What Is Cerebral Palsy – Causes, Symptoms, Treatment

What Is Cerebral Palsy/Cerebral palsy (CP) is a group of non-progressive, permanent, development of movement disorders including impaired muscle tone, impaired movement control, and impaired co-ordination movement, posture, musculoskeletal problems, intellectual disability, feeding difficulties, visual abnormalities, hearing abnormalities, and communication difficulties that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain.

Types of Cerebral Palsy

Cerebral palsy is a tone abnormality and the distribution of motor abnormalities. The subtypes of cerebral palsy are

• Spastic diplegic – The patient has spasticity and motor difficulties that affecting the movement of legs more than the arms
• Spastic hemiplegic – The patient has spasticity and motor difficulties that are affecting the movement one side of the body; the arms are often involved more than the legs
• Spastic quadriplegic – The patient has spasticity and motor difficulties that are affecting the movement of all four extremities; often, there is often greater involvement of the upper extremities than the legs or lower extremities.
• Dyskinetic or hyperkinetic (choreoathetosis) – The patient has excessive, involuntary movements characterized as a combination of rapid, dance-like contractions in upper and lower extremity muscles and slow writhing movements.
• Dystonic – The patient has involuntary, sustained muscle contractions that are causing twisting and repetitive movements.
• Ataxic – The patient has unsteadiness and incoordination of muscular balance, they are often hypotonic.[rx]

Geographical classification of cerebral palsy.

