Development of a Cerebral Palsy Follow-up Registry in Jordan (CPUP-Jordan)

Saudi Cerebral Palsy Register (SCPR): Protocol on the Methods and Technical Details

This protocol presents a comprehensive proposal for the establishment of the Saudi Cerebral Palsy Register (SCPR), a crucial project for investigating and addressing the prevalence, etiology, and management of cerebral palsy (CP) in Saudi Arabia. The SCPR will not only provide a robust database for ongoing research and analysis but will also serve as a platform for investigating the causes of CP, implementing preventative strategies, and improving the quality of care and outcomes for people with CP and their families in Saudi Arabia. Detailed case definitions, inclusion/exclusion criteria, and data collection protocols are discussed to ensure the integrity and comparability of the data. The plan also outlines strategic funding, institutional and government endorsement, sustainability considerations, potential challenges and proposed solutions, and expected outcomes and impact. These include creating research and educational opportunities, fostering regional and international collaborations, and significantly contributing to CP prevention strategies. Overcoming anticipated obstacles, such as stigma, institutional policies, and collaborations, and securing both necessary funding and endorsements are highlighted as critical for the success of the SCPR. The project is not only aligned with promote prevention of health risks, a target of Vision 2030 in Saudi Arabia, but is also expected to have a substantial impact on the health and quality of life of people with CP and their families in Saudi Arabia, serving as inspiration for similar efforts worldwide.

Pain in children with cerebral palsy as reported by parents

BACKGROUND

Pain in children with cerebral palsy (CP) is a problem that has not received adequate attention in developing countries. The aim of this study was to explore the presence of pain and common sites of pain in children with CP based on age, gender and ambulatory status as determined by the Gross Motor Function Classification System (GMFCS) level.

METHODS

This was a cross-sectional study based on data from a CP registry (CPUP-Jordan). Participants were 310 children with CP (mean age: 3.3 ± 2.9 years, range: 5 months to 15.9 years), 77.1% were below 5 years of age, 56.8% were boys and 49% were classified as Levels IV and V of the GMFCS. Parents were asked to indicate whether their child is currently experiencing pain (yes/no); if yes, they were asked to report the sites of pain.

RESULTS

Seventy-nine (25.5%) children experienced pain (34.1% had pain in the stomach, 15.2% at the hips and knees and 12.7% in their feet). The presence of pain did not significantly differ by age or gender. More children in GMFCS Levels V (34.7%) and IV (31.6%) experienced pain. Compared with Level V on the GMFCS (non-ambulant children), children in Level I and children in Level III experienced less pain (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.087-0.727, p = 0.011; OR = 0.42, 95% CI = 0.18-0.98, p = 0.045, respectively). Pain sites differed with age and GMFCS.

CONCLUSIONS

Pain was reported to be less than previous studies. Non-ambulant children experienced more pain. Pain monitoring and management should be a regular practice in rehabilitation for this population, with special attention for non-ambulant children.

Providing a framework for evaluation disease registry and health outcomes Software: Updating the CIPROS checklist

BACKGROUND AND AIMS

Properly designed and implemented registry systems play an important role in improving health outcomes and reducing care costs, and can provide a true representation of clinical practice, disease outcomes, safety, and efficacy. Therefore, the aim of this study was to redesign and develop a checklist with items for a patient registry software system (CIPROS) Checklist.

METHOD

The study is descriptive-cross-sectional. The extraction of the data elements of the checklist was first done through a comprehensive review of the texts in PubMed, Science Direct and Scopus databases and receiving articles related to the evaluation of registry systems. Based on the extracted data, a five-point Likert scale questionnaire was created and 30 experts in this field were asked for their opinions using the two-step Delphi method.

RESULTS

A total of 100 information items were determined as a registry software evaluation checklist. This checklist included 12 groups of software architecture factors, development, interfaces and interactivity, semantics and standardization, internationality, data management, data quality and usability, data analysis, security, privacy, organizational, education and public factors.

CONCLUSION

By using the results of this research, it is possible to identify the defects and possible strengths of the registry software and put it at the disposal of the relevant officials to make a decision in this field. In this way, among the designers and developers of these softwares, the best and most appropriate ones are selected with the needs of the registry programs.

