Cerebral Palsies Research Articles

Combined generalized and focal epilepsy with reflex features in Adaptor protein complex 4-associated hereditary spastic paraplegias: A cohort observational study

BackgroundPatients with genetic deficiency of the adaptor protein complex 4 (AP-4) exhibit earlyonset developmental delay, spastic diplegia, intellectual disability, speech impairment. The phenotype overlaps with other hereditary spastic paraplegias and cerebral palsies. Febrile seizures are common at onset. Epilepsy has been described in more than half of cases, arising in early infancy often with status epilepticus, but no typical seizure semiology or electroencephalographic features have been identified thus far. PurposeWe aimed to specifically investigate the epileptological characteristics of the syndrome to unveil possible biomarkers of seizure development and prognosis in AP-4 deficiency. MethodsObservational cohort study on patients with bi-allelic pathogenic variants in AP-4 subunits and epilepsy. We focused on the seizure semiology, electroencephalographic characteristics and response to antiseizure medications. ResultsPatients harboured pathogenic variants in AP4S1 (n = 5) or AP4M1 (n = 1). The phenotype included spastic paraparesis, intellectual disability, speech/language impairment, microcephaly, and MRI evidence of hypoplasia of the corpus callosum. In 66 % of the patients, febrile seizures preceded the onset of epilepsy, which spanned from infancy to adolescence (range=14 months-13 years). Absences (66 %) and focal motor seizures (50 %) were common. No patient met the criteria for drug-resistance. Peculiar electroencephalographic features arose after the epilepsy onset and persisted at long-term follow-up: bilateral and asynchronous focal discharges combined with independent diffuse spike-wave-discharges (100 %) and reflex abnormalities (66 %). ConclusionIn AP-4 complex disease, epilepsy could arise beyond early infancy, until adolescence, with variable combination of generalized and focal seizures. The prognosis was favourable. We observed a common electroencephalographic signature - combined focal/generalized and reflex abnormalities - which may constitute a biomarker of AP-4 deficiency with epilepsy, applicable to inform genetic testing and disentangle the differential diagnosis.

Redefining cerebral palsies as a diverse group of neurodevelopmental disorders with genetic aetiology.

Cerebral palsy is a clinical descriptor covering a diverse group of permanent, non-degenerative disorders of motor function. Around one-third of cases have now been shown to have an underlying genetic aetiology, with the genetic landscape overlapping with those of neurodevelopmental disorders including intellectual disability, epilepsy, speech and language disorders and autism. Here we review the current state of genomic testing in cerebral palsy, highlighting the benefits for personalized medicine and the imperative to consider aetiology during clinical diagnosis. With earlier clinical diagnosis now possible, we emphasize the opportunity for comprehensive and early genomic testing as a crucial component of the routine diagnostic work-up in people with cerebral palsy.

The Relationship Between Speech Delay with Cerebral Palsies in Children at Rs Haji Medan

Speech delay in children is a condition in which the child's expressive language development is inappropriate or below his age. The incidence of speech delay for Indonesian children who are not in school yet reaches 5–10%. There are more male children with speech disorders than females. The causes of speech delay can be hearing loss, cerebral palsy, low thinking ability, or autism. Cerebral palsy patients may experience uncontrollable movements and muscle spasms in the mouth. This will have an impact on the development of children's speech. This research is a descriptive-analytical study with a cross-sectional approach. The subjects of this study are patients with cerebral palsy in RS Haji Medan, with a total sample size of 132 people. Data analysis using the Chi-square tes. There was a significant relationship between speech delay and cerebral palsy among pediatric patients in RS Haji Medan. The result using Fisher’s exact test showed a P value less than 0.05, which validated the hypothesis. There was a significant relationship between speech delay and cerebral palsy among pediatric patients in RS Haji Medan.

