Cerebral palsy
Encyclopedia
Cerebral palsy is an umbrella term
encompassing a group of non-progressive, non-contagious motor conditions that cause physical disability
in human development
, chiefly in the various areas of body movement.
Cerebral refers to the cerebrum, which is the affected area of the brain (although the disorder most likely involves connections between the cortex
and other parts of the brain such as the cerebellum
), and palsy
refers to disorder of movement. Furthermore, "paralytic disorder
s" are not cerebral palsy – the condition of quadriplegia
, therefore, should not be confused with spastic quadriplegia
, nor Tardive dyskinesia
with dyskinetic cerebral palsy, nor diplegia
with spastic diplegia
, and so on.
Cerebral palsy's nature as an umbrella term means it is defined mostly via several different subtypes, especially spastic
, and also mixtures of those subtypes.
Cerebral palsy is caused by damage to the motor control centers of the developing brain and can occur during pregnancy
, during childbirth
or after birth up to about age three. Resulting limits in movement and posture cause activity limitation and are often accompanied by disturbances of sensation, depth perception
and other sight-based perceptual problems, communication ability; impairments can also be found in cognition
, and epilepsy
is found in about one-third of cases. CP, no matter what the type, is often accompanied by secondary musculoskeletal problems that arise as a result of the underlying etiology.
Improvements in neonatology
, (specialized medical treatment of newborn babies), have helped reduce the number of babies who develop cerebral palsy, and increased the survival of babies with very low birth weights; babies more likely to have cerebral palsy.A 2007 6 country survey found an incidence of CP of 2.12–2.45 per 1,000 live births, indicating a slight rise in recent years. A 2003 study put the economic cost for people with CP in the US at $921,000 per individual, including lost income.
Of the many types and subtypes of CP, none has a known cure
. Usually, medical intervention is limited to the treatment and prevention of complications arising from CP's effects.
cerebral palsy is by far the most common type of overall cerebral palsy, occurring in 80% of all cases. People with this type of CP are hypertonic
and have what is essentially a neuromuscular mobility impairment (rather than hypotonia
or paralysis
) stemming from an upper motor neuron lesion in the brain as well as the corticospinal tract
or the motor cortex
. This damage impairs the ability of some nerve receptors in the spine
to properly receive gamma amino butyric acid, leading to hypertonia
in the muscles signaled by those damaged nerves.
As compared to other types of CP, and especially as compared to hypotonic or paralytic mobility disabilities, spastic CP is typically more easily manageable by the person affected, and medical treatment can be pursued on a multitude of orthopedic
and neurological
fronts throughout life. Spastic CP is classified by topography
dependent on the region of the body affected; these include:
In any form of spastic CP, clonus
of the affected limb(s) may sometimes result, as well as muscle spasms resulting from the pain and/or stress of the tightness experienced. The spasticity can and usually does also lead to very early onset of muscle-stress symptoms like arthritis
and tendinitis, especially in ambulatory individuals in their mid-20s and early-30s. Physical therapy
and occupational therapy
regimens of assisted stretching, strengthening, functional tasks, and/or targeted physical activity and exercise are usually the chief ways to keep spastic CP well-managed, although if the spasticity is too much for the person to handle, other remedies may be considered, such as various antispasmodic
medications, botox, baclofen
, or even a neurosurgery
known as a selective dorsal rhizotomy (which eliminates the spasticity by eliminating the nerves causing it).
type symptoms can be caused by damage to the cerebellum
. The forms of ataxia are less common types of cerebral palsy, occurring in at most 10% of all cases. Some of these individuals have hypotonia
and tremor
s. Motor skills such as writing, typing, or using scissors might be affected, as well as balance, especially while walking. It is common for individuals to have difficulty with visual and/or auditory processing.
– both hypertonia
and hypotonia
. People with Dyskinetic CP have trouble holding themselves in an upright, steady position for sitting or walking, and often show involuntary motions. For some people with dyskinetic CP, it takes a lot of work and concentration to get their hand to a certain spot (like scratching their nose or reaching for a cup). Because of their mixed tone and trouble keeping a position, they may not be able to hold onto objects, especially small ones requiring fine motor control (such as a toothbrush or pencil). About 10% of individuals with CP are classified as dyskinetic CP but some have mixed forms with spasticity and dyskinesia. The damage occurs to the extrapyramidal motor system and/or pyramidal tract and to the basal ganglia
. In newborn infants, high bilirubin levels in the blood, if left untreated, can lead to brain damage in in the basal ganglia (kernicterus
), which can lead to dyskinetic cerebral palsy.
s (permanently fixed, tight muscles and joints). The classical symptoms are spasticities, spasms, other involuntary movements (e.g. facial gestures), unsteady gait, problems with balance, and/or soft tissue findings consisting largely of decreased muscle mass. Scissor walking (where the knees come in and cross) and toe walking (which can contribute to a gait reminiscent of a marionette) are common among people with CP who are able to walk, but taken on the whole, CP symptomatology is very diverse. The effects of cerebral palsy fall on a continuum of motor dysfunction which may range from slight clumsiness at the mild end of the spectrum to impairments so severe that they render coordinated movement virtually impossible at the other end the spectrum.
Babies born with severe CP often have an irregular posture; their bodies may be either very floppy or very stiff. Birth defects, such as spinal curvature, a small jawbone, or a small head sometimes occur along with CP. Symptoms may appear or change as a child gets older. Some babies born with CP do not show obvious signs right away. Classically, CP becomes evident when the baby reaches the developmental stage at six and a half to 9 months and is starting to mobilise, where preferential use of limbs, asymmetry or gross motor developmental delay is seen.
Secondary conditions can include seizures, epilepsy
, apraxia
, dysarthria
or other communication disorders, eating problems, sensory impairments, mental retardation
, learning disabilities, urinary incontinence
, fecal incontinence
and/or behavioral disorders.
Speech and language disorders are common in people with cerebral palsy. The incidence of dysarthria is estimated to range from 31% to 88%. Speech problems are associated with poor respiratory control, laryngeal
and velopharyngeal dysfunction as well as oral articulation
disorders that are due to restricted movement in the oral-facial muscles. There are three major types of dysarthria in cerebral palsy: spastic, dyskinetic (athetosis) and ataxic.
Speech impairments in spastic dysarthria involves four major abnormalities of voluntary movement: spasticity, weakness, limited range of motion and slowness of movement. Speech mechanism impairment in athetosis involves a disorder in the regulation of breathing patterns, laryngeal dysfunction (monopitch, low, weak and breathy voice quality). It is also associated with articulatory dysfunction (large range of jaw movements), inappropriate positioning of the tongue, instability of velar elevation. Athetoid dysarthria is caused by disruption of the internal sensorimotor feedback system for appropriate motor commands, which leads to the generation of faulty movements that are perceived by others as involuntary. Ataxic dysarthria is uncommon in cerebral palsy. The speech characteristics are: imprecise consonants, irregular articulatory breakdown, distorted vowels, excess and equal stress, prolonged phonemes, slow rate, monopitch, monoloudness and harsh voice. Overall language delay
is associated with problems of mental retardation, hearing impairment and learned helplessness.
Children with cerebral palsy are at risk of learned helplessness
and becoming passive communicators, initiating little communication. Early intervention with this clientele often targets situations in which children communicate with others, so that they learn that they can control people and objects in their environment through this communication, including making choices, decisions and mistakes.
is common, and may result from the inherent deficits associated with the condition, along with the numerous procedures children typically face. There is also a high likelihood of suffering from chronic sleep disorders associated with both physical and environmental factors. Pain is also associated with tight and/or shortened muscle, abnormal posture, stiff joints, unsuitable orthosis etc.
before birth, hypoxia
of the brain, and birth trauma during labor and delivery, and complications in the perinatal period or during childhood. CP is also more common in multiple birth
s.
Between 40% and 50% of all children who develop cerebral palsy were born prematurely. Premature infants are vulnerable, in part because their organs are not fully developed, increasing the risk of hypoxic injury to the brain that may manifest as CP. A problem in interpreting this is the difficulty in differentiating between cerebral palsy caused by damage to the brain that results from inadequate oxygenation and CP that arises from prenatal brain damage that then precipitates premature delivery.
Recent research has demonstrated that intrapartum asphyxia is not the most important cause, probably accounting for no more than 10 percent of all cases; rather, infections in the mother, even infections that are not easily detected, may triple the risk of the child developing the disorder, mainly as the result of the toxicity to the fetal brain of cytokine
s that are produced as part of the inflammatory response.
Low birthweight is a risk factor for CP—and premature infants usually have low birth weights, less than 2.0 kg, but full-term infants can also have low birth weights. Multiple-birth infants are also more likely than single-birth infants to be born early or with a low birth weight.
After birth, other causes include toxins, severe jaundice
, lead poisoning
, physical brain injury, shaken baby syndrome
, incidents involving hypoxia to the brain (such as near drowning), and encephalitis
or meningitis
. The three most common causes of asphyxia in the young child are: choking on foreign objects such as toys and pieces of food, poisoning, and near drowning.
Some structural brain anomalies such as lissencephaly
may present with the clinical features of CP, although whether that could be considered CP is a matter of opinion (some people say CP must be due to brain damage, whereas people with these anomalies didn't have a normal brain). Often this goes along with rare chromosome disorders and CP is not genetic or hereditary.
It has been hypothetized that many cases of cerebral palsy are caused by the death in very early pregnancy of an identical twin.
published an article in 2004 reviewing the literature and evidence available on CT
and MRI imaging. They suggested that neuroimaging with CT or MRI is warranted when the etiology
of a patient's cerebral palsy has not been established – an MRI is preferred over CT due to diagnostic yield and safety. When abnormal, the neuroimaging study can suggest the timing of the initial damage. The CT or MRI is also capable of revealing treatable conditions, such as hydrocephalus
, porencephaly
, arteriovenous malformation
, subdural hematoma
s and hygromas, and a vermian tumor (which a few studies suggest are present 5 to 22%). Furthermore, an abnormal neuroimaging study indicates a high likelihood of associated conditions, such as epilepsy
and mental retardation
.
Unusually, cerebral palsy is notable for a glaring overall research deficiency – the fact that it is one of the very few major group of conditions on the planet in human beings for which medical science has not yet (as of 2011) collected wide-ranging empirical data on the development and experiences of young adult
s, the middle age
d and older adult
s. An especially puzzling aspect of this lies in the fact that cerebral palsy as defined by modern science was first 'discovered' and specifically addressed well over 100 years ago and that it would therefore be reasonable to expect by now that at least some empirical data on the adult populations with these conditions would have long since been collected, especially over the second half of the 20th century when existing treatment technologies rapidly improved and new ones came into being. The vast majority of empirical data on the various forms of cerebral palsy is concerned near-exclusively with children (birth to about 10 years of age) and sometimes pre-teens and early teens (11-13). Some doctors attempt to provide their own personal justifications for keeping their CP specialities purely paediatric, but there is no objectively apparent set of reasons backed by any scientific consensus
as to why medical science has made a point of researching adult cases of multiple sclerosis
, muscular dystrophy
and the various forms of cancer
in young and older adults, but has failed to do so with CP. There are a few orthopaedic surgeons and neurosurgeons who claim to be gathering pace with various studies as of the past few years , but these claims do not yet seem to have been matched by real-world, easily-accessible (verifiable) resources available to the general public (including researchers and doctors).
