Risk factors for spastic cerebral palsy: a retrospective cross-sectional study and literature review

Abstract

Background

Cerebral Palsy (CP), a lifelong neurodevelopmental disorder, primarily manifests in early childhood, with spastic CP constituting 70% of cases. This study investigates spastic CP risk factors through a retrospective cross-sectional analysis of medical records and literature review to guide clinical strategies for reducing its incidence.

Methods

The study analyzed the records of patients with spastic CP from Xi’an Encephalopathy Hospital affiliated to Shaanxi University of Chinese Medicine, between October 2021 and September 2022, aged 4–14 years old. Demographic and risk factor analysis was conducted among 231 patients, utilizing count data and percentages. Additionally, recent literature on spastic CP risk factors was reviewed.

Results

Among the 231 cases, 55.41% were male, and 52.84% were urban residents. Age distribution was most concentrated at 4 years old (18.18%), followed by 5 years old (11.69%), and 8 years old (11.26%). Disease duration ranged from less than 3 months (10.82%) to 12–24 months (30.30%). Identified risk factors included neonatal diseases such as neonatal asphyxia (63.20%), premature birth (49.78%), and low birth weight (49.35%). Maternal prenatal illnesses and medication use (4.76%), delivery methods including cesarean Sect. (32.90% preterm), and environmental pollutants were also significant.

Conclusion

This study enhances the understanding of spastic CP risk factors and provides actionable insights for prevention and management. Key recommendations include improved prenatal care (e.g., regular monitoring and infection control) and reducing maternal exposure to modifiable risks like environmental toxins, alcohol, and unnecessary medications. These findings support earlier, personalized interventions for at-risk cases.

Introduction

Cerebral Palsy (CP) is a group of permanent movement and posture development disorders that typically emerges during childhood and impacts muscle control and motor skills [1]. It results from atypical brain development or damage, often arising during pregnancy, childbirth, or early infancy due to factors like head injuries or brain infections. CP ranks as one of the most prevalent neurodevelopmental disorders among children worldwide, with an estimated incidence of 3 to 4 cases per 1,000 live births. Furthermore, the gradual rise in the prevalence of CP in recent years underscores the heightened urgency in exploring the risk factors associated with CP [2]. Among the various CP subtypes, spastic CP is the most prevalent, accounting for over 70% of all CP cases, distinguished by muscle stiffness, motor difficulties, and impaired limb coordination [3, 4]. Spastic CP can be further categorized into different forms based on the parts of the body affected, such as spastic diplegia, spastic hemiplegia, and spastic quadriplegia. The condition leads to hypertonia, where muscles are continuously contracted, resulting in jerky movements and difficulty in controlling muscle movement. The severity of this condition can vary greatly, ranging from mild effects in some individuals to the need for long-term treatment and support in others, and impose enduring physical, cognitive, and psychological burdens upon afflicted individuals and their families.

Despite extensive research on spastic CP, a deep understanding of its risk factors remains elusive, making it a complex puzzle to unravel. The development of spastic CP may encompass a multitude of contributing elements [5]spanning genetic, environmental, and biological factors during the perinatal and early childhood periods. Moreover, the risk factors associated with the disease may exhibit geographical, ethnic, and individual variations, further complicating research endeavors. Over the past several decades, investigators have directed their efforts towards investigating various facets of spastic CP, encompassing aspects such as fetal and neonatal health [6]maternal exposure to toxins [7]perinatal complications [8]prematurity [9]and low birth weight [10]. Nevertheless, inconsistencies and contradictions persist in the outcomes of distinct studies, necessitating a comprehensive research approach to elucidate the risk factors associated with spastic CP.

The primary objective of this study is to address this knowledge gap by conducting a comprehensive investigation, synthesizing medical records and literature reviews, to probe into the risk factors relevant to spastic CP. Through in-depth analysis of extensive medical records, we endeavor to identify factors linked to the pathogenesis of spastic CP and discern latent risk factors. The aim is to furnish more precise information that can enhance early diagnosis and intervention support. This undertaking is poised to empower healthcare professionals with an improved understanding of spastic CP’s pathogenesis, with the ultimate goal of reducing the incidence of the disease and ameliorating the quality of life for affected individuals. Furthermore, the outcomes of this research endeavor are poised to supply policymakers with robust data to facilitate the enhancement of preventive and management strategies for spastic CP, thereby ushering in profound implications for the realms of pediatric medicine and public health.

