Cerebral Palsy: Hope Through Research
Table of Contents:
In the 1860s, an English surgeon named William Little wrote the
first medical descriptions of a puzzling disorder that struck
children in the first years of life, causing stiff, spastic muscles
in their legs and, to a lesser degree, their arms. These children
had difficulty grasping objects, crawling, and walking. They did
not get better as they grew up nor did they become worse. Their
condition, which was called Little's disease for many years, is
now known as spastic diplegia. It is just one of several disorders
that affect control of movement and are grouped together under
the term cerebral palsy.
Because it seemed that many of these children were born following
premature or complicated deliveries, Little suggested their condition
resulted from a lack of oxygen during birth. This oxygen shortage
damaged sensitive brain tissues controlling movement, he proposed.
But in 1897, the famous psychiatrist Sigmund Freud disagreed.
Noting that children with cerebral palsy often had other problems
such as mental retardation, visual disturbances, and seizures,
Freud suggested that the disorder might sometimes have roots earlier
in life, during the brain's development in the womb. "Difficult
birth, in certain cases," he wrote, "is merely a symptom
of deeper effects that influence the development of the fetus."
Despite Freud's observation, the belief that birth complications
cause most cases of cerebral palsy was widespread among physicians,
families, and even medical researchers until very recently. In
the 1980s, however, scientists analyzed extensive data from a
government study of more than 35,000 births and were surprised
to discover that such complications account for only a fraction
of cases -- probably less than 10 percent. In most cases of cerebral
palsy, no cause of the factors explored could be found. These
findings from the NINDS perinatal study have profoundly altered
medical theories about cerebral palsy and have spurred today's
researchers to explore alternative causes.
At the same time, biomedical research has also led to significant
changes in understanding, diagnosing, and treating persons with
cerebral palsy. Risk factors not previously recognized have been
identified, notably intrauterine exposure to infection and disorders
of coagulation, and others are under investigation. Identification
of infants with cerebral palsy very early in life gives youngsters
the best opportunity to receive treatment for sensory disabilities
and for prevention of contractures. Biomedical research has led
to improved diagnostic techniques such as advanced brain imaging
and modern gait analysis. Certain conditions known to cause cerebral
palsy, such as rubella (German measles) and jaundice, can now
be prevented or treated. Physical, psychological, and behavioral
therapy that assist with such skills as movement and speech and
foster social and emotional development can help children who
have cerebral palsy to achieve and succeed. Medications, surgery,
and braces can often improve nerve and muscle coordination, help
treat associated medical problems, and either prevent or correct
deformities.
Much of the research to improve medical understanding of cerebral
palsy has been supported by the National Institute of Neurological
Disorders and Stroke (NINDS), one of the federal government's
National Institutes of Health. The NINDS is America's leading
supporter of biomedical research into cerebral palsy and other
neurological disorders. Through this publication, the NINDS hopes
to help the more than 4,500 American babies and infants diagnosed
each year, their families, and others concerned about cerebral
palsy benefit from these research results.
top
Cerebral palsy is an umbrella-like term used to describe a group
of chronic disorders impairing control of movement that appear
in the first few years of life and generally do not worsen over
time. The term cerebral refers to the brain's two halves, or hemispheres,
and palsy describes any disorder that impairs control of body
movement. Thus, these disorders are not caused by problems in
the muscles or nerves. Instead, faulty development or damage to
motor areas in the brain disrupts the brain's ability to adequately
control movement and posture.
Symptoms of cerebral palsy lie along a spectrum of varying severity.
An individual with cerebral palsy may have difficulty with fine
motor tasks, such as writing or cutting with scissors; experience
trouble with maintaining balance and walking; or be affected by
involuntary movements, such as uncontrollable writhing motion
of the hands or drooling. The symptoms differ from one person
to the next, and may even change over time in the individual.
Some people with cerebral palsy are also affected by other medical
disorders, including seizures or mental impairment. Contrary to
common belief, however, cerebral palsy does not always cause profound
handicap. While a child with severe cerebral palsy might be unable
to walk and need extensive, lifelong care, a child with mild cerebral
palsy might only be slightly awkward and require no special assistance.
Cerebral palsy is not contagious nor is it usually inherited from
one generation to the next. At this time, it cannot be cured,
although scientific research continues to yield improved treatments
and methods of prevention.
top
The United Cerebral Palsy Associations estimate that more than
500,000 Americans have cerebral palsy. Despite advances in preventing
and treating certain causes of cerebral palsy, the number of children
and adults it affects has remained essentially unchanged or perhaps
risen slightly over the past 30 years. This is partly because
more critically premature and frail infants are surviving through
improved intensive care. Unfortunately, many of these infants
have developmental problems of the nervous system or suffer neurological
damage. Research is under way to improve care for these infants,
as in ongoing studies of technology to alleviate troubled breathing
and trials of drugs to prevent bleeding in the brain before or
soon after birth.
top
What Are the Different Forms?
Spastic diplegia, the disorder first described by Dr. Little
in the 1860s, is only one of several disorders called cerebral
palsy. Today doctors classify cerebral palsy into four broad categories
-- spastic, athetoid, ataxic, and mixed forms -- according to
the type of movement disturbance.
Spastic cerebral palsy. In this form of cerebral palsy, which
affects 70 to 80 percent of patients, the muscles are stiffly
and permanently contracted. Doctors will often describe which
type of spastic cerebral palsy a patient has based on which limbs
are affected. The names given to these types combine a Latin description
of affected limbs with the term plegia or paresis, meaning paralyzed
or weak. The four commonly diagnosed types of spastic cerebral
palsy are illustrated in the figure.
When both legs are affected by spasticity, they may turn in and
cross at the knees. As these individuals walk, their legs move
awkwardly and stiffly and nearly touch at the knees. This causes
a characteristic walking rhythm, known as the scissors gait.
Individuals with spastic hemiparesis may also experience hemiparetic
tremors, in which uncontrollable shaking affects the limbs on
one side of the body. If these tremors are severe, they can seriously
impair movement.
Athetoid, or dyskinetic, cerebral palsy. This form of cerebral
palsy is characterized by uncontrolled, slow, writhing movements.
These abnormal movements usually affect the hands, feet, arms,
or legs and, in some cases, the muscles of the face and tongue,
causing grimacing or drooling. The movements often increase during
periods of emotional stress and disappear during sleep. Patients
may also have problems coordinating the muscle movements needed
for speech, a condition known as dysarthria. Athetoid cerebral
palsy affects about 10 to 20 percent of patients.
