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Cerebral palsy

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  • 1. Cerebral palsyFrom Wikipedia, the free encyclopediaJump to: navigation, search Cerebral palsy Classification and external resources A child with cerebral palsy being examined.ICD-10 G80.ICD-9 343OMIM 603513 605388DiseasesDB 2232eMedicine neuro/533 pmr/24MeSH D002547Cerebral palsy (CP) is an umbrella term encompassing a group of non-progressive,[1][2] non-contagious motor conditions that cause physical disability in human development, chiefly in thevarious areas of body movement.[3]Cerebral refers to the cerebrum, which is the affected area of the brain (although the disordermost likely involves connections between the cortex and other parts of the brain such as thecerebellum), and palsy refers to disorder of movement. However, "paralytic disorders" are notcerebral palsy — the condition of quadriplegia, therefore, should not be confused with spasticquadriplegia, nor Tardive dyskinesia with dyskinetic cerebral palsy, nor diplegia with spasticdiplegia, and so on.Cerebral palsys nature as an umbrella term means it is defined mostly via several differentsubtypes, especially spastic, and also mixtures of those subtypes.Cerebral palsy is caused by damage to the motor control centers of the developing brain and canoccur during pregnancy, during childbirth or after birth up to about age three.[4][5] Resultinglimits in movement and posture cause activity limitation and are often accompanied bydisturbances of sensation, depth perception and other sight-based perceptual problems,communication ability, and sometimes even cognition; sometimes a form of CP may beaccompanied by epilepsy. CP, no matter what the type, is often accompanied by secondarymusculoskeletal problems that arise as a result of the underlying etiology.[6]Of the many types and subtypes of CP, none of them has a known cure. Usually, medicalintervention is limited to the treatment and prevention of complications arising from CPs effects.A 2003 study put the economic cost for people with CP in the US at $921,000 per individual,including lost income.[7] In another study, the incidence in six countries surveyed was 2.12–2.45
  • 2. per 1,000 live births,[8] indicating a slight rise in recent years. Improvements in neonatology, orthe medical specialty which is involved with treatment of neonates, have helped reduce thenumber of babies who develop cerebral palsy, but the survival of babies with very low birthweights has increased, and these babies are more likely to have cerebral palsy.[9][10]Contents[hide] 1 Classification o 1.1 Spastic o 1.2 Ataxic o 1.3 Athetoid/dyskinetic o 1.4 Hypotonic 2 Signs and symptoms o 2.1 Skeleton o 2.2 Pain and sleep disorders 3 Causes 4 Diagnosis 5 Treatment o 5.1 Interpersonal therapy  5.1.1 Occupational therapy o 5.2 Medication o 5.3 Surgery and orthoses o 5.4 Other treatments 6 Prognosis o 6.1 Self-care o 6.2 Productivity o 6.3 Leisure o 6.4 Participation and barriers 7 Epidemiology 8 History 9 Society and culture o 9.1 Economic impact o 9.2 Use of the term o 9.3 Misconceptions o 9.4 Media o 9.5 Notable cases 10 References 11 External links[edit] Classification
  • 3. Cerebral palsy (CP) is divided into four major classifications to describe different movementimpairments. These classifications also reflect the areas of the brain that are damaged. The fourmajor classifications are:[edit] SpasticMain article: Spastic cerebral palsySpastic cerebral palsy is by far the most common type of overall cerebral palsy, occurring in70% to 80% of all cases. Moreover, spastic CP accompanies any of the other types of CP in 30%of all cases.[citation needed]People with this type of CP are hypertonic and have what is essentially a neuromuscular mobilityimpairment (rather than hypotonia or paralysis) stemming from an upper motor neuron lesion inthe brain as well as the corticospinal tract or the motor cortex, this damage impairs the ability ofsome nerve receptors in the spine to properly receive gamma amino butyric acid, leading tohypertonia in the muscles signaled by those damaged nerves.As compared to other types of CP, and especially as compared to hypotonic or paralytic mobilitydisabilities, spastic CP is typically more easily manageable by the person affected, and medicaltreatment can be pursued on a multitude of orthopedic and neurological fronts throughout life.Spastic CP is classified by topography dependent on the region of the body affected; theseinclude: Spastic hemiplegia is one side being affected. Generally, injury to muscle-nerves controlled by the brains left side will cause a right body deficit, and vice versa. Typically, people that have spastic hemiplegia are the most ambulatory of all the forms, although they generally have dynamic equinus (a limping instability) on the affected side and are primarily prescribed ankle-foot orthoses to prevent said equinus.[11] Spastic diplegia is the lower extremities affected, with little to no upper-body spasticity. The most common form of the spastic forms (70-80% of known cases), most people with spastic diplegia are fully ambulatory, but are "tight" and have a scissors gait. Flexed knees and hips to varying degrees, and moderate to severe adduction (stemming from tight adductor muscles and comparatively weak abductor muscles), are present. Gait analysis is often done in early life on a semi-regular basis, and assistive devices are often provided like walkers, crutches or canes; any ankle-foot orthotics provided usually go on both legs rather than just one. In addition, these individuals are often nearsighted. The intelligence of a person with spastic diplegia is unaffected by the condition. Over time, the effects of the spasticity sometimes produce hip problems and dislocations (see the main article and spasticity for more on spasticity effects). In three-quarters of spastic diplegics, also strabismus (crossed eyes) can be present as well. Spastic monoplegia is one single limb being affected. Spastic triplegia is three limbs being affected. Spastic quadriplegia is all four limbs more or less equally affected. People with spastic quadriplegia are the least likely to be able to walk, or if they can, to desire to walk, because their muscles are too tight and it is too much of an effort to do so. Some children