(NICU)
. Treatment may include one or more of the following: physical therapy; occupational therapy; speech therapy; drugs to control seizures, alleviate pain, or relax muscle spasms (e.g. benzodiazepines, baclofen and intrathecal phenol/baclofen); hyperbaric oxygen; the use of Botox to relax contracting muscles; surgery to correct anatomical abnormalities or release tight muscles; braces and other orthotic devices; rolling walkers; and communication aids such as computers with attached voice synthesizers. For instance, the use of a standing frame
can help reduce spasticity and improve range of motion
for people with CP who use wheelchairs. Nevertheless, there is only some benefit from therapy. Treatment is usually symptomatic and focuses on helping the person to develop as many motor skills as possible or to learn how to compensate for the lack of them. Non-speaking people with CP are often successful availing themselves of augmentative and alternative communication
systems such as Blissymbols
. Constraint-induced movement therapy
(CIMT) has shown promising evidence in helping individuals with neurological disorders that have lost most of the use of an extremity. Research has proven the positive benefits of CIMT for people who have had a stroke and traumatic brain injury. However, later studies have addressed the application of CIMT for children with CP challenged with hemiparesis
, that show a significant benefit in constraint induced movement therapy for children with cerebral palsy who are challenged with hemiparesis.
Occupational therapy
helps adults and children maximise their function, adapt to their limitations and live as independently as possible.
Speech therapy helps control the muscles of the mouth and jaw, and helps improve communication. Just as CP can affect the way a person moves their arms and legs, it can also affect the way they move their mouth, face and head. This can make it hard for the person to breathe; talk clearly; and bite, chew and swallow food. Speech therapy often starts before a child begins school and continues throughout the school years.
Conductive education
was developed in Hungary from 1945 based on the work of András Pető
. It is a unified system of rehabilitation for people with neurological disorders including cerebral palsy, Parkinson's disease and multiple sclerosis, amongst other conditions. It is theorised to improve mobility, self-esteem, stamina and independence as well as daily living skills and social skills. The conductor is the professional who delivers CE in partnership with parents and children. Skills learned during CE should be applied to everyday life and can help to develop age-appropriate cognitive, social and emotional skills. It is available at specialized centers.
Biofeedback
is an alternative therapy
in which people with CP learn how to control their affected muscles. Some people learn ways to reduce muscle tension with this technique. Biofeedback does not help everyone with CP.
Patterning is a controversial form of alternative therapy for people with CP. The method is promoted by The Institutes for the Achievement of Human Potential
(IAHP), a Philadelphia nonprofit, but has been criticized by the American Academy of Pediatrics
. The IAHP's methods have been endorsed by Linus Pauling
, as well as some parents of children treated with their methods.
Massage therapy is designed to help relax tense muscles, strengthen muscles, and keep joints flexible. More research is needed to determine the health benefits of these therapies for people with CP.
A injections are given into muscles that are spastic or sometimes dystonic, the aim being to reduce the muscle hypertonus that can be painful. A reduction in muscle tone can also facilitate bracing and the use of orthotics.Most often lower extremity muscles are injected. Botulinumtoxin is focal treatment meaning that a limited amount of muscles can be injected at the same time. The effect of the toxin is reversible and a reinjection is needed every 4-6 month.
Orthotic devices
such as ankle-foot orthoses (AFOs) are often prescribed to minimise gait irregularities. AFOs have been found to improve several measures of ambulation, including reducing energy expenditure and increasing speed and stride length.
Early nutritional support: In one cohort study
of 490 premature infants discharged from the NICU, the rate of growth during hospital stay was related to neurological function at 18 and 22 months of age. The study found a significant
decrease in the incidence
of cerebral palsy in the group of premature infants with the highest growth velocity. This study suggests that adequate nutrition and growth play a protective role in the development of cerebral palsy.
Hyperbaric oxygen therapy
(HBOT), in which pressurized oxygen
is inhaled inside a hyperbaric chamber, has been studied under the theory that improving oxygen availability to damaged brain cells can reactivate some of them to function normally. A 2007 systematic review
concluded that treatment with HBOT showed no significant difference from that of pressurized room air, and that some children undergoing HBOT may experience adverse event
s such as seizures and the need for ear pressure equalization tubes; due to poor quality of data assessment the review also concluded that estimates of the prevalence of adverse events are uncertain.
The full intellectual potential of a child born with CP will often not be known until the child starts school. People with CP are more likely to have learning disabilities
, although these may be unrelated to IQ, and are more likely to show varying degrees of intellectual disability
. Intellectual level among people with CP varies from genius to intellectually impaired, as it does in the general population, and experts have stated that it is important to not underestimate a person with CP's capabilities and to give them every opportunity to learn.
The ability to live independently with CP varies widely depending on the severity of each case. Some individuals with CP will require personal assistant services for all activities of daily living. Others can lead semi-independent lives, needing support only for certain activities. Still others can live in complete independence. The need for personal assistance often changes with increasing age and associated functional decline. However, in most cases persons with CP can expect to have a normal life expectancy; survival has been shown to be associated with the ability to ambulate, roll, and self-feed. As the condition does not directly affect reproductive function, some persons with CP have children and parent successfully.
According to OMIM, only 2% of cases of CP are inherited (with glutamate decarboxylase-1
as one known enzyme involved.) There is no evidence of an increased chance of a person with CP having a child with CP.
The common signs and symptoms associated with CP can have a significant impact on participation in occupations. Occupation is a term used in occupational therapy that refers to all activities a person does throughout their day. These activities may be grouped into the categories of self-care, productivity and leisure activities. Impairments related to CP can impact these activities. For example, children with motor impairments may also experience difficulties moving around their home and community, such as transportation, moving from room to room or transferring from wheelchair to toilet.
Sensory impairments can make getting dressed and brushing teeth difficult. Along with sensory impairments, motor impairments of the hand are thought to be responsible for difficulties experienced in daily, self-care activities. However, motor impairments are more important than sensory impairments, with the most prevalent impairment being finger dexterity (ability to manipulate small objects). Finger dexterity is essential in fastening buttons, doing up zippers and tying shoelaces. With upper limb spasticity, it may be difficult to get dressed in the morning. If the individual with CP also has cognitive deficits, this may add an additional challenge to dressing and grooming.
Children with CP often have oral sensory disturbances meaning that they have too little or too much sensitivity around and in the mouth. An infant with CP may not be able to suck, swallow or chew and this can result in difficulty eating. As mentioned in the above paragraph, finger dexterity is the most prevalent motor impairment. Finger dexterity is essential for manipulating cutlery or bringing food to the mouth. Fine finger dexterity, like picking up a spoon, is more frequently impaired than gross manual dexterity, like spooning food onto a plate. Grip strength impairments are less common. Overall, children with CP may have difficulty chewing and swallowing food, holding utensils, and preparing food due to sensory and motor impairments.
Play is considered the main occupation for children. If play becomes difficult due to a disability, like CP, this can cause problems for the child. These difficulties can affect a child’s self-esteem. In addition, the sensory and motor problems experienced by children with CP affect how the child interacts with their surroundings, including the environment and other people. Not only do physical limitations affect a child’s ability to play, the limitations perceived by the child’s caregivers and playmates also impact the child’s play activities. Typically, children with disabilities spend more time playing by themselves. When a disability prevents a child from playing, there may be social, emotional and psychological problems which can lead to increased dependence on others, less motivation and poor social skills.
In school, students are asked to complete many tasks and activities, many of which involve handwriting. Many children with CP have the capacity to learn and write in the school environment. However, students with CP may find it difficult to keep up with the handwriting demands of school and their writing may be difficult to read. In addition, writing may take longer and require greater effort on the student’s part. Factors linked to handwriting include: postural stability, sensory and perceptual abilities of the hand and writing tool pressure.
Also, speech impairments may be seen in children with CP depending on the severity of brain damage. Communication in a school setting is quite important because communicating with peers and teachers is very much a part of the “school experience” and enhances social interaction. Problems with language or motor dysfunction can lead to underestimating a student’s intelligence. In summary, children with CP may experience difficulties in school, such as difficulty with handwriting, carrying out school activities, communicating verbally and interacting socially.
Leisure can be divided into structured (formal) and unstructured (informal) activities. Studies show that children with disabilities, like CP, participate mainly in informal activities that are carried out in the family environment and are organized by adults. Typically, children with disabilities carry out leisure activities by themselves or with their parents rather than with friends. Therefore, children may experience limited diversity of activities and social engagements, as well as a more passive lifestyle than their peers. Although leisure is important for children with CP, they may have difficulties carrying out leisure activities due to social and physical barriers.
of cerebral palsy is about 2 per 1000 live births. The incidence is higher in males than in females; the Surveillance of Cerebral Palsy in Europe (SCPE) reports a M:F ratio of 1.33:1. Variances in reported rates of incidence across different geographical areas in industrialised countries are thought to be caused primarily by discrepancies in the criteria used for inclusion and exclusion. When such discrepancies are taken into account in comparing two or more registers of patients with cerebral palsy (for example, the extent to which children with mild cerebral palsy are included), the incidence rates converge toward the average rate of 2:1000.
In the United States, approximately 10,000 infants and babies are diagnosed with CP each year, and 1200–1500 are diagnosed at preschool age.
Overall, advances in care of pregnant mothers and their babies has not resulted in a noticeable decrease in CP. This is generally attributed to medical advances in areas related to the care of premature babies (which results in a greater survival rate). Only the introduction of quality medical care to locations with less-than-adequate medical care has shown any decreases. The incidence of CP increases with premature or very low-weight babies regardless of the quality of care.
Prevalence
of cerebral palsy is best calculated around the school entry age of about six years, the prevalence in the U.S. is estimated to be 2.4 out of 1000 children
The SCPE reported the following incidence of comorbidities in children with CP (over 4,500 children over age 4 whose CP was acquired during the prenatal or neonatal period were included):
The SCPE noted that the incidence of comorbidities is difficult to measure accurately, particularly across centers. For example, the actual rate of an intellectual impairment may be difficult to determine, as the physical and communicational limitations of people with CP would likely lower their scores on an IQ test if they were not given a correctly modified version.
in 1860. Little raised the possibility of asphyxia
during birth as a chief cause of the disorder. It was not until 1897 that Sigmund Freud
, then a neurologist, suggested that a difficult birth was not the cause but rather only a symptom of other effects on fetal development. Research conducted during the 1980s by the National Institute of Neurological Disorders and Stroke (NINDS) suggested that only a small number of cases of CP are caused by lack of oxygen during birth.
In 2007, the financial cost of CP was $1.47 billion (0.14% of GDP). Of this:
Additionally, the value of the lost well-being (disability and premature death) was a further $2.4 billion.
In per capita terms, this amounts to a financial cost of $43,431 per person with CP per annum. Including the value of lost well-being, the cost is over $115,000 per person per annum.
Individuals with CP bear 37% of the financial costs, and their families and friends bear a further 6%. Federal government bears around one third (33%) of the financial costs (mainly through taxation revenues forgone and welfare payments). State governments bear under 1% of the costs, while employers bear 5% and the rest of society bears the remaining 19%. If the burden of disease (lost well-being) is included, individuals bear 76% of the costs.
offers the following guidelines:
The term "spastic
" describes the attribute of spasticity in types of spastic CP. In 1952 a UK charity called The Spastics Society was formed. The term "spastics" was used by the charity as a term for people with CP. The words "spastic" and "spaz" have since been used extensively as a general insult to disabled people, which some see as extremely offensive. They are also frequently used to insult able-bodied people when they seem overly uncoordinated, anxious, or unskilled in sports. The charity changed its name to Scope
in 1994. In the United States the word spaz has the same usage as an insult, but is not generally associated with CP.
