Section I: Evidence Summary
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Cerebral palsy has traditionally been diagnosed between 12-24 months of age because there is no laboratory biomarker for cerebral palsy. Cerebral palsy is a clinical diagnosis, diagnosed based on a combination of clinical signs, neurological symptoms and physical limitations. Late diagnosis means some infants do not receive early intervention when they would benefit most. Cerebral palsy or high-risk of cerebral palsy can now be detected accurately and early using a combination of standardized assessment tools. Early detection enables timely early intervention when the greatest gains are possible from neuroplasticity.
Cerebral palsy should be detected as soon as possible because:
It is not good practice to offer conservative “wait and see” monitoring, when clear clinical diagnostic indicators exist, especially in contexts where the absence of a diagnostic label precludes the infant from accessing the recommended early intervention. There is evidence that delayed diagnosis worsens parental mental health (Baird et al, 2000) and clinical trial evidence is emerging that the lack of intense early intervention may restrict the infant’s motor and cognitive gains (Morgan et al, 2016). Neuroscience evidence indicates that brain development and refinement of the motor system continues in the postnatal period, driven by activity in the motor cortex (Eyre et al, 2014; Martin et al, 2011). Early active movement and intervention is essential because infants not actively using their motor cortex risk losing cortical connections and dedicated function (Eyre et al, 2014; Martin et al, 2011). Furthermore, there is increasing evidence that the infant’s motor behavior, through discovery and interaction with the environment, controls and generates the growth and development of muscle, ligament, and bone, as well as driving the ongoing development of the neuromotor system. These recent discoveries about brain and muscle plasticity support the earliest possible intervention to: (a) exercise muscles through their functional length (as muscles grow throughout development in response to the infant’s actions); and (b) train specific actions, in order to promote motor learning and ‘drive’ plasticity and effective functional motor performance (Eyre et al, 2014; Martin et al, 1999; Shepherd 2014).
Randomized controlled trial (RCT) data is beginning to indicate that infants with unilateral/hemiplegic cerebral palsy, who receive early Constraint Induced Movement Therapy (CIMT) have better hand function than controls short-term and probably substantially better hand function long-term (Eliasson et al, 2015). Population register data indicates that children with bilateral cerebral palsy, who receive regular surveillance and intervention have lower rates of hip displacement, contracture and scoliosis complications (Elkamil et al, 2011; Hägglund et al, 2005; Scrutton et al, 2001). Hip Surveillance guidelines can be found on the care pathways website. RCT data is also beginning to indicate that infants with any type and topography of cerebral palsy, who receive “GAME” (Goals – Activity – Motor Enrichment, which is an early, intense, enriched, task-specific, training-based interventions at home), have better motor and cognitive skills at 1-year, than those who received usual care (Morgan et al, 2016). Importantly, RCTs also suggest that, improvements are even better when training occurs at home (Novak et al, 2009; Rostami et al, 2012) because children learn best in supported natural settings, where training is personalized to their enjoyment – translating to more intense, specific and relevant practice. Task-specific, motor learning training-based early intervention (e.g. GAME and CIMT) are recommended as the new paradigm of care for infants with cerebral palsy as they induce neuroplasticity and produce functional gains (Morgan et al, 2016b). Larger replication studies are underway, meaning more evidence will inform our estimate in the confidence of the effects.
Infants with cerebral palsy and their parents.
Neurologists, pediatricians, neonatologists, pediatric rehabilitation specialists/physiatrists, general practitioners, neuro-radiologists, physiotherapists, occupational therapists, speech pathologists, nurses and early educators.
Evidence indicates that there are two major pathways to accurate and early detection of cerebral palsy depending on the infant’s age at the time of assessment using different tests in combination with the clinical examination.
Reproduced with permission from JAMA Pediatrics. 2017. 171(9): Figure 1. Copyright© 2020 American Medical Association. All rights reserved.
