Across Cultures
Cerebral palsy is a disease that affects people around the world and begins in young childhood. It is present on every populated continent. The symptoms and etiologies of the disease appear to be similar everywhere; what differs between locations is prevalence of the disease and the measures that are taken to prevent and treat it. Cerebral palsy is more likely to occur in children who are born into sub-par living conditions which tend to be unsanitary (and therefore promote the chance of perinatal infection, which is a known risk factor for cerebral palsy), and this fact may account for varying levels of prevalence of cerebral palsy around the globe. Moreover, cultural factors, such as education, socioeconomic status and gender discrimination, affect one’s ability to gain information and may limit assess to proper medical care (e.g., of the mother during pregnancy or of the baby during and after birth). Additionally, differing methods of treatment of the disease – for example, conventional Western use of pharmaceuticals versus traditional Eastern use of herbal remedies – yield different outcomes.
1. Cerebral palsy in Riyadh, Saudi Arabia: I. Aetiological factors
Aetiological factors predisposing to cerebral palsy were investigated in 190 children with this condition seen in Riyadh , Saudi Arabia since January 1980. Ninety-four (49.5%) of the cases were natal in origin, 63 (33.1%) prenatal and 33 (17.4%) postnatal. Anoxia was the most common aetiological factor, accounting for 38 cases (20%), followed by prematurity in 18 (9.5%). These two factors combined accounted for 29.5% of all cases and 59.5% of those in the natal group. Idiopathic cases, the third largest group, accounted for 9.0%. Certain factors were shown to predispose to specific neurological deficits, the majority of the 190 patients being spastic diplegic (31%) or quadriplegic (26.3%). Saudi Arabia is going through a process of massive economic, social and medical progress. In view of improvements in all these areas and of other factors, a change in the pattern of incidence of cerebral palsy in Saudi Arabia is expected in the future.
[el Rifai, M. R., Ramia, S. & Moore, V. (1984). Cerebral palsy in Riyadh, Saudi Arabia: I. Aetiological factors. Annals of Tropical Paediatrics,4(1), 7-12.]
2. Participation in age-related activities and influence of cultural factors—comments from youth and parents of children with postnatal post infectious hemiplegia in Stockholm, Sweden
PURPOSE: To investigate whether children with postnatal post-infectious hemiplegic cerebral palsy, and their parents, felt that participation in activities typical for the child's age and gender was affected. To identify factors, intra- and extra-personal that influenced disability with emphasis on factors related to immigration. METHOD: Interviews with six youths and 15 caregivers regarding the child's ability to participate in age-related activities, the consequences of disability in their home country compared to Sweden, and whether immigration influenced being a parent to a disabled child. RESULTS: All reported large difficulties participating in age-related activities. Positive and negative differences in participation in different cultures were described. War, culture, eating habits, hygiene habits, and school could differ and create difficulties when in Sweden. Language skills and intra personal factors influenced information gathering and participation in parental activities. CONCLUSIONS: Surprisingly large difficulties in participation may separate those with a postnatal post-infectious aetiology from hemiplegia of other aetiologies. High degrees of additional impairments may influence participation more than the physical disability. Language skills and cultural factors influence ability to seek and gain information. A mutual process where both Swedes and immigrants know traditions of care for disabled in both places may create understanding and improved dialogue.
[Radell, U., Tillberg, E., Mattsson, E. & Amark, P. (2008). Participation in age-related activities and influence of cultural factors—comments from youth and parents of children with postnatal post infectious hemiplegia in Stockholm, Sweden. Disability and Rehabilitation, 30(11), 891-7.]
