Cerebral Palsy
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Cerebral palsy (CP) is a group of
movement disorders Movement disorder refers to any clinical syndrome with either an excess of movement or a paucity of voluntary and involuntary movements, unrelated to weakness or spasticity. Movement disorders are synonymous with basal ganglia or extrapyramidal d ...
that appear in early childhood. Signs and symptoms vary among people and over time, but include poor coordination, stiff muscles, weak muscles, and tremors. There may be problems with
sensation Sensation (psychology) refers to the processing of the senses by the sensory system. Sensation or sensations may also refer to: In arts and entertainment In literature * Sensation (fiction), a fiction writing mode * Sensation novel, a Britis ...
,
vision Vision, Visions, or The Vision may refer to: Perception Optical perception * Visual perception, the sense of sight * Visual system, the physical mechanism of eyesight * Computer vision, a field dealing with how computers can be made to gain un ...
,
hearing Hearing, or auditory perception, is the ability to perceive sounds In physics, sound is a vibration that propagates as an acoustic wave, through a transmission medium such as a gas, liquid or solid. In human physiology and psycholog ...
, and
speaking Speech is a human vocal communication using language. Each language uses phonetic combinations of vowel and consonant sounds that form the sound of its words (that is, all English words sound different from all French words, even if they are th ...
. Often, babies with cerebral palsy do not roll over, sit, crawl or walk as early as other children of their age. Other symptoms include
seizures An epileptic seizure, informally known as a seizure, is a period of symptoms due to abnormally excessive or synchronous neuronal activity in the brain. Outward effects vary from uncontrolled shaking movements involving much of the body with l ...
and problems with thinking or reasoning, which each occur in about one-third of people with CP. While symptoms may get more noticeable over the first few years of life, underlying problems do not worsen over time. Cerebral palsy is caused by abnormal development or damage to the parts of the brain that control movement, balance, and posture. Most often, the problems occur during pregnancy, but they may also occur during childbirth or shortly after birth. Often, the cause is unknown. Risk factors include
preterm birth Preterm birth, also known as premature birth, is the Childbirth, birth of a baby at fewer than 37 weeks Gestational age (obstetrics), gestational age, as opposed to full-term delivery at approximately 40 weeks. Extreme preterm is less than 28 we ...
, being a
twin Twins are two offspring produced by the same pregnancy.MedicineNet > Definition of TwinLast Editorial Review: 19 June 2000 Twins can be either ''monozygotic'' ('identical'), meaning that they develop from one zygote, which splits and forms two em ...
, certain infections during pregnancy, such as
toxoplasmosis Toxoplasmosis is a parasitic disease caused by ''Toxoplasma gondii'', an apicomplexan. Infections with toxoplasmosis are associated with a variety of neuropsychiatric and behavioral conditions. Occasionally, people may have a few weeks or months ...
or
rubella Rubella, also known as German measles or three-day measles, is an infection caused by the rubella virus. This disease is often mild, with half of people not realizing that they are infected. A rash may start around two weeks after exposure and ...
, exposure to methylmercury during pregnancy, a difficult delivery, and head trauma during the first few years of life, among others. About 2% of cases are believed to be due to an inherited genetic cause. A number of sub-types are classified, based on the specific problems present. For example, those with stiff muscles have
spastic cerebral palsy Spastic cerebral palsy is the type of cerebral palsy characterized by spasticity or high muscle tone often resulting in stiff, jerky movements. Cases of spastic CP are further classified according to the part or parts of the body that are most af ...
, those with poor coordination in locomotion have ataxic cerebral palsy, and those with writhing movements have dyskinetic cerebral palsy. Diagnosis is based on the child's development over time. Blood tests and medical imaging may be used to rule out other possible causes. Some of the causes of CP are preventable through immunization of the mother, and through efforts to prevent head injuries in children such as through improved safety. There is no known cure for CP, but supportive treatments, medication and surgery may help many individuals. This may include physical therapy, occupational therapy and speech therapy. Medications such as
diazepam Diazepam, first marketed as Valium, is a medicine of the benzodiazepine family that acts as an anxiolytic. It is commonly used to treat a range of conditions, including anxiety, seizures, alcohol withdrawal syndrome, muscle spasms, insomnia, ...
,
baclofen Baclofen, sold under the brand name Lioresal among others, is a medication used to treat muscle spasticity such as from a spinal cord injury or multiple sclerosis. It may also be used for hiccups and muscle spasms near the end of life. It is ta ...
and botulinum toxin may help relax stiff muscles. Surgery may include lengthening muscles and cutting overly active nerves. Often, external braces and other assistive technology are helpful. Some affected children can achieve near normal adult lives with appropriate treatment. While
alternative medicine Alternative medicine is any practice that aims to achieve the healing effects of medicine despite lacking biological plausibility, testability, repeatability, or evidence from clinical trials. Complementary medicine (CM), complementary and alt ...
s are frequently used, there is no evidence to support their use. Cerebral palsy is the most common movement disorder in children. It occurs in about 2.1 per 1,000 live births. Cerebral palsy has been documented throughout history, with the first known descriptions occurring in the work of
Hippocrates Hippocrates of Kos (; grc-gre, Ἱπποκράτης ὁ Κῷος, Hippokrátēs ho Kôios; ), also known as Hippocrates II, was a Greek physician of the classical period who is considered one of the most outstanding figures in the history of ...
in the 5th century BCE. Extensive study of the condition began in the 19th century by
William John Little William John Little (1810–1894) was an English surgeon who is credited with the first medical identification of spastic diplegia, when he observed it in the 1860s amongst children. While spasticity surely existed before that point, Little was ...
, after whom spastic diplegia was called "Little's disease".
William Osler Sir William Osler, 1st Baronet, (; July 12, 1849 – December 29, 1919) was a Canadian physician and one of the "Big Four" founding professors of Johns Hopkins Hospital. Osler created the first residency program for specialty training of phys ...
first named it "cerebral palsy" from the German (cerebral child-paralysis). A number of potential treatments are being examined, including stem cell therapy. However, more research is required to determine if it is effective and safe.


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." While movement problems are the central feature of CP, difficulties with thinking, learning, feeling, communication and behavior often co-occur, with 28% having
epilepsy Epilepsy is a group of non-communicable neurological disorders characterized by recurrent epileptic seizures. Epileptic seizures can vary from brief and nearly undetectable periods to long periods of vigorous shaking due to abnormal electrica ...
, 58% having difficulties with communication, at least 42% having problems with their vision, and 2356% having
learning disabilities Learning disability, learning disorder, or learning difficulty (British English) is a condition in the brain that causes difficulties comprehending or processing information and can be caused by several different factors. Given the "difficult ...
.
Muscle contractions Muscle contraction is the activation of tension-generating sites within muscle cells. In physiology, muscle contraction does not necessarily mean muscle shortening because muscle tension can be produced without changes in muscle length, such as ...
in people with cerebral palsy are commonly thought to arise from overactivation. Cerebral palsy is characterized by abnormal
muscle tone In physiology, medicine, and anatomy, muscle tone (residual muscle tension or tonus) is the continuous and passive partial muscle contraction, contraction of the muscles, or the muscle's resistance to passive stretch during resting state.O’Sull ...
, reflexes, or motor development and coordination. The neurological lesion is primary and permanent while orthopedic manifestations are secondary and progressive. In cerebral palsy unequal growth between muscle-tendon units and bone eventually leads to bone and joint deformities. At first, deformities are dynamic. Over time, deformities tend to become static, and joint contractures develop. Deformities in general and static deformities in specific ( joint contractures) cause increasing gait difficulties in the form of tip-toeing gait, due to tightness of the Achilles tendon, and
scissoring gait Scissor gait is a form of gait abnormality primarily associated with spastic cerebral palsy. That condition and others like it are associated with an upper motor neuron lesion. __TOC__ Presentation This gait pattern is reminiscent of a marionette. ...
, due to tightness of the hip adductors. These gait patterns are among the most common gait abnormalities in children with cerebral palsy. However, orthopaedic manifestations of cerebral palsy are diverse. Additionally, crouch gait (excessive knee flexion gait) is prevalent among children who possess the ability to walk. 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 of the spectrum. Although most people with CP have problems with increased muscle tone, some have normal or low muscle tone. High muscle tone can either be due to
spasticity Spasticity () is a feature of altered skeletal muscle performance with a combination of paralysis, increased tendon reflex activity, and hypertonia. It is also colloquially referred to as an unusual "tightness", stiffness, or "pull" of muscles ...
or
dystonia Dystonia is a neurological hyperkinetic movement disorder in which sustained or repetitive muscle contractions result in twisting and repetitive movements or abnormal fixed postures. The movements may resemble a tremor. Dystonia is often inten ...
. 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. 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. 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. It can additionally cause choking. An average of 55.5% of people with cerebral palsy experience
lower urinary tract symptoms Lower urinary tract symptoms (LUTS) refer to a group of clinical symptoms involving the bladder, urinary sphincter, urethra and, in men, the prostate. The term is more commonly applied to men—over 40% of older men are afected—but lower urina ...
, more commonly excessive storage issues than voiding issues. Those with voiding issues and
pelvic floor The pelvic floor or pelvic diaphragm is composed of muscle fibers of the levator ani, the coccygeus muscle, and associated connective tissue which span the area underneath the pelvis. The pelvic diaphragm is a muscular partition formed by the lev ...
overactivity can deteriorate as adults and experience upper urinary tract dysfunction. Children with CP may also have
sensory processing Sensory processing is the process that organizes sensation from one's own body and the environment, thus making it possible to use the body effectively within the environment. Specifically, it deals with how the brain processes multiple sensory mod ...
issues. Adults with cerebral palsy have a higher risk of
respiratory failure Respiratory failure results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels. A drop in the oxygen carried in the blood is known as hypoxemia; a rise ...
.