  • 4. with spastic quadriplegia also have hemiparetic tremors, an uncontrollable shaking that affects the limbs on one side of the body and impairs normal movement.In any form of spastic CP, clonus of the affected limb(s) may sometimes result, as well as musclespasms resulting from the pain and/or stress of the tightness experienced. The spasticity can andusually does also lead to very early onset of muscle-stress symptoms like arthritis and tendinitis,especially in ambulatory individuals in their mid-20s and early-30s. Physical therapy andoccupational therapy regimens of assisted stretching, strengthening, functional tasks, and/ortargeted physical activity and exercise are usually the chief ways to keep spastic CP well-managed, although if the spasticity is too much for the person to handle, other remedies may beconsidered, such as various antispasmodic medications, botox, baclofen, or even a neurosurgeryknown as a selective dorsal rhizotomy (which eliminates the spasticity by eliminating the nervescausing it).[edit] AtaxicAtaxia type symptoms can be caused by damage to the cerebellum. The forms of ataxia are lesscommon types of cerebral palsy, occurring in at most 10% of all cases. Some of these individualshave hypotonia and tremors. Motor skills such as writing, typing, or using scissors might beaffected, as well as balance, especially while walking. It is common for individuals to havedifficulty with visual and/or auditory processing.[edit] Athetoid/dyskineticAthetoid or dyskinetic cerebral palsy is mixed muscle tone — both hypertonia and hypotonia.People with athetoid CP have trouble holding themselves in an upright, steady position for sittingor walking, and often show involuntary motions. For some people with athetoid CP, it takes a lotof work and concentration to get their hand to a certain spot (like scratching their nose orreaching for a cup). Because of their mixed tone and trouble keeping a position, they may not beable to hold onto objects, especially small ones requiring fine motor control (such as a toothbrushor pencil). About one-quarter of all people with CP have athetoid CP; it occurs in 10% to 20% ofall cases.[12] The damage occurs to the extrapyramidal motor system and/or pyramidal tract andto the basal ganglia. In newborn infants, high bilirubin levels in the blood, if left untreated, canlead to brain damage in certain areas (kernicterus), which can lead to athetoid cerebral palsy.[edit] HypotonicHypotonia is the opposite of hypertonia; people with hypotonic CP have musculature that islimp, and can move only a little or not at all. Although physical therapy is usually attempted tostrengthen the muscles (in a similar way to how PT is used to stretch and loosen the tightmuscles of hypertonic individuals), it is not always fundamentally effective.[edit] Signs and symptoms
  • 5. All types of cerebral palsy are characterized by abnormal muscle tone (i.e. slouching over whilesitting), reflexes, or motor development and coordination. There can be joint and bonedeformities and contractures (permanently fixed, tight muscles and joints). The classicalsymptoms are spasticities, spasms, other involuntary movements (e.g. facial gestures), unsteadygait, problems with balance, and/or soft tissue findings consisting largely of decreased musclemass. Scissor walking (where the knees come in and cross) and toe walking (which cancontribute to a gait reminiscent of a marionette) are common among people with CP who areable to walk, but taken on the whole, CP symptomatology is very diverse. The effects of cerebralpalsy fall on a continuum of motor dysfunction which may range from slight clumsiness at themild end of the spectrum to impairments so severe that they render coordinated movementvirtually impossible at the other end the spectrum.Babies born with severe CP often have an irregular posture; their bodies may be either veryfloppy or very stiff. Birth defects, such as spinal curvature, a small jawbone, or a small headsometimes occur along with CP. Symptoms may appear or change as a child gets older. Somebabies born with CP do not show obvious signs right away. Classically, CP becomes evidentwhen the baby reaches the developmental stage at six and a half to 9 months and is starting tomobilise, where preferential use of limbs, asymmetry or gross motor developmental delay isseen.Secondary conditions can include seizures, epilepsy, apraxia, dysarthria or other communicationdisorders, eating problems, sensory impairments, mental retardation, learning disabilities, and/orbehavioral disorders.Speech and language disorders are common in people with cerebral palsy. The incidence ofdysarthria is estimated to range from 31% to 88%. Speech problems are associated with poorrespiratory control, laryngeal and velopharyngeal dysfunction as well as oral articulationdisorders that are due to restricted movement in the oral-facial muscles. There are three majortypes of dysarthria in cerebral palsy: spastic, dyskinetic (athetosis) and ataxic. Speechimpairments in spastic dysarthria involves four major abnormalities of voluntary movement:spasticity, weakness, limited range of motion and slowness of movement. Speech mechanismimpairment in athetosis involves a disorder in the regulation of breathing patterns, laryngealdysfunction (monopitch, low, weak and breathy voice quality). It is also associated witharticulatory dysfunction (large range of jaw movements), inappropriate positioning of the tongue,instability of velar elevation. Athetoid dysarthria is caused by disruption of the internalsensorimotor feedback system for appropriate motor commands, which leads to the generation offaulty movements that are perceived by others as involuntary. Ataxic dysarthria is uncommon incerebral palsy. The speech characteristics are: imprecise consonants, irregular articulatorybreakdown, distorted vowels, excess and equal stress, prolonged phonemes, slow rate,monopitch, monoloudness and harsh voice.[13] Overall language delay is associated withproblems of mental retardation, hearing impairment and learned helplessness.[3] Children withcerebral palsy are at risk of learned helplessness and becoming passive communicators, initiatinglittle communication.[3] Early intervention with this clientele often targets situations in whichchildren communicate with others, so that they learn that they can control people and objects intheir environment through this communication, including making choices, decisions andmistakes.[3]
