# 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.

**Symptoms**

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.

Therapies
              - 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.

Surgery
              - 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.

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## 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 FoundationPhone: 212-520-1686

Cerebral Palsy Research Network

Children's Hemiplegia and Stroke Association

Child Neurology FoundationPhone: 612-928-6325

Easter SealsPhone: 800-221-6827​​​​​

March of DimesPhone: 888-663-4637

*Eunice Kennedy Shriver*National Institute of Child Health and Human Development (NICHD)

Pathways.orgPhone: 800-955-2445

United Cerebral Palsy (UCP)Phone: 202-776-0406 or 800-872-5827

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