Skeleton

For bones to attain their normal shape and size, they require the stresses from normal musculature. People with cerebral palsy are at risk of low
bone mineral density Bone density, or bone mineral density, is the amount of bone mineral in bone tissue. The concept is of mass of mineral per volume of bone (relating to density in the physics sense), although clinically it is measured by proxy according to optica ...
. The shafts of the bones are often thin (gracile), and become thinner during growth. When compared to these thin shafts (
diaphyses The diaphysis is the main or midsection (shaft) of a long bone. It is made up of cortical bone and usually contains bone marrow and adipose tissue (fat). It is a middle tubular part composed of compact bone which surrounds a central marrow cavity ...
), the centres (
metaphyses The metaphysis is the neck portion of a long bone between the epiphysis and the diaphysis. It contains the growth plate, the part of the bone that grows during childhood, and as it grows it ossifies near the diaphysis and the epiphyses. The metaph ...
) often appear quite enlarged (ballooning). Due to more than normal joint compression caused by muscular imbalances,
articular cartilage Hyaline cartilage is the glass-like (hyaline) and translucent cartilage found on many joint surfaces. It is also most commonly found in the ribs, nose, larynx, and trachea. Hyaline cartilage is pearl-gray in color, with a firm consistency and has ...
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 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. Children with CP are prone to
low trauma fractures Low or LOW or lows, may refer to: People * Low (surname), listing people surnamed Low Places * Low, Quebec, Canada * Low, Utah, United States * Lo Wu station (MTR code LOW), Hong Kong; a rail station * Salzburg Airport (ICAO airport code: LOW ...
, particularly children with higher
Gross Motor Function Classification System The Gross Motor Function Classification System or GMFCS is a 5 level clinical classification system that describes the gross motor function of people with cerebral palsy on the basis of self-initiated movement abilities. Particular emphasis in cre ...
(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. These children generally have fractures in the legs, whereas non-affected children mostly fracture their arms in the context of sporting activities.
Hip dislocation A hip dislocation is when the thighbone (femur) separates from the hip bone (pelvis). Specifically it is when the ball–shaped head of the femur (femoral head) separates from its cup–shaped socket in the hip bone, known as the acetabulum. Th ...
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 The femur (; ), or thigh bone, is the proximal bone of the hindlimb in tetrapod vertebrates. The head of the femur articulates with the acetabulum in the pelvic bone forming the hip joint, while the distal part of the femur articulates with ...
and
tibia The tibia (; ), also known as the shinbone or shankbone, is the larger, stronger, and anterior (frontal) of the two bones in the leg below the knee in vertebrates (the other being the fibula, behind and to the outside of the tibia); it connects ...
are also encountered, among others. Children may develop scoliosis before the age of 10 – estimated
prevalence In epidemiology, prevalence is the proportion of a particular population found to be affected by a medical condition (typically a disease or a risk factor such as smoking or seatbelt use) at a specific time. It is derived by comparing the number o ...
of scoliosis in children with CP is between 21% and 64%. Higher levels of impairment on the GMFCS are associated with scoliosis and hip dislocation. Scoliosis can be corrected with surgery, but CP makes surgical complications more likely, even with improved techniques. 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. Equinus deformity is managed by conservative methods especially when dynamic. If fixed/static deformity ensues surgery may become mandatory. Growth spurts during
puberty Puberty is the process of physical changes through which a child's body matures into an adult body capable of sexual reproduction. It is initiated by hormonal signals from the brain to the gonads: the ovaries in a girl, the testes in a boy. ...
can make walking more difficult for people with CP.


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.
Gastro-oesophageal reflux Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is one of the upper gastrointestinal chronic diseases where stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/ ...
is common in children with CP. Children with CP may have too little or too much sensitivity around and in the mouth. Poor balance when sitting, lack of control of the head, mouth, and trunk, not being able to bend the hips enough to allow the arms to stretch forward to reach and grasp food or utensils, and lack of hand-eye coordination can make self-feeding difficult. Feeding difficulties are related to higher GMFCS levels. Dental problems can also contribute to difficulties with eating.
Pneumonia Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severity ...
is also common where eating difficulties exist, caused by undetected aspiration of food or liquids. Fine finger dexterity, like that needed for picking up a utensil, is more frequently impaired than gross manual dexterity, like that needed for spooning food onto a plate. Grip strength impairments are less common. Children with severe cerebral palsy, particularly with
oropharyngeal The pharynx (plural: pharynges) is the part of the throat behind the mouth and nasal cavity, and above the oesophagus and trachea (the tubes going down to the stomach and the lungs). It is found in vertebrates and invertebrates, though its struct ...
issues, are at risk of
undernutrition Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is "a deficiency, excess, or imbalance of energy, protein and other nutrients" which adversely affects the body's tissues ...
. Triceps skin fold tests have been found to be a very reliable indicator of malnutrition in children with cerebral palsy.


Language

Speech and language disorders are common in people with cerebral palsy. The incidence of
dysarthria Dysarthria is a speech sound disorder resulting from neurological injury of the motor component of the motor–speech system and is characterized by poor articulation of phonemes. In other words, it is a condition in which problems effectively ...
is estimated to range from 31% to 88%, and around a quarter of people with CP are non-verbal. Speech problems are associated with poor
respiratory The respiratory system (also respiratory apparatus, ventilatory system) is a biological system consisting of specific organs and structures used for gas exchange in animals and plants. The anatomy and physiology that make this happen varies gre ...
control, laryngeal and velopharyngeal dysfunction, and 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 (athetotic), and ataxic. Early use of
augmentative and alternative communication Augmentative and alternative communication (AAC) encompasses the communication methods used to supplement or replace speech or writing for those with impairments in the production or comprehension of spoken or written language. AAC is used by t ...
systems may assist the child in developing spoken language skills. Overall
language delay A language delay is a language disorder in which a child fails to develop language abilities at the usual age-appropriate period in their developmental timetable. It particularly affects deaf children who are denied sign language. It is most co ...
is associated with problems of cognition,
deafness Deafness has varying definitions in cultural and medical contexts. In medical contexts, the meaning of deafness is hearing loss that precludes a person from understanding spoken language, an audiological condition. In this context it is written ...
, and
learned helplessness Learned helplessness is the behavior exhibited by a subject after enduring repeated aversive stimuli beyond their control. It was initially thought to be caused by the subject's acceptance of their powerlessness, by way of their discontinuing atte ...
. Children with cerebral palsy are at risk of learned helplessness and becoming passive communicators, initiating little communication. 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.


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. When children with cerebral palsy are in pain, they experience worse muscle spasms. Pain is associated with tight or shortened muscles, abnormal posture, stiff joints, unsuitable
orthosis Orthotics ( el, Ορθός, translit=ortho, lit=to straighten, to align) is a medical specialty that focuses on the design and application of orthoses, or braces. An is "an externally applied device used to influence the structural and functio ...
, 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. Pain in CP has a number of different causes, and different pains respond to different treatments. There is also a high likelihood of chronic
sleep disorders A sleep disorder, or somnipathy, is a medical disorder of an individual's sleep patterns. Some sleep disorders are severe enough to interfere with normal physical, mental, social and emotional functioning. Polysomnography and actigraphy are tests ...
secondary to both physical and environmental factors. Children with cerebral palsy have significantly higher rates of sleep disturbance than typically developing children. Babies with cerebral palsy who have stiffness issues might cry more and be harder to put to sleep than non-disabled babies, or "floppy" babies might be lethargic.
Chronic pain Chronic pain is classified as pain that lasts longer than three to six months. In medicine, the distinction between acute and chronic pain is sometimes determined by the amount of time since onset. Two commonly used markers are pain that continue ...
is under-recognized in children with cerebral palsy, even though three out of four children with cerebral palsy experience pain. Adults with CP also experience more pain than the general population.


Associated disorders

Associated disorders include
intellectual disabilities Intellectual disability (ID), also known as general learning disability in the United Kingdom and formerly mental retardation,Rosa's Law, Pub. L. 111-256124 Stat. 2643(2010). is a generalized neurodevelopmental disorder characterized by signific ...
, seizures,
muscle contracture Muscle contractures can occur for many reasons, such as paralysis, muscular atrophy, and forms of muscular dystrophy. Fundamentally, the muscle and its tendons shorten, resulting in reduced flexibility. For example, in the case of partial paral ...
s, abnormal gait,
osteoporosis Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to bone fragility, and consequent increase in fracture risk. It is the most common reason for a broken bone ...
, communication disorders, malnutrition, sleep disorders, and mental health disorders, such as depression and anxiety. In addition to these, functional gastrointestinal abnormalities contributing to bowel obstruction, vomiting, and
constipation Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement ...
may also arise. Adults with cerebral palsy may have ischemic heart disease,
cerebrovascular disease Cerebrovascular disease includes a variety of medical conditions that affect the blood vessels of the brain and the cerebral circulation. Arteries supplying oxygen and nutrients to the brain are often damaged or deformed in these disorders. Th ...
,
cancer Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. These contrast with benign tumors, which do not spread. Possible signs and symptoms include a lump, abnormal b ...
, and
trauma Trauma most often refers to: * Major trauma, in physical medicine, severe physical injury caused by an external source * Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event *Traumatic i ...
more often.
Obesity Obesity is a medical condition, sometimes considered a disease, in which excess body fat has accumulated to such an extent that it may negatively affect health. People are classified as obese when their body mass index (BMI)—a person's we ...
in people with cerebral palsy or a more severe
Gross Motor Function Classification System The Gross Motor Function Classification System or GMFCS is a 5 level clinical classification system that describes the gross motor function of people with cerebral palsy on the basis of self-initiated movement abilities. Particular emphasis in cre ...
assessment in particular are considered risk factors for multimorbidity. Other medical issues can be mistaken for being symptoms of cerebral palsy, and so may not be treated correctly. Related conditions can include
apraxia Apraxia is a motor disorder caused by damage to the brain (specifically the posterior parietal cortex or corpus callosum), which causes difficulty with motor planning to perform tasks or movements. The nature of the damage determines the disorde ...
, sensory impairments,
urinary incontinence Urinary incontinence (UI), also known as involuntary urination, is any uncontrolled leakage of urine. It is a common and distressing problem, which may have a large impact on quality of life. It has been identified as an important issue in geria ...
,
fecal incontinence Fecal incontinence (FI), or in some forms encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents, both liquid stool elements and mucus, or solid feces. When this loss includes flatus (gas), it is referre ...
, or behavioural disorders. Seizure management is more difficult in people with CP as seizures often last longer. Epilepsy and
asthma Asthma is a long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, cou ...
are common co-occurring diseases in adults with CP. The associated disorders that co-occur with cerebral palsy may be more disabling than the motor function problems.