  • 6. [edit] SkeletonIn order for bones to attain their normal shape and size, they require the stresses from normalmusculature. Osseous findings will therefore mirror the specific muscular deficits in a givenperson with CP. The shafts of the bones are often thin (gracile) and become thinner duringgrowth. When compared to these thin shafts (diaphyses), the centers (metaphyses) often appearquite enlarged (ballooning). With lack of use, articular cartilage may atrophy, leading tonarrowed joint spaces. Depending on the degree of spasticity, a person with CP may exhibit avariety of angular joint deformities. Because vertebral bodies need vertical gravitational loadingforces to develop properly, spasticity and an abnormal gait can hinder proper and/or full boneand skeletal development. People with CP tend to be shorter in height than the average personbecause their bones are not allowed to grow to their full potential. Sometimes bones grow todifferent lengths, so the person may have one leg longer than the other.[edit] Pain and sleep disordersPain is common, and may result from the inherent deficits associated with the condition, alongwith the numerous procedures children typically face.[14] There is also a high likelihood ofsuffering from chronic sleep disorders associated with both physical and environmentalfactors.[15] Pain is also associated with tight and/or shortened muscle, abnormal posture, stiffjoints, unsuitable orthosis etc.[edit] CausesWhile in certain cases there is no identifiable cause, typical causes include problems inintrauterine development (e.g. exposure to radiation, infection), asphyxia before birth, hypoxia ofthe brain, and birth trauma during labor and delivery, and complications in the perinatal period orduring childhood.[3] CP is also more common in multiple births.It has been hypothetized that many cases of cerebral palsy are caused by the death in very earlypregnancy of an identical twin. This may occur when twins have a joint circulation throughsharing the same placenta. Not all identical twins share the same blood supply (monochorionictwins), but if they do, the suggestion is that perturbations in blood flow between them can causethe death of one and damage to the development of the surviving fetus.[16] It is commonknowledge amongst obstetricians and midwives that a small dead fetus (fetus papyraceus) maysometimes be found attached to a placenta following birth. In the past, this has not beenconsidered important and knowledge of the so called ‗vanishing twin‘ has been suppressed toavoid triggering feelings of loss, grief, or guilt in mothers and especially the survivingtwin.[citation needed] The pathological consequences depend on the severity and the stage ofdevelopment of the fetus when the imbalances in blood flow between the fetuses occur.[citationneeded]Between 40% and 50% of all children who develop cerebral palsy were born prematurely.Premature infants are vulnerable, in part because their organs are not fully developed, increasingthe risk of hypoxic injury to the brain that may manifest as CP. A problem in interpreting this isthe difficulty in differentiating between cerebral palsy caused by damage to the brain that results
  • 7. from inadequate oxygenation and CP that arises from prenatal brain damage that thenprecipitates premature delivery.Recent research has demonstrated that intrapartum asphyxia is not the most important cause,probably accounting for no more than 10 percent of all cases; rather, infections in the mother,even infections that are not easily detected, may triple the risk of the child developing thedisorder, mainly as the result of the toxicity to the fetal brain of cytokines that are produced aspart of the inflammatory response.[17] Low birthweight is a risk factor for CP—and prematureinfants usually have low birth weights, less than 2.0 kg, but full-term infants can also have lowbirth weights. Multiple-birth infants are also more likely than single-birth infants to be born earlyor with a low birth weight.After birth, other causes include toxins, severe jaundice, lead poisoning, physical brain injury,shaken baby syndrome, incidents involving hypoxia to the brain (such as near drowning), andencephalitis or meningitis. The three most common causes of asphyxia in the young child are:choking on foreign objects such as toys and pieces of food, poisoning, and near drowning.Some structural brain anomalies such as lissencephaly may present with the clinical features ofCP, although whether that could be considered CP is a matter of opinion (some people say CPmust be due to brain damage, whereas people with these anomalies didnt have a normal brain).Often this goes along with rare chromosome disorders and CP is not genetic or hereditary.[edit] DiagnosisThe diagnosis of cerebral palsy has historically rested on the patients history and physicalexamination. Once diagnosed with cerebral palsy, further diagnostic tests are optional. TheAmerican Academy of Neurology published an article in 2004 reviewing the literature andevidence available on CT and MRI imaging. They suggested that neuroimaging with CT or MRIis warranted when the etiology of a patients cerebral palsy has not been established - an MRI ispreferred over CT due to diagnostic yield and safety. When abnormal, the neuroimaging studycan suggest the timing of the initial damage. The CT or MRI is also capable of revealingtreatable conditions, such as hydrocephalus, porencephaly, arteriovenous malformation, subduralhematomas and hygromas, and a vermian tumor[18] (which a few studies suggest are present 5 to22%). Furthermore, an abnormal neuroimaging study indicates a high likelihood of associatedconditions, such as epilepsy and mental retardation.[19][edit] TreatmentTreatment for cerebral palsy is a lifelong multi-dimensional process focused on the maintenanceof associated conditions. In order to be diagnosed with cerebral palsy the damage that occurredto the brain must be non-progressive and not disease like in nature. The manifestation of thatdamage will change as the brain and body develop, but the actual damage to the brain will notincrease. Treatment in the life of cerebral palsy is the constant focus on preventing the damage inthe brain from prohibiting healthy development on all levels. The brain, up to about the age of 8,is not concrete in its development. It has the ability to re-organize and re-route many signal paths
