Cerebral Palsy

Paragraph 1: Definition, incidence and etiology

I. Definition
Cerebral palsy is the most common cause of severe physical disability in childhood.
Cerebral palsy describes 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 motor disorders of
CP are often accompanied by disturbances of sensation, perception, cognition,
communication, behavior, by epilepsy and by secondary musculoskeletal problems.
(Rosenbaum et al. 2007)
Clarification of the definition
-

Disorder of movement and posture:

Abnormal motor behaviour is the core feature of CP. It is characterised by various
abnormal patterns of movement and posture related to defective coordination of
movements and/ or regulation of muscle tone.

Non-progressive disturbances of the brain:

The non-progressive disturbance of the brain is in contrast to the evolution in clinical
picture with time, development, learning, training, therapy and other pictures.

Developing fetal or infant brain: the lesion occurs before, at, or within 2 years of birth

Associated impairments:
Sensation: vision, hearing and other sensory modalities may be affected
Cognition: both global and specific cognitive processes may be affected,
including attention
Communication: expressive and/or receptive communication and/or social
interaction skills may be affected
Perception: the capacity to incorporate and interpret sensory and/ or cognitive
information may be impaired
Behaviour: behavioural problems in the context of psychiatric disorders, such as
features of autism, ADHD, mood disorders and anxiety disorders may be
included
Seizure disorder: every seizure type and many epileptic syndromes may be seen
in CP

II. Incidence
Overall, the rate of CP is between 2 and 3 per 1000 live births. This rate increases to 40100 per 1000 live births among babies born very early or with very low birth weight.
(Cans 2000) During the past 20 years, there have been increases in the incidence and
prevalence of cerebral palsy that may be related to improved documentation of cases by
national registries, advances in neonatal care and other factors. (Koman et al. 2004)

III. Etiology
Cerebral Palsy is not caused by a uniform neurological abnormality. Risk factors are
frequently categorized according to the developmental period in which they are
considered to exert their etiological effect, leading to the categorization of etiology as
pre-, peri or postnatal.
Prenatal causes include congenital brain malformation, infection, exposure to
teratogens (e.g. tobacco, alcohol,), intrauterine vascular accident.
Perinatal

causes include peripartal asphyxia,

preterm

birth and Rhesus

incompatibility.
Postnatal causes include infection and trauma, which are responsible for most of
the cases of postnatal/acquired CP, but there are many other possible causes like
cerbrovascular accident e.g. after cardiac surgery/ problems

Paragraph 2: Clinical presentation

I. Classification
CP is an umbrella term covering a wide range of clinical presentations and degrees of
severity. Therefore, it is necessary to further categorize children with CP.
The purposes of classification have been described as follows:
Description: providing the level of detail about an individual with CP that will
clearly delineate the nature of the problem and its severity
Prediction: providing information that can inform health care professionals of the
current and future service needs of individuals with CP
Comparison: providing sufficient information to permit reasonable comparison of
series of cases of CP assembled in different places

Evaluation of change: providing information that will allow comparison of the

same individual with CP at different points in time.
Traditional classification schemes have focused principally on the distributional pattern
of affected limbs with an added modifier describing the predominant type of tone or
movement abnormality. However, it has become apparent that additional characteristics
must be taken into account for a classification scheme to contribute substantively to the
understanding and management of this disorder (Rosenbaum et al. 2007).
Therefore, four major dimensions of classification were recently proposed, which are
elaborated upon below (Bax et al. 2005).
Four types of classification:
A. Classification according to the nature and typology of the motor disorder
B. Topographic classification: according to the anatomic distribution
C. Classification according to the functional severity
D. Classification according to the causation and the timing of the brain injury
A. Classification according to the nature and typology of the motor disorder
The Surveillance of Cerebral Palsy in Europe (SCPE) classified cerebral palsy into
three main groups based on the predominant neuromotor dysfunction: spastic, ataxic
and dyskinetic cerebral palsy. Agreement has been reached on the clinical findings
associated with each classification sub-group as follows:

Spastic cerebral palsy is characterised by at least two of following

characteristics:
- abnormal pattern of posture and/or movement
- increased tone (not necessarily constantly)
- pathological reflexes (hyper-reflexia or pyramidal signs)
spastic CP may be unilateral or bilateral

Dyskinetic cerebral palsy is characterised by both of

- abnormal pattern of posture and/ or movement
- involuntary,

uncontrolled,

recurring,

occasionally

stereotyped

movements of affected body parts

Dyskinetic CP is further differentiated into:

Dystonic cerebral palsy, dominated by both hypokinesia and
hypertonia


Choreo-athetotic cerebral palsy, dominated by hyperkinesia

and hypotonia

Ataxic cerebral palsy is characterised by both of

- abnormal pattern of posture and/or movement
- loss of orderly muscular co-ordination, so that movements are
performed with abnormal force, rhythm and accuracy

(Cans 2000)
(http://www-rheop.ujf-grenoble.fr/scpe2/site_scpe/index.php)
Figure 1 shows the classification tree for the different subtypes of Cerebral Palsy
according to the SCPE.
Figure 1. Classification tree (SCPE, 2000)

B. Topographic classification: according to the anatomic distribution

- Original classification

Hemiplegia: upper and lower extremity involvement on one side

Quadriplegia: equal involvement of upper and lower extremities

Diplegia: lower limbs more involved than upper limbs

Triplegia/monoplegia: rarely used in practice: three or one limb(s)

affected respectively

- Classification according to the SCPE

Unilateral CP: limbs on one side of the body are involved

Bilateral CP: limbs on both sides of the body are involved

C. Classification according to the functional severity

Bax et al. 2005 have classified the functional severity of children with CP in 3 categories:
mild, moderate and severe.
Mild: a child with a mild form of CP performs gross motor skills but speed, balance and
coordination are reduced.
Moderate: CP is defined as moderate if the child reaches independent walking with or
without walking aids.
Severe: When the child has no basic antigravity postural control and is unable to walk,
CP is classified as severe.
Recently children are also classified according to their motor abilities with standardised
classification systems. The Gross Motor Function Classification System (GMFCS)
classifies the functional mobility, whereas the Manual Ability Classification System
(MACS) classifies manual ability.
C1. The Gross Motor Function Classification System (GMFCS) has been widely
used to group individuals with CP into one of five levels based on functional mobility
(Palisano et al. 1997). Figure 2 shows the 5 different levels for children with cerebral
palsy.

Figure 2. Gross Motor Function Classification System (Rosenbaum et al. 2002)

C2. The Manual Ability Classification System (MACS) is designed to classify how
children with CP use their hands when handling objects in daily activities. The MACS is
not an assessment of each hand separately, but looks for the childrens manual ability to
handle objects in daily life. That means those activities that are relevant and age
appropriate for the child including for example: eating, dressing, playing, writing,
(Eliasson et al. 2006)
Figure 3 gives the MACS level description and explanation of the 5 different levels.

Figure 3. Manual Ability Classification System (Eliasson et al. 2006)

D. Classification according to the causation and the timing of the brain injury
The human brain undergoes complex organizational changes during development, in
and ex utero. Pathogenic events affecting the developing brain can cause abnormalities
or lesions. The pattern of those abnormalities or lesions depends on the stage of brain
development (Krgeloh-Mann et al. 2007). CP thus results from an injury in the
developing central nervous system, which can occur in utero, during delivery, or during
the first years of life.
Lesions can be divided in four main categories:
1. Malformations develop during the first and second trimester of gestation and include
predominantly cortical maldevelopments in bilateral distribution such as schizencephaly
(abnormal slits, or clefts, in the cerebral hemispheres), lissencephaly (literally smooth
brain, lack of development of brain folds (gyri) and grooves (sulci)) or polymicrogyria
(excessive number of small convolutions (gyri) on the surface of the brain).