3. Epidemiology of spastic tetraplegic cerebral palsy in Sweden. II. Prevalence, birth data and origin.
The prevalence and origin of spastic tetraplegic cerebral palsy (TPL) was investigated in a population-based study from 15 Swedish counties and the city of Gothenburg. The series comprised 96 children and adolescents born in 1959-1978. The prevalence at the ages of 5-24 years was 8 per 100,000. The etiological analysis was based on the 91 TPL subjects, born in Sweden. The preterm rate was 7%. There were 46 males and 45 females. Excluding postnatal cases, the mean birth weight was 2949 g and the proportion of SGA 21%. An obvious prenatal origin was found in 21 (mainly microcephaly, other CNS maldevelopment, intrauterine CMV-infection), an obvious perinatal origin in nine (mainly cerebral hemorrhage), and an obvious postnatal origin in 16 (mainly CNS infection). A potential prenatal origin was considered in six, a combined pre- and perinatal in 15, a perinatal in 13 and in 11 the origin of TPL was untraceable. An optimality analysis showed that reduced optimality in the partum and postpartum periods discriminated between pre- and perinatal etiology of TPL. Cases with obvious perinatally derived TPL had a high load of complications in the partum and postpartum periods, whereas these periods had been fairly uncomplicated in cases with an obviously prenatal origin of TPL. - It was indicated that some 50-55% of TPL was prenatally, around 30% perinatally and some 15-20% postnatally derived. The low preterm rate as well as the proportion of perinatal brain damage in TPL cases has probably increased in recent birth year periods due to the appearance of very preterm, severely multi-impaired children in the CP panorama.
[Edebol-Tysk, K. Hagberg, B. & Hagberg, G. (1989). Epidemiology of spastic tetraplegic cerebral palsy in Sweden. II. Prevalence, birth data and origin. Neuropediatrics, 20(1), 46-52.]
4. An epidemiological study of cerebral palsy in Western Australia, 1956-1975. III: Postnatal aetiology
Cases of cerebral palsy which apparently were due to some postnatal event were studied in the Western Australian Cerebral Palsy Register. 11 per cent (89) of all cases were thought to be so acquired, a rate of 2.4 per 10,000 neonatal survivors. Males, particularly under 12 months of age, were especially vulnerable. Infections such as meningitis and encephalitis, particularly among aboriginal children, were responsible for over half the cases and accidents were responsible for one-quarter. Other causes included epileptic fits and cerebrovascular accidents. There was a positive association with parity and neonatal problems and a negative one with birthweight, suggesting that children 'at risk' neonatally are more susceptible to a postnatal brain-damaging event. Preventive programmes should include improvement in aboriginal living conditions; legislation for car restraints for infants; and health education for parents on the vulnerability of infants, the importance of immunisation, and how to recognize early the signs of potentially serious infections.
[Blair, E. & Stanley, F. J. (1982). An epidemiological study of cerebral palsy in Western Australia, 1956-1975. III: Postnatal aetiology. Developmental Medicine and Child Neurology, 24(5), 575-85.]
5. Prevalence of cerebral palsy in Okinawa between 1995 and 2001
We report a population based study of prevalence of cerebral palsy in children born between 1995 and 2001 in Okinawa. The overall prevalence of cerebral palsy was 2.3 per 1,000 live-births; this result was higher than that reported in our previous study conducted between 1988 and 1994. We found a high prevalence of cerebral palsy in children weighing less than 2,500 g, especially in those weighing less than 1,500 g at birth. Moreover we found children weighing more than 1,800 g or those who had more than 33 weeks of gestation period at birth showed a lower risk for cerebral palsy.
[Touyama, M. & Touyama, J. (2008). Prevalence of cerebral palsy in Okinawa between 1995 and 2001 [Japanese]. No To Hattatsu. Brain and Development, 40(5), 387-92.
6. The prevalence of cerebral palsy in British Columbia, 1991-1995
OBJECTIVE: To quantify the prevalence of cerebral palsy (CP) in British Columbia within a four-year birth cohort. METHODS: The study was a population-based record linkage study of a birth cohort of British Columbian children born between April 1, 1991 and March 31, 1995. Cases were identified by the presence of International Classification of Diseases, Version 9 (ICD-9) diagnostic code "343" recorded at three years of age or older or by having the ICD-9 diagnostic code "343" recorded prior to the third birthday with two confirmatory diagnoses within the first three years of life through a record search of the BC Medical Services Plan billing files for the fiscal years 1991 to 1995. RESULTS/CONCLUSION: This research has provided an estimate of the prevalence of CP in the four-year birth cohort 1991 to 1995 in British Columbia. An aggregate prevalence rate of CP was measured as 2.68 per 1000 live births, and a congenital rate was measured at 2.57 for the same population. Birth weight and gestational age demonstrated a significant relationship with the development of CP. This study should lend credence to the establishment of a CP register in British Columbia.
[Smith, L., Kelly, K. D., Prkachin, G. & Voaklander, D. C. (2008). The prevalence of cerebral palsy in British Columbia, 1991-1995. The Canadian Journal of Neurological Sciences, 35(3), 342-7.]
