Prevalence and disabilities in 4 to 8 year olds with cerebral palsy

Cerebral Palsy in North Indian Children: Clinico-etiological Profile and Comorbidities

Aims and Objectives

Cerebral palsy (CP) is a common motor disability in children. This study aimed at elaborating various comorbidities and etiologies and also at correlating motor disability with other disabilities.

Material and Methods

This hospital-based study was conducted in the outpatient department of a tertiary care hospital in Delhi on 160 children with CP in the age group 2-15 years. A detailed history taking and examination were conducted for each patient and appropriate investigations were performed.

Results

Most patients, that is 64.4%, were younger than 5 years of age and 72.5% were males. Most common etiology was birth asphyxia (41.9%). Maximum patients were of bilateral spastic (spastic quadriplegic) CP accounting 43.1%. Intellectual disability was the most common comorbidity across all subtypes of CP followed by epilepsy. Comorbidities such as epilepsy and all visual problems except optic atrophy were more common in spastic quadriplegic CP. Hearing, speech impairment, and optic atrophy were more common in dyskinetic CP. Chewing, swallowing, and drooling problems were more common in spastic quadriplegic CP.

Conclusion

Most common risk factor of CP is birth asphyxia; thus, by improving health care facilities, its incidence can be reduced. CP affects not only motor functions but also other important functions of body as well, and the more severe the motor disabilities, the more are other comorbidities and their intensity also increases with that of the intensity of brain insult.

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

AIMS

This study aims to describe the development of a Cerebral Palsy Follow-up Registry in Jordan (CPUP-Jordan) and to provide a baseline child and parent demographic information, birth history of the child participants, and distribution of the participants based on topographical distribution of cerebral palsy (CP) and functional classification systems.

METHODS

The CPUP-Jordan was developed using a similar framework of a follow-up surveillance programme for persons with CP in Sweden (CPUP). Standard assessment forms were utilized to collect data related to child and family demographics, child birth history, and functional classifications and physiotherapy and occupational therapy assessments and interventions. Research assistants were trained to conduct the assessments. A secured web-based system was developed to store data and disseminate knowledge maintained in the registry. Children with CP were included in the registry if they have confirmed diagnosis of CP. The ascertainment age of inclusion and the minimum age of survival required are 4 years.

RESULTS

One hundred sixty-seven children were registered between 2013 and 2015 (mean age is 3.6 ± 3.0 years). Forty-two percent were born premature, and 48% were less than the normal birthweight. Perinatal causes were reported for 54% of the participants. The most common type of CP based on tone disturbance was spastic type, and the most common topographical distributions of motor dysfunction were quadriplegia followed by diplegia. Fifty-six percent of the participants had severe limitation in ambulation; 48% had restricted manual abilities, and 47% had limited communication abilities even with familiar family members and partners.

CONCLUSIONS

The development of CPUP-Jordan registry for children with CP proved to be both feasible and informative. The registry baseline descriptive data were similar to those reported in previous research in Jordan supporting validity of the data. The implementation of CPUP-Jordan at national level is expected to have a positive impact on children with CP, clinicians, policymakers, and researchers.

Motor vehicle crashes during pregnancy and cerebral palsy during infancy: a longitudinal cohort analysis

OBJECTIVES

To assess the incidence of cerebral palsy among children born to mothers who had their pregnancy complicated by a motor vehicle crash.

DESIGN

Retrospective longitudinal cohort analysis of children born from 1 April 2002 to 31 March 2012 in Ontario, Canada.

PARTICIPANTS

Cases defined as pregnancies complicated by a motor vehicle crash and controls as remaining pregnancies with no crash.

MAIN OUTCOME

Subsequent diagnosis of cerebral palsy by age 3 years.

RESULTS

A total of 1 325 660 newborns were analysed, of whom 7933 were involved in a motor vehicle crash during pregnancy. A total of 2328 were subsequently diagnosed with cerebral palsy, equal to an absolute risk of 1.8 per 1000 newborns. For the entire cohort, motor vehicle crashes correlated with a 29% increased risk of subsequent cerebral palsy that was not statistically significant (95% CI -16 to +110, p=0.274). The increased risk was only significant for those with preterm birth who showed an 89% increased risk of subsequent cerebral palsy associated with a motor vehicle crash (95% CI +7 to +266, p=0.037). No significant increase was apparent for those with a term delivery (95% CI -62 to +79, p=0.510). A propensity score-matched analysis of preterm births (n=4384) yielded a 138% increased relative risk of cerebral palsy associated with a motor vehicle crash (95% CI +27 to +349, p=0.007), equal to an absolute increase of about 10.9 additional cases per 1000 newborns (18.2 vs 7.3, p=0.010).

CONCLUSIONS

Motor vehicle crashes during pregnancy may be associated with an increased risk of cerebral palsy among the subgroup of cases with preterm birth. The increase highlights a specific role for traffic safety advice in prenatal care.

