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Cerebral Palsy and Associated Conditions

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Introduction

Figure 1. Multisystem impairments in cerebral palsy

Cerebral palsy (CP) is a group of non-progressive neurological disorders caused by injury to the developing brain. It affects movement, posture and motor control and is the most common cause of disability in children.[1] These motor changes are "often accompanied by disturbances of sensation, cognition, communication, perception and/or behaviour and/or by a seizure disorder."[2]


As this definition highlights, CP can have complex, multi-system impacts that can profoundly affect a child's overall health and well-being. It can affect many different systems, from the neuromuscular to the integumentary, cardiopulmonary, musculoskeletal, urinary, respiratory, and gastrointestinal systems. Understanding the multi-system consequences of CP enables health professionals to intervene early, potentially influencing their progression and improving quality of life for children with cerebral palsy.[3]

This page introduces some conditions that are related to or associated with cerebral palsy. It provides links to more information and, for some conditions, offers some brief intervention ideas or ways to accommodate specific challenges in rehabilitation sessions. Please check out the linked articles if you would like to learn more about these conditions.

Conditions or impairments can be related or unrelated, but commonly associated, with CP.[4] A related condition is typically caused by primary CP impairments. When a condition occurs with CP impairments but not because of them, it is said to be 'in association' with the primary impairments of CP.[2] Impairments and resulting conditions often overlap.

Intellectual and Cognitive Impairments

Children with cerebral palsy may have co-existing intellectual and cognitive impairments, learning difficulties and neurodevelopmental conditions.

Intellectual Impairments

It is estimated that almost half of all children with CP have an intellectual impairment. This can have a significant impact on their ability to achieve in academic or vocational settings.[5] A child with an intellectual disability may have problems with their cognitive functioning, thinking skills that lead to knowledge, and adaptive behaviour (i.e. their ability to adapt to the environment and function in daily life). Intellectual disabilities can be categorised as mild, moderate or severe.[6]

Learning Difficulties

Children with cerebral palsy may find school or academic environments challenging for a range of reasons, including problems with behaviour, motivation, psychosocial challenges or decreased language skills. They might also have specific learning disabilities, including dyslexia (reading and spelling impairment), dysgraphia (difficulty with written expression) and dyscalculia (impairment with mathematical reasoning).[5] Learning disabilities can affect higher-level skills, such as organisation, sequencing and abstract reasoning.[7]

Neurodevelopmental Conditions

Children with cerebral palsy are also more likely to have neurodevelopmental or neuropsychiatric conditions, such as attention deficit hyperactivity disorder (ADHD) and / or autism.[8] One study has found that 45% of children with cerebral palsy also had autism, ADHD, or both.[8] If you would like to learn more about the management of ADHD, please see: Attention Deficit Disorders. If you would like to learn more about autism, please see: Autism Spectrum Disorder.

Impact on Rehabilitation Interventions

When rehabilitation professionals recognise learning difficulties or intellectual impairments, they must accommodate these challenges in therapy sessions.[9] This may include: (1) adjusting the task and instructions to match the individual's cognitive ability, and (2) collaborating with other professionals, such as neuropsychologists and educators, to help develop comprehensive interaction and intervention plans to address their cognitive needs.[9]

Communication Difficulties

Children with cerebral palsy might experience a range of communication challenges, affecting their comprehension and / or ability to express themselves. They may need assistance understanding directions, forming complete sentences, sharing precise details, or creating coherent narratives. These communication difficulties can also impact their educational progress.

When working with children with communication difficulties, healthcare professionals should (1) have an understanding of alternative communication methods to facilitate more effective communication and (2) collaborate with speech therapists to help optimise communication interventions to allow children to participate fully in therapy and their daily activities.[9]

If you would like to learn more about communication strategies in early intervention, please see: Communication in Early Intervention.

Mental Health Issues

Individuals with CP are at an increased risk of mental health conditions, such as anxiety,[10] depression and post-traumatic stress disorder (PTSD). Different factors can contribute to mental health issues in individuals with CP, including biological and environmental factors, the progression of musculoskeletal impairments and changes in psychological and social development.[11]

If you want to learn more about mental health issues with cerebral palsy, including signs and symptoms and the multidisciplinary approach, please see: Mental Health Considerations With Cerebral Palsy.

