Cerebral palsy

About one in 400 children born alive has cerebral palsy (CP). 40% of CP cases are related to a premature birth and can be c
a number of foactors such as

Infection in early pregnancy

A difficult or premature birth

Bleeding in the baby's brain

Abnormal brain development in the baby (NHS 2012)

CP can be thought as an 'umbrella' term that describes a disorder of posture or movement. It is caused by injury to the immature brain. This usuall
during or shortly after birth (Gage 1991). The symptoms can range from mild to severe depending where the brain injury is, for example the motor
brain tends to be the most vulnerable or susceptible to brain injury during embryonic development.

CP can be classified into two categories, but in the interest of of patient respect and to maintain dignity, this should not be a method of labelling in
like many movment disorders, CP can be very distressing for the patient and parents.

In the past there has been confusion and disagreement with regards to the pathophysiology , and this was related to a lack of a universally accepte
classification system. In 1956 a classification was established and still used today (Gage 1991).

One classification is by the number of limbs that are affected. They are as follows,

Quadriplegia, where all 4 limbs are affected equally.

Diplegia, where all 4 limbs are affected however the legs are affected more severely than the arms.

Hemiplegia, where one side of the body is affected.

Triplegia, where 3 limbs are affected with the arms more severe.

Monoplegia, where only one arm is affected, usually an arm.

Another way of classifying CP is by movment, for example,

Spastic CP is the most common affecting the cerebral cortex accounts for 70% of patients. Symptoms include muscle imbalance with tightn
heavy resistance within the limbs.

Athetoid CP affects the basal ganglia. 20% of patients experience athetoid CP and can experience speech difficulties as well as movment di

Ataxic CP affects the brains major movment centre, the cerebellum. This accounts for 10% of CP cases.

In some cases it is possible to experience a combined condition, for example, Spastic quadriplegia is a very severe type where the patient may als
learning difficulties.
The photo below summarises movement disorder types.

As stated, CP is a movement disorder. Symptoms of CP depend on the type but all types will provide symptoms that involve tightness of muscles,
with balance and in severe cases, speech problems and difficulties co-ordinating oral movements.

Spasticity is defined as increased stretch reflex determined by passive flexing and extending muscle groups across a joint (Gage 1991). This is a m
when considering the gait in a patient with CP, as tightness and drawing of the muscles in the limbs make it very hard to achieve locomotion smoo
This is described in more detail in the following page.

The 'normal' gait

The gait cycle can be described as a series of events that occur during walking. Many muscles, joints, and neural pathways
communicate with the brain to ensure that transportation of the body occurs safely and efficiently with minimal expenditure of
energy.
The gait cycle can be defined as the time interval between two successive occurrences of one of the repetitive events of
walking (Whittle 2004).
In order to perform locomotion, the body must be able to achieve certain things, for example, each leg must be able to support
the body weight without collapsing, balance must be maintained throughout the whole gait cycle and the swing leg must be
able to achieve ground clearance and support the body one it makes ground contact. This all contributes to achieving
locomotion.
During locomotion, a complete gait cycle occurs once the heel of the foot makes ground contact and finishes when the same
heel makes the same ground contact.
There are two main phases during the gait cycle. They are the 'stance phase' and the 'swing' phase.

The above picture displays the gait cycle. Beginning from the left hand side we have heel strike of the left foot. The left foot
then goes through the stance phase which includes foot flat,heel raise and toe off. Once toe off has been achieved, the foot and
leg will then enter the swing phase. You can see circled above is the left foot achieving the swing phase and is about to heel
strike, thus performing one full gait cycle. The stance phase occurs when the foot is in ground contact, where the swing phase
occurs when there is no contact with the walking surface. The stance phase occurs for 60% of a whole gait cycle and the swing
phase occurs for 40%. The picture below describes this.

We are now going to detail the significant events that occur in the foot during the gait cycle. This section has been broken
down into 3 parts, (Initial contact/foot flat, Mid stance and Heel lift).
1. Initial contact
As we have already mentioned, initial contact and the gait cycle begins when the heel of the foot makes ground contact. At this
point the ankle joint is at a 90 degree position, or a neutral position but with a slightly supinated fore foot. Newtons 3rd law of
motion states that 'for every action, there is an opposite and equal reaction'. It is within this reference where plantar flexion of
the ankle joint occurs. The heel will strike the surface with force, creating an opposite and equal reaction, plantarflexing the
ankle and foot creating the loading response.

The picture to the left shows the human foot performing heel strike. Notice the neutral position of the ankle, prior to the
plantarflexion created by the ground reaction force and the almost fully extended knee joint.
In order to control the foot as it plantarflexes, the muscle tibialis anterior will contract eccentrically which de-accelerates the
loading phase while the foot pronates, and while the tibia rotates internally to achieve planter grade position on the surface.
The photo to the right shows the tibialis anterior muscle. When contracting concentrically its primary function is the dorsiflex
and invert the foot, but when contracting eccentrically it provides a controlled movement of plantarflexion. See muscles
contractures for more information on the different types of contractures.

2. Mid stance
The mid stance phase occurs between toe off on the opposite foot and heel life. The swing leg will pass at the time of mid
stance and at this time the ankle position will change from plantarflexion to dorsiflexion as the tibia moves over the ankle joint.

This picture shows the mid stance phase of the gait cycle. Notice the ankle is now in a dorsiflexed position and the knee is fully
extended.