Causes of Cerebral Palsy

• Brain injury or abnormal brain development – Due to injury to the developing brain can occur anytime from gestation to early childhood time. Contrary to some scientist belief, fewer than 10% of injuries occurring during the birth process result in cerebral palsy.
• Prematurity and postmaturity – In cohort studies have shown an increased risk of cerebral palsy in children born slightly preterm (37–38 weeks) or post-term (42 weeks) compared with children born at term (40 weeks).^[rx]
• Cerebral leukomalacia – It is one of the most important causes of cerebral palsy.
• Damage to the white matter of the brain (periventricular leukomalacia, or PVL) – The white matter of the brain is responsible for transmitting signals and massage inside the brain and to the rest of the body.  The damage from PVL looks like tiny holes in the white matter of an infant’s brain. These gaps or absent in brain tissue interfere with the normal transmission of signals. Researchers and scientists have identified a period of selective vulnerability in the developing fetal brain, in a period of time between 26 and 34 weeks of gestation age, in which periventricular white matter is particularly sensitive to insults and injury.
• Abnormal development of the brain (cerebral dysgenesis) –  Any interruption of the normal process of brain growth in time or during fetal development can cause brain malformations that disrupted the transmission of brain signals. On the genetic engineering side, the mutations in the genes that control brain development during this early period of gestation can keep the brain from developing normally. Generally, infections, fevers, trauma, or other conditions that cause unhealthy conditions in the womb or ovum also put an unborn baby’s nervous system at risk.
• Bleeding in the brain or intracranial hemorrhage – Bleeding inside the brain from blocked or broken blood vessels with clot blood is commonly caused by fetal stroke.   Some babies suffer a stroke while still in the womb because of blood clots in the placenta that block blood flow in the brain.  Other types of fetal major stroke are caused by malformed or weak blood vessels in the brain or by blood-clotting abnormalities.  Maternal high blood pressure is a common medical disorder during pregnancy and is more common in babies with fetal stroke.  Maternal infection, especially pelvic inflammatory disease, has also been shown to increase the risk of fatal stroke and other neurodevelopmental abnormalities.
• Severe lack of oxygen in the brain –  Asphyxia meaning, a lack of oxygen in the brain caused by an interruption in breathing or poor oxygen supply during the gestational time and later, is common for a brief period of time in babies due to the stress of labor and delivery.  If the proper supply of oxygen is cut off or reduced for lengthy periods, an infant can develop a type of brain damage called hypoxic-ischemic encephalopathy disease abnormality, which destroys tissue in the cerebral motor cortex, cerebrum, and other areas of the brain. This kind of damage can also be caused by severe maternal low blood pressure, rupture of the uterus, detachment of the placenta in some cases, or problems involving the umbilical cord, or severe trauma to the head during labor and delivery.
• Periventricular–intraventricular hemorrhage, hypoperfusion injuries –  It is another type of abnormality in the distribution of the middle cerebral artery, basal ganglia, or other regions of the brain.
• Cerebral infections or inflammations – It is the most common life-threatening disease condition that most frequently causes cerebral palsy.
• Low birth weight and premature birth – Premature babies mean early delivery (born less than 37 weeks into pregnancy) and babies weighing less than 5 ½ pounds at birth or less have a much higher risk of developing cerebral palsy than full-term, heavier-weight babies.  Tiny babies born or low weight at very early gestational ages are especially at risk.
• Multiple births – The twins, triplets, and other multiple births even those born at term are linked to an increased risk of cerebral palsy. The death of a baby’s twin or triplet further increases the changing risk.
• Infections during pregnancy – Infections such as toxoplasmosis, rubella (German measles), cytomegalovirus, and herpes, can cause infection in the womb and placenta. The inflammation triggered by infection may then go on to damage the developing nervous system in an unborn baby or an unhealthy baby. Maternal fever during pregnancy or delivery can also cause this kind of inflammatory response.
• Blood type incompatibility between mother and child – Rh incompatibility is a condition that develops when a mother’s Rh blood type either positive or negative is different from the blood type of her baby. The mother’s system doesn’t tolerate the baby’s different blood type and infection and her body will begin to make antibodies that will attack and kill her baby’s blood cells, which can cause brain damage and causes cerebral palsy.
• Exposure to toxic substances – Mothers who have been exposed and drinks to toxic substances during pregnancy, such as methyl mercury and heavy metal, are at a heightened risk of having a baby with cerebral palsy.
• Mothers with thyroid abnormalities, intellectual disability, excess protein in the urine, or seizures –  Mothers with any of these hormonal conditions are slightly more likely to have a child with CP. There are also medical conditions during labor and delivery, and immediately after delivery that may act as warning signs for an increased risk of cerebral palsy.
• Breech presentation – Babies with cerebral palsy are more likely to be in breech position feet first instead of head first at the beginning of labor and delivery. Babies who are unusually floppy, underweight as fetuses are more likely to be born in the breech position.
• Complicated labor and delivery – A baby who has vascular or respiratory problems during labor, after labor, and delivery may already have suffered brain damage, injured, or abnormalities.
• Small for gestational age –  Babies born smaller than normal for their gestational age are at risk for cerebral palsy because of factors that kept them from growing naturally in the womb.
• Low Apgar score –  The Apgar score is the health measurement scale is a numbered rating that reflects a newborn’s physical health. Doctors periodically score a baby’s heart rate, breathing, muscle tone, reflexes, and also skin color during the first minutes after birth. A low score at 10-20 minutes after delivery is often considered an important sign, symptoms of potential problems such as CP.
• Jaundice – More than 50 percent of newborns develop jaundice and pre, postnatal jaundice (yellowing of the skin or whites of the eyes) after birth when bilirubin, a substance normally found in bile, and bile duct builds up faster than their livers can break it down and pass it from the body. Severe, untreated jaundice can kill brain cells and can cause deafness, toneless and CP.
• Seizures – An infant who has seizures faces that make a higher risk of being diagnosed later in childhood with CP.

Abnormal development or damage to the fetal or infant’s brain causes cerebral palsy. The brain insult injury-causing CP is non-progressive (static) and also can occur in the prenatal, perinatal, or postnatal periods. There are more causes of cerebral palsy.

Prenatal Causes

• Congenital brain malformations
• Intrauterine infections
• Intrauterine stroke
• Chromosomal abnormalities[rx][rx]

Perinatal Causes

• Hypoxic-ischemic insults
• Central nervous system (CNS) infections
• Stroke
• Kernicterus[rx][rx]

Postnatal Causes

• Accidental and non-accidental trauma
• CNS infections
• Stroke
• Anoxic insults[rx][rx]

Spasticity

• Hereditary spastic paraplegia
• Tethered cord
• Spinal cord tumor
• Adrenoleukodystrophy
• Arginase deficiency
• Pyruvate dehydrogenase deficiency
• Rett syndrome
• Lesch-Nyhan syndrome
• Pelizaeus-Merzbacher
• Glut 1 transporter deficiency

