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Demographic and clinical findings of cerebral palsy patients in istanbul: a multicenter study/Istanbul'daki serebral palsi olgularinin klinik ve demografik ozellikleri: cok merkezli calisma.


Cerebral palsy (CP) describes a group of permanent disorders of the development of movement and posture, causing activity limitation that is attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication, and behavior; by epilepsy; and by secondary musculoskeletal problems (1). The prevalence of cerebral palsy (CP) has risen to well above 2.0 per 1000 live births over the last 40 years (2). The brain lesions that cause CP may occur during the prenatal, perinatal, or postnatal period. Any functional collapse caused by a non-progressive central nervous system (CNS) injury occurring during the first 2 years of life is considered to be CP Classification is based on changes in muscle tone, the anatomical region affected, and severity of the impairment. Classification provides a clearer understanding of the individual patient's impairment and guides management of care (3).

Few studies have investigated the demographic and clinical features of CP in Turkey. The prevalence of CP was determined as 4.4 per 1000 live births in Turkey (4,5). Istanbul is home to 17% of the Turkish population and is the largest city in Turkey (12,915,158 people in 2009) (6). Moreover, Istanbul has the highest migration rate in the country and, as such, represents a wide variety of the Turkish population (7).

The present study aimed to identify demographic characteristics, clinical type, risk factors, and supplementary clinical findings in children with CP in Istanbul.

Material and Methods

This retrospective, multicenter study was conducted at 11 centers in Istanbul: three university hospitals, seven public training and research hospitals, and one private rehabilitation center. Clinical and demographic data received from each study center were combined and analyzed by the Istanbul Cerebral Palsy Study Group (ICPSG) in October 2007. The ISPSG is comprised of physiatrists, pediatricians, neurologists, orthopedists, neurosurgeons, ophthalmologists, and physiotherapists interested in CP The medical records of 785 children with CP who attended the 11 study center outpatient clinic were collected. Common cases were removed from the study population to prevent duplication of data.

The following data were obtained for each patient: sex, age (at present time), age when impairment was first noticed, etiological risk factors classified as prenatal, natal, and postnatal, and specific risk factors, such as intermarriage, mother's age at birth, a history of abortus or stillbirth. Clinical type and CP-associated medical problems were noted. Every study center used the conventional CP classification system for clinical typing (4).

Statistical Analysis

Descriptive statistical tests were performed.


Medical records were collected from 785 children with CP across the 11 study centers. A review of the records found that 55 patients had attended more than one center. Following the exclusion of duplicate cases, the study included 730 children (mean age, 7.27[+ or -]4.63 years; range, 2-18 years), of whom 429 (58.8%) were males and 301 (41.2%) were females, with a male to female ratio was 1.4:1.

Clinical type was determined according to motor function, and subtyping was based on topographic involvement. We found that 88.2% of the patients were diagnosed as spastic, 3.2% was dyskinetic, and 0.7% was ataxic (Table 1). The most common spastic subtype was hemiplegia (31.4%), followed by diplegia (27.4%) and tetraplegia (25.3%). The least common clinical type was athetoid (0.5%), and CP type was unknown in the remaining 2.9% of patients.

The analysis of risk factors revealed that the cause of CP was related to natal, prenatal, and postnatal factors in 35.1%, 14.5%, and 22% of patients, respectively. Moreover, 28.4% of the patients had more than one risk factor (Table 2). The ratio of intermarriage, a unique risk factor for CP in Turkey, was 21.4%. Risk factors specific to maternal history are shown in Table 3. CP was clinically recognized during the first 6 months of life in 51.9% of the patients, 24.6% was diagnosed between the ages of 6 and 12 months, and 23.5% of the patients were diagnosed after 12 months of age (Figure 1).

A total of 32% of the patients had speech impairments, and these, together with mental retardation, were the two most common CP-associated disorders. Visual disorders, epilepsy, growth retardation, dental problems, dysphagia, and behavioral disorders were less frequently reported (Figure 2).