2. Periventricular lesions (PVL-group) occur during the late second and early third
trimester and comprise periventricular venous infarction and periventricular leukomalacia
(white-matter brain injury, characterized by the necrosis of white matter near the lateral
ventricles)
3. Congenital cortical-subcortical lesions (CSC-group) occur in the late third trimester
or around birth and involve lesions of the gray matter structures, e.g. cortico-subcortical
infarctions, lesions of the basal ganglia and/ or thalamus.
4. Acquired brain lesions (ACQ-group) reflect all non-progressive brain lesions
occurring after the first 28 days of life and before the age of two or three, e.g. as a result
of trauma or infectious diseases.
(Steinlin et al. 1993; Cioni et al. 1999; Truwit et al. 2000)

II. Motor Function

Motor function in children with CP can be described according to the International
Classification of Functioning, Disability and Health (ICF-model). This model distinguishes
3 levels: the level of body function and structure; the activity level and the level of
participation. Each of the levels can be influenced by environmental and personal factors
(see Figure 4).
Figure 4. The ICF-model (WHO, 2001)

A. Body Function and Structure

At the level of body function and structure we can distinguish: primary problems and
secondary problems. Primary problems are directly related to the neuronal lesion,
whereas secondary problems refer to the orthopaedic problems.
A1. Primary problems
Type of motor disorder
a. Spasticity
Spasticity is present in 75-88 % of the children with cerebral palsy. (Blair et al.
1993). Spasticity is characterised by a velocity-dependent increase in tonic stretch
reflexes with exaggerated tendon jerks, resulting from hyper-excitability of the
stretch reflex (Lance et al. 1980). Spasticity is characterised by an increased reflex
activity and increased resistance during passive and active movement. Resistance
to movement increases with increasing speed. (Sanger et al. 2003). The tone is
also dependent of posture and movement.
Children with spasticity typically also show:
-

co-contractions

posture and movements in intermediate positions

stereotyped postural and movement patterns

b. Dyskinesia
Dyskinetic CP occurs in around 15% of the children with cerebral palsy (Odding et
al. 2006). Dyskinesia may include dystonia and/ or choreo-athetosis. Often, both
clinical phenomena are simultaneously present.
Dystonia is characterised by involuntary sustained or intermittent muscle
contractions causing twisting and repetitive movements, abnormal postures or both
(Sanger et al. 2003). It is dominated by abnormal postures, which may give the
impression of hypokinesia and tone fluctuation with easily tone increase.
Choreo-athetosis is characterised by hyperkinesia (e.g. increased activity)
and hypotonia (SCPE 2000). Choreo-athetosis can in turn be subdivided into
chorea and athetosis.
Chorea is characterised by rapid, involuntary, jerky, often fragmented
movements. Chorea is a ongoing random-appearing sequence of one or
more discrete involuntary movements or movement fragments.

Athetosis are slower, constantly changing, writhing or contorting

movements and these movements prevent maintenance of a stable
posture.
In general, dyskinesia is thus characterised by involuntary, uncontrolled, recurring,
occasionally stereotyped movements. Primitive reflex patterns also predominate
movement. The muscle tone is varying.
These involuntary movements and muscle tone fluctuations seen in dyskinetic
cerebral palsy generally affect the hands, arms, feet or legs, but also the entire
body, resulting in difficulties with maintaining an upright posture, or with sitting or
walking. Dyskinesia can cause a person to appear restless, only being still when
fully relaxed or asleep.

Following characteristics are also seen in children with dyskinesia

-

axial hypotonia

unvoluntary movements (increasing with emotions, anxiety, cognitive

tasks)

no intermediate positions, always caught in extreme positions, mostly in

extension

mostly upper limbs are more affected than lower limbs

asymmetric postures

laxity of the joints

often scoliosis and hip problems

c. Ataxia
Ataxia is a feature of central nervous system motor dysfunction, particularly
cerebellar abnormality, and is present in around 4% of people with cerebral palsy
(Bax et al. 2006).
Ataxia is defined as an inability to activate the correct pattern of muscles during
movement (Sanger et al. 2006), resulting in an abnormal trajectory of movement
and inaccurate limb placement.
Characteristics of children with ataxia that are observed are
-

