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Cerebral Palsy (CP)

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Introduction

Cerebral palsy (CP) is a group of permanent movement disorders that appear in early childhood. Signs and symptoms vary between people. Often, symptoms include poor coordination, stiff muscles, weak muscles, and tremors. There may be problems with sensation, vision, hearing, swallowing, and speaking. Often babies with cerebral palsy do not roll over, sit, crawl, or walk as early as other children their age. Difficulty with the ability to think or reason and seizures each occurs in about one third of people with CP. While the symptoms may get more noticeable over the first few years of life, the underlying problems do not worsen over time.

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. More than three-quarters of cases are believed to result from issues that occur during pregnancy.

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)
  • hypoxia of the brain (thrombotic events, placental conditions)
  • birth trauma during labor and delivery
  • complications around birth or during childhood.
  • 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.

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).

Other risk factors include:

  • preterm birth
  • being a twin
  • certain infections during pregnancy such as toxoplasmosis or rubella
  • exposure to methylmercury during pregnancy
  • a difficult delivery
  • head trauma during the first few years of life
  • About 2% of cases are believed to be due to an inherited genetic cause.

Term Infants

In babies that are born at term risk factors include:

  • problems with the placenta
  • birth defects
  • low birthweight
  • breathing meconium into the lungs
  • a delivery requiring either the use of instruments or an emergency Caesarean section
  • birth asphyxia
  • seizures just after birth
  • respiratory distress syndrome
  • low blood sugar
  • infections in the baby.

It is believed, that only a small number of cases are caused by lack of oxygen during birth. It is unclear if the size of the placenta plays a role. In advantaged countries, most cases of cerebral palsy in term or near-term neonates have explanations other than asphyxia.

Genetics

About 2% of all CP cases are inherited, with glutamate decarboxylase-1 being one of the possible enzymes involved. Most inherited cases are autosomal recessive,meaning both parents must be carriers for the disorder in order to have a child with the disorder.

Early Childhood

After birth, other causes include:

  • toxins
  • severe jaundice
  • lead poisoning
  • physical brain injury
  • stroke
  • shaken baby syndrome
  • incidents involving hypoxia to the brain (such as near drowning), and encephalitis or meningitis.
  • Infections in the mother, even infections that are not easily detected, may triple the risk of the child developing the disorder.
  • Infections of the fetal membranes known as chorioamnionitis increases the risk.
  • Intrauterine and neonatal insults (many of which are infectious in nature) increase the risk.
  • It has been hypothesised that some cases of cerebral palsy are caused by the death in very early pregnancy of an identical twin.

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.

Diagnosis

The diagnosis of cerebral palsy has historically rested on the person's history and physical examination. A general movements assessment, which involves measuring movements that occur spontaneously among those less than four months of age, appears to be most accurate. It is a developmental disability.

Once a person is diagnosed with cerebral palsy, further diagnostic tests are optional. Neuroimaging with CT or MRI 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, porencephaly, arteriovenous malformation, subdural hematomas 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 and intellectual disability.

The age at which CP is diagnosed is important, the earlier CP is diagnosed correctly, the better the opportunities are to provide the child with physical and educational help, but there also might be a greater chance that CP will be confused 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 also appear to be CP, and metabolic disorders, in particular, can produce brain problems that look like CP on an MRI. Disorders that deteriorate the white matter in the brain, and certain kinds of problems that cause spasms and weakness in the legs, may also be mistaken for CP when they first appear early in life.

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. Fragile X syndrome (a cause of autism and intellectual disability) and general intellectual disability must also be ruled out.It is recommended to wait until the child is 36 months of age before making a diagnosis.

A number of sub-types are classified based on the specific problems present.

For example, those with:

  • stiff muscles have spastic cerebral palsy
  • those with poor coordination have ataxic cerebral palsy
  • those with writhing movements have athetoid 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.

CP is the most common movement disorder in children. It occurs in about 2.1 per 1,000 live births. 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."

The central feature of CP is a disorder with:

  • movement
  • difficulties with thinking
  • learning
  • feeling
  • communication and behavior often occur along with cerebral palsy.

