypotonia is a common manifestation of ataxic CP. Unlike the rare form of degenerative neurological disease ataxia, ataxic cerebral palsy is a non-progressive condition (11). It is common for children with ataxic cerebral palsy to have difficulty with visual processing (depth perception and eye movement control) and/or speech (12).
Athetoid/dyskinetic cerebral palsy
Athetoid/dyskinetic cerebral palsy (ADCP) occurs in roughly 0.27 per 1,000 live births (13), and comprises 15-20% of CP cases. This subtype is the result of damage to the basal ganglia, the part of the brain responsible for regulating voluntary movements (14). In many cases, ADCP is caused by hypoxic-ischemic encephalopathy/HIE (brain damage due to a lack of oxygenated blood) or kernicterus (brain damage due to severe or improperly-managed jaundice).
ADCP causes a combination of hypertonia, hypotonia, and involuntary motions. Children with ADCP may have trouble sitting upright, walking, grasping objects, performing fine motor tasks (15), sucking, swallowing, and talking (4). ADCP is further characterized into three subgroups based on the nature of the movements (16):
- Dystonia (dystonic cerebral palsy): Involuntary muscular contractions that cause repetitive twisting motions, postural abnormalities, and painful movement.
- Athetosis: Abnormal muscle contractions that cause slow, involuntary writhing movements.
- Chorea: Irregular, unpredictable jerking movements. When chorea occurs in conjunction with athetosis, it is known as choreoathetosis.
Mixed cerebral palsy
Mixed cerebral palsy involves a combination of symptoms that don’t all fit within a single subtype of CP. For example, a child may have both hypertonia and hypotonia. In other words, some of their muscles are too tight, while others are too loose (3).
How is cerebral palsy classified?
In addition to being divided into the main types discussed above (spastic, ataxic, athetoid/dyskinetic, and mixed), cerebral palsy can also be classified by using a variety of organizational/diagnostic systems. These include the following:
- Classification based on muscle tone
- Classification based on limb involvement
- Gross Motor Function Classification System (GMFCS)
- Manual Ability Classification System (MACS)
- Communication Function Classification System (CFCS)
It is important to know that the cerebral palsy classification systems can be used in conjunction to reveal various aspects of a patient’s condition. In other words, they’re not conflicting or mutually-exclusive, and a child may receive a diagnosis using terms from various classification systems.
1. Classification based on muscle tone
Cerebral palsy may be described based on how muscle tone is impaired. The following terms are often used:
- Hypertonic cerebral palsy: Hypertonic or hypertonia refers to abnormally high muscle tone, which creates muscular stiffness and rigidity. Spastic cerebral palsy is characterized by hypertonia.
- Hypotonic cerebral palsy: Hypotonic or hypotonia refers to abnormally low muscle tone. Symptoms of hypotonia include floppiness and weakness.
Mixed cerebral palsy is characterized by both hypotonia and hypertonia.
2. Classification based on limb involvement
This classification system categorizes cerebral palsy by which limbs are affected (17, 18, 19):
|Type of Cerebral Palsy||# Limbs Affected||Location of Affected Limbs|
|Monoplegic cerebral palsy (monoplegia; monoparesis)||1||Can be any one limb.|
|Hemiplegic cerebral palsy||2||Limbs affected on the same side of the body (ex: left arm and left leg).|
|Diplegic cerebral palsy||2||CP that affects two symmetrical limbs, usually the legs. However, other parts of the body may also be affected, to a lesser degree.|
|Paraplegic cerebral palsy||2||Impairs the lower body, affecting both legs.|
|Triplegic cerebral palsy||3||Impacts three limbs.|
|Quadriplegic cerebral palsy||4||Involves all four limbs; other areas of the body may also be affected.|
|Pentaplegic cerebral palsy||5||Impacts both legs, both arms, and the head and neck.|
3. Gross Motor Classification System (GMFCS)
The Gross Motor Function Classification System (GMFCS) is a system that is used to classify infants, children, and adolescents with cerebral palsy into five groups based on the following categories (20):
- Extent of movement impairment: The GMFCS measures a child’s ability to perform gross motor functions independently. It takes into consideration walking ability, balance, dependence on equipment, and related factors.
