It is usually fairly easy to identify a person with cerebral palsy. They stand out because of their abnormal posture and gait, not to mention their irregular, spastic movements. Conventionally, cerebral palsy is diagnosed within the first few years of one's life, as it is considered to be a disease of the developing fetal or infant brain. Hence, diagnosis does not usually occur beyond two or three years of age. Cerebral palsy is most commonly diagnosed via a motor function (or dysfunction) assessment, but may also be identified through other methods, such as neuroimaging.
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Cerebral palsy (CP) is a term of convenience applied to a group of motor disorders of central origin defined by clinical description. It is not a diagnosis in that its application infers nothing about pathology, aetiology, or prognosis. It is an umbrella term covering a wide range of cerebral disorders which result in childhood motor impairment. The precise inclusion criteria vary with the objectives for using the term. For meaningful comparison of rates of CP, as performed by and between CP registers, it is important that the rates should be generated using the same criteria. As generally understood there must be motor impairment, and this impairment must stem from a malfunction of the brain (rather than spinal cord or muscles). Furthermore, the brain malfunction must be non-progressive and it must be manifest early in life. For the purposes of comparisons of rates across time even when the condition meets all the above criteria, it must not historically have been excluded from the category of CP. This paper addresses the problem of standardizing the inclusion criteria for selecting people included on CP registers with particular reference to this last criterion.
[Badawi, N., Watson, L., Petterson, B., Blair, E., Slee, J., Haan, E. & Stanley, F. (1998). What constitutes cerebral palsy? Developmental Medicine and Child Neurology, 40(8), 520-7.]
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The purpose of this article was to present the etiologic factors involved in the nonprogressive, early brain damage that leads to cerebral palsy. Progress in the diagnostics and management of postural and motor function disabilities are described. A major contribution to this progress was made by improved understanding of the neurophysiological basis of motor development and developmental diagnosis in pediatric practice.
[Jozwiak, M. (2001). Cerebral palsy: Progress in diagnosis and management. Ortopedia, Traumatologia, Rehabilitacja, 3(4), 445-9.]
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Abstract . Strategies for the early detection and diagnosis of cerebral palsy include multiple measures of the underlying brain abnormalities and their neurodevelopmental consequences. These measures can be grouped into the categories of pathogenesis, impairment, and functional limitation. Neuroimaging techniques are the most predictive measures of pathogenesis of cerebral palsy in both the preterm and term infant. Measures of neurological impairment focusing on muscle tone, reflexes, and other features of the neurological examination are poorly predictive in the first months of life. Detection of functional limitations manifested by motor developmental delay is sensitive and specific for later cerebral palsy, but not until well into the second 6 months of life. Abnormal spontaneous general movements in the infant 16 to 20 weeks postterm and earlier reflect functional limitations in the first months of life and have been shown to predict later cerebral palsy. Recognition of abnormal spontaneous general movements may improve early detection and diagnosis of cerebral palsy if these techniques can be successfully incorporated into organized follow-up programs and developmental surveillance. Copyright 2004 Elsevier Inc.
[Palmer, F. B. (2004). Strategies for the early diagnosis of cerebral palsy. The Journal of Pediatrics, 145(2 Suppl.)., S8-S11.]
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Cerebral palsy (CP) is a diagnosis of considerable concern to obstetricians, but the diagnosis of CP can be challenging, and may need to be confirmed by an experienced practitioner, ideally a child neurologist or psychiatrist. It is important not to make the diagnosis too early in infancy, especially when the signs are not severe, as resolution of early neuromotor abnormalities does occur, particularly in premature infants. Exclusion of genetic/metabolic disorders presenting with CP-like findings is important. The degree of activity limitation should be characterized; labeling children as having CP on the basis of abnormal examination findings alone without evidence of activity limitation is not useful. Brain imaging can be helpful in pinpointing the location of the underlying brain abnormality and sometimes provides etiologically useful information.
[Paneth, N. (2008). Establishing the diagnosis of cerebral palsy. Clinical Obstetrics and Gynecology, 51(4), 742-8.]