Validation of School Function Assessment with Elementary School Children

The present study was conducted to examine the validity of the School Function Assessment (SFA). The study sample consisted of 64 children: 29 in general education (GEN) without disabilities, 18 with learning disabilities (LD), and 17 with cerebral palsy (CP). Convergent validity was supported by the significant correlation (r values ranged from .56 to .72) found between the scores on the Vineland Adaptive Behavior Scales (classroom edition) to comparable scales of the SFA. Construct validity of the SFA using the known groups method was also supported. Significant differences in SFA scores among the 3 groups were found using the Kruskal-Wallis analysis of variance and multiple comparisons. The GEN group differed from the LD group in cognitive/behavioral subtests, the CP group differed from the GEN group in all areas of the SFA, and the LD and CP groups differed on the physical domain of the SFA. Finally, the discriminant analysis of scores on the SFA showed the high percentage of participants being correctly classified in the respective groups (93.1% for GEN, 55.8% for LD, and 88.2% for CP). These results provide new evidence for the validity of the SFA using methodologies not previously reported in the literature. Given the unique features as well as the provided psychometrical properties of the SFA, this recently developed functional assessment should be considered a valid instrument for use in school settings.

Systematic Review of Cerebral Palsy Registries/Surveillance Groups: Relationships between Registry Characteristics and Knowledge Dissemination

The aims of this study were to provide a comprehensive summary of the body of research disseminated by Cerebral Palsy (CP) registries and surveillance programs from January 2009 through May 2014 in order to describe the influence their results have on our overall understanding of CP. Secondly, registries/surveillance programs and the work they produced were evaluated and grouped using standardized definitions and classification systems.

METHOD

A systematic review search in PubMed, CINAH and Embase for original articles published from 1 January 2009 to 20 May 2014 originating from or supported by population based CP registries and surveillance programs or population based national registries including CP were included. Articles were grouped by 2009 World CP Registry Congress aim, registry/surveillance program classification, geographical region, and the International Classification of Function, Disability and Health (ICF) domain. Registry variables were assessed using the ICF-CY classification.

RESULTS

Literature searches returned 177 articles meeting inclusion criteria. The majority (69%) of registry/surveillance program productivity was related to contributions as a Resource for CP Research. Prevention (23%) and Surveillance (22%) articles were other areas of achievement, but fewer articles were published in the areas of Planning (17%) and Raising the Profile of CP (2%). There was a range of registry/surveillance program classifications contributing to this productivity, and representation from multiple areas of the globe, although most of the articles originated in Europe, Australia, and Canada. The domains of the ICF that were primarily covered included body structures and function at the early stages of life. Encouragingly, a variety of CP registry/surveillance program initiatives included additional ICF domains of participation and environmental and personal factors.

INTERPRETATION

CP registries and surveillance programs, including novel non-traditional ones, have significantly contributed to the understanding of how CP affects individuals, families and society. Moving forward, the global CP registry/surveillance program community should continue to strive for uniformity in CP definitions, variables collected and consistency with international initiatives like the ICF so that databases can be consolidated for research use. Adaptation to new technologies can improve access, reduce cost and facilitate information transfer between registrants, researchers and registries/surveillance programs. Finally, increased efforts in documenting variables of individuals with CP into adulthood should be made in order to expand our understanding of CP across the lifespan.

Risk of cerebral palsy among the offspring of immigrants

BACKGROUND

Cerebral palsy (CP) has a multifactorial etiology, and placental vascular disease may be one major risk factor. The risk of placental vascular disease may be lower among some immigrant groups. We studied the association between immigrant status and the risk of CP.

METHODS

We conducted a population-based retrospective cohort study of all singleton and twin livebirths in Ontario between 2002-2008, and who survived ≥28 days after birth. Each child was assessed for CP up to age 4 years, based on either a single inpatient or ≥2 outpatient pediatric diagnoses of CP. Relative to non-immigrants (n = 566,668), the risk of CP was assessed for all immigrants (n = 177,390), and further evaluated by World region of origin. Cox proportional hazard ratios (aHR) were adjusted for maternal age, income, diabetes mellitus, obesity, tobacco use, Caesarean delivery, year of delivery, physician visits, twin pregnancy, preterm delivery, as well as small- and large-for-gestational age birthweight.

RESULTS

There were 1346 cases of CP, with a lower rate among immigrants (1.45 per 1000) than non-immigrants (1.92 per 1000) (aHR 0.77, 95% confidence interval [CI] 0.67 to 0.88). Mothers from East Asia and the Pacific (aHR 0.54, 95% CI 0.39 to 0.77) and the Caribbean (aHR 0.58, 95% CI 0.37 to 0.93) were at a significantly lower risk of having a child with CP. Whether further adjusting for preeclampsia, gestational hypertension, placental abruption or placental infraction, or upon using a competing risk analysis that further accounted for stillbirth and neonatal death, these results did not change.

