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Journal ArticleDOI

A systematic review of tests to predict cerebral palsy in young children.

TL;DR: This systematic review evaluates the accuracy of predictive assessments and investigations used to assist in the diagnosis of cerebral palsy in preschool‐age children (<5y).
Abstract: Aim This systematic review evaluates the accuracy of predictive assessments and investigations used to assist in the diagnosis of cerebral palsy (CP) in preschool-age children (<5y). Method Six databases were searched for studies that included a diagnosis of CP validated after 2 years of age. The validity of the studies meeting the criteria was evaluated using the Standards for Reporting Diagnostic Accuracy criteria. Where possible, results were pooled and a meta-analysis was undertaken. Results Nineteen out of 351 studies met the full inclusion criteria, including studies of general movements assessment (GMA), cranial ultrasound, brain magnetic resonance imaging (MRI), and neurological examination. All studies assessed high-risk populations including preterm (gestational range 23–41wks) and low-birthweight infants (range 500–4350g). Summary estimates of sensitivity and specificity of GMA were 98% (95% confidence interval [CI] 74–100%) and 91% (95% CI 83–93%) respectively; of cranial ultrasound 74% (95% CI 63–83%) and 92% (95% CI 81–96%) respectively; and of neurological examination 88% (95% CI 55–97%) and 87% (95% CI 57–97%) respectively. MRI performed at term corrected age (in preterm infants) appeared to be a strong predictor of CP, with sensitivity ranging in individual studies from 86 to 100% and specificity ranging from 89 to 97% There was inadequate evidence for the use of other predictive tools. Summary This review found that the assessment with the best evidence and strength for predictive accuracy is the GMA. MRI has a good predictive value when performed at term-corrected age. Cranial ultrasound is as specific as MRI and has the advantage of being readily available at the bedside. Studies to date have focused on high-risk infants. The accuracy of these tests in low-risk infants remains unclear and requires further research.
Citations
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Journal ArticleDOI
TL;DR: Best available evidence about cerebral palsy–specific early intervention that should follow early diagnosis to optimize neuroplasticity and function is summarized.
Abstract: Importance Cerebral palsy describes the most common physical disability in childhood and occurs in 1 in 500 live births. Historically, the diagnosis has been made between age 12 and 24 months but now can be made before 6 months’ corrected age. Objectives To systematically review best available evidence for early, accurate diagnosis of cerebral palsy and to summarize best available evidence about cerebral palsy–specific early intervention that should follow early diagnosis to optimize neuroplasticity and function. Evidence Review This study systematically searched the literature about early diagnosis of cerebral palsy in MEDLINE (1956-2016), EMBASE (1980-2016), CINAHL (1983-2016), and the Cochrane Library (1988-2016) and by hand searching. Search terms included cerebral palsy , diagnosis , detection , prediction , identification , predictive validity , accuracy , sensitivity , and specificity . The study included systematic reviews with or without meta-analyses, criteria of diagnostic accuracy, and evidence-based clinical guidelines. Findings are reported according to the PRISMA statement, and recommendations are reported according to the Appraisal of Guidelines, Research and Evaluation (AGREE) II instrument. Findings Six systematic reviews and 2 evidence-based clinical guidelines met inclusion criteria. All included articles had high methodological Quality Assessment of Diagnostic Accuracy Studies (QUADAS) ratings. In infants, clinical signs and symptoms of cerebral palsy emerge and evolve before age 2 years; therefore, a combination of standardized tools should be used to predict risk in conjunction with clinical history. Before 5 months’ corrected age, the most predictive tools for detecting risk are term-age magnetic resonance imaging (86%-89% sensitivity), the Prechtl Qualitative Assessment of General Movements (98% sensitivity), and the Hammersmith Infant Neurological Examination (90% sensitivity). After 5 months’ corrected age, the most predictive tools for detecting risk are magnetic resonance imaging (86%-89% sensitivity) (where safe and feasible), the Hammersmith Infant Neurological Examination (90% sensitivity), and the Developmental Assessment of Young Children (83% C index). Topography and severity of cerebral palsy are more difficult to ascertain in infancy, and magnetic resonance imaging and the Hammersmith Infant Neurological Examination may be helpful in assisting clinical decisions. In high-income countries, 2 in 3 individuals with cerebral palsy will walk, 3 in 4 will talk, and 1 in 2 will have normal intelligence. Conclusions and Relevance Early diagnosis begins with a medical history and involves using neuroimaging, standardized neurological, and standardized motor assessments that indicate congruent abnormal findings indicative of cerebral palsy. Clinicians should understand the importance of prompt referral to diagnostic-specific early intervention to optimize infant motor and cognitive plasticity, prevent secondary complications, and enhance caregiver well-being.