Dystonia

• Dopa-responsive dystonia
• Glutaric aciduria type 1
• Pyruvate dehydrogenase deficiency
• Lesch-Nyhan syndrome
• Leigh’s disease
• Niemann-Pick type C
• Glut 1 transporter deficiency

Hypotonia

• holocarboxylase synthetase deficiency
• Zellweger syndrome
• Infantile Refsum disease
• Pontocerebellar hypoplasias
• Metachromatic leukodystrophy

Ataxia

• Ataxia-telangiectasia
• X-linked spinocerebellar ataxia
• Angelman’s syndrome
• Glut 1 transporter deficiency
• Leigh disease
• Joubert syndrome

Choreoathetosis

• Pelizaeus-Merzbacher
• Lesch-Nyhan syndrome

Weakness

• Muscular dystrophies
• Metachromatic leukodystrophy
• Pontocerebellar hypoplasias

Prematurity is the most significant risk factor for cerebral palsy. Complications of prematurity that can cause cerebral palsy include [rx][rx]:

• Periventricular leukomalacia
• Intraventricular hemorrhage
• Periventricular infarcts.

Other risk factors associated with cerebral palsy are multiple gestation, intrauterine growth restriction, maternal substance abuse, preeclampsia, chorioamnionitis, abnormal placental pathology, meconium aspiration, perinatal hypoglycemia, and genetic susceptibility.[rx][rx]

Effects of Cerebral Palsy

• Intellectual disability – Approximately 30 – 50 percent of individuals with cerebral palsy will be intellectually impaired. Mental impairment is more common among those with spastic quadriplegia, paraplegia than in those with other types of cerebral palsy.
• Seizure disorder –  As many as half of all children with cerebral palsy have one or more seizures. Children with both cerebral palsy and epilepsy are more at risk to have intellectual disabilities in later life.
• Delayed growth and development –  Children with moderate to severe cerebral palsy, especially those with spastic quadriparesis, diplegia, paraplegia often leg behind in growth and development. In babies, this lag usually takes the form of too little weight gain problem in most cases. In young children, it can appear as abnormal shortness, and in teenagers, it may appear as a combination of shortness and lack or want of sexual development problem also found. The involving muscles and limbs affected by cerebral palsy tend to be smaller than normal, especially in children with spastic hemiplegia, whose limbs on the affected side of your body may not grow as quickly or as long as those on the normal side of a body part.
• Spinal deformities and osteoarthritis – The deformities of the spine curvature called scoliosis, humpback called kyphosis, and saddleback called lordosis is associated with cerebral palsy. Spinal deformities can make sitting, standing, and walking difficult and cause chronic back pain with leg pain. Pressure on and misalignment of the joints may result in osteoporosis a breakdown of cartilage in the joints and bone enlargement.
• Impaired vision – Many children with cerebral palsy have strabismus, commonly called cross-eyes, which left untreated can lead to poor vision in one eye or both eyes and can interfere with the ability to judge distance. Some children with cerebral palsy have difficulty understanding and organizing visual information. Other children may have a loss of vision or blindness that blurs the normal field of vision in one or both eyes.
• Hearing loss – Impaired hearing is also more frequent among those with cerebral palsy than in the general population.  Some children have partial or complete hearing loss, particularly as a result of jaundice or lack of oxygen to the developing brain.
  Speech and language disorders –  Speech and language disorders, such as difficulty forming words and speaking clearly, are present in more than a third of persons with cerebral palsy. Poor speech impairs communication and is often interpreted as a sign of cognitive impairment problem, which can be very frustrating to children with cerebral palsy, especially the majority who have average to above-average intelligence are found.
• Drooling –  Some individuals with cerebral palsy drool because they have poor control of the muscles of the throat, mouth, and tongue.
• Incontinence – A possible complication of cerebral palsy is incontinence, caused by poor control of the muscles that keep the bladder closed.
• Abnormal sensations and perceptions – Some individuals with cerebral palsy experience pain or have difficulty feeling simple sensations, such as touch.
• Learning difficulties – Children with cerebral palsy may have difficulty processing particular types of spatial and auditory information. Brain damage may affect the development of language and intellectual functioning.
• Infections and long-term illnesses – Many adults with cerebral palsy have a higher risk of heart and lung disease, and pneumonia (often from inhaling bits of food into the lungs), than those without the disorder.
• Contractures – The muscles can become painfully fixed into abnormal positions in the body, called contractures, which can increase muscle spasticity with muscle spasm and joint deformities in people and children with cerebral palsy.
• Malnutrition – Swallowing, sucking, or feeding difficulties can make it difficult for many individuals with cerebral palsy, particularly infants, to get proper nutrition and gain or maintain weight.
• Dental problems – Many children with cerebral palsy are at risk of developing gum disease and cavities because of poor dental hygiene. Certain medications, which are seizure drugs, can exacerbate these problems.
• Inactivity – Childhood inactivity is magnified in children with cerebral palsy due to impairment of the motor centers of the brain that produce and control voluntary movement. While children with cerebral palsy may exhibit increased energy expenditure during activities of daily living, movement impairments make it difficult for them to participate in sports and other activities at a level of intensity sufficient to develop and maintain strength and fitness properly. Inactive adults with disabilities exhibit increased severity of disease condition and reduced overall health and well-being.

