Cerebral palsy
1
Cerebral palsy
Cerebral palsy
Classification and external resources
A child with cerebral palsy being examined.
[1]
ICD-10
G80.
ICD-9
343
OMIM
603513
DiseasesDB
2232
eMedicine
neuro/533
MeSH
D002547
[2]
[3]
605388
[4]
[5]
[6]
pmr/24
[7]
[8]
Cerebral palsy (CP) is an umbrella term encompassing a group of non-progressive,[9] [10] non-contagious motor
conditions that cause physical disability in human development, chiefly in the various areas of body movement.[11]
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. However, "paralytic disorders" 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.[12] [13] 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 1/3. CP, no matter what the type, is often accompanied by secondary musculoskeletal problems that arise as
a result of the underlying etiology.[14]
Of the many types and subtypes of CP, none have a known cure. Usually, medical intervention is limited to the
treatment and prevention of complications arising from CP's effects. A 2003 study put the economic cost for people
with CP in the US at $921,000 per individual, including lost income.[15] In another study, the incidence in six
countries surveyed was 2.12–2.45 per 1,000 live births,[16] indicating a slight rise in recent years. Improvements in
neonatology, or the medical specialty which is involved with treatment of neonates, have helped reduce the number
of babies who develop cerebral palsy, but the survival of babies with very low birth weights has increased, and these
Cerebral palsy
babies are more likely to have cerebral palsy.[17] [18]
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
Spastic cerebral palsy is by far the most common type of overall cerebral palsy, occurring in 90% of all cases
according to SCPE.
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:
• 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.[19]
• Spastic diplegia 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 analysis 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 article and spasticity
for more on spasticity effects). In three-quarters of spastic diplegics, also strabismus (crossed eyes) can be present
as well.
• Spastic monoplegia is one single limb being affected.
• Spastic triplegia is three limbs being affected.
• Spastic 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 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).
2
Cerebral palsy
Ataxic
Ataxia 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 tremors. 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 tone — 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.[20] 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.
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 contractures (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,
3
Cerebral palsy
4
irregular articulatory breakdown, distorted vowels, excess and equal stress, prolonged phonemes, slow rate,
monopitch, monoloudness and harsh voice.[21] Overall language delay is associated with problems of mental
retardation, hearing impairment and learned helplessness.[11] Children with cerebral palsy are at risk of learned
helplessness and becoming passive communicators, initiating little communication.[11] 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.[11]
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
Pain is common, and may result from the inherent deficits associated with the condition, along with the numerous
procedures children typically face.[22] There is also a high likelihood of suffering from chronic sleep disorders
associated with both physical and environmental factors.[23] 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), asphyxia before birth, hypoxia of the brain, and
birth trauma during labor and delivery, and complications in the
perinatal period or during childhood.[11] CP is also more common in
multiple births.
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.
Micrograph showing a fetal (placental) vein
thrombosis, in a case of fetal thrombotic
vasculopathy (FTV). FTV is associated with
cerebral palsy and is suggestive of a
hypercoagulable state as an underlying cause.
H&E stain.
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
cytokines that are produced as part of the inflammatory response.[24] 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
Cerebral palsy
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.[25]
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 Neurology 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 hematomas and hygromas, and a vermian
tumor[26] (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.[27]
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 adults, the middle aged and
older adults. 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 actualisation in terms of easily-accessible and objectively-verifiable
resources available to the general public on the internet and in-person, where many, including medical-science
researchers and doctors themselves, would more than likely agree such resources would ideally belong.
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Cerebral palsy
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 unit (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.[28]
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 helps adults and children maximise their function, adapt to their limitations and live as
independently as possible.[29] [30]
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.[31]
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.
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Cerebral palsy
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.[32] The IAHP's methods have been endorsed by Linus Pauling,[33] as well as some
parents of children treated with their methods.[34] [35] [36]
Massage therapy[37] 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.[38] 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.[39] [40] 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.[40] 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.[40] [41]
Medication
Botulinum toxin 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.[42]
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 baclofen 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.[43]
• Cutting nerves on the limbs most affected by movements and spasms. This procedure, called a rhizotomy, "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.[44]
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[45] and increasing
speed and stride length.[46]
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Cerebral palsy
Other treatments
Cooling high-risk full-term babies shortly after birth may significantly reduce disability or death.[47]
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.[48]
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 the effect of HBOT is no different from that of
pressurized room air, and that some children undergoing HBOT will experience adverse events 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.[49]
Prognosis
CP is not a progressive disorder (meaning the brain damage neither improves nor worsens), 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 for fundamental improvement. People who have CP tend to develop
arthritis at a younger age than normal because of the pressure placed on joints by excessively toned and stiff
muscles.
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.[50]
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.[51] 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.)[52] 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.
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Cerebral palsy
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.[53] 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.[54] 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.[55] 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.[56] However, motor impairments are more important than sensory impairments, with the most
prevalent impairment being finger dexterity (ability to manipulate small objects).[55] 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.[57] An infant with CP may not be able to suck, swallow or chew and this can result in
difficulty eating.[57] As mentioned in the above paragraph, finger dexterity is the most prevalent motor
impairment.[55] 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.[55] Grip strength impairments are less common.[55] 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.[58] Play is also included as a productive occupation as it is often the primary activity
for children.[59]
Play is considered the main occupation for children.[59] If play becomes difficult due to a disability, like CP, this can
cause problems for the child.[60] These difficulties can affect a child’s self-esteem.[60] 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.[60] 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.[61] Typically, children with
disabilities spend more time playing by themselves.[62] When a disability prevents a child from playing, there may be
social, emotional and psychological problems [63] which can lead to increased dependence on others, less motivation
and poor social skills.[64]
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.[65] 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.[65] In
addition, writing may take longer and require greater effort on the student’s part.[65] Factors linked to handwriting
include: postural stability, sensory and perceptual abilities of the hand and writing tool pressure.[65]
Also, speech impairments may be seen in children with CP depending on the severity of brain damage.[66]
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.[67] In summary, children with CP may experience difficulties in
school, such as difficulty with handwriting, carrying out school activities, communicating verbally and interacting
socially.