744 citations


Cites result from "A systematic review of tests to pre..."

  • ...High-quality evidence also indicates that a trajectory of abnormal GMs or HINE scores, in combination with abnormal MRI, producing congruent findings, is even more accurate than individual clinical assessments in isolation.(21,25)...

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Journal ArticleDOI
TL;DR: The aims were to survey the questions parents asked neurologists and provide evidence-based answers, using knowledge translation techniques, to provide an overview of the most up-to-date diagnostic practices and evidence- based intervention options for cerebral palsy.
Abstract: Safer and more effective interventions have been invented for children with cerebral palsy, but the rapid expansion of the evidence base has made keeping up-to-date difficult. Unfortunately, outdat...

175 citations


Cites background from "A systematic review of tests to pre..."

  • ...The facts Substantial risks for cerebral palsy existed in the medical history: multiple birth, extreme prematurity, male gender, feeding issues, and prolonged hospitalization(14) The General Movements assessment has the best sensitivity of all tools for detecting cerebral palsy early (98% sensitivity and 91% specificity at 10-20 weeks post term age; versus gold standard MRI with 80%-87% sensitivity; versus neurologic examination with 57%-86% sensitivity in preterms and 68%-96% sensitivity post-term age).(17,18) 12%-20% of children with cerebral palsy will have normal neuroimaging and neuroimaging should not be used in isolation....

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Journal ArticleDOI
TL;DR: Abnormal, absent, or sporadic FMs indicate an increased risk for later neurological dysfunction, whereas normal FMs are highly predictive of normal development, especially if they co-occur with other smooth and fluent movements.
Abstract: Objectives: To describe fidgety movements (FMs), i.e., the spontaneous movement pattern that typically occurs at 3–5 months after term age, and discuss its clinical relevance. Sources: A comprehensive literature search was performed using the following databases: MEDLINE/PubMed, CINAHL, The Cochrane Library, Science Direct, PsycINFO, and EMBASE. The search strategy included the MeSH terms and search strings (‘fidgety movement*’) OR [(‘general movement*’) AND (‘three month*’) OR (‘3 month*’)], as well as studies published on the General Movements Trust website (www.general-movements-trust.info). Summary of the data: Virtually all infants develop normally if FMs are present and normal, even if their brain ultrasound findings and/or clinical histories indicate a disposition to later neurological deficits. Conversely, almost all infants who never develop FMs have a high risk for neurological deficits such as cerebral palsy, and for genetic disorders with a late onset. If FMs are normal but concurrent postural patterns are not age-adequate or the overall movement character is monotonous, cognitive and/or language skills at school age will be suboptimal. Abnormal FMs are unspecific and have a low predictive power, but occur exceedingly in infants later diagnosed with autism. Conclusions: Abnormal, absent, or sporadic FMs indicate an increased risk for later neurological dysfunction, whereas normal FMs are highly predictive of normal development, especially if they co-occur with other smooth and fluent movements. Early recognition of neurological signs facilitates early intervention. It is important to re-assure parents of infants with clinical risk factors that the neurological outcome will be adequate if FMs develop normally.

152 citations


Cites background from "A systematic review of tests to pre..."

  • ...GMA is non-invasive, even non-intrusive, cost-efficient, and easy to learn within three to five days of training.3,5 Bosanquet et al.13 recently compared different structural and functional assessments used for early identification of CP risk and found that GMA had the best predictive power and…...

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Journal ArticleDOI
TL;DR: The opportunities and challenges for early diagnosis and early intervention in cerebral palsy, a group of disorders of the development of movement and posture, suggest that programs that stimulate all aspects of infant development by means of family coaching are most promising.
Abstract: This paper reviews the opportunities and challenges for early diagnosis and early intervention in cerebral palsy (CP). CP describes a group of disorders of the development of movement and posture, causing activity limitation that is attributed to disturbances that occurred in the fetal or infant brain. Therefore, the paper starts with a summary of relevant information from developmental neuroscience. Most lesions underlying CP occur in the second half of gestation, when developmental activity in the brain reaches its summit. Variations in timing of the damage not only result in different lesions but also in different neuroplastic reactions and different associated neuropathologies. This turns CP into a heterogeneous entity. This may mean that the best early diagnostics and the best intervention methods may differ for various subgroups of children with CP. Next, the paper addresses possibilities for early diagnosis. It discusses the predictive value of neuromotor and neurological exams, neuroimaging techniques, and neurophysiological assessments. Prediction is best when complementary techniques are used in longitudinal series. Possibilities for early prediction of CP differ for infants admitted to neonatal intensive care and other infants. In the former group, best prediction is achieved with the combination of neuroimaging and the assessment of general movements, in the latter group, best prediction is based on carefully documented milestones and neurological assessment. The last part reviews early intervention in infants developing CP. Most knowledge on early intervention is based on studies in high-risk infants without CP. In these infants, early intervention programs promote cognitive development until preschool age; motor development profits less. The few studies on early intervention in infants developing CP suggest that programs that stimulate all aspects of infant development by means of family coaching are most promising. More research is urgently needed.

