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Thursday, February 23, 2023

Sustainable living

From Wikipedia, the free encyclopedia

Sustainable living describes a lifestyle that attempts to reduce the use of Earth's natural resources by an individual or society. It is referred to as "zero wastage living" or "net zero living". Its practitioners often attempt to reduce their ecological footprint (including their carbon footprint) by altering their home designs and methods of transportation, energy consumption and diet. Its proponents aim to conduct their lives in ways that are consistent with sustainability, naturally balanced, and respectful of humanity's symbiotic relationship with the Earth's natural ecology. The practice and general philosophy of ecological living closely follows the overall principles of sustainable development.

One approach to sustainable living, exemplified by small-scale urban transition towns and rural ecovillages, seeks to create self-reliant communities based on principles of simple living, which maximize self-sufficiency, particularly in food production. These principles, on a broader scale, underpin the concept of a bioregional economy. Additionally, practical ecovillage builders like Living Villages maintain that the shift to alternative technologies will only be successful if the resultant built environment is attractive to a local culture and can be maintained and adapted as necessary over multiple generations.

Definition

The three pillars of sustainability.
 
Circles of Sustainability image (Melbourne, 2011)

Sustainable living is fundamentally the application of sustainability to lifestyle choices and decisions. One conception of sustainable living expresses what it means in triple-bottom-line terms as meeting present ecological, societal, and economical needs without compromising these factors for future generations. Another broader conception describes sustainable living in terms of four interconnected social domains: economics, ecology, politics, and culture. In the first conception, sustainable living can be described as living within the innate carrying capacities defined by these factors. In the second or Circles of Sustainability conception, sustainable living can be described as negotiating the relationships of needs within limits across all the interconnected domains of social life, including consequences for future human generations and non-human species.

Sustainable design and sustainable development are critical factors to sustainable living. Sustainable design encompasses the development of appropriate technology, which is a staple of sustainable living practices. Sustainable development in turn is the use of these technologies in infrastructure. Sustainable architecture and agriculture are the most common examples of this practice.

Lester R. Brown, a prominent environmentalist and founder of the Worldwatch Institute and Earth Policy Institute, describes sustainable living in the twenty-first century as "shifting to a renewable energy-based, reuse/recycle economy with a diversified transport system." Derrick Jensen ("the poet-philosopher of the ecological movement"), a celebrated American author, radical environmentalist and prominent critic of mainstream environmentalism argues that "industrial civilization is not and can never be sustainable". From this statement, the natural conclusion is that sustainable living is at odds with industrialization. Thus, practitioners of the philosophy potentially face the challenge of living in an industrial society and adapting alternative norms, technologies, or practices.

History

  • 1954 The publication of Living the Good Life by Helen and Scott Nearing marked the beginning of the modern day sustainable living movement. The publication paved the way for the "back-to-the-land movement" in the late 1960s and early 1970s.
  • 1962 The publication of Silent Spring by Rachel Carson marked another major milestone for the sustainability movement.
  • 1972 Donella Meadows wrote the international bestseller The Limits to Growth, which reported on a study of long-term global trends in population, economics and the environment. It sold millions of copies and was translated into 28 languages.
  • 1973 E. F. Schumacher published a collection of essays on shifting towards sustainable living through the appropriate use of technology in his book Small Is Beautiful.
  • 1992–2002 The United Nations held a series of conferences, which focused on increasing sustainability within societies to conserve the Earth's natural resources. The Earth Summit conferences were held in 1992, 1972 and 2002.
  • 2007 the United Nations published Sustainable Consumption and Production, Promoting Climate-Friendly Household Consumption Patterns, which promoted sustainable lifestyles in communities and homes.

Shelter

An example of ecological housing

On a global scale, shelter is associated with about 25% of the greenhouse gas emissions embodied in household purchases and 26% of households' land use.

Sustainable homes are built using sustainable methods, materials, and facilitate green practices, enabling a more sustainable lifestyle. Their construction and maintenance have neutral impacts on the Earth. Often, if necessary, they are close in proximity to essential services such as grocery stores, schools, daycares, work, or public transit making it possible to commit to sustainable transportation choices. Sometimes, they are off-the-grid homes that do not require any public energy, water, or sewer service.

If not off-the-grid, sustainable homes may be linked to a grid supplied by a power plant that is using sustainable power sources, buying power as is normal convention. Additionally, sustainable homes may be connected to a grid, but generate their own electricity through renewable means and sell any excess to a utility. There are two common methods to approaching this option: net metering and double metering.

Net metering uses the common meter that is installed in most homes, running forward when power is used from the grid, and running backward when power is put into the grid (which allows them to “net“ out their total energy use, putting excess energy into the grid when not needed, and using energy from the grid during peak hours, when you may not be able to produce enough immediately). Power companies can quickly purchase the power that is put back into the grid, as it is being produced. Double metering involves installing two meters: one measuring electricity consumed, the other measuring electricity created. Additionally, or in place of selling their renewable energy, sustainable home owners may choose to bank their excess energy by using it to charge batteries. This gives them the option to use the power later during less favorable power-generating times (i.e.: night-time, when there has been no wind, etc.), and to be completely independent of the electrical grid.

Sustainably designed (see Sustainable Design) houses are generally sited so as to create as little of a negative impact on the surrounding ecosystem as possible, oriented to the sun so that it creates the best possible microclimate (typically, the long axis of the house or building should be oriented east–west), and provide natural shading or wind barriers where and when needed, among many other considerations. The design of a sustainable shelter affords the options it has later (i.e.: using passive solar lighting and heating, creating temperature buffer zones by adding porches, deep overhangs to help create favorable microclimates, etc.) Sustainably constructed houses involve environmentally friendly management of waste building materials such as recycling and composting, use non-toxic and renewable, recycled, reclaimed, or low-impact production materials that have been created and treated in a sustainable fashion (such as using organic or water-based finishes), use as much locally available materials and tools as possible so as to reduce the need for transportation, and use low-impact production methods (methods that minimize effects on the environment).

In April 2019, New York City passed a bill to cut greenhouse gas emissions. The bill's goal was to minimize the climate pollution stemming from the hub that is New York City. It was approved in a 42 to 5 vote, showing a strong favor of the bill. The bill will restrict energy use in larger buildings. The bill imposes greenhouse gas caps on buildings that are over 25,000 square feet. The calculation of the exact cap is done by square feet per building. A similar emission cap had existed already for buildings of 50,000 square feet or more. This bill expands the legislation to cover more large buildings. The bill protects rent-regulated buildings of which there are around 990,000. Due to the implementation of the bill, around 23,000 new green jobs will be created. The bill received support from Mayor Bill de Blasio. New York is taking action based on the recognition that their climate pollution has effects far beyond the city limits of New York. In discussion of a possible new Amazon headquarters in NYC, De Blasio specified that the bill applies to everyone, regardless of prestige. Mayor de Blasio also announced a lawsuit by the city (of New York) to five major oil companies due to their harm on the environment and climate pollution. This also raises the question of the possible closing of the 24 oil and gas burning power plants in New York City, due to the aimed declining use of these sources of energy. With the emission cap, New York will likely see a turn to renewable energy sources. It is possible that these plants will be transitioned to hubs of renewable energy to power the city. This new bill will go into action in three years (2022) and is estimated to cut climate pollution by 40% in eight years (by 2030).

Many materials can be considered a “green” material until its background is revealed. Any material that has used toxic or carcinogenic chemicals in its treatment or manufacturing (such as formaldehyde in glues used in woodworking), has traveled extensively from its source or manufacturer, or has been cultivated or harvested in an unsustainable manner might not be considered green. In order for any material to be considered green, it must be resource efficient, not compromise indoor air quality or water conservation, and be energy efficient (both in processing and when in use in the shelter). Resource efficiency can be achieved by using as much recycled content, reusable or recyclable content, materials that employ recycled or recyclable packaging, locally available material, salvaged or remanufactured material, material that employs resource efficient manufacturing, and long-lasting material as possible.

Sustainable building materials

Some building materials might be considered "sustainable" by some definitions and under some conditions. For example, wood might be thought of as sustainable if it is grown using sustainable forest management, processed using sustainable energy. delivered by sustainable transport, etc.: Under different conditions, however, it might not be considered as sustainable. The following materials might be considered as sustainable under certain conditions, based on a Life-cycle assessment.

