Cerebral palsy
Cerebral palsy | |
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A child with cerebral palsy being assessed by a physician | |
Specialty |
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Symptoms | |
Complications | |
Usual onset | Prenatal to early childhood[1] |
Duration | Lifelong[1] |
Causes | Often unknown[1] or brain injury |
Risk factors |
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Diagnostic method | Based on child's development[1] |
Treatment |
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Medication | |
Frequency | 2.1 per 1,000[2] |
Cerebral palsy (CP) is a group of
Cerebral palsy is caused by abnormal development or damage to the parts of the brain that control movement, balance, and posture.[1][4] Most often, the problems occur during pregnancy, but may occur during childbirth or shortly afterwards.[1] Often, the cause is unknown.[1] Risk factors include preterm birth, being a twin, certain infections or exposure to methylmercury during pregnancy, a difficult delivery, and head trauma during the first few years of life.[1] About 2% of cases are believed to be due to an inherited genetic cause.[5]
Sub-types are classified, based on the specific problems present.[1] For example, those with stiff muscles have spastic cerebral palsy, poor coordination in locomotion have ataxic cerebral palsy, and writhing movements have dyskinetic cerebral palsy.[6] Diagnosis is based on the child's development.[1] Blood tests and medical imaging may be used to rule out other possible causes.[1]
Some causes of CP are preventable through immunization of the mother, and efforts to prevent head injuries in children such as improved safety. There is no known cure for CP, but supportive treatments, medication and surgery may help individuals.
Cerebral palsy is the most common movement disorder in children,[12] occurring in about 2.1 per 1,000 live births.[2] It has been documented throughout history, with the first known descriptions occurring in the work of Hippocrates in the 5th century BCE.[13] Extensive study began in the 19th century by William John Little, after whom spastic diplegia was called "Little's disease".[13] William Osler first named it "cerebral palsy" from the German zerebrale Kinderlähmung (cerebral child-paralysis).[14]
Signs and symptoms
Cerebral palsy is defined as "a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain."
Cerebral palsy is characterized by abnormal
Babies born with severe cerebral palsy often have 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. Babies born with cerebral palsy do not immediately present with symptoms.[25] Classically, CP becomes evident when the baby reaches the developmental stage at 6 to 9 months and is starting to mobilise, where preferential use of limbs, asymmetry, or gross motor developmental delay is seen.[20]
Drooling is common among children with cerebral palsy, which can have a variety of impacts including social rejection, impaired speaking, damage to clothing and books, and mouth infections.[26][27] It can additionally cause choking.[27][28]
An average of 55.5% of people with cerebral palsy experience lower urinary tract symptoms, more commonly excessive storage issues than voiding issues. Those with voiding issues and pelvic floor overactivity can deteriorate as adults and experience upper urinary tract dysfunction.[29]
Children with CP may also have sensory processing issues.[30] Adults with cerebral palsy have a higher risk of respiratory failure.[31]
Skeleton
For bones to attain their normal shape and size, they require the stresses from normal musculature.
Children with CP are prone to low trauma fractures, particularly children with higher Gross Motor Function Classification System (GMFCS) levels who cannot walk. This further affects a child's mobility, strength, and experience of pain, and can lead to missed schooling or child abuse suspicions.[32] These children generally have fractures in the legs, whereas non-affected children mostly fracture their arms in the context of sporting activities.[38]
Hip dislocation and ankle equinus or plantar flexion deformity are the two most common deformities among children with cerebral palsy. Additionally, flexion deformity of the hip and knee can occur. Torsional deformities of long bones such as the femur and tibia are also encountered, among others.[19][39] Children may develop scoliosis before the age of 10 – estimated prevalence of scoliosis in children with CP is between 21% and 64%.[40] Higher levels of impairment on the GMFCS are associated with scoliosis and hip dislocation.[19][41] Scoliosis can be corrected with surgery, but CP makes surgical complications more likely, even with improved techniques.[40] Hip migration can be managed by soft tissue procedures such as adductor musculature release. Advanced degrees of hip migration or dislocation can be managed by more extensive procedures such as femoral and pelvic corrective osteotomies. Both soft tissue and bony procedures aim at prevention of hip dislocation in the early phases or aim at hip containment and restoration of anatomy in the late phases of disease.[19] Equinus deformity is managed by conservative methods especially when dynamic. If fixed/static deformity ensues surgery may become mandatory.[39]
Growth spurts during puberty can make walking more difficult for people with CP.[42]
Eating
Due to sensory and motor impairments, those with CP may have difficulty preparing food, holding utensils, or chewing and swallowing. An infant with CP may not be able to suck, swallow or chew.