3. Heel lift/propulsion
Heel lift phase creates a transition from mid stance to propulsion and begins when the heel begins to lift from the surface
caused by concentric actions of the gastrocnemius muscle. As the knee joint reaches peak extension the ankle will have
reached peak dorsiflexion and begins to plantar flex late on in the mid stance. The tibia will then externally rotate as the foot
supinates (this can be considered an opposite movement to when the foot makes initial contact). The toes will remain in ground
contact, but will dorsiflex at the metatarsal phalangeal joints.
Summary
Above are the main phases of the gait cycle. Each phase is paramount to achieving effective locomotion. There are also other
joints and muscles involved in the gait cycle. Hip flexors such as illiopasoas and muscles that perform flexion and extension at
the knee (quads and hammstrings) all play an important part in the gait cycle. The foot is a complex structure with many joints,
bones, muscles and tendons that all need to work in order to achieve successful locomotion.

This picture shows the main joints that are involved in the foot during walking.

Pathological gait, cerebral palsy

In a child with Cerebral palsy (CP), the central control system is damaged. As previously explained, the lesion can be eithe
athetoid or ataxic In a patient who has purely spacticity, only the pyramidal system is damaged; in athetoid CP only the
extrapyramidal system is involved while a mixed pattern can involve both systems.
(gage 1991)

It must be remembered that CP involves damage to the central nervous system, and that the changes to length and structu
bones and muscles are all secondary to the CNS lesion. Damage to the central control system will produce some or all of th
following features,
1. Loss of selective muscle control
2. Dependence on primitive reflex patterns for ambulation
3. Abnormal muscle tone
4. Relative imbalance between muscle agonists and antagonists across joints
5. deficient equilibrium reactions (gage,1991)

As previously mentioned either some or all of the above features will be present in a patient with CP. Therefore the gait th
patient will present with will express more than one symptom as these symptoms do not occur on their own and will be acc
by another abnormality.
Compensatory mechanisms are then forced into action in order to help the patient deal with the abnormalities.

A good example of this compensatory mechanism can involve the spaticity around the tricep surae muscle group. A decrea
muscle tone around the calf muscle can cause the foot to be constantly plantar flexed causing difficulties clearing the floor
during the swing phase of gait. The patient may introduce hip hiking or hip circumduction in order to ensure ground cleara

You can see here in the picture that the patient on the left side has a plantarflexed foot. He will most likely be using hip
circumduction or hip hiking as a compensatory mechanism in order to ensure his foot clears the ground, and does not 'drag

The Scissor gait

The patient on the right side of the picture is displaying the scissor gait. This gait abnormality is found in the most commo
in spastic cerebral palsy,usually found in spastic diplegic patients.

This patient will present with symptoms including ridigity and flexion of the knee joint. What is very common in this type o
over-adduction or hyper-adduction at the hip joint. This is what causes the patient to walk with the knees close together. T
contractures in the adductor muscles will pull the thigh region medially giving the scissor like appearance. Other contractu
force the patient to walk on their tip toes

Adduction, flexion and internal rotation are the 3 most common and noticeable features of this type of gait, all of which co
the scissor gait.

Refer to the video below, for an example of the Scissor gait.

YouTube Video

The Ataxic gait

The ataxic gait is considered to be a very unstable and uncoordinated walking style that is assisted with fast involuntary m

of the upper body extremities. The gait will be very irregular and the person will be walking with a wide base of gait in atte
provide stability. Tremors, typically seen in parkinson's disease will be present too, contributing to the instability of the ga

This type of gait differs from other types as the patient may experience mental problems as well, with mental retardation o
commonly found in this type of cerebral palsy.

There has been debate regarding levels of ataxia. Arguments have been made that an extremely mild ataxic patient should
referred to as 'apraxic'. Children who are 'apraxic' do not experience the clinical signs such as the poor coordination or poo
however they are unable to correctly or safely perform other motor skills such as skipping.

If motor limitations are minimal, and the impairment is so mild that orthopaedic care is unlikely, it is perhaps preferable to
termapraxia rather than labeling the child as having cerebral palsy. (Gage 1991).
Below is a video describing the ataxic gait, found in ataxic cerebral palsy.

YouTube Video

One thing is for sure, that is that each type of gait a patient with cerebral palsy experiences, will all have similar symptom

features. There are however specific changes and clinical observations that will define which type of gait that person posse
Certain features are common to all types of gait.

As mentioned in the normal gait chapter, in order to achieve normal and effective locomotion, the following 4 points must b
effective.

Stability

Sufficient foot clearance

Effective swing phase

Energy conservation.

In cerebral palsy, these 4 points are all lost.

When looking a the sagittal plane, two very common contractures and features are excessive flexion of the knee joint and
plantarflexion of the ankle joint. In most cases the knee will be flexed as a compensatory mechanism. This is due to rectus
being used to flex the hip which encourages the hammstrings to contract as an antagonistic, flexing the knee. Foot drop is
also due to the excessive plantar flexion of the the foot, however if the foot is excessively dorsiflexed, foot slap may occur.

Foot clearance tends to be a common problem. Even in normal gait, foot clearance is only around 2cm (Begg et al 2007). Th
you can understand why a patient who has spastic paralysis will find it hard to achieve a sufficient swing phase in order to
ground. Also due to poor ankle control and poor dorsiflexion/plantar flexion this will also provide difficulties when in the pr
phase of gait.