Symptoms of Cerebral Palsy

Symptoms of Cerebral Palsy

• Variations in muscle tone, such as being either too stiff or  floppy
• Stiff muscles in upper and lower extremities and exaggerated reflexes (spasticity)
• Stiff muscles with normal reflexes are found(rigidity)
• Lack of balance and muscle coordination problem (ataxia)
• Tremors or involuntary movements disorders
• Slow, writhing movements problem
• Delays in reaching motor skills milestones comparing other , such as pushing up on arms, sitting up or crawling, and rolling
• Favoring one side of the body, such as reaching with one hand or dragging a leg while crawling difficulty happen
• Difficulty walking, such as walking on toes, a crouched gait problem, a scissors-like gait with knees crossing problem, a wide gait, or an asymmetrical gait.
• Excessive drooling or problems with swallowing problem.
• Difficulty with sucking or eating difficulty
• Delays in speech development or difficulty speaking
• Learning difficulties in most cases.
• Difficulty with fine motor skills, such as buttoning clothes or picking up utensils
• Seizures types difficulty
• Low muscle tone and bulky types tone (baby feels floppy when picked up)
• Unable to hold up its own head while lying down on its stomach or in a supported sitting position
• Muscle spasms or feeling stiffness.
• Poor muscle control, reflexes, contracture, and posture
• Delayed development may be found (can’t sit up or independently roll over by 6 months)
• Feeding or swallowing difficulties can also see
• Preference to use one side of their body in most cases.

Children with cerebral palsy exhibit a wide variety of symptoms, including

• Lack of muscle coordination when performing voluntary movements in most cases (ataxia);
• Weakness in one or more arm or leg is found;
• Walking on the toes, a crouched gait problem, or a scissored gait;
• Variations in the co-ordination of muscle tone, either too stiff or too floppy;
• Excessive drooling or difficulties swallowing or speaking may be found;
• Shaking jerking movement(tremor) or random involuntary movements;
• Delays in reaching motor skill milestones difficulty; and
• Difficulty with precise movements such as writing or buttoning a shirt in daily activity.

Diagnosis of Cerebral Palsy

• MRI –  An MRI scan uses radiofrequency waves and a magnetic field to produce detailed 3D or cross-sectional images of your child’s brain. An MRI can often identify lesions with or abnormalities in your child’s brain. This test is painless and invisible, but it’s noisy so there no need to afraid, and can take up to an hour to complete. Your child will likely receive a sedative or light general anesthesia beforehand and near.
• Cranial ultrasound – This must be performed during infancy. Cranial ultrasound is very useful in high-frequency sound waves to produce images of the brain. Ultrasound doesn’t produce a detailed image only, but it may be used because it’s a quick and inexpensive test or diagnosis, and it can provide a valuable preliminary assessment of the brain.
• Electroencephalogram (EEG) – If your child is suspected of having seizures, convulsion, an EEG can evaluate the condition further. Seizures can develop in a child with epilepsy and others associate problems. In an EEG test, a series of electrodes are placed or attached to your child’s scalp. The EEG records the electrical activity of your child’s brain and counts records. It’s most common for there to be changes in normal brain wave patterns in epilepsy.
• Cranial ultrasound – It uses high-frequency sound waves to produce pictures of the brains of young babies in most cases. It is used for high-risk infants because it is the least intrusive of the imaging techniques to find an abnormality, although it is not as successful as computed tomography (CT scan) or magnetic resonance imaging at capturing subtle changes in white matter—the type of brain tissue that is damaged in cerebral palsy.