Characteristics of Children with Cerebral Palsy and Their Utilization of Services in Saudi Arabia

The recent emergence of research on cerebral palsy (CP) in developing countries aims to improve knowledge on affected children and the utilization of the available services. This study seeks to describe children with CP in Saudi Arabia and service utilization as per Gross Motor Function Classification System (GMFCS) levels and geographic regions. A cross-sectional survey of 227 children with CP (Mean age 6.3, SD 3.9 years) was conducted. Parents reported on children's demographics, impairments, and service utilization. Half of the children (n = 113, 49.8%) had ≥3 impairments with speech, visual and learning impairments being the most frequent. The total number of impairments differed significantly by GMFCS, F (4, 218) = 8.87, p < 0.001. Most of the children (n = 86, 83.4%) used 2-5 services. Moreover, 139 (62.3%) did not attend school, 147 (65.9%) did not receive occupational therapy, and only 32 (14.3%) received speech therapy. More children in GMFCS level I did not receive neurologist services. Profiles of children and services were described by GMFCS and by regions. This was the first study to describe children with CP and service utilization in Saudi Arabia. Although many impairments affected the children, there was low utilization of related services. Data on service utilization and on unmet needs support a comprehensive approach to rehabilitation and the proper service allocation.

Establishing a cerebral palsy registry in Kuwait: An exploratory study

Background

Cerebral palsy (CP), the most common motor disability in childhood, comprises a group of permanent non-progressive disorders affecting the antenatal, neonatal, or early postnatal development of areas in the brain responsible for posture and movement. Registries for children with CP, or surveillance programs, have been a source of consistently increasing research productivity; 38 related articles were published in 2013. In Kuwait, a CP registry would provide baseline information on children with CP and their parents. The registry could include demographic information obtained through parental interviews, or review of the mothers' and the children's medical charts.

Objective

This study was aimed at exploring the establishment of a pediatric CP registry in Kuwait.

Methods

In this exploratory study, caregivers of children with CP were recruited from rehabilitation clinics around Kuwait. The inclusion criteria were 1) boys or girls with a documented diagnosis of CP made between 6 months and 18 years of age, 2) caregivers with permanent residency in Kuwait, and 4) caregivers speaking Arabic and/or English fluently. The variables collected comprised registry and feasibility variables. Registry-associated variables comprised demographic and medical information about the children, and caregivers' willingness to be contacted for a follow-up or participation in other research projects. Feasibility variables were the percentage of information gathered, and the willingness of caregivers to participate in, and of therapists to recruit for, the registry.

Results

Fifty-three caregivers of children with CP participated in this study. The mean age of the recruited children with CP was 5 years and 5 months (SD = 3 y 4 m, range = 11 m to 16 y 8 m/female n = 25). GMFCS level V was reported by half of the sample (n = 29/55.77%). Of the 112 caregivers screened, fewer than half (n = 53 of 112/47.32%) participated in the study. Most caregivers (n = 48/90.56%) used the Arabic version of the form.

Conclusion

The establishment of a pediatric CP registry in Kuwait is feasible, on the basis of our data.

Prevalence, Incidence, and Surgical Treatment Trends of Cerebral Palsy across Türkiye: A Nationwide Cohort Study

BACKGROUND

Cerebral Palsy (CP) is the most prevalent neurodevelopmental disorder in childhood. Our aim is to identify the demographics of CP in Turkish children in addition to clinical associations and surgical preferences.

METHODS

Based on national health system data and the International Classification of Diseases (ICD)-10 code for CP, data were evaluated from a total of 53,027 children with CP born between 2016 and 2022, and 9658 of them underwent orthopedic surgery in those years. The incidence and frequency of CP were assessed for the parameters of age and gender. Age at the time of surgery; codes pertaining to surgical interventions; and regions, cities, and hospitals where diagnoses and surgical procedures were performed were also evaluated.

RESULTS

There were 29,606 male (55.8%) and 23,421 (44.2%) female patients. The diagnoses of the patients were mostly (76.1%) performed in secondary and tertiary hospitals. The prevalence of CP among children in 2016-2022 was estimated to be 7.74/1000 children. The minimum and maximum incidence rates of cerebral palsy among children between 2016 and 2022 were calculated to be 0.45 and 1.05 per 1000, respectively. Tenoplasty-myoplasty tendon transfer operations were the most common surgeries (47.1%).

CONCLUSION

CP remains a significant health challenge, underpinning a considerable proportion of childhood motor dysfunction. A dedicated national registry system for CP focused on classifying the condition, streamlining treatment, and tracking outcomes would be a valuable tool in our collective efforts to address this critical issue more effectively.

