Cerebral palsy

Cerebral palsy is defined as "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." with 28% having epilepsy, 58% having difficulties with communication, at least 42% having problems with their vision, and 2356% having learning disabilities. Although most people with CP have problems with increased muscle tone, some have low muscle tone instead. High muscle tone can either be due to spasticity or dystonia. Cerebral palsy is characterized by abnormal muscle tone, reflexes, or motor development and coordination. The neurological lesion is primary and permanent while orthopedic manifestations are secondary to high muscle tone and progressive. In cerebral palsy with high muscle tone, unequal growth between muscle-tendon units and bone eventually leads to bone and joint deformities. At first, deformities are dynamic. Over time, deformities tend to become static, and joint contractures develop. Deformities in general and static deformities in specific (joint contractures) cause increasing gait difficulties in the form of tip-toeing gait, due to tightness of the Achilles tendon, and scissoring gait, due to tightness of the hip adductors. These gait patterns are among the most common gait abnormalities in children with cerebral palsy. However, orthopaedic manifestations of cerebral palsy are diverse. is prevalent among children who possess the ability to walk. Babies born with severe cerebral palsy often have irregular posture; their bodies may be either very floppy or very stiff. Birth defects, such as spinal curvature, a small jawbone, or a small head sometimes occur along with CP. Symptoms may appear or change as a child gets older. Babies born with cerebral palsy do not immediately present with symptoms. Classically, CP becomes evident when the baby reaches the developmental stage at 6 to 9 months and is starting to mobilise, where preferential use of limbs, asymmetry, or gross motor developmental delay is seen. It can additionally cause choking. Children with CP may also have sensory processing issues. Adults with cerebral palsy have a higher risk of respiratory failure. Skeleton For bones to attain their normal shape and size, they require the stresses from normal musculature. The shafts of the bones are often thin (gracile), Due to more than normal joint compression caused by muscular imbalances, articular cartilage may atrophy, Children with CP are prone to low trauma fractures, particularly children with higher Gross Motor Function Classification System (GMFCS) levels who cannot walk. This further affects a child's mobility, strength, and experience of pain, and can lead to missed schooling or child abuse suspicions. Hip dislocation and ankle equinus or plantar flexion deformity are the two most common deformities among children with cerebral palsy. Additionally, flexion deformity of the hip and knee can occur. Torsional deformities of long bones such as the femur and tibia are also encountered, among others. Scoliosis can be corrected with surgery, but CP makes surgical complications more likely, even with improved techniques. Eating Due to sensory and motor impairments, those with CP may have difficulty preparing food, holding utensils, or chewing and swallowing. An infant with CP may not be able to suck, swallow or chew. Triceps skin fold tests have been found to be a very reliable indicator of malnutrition in children with cerebral palsy. Language Speech and language disorders are common in people with cerebral palsy. The incidence of dysarthria is estimated to range from 31% to 88%, Early use of augmentative and alternative communication systems may assist the child in developing spoken language skills. Early intervention with this clientele, and their parents, often targets situations in which children communicate with others so that they learn that they can control people and objects in their environment through this communication, including making choices, decisions, and mistakes. Pain is associated with tight or shortened muscles, abnormal posture, stiff joints, unsuitable orthosis, etc. Hip migration or dislocation is a recognizable source of pain in CP children and especially in the adolescent population. Nevertheless, the adequate scoring and scaling of pain in CP children remains challenging. There is also a high likelihood of chronic sleep disorders secondary to both physical and environmental factors. Babies with cerebral palsy who have stiffness issues might cry more and be harder to put to sleep than non-disabled babies, or "floppy" babies might be lethargic. Chronic pain is under-recognized in children with cerebral palsy, even though three out of four children with cerebral palsy experience pain. Adults with CP also experience more pain than the general population. Associated disorders Associated disorders include intellectual disabilities, seizures, muscle contractures, abnormal gait, osteoporosis, communication disorders, malnutrition, sleep disorders, and mental health disorders, such as depression and anxiety. Epilepsy is often found in the child before they are 1 year old, or also before they are four or five. In addition to these, functional gastrointestinal abnormalities contributing to bowel obstruction, vomiting, and constipation may also arise. Adults with cerebral palsy may have ischemic heart disease, cerebrovascular disease, cancer, and trauma more often. Obesity