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Validity and reliability of the guidelines of the Surveillance of Cerebral Palsy in Europe for the classification of cerebral palsy
Developmental Medicine & Child Neurology
Abstract
The validity and reliability of the guidelines of the Surveillance of Cerebral Palsy in Europe (SCPE) for the classification of cerebral palsy (CP) were tested by administering 10 written case vignettes via an interactive web-based link to 30 SCPE partners. There was a moderately good level of agreement (κ=0.59) about inclusion as a CP case on the SCPE database. Classification by CP subtype differed in two main areas: assigning spastic versus dyskinetic and judgement of distribution of spastic involvement. Agreement on Gross Motor Function Classification System (GMFCS) level was less good than reported in previous studies. Twenty respondents repeated the test 5 months later and there was good repeatability for case inclusion (κ= 0.72) but considerable variation in assignment of CP subtype and GMFCS level. There is a need for further collaborative work and training to improve harmonization of the classification of CP, including examination, application of SCPE guidelines, and register coding.
... The term 'cerebral palsy' (CP) stands for a wide group of disorders of motor and postural development, caused by nonprogressive lesions occurring in the fetal or infant brain. 1,2 According to the Surveillance of Cerebral Palsy in Europe, [1][2][3][4][5] CP can be classified into three main subgroups, on the basis of the predominant clinical features: spastic (which accounts for the 85%-90%), dyskinetic (between 6.5% and 14.4%), and ataxic (up to 4% of the total CP population). [4][5][6][7] The nosography of movement disorders in CP shows slight but significant differences in terminology if compared with classical, adult neurology, and this has been an important confounding factor in the past. ...
... 1,2 According to the Surveillance of Cerebral Palsy in Europe, [1][2][3][4][5] CP can be classified into three main subgroups, on the basis of the predominant clinical features: spastic (which accounts for the 85%-90%), dyskinetic (between 6.5% and 14.4%), and ataxic (up to 4% of the total CP population). [4][5][6][7] The nosography of movement disorders in CP shows slight but significant differences in terminology if compared with classical, adult neurology, and this has been an important confounding factor in the past. According to Surveillance of Cerebral Palsy in Europe, dyskinetic CP is characterized by the presence of involuntary, disorganized, and often stereotyped movements, associated with a fluctuating muscular tone. ...
... It may be further defined as 'dystonic' or 'choreoathetotic': in the dystonic type, the predominant state of involuntary muscular co-contraction and hypertonia leads to sustained or intermittent, twisting, and repetitive movements and/or postures of trunk, arms and legs; the choreoathetotic type is characterized by the prevalence of distal and/or proximal hyperkinetic movements, often associated with hypotonia. [1][2][3][4]7 Both dystonia and choreoathetosis can occur either at rest and/or during action or specific tasks, and usually coexist in patients with dyskinetic CP. This may represent a very disabling burden in terms of impairment of motor abilities, postural discomfort, and painful contractions, affecting the quality of life of both patients and caregivers. ...
Aim:
To evaluate the actual evidence of efficacy of oral pharmacological treatments in the management of dyskinetic cerebral palsy (CP).
Method:
A systematic review was performed according to the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. Articles were searched for in PubMed/MEDLINE, Scopus, Web of Science, Cochrane Library, Database of Reviews of Effectiveness, OTSeeker, Physiotherapy Evidence Database, REHABDATA, and ClinicalTrials.gov.
Results:
Sixteen articles met the eligibility criteria. Eight studies on trihexyphenidyl and two on levodopa showed contradictory results. Low efficacy was reported for diazepam, dantrolene sodium, perphenazine, and etybenzatropine. Tetrabenazine, gabapentin and levetiracetam should be studied in more detail. The updated available evidence does not support any therapeutic algorithm for the management of dyskinetic CP.
Interpretation:
This lack of evidence is partially owing to the inconsistency of classifications of patients and of outcome measures used in the reviewed studies. Further randomized, double-blind, placebo-controlled pharmacological trials, optimized for different age groups, based on valid, reliable, and disease-specific rating scales are strongly needed. Outcome measures should be selected within the framework of the International Classification of Functioning, Disability and Health.
... Cerebral palsy (CP) is the most common cause of childhood motor disability and requires neurologic care across the lifespan. 1,2 Multiple publications have informed the CP definition, [3][4][5][6][7][8][9][10][11] but the 2006 definition serves as the primary guide for current practice. 11 This statement defines CP as: ...
... The copyright holder for this preprint this version posted July 3, 2023. 8 year old (yo) boy with spastic diplegia. Birth was at 24 weeks gestation. ...