CT Scanning Findings in Clinically Diagnosed Cerebral Palsy

Background: Cerebral Palsy is a non-progressive disorder due to insult in the developing brain. This causes disorders in muscle tone, posture and movement. Cerebral palsy is usually diagnosed by clinical features. Though risk factors are identified in about 75% of cases, the etiology remains unclear. Magnetic resonance imaging is the standard method to detect central nervous system abnormalities; but in resource poor areas CT Scanning may be an alternative method to elucidate the underlying Central Nervous System abnormalities. Objectives: The objective was to detect CT Scanning findings in different types of Cerebral palsies. Methodology: This was a prospective and cross-sectional study conducted on 525 Children registered at Child Development Center attached to Rangpur Mother and Children Hospital. Cerebral palsy was diagnosed by using an Interview Schedule. During from 1.1.2016 to 31.12.2019 CT scanning of brain was performed purposefully to all children to detect the underlying Central Nervous System abnormalities. The purpose was explained to parents and consent was taken before performing the tests. The children were in sedation during the procedure. Result: A total of 1800 registered children, 525 (29.10%) children were suffering from Cerebral Palsy. The male and female ratio was 3:2 and age distribution was 2.6±1.5 years. Seventy nine percent (79.0%) of children came from poor families. Parental education up to class V was in 65% cases. Maximum number (63.0%) of cases was suffering from spastic type of Cerebral Palsy followed by athetoid type (18.3%) and 7.1% ataxic type. Among spastics, quadriplegia was present in 68.5% of cases followed by hemiplegia (18.5%). Perinatal asphyxia was the commonest (56.1%) risk factor of Cerebral Palsy. Among all the CTs 116 (22.0%) were with normal finding and 409 (78.0%) were with various types of abnormal findings. White Matter Injury was present in 79 (15.0%) of cases and among these volume loss in periventricular areas with ventricular dilatation and deep white matter damage was common. The next abnormalities were Focal Vascular Insults (9.0%), Malformations (5.0%) and Unclassified lesions (4.0%). Grey Matter Injury was common in spastic type of cerebral palsy but there was much overlapping of abnormal findings and most (66.3%) insults occurred in perinatal period. Conclusion: CT scanning of brain is a comparable test to detect the central nervous system abnormalities in resource poor areas. Grey matter injury is the common abnormality in Cerebral palsy but there is much overlapping between CT Scanning findings and clinical diagnosis. J Bangladesh Coll Phys Surg 2022; 40: 31-38

CORRELATION OF MRI BRAINS WITH NEUROLOGICAL OUTCOME AT 12 MONTHS OF AGE IN NEWBORNS WITH HYPOXIC ISCHAEMIC ENCEPHALPATHY AT A TERTIARY REFERRAL HOSPITAL OF KOLKATA: A PROSPECTIVE LONGITUDINAL STUDY

Introduction:In spite of an improved understanding of its pathogenesis , perinatal asphyxia and resulting hypoxic ischemic encephalopathy (HIE) is one of the most dreaded neurological disease of the newborn. Published data show that 25-60% of the babies who survive, suffer from permanent neuro developmental handicaps including cerebral palsy, seizures, mental retardation, and learning disabilities. Aims & Objectives: To correlate Magnetic Resonance Imaging (MRI) Brain with neurological outcome at 12 months in term (more than or equal to 37 weeks gestational age) neonates with Hypoxic Ischemic Encephalopathy. Materials And Methods: Sick Newborn Care Unit (SNCU) and Neonatal Intensive Care Unit (NICU) of R G Kar Medical College & Hospital, Kolkata(2) Department of Radiology of R.G.Kar Medical College & Hospital, Kolkata. From February 1st, 2019 to July 31st 2020. Aprospective observational study in longitudinal design. Results:All the babies with fetal bradycardia(N=19) had abnormal cardiotocographical ndings, out of them 16 babies had suspicious suspicious ndings and 3 had pathological cardiotocographical ndings. Most of the cases with abnormal CTS (N=19) i.e. Suspicious(N1=16)+ Pathological(N2=3) were delivered by LSCS(18) followed by breech vaginal (1). About 45.5 % of the study population had MSL (meconium stained liquor), followed by clear liquor(27.3%), blood stained (21.21%). Only 6.1% showed features of chorioamionitis with foul smelling liquor. Summary & Conclusion:Though normal MRI babies can later be normal or may have minor disabilities in future. But MRIs showing moderate to severe grade of injuries always resulted in severe neuromotor disabilities like cerebral palsies. Further large population studies in other regions of India are to be conducted to emphasize the role of a validated MRI Scoring system to determine the possible clinical outcomes. This will help to initiate early interventions and thus can improve outcomes.