Of those with CP, 28% have epilepsy, 58% have difficulties with communication, at least 42% have problems with their vision, and 23–56% have learning disabilities.

Cerebral palsy is characterized by abnormal:

  • muscle tone
  • reflexes
  • motor development and coordination.
  • There can be joint and bone deformities and contractures (permanently fixed, tight muscles and joints).

The classical symptoms are:

  • spasticity
  • spasms, other involuntary movements (e.g., facial gestures)
  • unsteady gait
  • problems with balance
  • soft tissue findings consisting largely of decreased muscle mass.
  • Scissor walking (where the knees come in and cross)
  • toe walking (which can contribute to a gait reminiscent of a marionette) are common among people with CP who are able to walk.

CP symptomatology is very diverse. The effects of cerebral palsy fall on a continuum of motor dysfunction, which may range from slight clumsiness at the mild end of the spectrum to impairments so severe that they render coordinated movement virtually impossible at the other end of the spectrum.

Babies born with severe CP often have:

  • an irregular posture
  • their bodies may be either very floppy or very stiff.
  • Birth defects, such as spinal curvature, a small jawbone, or a small head sometimes occur along with CP.

Symptoms may appear or change as a child gets older. Some babies born with CP do not show obvious signs right away. Classically, CP becomes evident when the baby reaches the developmental stage at 61⁄2 to 9 months and is starting to mobilise.

Related conditions can include seizures, apraxia, dysarthria or other communication disorders, eating problems, sensory impairments, intellectual disability, learning disabilities, urinary incontinence, fecal incontinence, and/or behavioural disorders.

Problems

Language

Speech and language disorders are common in people with cerebral palsy. Overall language delay is associated with problems of intellectual disability, deafness, and learned helplessness. Children with cerebral palsy are at risk of learned helplessness and becoming passive communicators, initiating little communication. Early intervention with this clientele, 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.

The incidence of dysarthria is estimated to range from 31% to 88%.

There are three major types of dysarthria in cerebral palsy:

  • spastic
  • dyskinetic (athetosis)
  • ataxic.

Skeleton

In order for bones to attain their normal shape and size, they require the stresses from normal musculature. With a lack of use, articular cartilage may atrophy, leading to narrowed joint spaces. Depending on the degree of spasticity, a person with CP may exhibit a variety of angular joint deformities. Because vertebral bodies need vertical gravitational loading forces to develop properly, spasticity and an abnormal gait can hinder proper and/or full bone and skeletal development. People with CP tend to be shorter in height than the average person because their bones are not allowed to grow to their full potential. Sometimes bones grow to different lengths, so the person may have one leg longer than the other.

Pain and sleep

Pain is common and may result from the inherent deficits associated with the condition, along with the numerous procedures children typically face. Pain is associated with tight or shortened muscles, abnormal posture, stiff joints, unsuitable orthosis, etc. There is also a high likelihood of chronic sleep disorders secondary to both physical and environmental factors.

Eating

Those with CP may have difficulty preparing food, holding utensils, or chewing and swallowing due to sensory and motor impairments. An infant with CP may not be able to suck, swallow or chew. Children with CP may have too little or too much sensitivity around and in the mouth. 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.

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. There are three main CP classifications by motor impairment:

  • spastic
  • ataxic
  • athetoid/dyskinetic.
  • Additionally, there is a mixed type that shows a combination of features of the other types.

These classifications also reflect the areas of the brain that are damaged.

Spastic

Spastic cerebral palsy, or cerebral palsy where spasticity (muscle tightness) is the exclusive or almost exclusive impairment present, is by far the most common type of overall cerebral palsy, occurring in upwards of 70% of all cases. People with this type of CP are hypertonic and have what is essentially a neuromuscular mobility impairment (rather than hypotonia or paralysis) stemming from an upper motor neuron lesion in the brain as well as the corticospinal tract or the motor cortex. This damage impairs the ability of some nerve receptors in the spine to receive gamma-Aminobutyric acid properly, leading to hypertonia in the muscles signaled by those damaged nerves.