Umbrella term
An umbrella term is a word that provides a superset or grouping of concepts that all fall under a single common category. Umbrella term is also called a hypernym. For example, cryptology is an umbrella term that encompasses cryptography and cryptanalysis, among other fields...
encompassing a group of non-progressive, non-contagious motor conditions that cause physical disability
Physical disability
A physical disability is any impairment which limits the physical function of one or more limbs or fine or gross motor ability. Other physical disabilities include impairments which limit other facets of daily living, such as respiratory disorders and epilepsy....
in human development
Human development (biology)
Human development is the process of growing to maturity. In biological terms, this entails growth from a one-celled zygote to an adult human being.- Biological development:...
, chiefly in the various areas of body movement.
Cerebral refers to the cerebrum, which is the affected area of the brain (although the disorder most likely involves connections between the cortex
Cerebral cortex
The cerebral cortex is a sheet of neural tissue that is outermost to the cerebrum of the mammalian brain. It plays a key role in memory, attention, perceptual awareness, thought, language, and consciousness. It is constituted of up to six horizontal layers, each of which has a different...
and other parts of the brain such as the cerebellum
Cerebellum
The cerebellum is a region of the brain that plays an important role in motor control. It may also be involved in some cognitive functions such as attention and language, and in regulating fear and pleasure responses, but its movement-related functions are the most solidly established...
), and palsy
Palsy
In medicine, palsy is the paralysis of a body part, often accompanied by loss of sensation and by uncontrolled body movements, such as shaking. Medical conditions involving palsy include cerebral palsy , brachial palsy , and Bell's palsy ....
refers to disorder of movement. Furthermore, "paralytic disorder
Paralysis
Paralysis is loss of muscle function for one or more muscles. Paralysis can be accompanied by a loss of feeling in the affected area if there is sensory damage as well as motor. A study conducted by the Christopher & Dana Reeve Foundation, suggests that about 1 in 50 people have been diagnosed...
s" are not cerebral palsy – the condition of quadriplegia
Quadriplegia
Tetraplegia, also known as quadriplegia, is paralysis caused by illness or injury to a human that results in the partial or total loss of use of all their limbs and torso; paraplegia is similar but does not affect the arms...
, therefore, should not be confused with spastic quadriplegia
Spastic quadriplegia
Spastic quadriplegia, sometimes called spastic tetraplegia, is the version of spastic diplegia that affects all four limbs rather than just the legs. It is defined by spasticity, rather than the paralysis that defines quadriplegia...
, nor Tardive dyskinesia
Tardive dyskinesia
Tardive dyskinesia is a difficult-to-treat form of dyskinesia that can be tardive...
with dyskinetic cerebral palsy, nor diplegia
Diplegia
Diplegia, when used singularly, refers to paralysis affecting symmetrical parts of the body. This should not be confused with hemiplegia which refers to spasticity restricted to one side of the body, or quadriplegia which requires the involvement of all four limbs but not necessarily...
with spastic diplegia
Spastic diplegia
Spastic diplegia, historically known as Little's Disease, is a form of cerebral palsy that is a neuromuscular condition of hypertonia and spasticity in the muscles of the lower extremities of the human body, usually those of the legs, hips and pelvis...
, and so on.
Cerebral palsy's nature as an umbrella term means it is defined mostly via several different subtypes, especially spastic
Spasticity
Spasticity is a feature of altered skeletal muscle performance in muscle tone involving hypertonia, which is also referred to as an unusual "tightness" of muscles...
, and also mixtures of those subtypes.
Cerebral palsy is caused by damage to the motor control centers of the developing brain and can occur during pregnancy
Pregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
, during childbirth
Childbirth
Childbirth is the culmination of a human pregnancy or gestation period with the birth of one or more newborn infants from a woman's uterus...
or after birth up to about age three. Resulting limits in movement and posture cause activity limitation and are often accompanied by disturbances of sensation, depth perception
Depth perception
Depth perception is the visual ability to perceive the world in three dimensions and the distance of an object. Depth sensation is the ability to move accurately, or to respond consistently, based on the distances of objects in an environment....
and other sight-based perceptual problems, communication ability; impairments can also be found in cognition
Cognition
In science, cognition refers to mental processes. These processes include attention, remembering, producing and understanding language, solving problems, and making decisions. Cognition is studied in various disciplines such as psychology, philosophy, linguistics, and computer science...
, and epilepsy
Epilepsy
Epilepsy is a common chronic neurological disorder characterized by seizures. These seizures are transient signs and/or symptoms of abnormal, excessive or hypersynchronous neuronal activity in the brain.About 50 million people worldwide have epilepsy, and nearly two out of every three new cases...
is found in about one-third of cases. CP, no matter what the type, is often accompanied by secondary musculoskeletal problems that arise as a result of the underlying etiology.
Improvements in neonatology
Neonatology
Neonatology is a subspecialty of pediatrics that consists of the medical care of newborn infants, especially the ill or premature newborn infant. It is a hospital-based specialty, and is usually practiced in neonatal intensive care units...
, (specialized medical treatment of newborn babies), have helped reduce the number of babies who develop cerebral palsy, and increased the survival of babies with very low birth weights; babies more likely to have cerebral palsy.A 2007 6 country survey found an incidence of CP of 2.12–2.45 per 1,000 live births, indicating a slight rise in recent years. A 2003 study put the economic cost for people with CP in the US at $921,000 per individual, including lost income.
Of the many types and subtypes of CP, none has a known cure
Cure
A cure is a completely effective treatment for a disease.The Cure is an English rock band.Cure, or similar, may also refer to:-Film and television:* The Cure , a short film starring Charlie Chaplin...
. Usually, medical intervention is limited to the treatment and prevention of complications arising from CP's effects.
Classification
Cerebral palsy (CP) is divided into four major classifications to describe different movement impairments. These classifications also reflect the areas of the brain that are damaged. The four major classifications are: spastic, ataxic, athethoid/dyskinetic and mixed.Spastic
SpasticSpasticity
Spasticity is a feature of altered skeletal muscle performance in muscle tone involving hypertonia, which is also referred to as an unusual "tightness" of muscles...
cerebral palsy is by far the most common type of overall cerebral palsy, occurring in 80% of all cases. People with this type of CP are hypertonic
Hypertonia
Hypertonia a condition marked by an abnormal increase in muscle tension and a reduced ability of a muscle to stretch. It is caused by lesions to upper motor neurons in the central nervous system, which carry information from the central nervous system to the muscles and control posture, muscle...
and have what is essentially a neuromuscular mobility impairment (rather than hypotonia
Hypotonia
Hypotonia is a state of low muscle tone , often involving reduced muscle strength. Hypotonia is not a specific medical disorder, but a potential manifestation of many different diseases and disorders that affect motor nerve control by the brain or muscle strength...
or paralysis
Paralysis
Paralysis is loss of muscle function for one or more muscles. Paralysis can be accompanied by a loss of feeling in the affected area if there is sensory damage as well as motor. A study conducted by the Christopher & Dana Reeve Foundation, suggests that about 1 in 50 people have been diagnosed...
) stemming from an upper motor neuron lesion in the brain as well as the corticospinal tract
Corticospinal tract
The corticospinal or pyramidal tract is a collection of axons that travel between the cerebral cortex of the brain and the spinal cord....
or the motor cortex
Motor cortex
Motor cortex is a term that describes regions of the cerebral cortex involved in the planning, control, and execution of voluntary motor functions.-Anatomy of the motor cortex :The motor cortex can be divided into four main parts:...
. This damage impairs the ability of some nerve receptors in the spine
Vertebral column
In human anatomy, the vertebral column is a column usually consisting of 24 articulating vertebrae, and 9 fused vertebrae in the sacrum and the coccyx. It is situated in the dorsal aspect of the torso, separated by intervertebral discs...
to properly receive gamma amino butyric acid, leading to hypertonia
Hypertonia
Hypertonia a condition marked by an abnormal increase in muscle tension and a reduced ability of a muscle to stretch. It is caused by lesions to upper motor neurons in the central nervous system, which carry information from the central nervous system to the muscles and control posture, muscle...
in the muscles signaled by those damaged nerves.
As compared to other types of CP, and especially as compared to hypotonic or paralytic mobility disabilities, spastic CP is typically more easily manageable by the person affected, and medical treatment can be pursued on a multitude of orthopedic
Orthopedic surgery
Orthopedic surgery or orthopedics is the branch of surgery concerned with conditions involving the musculoskeletal system...
and neurological
Neurosurgery
Neurosurgery is the medical specialty concerned with the prevention, diagnosis, treatment, and rehabilitation of disorders which affect any portion of the nervous system including the brain, spine, spinal cord, peripheral nerves, and extra-cranial cerebrovascular system.-In the United States:In...
fronts throughout life. Spastic CP is classified by topography
Topography
Topography is the study of Earth's surface shape and features or those ofplanets, moons, and asteroids...
dependent on the region of the body affected; these include:
- Spastic hemiplegia is one side being affected. Generally, injury to muscle-nerves controlled by the brain's left side will cause a right body deficit, and vice versa. Typically, people that have spastic hemiplegia are the most ambulatory of all the forms, although they generally have dynamic equinus (a limping instability) on the affected side and are primarily prescribed ankle-foot orthoses to prevent said equinus.
- Spastic diplegiaSpastic diplegiaSpastic diplegia, historically known as Little's Disease, is a form of cerebral palsy that is a neuromuscular condition of hypertonia and spasticity in the muscles of the lower extremities of the human body, usually those of the legs, hips and pelvis...
is the lower extremities affected, with little to no upper-body spasticity. The most common form of the spastic forms (70-80% of known cases), most people with spastic diplegia are fully ambulatory, but are "tight" and have a scissors gait. Flexed knees and hips to varying degrees, and moderate to severe adduction (stemming from tight adductor muscles and comparatively weak abductor muscles), are present. Gait analysisGait analysisGait analysis is the systematic study of animal locomotion, more specific as a study of human motion, using the eye and the brain of observers, augmented by instrumentation for measuring body movements, body mechanics, and the activity of the muscles. Gait analysis is used to assess, plan, and...
is often done in early life on a semi-regular basis, and assistive devices are often provided like walkers, crutches or canes; any ankle-foot orthotics provided usually go on both legs rather than just one. In addition, these individuals are often nearsighted. The intelligence of a person with spastic diplegia is unaffected by the condition. Over time, the effects of the spasticity sometimes produce hip problems and dislocations (see the main articleSpastic diplegiaSpastic diplegia, historically known as Little's Disease, is a form of cerebral palsy that is a neuromuscular condition of hypertonia and spasticity in the muscles of the lower extremities of the human body, usually those of the legs, hips and pelvis...
and spasticitySpasticitySpasticity is a feature of altered skeletal muscle performance in muscle tone involving hypertonia, which is also referred to as an unusual "tightness" of muscles...
for more on spasticity effects). In three-quarters of spastic diplegics, also strabismusStrabismusStrabismus is a condition in which the eyes are not properly aligned with each other. It typically involves a lack of coordination between the extraocular muscles, which prevents bringing the gaze of each eye to the same point in space and preventing proper binocular vision, which may adversely...