Insulation of a sustainable home is important because of the energy it conserves throughout the life of the home. Well insulated walls and lofts using green materials are a must as it reduces or, in combination with a house that is well designed, eliminates the need for heating and cooling altogether. Installation of insulation varies according to the type of insulation being used. Typically, lofts are insulated by strips of insulating material laid between rafters. Walls with cavities are done in much the same manner. For walls that do not have cavities behind them, solid-wall insulation may be necessary which can decrease internal space and can be expensive to install. Energy-efficient windows are another important factor in insulation. Simply assuring that windows (and doors) are well sealed greatly reduces energy loss in a home. Double or Triple glazed windows are the typical method to insulating windows, trapping gas or creating a vacuum between two or three panes of glass allowing heat to be trapped inside or out. Low-emissivity or Low-E glass is another option for window insulation. It is a coating on windowpanes of a thin, transparent layer of metal oxide and works by reflecting heat back to its source, keeping the interior warm during the winter and cool during the summer. Simply hanging heavy-backed curtains in front of windows may also help their insulation. “Superwindows,” mentioned in Natural Capitalism: Creating the Next Industrial Revolution, became available in the 1980s and use a combination of many available technologies, including two to three transparent low-e coatings, multiple panes of glass, and a heavy gas filling. Although more expensive, they are said to be able to insulate four and a half times better than a typical double-glazed windows.

Equipping roofs with highly reflective material (such as aluminum) increases a roof's albedo and will help reduce the amount of heat it absorbs, hence, the amount of energy needed to cool the building it is on. Green roofs or “living roofs” are a popular choice for thermally insulating a building. They are also popular for their ability to catch storm-water runoff and, when in the broader picture of a community, reduce the heat island effect (see urban heat island) thereby reducing energy costs of the entire area. It is arguable that they are able to replace the physical “footprint” that the building creates, helping reduce the adverse environmental impacts of the building's presence.

Energy efficiency and water conservation are also major considerations in sustainable housing. If using appliances, computers, HVAC systems, electronics, or lighting the sustainable-minded often look for an Energy Star label, which is government-backed and holds stricter regulations in energy and water efficiency than is required by law. Ideally, a sustainable shelter should be able to completely run the appliances it uses using renewable energy and should strive to have a neutral impact on the Earth's water sources.

Greywater, including water from washing machines, sinks, showers, and baths may be reused in landscape irrigation and toilets as a method of water conservation. Likewise, rainwater harvesting from storm-water runoff is also a sustainable method to conserve water use in a sustainable shelter. Sustainable Urban Drainage Systems replicate the natural systems that clean water in wildlife and implement them in a city's drainage system so as to minimize contaminated water and unnatural rates of runoff into the environment.

See related articles in: LEED (Leadership in Energy and Environmental Design) and also it is one of the most important factor of sustainable lifestyle.

Power

Sustainable urban design and innovation: Photovoltaic ombrière SUDI is an autonomous and mobile station that replenishes energy for electric vehicles using solar energy.

As mentioned under Shelter, some sustainable households may choose to produce their own renewable energy, while others may choose to purchase it through the grid from a power company that harnesses sustainable sources (also mentioned previously are the methods of metering the production and consumption of electricity in a household). Purchasing sustainable energy, however, may simply not be possible in some locations due to its limited availability. 6 out of the 50 states in the US do not offer green energy, for example. For those that do, its consumers typically buy a fixed amount or a percentage of their monthly consumption from a company of their choice and the bought green energy is fed into the entire national grid. Technically, in this case, the green energy is not being fed directly to the household that buys it. In this case, it is possible that the amount of green electricity that the buying household receives is a small fraction of their total incoming electricity. This may or may not depend on the amount being purchased. The purpose of buying green electricity is to support their utility's effort in producing sustainable energy. Producing sustainable energy on an individual household or community basis is much more flexible, but can still be limited in the richness of the sources that the location may afford (some locations may not be rich in renewable energy sources while others may have an abundance of it).

When generating renewable energy and feeding it back into the grid (in participating countries such as the US and Germany), producing households are typically paid at least the full standard electricity rate by their utility and are also given separate renewable energy credits that they can then sell to their utility, additionally (utilities are interested in buying these renewable energy credits because it allows them to claim that they produce renewable energy). In some special cases, producing households may be paid up to four times the standard electricity rate, but this is not common.

An installation of solar panels in rural Mongolia

Solar power harnesses the energy of the sun to make electricity. Two typical methods for converting solar energy into electricity are photo-voltaic cells that are organized into panels and concentrated solar power, which uses mirrors to concentrate sunlight to either heat a fluid that runs an electrical generator via a steam turbine or heat engine, or to simply cast onto photo-voltaic cells. The energy created by photo-voltaic cells is a direct current and has to be converted to alternating current before it can be used in a household. At this point, users can choose to either store this direct current in batteries for later use, or use an AC/DC inverter for immediate use. To get the best out of a solar panel, the angle of incidence of the sun should be between 20 and 50 degrees. Solar power via photo-voltaic cells are usually the most expensive method to harnessing renewable energy, but is falling in price as technology advances and public interest increases. It has the advantages of being portable, easy to use on an individual basis, readily available for government grants and incentives, and being flexible regarding location (though it is most efficient when used in hot, arid areas since they tend to be the most sunny). For those that are lucky, affordable rental schemes may be found. Concentrated solar power plants are typically used on more of a community scale rather than an individual household scale, because of the amount of energy they are able to harness but can be done on an individual scale with a parabolic reflector.

Solar thermal energy is harnessed by collecting direct heat from the sun. One of the most common ways that this method is used by households is through solar water heating. In a broad perspective, these systems involve well insulated tanks for storage and collectors, are either passive or active systems (active systems have pumps that continuously circulate water through the collectors and storage tank) and, in active systems, involve either directly heating the water that will be used or heating a non-freezing heat-transfer fluid that then heats the water that will be used. Passive systems are cheaper than active systems since they do not require a pumping system (instead, they take advantage of the natural movement of hot water rising above cold water to cycle the water being used through the collector and storage tank).

Other methods of harnessing solar power are solar space heating (for heating internal building spaces), solar drying (for drying wood chips, fruits, grains, etc.), solar cookers, solar distillers, and other passive solar technologies (simply, harnessing sunlight without any mechanical means).

Wind power is harnessed through turbines, set on tall towers (typically 20’ or 6m with 10‘ or 3m diameter blades for an individual household's needs) that power a generator that creates electricity. They typically require an average of wind speed of 9 mi/hr (14 km/hr) to be worth their investment (as prescribed by the US Department of Energy), and are capable of paying for themselves within their lifetimes. Wind turbines in urban areas usually need to be mounted at least 30’ (10m) in the air to receive enough wind and to be void of nearby obstructions (such as neighboring buildings). Mounting a wind turbine may also require permission from authorities. Wind turbines have been criticized for the noise they produce, their appearance, and the argument that they can affect the migratory patterns of birds (their blades obstruct passage in the sky). Wind turbines are much more feasible for those living in rural areas and are one of the most cost-effective forms of renewable energy per kilowatt, approaching the cost of fossil fuels, and have quick paybacks.

For those that have a body of water flowing at an adequate speed (or falling from an adequate height) on their property, hydroelectricity may be an option. On a large scale, hydroelectricity, in the form of dams, has adverse environmental and social impacts. When on a small scale, however, in the form of single turbines, hydroelectricity is very sustainable. Single water turbines or even a group of single turbines are not environmentally or socially disruptive. On an individual household basis, single turbines are the probably the only economically feasible route (but can have high paybacks and is one of the most efficient methods of renewable energy production). It is more common for an eco-village to use this method rather than a singular household.

Geothermal energy production involves harnessing the hot water or steam below the earth's surface, in reservoirs, to produce energy. Because the hot water or steam that is used is reinjected back into the reservoir, this source is considered sustainable. However, those that plan on getting their electricity from this source should be aware that there is controversy over the lifespan of each geothermal reservoir as some believe that their lifespans are naturally limited (they cool down over time, making geothermal energy production there eventually impossible). This method is often large scale as the system required to harness geothermal energy can be complex and requires deep drilling equipment. There do exist small individual scale geothermal operations, however, which harness reservoirs very close to the Earth's surface, avoiding the need for extensive drilling and sometimes even taking advantage of lakes or ponds where there is already a depression. In this case, the heat is captured and sent to a geothermal heat pump system located inside the shelter or facility that needs it (often, this heat is used directly to warm a greenhouse during the colder months). Although geothermal energy is available everywhere on Earth, practicality and cost-effectiveness varies, directly related to the depth required to reach reservoirs. Places such as the Philippines, Hawaii, Alaska, Iceland, California, and Nevada have geothermal reservoirs closer to the Earth's surface, making its production cost-effective.