9
Cerebral palsy
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.[68] Common benefits
identified are stress reduction, development of coping skills, companionship, enjoyment, relaxation and a positive
effect on life satisfaction.[69] In addition, for children with CP, leisure appears to enhance adjustment to living with a
disability.[69]
Leisure can be divided into structured (formal) and unstructured (informal) activities.[70] 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.[71] 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.[71] 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.[72] 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.[72] Barriers can exist on three levels: micro, meso and macro.[73] Firstly, the barriers at the micro level
involve the person.[73] 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.[74] 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.[73] These may include negative attitudes of people towards disability or lack of support
within the family or in the community.[75] 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.[75]
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.[75] For example, a building without an elevator may prevent the child from accessing higher floor
levels.
Epidemiology
In the industrialized world, the incidence of cerebral palsy is about 2 per 1000 live births.[76] 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.[77]
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.[78]
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.
10
Cerebral palsy
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[79]
The SCPE reported the following incidence of comorbidities in children with CP (the data are from 1980–1990 and
included over 4,500 children over age 4 whose CP was acquired during the prenatal or neonatal period):
•
•
•
•
Mental disadvantage (IQ < 50): 31%
Active seizures: 21%
Mental disadvantage (IQ < 50) and not walking: 20%
Blindness: 11%[77]
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.
Apgar scores have sometimes been used as one factor to predict whether or not an individual will develop CP.[80]
History
CP, formerly known as "Cerebral Paralysis," was first identified by English surgeon William Little 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.[81] 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.[82]
Society and culture
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.[83]
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.
11
Cerebral palsy
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 Delaware offers the following guidelines:[84]
Impairment is the correct term to use to define a deviation from normal, such as not being able to make a
muscle move or not being able to control an unwanted movement. Disability is the term used to define a
restriction in the ability to perform a normal activity of daily living which someone of the same age is able to
perform. For example, a three year old child who is not able to walk has a disability because a normal three
year old can walk independently. Handicap is the term used to describe a child or adult who, because of the
disability, is unable to achieve the normal role in society commensurate with his age and socio-cultural milieu.
As an example, a sixteen-year-old who is unable to prepare his own meal or care for his own toileting or
hygiene needs is handicapped. On the other hand, a sixteen-year-old who can walk only with the assistance of
crutches but who attends a regular school and is fully independent in activities of daily living is disabled but
not handicapped. All disabled people are impaired, and all handicapped people are disabled, but a person can
be impaired and not necessarily be disabled, and a person can be disabled without being handicapped.
The term "spastic" describes the attribute of spasticity in types of spastic CP. In 1952 a UK charity called The
Spastics Society was formed.[85] 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.[85] In the United
States the word spaz has the same usage as an insult, but is not generally associated with CP.[86]
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.[87]
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.[88]
Notable cases
• Josh Blue, winner of the fourth season of NBC's Last Comic Standing, whose act revolves around his CP.[89] Blue
was also on the 2004 U.S. Paralympic soccer team.[90]
• Emperor Claudius, the Roman Emperor who was also a stutterer and walked with a limp is believed to have had
CP.[91]
• Abbey Curran, American beauty queen who represented Iowa at Miss USA 2008 and was the first contestant with
a disability to compete. She also made an appearance on The Ellen DeGeneres Show and CBS 'The Early
Show'.[92] [93] [94]
• Jhamak Ghimire, 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 Hopkins, signer of USA Declaration of Independence, reputed to have stated, "My hand trembles, but my
heart does not."[95]
12
Cerebral palsy
• Arun Shourie's son Aditya about whom he has written a book Does He Know a Mother’s Heart[96]
• Geri Jewell, who was the first person with a disability to have a regular role in prime-time series on The Facts of
Life.[97] She has had roles on Sesame Street, 21 Jump Street, The Young and the Restless and Deadwood.[98]
• Karen Killilea, the subject of the book Karen (1952) and its sequel, With Love from Karen (1963), by her mother
Marie Killilea.[99]
• Gregory Iron, a professional wrestler working in the mid-west. [100] Born with cerebral palsy but still able to
perform.
• Christy Brown, Irish author, painter, and poet. He is the author of the book My Left Foot (book).
• Rick Hoyt was born with cerebral palsy and today is a member of Team Hoyt with his father, Dick.
• RJ Mitte, American actor best known for his role as Walter White Jr. on the AMC television series, Breaking
Bad.
References
[1]
[2]
[3]
[4]
[5]
http:/ / apps. who. int/ classifications/ apps/ icd/ icd10online/ ?gg80. htm+ g80
http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=343
http:/ / omim. org/ entry/ 603513
http:/ / omim. org/ entry/ 605388
http:/ / www. diseasesdatabase. com/ ddb2232. htm
[6]
[7]
[8]
[9]
http:/ / www. emedicine. com/ neuro/ topic533. htm
http:/ / www. emedicine. com/ pmr/ topic24. htm#
http:/ / www. nlm. nih. gov/ cgi/ mesh/ 2011/ MB_cgi?field=uid& term=D002547
"Cerebral Palsy." (National Center on Birth Defects and Developmental Disabilities, October 3, 2002), www.cdc.gov (http:/ / www. cdc. gov/
ncbddd/ dd/ ddcp. htm)
[10] " cerebral palsy (http:/ / www. mercksource. com/ pp/ us/ cns/ cns_hl_dorlands_split. jsp?pg=/ ppdocs/ us/ common/ dorlands/ dorland/ nine/
20113760. htm)" at Dorland's Medical Dictionary
[11] Beukelman, David R.; Mirenda, Pat (1999). Augmentative and Alternative Communication: Management of severe communication disorders
in children and adults (2nd ed.). Baltimore: Paul H Brookes Publishing Co. pp. 246–249. ISBN 1557663335.