(crossed eyes) can be present as well. - Spastic monoplegia is one single limb being affected.
- Spastic triplegia is three limbs being affected.
- Spastic quadriplegiaSpastic quadriplegiaSpastic quadriplegia, sometimes called spastic tetraplegia, is the version of spastic diplegia that affects all four limbs rather than just the legs. It is defined by spasticity, rather than the paralysis that defines quadriplegia...
is all four limbs more or less equally affected. People with spastic quadriplegia are the least likely to be able to walk, or if they can, to desire to walk, because their muscles are too tight and it is too much of an effort to do so. Some children with spastic quadriplegia also have hemiparetic tremors, an uncontrollable shaking that affects the limbs on one side of the body and impairs normal movement.
In any form of spastic CP, clonus
Clonus
Clonus is a series of involuntary muscular contractions and relaxations. Clonus is a sign of certain neurological conditions, and is particularly associated with upper motor neuron lesions such as in stroke, multiple sclerosis, spinal cord damage and hepatic encephalopathy...
of the affected limb(s) may sometimes result, as well as muscle spasms resulting from the pain and/or stress of the tightness experienced. The spasticity can and usually does also lead to very early onset of muscle-stress symptoms like arthritis
Arthritis
Arthritis is a form of joint disorder that involves inflammation of one or more joints....
and tendinitis, especially in ambulatory individuals in their mid-20s and early-30s. Physical therapy
Physical therapy
Physical therapy , often abbreviated PT, is a health care profession. Physical therapy is concerned with identifying and maximizing quality of life and movement potential within the spheres of promotion, prevention, diagnosis, treatment/intervention,and rehabilitation...
and occupational therapy
Occupational therapy
Occupational therapy is a discipline that aims to promote health by enabling people to perform meaningful and purposeful activities. Occupational therapists work with individuals who suffer from a mentally, physically, developmentally, and/or emotionally disabling condition by utilizing treatments...
regimens of assisted stretching, strengthening, functional tasks, and/or targeted physical activity and exercise are usually the chief ways to keep spastic CP well-managed, although if the spasticity is too much for the person to handle, other remedies may be considered, such as various antispasmodic
Antispasmodic
An antispasmodic is a drug or a herb that suppresses muscle spasms.-Smooth muscle spasm:One type of antispasmodics is used for smooth muscle contraction, especially in tubular organs of the gastrointestinal tract...
medications, botox, baclofen
Baclofen
Baclofen is a derivative of gamma-aminobutyric acid . It is primarily used to treat spasticity and is under investigation for the treatment of alcoholism....
, or even a neurosurgery
Neurosurgery
Neurosurgery is the medical specialty concerned with the prevention, diagnosis, treatment, and rehabilitation of disorders which affect any portion of the nervous system including the brain, spine, spinal cord, peripheral nerves, and extra-cranial cerebrovascular system.-In the United States:In...
known as a selective dorsal rhizotomy (which eliminates the spasticity by eliminating the nerves causing it).
Ataxic
AtaxiaAtaxia
Ataxia is a neurological sign and symptom that consists of gross lack of coordination of muscle movements. Ataxia is a non-specific clinical manifestation implying dysfunction of the parts of the nervous system that coordinate movement, such as the cerebellum...
type symptoms can be caused by damage to the cerebellum
Cerebellum
The cerebellum is a region of the brain that plays an important role in motor control. It may also be involved in some cognitive functions such as attention and language, and in regulating fear and pleasure responses, but its movement-related functions are the most solidly established...
. The forms of ataxia are less common types of cerebral palsy, occurring in at most 10% of all cases. Some of these individuals have hypotonia
Hypotonia
Hypotonia is a state of low muscle tone , often involving reduced muscle strength. Hypotonia is not a specific medical disorder, but a potential manifestation of many different diseases and disorders that affect motor nerve control by the brain or muscle strength...
and tremor
Tremor
A tremor is an involuntary, somewhat rhythmic, muscle contraction and relaxation involving to-and-fro movements of one or more body parts. It is the most common of all involuntary movements and can affect the hands, arms, eyes, face, head, vocal folds, trunk, and legs. Most tremors occur in the...
s. Motor skills such as writing, typing, or using scissors might be affected, as well as balance, especially while walking. It is common for individuals to have difficulty with visual and/or auditory processing.
Athetoid/Dyskinetic
Athetoid or dyskinetic cerebral palsy is mixed muscle toneMuscle tone
In physiology, medicine, and anatomy, muscle tone is the continuous and passive partial contraction of the muscles, or the muscle’s resistance to passive stretch during resting state. It helps maintain posture, and it declines during REM sleep.-Purpose:Unconscious nerve impulses maintain the...
– both hypertonia
Hypertonia
Hypertonia a condition marked by an abnormal increase in muscle tension and a reduced ability of a muscle to stretch. It is caused by lesions to upper motor neurons in the central nervous system, which carry information from the central nervous system to the muscles and control posture, muscle...
and hypotonia
Hypotonia
Hypotonia is a state of low muscle tone , often involving reduced muscle strength. Hypotonia is not a specific medical disorder, but a potential manifestation of many different diseases and disorders that affect motor nerve control by the brain or muscle strength...
. People with Dyskinetic CP have trouble holding themselves in an upright, steady position for sitting or walking, and often show involuntary motions. For some people with dyskinetic CP, it takes a lot of work and concentration to get their hand to a certain spot (like scratching their nose or reaching for a cup). Because of their mixed tone and trouble keeping a position, they may not be able to hold onto objects, especially small ones requiring fine motor control (such as a toothbrush or pencil). About 10% of individuals with CP are classified as dyskinetic CP but some have mixed forms with spasticity and dyskinesia. The damage occurs to the extrapyramidal motor system and/or pyramidal tract and to the basal ganglia
Basal ganglia
The basal ganglia are a group of nuclei of varied origin in the brains of vertebrates that act as a cohesive functional unit. They are situated at the base of the forebrain and are strongly connected with the cerebral cortex, thalamus and other brain areas...
. In newborn infants, high bilirubin levels in the blood, if left untreated, can lead to brain damage in in the basal ganglia (kernicterus
Kernicterus
Kernicterus is damage to the brain centers of infants caused by increased levels of unconjugated bilirubin. This may be due to several underlying pathologic processes. Newborn babies are often polycythemic. When they break down the erythrocytes, one of the byproducts is bilirubin, which circulates...
), which can lead to dyskinetic cerebral palsy.
Signs and symptoms
All types of cerebral palsy are characterized by abnormal muscle tone (i.e. slouching over while sitting), reflexes, or motor development and coordination. There can be joint and bone deformities and contractureContracture
A muscle contracture is a permanent shortening of a muscle or joint.. It is usually in response to prolonged hypertonic spasticity in a concentrated muscle area, such as is seen in the tightest muscles of people with conditions like spastic cerebral palsy....
s (permanently fixed, tight muscles and joints). The classical symptoms are spasticities, spasms, other involuntary movements (e.g. facial gestures), unsteady gait, problems with balance, and/or soft tissue findings consisting largely of decreased muscle mass. Scissor walking (where the knees come in and cross) and toe walking (which can contribute to a gait reminiscent of a marionette) are common among people with CP who are able to walk, but taken on the whole, CP symptomatology is very diverse. The effects of cerebral palsy fall on a continuum of motor dysfunction which may range from slight clumsiness at the mild end of the spectrum to impairments so severe that they render coordinated movement virtually impossible at the other end the spectrum.
Babies born with severe CP often have an irregular posture; their bodies may be either very floppy or very stiff. Birth defects, such as spinal curvature, a small jawbone, or a small head sometimes occur along with CP. Symptoms may appear or change as a child gets older. Some babies born with CP do not show obvious signs right away. Classically, CP becomes evident when the baby reaches the developmental stage at six and a half to 9 months and is starting to mobilise, where preferential use of limbs, asymmetry or gross motor developmental delay is seen.
Secondary conditions can include seizures, epilepsy
Epilepsy
Epilepsy is a common chronic neurological disorder characterized by seizures. These seizures are transient signs and/or symptoms of abnormal, excessive or hypersynchronous neuronal activity in the brain.About 50 million people worldwide have epilepsy, and nearly two out of every three new cases...
, apraxia
Apraxia
Apraxia is a disorder caused by damage to specific areas of the cerebrum. Apraxia is characterized by loss of the ability to execute or carry out learned purposeful movements, despite having the desire and the physical ability to perform the movements...
, dysarthria
Dysarthria
Dysarthria is a motor speech disorder resulting from neurological injury of the motor component of the motor-speech system and is characterized by poor articulation of phonemes...
or other communication disorders, eating problems, sensory impairments, mental retardation
Mental retardation
Mental retardation is a generalized disorder appearing before adulthood, characterized by significantly impaired cognitive functioning and deficits in two or more adaptive behaviors...
, learning disabilities, urinary incontinence
Urinary incontinence
Urinary incontinence is any involuntary leakage of urine. It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners...
, fecal incontinence
Fecal incontinence
Fecal incontinence is the loss of regular control of the bowels. Involuntary excretion and leaking are common occurrences for those affected. Subjects relating to defecation are often socially unacceptable, thus those affected may be beset by feelings of shame and humiliation...
and/or behavioral disorders.
Speech and language disorders are common in people with cerebral palsy. The incidence of dysarthria is estimated to range from 31% to 88%. Speech problems are associated with poor respiratory control, laryngeal
Larynx
The larynx , commonly called the voice box, is an organ in the neck of amphibians, reptiles and mammals involved in breathing, sound production, and protecting the trachea against food aspiration. It manipulates pitch and volume...
and velopharyngeal dysfunction as well as oral articulation
Manner of articulation
In linguistics, manner of articulation describes how the tongue, lips, jaw, and other speech organs are involved in making a sound. Often the concept is only used for the production of consonants, even though the movement of the articulars will also greatly alter the resonant properties of the...
disorders that are due to restricted movement in the oral-facial muscles. There are three major types of dysarthria in cerebral palsy: spastic, dyskinetic (athetosis) and ataxic.
Speech impairments in spastic dysarthria involves four major abnormalities of voluntary movement: spasticity, weakness, limited range of motion and slowness of movement. Speech mechanism impairment in athetosis involves a disorder in the regulation of breathing patterns, laryngeal dysfunction (monopitch, low, weak and breathy voice quality). It is also associated with articulatory dysfunction (large range of jaw movements), inappropriate positioning of the tongue, instability of velar elevation. Athetoid dysarthria is caused by disruption of the internal sensorimotor feedback system for appropriate motor commands, which leads to the generation of faulty movements that are perceived by others as involuntary. Ataxic dysarthria is uncommon in cerebral palsy. The speech characteristics are: imprecise consonants, irregular articulatory breakdown, distorted vowels, excess and equal stress, prolonged phonemes, slow rate, monopitch, monoloudness and harsh voice. Overall language delay
Language delay
Language delay is a failure to develop language abilities on the usual developmental timetable. Language delay is distinct from speech delay, in which the speech mechanism itself is the focus of delay...
is associated with problems of mental retardation, hearing impairment and learned helplessness.