- Age: The GMFCS measures individuals by age groups: 0-2, 2-4, 4-6, 6-12, and 12-18.
- Performance in a variety of settings: The GMFCS measures a child’s functional ability in settings such as the home, school, and community.
The GMFCS levels progress in severity, with level one indicating the lowest level of impairment and level five the highest. By classifying a child with cerebral palsy based on the GMFCS, parents, medical professionals, and caregivers can determine appropriate therapy regimens, plan lifestyle adjustments, and estimate rehabilitation potential.
Broadly, the five levels are described as follows:
- Level I – Has functional gross motor skills, though may struggle with speed, balance, and coordination. Moves independently without the aid of adaptive equipment.
- Level II – Can walk with limitations and may need assistance with inclined or uneven surfaces.
- Level III – Can walk with the use of hand-held adaptive equipment, but may use wheeled mobility under certain circumstances.
- Level IV – Is self-mobile only with significant limitations. Many use powered-wheelchairs, require significant help with transfers, and are dependent on adaptive and assistive equipment.
- Level V – Voluntary movement is typically very difficult, and the individual is extremely dependent on adaptive equipment, assistive technology, and help from other people for mobility.
For more detailed information on GMFCS levels, click here.
4. Manual Ability Classification System (MACS)
The Manual Ability Classification System (MACS) (21) categorizes cerebral palsy based on an individual’s ability to manipulate objects with their hands, which is closely tied to one’s ability to complete tasks independently. The MACS is applicable to children ages 4-18. As with the GMFCS, it is divided into five levels, with level five being the most severe:
- MACS Level I: The child handles objects with ease.
- MACS Level II: The child largely handles objects successfully, but with compromised speed or quality.
- MACS Level III: The child experiences difficulty handling objects and often requires help.
- MACS Level IV: The child can handle certain objects (with difficulty), but requires extensive help from others.
- MACS Level V: The child has extremely limited ability to perform manual activities.
For more information on the MACS levels, click here.
5. Communication Function Classification System (CFCS)
The Communication Function Classification System (CFCS) categorizes individuals with cerebral palsy and other disabilities based on everyday communication performance (22). As with the GMFCS and the MACS, the CFCS has five levels that represent increasing severity.
- CFCS Level I: The person can effectively send and receive communicative information with unfamiliar and familiar partners.
- CFCS Level II: The person effectively, but slowly, sends and receives communicative information with both unfamiliar and familiar partners.
- CFCS Level III: The person is usually able to effectively send and receive communication information with familiar partners, but may struggle to communicate with unfamiliar partners.
- CFCS Level IV: The person inconsistently sends and receives communication information with familiar partners, and rarely can communicate with unfamiliar partners.
- CFCS Level V: The person rarely communicates effectively, even with familiar people.
For more information on the CFCS levels, click here.
Signs and symptoms of cerebral palsy
Although “signs” and “symptoms” are often used as interchangeable terms, they have their own specific definitions:
- Signs can be detected, measured, and confirmed in a clinical setting by medical practitioners. Examples include seizures and tremors.
- Symptoms are solely based on a patient’s personal experience of his or her medical conditions. Examples include pain and irritability.
Because cerebral palsy affects different people in different ways, there is no one sign or symptom used individually to diagnose it. Most people with cerebral palsy are diagnosed as infants or toddlers, but others do not show clear signs or express symptoms until they are a bit older and developmental delays (missed milestones) become more obvious. Click here to learn more about early signs of cerebral palsy.