Epilepsy

Epilepsy occurs in between 15 to 55% of individuals with CP.[12] There are different types of seizures, and symptoms depend on what type of seizure a person experiences.[13] Seizures can be categorised as focal onset, generalised onset or unknown onset.[14]

Focal onset seizures start in one area on one side of the brain, but they can spread to other areas. There are two types: focal onset aware seizures and focal onset impaired awareness.[15]

Generalised onset seizures affect both sides of the brain and can cause a loss of consciousness. They can be convulsive or non-convulsive, and can be divided into different types.[13]

  • Absence seizures: cause a child to briefly blank out, often staring into space. They can be accompanied by small and subtle body movements, such as eye blinking and lip-smacking.
  • Atonic seizures: can cause a temporary loss of muscle tone. They may cause a child to collapse onto the floor without warning.
  • Clonic seizures: marked by jerking movements on both sides of the body.
  • Myoclonic seizures: can cause sudden body or limb jerking movements.
  • Tonic-clonic seizures: can evolve from any focal onset or generalised onset seizure. They are the most severe type of seizures, marked by body shakes, loss of consciousness, stiffening of the body, and in some instances, loss of bladder control.

If you would like to learn more about the classification of seizures, please see: ILAE 2017 Classification of Seizure Types Checklist. The general management of epilepsy is discussed here: Epilepsy.

Cardiopulmonary System

Respiratory Problems

Respiratory issues are common in children with cerebral palsy.[16] These problems can be caused or exacerbated by swallowing problems, low activity levels, excessive drooling, blocked airways, and the inability to cough effectively. Respiratory issues have the potential to become serious conditions, so monitoring breathing and respiratory function is vital. Numerous respiratory conditions are associated with cerebral palsy, including bronchitis, pneumonia, bronchopulmonary dysplasia, respiratory distress syndrome (RDS), asthma and aspiration.[17]

Various rehabilitation interventions aim to optimise respiratory function. These interventions may include (1) airway clearance techniques, such as chest physiotherapy, percussion, vibration, high-velocity chest wall oscillation techniques, postural drainage, and breathing techniques, (2) positioning for optimal breath support and alignment to promote phonation and to decrease aspiration risk during feeding, (3) respiratory muscle training, including diaphragmatic breathing exercises and inspiratory muscle training to improve respiratory muscle strength and endurance, and (4) collaboration with other healthcare professionals, such as pulmonologists, speech and language therapists, and nutritionists to assure a comprehensive management programme for respiratory challenges.[9]

If you would like to read more about preventing and managing respiratory conditions in children with cerebral palsy, please see this article: Prevention and management of respiratory disease in young people with cerebral palsy: consensus statement.[18]

Digestive System

Structural changes in the digestive system of children with cerebral palsy can have long-term consequences, including feeding difficulties, gastro-oesophageal reflux, constipation and bowel dysfunction.

Feeding difficulties may cause sucking, chewing, and swallowing difficulties due to oral motor dysfunction, impaired coordination, and also sensory issues. Rehabilitation interventions may include positioning modifications, oral motor exercises, sensory integration techniques, and using adaptive feeding equipment to facilitate safe and efficient feeding.[9]

Gastro-oesophageal reflux (GORD/GERD) can develop due to coexisting gut dysmotility and liquid diets.[19] GORD is a backward flow of the stomach contents into the oesophagus. Rehabilitation focuses on providing education on (1) supportive positioning during feeding and after feeding, (2) maintaining upright alignment and elongating the stomach to minimise reflux, and (3) holding the child upright against gravity for a while and then laying them on their left side to help elongate their stomach.[9]

ILU massage
Figure 2, I-L-U (or I love you) massage.