CONCLUSIONS

Immigration and ethnicity appear to attenuate the risk of CP, and this effect is not fully explained by known risk factors.

Spectrum of visual disorders in a population-based cerebral palsy cohort

BACKGROUND

Children with cerebral palsy are known to be at increased risk for visual impairment.

METHODS

In a population-based sample drawn from a geographically defined registry, the profile of visual impairment in children with cerebral palsy was investigated.

RESULTS

Close to half (49.8%; 106/213) had a visual impairment. The majority of these individuals had strabismus (55.7%; 59/106) and a slightly lesser fraction had refractive errors (20.7%; 22/106) or severe visual loss (18.9%; 20/106). The vast majority of children with severe visual loss had spastic quadriplegia (83%; 17/20) or were nonambulatory (i.e., Gross Motor Function Classification Scale IV/V, 80%; 16/20).

CONCLUSIONS

Knowledge of this profile will assist practitioners to heighten their appreciation of potential visual disturbances in certain subsets of children with cerebral palsy.

A population-based study and systematic review of hearing loss in children with cerebral palsy

AIM

The aims of this study were to estimate the frequency of hearing loss in children with cerebral palsy (CP), to examine factors associated with hearing loss, and to describe aspects of hearing in a population sample of children with CP and hearing loss.

METHOD

A systematic review of the international literature was undertaken, and data on the frequency of hearing loss or severe hearing loss were extracted from 14 data sets based on previously devised criteria. Six hundred and eight-five children with CP (406 males, 279 females) born in Victoria, Australia, between 1999 and 2004 were identified from the Victorian Cerebral Palsy Register. Children were included if they had an established post neonatal cause for their CP before the age of 2 years. Additional information was collected on 48 children with documented hearing loss based on a four-tone pure tone average in the better ear.

RESULTS

There was considerable variation in the definitions and proportions of hearing loss (range 4-13%) and severe hearing loss (range 2-12%) reported by CP registries in developed countries. In Victoria, 7% of individuals with CP had bilateral hearing loss of a moderate to profound degree, whereas the subgroup with a severe-profound degree of loss constituted 3% to 4% of the CP population.

INTERPRETATION

These population-based data are likely to more accurately reflect the true frequency of defined hearing loss in children with CP than previous reviews.

Distribution of motor types in cerebral palsy: how do registry data compare?

AIM

The aim of this study was to describe the distribution of types of motor disorder (motor type) in a population-based registry of children with cerebral palsy (CP), to examine any trends in motor type distribution over time, and to make comparisons with other populations.

METHOD

Individuals born in Victoria, Australia, between 1970 and 2003 with congenital CP were identified from the Victorian Cerebral Palsy Register, 3297 of whom were included in the study (1840 males, 1457 females). Those who had a hypotonic motor type, those whose brain abnormality was believed to have developed after 28 days of life, and those with missing data were excluded from the study. The proportions of each motor type were calculated and plotted by year of birth. Logistic regression analyses were used to assess the mean change in odds per year of birth. A systematic review of the international literature was undertaken and comparison data were extracted based on previously devised criteria. The degree of heterogeneity was assessed and comparisons were made according to geographical region and reporting period.

RESULTS

In Victoria, the predominant motor types for individuals with CP born between 1970 and 2003 were spasticity (91%), ataxia (5%), and dyskinesia (4%). There was no clear trend for any motor type over time. The mean proportions from two other large data sets were similar but there was considerable heterogeneity between 29 individual CP registries, mainly because of differences in the classification of mixed motor types.

INTERPRETATION

A more objective method for determining the predominant motor type is required to make the classification of motor type in CP more consistent and reliable.

Nonprimary dystonias

Dystonias can be classified as primary or secondary, as dystonia-plus syndromes, and as heredodegenerative dystonias. Their prevalence is difficult to determine. In our experience 80-90% of all dystonias are primary. About 20-30% of those have a genetic background; 10-20% are secondary, with tardive dystonia and dystonia in cerebral palsy being the most common forms. If dystonia in spastic conditions is accepted as secondary dystonia, this is the most common form of all dystonia. In primary dystonias, the dystonic movements are the only symptoms. In secondary dystonias, dystonic movements result from exogenous processes directly or indirectly affecting brain parenchyma. They may be caused by focal and diffuse brain damage, drugs, chemical agents, physical interactions with the central nervous system, and indirect central nervous system effects. Dystonia-plus syndromes describe brain parenchyma processes producing predominantly dystonia together with other movement disorders. They include dopa-responsive dystonia and myoclonus-dystonia. Heredodegenerative dystonias are dystonic movements occurring in the context of other heredodegenerative disorders. They may be caused by impaired energy metabolism, impaired systemic metabolism, storage of noxious substances, oligonucleotid repeats and other processes. Pseudodystonias mimic dystonia and include psychogenic dystonia and various orthopedic, ophthalmologic, vestibular, and traumatic conditions. Unusual manifestations, unusual age of onset, suspect family history, suspect medical history, and additional signs may indicate nonprimary dystonia. If they are suspected, etiological clarification becomes necessary. Unfortunately, potential etiologies are legion. Diagnostic algorithms can be helpful. Treatment of nonprimary dystonias, with few exceptions, does not differ from treatment of primary dystonias. The most effective treatment for focal and segmental dystonias is local botulinum toxin injections. Deep brain stimulation of the globus pallidus internus is effective for generalized dystonia. Antidystonic drugs, including anticholinergics, tetrabenazine, clozapine, and gamma-aminobutyric acid receptor agonists, are less effective and often produce adverse effects. Dopamine is extremely effective in dopa-responsive dystonia. The Bertrand procedure can be effective in cervical dystonia. Other peripheral surgery, including myotomy, myectomy, neurotomy, rhizotomy, ramizectomy, and accessory nerve neurolysis, has largely been abandoned. Central surgery other than deep brain stimulation is obsolete. Adjuvant therapies, including orthoses, physiotherapy, ergotherapy, behavioral therapy, social support, and support groups, may be helpful. Analgesics should also be considered where appropriate.