Ataxic cerebral palsy. This rare form affects the sense of balance
and depth perception. Affected persons often have poor coordination;
walk unsteadily with a wide-based gait, placing their feet unusually
far apart; and experience difficulty when attempting quick or
precise movements, such as writing or buttoning a shirt. They
may also have intention tremor. In this form of tremor, beginning
a voluntary movement, such as reaching for a book, causes a trembling
that affects the body part being used and that worsens as the
individual gets nearer to the desired object. The ataxic form
affects an estimated 5 to 10 percent of cerebral palsy patients.
Mixed forms. It is common for patients to have symptoms of more
than one of the previous three forms. The most common mixed form
includes spasticity and athetoid movements but other combinations
are also possible.
top
Many individuals who have cerebral palsy have no associated medical
disorders. However, disorders that involve the brain and impair
its motor function can also cause seizures and impair an individual's
intellectual development, attentiveness to the outside world,
activity and behavior, and vision and hearing. Medical disorders
associated with cerebral palsy include:
- Mental impairment. About one-third
of children who have cerebral palsy are mildly intellectually
impaired, one-third are moderately or severely impaired, and
the remaining third are intellectually normal. Mental impairment
is even more common among children with spastic quadriplegia.
- Seizures or epilepsy. As many
as half of all children with cerebral palsy have seizures. During
a seizure, the normal, orderly pattern of electrical activity
in the brain is disrupted by uncontrolled bursts of electricity.
When seizures recur without a direct trigger, such as fever,
the condition is called epilepsy. In the person who has cerebral
palsy and epilepsy, this disruption may be spread throughout
the brain and cause varied symptoms all over the body -- as
in tonic-clonic seizures -- or may be confined to just one part
of the brain and cause more specific symptoms -- as in partial
seizures.
Tonic-clonic seizures generally cause patients to cry out and
are followed by loss of consciousness, twitching of both legs
and arms, convulsive body movements, and loss of bladder control.
Partial seizures are classified as simple or complex. In simple
partial seizures, the individual has localized symptoms, such
as muscle twitches, chewing movements, and numbness or tingling.
In complex partial seizures, the individual may hallucinate, stagger,
perform automatic and purposeless movements, or experience impaired
consciousness or confusion.
- Growth problems. A syndrome
called failure to thrive is common in children with moderate-to-severe
cerebral palsy, especially those with spastic quadriparesis.
Failure to thrive is a general term physicians use to describe
children who seem to lag behind in growth and development despite
having enough food. In babies, this lag usually takes the form
of too little weight gain; in young children, it can appear
as abnormal shortness; in teenagers, it may appear as a combination
of shortness and lack of sexual development. Failure to thrive
probably has several causes, including, in particular, poor
nutrition and damage to the brain centers controlling growth
and development. In addition, the muscles and limbs affected
by cerebral palsy tend to be smaller than normal. This is especially
noticeable in some patients with spastic hemiplegia, because
limbs on the affected side of the body may not grow as quickly
or as large as those on the more normal side. This condition
usually affects the hand and foot most severely. Since the involved
foot in hemiplegia is often smaller than the unaffected foot
even among patients who walk, this size difference is probably
not due to lack of use. Scientists believe the problem is more
likely to result from disruption of the complex process responsible
for normal body growth.
- Impaired vision or hearing.
A large number of children with cerebral palsy have strabismus,
a condition in which the eyes are not aligned because of differences
in the left and right eye muscles. In an adult, this condition
causes double vision. In children, however, the brain often
adapts to the condition by ignoring signals from one of the
misaligned eyes. Untreated, this can lead to very poor vision
in one eye and can interfere with certain visual skills, such
as judging distance. In some cases, physicians may recommend
surgery to correct strabismus. Children with hemiparesis may
have hemianopia, which is defective vision or blindness that
impairs the normal field of vision of one eye. For example,
when hemianopia affects the right eye, a child looking straight
ahead might have perfect vision except on the far right. In
homonymous hemianopia, the impairment affects the same part
of the visual field of both eyes. Impaired hearing is also more
frequent among those with cerebral palsy than in the general
population.
- Abnormal sensation and perception.
Some children with cerebral palsy have impaired ability to feel
simple sensations like touch and pain. They may also have stereognosia,
or difficulty perceiving and identifying objects using the sense
of touch. A child with stereognosia, for example, would have
trouble identifying a hard ball, sponge, or other object placed
in his hand without looking at the object.
top
Cerebral palsy is not one disease with a single cause, like chicken
pox or measles. It is a group of disorders with similar problems
in control of movement, but probably with different causes. When
physicians try to uncover the cause of cerebral palsy in an individual
child, they look at the form of cerebral palsy, the mother's and
child's medical history, and onset of the disorder.
In the United States, about 10 to 20 percent of children who
have cerebral palsy acquire the disorder after birth. (The figures
are higher in underdeveloped countries.) Acquired cerebral palsy
results from brain damage in the first few months or years of
life and can follow brain infections, such as bacterial meningitis
or viral encephalitis, or results from head injury -- most often
from a motor vehicle accident, a fall, or child abuse.
Congenital cerebral palsy, on the other hand, is present at birth,
although it may not be detected for months. In most cases, the
cause of congenital cerebral palsy is unknown. Thanks to research,
however, scientists have pinpointed some specific events during
pregnancy or around the time of birth that can damage motor centers
in the developing brain. Some of these causes of congenital cerebral
palsy include:
- Infections during pregnancy.
German measles, or rubella, is caused by a virus that can infect
pregnant women and, therefore, the fetus in the uterus, to cause
damage to the developing nervous system. Other infections that
can cause brain injury in the developing fetus include cytomegalovirus
and toxoplasmosis. There is relatively recent evidence that
placental and perhaps other maternal infection can be associated
with cerebral palsy.
- Jaundice in the infant. Bile
pigments, compounds that are normally found in small amounts
in the bloodstream, are produced when blood cells are destroyed.
When many blood cells are destroyed in a short time, as in the
condition called Rh incompatibility (see below), the yellow-colored
pigments can build up and cause jaundice. Severe, untreated
jaundice can damage brain cells.
- Rh incompatibility. In this
blood condition, the mother's body produces immune cells called
antibodies that destroy the fetus's blood cells, leading to
a form of jaundice in the newborn.
- Severe oxygen shortage in
the brain or trauma to the head during labor and delivery. The
newborn infant's blood is specially equipped to compensate for
low levels of oxygen, and asphyxia (lack of oxygen caused by
interruption in breathing or poor oxygen supply) is common in
babies during the stresses of labor and delivery. But if asphyxia
severely lowers the supply of oxygen to the infant's brain for
lengthy periods, the child may develop brain damage called hypoxic-ischemic
encephalopathy. A significant proportion of babies with this
type of brain damage die, and others may develop cerebral palsy,
which is then often accompanied by mental impairment and seizures.