Children with cerebral palsy are at risk of learned helplessness
Learned helplessness
Learned helplessness, as a technical term in animal psychology and related human psychology, means a condition of a human person or an animal in which it has learned to behave helplessly, even when the opportunity is restored for it to help itself by avoiding an unpleasant or harmful circumstance...
and becoming passive communicators, initiating little communication. Early intervention with this clientele often targets situations in which children communicate with others, so that they learn that they can control people and objects in their environment through this communication, including making choices, decisions and mistakes.
Skeleton
In order for bones to attain their normal shape and size, they require the stresses from normal musculature. Osseous findings will therefore mirror the specific muscular deficits in a given person with CP. The shafts of the bones are often thin (gracile) and become thinner during growth. When compared to these thin shafts (diaphyses), the centers (metaphyses) often appear quite enlarged (ballooning). With lack of use, articular cartilage may atrophy, leading to narrowed joint spaces. Depending on the degree of spasticity, a person with CP may exhibit a variety of angular joint deformities. Because vertebral bodies need vertical gravitational loading forces to develop properly, spasticity and an abnormal gait can hinder proper and/or full bone and skeletal development. People with CP tend to be shorter in height than the average person because their bones are not allowed to grow to their full potential. Sometimes bones grow to different lengths, so the person may have one leg longer than the other.Pain and sleep disorders
PainPain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
is common, and may result from the inherent deficits associated with the condition, along with the numerous procedures children typically face. There is also a high likelihood of suffering from chronic sleep disorders associated with both physical and environmental factors. Pain is also associated with tight and/or shortened muscle, abnormal posture, stiff joints, unsuitable orthosis etc.
Causes
While in certain cases there is no identifiable cause, typical causes include problems in intrauterine development (e.g. exposure to radiation, infection), asphyxiaAsphyxia
Asphyxia or asphyxiation is a condition of severely deficient supply of oxygen to the body that arises from being unable to breathe normally. An example of asphyxia is choking. Asphyxia causes generalized hypoxia, which primarily affects the tissues and organs...
before birth, hypoxia
Hypoxia (medical)
Hypoxia, or hypoxiation, is a pathological condition in which the body as a whole or a region of the body is deprived of adequate oxygen supply. Variations in arterial oxygen concentrations can be part of the normal physiology, for example, during strenuous physical exercise...
of the brain, and birth trauma during labor and delivery, and complications in the perinatal period or during childhood. CP is also more common in multiple birth
Multiple birth
A multiple birth occurs when more than one fetus is carried to term in a single pregnancy. Different names for multiple births are used, depending on the number of offspring. Common multiples are two and three, known as twins and triplets...
s.
Between 40% and 50% of all children who develop cerebral palsy were born prematurely. Premature infants are vulnerable, in part because their organs are not fully developed, increasing the risk of hypoxic injury to the brain that may manifest as CP. A problem in interpreting this is the difficulty in differentiating between cerebral palsy caused by damage to the brain that results from inadequate oxygenation and CP that arises from prenatal brain damage that then precipitates premature delivery.
Recent research has demonstrated that intrapartum asphyxia is not the most important cause, probably accounting for no more than 10 percent of all cases; rather, infections in the mother, even infections that are not easily detected, may triple the risk of the child developing the disorder, mainly as the result of the toxicity to the fetal brain of cytokine
Cytokine
Cytokines are small cell-signaling protein molecules that are secreted by the glial cells of the nervous system and by numerous cells of the immune system and are a category of signaling molecules used extensively in intercellular communication...
s that are produced as part of the inflammatory response.
Low birthweight is a risk factor for CP—and premature infants usually have low birth weights, less than 2.0 kg, but full-term infants can also have low birth weights. Multiple-birth infants are also more likely than single-birth infants to be born early or with a low birth weight.
After birth, other causes include toxins, severe jaundice
Jaundice
Jaundice is a yellowish pigmentation of the skin, the conjunctival membranes over the sclerae , and other mucous membranes caused by hyperbilirubinemia . This hyperbilirubinemia subsequently causes increased levels of bilirubin in the extracellular fluid...
, lead poisoning
Lead poisoning
Lead poisoning is a medical condition caused by increased levels of the heavy metal lead in the body. Lead interferes with a variety of body processes and is toxic to many organs and tissues including the heart, bones, intestines, kidneys, and reproductive and nervous systems...
, physical brain injury, shaken baby syndrome
Shaken baby syndrome
Shaken baby syndrome is a triad of medical symptoms: subdural hematoma, retinal hemorrhage, and brain swelling from which doctors, consistent with current medical understanding, infer child abuse caused by intentional shaking...
, incidents involving hypoxia to the brain (such as near drowning), and encephalitis
Encephalitis
Encephalitis is an acute inflammation of the brain. Encephalitis with meningitis is known as meningoencephalitis. Symptoms include headache, fever, confusion, drowsiness, and fatigue...
or meningitis
Meningitis
Meningitis is inflammation of the protective membranes covering the brain and spinal cord, known collectively as the meninges. The inflammation may be caused by infection with viruses, bacteria, or other microorganisms, and less commonly by certain drugs...
. The three most common causes of asphyxia in the young child are: choking on foreign objects such as toys and pieces of food, poisoning, and near drowning.
Some structural brain anomalies such as lissencephaly
Lissencephaly
Lissencephaly, which literally means smooth brain, is a rare brain formation disorder caused by defective neuronal migration during the 12th to 24th weeks of gestation, resulting in a lack of development of brain folds and grooves . It is a form of cephalic disorder...
may present with the clinical features of CP, although whether that could be considered CP is a matter of opinion (some people say CP must be due to brain damage, whereas people with these anomalies didn't have a normal brain). Often this goes along with rare chromosome disorders and CP is not genetic or hereditary.
It has been hypothetized that many cases of cerebral palsy are caused by the death in very early pregnancy of an identical twin.
Diagnosis
The diagnosis of cerebral palsy has historically rested on the patient's history and physical examination. Once diagnosed with cerebral palsy, further diagnostic tests are optional. The American Academy of NeurologyAmerican Academy of Neurology
The American Academy of Neurology is a professional society for neurologists and neuroscientists. As a medical specialty society it was established in 1949 by A.B. Baker of the University of Minnesota to advance the art and science of neurology, and thereby promote the best possible care for...
published an article in 2004 reviewing the literature and evidence available on CT
Computed tomography
X-ray computed tomography or Computer tomography , is a medical imaging method employing tomography created by computer processing...
and MRI imaging. They suggested that neuroimaging with CT or MRI is warranted when the etiology
Etiology
Etiology is the study of causation, or origination. The word is derived from the Greek , aitiologia, "giving a reason for" ....
of a patient's cerebral palsy has not been established – an MRI is preferred over CT due to diagnostic yield and safety. When abnormal, the neuroimaging study can suggest the timing of the initial damage. The CT or MRI is also capable of revealing treatable conditions, such as hydrocephalus
Hydrocephalus
Hydrocephalus , also known as "water in the brain," is a medical condition in which there is an abnormal accumulation of cerebrospinal fluid in the ventricles, or cavities, of the brain. This may cause increased intracranial pressure inside the skull and progressive enlargement of the head,...
, porencephaly
Porencephaly
Porencephaly is a type of cephalic disorder involving encephalomalacia. This is an extremely rare disorder of the central nervous system involving a cyst or cavity in a cerebral hemisphere. The cysts or cavities are usually the remnants of destructive lesions, but are sometimes the result of...
, arteriovenous malformation
Arteriovenous malformation
Arteriovenous malformation or AVM is an abnormal connection between veins and arteries, usually congenital. This pathology is widely known because of its occurrence in the central nervous system, but can appear in any location. An arteriovenous malformation is a vascular anomaly. It is a...
, subdural hematoma
Subdural hematoma
A subdural hematoma or subdural haematoma , also known as a subdural haemorrhage , is a type of haematoma, a form of traumatic brain injury. Blood gathers within the outermost meningeal layer, between the dura mater, which adheres to the skull, and the arachnoid mater, which envelops the brain...
s and hygromas, and a vermian tumor (which a few studies suggest are present 5 to 22%). Furthermore, an abnormal neuroimaging study indicates a high likelihood of associated conditions, such as epilepsy
Epilepsy
Epilepsy is a common chronic neurological disorder characterized by seizures. These seizures are transient signs and/or symptoms of abnormal, excessive or hypersynchronous neuronal activity in the brain.About 50 million people worldwide have epilepsy, and nearly two out of every three new cases...
and mental retardation
Mental retardation
Mental retardation is a generalized disorder appearing before adulthood, characterized by significantly impaired cognitive functioning and deficits in two or more adaptive behaviors...
.
Unusually, cerebral palsy is notable for a glaring overall research deficiency – the fact that it is one of the very few major group of conditions on the planet in human beings for which medical science has not yet (as of 2011) collected wide-ranging empirical data on the development and experiences of young adult
Young adult
Young adult may refer to:* Young adult , persons aged 20 to 40* Young-adult fiction, works targeted at ages 14 to 21* Young Adult , an upcoming film* Youth...
s, the middle age
Middle age
Middle age is the period of age beyond young adulthood but before the onset of old age. Various attempts have been made to define this age, which is around the third quarter of the average life span of human beings....
d and older adult
Senior citizen
Senior citizen is a common polite designation for an elderly person in both UK and US English, and it implies or means that the person is retired. This in turn implies or in fact means that the person is over the retirement age, which varies according to country. Synonyms include pensioner in UK...
s. An especially puzzling aspect of this lies in the fact that cerebral palsy as defined by modern science was first 'discovered' and specifically addressed well over 100 years ago and that it would therefore be reasonable to expect by now that at least some empirical data on the adult populations with these conditions would have long since been collected, especially over the second half of the 20th century when existing treatment technologies rapidly improved and new ones came into being. The vast majority of empirical data on the various forms of cerebral palsy is concerned near-exclusively with children (birth to about 10 years of age) and sometimes pre-teens and early teens (11-13). Some doctors attempt to provide their own personal justifications for keeping their CP specialities purely paediatric, but there is no objectively apparent set of reasons backed by any scientific consensus
Scientific consensus
Scientific consensus is the collective judgment, position, and opinion of the community of scientists in a particular field of study. Consensus implies general agreement, though not necessarily unanimity. Scientific consensus is not by itself a scientific argument, and it is not part of the...
as to why medical science has made a point of researching adult cases of multiple sclerosis
Multiple sclerosis
Multiple sclerosis is an inflammatory disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms...
, muscular dystrophy
Muscular dystrophy
Muscular dystrophy is a group of muscle diseases that weaken the musculoskeletal system and hamper locomotion. Muscular dystrophies are characterized by progressive skeletal muscle weakness, defects in muscle proteins, and the death of muscle cells and tissue.In the 1860s, descriptions of boys who...
and the various forms of cancer
Cancer
Cancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
in young and older adults, but has failed to do so with CP. There are a few orthopaedic surgeons and neurosurgeons who claim to be gathering pace with various studies as of the past few years , but these claims do not yet seem to have been matched by real-world, easily-accessible (verifiable) resources available to the general public (including researchers and doctors).
