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I. Intensive and convalescent care

  1. Definition

    1. Cerebral palsy (CP) describes a group of permanent disorders of the development of movement and posture, causing activity limitation, which are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain.

    2. The motor disorders are often accompanied by disturbances of sensation, perception, cognition, communication, and behavior, by epilepsy, and by secondary musculoskeletal problems.

  2. Incidence

    1. Survival following extreme premature birth has dramatically improved (60% to 90% depending on gestational age and birthweight), but survival without disability remains an elusive challenge for the field.

    2. Cerebral palsy is one of the most frequent major neurodevelopmental impairments following prematurity. The earlier the baby is born, the greater the risk for CP. As a result, the incidence of CP among premature infants is most accurately reported as a range, which is conventionally described as 3-80/1000 neonatal survivors.

    3. Cerebral palsy is in fact the most common physical disability in childhood, occurring in 2-2.5/1000 births. The overall rate has remained remarkably stable for the last 60 years.

    4. When thinking about incidence, it is important to recognize that CP occurs in both preterms (40% of cases) and in term born infants (60% of cases), except the risk is much higher among premature infants.

    5. The rate of CP among premature infants initially increased in the 1970s-1980s as younger and younger children survived extreme prematurity. Credit to advances in neonatal care, the rise in frequency of CP among extremely preterm infants appears to have stabilized and is encouragingly now dipping in some developed countries. Therefore, the rate and epidemiological profile of cerebral palsy is most accurate when consideration is given to the time and place of birth.

  3. Pathophysiology

    1. The cerebral insults that give rise to the motor impairments of cerebral palsy have wide ranging origins including vascular, traumatic, hypoxic-ischemic, metabolic, infectious, and genetic causal pathways.

    2. Injuries can occur both within the white and gray matter of the brain and most often include:

      1. White matter damage or periventricular leukomalacia (PVL) (40% to 60% of cases)

      2. Cortical, subcortical, and deep gray matter lesions (10% to 20% of cases)

      3. Brain malformations (10% of cases)

    3. The brain injury patterns most commonly associated with prematurity include

      1. Intraventricular hemorrhage

      2. Dilated ventricles (ventriculomegaly)

      3. Periventricular leukomalacia (PVL) or white matter injury

    4. A correlation usually exists between the location and size of the injury and the severity of the child's motor impairment, but this is not always the case. Advanced serial neuroimaging can now provide important prognostic insights about developmental motor outcomes.

    5. Children with brain malformations and cortical/subcortical and basal ganglia lesions generally exhibit more severe motor impairments and have the highest risks for being nonambulatory.

    6. Children with periventricular white-matter lesions generally exhibit milder motor impairments (ie, are usually ambulatory) and also contend with less-associated impairments. However, there is a subgroup of preterm infants with more severe white matter injury who may fair worse than those born at term age, with respect to long-term motor and developmental outcomes.

    7. Three major classifications ...

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