In the past, physicians and scientists attributed most cases
of cerebral palsy to asphyxia or other complications during birth
if they could not identify another cause. However, extensive research
by NINDS scientists and others has shown that very few babies
who experience asphyxia during birth develop encephalopathy soon
after birth. Research also shows that a large proportion of babies
who experience asphyxia do not grow up to have cerebral palsy
or other neurological disorders. Birth complications including
asphyxia are now estimated to account for about 6 percent of congenital
cerebral palsy cases.
- Stroke. Coagulation disorders
in mothers or infants can produce stroke in the fetus or newborn
baby. Bleeding in the brain has several causes -- including
broken blood vessels in the brain, clogged blood vessels, or
abnormal blood cells -- and is one form of stroke. Although
strokes are better known for their effects on older adults,
they can also occur in the fetus during pregnancy or the newborn
around the time of birth, damaging brain tissue and causing
neurological problems. Ongoing research is testing potential
treatments that may one day help prevent stroke in fetuses and
newborns.
top
Research scientists have examined thousands of expectant mothers,
followed them through childbirth, and monitored their children's
early neurological development. As a result, they have uncovered
certain characteristics, called risk factors, that increase the
possibility that a child will later be diagnosed with cerebral
palsy:
- Breech presentation. Babies
with cerebral palsy are more likely to present feet first, instead
of head first, at the beginning of labor.
- Complicated labor and delivery.
Vascular or respiratory problems of the baby during labor and
delivery may sometimes be the first sign that a baby has suffered
brain damage or that a baby's brain has not developed normally.
uch complications can cause permanent brain damage.
- Low Apgar score. The Apgar
score (named for anesthesiologist Virginia Apgar) is a numbered
rating that reflects a newborn's condition. To determine an
Apgar score, doctors periodically check the baby's heart rate,
breathing, muscle tone, reflexes, and skin color in the first
minutes after birth. They then assign points; the higher the
score, the more normal the baby's condition. A low score at
10-20 minutes after delivery is often considered an important
sign of potential problems.
- Low birthweight and premature
birth. The risk of cerebral palsy is higher among babies who
weigh less than 2500 grams (5 lbs., 7 1/2 oz.) at birth and
among babies who are born less than 37 weeks into pregnancy.
This risk increases as birthweight falls.
- Multiple births. Twins, triplets,
and other multiple births are linked to an increased risk of
cerebral palsy.
- Nervous system malformations.
Some babies born with cerebral palsy have visible signs of nervous
system malformation, such as an abnormally small head (microcephaly).
This suggests that problems occurred in the development of the
nervous system while the baby was in the womb.
- Maternal bleeding or severe
proteinuria late in pregnancy. Vaginal bleeding during the sixth
to ninth months of pregnancy and severe proteinuria (the presence
of excess proteins in the urine) are linked to a higher risk
of having a baby with cerebral palsy.
- Maternal hyperthyroidism,
mental retardation, or seizures. Mothers with any of these conditions
are slightly more likely to have a child with cerebral palsy.
- Seizures in the newborn. An
infant who has seizures faces a higher risk of being diagnosed,
later in childhood, with cerebral palsy.
Knowing these warning signs helps doctors keep a close eye on
children who face a higher risk for long-term problems in the
nervous system. However, parents should not become too alarmed
if their child has one or more of these factors. Most such children
do not have and do not develop cerebral palsy.
top
Several of the causes of cerebral palsy that have been identified
through research are preventable or treatable:
- Head injury can be prevented
by regular use of child safety seats when driving in a car and
helmets during bicycle rides, and elimination of child abuse.
In addition, common sense measures around the household -- like
close supervision during bathing and keeping poisons out of
reach -- can reduce the risk of accidental injury.
- Jaundice of newborn infants
can be treated with phototherapy. In phototherapy, babies are
exposed to special blue lights that break down bile pigments,
preventing them from building up and threatening the brain.
In the few cases in which this treatment is not enough, physicians
can correct the condition with a special form of blood transfusion.
- Rh incompatibility is easily
identified by a simple blood test routinely performed on expectant
mothers and, if indicated, expectant fathers. This incompatibility
in blood types does not usually cause problems during a woman's
first pregnancy, since the mother's body generally does not
produce the unwanted antibodies until after delivery. In most
cases, a special serum given after each childbirth can prevent
the unwanted production of antibodies. In unusual cases, such
as when a pregnant woman develops the antibodies during her
first pregnancy or antibody production is not prevented, doctors
can help minimize problems by closely watching the developing
baby and, when needed, performing a transfusion to the baby
while in the womb or an exchange transfusion (in which a large
volume of the baby's blood is removed and replaced) after birth.
- Rubella, or German measles,
can be prevented if women are vaccinated against this disease
before becoming pregnant.
In addition, it is always good to work toward a healthy pregnancy
through regular prenatal care and good nutrition and by eliminating
smoking, alcohol consumption, and drug abuse. Despite the best
efforts of parents and physicians, however, children will still
be born with cerebral palsy. Since in most cases the cause of
cerebral palsy is unknown, little can currently be done to prevent
it. As investigators learn more about the causes of cerebral palsy
through basic and clinical research, doctors and parents will
be better equipped to help prevent this disorder.
top
Early signs of cerebral palsy usually appear before 3 years of
age, and parents are often the first to suspect that their infant
is not developing motor skills normally. Infants with cerebral
palsy are frequently slow to reach developmental milestones, such
as learning to roll over, sit, crawl, smile, or walk. This is
sometimes called developmental delay.
Some affected children have abnormal muscle tone. Decreased muscle
tone is called hypotonia; the baby may seem flaccid and relaxed,
even floppy. Increased muscle tone is called hypertonia, and the
baby may seem stiff or rigid. In some cases, the baby has an early
period of hypotonia that progresses to hypertonia after the first
2 to 3 months of life. Affected children may also have unusual
posture or favor one side of their body.
Parents who are concerned about their baby's development for
any reason should contact their physician, who can help distinguish
normal variation in development from a developmental disorder.
top
Doctors diagnose cerebral palsy by testing an infant's motor
skills and looking carefully at the infant's medical history.
In addition to checking for those symptoms described above --
slow development, abnormal muscle tone, and unusual posture --
a physician also tests the infant's reflexes and looks for early
development of hand preference.
Reflexes are movements that the body makes automatically in response
to a specific cue. For example, if a newborn baby is held on its
back and tilted so the legs are above its head, the baby will
automatically extend its arms in a gesture, called the Moro reflex,
that looks like an embrace. Babies normally lose this reflex after
they reach 6 months, but those with cerebral palsy may retain
it for abnormally long periods. This is just one of several reflexes
that a physician can check.
Doctors can also look for hand preference -- a tendency to use
either the right or left hand more often. When the doctor holds
an object in front and to the side of the infant, an infant with
hand preference will use the favored hand to reach for the object,
even when it is held closer to the opposite hand. During the first
12 months of life, babies do not usually show hand preference.
