Cerebral Palsy Review
Cerebral Palsy Review
Cerebral Palsy Review
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International Journal of Therapeutic Applications, Volume 3, 2012, 15 - 24
Mental disadvantage (IQ < 50) and not walking: are hypertonic and have what is essentially
20% a neuromuscular mobility (rather
than hypotonia or paralysis) stemming from
Blindness: 11%.
an upper motor neuron lesion in the brain as well as
The SCPE noted that the incidence of co the corticospinal tract or the motor cortex. This
morbidities is difficult to measure accurately, damage impairs the ability of some nerve receptors
particularly across centers. in the spine to properly receive gamma amino
butyric acid, leading to hypertonia in the muscles
HISTORY OF CEREBRAL PALSY IN CHILDREN
signaled by those damaged nerves.
Cerebral palsy is not a new disorder. But the
Spastic cerebral palsy is further classified as:
medical profession did not begin to study cerebral
palsy as a distinct medical condition until 1861. In Spastic hemiplegia: in this one side is affected.
that year, an English orthopedic surgeon, Dr. William Generally, injury to muscle-nerves controlled by
John Little, published the first paper describing the the brain's left side will cause a right body
6
neurological problems of children with spastic deficit, and vice versa.
diplegia. Spastic diplegia is still sometimes called
Spastic diplegia: in this the lower extremities are
Little's Disease. This was a disorder that struck
affected, with little to no upper-body spasticity.
children in the first years of life, characterized by
The most common form of the spastic forms
stiff, spastic muscles in their arms and legs. These
(70-80% of known cases), most people with
children had difficulty in grasping objects, crawling
spastic diplegia are fully ambulatory, but are
and walking. The term cerebral palsy came into use
"tight" and have a scissors gait. Flexed knees
in the late 1800's. Sir William Osler, a British medical
and hips to varying degrees, and moderate to
doctor, is believed to have coined the term. Dr.
severe adduction (stemming from
Sigmund Freud, the Austrian neurologist better
tight adductor muscles and comparatively
known for his work in psychiatry, published some of
weak abductor muscles), are present. Over time,
the earliest medical papers on cerebral palsy. In the
the effects of the spasticity sometimes produce
early years, Dr. Little believed most cases of cerebral
hip problems and dislocations (see the main
palsy were caused by obstetrical complications at
article and spasticity for more on spasticity
birth. He suggested that children born with cerebral
effects). In three-quarters of spastic diplegics,
palsy were born following complicated deliveries,
also strabismus (crossed eyes) can be present as
and that their condition was a result of lack of
well.
oxygen to the brain. He said this oxygen shortage
damaged sensitive brain tissues controlling Spastic monoplegia: in this one single limb being
movement. But in the late 1800's, Freud is affected.
disagreed. Noting that children with cerebral palsy
Spastic triplegia: In these three limbs being is
often had other problems such as mental
affected.
retardation, visual disturbances, and seizures, Freud
suggested that the disorder might be caused earlier Spastic quadriplegia: in this all four limbs more
in life, during the brain’s development in the womb. or less equally are affected. People with spastic
In the 1980's, scientists analyzed extensive data from quadriplegia are the least likely to be able to
a government study of more than 35,000 births. walk, or if they can, to desire to walk, because
While they found that birth trauma was the cause of their muscles are too tight and it is too much of
thousands of cerebral palsy cases, no cause could be an effort to do so. Some children with spastic
found in the majority of cases. This has influenced quadriplegia also have hemiparetic tremors, an
researchers to explore other causes, and look at uncontrollable shaking that affects the limbs on
4
medical theories about cerebral palsy more closely. one side of the body and impairs normal
CLASSIFICATION OF CEREBRAL PALSY movement.