Review of electrical stimulation in cerebral palsy and recommendations for future directions

Electrical stimulation (ES) for treatment of neuromuscular disorders is introduced. Various forms of ES are defined. Characteristics of cerebral palsy (CP) and treatment options are given. The clinical objectives of ES for CP treatment are stated. A review of the literature for treatment in CP is given. Several common themes within the literature and limitations in prior studies are explored. The majority of studies have used surface stimulation, which has several inherent limitations. To address these limitations, implanted devices may be used. Implanted device systems include percutaneous stimulation systems, and fully implantable leaded systems. While both of these technologies have advantages over surface stimulation, they also have their own limitations. To further address the limitations of percutaneous and fully implantable leaded systems, the Alfred Mann Foundation has developed a completely implantable, telemetered device known as the Radio Frequency Microstimulator (RFM). Results from a study using the RFM for arm rehabilitation in poststroke patients are given. A list of desirable design features for an ES system for CP is given. The next generation microstimulator device under development at the Alfred Mann Foundation is presented. This device may well serve the needs for ES in CP.

The relationship between medical impairments and arithmetic development in children with cerebral palsy

Arithmetic ability was tested in children with cerebral palsy without severe intellectual impairment (verbal IQ >or= 70) attending special (n = 41) or mainstream education (n = 16) as well as control children in mainstream education (n = 16) throughout first and second grade. Children with cerebral palsy in special education did not appear to have fully automatized arithmetic facts by the end of second grade. Their lower accuracy and consistently slower (verbal) response times raise important concerns for their future arithmetic development. Differences in arithmetic performance between children with cerebral palsy in special or mainstream education were not related to localization of cerebral palsy or to gross motor impairment. Rather, lower accuracy and slower verbal responses were related to differences in nonverbal intelligence and the presence of epilepsy. Left-hand impairment was related to slower verbal responses but not to lower accuracy.

Effect of serial casting in spastic cerebral palsy

OBJECTIVE

Cerebral palsy (CP) is a range of non progressive syndromes of posture and motor impairment due to an insult to developing brain. Spasticity and incoordination are major causes of disability in these children which can be managed by different modalities like casting, botulinum toxin, surgery etc. Cast application in spastic equinus is a well established procedure in CP but cast application in patients of CP with bilateral involvement of hip, knee and ankle is not document.

METHODS

A study was conducted on 22 children of spastic CP in age range of 3-8 years with bilateral involvement of hip, knee and ankle in 20 cases, hip and ankle in one case and only ankle in one case. Sixty eight % children were spastic diplegics. Serial weekly cast with (11 cases) or without abductor bar (11 cases) was applied for four weeks. They were followed up variably with an average period of 7 months.

RESULTS

Significant improvement was noticed in range of motion around hip, knee and ankle which as maintained over hip and knee after average follow up. Spasticity was also reduced as measured by Modified Ashworth Scale (MAS). This ultimately improved the ambulatory status and functional ability of these children.

CONCLUSION

Thus serial casting is a very simple, safe and cost effective procedure which can be applied even in children with mental sub normality having all three major joints involved bilaterally.

Epidemiology of stillbirth and fetal central nervous system injury

The epidemiology of stillbirth and fetal central nervous system (CNS) injury is described with some emphasis on maternal and feto-placental risk factors. To maximize utility of the discussion and because it also represents the classical manifestation of fetal CNS injury, we have selected cerebral palsy (CP) to illustrate the epidemiologic aspects of injury to the fetal CNS in general. While trends in stillbirth rates have modestly decreased over time, those of CP seem to be increasing. Interestingly, both stillbirth and CP share traditional as well as emerging risk factors lending credence to the hypothesis that fetuses that would previously have been stillborn are increasingly surviving albeit with some form of morbidity. The existence of shared risk factors also suggests that in some cases of stillbirth fetal CNS injury precedes the in utero fetal demise. Pregnant women bearing these risk indicators represent potential candidates for appropriate and tailored protocols for antenatal fetal testing.