  • 8. that may have been affected by the initial trauma; the earlier it has help in doing this the moresuccessful it will be. Various forms of therapy are available to people living with cerebral palsyas well as caregivers and parents caring for someone with this disability. They can all be usefulat all stages of this disability and are vital in a person with cerebral palsys ability to function andlive more effectively. In general, the earlier treatment begins the better chance children have ofovercoming developmental disabilities or learning new ways to accomplish the tasks thatchallenge them. The earliest proven intervention occurs during the infants recovery in theneonatal intensive care unit (NICU). Treatment may include one or more of the following:physical therapy; occupational therapy; speech therapy; drugs to control seizures, alleviate pain,or relax muscle spasms (e.g. benzodiazepienes, baclofen and intrathecal phenol/baclofen);hyperbaric oxygen; the use of Botox to relax contracting muscles; surgery to correct anatomicalabnormalities or release tight muscles; braces and other orthotic devices; rolling walkers; andcommunication aids such as computers with attached voice synthesizers. For instance, the use ofa standing frame can help reduce spasticity and improve range of motion for people with CP whouse wheelchairs. Nevertheless, there is only some benefit from therapy. Treatment is usuallysymptomatic and focuses on helping the person to develop as many motor skills as possible or tolearn how to compensate for the lack of them. Non-speaking people with CP are often successfulavailing themselves of augmentative and alternative communication systems such asBlissymbols. Constraint-induced movement therapy (CIMT) has shown promising evidence inhelping individuals with neurological disorders that have lost most of the use of an extremity.Research has proven the positive benefits of CIMT for people who have had a stroke andtraumatic brain injury. However, later studies have addressed the application of CIMT forchildren with CP challenged with hemiparesis, that show a significant benefit in constraintinduced movement therapy for children with cerebral palsy who are challenged withhemiparesis.[20][edit] Interpersonal therapyPhysiotherapy programs are designed to encourage the patient to build a strength base forimproved gait and volitional movement, together with stretching programs to limit contractures.Many experts believe that life-long physiotherapy is crucial to maintain muscle tone, bonestructure, and prevent dislocation of the joints.Occupational therapy helps adults and children maximise their function, adapt to their limitationsand live as independently as possible.[21][22]Speech therapy helps control the muscles of the mouth and jaw, and helps improvecommunication. Just as CP can affect the way a person moves their arms and legs, it can alsoaffect the way they move their mouth, face and head. This can make it hard for the person tobreathe; talk clearly; and bite, chew and swallow food. Speech therapy often starts before a childbegins school and continues throughout the school years.[23]Conductive education was developed in Hungary from 1945 based on the work of András Pető.It is a unified system of rehabilitation for people with neurological disorders including cerebralpalsy, Parkinsons disease and multiple sclerosis, amongst other conditions. It is theorised toimprove mobility, self-esteem, stamina and independence as well as daily living skills and social
  • 9. skills. The conductor is the professional who delivers CE in partnership with parents andchildren. Skills learned during CE should be applied to everyday life and can help to developage-appropriate cognitive, social and emotional skills. It is available at specialized centers.Biofeedback is an alternative therapy in which people with CP learn how to control their affectedmuscles. Some people learn ways to reduce muscle tension with this technique. Biofeedbackdoes not help everyone with CP.Neuro-cognitive therapy. It is based upon two proven principles. (1) Neural Plasticity. The brainis capable of altering its own structure and functioning to meet the demands of any particularenvironment. Consequently if the child is provided with an appropriate neurologicalenvironment, he will have the best chance of making progress. (2) Learning can lead todevelopment. As early as the early 1900s, this was being proven by a psychologist named LevVygotsky. He proposed that childrens learning is a social activity, which is achieved byinteraction with more skilled members of society. There are many studies which provideevidence for this claim. There are however, as yet no controlled studies on neuro-cognitivetherapy.Patterning is a controversial form of alternative therapy for people with CP. The method ispromoted by The Institutes for the Achievement of Human Potential (IAHP), a Philadelphianonprofit, but has been criticized by the American Academy of Pediatrics.[24] The IAHPsmethods have been endorsed by Linus Pauling,[25] as well as some parents of children treatedwith their methods.[26][27][28]Massage therapy[29] is designed to help relax tense muscles, strengthen muscles, and keep jointsflexible. More research is needed to determine the health benefits of these therapies for peoplewith CP.[edit] Occupational therapyMain article: Occupational therapy in the management of cerebral palsyOccupational Therapy (OT) enables individuals with CP to participate in activities of daily livingthat are meaningful to them. A family-centred philosophy is used with children who have CP.Occupational therapists work closely with families in order to address their concerns andpriorities for their child.