Spastic cerebral palsy is by far the most common This rare type of cerebral palsy affects balance
type of overall cerebral palsy, occurring in 80% of all and depth perception. Children will often have poor
5
cases. People with this type of CP coordination and walk unsteadily with a wide-based
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International Journal of Therapeutic Applications, Volume 3, 2012, 15 - 24
gait, placing their feet unusually far apart. They 6) Mental retardation: Some, although not all,
have difficulty with quick or precise movements, children with cerebral palsy are affected by
such as writing or buttoning a shirt. They may also mental retardation. Generally, the more severe
have intention tremor, in which a voluntary the retardation, the more severe the disability
movement, such as reaching for a book, is overall.
accompanied by trembling that gets worse the closer
7) Seizures: About one third of people with
their hand gets to the object.
cerebral palsy have seizures. Seizures may
3) Dyskinetic cerebral palsy: appear early in life or years after the brain
damage that causes cerebral palsy. The
Dyskinetic cerebral palsy is mixed tone both
physical signs of a seizure may be partly
hypertonia and hypotonia mixed with involuntary masked by the abnormal movements of a
motions. People with Dyskinetic CP have trouble
person with cerebral palsy.
holding themselves in an upright, steady position for
sitting or walking, and often show involuntary 8) Speech problems: Speech is partly controlled
motions. The damage occurs to the extra pyramidal by movements of muscles of the tongue,
motor system and/or pyramidal tract and to the mouth, and throat. Some individuals with
7
basal ganglia. cerebral palsy are unable to control these
muscles and thus cannot speak normally.
SIGNS AND SYMPTOMS
9) Swallowing problems: Swallowing is a very
The signs of cerebral palsy are usually not complex function that requires precise
noticeable in early infancy but become more obvious interaction of many groups of muscles. People
as the child’s nervous system matures. Problems and with cerebral palsy who are unable to control
disabilities related to CP range from very mild to very these muscles will have problems sucking,
severe. Their severity is related to the severity of the eating, drinking, and controlling their saliva.
brain damage. They may be very subtle, noticeable They may drool. An even greater risk is
only to medical professionals, or may be obvious to aspiration, the inhalation into the lungs of food
the parents and other caregivers. The signs include or fluids from the mouth or nose. This can
the following: cause infection or even suffocation.
1) Delayed milestones such as controlling head, 10) Hearing loss: Partial hearing loss is not unusual
rolling over, reaching with one hand, sitting in people with cerebral palsy. The child may not
without support, crawling, or walking. respond to sounds or may have delayed
2) Abnormal muscle tone: Muscles may be very speech.
stiff (spastic) or unusually relaxed and “floppy.” 11) Vision problems: Three quarters of people with
Limbs may be held in unusual or awkward cerebral palsy have strabismus, which is the
positions turning in or out of one eye. This is due to
3) Abnormal movements: Movements may be weakness of the muscles that control eye
unusually jerky or abrupt, or slow and writhing. movement. These people are often
They may appear uncontrolled or without nearsighted. If not corrected, strabismus can
purpose. lead to more severe vision problems over time.
4) Skeletal deformities: People who have cerebral 12) Dental problems: People with cerebral palsy
palsy on only one side may have shortened tend to have more cavities than usual. This
limbs on the affected side. If not corrected by results from both defects in tooth enamel and
surgery or a device, this can lead to tilting of difficulties brushing the teeth.
the pelvic bones and scoliosis (curvature of 13) Bowel and/or bladder control problems: These
the spine). are caused by lack of muscle control.
8
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International Journal of Therapeutic Applications, Volume 3, 2012, 15 - 24
cerebral palsy. In the past, if doctors couldn’t in the brain caused by an interruption in breathing or
identify another cause, they attributed most cases of poor oxygen supply, is common in babies due to the
congenital cerebral palsy to problems or stress of labor and delivery. But even though a
complications during labor that caused asphyxia (a newborn’s blood is equipped to compensate for
lack of oxygen) during birth. However, extensive short-term low levels of oxygen, if the supply of
research has shown that few babies who experience oxygen is cut off or reduced for lengthy periods, an
asphyxia during birth grow up to have cerebral palsy infant can develop a type of brain damage called
or any other neurological disorder. Birth hypoxic-ischemic encephalopathy, which destroys
complications, including asphyxia, are now tissue in the cerebral motor cortex and other areas
estimated to account for only 5 to 10 percent of the of the brain. This kind of damage can also be
9, 10
babies born with congenital cerebral palsy. caused by severe maternal low blood pressure,
rupture of the uterus, detachment of the placenta,
Damage to the white matter of the brain 12
or problems involving the umbilical cord.