Causes

Cerebral palsy is due to abnormal development or damage occurring to the developing brain. This damage can occur during pregnancy, delivery, the first month of life, or less commonly in early childhood. Structural problems in the brain are seen in 80% of cases, most commonly within the
white matter White matter refers to areas of the central nervous system (CNS) that are mainly made up of myelinated axons, also called tracts. Long thought to be passive tissue, white matter affects learning and brain functions, modulating the distribution ...
. More than three-quarters of cases are believed to result from issues that occur during pregnancy. Most children who are born with cerebral palsy have more than one risk factor associated with CP. While in certain cases there is no identifiable cause, typical causes include problems in intrauterine development (e.g. exposure to radiation, infection,
fetal growth restriction Intrauterine growth restriction (IUGR), or fetal growth restriction, refers to poor growth of a fetus while in the womb during pregnancy. IUGR is defined by clinical features of malnutrition and evidence of reduced growth regardless of an infant's ...
), hypoxia of the brain (thrombotic events,
placental insufficiency Placental insufficiency or utero-placental insufficiency is the failure of the placenta to deliver sufficient nutrients to the fetus during pregnancy, and is often a result of insufficient blood flow to the placenta. The term is also sometimes use ...
,
umbilical cord prolapse Umbilical cord prolapse is when the umbilical cord comes out of the uterus with or before the presenting part of the baby. The concern with cord prolapse is that pressure on the cord from the baby will compromise blood flow to the baby. It usual ...
), birth trauma during labor and delivery, and complications around birth or during childhood. In Africa
birth asphyxia Perinatal asphyxia (also known as neonatal asphyxia or birth asphyxia) is the medical condition resulting from deprivation of oxygen to a newborn infant that lasts long enough during the birth process to cause physical harm, usually to the brain. ...
, high bilirubin levels, and infections in newborns of the central nervous system are main cause. Many cases of CP in Africa could be prevented with better resources available.


Preterm birth

Between 40% and 50% of all children who develop cerebral palsy were born prematurely. Most of these cases (75–90%) are believed to be due to issues that occur around the time of birth, often just after birth. Multiple-birth infants are also more likely than single-birth infants to have CP. They are also more likely to be born with a
low birth weight Low birth weight (LBW) is defined by the World Health Organization as a birth weight of an infant of or less, regardless of gestational age. Infants born with LBW have added health risks which require close management, often in a neonatal inten ...
. In those who are born with a weight between 1 kg and 1.5 kg CP occurs in 6%. Among those born before 28 weeks of
gestation Gestation is the period of development during the carrying of an embryo, and later fetus, inside viviparous animals (the embryo develops within the parent). It is typical for mammals, but also occurs for some non-mammals. Mammals during pregna ...
it occurs in 8%. Genetic factors are believed to play an important role in prematurity and cerebral palsy generally. While in those who are born between 34 and 37 weeks the risk is 0.4% (three times normal).


Term infants

In babies that are born at term risk factors include problems with the placenta,
birth defect A birth defect, also known as a congenital disorder, is an abnormal condition that is present at birth regardless of its cause. Birth defects may result in disabilities that may be physical, intellectual, or developmental. The disabilities ca ...
s, low birth weight, breathing meconium into the lungs, a delivery requiring either the use of instruments or an emergency Caesarean section, birth asphyxia,
seizure An epileptic seizure, informally known as a seizure, is a period of symptoms due to abnormally excessive or synchronous neuronal activity in the brain. Outward effects vary from uncontrolled shaking movements involving much of the body with l ...
s just after birth, respiratory distress syndrome,
low blood sugar Hypoglycemia, also called low blood sugar, is a fall in blood sugar to levels below normal, typically below 70 mg/dL (3.9 mmol/L). Whipple's triad is used to properly identify hypoglycemic episodes. It is defined as blood glucose bel ...
, and infections in the baby. , it was unclear how much of a role birth asphyxia plays as a cause. It is unclear if the size of the placenta plays a role. it is evident that in advanced countries, most cases of cerebral palsy in term or near-term neonates have explanations other than asphyxia.


Genetics

Cerebral palsy is not commonly considered a genetic disease. About 2% of all CP cases are expected to be inherited, with glutamate decarboxylase-1 being one of the possible enzymes involved. Most inherited cases are
autosomal recessive In genetics, dominance is the phenomenon of one variant (allele) of a gene on a chromosome masking or overriding the effect of a different variant of the same gene on the other copy of the chromosome. The first variant is termed dominant and t ...
. However, the vast majority of CP cases are connected to brain damage during birth and in infancy. There is a small percentage of CP cases caused by brain damage that stemmed from the prenatal period, which is estimated to be less than 5% of CP cases overall. Moreover, there is no one reason why some CP cases come from prenatal brain damage, and it's not known if those cases have a genetic basis.
Cerebellar hypoplasia Cerebellar hypoplasia is characterized by reduced cerebellar volume, even though cerebellar shape is (near) normal. It consists of a heterogeneous group of disorders of cerebellar maldevelopment presenting as early-onset non–progressive conge ...
is sometimes genetic and can cause ataxic cerebral palsy.


Early childhood

After birth, other causes include toxins, severe
jaundice Jaundice, also known as icterus, is a yellowish or greenish pigmentation of the skin and sclera due to high bilirubin levels. Jaundice in adults is typically a sign indicating the presence of underlying diseases involving abnormal heme meta ...
, lead poisoning, physical brain injury, stroke,
abusive head trauma Shaken baby syndrome (SBS), also known as abusive head trauma (AHT), is the leading cause of fatal head injuries in children younger than two years. Diagnosing the syndrome has proved both challenging and contentious for medical professionals, ...
, incidents involving hypoxia to the brain (such as
near drowning Drowning is a type of Asphyxia, suffocation induced by the submersion of the mouth and nose in a liquid. Most instances of fatal drowning occur alone or in situations where others present are either unaware of the victim's situation or unable t ...
), and
encephalitis Encephalitis is inflammation of the brain. The severity can be variable with symptoms including reduction or alteration in consciousness, headache, fever, confusion, a stiff neck, and vomiting. Complications may include seizures, hallucinations, ...
or
meningitis Meningitis is acute or chronic inflammation of the protective membranes covering the brain and spinal cord, collectively called the meninges. The most common symptoms are fever, headache, and neck stiffness. Other symptoms include confusion or ...
.


Others

Infections in the mother, even those not easily detected, can triple the risk of the child developing cerebral palsy. Infections of the fetal membranes known as
chorioamnionitis Chorioamnionitis, also known as intra-amniotic infection (IAI), is inflammation of the fetal membranes ( amnion and chorion), usually due to bacterial infection. In 2015, a National Institute of Child Health and Human Development Workshop expert ...
increases the risk. Intrauterine and neonatal insults (many of which are infectious) increase the risk. Rh blood type incompatibility can cause the mother's immune system to attack the baby's red blood cells. It has been hypothesised that some cases of cerebral palsy are caused by the death in very early pregnancy of an identical twin.


Diagnosis

The diagnosis of cerebral palsy has historically rested on the 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. 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 Primitive reflexes are reflex actions originating in the central nervous system that are exhibited by normal infants, but not neurologically intact adults, in response to particular stimuli. These reflexes are suppressed by the development of the ...
are the main early symptoms of CP. Symptoms and diagnosis typically occur by the age of two, although depending on factors like malformations and congenital issues, persons with milder forms of cerebral palsy may be over the age of five, if not in adulthood, when finally diagnosed. 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. Early diagnosis and intervention are seen as being a key part of managing cerebral palsy. Machine learning algorithms facilitate automatic early diagnosis, with methods such as deep neural network and geometric feature fusion producing high accuracy in predicting cerebral palsy from short videos. It is a
developmental disability Developmental disability is a diverse group of chronic conditions, comprising mental or physical impairments that arise before adulthood. Developmental disabilities cause individuals living with them many difficulties in certain areas of life, espe ...
. Once a person is diagnosed with cerebral palsy, further diagnostic tests are optional.
Neuroimaging Neuroimaging is the use of quantitative (computational) techniques to study the structure and function of the central nervous system, developed as an objective way of scientifically studying the healthy human brain in a non-invasive manner. Incr ...
with CT or
MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio waves ...
is warranted when the cause of a person's cerebral palsy has not been established. An MRI is preferred over CT, due to diagnostic yield and safety. When abnormal, the neuroimaging study can suggest the timing of the initial damage. The CT or MRI is also capable of revealing treatable conditions, such as
hydrocephalus Hydrocephalus is a condition in which an accumulation of cerebrospinal fluid (CSF) occurs within the brain. This typically causes increased intracranial pressure, pressure inside the skull. Older people may have headaches, double vision, poor ...
,
porencephaly Porencephaly is an extremely rare cephalic disorder involving encephalomalacia. It is a neurological disorder of the central nervous system characterized by cysts or Body cavity, cavities within the cerebral hemisphere.Parker, J. (2004). The offi ...
, arteriovenous malformation,
subdural hematoma A subdural hematoma (SDH) is a type of bleeding in which a collection of blood—usually but not always associated with a traumatic brain injury—gathers between the inner layer of the dura mater and the arachnoid mater of the meninges surround ...
s and hygromas, and a vermian tumour (which a few studies suggest are present 5–22% of the time). Furthermore, an abnormal neuroimaging study indicates a high likelihood of associated conditions, such as
epilepsy Epilepsy is a group of non-communicable neurological disorders characterized by recurrent epileptic seizures. Epileptic seizures can vary from brief and nearly undetectable periods to long periods of vigorous shaking due to abnormal electrica ...
and intellectual disability. There is a small risk associated with sedating children to facilitate a clear MRI. The age when CP is diagnosed is important, but medical professionals disagree over the best age to make the diagnosis. 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. Infants may have temporary problems with muscle tone or control that can be confused with CP, which is permanent. 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. Disorders that deteriorate the
white matter White matter refers to areas of the central nervous system (CNS) that are mainly made up of myelinated axons, also called tracts. Long thought to be passive tissue, white matter affects learning and brain functions, modulating the distribution ...
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. However, these disorders get worse over time, and CP does not (although it may change in character). In infancy it may not be possible to tell the difference between them. In the UK, not being able to sit independently by the age of 8 months is regarded as a clinical sign for further monitoring. Fragile X syndrome (a cause of autism and intellectual disability) and general intellectual disability must also be ruled out. 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.