Constipation and bowel dysfunction are caused by decreased mobility, inadequate fluid intake, dietary restrictions, and side effects of medications. Interventions focus on promoting bowel regularity and motility, as well as education on bowel management strategies, dietary fibre intake, and hydration practices. Additional interventions may include wearing an abdominal binder to increase intra-abdominal pressure and massage to the abdominal area (e.g. the I-L-U massage technique).[9][20]

Urinary System

Urinary incontinence is common in individuals with CP. It can be caused by a range of factors, such as impaired bladder control, muscle weakness or spasticity affecting the pelvic floor, and sensory deficits.[21] In addition, there is an increased risk of urinary tract infections in children with CP, associated with urinary retention, incomplete bladder emptying, catheterisation, and impaired mobility.[21] Interventions include education on good hygiene practices, adequate fluid intake, and timely bladder emptying.[9]

Neuromuscular System

Pain

Pain is common in children with cerebral palsy - up to 76% of children and young people experience pain and around one-third experience chronic or persistent pain. These rates tend to be higher in females, older children, individuals with dyskinesia and those with higher levels of motor impairment.[22]

Pain is multifactorial in CP and can be caused by a range of conditions, including musculoskeletal complications, increased muscle tone, spasticity, hip dislocation and gastrointestinal dysfunctions.[23] It can also be caused by specific interventions, such as casting, botulinum toxin injections, and various therapeutic procedures.[23]

Yet despite its high prevalence, pain in children with CP is not fully understood or well managed.[22] Current non-pharmacological interventions include: physical activity, positioning, stretching, massage, heat and cold therapy, rest, controlled breathing exercises, short-acting analgesics, and hydrotherapy.[22]

If you would like to learn a bit more about pain in CP, please see: Chronic pain in children and young people with cerebral palsy: a narrative review of challenges, advances, and future directions.[22]

Altered Muscle Tone

Altered muscle tone, including hypertonia and hypotonia are common impairments caused by CP. Hypertonia is characterised by increased muscle tone, stiffness, and resistance to passive movement. Hypotonia is characterised by decreased muscle tone. It can lead to weakness, and affect posture and functional abilities.

Current research-supported interventions for altered muscle tone include: botox, selective dorsal rhizotomy, diazepam and intrathecal baclofen. These interventions are considered Green Light interventions in Novak et al.'s[20] systematic review of CP interventions. Rehabilitation interventions include regular stretching programmes, orthotics and serial casting, hippotherapy, etc.[20][24]

If you would like to learn more, please see: State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy.

Musculoskeletal System

Musculoskeletal system impairments linked with CP include (1) joint deformities and contractures, (2) muscle weakness, immobility, and impaired neuromuscular control, and (3) spinal deformity (scoliosis). Interventions include strengthening, positioning, stretching and standing programmes. Surgical interventions might consist of varus derotational osteotomy, dorsal rhizotomies or botox injections. Adaptive equipment can also be beneficial, including seating systems, standers, different types of gait trainers, dynamic movement orthoses, abdominal binders, and stabilising input pressure orthoses (SPIO).[9]

If you would like to recap general interventions for CP, please see: Cerebral Palsy Interventions. If you would like to learn more about adaptive equipment for CP, please see: Adaptive Seating for Children and Standers.

Integumentary System

Pressure Injuries

Children with CP are at risk for pressure injuries (previously called pressure ulcers). Various factors contribute to this risk. A child's body composition typically has less muscle and more fat than adults. Therefore, the subcutaneous tissue in a child is softer and more susceptible to deformation under the same force. Body proportions are also different in infants and young children compared to adolescents and adults (e.g. the occiput is the largest bony prominence in young children and it is a site of higher supine pressure).

Interventions to reduce the risk of pressure injuries include pressure reduction surfaces for chairs and beds, float heels, and carefully chosen seat cushions for patients who mobilise exclusively in wheelchairs.[25] Other prevention strategies include regular repositioning, proper seating and positioning support, and education on skin care and hygiene.[9]

Contracture-Related Skin Changes

Contracture-related skin changes can be related to muscle imbalance and spasticity. Muscle imbalance and spasticity can lead to altered joint alignment and increased pressure on surrounding soft tissues. This predisposes children with CP to friction, shearing injuries and abrasion injuries. Contracture-prevention strategies, such as stretching, application of orthoses, and positioning, can alleviate pressure and reduce friction on vulnerable skin areas.[9]

Hygiene and Skin Care

Children with CP can face challenges with bathing, dressing, and grooming. This can impact skin hygiene and contribute to skin-related issues. A key part of rehabilitation should focus on optimising a child's ability to perform or participate in self-care tasks.[9]

Sensory Impairments

Problems with Perception

Perception is the process of making sense of information gained from the senses. It enables children to move around obstacles, judge the size and shape of objects, and understand how lines are connected to form letters. Children with perceptual difficulties have difficulty making sense of the sensory information they take in, which can impact many areas of learning. Problems with perception often do not become apparent until preschool or school.