(periventricular leukomalacia [PVL]). The white
matter of the brain is responsible for transmitting DIAGNOSIS:
signals inside the brain and to the rest of the body.
PVL describes a type of damage that looks like tiny There is no medical test that confirms
holes in the white matter of an infant’s brain. These the diagnosis of cerebral palsy. The diagnosis is
gaps in brain tissue interfere with the normal made on the basis of various types of information
transmission of signals. There are a number of gathered by the child’s health care provider and, in
events that can cause PVL, including maternal or some cases, other consultants. This
fetal infection. information includes a detailed medical interview
concerning medical histories of both mother’s and
Abnormal development of the brain (cerebral father’s families, the mother’s medical problems
dysgenesis). Any interruption of the normal process before and during pregnancy, and a detailed account
of brain growth during fetal development can cause of the pregnancy, labor, delivery, and neonatal
brain malformations that interfere with the (newborn) period.
transmission of brain signals. The fetal brain is
particularly vulnerable during the first 20 weeks of Some of the major laboratory diagnosis tests include
development. Mutations in the genes that control the following:
brain development during this early period can keep 1) Ultrasound of the brain: Ultrasound uses
the brain from developing normally. Infections, harmless sound waves to detect certain types
fevers, trauma, or other conditions that cause of structural and anatomic abnormalities. For
unhealthy conditions in the womb also put an instance, it can show hemorrhage (bleeding) in
unborn baby’s nervous system at risk. the brain or damage caused by lack of oxygen
Bleeding in the brain (intracranial to the brain.
hemorrhage). Intracranial hemorrhage describes 2) CT scan of the brain: This scan is similar to an x-
bleeding inside the brain caused by blocked or ray but shows greater detail and gives a more
broken blood vessels. A common cause of this kind 3-dimensional image. It identifies
of damage is fetal stroke. Some babies suffer a malformations, hemorrhage, and certain other
stroke while still in the womb because of blood clots abnormalities in infants more clearly than
in the placenta that block blood flow. Other types of ultrasound.
fetal stroke are caused by malformed or weak blood
vessels in the brain or by blood-clotting 3) MRI of the brain: This is the preferred test,
abnormalities. Maternal high blood pressure since it defines brain structures and
(hypertension) is a common medical disorder during abnormalities more clearly than any other
pregnancy that has been known to cause fetal method.
stroke. Maternal infection, especially pelvic
4) MRI of the spinal cord: This may be necessary
inflammatory disease, has also been shown to
11 in children with spasticity of the legs and
increase the risk of fetal stroke.
worsening of bowel and bladder function,
Brain damage caused by a lack of oxygen in the which suggest an abnormality of the spinal
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brain (hypoxic-ischemic encephalopathy or cord.
intrapartum asphyxia). Asphyxia, a lack of oxygen
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International Journal of Therapeutic Applications, Volume 3, 2012, 15 - 24
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International Journal of Therapeutic Applications, Volume 3, 2012, 15 - 24
disease. The individuals most at risk for these are mild and short-lived, consisting of pain upon
problems are those with spastic quadriplegia. injection and occasionally mild flu-like symptoms.
Initially, children should be evaluated for their BT-A injections are most effective when followed by
swallowing ability, which is usually done with a a stretching program including physical therapy and
modified barium swallow study. Recommendations splinting. BT-A injections work best for children who
regarding diet modifications will be derived from the have some control over their motor movements and
results of this study. In severe cases where have a limited number of muscles to treat, none of
swallowing problems are causing malnutrition, a which is fixed or rigid.
doctor may recommend tube feeding, in which a
Because BT-A does not have FDA approval to
tube delivers food and nutrients down the throat
treat spasticity in children, parents and caregivers
and into the stomach, or gastrostomy, in which a
should make sure that the doctor giving the injection
surgical opening allows a tube to be placed directly
is trained in the procedure and has experience using
into the stomach. Although numerous treatments 21
it in children.