Treatment of Cerebral Palsy

Non-Pharmacological treatment

• Physical therapy – It is usually begun in the first few years of baby life or soon after the diagnosis is made, is a cornerstone of cerebral palsy treatment in most cases. Specific sets of exercises such as resistive, or strength training programs and activities can maintain or improve muscle power, strength, balance, and motor skills, and prevent contractures. Special braces called orthotic devices may be used to improve mobility and stretch spastic muscles.
• Occupational therapy – It is focused on optimizing upper body function properly, improving posture, and making the most of a child’s mobility. Occupational therapists can help individuals new ways to meet everyday activities such as dressing, going to school, and participating in day-to-day activities.
• Recreation therapy – It encourages participation in art, sport, cultural programs, and other events that help an individual expand physical and cognitive skills and abilities. Parents of children who participate in recreational therapies and activities, usually notice in abnormal position an improvement in their child’s speech, self-esteem, and emotional well-being.
• Speech and language therapy – It can improve a child’s ability to speak, movement, working, more clearly, help with swallowing disorders, with learning new ways to communicate using sign language and special communication devices in most cases condition a computer with a voice synthesizer, or a special board covered by symbols of everyday objects and activities in which a child can point out to indicate his or her wishes.
• Treatments for problems with eating and drooling – It is most often necessary when children by cerebral palsy have difficulty eating and some drinking because they have little control over the muscles that move their mouth, jaw, and tongue. They are also at higher risk for breathing food or fluid into the lungs, as well as for malnutrition, recurrent lung infections, and progressive major lung disease.
• Constraint-induced therapy (CIT) – It is a promising therapy for cerebral palsy. CIT typically involves restraining or stronger limb (such as the “best” arm in a person who has been affected by a stroke on one side or both sides of the body) in a cast and forcing the weaker arm to perform intensive activities every day over a period of weeks.  A clinical study sponsored by the NICHD is examining the use of different dosage levels of daily training using either full-time cast immobilization versus part-time splint restraint condition improving upper body extremity skills in children with weakness on both sides of their body. Study findings will also establish evidence-based practice standards to improve lifelong neuromotor and neurological capacity in individuals with cerebral palsy.
• Functional electrical stimulation (FES) – It is the therapeutic use of low-level electrical current to stimulate muscle movement, posture, restore useful movements such as standing or stepping is the most effective way to target and strengthen spastic muscles. Researchers are evaluating how FES-assisted stationary cycling also improves physical conditioning with general lower extremity muscle strength adolescents age.
• Robotic therapy – It is applies controlled force to the leg during the swing phase of gait is may improve the efficacy of body weight-supported treadmill training in children with cerebral palsy. The results from this NICHD study will lead to an innovative clinical therapy aimed at improving locomotor function in children with CP.
• Stem cell therapy – It is being investigated as a treatment for cerebral palsy, but research is in the early stages and large-scale clinical trials are needed to learn if stem cell therapy is safe and effective in humans in near future. Stem cells are capable of becoming other types of cells in the body. Scientists are hopeful that stem cells may be able to repair damaged nerves, central nervous system, and brain tissues. Studies in the U.S. hopefully examining the safety and tolerability of umbilical cord blood stem cell infusion in children for cerebral palsy.
• Deep brain stimulation (DBS) – It has been used increasingly in those types of dyskinetic cerebral palsy. It is often used to decrease dystonia. Though it does decrease dystonia, hemiplagiain those  DCP, there is less benefit in quality of life and functionality compared to that seen in patients with primary (inherited) dystonia.