Other terms and language

There are a number of other words you may here to describe CP

These include:
Hypertonia- high muscle tone leading to stiffness
Hypotonia- low muscle tone which leads to floppiness
Dystonia muscle tone fluctuates between floppy and stiff
Rigidity Sustained stiffness of limbs
Spasm involuntary contraction of a muscle
Tremor rhythmic uncontrolled, repetitive movements
Minimal or mild CP Little obvious physical impairment but children experience poor coordination and clumsiness.
This can be associated with learning difficulties.
[4]

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Signs and Symptoms

Reaching the expected developmental benchmarks of infancy and childhood sitting, rolling over, crawling, standing and walking are a
matter of great joy for parents, but what if a childs developmental timetable seems delayed? There are many tell-tale signs that a child may
have cerebral palsy, but those factors can be indicative of many conditions.

Signs and symptoms of cerebral palsy

Signs of cerebral palsy are different from symptoms of cerebral palsy.
Signs are clinically identifiable effects of brain injury or malformation that cause cerebral palsy. A doctor will discern signs of a health concern during
the exam and testing.
Symptoms, on the other hand, are effects the child feels or expresses; symptoms are not necessarily visible.
Impairments resulting from cerebral palsy range in severity, usually in correlation with the degree of injury to the brain. Because cerebral palsy is a
group of conditions, signs and symptoms vary from one individual to the next.
The primary effect of cerebral palsy is impairment of muscle tone, gross and fine motor functions, balance, control, coordination, reflexes, and posture.
Oral motor dysfunction, such as swallowing and feeding difficulties, speech impairment, and poor facial muscle tone can also indicate cerebral palsy.
Associative conditions, such as sensory impairment, seizures, and learning disabilities that are not a result of the same brain injury, occur frequently
with cerebral palsy. When present, these associative conditions may contribute to a clinical diagnosis of cerebral palsy.
Many signs and symptoms are not readily visible at birth, except in some severe cases, and may appear within the first three to five years of life as the
brain and child develop.
In these instances, the most apparant early sign of cerebral palsy is developmental delay. Delay in reaching key growth milestones, such as rolling
over, sitting, crawling and walking are cause for concern. Practitioners will also look for signs such as abnormal muscle tone, unusual posture,
persistent infant reflexes, and early development of hand preference.
If the delivery was traumatic, or if significant risk factors were encountered during pregnancy or birth, doctors may suspect cerebral palsy immediately.
In moderate to mild cases of cerebral palsy, parents are often first to notice if the child doesnt appear to be developing on schedule. If parents do
begin to suspect cerebral palsy, they will likely want to ask their physician to evaluate their child for cerebral palsy.
Most experts agree; the earlier a cerebral palsy diagnosis can be made, the better.

However, some caution against making a diagnosis too early, and warn that other conditions need to be ruled out first. Because cerebral palsy is the
result of brain injury, and because the brain continues to develop during the first years of life, early tests may not detect the condition. Later, however,
the same test may, in fact, reveal the issue.
The earlier a diagnosis is made the sooner a child can be enrolled in early intervention programs and treatment protocols. Early interventions and
therapies have proven to help a child maximize their future potential. Early diagnosis also helps families qualify for government benefit programs to
pay for such measures.

Are you interested in learning more about the process of diagnosing or ruling out cerebral palsy?

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Eight clinical signs of cerebral palsy

Since cerebral palsy is most often diagnosed in the first several years of life, when a child is too young to effectively communicate his or her
symptoms, signs are the primary method of recognizing the likelihood of cerebral palsy.
Cerebral palsy is a neurological condition which primarily causes orthopedic impairment. Cerebral palsy is caused by a brain injury or brain
abnormality that interferes with the brain cells responsible for controlling muscle tone, strength, and coordination. As a child grows, these changes
affect skeletal and joint development, which may lead to impairment and possibly deformities.
The eight clinical signs include muscle tone, movement coordination and control, reflexes, posture, balance, gross motor function, fine motor function
and oral motor function. These are detailed below.

Muscle tone
The most noticeable sign of cerebral palsy is impairment of muscle tone the ability of muscles to work together by maintaining proper resistance.
Muscles coordinate with other muscles, oftentimes in pairs. As some muscles contract, others must relax. Even something as simple as sitting
requires coordination of many muscles; some flexing while others relax. The brain injury or malformation that caused cerebral palsy impairs the ability
of the central nervous system to coordinate muscle movement.
Proper muscle tone allows limbs to bend and contract without difficulty, enabling an individual to sit, stand, and maintain posture without assistance.
Improper muscle tone occurs when muscles do not coordinate together.
When this happens, those muscles that work in pairs biceps and triceps, for example may both contract or relax at the same time, impeding
movement and coordination. Trunk muscles might relax too much, making it difficult to maintain a tight core; this can result in impaired posture and an
inability to sit or to move from a sitting to standing position.

A child with cerebral palsy may demonstrate any combination of these signs. Different limbs may be affected by different impairments. The two most
common signs of abnormal muscle tone are hypotonia and hypertonia, but tone can be defined in other ways as well:

Hypotonia decreased muscle tone or tension (flaccid, relaxed, or floppy limbs)

Hypertonia increased muscle tone or tension (stiff or rigid limbs)

Dystonia fluctuating muscle tone or tension (too loose at times and too tight at others)

Mixed the trunk of the body may be hypotonic while the arms and legs are hypertonic

Muscle spasms sometimes painful, involuntary muscular contraction

Fixed joints joints that are effectively fused together preventing proper motion

Abnormal neck or truncal tone decreased hypotonic or increased hypertonic, depending on age and cerebral palsy type