Influence of the upper limb motor deficit on the functional independence in patients with cerebral palsy

Cerebral palsies (CPs) disturb the voluntary movement control at extremities’ level, entailing various disability degrees. In over 80% of the CP cases there is an upper limb disorder, mainly manifested by the decrease in hand control and the presence of contractures, which, in time, lead to the adoption of abnormal postures which affect the abilities of the CP patients’ hands. The aim of this study was to identify the way the motor deficit at upper limb level – reflected by coordination disturbances and by the condition of the three fingered (tripod) grasp – influences the CP patient’s functional independence. The study demonstrated the existence of significant correlations between Functional Independence Measure (FIM) score, coordination and three fingered grasp. It was proven that the unilateral coordination dysfunctions have a strong negative influence on the coordination of the opposite side and lead to a decrease of the functional independence level. Therefore, the rehabilitation treatment is recommended to be based on a bilateral training, both in order to improve coordination and to obtain a functional level of the three fingered grasp power and of the physiological amplitude at wrist flexion level.

CHILDREN WITH CEREBRAL PALSY USING A TRI-AXIAL ACCELEROMETER

Worldwide children’s walking disabilities that are caused mainly by cerebral palsy display multiple conditions of both permanent and non-developing motor dysfunction that in turn upsets posture, mobility, or muscle tone in general. In order to estimate the influence of instrumented gait analysis on the walking ability in cerebral palsied children the Dynaport Minimod, based on a triaxial accelerometer was employed. A Dynaport Minimod was used for collecting the spatial and temporal gait data. An evaluation of the gait data carried out via online services application for 80 children with cerebral palsies from April 1 st , 2018 to October 30 th , 2019. The Dynaport Minimod is capable of capturing most of the spatiotemporal gait parameters which indicate that this technique is quite cooperative and objective in the detection of gait changes and the evaluation of consequences, respectively. The most useful practice for the managing of children with cerebral palsy is a gait analysis system in which its clinical utilization is considered to be a developing technology especially in providing guidance to service planning centres and hospitals.

Silent sounding: Communicability, musicality, and the use of music with nonspeaking individuals with cerebral palsies and multiple disabilities

ABSTRACT Introduction This study explores the intersubjective potentials of nonspeaking young individuals with the more severe forms of cerebral palsy through their musicality and appropriation of music. Here, these forms are called cerebral palsies and multiple disabilities (CPMD). Method A pluralistic research approach, specifically a combined qualitative approach was applied due to the sensitive and unexplored population. The philosophical framework was IPA, suitable for studying unique persons or phenomena in given contexts. A three-interview series was applied. First, the communicability, musicality, and the musicking of six individuals with (CPMD) were studied through two semi-structured life world interviews with their parents: five Israeli women and one man, religious and non-religious Jews in their 40s. Musical home videos were viewed during every second interview. Grounded theory (GT) coding took place with the transcribed interviews and the researcher’s journal. GT was not aimed to generate theory, but gain an additional perspective and thicker data. Subsequently, the GT findings were discussed with the parents through a third interview, and the results were finalized with IPA analysis. Findings Three superordinate themes emerged in relation to the musicality, appropriation of music in everyday life, and the parents’ low awareness of their children’s potentials. Discussion Parental-professional collaboration and a consumer-led approach are recommended in order to improve the parents’ low awareness of their children’s potentials, and to encourage more aware use of music’s affordances. The study’s limitations are discussed and future directions suggested.