But infants with spastic hemiplegia, in particular, may develop
a preference much earlier, since the hand on the unaffected side
of their body is stronger and more useful.
The next step in diagnosing cerebral palsy is to rule out other
disorders that can cause movement problems. Most important, doctors
must determine that the child's condition is not getting worse.
Although its symptoms may change over time, cerebral palsy by
definition is not progressive. If a child is continuously losing
motor skills, the problem more likely springs from elsewhere --
including genetic diseases, muscle diseases, disorders of metabolism,
or tumors in the nervous system. The child's medical history,
special diagnostic tests, and, in some cases, repeated check-ups
can help confirm that other disorders are not at fault.
The doctor may also order specialized tests to learn more about
the possible cause of cerebral palsy. One such test is computed
tomography, or CT, a sophisticated imaging technique that uses
X rays and a computer to create an anatomical picture of the brain's
tissues and structures. A CT scan may reveal brain areas that
are underdeveloped, abnormal cysts (sacs that are often filled
with liquid) in the brain, or other physical problems. With the
information from CT scans, doctors may be better equipped to judge
the long-term outlook for an affected child.
Magnetic resonance imaging, or MRI, is a relatively new brain
imaging technique that is rapidly gaining widespread use for identifying
brain disorders. This technique uses a magnetic field and radio
waves, rather than X rays. MRI gives better pictures of structures
or abnormal areas located near bone than CT.
A third test that can expose problems in brain tissues is ultrasonography.
This technique bounces sound waves off the brain and uses the
pattern of echoes to form a picture, or sonogram, of its structures.
Ultrasonography can be used in infants before the bones of the
skull harden and close. Although it is less precise than CT and
MRI scanning, this technique can detect cysts and structures in
the brain, is less expensive, and does not require long periods
of immobility.
Finally, physicians may want to look for other conditions that
are linked to cerebral palsy, including seizure disorders, mental
impairment, and vision or hearing problems.
When the doctor suspects a seizure disorder, an electroencephalogram,
or EEG, may be ordered. An EEG uses special patches called electrodes
placed on the scalp to record the natural electrical currents
inside the brain. This recording can help the doctor see telltale
patterns in the brain's electrical activity that suggest a seizure
disorder.
Intelligence tests are often used to determine if a child with
cerebral palsy is mentally impaired. Sometimes, however, a child's
intelligence may be underestimated because problems with movement,
sensation, or speech due to cerebral palsy make it difficult for
him or her to perform well on these tests.
If problems with vision are suspected, the doctor may refer the
patient to an ophthalmologist for examination; if hearing impairment
seems likely, an otologist may be called in.
Identifying these accompanying conditions is important and is
becoming more accurate as ongoing research yields advances that
make diagnosis easier. Many of these conditions can then be addressed
through specific treatments, improving the long-term outlook for
those with cerebral palsy.
top
Cerebral palsy can not be cured, but treatment can often improve
a child's capabilities. In fact, progress due to medical research
now means that many patients can enjoy near-normal lives if their
neurological problems are properly managed. There is no standard
therapy that works for all patients. Instead, the physician must
work with a team of health care professionals first to identify
a child's unique needs and impairments and then to create an individual
treatment plan that addresses them.
Some approaches that can be included in this plan are drugs to
control seizures and muscle spasms, special braces to compensate
for muscle imbalance, surgery, mechanical aids to help overcome
impairments, counseling for emotional and psychological needs,
and physical, occupational, speech, and behavioral therapy. In
general, the earlier treatment begins, the better chance a child
has of overcoming developmental disabilities or learning new ways
to accomplish difficult tasks.
The members of the treatment team for a child with cerebral palsy
should be knowledgeable professionals with a wide range of specialties.
A typical treatment team might include:
- a physician, such as a pediatrician,
a pediatric neurologist, or a pediatric physiatrist, trained
to help developmentally disabled children. This physician, often
the leader of the treatment team, works to synthesize the professional
advice of all team members into a comprehensive treatment plan,
implements treatments, and follows the patient's progress over
a number of years.
- an orthopedist, a surgeon
who specializes in treating the bones, muscles, tendons, and
other parts of the body's skeletal system. An orthopedist might
be called on to predict, diagnose, or treat muscle problems
associated with cerebral palsy.
- a physical therapist, who
designs and implements special exercise programs to improve
movement and strength.
- an occupational therapist,
who can help patients learn skills for day-to-day living, school,
and work.
- a speech and language pathologist,
who specializes in diagnosing and treating communication problems.
- a social worker, who can help
patients and their families locate community assistance and
education programs.
- a psychologist, who helps
patients and their families cope with the special stresses and
demands of cerebral palsy. In some cases, psychologists may
also oversee therapy to modify unhelpful or destructive behaviors
or habits.
- an educator, who may play
an especially important role when mental impairment or learning
disabilities present a challenge to education.
Individuals who have cerebral palsy and their family or caregivers
are also key members of the treatment team, and they should be
intimately involved in all steps of planning, making decisions,
and applying treatments. Studies have shown that family support
and personal determination are two of the most important predictors
of which individuals who have cerebral palsy will achieve long-term
goals.
Too often, however, physicians and parents may focus primarily
on an individual symptom -- especially the inability to walk.
While mastering specific skills is an important focus of treatment
on a day-to-day basis, the ultimate goal is to help individuals
grow to adulthood and have maximum independence in society. In
the words of one physician, "After all, the real point of
walking is to get from point A to point B. Even if a child needs
a wheelchair, what's important is that they're able to achieve
this goal."
top
Physical, Behavioral, and Other Therapies
Therapy -- whether for movement, speech, or practical tasks --
is a cornerstone of cerebral palsy treatment. The skills a 2-year-old
needs to explore the world are very different from those that
a child needs in the classroom or a young adult needs to become
independent. Cerebral palsy therapy should be tailored to reflect
these changing demands.
Physical therapy usually begins in the first few years of life,
soon after the diagnosis is made. Physical therapy programs use
specific sets of exercises to work toward two important goals:
preventing the weakening or deterioration of muscles that can
follow lack of use (called disuse atrophy) and avoiding contracture,
in which muscles become fixed in a rigid, abnormal position.
Contracture is one of the most common and serious complications
of cerebral palsy. Normally, a child whose bones are growing stretches
the body's muscles and tendons through running and walking and
other daily activities. This ensures that muscles will grow at
the same rate. But in children with cerebral palsy, spasticity
prevents this stretching and, as a result, muscles do not grow
fast enough to keep up with lengthening bones. The resulting contracture
can disrupt balance and trigger loss of previous abilities. Physical
therapy alone, or in combination with special braces (sometimes
called orthotic devices), works to prevent this complication by
stretching spastic muscles. For example, if a child has spastic
hamstrings (tendons located behind the knee), the therapist and
parents should encourage the child to sit with the legs extended
to stretch them.