Clonus muscular spasms with regular contractions

o

Ankle/foot clonus spasmodic abnormal movement of the foot

Wrist clonus spasmodic movement of the hand

Movement coordination and control

The impairment of muscle tone affects a childs limbs and body in different ways, although all children with cerebral palsy will likely feel some effect on
muscle control and coordination. Different muscle control impairments can combine to cause limbs to be perpetually extended, contracted, constantly
moving in rhythmic patterns or jerking spastically.
Some signs will be more apparent when the child is under stress. Some may be task related, such as reaching for an object. Sometimes signs will
seem to disappear when the child is asleep and muscles are relaxed.
It is common for a child to experience different types of impaired muscle control in opposite limbs. Coordination and control can likewise be affected
differently in each limb.
The impairment of coordination and control fall under the following types:

Spastic movements hypertonic movements where the muscles are too tight resulting in muscle spasms, scissoring of the legs, clonus,
contracture, fixed joints, and over-flexed limbs

Athetoid or dyskinetic movements fluctuating muscle tone causing uncontrolled, sometimes slow, writhing movements which can worsen
with stress

Ataxic movements - poor coordination and balance making tasks such as writing, brushing teeth, buttoning shirts, tying shoes, and putting
keys into slots difficult

Mixed movements a mixture of movement impairments, most commonly a combination of spastic and athetoid types, affecting different
limbs

Gait disturbances control impairments affecting the way a child walks

Gait disturbances include:

In-toeing toes angle or rotate inward

Out-toeing - toes angle or rotate outward

Limping - more weight is placed on one foot than the other, causing a dipping, or wavy stride

Toe walking the weight is unevenly placed on the toes

Propulsive gait a child walks hunched over in a stiff posture with the head and shoulders bent forward

Spastic and scissor gait - the hips flex slightly making it look like the child is crouching while knees and thighs slide past one another like
scissors

Spastic gait one leg drags due to muscle spasticity

Steppage gait toes drag because the foot drags

Waddling gait - duck-like walking pattern that can appear later in life

Reflex
Reflexes are involuntary movements the body makes in response to a stimulus. Certain primitive reflexes are present at or shortly after birth, but
disappear at predictable stages of development as the child grows. Specific reflexes that do not fade away or those that dont develop as the child
grows can be a sign of cerebral palsy.
Certain abnormal reflexes may also indicate cerebral palsy. Hyperreflexia are excessive reflex responses that cause twitching and spasticity.
Underdeveloped or lacking postural and protective reflexes are warning signs for abnormal development, including cerebral palsy.

Abnormal primitive reflexes may not function properly in children with cerebral palsy, or they may not disappear at specific points in development as
they do with children with no impairment. Common primitive reflexes that may improperly function or persist include, but are not limited to:
Common primitive reflexes that may improperly function or persist include, but are not limited to:

Asymmetrical tonic reflex when the head turns, the legs on the same side will extend, and the opposite limbs contract like in a fencing
pose. Asymmetrical tonic reflex should disappear around six months of age.

Symmetrical tonic neck reflex the infant assumes a crawling position when the head is extended. Symmetrical tonic neck reflex should
disappear between eight and 11 months.

Spinal gallant reflexes when the infant lies on its stomach, the hips will turn towards the side of the body that is touched. Spinal gallant
reflexes should disappear between three and nine months.

Tonic labyrinthine reflex when the head is tilted back, the back arches, the legs straighten, and the arms bend. Tonic labyrinthine reflex
should disappear by three-and-a-half years of age.

Palmer grasp reflex when stimulating the palm the hand flexes in a grasping motion. Palmer grasp reflex should disappear around four to
six months.

Placing reflex when an infant is held upright and the back of a foot touches the surface, the legs will flex. Placing reflex should disappear by
five months.

Moro (startle) reflex when the infant is tilted so his or her legs are above their head, the arms will extend. Moro reflex should disappear by
six months.

Early hand preference can also indicate possible impairments. A child normally develops hand preference in his or her second year. As this is a wide
timeframe and rough average, development of hand preference, especially if it is early preference, is cause for concern. Various sources state that
early hand preference falls between six-18 months.

Posture
Cerebral palsy affects posture and balance. Signs may appear as an infant begins to sit up and learn to move about. Typically, posture is expected to
be symmetrical. For example, a baby in a sitting position would normally have both legs in front. When bent, they become mirror images of one
another.
Asymmetrical posture means the right and left limbs will not mirror one another. The hip-joints are one area where this is often prominent in instances
of cerebral palsy. One leg will bend inward at the hip, and the other will bend outward.
Much like reflexes, postural responses are expected reactions when putting a baby in certain positions. They typically appear as the baby develops.
Impairment may be a possibility if the responses do not develop, or if they are asymmetric.
Much like reflexes, postural responses are expected reactions when putting a baby in certain positions. They typically appear as the baby develops.
Impairment may be a possibility if the responses do not develop, or if they are asymmetric.

Common postural responses are:

Traction

Landau reflex when the infant is supported in a lying position, pushing the head down will cause the legs to drop, and lifting the head will
cause them to rise. This response appears around four or five months of age.

Parachute response when the infant is positioned with his or her head towards the ground, the infant should instinctively reach as if bracing
for impact. This response appears around eight to 10 months of age.

Head righting when an infant is swayed back and forth, his or her head will remain straight. This response appears around four months of
age.

Trunk righting when a sitting infant is quickly pushed to the side, the infant will resist the force and use opposite hand and arm to brace
against impact. This response appears around eight months of age.