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. The
Gross Motor Function Classification System The Gross Motor Function Classification System or GMFCS is a 5 level clinical classification system that describes the gross motor function of people with cerebral palsy on the basis of self-initiated movement abilities. Particular emphasis in cre ...
-Expanded and Revised and the
Manual Ability Classification System The Manual Ability Classification System (MACS) is a medical classification system used to describe how children aged from 4 to 18 years old with cerebral palsy use their hands with objects during activities of daily living, with a focus on the use ...
are used to describe mobility and manual dexterity in people with cerebral palsy, and recently the
Communication Function Classification System The Communication Function Classification System (CFCS) for individuals with cerebral palsy (CP) is a five-level classification system which began development at Michigan State University and currently under further refinement at the University ...
, and the Eating and Drinking Ability Classification System have been proposed to describe those functions. 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. Cerebral palsy is also classified according to the topographic distribution of muscle spasticity. This method classifies children as diplegic, (bilateral involvement with leg involvement greater than arm involvement),
hemiplegic Hemiparesis, or unilateral paresis, is weakness of one entire side of the body ('' hemi-'' means "half"). Hemiplegia is, in its most severe form, complete paralysis of half of the body. Hemiparesis and hemiplegia can be caused by different medic ...
(unilateral involvement), or
quadriplegic Tetraplegia, also known as quadriplegia, is defined as the dysfunction or loss of motor and/or sensory function in the cervical area of the spinal cord. A loss of motor function can present as either weakness or paralysis leading to partial or ...
(bilateral involvement with arm involvement equal to or greater than leg involvement).


Spastic

Spastic cerebral palsy is the type of cerebral palsy characterized by
spasticity Spasticity () is a feature of altered skeletal muscle performance with a combination of paralysis, increased tendon reflex activity, and hypertonia. It is also colloquially referred to as an unusual "tightness", stiffness, or "pull" of muscles ...
or high muscle tone often resulting in stiff, jerky movements. Itself an
umbrella term In linguistics, semantics, general semantics, and ontologies, hyponymy () is a semantic relation between a hyponym denoting a subtype and a hypernym or hyperonym (sometimes called umbrella term or blanket term) denoting a supertype. In other wor ...
encompassing spastic hemiplegia,
spastic diplegia Spastic diplegia is a form of cerebral palsy (CP) that is a chronic neuromuscular condition of hypertonia and spasticity—manifested as an especially high and constant "tightness" or "stiffness"—in the muscles of the lower extremities of the ...
,
spastic quadriplegia Spastic quadriplegia, also known as spastic tetraplegia, is a subset of spastic cerebral palsy that affects all four limbs (both arms and legs). Compared to quadriplegia, spastic tetraplegia is defined by spasticity of the limbs as opposed to ...
and – where solely one limb or one specific area of the body is affected – spastic monoplegia. Spastic cerebral palsy affects the
motor cortex The motor cortex is the region of the cerebral cortex believed to be involved in the planning, control, and execution of voluntary movements. The motor cortex is an area of the frontal lobe located in the posterior precentral gyrus immediately ...
of the brain, a specific portion of the
cerebral cortex The cerebral cortex, also known as the cerebral mantle, is the outer layer of neural tissue of the cerebrum of the brain in humans and other mammals. The cerebral cortex mostly consists of the six-layered neocortex, with just 10% consisting of ...
responsible for the planning and completion of voluntary movement. Spastic CP is the most common type of overall cerebral palsy, representing about 80% of cases. Botulinum toxin is effective in decreasing
spasticity Spasticity () is a feature of altered skeletal muscle performance with a combination of paralysis, increased tendon reflex activity, and hypertonia. It is also colloquially referred to as an unusual "tightness", stiffness, or "pull" of muscles ...
. It can help increase range of motion which could help mitigate CPs effects on the growing bones of children. There may be an improvement in motor functions in the children and ability to walk. however, the main benefit derived from botulinum toxin A comes from its ability to reduce muscle tone and spasticity and thus prevent or delay the development of fixed muscle contractures.


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. Ataxic cerebral palsy is caused by damage to cerebellar structures. Because of the damage to the
cerebellum The cerebellum (Latin for "little brain") is a major feature of the hindbrain of all vertebrates. Although usually smaller than the cerebrum, in some animals such as the mormyrid fishes it may be as large as or even larger. In humans, the cerebel ...
, 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. 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.


Dyskinetic

Dyskinetic cerebral palsy (sometimes abbreviated DCP) is primarily associated with damage to the
basal ganglia The basal ganglia (BG), or basal nuclei, are a group of subcortical nuclei, of varied origin, in the brains of vertebrates. In humans, and some primates, there are some differences, mainly in the division of the globus pallidus into an extern ...
and the
substantia nigra The substantia nigra (SN) is a basal ganglia structure located in the midbrain that plays an important role in reward and movement. ''Substantia nigra'' is Latin for "black substance", reflecting the fact that parts of the substantia nigra app ...
in the form of
lesions A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals. Types There is no designated classifi ...
that occur during brain development due to
bilirubin Bilirubin (BR) (Latin for "red bile") is a red-orange compound that occurs in the normal catabolic pathway that breaks down heme in vertebrates. This catabolism is a necessary process in the body's clearance of waste products that arise from the ...
encephalopathy Encephalopathy (; from grc, ἐνκέφαλος "brain" + πάθος "suffering") means any disorder or disease of the brain, especially chronic degenerative conditions. In modern usage, encephalopathy does not refer to a single disease, but r ...
and hypoxic-ischemic
brain A brain is an organ that serves as the center of the nervous system in all vertebrate and most invertebrate animals. It is located in the head, usually close to the sensory organs for senses such as vision. It is the most complex organ in a v ...
injury. DCP is characterized by both
hypertonia Hypertonia is a term sometimes used synonymously with spasticity and rigidity in the literature surrounding damage to the central nervous system, namely upper motor neuron lesions. Impaired ability of damaged motor neurons to regulate descending ...
and
hypotonia Hypotonia is a state of low muscle tone (the amount of tension or resistance to stretch in a muscle), often involving reduced muscle strength. Hypotonia is not a specific medical disorder, but a potential manifestation of many different diseases a ...
, due to the affected individual's inability to control muscle tone. Clinical diagnosis of DCP typically occurs within 18 months of birth and is primarily based upon motor function and
neuroimaging Neuroimaging is the use of quantitative (computational) techniques to study the structure and function of the central nervous system, developed as an objective way of scientifically studying the healthy human brain in a non-invasive manner. Incr ...
techniques. Dyskinetic cerebral palsy is an extrapyramidal form of cerebral palsy. Dyskinetic cerebral palsy can be divided into two different groups;
choreoathetosis Choreoathetosis is the occurrence of involuntary movements in a combination of chorea (irregular migrating contractions) and athetosis (twisting and writhing). It is caused by many different diseases and agents. It is a symptom of several diseases ...
and
dystonia Dystonia is a neurological hyperkinetic movement disorder in which sustained or repetitive muscle contractions result in twisting and repetitive movements or abnormal fixed postures. The movements may resemble a tremor. Dystonia is often inten ...
. Choreo-athetotic CP is characterized by involuntary movements, whereas dystonic CP is characterized by slow, strong contractions, which may occur locally or encompass the whole body.


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.


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. 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. 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. Gait types 5 is also known as crouch gait.


Prevention

Because the causes of CP are varied, a broad range of preventive interventions have been investigated.
Electronic fetal monitoring Cardiotocography (CTG) is a technique used to monitor the fetal heartbeat and the uterine contractions during pregnancy and labour. The machine used to perform the monitoring is called a cardiotocograph. Fetal heart sounds was described as earl ...
has not helped to prevent CP, and in 2014 the
American College of Obstetricians and Gynecologists The American College of Obstetricians and Gynecologists (ACOG) is a professional association of physicians specializing in obstetrics and gynecology in the United States. Several Latin American countries are also represented within Districts of ...
, the
Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) is a not-for-profit organisation dedicated to the establishment of high standards of practice in obstetrics and gynaecology and women’s health. The C ...
, and the
Society of Obstetricians and Gynaecologists of Canada The Society of Obstetricians and Gynaecologists of Canada (SOGC) is a national medical society in Canada, representing over 4,000 obstetricians/gynaecologists, family physicians, nurses, midwives, and allied health professionals in the field of s ...
have acknowledged that there are no long-term benefits of electronic fetal monitoring. Before this, electronic fetal monitoring was widely used to prop up obstetric litigation. In those at risk of an early delivery,
magnesium sulphate Magnesium sulfate or magnesium sulphate (in English-speaking countries other than the US) is a chemical compound, a salt with the formula , consisting of magnesium cations (20.19% by mass) and sulfate anions . It is a white crystalline solid, s ...
appears to decrease the risk of cerebral palsy. It is unclear if it helps those who are born at term. In those at high risk of preterm labor a review found that moderate to severe CP was reduced by the administration of magnesium sulphate, and that adverse effects on the babies from the magnesium sulphate were not significant. Mothers who received magnesium sulphate could experience side effects such as respiratory depression and nausea. However, guidelines for the use of magnesium sulfate in mothers at risk of preterm labour are not strongly adhered to.
Caffeine Caffeine is a central nervous system (CNS) stimulant of the methylxanthine class. It is mainly used recreationally as a cognitive enhancer, increasing alertness and attentional performance. Caffeine acts by blocking binding of adenosine t ...
is used to treat
apnea of prematurity Apnea of prematurity is defined as cessation of breathing by a premature infant that lasts for more than 20 seconds and/or is accompanied by hypoxia or bradycardia. Apnea is traditionally classified as either ''obstructive, central, or mixed''. Ob ...
and reduces the risk of cerebral palsy in premature babies, but there are also concerns of long term negative effects. A moderate quality level of evidence indicates that giving women
antibiotic An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention of ...
s during preterm labor before her membranes have ruptured (water is not yet not broken) may increase the risk of cerebral palsy for the child. Additionally, for preterm babies for whom there is a chance of fetal compromise, allowing the birth to proceed rather than trying to delay the birth may lead to an increased risk of cerebral palsy in the child. Corticosteroids are sometimes taken by pregnant women expecting a preterm birth to provide neuroprotection to their baby. Taking corticosteroids during pregnancy is shown to have no significant correlation with developing cerebral palsy in preterm births. Cooling high-risk full-term babies shortly after birth may reduce disability, but this may only be useful for some forms of the brain damage that causes CP.