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Cerebral palsy is the most prevalent cause of persisting motor function impairment with a frequency of about 1/500 births. In developed countries, the prevalence rose after introduction of neonatal intensive care, but in the past decade, this trend has reversed. A recent international workshop defined cerebral palsy 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." In a majority of cases, the predominant motor abnormality is spasticity; other forms of cerebral palsy include dyskinetic (dystonia or choreo-athetosis) and ataxic cerebral palsy. In preterm infants, about one-half of the cases have neuroimaging abnormalities, such as echolucency in the periventricular white matter or ventricular enlargement on cranial ultrasound. Among children born at or near term, about two-thirds have neuroimaging abnormalities, including focal infarction, brain malformations, and periventricular leukomalacia. In addition to the motor impairment, individuals with cerebral palsy may have sensory impairments, cognitive impairment, and epilepsy. Ambulation status, intelligence quotient, quality of speech, and hand function together are predictive of employment status. Mortality risk increases incrementally with increasing number of impairments, including intellectual, limb function, hearing, and vision. The care of individuals with cerebral palsy should include the provision of a primary care medical home for care coordination and support; diagnostic evaluations to identify brain abnormalities, severity of neurologic and functional abnormalities, and associated impairments; management of spasticity; and care for associated problems such as nutritional deficiencies, pain, dental care, bowel and bladder continence, and orthopedic complications. Current strategies to decrease the risk of cerebral palsy include interventions to prolong pregnancy (eg, 17alpha-progesterone), limiting the number of multiple gestations related to assisted reproductive technology, antenatal steroids for mothers expected to deliver prematurely, caffeine for extremely low birth weight neonates, and induced hypothermia for a subgroup of neonates diagnosed with hypoxic-ischemic encephalopathy.
[O'Shea, T. M. (2008). Diagnosis, treatment, and prevention of cerebral palsy. Clinical Obstetrics and Gynecology, 51(4), 816-28.]
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OBJECTIVE: To evaluate the prospective validity and predictive value of cerebral palsy during infancy, using 'Infant Motor Malfunction Profile'. METHODS: Items of motor milestone in the profile was used as the first step to screen cerebral palsy on 8137 infants who were screened at 3, 6, 9, 12 months of age. The positive cases who had one of 7 developmental abnormal motor milestone items were examined using the items of primitive reflexes or postural reaction as the secondary step of cerebral palsy screening. The cases who had at least one abnormal item of primitive reflex or postural reaction received neurological examination by doctors to diagnose cerebral palsy. RESULTS: According to our data, sensitivity, specificity, positive prospective value, positive and negative likelihood ratio of the profile in screening cerebral during infancy were 94.1%, 99.8%, 48.5%, 449.6 and 0.06, respectively. CONCLUSION: The profile seemed to be an acceptable instrument for early identification of cerebral palsy.
[Tao, F. B., Xu, J., Deng, G. Z., Ni, J. F., Zhang, H. B., Wu, X. K., Yin, H. P. & Xu, Z. Y. (2004). Early screening of cerebral palsy during infancy using 'Infant Motor Malfunction Profile' in the communities of two cities [Chinese]. Zhonghua Liuxingbingxue Zazhi, 25(2), 127-30.]
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OBJECTIVE: To determine whether a profile of abnormal motor patterns can identify children with cerebral palsy (CP) in the first year of life. METHODS: The Early Motor Pattern Profile (EMPP) consists of 15 items reflecting variations in muscle tone, reflexes, and movement that have been organized into a standardized format to provide the clinician with an objective picture of neurologic status. A three-point scoring system was applied to each item, delineating a clearly normal response from a clearly abnormal one and placing all partial or inconsistent responses in the middle. Twelve hundred forty-seven high-risk infants who were enrolled in a neonatal intensive care unit follow-up program were examined at 6 and/or 12 months' corrected age using the EMPP. These infants were followed to at least 36 months of age to distinguish those with CP from those with normal motor outcome or minimal impairment (no CP). RESULTS: Predictive validity of the EMPP at the 6- and 12-month examinations was determined using various pass-fail cutoffs. The optimal cutoff score at 6 months was between 9 and 10, at which the positive predictive value was 89.4, sensitivity was 87.1, and specificity was 97.8. The optimal cutoff score at 12 months was between 3 and 4, at which the positive predictive value was 91.0, sensitivity was 91.5, and specificity was 97.9. CONCLUSIONS: The EMPP offers the clinician an effective instrument to identify children in the first year of life who are at greatest risk for the development of CP. The EMPP can be incorporated into a routine health maintenance visit, adding only a few minutes to the process, and has high sensitivity and specificity.
[Morgan, A. M. & Aldag, J. C. (1996). Early identification of cerebral palsy using a profile of abnormal motor patterns. Pediatrics, 98(4 Pt. 1), 692-7.]