Balance
The impairment of gross motor function can affect a childs ability to balance. Signs become recognizable as a child learns to sit, rise from a sitting
position, and begins crawling or walking. Infants need to use their hands often as they learn these skills. They develop the strength, coordination, and
balance to accomplish the task when mastering it without the use of their hands.
A childs inability to sit without support can be a sign of cerebral palsy. The Gross Motor Function Classification System, or GMFCS, a five-level
system commonly used to classify function levels, uses balance while sitting as part of its severity level system.
Signs to look for when a child sits include:

Requiring both hands for support

Having difficulty balancing when not using hands for support

Unable to sit without using hands for support

Other signs to look for include, but are not limited to:

Swaying when standing

Unsteady when walking

Difficulty making quick movements

Needing hands for activities that require balance

Walking with abnormal gait

Balance is often the same whether a childs eyes are open or closed. Balance impairment is most often associated with ataxic, and to a lesser degree,
spastic cerebral palsy.

Gross motor function

As a child develops, signs of impaired or delayed gross motor function may be noticeable. The ability to make large, coordinating movements using
multiple limbs and muscle groups is considered gross motor function.
Gross motor function may be impaired by abnormal muscle tone, especially hypertonia or hypotonia.
For example, hypertonic limbs can be too tight, or inflexible, to allow proper flexion and movement; whereas hypotonic limbs may be too loose to
properly support a childs movements.
As a babys brain and body develop, they are expected to reach developmental milestones. Reaching the milestone later than expected, or reaching it
but with low quality of movement (such as favoring one side while crawling), are possible signs of cerebral palsy.

Impaired gross motor functions limited capability of accomplishing common physical skills such as walking, running, jumping, and
maintaining balance.

Delayed gross motor functions physical skills developed later than expected; often used in conjunction with developmental milestones for
predictable stages of development.

Significant milestones of gross motor function include:

Rolling

Sitting up

Crawling

Standing

Walking

Balancing

These should be monitored to note when the baby reaches the milestone, and the quality of movement.

Fine motor function

Executing precise movements defines the category of fine motor function. Fine motor control encompasses many activities that are learned, and
involve a combination of both mental (planning and reasoning) and physical (coordination and sensation) skills to master.
Impaired or delayed fine motor skills are an indicator of possible cerebral palsy. Intention tremors, where a task becomes more difficult as it gets closer
to completion, is one such sign.
Examples of fine motor function development are:

Grasping small objects

Holding objects between thumb and forefinger

Setting objects down gently

Using crayons

Turning pages in a book

Oral motor function

Difficulty in using the lips, tongue, and jaw indicate impaired oral motor function; this is a sign that may be present in up to 90% of preschool-aged
children diagnosed with cerebral palsy. Signs of oral motor function impairment include, but are not limited to difficulty with:

Speaking

Swallowing

Feeding/chewing

Drooling

Speech requires proper intellectual and physical development. Cerebral palsy impairs the physical aspects of speaking by improperly controlling the
muscles required to speak. Oral motor impairment can affect:

Breathing the lungs, and specifically the muscles controlling inhalation and exhalation necessary for proper speech patterns. The
diaphragm and abdominal muscles are important for proper air flow and posture.

Articulating muscles controlling the face, throat, mouth, tongue, jaw, and palate all must work together to form the proper shape necessary
for pronunciation of words and syllables.

Voicing vocal cords are controlled by muscles that essentially stretch the vocal folds between two regions of cartilage.

Apraxia, an inability of the brain to effectively transmit proper signals to the muscles used in speaking, is one type of speech impairment common to
cerebral palsy. It is divided into two types:

Verbal apraxia affects the articulation muscles, especially regarding the specific sequence of movements needed to carry out proper
pronunciation. It is common in children with hypotonia.

Oral apraxia affects the ability to make nonspeaking movements of the mouth, but is not related solely to speaking. Example of oral apraxia
would be the inability to lick the lips, or inflate the cheeks.

Dysarthria is another speech impairment common to cerebral palsy. Like apraxia it is a neurological impairment, as opposed to a muscular condition.
It is often found in cerebral palsy that result in hypertonia and hypotonia. Dysarthria is broken into the following subgroups:

Ataxic dysarthria slow, erratic, inarticulate speech caused by poor breathing and muscular coordination

Flaccid dysarthria nasal, whiny, breathy speech caused by the inability of the vocal chords to open and close properly. There may be
difficulty with consonants.

Spastic dysarthria slow, strenuous, monotone speech and difficulty with consonants

Mixed dysarthria all three may be present.

Drooling is another sign of cerebral palsy that results from muscles in the face and mouth not being able to properly control coordination. Some
specific factors which can contribute to drooling are impairments in:

Swallowing

Closing the mouth

Positioning the teeth

Inability to move saliva to back of mouth

Tongue thrusting

Feeding difficulties can be present with cerebral palsy. They typically manifest as decreased ability to chew and swallow, and may also involve
choking, coughing, gagging, and vomiting.

12-Step Process
for Diagnosing Cerebral Palsy
Parents that suspect a child has cerebral palsy likely wish that a one-step, quick test would confirm that diagnosis. That, however, is not
how physicians make a determination regarding cerebral palsy. Getting to a diagnosis is a multi-step, complex process of tests,

evaluations, and eliminations that in the end, rule everything else out. Understanding the diagnosis process can be a source of comfort for
parents anxious about the process.