in people with cerebral palsy or a more severe Gross Motor Function Classification System assessment in particular are considered risk factors for multimorbidity. The risk factors for cerebral palsy and the comorbidity rates (co-occurring complications) are much higher in low-resource or low- and middle-income countries compared to high-income countries. This is mostly due to differences in the quality of healthcare services for example in the obstetric and neonatal care, which are generally better in high-income countries. Other medical issues can be mistaken for being symptoms of cerebral palsy, and so may not be treated correctly. Related conditions can include apraxia, sensory impairments, urinary incontinence, fecal incontinence, or behavioural disorders. Seizure management is more difficult in people with CP as seizures often last longer. Epilepsy and asthma are common co-occurring diseases in adults with CP. ==Causes==

showing a fetal (placental) vein thrombosis, in a case of fetal thrombotic vasculopathy. This is associated with cerebral palsy and is suggestive of a hypercoagulable state as the underlying cause. Cerebral palsy is due to abnormal development or damage occurring to the developing brain. Cerebral palsy is not contagious and cannot be contracted in adulthood. CP is almost always developed in utero, or prior to birth. While in certain cases there is no identifiable cause, typical causes include problems in intrauterine development (e.g. exposure to radiation, infection, fetal growth restriction), hypoxia of the brain (thrombotic events, placental insufficiency, umbilical cord prolapse), birth trauma during labor and delivery, and complications around birth or during childhood. Preterm birth Between 40% and 50% of all children who develop cerebral palsy were born prematurely. In those who are born with a weight between 1 kg (2.2 lbs) and 1.5 kg (3.3 lbs) CP occurs in 6%. Genetic factors are believed to play an important role in prematurity and cerebral palsy generally. Moreover, there is no one reason why some CP cases come from prenatal brain damage, and it is not known if those cases have a genetic basis. and can cause ataxic cerebral palsy. Early childhood After birth, other causes include toxins, severe jaundice, abusive head trauma, incidents involving hypoxia to the brain (such as near drowning), and encephalitis or meningitis. Others Infections in the mother, even those not easily detected, can triple the risk of the child developing cerebral palsy. Infection of the fetal membranes known as chorioamnionitis increases the risk. Intrauterine and neonatal insults (many of which are infectious) increase the risk. Rh blood type incompatibility can cause the mother's immune system to attack the baby's red blood cells. It has been hypothesised that some cases of cerebral palsy are caused by the death in very early pregnancy of an identical twin. ==Diagnosis==

The diagnosis of cerebral palsy has historically rested on the person's history and physical examination and is generally assessed at a young age. A general movements assessment, which involves measuring movements that occur spontaneously among those less than four months of age, appears most accurate. persons with milder forms of cerebral palsy may be over the age of five, if not in adulthood, when finally diagnosed. It is a developmental disability. There is a small risk associated with sedating children to facilitate a clear MRI. Cerebral palsy is also classified according to the topographic distribution of muscle spasticity. Spastic CP is the most common type of overall cerebral palsy, representing about 80% of cases. Botulinum toxin is effective in decreasing spasticity. Ataxic Ataxic cerebral palsy is observed in approximately 5–10% of all cases of cerebral palsy, making it the least frequent form of cerebral palsy. Ataxic cerebral palsy is caused by damage to cerebellar structures. Because of the damage to the cerebellum, which is essential for coordinating muscle movements and balance, patients with ataxic cerebral palsy experience problems in coordination, specifically in their arms, legs, and trunk. Ataxic cerebral palsy is known to decrease muscle tone. The most common manifestation of ataxic cerebral palsy is intention (action) tremor, which is especially apparent when carrying out precise movements, such as tying shoe laces or writing with a pencil. This symptom gets progressively worse as the movement persists, making the hand shake. As the hand gets closer to accomplishing the intended task, the trembling intensifies, which makes it even more difficult to complete. Gait classification facilitates the assessment of the gait pattern in CP patients. It helps to facilitate communication in the interdisciplinary team between those affected, doctors, physiotherapists and orthotists. In patients with spastic hemiplegia or diplegia, various gait patterns can be observed, the exact form of which can only be described with the help of complex gait analysis systems. In order to facilitate interdisciplinary communication in the interdisciplinary team between those affected, doctors, physiotherapists and orthotists, a simple description of the gait pattern is useful. J. Rodda and H. K. Graham already described in 2001 how gait patterns of CP patients can be more easily recognized and defined gait types which they compared