slight axial hypotonia

tremor

dysmetria, problems with fine regulation of movements

problems with coordination

visual problems

balance problems in higher positions

d. Hypotonia
Hypotonia is more common in young children, and particularly in children with
quadriplegic CP. The prevalence of this form is relatively low (1% according Blair
and Stanly 1997). More recent reports indicate that pure hypotonia is not a feature
of cerebral palsy (Krgeloh-Mann et al. 2009). Like those with hypertonia, children
with hypotonia have a reduced ability to respond to movement demands.
Characteristics of children with hypotonia
-

low muscle tone

do not move a lot, passive

problems with alignment: asymmetry

transient phase  evolve into an other type

Strength and selectivity

A range of problems with motor control can occur including muscle weakness,
stereotyped and restricted patterns of movement, slow initiation of voluntary movement,
muscle incoordination as well as involuntary muscle activity.
A study of Eek et al. 2011 investigated the relation between muscle strength and kinetic
gait patterns in children with bilateral spastic CP and compared them with a reference
group. The children with CP had significant lower muscle strength values than the
reference group for 8 muscle groups: hip extensors and flexors, hip ab- and adductors,
knee flexors and extensors, ankle dorsi- and plantarflexors.
A recent study on muscle strength in the upper limb in children with unilateral CP
showed that weakness was very prominent in the supinators/ pronators, wrist
extensors/flexors and finger flexors (Klingels et al. 2011).

Stability or balance
Children with CP also experience problems with their equilibrium or balance and
frequently show impaired trunk control, which can affect performances of activities of
daily life such a sitting, reaching and walking (Hadders-Algra & Brogren 2008; Prosser et
al. 2010; Heyrman et al. 2011).
The problems in the adaptation of the degree of muscle contraction might be the reason
that children with CP, more often than typically developing children, show an excess of
antagonistic co-activation during difficult balancing tasks (Van der Heide et al. 2005).
A2. Secondary problems = orthopaedic problems
The abnormal muscle function (increased muscle tone, muscle inactivity) and abnormal
load or non-loading increase the risk to develop secondary orthopedic problems such as
contractures and bony deformities especially during growth.
A deformity can be defined as a structural stand deviation or lever arm dysfunction.
Orthopedic problems occur at all levels including spine, lower limbs and upper limbs.
a. Spinal deformities
Deformities of the spine such as scoliosis, kyphosis and lordosis are associated
with CP. Scoliosis can lead to serious outcomes, while kyphosis and lordosis are
not associated with significant comorbidity. (Renshaw et al. 1995)
In CP, scoliosis is neuromuscular and originating from an upper motor neuron
lesion. Patients with neuromuscular scoliosis may have a variety of scoliotic curve
types depending on the severity of CP involvement. Scoliosis is most common in
children with quadriplegia. Most curves are progressive; the progression of
scoliosis is highest during the adolescent growth spurt, especially when associated
with pelvic obliquity. (Jones et al. 2010)
Scoliosis shows a high prevalence of medical comorbidities in children with CP
like,

respiratory

problems

problems,

gastro-intestinal

disorders,

other

orthopaedic

Figure 5. Images of a 16-year-old girl with CP and moderate mental retardation. The
posteroanterior radiograph (A) and photographs (B, C) show that the patient had a 95,
long, sweeping thoracolumbar curve and severe lordosis. She was malnourished and
experienced intractable vomiting. An upper gastrointestinal series revealed a superior
mesentery artery syndrome related to the scoliosis. A percutaneous jejunostomy tube was
placed to hyperaliment her before the spine surgery. However, prior to surgery the patient
died of bronchoaspiration. (Jones et al. 2010)

b. Lower limb deformities

Deformities can occur at 3 levels: the ankle/ foot region, the knee and the hip.
Ankle/ foot
- Frequent contractures of M. Gastrocnemius; M. tibialis posterior
- Deformities of the calcaneum (medium part longer than lateral part
due to higher loading in case of valgus)
 Common problems are eg. equinus; hindfoot varus or valgus; or
combination of both; equinovarus-equinovalgus; hallux valgus; supination or
pronation of the midfoot-forefoot complex

Figure 6. Hindfoot Valgus (Fabry et al. 2002)