Visual development in infants with prenatal post-haemorrhagic ventricular dilatation

OBJECTIVE

The aim of this study was to assess visual function in 13 infants with evidence of prenatal post haemorrhagic ventricular dilatation.

DESIGN

Infants were assessed at 5, 12 and 24 months using a battery of tests specifically designed to assess various aspects of visual function in infancy. Visual findings were correlated with several variables, including extent of the lesion and presence of epilepsy.

RESULTS AND CONCLUSIONS

Abnormalities of visual function were frequent (over 60%) in our cohort at age 2 years, ranging from isolated abnormal ocular movements to severe abnormalities of all the aspects of visual function assessed. The most severe and persistent abnormalities of visual function were found in infants with grade IV intraventricular haemorrhage and shunted hydrocephalus who also had epilepsy in the first year.

Primary care of the child with cerebral palsy: a review of systems (part II)

Cerebral palsy (CP) is a disorder of movement and posture with additional potential to affect cognitive status. Thus, the goals for management of the child with CP include the following: to promote optimal function; to maintain general health; to foster acquisition of new skills; to assist and educate parents and caregivers; and to anticipate, prevent, and treat the complications of this disorder. Pediatric management of the child with CP should begin at the time of diagnosis. This article is the second of two articles on CP. The first article focused on the diagnosis of CP, and this article will focus on a review of systems approach for management as well as resources for the family and the nurse practitioner.

The epidemiology of cerebral palsy: incidence, impairments and risk factors

PURPOSE

Describing the epidemiology of cerebral palsy (CP), its impairments and risk factors.

METHOD

Literature review 1965-2004. Search terms: Cerebral palsy, incidence, prevalence, impairments, risk factors.

RESULTS

In the last 40 years the prevalence of CP has risen to well above 2.0 per 1000 life births. In this time span the proportion of low-birthweight infants rose, the proportion of diplegia decreased, while the proportion of hemiplegia increased. CP is more prevalent in more deprived socio-economic populations. The majority of people with CP have the spastic syndrome of which the diplegic group is the smallest. Dependent on the subgroup of CP, 25-80% have additional impairments. A large proportion has some kind of cognitive impairment; the prevalence varies with the type of CP and especially increases when epilepsy is present. Epilepsy is present in 20-40%; it is most common among the hemi- and tetraplegics. Sensibility of the hands is impaired in about half. Chronic pain is reported by more than a quarter of the adults. Up to 80% have at least some impairment of speech. Low visual acuity is reported in almost three-quarters of all children. Half of all children have gastrointestinal and feeding problems. Stunted growth occurs in a quarter, while under- or overweight problems are present in half of the children. Almost 70% of people with spastic CP have abnormal brain CT findings; abnormal cranial ultrasounds is most strongly associated with hemiplegia, normal cranial ultrasounds with diplegia. The most important risk factors for CP are low birthweight, intrauterine infections and multiple gestation.

Long-term survival for a cohort of adults with cerebral palsy

The aim of this study was to investigate long-term survival and examine causes of death in adult patients with cerebral palsy (CP). A 1940-1950 birth cohort based on paediatric case referral allows for long-term survival follow-up. Survival is analyzed by birth characteristics and severity of disability from age 20 years (and age 2y for a subset of the data). Survival outcome compared with that expected in the general population based on English life tables. The main cohort consisted of 341 individuals, with 193 males and 148 females. Conditional on surviving to age 20 years, almost 85% of the cohort survived to age 50 years (a comparable estimate for the general population is 96%). Very few deaths were attributed to CP for those people dying over 20 years of age. Females survived better than males. However, females faced a greater increase in risk relative to the general population than did males. We conclude that survival outlook is good though lower than in the general population. The relative risk of death compared with the UK population decreases with age, although it shows some indication of rising again after age 50 years. Many more deaths were caused by diseases of the respiratory system among those dying in their 20s and 30s than would be expected in the general population. Many fewer deaths than expected in this age group are caused by injuries and accidents. For those people who die in their 40s and 50s, an increase in deaths due to diseases of the circulatory system and neoplasms is observed. More deaths than expected in this age group are due to diseases of the nervous system.

Global and Specific Behavioral Measures of Pain in Children With Cerebral Palsy

OBJECTIVES

The aim of this research was to validate global and behavioral observation methods for measuring pain in children with cerebral palsy (CP).