Determinants of functional mobility in children with cerebral palsy in three different environments: A registry-based study

BACKGROUND

Functional mobility in children with cerebral palsy (CP) varies widely and is affected by many factors related to the child and environment. Understanding this variability in child's natural environments: home, school, and community; and its determinants are important for effective child management.

METHODS

This cross-sectional study aims to investigate the functional mobility of children with CP within home, school, and community, and explore its determinants. Participants were 107 children with CP (aged 6.4 ± 2.9 years). Functional Mobility Scale was the outcome variable. Potential determinants included child-associated impairments and interventions. Three ordinal logistic regression analyses were conducted.

RESULTS

Children in Gross Motor Functional Classification System-Expanded and Revised level I walked without assistive devices in all environments, while children in levels II/III used different mobility methods in different environments. Children in levels IV/V used a wheelchair or had no form of functional mobility in all environments. Determinants of mobility varied across different environments but included impairments (visual impairments, scoliosis) and interventions (Botox, medications for spasticity, orthoses).

CONCLUSIONS

Child impairments and interventions received should be considered when exploring mobility options for children with CP in different environments. Further research is needed to examine other environmental and personal factors affecting mobility.

Effectiveness of virtual reality on functional mobility during treadmill training in children with cerebral palsy: a single-blind, two-arm parallel group randomised clinical trial (VirtWalkCP Project)

INTRODUCTION

Treadmill training and virtual reality have been investigated in children with cerebral palsy. However, few studies have assessed the effectiveness of the combination of both treatments on children's functional and balance activities. The project aims to compare the effects of treadmill training with and without virtual reality on walking endurance and speed, static and dynamic balance, gross motor function, functional independence, quality of life and occupational participation in children with spastic cerebral palsy between the ages of 4 and 12 years classified at levels I, II and III of the Gross Motor Function Classification System.

METHODS AND ANALYSIS

This study is a single-blind, two-arm parallel group, randomised, controlled clinical trial. Participants will be recruited at the Pediatric Department of the Vic Hospital Consortium, and the research will be conducted at the University of Vic - Central University of Catalonia. The participants will be randomly allocated into two groups: (1) the experimental group, which will receive the treadmill training at the same time as the virtual reality; and (2) the control group, which will undertake treadmill gait training alone. The training will be provided in 10 sessions over 2 weeks with 30 min for each session. Assessments will be performed on three occasions: 1 week before the intervention, 1 week following the intervention and 1 month after the end of the intervention. The evaluations will involve the 6 min walk test, stabilometry, the Berg Balance Scale, the 10 m walk test, the Gross Motor Function Measure, the Functional Independence Measure, the paediatric quality of life inventory and the Children Participation Questionnaire. For between-within group comparison, a mixed-effect linear model will be used.

ETHICS AND DISSEMINATION

The study has been approved by the Clinical Research Ethics Committee of the Osona Foundation for Health Research and Education (2021061). Results will be published in peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBER

NCT05131724.

Epidemiology of Cerebral Palsy among Children and Adolescents in Arabic-Speaking Countries: A Systematic Review and Meta-Analysis

Background: Studies on cerebral palsy among children and adolescents in Arabic-speaking countries are scarce. In this systematic review, we aimed to describe the epidemiology of cerebral palsy among children and adolescents in Arabic-speaking countries in terms of prevalence, risk factors, motor types, and rehabilitation. Methods: Six key bibliographic databases were searched for relevant literature published to 17 July 2021. Titles and abstracts were screened for potential inclusion and two independent reviewers screened the full texts of potential articles following pre-defined inclusion/exclusion criteria. The included studies were evaluated independently by three reviewers. The risk of bias was assessed, and data were extracted and analysed. Results: A total of 32 studies from 7 countries met our inclusion criteria. The prevalence of cerebral palsy in Arabic-speaking countries was 1.8/1000 live births (95% CI: 1.2–2.5). Spastic cerebral palsy was the most common motor type, representing 59.8% (95% CI: 46.2–72.7) of pooled estimates. This included children with spastic quadriplegia, diplegia, and hemiplegia; 25.1% (95% CI: 18.2–32.8), 16.2% (95% CI: 11.4–23.3), and 10.4% (95% CI: 7.3–13.8), respectively. Consanguinity was high and represented 37.7% (95% CI: 29.3–46.6). Only one included study reported the types of rehabilitation received (e.g., physiotherapy and assistance devices). Conclusions: This paper provides a summary of the epidemiology of cerebral palsy in Arabic-speaking countries and highlights areas for future research. There is still a substantial knowledge gap on the epidemiology of cerebral palsy in these regions. Countries in the Arab region should follow examples of countries that have successfully established cerebral palsy registries to generate evidence on epidemiology of cerebral palsy and opportunities for prevention.