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Detection of children with a developmental disorder, such as cerebral palsy, at an early age is notoriously difficult. Recently, a new form of neuromotor assessment of young infants was developed, based on the assessment of the quality of general movements (GMs). GMs are movements of the fetus and young infant in which all parts of the body participate. The technique of GM assessment is presented and the features of normal, mildly abnormal, and definitely abnormal GMs discussed. Essential to GM assessment is the Gestalt evaluation of movement complexity and variation. The quality of GMs at 2 to 4 months postterm (so-called fidgety GM age) has been found to have the highest predictive value. The presence of definitely abnormal GMs at this age--that is, GMs devoid of complexity and variation--puts a child at very high risk for cerebral palsy. This implies that definitely abnormal GMs at fidgety age are an indication for early physiotherapeutic intervention. Copyright 2004 Elsevier Inc.
[Hadders-Algra, M. (2004). General movements: A window for early identification of children at high risk for developmental disorders. The Journal of Pediatrics, 145(2 Suppl.), S12-18.]
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AIM: To evaluate the effectiveness of a complex neurological screening (cns clinical examination, magnetic resonance imaging of the head, serial cranial ultrasound record) -- in the diagnosis of cerebral palsy in infants born preterm, with symptoms of perinatal hypoxia. MATERIAL AND METHODS: Prospective study in 23 preterm infants born between 27 and 36 weeks of pregnancy with features of intrauterine and postnatal hypoxia. In the study infants underwent a complete neurological examination: MRI and cranial ultrasound were carried out approximately from the term of birth and then follow-up with repeated neurological examination and cranial ultrasound at 3rd, 6th and after the 12th month of corrected age. RESULTS: Significant statistical relationship has been found between cerebral palsy and the following changes: hypoxic-ischaemic changes diagnosed by MRI, hypoxic-ischaemic changes diagnosed by ultrasound conducted about term of birth as well as cerebral atrophy observed in ultrasound scans within the first six months of adjusted age and incorrect primitive reflexes within the first six months of adjusted age. Combination of the MRI findings at term of birth with the evaluation of primitive reflexes within the first six months of corrected age showed 100% sensitivity and 100% specificity. No statistically significant relationship has been found between the neurological conditions after the 12th month and at 40 weeks after conception and with psychomotor development within the first six months of corrected age. CONCLUSION: Magnetic resonance imaging at term of birth combined with repeated complete neurological examination within the first six months of corrected age is an effective method ensuring early diagnosis of cerebral palsy in preterm infants. The assessment of psychomotor development in preterm infants within the first six months of corrected age without a full neurological examination is insufficient for an early diagnosis of cerebral palsy.
[Hnatyszyn, G. (2005). Effectiveness of complex screening procedure in the diagnostics of cerebral palsy in preterm infants with suspected hypoxic-ischaemic brain injury [Polish]. Medycyna Wieku Rozwojowego, 9(3 Pt. 1), 293-310.]
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We evaluated the efficacy of various delay criteria (12.5%, 25%, 37.5%, 5%, 50% delay) for motor milestone attainment to screen a sample of 173 high-risk preterm infants with gestational age < 32 weeks who had been sequentially followed for 18 to 24 months. Sensitivities were best with 12.5% and 25% delays, but specificities and positive predictive values were relatively lower. Since societal resources for evaluation and treatment of cerebral palsy are limited, the excellent specificities (81% to 95%) and positive predictive values (48% to 85%) with 50% delay are more important than the somewhat lower sensitivities, especially since milestones involve a multistep screening process. Screening preterm infants by obtaining a history of motor milestone attainment with each child care visit, correcting for degree of prematurity, and using a 50% delay criteria is a practical, inexpensive method of identifying infants at highest risk of cerebral palsy.
[Allen, M. C. & Alexander, G. R. (1994). Screening for cerebral palsy in preterm infants: Delay criteria for motor milestone attainment. Journal of Perinatology, 14(3), 190-3.]
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Pediatricians often informally use motor milestones to screen infant motor development, and one advantage is that they can be used during sequential office visits, as a multistep screening process. In this study we evaluated six motor milestones (roll prone to supine, roll supine to prone, sit with support, sit without support, crawl and cruise) as a multistep process in screening for cerebral palsy in 173 high-risk preterm infants (<33 weeks gestational age) who had been followed with sequential developmental assessments for at least 18 months. At the 18 to 24 month evaluation, 31 (18%) had cerebral palsy. We found that using the motor milestones as serial screening tests for cerebral palsy was more effective in terms of positive predictive value than any individual milestone alone. Limited community resources can be more efficiently used if preterm infants with delays in more than four motor milestones are referred for further evaluation and early intervention services.
[Allen, M. C. & Alexander, G. R. (1997). Using motor milestones as a multistep process to screen preterm infants for cerebral palsy. Developmental Medicine and Child Neurology, 39(1), 12-6.]
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