Biomass power is created when any biological matter is burned as fuel. As with the case of using green materials in a household, it is best to use as much locally available material as possible so as to reduce the carbon footprint created by transportation. Although burning biomass for fuel releases carbon dioxide, sulfur compounds, and nitrogen compounds into the atmosphere, a major concern in a sustainable lifestyle, the amount that is released is sustainable (it will not contribute to a rise in carbon dioxide levels in the atmosphere). This is because the biological matter that is being burned releases the same amount of carbon dioxide that it consumed during its lifetime. However, burning biodiesel and bioethanol (see biofuel) when created from virgin material, is increasingly controversial and may or may not be considered sustainable because it inadvertently increases global poverty, the clearing of more land for new agriculture fields (the source of the biofuel is also the same source of food), and may use unsustainable growing methods (such as the use of environmentally harmful pesticides and fertilizers).

List of organic matter that can be burned for fuel

Digestion of organic material to produce methane is becoming an increasingly popular method of biomass energy production. Materials such as waste sludge can be digested to release methane gas that can then be burnt to produce electricity. Methane gas is also a natural by-product of landfills, full of decomposing waste, and can be harnessed here to produce electricity as well. The advantage in burning methane gas is that is prevents the methane from being released into the atmosphere, exacerbating the greenhouse effect. Although this method of biomass energy production is typically large scale (done in landfills), it can be done on a smaller individual or community scale as well.

Food

Globally, food accounts for 48% and 90% of household environmental impacts on land and water resources respectively, with consumption of meat, dairy and processed food rising quickly with income.

Environmental impacts of industrial agriculture

Industrial agricultural production is highly resource and energy intensive. Industrial agriculture systems typically require heavy irrigation, extensive pesticide and fertilizer application, intensive tillage, concentrated monoculture production, and other continual inputs. As a result of these industrial farming conditions, today's mounting environmental stresses are further exacerbated. These stresses include: declining water tables, chemical leaching, chemical runoff, soil erosion, land degradation, loss in biodiversity, and other ecological concerns.

Conventional food distribution and long distance transport

Conventional food distribution and long-distance transport are additionally resource and energy exhaustive. Substantial climate-disrupting carbon emissions, boosted by the transport of food over long distances, are of growing concern as the world faces such global crisis as natural resource depletion, peak oil and climate change. “The average American meal currently costs about 1500 miles, and takes about 10 calories of oil and other fossil fuels to produce a single calorie of food.”

Local and seasonal foods

A more sustainable means of acquiring food is to purchase locally and seasonally. Buying food from local farmers reduces carbon output, caused by long-distance food transport, and stimulates the local economy. Local, small-scale farming operations also typically utilize more sustainable methods of agriculture than conventional industrial farming systems such as decreased tillage, nutrient cycling, fostered biodiversity and reduced chemical pesticide and fertilizer applications. Adapting a more regional, seasonally based diet is more sustainable as it entails purchasing less energy and resource demanding produce that naturally grow within a local area and require no long-distance transport. These vegetables and fruits are also grown and harvested within their suitable growing season. Thus, seasonal food farming does not require energy intensive greenhouse production, extensive irrigation, plastic packaging and long-distance transport from importing non-regional foods, and other environmental stressors. Local, seasonal produce is typically fresher, unprocessed and argued to be more nutritious. Local produce also contains less to no chemical residues from applications required for long-distance shipping and handling. Farmers' markets, public events where local small-scale farmers gather and sell their produce, are a good source for obtaining local food and knowledge about local farming productions. As well as promoting localization of food, farmers markets are a central gathering place for community interaction. Another way to become involved in regional food distribution is by joining a local community-supported agriculture (CSA). A CSA consists of a community of growers and consumers who pledge to support a farming operation while equally sharing the risks and benefits of food production. CSA's usually involve a system of weekly pick-ups of locally farmed vegetables and fruits, sometimes including dairy products, meat and special food items such as baked goods. Considering the previously noted rising environmental crisis, the United States and much of the world is facing immense vulnerability to famine. Local food production ensures food security if potential transportation disruptions and climatic, economical, and sociopolitical disasters were to occur.

Reducing meat consumption

Industrial meat production also involves high environmental costs such as land degradation, soil erosion and depletion of natural resources, especially pertaining to water and food. Mass meat production increase the amount of methane in the atmosphere. For more information on the environmental impact of meat production and consumption, see the ethics of eating meat. Reducing meat consumption, perhaps to a few meals a week, or adopting a vegetarian or vegan diet, alleviates the demand for environmentally damaging industrial meat production. Buying and consuming organically raised, free range or grass fed meat is another alternative towards more sustainable meat consumption.

Organic farming

Purchasing and supporting organic products is another fundamental contribution to sustainable living. Organic farming is a rapidly emerging trend in the food industry and in the web of sustainability. According to the USDA National Organic Standards Board (NOSB), organic agriculture is defined as "an ecological production management system that promotes and enhances biodiversity, biological cycles, and soil biological activity. It is based on minimal use of off-farm inputs and on management practices that restore, maintain, or enhance ecological harmony. The primary goal of organic agriculture is to optimize the health and productivity of interdependent communities of soil life, plants, animals and people." Upon sustaining these goals, organic agriculture uses techniques such as crop rotation, permaculture, compost, green manure and biological pest control. In addition, organic farming prohibits or strictly limits the use of manufactured fertilizers and pesticides, plant growth regulators such as hormones, livestock antibiotics, food additives and genetically modified organisms. Organically farmed products include vegetables, fruit, grains, herbs, meat, dairy, eggs, fibers, and flowers. See organic certification for more information.

Urban gardening

"Edible landscaping": a vegetable garden incorporated by the local residents into a roadside park. Qixia District, Nanjing, China

In addition to local, small-scale farms, there has been a recent emergence in urban agriculture expanding from community gardens to private home gardens. With this trend, both farmers and ordinary people are becoming involved in food production. A network of urban farming systems helps to further ensure regional food security and encourages self-sufficiency and cooperative interdependence within communities. With every bite of food raised from urban gardens, negative environmental impacts are reduced in numerous ways. For instance, vegetables and fruits raised within small-scale gardens and farms are not grown with tremendous applications of nitrogen fertilizer required for industrial agricultural operations. The nitrogen fertilizers cause toxic chemical leaching and runoff that enters our water tables. Nitrogen fertilizer also produces nitrous oxide, a more damaging greenhouse gas than carbon dioxide. Local, community-grown food also requires no imported, long-distance transport which further depletes our fossil fuel reserves. In developing more efficiency per land acre, urban gardens can be started in a wide variety of areas: in vacant lots, public parks, private yards, church and school yards, on roof tops (roof-top gardens), and many other places. Communities can work together in changing zoning limitations in order for public and private gardens to be permissible. Aesthetically pleasing edible landscaping plants can also be incorporated into city landscaping such as blueberry bushes, grapevines trained on an arbor, pecan trees, etc. With as small a scale as home or community farming, sustainable and organic farming methods can easily be utilized. Such sustainable, organic farming techniques include: composting, biological pest control, crop rotation, mulching, drip irrigation, nutrient cycling and permaculture. For more information on sustainable farming systems, see sustainable agriculture.

Food preservation and storage

Preserving and storing foods reduces reliance on long-distance transported food and the market industry. Home-grown foods can be preserved and stored outside of their growing season and continually consumed throughout the year, enhancing self-sufficiency and independence from the supermarket. Food can be preserved and saved by dehydration, freezing, vacuum packing, canning, bottling, pickling and jellying. For more information, see food preservation.

Transportation

Cycling on an upright bicycle along the Fietspad in Amsterdam, safe from traffic.
 
The Artic X34 tram vehicle along the Hämeenkatu street in Tampere, Finland where nuclear is the main power source for electricity

With rising concerns over non-renewable energy source usage and climate change caused by carbon emissions, the phase-out of fossil fuel vehicles is becoming more and more important to the conversation of sustainability. Zero-emission urban transport systems that foster mobility, accessible public transportation and healthier urban environments are needed. Such urban transport systems should consist of rail transport, electric buses, bicycle pathways, provision for human-powered transport and pedestrian walkways. Public transport systems such as underground rail systems and bus transit systems shift huge numbers of people away from reliance on car dependency and dramatically reduce the rate of carbon emissions caused by automobile transport.

In comparison to automobiles, bicycles are a paragon of energy efficient personal transportation with the bicycle roughly 50 times more energy efficient than driving. Bicycles increase mobility while alleviating congestion, lowering air and noise pollution, and increasing physical exercise. Most importantly, they do not emit climate-damaging carbon dioxide. Bike-sharing programs are beginning to boom throughout the world and are modeled in leading cities such as Paris, Amsterdam and London. Bike-sharing programs offer kiosks and docking stations that supply hundreds to thousands of bikes for rental throughout a city through small deposits or affordable memberships.

A recent boom has occurred in electric bikes especially in China and other Asian countries. Electric bikes are similar to electric cars in that they are battery-powered and can be plugged into the provincial electric grid for recharging as needed. In contrast to electric cars, electric bikes do not directly use any fossil fuels. Adequate sustainable urban transportation is dependent upon proper city transport infrastructure and planning that incorporates efficient public transit along with bicycle and pedestrian-friendly pathways.