The process of diagnosis

The process for diagnosing cerebral palsy involves monitoring the childs development and watching for possible signs of impairment. If a baby is born
prematurely, or at a low birth weight, he or she is monitored closely in the neonatal intensive care unit of the hospital. If the infant attends regular wellbaby visits, during examination of the child the pediatrician may be first to notice signs of cerebral palsy. In some cases, it is the parents who notice
symptoms they relay to the childs doctor.
Parents are often disheartened to learn that there is no singular test that will definitively diagnose a child with cerebral palsy. Once a round of medical
evaluations are initiated in order to form a diagnosis, parents prepare for a long and sometimes frustrating process that will, in time, provide answers
about a childs condition.
The diagnosis process can seem intimidating. Understanding the diagnosis process can be a source of comfort for parents anxious about the process.
The 12-Step Diagnostic Process entails the following steps:

Step 1: Parental Observation

Step 2: Clinical Observations

Step 3: Motor Skill Development Analysis

Step 4: Medical History Review

Step 5: Documenting Associative Conditions, Co-Mitigating Factors, and Ruling-Out Other Conditions

Step 6: Obtaining Test Results

Step 7: Diagnosis

Step 8: Obtaining a Second Opinion

Step 9: Determining Cause

Step 10: Care Team Assembly

Step 11: Care Plan Creation

Step 12: Embracing a Life with Cerebral Palsy

These steps are detailed below.

Step 1: Parental Observations

Outside severe cases, which are often diagnosed at or within days of birth, parents may question noticeable signs. The primary indicators parents will
notice are developmental delay and impaired muscle tone.
Developmental delay occurs when a child does not develop specific skills within the predicted time period. Parents might notice the child is not
reaching for toys at three or four months, sitting up by six or seven months or walking at 12-14 months. In some cases, the child might appear to
develop motor skills ahead of schedule. Rolling over is a significant milestone, but when rolling occurs too early, it can be a sign of abnormal reflexes.
It can also indicate spasticity. Demonstrating hand preference before 12 months is also an indicator of possible cerebral palsy.
Muscle tone is another indicator. Normally, muscles contract when a limb is flexed and relax when the limb is extended. Muscles that are very tight, or
inappropriately relaxed, can be a sign of cerebral palsy, which directly affects muscle tone and posture. Tremors are also a sign.

Additionally, parents may notice the child seems stiff, has problems swallowing, does not appear to hear or has eyes that do not seem to focus. The
child may experience gastrointestinal problems, such as vomiting, constipation, or bowel obstruction. Some children demonstrate impaired oral-motor
function with signs of vomiting, aspiration pneumonia, failure to thrive, drooling or communication difficulties. One half of children with cerebral palsy
experience seizure activity. Any of these signs, or others, should be discussed with the childs primary care physician, preferably during well-baby
visits.

Step 2: Clinical Observations

Parent observations are an important part of a doctors evaluation. Pediatricians use parental input as a basis for further examination. They will
explore signs parents notice and gauge the possibility of impairment. Well-baby visits are designed for clinical documentation of developmental
milestones. Height, weight, reflex, and age-appropriate behavior are part of developmental surveillance recommended by the American Academy of
Pediatrics for infants at the ages of nine months, 18 months, and 30-months of age. When surveillance of a child spurs concern, the Academy
recommends standardized developmental screening tool assessment and early return visits.
In addition, doctors will look for the persistence of primitive reflexes that, in typical development, appear and disappear in a predictable order during
infancy. The tonic reflex (when the babys head is turned to the side, the baby will extend the arm on the side the head is facing, while flexing the other
arm) appears around four months and then fades away. It is not a strong reflex, yet in children with cerebral palsy the tonic reflex does not always
fade, and sometimes continues to grow stronger, even dominating a childs motor skills. Doctors examine the childs supine position (retraction of the
head, neck and shoulders); prone position (protective head turns, arm flexor spasticity, and extensor spasticity of legs); and upright posture (extensor
spasticity of legs, reflexes, and protective arm extension).
Many other reflexes develop, then disappear over time. Doctors test and document the childs development. The information recorded in these records
is then used to confirm or rule out cerebral palsy or other conditions.

Step 3: Motor Skill Development Analysis

The cause of cerebral palsy is either brain injury or brain malformation occurring during fetal development, birth, or after birth while the brain is still
developing. The brain damage occurs in parts of the brain that affect motor control. It does not progress, which differentiates cerebral palsy from
similar conditions. Motor skill development analysis is used at various intervals to gauge key developmental milestones. The following are essential in
determining the extent, location, and severity of cerebral palsy:
In the case of cerebral palsy, developmental motor delay is a key indicator. The pediatrician will be evaluating:

Muscle tone

Movement coordination and control

Reflex irregularity

Posture

Balance

Fine motor function

Gross motor function

Oromotor function

The evaluation of motor skills may help establish the type(s) of impairment and degree of severity. This is essential in determining the cause or source
of impairment. The severity of impairment also may be necessary in qualifying for benefits and support services.

Step 4: Medical History Review

Eliminating other possibilities is a crucial factor in diagnosis of cerebral palsy. Both parents medical histories are important to this process. By
reviewing medical history of parents, doctors can look for possible genetic, progressive, or degenerative nervous system disorders. Economic status
and social habits may also be reviewed.
Doctors will also want to know about the childs prenatal history, as well as any complications during labor and delivery.