146 citations


Cites background or methods from "A systematic review of tests to pre..."

  • ...Meta-analysis of six studies including over 2400 preterm infants on the power of neonatal cUS to predict CP indicated an estimated sensitivity of 74% and an estimated specificity of 92% (77)....

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  • ...However, existing data suggest that high sensitivity and high specificity (38, 77)....

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  • ...However, calculation of predictive values for CP is precluded due to the limited data on prediction available, or due to the fact that studies evaluating the predictive properties used more global “abnormality” outcomes (77, 85, 92)....

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  • ...When a single assessment is used, prediction is best when GMA is carried around 3 months post-term [median sensitivity 98% (range 50–100%), specificity 94% (range 35–100%) (77, 85, 86)]....

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  • ...Predictive validity of these assessments is generally good (82), with an estimated sensitivity and specificity for CP of 88–92%, respectively (77)....

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Journal ArticleDOI
TL;DR: Current views on definitions, risk factors, diagnostics and treatment of CP as well as comorbid problems, eg, drug-resistant epilepsy are presented.
Abstract: Cerebral palsy (CP) is one of the most frequent causes of motor disability in children. According to the up-to-date definition, CP is a group of permanent disorders of the development of movement and posture, causing activity limitations that are attributed to non-progressive disturbances that occurred in the developing foetal or infant brain. The CP definition has evolved over time; the problem is aetiologically and clinically very heterogeneous. According to European data, the average frequency of CP is 2.08 per 1000 live births, but in the group of children born with a body weight below 1500 g, the frequency is 70 times higher when compared with the group of children with a body weight over 2500 g at birth. The risk factors for CP can be divided into pre-conception, prenatal, perinatal and postnatal ones. CP commonly co-exists with epilepsy, in particular drug-resistant epilepsy, but also with mental retardation, visual and hearing impairment, as well as feeding and behavioral disorders. The degree of motor problem varies from mild to very severe making the child totally dependent on caregivers. Cerebral palsy is divided into forms depending on the type of motor disorders which dominate the clinical presentation; the traditional classifications by Ingram and Hagberg have now been replaced by the Surveillance of Cerebral Palsy in Europe classification which divides CP into spastic, dyskinetic and ataxic forms. Although cerebral palsy is a clinical diagnosis, modern diagnostic imaging provides information that allows the division of the results of magnetic resonance imaging in children with cerebral palsy into five groups according to the magnetic resonance imaging classification system. Just as the clinical presentation and the factors predisposing for CP are very diverse, treatment is also a very complex problem. Modern treatment of spasticity includes both botulinum toxin therapies and surgical techniques, eg, rhizotomy. The authors present current views on definitions, risk factors, diagnostics and treatment of CP as well as comorbid problems, eg, drug-resistant epilepsy.

141 citations

References
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Journal ArticleDOI
TL;DR: A five‐level classification system analogous to the staging and grading systems used in medicine, which has application for clinical practice, research, teaching, and administration is developed.
Abstract: To address the need for a standardized system to classify the gross motor function of children with cerebral palsy, the authors developed a five-level classification system analogous to the staging and grading systems used in medicine. Nominal group process and Delphi survey consensus methods were used to examine content validity and revise the classification system until consensus among 48 experts (physical therapists, occupational therapists, and developmental pediatricians with expertise in cerebral palsy) was achieved. Interrater reliability (kappa) was 0.55 for children less than 2 years of age and 0.75 for children 2 to 12 years of age. The classification system has application for clinical practice, research, teaching, and administration.