7. Life expectancy among people with cerebral palsy in Western Australia
This report describes trends, predictors, and causes of mortality in persons with cerebral palsy (CP) using individuals identified by the Western Australian Cerebral Palsy Register and born between 1958 and 1994. Two thousand and fourteen people were identified (1154 males, 860 females), of whom 225 had died by 1 June 1997. Using date-of-death data, crude and standardized mortality rates were estimated and predictors of mortality sought using survival analysis stratified by decade of birth, description of impairments, and demographic and perinatal variables. For those born after 1967, the cause of death profile was examined over time. Mortality exceeded 1% per annum in the first 5 years and declined to age 15 years after which it remained steady at about 0.35% for the next 20 years. The strongest single predictor was intellectual disability, but all forms of disability contributed to decreased life expectancy. Half of those with IQ/DQ score <20 survived to adulthood, increasing to 76% with IQ/DQ score 20-34, and exceeding 92% for higher scores. Severe motor impairment primarily increased the risk of early mortality. Despite there being 72 persons aged from 25 to 41 years with severe motor impairment in our data set, none had died after the age of 25 years. Infants born after more than 32 weeks' gestation were at significantly higher risk of mortality than very preterm infants, accounted for by their higher rates of intellectual disability. No improvements in survival of persons with CP were seen over the study period despite advances in medical care, improved community awareness, and the increasing proportion of very preterm births among people with CP. This may be the result of improved neonatal care enabling the survival of infants with increasingly severe disabilities.
[Blair, E., Watson, L., Badawi, N. & Stanley, F. J. (2001). Life expectancy among people with cerebral palsy in Western Australia. Developmental Medicine and Child Neurology, 43(8), 508-15.]
8. ‘I am what I am because of who we all are:’ International perspectives on rehabilitation: South Africa
This article provides an overview of some of the important factors that impinge on people with cerebral palsy and their families, on medical and rehabilitation personnel, and on systems of healthcare and education in South Africa. Information is provided with regard to the national contextual variables that influence intervention in the country. The incidence of cerebral palsy is related to some of the more prominent aetiological variables including poverty, malaria, HIV/Aids and premature birth. Health care systems available for children with cerebral palsy are discussed, including the role of traditional healers. Access to education, training and care of children with cerebral palsy is described, including a brief history of specialized education in South Africa. An overview of the personnel, approaches and work contexts involved in rehabilitation highlights the unique nature of intervention in South Africa. The article concludes with recommendations for interventionists with reference to lessons that can be learned in terms of adapting skills and knowledge to local needs, in order to work successfully with children with cerebral palsy and to develop the resilience of their families. In addition, it is suggested that the definition of cerebral palsy needs to reflect the context in which the person lives.
[Levin, K. (2006). ‘I am what I am because of who we all are:’ International perspectives on rehabilitation: South Africa. Pediatric Rehabilitation, 9(3), 285-92.]
9. Treatment of 140 cerebral palsied children with a combined method based on traditional Chinese medicine (TCM) and western medicine
OBJECTIVE: To observe and evaluate a method that is effective and practical for treatment of cerebral palsied (CP) children in China. METHOD: The patient's age and disease type and individual specific conditions were considered in choosing therapy methods accordingly: Chinese herbs, acupuncture, auricular seed pressure, point finger pressing, massage, orthopedic hand manipulation, physiotherapy, occupational therapy, language therapy, etc. Meanwhile we created a new CP treatment model that combines hospitalized treatment with family therapy. RESULTS: The majority of CP patients improved greatly in motor and social adaptation capacities after treatment. Wilcoxon paired rank sum test analysis showed that there were significant differences between the data before and after treatment (P<0.01). CONCLUSION: This combined therapy method, based on traditional Chinese medicine and western medicine plus family supplemental therapy, is an effective and practical treatment strategy for CP children in China.
[Zhou, X. J. & Zheng, K. (2005). Treatment of 140 cerebral palsied children with a combined method based on traditional Chinese medicine (TCM) and western medicine. Journal of Zhejiang University. Science. B, 6(1), 57-60.]