[30] Occupational therapists may address issues relating to sensory,cognitive, or motor impairments resulting from CP that affect the childs participation in self-care, productivity, or leisure. Parent counselling is also an important aspect of occupationaltherapy treatment with regard to optimizing the parents skills in caring for and playing with theirchild to support improvement of their childs abilities to do things.[31][32] The occupationaltherapist typically assesses the child to identify abilities and difficulties, and environmentalconditions, such as physical and cultural influences, that affect participation in daily activities.[32]Occupational therapists may also recommend changes to the play space, changes to the structureof the room or building, and seating and positioning techniques to allow the child to play andlearn effectively.[32][33]
  • 10. [edit] MedicationBotulinum toxin A (Botox) injections into muscles that are either spastic or have contractures,the aim being to relieve the disability and pain produced by the inappropriately contractingmuscle.[34][edit] Surgery and orthosesSurgery usually involves one or a combination of: Loosening tight muscles and releasing fixed joints, most often performed on the hips, knees, hamstrings, and ankles. In rare cases, this surgery may be used for people with stiffness of their elbows, wrists, hands, and fingers. The insertion of a baclofen pump usually during the stages while a patient is a young adult. This is usually placed in the left abdomen. It is a pump that is connected to the spinal cord, whereby it sends bits of Baclofen alleviating the continuous muscle flexion. Baclofen is a muscle relaxant and is often given PO "per os" (Latin for "by mouth") to patients to help counter the effects of spasticity. Straightening abnormal twists of the leg bones, i.e. femur (termed femoral anteversion or antetorsion) and tibia (tibial torsion). This is a secondary complication caused by the spastic muscles generating abnormal forces on the bones, and often results in intoeing (pigeon-toed gait). The surgery is called derotation osteotomy, in which the bone is broken (cut) and then set in the correct alignment.[35] Cutting nerves on the limbs most affected by movements and spasms. This procedure, called a rhizotomy, "rhizo" meaning root and "tomy" meaning "a cutting of" from the Greek suffix tomia reduces spasms and allows more flexibility and control of the affected limbs and joints.[36]Orthotic devices such as ankle-foot orthoses (AFOs) are often prescribed to minimise gaitirregularities. AFOs have been found to improve several measures of ambulation, includingreducing energy expenditure[37] and increasing speed and stride length.[38][edit] Other treatmentsCooling high-risk full-term babies shortly after birth may significantly reduce disability ordeath.[39]Early nutritional support: In one cohort study of 490 premature infants discharged from theNICU, the rate of growth during hospital stay was related to neurological function at 18 and 22months of age. The study found a significant decrease in the incidence of cerebral palsy in thegroup of premature infants with the highest growth velocity. This study suggests that adequatenutrition and growth play a protective role in the development of cerebral palsy.[40]
  • 11. Hyperbaric oxygen therapy (HBOT), in which pressurized oxygen is inhaled inside a hyperbaricchamber, has been studied under the theory that improving oxygen availability to damaged braincells can reactivate some of them to function normally. A 2007 systematic review concluded thatthe effect of HBOT is no different from that of pressurized room air, and that some childrenundergoing HBOT will experience adverse events such as seizures and the need for ear pressureequalization tubes; due to poor quality of data assessment the review also concluded thatestimates of the prevalence of adverse events are uncertain.[41]There are some experimental treatment techniques. One of them is a stem cell treatment, whichis administered at Tiantan Puhua hospital in China,[42] with certain amount of success.[edit] PrognosisCP is not a progressive disorder (meaning the brain damage neither improves nor worsens), butthe symptoms can become more severe over time due to subdural damage. A person with thedisorder may improve somewhat during childhood if he or she receives extensive care fromspecialists, but once bones and musculature become more established, orthopedic surgery may berequired for fundamental improvement. People who have CP tend to develop arthritis at ayounger age than normal because of the pressure placed on joints by excessively toned and stiffmuscles.The full intellectual potential of a child born with CP will often not be known until the childstarts school. People with CP are more likely to have learning disabilities, although these may beunrelated to IQ, and are more likely to show varying degrees of intellectual disability.Intellectual level among people with CP varies from genius to intellectually impaired, as it doesin the general population, and experts have stated that it is important to not underestimate aperson with CPs capabilities and to give them every opportunity to learn.[43]The ability to live independently with CP varies widely depending on the severity of each case.Some individuals with CP will require personal assistant services for all activities of daily living.Others can lead semi-independent lives, needing support only for certain activities. Still otherscan live in complete independence. The need for personal assistance often changes withincreasing age and associated functional decline. However, in most cases persons with CP canexpect to have a normal life expectancy; survival has been shown to be associated with theability to ambulate, roll, and self-feed.[44] As the condition does not directly affect reproductivefunction, some persons with CP have children and parent successfully.According to OMIM, only 2% of cases of CP are inherited (with glutamate decarboxylase-1 asone known enzyme involved.)[45] There is no evidence of an increased chance of a person withCP having a child with CP.The common signs and symptoms associated with CP can have a significant impact onparticipation in occupations. Occupation is a term used in occupational therapy that refers to allactivities a person does throughout their day. These activities may be grouped into the categoriesof self-care, productivity and leisure activities. Impairments related to CP can impact theseactivities. For example, children with motor impairments may also experience difficulties