A third goal of some physical therapy programs is to improve
the child's motor development. A widespread program of physical
therapy that works toward this goal is the Bobath technique, named
for a husband and wife team who pioneered this approach in England.
This program is based on the idea that the primitive reflexes
retained by many children with cerebral palsy present major roadblocks
to learning voluntary control. A therapist using the Bobath technique
tries to counteract these reflexes by positioning the child in
an opposing movement. So, for example, if a child with cerebral
palsy normally keeps his arm flexed, the therapist would repeatedly
extend it.
A second such approach to physical therapy is "patterning,"
which is based on the principle that motor skills should be taught
in more or less the same sequence that they develop normally.
In this controversial approach, the therapist guides the child
with movement problems along the path of normal motor development.
For example, the child is first taught elementary movements like
pulling himself to a standing position and crawling before he
is taught to walk -- regardless of his age. Some experts and organizations,
including the American Academy of Pediatrics, have expressed strong
reservations about the patterning approach, because studies have
not documented its value.
Physical therapy is usually just one element of an infant development
program that also includes efforts to provide a varied and stimulating
environment. Like all children, the child with cerebral palsy
needs new experiences and interactions with the world around him
in order to learn. Stimulation programs can bring this valuable
experience to the child who is physically unable to explore.
As the child with cerebral palsy approaches school age, the emphasis
of therapy shifts away from early motor development. Efforts now
focus on preparing the child for the classroom, helping the child
master activities of daily living, and maximizing the child's
ability to communicate.
Physical therapy can now help the child with cerebral palsy prepare
for the classroom by improving his or her ability to sit, move
independently or in a wheelchair, or perform precise tasks, such
as writing. In occupational therapy, the therapist works with
the child to develop such skills as feeding, dressing, or using
the bathroom. This can help reduce demands on caregivers and boost
self-reliance and self-esteem. For the many children who have
difficulty communicating, speech therapy works to identify specific
difficulties and overcome them through a program of exercises.
For example, if a child has difficulty saying words that begin
with "b," the therapist may suggest daily practice with
a list of "b" words, increasing their difficulty as
each list is mastered. Speech therapy can also work to help the
child learn to use special communication devices, such as a computer
with voice synthesizers.
Behavioral therapy provides yet another avenue to increase a
child's abilities. This therapy, which uses psychological theory
and techniques, can complement physical, speech, or occupational
therapy. For example, behavioral therapy might include hiding
a toy inside a box to reward a child for learning to reach into
the box with his weaker hand. Likewise, a child learning to say
his "b" words might be given a balloon for mastering
the word. In other cases, therapists may try to discourage unhelpful
or destructive behaviors, such as hair-pulling or biting, by selectively
presenting a child with rewards and praise during other, more
positive activities.
As a child with cerebral palsy grows older, the need for and
types of therapy and other support services will continue to change.
Continuing physical therapy addresses movement problems and is
supplemented by vocational training, recreation and leisure programs,
and special education when necessary. Counseling for emotional
and psychological challenges may be needed at any age, but is
often most critical during adolescence. Depending on their physical
and intellectual abilities, adults may need attendant care, living
accommodations, transportation, or employment opportunities.
Regardless of the patient's age and which forms of therapy are
used, treatment does not end when the patient leaves the office
or treatment center. In fact, most of the work is often done at
home. The therapist functions as a coach, providing parents and
patients with the strategy and drills that can help improve performance
at home, at school, and in the world. As research continues, doctors
and parents can expect new forms of therapy and better information
about which forms of therapy are most effective for individuals
with cerebral palsy.
Drug Therapy
Physicians usually prescribe drugs for those who have seizures
associated with cerebral palsy, and these medications are very
effective in preventing seizures in many patients. In general,
the drugs given to individual patients are chosen based on the
type of seizures, since no one drug controls all types. However,
different people with the same type of seizure may do better on
different drugs, and some individuals may need a combination of
two or more drugs to achieve good seizure control.
Drugs are also sometimes used to control spasticity, particularly
following surgery. The three medications that are used most often
are diazepam, which acts as a general relaxant of the brain and
body; baclofen, which blocks signals sent from the spinal cord
to contract the muscles; and dantrolene, which interferes with
the process of muscle contraction. Given by mouth, these drugs
can reduce spasticity for short periods, but their value for long-term
control of spasticity has not been clearly demonstrated. They
may also trigger significant side effects, such as drowsiness,
and their long-term effects on the developing nervous system are
largely unknown. One possible solution to avoid such side effects
may lie in current research to explore new routes for delivering
these drugs.
Patients with athetoid cerebral palsy may sometimes be given
drugs that help reduce abnormal movements. Most often, the prescribed
drug belongs to a group of chemicals called anticholinergics that
work by reducing the activity of acetylcholine. Acetylcholine
is a chemical messenger that helps some brain cells communicate
and that triggers muscle contraction. Anticholinergic drugs include
trihexyphenidyl, benztropine, and procyclidine hydrochloride.
Occasionally, physicians may use alcohol "washes" --
or injections of alcohol into a muscle -- to reduce spasticity
for a short period. This technique is most often used when physicians
want to correct a developing contracture. Injecting alcohol into
a muscle that is too short weakens the muscle for several weeks
and gives physicians time to work on lengthening the muscle through
bracing, therapy, or casts. In some cases, if the contracture
is detected early enough, this technique may avert the need for
surgery.
Surgery
Surgery is often recommended when contractures are severe enough
to cause movement problems. In the operating room, surgeons can
lengthen muscles and tendons that are proportionately too short.
First, however, they must determine the exact muscles at fault,
since lengthening the wrong muscle could make the problem worse.
Finding problem muscles that need correction can be a difficult
task. To walk two strides with a normal gait, it takes more than
30 major muscles working at exactly the right time and exactly
the right force. A problem in any one muscle can cause abnormal
gait. Furthermore, the natural adjustments the body makes to compensate
for muscle problems can be misleading. A new tool that enables
doctors to spot gait abnormalities, pinpoint problem muscles,
and separate real problems from compensation is called gait analysis.
Gait analysis combines cameras that record the patient while walking,
computers that analyze each portion of the patient's gait, force
plates that detect when feet touch the ground, and a special recording
technique that detects muscle activity (known as electromyography).
Using these data, doctors are better equipped to intervene and
correct significant problems. They can also use gait analysis
to check surgical results.
Because lengthening a muscle makes it weaker, surgery for contractures
is usually followed by months of recovery. For this reason, doctors
try to fix all of the affected muscles at once when it is possible
or, if more than one surgical procedure is unavoidable, they may
try to schedule operations close together.