10. Cerebral palsy in Norway: Prevalence, subtypes and severity
BACKGROUND/AIM: To describe prevalence, subtypes and severity of cerebral palsy (CP) in Norway using criteria proposed by the Surveillance of Cerebral Palsy in Europe (SCPE) network. MATERIAL: All children in Norway with CP born in January 1996-December 1998 were registered in the Cerebral Palsy Registry of Norway. The Medical Birth Registry of Norway provided the perinatal data. RESULTS: A total of 374 children with CP were identified with a prevalence of 2.1 per 1000 live births. Detailed information was obtained from 294 (79%) children. Median age at clinical assessment was 6.9 years (range: 1.9-10.2 years). Thirty-three percent of the children had spastic unilateral CP, 49% spastic bilateral, 6% dyskinetic, 5% ataxic CP and 7% were not classified. Severely impaired vision and hearing were present in 5% and 4% of the children, respectively. Active epilepsy was present in 28%, mental retardation in 31% and severely impaired or no speech in 28% children. The most severe impairments in gross motor function were observed in children with low Apgar scores, and the most severe impairments in fine motor function in children born at term, with normal birth weight and low Apgar scores. CONCLUSION: Compared with other populations, the prevalence of CP as well as the proportions of subtypes and gross motor impairments were similar, whereas fine motor impairments and associated impairments were more common. The classification of children with mixed forms of CP is still a challenge. Children were more severely affected if Apgar scores were low, and if they were born at term.
[Anderson, G. L., Irgens, L. M., Haagaas, I., Skranes, J. S., Meberg, A. E. & Vik, T. (2008). Cerebral palsy in Norway: Prevalence, subtypes and severity. European Journal of Paediatric Neurology, 121, 4-13.]
11. Cerebral palsy among children in Nordland 1977-91. Occurrence, etiology, disability
An increasing prevalence of cerebral palsy has been reported in Sweden and other countries. One Norwegian study shows decreasing incidence, another shows increasing incidence among preterm children. The aim of this study is to describe prevalence of cerebral palsy and its etiology and disability among children in Nordland county who were born between 1977 and 1991. Perinatal mortality in the county declined from 11 per 1,000 in 1973-83 to 7.9 per 1,000 in 1987-91. 62 boys and 31 girls were diagnosed with cerebral palsy. The prevalence was 1.91 in 1977-81, 1.98 in 1982-86 and 2.05 per 1,000 i 1987-91. Among children with a birthweight < 1,500 g the prevalence decreased significantly to; 88.9, 42.7 and 28.8 per 1,000 respectively. Causative factors and disability are presented. Prevalence of cerebral palsy as a measure of quality of perinatal care is discussed, and a recommendation for a central register is made.
[Herder, G. A. (1998). Cerebral palsy among children in Nordland 1977-91. Occurrence, etiology, disability. Tidsskrift for den Norske Laegeforening, 118(5), 706-9.]
12. Incidence patterns of cerebral palsy in Shiga Prefecture, Japan, 1977-1991
The prevalence of cerebral palsy (CP) in 6-year-old children in Shiga Prefecture, Japan, born between 1977 and 1991, was compared in three successive 5-year periods: period I (1977-1981), period II (1982-1986) and period III (1987-1991). Data on the accumulated age-specific prevalence of CP were collected and analyzed. During the study period, 242293 children entered elementary school, and 325 cases (194 boys, 131 girls) of CP were ascertained in Shiga Prefecture. The overall prevalence of CP per 1000 6-year-old children was 1.34. The prevalence of CP for 6-year-old children increased from period II to period III, although it did not vary from period I to period II. The proportion of low birth weight (LBW) infants and preterm infants among those with CP increased with time during the study periods. The prevalence of CP in infants born at term and with birth weight > or =2500 g did not vary over the study period. The prevalence of CP in preterm and LBW infants, especially in infants with gestational age<32 weeks and birth weight<1500 g, increased from period II to period III, while the prevalence did not increase from period I to period II. Multiple births and use of mechanical ventilation increased from period II to period III. The changes in the prevalence of CP in Shiga Prefecture may have been due to increased survival of preterm and LBW infants in period II owing to better obstetric and neonatal care, and to further improvement in the survival of very small babies receiving intensive care, which increased the prevalence of CP in period III. Further improvement of perinatal care might decrease the incidence of CP in Shiga Prefecture in the future.
[Suzuki, J. & Ito, M. (2002). Incidence patterns of cerebral palsy in Shiga Prefecture, Japan, 1977-1991. Brain & Development, 24(1), 39-48.]