  • 12. moving around their home and community, such as transportation, moving from room to room ortransferring from wheelchair to toilet.[edit] Self-careSelf-care is any activity children do to care for themselves. For many children with CP, parentsare heavily involved in self-care activities. Self-care activities, such as bathing, dressing,grooming and eating, can be difficult for children with CP as self-care depends primarily on useof the upper limbs.[46] For those living with CP, impaired upper limb function affects almost 50%of children and is considered the main factor contributing to decreased activity andparticipation.[47] Since the hands are used for many self-care tasks, it is logical that sensory andmotor impairments would impact daily self-care. The extent of the hand impairment depends onthe location and degree of brain damage.[48] Sensory impairments can make getting dressed andbrushing teeth difficult. Along with sensory impairments, motor impairments of the hand arethought to be responsible for difficulties experienced in daily, self-care activities.[49] However,motor impairments are more important than sensory impairments, with the most prevalentimpairment being finger dexterity (ability to manipulate small objects).[48] Finger dexterity isessential in fastening buttons, doing up zippers and tying shoelaces. With upper limb spasticity,it may be difficult to get dressed in the morning. If the individual with CP also has cognitivedeficits, this may add an additional challenge to dressing and grooming.Children with CP often have oral sensory disturbances meaning that they have too little or toomuch sensitivity around and in the mouth.[50] An infant with CP may not be able to suck,swallow or chew and this can result in difficulty eating.[50] As mentioned in the above paragraph,finger dexterity is the most prevalent motor impairment.[48] Finger dexterity is essential formanipulating cutlery or bringing food to the mouth. Fine finger dexterity, like picking up aspoon, is more frequently impaired than gross manual dexterity, like spooning food onto aplate.[48] Grip strength impairments are less common.[48] Overall, children with CP may havedifficulty chewing and swallowing food, holding utensils, and preparing food due to sensory andmotor impairments.[edit] ProductivityThe effects of sensory, motor and cognitive impairments not only affect self-care occupations inchildren with CP, but also productivity occupations. Productivity can include, but is not limitedto: school, work, household chores and contributing to the community.[51] Play is also includedas a productive occupation as it is often the primary activity for children.[52]Play is considered the main occupation for children.[52] If play becomes difficult due to adisability, like CP, this can cause problems for the child.[53] These difficulties can affect a child‘sself-esteem.[53] In addition, the sensory and motor problems experienced by children with CPaffect how the child interacts with their surroundings, including the environment and otherpeople.[53] Not only do physical limitations affect a child‘s ability to play, the limitationsperceived by the child‘s caregivers and playmates also impact the child‘s play activities.[54]Typically, children with disabilities spend more time playing by themselves.[55] When a disability
  • 13. prevents a child from playing, there may be social, emotional and psychological problems [56]which can lead to increased dependence on others, less motivation and poor social skills.[57]In school, students are asked to complete many tasks and activities, many of which involvehandwriting. Many children with CP have the capacity to learn and write in the schoolenvironment.[58] However, students with CP may find it difficult to keep up with the handwritingdemands of school and their writing may be difficult to read.[58] In addition, writing may takelonger and require greater effort on the student‘s part.[58] Factors linked to handwriting include:postural stability, sensory and perceptual abilities of the hand and writing tool pressure.[58]Also, speech impairments may be seen in children with CP depending on the severity of braindamage.[59] Communication in a school setting is quite important because communicating withpeers and teachers is very much a part of the ―school experience‖ and enhances socialinteraction. Problems with language or motor dysfunction can lead to underestimating a student‘sintelligence.[60] In summary, children with CP may experience difficulties in school, such asdifficulty with handwriting, carrying out school activities, communicating verbally andinteracting socially.[edit] LeisureLeisure occupations are any activities that are done for enjoyment. Enjoyable activities dependon the child‘s personality and environment. Leisure activities can have several positive effects onphysical health, mental health, life satisfaction and psychological growth for children withphysical disabilities like CP.[61] Common benefits identified are stress reduction, development ofcoping skills, companionship, enjoyment, relaxation and a positive effect on life satisfaction.[62]In addition, for children with CP, leisure appears to enhance adjustment to living with adisability.[62]Leisure can be divided into structured (formal) and unstructured (informal) activities.[63] Studiesshow that children with disabilities, like CP, participate mainly in informal activities that arecarried out in the family environment and are organized by adults.