Children with severe cerebral palsy, particularly with
Language
Speech and language disorders are common in people with cerebral palsy. The incidence of
Early use of augmentative and alternative communication systems may assist the child in developing spoken language skills.[49] Overall language delay is associated with problems of cognition, deafness, and learned helplessness.[51] Children with cerebral palsy are at risk of learned helplessness and becoming passive communicators, initiating little communication.[51][52] Early intervention with this clientele, and their parents, 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.[51]
Pain and sleep
Pain is common and may result from the inherent deficits associated with the condition, along with the numerous procedures children typically face.[53] When children with cerebral palsy are in pain, they experience worse muscle spasms.[54] Pain is associated with tight or shortened muscles, abnormal posture, stiff joints, unsuitable orthosis, etc. Hip migration or dislocation is a recognizable source of pain in CP children and especially in the adolescent population. Nevertheless, the adequate scoring and scaling of pain in CP children remains challenging.[19] Pain in CP has a number of different causes, and different pains respond to different treatments.[55]
There is also a high likelihood of chronic
Associated disorders
Associated disorders include intellectual disabilities, seizures, muscle contractures, abnormal gait, osteoporosis, communication disorders, malnutrition, sleep disorders, and mental health disorders, such as depression and anxiety.[62] Epilepsy is often found in the child before they are 1 year old, or also before they are four or five.[63] In addition to these, functional gastrointestinal abnormalities contributing to bowel obstruction, vomiting, and constipation may also arise. Adults with cerebral palsy may have ischemic heart disease, cerebrovascular disease, cancer, and trauma more often.[64] Obesity in people with cerebral palsy or a more severe Gross Motor Function Classification System assessment in particular are considered risk factors for multimorbidity.[65] Other medical issues can be mistaken for being symptoms of cerebral palsy, and so may not be treated correctly.[66]
Related conditions can include apraxia, sensory impairments, urinary incontinence, fecal incontinence, or behavioural disorders.[67]
Seizure management is more difficult in people with CP as seizures often last longer.[68] Epilepsy and asthma are common co-occurring diseases in adults with CP.[69] The associated disorders that co-occur with cerebral palsy may be more disabling than the motor function problems.[28]
Causes
Cerebral palsy is due to abnormal development or damage occurring to the developing brain.[70] This damage can occur during pregnancy, delivery, the first month of life, or less commonly in early childhood.[70] Structural problems in the brain are seen in 80% of cases, most commonly within the white matter.[70] More than three-quarters of cases are believed to result from issues that occur during pregnancy.[70] Most children who are born with cerebral palsy have more than one risk factor associated with CP.[71] Cerebral palsy is not contagious and cannot be contracted in adulthood. CP is almost always developed en utero, or prior to birth.[72]
While in certain cases there is no identifiable cause, typical causes include problems in intrauterine development (e.g. exposure to radiation, infection,
In Africa
Preterm birth
Between 40% and 50% of all children who develop cerebral palsy were born prematurely.[76] Most of these cases (75–90%) are believed to be due to issues that occur around the time of birth, often just after birth.[70] Multiple-birth infants are also more likely than single-birth infants to have CP.[77] They are also more likely to be born with a low birth weight.[78]
In those who are born with a weight between 1 kg (2.2 lbs) and 1.5 kg (3.3 lbs) CP occurs in 6%.[2] Among those born before 28 weeks of gestation it occurs in 8%.[79][a] Genetic factors are believed to play an important role in prematurity and cerebral palsy generally.[80] In those who are born between 34 and 37 weeks the risk is 0.4% (three times normal).[81]
Term infants
In babies who are born at term risk factors include problems with the placenta,
As of 2013[update], it was unclear how much of a role birth asphyxia plays as a cause.[83] It is unclear if the size of the placenta plays a role.[84] As of 2015[update] it is evident that in advanced countries, most cases of cerebral palsy in term or near-term neonates have explanations other than asphyxia.[74]
Genetics
Cerebral palsy is not commonly considered a genetic disease. About 2% of all CP cases are expected to be inherited, with
Cerebellar hypoplasia is sometimes genetic[86] and can cause ataxic cerebral palsy.[87]
Early childhood
After birth, other causes include toxins, severe
Others
Infections in the mother, even those not easily detected, can triple the risk of the child developing cerebral palsy.[90] Infection of the fetal membranes known as chorioamnionitis increases the risk.[91]
Intrauterine and neonatal insults (many of which are infectious) increase the risk.[92]
Rh blood type incompatibility can cause the mother's immune system to attack the baby's red blood cells.[1]