This optional reading, Sensory Integration, introduces sensory integration, common sensory processing challenges and practical examples of therapeutic interventions for sensory stimulation.

Visual Impairment

75-90% of all children with CP have a visual impairment; for one in ten children, this will be a severe visual impairment. Visual impairments in CP include:

  • cortical (cerebral) visual impairment
  • amblyopia (lazy eye)
  • optic atrophy (deterioration of the optic nerve due to damage)
  • nystagmus (repetitive, uncontrollable eye movements in a vertical or horizontal direction)
  • visual field defects (loss of one side of the visual field)
  • refractive errors (near and farsightedness and astigmatism or blurred vision)
  • strabismus or 'squint', where one or both eyes are turned in or out (this prevents them from working together, and can cause double vision or focusing with one eye at a time) - it affects up to half of all children with spastic cerebral palsy
  • hyperopia (long-sightedness)

If you would like to learn more, this optional reading, Introduction to Cerebral Visual Impairment and Cerebral Palsy provides an overview of visual impairment in CP.

Hearing Impairment

Hearing impairments, which affect an individual's ability to hear sound, can also occur in individuals with CP. Hearing loss can be classified as slight, mild, moderate, profound or severe.

There are three main types of hearing loss. Conductive hearing loss occurs when there is a problem in the outer or middle ear, meaning that the person will only hear faint sounds. Sensorineural hearing loss occurs when the inner ear (cochlea) or the auditory nerve is damaged. This type of hearing impairment reduces a person's ability to hear faint sounds, and speech will often sound muffled. Central hearing loss occurs due to damage in the central nervous system, rather than the ear. Central hearing loss affects a person's ability to interpret or understand language. While they may be able to hear perfectly, they cannot interpret or understand the language. Children with CP are more likely to experience conductive hearing loss and sensorineural hearing loss.[26]

Hearing impairments can potentially affect a child's speech / language, cognitive, and psychosocial development.[27] Children with CP should be screened early for hearing impairments to ensure access to early intervention.[26]