[12] "Cerebral Palsy - Topic Overview" (http:/ / children. webmd. com/ tc/ cerebral-palsy-topic-overview). . Retrieved 2008-02-06.
[13] WebMD Medical Reference from Healthwise.
[14] Anonymus; Paneth, N; Leviton, A; Goldstein, M; Bax, M; Damiano, D; Dan, B; Jacobsson, B (2007). "Definition and classification of
cerebral palsy, Feb 2007". Developmental medicine and child neurology 49 (8): 8–14. doi:10.1111/j.1469-8749.2007.tb12610.x.
PMID 17370477.
[15] Centers for Disease Control and Prevention (CDC) (2004). "Economic costs associated with mental retardation, cerebral palsy, hearing loss,
and vision impairment—United States, 2003" (http:/ / www. cdc. gov/ mmwr/ preview/ mmwrhtml/ mm5303a4. htm). MMWR Morb. Mortal.
Wkly. Rep. 53 (3): 57–9. PMID 14749614. . Retrieved 2007-08-12.
[16] "Summary of "The Epidemiology of cerebral palsy: incidence, impairments and risk factors"" (http:/ / www. ucpresearch. org/ fact-sheets/
epidemiology-cerebral-palsy. php). United Cerebral Palsy Research and Education Foundation (U.S.). . Retrieved 5 July 2007.
[17] "Information: Scope" (http:/ / www. scope. org. uk/ information/ cp. shtml). . Retrieved 2007-12-08.
[18] Groch, Judith (January 5). "Medical news: Cerebral palsy rates decline in very low birthweight children" (http:/ / www. medpagetoday. com/
Neurology/ GeneralNeurology/ tb2/ 4812). MedPage Today. MedPage Today. . Retrieved 2007-12-08.
[19] Birol Balaban, Evren Yasar, Ugur Dal, Kamil Yazicioglu, Haydar Mohur & Tunc Alp Kalyon "The effect of hinged ankle-foot orthosis on
gait and energy expenditure in spastic hemiplegic cerebral palsy" Disability and Rehabilitation, January 2007; 29(2): 139–144
[20] "Athetoid/Dyskinetic Cerebral Palsy" (http:/ / www. cerebral-palsy-information. com/ athetoid-dyskinetic-cerebral-palsy). . Retrieved
2009-10-27.
[21] Childhood dysarthria: Notes from Childhood Motor Speech Disability by Love
[22] McKearnan K. A., Kieckhefer G. M., Engel J. M., Jensen M. P., Labyak S. (2004). "Pain in children with cerebral palsy: A review". Journal
of Neuroscience Nursing 26 (5): 252–259.
[23] Newman C. J., O'Regan M., Hensey O. (2006). "Sleep disorders in children with cerebral palsy". Developmental Medicine and Child
Neurology 48 (7): 564–8. doi:10.1017/S0012162206001198. PMID 16780625.
[24] "Infection in the Newborn as a Cause of Cerebral Palsy, 12/2004" (http:/ / www. ucpresearch. org/ fact-sheets/ infection-newborn. php).
United Cerebral Palsy Research and Education Foundation (U.S.). . Retrieved 2007-07-05.
[25] Pharoah PO (December 2005). "Causal hypothesis for some congenital anomalies". Twin Res Hum Genet 8 (6): 543–550.
doi:10.1375/183242705774860141. PMID 16354495.
[26] Kolawole TM, Patel PJ, Mahdi AH (1989). "Computed tomographic (CT) scans in cerebral palsy (CP)". Pediatr Radiol 20 (1–2): 23–27.
doi:10.1007/BF02010628. PMID 2602010.
13
Cerebral palsy
[27] Ashwal S, Russman BS, Blasco PA et al. (2004). "Practice parameter: diagnostic assessment of the child with cerebral palsy: report of the
Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society".
Neurology 62 (6): 851–63. PMID 15037681.
[28] Taub, Edward; Ramey, S., De Luca, S., Echols, K. (1). "Efficacy of Constraint-Induced Movement Therapy for Children With Cerebral
Palsy With Asymmetric Motor Impairment" (http:/ / pediatrics. aappublications. org/ content/ 113/ 2/ 305. full. pdf+ html). Pediatrics 113 (2):
305–312. doi:10.1542/peds.113.2.305. PMID 14754942. . Retrieved 2011-05-12.
[29] Hansen, Ruth A.; Atchison, Ben (2000). Conditions in occupational therapy: effect on occupational performance. Hagerstown, MD:
Lippincott Williams & Wilkins. ISBN 0-683-30417-8.
[30] Crepeau, Elizabeth Blesedell; Willard, Helen S.; Spackman, Clare S.; Neistadt, Maureen E. (1998). Willard and Spackman's occupational
therapy. Philadelphia: Lippincott-Raven Publishers. ISBN 0-397-55192-4.
[31] Pennington L, Goldbart J, Marshall J (2004). Pennington, Lindsay. ed. "Speech and language therapy to improve the communication skills
of children with cerebral palsy". Cochrane database of systematic reviews (Online) (2): CD003466. doi:10.1002/14651858.CD003466.pub2.
PMID 15106204.