Treatment
Treatment for cerebral palsy is a lifelong multi-dimensional process focused on the maintenance of associated conditions. In order to be diagnosed with cerebral palsy the damage that occurred to the brain must be non-progressive and not disease like in nature. The manifestation of that damage will change as the brain and body develop, but the actual damage to the brain will not increase. Treatment in the life of cerebral palsy is the constant focus on preventing the damage in the brain from prohibiting healthy development on all levels. The brain, up to about the age of 8, is not concrete in its development. It has the ability to re-organize and re-route many signal paths that may have been affected by the initial trauma; the earlier it has help in doing this the more successful it will be. Various forms of therapy are available to people living with cerebral palsy as well as caregivers and parents caring for someone with this disability. They can all be useful at all stages of this disability and are vital in a person with cerebral palsy's ability to function and live more effectively. In general, the earlier treatment begins the better chance children have of overcoming developmental disabilities or learning new ways to accomplish the tasks that challenge them. The earliest proven intervention occurs during the infant's recovery in the neonatal intensive care unitNeonatal intensive care unit
A Neonatal Intensive Care Unit —also called a Special Care Nursery, newborn intensive care unit, intensive care nursery , and special care baby unit —is an intensive care unit specializing in the care of ill or premature newborn infants.The problem of premature and congenitally ill infants is not a...
(NICU)
Neonatal intensive care unit
A Neonatal Intensive Care Unit —also called a Special Care Nursery, newborn intensive care unit, intensive care nursery , and special care baby unit —is an intensive care unit specializing in the care of ill or premature newborn infants.The problem of premature and congenitally ill infants is not a...
. Treatment may include one or more of the following: physical therapy; occupational therapy; speech therapy; drugs to control seizures, alleviate pain, or relax muscle spasms (e.g. benzodiazepines, baclofen and intrathecal phenol/baclofen); hyperbaric oxygen; the use of Botox to relax contracting muscles; surgery to correct anatomical abnormalities or release tight muscles; braces and other orthotic devices; rolling walkers; and communication aids such as computers with attached voice synthesizers. For instance, the use of a standing frame
Standing frame
A standing frame is assistive technology that can be used by a person who relies on a wheelchair for mobility...
can help reduce spasticity and improve range of motion
Range of motion
Range of motion , is the distance that a movable object may normally travel while properly attached to another object. It is also called range of travel, particularly when talking about mechanical devices and in mechanical engineering fields...
for people with CP who use wheelchairs. Nevertheless, there is only some benefit from therapy. Treatment is usually symptomatic and focuses on helping the person to develop as many motor skills as possible or to learn how to compensate for the lack of them. Non-speaking people with CP are often successful availing themselves of augmentative and alternative communication
Augmentative and alternative communication
Augmentative and alternative communication is an umbrella term that encompasses the communication methods used to supplement or replace speech or writing for those with impairments in the production or comprehension of spoken or written language...
systems such as Blissymbols
Blissymbols
Blissymbols or Blissymbolics was conceived as an ideographic writing system called Semantography consisting of several hundred basic symbols, each representing a concept, which can be composed together to generate new symbols that represent new concepts...
. Constraint-induced movement therapy
Constraint-induced movement therapy
Constraint-induced movement therapy is a form of rehabilitation therapy that improves upper extremity function in stroke and other Central Nervous System damage victims by increasing the use of their affected upper limb....
(CIMT) has shown promising evidence in helping individuals with neurological disorders that have lost most of the use of an extremity. Research has proven the positive benefits of CIMT for people who have had a stroke and traumatic brain injury. However, later studies have addressed the application of CIMT for children with CP challenged with hemiparesis
Hemiparesis
Hemiparesis is weakness on one side of the body. It is less severe than hemiplegia - the total paralysis of the arm, leg, and trunk on one side of the body. Thus, the patient can move the impaired side of his body, but with reduced muscular strength....
, that show a significant benefit in constraint induced movement therapy for children with cerebral palsy who are challenged with hemiparesis.
Interpersonal therapy
Physiotherapy programs are designed to encourage the patient to build a strength base for improved gait and volitional movement, together with stretching programs to limit contractures. Many experts believe that life-long physiotherapy is crucial to maintain muscle tone, bone structure, and prevent dislocation of the joints.Occupational therapy
Occupational therapy
Occupational therapy is a discipline that aims to promote health by enabling people to perform meaningful and purposeful activities. Occupational therapists work with individuals who suffer from a mentally, physically, developmentally, and/or emotionally disabling condition by utilizing treatments...
helps adults and children maximise their function, adapt to their limitations and live as independently as possible.
Speech therapy helps control the muscles of the mouth and jaw, and helps improve communication. Just as CP can affect the way a person moves their arms and legs, it can also affect the way they move their mouth, face and head. This can make it hard for the person to breathe; talk clearly; and bite, chew and swallow food. Speech therapy often starts before a child begins school and continues throughout the school years.
Conductive education
Conductive education
Conductive Education, or CE, is an educational system that has been specifically developed for children and adults who have motor disorders of neurological origin such as cerebral palsy. It is based on the premise that a person who has a motor disorder may not only have a medical condition...
was developed in Hungary from 1945 based on the work of András Pető
András Peto
András Pető was a practitioner of physical rehabilitation whose work provided the foundation for conductive education....
. It is a unified system of rehabilitation for people with neurological disorders including cerebral palsy, Parkinson's disease and multiple sclerosis, amongst other conditions. It is theorised to improve mobility, self-esteem, stamina and independence as well as daily living skills and social skills. The conductor is the professional who delivers CE in partnership with parents and children. Skills learned during CE should be applied to everyday life and can help to develop age-appropriate cognitive, social and emotional skills. It is available at specialized centers.
Biofeedback
Biofeedback
Biofeedback is the process of becoming aware of various physiological functions using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will...
is an alternative therapy
Alternative medicine
Alternative medicine is any healing practice, "that does not fall within the realm of conventional medicine." It is based on historical or cultural traditions, rather than on scientific evidence....
in which people with CP learn how to control their affected muscles. Some people learn ways to reduce muscle tension with this technique. Biofeedback does not help everyone with CP.
Patterning is a controversial form of alternative therapy for people with CP. The method is promoted by The Institutes for the Achievement of Human Potential
The Institutes for The Achievement of Human Potential
The Institutes for The Achievement of Human Potential is a non-profit organization providing teaching programs and literature which it promotes as improving the health and neurological development of normal children and of children who have sustained a brain injury.Although the institute's programs...
(IAHP), a Philadelphia nonprofit, but has been criticized by the American Academy of Pediatrics
American Academy of Pediatrics
The American Academy of Pediatrics is the major professional association of pediatricians in the United States. The AAP was founded in 1930 by 35 pediatricians to address pediatric healthcare standards. It currently has 60,000 members in primary care and sub-specialist areas...
. The IAHP's methods have been endorsed by Linus Pauling
Linus Pauling
Linus Carl Pauling was an American chemist, biochemist, peace activist, author, and educator. He was one of the most influential chemists in history and ranks among the most important scientists of the 20th century...
, as well as some parents of children treated with their methods.
Massage therapy is designed to help relax tense muscles, strengthen muscles, and keep joints flexible. More research is needed to determine the health benefits of these therapies for people with CP.
Occupational therapy
Occupational Therapy (OT) enables individuals with CP to participate in activities of daily living that are meaningful to them. A family-centred philosophy is used with children who have CP. Occupational therapists work closely with families in order to address their concerns and priorities for their child. Occupational therapists may address issues relating to sensory, cognitive, or motor impairments resulting from CP that affect the child's participation in self-care, productivity, or leisure. Parent counselling is also an important aspect of occupational therapy treatment with regard to optimizing the parent's skills in caring for and playing with their child to support improvement of their child's abilities to do things. The occupational therapist typically assesses the child to identify abilities and difficulties, and environmental conditions, such as physical and cultural influences, that affect participation in daily activities. Occupational therapists may also recommend changes to the play space, changes to the structure of the room or building, and seating and positioning techniques to allow the child to play and learn effectively.Medication
Botulinum toxinBotulinum toxin
Botulinum toxin is a protein produced by the bacterium Clostridium botulinum, and is considered the most powerful neurotoxin ever discovered. Botulinum toxin causes Botulism poisoning, a serious and life-threatening illness in humans and animals...
A injections are given into muscles that are spastic or sometimes dystonic, the aim being to reduce the muscle hypertonus that can be painful. A reduction in muscle tone can also facilitate bracing and the use of orthotics.Most often lower extremity muscles are injected. Botulinumtoxin is focal treatment meaning that a limited amount of muscles can be injected at the same time. The effect of the toxin is reversible and a reinjection is needed every 4-6 month.
Surgery and orthoses
Surgery usually involves one or a combination of:- Loosening tight muscles and releasing fixed joints, most often performed on the hips, knees, hamstrings, and ankles. In rare cases, this surgery may be used for people with stiffness of their elbows, wrists, hands, and fingers.
- The insertion of a baclofenBaclofenBaclofen is a derivative of gamma-aminobutyric acid . It is primarily used to treat spasticity and is under investigation for the treatment of alcoholism....
pump usually during the stages while a patient is a young adult. This is usually placed in the left abdomen. It is a pump that is connected to the spinal cord, whereby it sends bits of Baclofen alleviating the continuous muscle flexion. Baclofen is a muscle relaxant and is often given PO "per orem" (Latin for "by mouth") to patients to help counter the effects of spasticity.
- Straightening abnormal twists of the leg bones, i.e. femur (termed femoral anteversion or antetorsion) and tibia (tibial torsion). This is a secondary complication caused by the spastic muscles generating abnormal forces on the bones, and often results in intoeing (pigeon-toed gait). The surgery is called derotation osteotomy, in which the bone is broken (cut) and then set in the correct alignment.
- Cutting nerves on the limbs most affected by movements and spasms. This procedure, called a rhizotomyRhizotomyA rhizotomy is a term chiefly referring to a neurosurgical procedure that selectively severs problematic nerve roots in the spinal cord, most often to relieve the symptoms of neuromuscular conditions such as spastic diplegia and other forms of spastic cerebral palsy...
, "rhizo" meaning root and "tomy" meaning "a cutting of" from the Greek suffix 'tomia' reduces spasms and allows more flexibility and control of the affected limbs and joints.
Orthotic devices
Orthotics
Orthotics is a specialty within the medical field concerned with the design, manufacture and application of orthoses. An orthosis is an orthopedic device that supports or corrects the function of a limb or the torso...
such as ankle-foot orthoses (AFOs) are often prescribed to minimise gait irregularities. AFOs have been found to improve several measures of ambulation, including reducing energy expenditure and increasing speed and stride length.
Other treatments
Cooling high-risk full-term babies shortly after birth may reduce disability or death.Early nutritional support: In one cohort study
Cohort study
A cohort study or panel study is a form of longitudinal study used in medicine, social science, actuarial science, and ecology. It is an analysis of risk factors and follows a group of people who do not have the disease, and uses correlations to determine the absolute risk of subject contraction...
of 490 premature infants discharged from the NICU, the rate of growth during hospital stay was related to neurological function at 18 and 22 months of age. The study found a significant
Statistical significance
In statistics, a result is called statistically significant if it is unlikely to have occurred by chance. The phrase test of significance was coined by Ronald Fisher....
decrease in the incidence
Incidence (epidemiology)
Incidence is a measure of the risk of developing some new condition within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during some time period, it is better expressed as a proportion or a rate with a denominator.Incidence proportion is the...
of cerebral palsy in the group of premature infants with the highest growth velocity. This study suggests that adequate nutrition and growth play a protective role in the development of cerebral palsy.