As compared to other types of CP, and especially as compared to hypotonic or paralytic mobility disabilities, spastic CP is typically more easily manageable by the person affected, and medical treatment can be pursued on a multitude of orthopedic and neurological fronts throughout life. In any form of spastic CP, clonus of the affected limb(s) may sometimes result, as well as muscle spasms resulting from the pain and/or stress of the tightness experienced. The spasticity can and usually does also lead to a very early onset of muscle stress symptoms like arthritis and tendinitis, especially in ambulatory individuals in their mid-20s and early-30s. Occupational therapy and physical therapy regimens of assisted stretching, strengthening, functional tasks, and/or targeted physical activity and exercise are usually the chief ways to keep spastic CP well-managed, although if the spasticity is too much for the person to handle, other remedies may be considered, such as various antispasmodic medications, botulinum toxin, baclofen, or even a neurosurgery known as a selective dorsal rhizotomy (which eliminates the spasticity by eliminating the nerves causing it).

Ataxic

Ataxia-type symptoms can be caused by damage to the cerebellum. Ataxia is a less common type of cerebral palsy, occurring between 5% and 10% of all cases. Some of these individuals have hypotonia and tremors. Motor skills such as writing, typing, or using scissors might be affected, as well as balance, especially while walking. It is common for individuals to have difficulty with visual and/or auditory processing. They usually have an awkward gait and as well with some dysarthria.[citation needed]

Athetoid

Athetoid cerebral palsy or dyskinetic cerebral palsy is mixed muscle tone – both hypertonia and hypotonia mixed with involuntary motions. People with dyskinetic CP have trouble holding themselves in an upright, steady position for sitting or walking, and often show involuntary motions. For some people with dyskinetic CP, it takes a lot of work and concentration to get their hand to a certain spot (like scratching their nose or reaching for a cup). Because of their mixed tone and trouble keeping a position, they may not be able to hold onto objects, especially small ones requiring fine motor control (such as a toothbrush or pencil). About 10% of individuals with CP are classified as dyskinetic CP but some have mixed forms with spasticity and dyskinesia. The damage occurs to the extrapyramidal motor system and/or pyramidal tract and to the basal ganglia. In newborn infants, high bilirubin levels in the blood, if left untreated, can lead to brain damage in the basal ganglia (kernicterus), which can lead to dyskinetic cerebral palsy.

Mixed

Mixed cerebral palsy is symptoms of athetoid, ataxic and spastic CP appearing simultaneously, each to varying degrees, and both with and without certain 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.

Prevention

In those at risk of an early delivery magnesium sulphate appears to decrease the risk of cerebral palsy. It is unclear if it helps those who are born at term. Cooling high-risk full-term babies shortly after birth may reduce disability.

Management

Treatment of cerebral palsy is a lifelong process focused on the management of associated conditions. It tries to allow healthy development on all levels. The brain, up to about the age of 8, is not set and has the ability to reroute many signal paths that may have been affected by the initial trauma; the earlier it has helped in doing this the more successful it will be.

The treatments with the best evidence are:

  • medication
  • therapy (bimanual training)
  • casting
  • constraint-induced movement therapy
  • context-focused therapy
  • fitness training
  • goal-directed training
  • hip surveillance
  • home programmes
  • occupational therapy after botulinum toxin, pressure care) and surgery (selective dorsal rhizotomy).

Treatment

CP is partly preventable through immunization of the mother and efforts to prevent head injuries in children such as through improved safety.

There is no cure for CP; however, supportive treatments, medications, and surgery may help many individuals. 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. Medications such as diazepam, baclofen, and botulinum toxin may help relax stiff muscles.
  • Surgery to correct anatomical abnormalities or release tight muscles. Surgery may include lengthening muscles and cutting overly active nerves.
  • Often external braces and other assistive technology are helpful, such as orthotic devices; rolling walkers; and communication aids such as computers with attached voice synthesisers.
  • Alternative medicines are frequently used there is no evidence to support their use.

Some children have near normal adult lives with appropriate treatment.