Materials and methods

Study design

This was a retrospective observational study that combined a literature review analysis.

Retrospective study

Descriptive data were extracted from the medical records of Xi’an Encephalopathy Hospital affiliated to Shaanxi University of Chinese Medicine. The study focused on children aged 4–14 years old diagnosed with spastic CP at the hospital. Data were collected from October 2021 to September 2022, and duplicate admissions were removed during the initial data processing. The final study cohort included 231 participants, whose medical records indicated a diagnosis of spastic CP. Data from participants of different genders and children within the age group of 4 to 14 years were included. The diagnostic criteria for spastic CP used in this study were according to the committee members’ determinations in the Guidelines for Rehabilitation and Treatment of Cerebral Palsy in China [11].

Literature review analysis

We conducted a literature search on PubMed using ‘spastic cerebral palsy’ and ‘risk factor’ as search terms. Titles and abstracts of the identified articles were initially screened for relevance. Articles were included if they focused on risk factors associated with spastic CP and were excluded if they did not meet these criteria or were not primary research articles. Full-text articles that passed the screening process were reviewed in detail. Data on identified risk factors, study populations, methodologies, and findings were extracted and integrated into our study to provide a comprehensive overview of the current knowledge on spastic CP risk factors.

Data collection

The following data were collected from medical records: age, gender, living area, and disease duration; together with identified risk factors contributing to the children’s condition.

Sample size

To accurately assess the risk factors associated with spastic cerebral palsy, we aimed to include as many eligible medical records as possible. This approach ensures a comprehensive analysis and enhances the statistical power of our study.

Identification of risk factors

Risk factors were identified through a comprehensive review of patient histories, clinical notes, diagnostic test results, and birth records.

Criteria for selecting risk factors

We focused on factors documented in prior research as potential contributors to spastic CP, including prenatal, perinatal, and postnatal variables.

Prenatal factors

Included maternal health conditions (e.g., infections, hypertension), maternal exposure to toxins, and genetic factors.

Perinatal factors

Included birth complications (e.g., asphyxia, prematurity), mode of delivery, and birth weight.

Postnatal factors

Included neonatal infections, head injuries, and other significant health events occurring within the first month of life.

Data recording process

Trained medical professionals and researchers extracted and recorded the data using standardized forms. Data entry was cross-checked by multiple team members to minimize errors and ensure reliability.

Statistical analysis

Data analysis was performed using SPSS version 23 software. Descriptive statistics was used in this study. Counts and percentages were used to describe categorical variables.

Results

Demographic information

Among the 231 cases of spastic CP children included in this study, there were 128 male patients, constituting 55.41%, and 103 female patients, accounting for 44.59% of the total. There were 122 urban patients, constituting 52.84%, and 109 rural patients, making up 47.16% of the total cohort. The age distribution was most concentrated at 4 years old, with 42 cases, representing 41.35% of the cohort. Following that, the second-highest concentration was observed at 5 years old, with 27 cases, making up 40.35% of the entire group. Subsequently, there were 26 cases at 8 years old, constituting 11.26%, and 24 cases at 6 years old, representing 10.39%. The least prevalent age groups were 13 years old and 14 years old, each having only 9 cases, corresponding to 3.90% of the total. Regarding the distribution of disease duration, the most concentrated range was found within the 12 to 24 months period, comprising 70 cases, accounting for 30.30%. The second-highest distribution was observed in the 6 to 12 months range, with 55 cases, representing 23.46%. The least prevalent distribution was noted in the less than 3 months range, with 25 cases, constituting 11.65%. Data details can be seen in Table 1.

Table 1.

Demographic information of included patients

	Numbers	Percent(%)
Gender
Male	128	55.41%
Female	103	44.59%
Living area
Urban	122	52.81%
Rural	109	47.19%
Age
4–6 years	93	40.26%
7–10 years	88	38.10%
11–14 years	80	21.64%
The length of the disease
< 3 months	25	10.82%
3—6 months	28	12.12%
6—12 months	55	23.81%
12—24 months	70	30.30%
< 24 months	53	22.9 4%

Analysis of risk factors for the onset of spastic CP

We conducted an analysis of medical records from 231 spastic CP patients included in the study, examining their medical history, personal history, maternal prenatal anomalies, delivery methods, neonatal medical history, family history, and significant medical events. Additionally, we performed statistical assessments of early developmental anomalies and delivery methods. Please refer to Table 2 for detailed information.