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. 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. 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. Although such cross-over benefit might happen, not enough high-quality studies have been done to demonstrate it. Because cerebral palsy has "varying severity and complexity" across the lifespan, it can be considered a collection of conditions for management purposes. A
multidisciplinary Interdisciplinarity or interdisciplinary studies involves the combination of multiple academic disciplines into one activity (e.g., a research project). It draws knowledge from several other fields like sociology, anthropology, psychology, ec ...
approach for cerebral palsy management is recommended, focusing on "maximising individual function, choice and independence" in line with the
International Classification of Functioning, Disability and Health The International Classification of Functioning, Disability and Health (ICF) is a classification of the health components of functioning and disability. The ICF received approval from all 191 World Health Organization (WHO) member states on May 22 ...
's goals. The team may include a paediatrician, a health visitor, a social worker, a physiotherapist, an orthotist, a speech and language therapist, an
occupational therapist Occupational therapists (OTs) are health care professionals specializing in occupational therapy and occupational science. OTs and occupational therapy assistants (OTAs) use scientific bases and a holistic perspective to promote a person's abi ...
, a teacher specialising in helping children with visual impairment, an educational psychologist, an
orthopaedic surgeon Orthopedic surgery or orthopedics ( alternatively spelt orthopaedics), is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal ...
, a neurologist and a neurosurgeon. 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. Surgical intervention in CP children may include various
orthopaedic Orthopedic surgery or orthopedics ( alternatively spelt orthopaedics), is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal ...
or neurological surgeries to improve quality of life, such as tendon releases, hip rotation,
spinal fusion Spinal fusion, also called spondylodesis or spondylosyndesis, is a neurosurgical or orthopedic surgical technique that joins two or more vertebrae. This procedure can be performed at any level in the spine (cervical, thoracic, or lumbar) and pre ...
, (
selective dorsal rhizotomy ::''This article deals with Selective Dorsal Rhizotomy (SDR) rather than the rhizotomy procedures for pain relief; for those procedures, which have begun to take the name "rhizotomy" in certain instances, see facet rhizotomy and similar. A face ...
) or placement of an
intrathecal Intrathecal administration is a route of administration for drugs via an injection into the spinal canal, or into the subarachnoid space so that it reaches the cerebrospinal fluid (CSF) and is useful in spinal anesthesia, chemotherapy, or pain ma ...
baclofen pump. 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. 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 (
anticonvulsant Anticonvulsants (also known as antiepileptic drugs or recently as antiseizure drugs) are a diverse group of pharmacological agents used in the treatment of epileptic seizures. Anticonvulsants are also increasingly being used in the treatment of b ...
s, botulinum toxin,
bisphosphonate Bisphosphonates are a class of drugs that prevent the loss of bone density, used to treat osteoporosis and similar diseases. They are the most commonly prescribed drugs used to treat osteoporosis. They are called bisphosphonates because they ...
s,
diazepam Diazepam, first marketed as Valium, is a medicine of the benzodiazepine family that acts as an anxiolytic. It is commonly used to treat a range of conditions, including anxiety, seizures, alcohol withdrawal syndrome, muscle spasms, insomnia, ...
), therapy (bimanual training,
casting Casting is a manufacturing process in which a liquid material is usually poured into a mold, which contains a hollow cavity of the desired shape, and then allowed to solidify. The solidified part is also known as a ''casting'', which is ejected ...
,
constraint-induced movement therapy Constraint-induced movement therapy (CI, CIT, or CIMT) is a form of rehabilitation therapy that improves upper extremity function in stroke and other central nervous system damage patients by increasing the use of their affected upper limb.
, 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. 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 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 Orthotics ( el, Ορθός, translit=ortho, lit=to straighten, to align) is a medical specialty that focuses on the design and application of orthoses, or braces. An is "an externally applied device used to influence the structural and functio ...
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. 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. 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. Modern materials and new functional elements enable the rigidity to be specifically adapted to the requirements that fits to the gait pattern of the CP patient. The adjustment of the stiffness has a decisive influence on the gait pattern and on the energy cost of walking. It is of great advantage if the stiffness of the orthosis can be adjusted separately from one another via resistances of the two functional elements in the two directions of movement,
dorsiflexion Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relative ...
and
plantar flexion Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relativ ...
.


Prognosis

CP is not a progressive disorder (meaning the brain damage does not worsen), but the symptoms can become more severe over time. A person with the disorder may improve somewhat during childhood if he or she receives extensive care, but once bones and musculature become more established, orthopedic surgery may be required. People with CP can have varying degrees of
cognitive impairment Cognitive deficit is an inclusive term to describe any characteristic that acts as a barrier to the cognition process. The term may describe * deficits in overall intelligence (as with intellectual disabilities), * specific and restricted defici ...
or none whatsoever. The full intellectual potential of a child born with CP is often not known until the child starts school. People with CP are more likely to have
learning disorders Learning disability, learning disorder, or learning difficulty (British English) is a condition in the brain that causes difficulties comprehending or processing information and can be caused by several different factors. Given the "difficult ...
but have normal intelligence. Intellectual level among people with CP varies from
genius Genius is a characteristic of original and exceptional insight in the performance of some art or endeavor that surpasses expectations, sets new standards for future works, establishes better methods of operation, or remains outside the capabili ...
to
intellectually disabled Intellectual disability (ID), also known as general learning disability in the United Kingdom and formerly mental retardation, Rosa's Law, Pub. L. 111-256124 Stat. 2643(2010). is a generalized neurodevelopmental disorder characterized by signifi ...
, as it does in the general population, and experts have stated that it is important not to underestimate the capabilities of a person with CP and to give them every opportunity to learn. 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
activities of daily living Activity may refer to: * Action (philosophy), in general * Human activity: human behavior, in sociology behavior may refer to all basic human actions, economics may study human economic activities and along with cybernetics and psychology may s ...
. Others only need assistance with certain activities, and still others do not require any physical assistance. But regardless of the severity of a person's physical impairment, a person's ability to live independently often depends primarily on the person's capacity to manage the physical realities of his or her life autonomously. In some cases, people with CP recruit, hire, and manage a staff of
personal care assistant Unlicensed assistive personnel (UAP) are paraprofessionals who assist individuals with physical disabilities, mental impairments, and other health care needs with their activities of daily living (ADLs). UAPs also provide bedside care—includ ...
s (PCAs). PCAs facilitate the independence of their employers by assisting them with their daily personal needs in a way that allows them to maintain control over their lives. Puberty in young adults with cerebral palsy may be
precocious Precocious refers to earlier-than-normal development, as in a "precocious child". The term may also refer to: Films *''A Precocious Girl'' (German title: ''Csibi, der Fratz aka Früchtchen''), a 1934 Austrian comedy film *'' Precocious Youth'' (G ...
or delayed. Delayed puberty is thought to be a consequence of nutritional deficiencies. There is currently no evidence that CP affects fertility, although some of the secondary symptoms have been shown to affect sexual desire and performance. Adults with CP were less likely to get routine reproductive health screening as of 2005.
Gynecological examination A pelvic examination is the physical examination of the external and internal female pelvic organs. It is frequently used in gynecology for the evaluation of symptoms affecting the female reproductive and urinary tract, such as pain, bleeding, di ...
s may have to be performed under anesthesia due to spasticity, and equipment is often not accessible.
Breast self-examination Breast self-examination (BSE) is a screening method used in an attempt to detect early breast cancer. The method involves the woman herself looking at and feeling each breast for possible lumps, distortions or swelling. BSE was once promoted hea ...
may be difficult, so partners or carers may have to perform it. Women with CP reported higher levels of spasticity and urinary incontinence during
menstruation Menstruation (also known as a period, among other colloquial terms) is the regular discharge of blood and mucosal tissue from the inner lining of the uterus through the vagina. The menstrual cycle is characterized by the rise and fall of hor ...
in a study. Men with CP have higher levels of
cryptorchidism Cryptorchidism, also known as undescended testis, is the failure of one or both testes to descend into the scrotum. The word is from Greek () 'hidden' and () 'testicle'. It is the most common birth defect of the male genital tract. About 3% of ...
at the age of 21. CP can significantly reduce a person's life expectancy, depending on the severity of their condition and the quality of care they receive. 5–10% of children with CP die in childhood, particularly where seizures and intellectual disability also affect the child. The ability to ambulate, roll, and self-feed has been associated with increased life expectancy. While there is a lot of variation in how CP affects people, it has been found that "independent gross motor functional ability is a very strong determinant of life expectancy". According to the
Australian Bureau of Statistics The Australian Bureau of Statistics (ABS) is the independent statutory agency of the Australian Government responsible for statistical collection and analysis and for giving evidence-based advice to federal, state and territory governments ...
, in 2014, 104
Australians Australians, colloquially known as Aussies, are the citizens, nationals and individuals associated with the country of Australia. This connection may be residential, legal, historical or ethno-cultural. For most Australians, several (or all) ...
died of cerebral palsy. The most common causes of death in CP are related to respiratory causes, but in middle age cardiovascular issues and neoplastic disorders become more prominent.


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. 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. As the hands are used for many self-care tasks, sensory and motor impairments of the hands make daily self-care more difficult. Motor impairments cause more problems than sensory impairments. The most common impairment is that of finger dexterity, which is the ability to manipulate small objects with the fingers. Compared to other disabilities, people with cerebral palsy generally need more help in performing daily tasks. Occupational therapists are healthcare professionals that help individuals with disabilities gain or regain their independence through the use of meaningful activities.


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. Play is included as a productive occupation as it is often the primary activity for children. If play becomes difficult due to a disability, like CP, this can cause problems for the child. These difficulties can affect a child's self-esteem. In addition, the sensory and motor problems experienced by children with CP affect how the child interacts with their surroundings, including the environment and other people. Not only do physical limitations affect a child's ability to play, the limitations perceived by the child's caregivers and playmates also affect the child's play activities. Some children with disabilities spend more time playing by themselves. When a disability prevents a child from playing, there may be social, emotional and psychological problems, which can lead to increased dependence on others, less motivation, and poor social skills. In school, students are asked to complete many tasks and activities, many of which involve handwriting. Many children with CP have the capacity to learn and write in the school environment. However, students with CP may find it difficult to keep up with the handwriting demands of school and their writing may be difficult to read. In addition, writing may take longer and require greater effort on the student's part. Factors linked to handwriting include postural stability, sensory and perceptual abilities of the hand, and writing tool pressure. Speech impairments may be seen in children with CP depending on the severity of brain damage. 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. In summary, children with CP may experience difficulties in school, such as difficulty with handwriting, carrying out school activities, communicating verbally, and interacting socially.