Water

A major factor of sustainable living involves that which no human can live without, water. Unsustainable water use has far reaching implications for humankind. Currently, humans use one-fourth of the Earth's total fresh water in natural circulation, and over half the accessible runoff. Additionally, population growth and water demand is ever increasing. Thus, it is necessary to use available water more efficiently. In sustainable living, one can use water more sustainably through a series of simple, everyday measures. These measures involve considering indoor home appliance efficiency, outdoor water use, and daily water use awareness.

Indoor home appliances

Housing and commercial buildings account for 12 percent of America's freshwater withdrawals. A typical American single family home uses about 70 US gallons (260 L) per person per day indoors. This use can be reduced by simple alterations in behavior and upgrades to appliance quality.

Toilets

Toilets accounted for almost 30% of residential indoor water use in the United States in 1999. One flush of a standard U.S. toilet requires more water than most individuals, and many families, in the world use for all their needs in an entire day. A home's toilet water sustainability can be improved in one of two ways: improving the current toilet or installing a more efficient toilet. To improve the current toilet, one possible method is to put weighted plastic bottles in the toilet tank. Also, there are inexpensive tank banks or float booster available for purchase. A tank bank is a plastic bag to be filled with water and hung in the toilet tank. A float booster attaches underneath the float ball of pre-1986 three and a half gallon capacity toilets. It allows these toilets to operate at the same valve and float setting but significantly reduces their water level, saving between one and one and a third gallons of water per flush. A major waste of water in existing toilets is leaks. A slow toilet leak is undetectable to the eye, but can waste hundreds of gallons each month. One way to check this is to put food dye in the tank, and to see if the water in the toilet bowl turns the same color. In the event of a leaky flapper, one can replace it with an adjustable toilet flapper, which allows self-adjustment of the amount of water per flush.

In installing a new toilet there are a number of options to obtain the most water efficient model. A low flush toilet uses one to two gallons per flush. Traditionally, toilets use three to five gallons per flush. If an eighteen-liter per flush toilet is removed and a six-liter per flush toilet is put in its place, 70% of the water flushed will be saved while the overall indoor water use by will be reduced by 30%. It is possible to have a toilet that uses no water. A composting toilet treats human waste through composting and dehydration, producing a valuable soil additive. These toilets feature a two-compartment bowl to separate urine from feces. The urine can be collected or sold as fertilizer. The feces can be dried and bagged or composted. These toilets cost scarcely more than regularly installed toilets and do not require a sewer hookup. In addition to providing valuable fertilizer, these toilets are highly sustainable because they save sewage collection and treatment, as well as lessen agricultural costs and improve topsoil.

Additionally, one can reduce toilet water sustainability by limiting total toilet flushing. For instance, instead of flushing small wastes, such as tissues, one can dispose of these items in the trash or compost.

Showers

On average, showers were 18% of U.S. indoor water use in 1999, at 6–8 US gallons (23–30 L) per minute traditionally in America. A simple method to reduce this use is to switch to low-flow, high-performance showerheads. These showerheads use only 1.0–1.5 gpm or less. An alternative to replacing the showerhead is to install a converter. This device arrests a running shower upon reaching the desired temperature. Solar water heaters can be used to obtain optimal water temperature, and are more sustainable because they reduce dependence on fossil fuels. To lessen excess water use, water pipes can be insulated with pre-slit foam pipe insulation. This insulation decreases hot water generation time. A simple, straightforward method to conserve water when showering is to take shorter showers. One method to accomplish this is to turn off the water when it is not necessary (such as while lathering) and resuming the shower when water is necessary. This can be facilitated when the plumbing or showerhead allow turning off the water without disrupting the desired temperature setting (common in the UK but not the United States).

Dishwashers and sinks

On average, sinks were 15% of U.S. indoor water use in 1999. There are, however, easy methods to rectify excessive water loss. Available for purchase is a screw-on aerator. This device works by combining water with air thus generating a frothy substance with greater perceived volume, reducing water use by half. Additionally, there is a flip-valve available that allows flow to be turned off and back on at the previously reached temperature. Finally, a laminar flow device creates a 1.5–2.4 gpm stream of water that reduces water use by half, but can be turned to normal water level when optimal.

In addition to buying the above devices, one can live more sustainably by checking sinks for leaks, and fixing these links if they exist. According to the EPA, "A small drip from a worn faucet washer can waste 20 gallons of water per day, while larger leaks can waste hundreds of gallons". When washing dishes by hand, it is not necessary to leave the water running for rinsing, and it is more efficient to rinse dishes simultaneously.

On average, dishwashing consumes 1% of indoor water use. When using a dishwasher, water can be conserved by only running the machine when it is full. Some have a "low flow" setting to use less water per wash cycle. Enzymatic detergents clean dishes more efficiently and more successfully with a smaller amount of water at a lower temperature.

Washing machines

On average, 23% of U.S. indoor water use in 1999 was due to clothes washing. In contrast to other machines, American washing machines have changed little to become more sustainable. A typical washing machine has a vertical-axis design, in which clothes are agitated in a tubful of water. Horizontal-axis machines, in contrast, put less water into the bottom of the rub and rotate clothes through it. These machines are more efficient in terms of soap use and clothing stability.

Outdoor water use

There are a number of ways one can incorporate a personal yard, roof, and garden in more sustainable living. While conserving water is a major element of sustainability, so is sequestering water.

Conserving water

In planning a yard and garden space, it is most sustainable to consider the plants, soil, and available water. Drought resistant shrubs, plants, and grasses require a smaller amount of water in comparison to more traditional species. Additionally, native plants (as opposed to herbaceous perennials) will use a smaller supply of water and have a heightened resistance to plant diseases of the area. Xeriscaping is a technique that selects drought-tolerant plants and accounts for endemic features such as slope, soil type, and native plant range. It can reduce landscape water use by 50 – 70%, while providing habitat space for wildlife. Plants on slopes help reduce runoff by slowing and absorbing accumulated rainfall. Grouping plants by watering needs further reduces water waste.

After planting, placing a circumference of mulch surrounding plants functions to lessen evaporation. To do this, firmly press two to four inches of organic matter along the plant's dripline. This prevents water runoff. When watering, consider the range of sprinklers; watering paved areas is unnecessary. Additionally, to conserve the maximum amount of water, watering should be carried out during early mornings on non-windy days to reduce water loss to evaporation. Drip-irrigation systems and soaker hoses are a more sustainable alternative to the traditional sprinkler system. Drip-irrigation systems employ small gaps at standard distances in a hose, leading to the slow trickle of water droplets which percolate the soil over a protracted period. These systems use 30 – 50% less water than conventional methods. Soaker hoses help to reduce water use by up to 90%. They connect to a garden hose and lay along the row of plants under a layer of mulch. A layer of organic material added to the soil helps to increase its absorption and water retention; previously planted areas can be covered with compost.

In caring for a lawn, there are a number of measures that can increase the sustainability of lawn maintenance techniques. A primary aspect of lawn care is watering. To conserve water, it is important to only water when necessary, and to deep soak when watering. Additionally, a lawn may be left to go dormant, renewing after a dry spell to its original vitality.

Sequestering water

A common method of water sequestrations is rainwater harvesting, which incorporates the collection and storage of rain. Primarily, the rain is obtained from a roof, and stored on the ground in catchment tanks. Water sequestration varies based on extent, cost, and complexity. A simple method involves a single barrel at the bottom of a downspout, while a more complex method involves multiple tanks. It is highly sustainable to use stored water in place of purified water for activities such as irrigation and flushing toilets. Additionally, using stored rainwater reduces the amount of runoff pollution, picked up from roofs and pavements that would normally enter streams through storm drains. The following equation can be used to estimate annual water supply:

Collection area (square feet) × Rainfall (inch/year) / 12 (inch/foot) = Cubic Feet of Water/Year

Cubic Feet/Year × 7.43 (Gallons/Cubic Foot) = Gallons/year

Note, however, this calculation does not account for losses such as evaporation or leakage.

Greywater systems function in sequestering used indoor water, such as laundry, bath and sink water, and filtering it for reuse. Greywater can be reused in irrigation and toilet flushing. There are two types of greywater systems: gravity fed manual systems and package systems. The manual systems do not require electricity but may require a larger yard space. The package systems require electricity but are self-contained and can be installed indoors.

Waste

As populations and resource demands climb, waste production contributes to emissions of carbon dioxide, leaching of hazardous materials into the soil and waterways, and methane emissions. In America alone, over the course of a decade, 500 trillion pounds (230 Gt) of American resources will have been transformed into nonproductive wastes and gases. Thus, a crucial component of sustainable living is being waste conscious. One can do this by reducing waste, reusing commodities, and recycling.