The point prevalence of CP among children between the ages of 2 and 16 years in Turkey was 4.4 per 1000 live births (95% CI=0.36-0.57) in 1996 (4). The male-to-female ratio has been reported to be 1.4:1 and 1.9/1, suggesting a slight male predominance (8,9). The male-to-female ratio of 1.4:1 found in our study was similar to that previously reported.

Our findings that 88.2% of patients were classified as spastic and 3.2% was classified as dyskinetic were consistent with previous studies (10,11). However, the ratio of our patients with the diplegia (31.5%) and hemiplegia (31.4%) spasticity subtypes differed from previous reports (10,11). Furthermore, our data were not consistent with previous Turkish studies. Serdaroglu et al. (4) reported that the most common spastic subtype in their sample was diplegia (39.8%), followed by hemiplegia (28.0%). A study conducted in Ankara by Erkin et al. (5) found that hemiplegia was the third most common subtype of spasticity, with a proportion of 12.8% of patients. However, a Swedish study conducted by Hagberg (12) found that 44% of 241 patients with CP were diplegic and 33% was hemiplegic. Ozmen et al. (13) found spastic quadriplegic as most common type. Varying classification systems may explain the nearly equal ratio of diplegic and hemiplegic patients in our study. Clinical typing in the 11 centers from which our data were taken was determined by the conventional classification system, whereas the Surveillance of Cerebral Palsy in Europe (SCPE) classification was used in other studies (9,14). The SCPE classification is a new and easy-to-use system that assesses spastic subtypes as unilateral (limbs on one side of the body are involved) or bilateral (limbs on both sides of the body are involved). Ataxic and dyskinetic are the other major types, according to this classification system (14). The comparison of varying classification systems was a limitation of our study.

Consanguinity is a risk factor for CP and elevated rates of CP have been reported among a Pakistani community in the United Kingdom (15). Turkey has a high rate of consanguineous marriage (21.1%), and between 16.1% and 23.8% of the parents of patients with CP were found to have consanguineous marriages (16,17). Our finding of consanguineous marriages in 21.4% of the parents is similar to the 21% penetration reported by Serdaroglu et al. (4).

Previous studies have found a higher prevalence of natal and prenatal, as compared to postnatal, risk factors; (14,17) however, prenatal risk factors were the least prevalent in our study.

Accompanying pathologies compound the difficulty in coping with motor dysfunction in patients with CP Intellectual disability is the single strongest predictor of survival, and severity of physical impairment is the second most significant predictor of life expectancy (18). Nordmark et al. (14,19) found that 26% of patients with CP in Sweden were severely retarded, and the SCPE reported that 31% of patients with CP in Europe had a severe intellectual deficit. Please indicate which reference is Nor dmark and which the SCPE study. The medical records verified mental retardation in 23.1% of our patients, which was slightly lower than that of previous studies.

Epilepsy has been estimated to be present in 15%-60% of patients with CP (20). We found that 22.9% of our patients had epilepsy.

In general, visual disorders in patients with CP are studied according to specific subtype and MRI findings (21,22). In our study, the frequency of basic visual disorders was found in 22.8% of the patients. The proportion of patients with moderate and severe visual impairments has been reported to be between 62%-71% (23). A previous study found that 58% of patients with CP had a vision disorder, of which strabismus (43.9%) was the most common impairment (24). The low proportion of patients reported to have vision impairments in our study is a reminder of the importance of administering ophthalmological examinations.

Dysarthria is a speech impairment in which the child has difficulty producing sound and articulating words. Dysarthria occurs in 40% of patients with CP (25). Involvement of the respiratory muscles and larynx and oromotor dysfunction cause respiratory, phonation, and articulation difficulties (25). Russman and Ashwal (26) found both speech and language disorders in 38% of their patients with CP Speech disorders (32%) were the most common CP-associated dysfunction in our patients, followed by dysphagia (7.4%) and dental disorders (9.8%).