Knee
- Flexion contractures: shortening of the hamstrings
- Rotational deformities of the tibia: external rotation (common in
spastic diplegia) (Figure 7)
Figure 7. Spastic diplegia with external rotation of the tibia and hindfoot valgus
(Fabry et al. 2002)

Hips
- Contractures:
- flexion/ adduction
- abduction
- abduction and adduction contracture= wind-swept (Figure 8)
The flexion/adduction contractures are most common.
- Rotational deformities: internal rotation: increased femoral anteversion
(normal

8-15; CP > 15) (Figure 9)

- Subluxation-luxation (Figure 10)

 Cause: dysbalance muscle function: increased tone hip flexors and
weakness in Mm. Glutei
Subluxation is frequently seen in children with spastic quadriplegia or
hypotonia
(Koman et al. 2004; Fabry et al.2002; Moreira et al. 2002; Campbell et al.
2000; Pountney et al. 2006)
Figure 8. Windswept position (Fabry et al. 2002)

Figure 9. Rotational deformities: femoral anteversion (Moreira et al. 2002;

Campbell et al. 2000)

Figure 10. Hip dislocation of the right hip (Pountney et al. 2006)

c. Upper limb deformities

- Contractures:

Shoulder internal rotation: contracture of the pectoralis major and/ or

subscapularis

Elbow flexion

Forearm pronation

Wrist flexion

Finger flexion

Thumb adduction: contracture of the first web space

- Deformities:

Thumb-in-palm deformity (Figure 11)

Swan neck deformity (Figure 12)

- Joint instability

Joint instability of:

o Metacarpo phalangeal joint (MCP)
o Thumb: luxations

(Koman et al. 1990; Goldner et al. 1990; Goldner et al. 1988; House et al. 1981)
Figure 11. Thumb-in-palm deformity (House et al. 1981)

Figure 12. Swan Neck Deformity

B. Activity
At the activity level, limitations will be described for gross motor function, gait and upper
limb function.

B1. Gross motor function

A child with CP will be recognised by delayed gross motor development (Woollacott et
al. 1996). Gross motor function in CP can be described and predicted in terms of motor
growth curves using the Gross Motor Function Measure (GMFM) and the Gross Motor
Classification System (GMFCS) in combination (Rosenbaum et al. 2002). The GMFCS
has been described previously. The GMFM measures gross motor function in lying and
rolling, crawling and kneeling, sitting, standing and walk-run-jump activities. (see also
Paragraph 3: Evaluation; III. Evaluation at the activity level)
Himmelman et al. 2006 also assessed the distribution of the GMFCS levels in a large
population-based study. The study included 411 children with a diagnosis of CP
ascertained at 4 to 8 years of age.
.
The Gross motor function of the total group expressed by GMFCS levels was distributed
as in table 1.
Table 1: Distribution of total group CP children over the different GMFCS levels.
(Himmelmann et al. 2006)

GMFCS

II

II

IV

32%

29%

8%

15%

16%

The bar chart below (Figure 13) illustrates the relation between the GMFCS and the
different subtypes of CP

Figure 13. Relation between GMFCS and subtypes of CP (Himmelmann et al. 2006)

The distribution of the children over the 5 GMFCS-levels in fig. 13 differed significantly
between the different CP types (p<0.01).
The main findings for the different subtypes of CP are:

Spastic hemiplegia: 95% level I-II; with most (66%) at level I

Spastische diplegie: 54% level I-II; with most (38%) at level II (38%) and 31%
at levels IV-V

Spastic quadriplegia: 9% at level IV and 91% at level V

Dyskinetic CP: 4% at level I; 50% at level V

Ataxia: 93% at level I-II; with most (80%) at level II

Rosenbaum et al. 2002 made a prediction of the gross motor developmental patterns in
children with cerebral palsy according to the severity by longitudinal observations of 657
children with CP, using the GMFCS (for severity) and the GMFM (for functionality). They
created motor development curves based on these two parameters. Fig. 14 shows the
predicted average development in gross motor function measured by the GMFM
according to the 5 levels of the GMFCS.