Table 2.

Risk factors for the onset of spastic CP in children

Classification	High-risk factors	Numbers	Percent(%)
Neonatal Diseases	Neonatal asphyxia and history of treatment	146	63.20%
	History of premature birth in neonates	115	49.78%
	History of low birth weight in neonates	114	49.35%
	Pathological jaundice in neonates and history of treatment	47	20.35%
	Neonatal aspiration pneumonia	2	0.87%
	Neonatal hyperbilirubinemia	1	0.43%
	Neonatal sepsis	1	0.43%
Maternal Prenatal Illness and Medication	Maternal history of medication use during pregnancy (Upper respiratory tract infections)	11	4.76%
	Maternal history of threatened miscarriage and medication use	8	3.46%
	Pregnancy-induced hypertension	7	3.03%
	Advanced maternal age	6	2.59%
	Abnormal emotional state during pregnancy	4	1.73%
	Maternal history of medication use during pregnancy (for anemia, neurological conditions, nutritional deficiencies, high fever, others)	2	0.87%
	Intermittent shortness of breath during pregnancy	1	0.43%
	Maternal history of hyperthyroidism during pregnancy	1	0.43%
	Trauma	1	0.43%
Delivery Method	Full-term pregnancy (natural delivery)	79	34.20%
	Full-term pregnancy (cesarean section)	32	13.85%
	Preterm birth (natural delivery)	39	16.88%
	Preterm birth (cesarean section)	76	32.90%
	Post-term pregnancy (natural delivery)	0	0
	Post-term pregnancy (cesarean section)	4	1.73%
	Unknown	1	0.43%
Birth situation	Umbilical cord around the neck	12	5.19%
	Abnormal fetal positioning	11	4.76%
	Premature rupture of membranes	2	0.87%
	Rapid fetal heart rate	1	0.43%
	In Vitro Fertilization	1	0.43%
	Placenta previa	1	0.43%
Amniotic Fluid situation	Amniotic fluid leakage	3	1.30%
	Insufficient amniotic fluid	3	1.30%
	Contaminated amniotic fluid	2	0.87%
	Excessive amniotic fluid	1	0.43%
Environmental Pollution Exposure	History of environmental pollution (methanol)	2	0.87%

Review of literature and discussion

Within the scope of this study, a comprehensive analysis of patient general demographics reveals differences in terms of both gender distribution and urban-rural distribution among children diagnosed with spastic CP. Nonetheless, the ratios remain relatively even, with a minor male predominance and a slight urban bias, specifically, there are slightly more boys than girls and slightly more urban than rural patients. This observation is similar with earlier epidemiological studies in China and other Countries [2, 12–15]. In relation to male children being slightly more affected, we consider this could be attributed to the biological vulnerability in males, believed to be based on multiple factors, ranging from potential differences in brain organization to the influence of genetic conditions or female hormones that might mitigate the impact of brain injury [16]. Moreover, urban-rural disparities appear to be influenced more by factors such as affordability of medical costs and caregivers’ perspectives.

CP often originating in early childhood and persisting throughout an individual’s lifetime [17]. It significantly impacts movement, muscle tone, and motor skills due to damage to the developing brain, which can occur during pregnancy, childbirth, or shortly after birth. In low- and middle-income countries, the birth prevalence of pre- and perinatal CP stands at approximately 3.4 per 1000 live births, whereas in high-income countries, this rate is lower, at 1.5 per 1000 live births (1.6 per 1000 when post-neonatal CP is taken into account) [2], The incidence of CP is multi factorial, influenced by a range of variables. Notable risk factors include premature birth, complications during birth, and the overall health of the mother during pregnancy [18, 19].

Our study focus on these factors, shedding light on critical risk factors associated with spastic CP. The research highlighted the significance of a history of neonatal asphyxia and subsequent treatments, premature birth, low birth weight in neonates, neonatal pathological jaundice, and specific medical interventions during the neonatal period as substantial risk factors for spastic CP [20]. Moreover, maternal prenatal conditions, including medication use during pregnancy, maternal history of threatened miscarriage, history of certain medications, pregnancy-induced hypertension, emotional disturbances during pregnancy, and advanced maternal age, were identified as frequent contributors to the incidence of spastic CP. Prenatal care that addresses these risk factors can play a pivotal role in reducing the incidence of CP and improving outcomes for both the mother and the child. When examining the mode of delivery revealed a higher prevalence of preterm births and cesarean section among children with CP. Conversely, cases involving in situation amniotic fluid and exposure to environmental pollutants were remarkably rare among children diagnosed with spastic CP, suggesting a need for further research to comprehend these intriguing correlations fully.