There are a number of ways to reduce waste in sustainable living. Two methods to reduce paper waste are canceling junk mail like credit card and insurance offers and direct mail marketing and changing monthly paper statements to paperless emails. Junk mail alone accounted for 1.72 million tons of landfill waste in 2009. Another method to reduce waste is to buy in bulk, reducing packaging materials. Preventing food waste can limit the amount of organic waste sent to landfills producing the powerful greenhouse gas methane. Another example of waste reduction involves being cognizant of purchasing excessive amounts when buying materials with limited use like cans of paint. Non-hazardous or less hazardous alternatives can also limit the toxicity of waste.

By reusing materials, one lives more sustainably by not contributing to the addition of waste to landfills. Reusing saves natural resources by decreasing the necessity of raw material extraction. For example, reusable bags can reduce the amount of waste created by grocery shopping eliminating the need to create and ship plastic bags and the need to manage their disposal and recycling or polluting effects.

Recycling, a process that breaks down used items into raw materials to make new materials, is a particularly useful means of contributing to the renewal of goods. Recycling incorporates three primary processes; collection and processing, manufacturing, and purchasing recycled products. A natural example of recycling involves using food waste as compost to enrich the quality of soil, which can be carried out at home or locally with community composting. An offshoot of recycling, upcycling, strives to convert material into something of similar or greater value in its second life. By integrating measures of reusing, reducing, and recycling one can effectively reduce personal waste and use materials in a more sustainable manner.

Reproductive choices

Though it is not always included in discussions of sustainable living, some consider reproductive choices to be a key part of sustainable living. Reproductive choices refers, in this case, to the number of children that an individual has, whether they are conceived biologically or adopted. Some researchers have claimed that for people living in wealthy, high-consumption countries such as the United States, having fewer children is by far the most effective way to decrease one's carbon footprint, and one's ecological footprint more broadly. However, the scholarship that has led to this claim has been questioned, as has the misleading way that it's often been presented in popular newspaper and web articles. Some ethicists and environmental activists have made similar arguments about the need for a "small family ethic" and research has found that in some countries, these ecological concerns are leading some people to report having fewer children than they would otherwise, or no children at all.

However, there have been multiple critiques of the idea that having fewer children is part of a sustainable lifestyle. Some argue that it is an example of the kind of Malthusian thinking that has led to coercion and violence in the past (including forced sterilizations and forced abortions), and that it might lead to similar policies that deny women reproductive freedom in the future. Additionally, research has found that some environmentalists consider having children, and even having more children than they might otherwise, to be a part of sustainable living. They assert that parenting can be an important way that individuals can exert a positive environmental influence, by educating the next generation and as a way to remain engaged in one's commitment to environmental action.

Provision, supply and expenditure in general

A study that reviewed 217 analyses of on-the-market products and services and analyzed existing alternatives to mainstream food, holidays, and furnishings, concluded that total greenhouse gas emissions by Swedes could be lowered by as of 2021 up to 36–38 % if consumers – without a decrease in total estimated expenditure or considerations of self-interest rationale – instead were to obtain those they – using available datacould assess to be more sustainable. Provision, supply/availability, product development/success/price, comparative benefits as well as incentives, purposes/demands and effects of expenditure-choices are part of or embedded in the human neuro-socioeconomic system and therefore overall largely beyond the control of an individual seeking to make rational and ethical choices within it even if all relevant life-cycle assessment/product and manufacturing information was available to this consumer . and it leads the consumer

Cerebral palsy

From Wikipedia, the free encyclopedia
 
Cerebral palsy
USS Kearsarge medical team treat patients at Arima District Health Facility DVIDS126489.jpg
A child with cerebral palsy being assessed by a physician
Specialty
Symptoms
Complications
Usual onsetPrenatal to early childhood
DurationLifelong
CausesOften unknown or brain injury
Risk factors
Diagnostic methodBased on child's development
Treatment
Medication
Frequency2.1 per 1,000

Cerebral palsy (CP) is a group of movement disorders that appear in early childhood. Signs and symptoms vary among people and over time, but include poor coordination, stiff muscles, weak muscles, and tremors. There may be problems with sensation, vision, hearing, and speaking. Often, babies with cerebral palsy do not roll over, sit, crawl or walk as early as other children of their age. Other symptoms include seizures and problems with thinking or reasoning, which each occur in about one-third of people with CP. While symptoms may get more noticeable over the first few years of life, underlying problems do not worsen over time.

Cerebral palsy is caused by abnormal development or damage to the parts of the brain that control movement, balance, and posture. Most often, the problems occur during pregnancy, but they may also occur during childbirth or shortly after birth. Often, the cause is unknown. Risk factors include preterm birth, being a twin, certain infections during pregnancy, such as toxoplasmosis or rubella, exposure to methylmercury during pregnancy, a difficult delivery, and head trauma during the first few years of life, among others. About 2% of cases are believed to be due to an inherited genetic cause. A number of sub-types are classified, based on the specific problems present. For example, those with stiff muscles have spastic cerebral palsy, those with poor coordination in locomotion have ataxic cerebral palsy, and those with writhing movements have dyskinetic cerebral palsy. Diagnosis is based on the child's development over time. Blood tests and medical imaging may be used to rule out other possible causes.

Some of the causes of CP are preventable through immunization of the mother, and through efforts to prevent head injuries in children such as through improved safety. There is no known cure for CP, but supportive treatments, medication and surgery may help many individuals. This may include physical therapy, occupational therapy and speech therapy. Medications such as diazepam, baclofen and botulinum toxin may help relax stiff muscles. Surgery may include lengthening muscles and cutting overly active nerves. Often, external braces and Lycra splints and other assistive technology are helpful with mobility. Some affected children can achieve near normal adult lives with appropriate treatment. While alternative medicines are frequently used, there is no evidence to support their use.

Cerebral palsy is the most common movement disorder in children. It occurs in about 2.1 per 1,000 live births. Cerebral palsy has been documented throughout history, with the first known descriptions occurring in the work of Hippocrates in the 5th century BCE. Extensive study of the condition began in the 19th century by William John Little, after whom spastic diplegia was called "Little's disease". William Osler first named it "cerebral palsy" from the German zerebrale Kinderlähmung (cerebral child-paralysis). A number of potential treatments are being examined, including stem cell therapy. However, more research is required to determine if it is effective and safe.

Signs and symptoms

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." While movement problems are the central feature of CP, difficulties with thinking, learning, feeling, communication and behavior often co-occur, with 28% having epilepsy, 58% having difficulties with communication, at least 42% having problems with their vision, and 23–56% having learning disabilities. Muscle contractions in people with cerebral palsy are commonly thought to arise from overactivation.

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 and progressive. In cerebral palsy 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. Additionally, crouch gait (also described as knee flexion gait) is prevalent among children who possess the ability to walk. The effects of cerebral palsy fall on a continuum of motor dysfunction, which may range from slight clumsiness at the mild end of the spectrum to impairments so severe that they render coordinated movement virtually impossible at the other end of the spectrum. Although most people with CP have problems with increased muscle tone, some have normal or low muscle tone. High muscle tone can either be due to spasticity or dystonia.

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.

Drooling is common among children with cerebral palsy, which can have a variety of impacts including social rejection, impaired speaking, damage to clothing and books, and mouth infections. It can additionally cause choking.

An average of 55.5% of people with cerebral palsy experience lower urinary tract symptoms, more commonly excessive storage issues than voiding issues. Those with voiding issues and pelvic floor overactivity can deteriorate as adults and experience upper urinary tract dysfunction.

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. People with cerebral palsy are at risk of low bone mineral density. The shafts of the bones are often thin (gracile), and become thinner during growth. When compared to these thin shafts (diaphyses), the centres (metaphyses) often appear quite enlarged (ballooning). Due to more than normal joint compression caused by muscular imbalances, articular cartilage may atrophy, leading to narrowed joint spaces. Depending on the degree of spasticity, a person with CP may exhibit a variety of angular joint deformities. Because vertebral bodies need vertical gravitational loading forces to develop properly, spasticity and an abnormal gait can hinder proper or full bone and skeletal development. People with CP tend to be shorter in height than the average person because their bones are not allowed to grow to their full potential. Sometimes bones grow to different lengths, so the person may have one leg longer than the other.

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. These children generally have fractures in the legs, whereas non-affected children mostly fracture their arms in the context of sporting activities.