Hyperbaric oxygen therapy
Hyperbaric oxygen therapy
Hyperbaric medicine, also known as hyperbaric oxygen therapy , is the medical use of oxygen at a level higher than atmospheric pressure. The equipment required consists of a pressure chamber, which may be of rigid or flexible construction, and a means of delivering 100% oxygen...
(HBOT), in which pressurized oxygen
Oxygen
Oxygen is the element with atomic number 8 and represented by the symbol O. Its name derives from the Greek roots ὀξύς and -γενής , because at the time of naming, it was mistakenly thought that all acids required oxygen in their composition...
is inhaled inside a hyperbaric chamber, has been studied under the theory that improving oxygen availability to damaged brain cells can reactivate some of them to function normally. A 2007 systematic review
Systematic review
A systematic review is a literature review focused on a research question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question. Systematic reviews of high-quality randomized controlled trials are crucial to evidence-based medicine...
concluded that treatment with HBOT showed no significant difference from that of pressurized room air, and that some children undergoing HBOT may experience adverse event
Adverse event
An adverse event is any adverse change in health or side effect that occurs in a person who participates in a clinical trial while the patient is receiving the treatment or within a previously specified period of time after the treatment has been completed.AEs in patients participating in...
s such as seizures and the need for ear pressure equalization tubes; due to poor quality of data assessment the review also concluded that estimates of the prevalence of adverse events are uncertain.
Prognosis
CP is not a progressive disorder (meaning the brain damage does not worsen), but the symptoms can become more severe over time due to subdural damage. A person with the disorder may improve somewhat during childhood if he or she receives extensive care from specialists, but once bones and musculature become more established, orthopedic surgery may be required .The full intellectual potential of a child born with CP will often not be known until the child starts school. People with CP are more likely to have learning disabilities
Learning disability
Learning disability is a classification including several disorders in which a person has difficulty learning in a typical manner, usually caused by an unknown factor or factors...
, although these may be unrelated to IQ, and are more likely to show varying degrees of intellectual disability
Intellectual disability
Intellectual disability is a broad concept encompassing various intellectual deficits, including mental retardation , deficits too mild to properly qualify as MR, various specific conditions , and problems acquired later in life through acquired brain injuries or neurodegenerative diseases like...
. Intellectual level among people with CP varies from genius to intellectually impaired, as it does in the general population, and experts have stated that it is important to not underestimate a person with CP's capabilities and to give them every opportunity to learn.
The ability to live independently with CP varies widely depending on the severity of each case. Some individuals with CP will require personal assistant services for all activities of daily living. Others can lead semi-independent lives, needing support only for certain activities. Still others can live in complete independence. The need for personal assistance often changes with increasing age and associated functional decline. However, in most cases persons with CP can expect to have a normal life expectancy; survival has been shown to be associated with the ability to ambulate, roll, and self-feed. As the condition does not directly affect reproductive function, some persons with CP have children and parent successfully.
According to OMIM, only 2% of cases of CP are inherited (with glutamate decarboxylase-1
Glutamate decarboxylase
Glutamate decarboxylase or glutamic acid decarboxylase is an enzyme that catalyzes the decarboxylation of glutamate to GABA and CO2. GAD uses PLP as a cofactor. The reaction proceeds as follows:...
as one known enzyme involved.) There is no evidence of an increased chance of a person with CP having a child with CP.
The common signs and symptoms associated with CP can have a significant impact on participation in occupations. Occupation is a term used in occupational therapy that refers to all activities a person does throughout their day. These activities may be grouped into the categories of self-care, productivity and leisure activities. Impairments related to CP can impact these activities. For example, children with motor impairments may also experience difficulties moving around their home and community, such as transportation, moving from room to room or transferring from wheelchair to toilet.
Self-care
Self-care is any activity children do to care for themselves. For many children with CP, parents are heavily involved in self-care activities. Self-care activities, such as bathing, dressing, grooming and eating, can be difficult for children with CP as self-care depends primarily on use of the upper limbs. For those living with CP, impaired upper limb function affects almost 50% of children and is considered the main factor contributing to decreased activity and participation. Since the hands are used for many self-care tasks, it is logical that sensory and motor impairments would impact daily self-care. The extent of the hand impairment depends on the location and degree of brain damage.Sensory impairments can make getting dressed and brushing teeth difficult. Along with sensory impairments, motor impairments of the hand are thought to be responsible for difficulties experienced in daily, self-care activities. However, motor impairments are more important than sensory impairments, with the most prevalent impairment being finger dexterity (ability to manipulate small objects). Finger dexterity is essential in fastening buttons, doing up zippers and tying shoelaces. With upper limb spasticity, it may be difficult to get dressed in the morning. If the individual with CP also has cognitive deficits, this may add an additional challenge to dressing and grooming.
Children with CP often have oral sensory disturbances meaning that they have too little or too much sensitivity around and in the mouth. An infant with CP may not be able to suck, swallow or chew and this can result in difficulty eating. As mentioned in the above paragraph, finger dexterity is the most prevalent motor impairment. Finger dexterity is essential for manipulating cutlery or bringing food to the mouth. Fine finger dexterity, like picking up a spoon, is more frequently impaired than gross manual dexterity, like spooning food onto a plate. Grip strength impairments are less common. Overall, children with CP may have difficulty chewing and swallowing food, holding utensils, and preparing food due to sensory and motor impairments.
Productivity
The effects of sensory, motor and cognitive impairments not only affect self-care occupations in children with CP, but also productivity occupations. Productivity can include, but is not limited to: school, work, household chores and contributing to the community. Play is also included as a productive occupation as it is often the primary activity for children.Play is considered the main occupation for children. If play becomes difficult due to a disability, like CP, this can cause problems for the child. These difficulties can affect a child’s self-esteem. In addition, the sensory and motor problems experienced by children with CP affect how the child interacts with their surroundings, including the environment and other people. Not only do physical limitations affect a child’s ability to play, the limitations perceived by the child’s caregivers and playmates also impact the child’s play activities. Typically, children with disabilities spend more time playing by themselves. When a disability prevents a child from playing, there may be social, emotional and psychological problems which can lead to increased dependence on others, less motivation and poor social skills.
In school, students are asked to complete many tasks and activities, many of which involve handwriting. Many children with CP have the capacity to learn and write in the school environment. However, students with CP may find it difficult to keep up with the handwriting demands of school and their writing may be difficult to read. In addition, writing may take longer and require greater effort on the student’s part. Factors linked to handwriting include: postural stability, sensory and perceptual abilities of the hand and writing tool pressure.
Also, speech impairments may be seen in children with CP depending on the severity of brain damage. Communication in a school setting is quite important because communicating with peers and teachers is very much a part of the “school experience” and enhances social interaction. Problems with language or motor dysfunction can lead to underestimating a student’s intelligence. In summary, children with CP may experience difficulties in school, such as difficulty with handwriting, carrying out school activities, communicating verbally and interacting socially.
Leisure
Leisure occupations are any activities that are done for enjoyment. Enjoyable activities depend on the child’s personality and environment. Leisure activities can have several positive effects on physical health, mental health, life satisfaction and psychological growth for children with physical disabilities like CP. Common benefits identified are stress reduction, development of coping skills, companionship, enjoyment, relaxation and a positive effect on life satisfaction. In addition, for children with CP, leisure appears to enhance adjustment to living with a disability.Leisure can be divided into structured (formal) and unstructured (informal) activities. Studies show that children with disabilities, like CP, participate mainly in informal activities that are carried out in the family environment and are organized by adults. Typically, children with disabilities carry out leisure activities by themselves or with their parents rather than with friends. Therefore, children may experience limited diversity of activities and social engagements, as well as a more passive lifestyle than their peers. Although leisure is important for children with CP, they may have difficulties carrying out leisure activities due to social and physical barriers.
Participation and barriers
Participation is considered involvement in life situations and everyday activities. Participation includes the domains of self-care, productivity and leisure. In fact, communication, mobility, education, home life, leisure and social relationships require participation and are indicators of the extent to which a child functions in his or her environment. Barriers can exist on three levels: micro, meso and macro. Firstly, the barriers at the micro level involve the person. Barriers at the micro level include the child’s physical limitations (motor, sensory and cognitive impairments) or their subjective feelings regarding their ability to participate. For example, the child may not participate in group activities due to lack of confidence. Secondly, the barriers at the meso level include the family and community. These may include negative attitudes of people towards disability or lack of support within the family or in the community. One of the main reasons for this limited support appears to be the result of a lack of awareness and knowledge regarding the child’s ability to engage in activities despite his or her disability. Thirdly, barriers at the macro level incorporate the systems and policies that are not in place or hinder children with CP. These may be environmental barriers to participation such as architectural barriers, lack of relevant assistive technology and transportation difficulties due to limited wheelchair or public transit that can accommodate the children with CP. For example, a building without an elevator may prevent the child from accessing higher floor levels.Epidemiology
In the industrialized world, the incidenceIncidence (epidemiology)
Incidence is a measure of the risk of developing some new condition within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during some time period, it is better expressed as a proportion or a rate with a denominator.Incidence proportion is the...
of cerebral palsy is about 2 per 1000 live births. The incidence is higher in males than in females; the Surveillance of Cerebral Palsy in Europe (SCPE) reports a M:F ratio of 1.33:1. Variances in reported rates of incidence across different geographical areas in industrialised countries are thought to be caused primarily by discrepancies in the criteria used for inclusion and exclusion. When such discrepancies are taken into account in comparing two or more registers of patients with cerebral palsy (for example, the extent to which children with mild cerebral palsy are included), the incidence rates converge toward the average rate of 2:1000.
In the United States, approximately 10,000 infants and babies are diagnosed with CP each year, and 1200–1500 are diagnosed at preschool age.
Overall, advances in care of pregnant mothers and their babies has not resulted in a noticeable decrease in CP. This is generally attributed to medical advances in areas related to the care of premature babies (which results in a greater survival rate). Only the introduction of quality medical care to locations with less-than-adequate medical care has shown any decreases. The incidence of CP increases with premature or very low-weight babies regardless of the quality of care.
Prevalence
Prevalence
In epidemiology, the prevalence of a health-related state in a statistical population is defined as the total number of cases of the risk factor in the population at a given time, or the total number of cases in the population, divided by the number of individuals in the population...
of cerebral palsy is best calculated around the school entry age of about six years, the prevalence in the U.S. is estimated to be 2.4 out of 1000 children
The SCPE reported the following incidence of comorbidities in children with CP (over 4,500 children over age 4 whose CP was acquired during the prenatal or neonatal period were included):
- Mental disadvantage (IQ < 50): 31%
- Active seizures: 21%
- Mental disadvantage (IQ < 50) and not walking: 20%
- Blindness: 11%
The SCPE noted that the incidence of comorbidities is difficult to measure accurately, particularly across centers. For example, the actual rate of an intellectual impairment may be difficult to determine, as the physical and communicational limitations of people with CP would likely lower their scores on an IQ test if they were not given a correctly modified version.