Novak I, Morgan C, Adde L, Badawi N, Blackman J, Boyd R, Cioni G, Damiano D, Darrah J, deVries L, Einspieler C, Fehlings D, Ferrerio D, Fetters L, Forssberg H, Gordon A, Guzzetta A, Karlsson P, Maitre N, McIntyre S, Noritz G, Pennington L, Romeo D, Shepherd R, Valentine J, Walker K, White R (2017). Early, accurate diagnosis and early intervention in cerebral palsy: advances in diagnosis and treatment. JAMA Pediatrics, 171(9), 897-907.
Ashwal S, Russman BS, Blasco PA, Miller G, Sandler A, Shevell M, et al. Practice Parameter: Diagnostic assessment of the child with cerebral palsy. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurol 2004; 62: 851-63.
Bosanquet M, Copeland L, Ware R, Boyd R. A systematic review of tests to predict cerebral palsy in young children. Dev Med Child Neurol 2013; 55: 418-26.
Ment LR, Bada HS, Barnes P, Grant PE, Hirtz D, Papile LA, et al. Practice parameter: Neuroimaging of the neonate Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurol 2002; 58: 1726-38.
Romeo DM, Ricci D, Brogna C, Mecuri E. Use of the Hammersmith Infant Neurological Examination in infants with cerebral palsy: a critical review of the literature. Dev Med Child Neurol 2015, 58(3), 240-245.
Baird G, McConachie H, Scrutton D. Parents' perceptions of disclosure of the diagnosis of cerebral palsy. Arch Dis Child 2000; 83: 475-80.
Cowan FM, de Vries LS. The internal capsule in neonatal imaging. In Semin Fetal Neonatal Med 2005; 10: 461-474. WB Saunders.
de Vries LS, Roelants-van Rijn AM, Rademaker KJ, van Haastert IC, Beek FJ, Groenendaal F. Unilateral parenchymal haemorrhagic infarction in the preterm infant. Eur J Paediatr Neurol 2001; 5: 139-49.
de Vries LS, Benders MJ, Groenendaal F. Progress in Neonatal Neurology with a Focus on Neuroimaging in the Preterm Infant. Neuropediatrics 2015; 46: 234-41.
Eliasson AC, Holmefur M. The influence of early modified constraint‐induced movement therapy training on the longitudinal development of hand function in children with unilateral cerebral palsy. Dev Med Child Neurol 2015; 57: 89-94.
Elkamil AI, Andersen GL, Hägglund G, Lamvik T, Skranes J, Vik T. Prevalence of hip dislocation among children with cerebral palsy in regions with and without a surveillance programme: a cross sectional study in Sweden and Norway. BMC Musculoskelet Disord 2011; 12: 284.
Eyre J. Corticospinal tract development and activity dependent plasticity. In R Shepherd (Ed). Cerebral palsy in infancy. Oxford: Elsevier; 2014. 53-66.
Hägglund G, Andersson S, Düppe H, Lauge-Pedersen H, Nordmark E, Westbom L. Prevention of dislocation of the hip in children with cerebral palsy the first ten years of a population-based prevention programme. J Bone Joint Surg Br 2005; 87: 95-101.
Kirton, A., Shroff, M., & Visvanathan, T. Quantified corticospinal tract diffusion restriction predicts neonatal stroke outcome. Stroke 2007;38:974-980.
Kwon SH, Vasung L, Ment LR, Huppi PS. The role of neuroimaging in predicting neurodevelopmental outcomes of preterm neonates. Clin Perinatol 2014; 41: 257-83.
Maitre NL, Slaughter JC, Aschner JL. Early prediction of cerebral palsy after neonatal intensive care using motor development trajectories in infancy. Early Hum Dev 2013; 89: 781-6.
Martin JH, Chakrabarty S, Friel KM. Harnessing activity-dependent plasticity to repair the damaged corticospinal tract in an animal model of cerebral palsy. Developmental Medicine & Child Neurology. 2011;53:9-13.
Martin JH, Kably B, Hacking A. Activity-dependent development of cortical axon terminations in the spinal cord and brain stem. Exp Brain Res 1999; 125: 184-99.
Morgan CJ, Novak I, Dale RC, Guzzetta A, Badawi N. Single blind randomised controlled trial of GAME (Goals - Activity - Motor Enrichment) in infants at high risk of cerebral palsy. Res Dev Disabil 2016; 55:256-267.
