Cerebral Palsy

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Basics

Description

Cerebral palsy (CP) is a group of clinical syndromes characterized by motor and postural dysfunction due to permanent and nonprogressive disruptions in the developing brain. Motor impairment resulting in activity limitation is necessary for this diagnosis. CP is classified by the nature of the movement disorder and its functional severity. Individuals with this disorder are affected with secondary musculoskeletal and neurologic problems (intellectual, sensory, speech and language impairment, and seizures).

Epidemiology

Incidence
  • Overall, 1.5 to 2.5/1,000 live births
  • Incidence increases as gestational age (GA) at birth decreases:
    • 146/1,000 for GA of 22 to 27 weeks
    • 62/1,000 for GA of 28 to 31 weeks
    • 7/1,000 for GA of 32 to 36 weeks
    • 1/1,000 for GA of 37+ weeks

Prevalence
3 to 4/1,000 of the population

Etiology and Pathophysiology

  • Multifactorial; CP results from static injury or lesions in the developing brain, occurring prenatally, perinatally, or postnatally.
  • Neuropathology linked to GA at time of brain insult
  • Cytokines, free radicals, and inflammatory response are likely contributing factors.
  • Etiology is most likely multifactorial and depends on timing of brain insult: prenatally, perinatally, or postnatally (see “Risk Factors”).
  • Spastic CP is most common, usually related to premature birth, with either periventricular leukomalacia or germinal matrix hemorrhage.
  • Dystonic or athetotic CP, often resulting from kernicterus, is now rare due to improved management of hyperbilirubinemia.

Genetics
There are reports of associations between CP and polymorphisms of certain genes: thrombophilic, cytokines, and apolipoprotein E.

Risk Factors

  • Prenatal: congenital anomalies, multiple gestation, in utero stroke, intrauterine infection (cytomegalovirus [CMV], varicella), intrauterine growth retardation (IUGR), clinical and histologic chorioamnionitis, antepartum bleeding, maternal factors (cognitive impairment, seizure disorders, hyperthyroidism), abnormal fetal position (e.g., breech)
  • Perinatal: preterm birth, low-birth weight, periventricular leukomalacia, perinatal hypoxia/asphyxia, intracranial hemorrhage/intraventricular hemorrhage, neonatal seizure or stroke, hyperbilirubinemia
  • Postnatal: traumatic brain injury or stroke, sepsis, meningitis, encephalitis, asphyxia, and progressive hydrocephalus

General Prevention

  • Treating mothers with magnesium sulfate during preterm delivery is neuroprotective for fetus and may reduce the risk of CP. Effect on term fetus is unknown.
  • Improved management of hyperbilirubinemia with decrease in kernicterus has greatly reduced dyskinetic CP.
  • Prevention or reduction of chorioamnionitis and premature births

Commonly Associated Conditions

  • Seizure disorder (22–40%)
  • Intellectual impairment (23–44%)
  • Behavioral problems
  • Speech and language impairment (42–81%)
    • May have an impact on expressive and/or receptive language
    • May be nonverbal
  • Sensory impairments
    • Hearing deficits
    • Visual (62–71%): poor visual acuity, strabismus (50%), or hemianopsia
  • Feeding impairment, swallowing dysfunction, and aspiration: when severe, may require gastrostomy feedings
  • Poor dentition, excessive drooling
  • GI conditions: constipation (59%), vomiting (22%), gastroesophageal reflux
  • Decreased linear growth and weight abnormalities (under- and overweight)
  • Osteopenia
  • Bowel and bladder incontinence
  • Orthopedic: contractures, hip subluxation/dislocation, scoliosis (60%)

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