It has been hypothesised that some cases of cerebral palsy are caused by the death in very early pregnancy of an identical twin.[93]
Diagnosis
The diagnosis of cerebral palsy has historically rested on the person's history and physical examination and is generally assessed at a young age. A general movements assessment, which involves measuring movements that occur spontaneously among those less than four months of age, appears most accurate.[94][95] Children who are more severely affected are more likely to be noticed and diagnosed earlier. Abnormal muscle tone, delayed motor development and persistence of primitive reflexes are the main early symptoms of CP.[44] Symptoms and diagnosis typically occur by the age of two,[96] although depending on factors like malformations and congenital issues,[97] persons with milder forms of cerebral palsy may be over the age of five, if not in adulthood, when finally diagnosed.[98]
Cognitive assessments and medical observations are also useful to help confirm a diagnosis. Additionally, evaluations of the child's mobility, speech and language, hearing, vision, gait, feeding and digestion are also useful to determine the extent of the disorder.[97] Early diagnosis and intervention are seen as being a key part of managing cerebral palsy.[99] Machine learning algorithms facilitate automatic early diagnosis, with methods such as deep neural network[100] and geometric feature fusion[101] producing high accuracy in predicting cerebral palsy from short videos. It is a developmental disability.[94]
Once a person is diagnosed with cerebral palsy, further diagnostic tests are optional.
The age when CP is diagnosed is important, but medical professionals disagree over the best age to make the diagnosis.[95] The earlier CP is diagnosed correctly, the better the opportunities are to provide the child with physical and educational help, but there might be a greater chance of confusing CP with another problem, especially if the child is 18 months of age or younger.[95] Infants may have temporary problems with muscle tone or control that can be confused with CP, which is permanent.[95] A metabolism disorder or tumors in the nervous system may appear to be CP; metabolic disorders, in particular, can produce brain problems that look like CP on an MRI.[1] Disorders that deteriorate the white matter in the brain and problems that cause spasms and weakness in the legs, may be mistaken for CP if they first appear early in life.[95] However, these disorders get worse over time, and CP does not[95] (although it may change in character).[1] In infancy it may not be possible to tell the difference between them.[95] In the UK, not being able to sit independently by the age of 8 months is regarded as a clinical sign for further monitoring.[98] Fragile X syndrome (a cause of autism and intellectual disability) and general intellectual disability must also be ruled out.[95] Cerebral palsy specialist John McLaughlin recommends waiting until the child is 36 months of age before making a diagnosis because, by that age, motor capacity is easier to assess.[95]
Classification
CP is classified by the types of motor impairment of the limbs or organs, and by restrictions to the activities an affected person may perform.[104] The Gross Motor Function Classification System-Expanded and Revised and the Manual Ability Classification System are used to describe mobility and manual dexterity in people with cerebral palsy, and recently the Communication Function Classification System, and the Eating and Drinking Ability Classification System have been proposed to describe those functions.[105] There are three main CP classifications by motor impairment: spastic, ataxic, and dyskinetic. Additionally, there is a mixed type that shows a combination of features of the other types. These classifications reflect the areas of the brain that are damaged.[106]
Cerebral palsy is also classified according to the topographic distribution of muscle spasticity.[107] This method classifies children as diplegic, (bilateral involvement with leg involvement greater than arm involvement), hemiplegic (unilateral involvement), or quadriplegic (bilateral involvement with arm involvement equal to or greater than leg involvement).[108][107]
Spastic
Spastic cerebral palsy is the type of cerebral palsy characterized by
Ataxic
Ataxic cerebral palsy is observed in approximately 5–10% of all cases of cerebral palsy, making it the least frequent form of cerebral palsy.[113] Ataxic cerebral palsy is caused by damage to cerebellar structures.[114] Because of the damage to the cerebellum, which is essential for coordinating muscle movements and balance, patients with ataxic cerebral palsy experience problems in coordination, specifically in their arms, legs, and trunk. Ataxic cerebral palsy is known to decrease muscle tone.[115] The most common manifestation of ataxic cerebral palsy is intention (action) tremor, which is especially apparent when carrying out precise movements, such as tying shoe laces or writing with a pencil. This symptom gets progressively worse as the movement persists, making the hand shake. As the hand gets closer to accomplishing the intended task, the trembling intensifies, which makes it even more difficult to complete.[108]
Dyskinetic
Dyskinetic cerebral palsy (sometimes abbreviated DCP) is primarily associated with damage to the