Neonatal predictors of cerebral palsy
- Low birth weight
- Unusually small or large head circumference
- Low Apgar scores
- Low activity
- Diminished cry
- Problems with temperature regulation
- Feeding problems
- Breathing problems (e.g. apnea) or need for resuscitation
- Hypotonia (baby appears floppy)
- Hypertonia (baby appears stiff)
- Low red blood cell count (anemia) (23, 24)
- Metabolic acidosis
Other common signs of cerebral palsy
- Involuntary movements (spasms, writhing, etc.)
- Poor coordination (ataxia) or balance
- Unusual posture or limb positioning
- Difficulty bringing hands together or manipulating objects
- Favoring one side of the body over another (i.e. a strong preference for reaching out with one hand)
- Failure to reach (or delay in reaching) developmental milestones such as sitting up, crawling, or walking
- Speech-language problems
- Difficulty swallowing or excessive drooling
- Cognitive impairments
- Vision or hearing problems
- Behavioral and emotional problems
- Retention of primitive reflexes (e.g. Moro reflex)
Birth injuries and other causes of cerebral palsy
Cerebral palsy can be caused by environmental and/or genetic factors. However, in most cases, it is attributable to a birth injury (i.e. something that goes wrong during pregnancy, birth, or the neonatal period). Unfortunately, birth injuries that result in cerebral palsy are often linked to medical malpractice.
The following are some examples of birth injuries and other environmental factors that can cause or increase the risk of cerebral palsy:
- Abnormal fetal position/presentation
- Birth asphyxia/hypoxic-ischemic encephalopathy (HIE)
- Birth trauma
- Brain bleeds (intracranial hemorrhages)
- C-section errors and delays/failure to timely deliver
- Forceps and vacuum extractor injuries
- Low birth weight
- Maternal infections
- Meconium aspiration syndrome (MAS)
- Mismanaged fetal distress (or failure to provide proper fetal monitoring)
- Mismanaged high-risk pregnancy (or failure to diagnose a high-risk pregnancy)
- Periventricular leukomalacia (PVL)
- Placental abruption
- Premature birth
- Prolonged and arrested labor
- Twin or multiples pregnancy
- Umbilical cord problems
- Uterine tachysystole/hyperstimulation
- Uterine rupture
It is worth noting, however, that these issues do not guarantee that a child will necessarily develop cerebral palsy. In many cases, cerebral palsy is a preventable condition. This means that medical practitioners can avoid cerebral palsy by following the standards of care for a given pregnancy, labor, or birth. If they mismanage the conditions above, cerebral palsy is much more likely to result.
Conditions associated with cerebral palsy
No two cases of cerebral palsy are identical. Depending on the location and severity of the initial brain injury, the conditions and side effects associated with cerebral palsy will vary. Factors such as treatment, therapy, environment, and age also affect a person’s functional potential. However, common conditions associated with CP – aside from mobility impairments – include the following. Please note that incidence estimates have been rounded to the nearest five, and that some come from studies with small sample sizes:
- Chronic pain (50-75%) (25)
- Cognitive disabilities (50%) (11)
- Speech-language problems (40-50%; approximately 25% are nonverbal) (11, 25)
- Epilepsy (25-45%) (11, 25)
- Visual impairments (30-50%) (11)
- Hearing impairments (5-20%) (11, 25)
- Hip displacements (35%) (25)
- Scoliosis (20-65%) (26)
- Behavioral disorders from cerebral palsy (25%) (25)
- Bladder control problems (25%) (25)
- Sleep disorders from cerebral palsy (20-45%) (25, 27)
- Saliva control problems (20%) (25)
- Eating problems (5% use a feeding tube) (25)
Diagnosing cerebral palsy
The diagnosis of cerebral palsy is typically based on a physical examination and the child’s medical history. Neuroimaging with CT or MRI is warranted when the cause of a child’s cerebral palsy has not been established. These tests can also help to determine the timing of the initial damage and the likelihood of associated conditions such as epilepsy and developmental disabilities.