Step 5: Documenting Associative Conditions, Co-Mitigating Factors and

Ruling-Out Other Conditions
Because there is no test that definitely confirms or rules out cerebral palsy, there is always a chance other conditions must be excluded from a list of
possibilities, and cerebral palsy must be fully considered. Other disorders and conditions can appear as cerebral palsy, and cerebral palsy is often
accompanied by associated conditions that complicate the process of diagnosis.
The medical examination process can involve multiple doctors, tests, and appointments. During this time doctors will rule out other similar conditions
such as:

Degenerative nervous disorders

Genetic diseases

Muscle diseases

Metabolism disorders

Nervous system tumors

Coagulation disorders

Other injuries or disorders which delay early development, some of which can be outgrown

The brain injury or malformation that caused cerebral palsy is non-progressive. Many nervous system disorders do progress. They may start with
minor symptoms, but over time, the symptoms continue to worsen or multiply. If the childs condition is showing signs of progression, these signs will
help doctors rule out a cerebral palsy diagnosis. Like many aspects of diagnosing cerebral palsy, this requires observation over time.

Step 6: Obtaining Test Results

Many screens, tests and medical specialists are part of the process of diagnosis. Every state mandates newborn screens at the time of birth. The tests
performed vary by state, but may yield some early results.
Infants who test positive for a developmental delay may be referred to medical specialists for further evaluations. The pediatrician will document all
surveillance, screening, evaluation, and referral activities in the childs health record. It is suggested that parents request a written copy of all test
results and advice rendered, as well as any other information presented at various visits to the the doctors office. These documents become valuable
when speaking with the multitude of practitioners that may be required in the childs future care. Having the documents on hand will save money and
allow parents to be informed and efficient.
Common tests that involve neurologists or neuroradiologists, include neuroimaging, such as cranial ultrasound, computed tomography scan (CT
Scan), and magnetic resonance imaging scans (MRIs). These tests allow neurologists to actually see the brain. Various disorders, injuries, and
conditions yield different results. These can be used to rule out cerebral palsy. Or, if cerebral palsy is eventually diagnosed, they can provide doctors
an exact picture of the injury to the brain. Blood tests may be ordered to check chemistry, plasma and chromosome levels. Seizure activity will be
monitored.
Medical specialists are brought in to test hearing, vision, and perception, as well as cognitive, behavioral, and physical development. A child may be
sent to an orthopedic surgeon to ascertain delay in motor development, record persistence of primitive reflexes, examine for dislocated hips, and
check on abnormal postural reactions.

A genetic specialist may look for hereditary components.

The lengthy and detailed process can help rule out or confirm cerebral palsy, while also providing a broader assessment of the childs abilities.

Step 7: Diagnosis
The months or years it takes to confirm a cerebral palsy diagnosis does not lessen the impact of the news. It can be an emotional moment for parents.
Many issues that surround the diagnosis of cerebral palsy do not have anything to do with the medical tests and observations necessary to confirm
the condition. For example, parents may initially shy away from the news, especially if they were fostering hope that their child would outgrow the
condition. The diagnosis may bring a mixture of fear, guilt, or apprehension. Some parents wonder if the cause of the childs impairment is somehow
their fault, or whether they did something wrong. Others may be relieved that their child has a physical impairment, but is expected to live a full, long
life.
Doctors, likewise, may not want to deliver a cerebral palsy diagnosis until they are fully certain. A major fear is that a diagnosis of cerebral palsy will
interfere with bonding between parents and child. Doctors do not want to misdiagnose the condition and cause undue stress.
Doctors and parents are aware that early diagnosis can lead to early intervention options. Some treatment protocols have proven more effective when
provided early. A formal diagnosis is required to obtain government benefits that help a family mitigate the financial burden as expenses for ongoing
testing and medical care pile up.
Debate exists over the best time to diagnose cerebral palsy. Issues surrounding the timeliness of diagnosis focus on three areas:

Early diagnosis Early diagnosis can lead to early intervention, treatments, therapies, funding and benefit programs. It can result in
misdiagnosis.

Delayed diagnosis A delay in diagnosis can allow time for the family to bond before the condition is known. It allows time to observe
developmental milestones; rule out other conditions; and confidently confirm cerebral palsy.

Misdiagnosis Misdiagnosis can occur if signs are not properly monitored, tested, and confirmed. Or, when other conditions arent ruled out
properly. The diagnosis of cerebral palsy may be correct, but the severity, extent, or co-mitigating factors may be improperly diagnosed.

Step 8: Obtaining a Second Opinion

Parents may seek a second opinion to confirm the diagnosis of cerebral palsy and to rule out the possibility of misdiagnosis. A diagnosis of cerebral
palsy is enough to warrant a second opinion. Additional factors that might increase the need for a second opinion include:

When surgery is presented as a treatment option

When there are many possible treatment options

When the proposed treatment is unsatisfactory for any reason

When no treatment is presented

When parents just feel they require another opinion

The current doctor should not be offended if parents ask for a referral for a second opinion by explaining that this is a complicated and important issue
for the family. Those who feel uncomfortable asking one provider for a referral may ask another trusted family doctor, or their health insurance provider
network. The costs and procedure for seeking a second opinion vary depending on the health care provider, and parents should therefore discuss the
intention of seeking a second opinion with their health insurance provider to fully ascertain whether it will be covered under the insurance plan.
Second opinions can assist with outstanding questions; remove any doubts; provide a second opinion on treatment options; and allow for a more
informed, educated decision on appropriate treatment when moving forward.