Predictors of range of motion restrictions in children with spastic cerebral palsy: A registry-based study

BACKGROUND

Although children with spastic cerebral palsy (CP) commonly present with restricted passive range of motion (PROM) and contractures, knowledge about the child's characteristics that increase the risk of development of restricted PROM is limited. Identifying children who are more likely to develop contractures is important for early detection and the provision of appropriate medical management. This study aims to identify the most commonly restricted PROM of children with spastic CP and (2) to examine the combined effect of a child's age, gender, gross motor functional classification level and CP subtype on the development of restricted PROM in children with spastic CP.

METHODS

The PROM of 233 children diagnosed with CP was extracted from the national registry of CP in Jordan (CPUP-Jordan) in addition to information about children's age, gender, level of Gross Motor Function Classification System-Expanded and Revised (GMFCS-E&R) and subtype of CP. The mean age of the participants was 3.73 years (SD = 3.14), 57.5% were males and 80.3% had bilateral spastic CP. Point biserial correlations were calculated between the PROM and the child's variables. Multiple binary logistic regressions were conducted to identify the predictors of PROM.

RESULTS

Hip abduction was the most common restricted PROM (57.9%), whereas the hip extension was the least (2.1%). Children with older ages demonstrated more restrictions in knee extension and ankle dorsiflexion; males demonstrated more restriction in hip abduction than females; children with lower GMFCS-E&R levels had more restrictions in hip internal rotation but fewer restrictions in hip abduction and ankle dorsiflexion; and children with bilateral spastic CP had more restrictions in hip abduction than children with unilateral spastic CP.

CONCLUSIONS

PROM of the hip, knee and ankle joints of children with spastic CP was predicted by different sets of child characteristics. Implications for health professionals and follow-up registries of children with CP are provided.

Determinants of Manual Abilities of Children with Cerebral Palsy: A National Registry-Based Study

PURPOSE

This cross-sectional study aimed to identify determinants of manual abilities of children with cerebral palsy (CP), as measured by the Manual Ability Classification System (MACS), in terms of intrinsic (child-related) and extrinsic (service-related) variables.

METHODS

The participants were 106 children with a confirmed diagnosis of CP (aged 4-16 years). Two ordinal logistic regression models were conducted to identify intrinsic and extrinsic determinants of manual abilities.

RESULTS

Four child-related (intrinsic) variables were found to be significant determinants of manual abilities: bimanual ability, ability to maintain and assume chair sitting, presence of seizures, and gross motor function, and only one service-related (extrinsic) significant variable was identified, which was receiving spasticity medications.

DISCUSSION

The results highlight several determinants that should be considered when assessing and intervening to improve manual abilities of children with CP. The findings are discussed in relation to the intervention approach, contextual modification, and assistive device prescription.

The Effect of Bilateral Anodal Transcranial Direct Current Stimulation versus Treadmill Training on Brain Activities, Gait Functions, Level of Participation and Enjoyment of Children with Cerebral Palsy: A Randomized Controlled Trial Protocol

BACKGROUND

Cerebral palsy (CP) possesses bilateral sensory-motor cortical excitability alterations. In past studies, researchers have applied unilateral anodal transcranial direct stimulation (tDCS) with inconsistent findings.

OBJECTIVE

Examining the effects of treadmill training with either unilateral or bilateral anodal tDCS stimulation on brain activities, gait, and body functions of children with CP.

DESIGN

Randomized-clinical-trial.

PARTICIPANTS

Eighty children with CP will be allocated into: treadmill/bilateral-tDCS, treadmill/unilateral-tDCS, treadmill/sham-tDCS, and treadmill groups. Additional 20 neurotypical children will be recruited for comparison.

INTERVENTION

Planned intervention will implement ten-sessions of treadmill training (50% of maximum-ground speed) either with unilateral-tDCS over left sensory-motor, or bilateral-tDCS over left/right sensory-motor areas. Brain activities, gait, body functions, and participation will be assessed at pre-intervention, post-intervention, and at one-month follow-up.

RESULT AND DISCUSSION

This study would contribute to extant findings on the use of tDCS stimulation in children with CP and to our understanding of the appropriateness of the planned outcome measures.