БОЛАЛАР ЦЕРЕБРАЛ ФАЛАЖЛИГИ: КЛИНИК ТАҲЛИЛ

Cerebral palsy (CP) is a disorder characterized by abnormal tone, posture and movement. The incidence of CP is 2–4 per 1,000 live births in the world. Prematurityand low birth weight are important risk factors for CP; however, multiple other factors have been associated with an increased risk for CP, including maternal infections and diseases, and abnormal birth process. In most cases of CP the initial injury to the brain occurs during early fetal brain development, later a brain area that is injured cannot function properly in the future. CP is classified clinically based on the predominant motor syndrome—spastic hemiplegia, spastic diplegia, spastic quadriplegia, ataxic and dyskinetic cerebral palsies. The diagnosis of CPis based on a combination of clinical history, use of standardized neuromotor assessment and findings on magnetic resonance imaging (MRI). If there is a suspicionof genetic or inborn metabolic disorders, screening tests should be provided additionally. Because CP is associated with multiple associated and secondary medical conditions, its management requires a multidisciplinary team approach

The Origin of the Cerebral Palsies: Contribution of Population-Based Neuroimaging Data

Surveillance of cerebral palsy in Europe (SCPE) presents the first population-based results on neuroimaging findings in children with cerebral palsy (CP) using a magnetic resonance imaging classification system (MRICS). MRIs of children with CP born between 1999 and 2009 from 18 European countries were analyzed. MRICS identifies patterns of brain pathology according to timing during brain development which was analyzed with respect to CP subtypes and gestational age. MRIs or written reports from 3,818 children were available. The main clinical characteristics were similar to the 5,415 without such data. Most frequent was predominant white matter injury (49%), followed by predominant gray matter injury (21%). Maldevelopments were found in 11% of cases. Miscellaneous findings were present in 8.5% and normal findings in 10.6%. MRI patterns of children with unilateral spastic, bilateral spastic, and dyskinetic CP were mainly lesional (77, 71, and 59%, respectively), whereas children with ataxic CP had more maldevelopments, miscellaneous, and normal findings (25, 21, and 32%, respectively). In children born preterm, predominant white matter injury was most prevalent (80% in children born <32 weeks of gestation). Analysis of MRI in the European CP database identified CP as a mainly lesional condition on a large population basis, maldevelopments were relatively uncommon. An exception was ataxic CP. Children born preterm mostly presented with a lesion typical for their gestational age (GA) at birth. The decreasing prevalence of CP in this group suggests that progress in perinatal and neonatal medicine may lead to a reduction of these lesions.

Secondary care provision for children and young people with Cerebral palsy: A data-linkage study

IntroductionData on children with cerebral palsies are often held in registries, but these contain limited information with varying levels of follow-up. Here we show how record-linkage with healthcare datasets has enabled longitudinal follow-up if these children to understand how they use secondary care health services.&#x0D; Objectives and ApproachOur primary aim was to explore healthcare utilisation for children and young people (CYP) with CP aged 0-25 years between 2004 and 2014 by severity, measured by recorded Gross Motor Function Classification System (GMFCS) level. This was achieved by linking Northern Ireland Cerebral Palsy Register (NICPR) data to routinely collected secondary care data. Comparison was made to the population of CYP who were not on the NICPR i.e. non CP cases.&#x0D; ResultsThere were 1,693 cases in the NICPR cohort born 1981-2011. Of those, 286 (16.9%) were GMFCS 1, 662 (39.1%) GMFCS 2, 277 (16.4%) GMFCS 3, 105 (6.2%) GMFCS 4 and 342 (20.2%) were GMFCS 5 (21 (1.2%) missing).&#x0D; NICPR cases had 11,844 hospital admissions and 19,750 outpatient appointments during the study period accounting for 1.7% of both inpatient and outpatient attendances. Those with severe CP were more likely to have an inpatient admission and had longer stays in hospital than those with less severe CP and those without CP. 592/948 (62.4%) patients with GMFCS 1&amp;2 had an admission compared to 345/447 (77.2%) of GMFCS 4&amp;5 cases. The proportion of elective to emergency admissions was 72.4% versus 53.7% for non CP.&#x0D; Conclusion/ImplicationsThis study adds to understanding of service utilisation for those with CP in the UK, and provides comparable figures with a recent study in Australia. Thus, further demonstrating that linkage between CP registers and routinely collected healthcare may be useful for health services research and informing healthcare delivery.