in a classification. They also described that gait patterns can vary with age. Building on this, the Amsterdam Gait Classification was developed at the free university in Amsterdam, the VU medisch centrum. A special feature of this classification is that it makes different gait patterns very easy to recognize and can be used in CP patients in whom only one leg and both legs are affected. According to the Amsterdam Gait Classification, five gait types are described. To assess the gait pattern, the patient is viewed visually or via a video recording from the side of the leg to be assessed. At the point in time at which the leg to be viewed is in mid stance and the leg not to be viewed is in mid swing, the knee angle and the contact of the foot with the ground are assessed on the one hand. Classification of the gait pattern according to the Amsterdam Gait Classification: In gait type 1, the knee angle is normal and the foot contact is complete. In gait type 2, the knee angle is hyperextended and the foot contact is complete. In gait type 3, the knee angle is hyperextended and foot contact is incomplete (only on the forefoot). In gait type 4, the knee angle is bent and foot contact is incomplete (only on the forefoot). With gait type 5, the knee angle is bent and the foot contact is complete. ==Prevention==

Because the causes of CP are varied, a broad range of preventive interventions have been investigated. It is unclear if it helps those who are born at term. However, guidelines for the use of magnesium sulfate in mothers at risk of preterm labour are not strongly adhered to; An NHS quality improvement programme increased its usage in England from 71% in 2018 to 83% in 2020. Caffeine is used to treat apnea of prematurity and reduces the risk of cerebral palsy in premature babies, but there are also concerns of long term negative effects. A moderate quality level of evidence indicates that giving women antibiotics during preterm labor before her membranes have ruptured (water is not yet not broken) may increase the risk of cerebral palsy for the child. Taking corticosteroids during pregnancy is shown to have no significant correlation with developing cerebral palsy in preterm births. Cooling high-risk full-term babies shortly after birth may reduce disability, but this may only be useful for some forms of the brain damage that causes CP. ==Management==

, which causes tripping when walking. Over time, the approach to CP management has shifted away from narrow attempts to fix individual physical problems such as spasticity in a particular limb to making such treatments part of a larger goal of maximizing the person's independence and community engagement. Various forms of therapy are available to people living with cerebral palsy as well as caregivers and parents. Treatment may include one or more of the following: physical therapy; occupational therapy; speech therapy; water therapy; drugs to control seizures, alleviate pain, or relax muscle spasms (e.g. benzodiazepines); surgery to correct anatomical abnormalities or release tight muscles; braces and other orthotic devices; rolling walkers; and communication aids such as computers with attached voice synthesisers. Surgical intervention in CP children may include various orthopaedic or neurological surgeries to improve quality of life, such as tendon releases, hip rotation, spinal fusion, (selective dorsal rhizotomy) or placement of an intrathecal baclofen pump. A Cochrane review published in 2004 found a trend toward the benefit of speech and language therapy for children with cerebral palsy but noted the need for high-quality research. A 2013 systematic review found that many of the therapies used to treat CP have no good evidence base; the treatments with the best evidence are medications (anticonvulsants, botulinum toxin, bisphosphonates, diazepam), therapy (bimanual training, casting, constraint-induced movement therapy, context-focused therapy, fitness training, goal-directed training, hip surveillance, home programmes, occupational therapy after botulinum toxin, pressure care) and surgery. There is also research on whether the sleeping position might improve hip migration, but there are not yet high-quality evidence studies to support that theory. Research papers also call for an agreed consensus on outcome measures which will allow researchers to cross-reference research. Also, the terminology used to describe orthoses needs to be standardised to ensure studies can be reproduced and readily compared and evaluated. == Orthotics in the concept of therapy ==

with adjustable functional elements to improve safety when standing and walking To improve the gait pattern, orthotics can be included in the therapy concept. An orthosis can support physiotherapeutic treatment in setting the right motor impulses in order to create new cerebral connections. The orthosis must meet the requirements of the medical prescription. In addition, the orthosis must be designed by the orthotist in such a way that it achieves the effectiveness of the necessary levers, matching the gait pattern, in order to support the proprioceptive approaches of physiotherapy. The characteristics of the stiffness of the orthosis shells and the adjustable dynamics in the ankle joint are important elements of the orthosis to be considered. Due to these requirements, the development of orthoses has changed significantly in recent years, especially since around 2010. At about the same time, care concepts were developed that deal intensively with the orthotic treatment of the lower extremities in cerebral palsy. Modern materials and new functional elements enable the rigidity to be specifically adapted to the requirements that fits to the gait pattern of the CP patient. The adjustment of the stiffness has a decisive influence on the gait pattern and on the energy cost of walking. It is of great advantage if the stiffness of the orthosis can be adjusted separately from one another via resistances of the two functional elements in the two directions of movement, dorsiflexion and plantar flexion. ==Prognosis==