[32] American Academy of Pediatrics. Committee on Children with Disabilities (1999). "The treatment of neurologically impaired children using
patterning" (http:/ / pediatrics. aappublications. org/ cgi/ content/ full/ 104/ 5/ 1149). Pediatrics 104 (5): 1149–1151.
doi:10.1542/peds.104.5.1149. PMID 10545565. .
[33] Pauling, Linus (November 1978). "Orthomolecular enhancement of human development". Human Neurological Development: Past, Present,
and Future. A Joint Symposium Sponsored by NASA/Ames Research Center and the Institutes for the Achievement of Human Potential.
NASA CP 2063: 47–51.
[34] David Melton, Todd: The Story of a Brain-Injured Child, Philadelphia: The Better Baby Press, 1985.
[35] Berg, Kevin (January 2005). "chapter 3: patterning", A Life with Purpose. Kevin Berg Books, 80. ISBN 1-4116-2252-9.
[36] Leone Nunley with Dean Merrill, Fighting for David. Carol, Illinois: Tyndale House Publishers, Inc., 2006
[37] Macgregor R, Campbell R, Gladden MH, Tennant N, Young D (2007). "Effects of massage on the mechanical behaviour of muscles in
adolescents with spastic diplegia: a pilot study". Developmental medicine and child neurology 49 (3): 187–191.
doi:10.1111/j.1469-8749.2007.00187.x. PMID 17355474.
[38] Mulligan S, Neistadt ME. Occupational therapy evaluation for children: a pocket guide. : Lippincott Williams & Wilkins; 2003.
[39] Steultjens E, Dekker J, Bouter LM, JCM, Lambregts B, CHM. Occupational therapy for children with cerebral palsy: a systematic review.
Clin.Rehabil. 2004 02;18(1):1-14.
[40] Neistadt ME. Occupational therapy evaluation for adults: a pocket guide. : Lippincott Williams & Wilkins; 2000.
[41] Guidetti S, Söderback I. Description of self-care training in occupational therapy: case studies of five Kenyan children with cerebral palsy.
OCCUP THER INT 2001 03;8(1):34-48.
[42] Heinen F, Desloovere K, Schroeder AS, Berweck S, Borggraefe I, van Campenhout et al, The updated European Consensus 2009 on the use
of Botulinum toxinfor children with cerebral palsy. Eur J Paediatr Neurol. 2010 Jan;14(1):45-66.Epub 2009 Nov 14. Review. PubMed PMID:
19914110.
[43] Schejbalová A (2006). "[Derotational subtrochanteric osteotomy of the femur in cerebral palsy patients]" (in Czech). Acta chirurgiae
orthopaedicae et traumatologiae Cechoslovaca 73 (5): 334–9. PMID 17140515.
[44] Farmer JP, Sabbagh AJ (2007). "Selective dorsal rhizotomies in the treatment of spasticity related to cerebral palsy". Child s Nervous System
23 (9): 991–1002. doi:10.1007/s00381-007-0398-2. PMID 17643249.
[45] Balaban B, Yasar E, Dal U, Yazicioglu K, Mohur H, Kalyon TA (2007). "The effect of hinged ankle-foot orthosis on gait and energy
expenditure in spastic hemiplegic cerebral palsy". Disability and rehabilitation 29 (2): 139–144. doi:10.1080/17483100600876740.
PMID 17373095.
[46] White H, Jenkins J, Neace WP, Tylkowski C, Walker J (2002). "Clinically prescribed orthoses demonstrate an increase in velocity of gait in
children with cerebral palsy: a retrospective study". Developmental medicine and child neurology 44 (4): 227–32.
doi:10.1017/S0012162201001992. PMID 11995890.
[47] Shankaran S, Laptook AR, Ehrenkranz RA et al. (2005). "Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy". N.
Engl. J. Med. 353 (15): 1574–1584. doi:10.1056/NEJMcps050929. PMID 16221780.
[48] Ehrenkranz RA, Dusick AM, Vohr BR, Wright LL, Wrage LA, Poole WK (2006). "Growth in the neonatal intensive care unit influences
neurodevelopmental and growth outcomes of extremely low birth weight infants". Pediatrics 117 (4): 1253–1261.
doi:10.1542/peds.2005-1368. PMID 16585322.
[49] McDonagh MS, Morgan D, Carson S, Russman BS (2007). "Systematic review of hyperbaric oxygen therapy for cerebral palsy: the state of
the evidence". Dev Med Child Neurol 49 (12): 942–947. doi:10.1111/j.1469-8749.2007.00942.x. PMID 18039243.
[50] Jenks KM, de Moor J, van Lieshout EC, Maathuis KG, Keus I, Gorter JW (2007). "The effect of cerebral palsy on arithmetic accuracy is
mediated by working memory, intelligence, early numeracy, and instruction time". Dev Neuropsychol 32 (3): 861–79.
doi:10.1080/87565640701539758. PMID 17956186.
[51] Strauss D, Brooks J, Rosenbloom R, Shavelle R (2008). "Life Expectancy in cerebral palsy: an update". Developmental Medicine & Child
Neurology 50 (7): 487–493. doi:10.1111/j.1469-8749.2008.03000.x. PMID 18611196.
[52] Online 'Mendelian Inheritance in Man' (OMIM) CEREBRAL PALSY, SPASTIC, SYMMETRIC, AUTOSOMAL RECESSIVE -603513
(http:/ / omim. org/ entry/ 603513)
14
Cerebral palsy
[53] Van Zelst, B.; Miller, M.; Russo, R.; Murchland, S.; Crotty, M. (2006). "Activities of daily living in children with hemiplegic cerebral palsy:
a cross-sectional evaluation using the Assessment of Motor and Process Skills". Developmental Medicine & Child Neurology 48 (9): 723–7.
doi:10.1017/S0012162206001551. PMID 16904017.