Morgan C, Darrah J, Gordon AM, Harbourne R, Spittle A, Johnson R, Fetters L. Effectiveness of motor interventions in infants with cerebral palsy: a systematic review. Dev Med Child Neurol 2016b; 58(9), 900-909.
Morgan C., Romeo D., Chorna O., Novak I., Galea C., Del Secco S. & Guzzetta A. (2019). The pooled diagnostic accuracy of three tests for diagnosing cerebral palsy early in high risk infants: a case control study. Journal of Clinical Medicine (In Press).
Novak I, Cusick A, Lannin N. Occupational therapy home programs for cerebral palsy: double-blind, randomized, controlled trial. Pediatr 2009; 124(4), e606-e614.
Reid SM, Dagia CD, Ditchfield MR, Carlin JB, Reddihough DS. Population‐based studies of brain imaging patterns in cerebral palsy. Dev Med Child Neurol 2014; 56: 222-32.
Rostami HR, Malamiri RA. Effect of treatment environment on modified constraint-induced movement therapy results in children with spastic hemiplegic cerebral palsy: a randomized controlled trial. Disabil Rehabil 2012; 34(1), 40-44.
Pizzardi A, Romeo DM, Cioni M, Romeo MG, Guzzetta A. Infant neurological examination from 3 to 12 months: predictive value of the single items. Neuropediatrics 2008; 39: 344-6.
Scrutton D, Baird G, Smeeton N. Hip dysplasia in bilateral cerebral palsy: incidence and natural history in children aged 18 months to 5 years. Dev Med Child Neurol 2001; 43: 586-600.
Shepherd RB. (Ed). Cerebral palsy in infancy: Targeted activity to optimize early growth and development. Oxford: Elsevier Health Sciences, 2014.
Spittle AJ, Doyle LW, Boyd RN. A systematic review of the clinimetric properties of neuromotor assessments for preterm infants during the first year of life. Dev Med Child Neurol 2008; 50: 254-66.
Woodward LJ, Anderson PJ, Austin NC, Howard K, Inder TE. Neonatal MRI to predict neurodevelopmental outcomes in preterm infants. N Engl J Med 2006; 355: 685-94.
Parent Fact Sheets and an Infographic Video are available here:
Training in the General Movement’s Assessment dates and locations can be found here:
A Continuing Medical Education e-learning program is being built for professionals to provide in-depth information on how to diagnose early. To learn more or express an interest in obtaining more information contact: Lynda McNamara Lynda.McNamara@health.qld.gov.au.
Three families with children aged between 3 months and 6 years-of-age with varying degrees of hypotonia reviewed the pathway and provided written feedback that was incorporated into the care pathway.
Expert Consensus Team:
|Iona Novak||Cerebral Palsy Alliance, The University of Sydney||Sydney, NSW, Australia||Occupational Therapist|
|Cathy Morgan||Cerebral Palsy Alliance, The University of Sydney||Sydney, NSW, Australia||Physical Therapist|
|Lars Adde||Norwegian University of Science and Technology; St Olavs University Hospital||Trondheim, Norway||Physical Therapist|
|Nadia Badawi||Cerebral Palsy Alliance, The University of Sydney, Children’s Hospital Westmead The University of Sydney||Sydney, NSW Australia||Neonatologist|
|James Blackman||Cerebral Palsy Alliance Research Foundation||New York, NY, USA||Pediatrician|
|Roslyn N Boyd||The University of Queensland||Brisbane, QLD, Australia P||hysical Therapist|
|Janice Brunstrom-Hernandez||Children’s Medical Centre, Dallas||Dallas, TX, USA||Child Neurologist|
|Giovanni Cioni||University of Pisa, Stella Maris Scientific Institute||Pisa, Italy||Child Neurologist & Psychiatrist|
|Diane Damiano||National Institutes of Health||Washington, DC, USA P||hysical Therapist|