MATERIALS AND METHODS

Nineteen children diagnosed with CP (2-21 years of age) and their primary caregivers participated in this study. Children and their caregivers were videotaped in their home before, during, and after a stretching exercise, and tests of cognitive and social development were administered. Children who were able to pass a training task were also asked to rate their experience of pain using a numerical rating scale (self-report NRS), but only 5 children (24%) passed so their self-report scores were not included. Healthcare professionals rated videotaped segments for each of the 3 time periods in a randomized order using an observer NRS and the Non-Communicating Children's Pain Checklist-Postoperative Version (NCCPC-PV). Raters trained in the Child Facial Coding System (CFCS) examined the same videotaped segments.

RESULTS

Results showed significantly greater pain behavior (observer NRS, NCCP- PV) during the stretching procedure than during the baseline and recovery segments. There were no significant differences in CFCS scores, across time segments.

CONCLUSIONS

These findings support the hypothesis that children with CP express discernible pain behaviors regardless of cognitive or language ability. These results contribute to multidimensional assessment of pain in children with neurologic impairment.

Cerebral palsy

Cerebral palsy, a range of non-progressive syndromes of posture and motor impairment, is a common cause of disability in childhood. The disorder results from various insults to different areas within the developing nervous system, which partly explains the variability of clinical findings. Management options include physiotherapy, occupational and speech therapy, orthotics, device-assisted modalities, pharmacological intervention, and orthopaedic and neurosurgical procedures. Since 1980, modification of spasticity by means of orally administered drugs, intramuscular chemodenervation agents (alcohol, phenol, botulinum toxin A), intrathecally administered drugs (baclofen), and surgery (neurectomy, rhizotomy) has become more frequent. Family-directed use of holistic approaches for their children with cerebral palsy includes the widespread adoption of complementary and alternative therapies; however, the prevalence of their use and the cost of these options are unknown. Traditional medical techniques (physiotherapy, bracing, and orthopaedic musculoskeletal surgery) remain the mainstay of treatment strategies at this time. This seminar addresses only the musculoskeletal issues associated with cerebral palsy and only indirectly discusses the cognitive, medical, and social issues associated with this diagnosis.

The "Bermuda triangle" of neonatal neurology: cerebral palsy, neonatal encephalopathy, and intrapartum asphyxia

The terms "cerebral palsy," "neonatal encephalopathy," and "intrapartum asphyxia" are frequently used in pediatric neurology. This article presents concise, verifiable definitions for each of these entities based on our current understanding and formulates the nature of the interrelationships between them. The aim is to provide a level of clarity that will enhance diagnostic and pathogenetic precision and minimize conceptual misunderstanding. This should aid future therapeutic and research efforts in this important area.

Cerebral palsy: defining the problem

The term "cerebral palsy" has had varied meanings over the past century. This article presents the current consensus definition that best captures the core elements of this heterogeneous entity. Elements comprising the components of the consensus definition are elaborated upon to provide clarity. Areas of remaining lack of consensus, mostly reflecting the timing of diagnosis and the exclusion of various etiologic entities are highlighted.

Electrical stimulation in the management of spastic deformity

This article outlines a nonsurgical approach that includes neuromuscular electrical stimulation and dynamic bracing for the management of spastic deformity in cerebral palsy. Neuromuscular electrical stimulation is used commonly for lower extremity spasticity. Its clinical application in upper extremity spasticity, together with dynamic bracing, is a new entity providing predictable and quick short-term results with significant improvement in quality of life.

Decreased access to health care and social isolation among young adults with cerebral palsy after leaving school

OBJECTIVE

To examine if leaving special schools has a negative impact on the health care and social isolation of young adults with cerebral palsy.

METHODS

Young adults with cerebral palsy, aged between 15 and 22 years, were divided into 2 cohorts: current students, who were still receiving services from special schools, and school-leavers, who had since been discharged from care. A questionnaire and physical examination were administered to assess the extent of disability, health care received by, and social isolation of these young adults.

RESULTS

School-leavers had a greater degree of dissability than did students, although the results were not statistically significant. Health care exposure to specialists, general practitioners, therapists physiotherapists, occupational therapists, and/or speech therapists), and medical social workers decreased after leaving school; with the exception of contact with general practitioners, these results were significant (p<0.05). The entire cohort was more socially isolated than a control cohort. School-leavers participated in fewer activities outside their homes, but showed less concern about their disability than did current students.

CONCLUSIONS

Young adults with cerebral palsy continue to have health care and lifestyle needs after leaving school, which are currently not being adequately met.

Supporting young adults with hemiplegia: services and costs

This paper lays out the service and cost consequences of supporting a nationally representative sample of young adults with hemiplegic cerebral palsy. The total costs burden and the additional costs that accrue to the public and independent sector due to their disabilities are calculated. Most of the young adults live at home. Many lead "ordinary" lives and attend further or higher education establishments or go to work. A small number of study members, however, make intensive use of expensive, often segregated facilities such as residential homes or schools and make considerable use of other support services. In total, this group of 81 people cost just over 1 million pounds to support during the year prior to interview, 43% of which was related to their impairments. When the sample is divided into two groups, people with a combination of associated conditions are found to have hemiplegia-associated costs almost 50 times greater than those with simple hemiplegia.