[54] Nieuwenhuijsen, C.; Donkervoort, M.; Nieuwstraten, W.; Stam, H. J.; Roebroeck, M. E.; Transition Research Group South West
Netherlands (2009). "Experienced problems of young adults with cerebral palsy: targets for rehabilitation care". Archives of Physical Medicine
and Rehabilitation 90 (11): 1891–1897. doi:10.1016/j.apmr.2009.06.014. PMID 19887214.
[55] Donkervoort, M.; Roebroeck, M.; Wiegerink, D.; Van der Heijden-Maessen, H.; Stam, H.; The Transition Research Group South (2007).
"Determinants of functioning of adolescents and young adults with cerebral palsy". Disability & Rehabilitation 29 (6): 453–463.
doi:10.1080/09638280600836018. PMID 17364800.
[56] Arnould, C.; Penta, M.; Thonnard, J. (2008). "Hand impairments and their relationship with manual ability in children with cerebral palsy".
Journal of Rehabilitation Medicine 39 (9): 708–714. doi:10.2340/16501977-0111. PMID 17999009.
[57] Klingels, K.; De Cock, P.; Molenaers, G.; Desloovere, K.; Huenaerts, C.; Jaspers, E.; Feys, H. (2010). "Upper limb motor and sensory
impairments in children with hemiplegic cerebral palsy. Can they be measured reliably?". Disability & Rehabilitation 32 (5): 409–416.
doi:10.3109/09638280903171469. PMID 20095955.
[58] Fedrizzi E, Pagliano E, Andreucci E, Oleari G. Hand function in children with hemiplegic cerebral palsy: prospective follow-up and
functional outcome in adolescence. Dev.Med.Child Neurol. 2003 02;45(2):85-91.
[59] Blesedell CE, Cohn ES, Schell AB. Willard and Spackman’s occupational therapy. : Philadelphia, PA: Lippincot, Williams and Wilkins;
2003. p. 705-709.
[60] Townsend E, Stanton S, Law M. Enabling occupation: An occupational therapy perspective. : Canadian Association of Occupational
Therapists Ottawa, ON, Canada; 1997/2002. p. 34.
[61] Parham LD, Primeau LA. Play and occupational therapy. Play in occupational therapy for children: Mosby St. Louis, MO; 1997.
[62] Miller S, Reid D. Doing play: competency, control, and expression. Cyberpsychol Behav 2003 12;6(6):623-632.
[63] Okimoto AM, Bundy A, Hanzlik J. Playfulness in children with and without disability: measurement and intervention. Am.J.Occup.Ther.
2000 2000;54(1):73-82.
[64] Hestenes LL, Carroll DE. The play interactions of young children with and without disabilities: Individual and environmental influences.
Early Childhood Research Quarterly 2000;15(2):229-246.
[65] Missiuna, C; Pollock N (1991 Oct). "Play deprivation in children with physical disabilities: the role of the occupational therapist in
preventing secondary disability". Am.J.Occup.Ther. 45 (10): 882–8. PMID 1835302.
[66] Howard L. A comparison of leisure-time activities between able-bodied children and children with physical disabilities. BR J OCCUP
THER 1996 12;59(12):570-574.
[67] Rigby P, Schwellnus H. Occupational therapy decision making guidelines for problems in written productivity. Phys.Occup.Ther.Pediatr.
1999 03;19(1):5-27.
[68] Smith M, Sandberg AD, Larsson M. Reading and spelling in children with severe speech and physical impairments: a comparative study.
Int.J.Lang.Commun.Disord. 2009 2009;44(6):864-882.
[69] Pruitt DW, Tsai T. Common medical comorbidities associated with cerebral palsy. PHYS MED REHABIL CLIN NORTH AM 2009
08;20(3):453-467.
[70] Cassidy T. All work and no play: a focus on leisure time as a means for promoting health. COUNS PSYCHOL Q 1996 03;9(1):77-90.
[71] Reynolds F. Coping with chronic illness and disability through creative needlecraft. BR J OCCUP THER 1997 08;60(8):352-356.
[72] King G, Law M, King S, Rosenbaum P, Kertoy MK, Young NL. A conceptual model of the factors affecting the recreation and leisure
participation of children with disabilities. Phys.Occup.Ther.Pediatr. 2003;23(1):63-90.
[73] Aitchison C. From Leisure and Disability to Disability Leisure: developing data, definitions and discourses. Disability & Society 2003
12;18(7):955-969.
[74] Imms C. Children with cerebral palsy participate: a review of the literature. Disabil.Rehabil. 2008 11/30;30(24):1867-1884.
[75] Specht J, King G, Brown E, Foris C. The importance of leisure in the lives of persons with congenital physical disabilities.
Am.J.Occup.Ther. 2002 2002;56(4):436-445.
[76] "Thames Valley Children's Centre - Cerebral Palsy - Causes and Prevalence" (http:/ / web. archive. org/ web/ 20070823084944/ http:/ /
www. tvcc. on. ca/ gateway. php?id=167& cid=2). Archived from the original (http:/ / www. tvcc. on. ca/ gateway. php?id=167& cid=2) on
2007-08-23. . Retrieved 2007-06-11.
[77] Johnson, Ann (2002). "Prevalence and characteristics of children with cerebral palsy in Europe" (http:/ / journals. cambridge. org/
production/ action/ cjoGetFulltext?fulltextid=120612). Developmental medicine and child neurology 44 (9): 633–40.
doi:10.1017/S0012162201002675. PMID 12227618. .