Leisure

Leisure activities can have several positive effects on physical health, mental health, life satisfaction, and psychological growth for people with physical disabilities like CP. Common benefits identified are stress reduction, development of coping skills, companionship, enjoyment, relaxation and a positive effect on life satisfaction. In addition, for children with CP, leisure appears to enhance adjustment to living with a disability. Leisure can be divided into structured (formal) and unstructured (informal) activities. Children and teens with CP engage in less habitual
physical activity Physical activity is defined as any voluntary bodily movement produced by skeletal muscles that requires energy expenditure.Global Recommendations on Physical Activity for Health, 2009. World Health Organization. Geneva, Switzerland. Accessed 13/ ...
than their peers. Children with CP primarily engage in physical activity through therapies aimed at managing their CP, or through organized sport for people with disabilities. It is difficult to sustain behavioural change in terms of increasing physical activity of children with CP. Gender, manual dexterity, the child's preferences, cognitive impairment and epilepsy were found to affect children's leisure activities, with manual dexterity associated with more leisure activity. Although leisure is important for children with CP, they may have difficulties carrying out leisure activities due to social and physical barriers. 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.


Participation and barriers

Participation is involvement in life situations and everyday activities. 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. Barriers can exist on three levels: micro, meso, and macro. First, the barriers at the micro level involve the person. Barriers at the micro level include the child's physical limitations (motor, sensory and cognitive impairments) or their subjective feelings regarding their ability to participate. For example, the child may not participate in group activities due to lack of confidence. Second, barriers at the meso level include the family and community. These may include negative attitudes of people toward disability or lack of support within the family or in the community. One of the main reasons for this limited support appears to be the result of a lack of awareness and knowledge regarding the child's ability to engage in activities despite his or her disability. 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. For example, a building without an elevator can prevent the child from accessing higher floors. 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". 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. A study in
young adults A young adult is generally a person in the years following adolescence. Definitions and opinions on what qualifies as a young adult vary, with works such as Erik Erikson's stages of human development significantly influencing the definition of ...
(18–34) on transitioning to adulthood found that their concerns were physical health care and understanding their bodies, being able to navigate and use services and supports successfully, and dealing with prejudices. A feeling of being "thrust into adulthood" was common in the study.


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. Quality of life outcomes tend to decline for adults with cerebral palsy. Because children with cerebral palsy are often told that it is a non-progressive disease, they may be unprepared for the greater effects of the
aging Ageing ( BE) or aging ( AE) is the process of becoming older. The term refers mainly to humans, many other animals, and fungi, whereas for example, bacteria, perennial plants and some simple animals are potentially biologically immortal. In ...
process as they head into their 30s. Young adults with cerebral palsy experience problems with aging that non-disabled adults experience "much later in life". 25% or more adults with cerebral palsy who can walk experience increasing difficulties walking with age. Hand function does not seem to have similar declines. Chronic disease risk, such as
obesity Obesity is a medical condition, sometimes considered a disease, in which excess body fat has accumulated to such an extent that it may negatively affect health. People are classified as obese when their body mass index (BMI)—a person's we ...
, is also higher among adults with cerebral palsy than the general population. Common problems include increased pain, reduced flexibility, increased spasms and contractures, post-impairment syndrome and increasing problems with balance. Increased fatigue is also a problem. When adulthood and cerebral palsy is discussed, , it is not discussed in terms of the different stages of adulthood. 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 Salutogenesis is the study of the origins of health and focuses on factors that support human health and well-being, rather than on factors that cause disease (pathogenesis). More specifically, the "salutogenic model" was originally concerned wi ...
may improve the coping potential of adults with CP as they age.


Epidemiology

Cerebral palsy occurs in about 2.1 per 1000 live births. In those born at term rates are lower at 1 per 1000 live births. Within a population it may occur more often in poorer people. The rate is higher in males than in females; in Europe it is 1.3 times more common in males. 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 Low birth weight (LBW) is defined by the World Health Organization as a birth weight of an infant of or less, regardless of gestational age. Infants born with LBW have added health risks which require close management, often in a neonatal inten ...
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 The Baby Doe Law or Baby Doe Amendment is an amendment to the Child Abuse Prevention and Treatment Act of 1974, passed in 1984, that sets forth specific criteria and guidelines for the treatment of disabled newborns in the United States, regardles ...
. As of 2005, advances in the care of pregnant mothers and their babies have 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. , 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. It has been found that high-income countries have lower rates of children born with cerebral palsy than low or middle-income countries. 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.


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 Akhenre Setepenre Siptah or Merenptah Siptah was the penultimate ruler of the Nineteenth Dynasty of Egypt. His father's identity is currently unknown. Both Seti II and Amenmesse have been suggested although the fact that Siptah later changed his r ...
, an Egyptian
Pharaoh Pharaoh (, ; Egyptian: ''pr ꜥꜣ''; cop, , Pǝrro; Biblical Hebrew: ''Parʿō'') is the vernacular term often used by modern authors for the kings of ancient Egypt who ruled as monarchs from the First Dynasty (c. 3150 BC) until the an ...
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. The medical literature of the
ancient Greeks Ancient Greece ( el, Ἑλλάς, Hellás) was a northeastern Mediterranean civilization, existing from the Greek Dark Ages of the 12th–9th centuries BC to the end of classical antiquity ( AD 600), that comprised a loose collection of cult ...
discusses paralysis and weakness of the arms and legs; the modern word ''palsy'' comes from the
Ancient Greek Ancient Greek includes the forms of the Greek language used in ancient Greece and the ancient world from around 1500 BC to 300 BC. It is often roughly divided into the following periods: Mycenaean Greek (), Dark Ages (), the Archaic peri ...
words ''παράλυση'' or ''πάρεση'', meaning paralysis or paresis respectively. The works of the school of Hippocrates (460c. 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 Tiberius Claudius Caesar Augustus Germanicus (; 1 August 10 BC – 13 October AD 54) was the fourth Roman emperor, ruling from AD 41 to 54. A member of the Julio-Claudian dynasty, Claudius was born to Nero Claudius Drusus, Drusu ...
(10 BCE54 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 Jusepe de Ribera (1591 – 1652) was a painter and printmaker, who along with Francisco de Zurbarán, Bartolomé Esteban Murillo, and the singular Diego Velázquez, are regarded as the major artists of Spanish Baroque painting. Referring to ...
's 1642 painting ''
The Clubfoot ''The Clubfoot'' (also known as ''The Club-Footed Boy'') is a 1642 oil on canvas painting by Jusepe de Ribera. It is housed in the Musée du Louvre in Paris (part of the La Caze bequest of 1869), and was painted in Naples. Art historian Ellis W ...
''. 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 Johann Christian Reil (20 February 1759 – 22 November 1813) was a German physician, physiologist, anatomist, and psychiatrist. He coined the term psychiatry – ''Psychiatrie'' in German – in 1808. Medical conditions and anatomical feature ...
, Claude François Lallemand and
Philippe Pinel Philippe Pinel (; 20 April 1745 – 25 October 1826) was a French physician, precursor of psychiatry and incidentally a zoologist. He was instrumental in the development of a more humane psychological approach to the custody and care of ps ...
. Later physicians used this research to connect problems in the brain with specific symptoms. The English surgeon
William John Little William John Little (1810–1894) was an English surgeon who is credited with the first medical identification of spastic diplegia, when he observed it in the 1860s amongst children. While spasticity surely existed before that point, Little was ...
(18101894) 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 Preterm birth, also known as premature birth, is the Childbirth, birth of a baby at fewer than 37 weeks Gestational age (obstetrics), gestational age, as opposed to full-term delivery at approximately 40 weeks. Extreme preterm is less than 28 we ...
and
perinatal asphyxia Perinatal asphyxia (also known as neonatal asphyxia or birth asphyxia) is the medical condition resulting from deprivation of oxygen to a newborn infant that lasts long enough during the birth process to cause physical harm, usually to the brain. ...
in particular as risk factors. The
spastic diplegia Spastic diplegia is a form of cerebral palsy (CP) that is a chronic neuromuscular condition of hypertonia and spasticity—manifested as an especially high and constant "tightness" or "stiffness"—in the muscles of the lower extremities of the ...
form of CP came to be known as Little's disease. At around this time, a German surgeon was also working on cerebral palsy, and distinguished it from polio. 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. Working in the US in the 1880s, Canadian-born physician
William Osler Sir William Osler, 1st Baronet, (; July 12, 1849 – December 29, 1919) was a Canadian physician and one of the "Big Four" founding professors of Johns Hopkins Hospital. Osler created the first residency program for specialty training of phys ...
(18491919) reviewed dozens of CP cases to further classify the disorders by the site of the problems on the body and by the underlying cause. Osler made further observations tying problems around the time of delivery with CP, and concluded that problems causing bleeding inside the brain were likely the root cause. Osler also suspected polioencephalitis as an infectious cause. Through the 1890s, scientists commonly confused CP with
polio Poliomyelitis, commonly shortened to polio, is an infectious disease caused by the poliovirus. Approximately 70% of cases are asymptomatic; mild symptoms which can occur include sore throat and fever; in a proportion of cases more severe s ...
. Before moving to psychiatry, Austrian neurologist
Sigmund Freud Sigmund Freud ( , ; born Sigismund Schlomo Freud; 6 May 1856 – 23 September 1939) was an Austrian neurologist and the founder of psychoanalysis, a clinical method for evaluating and treating psychopathology, pathologies explained as originatin ...
(18561939) 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. 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
musculoskeletal The human musculoskeletal system (also known as the human locomotor system, and previously the activity system) is an organ system that gives humans the ability to move using their muscular and skeletal systems. The musculoskeletal system prov ...
perspective instead of a neurological one. Phelps developed surgical techniques for operating on the muscles to address issues such as spasticity and muscle rigidity. Hungarian
physical rehabilitation Physical therapy (PT), also known as physiotherapy, is one of the allied health professions. It is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, management, prognosis, patien ...
practitioner
András Pető András Pető (11 September 1893 in Szombathely, Hungary – 11 September 1967 in Budapest, Hungary) was a practitioner of physical rehabilitation whose work provided the foundation for conductive education. Early life and career András Pet ...
developed a system to teach children with CP how to walk and perform other basic movements. Pető's system became the foundation for
conductive education Conductive Education (CE) is an educational system, based on the work of Hungarian Professor András Pető, that has been specifically developed for children and adults who have motor disorders of neurological origin such as cerebral palsy. CE i ...
, widely used for children with CP today. Through the remaining decades, physical therapy for CP has evolved, and has become a core component of the CP management program. In 1997, Robert Palisano ''et al.'' introduced the
Gross Motor Function Classification System The Gross Motor Function Classification System or GMFCS is a 5 level clinical classification system that describes the gross motor function of people with cerebral palsy on the basis of self-initiated movement abilities. Particular emphasis in cre ...
(GMFCS) as an improvement over the previous rough assessment of limitation as either mild, moderate, or severe. 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.