History
CP, formerly known as "Cerebral Paralysis," was first identified by English surgeon William LittleWilliam Little (English surgeon)
William John Little was an English surgeon who is credited with the first medical identification of spastic diplegia, when he observed it in the 1860s amongst children. While spasticity surely existed before that point, Little was the first person to medically record the condition in writing...
in 1860. Little raised the possibility of asphyxia
Asphyxia
Asphyxia or asphyxiation is a condition of severely deficient supply of oxygen to the body that arises from being unable to breathe normally. An example of asphyxia is choking. Asphyxia causes generalized hypoxia, which primarily affects the tissues and organs...
during birth as a chief cause of the disorder. It was not until 1897 that Sigmund Freud
Sigmund Freud
Sigmund Freud , born Sigismund Schlomo Freud , was an Austrian neurologist who founded the discipline of psychoanalysis...
, then a neurologist, suggested that a difficult birth was not the cause but rather only a symptom of other effects on fetal development. Research conducted during the 1980s by the National Institute of Neurological Disorders and Stroke (NINDS) suggested that only a small number of cases of CP are caused by lack of oxygen during birth.
Economic impact
Access Economics has released a report on the economic impact of cerebral palsy in Australia. Launched by the Hon. Bill Shorten, MP, the report found that, in 2007, the financial cost of cerebral palsy (CP) in Australia was $1.47 billion or 0.14% of GDP. When the value of lost well-being (disability and premature death) was added, the cost rose a further $2.4 billion.In 2007, the financial cost of CP was $1.47 billion (0.14% of GDP). Of this:
- 1.03 billion (69.9%) was productivity lost due to lower employment, absenteeism and premature death of Australians with CP;
- 141 million (9.6%) was the DWL from transfers including welfare payments and taxation forgone;
- 131 million (9.0%) was other indirect costs such as direct program services, aides and home modifications and the bringing-forward of funeral costs;
- 129 million (8.8%) was the value of the informal care for people with CP; and
- 40 million (2.8%) was direct health system expenditure.
Additionally, the value of the lost well-being (disability and premature death) was a further $2.4 billion.
In per capita terms, this amounts to a financial cost of $43,431 per person with CP per annum. Including the value of lost well-being, the cost is over $115,000 per person per annum.
Individuals with CP bear 37% of the financial costs, and their families and friends bear a further 6%. Federal government bears around one third (33%) of the financial costs (mainly through taxation revenues forgone and welfare payments). State governments bear under 1% of the costs, while employers bear 5% and the rest of society bears the remaining 19%. If the burden of disease (lost well-being) is included, individuals bear 76% of the costs.
Use of the term
Many people would rather be referred to as a person with a disability instead of handicapped. "Cerebral Palsy: A Guide for Care" at the University of DelawareUniversity of Delaware
The university is organized into seven colleges:* College of Agriculture and Natural Resources* College of Arts and Sciences* Alfred Lerner College of Business and Economics* College of Earth, Ocean and Environment* College of Education and Human Development...
offers the following guidelines:
The term "spastic
Spastic
The word spastic is used differently depending on location which has led to some controversy and misunderstanding. Derived via Latin from the Greek spastikos , the word originally referred to a change in muscles affected by the medical condition spasticity, which is seen in spastic diplegia and...
" describes the attribute of spasticity in types of spastic CP. In 1952 a UK charity called The Spastics Society was formed. The term "spastics" was used by the charity as a term for people with CP. The words "spastic" and "spaz" have since been used extensively as a general insult to disabled people, which some see as extremely offensive. They are also frequently used to insult able-bodied people when they seem overly uncoordinated, anxious, or unskilled in sports. The charity changed its name to Scope
Scope (British charity)
Scope is a London-based charity, which operates in England and Wales, focusing on people with cerebral palsy particularly, and disabled people in general. Its aim is that disabled people achieve equality....
in 1994. In the United States the word spaz has the same usage as an insult, but is not generally associated with CP.
Misconceptions
Spastic cerebral palsy, the most common form of CP, causes the muscles to be tense, rigid and movements are slow and difficult. This can be misinterpreted as cognitive delay due to difficulty of communication. Individuals with cerebral palsy can have learning difficulties, but sometimes it is the sheer magnitude of problems caused by the underlying brain injury that prevents the individual from expressing what cognitive abilities they do possess.Media
Maverick documentary filmmaker Kazuo Hara criticizes the mores and customs of Japanese society in an unsentimental portrait of adults with cerebral palsy in his 1972 film Goodbye CP (Sayonara CP). Focusing on how the CP victims are generally ignored or disregarded in Japan, Hara challenges his society's taboos about physical handicaps. Using a deliberately harsh style, with grainy black-and-white photography and out-of-sync sound, Hara brings a stark realism to his subject.Notable cases
- Josh BlueJosh BlueJosh Blue is an American comedian. He was voted the Last Comic Standing on NBC's reality show Last Comic Standing during its fourth season, which aired May–August 2006...
, winner of the fourth season of NBC's Last Comic Standing, whose act revolves around his CP. Blue was also on the 2004 U.S. Paralympic soccer team. - Emperor Claudius, the Roman Emperor who was also a stutterer and walked with a limp is believed to have had CP.
- Abbey CurranAbbey CurranAbbey Nicole Curran is an American beauty pageant contestant from Davenport, Iowa, who competed in the Miss USA pageant in 2008. Curran is the current chairman of her very own non-profit pageant "The Miss You Can Do It Pageant" for young girls and women with special needs and challenges -Miss USA...
, American beauty queen who represented Iowa at Miss USA 2008Miss USA 2008Miss USA 2008, the 57th Miss USA beauty pageant, was held in Las Vegas, Nevada on April 11, 2008. At the conclusion of the final night of competition, Crystle Stewart, Miss Texas USA, was crowned the winner by outgoing titleholder, Rachel Smith of Tennessee...
and was the first contestant with a disability to compete. She also made an appearance on The Ellen DeGeneres ShowThe Ellen DeGeneres ShowThe Ellen DeGeneres Show, often shortened to Ellen, is an American television talk show hosted by comedian/actress Ellen DeGeneres. Debuting on September 8, 2003, it is produced by Telepictures and airs in syndication, including stations owned by NBC Universal. For its first five seasons, the show...
and CBS 'The Early Show'. - Jhamak GhimireJhamak GhimireJhamak Kumari Ghimire, born in July 1980 in Kachide village development of Dhankuta district is a Nepalese writer. She is born with cerebral palsy and writes with her left foot...
, winner of Nepal's most prestigious award Madan Puraskar, was born with cerebral palsy[2][3] and writes with her left foot. She is columnist at the Kantipur newspaper. - Stephen HopkinsStephen Hopkins (politician)Stephen Hopkins was an American political leader from Rhode Island who signed the Declaration of Independence. He served as the Chief Justice and Governor of the English Colony of Rhode Island and Providence Plantations and was a Delegate to the Colonial Congress in Albany in 1754 and to the...
, signer of USA Declaration of Independence, reputed to have stated, "My hand trembles, but my heart does not." - Arun ShourieArun ShourieArun Shourie is an Indian journalist, author, intellectual and politician. He has been an economist with the World Bank , a consultant to the Planning Commission, India, editor of the Indian Express and Times of India and a minister in the government of India . He was awarded the Ramon Magsaysay...
's son Aditya about whom he has written a book Does He Know a Mother’s Heart - Geri JewellGeri Jewell-External links:*...
, who was the first person with a disability to have a regular role in prime-time series on The Facts of LifeThe Facts of Life (TV series)The Facts of Life is an American sitcom that originally ran on the NBC television network from August 24, 1979 to May 7, 1988. A spin-off of the sitcom Diff'rent Strokes, the series' premise focused on Edna Garrett as she becomes a housemother at the fictional Eastland School, a prestigious...
. She has had roles on Sesame StreetSesame StreetSesame Street has undergone significant changes in its history. According to writer Michael Davis, by the mid-1970s the show had become "an American institution". The cast and crew expanded during this time, including the hiring of women in the crew and additional minorities in the cast. The...
, 21 Jump Street21 Jump Street21 Jump Street is an American police procedural crime drama television series that aired on the Fox Network from April 12, 1987, to April 27, 1991, with a total of 103 episodes. The series focused on a squad of youthful-looking undercover police officers investigating crimes in high schools,...
, The Young and the RestlessThe Young and the RestlessThe Young and the Restless is an American television soap opera created by William J. Bell and Lee Phillip Bell for CBS. The show is set in a fictional Wisconsin town called Genoa City, which is unlike and unrelated to the real life village of the same name, Genoa City, Wisconsin...
and DeadwoodDeadwood (TV series)Deadwood is an American Western drama television series created, produced and largely written by David Milch. The series aired on the premium cable network HBO from March 21, 2004, to August 27, 2006, spanning three 12-episode seasons. The show is set in the 1870s in Deadwood, South Dakota, before...
. - Karen KillileaKaren KillileaKaren Ann Killilea is the subject of two bestselling books by her mother Marie Killilea, Karen and With Love from Karen. These books were groundbreaking by asserting that children with cerebral palsy could lead productive lives....
, the subject of the book Karen (1952) and its sequel, With Love from Karen (1963), by her mother Marie KillileaMarie KillileaMarie Lyons Killilea is the mother of Karen Killilea and an American author, activist, and lobbyist for the rights of people with cerebral palsy. Her work culminated in the formation of the Cerebral Palsy Association of Westchester County...
. - Gregory IronGregory IronGregory Allen Smith , better known by his ring name Gregory Iron, is an American professional wrestler, who performs regularly in Absolute Intense Wrestling, Pro Wrestling Ohio, AAW, and Chikara promotions.-Early life:...
, a professional wrestler working in the mid-west. Born with cerebral palsy but still able to perform. - Christy BrownChristy BrownChristy Brown was an Irish author, painter and poet who had cerebral palsy. He is most famous for his autobiography My Left Foot, which was later made into an Academy Award-winning film of the same name....
, IrishIrish peopleThe Irish people are an ethnic group who originate in Ireland, an island in northwestern Europe. Ireland has been populated for around 9,000 years , with the Irish people's earliest ancestors recorded having legends of being descended from groups such as the Nemedians, Fomorians, Fir Bolg, Tuatha...
authorAuthorAn author is broadly defined as "the person who originates or gives existence to anything" and that authorship determines responsibility for what is created. Narrowly defined, an author is the originator of any written work.-Legal significance:...
, painter, and poetPoetA poet is a person who writes poetry. A poet's work can be literal, meaning that his work is derived from a specific event, or metaphorical, meaning that his work can take on many meanings and forms. Poets have existed since antiquity, in nearly all languages, and have produced works that vary...
. He is the author of the book My Left FootMy Left Foot (book)My Left Foot is the 1954 autobiography of Christy Brown, who was born with cerebral palsy on June 5, 1932 in Dublin, Ireland. As one of 13 surviving children, Brown went on to be an author, painter and poet.-Childhood:...
. - Rick Hoyt was born with cerebral palsy and today is a member of Team HoytTeam HoytTeam Hoyt is a father and son team from Holland, Massachusetts, who have competed together in various athletic endeavors, including marathons and triathlons...
with his father, Dick. - RJ MitteRJ MitteRoy Frank “RJ” Mitte III is an American actor best known for his role as Walter White Jr. on the AMC television series, Breaking Bad....
, American actor best known for his role as Walter White Jr. on the AMC television series, Breaking BadBreaking BadBreaking Bad is an American television drama series created and produced by Vince Gilligan. Set and produced in Albuquerque, New Mexico, Breaking Bad is the story of Walter White , a struggling high school chemistry teacher who is diagnosed with advanced lung cancer at the beginning of the series...
.