[78] United Cerebral Palsy Research and Education Foundation (U.S.). "Cerebral Palsy Fact Sheet" (http:/ / www. ucp. org/ uploads/
cp_fact_sheet. pdf) (PDF). . Retrieved 12 August 2007.
[79] Hirtz D, Thurman DJ, Gwinn-Hardy K, Mohamed M, Chaudhuri AR, Zalutsky R (2007). "How common are the "common" neurologic
disorders?". Neurology 68 (5): 326–337. doi:10.1212/01.wnl.0000252807.38124.a3. PMID 17261678.
[80] Thorngren-Jerneck K, Herbst A (2006). "Perinatal factors associated with cerebral palsy in children born in Sweden". Obstetrics and
gynecology 108 (6): 1499–1505. doi:10.1097/01.AOG.0000247174.27979.6b. PMID 17138786.
[81] "Cerebral Palsy - Facts & Figures: History" (http:/ / www. ucp. org/ ucp_generaldoc. cfm/ 1/ 9/ 37/ 37-37/ 447#history). United Cerebral
Palsy Research and Education Foundation (U.S.). . Retrieved 2007-07-06.
15
Cerebral palsy
[82] "Cerebral Palsy: Hope Through Research" (http:/ / www. ninds. nih. gov/ disorders/ cerebral_palsy/ detail_cerebral_palsy. htm). National
Institute of Neurological Disorders and Stroke (U.S.). NIH Publication No. 06-159. July 2006. . Retrieved 2010-04-26.
[83] Access Economics (2008) The Economic Impact of Cerebral Palsy in Australia in 2007. Access Economics, Canberra, ACT (http:/ / www.
thespasticcentre. com. au/ news/ news_items/ access-economics/ access-economics. htm)
[84] "Cerebral Palsy: a Guide for Care" (http:/ / gait. aidi. udel. edu/ res695/ homepage/ pd_ortho/ clinics/ c_palsy/ cpweb. htm). . Retrieved
2007-07-29.
[85] Brindle, David (2002-05-22). "A very telling tale" (http:/ / society. guardian. co. uk/ charitymanagement/ story/ 0,8150,719600,00. html).
The Guardian (London). . Retrieved 2007-07-29.
[86] Zimmer, Benjamin (2007-02-05). "A brief history of "spaz"" (http:/ / itre. cis. upenn. edu/ ~myl/ languagelog/ archives/ 003020. html).
Language Log. University of Pennsylvania. . Retrieved 2007-07-29.
[87] snowdrop.cc (http:/ / www. snowdrop. cc/ info2. cfm?info_id=62106)
[88] Erickson, Glenn (May 22, 2007). "DVD Savant Review: Goodbye CP" (http:/ / www. dvdtalk. com/ dvdsavant/ s2300cp. html). DVDtalk. .
[89] "Josh Blue wins "Last Comic Standing"" (http:/ / specialchildren. about. com/ b/ 2006/ 08/ 11/ josh-blue-wins-last-comic-standing. htm). .
Retrieved 2010-12-06.
[90] ""Last Comic Standing" biography" (http:/ / www. nbc. com/ Last_Comic_Standing/ comics/ josh_blue. shtml). . Retrieved 2010-12-06.
[91] Pearce JM (2000). "The emperor with the shaking head". Journal of the Royal Society of Medicine 93 (6): 335–6. PMC 1298048.
PMID 10911840.
[92] "Abbey Curran, junior" (http:/ / web. sau. edu/ feature/ abbey_curran. php). St Ambrose University. .
[93] "Abbey Curran Competing at the Miss USA Pageant!" (http:/ / ci. easterseals. com/ site/ PageServer?pagename=ILPR_AbbeyCurran).
Easter Seals. Peoria, Illinois. .
[94] "Pageant Is Her Crowning Achievement: Miss Iowa, In Las Vegas For Miss USA Pageant, Was Born With Cerebral Palsy" (http:/ / www.
cbsnews. com/ stories/ 2008/ 04/ 10/ entertainment/ main4006779. shtml). Las Vegas: CBS. April 10, 2008. . Retrieved 5 June 2010.
[95] "The Sheila Variations: August 2, 1776: "My hand trembles, but my heart does not"" (http:/ / www. sheilaomalley. com/ archives/ 000942.
html). . Retrieved 2007-07-29.
[96] "Does He Know a Mother’s Heart: How Suffering Refutes Religions by Arun Shourie" (http:/ / www. simplybooks. in/
does-he-know-a-arun-shourie-book-isbn-9789350290910-109857). .
[97] "Comedian Geri Jewell headlines diversity event" (http:/ / www. wmich. edu/ wmu/ news/ 2002/ 0205/ 0102-x210. html). WMU News. May
16, 2002. . Retrieved 6 December 2010.
[98] "No 2nd acts in film? Guess again" (http:/ / www. sfgate. com/ cgi-bin/ article. cgi?f=/ c/ a/ 2007/ 01/ 01/ DDGPKN9K6U1. DTL&
hw=Geri+ Jewell& sn=001& sc=1000l). Associated Press. Jan 1, 2007. . Retrieved 6 December 2010.
[99] "About Marie Killilea" (http:/ / web. archive. org/ web/ 20070929075340/ http:/ / www. parsley. org/ killilea/ about. html). parsley.org.
Archived from the original (http:/ / www. parsley. org/ killilea/ about. html) on Sep 29, 2007. . Retrieved 2007-07-29.
http://www.myrepublica.com/portal/index.php?action=news_details&news_id=34982
External links
• Cerebral palsy (http://www.dmoz.org/Health/Conditions_and_Diseases/Neurological_Disorders/
Cerebral_Palsy//) at the Open Directory Project: Includes links to more than a dozen sites with information on
CP, as well as support groups and CP organisations.