Drooling in cerebral palsy and its relationship with dysphagia and gross motor functioning

Objective To analyze the incidence and severity of drooling in children with cerebral palsy and explore its correlation with oral dyskinesia, dysphagia and gross motor function. Methods A hundred children with cerebral palsy treated in Qingdao Women′s and Children′s Hospital between July 2013 and 2016 and 50 healthy children examined in the health examination center were assessed using the drooling severity scale, oral motor assessment, a dysphagia disorders survey (DDS) and the gross motor function classification system (GMFCS). The relationship between drooling severity, oral dyskinesia, dysphagia and their gross motor function was analyzed. Results Of the 100 children with cerebral palsy, 32% displayed drooling (at levels II through V), which was significantly higher than among the healthy controls. Another sixty-eight displayed level I drooling. The severity of drooling was significantly different among children with different cerebral palsies. The drooling of children with spastic quadriplegia, dyskinesia or mixed-type cerebral palsy was the most severe, followed by those with ataxia and spastic diplegia whose drooling was often mild. No hemiplegic child drooled at level II. Drooling severity was negatively correlated with the oral motor score, but positively correlated with the average DDS and GMFCS scores. Conclusions About one third of cerebral palsy children suffer from drooling. Their drooling severity is closely associated with the type of the cerebral palsy, oral dyskinesia, dysphagia and GMFCS levels. Key words: Cerebral palsy; Drooling; Gross motor function classification; Dysphagia; Oral motor dysfunction

Cancers de vessie chez les patients neurologiques : étude rétrospective de prise en charge et de suivi

The prevalence of bladder cancer (BC) in neurological patients seems to be similar to that of the general population. However, they are more aggressive with a higher rate of muscle-invasive forms and squamous cells carcinomas. The aim of the current study was to report etiologies, management and outcomes of BC in neurological population. Were enrolled all neurological patients with a BC diagnosed between 2004 and 2017. The following data were retrospectively reported: age, gender, duration of the disease, mode of discovery, histological type, treatment and outcomes. In total, 27 patients were included: 11 spinal cord injuries, 7 Parkinson's disease, 5 multiple sclerosis, 3 head trauma, 3 brain strokes, 2 cerebral palsies and 1 spina bifida. The histological subtypes were as follows: 22 transitional cells carcinomas, 4 squamous cell carcinomas (SCC), one mucinous adenocarcinoma, one sarcomatoid and one neuroendocrine with 19 high-grade tumors and 15 muscle-invasive bladder cancer. Seven patients (26%) were diagnosed before 15years history of neurogenic bladder. The mean follow-up was 14months (1-210months). Eight deaths were observed, with 5 related to bladder cancer. In our study, smoking habits, voiding mode, lithiasis or infection histories were not related with a more aggressive pattern, such as SCC. The high rate of muscle-invasive bladder cancer and aggressive patterns justify neuro-urological follow-up, even before 15years of neurogenic bladder. 4.