Mixed
Mixed cerebral palsy has symptoms of dyskinetic, ataxic and spastic CP appearing simultaneously, each to varying degrees, and both with and without symptoms of each. Mixed CP is the most difficult to treat as it is extremely heterogeneous and sometimes unpredictable in its symptoms and development over the lifespan.[120][121][122][123]
Gait classification
In patients with spastic hemiplegia or diplegia, various gait patterns can be observed, the exact form of which can only be described with the help of complex gait analysis systems. In order to facilitate interdisciplinary communication in the interdisciplinary team between those affected, doctors, physiotherapists and orthotists, a simple description of the gait pattern is useful. J. Rodda and H. K. Graham already described in 2001 how gait patterns of CP patients can be more easily recognized and defined gait types which they compared in a classification. They also described that gait patterns can vary with age.[124] Building on this, the Amsterdam Gait Classification was developed at the free university in Amsterdam, the VU medisch centrum.
A special feature of this classification is that it makes different gait patterns very easy to recognize and can be used in CP patients in whom only one leg and both legs are affected. According to the Amsterdam Gait Classification, five gait types are described. To assess the gait pattern, the patient is viewed visually or via a video recording from the side of the leg to be assessed. At the point in time at which the leg to be viewed is in mid stance and the leg not to be viewed is in mid swing, the knee angle and the contact of the foot with the ground are assessed on the one hand.[125]
Classification of the gait pattern according to the Amsterdam Gait Classification: In gait type 1, the knee angle is normal and the foot contact is complete. In gait type 2, the knee angle is hyperextended and the foot contact is complete. In gait type 3, the knee angle is hyperextended and foot contact is incomplete (only on the forefoot). In gait type 4, the knee angle is bent and foot contact is incomplete (only on the forefoot). With gait type 5, the knee angle is bent and the foot contact is complete.[125]
Gait types 5 is also known as crouch gait.[126]
Prevention
Because the causes of CP are varied, a broad range of preventive interventions have been investigated.[127]
In those at risk of an early delivery,
Cooling high-risk full-term babies shortly after birth may reduce disability,[139] but this may only be useful for some forms of the brain damage that causes CP.[96]
Management
Over time, the approach to CP management has shifted away from narrow attempts to fix individual physical problems – such as spasticity in a particular limb – to making such treatments part of a larger goal of maximizing the person's independence and community engagement.[140]: 886 However, the evidence base for the effectiveness of intervention programs reflecting the philosophy of independence has not yet caught up: effective interventions for body structures and functions have a strong evidence base, but evidence is lacking for effective interventions targeted toward participation, environment, or personal factors.[140] There is also no good evidence to show that an intervention that is effective at the body-specific level will result in an improvement at the activity level or vice versa.[140] Although such cross-over benefit might happen, not enough high-quality studies have been done to demonstrate it.[140]
Because cerebral palsy has "varying severity and complexity" across the lifespan,
Various forms of therapy are available to people living with cerebral palsy as well as caregivers and parents. Treatment may include one or more of the following: physical therapy; occupational therapy; speech therapy; water therapy; drugs to control seizures, alleviate pain, or relax muscle spasms (e.g. benzodiazepines); 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 synthesisers.[142] Intensive rehabilitation is practiced in certain countries, but obtaining reliable data on its medium and long-term effectiveness is challenging.[143]
Surgical intervention in CP children may include various
A Cochrane review published in 2004 found a trend toward the benefit of speech and language therapy for children with cerebral palsy but noted the need for high-quality research.[145] A 2013 systematic review found that many of the therapies used to treat CP have no good evidence base; the treatments with the best evidence are medications (anticonvulsants, botulinum toxin, bisphosphonates, diazepam), therapy (bimanual training, casting, constraint-induced movement therapy, context-focused therapy, fitness training, goal-directed training, hip surveillance, home programmes, occupational therapy after botulinum toxin, pressure care) and surgery. There is also research on whether the sleeping position might improve hip migration, but there are not yet high-quality evidence studies to support that theory.[146] Research papers also call for an agreed consensus on outcome measures which will allow researchers to cross-reference research. Also, the terminology used to describe orthoses[147] needs to be standardised to ensure studies can be reproduced and readily compared and evaluated.