CP is not a progressive disorder (meaning the brain damage does not worsen), but the symptoms can become more severe over time. A person with the disorder may improve somewhat during childhood if he or she receives extensive care, but once bones and musculature become more established, orthopedic surgery may be required. People with CP can have varying degrees of cognitive impairment or none whatsoever. The full intellectual potential of a child born with CP is often not known until the child starts school. People with CP are more likely to have learning disorders but have normal intelligence. Intellectual level among people with CP varies from genius to intellectually disabled, as it does in the general population, and experts have stated that it is important not to underestimate the capabilities of a person with CP and to give them every opportunity to learn. The ability to live independently with CP varies widely, depending partly on the severity of each person's impairment and partly on the capability of each person to self-manage the logistics of life. Some individuals with CP require personal assistant services for all activities of daily living. Others only need assistance with certain activities, and still others do not require any physical assistance. But regardless of the severity of a person's physical impairment, a person's ability to live independently often depends primarily on the person's capacity to manage the physical realities of his or her life autonomously. In some cases, people with CP recruit, hire, and manage a staff of personal care assistants (PCAs). PCAs facilitate the independence of their employers by assisting them with their daily personal needs in a way that allows them to maintain control over their lives. Puberty in young adults with cerebral palsy may be precocious or delayed. Delayed puberty is thought to be a consequence of nutritional deficiencies. Adults with CP were less likely to get routine reproductive health screening as of 2005. Gynecological examinations may have to be performed under anesthesia due to spasticity, and equipment is often not accessible. Breast self-examination may be difficult, so partners or carers may have to perform it. Men with CP have higher levels of cryptorchidism at the age of 21. 5–10% of children with CP die in childhood, particularly where seizures and intellectual disability also affect the child. According to the Australian Bureau of Statistics, in 2014, 104 Australians died of cerebral palsy. The most common causes of death in CP are related to respiratory causes, but in middle age cardiovascular issues and neoplastic disorders become more prominent. Occupational therapists are healthcare professionals that help individuals with disabilities gain or regain their independence through the use of meaningful activities. Productivity The effects of sensory, motor, and cognitive impairments affect self-care occupations in children with CP and productivity occupations. Productivity can include but is not limited to, school, work, household chores, or contributing to the community. Leisure Leisure activities can have several positive effects on physical health, mental health, life satisfaction, and psychological growth for people with physical disabilities like CP. Children with CP primarily engage in physical activity through therapies aimed at managing their CP, or through organized sport for people with disabilities. It is difficult to sustain behavioural change in terms of increasing physical activity of children with CP. Gender, manual dexterity, the child's preferences, cognitive impairment and epilepsy were found to affect children's leisure activities, with manual dexterity associated with more leisure activity. Although leisure is important for children with CP, they may have difficulties carrying out leisure activities due to social and physical barriers. Children with cerebral palsy may face challenges when it comes to participating in sports. This comes with being discouraged from physical activity because of these perceived limitations imposed by their medical condition. Participation and barriers Participation is involvement in life situations and everyday activities. Adults with cerebral palsy may not seek physical therapy due to transport issues, financial restrictions and practitioners not feeling like they know enough about cerebral palsy to take people with CP on as clients. Because children with cerebral palsy are often told that it is a non-progressive disease, they may be unprepared for the greater effects of the aging process as they head into their 30s. Young adults with cerebral palsy experience problems with aging that non-disabled adults experience "much later in life". Hand function does not seem to have similar declines. Common problems include increased pain, reduced flexibility, increased spasms and contractures, post-impairment syndrome and increasing problems with balance. Like they did in childhood, adults with cerebral palsy experience psychosocial issues related to their CP, chiefly the need for social support, self-acceptance, and acceptance by others. Workplace accommodations may be needed to enhance continued employment for adults with CP as they age. Rehabilitation or social programs that include salutogenesis may improve the coping potential of adults with CP as they age. ==Epidemiology==