Medications

• GABA-B agonist – The most commonly used drug in DCP is oral baclofen, a GABA-B agonist. Trihexyphenidyl is often used for dystonia. Efficacy for both of these drugs in DCP is, however, low.[rx][rx] Adverse effects include the possibility of worsened choreoathetosis. This can occur when dystonia is reduced as dystonia masks the expression of choreoathetosis.[rx] Medications that are often used as an attempt to manage movement symptoms are below.
• For dystonia – It is dopamine agonists (levodopa), anticholinergics (trihexyphenidyl, benztropine), benzodiazepine receptor agonists drugs (diazepam, clonazepam), GABA-B receptor agonist drugs(baclofen), monoamine blockers drugs(tetrabenazine), and voltage-gated sodium channel blockers drugs(carbamazepine).[rx][rx]
• For chorea – It is benzodiazepine receptor agonist drugs (diazepam, clonazepam), dopamine antagonist drugs (pimozide, haloperidol), monoamine blockers, and calcium channel blockers drugs(levetiracetam).[rx][rx]
• Intrathecal baclofen – An alternative that is sometimes used instead of oral medication, which generally has low efficacy with more side effects, is intrathecal baclofen. It can be administered at a lower dosage the first time and with fewer side effects. There have been studies demonstrating a decrease in dystonia.[rx][rx]
• Muscle relaxant – Valium and clonazepam oral, Tizanidine and clonidine oral, Dantrolene oral
• Dantrolene – a peripheral acting drug, working at the level of skeletal muscle and selectively decreases abnormal muscle stretch reflexes and tone in your body. Dantrolene is used less frequently than other medications because some patients taking it to develop weakness, and there is a risk of hepatotoxicity with its long-term use.
• Botulinum toxin – is another treatment often used in the management of dystonia in DCP. There is some evidence that it decreases pain and dystonia in those with DCP However, as with DBS, there is more evidence of its therapeutic value in those with primary dystonia.[rx]

Congenital knee flexion contractures, congenital knee and muscle hyperextension and dislocation, developmental knee flexion contracture deformity, knee extension contractures, knee instability, internal derangements, crouch types of gait, knee dislocation, genu varum, genu valgum, genu recurvatum, patellar subluxation, and dislocation, knee instability.

Surgery

• Orthopedic surgery – is often recommended when spasticity and stiffness are severe in most time to make walking and moving about difficult or painful activities. For many people with cerebral palsy, improving the appearance of how they walk their gait that is also important. Surgeons can lengthen muscles and tendons that are proportionately too short in some cases, which can improve mobility and lessen pain. Tendon surgery could help the symptoms for some children with cerebral palsy but could also have negative effects long-term consequences. Orthopedic surgeries may be staggered at times appropriate to a child’s age and level of motor development. Surgery can also correct or greatly improve spinal cord deformities in people with cerebral palsy. Surgery may not be indicated for all gait abnormalities and the surgeon may request a quantitative gait analysis before surgery.
• Surgery to cut nerves – Selective dorsal rhizotomy (SDR) is a surgical procedure recommended for cases of severe spasticity when all of the more conservative treatments physical therapy, oral medications, and intrathecal baclofen have failed to reduce spasticity and chronic pain. A surgeon locates and selectively severs overactivated nerves at depending of the spinal column. SDR is most commonly used to relax muscles and decrease chronic pain in one or both of the lower or upper limbs. It is also sometimes used to correct an overactive bladder. Potential side effects include sensory loss, motor loss, numbness, or uncomfortable sensations in limb areas once supplied by the severed nerve.

References

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• https://www.ncbi.nlm.nih.gov/books/NBK538147/
• https://www.ncbi.nlm.nih.gov/books/NBK73427/
• https://www.ncbi.nlm.nih.gov/books/NBK563160/
• https://www.ncbi.nlm.nih.gov/books/NBK132442/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082248/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3872805/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3051278/
• https://www.ncbi.nlm.nih.gov/books/NBK115141/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1125882/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5439309/
• https://www.ncbi.nlm.nih.gov/books/NBK554569/
• https://www.ncbi.nlm.nih.gov/books/NBK542968/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7297454/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5304407/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6832653/
• https://www.cdc.gov/ncbddd/cp/facts.html
• https://en.wikipedia.org/wiki/Cerebral_palsy
• https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Hope-Through-Research/Cerebral-Palsy
• https://www.nhs.uk/conditions/cerebral-palsy/treatment/
• https://medlineplus.gov/cerebralpalsy.html
• https://www.cdc.gov/ncbddd/cp/features/cerebral-palsy-11-things.html
• https://rarediseases.org/rare-diseases/cerebral-palsy/
• http://rxharun.com/cerebral-palsy-causes-symptoms-diagnosis-treatment/

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