Orthotics in the concept of therapy
To improve the gait pattern, orthotics can be included in the therapy concept. An orthosis can support physiotherapeutic treatment in setting the right motor impulses in order to create new cerebral connections.[148] The orthosis must meet the requirements of the medical prescription. In addition, the orthosis must be designed by the orthotist in such a way that it achieves the effectiveness of the necessary levers, matching the gait pattern, in order to support the proprioceptive approaches of physiotherapy. The characteristics of the stiffness of the orthosis shells and the adjustable dynamics in the ankle joint are important elements of the orthosis to be considered.[149]
Due to these requirements, the development of orthoses has changed significantly in recent years, especially since around 2010. At about the same time, care concepts were developed that deal intensively with the orthotic treatment of the lower extremities in cerebral palsy.
Prognosis
CP is not a
The ability to live independently with CP varies widely, depending partly on the severity of each person's impairment and partly on the capability of each person to self-manage the logistics of life. Some individuals with CP require personal assistant services for all
Puberty in young adults with cerebral palsy may be
CP can significantly reduce a person's life expectancy, depending on the severity of their condition and the quality of care they receive.
Self-care
For many children with CP, parents are heavily involved in self-care activities. Self-care activities, such as bathing, dressing, and grooming, can be difficult for children with CP, as self-care depends primarily on the use of the upper limbs.[164] 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.[165] As the hands are used for many self-care tasks, sensory and motor impairments of the hands make daily self-care more difficult.[45][non-primary source needed][166] Motor impairments cause more problems than sensory impairments.[45] The most common impairment is that of finger dexterity, which is the ability to manipulate small objects with the fingers.[45] Compared to other disabilities, people with cerebral palsy generally need more help in performing daily tasks.[167] Occupational therapists are healthcare professionals that help individuals with disabilities gain or regain their independence through the use of meaningful activities.[168]
Productivity
The effects of sensory, motor, and cognitive impairments affect self-care occupations in children with CP and productivity occupations. Productivity can include but is not limited to, school, work, household chores, or contributing to the community.[169]
Play is included as a productive occupation as it is often the primary activity for children.[170] If play becomes difficult due to a disability, like CP, this can cause problems for the child.[171] These difficulties can affect a child's self-esteem.[171] 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.[171] Not only do physical limitations affect a child's ability to play, the limitations perceived by the child's caregivers and playmates also affect the child's play activities.[172] Some children with disabilities spend more time playing by themselves.[173] When a disability prevents a child from playing, there may be social, emotional and psychological problems,[174] which can lead to increased dependence on others, less motivation, and poor social skills.[175]
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.[176] 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.[176] In addition, writing may take longer and require greater effort on the student's part.[176] Factors linked to handwriting include postural stability, sensory and perceptual abilities of the hand, and writing tool pressure.[176]
Speech impairments may be seen in children with CP depending on the severity of brain damage.[177] Communication in a school setting is 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.[178] In summary, children with CP may experience difficulties in school, such as difficulty with handwriting, carrying out school activities, communicating verbally, and interacting socially.[citation needed]
Leisure
Leisure activities can have several positive effects on physical health, mental health, life satisfaction, and psychological growth for people with physical disabilities like CP.[179] Common benefits identified are stress reduction, development of coping skills, companionship, enjoyment, relaxation and a positive effect on life satisfaction.[180] In addition, for children with CP, leisure appears to enhance adjustment to living with a disability.[180]
Leisure can be divided into structured (formal) and unstructured (informal) activities.