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. Children may develop scoliosis before the age of 10 – estimated prevalence of scoliosis in children with CP is between 21% and 64%. Higher levels of impairment on the GMFCS are associated with scoliosis and hip dislocation. Scoliosis can be corrected with surgery, but CP makes surgical complications more likely, even with improved techniques. Hip migration can be managed by soft tissue procedures such as adductor musculature release. Advanced degrees of hip migration or dislocation can be managed by more extensive procedures such as femoral and pelvic corrective osteotomies. Both soft tissue and bony procedures aim at prevention of hip dislocation in the early phases or aim at hip containment and restoration of anatomy in the late phases of disease. Equinus deformity is managed by conservative methods especially when dynamic. If fixed/static deformity ensues surgery may become mandatory.

Growth spurts during puberty can make walking more difficult for people with CP.

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. Gastro-oesophageal reflux is common in children with CP. Children with CP may have too little or too much sensitivity around and in the mouth. Poor balance when sitting, lack of control of the head, mouth, and trunk, not being able to bend the hips enough to allow the arms to stretch forward to reach and grasp food or utensils, and lack of hand-eye coordination can make self-feeding difficult. Feeding difficulties are related to higher GMFCS levels. Dental problems can also contribute to difficulties with eating. Pneumonia is also common where eating difficulties exist, caused by undetected aspiration of food or liquids. Fine finger dexterity, like that needed for picking up a utensil, is more frequently impaired than gross manual dexterity, like that needed for spooning food onto a plate. Grip strength impairments are less common.

Children with severe cerebral palsy, particularly with oropharyngeal issues, are at risk of undernutrition. 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%, and around a quarter of people with CP are non-verbal. Speech problems are associated with poor respiratory control, laryngeal and velopharyngeal dysfunction, and oral articulation disorders that are due to restricted movement in the oral-facial muscles. There are three major types of dysarthria in cerebral palsy: spastic, dyskinetic (athetotic), and ataxic.

Early use of augmentative and alternative communication systems may assist the child in developing spoken language skills. Overall language delay is associated with problems of cognition, deafness, and learned helplessness. Children with cerebral palsy are at risk of learned helplessness and becoming passive communicators, initiating little communication. 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 and sleep

Pain is common and may result from the inherent deficits associated with the condition, along with the numerous procedures children typically face. When children with cerebral palsy are in pain, they experience worse muscle spasms. 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. Pain in CP has a number of different causes, and different pains respond to different treatments.

There is also a high likelihood of chronic sleep disorders secondary to both physical and environmental factors. Children with cerebral palsy have significantly higher rates of sleep disturbance than typically developing children. 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. 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. 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. The associated disorders that co-occur with cerebral palsy may be more disabling than the motor function problems.

Causes

refer to caption
Micrograph 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. This damage can occur during pregnancy, delivery, the first month of life, or less commonly in early childhood. Structural problems in the brain are seen in 80% of cases, most commonly within the white matter. More than three-quarters of cases are believed to result from issues that occur during pregnancy. Most children who are born with cerebral palsy have more than one risk factor associated with CP.

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.

In Africa birth asphyxia, high bilirubin levels, and infections in newborns of the central nervous system are main cause. Many cases of CP in Africa could be prevented with better resources available.

Preterm birth

Between 40% and 50% of all children who develop cerebral palsy were born prematurely. Most of these cases (75–90%) are believed to be due to issues that occur around the time of birth, often just after birth. Multiple-birth infants are also more likely than single-birth infants to have CP. They are also more likely to be born with a low birth weight.

In those who are born with a weight between 1 kg and 1.5 kg CP occurs in 6%. Among those born before 28 weeks of gestation it occurs in 8%. Genetic factors are believed to play an important role in prematurity and cerebral palsy generally. While in those who are born between 34 and 37 weeks the risk is 0.4% (three times normal).

Term infants

In babies that are born at term risk factors include problems with the placenta, birth defects, low birth weight, breathing meconium into the lungs, a delivery requiring either the use of instruments or an emergency Caesarean section, birth asphyxia, seizures just after birth, respiratory distress syndrome, low blood sugar, and infections in the baby.

As of 2013, it was unclear how much of a role birth asphyxia plays as a cause. It is unclear if the size of the placenta plays a role. As of 2015 it is evident that in advanced countries, most cases of cerebral palsy in term or near-term neonates have explanations other than asphyxia.

Genetics

Autosomal recessive inheritance pattern

Cerebral palsy is not commonly considered a genetic disease. About 2% of all CP cases are expected to be inherited, with glutamate decarboxylase-1 being one of the possible enzymes involved. Most inherited cases are autosomal recessive. However, the vast majority of CP cases are connected to brain damage during birth and in infancy. There is a small percentage of CP cases caused by brain damage that stemmed from the prenatal period, which is estimated to be less than 5% of CP cases overall. Moreover, there is no one reason why some CP cases come from prenatal brain damage, and it's not known if those cases have a genetic basis.

Cerebellar hypoplasia is sometimes genetic and can cause ataxic cerebral palsy.

Early childhood

After birth, other causes include toxins, severe jaundice, lead poisoning, physical brain injury, stroke, 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. Infections 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. Children who are more severely affected are more likely to be noticed and diagnosed earlier. Abnormal muscle tone, delayed motor development and persistence of primitive reflexes are the main early symptoms of CP. Symptoms and diagnosis typically occur by the age of two, although depending on factors like malformations and congenital issues, persons with milder forms of cerebral palsy may be over the age of five, if not in adulthood, when finally diagnosed. Cognitive assessments and medical observations are also useful to help confirm a diagnosis. Additionally, evaluations of the child's mobility, speech and language, hearing, vision, gait, feeding and digestion are also useful to determine the extent of the disorder. Early diagnosis and intervention are seen as being a key part of managing cerebral palsy. Machine learning algorithms facilitate automatic early diagnosis, with methods such as deep neural network and geometric feature fusion producing high accuracy in predicting cerebral palsy from short videos. It is a developmental disability.

Once a person is diagnosed with cerebral palsy, further diagnostic tests are optional. Neuroimaging with CT or MRI is warranted when the cause of a person's cerebral palsy has not been established. An MRI is preferred over CT, due to diagnostic yield and safety. When abnormal, the neuroimaging study can suggest the timing of the initial damage. The CT or MRI is also capable of revealing treatable conditions, such as hydrocephalus, porencephaly, arteriovenous malformation, subdural hematomas and hygromas, and a vermian tumour (which a few studies suggest are present 5–22% of the time). Furthermore, an abnormal neuroimaging study indicates a high likelihood of associated conditions, such as epilepsy and intellectual disability. There is a small risk associated with sedating children to facilitate a clear MRI.

The age when CP is diagnosed is important, but medical professionals disagree over the best age to make the diagnosis. The earlier CP is diagnosed correctly, the better the opportunities are to provide the child with physical and educational help, but there might be a greater chance of confusing CP with another problem, especially if the child is 18 months of age or younger. Infants may have temporary problems with muscle tone or control that can be confused with CP, which is permanent. A metabolism disorder or tumors in the nervous system may appear to be CP; metabolic disorders, in particular, can produce brain problems that look like CP on an MRI. Disorders that deteriorate the white matter in the brain and problems that cause spasms and weakness in the legs, may be mistaken for CP if they first appear early in life. However, these disorders get worse over time, and CP does not (although it may change in character). In infancy it may not be possible to tell the difference between them. In the UK, not being able to sit independently by the age of 8 months is regarded as a clinical sign for further monitoring. Fragile X syndrome (a cause of autism and intellectual disability) and general intellectual disability must also be ruled out. Cerebral palsy specialist John McLaughlin recommends waiting until the child is 36 months of age before making a diagnosis because, by that age, motor capacity is easier to assess.

Classification

CP is classified by the types of motor impairment of the limbs or organs, and by restrictions to the activities an affected person may perform. The Gross Motor Function Classification System-Expanded and Revised and the Manual Ability Classification System are used to describe mobility and manual dexterity in people with cerebral palsy, and recently the Communication Function Classification System, and the Eating and Drinking Ability Classification System have been proposed to describe those functions. There are three main CP classifications by motor impairment: spastic, ataxic, and dyskinetic. Additionally, there is a mixed type that shows a combination of features of the other types. These classifications reflect the areas of the brain that are damaged.

Cerebral palsy is also classified according to the topographic distribution of muscle spasticity. This method classifies children as diplegic, (bilateral involvement with leg involvement greater than arm involvement), hemiplegic (unilateral involvement), or quadriplegic (bilateral involvement with arm involvement equal to or greater than leg involvement).

Spastic

Spastic cerebral palsy is the type of cerebral palsy characterized by spasticity or high muscle tone often resulting in stiff, jerky movements. Itself an umbrella term encompassing spastic hemiplegia, spastic diplegia, spastic quadriplegia and – where solely one limb or one specific area of the body is affected – spastic monoplegia. Spastic cerebral palsy affects the motor cortex of the brain, a specific portion of the cerebral cortex responsible for the planning and completion of voluntary movement. Spastic CP is the most common type of overall cerebral palsy, representing about 80% of cases. Botulinum toxin is effective in decreasing spasticity. It can help increase range of motion which could help mitigate CPs effects on the growing bones of children. There may be an improvement in motor functions in the children and ability to walk. however, the main benefit derived from botulinum toxin A comes from its ability to reduce muscle tone and spasticity and thus prevent or delay the development of fixed muscle contractures.