• NINDS Cerebral Palsy Information Page. (http://www.ninds.nih.gov/disorders/cerebral_palsy/
detail_cerebral_palsy.htm)
16
Article Sources and Contributors
17
Article Sources and Contributors
Cerebral palsy Source: http://en.wikipedia.org/w/index.php?oldid=456814684 Contributors: 1ForTheMoney, 4twenty42o, 5ostilly, A8UDI, ABF, AJChang, AZard, Aaroncrick, Abb615,
Abreresnowdrop, AdjustShift, Aek002, Agent Conundrum, Ahoerstemeier, Aitias, Ajk, Alansohn, Alec - U.K., Alexgwhite, Ali, Allmightyduck, Alpha Quadrant, Alphasquadron, Althealth,
Alvis, AmyEliz, Andrewdoane, Andru nl, Annmbecker1, Anthonyhcole, Apple05, Aquaswim47, Aqwis, Arcadian, Argos'Dad, ArmadilloFromHell, Arman88, Armeria, ArnoldPlaton, Arnon
Chaffin, Asyndeton, AubreyEllenShomo, AuntFlo, Auric, AxelBoldt, Ayrton Prost, B5rm21sl2, BD2412, Baby Jenga, Bacchus87, Badger Drink, Banno, Bazzargh, Beccaviola, Beetstra,
Bender235, Bernard faraday, Big iron, Bkell, Blanchardb, Bllasae, Bobo192, Bonehed, Borgx, Brevan, Brianski, Brighterorange, BritishHobo, Bruce Perens, Buchanan-Hermit, Bunny-chan,
Butters757, Buxbaum666, Bwilkins, Bwthemoose, C777, CDN99, CH4ZM4N, Caelarch, Cahk, Calabraxthis, Can't sleep, clown will eat me, Catgut, Cattlemencare28, Cbrown1023, Cementkilla,
Centrx, Cereb5, CerebralMom, Charles walsh, Chill doubt, Chillum, Chinju, Chris 73, Chris the speller, Chrismewse, Chubbyblondebabe, CliffC, Closedmouth, Colin, Colonies Chris,
Cometstyles, Compgeek86, Computerjoe, Conversion script, Cosmic Latte, Croat Canuck, CryptoDerk, Cwlvaughn, Cybersaum, Cyrius, Cyrus Andiron, D0762, DARTH SIDIOUS 2, DHN,
DJBullfish, DWaterson, DabMachine, Damiens.rf, Danarmstrong, Dantendo, Dar-Ape, Darguz Parsilvan, Davewild, David.Mestel, DavidFarmbrough, Davidruben, Dawg1605, Dawn Bard,
Dcoetzee, Delicious carbuncle, Delldot, DerBorg, Dfern112, Diannaa, Digitylgoddess, DirtyB41, Discospinster, DivineAlpha, Dlae, Dob2008, Doc thurston, Docta247, DoctorW, Doctorlami,
Dogaru Florin, Dominic Hardstaff, Donimo, Dougher, Dr.DianeM, Dr.alf, Dskluz, Dspenciner, Dysprosia, EcoordinatorUCP, Edburke317, El C, Eliyahu S, Eliz81, Emc2, Emike7500, Emily370,
Epbr123, ErdemTuzun, Eric-Wester, ErikWarmelink, EronMain, Escape Orbit, EscapingLife, Eubulides, Euske, Evertype, Everyme, Ewachspress, Explain35, Faarisjourney, Failedwizard,
Falcon8765, Farquaadhnchmn, FatBoySlim011, Ferengi, Fgabor5480, Fieldday-sunday, Firsfron, Fizark, Fminow, Forwardset, FrozenPurpleCube, Frumfree, Fumitol, Funandtrvl, GDP852,
GNIstrategies, Gabbe, Gadfium, Gaius Cornelius, Gakusha, Garrondo, GcSwRhIc, Gene Hobbs, Geneb1955, Georomig, Ggodwin, Gh5046, GiantSnowman, Gibsonj338, Gilliam, GinaDana,
Glenn4pr, Gnourt, Gogo Dodo, GoldKanga, Graham87, GrahamHardy, Grayshi, Green453, Guthrie, Haakon, Hadal, Haham hanuka, Hajhouse, HalfShadow, Hamtechperson, Hardin MD,
Headbomb, Healthpop, HeavierThanHeaven, Helllogo, HelloDollyAllsorts, Hemikids, HexaChord, Hibernian, Hoof Hearted, Hooperbloob, Icairns, IceKarma, Iceberg3k, Ikmaton, Immunize,
ImperatorExercitus, Inoculatedcities, Iridescent, Isaac Guard, Iss246, Itai, Ivan Bajlo, Ixfd64, J.delanoy, JForget, JaGa, Jacksmack76, Jaksmith, Jameboy, James Kanjo, JamesAM, Jamesontai,
Janegalloway9, Jfdwolff, Jibbajabbas, Jjacobjs, Jknowles126, Jmh649, Jmitschwilliams, Jmorgan, Jni, Joconnor, John Broughton, JohnC, Jollygood, JonahMJohnson, Jonathan.s.kt, Jorgenev,
Jrm513, Julesd, Juliancolton, Junglecat, Jusdafax, Kafziel, Kain Nihil, Kaisershatner, Kannie, KasugaHuang, Kathleej, Kdehl, Ke4roh, Keaton, Keenan Pepper, Kendrick7, Kensai, Kernel NickM,
Ketsuekigata, Kevinbasil, Kikodawgzz, Kikodawgzzz, Kinaro, Kirsten07734, Kjoonlee, KlappCK, KnowledgeOfSelf, Kotra, Krited, Krsont, Kukini, Kurlysticks, Kyried, L Kensington, LOL,
Lakmiseiru, Lancastrianexile, Languagehat, Learnthesigns, Lee-Anne, Leedude, Leuko, Lhw1, Lilaclady61, Ling.Nut, Lisa mynx, Lisa-BFWM, Llaneerg, Llort, Lolipop25641, Lou.weird,