|Johanna Darrah||Faculty of Rehabilitation Medicine, University of Alberta||Alberta, Canada||Physical Therapist|
|Ann-Christin Eliasson||Karolinska Institutet||Stockholm, Sweden||Occupational Therapist|
|Prof Linda de Vries||University Medical Centre, Utrecht||Utrecht, The Netherlands||Neonatologist & Neurologist|
|Christa Einspieler||Medical University of Graz||Graz, Austria||Physiologist|
|Michael Fahey||Monash University, Australia||Melbourne, Vic, Australia||Neurologist & Geneticist|
|Darcy Fehlings||Holland Bloorview Kids Rehabilitation Hospital, University of Toronto||Toronto, ON, Canada||Developmental Pediatrician|
|Donna Ferriero||University California San Francisco||San Francisco, CA, USA||Child Neurologist|
|Linda Fetters||University of Southern California||Los Angeles, CA, USA||Physical Therapist|
|Simona Fiori||Stella Maris Scientific Institute, Pisa||Pisa, Italy||Child Neurologist & Psychiatrist|
|Hans Forssberg||Karolinska Institutet||Stockholm, Sweden||Neuroscientist|
|Andrew Gordon||Teachers College Columbia University||New York, NY, USA||Neuroscientist|
|Susan Greaves||The Royal Children’s Hospital, Melbourne, Australia||Melbourne, Vic, Australia||Occupational Therapist|
|Andrea Guzzetta||University of Pisa, Stella Maris Scientific Institute, Pisa||Pisa, Italy||Child Neurologist & Psychiatrist|
|Mijna Hadders-Algra||University of Groningen, University Medical Center Groningen, Dept Pediatrics||Groningen, The Netherlands||Developmental Neurologist|
|Regina Harbourne||Duquesne University||Pittsburgh, PA, USA||Physical Therapist|
|Angelina Kakooza-Mwesige||Makerere University||Kampala, Uganda||Neurologist|
|Petra Karlsson||Cerebral Palsy Alliance, The University of Sydney||Sydney, NSW, Australia||Occupational Therapist|
|Lena Krumlinde-Sundholm||Karolinska Institutet||Stockholm, Sweden||Occupational Therapist|
|Beatrice Latal||University Children’s Hospital Zurich||Zurich, Switzerland||Pediatrician|
|Alison Loughran-Fowlds||Children’s Hospital Westmead, The University of Sydney||Sydney, NSW, Australia||Neonatologist|
|Nathalie Maitre||Nationwide Children’s Hospital, The Ohio State University||Columbus, OH, USA||Neonatologist|
|Sarah McIntyre||Cerebral Palsy Alliance, The University of Sydney||Sydney, NSW, Australia||Epidemiologist|
|Garey Noritz||Nationwide Children’s Hospital, The Ohio State University, USA||Columbus, OH, USA||Pediatrician|
|Lindsay Pennington||Newcastle University||Newcastle, UK||Speech Language Pathologist|
|Domenico M. Romeo||Pediatric Neurology Unit, Fondazione Policlinico Gemelli and Catholic University||Rome, Italy||Child Neurologist & Psychiatrist|
|Roberta Shepherd||The University of Sydney||Sydney, NSW, Australia||Physical Therapist|
|Alicia Spittle||University of Melbourne, and Murdoch Childrens Research Institute||Melbourne, Vic, Australia||Physical Therapist|
|Marelle Thornton||Cerebral Palsy Alliance||Sydney, NSW, Australia||Teacher|
|Jane Valentine||Princess Margaret Hospital, University of Western Australia||Perth, WA, Australia||Rehabilitation Specialist|
|Karen Walker||Cerebral Palsy Alliance, The University of Sydney, Children’s Hospital Westmead, The University of Sydney||Sydney, NSW, Australia||Nurse|
|Rob White||Cerebral Palsy Alliance||Sydney, NSW, Australia||Psychologist|
The American Academy for Cerebral Palsy and Developmental Medicine has developed care pathways to assist the busy clinician. Please submit any advice or constructive feedback to make this pathway more useful.
NOTE: Feedback will be directed to the AACPDM Care Pathway Taskforce to review and consider on a queue 6-month basis.