for drooling have been tested over the years, there
is no one treatment that helps Intrathecal baclofen therapy uses an implantable
reliably. Anticholinergic drugs–-such as pump to deliver baclofen, a muscle relaxant, into the
glycopyrolate--can reduce the flow of saliva but may fluid surrounding the spinal cord. Baclofen works by
cause unpleasant side effects, such as dry mouth, decreasing the excitability of nerve cells in the spinal
constipation, and urinary retention. Some children cord, which then reduces muscle spasticity
benefit from biofeedback techniques that help them throughout the body. Because it is delivered directly
recognize more quickly when their mouths fall open into the nervous system, the intrathecal dose of
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and they begin to drool. baclofen can be as low as one one-hundredth of the
oral dose. Studies have shown it reduces spasticity
Drug treatments and pain and improves sleep.
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International Journal of Therapeutic Applications, Volume 3, 2012, 15 - 24
intrathecal baclofen--have failed to reduce spasticity palsy. Equipped with a computer and voice
or chronic pain. In the procedure, a surgeon locates synthesizer, a child or adult with cerebral palsy can
and selectively severs over activated nerves at the communicate successfully with others. For example,
base of the spinal column. Because it reduces the a child who is unable to speak or write but can make
amount of stimulation that reaches muscles via the head movements may be able to control a computer
nerves, SDR is most commonly used to relax muscles using a special light pointer that attaches to a
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and decrease chronic pain in one or both of the headband.
lower or upper limbs. It is also sometimes used to
Hyperbaric oxygen therapy (HBOT), in which
correct an overactive bladder. Potential side effects
include sensory loss, numbness, or uncomfortable pressurized oxygen is inhaled inside a hyperbaric
sensations in limb areas once supplied by the chamber, has been studied under the theory that
severed nerve. improving oxygen availability to damaged brain cells
Spinal cord stimulation was developed in the 1980s can reactivate some of them to function normally. A
to treat spinal cord injury and other neurological 2007 systematic review concluded that treatment
conditions involving motor neurons. An implanted with HBOT showed no significant difference from
electrode selectively stimulates nerves at the base of that of pressurized room air, and that some children
the spinal cord to inhibit and decrease nerve undergoing HBOT may experience adverse
activity. The effectiveness of spinal cord stimulation events such as seizures and the need for ear
for the treatment of cerebral palsy has yet to be
pressure equalization tubes; due to poor quality of
proven in clinical studies. It is considered a
treatment alternative only when other conservative data assessment the review also concluded that
or surgical treatments have been unsuccessful at estimates of the prevalence of adverse events are
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relaxing muscles or relieving pain. uncertain.
Orthotic devices Treatments for other conditions associated
Orthotic devices--such as braces and splints--use with cerebral palsy
external force to correct muscle abnormalities. The
Epilepsy: Twenty to 40 percent of children with
technology of orthotics has advanced over the past
30 years from metal rods that hooked up to bulky mental retardation and cerebral palsy also have
orthopedic shoes, to appliances that are individually epilepsy. Doctors usually prescribe medications to
molded from high-temperature plastics for a precise control seizures. The classic medications for this
fit. Ankle-foot orthoses are frequently prescribed purpose are phenobarbital, phenytoin,
for children with spastic diplegia to prevent muscle carbamazepine, and valproate. Although these
contracture and to improve gait. Splints are also
24 drugs generally are effective in controlling seizures,
used to correct spasticity in the hand muscles.
their use is hampered by harmful or unpleasant side
Assistive technology effects.
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Devices that help individuals move about more Incontinence: Medical treatments for incontinence
easily and communicate successfully at home, at
include special exercises, biofeedback, prescription
school, or in the workplace can help a child or adult
drugs, surgery, or surgically implanted devices to
with cerebral palsy overcome physical and
communication limitations. There are a number of replace or aid muscles. Specially designed absorbent
devices that help individuals stand straight and walk, undergarments can also be used to protect against
such as postural support or seating systems, open- accidental leaks.