Children with CP and their families must cope with a number of health-related issues. For example, two literature reviews found hearing impairments in approximately 12% (26) and 25% (23) of patients with CP None of the centers in our study had records of hearing impairments. This may be the result of parental neglect and the technical difficulties involved in conducting hearing tests in this patient group.

Nearly a quarter of children and adolescents with CP have primary urinary incontinence. Oddinga et al. (23) found that 85% of patients referred with daytime urinary incontinence at 10 years of age showed abnormal urinary patterns on a video urodynamic test. Our records did not contain information about urinary continence. This may be a type of medical neglect.


Our descriptive, retrospective study was the first extensive investigation of patients with CP in Istanbul. However, it was conducted as a preliminary study to identify a patient pool for further studies. Our study is unique in that it was multidisciplinary and involved multiple centers. Neurologists and orthopedists contributed patient records. The primary objective of the study was to create common interdisciplinary terminology and a standard CP evaluation form.

The primary limitation of our study was that we did not involve more medical disciplines. Furthermore, the analysis was limited by differences in terminology and scaling, which resulted in missing data. Nevertheless, the goal of this preliminary study was to identify a pool of patients with CP in Istanbul for further studies using common terminology among the various medical disciplines treating patients with CP

DOI: 10.5152/tftrd.2014.42402

Ethics Committee Approval: Ethics committee approval was received for this study from the ethics committee of Okmeydani Training and Research Hospital.

Informed Consent: There is not informed consent form because it was a retrospective and descriptive study. There was not any treatment method that applied to the patient and names of the patients were not displayed.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept--R.A.; Design--R.A., E.YY., B.H., U.D., D.D.; Supervision--R.A.; Funding--I.C.PS.G.O.M.; Materials --I.C.PS.G.O.M.; Data Collection and/or Processing--E.YY; Analysis and/or Interpretation--E.YY, B.H., U.D., D.D.; Literature Review --E.YY, B.H., R.A.; Writer--E.YY, B.H.; Critical Review--R.A., D.D., U.D.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

Etik Komite Onayi: Bu calisma icin etik komite onayi Okmeydani Egitim Arastirma Hastanesi'nden alinmistir.

Hasta Onami: Retrospektif tanimlayici bir calisma oldugundan hastalara herhangi bir tedavi yontemi uygulanmadigindan ve isimleri teshir edilmediginden onam formu yoktur.

Hakem degerlendirmesi: Dis bagimsiz.

Yazar Katkilari: Yazar Katkilari: Fikir--R.A.; Tasarim--R.A., E.Y.Y., B.H., U.D., D.D.; Denetleme--R.A.; Kaynaklar--I.C.PS.G.O.M.; Malzemeler--I.C.PS.G.O.M.; Veri toplanmasi ve/ veya islemesi--E.Y.Y.; Analiz ve/veya yorum--E.Y.Y., B.H., U.D., D.D.; Literatur taramasi--E.Y.Y., B.H., R.A.; Yaziyi yazan--E.Y.Y., B.H.; Elestirel Inceleme--R.A., D.D., U.D.

Cikar Catismasi: Yazarlar cikar catismasi bildirmemislerdir.

Finansal Destek: Yazarlar bu calisma icin finansal destek almadiklarini beyan etmislerdir.


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Ebru YILMAZ YALCINKAYA [1], Berrin HUNER [2], Umit DINCER [3], Demirhan DIRACOGLU [4], Resa AYDIN4, and Istanbul Cerebral Palsy Study Group Other Members, Afitap ICAGASIOGLU [5], Esma DEMIRHAN [5], Levent YALCIN [6], Kadriye ONES [1], Nil CAGLAR [1], Adnan YUKSEL [7], Safak Sahir KARAMEHMETOGLU [8], Dilsad TURKDOGAN [9], Gazi ZORER [10], Zuhal YAPICI [11], Belgin ERHAN [1], Bora AKYUREK [1], Banu KURAN [12], Hulya AKBAS [12], Nurdan PAKER [1], Demet UCAR [1], Kahraman OZTURK [13], Nihal OZARAS [14]