After the literature review study, the relevant studies and their findings are primarily presented in Table 3. However, it must be acknowledged that these references are not exhaustive, but they do, to some extent, address pertinent scientific questions. These studies also reflected that perinatal infection, chorioamnionitis, breech delivery, SGA, and drug exposure are all recognized as risk factors for spastic CP.

Table 3.

List of publications on risk factors associated with spastic CP in recent years

First author	Tittle	Number of participants	Study location	Types of article	Publication	Years	Risk factor
B J Polivka [21]	Urinary tract infection during pregnancy: a risk factor for cerebral palsy?	153	USA	Article	J Obstet Gynecol Neonatal Nurs	1997	Urinary tract infection during pregnancy
K H Harum [22]	Factor-V Leiden: a risk factor for cerebral palsy	/	UK	Review	Dev Med Child Neurol	1999	Factor-V Leiden
M Wheater [23]	Perinatal infection is an important risk factor for cerebral palsy in very-low-birthweight infants	923	USA	Article	Dev Med Child Neurol	2000	Perinatal infection
R Reading [24]	Perinatal infection is an important risk factor for cerebral palsy in very-low-birthweight infants	/	UK	letter	Dev Med Child Neurol	2000	Perinatal infection
Y W Wu [25]	Chorioamnionitis as a risk factor for cerebral palsy: A meta-analysis	1973	USA	Meta-analysis	JAMA	2000	Chorioamnionitis
Robert Newton [26]	A case-control study of vanishing twin as a risk factor for cerebral palsy	86	UK	Article	Twin Res	2003	Vanishing twin
Henrik Hagberg [27]	Chorioamnionitis–risk factor of cerebral palsy in fullterm infants	/	Sweden	Review	Lakartidningen	2004	Chorioamnionitis
Vered Yehezkely-Schildkraut [28]	Thrombophilia: a risk factor for cerebral palsy?	61	Israel	Article	Isr Med Assoc J	2005	Thrombophilia
Guro L Andersen [29]	Is breech presentation a risk factor for cerebral palsy? A Norwegian birth cohort study	177 272	Norway	Article	Dev Med Child Neurol	2009	Breech delivery
Mengwen Zhao [30]	SGA as a Risk Factor for Cerebral Palsy in Moderate to Late Preterm Infants: a System Review and Meta-analysis	135,650	China	Meta-analysis	Sci Rep	2016	Small for gestational age (SGA)
Priyanka Minocha [31]	Clinical Spectrum, Comorbidities, and Risk Factor Profile of Cerebral Palsy Children: A Prospective Study	180	India	Article	J Pediatr Neurosci	2017	Asphyxia
Kristen L Benninger [32]	Intrauterine drug exposure as a risk factor for cerebral palsy	5578	USA	Article	Dev Med Child Neurol	2022	Intrauterine drug exposure
Wei Gao [33]	Prenatal drug exposure as a risk factor for cerebral palsy and other developmental deficits	/	USA	Review	Dev Med Child Neurol	2022	Prenatal drug exposure

Based on cross-sectional analysis of medical records and prior literature, a preliminary overview of the risk factors associated with spastic CP can be outlined as follows:

Neonatal diseases refer to various health issues and disorders that occur during the neonatal period, which typically covers the first 28 days of an infant’s life [34]. These conditions may affect multiple organ systems, including the nervous system. Such diseases can potentially increase the risk of children developing spastic CP [35]. For instance, events such as neonatal asphyxia, hypoxia, infections, or other neurological issues that occur during the neonatal period can have adverse effects on brain development, thereby elevating the risk of developing spastic CP. This association is often rooted in the potential for neonatal brain damage to impact the motor control areas of the brain, subsequently manifesting as symptoms of spastic CP. Therefore, it is necessary to intervene in neonatal diseases and conduct long-term follow-up [36].