front walkers, quadrapedal canes (lightweight metal
canes with four feet), and gait poles. Electric Osteopenia: Children with cerebral palsy, who aren’t
wheelchairs let more severely impaired adults and able to walk risk developing poor bone density
children move about successfully. (osteopenia), which make them more likely to break
The computer is probably the most dramatic bones. In a study of older Americans funded by the
example of a communication device that can make a National Institutes of Health (NIH), a family of drugs
big difference in the lives of people with cerebral called bisphosphonates, which was recently
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International Journal of Therapeutic Applications, Volume 3, 2012, 15 - 24
approved by the FDA to treat mineral loss in elderly to recruit, hire, and manage a staff of Personal Care
patients, also appeared to increase bone mineral Assistants (PCAs). PCAs facilitate the independence
density. Doctors may choose to selectively prescribe of their employers by assisting them with their daily
personal needs in a way that allows them to
the drug off-label to children to prevent
maintain control over their lives. Many states
osteopenia. allow Medicaid beneficiaries to use
Pain: Pain can be a problem for people with their Medicaid funds to hire their own PCAs, instead
cerebral palsy due to spastic muscles and the stress of forcing them to utilize institutional or managed
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and strain on parts of the body that are care.
compensating for muscle abnormalities. Some
CONCLUSION
individuals may also have frequent and irregular
muscle spasms that can’t be predicted or medicated CP is a chronic motor disorder that various
in advance. efforts failed to prevent its occurrence. In most
cases, the cause is unknown and prematurity
Doctors often prescribe diazepam to reduce the
remains the commonest risk factor. Children with CP
pain associated with muscle spasms, but it’s not
suffer from multiple problems and potential
known exactly how the drug works to interfere with
disabilities such as mental retardation, epilepsy,
pain signals. The drug gabapentin has been used
feeding difficulties, vision, and hearing impairments.
successfully to decrease the severity and frequency
Screening for these conditions should be part of the
of painful spasms. BT-A injections have also been
initial assessment. The child with CP is best cared for
shown to decrease spasticity and pain, and are
with an individualized treatment plan that provides a
commonly given under anesthesia to avoid the pain
combination of interventions. This requires the
associated with the injections. Intrathecal baclofen
provision of a number of family centered services.
has shown good results in reducing pain, but its
Management is not curative; however, if provided
delivery is invasive, time intensive, and expensive.
optimally it can improve the quality of life of these
Some children and adults have been able to children and their families. Physicians, in
decrease pain by using noninvasive and drug-free cooperation with the child, family, and members of a
interventions such as distraction, relaxation training, multidisciplinary team, can coordinate a complex
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biofeedback, and therapeutic massage. care system to the maximal benefit of each child.
PROGNOSIS REFERENCES
CP is not a progressive disorder (meaning the 1) Beukelman, R David, Mirenda, Pat,
brain damage does not worsen), but the symptoms (1999). Augmentative and Alternative
can become more severe over time due to subdural Communication: Management of severe
damage. A person with the disorder may improve communication disorders in children and
somewhat during childhood if he or she receives adults (2nd ed.). Baltimore: Paul H Brookes
extensive care from specialists, but once bones and Publishing Co. pp. 246–249.
musculature become more established, orthopedic
surgery may be required. People with CP are more 2) "Cerebral Palsy Fact Sheet"(PDF), Retrieved 12
likely to have learning disabilities, although these August 2007. United Cerebral Palsy Research
may be unrelated to IQ, and are more likely to show and Education Foundation (U.S.).
varying degrees of intellectual disability. Intellectual
level among people with CP varies from genius to 3) RJ Palisano, LM Snider, MN Orlin, 2004. Recent
intellectually impaired, as it does in the general advances in physical and occupational therapy
population, and experts have stated that it is for children with cerebral palsy. Semin Pediatr
important to not underestimate a person with CP's Neurol; 11(1):66.77.
capabilities and to give them every opportunity to
learn. Some individuals with CP require personal 4) "Cerebral Palsy – Facts & Figures: History",
assistant services for all activities of daily living. Retrieved 2007-07-06, United Cerebral Palsy
Others only need assistance with certain activities, Research and Education Foundation (U.S.).
and still others do not require any physical
assistance at all. In some cases, people with CP learn
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International Journal of Therapeutic Applications, Volume 3, 2012, 15 - 24
5) F Stanley, E Blair, E Alberman, 2000. Cerebal 16) E Steultjens, J Dekker, LM Bouter, JCM, B
Palsies: Epidemiology and Causal Pathways. Lambregts, CHM, 2004. Occupational therapy
London, United Kingdom: MacKeith Press. for children with cerebral palsy: a systematic
review. Clin.Rehabil. 02; 18(1):1-14.