A second surgical technique, known as selective dorsal root rhizotomy,
aims to reduce spasticity in the legs by reducing the amount of
stimulation that reaches leg muscles via nerves. In the procedure,
doctors try to locate and selectively sever overactivated nerves
controlling leg muscles. Although there is scientific controversy
over how selective this technique actually is, recent research
results suggest it can reduce spasticity in some patients, particularly
those who have spastic diplegia. Ongoing research is evaluating
this surgery's effectiveness.
Experimental surgical techniques include chronic cerebellar stimulation
and stereotaxic thalamotomy. In chronic cerebellar stimulation,
electrodes are implanted on the surface of the cerebellum -- the
part of the brain responsible for coordinating movement -- and
are used to stimulate certain cerebellar nerves. While it was
hoped that this technique would decrease spasticity and improve
motor function, results of this invasive procedure have been mixed.
Some studies have reported improvements in spasticity and function,
others have not.
Stereotaxic thalamotomy involves precise cutting of parts of
the thalamus, which serves as the brain's relay station for messages
from the muscles and sensory organs. This has been shown effective
only for reducing hemiparetic tremors (see glossary).
Mechanical aids
Whether they are as humble as velcro shoes or as advanced as
computerized communication devices, special machines and gadgets
in the home, school, and workplace can help the child or adult
with cerebral palsy overcome limitations.
The computer is probably the most dramatic example of a new device
that can make a difference in the lives of those with cerebral
palsy. For example, a child who is unable to speak or write but
can make head movements may be able to learn to control a computer
using a special light pointer that attaches to a headband. Equipped
with a computer and voice synthesizer, this child could communicate
with others. In other cases, technology has led to new versions
of old devices, such as the traditional wheelchair and its modern
offspring that runs on electricity.
Many such devices are products of engineering research supported
by private foundations and other groups.
top
Poor control of the muscles of the throat, mouth and tongue sometimes
leads to drooling. Drooling can cause severe skin irritation and,
because it is socially unacceptable, can lead to further isolation
of affected children from their peers. Although numerous treatments
for drooling have been tested over the years, there is no one
treatment that always helps. Drugs called anticholinergics can
reduce the flow of saliva but may cause significant side effects,
such as mouth dryness and poor digestion. Surgery, while sometimes
effective, carries the risk of complications, including worsening
of swallowing problems. Some patients benefit from a technique
called biofeedback that can tell them when they are drooling or
having difficulty controlling muscles that close the mouth. This
kind of therapy is most likely to work if the patient has a mental
age of more than 2 or 3 years, is motivated to control drooling,
and understands that drooling is not socially acceptable.
Difficulty with eating and swallowing -- also triggered by motor
problems in the mouth -- can cause poor nutrition. Poor nutrition,
in turn, may make the individual more vulnerable to infections
and cause or aggravate "failure to thrive" -- a lag
in growth and development that is common among those with cerebral
palsy. To make swallowing easier, the caregiver may want to prepare
semisolid food, such as strained vegetables and fruits. Proper
position, such as sitting up while eating or drinking and extending
the individual's neck away from the body to reduce the risk of
choking, is also helpful. In severe cases of swallowing problems
and malnutrition, physicians may recommend tube feeding, in which
a tube delivers food and nutrients down the throat and into the
stomach, or gastrostomy, in which a surgical opening allows a
tube to be placed directly into the stomach.
A common complication is incontinence, caused by faulty control
over the muscles that keep the bladder closed. Incontinence can
take the form of bed-wetting (also known as enuresis), uncontrolled
urination during physical activities (or stress incontinence),
or slow leaking of urine from the bladder. Possible medical treatments
for incontinence include special exercises, biofeedback, prescription
drugs, surgery, or surgically implanted devices to replace or
aid muscles. Specially designed undergarments are also available.
top
Investigators from many arenas of medicine and health are using
their expertise to help improve treatment and prevention of cerebral
palsy. Much of their work is supported through the National Institute
of Neurological Disorders and Stroke (NINDS), the National Institute
of Child Health and Human Development, other agencies within the
Federal Government, nonprofit groups such as the United Cerebral
Palsy Research Foundation, and private institutions.
The ultimate hope for overcoming cerebral palsy lies with prevention.
In order to prevent cerebral palsy, however, scientists must first
understand the complex process of normal brain development and
what can make this process go awry.
Between early pregnancy and the first months of life, one cell
divides to form first a handful of cells, and then hundreds, millions,
and, eventually, billions of cells. Some of these cells specialize
to become brain cells. These brain cells specialize into different
types and migrate to their appropriate site in the brain. They
send out branches to form crucial connections with other brain
cells. Ultimately, the most complex entity known to us is created:
a human brain with its billions of interconnected neurons.
Mounting evidence is pointing investigators toward this intricate
process in the womb for clues about cerebral palsy. For example,
a group of researchers has recently observed that more than one-third
of children who have cerebral palsy also have missing enamel on
certain teeth. This tooth defect can be traced to problems in
the early months of fetal development, suggesting that a disruption
at this period in development might be linked both to this tooth
defect and to cerebral palsy.
As a result of this and other research, many scientists now believe
that a significant number of children develop cerebral palsy because
of mishaps early in brain development. They are examining how
brain cells specialize, how they know where to migrate, how they
form the right connections -- and they are looking for preventable
factors that can disrupt this process before or after birth.
Scientists are also scrutinizing other events -- such as bleeding
in the brain, seizures, and breathing and circulation problems
-- that threaten the brain of the newborn baby. Through this research,
they hope to learn how these hazards can damage the newborn's
brain and to develop new methods for prevention.
Some newborn infants, for example, have life-threatening problems
with breathing and blood circulation. A recently introduced treatment
to help these infants is extracorporeal membrane oxygenation,
in which blood is routed from the patient to a special machine
that takes over the lungs' task of removing carbon dioxide and
adding oxygen. Although this technique can dramatically help many
such infants, some scientists have observed that a substantial
fraction of treated children later experience long-term neurological
problems, including developmental delay and cerebral palsy. Investigators
are studying infants through pregnancy, delivery, birth, and infancy,
and are tracking those who undergo this treatment. By observing
them at all stages of development, scientists can learn whether
their problems developed before birth, result from the same breathing
problems that made them candidates for the treatment, or spring
from errors in the treatment itself. Once this is determined,
they may be able to correct any existing problems or develop new
treatment methods to prevent brain damage.
Other scientists are exploring how brain insults like hypoxic-ischemic
encephalopathy (brain damage from a shortage of oxygen or blood
flow), bleeding in the brain, and seizures can cause the abnormal
release of brain chemicals and trigger brain damage. For example,
research has shown that bleeding in the brain unleashes dangerously
high amounts of a brain chemical called glutamate. While glutamate
is normally used in the brain for communication, too much glutamate
overstimulates the brain's cells and causes a cycle of destruction.