Various forms of therapy are available to people living with cerebral palsy as well as caregivers and parents. However, there is only some benefit from therapy. Treatment is usually symptomatic and focuses on helping the person to develop as many motor skills as possible or to learn how to compensate for the lack of them. Nonspeaking people with CP are often successful availing themselves of augmentative and alternative communication (AAC).

Therapy

The treatment and the therapy should start in the initial stages so as to give your child a better future. The treatment also includes therapy of different types namely:

Physical Therapy

This therapy mainly includes working on the activities related to legs and hands. Walking, clutching and stretching are some of the most common activities related to the physical therapy. This helps the body to improve its flexibility and mobility.

Physiotherapy programs are designed to encourage the patient to build a strength base for improved gait and volitional movement, together with stretching programs to limit contractures. Some experts believe that lifelong physiotherapy is crucial to maintaining muscle tone, bone structure, and prevent dislocation of the joints.

Occupational Therapy

This therapy makes the body toned to the regular activities that a person carries out, throughout the day. This includes the working on fingers, mouth, toes and feet. These activities help in feeding, dressing, etc.

Occupational therapy helps adults and children maximise their function, adapt to their limitations and live as independently as possible. A family-centred philosophy is used with children who have CP. Occupational therapists work closely with families in order to address their concerns and priorities for their child.

Speech Therapy

This therapy helps to improve the communication skills of a child. The activities include the communication with the help of signs or by using pictures to express views.
The activities mentioned above can play a very important part in developing the skills of your child. But the most important thing to develop in your child is self-confidence and this can be done only when you provide the necessary love and affection.

Speech therapy helps control the muscles of the mouth and jaw, and helps improve communication. Just as CP can affect the way a person moves their arms and legs, it can also affect the way they move their mouth, face and head. This can make it hard for the person to breathe; talk clearly; and bite, chew and swallow food. Speech therapy often starts before a child begins school and continues throughout the school years.

Conductive education (CE) is theorised to improve mobility, self-esteem, stamina and independence as well as daily living skills and social skills. The conductor is the professional who delivers CE in partnership with parents and children. Skills learned during CE should be applied to everyday life and can help to develop age-appropriate cognitive, social and emotional skills. It is available at specialised centres.

Biofeedback is a therapy in which people learn how to control their affected muscles. Biofeedback therapy has been found to significantly improve gait in children with cerebral palsy.

Massage therapy is designed to help relax tense muscles, strengthen muscles, and keep joints flexible.

CP commonly causes hemiplegia. An emerging technique called constraint-induced movement therapy (CIMT) is designed to address this. In CIMT, the unaffected limbs are constrained, forcing the individual to learn to use the affected limbs. As of 2007 there was limited, preliminary evidence that CIMT is effective, but more study is needed before it can be recommended with confidence.

Activities

It is very is important that children with this acute problem are encouraged towards regular physiotherapy, exercises, games and outdoor activities. Apart from a definite improvement in physical skills, the fun factor can also bring the mental benefits and stress relief. Just make sure you choose activities that your child enjoys. Here's a list of some activities that would be helpful for your child.

Indore Activities

  • Put your child down on the floor and let him/her explore the surroundings at his or her own pace. If your child tends to lie still in one spot, make sure you help him/her change positions often.
  • Give your child musical instruments such as drums to play and try to engage him in music classes. Encourage him to learn songs and make him sing out loudly. This would improve his vocal ability. You can also provide him keyboards and calculators, this would prove to be a good exercise for the fingers.
  • Play games that encourage crawling. Weight-bearing on one hand or both hands and on legs is beneficial for developing good muscle tone. Place toys at some distance so the child has to reach out to pick them or crawl over to fetch them. Make sure the toys are stimulating in color, shape, texture and smell, as well as easy to play with.
  • Encourage your child to put away toys by himself, even if that takes up a lot of time.
    Encourage your child to draw and paint. This will instill a feeling of creative achievement and will also improve the ability to hold objects.
  • Give your child pictures to look at and ask him/her to identify the different objects in them.
  • Make a game of using signs, picture boards and so on as communication devices, especially if the child has speech problems. This will foster better communication and the ability to clearly indicate their exact likes and dislikes.