Children with cerebral palsy may face challenges when it comes to participating in sports. This comes with being discouraged from physical activity because of these perceived limitations imposed by their medical condition.[186]
Participation and barriers
Participation is involvement in life situations and everyday activities.[187] Participation includes self-care, productivity, and leisure. In fact, communication, mobility, education, home life, leisure, and social relationships require participation, and indicate the extent to which children function in their environment.[187] Barriers can exist on three levels: micro, meso, and macro.[188] First, the barriers at the micro level involve the person.[188] 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.[189] For example, the child may not participate in group activities due to lack of confidence. Second, barriers at the meso level include the family and community.[188] These may include negative attitudes of people toward disability or lack of support within the family or in the community.[190]
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.[190] Third, 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 access or public transit that can accommodate children with CP.[190] For example, a building without an elevator can prevent the child from accessing higher floors.[citation needed]
A 2013 review stated that outcomes for adults with cerebral palsy without intellectual disability in the 2000s were that "60–80% completed high school, 14–25% completed college, up to 61% were living independently in the community, 25–55% were competitively employed, and 14–28% were involved in long term relationships with partners or had established families".[191] Adults with cerebral palsy may not seek physical therapy due to transport issues, financial restrictions and practitioners not feeling like they know enough about cerebral palsy to take people with CP on as clients.[192]
Aging
Children with CP may not successfully transition into using adult services because they are not referred to one upon turning 18, and may decrease their use of services.
Like they did in childhood, adults with cerebral palsy experience psychosocial issues related to their CP, chiefly the need for social support, self-acceptance, and acceptance by others. Workplace accommodations may be needed to enhance continued employment for adults with CP as they age. Rehabilitation or social programs that include salutogenesis may improve the coping potential of adults with CP as they age.[200]
Epidemiology
Cerebral palsy occurs in about 2.1 per 1000 live births.[2] In those born at term rates are lower at 1 per 1000 live births.[70] Within a population it may occur more often in poorer people.[201] The rate is higher in males than in females; in Europe it is 1.3 times more common in males.[202]
There was a "moderate, but significant" rise in the prevalence of CP between the 1970s and 1990s. This is thought to be due to a rise in low birth weight of infants and the increased survival rate of these infants. The increased survival rate of infants with CP in the 1970s and 80s may be indirectly due to the disability rights movement challenging perspectives around the worth of infants with a disability, as well as the Baby Doe Law.[203] Between 1990 and 2003, rates of cerebral palsy remained the same.[204]
As of 2005, advances in the care of pregnant mothers and their babies did not result 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.[205] As of 2016[update], there is a suggestion that both incidence and severity are slightly decreasing – more research is needed to find out if this is significant, and if so, which interventions are effective.[127] It has been found that high-income countries have lower rates of children born with cerebral palsy than low or middle-income countries.[206]
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.[207]
History
Cerebral palsy has affected humans since antiquity. A decorated grave marker dating from around the 15th to 14th century BCE shows a figure with one small leg and using a crutch, possibly due to cerebral palsy. The oldest likely physical evidence of the condition comes from the mummy of Siptah, an Egyptian Pharaoh who ruled from about 1196 to 1190 BCE and died at about 20 years of age. The presence of cerebral palsy has been suspected due to his deformed foot and hands.[13]
The medical literature of the ancient Greeks discusses paralysis and weakness of the arms and legs; the modern word palsy comes from the Ancient Greek words παράλυση or πάρεση, meaning paralysis or paresis respectively. The works of the school of Hippocrates (460–c. 370 BCE), and the manuscript On the Sacred Disease in particular, describe a group of problems that matches up very well with the modern understanding of cerebral palsy. The Roman Emperor Claudius (10 BCE–54 CE) is suspected of having CP, as historical records describe him as having several physical problems in line with the condition. Medical historians have begun to suspect and find depictions of CP in much later art. Several paintings from the 16th century and later show individuals with problems consistent with it, such as Jusepe de Ribera's 1642 painting The Clubfoot.[13]
The modern understanding of CP as resulting from problems within the brain began in the early decades of the 1800s with a number of publications on brain abnormalities by Johann Christian Reil, Claude François Lallemand and Philippe Pinel. Later physicians used this research to connect problems in the brain with specific symptoms. The English surgeon William John Little (1810–1894) was the first person to study CP extensively. In his doctoral thesis he stated that CP was a result of a problem around the time of birth. He later identified a difficult delivery, a preterm birth and perinatal asphyxia in particular as risk factors. The spastic diplegia form of CP came to be known as Little's disease.[13] At around this time, a German surgeon was also working on cerebral palsy, and distinguished it from polio.[208] In the 1880s British neurologist William Gowers built on Little's work by linking paralysis in newborns to difficult births. He named the problem "birth palsy" and classified birth palsies into two types: peripheral and cerebral.[13]