Step 9: Determining Cause

Brain injury or brain malformation is the root cause of cerebral palsy. There are three types of brain injury and a form of brain malformation:

Periventricular leukomalacia (PVL) damage to the white matter of the brain tissue

Intracranial hemorrhage (IVH) brain hemorrhage

Hypoxic-ischemic encephalopathy (HIE) or intrapartum asphyxia lack of oxygen to the brain (asphyxia)

Cerebral dysgenesis brain malformation or abnormal brain development

The Academy of Pediatrics recommends that parents attempt to discern what caused the brain damage and at what point in the developmental
process the damage occurred. According to the Academy, cause of brain damage can be identified in approximately 25% of all cases. Identifying the
root cause will provide the following benefits:

Greater understanding of the childs impairment

Identify whether there is recurrent risk in future pregnancies or family planning

Identify specific medical treatments

Identify therapeutic intervention programs

Identify early intervention education programs

Identify government assistance, community resources, benefit programs, and funding sources

Further research for prevention and cures

Step 10: Care Team Assembly

One of the most important components of parenting a child with cerebral palsy is the responsibility of assembling the proper doctors, therapists,
educators, and organizations to provide the best care, treatment, and support for the child. The goal is to assemble resources that will help the child
succeed.
A care team can evolve over time and is subject to immediate and long-term needs of the child. The team consists of professionals from different
specialties, such as:

Caregivers daycare, respite, personal assistants, and guide dogs

Support organizations MyChild, cerebral palsy organizations, community support groups, disability organizations, counseling services,
friends, and family

Educators school administrators, teachers, speech therapists, and special education support staff

Lawyers lawyers concentrating in estate planning, disability rights, birth injury, family law, SSI, school rights, medical malpractice, and more

Government agencies government agencies (federal, state and local) offering benefits, education programs, information resources,
disability guidance, health care options, advocacy, and research

Tax and financial planners accountants and financial planners that advise in special needs tax advantages, financial planning, wills and
trusts, and planning for future expenses

Many health care professionals may assist throughout the childs life. Some will only be seen for specific needs such as diagnosis, whereas others
may oversee the childs overall treatment plan well into adulthood. Medical professionals often utilized in the diagnosis process include:

Pediatricians care for children from birth through early adulthood

Neurologists specialize in the nervous system of children, particularly neurological disorders and diagnosing the brain injury or
malformation that caused the childs cerebral palsy

Ophthalmologists focus on the eyes and visual pathways

Orthopedic surgeons specialize in motor development disorders, bones, joints, ligaments, tendons, and muscles.

Otologists study the ear, its diseases, and disorders

Neonatologists medical professionals who typically work in the neonatal intensive care units (NICU) who specialize in the care of newborn
infants, in particular the ill or premature babies

Geneticists study genetics and heredity disorders

However, depending on the childs signs and symptoms or the treatment protocol required, the following practitioners may also become involved in the
childs treatment plan at some point in the childs life span:

Audiologist

Behavioral Therapist

Counselors and Social Workers

Dentists/Orthodontists

Developmental Behavioral Specialists

Developmental Pediatrician

ENT/Otorhinolangologist

Geneticists

Neonatologists

Neurologists

Neuroradiologists

Nutritionists

Obstetrics Gynecologists

Occupational Therapist

Ophthalmologists

Orthopedist/Orthopedic Surgeons

Orthotist

Otologists

Pediatrician

Physical Therapists

Psychologist

Rehabilitation Medicine Specialist

Researchers

Speech and Language Pathologists

Urologists

A leader is essential to the success of the care team. Ideally, this would be the childs primary care physician who coordinates with the other health
professionals. Oftentimes doctors work in isolation, unaware of the treatments and therapies others may be utilizing. This can be counterproductive. A
leader can ensure all professionals involved in treating the child are aware of each others concerns, treatment goals, and progress. This allows the
care team to work together and optimize the childs treatment.
Sometimes doctors are unable or unwilling to take on the responsibility of being a childs care team leader. In this case a parent or guardian is best
suited to fill the role. Even if a doctor does assume the lead, the parent or guardian should maintain care plan documentation and save important
documentation related to the childs care. These documents can then be easily reviewed by others considering the childs care.
Medical records are essential to the care plan and coordinating the care team. Parents can request copies of their childs medical records.
Occasionally, parents may be asked to pay a fee to obtain the records, but if this cannot be afforded, doctors or hospital staff may have ways of
assisting.

Step 11: Care Plan Creation

A care plan tracks a childs treatment, including tests, diagnosis, and treatments received. This allows parents to share information between members
of the care team. The care plan is a diary of events, a scrapbook of medical records, a game plan for future treatment goals, and a collection of test
results. It is a history of the childs care and progress.
The care plan is more, though. Establishing and maintaining a care plan allows easy, efficient access to valuable information. Keeping receipts
organized helps in obtaining tax benefits. Medical records and test results may be required in an application for benefits and funding. Planning
treatment protocols can help parents plan for financial needs, while wills and trusts provide for future care of the child in the event the parent can no
longer support the child. Maintaining insurance records helps when paying bills; organized records provide peace-of-mind. Habits lead to efficiency,
and sharing thoughts, feelings and hopes can be inspiring when reviewing progress years later.
The care plan will continue to benefit the child, and those who will care for them, throughout the childs life.

Step 12: Embracing a Life with Cerebral Palsy

Raising a child who has cerebral palsy creates fresh challenges for the whole family. Research indicates a household with a special needs child is
more prone to depression, suicide, financial strain, relationship challenges, divorce, and bankruptcy. Others will boast that it can bring relationships
together with purpose.
Embracing a life with cerebral palsy requires planning, organization, perspective, adaptation, and inspiration. For parents, a review of their childs care
plan provides a chronology of choices theyve made, steps theyve taken, learning theyve experienced, and a glimpse at their hopes and dreams for
tomorrow; a true source of pride and accomplishment. Many learn how to embrace a life with cerebral palsy somewhere inside the journey itself.