6) B Balaban, E Yasar, U Dal, K. Y Haydar Mohur &
T Alp Kalyon ", 2007. The effect of hinged 17) L Pennington, J Goldbart, J Marshall, 2004.
ankle-foot orthosis on gait and energy Pennington, Lindsay. ed. "Speech and language
expenditure in spastic hemiplegic cerebral therapy to improve the communication skills of
palsy"Disability and Rehabilitation; 29(2): 139– children with cerebral palsy". Cochrane
144 database of systematic reviews (Online) (2):
7) "Athetoid/Dyskinetic Cerebral Palsy". Retrieved 18) S Harris and A Purdy, 1987. Drooling and its
2009-10-27. management in cerebral palsy, Dev Med and
Child Neurol 9:807-11,
8) Childhood dysarthria: Notes from Childhood
Motor Speech Disability by Love. 19) RN Yeh, MM Nypaver, TJ Deegan, R Ayyangar,
2004. Baclofen toxicity in an 8.year.old with an
9) "Infection in the Newborn as a Cause of intrathecal baclofen pump. J Emerg Med;
Cerebral Palsy, 12/2004", Retrieved 2007-07- 26(2):163.7.
05. United Cerebral Palsy Research and
Education Foundation (U.S.). 20) R Coffey, T Edgar, G Francisco, V Graziani, J
Meythaler, P Ridgely, 2002. Abrupt withdrawal
10) PO Pharoah 2005. "Causal hypothesis for some from intrathecal baclofen: recognition and
congenital anomalies". Twin Res Hum management of a potentially life threatening
Genet 8 (6): 543–550. syndrome. Arch Phys Med Rehabil; 83:735.739.
11) H Tanaka, A Araki, J Ito, T Tasaki, A Miyamoto, 21) C Butler, S Campbell, 2000. Evidence of the
K Cho, 1997. Improvement of hypertonus after effects of intrathecal baclofen for spastic and
treatment for sleep disturbances in three dystonic cerebral palsy. Dev Med Child Neurol;
patients with severe brain damage. Brain Dev; 42:634.645.
19:240.244.
22) A Schejbalová 2006. "[Derotational
12) Lindquist, B Heijbel, 1974. Bruxism in children subtrochanteric osteotomy of the femur in
with brain damage. Acta Odontal Scandinavian cerebral palsy patients]" (in Czech). Acta
32(5): 313-19. chirurgiae orthopaedicae et traumatologiae
Cechoslovaca 73 (5): 334–9
13) TM Kolawole, PJ Patel, AH Mahdi, 1989.
“Computed tomographic(CT) scans in cerebral 23) JP Farmer, AJ Sabbagh, 2007. "Selective dorsal
palsy(CP)”. Pediatr Radiol, 20 (1-2): 23-2. rhizotomies in the treatment of spasticity
related to cerebral palsy". Child s Nervous
14) Jan MMS: 2002. Assessment of the Utility of System 23 (9): 991–1002.
Pediatric Electroencephalography. Seizure;
11(2):99.103. 24) J Furumasu, P Guerette, D Tefft, 2004.
Relevance of the pediatric powered wheelchair
15) S Ashwal, BS Russman, PA Blasco et al, 2004. screening test in children with cerebral palsy.
"Practice parameter: diagnostic assessment of Dev Med Child Neurol; 46:468.74.
the child with cerebral palsy: report of the
Quality Standards Subcommittee of the 25) MS McDonagh, D Morgan, S Carson, BS
American Academy of Neurology and the Russman, 2007. "Systematic review of
Practice Committee of the Child Neurology hyperbaric oxygen therapy for cerebral palsy:
Society". Neurology 62 (6): 851–63. the state of the evidence". Dev Med Child
Neurol 49 (12): 942–947.
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