Standardized quantitative assessment of brain tumor survivors treated within clinical trials in childhood

Important morbidity and impairment of life quality arises from both the primary pathology and therapeutic interventions in children with central nervous system (CNS) tumors. Standardized and systematic collection of morbidity data is a prerequisite of clinical trials in this field. The perception of the survivor is paramount in the determination of quality of life as this variable is dependent on the beholder. Comprehensive assessment of outcome following therapeutic intervention should evaluate this in parallel with other physical and psycho-social outcome parameters. A structured, simple schema for the evaluation of survivors of childhood CNS tumors is presented. It is intended to be easily applicable by clinicians within the everyday clinical setting. Information relating to pre- and post-operative states, function, health status and emotional and psychological well-being is collected at regular intervals from diagnosis. Re-integration into society and independence are evaluated. Children self-complete health-status assessments where appropriate. Evidence to support this is presented. The schema is intended to provide a basic framework for the monitoring of health status following treatment of CNS tumors in childhood. Regular assessments may identify individuals in need of more detailed investigation and further understanding of the evolution of morbidity in this cohort. Survivors' perception of the impact of documented dysfunction on their health-related quality of life will be determined. Optimization of the planning of future clinical service provision and therapies will result.

Ocular abnormalities associated with cerebral palsy after preterm birth

PURPOSE

To document the ocular abnormalities in children with cerebral palsy (CP) after premature birth.

METHODS

All the children born before 32 weeks gestation between 1 January 1990 and 31 December 1991 in a geographically defined population of approximately 3 million, were examined by an ophthalmologist and a paediatrician at 2 years old.

RESULTS

Five hundred and fifty-eight children (98.8% of the study group) were examined, of whom 41 had disabling CP and 13 had non-disabling CP. Children with CP had a higher incidence of abnormalities compared with children without CP: cicatricial retinopathy of prematurity occurred in 8 children with CP (14.8%) compared with 8 without CP (1.6%, p < 0.0001), cortical visual impairment occurred in 6 with CP (11.1%) compared with 1 child without CP (0.2%, p < 0.0001) and concomitant strabismus in 28 with CP (51.9%) compared with 42 without CP (8.4%, p < 0.0001). The prevalence of refractive error without other ocular abnormalities was similar for children with CP (4/54, 7.4%) and those without CP (54/504, 10.7%, p = 0.90). Significant ocular abnormalities had been previously unrecognised in 8 children with CP (14.8%).

CONCLUSION

There are some differences between these results and previous series. These differences probably reflect the fact that previous work has studied severe CP of more diverse aetiology. The high frequency of abnormalities highlights the importance of ocular assessment of these children.

Prevalence of cerebral palsy in Slovenia: birth years 1981 to 1990

Changes in the prevalence of cerebral palsy (CP) in a population of Slovenian children born between 1981 and 1990 were determined. A population-based birth-cohort study was undertaken. Seven hundred and sixty-eight children with CP (aged 5 to 14 years) were identified from the National Cerebral Palsy Register in 1995. Spastic syndromes accounted for 84.8%. Of the 768 children studied, the total prevalence of CP per 1000 live births fell significantly from 3.3 in 1981 to 2.3 in 1990. This decreasing trend was observed in children born at < or = 38 weeks of gestation and in those with a birthweight of < 1500 g, but the prevalence of CP remained fairly constant in those born at > 38 weeks of gestation and in those with a birthweight of > or = 2500 g. The results show that a statistically significant improvement in the survival rate of infants born in Slovenia between 1981 and 1990 was not accompanied by an increase in the prevalence of CP. Additionally, in the group of very-low-birthweight infants the prevalence of CP considerably decreased.

Do incomplete ascertainment and recruitment matter? - a study in childhood hemiplegia

London children with hemiplegia were ascertained from multiple sources . The effectiveness of ascertainment varied markedly between different sectors of London, and many families did not respond to a written appeal to participate in the research (though most did respond to a personal appeal). Subjects from areas with high and low ascertainment rates had very similar demographic, medical, cognitive and behavioral variables, and so did easy- and hard-to-recruit subjects. The characteristics of the sample as a whole closely resembled those of previous epidemiological samples of hemiplegic children. It would be rash to assume that incomplete ascertainment and recruitment are innocuous, even though they did not make this sample unrepresentative.