[1] Clinic of Physical Medicine and Rehabilitation, Istanbul Physical Medicine and Rehabilitation Training and Research Hospital, Istanbul, Turkey

[2] Clinic of Physical Medicine and Rehabilitation, Istanbul Okmeydani Training and Research Hospital, Istanbul, Turkey

[3] Department of Physical Medicine and Rehabilitation, Gulhane Military Medical Academy Hospital, Istanbul, Turkey

[4] Department of Physical Medicine and Rehabilitation, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey

[5] Clinic of Physical Medicine and Rehabilitation, Goztepe Training and Research Hospital, Istanbul, Turkey

[6] Manus Hand Surgery Group

[7] Department of Pediatric Neurology, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey

[8] Department of Physical Medicine and Rehabilitation, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey

[9] Institute of Neurological Sciences, Marmara University Faculty of Medicine, Istanbul, Turkey

[10] Department of Orthopaedics, Bezmialem Foundation University Faculty of Medicine, Istanbul, Turkey

[11] Department of Pediatric Neurology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey

[12] Clinic of Physical Medicine and Rehabilitation, Sisli Etfal Training and Research Hospital, Istanbul, Turkey

[13] Department of Orthopedics, Baltalimani Bone Diseases Hospital, Istanbul, Turkey

[14] Department of Physical Medicine and Rehabilitation, Bezmialem Foundation University, Istanbul, Turkey

Address for Correspondence / Yazisma Adresi: Ebru Yilmaz Yalcinkaya MD, Department of Physical Therapy, Training and Research Hospital,

Istanbul, Turkey. Phone: +90 505 451 85 73 E-mail:

Received/Gelis Tarihi: May/Mayis 2013 Accepted/Kabul Tarihi: August/Agustos 2013
Table 1. Distribution of Cerebral Palsy (CP) subtypes in the
patient population

CP Subtype        Number (n=730)   Ratio (%)

Spastic                644           88.2
  Hemiplegic           229           31.4
  Diplegic             230           31.5
  Tetraplegic          185           25.3
Dyskinetic              23            3.2
  Athetoid              4            0.50
  Choreathetoic         8             1.1
  Dystonic              11            1.5
Ataxic                  5             0.7
Hypotonic               12            1.6
Mixed                   25            3.4
Unclassified            21            2.9
Total                  730            100

CP: cerebral palsy

Table 2. Distribution of risk factors for cerebral palsy in the
patient population

Type of risk factor       Number (n=730)   Ratio (%)

Prenatal                       106           14.5
(Peri)natal                    256           35.1
Postnatal                      161            22
Combined (More than one
  type risk factor)            207           28.4
Total                          730           1 00

Table 3. Maternal history of the patients

Risk Factors Specific          Number          Ratio (%)
To Maternal Anamnesis

Intermarriage                    156             21.4
Abortus                          138             18.9
Stillbirth                       54               7.4
Mother's age at birth    26.06 [+ or -] 5.99      --

Figure 1. Time problem first noticed

23.50% > 12 months
51.90% 0-6 months
24.60% 6-12 months

Note: Table made from pie chart.

Figure 2. Associated problems with cerebral palsy of the patients

behaviour disorders      4.90%
dysphagia                7.40%
teeth problems           9.80%
growth retardation      10.70%
visual disorders        22.80%
epilepsy                22.90%
mental retardation      23.10%
speech disorder         32%

Note: Table made from bar graph.
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Article Details
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Title Annotation:Original Article/Orijinal Makale
Author:Yalcinkaya, Ebru Yilmaz; Huner, Berrin; Dincer, Umit; Diracoglu, Demirhan; Aydin, Resa; Icagasioglu,
Publication:Turkish Journal of Physical Medicine and Rehabilitation
Article Type:Clinical report
Geographic Code:7TURK
Date:Jun 1, 2014
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