Scientists are now looking closely at glutamate to detect how
its release harms brain tissue and spreads the damage from stroke.
By learning how such brain chemicals that normally help us function
can hurt the brain, scientists may be equipped to develop new
drugs that block their harmful effects.
In related research, some investigators are already conducting
studies to learn if certain drugs can help prevent neonatal stroke.
Several of these drugs seem promising because they appear to reduce
the excess production of potentially dangerous chemicals in the
brain and may help control brain blood flow and volume. Earlier
research has linked sudden changes in blood flow and volume to
stroke in the newborn.
Low birthweight itself is also the subject of extensive research.
In spite of improvements in health care for some pregnant women,
the incidence of low birth-weight babies born each year in the
United States remains at about 7 1/2 percent. Some scientists
currently investigating this serious health problem are working
to understand how infections, hormonal problems, and genetic factors
may increase a woman's chances of giving birth prematurely. They
are also conducting more applied research that could yield: 1)
new drugs that can safely delay labor, 2) new devices to further
improve medical care for premature infants, and 3) new insight
into how smoking and alcohol consumption can disrupt fetal development.
While this research offers hope for preventing cerebral palsy
in the future, ongoing research to improve treatment brightens
the outlook for those who must face the challenges of cerebral
palsy today. An important thrust of such research is the evaluation
of treatments already in use so that physicians and parents have
the information they need to choose the best therapy. A good example
of this effort is an ongoing NINDS-supported study that promises
to yield new information about which patients are most likely
to benefit from selective dorsal root rhizotomy, a recently introduced
surgery that is becoming increasingly in demand for reduction
of spasticity.
Similarly, although physical therapy programs are a popular and
widespread approach to managing cerebral palsy, little scientific
evidence exists to help physicians, other health professionals,
and parents determine how well physical therapy works or to choose
the best approach among many. Current research on cerebral palsy
aims to provide this information through careful studies that
compare the abilities of children who have had physical and other
therapy with those who have not.
As part of this effort, scientists are working to create new
measures to judge the effectiveness of treatment, as in ongoing
research to precisely identify the specific brain areas responsible
for movement may yield one such approach. Using magnetic pulses,
researchers can locate brain areas that control specific actions,
such as raising an arm or lifting a leg, and construct detailed
maps. By comparing charts made before and after therapy among
children who have cerebral palsy, researchers may gain new insights
into how therapy affects the brain's organization and new data
about its effectiveness.
Investigators are also working to develop new drugs -- and new
ways of using existing drugs -- to help relieve cerebral palsy's
symptoms. In one such set of studies, early research results suggest
that doctors may improve the effectiveness of the anti-spasticity
drug called baclofen by giving the drug through spinal injections,
rather than by mouth. In addition, scientists are also exploring
the use of tiny implanted pumps that deliver a constant supply
of anti-spasticity drugs into the fluid around the spinal cord,
in the hope of improving these drugs' effectiveness and reducing
side effects, such as drowsiness.
Other experimental drug development efforts are exploring the
use of minute amounts of the familiar toxin called botulinum.
Ingested in large amounts, this toxin is responsible for botulism
poisoning, in which the body's muscles become paralyzed. Injected
in tiny amounts, however, this toxin has shown early promise in
reducing spasticity in specific muscles.
A large research effort is also directed at producing more effective,
nontoxic drugs to control seizures. Through its Antiepileptic
Drug Development Program, the NINDS screens new compounds developed
by industrial and university laboratories around the world for
toxicity and anticonvulsant activity and coordinates clinical
studies of efficacy and safety. To date, this program has screened
more than 13,000 compounds and, as a result, five new antiepileptic
drugs -- carbamazepine, clonazepam, valproate, clorazepate, and
felbamate -- have been approved for marketing. A new project within
the program is exploring how the structure of a given antiseizure
medication relates to its effectiveness. If successful, this project
may enable scientists to design better antiseizure medications
more quickly and cheaply.
As researchers continue to explore new treatments for cerebral
palsy and to expand our knowledge of brain development, we can
expect significant medical advances to prevent cerebral palsy
and many other disorders that strike in early life.
top
Magnesium sulfate and decreased risk of cerebral palsy
Research conducted and supported by the National Institute of
Neurological Disorders and Stroke (NINDS) continuously seeks to
uncover new clues about cerebral palsy (CP). Investigators from
the NINDS and the California Birth Defects Monitoring Program
(CBDMP) presented data suggesting that very low birthweight babies
have a decreased incidence of CP when their mothers are treated
with magnesium sulfate soon before giving birth. The results of
this study, which were based on observations of a group of children
born in four Northern California counties, were published in the
February 1995 issue of Pediatrics.*
Low birthweight babies are 100 times more likely to develop CP
than normal birthweight infants. If further research confirms
the study's findings, use of magnesium sulfate may prevent 25
percent of the cases of CP in the approximately 52,000 low birthweight
babies born each year in the United States.
Magnesium is a natural compound that is responsible for numerous
chemical processes within the body and brain. Obstetricians in
the United States often administer magnesium sulfate, an inexpensive
form of the compound, to pregnant women to prevent preterm labor
and high blood pressure brought on by pregnancy. The drug, administered
intravenously in the hospital, is considered safe when given under
medical supervision.
Scientists speculate that magnesium may play a role in brain
development and possibly prevent bleeding inside the brains of
preterm infants. Previous research has shown that magnesium may
protect against brain bleeding in very premature infants. Animal
studies have demonstrated that magnesium given after a traumatic
brain injury can reduce the severity of brain damage.
Despite these encouraging research findings, pregnant women should
not change their magnesium intake because the effects of high
doses have not yet been studied and the possible risks and benefits
are not known.
Researchers caution that more research will be required to establish
a definitive relationship between the drug and prevention of the
disorder. Clinical trials now underway, one of them a collaboration
between the NINDS and the National Institute of Child Health and
Human Development, are evaluating magnesium for the prevention
of cerebral palsy in prematurely born babies.
*Nelson KB, and Grether JK. Can magnesium sulfate reduce the
risk of cerebral palsy in very low birthweight infants? Pediatrics,
February 1995, vol. 95, no. 2, page 263.
top
The NINDS is the Federal Government's leading supporter of biomedical
research on brain and nervous system disorders, including cerebral
palsy. The NINDS conducts research in its own laboratories at
the National Institutes of Health in Bethesda, MD, and supports
research at institutions worldwide. The Institute also sponsors
an active public information program. Other NINDS publications
that may be of interest to those concerned about cerebral palsy
include "Seizures and Epilepsy: Hope Through Research"
and "The Dystonias." The Institute's address and phone
number, as well as information on other organizations that offer
various services to those affected by cerebral palsy, are provided
in the information resources section at the end of this brochure.
top
- Apgar score. A numbered score doctors use to assess a baby's
physical state at the time of birth.