(1) Neonatal asphyxia, also known as neonatal hypoxic-ischemic encephalopathy, primarily results from cerebral hypoxia due to oxygen deprivation, leading to brain injury and subsequently giving rise to a spectrum of neurodevelopmental issues, including spastic CP [37]. Specifically, during neonatal asphyxia, brain cells may become compromised due to oxygen deprivation and ischemia, which can lead to neuronal death or abnormal development, particularly within the motor control areas [38]. This damage may manifest as motor and coordination impairments in the infant’s developmental course, ultimately culminating in the symptoms of spastic CP. While there is a causal relationship between neonatal asphyxia and spastic CP, it’s essential to note that not all infants who experience neonatal asphyxia will develop spastic CP. Early diagnosis, intervention, and rehabilitative support are crucial in mitigating the symptoms and enhancing the quality of life for affected individuals.

(2) Premature birth, defined as the delivery of a baby before 37 weeks of pregnancy [39]typically occurring in the latter stages of gestation, poses a risk to infant development. Premature infants are often more susceptible to developmental delays, including neurodevelopmental issues [40]. Additionally, the premature infant’s brain is more vulnerable to external stimuli [41]such as hypoxia, infections, intracranial hemorrhage, among others, which can potentially lead to brain damage, affecting the motor control areas of the brain and resulting in muscle control problems, ultimately manifesting as symptoms of spastic CP. While not all premature infants will develop spastic CP, premature birth does indeed elevate the risk of this neurodevelopmental disorder. Premature infants typically require more extensive medical care and support, including monitoring and early rehabilitative interventions, to assist them in achieving as normal a growth and development as possible [42].

(3) Low birth weight refers to the condition in which a newborn’s weight at birth falls below the standard criteria for normal birth weight, typically defined as birth weight less than 2500 g (approximately 5.5 pounds) [43]. One of the primary concerns associated with low birth weight is the inadequate development of the brain and nervous system [44]which may lead to abnormal neuronal development, making infants more vulnerable to external injuries or other adverse factors, consequently resulting in a heightened risk of spastic CP. Abnormal brain development may encompass the motor control areas of the brain, leading to motor control issues. It is crucial to note that the etiology of spastic CP is a complex process involving various factors. Early medical care, rehabilitation, and monitoring are essential in reducing the risks faced by low-birth-weight infants and assisting them in achieving optimal development [45].

(4) Neonatal pathological jaundice refers to the condition in which a newborn experiences elevated levels of bilirubin in their body after birth, leading to the occurrence of yellowing of the skin and eyes [46]. In some cases, neonatal pathological jaundice may be caused by hemolytic diseases, which are conditions that can result in the breakdown of red blood cells. If hemolytic diseases are severe enough to affect the brain and nervous system, they may lead to neurodevelopmental issues, including spastic CP [47]. However, not every infant with neonatal pathological jaundice will develop spastic CP. It is crucial to emphasize that for newborns displaying noticeable jaundice after birth, timely medical assessment and treatment are of paramount importance to ensure the proper management of any potential health issues.

Maternal prenatal illnesses and medication use refer to health issues that pregnant women may experience or the need for medication to manage these issues during pregnancy, which can potentially impact the health of the developing fetus, especially during the early stages of pregnancy [48]. Certain chronic diseases, medication treatments, and other factors may increase the risk of children developing spastic CP. Therefore, pregnant women need to exercise caution when considering medication use to ensure they do not pose unnecessary risks to the fetus, particularly during the early stages of pregnancy. Some studies have indicated that maternal use of specific medications during early pregnancy, especially antiepileptic drugs and certain antidepressants, may elevate the risk of the infant developing spastic CP [49]. However, this association requires further research to confirm its level of risk. Addionally, maternal prenatal conditions and subsequent medication use or toxin exposure are not only potential risk factors for CP but aldo estabilished contributors to preterm birth and low birth weight that are the most represented risk factors in the database of this study (49.78% and 49.35%). So, since both preterm birth and low birth weight are well-documented risk factors for spastic CP, maternal health conditions and their managment could act as inderct risk factors, further increasing the likelihood of developing spastic CP. Including this information would provide a more comprehensive perspective on the role of maternal health in spastic CP risk, which is the only modifiable factor risk. It is essential to emphasize that not all medications pose risks to the fetus during pregnancy. The use of medications during pregnancy needs to carefully weigh the risks and benefits, following the guidance of a healthcare provider to ensure the health of the fetus.