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.

Dyskinetic

Dyskinetic cerebral palsy (sometimes abbreviated DCP) is primarily associated with damage to the basal ganglia and the substantia nigra in the form of lesions that occur during brain development due to bilirubin encephalopathy and hypoxic-ischemic brain injury. DCP is characterized by both hypertonia and hypotonia, due to the affected individual's inability to control muscle tone. Clinical diagnosis of DCP typically occurs within 18 months of birth and is primarily based upon motor function and neuroimaging techniques. Dyskinetic cerebral palsy is an extrapyramidal form of cerebral palsy. Dyskinetic cerebral palsy can be divided into two different groups; choreoathetosis and dystonia. Choreo-athetotic CP is characterized by involuntary movements, whereas dystonic CP is characterized by slow, strong contractions, which may occur locally or encompass the whole body.

Mixed

Mixed cerebral palsy has symptoms of dyskinetic, ataxic and spastic CP appearing simultaneously, each to varying degrees, and both with and without symptoms of each. Mixed CP is the most difficult to treat as it is extremely heterogeneous and sometimes unpredictable in its symptoms and development over the lifespan.

Gait Classification

The Amsterdam 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.

Gait types 5 is also known as crouch gait.

Prevention

Because the causes of CP are varied, a broad range of preventive interventions have been investigated.

Electronic fetal monitoring has not helped to prevent CP, and in 2014 the American College of Obstetricians and Gynecologists, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and the Society of Obstetricians and Gynaecologists of Canada have acknowledged that there are no long-term benefits of electronic fetal monitoring. Before this, electronic fetal monitoring was widely used to prop up obstetric litigation.

In those at risk of an early delivery, magnesium sulphate appears to decrease the risk of cerebral palsy. It is unclear if it helps those who are born at term. In those at high risk of preterm labor a review found that moderate to severe CP was reduced by the administration of magnesium sulphate, and that adverse effects on the babies from the magnesium sulphate were not significant. Mothers who received magnesium sulphate could experience side effects such as respiratory depression and nausea. However, guidelines for the use of magnesium sulfate in mothers at risk of preterm labour are not strongly adhered to. 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. Additionally, for preterm babies for whom there is a chance of fetal compromise, allowing the birth to proceed rather than trying to delay the birth may lead to an increased risk of cerebral palsy in the child. Corticosteroids are sometimes taken by pregnant women expecting a preterm birth to provide neuroprotection to their baby. 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

A girl wearing leg braces walks towards a woman in a gym, with a treadmill visible in the background.
Researchers are developing an electrical stimulation device specifically for children with cerebral palsy, who have foot drop, 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. However, the evidence base for the effectiveness of intervention programs reflecting the philosophy of independence has not yet caught up: effective interventions for body structures and functions have a strong evidence base, but evidence is lacking for effective interventions targeted toward participation, environment, or personal factors. There is also no good evidence to show that an intervention that is effective at the body-specific level will result in an improvement at the activity level or vice versa. Although such cross-over benefit might happen, not enough high-quality studies have been done to demonstrate it.

Because cerebral palsy has "varying severity and complexity" across the lifespan, it can be considered a collection of conditions for management purposes. A multidisciplinary approach for cerebral palsy management is recommended, focusing on "maximising individual function, choice and independence" in line with the International Classification of Functioning, Disability and Health's goals. The team may include a paediatrician, a health visitor, a social worker, a physiotherapist, an orthotist, a speech and language therapist, an occupational therapist, a teacher specialising in helping children with visual impairment, an educational psychologist, an orthopaedic surgeon, a neurologist and a neurosurgeon.

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

Child with cerebral palsy and orthotics 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. There is currently no evidence that CP affects fertility, although some of the secondary symptoms have been shown to affect sexual desire and performance. 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. Women with CP reported higher levels of spasticity and urinary incontinence during menstruation in a study. Men with CP have higher levels of cryptorchidism at the age of 21.

CP can significantly reduce a person's life expectancy, depending on the severity of their condition and the quality of care they receive. 5–10% of children with CP die in childhood, particularly where seizures and intellectual disability also affect the child. The ability to ambulate, roll, and self-feed has been associated with increased life expectancy. While there is a lot of variation in how CP affects people, it has been found that "independent gross motor functional ability is a very strong determinant of life expectancy". 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.

Self-care

For many children with CP, parents are heavily involved in self-care activities. Self-care activities, such as bathing, dressing, and grooming, can be difficult for children with CP, as self-care depends primarily on the use of the upper limbs. For those living with CP, impaired upper limb function affects almost 50% of children and is considered the main factor contributing to decreased activity and participation. As the hands are used for many self-care tasks, sensory and motor impairments of the hands make daily self-care more difficult. Motor impairments cause more problems than sensory impairments. The most common impairment is that of finger dexterity, which is the ability to manipulate small objects with the fingers. Compared to other disabilities, people with cerebral palsy generally need more help in performing daily tasks. 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.

Play is included as a productive occupation as it is often the primary activity for children. If play becomes difficult due to a disability, like CP, this can cause problems for the child. These difficulties can affect a child's self-esteem. In addition, the sensory and motor problems experienced by children with CP affect how the child interacts with their surroundings, including the environment and other people. Not only do physical limitations affect a child's ability to play, the limitations perceived by the child's caregivers and playmates also affect the child's play activities. Some children with disabilities spend more time playing by themselves. When a disability prevents a child from playing, there may be social, emotional and psychological problems, which can lead to increased dependence on others, less motivation, and poor social skills.

In school, students are asked to complete many tasks and activities, many of which involve handwriting. Many children with CP have the capacity to learn and write in the school environment. However, students with CP may find it difficult to keep up with the handwriting demands of school and their writing may be difficult to read. In addition, writing may take longer and require greater effort on the student's part. Factors linked to handwriting include postural stability, sensory and perceptual abilities of the hand, and writing tool pressure.

Speech impairments may be seen in children with CP depending on the severity of brain damage. Communication in a school setting is important because communicating with peers and teachers is very much a part of the "school experience" and enhances social interaction. Problems with language or motor dysfunction can lead to underestimating a student's intelligence. In summary, children with CP may experience difficulties in school, such as difficulty with handwriting, carrying out school activities, communicating verbally, and interacting socially.

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. Common benefits identified are stress reduction, development of coping skills, companionship, enjoyment, relaxation and a positive effect on life satisfaction. In addition, for children with CP, leisure appears to enhance adjustment to living with a disability.

Leisure can be divided into structured (formal) and unstructured (informal) activities. Children and teens with CP engage in less habitual physical activity than their peers. 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. Participation includes self-care, productivity, and leisure. In fact, communication, mobility, education, home life, leisure, and social relationships require participation, and indicate the extent to which children function in their environment. Barriers can exist on three levels: micro, meso, and macro. First, the barriers at the micro level involve the person. Barriers at the micro level include the child's physical limitations (motor, sensory and cognitive impairments) or their subjective feelings regarding their ability to participate. For example, the child may not participate in group activities due to lack of confidence. Second, barriers at the meso level include the family and community. These may include negative attitudes of people toward disability or lack of support within the family or in the community. One of the main reasons for this limited support appears to be the result of a lack of awareness and knowledge regarding the child's ability to engage in activities despite his or her disability. Third, barriers at the macro level incorporate the systems and policies that are not in place or hinder children with CP. These may be environmental barriers to participation such as architectural barriers, lack of relevant assistive technology, and transportation difficulties due to limited wheelchair access or public transit that can accommodate children with CP. For example, a building without an elevator can prevent the child from accessing higher floors.

A 2013 review stated that outcomes for adults with cerebral palsy without intellectual disability in the 2000s were that "60–80% completed high school, 14–25% completed college, up to 61% were living independently in the community, 25–55% were competitively employed, and 14–28% were involved in long term relationships with partners or had established families". 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.

A study in young adults (18–34) on transitioning to adulthood found that their concerns were physical health care and understanding their bodies, being able to navigate and use services and supports successfully, and dealing with prejudices. A feeling of being "thrust into adulthood" was common in the study.

Aging

Children with CP may not successfully transition into using adult services because they are not referred to one upon turning 18, and may decrease their use of services. Quality of life outcomes tend to decline for adults with cerebral palsy. 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". 25% or more adults with cerebral palsy who can walk experience increasing difficulties walking with age. Hand function does not seem to have similar declines. Chronic disease risk, such as obesity, is also higher among adults with cerebral palsy than the general population. Common problems include increased pain, reduced flexibility, increased spasms and contractures, post-impairment syndrome and increasing problems with balance. Increased fatigue is also a problem. When adulthood and cerebral palsy is discussed, as of 2011, it is not discussed in terms of the different stages of adulthood.