Exome Sequencing for cerebral palsies: Opening windows for differential diagnosis

Exome Sequencing for cerebral palsies: Opening windows for differential diagnosis

Case Report of a Child with Developmental Delay

The cerebral palsies are a group of conditions due to non progressive damage to the brain before, during or after birth. There are many causes. Although the brain damage itself doesn’t change nor is it curable, the symptoms may change with time. Classifications vary in different clinics and countries. usually there is the spastic, the athetoid and the ataxic type. The diagnostic classification may not play a direct role in the therapy plans. Diagnostic types are based on the predominant symptoms and there may be symptoms of the other types Although the motor delay and dysfunctions are the main problems in the cerebral palsies there is the possibility of other handicaps. The brain damage itself can be diffuse enough to affect speech and hearing, vision, perceptual function, mental ability and general behaviour. Epilepsy may occur. There may also be other associated handicaps which are due to lack of motor experiences in physically disabled children. Lack of motor exploration affects development of sensation perceptions, mental abilities and speech, emotional and social skills are also hampered. Parent-Child interaction is not always easy and may create emotional problems. Early therapy is advisable to minimize the degree of motor handicap and of the secondary development handicaps.Pulse Vol.8 January-December 2015 p.73-76

PPARγ Is Activated during Congenital Cytomegalovirus Infection and Inhibits Neuronogenesis from Human Neural Stem Cells.

Congenital infection by human cytomegalovirus (HCMV) is a leading cause of permanent sequelae of the central nervous system, including sensorineural deafness, cerebral palsies or devastating neurodevelopmental abnormalities (0.1% of all births). To gain insight on the impact of HCMV on neuronal development, we used both neural stem cells from human embryonic stem cells (NSC) and brain sections from infected fetuses and investigated the outcomes of infection on Peroxisome Proliferator-Activated Receptor gamma (PPARγ), a transcription factor critical in the developing brain. We observed that HCMV infection dramatically impaired the rate of neuronogenesis and strongly increased PPARγ levels and activity. Consistent with these findings, levels of 9-hydroxyoctadecadienoic acid (9-HODE), a known PPARγ agonist, were significantly increased in infected NSCs. Likewise, exposure of uninfected NSCs to 9-HODE recapitulated the effect of infection on PPARγ activity. It also increased the rate of cells expressing the IE antigen in HCMV-infected NSCs. Further, we demonstrated that (1) pharmacological activation of ectopically expressed PPARγ was sufficient to induce impaired neuronogenesis of uninfected NSCs, (2) treatment of uninfected NSCs with 9-HODE impaired NSC differentiation and (3) treatment of HCMV-infected NSCs with the PPARγ inhibitor T0070907 restored a normal rate of differentiation. The role of PPARγ in the disease phenotype was strongly supported by the immunodetection of nuclear PPARγ in brain germinative zones of congenitally infected fetuses (N = 20), but not in control samples. Altogether, our findings reveal a key role for PPARγ in neurogenesis and in the pathophysiology of HCMV congenital infection. They also pave the way to the identification of PPARγ gene targets in the infected brain.

New Insights about Congenital Infection by Human Cytomegalovirus: Unveiling the Role of PPARγ

Congenital infection by human cytomegalovirus (HCMV) might result in permanent neurological sequelae, including sensorineural deafness, cerebral palsies or devastating neurodevelopmental abnormalities. Neural progenitors have been suspected to be key targets of infection, hence a number of studies have shown that HCMV is able to infect neural cells and alter their differentiation. However, little was known about the molecular and genetic bases underlying homeostatic changes in the infected progenitor. We recently disclosed that Peroxisome Proliferator-Activated Receptor gamma (PPARγ), a transcription factor of the nuclear receptor superfamily, is a key determinant of HCMV pathogenesis in the developing brain. Using neural stem cells from human embryonic stem cells, we showed that HCMV infection strongly increases levels and activity of PPARγ in NSCs. Further in vitro experiments showed that PPARγ activity inhibits the neuronogenic differentiation of NSCs into neurons. Consistently, increased PPARγ expression was found in brain section of fetuses infected by HCMV, but not in uninfected controls, what strongly supported the in vitro data. Here we review and discuss past and recent findings on the neuropathogenesis of HCMV congenital infection.