Intrauterine infection refers to the condition in which the amniotic fluid or the fetal membranes in the mother’s uterus become infected with bacteria, viruses, or other microorganisms during fetal development [50]. One of the uterine infections associated with spastic CP is Chorioamnionitis [51]. It typically involves an infection of the fetal membranes, placenta, and amniotic fluid. This type of infection may have irreversible effects on the central nervous system. These effects may manifest as motor and neurological problems after birth, ultimately leading to the development of spastic CP [52]. While there is a certain association between intrauterine infection and spastic CP, not every affected fetus will develop CP. This is a complex medical issue influenced by various factors, including the extent of the infection, the stage of fetal development, and other genetic and environmental factors. Therefore, research is ongoing to better understand the relationship between intrauterine infection and CP and to take measures to mitigate this risk.

The relationship between delivery methods and spastic CP lies in the potential impact of the mode of delivery on the health of newborns. Natural delivery is typically a physiological and normal process, but in certain circumstances, it may lead to brain injury in newborns, especially if complications arise during the delivery, such as asphyxia, labor abnormalities, and so on [53]. In comparison to nature delivery, cesarean section may reduce certain delivery complications, such as asphyxia, consequently decreasing the risk of brain injury [54]. However, it is important to emphasize that the mode of delivery is just one potential risk factor for spastic CP, and not all individuals with spastic CP have a direct connection to the delivery methods. For pregnant women, the most crucial aspect is to receive medical care and guidance during pregnancy. Timely medical assessments and adherence to the advice of healthcare professionals are essential for minimizing potential risks.

Spastic CP is a neurodevelopmental disorder typically diagnosed in early childhood. Its etiology is multifactorial, encompassing genetic, prenatal, and neonatal factors. Our study also find some less common potential factors, such as birth situations, amniotic fluid conditions, and exposure to environmental pollutants. It is essential to highlight that the pathogenesis of spastic CP is typically a consequence of multiple factors, involving various potential risk factors. The risk factors listed above represent only a fraction of those possibly associated with spastic CP. Moreover, for the majority of spastic CP cases, the exact etiology remains unclear [55]. For expectant mothers and infants, the utmost priority is to receive medical care and guidance during pregnancy, thereby minimizing potential risks and ensuring maternal and infant health. Timely medical assessment and adherence to healthcare provider recommendations are paramount in mitigating potential risks.

Limitations

This study has several limitations, including its retrospective design, reliance on one-hospital data, and potential confounding factors like socioeconomic status and parental education levels. However, as a study on cerebral palsy, the sample size of 231 is not small and the comprehensive literature review provides valuable insights into the risk factors for spastic CP. Future research should focus on exploring the causal relationships between these identified risk factors and the development of spastic CP. Longitudinal studies or experimental approaches are needed to establish how these conditions directly contribute to the onset of spastic CP. Understanding these causal links will provide deeper insights into the mechanisms underlying spastic CP and support the development of more targeted prevention and intervention strategies.

Conclusion

Through a retrospective cross-sectional study of medical records and a literature review, we have substantiated the multifaceted nature of risk factors associated to spastic CP. This encompasses factors such as neonatal diseases, including a history of perinatal hypoxic-ischemic events and low birth weight, maternal prenatal illnesses and medication use, such as perinatal infections and drug exposures, intrauterine infection such as chorioamnionitis, delivery methods such as breech deliveries, birth situations, amniotic fluid conditions, and exposure to environmental pollutants, along with the synergistic interplay of other contributory elements. This revelation underscores the intricate and multidimensional nature of spastic CP. Our study not only offers a more comprehensive understanding of risk factors to spastic CP but also extends crucial insights for policy makers to enhance preventive and management strategies for CP.

Author contributions

XW wrote the initial manuscript, with XGD contributing statistic of the study. SHT and XHW designed the study, XHW revised the manuscript. All authors reviewed the final version before submission.

Funding

Supported by the Project of the National Famous Senior TCM Experts Heritage Studio of Hujie Song and Young Talent Project of Xi’an Yingcai Program.

Data availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study did not involve the disclosure of individual patient information, thus obtaining ethical exemption from the Ethics Committee of Xi’an Encephalopathy Hospital affiliated to Shaanxi University of Chinese Medicine. Stringent confidentiality measures were enacted to protect the study data. The research encompassed the secondary analysis of de-identified routine monitoring data, adhering to the all the principles delineated in the Helsinki Declaration.

Consent for publication

Not applicable.

Competing interests

The authors declare no conflicts of interest in relation to this study.