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. In those born at term rates are lower at 1 per 1000 live births. Within a population it may occur more often in poorer people. The rate is higher in males than in females; in Europe it is 1.3 times more common in males.

There was a "moderate, but significant" rise in the prevalence of CP between the 1970s and 1990s. This is thought to be due to a rise in low birth weight of infants and the increased survival rate of these infants. The increased survival rate of infants with CP in the 1970s and 80s may be indirectly due to the disability rights movement challenging perspectives around the worth of infants with a disability, as well as the Baby Doe Law.

As of 2005, advances in the care of pregnant mothers and their babies have not resulted 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. As of 2016, there is a suggestion that both incidence and severity are slightly decreasing – more research is needed to find out if this is significant, and if so, which interventions are effective. It has been found that high-income countries have lower rates of children born with cerebral palsy than low or middle-income countries.

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.

The medical literature of the ancient Greeks discusses paralysis and weakness of the arms and legs; the modern word palsy comes from the Ancient Greek words παράλυση or πάρεση, meaning paralysis or paresis respectively. The works of the school of Hippocrates (460–c. 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. The Roman Emperor Claudius (10 BCE–54 CE) is suspected of having CP, as historical records describe him as having several physical problems in line with the condition. Medical historians have begun to suspect and find depictions of CP in much later art. Several paintings from the 16th century and later show individuals with problems consistent with it, such as Jusepe de Ribera's 1642 painting The Clubfoot.

The modern understanding of CP as resulting from problems within the brain began in the early decades of the 1800s with a number of publications on brain abnormalities by Johann Christian Reil, Claude François Lallemand and Philippe Pinel. Later physicians used this research to connect problems in the brain with specific symptoms. The English surgeon William John Little (1810–1894) was the first person to study CP extensively. In his doctoral thesis he stated that CP was a result of a problem around the time of birth. He later identified a difficult delivery, a preterm birth and perinatal asphyxia in particular as risk factors. The spastic diplegia form of CP came to be known as Little's disease. At around this time, a German surgeon was also working on cerebral palsy, and distinguished it from polio. In the 1880s British neurologist William Gowers built on Little's work by linking paralysis in newborns to difficult births. 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 (1849–1919) 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 (1856–1939) 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. Access Economics has released a report on the economic impact of cerebral palsy in Australia. The report found that, in 2007, the financial cost of cerebral palsy (CP) in Australia was A$1.47 billion or 0.14% of GDP. Of this:

  • A$1.03 billion (69.9%) was productivity lost due to lower employment, absenteeism, and premature death of Australians with CP
  • A$141 million (9.6%) was the DWL from transfers including welfare payments and taxation forgone
  • A$131 million (9.0%) was other indirect costs such as direct program services, aides and home modifications, and the bringing-forward of funeral costs
  • A$129 million (8.8%) was the value of the informal care for people with CP
  • A$40 million (2.8%) was direct health system expenditure

The value of lost well-being (disability and premature death) was a further A$2.4 billion.

In per capita terms, this amounts to a financial cost of A$43,431 per person with CP per annum. Including the value of lost well-being, the cost is over $115,000 per person per annum.

Individuals with CP bear 37% of the financial costs, and their families and friends bear a further 6%. The federal government bears around one-third (33%) of the financial costs (mainly through taxation revenues forgone and welfare payments). State governments bear under 1% of the costs, while employers bear 5% and the rest of society bears the remaining 19%. If the burden of disease (lost well-being) is included, individuals bear 76% of the costs.

The average lifetime cost for people with CP in the US is US$921,000 per individual, including lost income.

In the United States, many states allow Medicaid beneficiaries to use their Medicaid funds to hire their own PCAs, instead of forcing them to use institutional or managed care.

In India, the government-sponsored program called "NIRAMAYA" for the medical care of children with neurological and muscular deformities has proved to be an ameliorating economic measure for persons with such disabilities. 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:

Impairment is the correct term to use to define a deviation from normal, such as not being able to make a muscle move or not being able to control an unwanted movement. Disability is the term used to define a restriction in the ability to perform a normal activity of daily living which someone of the same age can perform. For example, a three-year-old child who is not able to walk has a disability because a normal three-year-old can walk independently. A handicapped child or adult is one who, because of the disability, is unable to achieve the normal role in society commensurate with his age and socio-cultural milieu. As an example, a sixteen-year-old who is unable to prepare his own meal or care for his own toilet or hygiene needs is handicapped. On the other hand, a sixteen-year-old who can walk only with the assistance of crutches but who attends a regular school and is fully independent in activities of daily living is disabled but not handicapped. All disabled people are impaired, and all handicapped people are disabled, but a person can be impaired and not necessarily be disabled, and a person can be disabled without being handicapped.

The term "spastic" denotes the attribute of spasticity in types of spastic CP. In 1952 a UK charity called The Spastics Society was formed. The term "spastics" was used by the charity as a term for people with CP. The word "spastic" has since been used extensively as a general insult to disabled people, which some see as extremely offensive. They are also frequently used to insult non-disabled people when they seem overly uncoordinated, anxious, or unskilled in sports. The charity changed its name to Scope in 1994. In the United States the word spaz has the same usage as an insult but is not generally associated with CP.

Media

Maverick documentary filmmaker Kazuo Hara criticises the mores and customs of Japanese society in an unsentimental portrait of adults with cerebral palsy in his 1972 film Goodbye CP (Sayonara CP). Focusing on how people with cerebral palsy are generally ignored or disregarded in Japan, Hara challenges his society's taboos about physical handicaps. Using a deliberately harsh style, with grainy black-and-white photography and out-of-sync sound, Hara brings a stark realism to his subject.

Spandan (2012), a film by Vegitha Reddy and Aman Tripathi, delves into the dilemma of parents whose child has cerebral palsy. While films made with children with special needs as central characters have been attempted before, the predicament of parents dealing with the stigma associated with the condition and beyond is dealt in Spandan. In one of the songs of Spandan "Chal chaal chaal tu bala" more than 50 CP kids have acted. The famous classical singer Devaki Pandit has given her voice to the song penned by Prof. Jayant Dhupkar and composed by National Film Awards winner Isaac Thomas Kottukapally.

My Left Foot (1989) is a drama film directed by Jim Sheridan and starring Daniel Day-Lewis. It tells the true story of Christy Brown, an Irishman born with cerebral palsy, who could control only his left foot. Christy Brown grew up in a poor, working-class family, and became a writer and artist. It won the Academy Award for Best Actor (Daniel Day-Lewis) and Best Actress in a Supporting Role (Brenda Fricker). It was also nominated for Best Director, Best Picture and Best Writing, Screenplay Based on Material from Another Medium. It also won the New York Film Critics Circle Award for Best Film for 1989.

Call the Midwife (2012–) has featured two episodes with actor Colin Young, who himself has cerebral palsy, playing a character with the same disability. His storylines have focused on the segregation of those with disabilities in the UK in the 1950s, and also romantic relationships between people with disabilities.

Micah Fowler, an American actor with CP, stars in the ABC sitcom Speechless (2016–19), 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 young child 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.

Notable cases

Geri Jewell in 2009
  • Geri Jewell, who had a regular role in the prime-time series The Facts of Life.
  • Josh Blue, winner of the fourth season of NBC's Last Comic Standing, whose act revolves around his CP. Blue was also on the 2004 U.S. Paralympic soccer team.
  • Jason Benetti, play-by-play broadcaster for ESPN, Fox Sports, Westwood One, and Time Warner covering football, baseball, lacrosse, hockey, and basketball. Since 2016, he is also the television play-by-play announcer for Chicago White Sox home games.
  • Jack Carroll, British comedian and runner-up in the seventh season of Britain's Got Talent.
  • Abbey Curran, an American beauty queen who represented Iowa at Miss USA 2008 and was the first contestant with a disability to compete.
  • Robert Griswold, swimmer
  • Francesca Martinez, British stand-up comedian and actress.
  • Evan O'Hanlon, Australian Paralympian, the fastest athlete with cerebral palsy in the world.
  • Arun Shourie's son Aditya, about whom he has written a book Does He Know a Mother's Heart
  • Maysoon Zayid, the self-described "Palestinian Muslim virgin with cerebral palsy, from New Jersey", who is an actress, stand-up comedian, and activist. Zayid has been a resident of Cliffside Park, New Jersey. She is considered one of America's first Muslim women comedians and the first person ever to perform standup in Palestine and Jordan.

Litigation

Because of the false 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.

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