Lowellian, Lucas Jones, Luckas Blade, Lucylucy1994, Luke poa, Luzdanoite, MER-C, MONGO, Madcoverboy, Madhero88, Makelelecba, Makemi, Maralia, Marek69, Mark Pharoah,
MarkSutton, Markmichaelh, Martarius, MartinSpacek, MastCell, Mathsinger, Matt Deres, MattSutton1, Mav, Maxim, McSly, Mckeeman, Mdawg728, Melsaran, Mentifisto, Metboyjon,
Mewmuffin, Michael Frind, Michaelkourlas, Mikes1807, MilborneOne, Minority Report, Mirokado, Mmayberry, Mortek MC, Mr.cool98, MrKalamazoo, MrOllie, Mramo, Mrich, Muffinishous,
Mwanner, Myhealthy, Natcase, Natgoo, NawlinWiki, Ndenison, NeilN, NelsonJones, Nephron, Neutrality, Nikki887766, Nkuipers, Noctibus, Nomadicface, Norman22b, Normane2,
Nothingmore Nevermore, NuclearWarfare, NuclearWinner, Nucleusboy, Nunh-huh, Nuttycoconut, Oddtruth, Offenbach, Ohnoitsjamie, Onorem, Opelio, Orange Suede Sofa, Oxymoron83,
PL290, Paces, Patrick, Paul Benjamin Austin, Pb30, Pdcook, Peak, PeruAlonso, Philip Trueman, Phillipedison1891, Piano non troppo, PierreAbbat, Pill, Pinar, Pinethicket, Pingveno, Pixpie,
Pmjk, Poeloq, Pookmaus, Postlewaight, Poule, Prestonmcconkie, Proofreader77, PurpleUrge, Purplefeltangel, Purplewowies, Qubeh, Queenmomcat, RDBrown, RLent, Radical Mallard,
RadioFan, RainbowOfLight, Rajan111179, Ram-Man, Rameshmpt, Rchandra, Rdsmith4, Reach Out to the Truth, Recurring dreams, RedWolf, Redvers, Reedy, Repku, Research87, Revadarth,
Rhobite, Rhrad, Rich Farmbrough, RichardF, Rjwilmsi, Roastytoast, Robin S, Robin1225, Robyn189, RodC, Rojomoke, RolandR, Ronz, RoyBoy, Rrmadore, Ruakh, Rubicon, Runningonbrains,
Runoguy, S3000, Samuell, Sarahle613, Sarenne, Scarian, Schubert2, Scipilot, Scolbath, Scottandsteven, ScreaminEagle, Scubert1, Sean.hoyland, Seaphoto, Seraphim, Sflinders, Shadowjams,
Shibboleth, Shreemoy, Sidefall, SimonArlott, Sjakkalle, Skate Escape, Slakr, Slyguy135, SmartyBoots, Sole Soul, Spacebears, Srleffler, Stacylsteele, Steel, Stephaniegoddard-rox.ca, Stephenb,
StuHarris, Stupid girl, Stwalkerster, Succesfultroll, Sue Douglasss, Suprcrip2002, Svick, T, TBAmes, TPIRFanSteve, TRWBW, Talk2max, Tanner Swett, Tannerhelland, Tarquin, Tatterfly,
Taurusgump, Tb81, Tbplante, TedE, Tetty2, Tfox194026, Thayvian, The Anome, The Behnam, The Font, The Thing That Should Not Be, The Wednesday Island, TheEgyptian, Thekid21,
Theo10011, Tide rolls, TiffanyTran, Tim Starling, Timeshift9, Tito9586, Tommyfly, Tregoweth, Triona, Trnj2000, Trystan, Ttony21, Twirligig, Tyra50, Tyrol5, Umalee, Umdan2k, Uncle Milty,
UncleBubba, University513, Unused0029, Update321, Uppitycrip, Useight, Vanished User 1004, Verbal, Verne Equinox, Versus22, Vinsonowen, Viridian, VsevolodKrolikov, WHEREISMS,
Walk123, Waynelaw85, Welsh, WhatamIdoing, WikHead, Wikerchair, Wiki alf, Wikipe-tan, Wilberforcehumphries, William Avery, Willow1984, Wimt, Woohookitty, Wrestler51296,
YUL89YYZ, Yaie, Yamla, You05, Ysangkok, Zaf, Zargulon, Zigger, Zrulli, 55‫דוד‬, आलोक, 1518 anonymous edits
Image Sources, Licenses and Contributors
File:US Navy 081028-N-3173B-027 Cmdr. John King assesses the reflexes of a Cerebral Palsy patient at the Arima District Health Facility as part of the humanitarian-civic assistance
mission Continuing Promise (CP) 2008.jpg Source:
http://en.wikipedia.org/w/index.php?title=File:US_Navy_081028-N-3173B-027_Cmdr._John_King_assesses_the_reflexes_of_a_Cerebral_Palsy_patient_at_the_Arima_District_Health_Facility_as_part_of_the_humanitari
License: Public Domain Contributors: Image:Fetal thrombotic vasculopathy - intermed mag.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Fetal_thrombotic_vasculopathy_-_intermed_mag.jpg License: Creative
Commons Attribution-Sharealike 3.0 Contributors: Nephron
License
Creative Commons Attribution-Share Alike 3.0 Unported
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