Perceived Barriers, Enablers, and Modifications to Tests Assessing Pediatric Lower Limb Neurological Impairment: An International Delphi Survey

OBJECTIVES

Accurate, clinically meaningful outcome measures that are responsive to change are essential for selecting interventions and assessing their effects. Little guidance exists on the selection and administration of neurological impairment tests in children with a neurological condition. Clinicians therefore frequently modify adult assessments for use in children, yet the literature is inconsistent. This study aims to establish consensus on neurological conditions most likely to require neurological impairment test in pediatrics and the barriers, enablers, and modifications perceived to enhance test reliability.

METHODS

Over a 2-round modified Delphi study, a panel of experts (n = 24) identified neurological conditions perceived to typically require pediatric neurological testing and the modifications to address barriers/enablers to testing. Experts comprised physical therapists with evidence of advanced training or research in pediatrics. Using a 6-point Likert scale (6 = strongly agree, 5 = agree, 4 = somewhat agree, 3 = somewhat disagree, 2 = disagree, 1 = strongly disagree), experts rated statements from existing literature. Thematic analyses were conducted on responses to open-ended questions. A priori consensus was pre-set at 65% agreement/disagreement. Median, mode, and interquartile ranges estimated perceived importance. Cessation was pre-determined by non-consensus items <10% and panel fatigue.

RESULTS

Experts reached consensus on 107/112 (96%) items, including identifying 25/26 (96%) neurological conditions they perceived to require routine neurological testing. Experts strongly agreed with high importance that appropriately trained, experienced therapists are less variable when testing children. Communication modifications were perceived as most important.

CONCLUSION

High levels of consensus support the use of lower limb neurological testing in a range of pediatric neurological conditions. Trained clinicians should document modifications such as visual aid use. Using recommended modifications could encourage consistency among clinicians.

IMPACT

This is the first study to our knowledge to identify the barriers and enablers to pediatric neurological testing. Barriers and enablers were partially addressed through suggested modifications. Further rigorous examination of these modifications is required to support their use.

LAY SUMMARY

This study supports that clinicians should adapt their communication for children and young people with neurological problems to include visual aids and equipment demonstration.

Development and Psychometric Properties of the Arabic Parent Nutritional Assessment Scale (A-PNAS) for Children with Developmental Disabilities

Aims: To describe the development of the Arabic-Parent Nutritional Assessment Scale (A-PNAS), and to examine construct and known-group discriminant validity, internal consistency, and test-retest reliability of the A-PNAS.Methods: A cross-sectional design was used. Participants were 130-children with CP (mean age = 4.26 ± 3.29 years) who were registered in the national CP registry of Jordan with a matching group of 130-children with typical development (mean age = 4.65 ± 3.54 years). Parents completed the developed A-PNAS through a structured phone interview. Parents of children with CP confirmed their child's level of gross motor function classification system.Results: Exploratory factor analysis identified three subscales in the A-PNAS: Food Intake Problems, Health Problems, and Behavioral Problems which explained 31.6% of the variance in nutritional problems of children with CP. Cronbach's alpha indicated acceptable internal consistency for Food Intake (α = 0.61) and Health Problems (α = 0.67)subscales. Parents of children with CP reported that their children had more food intake, health, and behavioral problems compared to children with typical development (p<.001). Test-retest reliability was excellent for the subscales of the A-PNAS (ICCs = 0.96, 0.98, 0.96).Conclusions: The findings provide support for the face validity, construct validity, internal consistency, Known-Groups discriminant validity, and test-retest reliability of the A-PNAS.

Gender differences in treatments and interventions received by children and adolescents with cerebral palsy

Background

In the Swedish population-based follow-up program and national quality registry for individuals with cerebral palsy (CPUP), physiotherapy (PT) and occupational therapy (OT) treatments are regularly recorded along with functional status. By Swedish law, all citizens irrespective of personal characteristics or socioeconomic status, have the right to receive healthcare and medical treatments as applicable. Previous research has shown gender differences in treatments and interventions received by children with cerebral palsy (CP). The purpose of this study was to examine differences in treatments and interventions by gender and place of birth in children and adolescents participating in CPUP.

Methods

This was a cross-sectional registry study. Data from the latest PT (n = 2635) and OT assessment forms (n = 3480) in CPUP were extracted for individuals aged 0–17 years. Logistic regressions were used to assess the relationships between the outcome variables and gender and place of birth (including an interaction term gender X place of birth), adjusted for age, Gross Motor Function Classification System (GMFCS) levels and spasticity scores for PT interventions and Manual Ability Classification System (MACS) for OT interventions.