Some people with cerebral palsy are diagnosed in early infancy, and most receive their diagnosis by age two. However, cerebral palsy may go undetected until children miss major developmental milestones; sometimes, a diagnosis is not made until age four or five (3). Because clinical signs of cerebral palsy evolve as the nervous system matures, the diagnostic process usually involves multiple trips to the child’s primary physician, as well as several other specialists.
Furthermore, the time at which a cerebral palsy diagnosis is made often depends on the type of cerebral palsy the child has. For instance:
- Spastic cerebral palsy diagnoses are often made between 9.6 and 11 months if it is bilateral, and between 12.0 and 15.6 months if it is unilateral.
- Dyskinetic cerebral palsy diagnoses are often made between 6.0 and 8.4 months.
- Ataxic cerebral palsy diagnoses are often made between 12.6 and 30.0 months.
It is important to note that the degree of motor disability also influences diagnostic age. Those with more severe impairments are generally diagnosed earlier because the signs are more obvious (28).
Diagnostic tests for cerebral palsy
Medical professionals must thoroughly examine children to determine the severity of brain injury, location of brain damage, and the form of cerebral palsy. Repeated examinations over time are generally required to ensure the condition is static. Below are some common tests and procedures used to evaluate a baby at risk for cerebral palsy:
- Apgar Scoring: Apgar tests determine a newborn’s overall health within the first few minutes of life.
- Umbilical Cord Blood Gas Tests: Blood gas tests measure how much oxygen and carbon dioxide are in the baby’s blood, which impacts the blood’s pH (acidity). If the baby’s blood is acidic, this means the baby may have suffered oxygen deprivation, which could lead to cerebral palsy and other types of brain damage.
- Neuroimaging: These techniques allow medical personnel to produce images of brain structures and activity:
- CT Scan
- Evoked Potential Tests
- Reflex Tests: Reflex tests help diagnose cerebral palsy and developmental delays, and monitor abnormal reflex development in babies.
- Muscle tone, posture, and coordination tests
- Developmental testing: Developmental tests assess whether infants are meeting specific developmental milestones at the expected time.
- Screening for associated conditions (see “Conditions associated with cerebral palsy,” above)
- Scanning for coagulation or other blood disorders
It is very important that medical professionals diagnose cerebral palsy as early as possible. The sooner children are diagnosed, the sooner they can begin the treatment and therapy regimens designed to preserve brain function, lessen impairments, and improve functional abilities.
Treatment and therapy for cerebral palsy
Treatment for cerebral palsy is mostly supportive and focuses on helping the child develop as many motor skills as possible and/or to learn how to compensate for a lack of them. Typically, the earlier medical interventions begin, the better outcomes children have.
Various forms of treatment and therapy are available to children with cerebral palsy. The following are just a few examples (click here for more details):
Medications for cerebral palsy:
- Anticholinergic medications
- Anticonvulsant medications
- Anti-inflammatory medications
- Baclofen (some patients opt to have this delivered through a surgically-inserted baclofen pump)
Medical equipment for cerebral palsy:
- Baclofen pump
- Feeding tubes
- Hearing aids and cochlear implants
- Vagus-nerve stimulators
- Breathing aids
- Glasses and contact lenses
Surgeries for cerebral palsy:
- Baclofen pump insertion
- Feeding tube insertion
- Hearing correction surgery (e.g. cochlear implant)
- Neurosurgery (e.g. selective dorsal rhizotomy [SDR])
- Orthopedic surgery (e.g. hip muscle release)
- Pulmonary surgery (e.g. airway obstruction removal)
- Vision correction surgery (e.g. LASIK)
Therapies for cerebral palsy:
- Occupational therapy
- Physical therapy
- Speech therapy
- Complementary and alternative therapy (e.g. hippotherapy, hyperbaric oxygen therapy, music therapy, etc.)