Cerebral palsy occurs in about 2.1 per 1000 live births. The rate is higher in males than in females; in Europe it is 1.3 times more common in males. Between 1990 and 2003, rates of cerebral palsy remained the same. As of 2005, advances in the care of pregnant mothers and their babies did not result in a noticeable decrease in CP. This is generally attributed to medical advances in areas related to the care of premature babies (which results in a greater survival rate). Only the introduction of quality medical care to locations with less-than-adequate medical care has shown any decreases. The incidence of CP increases with premature or very low-weight babies regardless of the quality of care. Prevalence of cerebral palsy is best calculated around the school entry age of about six years; the prevalence in the U.S. is estimated to be 2.4 out of 1000 children. ==History==

Cerebral palsy has affected humans since antiquity. A decorated grave marker dating from around the 15th to 14th century BCE shows a figure with one small leg and using a crutch, possibly due to cerebral palsy. The oldest likely physical evidence of the condition comes from the mummy of Siptah, an Egyptian Pharaoh who ruled from about 1196 to 1190 BCE and died at about 20 years of age. The presence of cerebral palsy has been suspected due to his deformed foot and hands. In his treatise On the Eight-Month Foetus, he discussed associations between prematurity, maternal illness, and prenatal stress in the development of congenital conditions. He noted that infants born to mothers who experienced fever, unexplained weight loss, or other health issues during pregnancy were more likely to suffer from physical or neurological impairments. Hippocrates also described increased morbidity and mortality in children he referred to as having "intrauterine disease", suggesting an early understanding of fetal distress and its consequences The works of the school of Hippocrates (460c. 370 BCE), and the manuscript On the Sacred Disease in particular, describe a group of problems that matches up very well with the modern understanding of cerebral palsy. He named the problem "birth palsy" and classified birth palsies into two types: peripheral and cerebral. Working in the US in the 1880s, Canadian-born physician William Osler (18491919) reviewed dozens of CP cases to further classify the disorders by the site of the problems on the body and by the underlying cause. Osler made further observations tying problems around the time of delivery with CP, and concluded that problems causing bleeding inside the brain were likely the root cause. Osler also suspected polioencephalitis as an infectious cause. Through the 1890s, scientists commonly confused CP with polio. Before moving to psychiatry, Austrian neurologist Sigmund Freud (18561939) made further refinements to the classification of the disorder. He produced the system still being used today. Freud's system divides the causes of the disorder into problems present at birth, problems that develop during birth, and problems after birth. Freud also made a rough correlation between the location of the problem inside the brain and the location of the affected limbs on the body and documented the many kinds of movement disorders. In the early 20th century, the attention of the medical community generally turned away from CP until orthopedic surgeon Winthrop Phelps became the first physician to treat the disorder. He viewed CP from a musculoskeletal perspective instead of a neurological one. Phelps developed surgical techniques for operating on the muscles to address issues such as spasticity and muscle rigidity. Hungarian physical rehabilitation practitioner András Pető developed a system to teach children with CP how to walk and perform other basic movements. Pető's system became the foundation for conductive education, widely used for children with CP today. Through the remaining decades, physical therapy for CP has evolved, and has become a core component of the CP management program. In 1997, Robert Palisano et al. introduced the Gross Motor Function Classification System (GMFCS) as an improvement over the previous rough assessment of limitation as either mild, moderate, or severe. The GMFCS grades limitation based on observed proficiency in specific basic mobility skills such as sitting, standing, and walking, and takes into account the level of dependency on aids such as wheelchairs or walkers. The GMFCS was further revised and expanded in 2007. ==Society and culture==