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. 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. 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. 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. 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. The average lifetime cost for people with CP in the US is US$921,000 per individual, including lost income. In the United States, many states allow
Medicaid Medicaid in the United States is a federal and state program that helps with healthcare costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and pers ...
beneficiaries to use their Medicaid funds to hire their own PCAs, instead of forcing them to use institutional or managed care. 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. It has shown that persons with mental or physically debilitating congenital disabilities can lead better lives if they have financial independence.


Use of the term

"Cerebral" means "of, or pertaining to, the cerebrum or the brain" and "palsy" means "paralysis, generally partial, whereby a local body area is incapable of voluntary movement". It has been proposed to change the name to "cerebral palsy spectrum disorder" to reflect the diversity of presentations of CP. Many people would rather be referred to as a person with a disability (
people-first language People-first language (PFL), also called person-first language, is a type of linguistic prescription which puts a person before a diagnosis, describing what condition a person "has" rather than asserting what a person "is". It is intended to av ...
) instead of as "handicapped". "Cerebral Palsy: A Guide for Care" at the
University of Delaware The University of Delaware (colloquially UD or Delaware) is a public land-grant research university located in Newark, Delaware. UD is the largest university in Delaware. It offers three associate's programs, 148 bachelor's programs, 121 mas ...
offers the following guidelines: The term " spastic" denotes the attribute of spasticity in types of spastic CP. In 1952 a UK charity called
The Spastics Society Scope (previously known as the National Spastics Society) is a disability charity in England and Wales that campaigns to change negative attitudes about disability, provides direct services, and educates the public. The organisation was found ...
was formed. The term "spastics" was used by the charity as a term for people with CP. The word "spastic" has since been used extensively as a general insult to disabled people, which some see as extremely offensive. They are also frequently used to insult non-disabled people when they seem overly uncoordinated, anxious, or unskilled in sports. The charity changed its name to
Scope Scope or scopes may refer to: People with the surname * Jamie Scope (born 1986), English footballer * John T. Scopes (1900–1970), central figure in the Scopes Trial regarding the teaching of evolution Arts, media, and entertainment * Cinem ...
in 1994. In the United States the word spaz has the same usage as an insult but is not generally associated with CP.


Media

Maverick documentary filmmaker
Kazuo Hara is a Japanese documentary film director. After dropping out of university to work at a special education school, he made his 1972 debut work ''Goodbye CP'' about a group of individuals with cerebral palsy. He won the award for Best Director a ...
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. ''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 Devaki Pandit ( mr, देवकी पंडित; born 6 March 1965) is an Indian classical singer. With melody in her voice and charm in her persona, Devaki Pandit has developed her own unique style of singing and has won many hearts throu ...
has given her voice to the song penned by Prof. Jayant Dhupkar and composed by
National Film Awards The National Film Awards is the most prominent film award ceremony in India. Established in 1954, it has been administered, along with the International Film Festival of India and the Indian Panorama, by the Indian government's Directorat ...
winner Isaac Thomas Kottukapally. ''
My Left Foot ''My Left Foot: The Story of Christy Brown'', also known simply as ''My Left Foot'', is a 1989 biographical comedy-drama film directed by Jim Sheridan adapted by Sheridan and Shane Connaughton from the 1954 memoir of the same name by Christy ...
'' (1989) is a drama film directed by
Jim Sheridan Jim Sheridan (born 6 February 1949) is an Irish playwright and filmmaker. Between 1989 and 1993, Sheridan directed two critically acclaimed films set in Ireland, '' My Left Foot'' and '' In the Name of the Father'', and later directed the fi ...
and starring
Daniel Day-Lewis Sir Daniel Michael Blake Day-Lewis (born 29 April 1957) is an English retired actor. Often described as one of the preeminent actors of his generation, he received numerous accolades throughout his career which spanned over four decades, incl ...
. It tells the true story of
Christy Brown Christy Brown (5 June 1932 – 7 September 1981) was an Irish writer and painter who had cerebral palsy and was able to write or type only with the toes of one foot. His most recognized work is his autobiography, titled ''My Left Foot'' (1954). ...
, an Irishman born with cerebral palsy, who could control only his left foot. Christy Brown grew up in a poor, working-class family, and became a writer and artist. It won the
Academy Award The Academy Awards, better known as the Oscars, are awards for artistic and technical merit for the American and international film industry. The awards are regarded by many as the most prestigious, significant awards in the entertainment ind ...
for Best Actor (Daniel Day-Lewis) and Best Actress in a Supporting Role (Brenda Fricker). It was also nominated for Best Director, Best Picture and Best Writing, Screenplay Based on Material from Another Medium. It also won the
New York Film Critics Circle Award for Best Film The New York Film Critics Circle Award for Best Picture is an award given by the New York Film Critics Circle, honoring the finest achievements in filmmaking. Winners 1930s 1940s 1950s 1960s 1970s 1980s 1990s 2000s 2010s 2020s ...
for 1989. ''
Call the Midwife ''Call the Midwife'' is a BBC period drama series about a group of nurse midwives working in the East End of London in the late 1950s and 1960s. The principal cast of the show has included Jessica Raine, Miranda Hart, Helen George, Bryony Ha ...
'' (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.
Micah Fowler Micah D. Fowler (born March 5, 1998) is an American actor. He portrayed the lead of the ABC sitcom '' Speechless'' (2016–2019). Early life The younger brother of actress Kelsey Fowler, he grew up in Barnegat Township, New Jersey. He grew up ...
, an American actor with CP, stars in the
ABC ABC are the first three letters of the Latin script known as the alphabet. ABC or abc may also refer to: Arts, entertainment, and media Broadcasting * American Broadcasting Company, a commercial U.S. TV broadcaster ** Disney–ABC Television ...
sitcom '' Speechless'' (2016–19), which explores both the serious and humorous challenges a family faces with a teenager with CP. ''9-1-1'' (2018–) is a procedural drama series on
Fox Foxes are small to medium-sized, omnivorous mammals belonging to several genera of the family Canidae. They have a flattened skull, upright, triangular ears, a pointed, slightly upturned snout, and a long bushy tail (or ''brush''). Twelve sp ...
. 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 Special or specials may refer to: Policing * Specials, Ulster Special Constabulary, the Northern Ireland police force * Specials, Special Constable, an auxiliary, volunteer, or temporary; police worker or police officer Literature * ''Specia ...
'' (2019) is a
comedy series Television comedy is a category of broadcasting that has been present since the early days of entertainment media. While there are several genres of comedy, some of the first ones aired were variety shows. One of the first United States television ...
that premiered on
Netflix Netflix, Inc. is an American subscription video on-demand over-the-top streaming service and production company based in Los Gatos, California. Founded in 1997 by Reed Hastings and Marc Randolph in Scotts Valley, California, it offers a fil ...
on 12 April 2019. It was written, produced and stars Ryan O'Connell as a young
gay ''Gay'' is a term that primarily refers to a homosexual person or the trait of being homosexual. The term originally meant 'carefree', 'cheerful', or 'bright and showy'. While scant usage referring to male homosexuality dates to the late 1 ...
man with mild cerebral palsy. It is based on O'Connell's book ''I'm Special: And Other Lies We Tell Ourselves''. 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.