- apraxia. Impaired ability to carry out purposeful movements
in an individual who does not have significant motor problems.
- asphyxia. Lack of oxygen due to trouble with breathing or
poor oxygen supply in the air.
- bile pigments. Yellow-colored substances produced by the
human body as a by-product of digestion.
- cerebral. Relating to the two hemispheres of the human brain.
- computed tomography (CT). An imaging technique that uses
X rays and a computer to create a picture of the brain's tissues
and structures.
- congenital. Present at birth.
- contracture. A condition in which muscles become fixed in
a rigid, abnormal position causing distortion or deformity.
- dysarthria. Problems with speaking caused by difficulty
moving or coordinating the muscles needed for speech.
- electroencephalogram (EEG). A technique for recording the
pattern of electrical currents inside the brain.
- electromyography. A special recording technique that detects
muscle activity.
- failure to thrive. A condition characterized by lag in physical
growth and development.
- gait analysis. A technique that uses camera recording, force
plates, electromyography, and computer analysis to objectively
measure an individual's pattern of walking.
- gastrostomy. A surgical procedure to create an artificial
opening in the stomach.
- hemianopia. Defective vision or blindness that impairs half
of the normal field of vision.
- hemiparetic tremors. Uncontrollable shaking affecting the
limbs on the spastic side of the body in those who have spastic
hemiplegia.
- hypertonia. Increased tone.
- hypotonia. Decreased tone.
- hypoxic-ischemic encephalopathy. Brain damage caused by
poor blood flow or insufficient oxygen supply to the brain.
- jaundice. A blood disorder caused by the abnormal buildup
of bile pigments in the bloodstream.
- magnetic resonance imaging (MRI) -- an imaging technique
which uses radio waves, magnetic fields, and computer analysis
to create a picture of body tissues and structures.
- neonatal hemorrhage. Bleeding of brain blood vessels in
the newborn.
- orthotic devices. Special devices, such as splints or braces,
used to treat problems of the muscles, ligaments, or bones of
the skeletal system.
- paresis or plegia. Weakness or paralysis. In cerebral palsy,
these terms are typically combined with another phrase that
describes the distribution of paralysis and weakness, e.g.,
paraparesis.
- palsy. Paralysis, or problems in the control of voluntary
movement.
- reflexes. Movements that the body makes automatically in
response to a specific cue.
- Rh incompatibility. A blood condition in which antibodies
in a pregnant woman's blood can attack fetal blood cells, impairing
the fetus's supply of oxygen and nutrients.
- rubella. Also known as German measles, rubella is a viral
infection that can damage the nervous system in the developing
fetus.
- selective dorsal root rhizotomy. A surgical procedure in
which selected nerves are severed to reduce spasticity in the
legs.
- spastic diplegia. A form of cerebral palsy in which both
arms and both legs are affected, the legs being more severely
affected.
- spastic hemiplegia (or hemiparesis). A form of cerebral
palsy in which spasticity affects the arm and leg on one side
of the body.
- spastic paraplegia (or paraparesis). A form of cerebral
palsy in which spasticity affects both legs but the arms are
relatively or completely spared.
- spastic quadriplegia (or quadriparesis). A form of cerebral
palsy in which all four limbs are affected equally.
- stereognosia. Difficulty perceiving and identifying objects
using the sense of touch.
- strabismus. Misalignment of the eyes.
- ultrasonography. A technique that bounces sound waves off
of tissues and structures and uses the pattern of echoes to
form an image, called a sonogram.
top
For information on other neurological disorders or research programs
funded by the National Institute of Neurological Disorders and
Stroke, contact the Institute's Brain Resources and Information
Network (BRAIN) at:
For information on other neurological disorders or research programs
funded by the National Institute of Neurological Disorders and
Stroke, contact the Institute's Brain Resources and Information
Network (BRAIN) at:
BRAIN
P.O. Box 5801
Bethesda, MD 20824
(800) 352-9424
http://www.ninds.nih.gov/
*In addition, a number of private organizations offer a variety
of services and information that can help those affected by cerebral
palsy. They include:
Epilepsy Foundation
4351 Garden City Drive
Suite 500
Landover, MD 20785-7223
postmaster@efa.org
http://www.epilepsyfoundation.org/
Tel: 301-459-3700 800-EFA-1000 (332-1000)
Fax: 301-577-2684
National charitable organization dedicated to the welfare of people
with epilepsy. Works for children and adults affected by seizures
through education, advocacy, services, and research towards a
cure. Offers a Legal Defense Program through a fund.
March of Dimes Birth Defects Foundation
1275 Mamaroneck Avenue
White Plains, NY 10605
askus@marchofdimes.com
http://www.marchofdimes.com/
Tel: 914-428-7100 888-MODIMES (663-4637)
Fax: 914-428-8203
Works to improve the health of babies by preventing birth defects
and infant mortality through programs of research, community services,
education, and advocacy.
Easter Seals
230 West Monroe Street
Suite 1800
Chicago, IL 60606-4802
info@easter-seals.org
http://www.easter-seals.org/
Tel: 312-726-6200 800-221-6827
Fax: 312-726-1494
Provides services to help children and adults with disabilities
and/or special needs as well as support to their families. Supports
the National AgrAbility Project, a program for farmers, ranchers,
and farmworkers with disabilities.
United Cerebral Palsy (UCP)
1600 L Street, NW
Suite 700
Washington, DC 20036
national@ucp.org
http://www.ucp.org/
Tel: 202-973-7140 800-USA-5UCP (872-5827)
Fax: 202-776-0414
Works to advance the independence, productivity and full citizenship
of people with cerebral palsy and other disabilities, through
our commitment to the principles of independence, inclusion and
self-determination.
Children's Hemiplegia and Stroke Assocn. (CHASA)
4101 West Green Oaks Blvd.
PMB #149
Arlington, TX 76016
info5@chasa.org
http://www.hemikids.org/
Tel: 817-492-4325
Non-profit 501(c)(3) corporation that offers support and information
for families of children who have hemiplegia due to stroke or
other causes. Also provides information regarding research and
causes of any type of pediatric stroke.
Prepared by:
Office of Communications and Public Liaison
National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892
NINDS health-related material is provided for information purposes
only and does not necessarily represent endorsement by or an official
position of the National Institute of Neurological Disorders and
Stroke or any other Federal agency. Advice on the treatment or
care of an individual patient should be obtained through consultation
with a physician who has examined that patient or is familiar
with that patient's medical history.
All NINDS-prepared information is in the public domain and may
be freely copied. Credit to the NINDS or the NIH is appreciated.
Reviewed July 1, 2001