Outdoor Activities

  • Take your child out to parks, gardens, zoos, playgrounds, markets to help with sensory system development. Let him explore as much as possible in the outside world.
  • Engage him/her in activities so that he/she can get used to the outside world. Give him/her a bicycle or a tricycle to ride.
  • Take your child out for fishing or other activities which would provide pleasure to him/her.
  • Get your child to learn yoga and see to it that he practices on a regular basis. Meditation along with yoga would be quite beneficial for your child.
  • Swinging can also be quite helpful for the child. If your child is not able to sit properly, hold him and swing him slowly.
  • If your child uses a wheelchair but would want to play basketball, rugby, or tennis, there are opportunities for him. There are various institutions that provide facilities for such recreational activities. Take your child to such institutions and you two can enjoy the moments together.
  • Swimming is excellent for improving flexibility. Be present at all times, whenever your child is in the pool. Swimming along with him would be a good idea.
  • Encourage your child to make friends and, if possible, ensure that he/she is included in their play.
  • Place a well-anchored, strong plank at a small height from the ground and make a game of walking from one end to the other without falling off. This will help improve balance.
  • Play games with colorful balls to develop good coordination and motor skills. Teach him to kick and throw the ball which would be a good exercise for both hands and legs.
  • Give your child clay to roll or mold. This is a good exercise for the hands.

Medication

Botulinum toxin injections are given into muscles that are spastic or sometimes dystonic, the aim being to reduce the muscle hypertonus that can be painful. A reduction in muscle tone can also facilitate bracing and the use of orthotics. Most often lower extremity muscles are injected. Botulinum toxin is focal treatment, meaning that a limited number of muscles can be injected at the same time. The effect of the toxin is reversible and a reinjection is needed every 4–6 months.

In children it decreases spasticity and improve range of motion and thus has become commonly used.

Surgery

Surgery usually involves one or a combination of:

  • Loosening tight muscles and releasing fixed joints, most often performed on the hips, knees, hamstrings, and ankles. In rare cases, this surgery may be used for people with stiffness of their elbows, wrists, hands, and fingers. Selective Percutaneous Myofascial Lengthening (SPML) is one example.
  • The insertion of a baclofen pump usually during the stages while a person 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 releases doses of baclofen to alleviate continuous muscle flexion. Baclofen is a muscle relaxant and is often given by mouth to patients to help counter the effects of spasticity.
    Straightening abnormal twists of the leg bones, i.e. femur (termed femoral anteversion or antetorsion) and tibia (tibial torsion). This is a secondary complication caused by the spastic muscles generating abnormal forces on the bones, and often results in intoeing (pigeon-toed gait). The surgery is called derotation osteotomy, in which the bone is broken (cut) and then set in the correct alignment.
  • Cutting nerves on the limbs most affected by movements and spasms. This procedure, called a rhizotomy, reduces spasms and allows more flexibility and control of the affected limbs and joints.
  • Other surgical procedures are available to try to help with other problems. Those who have serious difficulties with eating may undergo a procedure called a gastrostomy: a hole is cut through the belly skin and into the stomach to allow for a feeding tube. There is no good evidence about the effectiveness or safety of gastrostomy.

Orthotics

Orthotic devices such as ankle-foot orthoses (AFOs) are often prescribed to achieve the following objectives:

  • correct and/or prevent deformity
  • provide a base of support
  • facilitate training in skills, and improve the efficiency of gait.

The available evidence suggests that orthoses can have positive effects on all temporal and spatial parameters of gait, i.e. velocity, cadence, step length, stride length, single and double support. AFOs have also been found to reduce energy expenditure.

Assistive technology

There are now assistive technologies designed to help when dealing with cerebral palsy, most often to aid with meal times. There are manual feeding aids, for example, one designed using viscous fluid damping to smooth out essential tremors associated with cerebral palsy. There are also electronic feeding aids on the market suitable for anyone who can chew and swallow but unable to feed themselves. There are manual drinking aids available, designed with non-return valves and holders or non-slip surfaces, to enable users who lack the ability to drink from a cup or glass, due to tremors, weakness or limited head mobility, to gain a route to hydration and nutrition.