Economic impact It is difficult to directly compare the cost and cost-effectiveness of interventions to prevent cerebral palsy or the cost of interventions to manage CP. It has shown that persons with mental or physically debilitating congenital disabilities can lead better lives if they have financial independence. Use of the term "Cerebral" means "of, or pertaining to, the cerebrum or the brain" and "palsy" means "paralysis, generally partial, whereby a local body area is incapable of voluntary movement". It has been proposed to change the name to "cerebral palsy spectrum disorder" to reflect the diversity of presentations of CP. Many people would rather be referred to as a person with a disability (people-first language) instead of as "handicapped". "Cerebral Palsy: A Guide for Care" at the University of Delaware offers the following guidelines: The term "spastic" denotes the attribute of spasticity in types of spastic CP. In 1952 a UK charity called The Spastics Society was formed. Rosie Jones also featured in a 13-1 episode having a child and finding a signficant other, Also dealing with resistance from her own mother. Micah Fowler, an American actor with CP, stars in the ABC sitcom Speechless (2016–2019), which explores both the serious and humorous challenges a family faces with a teenager with CP. 9-1-1 (2018–) is a procedural drama series on Fox. From season 2 onwards, it features Gavin McHugh (who himself has cerebral palsy) in the recurring role as Christopher Diaz – a semi recurring character who has cerebral palsy. Special (2019) is a comedy series that premiered on Netflix on 12 April 2019. It was written, produced and stars Ryan O'Connell as a young gay man with mild cerebral palsy. It is based on O'Connell's book ''I'm Special: And Other Lies We Tell Ourselves''. Australian drama serial The Heights (2019–) features a character with mild cerebral palsy, teenage girl Sabine Rosso, depicted by an actor who herself has mild cerebral palsy, Bridie McKim. 6,000 Waiting (2021) is a documentary by Michael Joseph McDonald. It is the first film to depict a person with cerebral palsy parachuting. It tells the story of three men with cerebral palsy seeking to live in their communities instead of institutions. Upon seeing the film, American politician Stacey Abrams interviewed one of the film's protagonists and publicly stated that her top priority was deinstitutionalization through Medicaid expansion. Notable cases • Christy Brown was the basis for the Academy Award-winning film, My Left Foot. • Two sons of Canadian rock musician Neil Young, Zeke and Ben. In 1986, Young helped found the Bridge School, an educational organization for children with severe verbal and physical disabilities, and its annual supporting Bridge School Benefit concerts, together with his wife Pegi. • Nicolas Hamilton, a British racing driver competing in BTCC. He is the half-brother of Formula 1 driver Lewis Hamilton. in 2009 • Geri Jewell, who had a regular role in the prime-time series The Facts of Life. • Jack Carroll, British comedian and runner-up in the seventh season of ''Britain's Got Talent'', • Jamie Beddard, Producer and Stage Actor, known for Extraordinary Bodies. • Abbey Curran, an American beauty queen who represented Iowa at Miss USA 2008 and was the first contestant with a disability to compete. • Evan O'Hanlon, Australian Paralympian, the fastest athlete with cerebral palsy in the world. • Zach Anner, an American comedian, actor, and writer. He had a television series on Oprah Winfrey's OWN called ''Rollin' With Zach and is the author of If at Birth You Don't Succeed.'' • Hannah Cockroft, is a British wheelchair athlete specialising in sprint distances in the T34 classification. She holds the Paralympic and world records for the 100 metres, 200 metres and 400 metres in her classification. • Keah Brown, American disability rights activist, author and journalist. • Kuli Kohli, Indian-British writer, poet, activist. • Simon James Stevens, a British disability issues consultant and activist, who starred in ''I'm Spazticus'' and founded Wheelies virtual nightclub • The Roman Emperor Claudius is hypothesized to have had cerebral palsy on the basis of his reported symptoms. • Tim Renkow, American comedian, comic actor and writer of the BBC comedy series, Jerk. • Rosie Jones, a British comedian and actress, is incorporating her cerebral palsy into her comedic style. • Christopher Nolan, an Irish Poet and Author, he wrote Damn-Burst of Dreams, The Banyan Tree, and Under The Eye Of The Clock. He died in 2009. • Lost Voice Guy, British Comedian, went on Britain's Got Talent and won • Nujeen Mustafa, Author and disabiltiy right awareness refugee from Syria. In 2019 she became the first disabled person to brief the United Nations Security Council, and was the recipient of the Alison Des Forges Award for Extraordinary Activism from Human Rights Watch. • Lionel Abrahams, South African poet and novelist, founder of the literary magazine Purple Renoster • Tina Friml, American stand-up comedian Litigation Because of the perception that cerebral palsy is mostly caused by trauma during birth, as of 2005, 60% of obstetric litigation was about cerebral palsy, which Alastair MacLennan, Professor of Obstetrics and Gynaecology at the University of Adelaide, regards as causing an exodus from the profession. In the latter half of the 20th century, obstetric litigation about the cause of cerebral palsy became more common, leading to the practice of defensive medicine. == See also ==