Notable cases

*
Christy Brown Christy Brown (5 June 1932 – 7 September 1981) was an Irish writer and painter who had cerebral palsy and was able to write or type only with the toes of one foot. His most recognized work is his autobiography, titled ''My Left Foot'' (1954). ...
was the basis for the Academy Award-winning film, ''
My Left Foot ''My Left Foot: The Story of Christy Brown'', also known simply as ''My Left Foot'', is a 1989 biographical comedy-drama film directed by Jim Sheridan adapted by Sheridan and Shane Connaughton from the 1954 memoir of the same name by Christy ...
''. * Two sons of Canadian rock musician
Neil Young Neil Percival Young (born November 12, 1945) is a Canadian-American singer and songwriter. After embarking on a music career in Winnipeg in the 1960s, Young moved to Los Angeles, joining Buffalo Springfield with Stephen Stills, Richie Furay ...
, Zeke and Ben. 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. *
Nicolas Hamilton Nicolas Hamilton (born 28 March 1992) is a British racing driver who currently competes in the British Touring Car Championship. He races with a specially-modified car due to his cerebral palsy. Hamilton is the paternal half-brother of seven- ...
, a British racing driver competing in
BTCC The Kwik Fit British Touring Car Championship is a touring car racing series held each year in the United Kingdom, currently organised and administered by TOCA. It was established in 1958 as the British Saloon Car Championship and was renamed as ...
. He is the half-brother of Formula 1 driver
Lewis Hamilton Sir Lewis Carl Davidson Hamilton (born 7 January 1985) is a British racing driver currently competing in Formula One for Mercedes. In Formula One, Hamilton has won a joint-record seven World Drivers' Championship titles (tied with Mic ...
. *
Geri Jewell Geraldine Ann "Geri" Jewell (born September 13, 1956) is an American actress, stand-up comedian, diversity consultant, and motivational speaker, noted for roles on the 1980s sitcom '' The Facts of Life'' and the mid-2000s western '' Deadwood''. S ...
, who had a regular role in the prime-time series '' The Facts of Life''. *
Josh Blue Josh is a masculine given name, frequently a diminutive (hypocorism) of the given names Joshua or Joseph, though since the 1970s, it has increasingly become a full name on its own. It may refer to: People A–J * "Josh", an early pseudonym of S ...
, winner of the fourth season of NBC's ''Last Comic Standing'', whose act revolves around his CP. Blue was also on the 2004 U.S. Paralympic soccer team. *
Jason Benetti Jason Benetti (born September 9, 1983) is an American sportscaster. Since 2016, he has been the primary television play-by-play announcer of Chicago White Sox baseball. He is also the alternate play-by-play announcer of Chicago Bulls basketball f ...
, play-by-play broadcaster for ESPN, Fox Sports, Westwood One, and Time Warner covering football, baseball, lacrosse, hockey, and basketball. Since 2016, he is also the television play-by-play announcer for Chicago White Sox home games. * Jack Carroll, British comedian and runner-up in the seventh season of ''
Britain's Got Talent ''Britain's Got Talent'' (often abbreviated to ''BGT'') is a televised British talent show competition, and part of the global ''Got Talent'' franchise created by Simon Cowell. Presented by Anthony McPartlin and Declan Donnelly (colloqui ...
''. * Abbey Curran, an American beauty queen who represented Iowa at
Miss USA 2008 Miss USA 2008 was the 57th Miss USA pageant, held in Las Vegas, Nevada on April 11, 2008. At the conclusion of the final night of competition, Crystle Stewart of Texas was crowned the winner by outgoing titleholder Rachel Smith of Tennessee. ...
and was the first contestant with a disability to compete. *
Robert Griswold Robert Griswold (born November 27, 1996) is an American swimmer. He was a member of the 2016 and 2020 U.S. Paralympic Swimming Teams. He holds multiple American and world paralympic swimming records in freestyle, backstroke, butterfly, and ind ...
, swimmer *
Francesca Martinez Francesca Martinez (born 1978) is an English comedian, writer and actress. She has cerebral palsy, but prefers to describe herself as "wobbly". Martinez first came to public attention in 1994, when she made her debut on the television series ' ...
, British stand-up comedian and actress. *
Evan O'Hanlon Evan George O'Hanlon, (born 4 May 1988) is an Australian Paralympic athlete, who competes mainly in category T38 sprint events. He has won five gold medals at two Paralympic Games – 2008 Beijing and 2012 London. He also represented Austral ...
, Australian Paralympian, the fastest athlete with cerebral palsy in the world. *
Arun Shourie Arun Shourie (born 2 November 1941) is an Indian economist, journalist, author and politician. He has worked as an economist with the World Bank, a consultant to the Planning Commission of India, editor of the ''Indian Express'' and ''The Times ...
's son Aditya, about whom he has written a
book A book is a medium for recording information in the form of writing or images, typically composed of many pages (made of papyrus, parchment, vellum, or paper) bound together and protected by a cover. The technical term for this physical arr ...
''Does He Know a Mother's Heart'' *
Maysoon Zayid Maysoon Zayid ( ar, ميسون زايد) is an American actress and comedian. Of Palestinian descent, she is known as one of America's first Muslim women comedians. Early life Zayid was born in New Jersey in 1974. She described herself in a ...
, the self-described "Palestinian Muslim virgin with cerebral palsy, from New Jersey", who is an actress, stand-up comedian, and activist. Zayid has been a resident of
Cliffside Park, New Jersey Cliffside Park is a borough in Bergen County, New Jersey, United States. As of the 2010 United States Census, the borough's population was 23,594, She is considered one of America's first Muslim women comedians and the first person ever to perform standup in Palestine and Jordan. *
RJ Mitte Roy Frank "RJ" Mitte III (; born August 21, 1992) is an American actor, best known for playing Walter "Flynn" White Jr. on the AMC series '' Breaking Bad'' (2008–2013). Like his character on the show, he has cerebral palsy. After moving to ...
, an American actor best known for his role as
Walter White Jr. Walter Hartwell White Jr. (also known as Flynn) is a fictional character in the crime drama series ''Breaking Bad''. Played by RJ Mitte, Walt Jr. is the son of protagonist Walter White (Breaking Bad), Walter White and his wife Skyler White, Sky ...
in '' Breaking Bad''. He is also a celebrity ambassador for
United Cerebral Palsy United Cerebral Palsy (UCP) is an international nonprofit charitable organization consisting of a network of affiliates. UCP is a leading service provider and advocate for adults and children with disabilities. As one of the largest health nonpro ...
. *
Zach Anner Zack or Zach may refer to: People * Zach (surname), various people * Zack (surname), various people * Zack (personal name), lists of people and fictional characters named Zack, Zach, Zac, Zak or Zakk * Záh (gens) or Zách, a ''gens'' (clan) in th ...
, an American comedian, actor, and writer. He had a television series on
Oprah Winfrey Oprah Gail Winfrey (; born Orpah Gail Winfrey; January 29, 1954), or simply Oprah, is an American talk show host, television producer, actress, author, and philanthropist. She is best known for her talk show, ''The Oprah Winfrey Show'', br ...
's
OWN Ownership is the state or fact of legal possession and control over property, which may be any asset, tangible or intangible. Ownership can involve multiple rights, collectively referred to as title, which may be separated and held by different ...
called ''Rollin' With Zach'' and is the author of ''If at Birth You Don't Succeed.'' * 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. *
Hannah Cockroft Hannah Lucy Cockroft (born 30 July 1992) is a British wheelchair racer specialising in sprint distances in the T34 classification. She holds the world records for the 100 metres, 200 metres, 400 metres, 800 metres ...
, is a British
wheelchair athlete Parasports are sports played by people with a disability, including physical and intellectual disabilities. Some parasports are forms of adapted physical activities from existing able-bodied sports, while others have been specifically created for ...
specialising in sprint distances in the T34 classification. She holds the
Paralympic The Paralympic Games or Paralympics, also known as the ''Games of the Paralympiad'', is a periodic series of international multisport events involving athletes with a range of physical disabilities, including impaired muscle power and impaire ...
and
world record A world record is usually the best global and most important performance that is ever recorded and officially verified in a specific skill, sport, or other kind of activity. The book ''Guinness World Records'' and other world records organization ...
s for the 100 metres,
200 metres The 200 metres, or 200-meter dash, is a sprint running event. On an outdoor 400 metre racetrack, the race begins on the curve and ends on the home straight, so a combination of techniques is needed to successfully run the race. A slightl ...
and
400 metres The 400 metres, or 400-meter dash, is a sprint event in track and field competitions. It has been featured in the athletics (sport), athletics programme at the Summer Olympics since 1896 for men and since 1964 for women. On a standard outdoor runn ...
in her classification. *
Keah Brown Keah Brown (born September 19, 1991) is a disability rights activist, author, journalist, and writer. She is also known as the creator of the hashtag #DisabledAndCute, which first went viral in February 2017 and caught the attention of such celebrit ...
, American
disability rights The disability rights movement is a global social movement that seeks to secure equal opportunities and equal rights for all people with disabilities. It is made up of organizations of disability activists, also known as disability advocat ...
activist, author and journalist. * Kuli Kohli, Indian-British writer, poet, activist. *
Simon James Stevens Simon Stevens, also known as Simon Walsh in Secondlife, born 1974, is an English activist, '' Huffington Post'' blogger, and disability consultant known for his discussions on disability issues in the UK and on social media. Stevens formed ''Wh ...
, a British disability issues consultant and activist, who starred in ''
I'm Spazticus ''I'm Spazticus'' is a British hidden camera prank show by Channel 4, produced by Jamie O'Leary. From the Channel 4 website, I'm Spazticus is where "A cast of disabled talent prank members of the public in a cheeky and irreverent way". Episode ...
'' and founded
Wheelies Wheelies is a disability themed virtual nightclub on the online platform ''Second Life''. Created by Simon Stevens, it was awarded the Revolutionary Award in 2008 by Gordon Brown. History Launched in September 2006, "Wheelies aims to make gues ...
virtual nightclub * The
Roman Roman or Romans most often refers to: *Rome, the capital city of Italy *Ancient Rome, Roman civilization from 8th century BC to 5th century AD *Roman people, the people of ancient Rome *''Epistle to the Romans'', shortened to ''Romans'', a letter ...
Emperor
Claudius Tiberius Claudius Caesar Augustus Germanicus (; 1 August 10 BC – 13 October AD 54) was the fourth Roman emperor, ruling from AD 41 to 54. A member of the Julio-Claudian dynasty, Claudius was born to Nero Claudius Drusus, Drusu ...
is hypothesized to have had cerebral palsy on the basis of his reported symptoms. * Rosie Jones, a British comedian and actress, is incorporating her cerebral palsy into her comedic style. *
Christopher Nolan Christopher Edward Nolan (born 30 July 1970) is a British-American filmmaker. Known for his lucrative Hollywood blockbusters with complex storytelling, Nolan is considered a leading filmmaker of the 21st century. His films have grossed $5&nb ...
, 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.


Litigation

Because of the false perception that cerebral palsy is mostly caused by trauma during birth, as of 2005, 60% of obstetric
litigation - A lawsuit is a proceeding by a party or parties against another in the civil court of law. The archaic term "suit in law" is found in only a small number of laws still in effect today. The term "lawsuit" is used in reference to a civil actio ...
was about cerebral palsy, which Alastair MacLennan, Professor of Obstetrics and Gynaecology at the
University of Adelaide The University of Adelaide (informally Adelaide University) is a public research university located in Adelaide, South Australia. Established in 1874, it is the third-oldest university in Australia. The university's main campus is located on N ...
, regards as causing an exodus from the profession. In the latter half of the 20th century, obstetric litigation about the cause of cerebral palsy became more common, leading to the practice of defensive medicine.


See also

* Cerebral palsy sport classification – describes the
disability sport classification Disability sports classification is a system that allows for fair competition between people with different types of disabilities. Historically, the process has been overseen by 2 groups: specific disability type sport organizations that cover mul ...
for cerebral palsy. * Inclusive recreation * World Cerebral Palsy Day


Notes


References


External links

*
Cerebral Palsy Information Page
at
NINDS The National Institute of Neurological Disorders and Stroke (NINDS) is a part of the U.S. National Institutes of Health (NIH). It conducts and funds research on brain and nervous system disorders and has a budget of just over US$2.03 billion. The ...
{{DEFAULTSORT:Cerebral Palsy Congenital disorders of nervous system Disorders causing seizures Neurological disorders in children Neurotrauma Wikipedia medicine articles ready to translate