The curved solid lines indicate average performance of the children classified in a
specific GMFCS-level according to their age.
Children in GMFCS-level 1 reached the highest scores on the GMFM, while overall
children in level 5 scored low on the GMFM.
Figure 14 suggests a trend for faster progression to the limit as severity of impairment
increases.
Figure 14. The predicted average development by the Gross Motor Function Classification
System Levels (Rosenbaum et al. 2002)

Explanation of the graph:

Vertical axis: diamonds on the axis
identify 4 items of the GMFM-66
that

predict

when children are

expected to have a 50% chance of

completing that item successfully.

A: Item 21: assesses whether a child can lift and maintain his/her head in a vertical
position with trunk support by a therapist while sitting
B: Item 24: assesses whether when in a sitting position on a mat, a child can
maintain sitting unsupported by his/ her arms for 3 seconds
C: Item 69: measures a childs ability to walk forward 10 steps unsupported
D: Item 87: assesses the task of walking down 4 steps alternating feet with arms
free

B2. Gait
Wren et al. studied gait abnormalities in 492 children (age 3-24 years old) with CP. The
most common gait abnormalities were stiff knee in swing (80%), crouch (69%),
excessive hip flexion (65%), intoeing gait (64%) and equinus (61%). The prevalence is
illustrated for the total group and for the different topographies in figure 15.

Explanation:

Stiff knee in swing: Decreased arc of knee motion from maximum knee
extension in stance to peak knee flexion in swing, and/ or delay in peak swing
knee flexion to mid- or terminal swing, hindering foot clearance.

Crouch: Knee flexion > 1 SD above the mean for normal in a significant portion
of stance phase.

Excessive hip flexion: Hip flexed > 0 in terminal stance

Intoeing gait: Internal foot progression > 1 SD more than mean for normal.

Equinus (61%): Ankle plantair flexion > 1 SD below the mean for normal
during stance phase, with or without hindfood and/ or forefoot varus or valgus.

Other less frequent gait abnormalities are:

-

Calcaneus

Ankle varus

Ankle valgus

Recurvatum

Scissoring

Out-toeing

Excessive hip adduction

Excessive internal hip rotation

Rotational malalignement

Figure 15. Prevalence of gait abnormalities in CP patients referred for gait analysis
(Wren et al. 2005)

In general, the typical gait pattern in children with diplegia is characterised by:

Lumbal lordosis

Hip: flexion, adduction, endorotation

Knee: flexion (crouch)

Ankle/ foot: equinus (equinovalgus)

A typical pattern in children with hemiplegia is:

Hip: flexion, circumduction and hitching

Knee: hyperextension or crouch

Ankle/ foot: equinus (equinovarus)

Typical position of the arm

B3. Upper Limb

Limitations in upper limb function are common in all types of CP. Upper limb involvement
can be classified by the Manual Ability Classification System (MACS).
Eliasson et al.2006 evaluated 168 children with Cerebral Palsy of all subtypes (hemi-, diand quadriplegic, ataxic and dyskinetic CP) between 4 and 18 years old.
The upper limb involvement of the total group expressed by MACS levels was distributed
as in table 2.
Table 2: Distribution of total group CP children over the different MACS levels. (Eliasson et
al. 2006)

MACS

II

II

IV

14%

38%

17%

17%

14%

The distribution of these children according to the different MACS-levels is given in

figure 16.
Figure 16. Distribution of the children over the MACS levels according to subtypes of CP
(Eliasson et al. 2006)

The children with hemiplegia were mainly seen in level II, but also in levels I and III.
Children with diplegia and ataxia were found in levels I to V, whereas children with
dyskinetic CP and tetra- or quadriplegia were apparent in levels IV and V.
In this study, the relationship between the MACS and GMFCS was also investigated
(Figure 17).
Figure 17. Distribution of the children with CP between the levels of the Manual Ability
Classification System (MACS) and the Gross Motor Function Classification System
(GMFCS) (Eliasson et al. 2006)

The correlation between GMFCS and MACS was 0.79 (p< 0.05), with complete
agreement in 49%. A large variation occurred at MACS level II, where 40% of the
children were scored and where the agreement between GMFCS and MACS was just
35%. Differences were also observed in other levels.
Unilateral spastic CP accounts for 38% of children with CP and is the most common type
of CP among children born at term and second to bilateral spastic CP among preterm
infants (Sellier et al. 2010). In children with unilateral CP, the upper limb is usually more
involved than the lower limb and the extent to which they can use their hands is critical
to their overall development. Consequently this target group is most investigated.