Working in the US in the 1880s, Canadian-born physician
Before moving to psychiatry, Austrian neurologist Sigmund Freud (1856–1939) made further refinements to the classification of the disorder. He produced the system still being used today. Freud's system divides the causes of the disorder into problems present at birth, problems that develop during birth, and problems after birth. Freud also made a rough correlation between the location of the problem inside the brain and the location of the affected limbs on the body and documented the many kinds of movement disorders.[13]
In the early 20th century, the attention of the medical community generally turned away from CP until orthopedic surgeon Winthrop Phelps became the first physician to treat the disorder. He viewed CP from a
In 1997, Robert Palisano et al. introduced the Gross Motor Function Classification System (GMFCS) as an improvement over the previous rough assessment of limitation as either mild, moderate, or severe.[104] The GMFCS grades limitation based on observed proficiency in specific basic mobility skills such as sitting, standing, and walking, and takes into account the level of dependency on aids such as wheelchairs or walkers. The GMFCS was further revised and expanded in 2007.[104]
Society and culture
Economic impact
It is difficult to directly compare the cost and cost-effectiveness of interventions to prevent cerebral palsy or the cost of interventions to manage CP.[132] Access Economics has released a report on the economic impact of cerebral palsy in Australia. The report found that, in 2007, the financial cost of cerebral palsy (CP) in Australia was A$1.47 billion or 0.14% of GDP.[209] Of this:
- A$1.03 billion (69.9%) was productivity lost due to lower employment, absenteeism, and premature death of Australians with CP
- A$141 million (9.6%) was the DWL from transfers including welfare payments and taxation forgone
- A$131 million (9.0%) was other indirect costs such as direct program services, aides and home modifications, and the bringing-forward of funeral costs
- A$129 million (8.8%) was the value of the informal care for people with CP
- A$40 million (2.8%) was direct health system expenditure
The value of lost well-being (disability and premature death) was a further A$2.4 billion.[citation needed]
In per capita terms, this amounts to a financial cost of A$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.[citation needed]
Individuals with CP bear 37% of the financial costs, and their families and friends bear a further 6%. The 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.[citation needed]
The average lifetime cost for people with CP in the US is US$921,000 per individual, including lost income.[210]
In the United States, many states allow Medicaid beneficiaries to use their Medicaid funds to hire their own PCAs, instead of forcing them to use institutional or managed care.[211]
In India, the government-sponsored program called "NIRAMAYA" for the medical care of children with neurological and muscular deformities has proved to be an ameliorating economic measure for persons with such disabilities.[212] It has shown that persons with mental or physically debilitating congenital disabilities can lead better lives if they have financial independence.[213]
Use of the term
"Cerebral" means "of, or pertaining to, the cerebrum or the brain"[214] and "palsy" means "paralysis, generally partial, whereby a local body area is incapable of voluntary movement".[215] It has been proposed to change the name to "cerebral palsy spectrum disorder" to reflect the diversity of presentations of CP.[216]
Many people would rather be referred to as a person with a disability (people-first language) instead of as "handicapped".[217][218] "Cerebral Palsy: A Guide for Care" at the University of Delaware offers the following guidelines:
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 can 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. A handicapped child or adult is one 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 toilet 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.[219]
The term "
Media
Maverick documentary filmmaker Kazuo Hara criticises 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 people with cerebral palsy 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.[221]
Spandan (2012), a film by Vegitha Reddy and Aman Tripathi, delves into the dilemma of parents whose child has cerebral palsy. While films made with children with special needs as central characters have been attempted before, the predicament of parents dealing with the stigma associated with the condition and beyond is dealt in Spandan. In one of the songs of Spandan "Chal chaal chaal tu bala" more than 50 CP kids have acted. The famous classical singer Devaki Pandit has given her voice to the song penned by Prof. Jayant Dhupkar and composed by National Film Awards winner Isaac Thomas Kottukapally.[222][223][224][225]
Call the Midwife (2012–) has featured two episodes with actor Colin Young, who himself has cerebral palsy, playing a character with the same disability. His storylines have focused on the segregation of those with disabilities in the UK in the 1950s, and also romantic relationships between people with disabilities.[227]
Micah Fowler, an American actor with CP, stars in the ABC sitcom Speechless (2016–2019), which explores both the serious and humorous challenges a family faces with a teenager with CP.[228]
9-1-1 (2018–) is a procedural drama series on Fox. From season 2 onwards, it features Gavin McHugh (who himself has cerebral palsy) in the recurring role as Christopher Diaz – a young child who has cerebral palsy.