[64] Typically, children withdisabilities carry out leisure activities by themselves or with their parents rather than withfriends. Therefore, children may experience limited diversity of activities and socialengagements, as well as a more passive lifestyle than their peers.[64] Although leisure isimportant for children with CP, they may have difficulties carrying out leisure activities due tosocial and physical barriers.[edit] Participation and barriersParticipation is considered involvement in life situations and everyday activities.[65] Participationincludes the domains of self-care, productivity and leisure. In fact, communication, mobility,education, home life, leisure and social relationships require participation and are indicators ofthe extent to which a child functions in his or her environment.[65] Barriers can exist on threelevels: micro, meso and macro.[66] Firstly, the barriers at the micro level involve the person.[66]Barriers at the micro level include the child‘s physical limitations (motor, sensory and cognitiveimpairments) or their subjective feelings regarding their ability to participate.[67] For example,
  • 14. the child may not participate in group activities due to lack of confidence. Secondly, the barriersat the meso level include the family and community.[66] These may include negative attitudes ofpeople towards disability or lack of support within the family or in the community.[68] One of themain reasons for this limited support appears to be the result of a lack of awareness andknowledge regarding the child‘s ability to engage in activities despite his or her disability.[68]Thirdly, barriers at the macro level incorporate the systems and policies that are not in place orhinder children with CP. These may be environmental barriers to participation such asarchitectural barriers, lack of relevant assistive technology and transportation difficulties due tolimited wheelchair or public transit that can accommodate the children with CP.[68] For example,a building without an elevator may prevent the child from accessing higher floor levels.[edit] EpidemiologyIn the industrialized world, the incidence of cerebral palsy is about 2 per 1000 live births.[69] Theincidence is higher in males than in females; the Surveillance of Cerebral Palsy in Europe(SCPE) reports a M:F ratio of 1.33:1.[70] Variances in reported rates of incidence across differentgeographical areas in industrialised countries are thought to be caused primarily by discrepanciesin the criteria used for inclusion and exclusion. When such discrepancies are taken into accountin comparing two or more registers of patients with cerebral palsy (for example, the extent towhich children with mild cerebral palsy are included), the incidence rates converge toward theaverage rate of 2:1000.In the United States, approximately 10,000 infants and babies are diagnosed with CP each year,and 1200–1500 are diagnosed at preschool age.[71]Overall, advances in care of pregnant mothers and their babies has not resulted in a noticeabledecrease in CP. This is generally attributed to medical advances in areas related to the care ofpremature babies (which results in a greater survival rate). Only the introduction of qualitymedical care to locations with less-than-adequate medical care has shown any decreases. Theincidence of CP increases with premature or very low-weight babies regardless of the quality ofcare.[citation needed]Prevalence of cerebral palsy is best calculated around the school entry age of about six years, theprevalence in the U.S. is estimated to be 2.4 out of 1000 children[72]The SCPE reported the following incidence of comorbidities in children with CP (the data arefrom 1980–1990 and included over 4,500 children over age 4 whose CP was acquired during theprenatal or neonatal period): Mental disadvantage (IQ < 50): 31% Active seizures: 21% Mental disadvantage (IQ < 50) and not walking: 20% Blindness: 11%[70]The SCPE noted that the incidence of comorbidities is difficult to measure accurately,particularly across centers. For example, the actual rate of an intellectual impairment may be
  • 15. difficult to determine, as the physical and communicational limitations of people with CP wouldlikely lower their scores on an IQ test if they were not given a correctly modified version.Apgar scores have sometimes been used as one factor to predict whether or not an individual willdevelop CP.[73][edit] HistoryCP, formerly known as "Cerebral Paralysis," was first identified by English surgeon WilliamLittle in 1860. Little raised the possibility of asphyxia during birth as a chief cause of thedisorder. It was not until 1897 that Sigmund Freud, then a neurologist, suggested that a difficultbirth was not the cause but rather only a symptom of other effects on fetal development.[74]Research conducted during the 1980s by the National Institute of Neurological Disorders andStroke (NINDS) suggested that only a small number of cases of CP are caused by lack of oxygenduring birth.[75][edit] Society and culture[edit] Economic impactAccess Economics has released a report on the economic impact of cerebral palsy in Australia.Launched by the Hon. Bill Shorten, MP, the report found that, in 2007, the financial cost ofcerebral palsy (CP) in Australia was $1.47 billion or 0.14% of GDP. When the value of lost well-being (disability and premature death) was added, the cost rose a further $2.4 billion.[76]In 2007, the financial cost of CP was $1.47 billion (0.14% of GDP). Of this: 1.03 billion (69.9%) was productivity lost due to lower employment, absenteeism and premature death of Australians with CP; 141 million (9.6%) was the DWL from transfers including welfare payments and taxation forgone; 131 million (9.0%) was other indirect costs such as direct program services, aides and home modifications and the bringing-forward of funeral costs; 129 million (8.8%) was the value of the informal care for people with CP; and 40 million (2.8%) was direct health system expenditure.Additionally, the value of the lost well-being (disability and premature death) was a further $2.4billion.In per capita terms, this amounts to a financial cost of $43,431 per person with CP per annum.Including the value of lost well-being, the cost is over $115,000 per person per annum.