5,582 citations

Journal ArticleDOI
TL;DR: Suggestions were made about the content of a revised definition and classification of CP that would meet the needs of clinicians, investigators, health officials, families and the public and would provide a common language for improved communication.
Abstract: For a variety of reasons, the definition and the classification of cerebral palsy (CP) need to be reconsidered. Modern brain imaging techniques have shed new light on the nature of the underlying brain injury and studies on the neurobiology of and pathology associated with brain development have further explored etiologic mechanisms. It is now recognized that assessing the extent of activity restriction is part of CP evaluation and that people without activity restriction should not be included in the CP rubric. Also, previous definitions have not given sufficient prominence to the non-motor neurodevelopmental disabilities of performance and behaviour that commonly accompany CP, nor to the progression of musculoskeletal difficulties that often occurs with advancing age. In order to explore this information, pertinent material was reviewed on July 11-13, 2004 at an international workshop in Bethesda, MD (USA) organized by an Executive Committee and participated in by selected leaders in the preclinical and clinical sciences. At the workshop, it was agreed that the concept 'cerebral palsy' should be retained. Suggestions were made about the content of a revised definition and classification of CP that would meet the needs of clinicians, investigators, health officials, families and the public and would provide a common language for improved communication. Panels organized by the Executive Committee used this information and additional comments from the international community to generate a report on the Definition and Classification of Cerebral Palsy, April 2006. The Executive Committee presents this report with the intent of providing a common conceptualization of CP for use by a broad international audience.

3,970 citations

Journal ArticleDOI
TL;DR: A network of CP surveys and registers was formed in 14 centres in eight countries across Europe to standardize the definition of CP, inclusion/exclusion criteria, classification, and description of children with CP, and a basis for services planning among European countries.
Abstract: Although cerebral palsy (CP) is the most common cause of motor deficiency in young children, it occurs in only 2 to 3 per 1000 live births. In order to monitor prevalence rates, especially within subgroups (birthweight, clinical type), it is necessary to study large populations. A network of CP surveys and registers was formed in 14 centres in eight countries across Europe. Differences in prevalence rates of CP in the centres prior to any work on harmonization of data are reported. The subsequent process to standardize the definition of CP, inclusion/exclusion criteria, classification, and description of children with CP is outlined. The consensus that was reached on these issues will make it possible to monitor trends in CP rate, to provide a framework for collaborative research, and a basis for services planning among European countries.

1,546 citations

Journal ArticleDOI
TL;DR: If medical journals adopt the STARD checklist and flow diagram, the quality of reporting of studies of diagnostic accuracy should improve to the advantage of clinicians, researchers, reviewers, journals, and the public.
Abstract: OBJECTIVE: To improve the accuracy and completeness of reporting of studies of diagnostic accuracy, to allow readers to assess the potential for bias in the study and to evaluate its generalisability. METHODS: The Standards for Reporting of Diagnostic Accuracy (STARD) steering group searched the literature to identify publications on the appropriate conduct and reporting of diagnostic studies and extracted potential items into an extensive list. Researchers, editors, and members of professional organisations shortened this list during a two-day consensus meeting with the goal of developing a checklist and a generic flow diagram for studies of diagnostic accuracy. RESULTS: The search for published guidelines regarding diagnostic research yielded 33 previously published checklists, from which we extracted a list of 75 potential items. At the consensus meeting, participants shortened the list to a 25-item checklist, using evidence, whenever available. A prototypical flow diagram provides information about th...

1,322 citations


"A systematic review of tests to pre..." refers methods in this paper

  • ...Study validity was analysed using the Standards for Reporting Diagnostic Accuracy (STARD) criteria with added specific questions for this review (Appendix SIIa, online supporting information).(27) Demographic variables collected included median and range of gestational age, birthweight, sex, age at diagnosis, age at confirmed diagnosis, classification and distribution of CP, identified differential diagnosis, and how differential diagnoses were handled (Table I and Table SI, online supporting information)....

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Journal ArticleDOI
19 Mar 1999-Science
TL;DR: Findings provide evidence for a gradual maturation, during late childhood and adolescence, of fiber pathways presumably supporting motor and speech functions.
Abstract: Structural maturation of fiber tracts in the human brain, including an increase in the diameter and myelination of axons, may play a role in cognitive development during childhood and adolescence. A computational analysis of structural magnetic resonance images obtained in 111 children and adolescents revealed age-related increases in white matter density in fiber tracts constituting putative corticospinal and frontotemporal pathways. The maturation of the corticospinal tract was bilateral, whereas that of the frontotemporal pathway was found predominantly in the left (speech-dominant) hemisphere. These findings provide evidence for a gradual maturation, during late childhood and adolescence, of fiber pathways presumably supporting motor and speech functions.

1,309 citations


"A systematic review of tests to pre..." refers methods in this paper

  • ...To be included, studies needed to confirm a diagnosis of CP after the age of 2 years, when motor function is considered more stable and myelination is largely complete.(25) As males are known to be at higher risk of CP (accounting for 55% of the total population),(26) a sex bias of 30% towards males was allowed for....

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