Other

Hyperbaric oxygen therapy (HBOT), in which pressurised oxygen is inhaled inside a hyperbaric chamber, has been studied under the theory that improving oxygen availability to damaged brain cells can reactivate some of them to function normally. HBOT results in no significant difference from that of pressurised room air, however, and some children undergoing HBOT may experience adverse events such as seizures and the need for ear pressure equalisation tubes.

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. The full intellectual potential of a child born with CP will often not be known until the child starts school. People with CP are more likely to have learning disabilities, although these may be unrelated to IQ, including varying degrees of intellectual disability. Intellectual level among people with CP varies from genius to intellectually impaired, as it does in the general population, and experts have stated that it is important not to underestimate the capabilities of a person with CP and to give them every opportunity to learn.

The life expectancy of those with CP is less than that of the general population but has improved with the utilization of modern medicine.

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. 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 assistants (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.

People with CP can usually expect to have a normal life expectancy; survival has been shown to be associated with the ability to ambulate, roll, and self-feed. As the condition does not affect reproductive function, people with CP can have children and parent successfully.

Self-care

Self-care is any activity people do to care for themselves. For many children with CP, parents are heavily involved in self-care activities. Self-care activities, such as bathing, dressing, grooming, can be difficult for children with CP as self-care depends primarily on use of the upper limbs. For those living with CP, impaired upper limb function affects almost 50% of children and is considered the main factor contributing to decreased activity and participation. As the hands are used for many self-care tasks, sensory and motor impairments of the hands make daily self-care more difficult.

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 and 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 impact 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 occupations are any activities that are done for enjoyment. Enjoyable activities depend on one's personality and environment. 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. Studies show that children with disabilities, like CP, participate mainly in informal activities that are carried out in the family environment and are organised by adults. Typically, children with disabilities carry out leisure activities by themselves or with their parents rather than with friends. Therefore, children may experience limited diversity of activities and social engagements, as well as a more passive lifestyle than their peers. Although leisure is important for children with CP, they may have difficulties carrying out leisure activities due to social and physical barriers.

Participation and barriers

Participation is involvement in life situations and everyday activities. Participation includes the domains of self-care, productivity and leisure. In fact, communication, mobility, education, home life, leisure and social relationships require participation and are indicators of the extent to which a child functions in his or her environment. Barriers can exist on three levels:

  1. micro
  2. meso
  3. macro.

Micro

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.

Meso

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.

Macro

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 will prevent the child from accessing higher floors.

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. Rates appear to be similar in both the developing and developed world. Within a population it may occur more often in poorer people. The rate is higher in males than in femalesOverall, advances in care of pregnant mothers and their babies has not resulted in a noticeable decrease in CP. This is generally attributed to medical advances in areas related to the care of premature babies (which results in a greater survival rate). Only the introduction of quality medical care to locations with less-than-adequate medical care has shown any decreases. The incidence of CP increases with premature or very low-weight babies regardless of the quality of care. Prevalence of cerebral palsy is best calculated around the school entry age of about 6 years.

History

The modern understanding of CP as resulting from problems within the brain began in the early decades of the 1800s. The English surgeon William John Little (1810–1894) was the first person to study CP extensively. In his doctoral thesis he stated that CP was a result of a problem around the time of birth. He later identified a difficult delivery, a preterm birth and perinatal asphyxia in particular as risk factors.

Working in Pennsylvania in the 1880s, Canadian-born physician William Osler (1849–1919) reviewed dozens of CP cases to further classify the disorders by the site of the problems. 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.

The classification of the disorder is named Freud's system divides the causes of the disorder into:

  • problems present at birth,
  • problems that develop during birth
  • 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.

Surgeon Winthrop Phelps became the first physician to treat the disorder. He viewed CP from a musculoskeletal 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 practitioner András Pető 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, 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.

Research 

A potential treatment for some forms of cerebral palsy may be deep brain stimulation. 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.

As of 2016 it is thought that research in genetics and genomics, teratology, and developmental neuroscience is going to yield greater understanding of cerebral palsy.

References

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