Peroxisome proliferator-activated receptor γ (PPARγ) activation: A key determinant of neuropathogeny during congenital infection by cytomegalovirus.

Congenital infection by human cytomegalovirus (HCMV) might result in permanent neurological sequelae, including sensorineural deafness, cerebral palsies or devastating neurodevelopmental abnormalities. We recently disclosed that Peroxisome Proliferator-Activated Receptor gamma (PPARγ), a transcription factor of the nuclear receptor superfamily, is a key determinant of HCMV pathogenesis in developing brain. Using neural stem cells from human embryonic stem cells, we showed that HCMV infection strongly increases levels and activity of PPARγ in NSCs. Further in vitro experiments showed that PPARγ activity inhibits the neuronogenic differentiation of NSCs into neurons. Consistently, increased PPARγ expression was found in brain section of fetuses infected by HCMV, but not in uninfected controls. In this commentary, we summarize and discuss our findings and the new insights they provide on the neuropathogenesis of HCMV congenital infection.

Variation in health care for children and young people with cerebral palsies: a retrospective multicentre audit study.

To explore the provision and variations in care for children and young people with cerebral palsies (CP) registered with the population-based North of England Collaborative Cerebral Palsy Survey (NECCPS). This is a retrospective multicentre record audit of 389 children with CP (220 males, 148 females, 21 no data; median age at time of audit 12y 3mo), born between 1995 and 2002. Data were collected on cranial magnetic resonance imaging (MRI), hip and spine surveillance and management, and pain presence and management. Variations over time and between the districts in the north of England (Northumberland, North and West Cumbria, North and South Tyneside, Newcastle-upon-Tyne, Gateshead, Sunderland, Durham, Darlington, Bishop Auckland, Hartlepool, Stockton-on-Tees, Middlesbrough, Redcar, and Cleveland), and by socio-economic status (SES) (estimated from the Index of Multiple Deprivation [IMD] 2004) were estimated by generalized estimating equations. There was significant variation between districts in access to MRI (p<0.001), orthopaedic surgeons (p=0.005), recording state of spine (p<0.001), and discussions about pain (p<0.001). Fifty-seven per cent (95% CI 52-62) had evidence of a reported MRI brain scan, the proportion of which increased over time (p<0.001). Sixty-seven per cent (95% CI 62-71) had a discussion about pain recorded. Of those in pain, 87% (95% CI 80-93) had a pain management plan. The proportion with documented discussion about pain increased with increasing SES (p=0.04). The provision of care for children with CP in the north of England varies between districts. Internationally agreed, evidence-based standards are urgently needed to ensure more equitable health care and improved outcomes for all.

DETERMINING THE FACILITATING FACTORS IN PARENTAL ADHERENCE TO A HOME-BASED EDUCATIONAL SPECIAL CARING PROGRAM FOR CHILDREN WITH CEREBRAL PALSY: A CONTENT ANALYSIS OF PARENTS’ EDUCATIONAL EXPERIENCES

introduction: Home special caring program is a treatment –caring program for children with cerebral palsy which has considered its effectiveness on parents and their children. This program used neurodevelopmental approach helps parent to improve parent ability into their children's caring and independence. To successfully implement program, occupational therapists should consider educational program (one phone follow-up) facilitator that were infleneced on parent implementation of home caring program. Materials and Methods: Data gathered and analyzed with qualitative content analysis method. 15 in-depth interviews were conducted with parents who participated and implemented the program at home for three months. Transcripts of interview were coded by usinginductive conventional qualitative content analysis. Results: Facilitator were grouped into three main categories: factors related to workshop, related to booklet, persistent relationship with children's therapists. Conclusions: There were several indicated that, occupational therapist should pay more attention to educational methods of cerebral palsies parent and hold their supportive relationships with parents during implementation of home- based educational caring program. Key words: cerebral palsy/ facilitator/ qualitative content analysis/ home-based educational special caring program