Results

Results are presented as odds ratios [95% confidence intervals] and p-values. Girls were significantly more likely to have spinal braces than boys; 1.54 [1.07, 2.22] p < 0.05, a significant interaction with place of birth indicated fewer spinal braces prescribed to children born outside of the Nordic countries; 0.20 [0.079, 0.53] p < 0.001. Girls were less likely to have undergone selective dorsal rhizotomy (SDR); 0.49 [0.25, 0.94] p < 0.05. Individuals born outside of the Nordic countries, were significantly less likely to have received intrathecal baclofen (ITB) 0.27 [0.074, 0.98] p < 0.05.

Conclusions

Of the treatments prescribed, gender differences were observed for spinal braces and having undergone SDR. A statistically significant difference based on place of birth was noted for spinal bracing and having received ITB treatment. Other PT and OT treatments were associated with age, level of spasticity, and functional severity as classified using the GMFCS and the MACS. Increased awareness of differences based on gender, and where a child is born, could be obtained by inter- and intraprofessional discussions.

Cerebral palsy information system with an approach to information architecture: a systematic review

Background

Long-term complications and high costs of cerebral palsy (CP) as well as inconsistency in data related to this disease reveal the need for extensive planning to obtain accurate and complete data for the effective management of patients.

Objective

The present study reviews the information architecture of CP information system.

Method

The relevant articles published from early 1988 to 31 July 2018 were extracted through searching PubMed, Scopus, Cochran, Web of Science and Embase databases conducted independently by two researchers.

Results

A total of 39 articles on CP information system were reviewed. Hospitals, rehabilitation centres and outpatient clinics were found to be the main organisations in charge of generating CP data. Each CP database used several data sources, with hospitals serving as the most important sources of information and the main generators of data. The main CP datasets were categorised into four groups of demographic data, diagnosis, motor function and visual impairment. The majority of data standards were related to the use of the International Classification of Functioning, Disability and Health and the Gross Motor Function Classification System. Finally, accuracy, completeness and consistency were the criteria employed in data quality control.

Conclusion

Developing a robust CP information system requires deploying the principles of information architecture when developing the system, as these can improve data structure and content of CP system, as well as data quality and data sharing.

Associations between impairments and activity limitations components of the international classification of functioning and the gross motor function and subtypes of children with cerebral palsy

[Purpose] Cerebral palsy (CP) encompasses a group of disorders of movement and posture with wide ranges of impairments, activity limitations and participation restrictions. Guiding management of children with CP by the ICF model is important to deliver quality services. This study aimed to explore relationship between CP subtypes and the Gross Motor Function Classification System-Expanded and Revised (GMFCS-E&R) and to examine differences in distribution of impairments and activity limitations across CP subtypes and GMFCS-E&R levels. [Participants and Methods] 70 children with CP (mean age: 6.5 ± 2.9 years) were classified using CP subtypes and GMFCS-E&R. Research assistants examined impairments including: scoliosis, scissoring, and inability to bear weight. Parents described their children’s transfers and functional mobility. [Results] CP subtypes and GMFCS-E&R levels were significantly associated. Scissoring and scoliosis were predominant in children in levels IV and V of the GMFCS-E&R. Only scoliosis was predominant in children with quadriplegia. Transfer activities and functional mobility were more limited in children with quadriplegia and in level V of the GMFCS-E&R. [Conclusion] Impairments and activity limitations components of the ICF can be differentiated by CP subtypes and GMFCS-E&R. Clinicians can use the two classification in providing comprehensive and individualized services for children with CP and their families.

The complex aetiology of cerebral palsy

Cerebral palsy (CP) is the most prevalent, severe and costly motor disability of childhood. Consequently, CP is a public health priority for prevention, but its aetiology has proved complex. In this Review, we summarize the evidence for a decline in the birth prevalence of CP in some high-income nations, describe the epidemiological evidence for risk factors, such as preterm delivery and fetal growth restriction, genetics, pregnancy infection and other exposures, and discuss the success achieved so far in prevention through the use of magnesium sulfate in preterm labour and therapeutic hypothermia for birth-asphyxiated infants. We also consider the complexities of disentangling prenatal and perinatal influences, and of establishing subtypes of the disorder, with a view to accelerating the translation of evidence into the development of strategies for the prevention of CP.