In addition to medical treatments and therapies, children with cerebral palsy may benefit greatly from assistive technology (AT). According to the Assistive Technology Industry Association, this is “any item, piece of equipment, software program, or product system used to increase, maintain, or improve the functional capabilities of persons with disabilities” (29). AT includes everything from low-tech items like weighted pens to more high-tech equipment, such as mouth-controlled wheelchairs. To learn more about forms of AT that may be useful to people with cerebral palsy, click here.
Preventing cerebral palsy
Since cerebral palsy is frequently the result of medical mistakes made during pregnancy, around the time of delivery, or in the neonatal period, it is often preventable. Because the effects of cerebral palsy can be severe, it is tragic that many cerebral palsy diagnoses may be the result of preventable medical errors and birth injuries.
Who is responsible for preventing cerebral palsy?
Medical professionals (including doctors, nurses, and midwives, among others) are required to meet a certain standard of care in order to prevent injury or harm to an expectant mother and her baby.
Medical personnel are responsible for:
- Providing proper prenatal care and recognizing risk factors for birth injury/cerebral palsy
- Taking actions to prevent birth injury or cerebral palsy (special caution must be taken if risk factors are present)
In particular, doctors should consider prescribing magnesium sulfate or betamethasone for babies who are likely to be born prematurely, because premature birth increases the likelihood of neonatal brain damage. When given in utero, these drugs can help to prevent cerebral palsy (30, 31).
Additionally, it is critical that medical professionals be well informed on pregnancy conditions and complications that make vaginal delivery dangerous and recommend a C-section if the safety of a mother or baby is in jeopardy. Many cases of cerebral palsy stem from the failure to perform a C-section when one is necessary.
Finally, research shows that birth-injured babies who are given therapeutic hypothermia (brain cooling or whole-body cooling) within the first hours of life have a decreased chance of having cerebral palsy, or may have a less severe form of the disorder.
Although it is solely the responsibility of medical professionals to prevent medical errors that can cause cerebral palsy, patients and their loved ones can also speak up with any questions or concerns they may have regarding their care. Many dangerous medical errors result from miscommunication between medical personnel and patients, so prioritizing clear, open communication with your doctors often helps.
Do you have a cerebral palsy case?
If a child’s cerebral palsy was caused by a birth injury, their family may be eligible for compensation to cover care, treatment, assistive technology, and other important resources. Unfortunately, a number of families avoid medical malpractice litigation for different reasons—some fear confrontation, some feel they don’t have the financial resources, some simply feel overwhelmed, and others doubt they have a case. The best—and only—way to find out if you have a cerebral palsy case is to reach out to an attorney for a legal consultation. An experienced birth injury attorney will do a thorough investigation of the medical records and review the case with expert medical professionals to determine whether negligent care was the cause of a child’s cerebral palsy. These case evaluations are free of charge. For that matter, if you pursue a case with ABC Law Centers, you pay nothing throughout the entire legal process unless we win. Reach out today to learn more.
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Video: Detroit, Michigan cerebral palsy attorneys discuss birth injuries and cerebral palsy
In this video, lawyers Jesse Reiter and Rebecca Walsh discuss how birth injuries and negligence can cause cerebral palsy, as well as a groundbreaking treatment that can prevent cerebral palsy. This treatment, known as therapeutic hypothermia, is the only known treatment for hypoxic-ischemic encephalopathy, a dangerous brain injury that often leads to cerebral palsy. Jesse and Rebecca also describe the symptoms to look for if you think your loved one may have cerebral palsy. To determine liability in a cerebral palsy case, the cerebral palsy attorneys and nurses at ABC Law Centers review hospital birth records, which include fetal monitoring strips, lab tests, and much more.
“When you see your child suffer because of someone’s mistake you want justice. As a mother you want someone in your corner to fight as hard as you would and I luckily found that in Jesse Reiter and his staff!” – Wendy, a former client
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