Special (2019) is a comedy series that premiered on Netflix on 12 April 2019. It was written, produced and stars Ryan O'Connell as a young gay man with mild cerebral palsy. It is based on O'Connell's book I'm Special: And Other Lies We Tell Ourselves.[229]
Australian drama serial The Heights (2019–) features a character with mild cerebral palsy, teenage girl Sabine Rosso, depicted by an actor who herself has mild cerebral palsy, Bridie McKim.[230]
6,000 Waiting (2021) is a documentary by Michael Joseph McDonald. It is the first film to depict a person with cerebral palsy parachuting. It tells the story of three men with cerebral palsy seeking to live in their communities instead of institutions.[231] Upon seeing the film, American politician Stacey Abrams interviewed one of the film's protagonists and publicly stated that her top priority was deinstitutionalization through Medicaid expansion.[232]
Notable cases
- Christy Brown was the basis for the Academy Award-winning film, My Left Foot.
- Two sons of Canadian rock musician Neil Young, Zeke and Ben.[233] In 1986, Young helped found the Bridge School, an educational organization for children with severe verbal and physical disabilities, and its annual supporting Bridge School Benefit concerts, together with his wife Pegi.[234][235]
- Formula 1 driver Lewis Hamilton.[236]
- Geri Jewell, who had a regular role in the prime-time series The Facts of Life.[237]
- Josh Blue, winner of the fourth season of NBC's Last Comic Standing, whose act revolves around his CP.[238] Blue was also on the 2004 U.S. Paralympic soccer team.[239]
- Jason Benetti, play-by-play broadcaster for ESPN, Fox Sports, Westwood One, and Time Warner covering football, baseball, lacrosse, hockey, and basketball. From 2016 until 2023, he was the television play-by-play announcer for Chicago White Sox home games. Since 2024, Benetti has been the play-by-play announcer for the Detroit Tigers.[240]
- Britain's Got Talent.[241]
- Abbey Curran, an American beauty queen who represented Iowa at Miss USA 2008 and was the first contestant with a disability to compete.[242]
- Robert Griswold, swimmer
- Francesca Martinez, British stand-up comedian and actress.[243]
- Evan O'Hanlon, Australian Paralympian, the fastest athlete with cerebral palsy in the world.[244]
- Arun Shourie's son Aditya, about whom he has written a book Does He Know a Mother's Heart[245]
- Maysoon Zayid, the self-described "Palestinian Muslim virgin with cerebral palsy, from New Jersey", who is an actress, stand-up comedian, and activist.[246] Zayid has been a resident of Cliffside Park, New Jersey.[247] She is considered one of America's first Muslim women comedians and the first person ever to perform standup in Palestine and Jordan.[248]
- RJ Mitte, an American actor best known for his role as Walter White Jr. in Breaking Bad. He is also a celebrity ambassador for United Cerebral Palsy.[249]
- OWN called Rollin' With Zach and is the author of If at Birth You Don't Succeed.[250]
- Kaine, a member of the American hip-hop duo The Ying Yang Twins, has a mild form of cerebral palsy that causes him to limp.[251][unreliable source?]
- Hannah Cockroft, is a British wheelchair athlete specialising in sprint distances in the T34 classification. She holds the Paralympic and world records for the 100 metres, 200 metres and 400 metres in her classification.[252][253][254]
- disability rights activist, author and journalist.[255]
- Kuli Kohli, Indian-British writer, poet, activist.[256]
- Simon James Stevens, a British disability issues consultant and activist, who starred in I'm Spazticus and founded Wheelies virtual nightclub [257]
- The Roman Emperor Claudius is hypothesized to have had cerebral palsy on the basis of his reported symptoms.[258]
- Rosie Jones, a British comedian and actress, is incorporating her cerebral palsy into her comedic style.
- Christopher Nolan, an Irish Poet and Author, he wrote Damn-Burst of Dreams, The Banyan Tree, and Under The Eye Of The Clock. He passed away in 2009.
- Lost Voice GuyBritish Comedian
Litigation
Because of the perception that cerebral palsy is mostly caused by trauma during birth, as of 2005, 60% of obstetric
See also
- Cerebral palsy sport classification – describes the disability sport classification for cerebral palsy.
- Inclusive recreation
- World Cerebral Palsy Day
Notes
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External links
- Cerebral palsy at Curlie
- Cerebral Palsy Information Page at NINDS