References

  1. ↑ Paul S, Nahar A, Bhagawati M, Kunwar AJ. A Review on Recent Advances of Cerebral Palsy. Oxid Med Cell Longev. 2022 Jul 30;2022:2622310.
  2. ↑ 2.0 2.1 Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N, Dan B, Jacobsson B, Damiano D; Executive Committee for the Definition of Cerebral Palsy. Proposed definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol. 2005 Aug;47(8):571-6.
  3. ↑ Wahyuni LK. Multisystem compensations and consequences in spastic quadriplegic cerebral palsy children. Front Neurol. 2023 Jan 9;13:1076316.
  4. ↑ Vitrikas K, Dalton H, Breish D. Cerebral palsy: an overview. American family physician. 2020 Feb 15;101(4):213-20.
  5. ↑ 5.0 5.1 Wotherspoon J, Whittingham K, Sheffield J, Boyd RN. Cognition and learning difficulties in a representative sample of school-aged children with cerebral palsy. Res Dev Disabil. 2023 Jul;138:104504.
  6. ↑ Lee K, Cascella M, Marwaha R. Intellectual Disability. [Updated 2023 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from https://www.ncbi.nlm.nih.gov/books/NBK547654/ [last access 12.12.2024]
  7. ↑ The Ins and Outs of Learning Disabilities. Available from https://ldaamerica.org/info/the-ins-and-outs-of-learning-with-ld/ [last access 12.12.2024]
  8. ↑ 8.0 8.1 Påhlman M, Gillberg C, Himmelmann K. Autism and attention-deficit/hyperactivity disorder in children with cerebral palsy: high prevalence rates in a population-based study. Dev Med Child Neurol. 2021 Mar;63(3):320-327.
  9. ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 9.11 Kapoor E. Understanding the Multisystem Impact of Cerebral Palsy Course. Plus, 2025.
  10. ↑ McMahon J, Harvey A, Reid SM, May T, Antolovich G. Anxiety in children and adolescents with cerebral palsy. J Paediatr Child Health. 2020 Aug;56(8):1194-1200.
  11. ↑ Sienko SE. An exploratory study investigating the multidimensional factors impacting the health and well-being of young adults with cerebral palsy. Disabil Rehabil. 2018 Mar;40(6):660-666.
  12. ↑ Dos Santos Rufino A, Påhlman M, Olsson I, Himmelmann K. Characteristics and challenges of epilepsy in children with cerebral palsy-a population-based study. J Clin Med. 2023 Jan 1;12(1):346.
  13. ↑ 13.0 13.1 Cerebral Palsy Guide. Cerebral palsy and epilepsy. Available from https://www.cerebralpalsyguide.com/cerebral-palsy/coexisting-conditions/epilepsy/ (accessed 12 December 2024).
  14. ↑ International League Against Epilepsy. ILAE 2017 Classification of Seizure Types Checklist. Available from: https://www.ilae.org/guidelines/definition-and-classification/operational-classification-2017/ilae-2017-classification-of-seizure-types-checklist (accessed 14 January 2025).
  15. ↑ Epilepsy Foundation. Types of seizures. Available from: https://www.epilepsy.com/what-is-epilepsy/seizure-types (accessed 14 January 2025).
  16. ↑ Proesmans M. Respiratory illness in children with disability: a serious problem?. Breathe. 2016 Dec 1;12(4):e97-103.
  17. ↑ Marpole R, Blackmore AM, Gibson N, Cooper MS, Langdon K, Wilson AC. Evaluation and Management of Respiratory Illness in Children With Cerebral Palsy. Front Pediatr. 2020 Jun 24;8:333.
  18. ↑ Gibson N, Blackmore AM, Chang AB, Cooper MS, Jaffe A, Kong WR, et al. Prevention and management of respiratory disease in young people with cerebral palsy: consensus statement. Dev Med Child Neurol. 2021 Feb;63(2):172-182.
  19. ↑ Mills S, Tuffrey C, Tbaily L, Tighe M. Modification of the Paediatric Gastro-oesophageal Reflux Disease Symptom and Quality of Life Questionnaire (PGSQ) for children with cerebral palsy: a preliminary study. BMJ Paediatr Open. 2024 Feb 20;8(1):e002256.
  20. ↑ 20.0 20.1 20.2 Novak I, Morgan C, Fahey M, Finch-Edmondson M, Galea C, Hines A, et al. State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy. Curr Neurol Neurosci Rep. 2020 Feb 21;20(2):3.
  21. ↑ 21.0 21.1 Samijn B, Van den Broeck C, Plasschaert F, Pascal A, Deschepper E, Hoebeke P, Van Laecke E. Incontinence training in children with cerebral palsy: A prospective controlled trial. J Pediatr Urol. 2022 Aug;18(4):447.e1-447.e9.
  22. ↑ 22.0 22.1 22.2 22.3 Harvey A, Smith N, Smith M, Ostojic K, Berryman C. Chronic pain in children and young people with cerebral palsy: a narrative review of challenges, advances, and future directions. BMC Med. 2024 Jun 11;22(1):238.
  23. ↑ 23.0 23.1 Peck J, Urits I, Kassem H, Lee C, Robinson W, Cornett EM, et al. Interventional approaches to pain and spasticity related to cerebral palsy. Psychopharmacol Bull. 2020 Oct 15;50(4 Suppl 1):108-120.
  24. ↑ Tilton AH. Therapeutic interventions for tone abnormalities in cerebral palsy. NeuroRx. 2006 Apr;3(2):217-24.
  25. ↑ Freundlich K. Pressure Injuries in Medically Complex Children: A Review. Children (Basel). 2017 Apr 7;4(4):25.
  26. ↑ 26.0 26.1 Cerebral Palsy Guidance. Cerebral Palsy and Hearing Problems. Available from: https://www.cerebralpalsyguidance.com/cerebral-palsy/associated-disorders/hearing-problems/ (accessed 22 January 2024).
  27. ↑ Reid SM, Modak MB, Berkowitz RG, Reddihough DS. A population-based study and systematic review of hearing loss in children with cerebral palsy. Dev Med Child Neurol. 2011 Nov;53(11):1038-45.
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