Children with unilateral cerebral palsy often present upper limb impairments including
increased muscle tone; impaired sensation; reduced strength and range of motion;
decreased speed (Brown et al. 1987), which results in difficulties in unimanual function
such as controlling grasp. (Eliasson et al. 1995; Sakzewski et al. 2010). Many children
with hemiplegia also present with deficits in bimanual coordination, which is problematic
as most daily activities involve the coordinated use of both hands (Sakzewski et al.
2010). Independence in these tasks is achieved using adaptive strategies to
compensate for poor bimanual skills. (Arner et al. 2008) Adaptive strategies may include
learning to do activities exclusively with the unimpaired hand, despite having reasonable
unimanual capacity of the impaired arm. This is called a developmental non-use.

C. Participation:
Impairments and limitations in activities influence the participation level such as in
school, sports or other social activities in the community.

D. Effect of environmental and personal factors

Environmental factors extrinsic to the individual such as the physical and material
features of the environment, formal and informal social structures as well as services
and systems in the community may influence an individuals experience of cerebral
palsy. As such, different environments may differentially affect the ability of the same
individual to perform successfully or participate in an activity.
The individuals personal characteristics such as their personality, age, sex, ethnic
group, fitness, habits, education and social background also interact with the health
condition and environment to affect the level and extent of functioning for an individual.
E.g. two people might have severe impairment and yet one persons level of fitness may
be better than the others, which may positively affect their ability to perform a physical
activity.

III. Associated Disturbances

Sensibility
Tactile sensation, proprioception, two-point discrimination and haptic perception are
impaired in up to 50% of children with cerebral palsy (Odding et al. 2006).

Vision
Overall visual impairments like strabismus, hemianopsia are presented in 62-71% of
the children with CP. Severe visual impairments are reported in 10-12% of the children
(Reid et al. 2005; Odding et al. 2006; Krgeloh-Mann et al. 2009).

Epilepsy
Epilepsy occurs in up to a third of children with CP. Seizure types vary and many
individuals will have more than one type (Carlsson et al. 2003).

Cognitive impairments
Cognitive impairments are common although the reported incidence varies between
studies because of differing definitions.
The SCPE reports frequencies ranging from 23-44% with any learning disability (IQ<70),
and 30 to 41% with severe disabilities (IQ<50). (SCPE, 2000).

Behavioural and psychosocial problems

Behavioural and psychosocial problems are more common in children with cerebral
palsy (25%) than general in children (5%) (McDermott et al. 1996).

Hearing impairment
Hearing impairment is much less common, occurring in less than 8% of the children with
CP (Reid et al. 2005; Odding et al. 2006; Surman et al. 2006).

Feeding problems
Gastrointestinal as well as feeding problems are frequently present in children with CP.
Sucking and swallowing problems the first 12 months of life are common: 57% and 38%
respectively. In 60% of the children severe feeding problems even precede the diagnosis
of CP (Odding et al. 2006).

Himmelmann et al. 2006 investigated the accompanying impairments in 353 children

with CP. Learning disability was present in 40% of the children, epilepsy in 33% and
severe visual impairment in 19%. The proportion of children with accompanying
impairments increased significantly with GMFCS levels (p< 0.001). This is also illustrated

by fig. 18. In children with motor function at GMFCS level 1, 79% had no accompanying
impairment, contrasting with 6% of those at GMFCS level 5. In children with GMFCS
level 5, 89% had two or more accompanying impairments.
Figure 18. Proportion of learning disability, epilepsy and severe visual impairments by
GMFCS levels in 353 children with CP. (Himmelmann et al. 2006)