  • 16. Individuals with CP bear 37% of the financial costs, and their families and friends bear a further6%. Federal government bears around one third (33%) of the financial costs (mainly throughtaxation 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 ofdisease (lost well-being) is included, individuals bear 76% of the costs.[edit] Use of the termMany people would rather be referred to as a person with a disability instead of handicapped."Cerebral Palsy: A Guide for Care" at the University of Delaware offers the followingguidelines:[77]Impairment is the correct term to use to define a deviation from normal, such as not being able tomake a muscle move or not being able to control an unwanted movement. Disability is the termused to define a restriction in the ability to perform a normal activity of daily living whichsomeone of the same age is able to perform. For example, a three year old child who is not ableto walk has a disability because a normal three year old can walk independently. Handicap is theterm used to describe a child or adult who, because of the disability, is unable to achieve thenormal role in society commensurate with his age and socio-cultural milieu. As an example, asixteen-year-old who is unable to prepare his own meal or care for his own toileting or hygieneneeds is handicapped. On the other hand, a sixteen-year-old who can walk only with theassistance of crutches but who attends a regular school and is fully independent in activities ofdaily living is disabled but not handicapped. All disabled people are impaired, and allhandicapped people are disabled, but a person can be impaired and not necessarily be disabled,and a person can be disabled without being handicapped.The term "spastic" describes the attribute of spasticity in types of spastic CP. In 1952 a UKcharity called The Spastics Society was formed.[78] The term "spastics" was used by the charityas a term for people with CP. The words "spastic" and "spaz" have since been used extensivelyas a general insult to disabled people, which some see as extremely offensive. They are alsofrequently used to insult able-bodied people when they seem overly uncoordinated, anxious, orunskilled in sports. The charity changed its name to Scope in 1994.[78] In the United States theword spaz has the same usage as an insult, but is not generally associated with CP.[79][edit] MisconceptionsSpastic cerebral palsy, the most common form of CP, causes the muscles to be tense, rigid andmovements are slow and difficult. This can be misinterpreted as cognitive delay due to difficultyof communication. Individuals with cerebral palsy can have learning difficulties, but sometimesit is the sheer magnitude of problems caused by the underlying brain injury that prevents theindividual from expressing what cognitive abilities they do possess.[80][edit] MediaMaverick documentary filmmaker Kazuo Hara criticizes the mores and customs of Japanesesociety in an unsentimental portrait of adults with cerebral palsy in his 1972 film Goodbye CP
  • 17. (Sayonara CP). Focusing on how the CP victims are generally ignored or disregarded in Japan,Hara challenges his societys 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 tohis subject.[81][Cerebral palsy
  • 18. Home Contact Uswhat is cerebralpalsy A Guide to cerebral palsy in India. News, updates and resources for Educators and Parentscerebral palsychildren The human brain is made of 3 main parts, the cerebrumcerebral palsy which accounts for 85% of the brain, the cerebellum andsymptoms the main stem. The cerebrum is responsible for thecauses of cerebral voluntary movements of the muscles, thinking,palsy communication and is also associated with the senses of touch, sight etc..spastic cerebralpalsy Damage to the cerebrum causes problems and theinformation on nomenclature attached to these problems is " cerebralcerebral palsy Palsy". "Cerebral" means brain and "Palsy" refers tochildren with problem in muscle movement It is essentially associatedcerebral palsy with children and affects them in different ways. Some children could have severe muscular problems whilecerebral palsy others might encounter learning problems while stilltreatment others might encounter speech problems.cerebral palsy lawyerfamous people with Before the late 19th century there was no writtencerebral palsy documentation about cerebral palsy. A surgeon named William Little was the first who medically document thiscerebral palsy rather enigmatic disorder. He noticed that children in theinformation first years of life encountered great difficulty in walking,athetoid cerebral crawling or holding objects. Initially called Littles disease,palsy it is now called spastic diplegia and is grouped under the term "cerebral Palsy". Scerebral palsyassociations ince this problem was in many cases an offshoot of complicated deliveries, the surgeon concluded that oxygen shortage during birth was in someway responsibleUseful Parenting / kids for damage of brain tissues, which controlled movement.sites However, Sigmund Freud, the father of psychoanalysischildrens books pointed out that other problems like seizures, or mental retardation could not be explained by Little"s theory. Hepreschools in india suggested that the problem was deep seated and could be a result of improper brain development.ngo india For a long time this was not accepted, but later on thechildren idea that defective development of the brain was connected with "cerebral palsy" caught on. Cerebral Palsywebsites for kids can be caused before birth, during birth or after birth. It can be categorized into 3 main types.girl child [NGO] Spastic cerebral palsy-- where movement and flexibility are drastically affected because of muscle stiffness, Athetoid or dyskinetic cerebral palsy, which affects speech and hearing due to an involuntary stiffening of the
  • 19. muscles and Ataxic cerebral palsy, which affects balance and coordination. Hence all Children who have cerebral palsy are not affected in the same way. The degree of disability could vary and the type of cerebral palsy the child is suffering from could also vary. Although motor control is affected in many children, their level of intelligence can be still be pretty high. They have sound minds but rebellious bodies and it is unfortunate but true that they are often mistreated by society. Therapy, support equipment, and medical intervention have gone a long way in aiding people with this disability. Home : General information / articles for children from ezines > party games - good manners - kids birthday cakes -amazing facts for kids - child games - baby shower - babysitting games - baby posters © 2004-2007. www.cerebralpalsyindia.com . Powered by inlinks. All rights reserved. Material on this site may be printed forpersonal classroom use without permission by students and instructors for non-profit, educational purposes only. All otherreproduction in whole or in part, including electronic reproduction or redistribution, for any purpose, except by expresswritten agreement is strictly prohibited.

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