Prevalence of cerebral palsy among ten-year-old children in metropolitan Atlanta, 1985 through 1987

The Metropolitan Atlanta Developmental Disabilities Study was a population-based study (1985 through 1987) to determine the prevalence of five developmental disabilities among 10-year-old children. The disabilities included cerebral palsy, mental retardation, visual impairment, hearing impairment, and epilepsy. The prevalence of cerebral palsy (CP) and a description of the children with CP are reported here. Using a record review approach, we identified 204 10-year-old children with CP (resulting in a prevalence of 2.3 per 1000). The rate of CP was significantly higher among boys (prevalence odds ratio = 1.5; 95% confidence interval = 1.1, 2.0), and the rate was also higher among black children than white children (prevalence odds ratio = 1.3; 95% confidence interval = 1.0, 1.7). Thirty-three of the children (16%) acquired CP postnatally; these children were more likely to be black or male. The gender and racial differences found for acquired CP were greater than those for congenital CP. Approximately 75% of the children had one of the other four disabilities studied; 65% of the children were mentally retarded, 46% had epilepsy, and 15% had a sensory impairment. Our multiple-source method of identifying children with CP gave us a population-based sample from which to determine the prevalence of the condition and to study factors that are associated with CP.

Impact of cerebral visual impairment on the everyday life of cerebral palsied children

A group of 43 patients suffering from cerebral palsy and cerebral visual impairment was compared with a group of 24 cerebral palsy patients with normal visual acuity, with regard to a functional level in daily life. Four categories were considered: communication, emotional contact, self-care and intelligence. Cerebral visual impairment-cerebral palsy patients scored significantly lower in all categories than cerebral palsy patients with normal visual acuity. In the cerebral visual impairment-cerebral palsy group, there was a higher frequency of tetraplegia compared with the group with normal acuity, but even after this predominance had been excluded, a significant difference remained. When dealing with cerebral palsy patients, occurrence of cerebral visual impairment must be taken into account. By initiating intervention programmes, one can prevent extra handicaps due to the consequences of diminished visual acuity.

The California Cerebral Palsy Project

The California Cerebral Palsy Project (CACP) is a population-based study of 192 children with moderate or severe congenital cerebral palsy who were born between 1983 and 1985 in four San Francisco Bay area counties and who were alive and residing in California at age 3 years. Initial ascertainment of cases was based on records of two agencies known to enrol virtually all CACP-eligible children. Final case status was established by standardised clinical examination in 67% of cases and extensive record review in 33%. The 192 cases gave a prevalence at age 3 of 1.23/1000 survivors. Twins were 10% of the cases with a prevalence of 6.7/1000. Overall, 53% of the cases had birthweight greater than or equal to 2500 g and 28% had birthweight less than 1500 g. There was no association between birthweight and severity of functional impairment and no consistent association between birthweight and the presence of associated disabilities. The CACP prevalence is lower than that reported in other studies and is believed to be due to the more stringent case inclusion criteria employed for this research data base.

Certified cause of death in children and young adults with cerebral palsy

The status of 732 children suffering from cerebral palsy from the South East Thames region (births from 1970-9) was ascertained at the end of 1989, and copies of death certificates of the 73 children who have died, aged 4 weeks to nearly 16 years, were obtained. Infantile cerebral palsy (ICD Code 343-) was coded as the underlying cause of death in only 16 (22%) cases. On 28 (38%) certificates there was no mention of any form of cerebral palsy, the proportion in which it was not mentioned increasing with age. In 20 (28%) cases the coded underlying cause of death was respiratory, hence in published national statistics the number of deaths from respiratory causes is inflated. A postmortem examination was known to have been performed in 23 cases, but the recorded information was in some cases limited to a 'terminal event'. The importance of good data on the death certificate, and the significance of published national statistics, need to be communicated to all those involved in the certification process if cerebral palsy and other chronic conditions, which raise the relative risk of death, are not to be under-represented.

Cerebral palsy: why we must plan for survival

The survival of children in the South East Thames region, born between 1970 and 1979 and diagnosed as having some form of cerebral palsy was investigated. Of the 732 children studied, 651 (90%) are still alive, and hence cerebral palsy must be regarded as a condition with which people live rather than a condition of which they die. Survival varies considerably among the different diagnostic groups: those suffering from spasic quadriplegia, dyskinetic and 'mixed' cerebral palsy are most severely affected. Our evidence suggests that, though immobility and severe mental subnormality are the strongest predictors of mortality in children with cerebral palsy, the majority of even the most severely affected patients survive to adulthood. It is therefore appropriate to plan for their survival by funding and evaluating programmes to maximise health, independence, and quality of life.

Spasticity in cerebral palsy and the selective posterior rhizotomy procedure

A review of the selective posterior rhizotomy procedure for reduction of spasticity in cerebral palsy is presented. The history of the procedure, selection of patients, operative technique, and results are described. The neurophysiologic basis for spasticity is considered, as well as the role of spasticity in the complex motor disorder of cerebral palsy. Cerebral palsy is a multifaceted disorder of which spasticity is only one aspect. Reduction of spasticity can be effectively achieved using the current technique of selective posterior rhizotomy, but careful patient selection and establishment of realistic goals are vital to successful outcome. Postoperative physical and occupational therapy are felt to be essential for regaining strength and improving motor function following the rhizotomy procedure. Further study in the areas of spasticity, cerebral palsy, and the effects of rhizotomy is expected to advance our treatment of spastic children.