Background and Objectives: Cerebral palsy (CP), the most common motor disability of childhood, is variably diagnosed. We hypothesized that child neurologists and neurodevelopmentalists, often on the frontlines of CP diagnosis in North America, harbor uncertainties regarding the practical application of the most recent CP consensus definition from 2006.
Methods: We conducted a cross-sectional survey of child neurologists and neurodevelopmentalists at the 2022 Child Neurology Society Annual Meeting. Attendees were provided the 2006 CP consensus definition and asked whether they had any uncertainties about the practical application of the definition across four hypothetical clinical vignettes.
Results: Of 230 attendees, 164 responded to the closing survey questions (71%). 145/164 (88%) expressed at least one uncertainty regarding the clinical application of the 2006 definition. Overwhelmingly, these areas of uncertainty focused on: 1) Age, both with regards to the minimum age of diagnosis and the maximum age of brain disturbance or motor symptom onset, (67/164, 41%), and 2) Interpretation of the term non-progressive (48/164, 29%). The vast majority of respondents (157/164, 96%) answered Yes to the question: Do you think we should revise the 2006 consensus definition of CP?
Discussion: We propose that the uncertainties we identified could be addressed by operationalizing the 2006 consensus definition to support a more uniform CP diagnosis. To address the most common CP diagnostic uncertainties we identified, we propose 3 points of clarification based on the available literature: 1) Motor symptoms/signs should be present by 2 years old; 2) CP can and should be diagnosed as early as possible, even if activity limitation is not yet present, if motor symptoms/signs can be reasonably predicted to yield activity limitation (e.g. by using standardized examination instruments, Brain MRI, and a suggestive clinical history); and 3) The clinical motor disability phenotype should be non-progressive through 5 years old. We anticipate that operationalizing the 2006 definition of CP in this manner could clarify the uncertainties we identified among child neurologists and neurodevelopmentalists and reduce the diagnostic variability that currently exists.
... It has thus emerged that severe motor and cognitive impairment, multiple accompanying impairments (e.g., severe learning disability, severe visual and hearing impairment, epilepsy), and perinatal adverse events (e.g., Apgar score at 5 min < 5, neonatal convulsions) are more frequent in dyskinetic as compared to spastic CP [15,16]. Moreover, recent population-based neuroimaging data showed that MRI patterns of children with unilateral spastic, bilateral spastic, and dyskinetic CP were mainly lesional (77, 71, and 59%, respectively), whereas children with ataxic CP had more maldevelopments, miscellaneous, and normal findings (25,21, and 32%, respectively) [17]. According to the MRI classification system of SCPE, pathogenic neuroimaging patterns that characterize specific timing periods of disturbance/insult to the developing brain and likely cause CP, can be classified as maldevelopments, predominant white matter injury, and predominant grey matter injury [18]. ...
... In particular, data regarding children with CP born 2007 to 2012 and registered between 2016 and 2021 were retrieved. Full information on definitions, classifications, data collection, and harmonization methods has been reported previously [4,25,26]. Population-based denominators (i.e., still births, live births, multiple pregnancies, and neonatal deaths) were retrieved from the Belgian statistical office (Federal Public Service Economy -STATBEL). The number of live births before 37 weeks' gestation was stratified by gestational age (GA) groups as follows: extremely preterm (EPT), <28 weeks; very preterm (VPT), 28-31 weeks; and moderately preterm (MPT), 32-36 weeks. ...
Aim:
To report on the prevalence, neuroimaging patterns, and function of children with cerebral palsy (CP) in Belgium for birth years 2007-2012, and identify distinctive risk indicators and differences in outcome between CP subtypes.
Methods:
Antenatal and perinatal/neonatal factors, motor and speech function, associated impairments, and neuroimaging patterns were extracted from the Belgian Cerebral Palsy Register. Prevalence was estimated per 1000 (overall, ante/perinatal, spastic, dyskinetic CP) or 10,000 (post-neonatal, ataxic CP) live births. Multinomial logistic regression analyses were performed to ascertain the effects of antenatal/perinatal/neonatal factors and neuroimaging patterns on the likelihood of dyskinetic or ataxic CP relative to spastic CP, and test the likelihood of the occurrence of impaired motor and speech function and associated impairments in dyskinetic or ataxic CP relative to spastic CP.
Results:
In total, 1127 children with CP were identified in Belgium. The birth prevalence of overall CP was 1.48 per 1000 live births. The likelihood of dyskinetic CP increases if the child was born to a mother aged ≥35 years, mechanically ventilated, and had predominant grey matter injury, while an increased likelihood of ataxic CP is associated with ≥2 previous deliveries. Children with dyskinetic and ataxic CP are more likely to function with impairments in motor, speech, and intellectual abilities.
Conclusion:
Distinctive risk indicators and differences in outcome between CP subtypes were identified. These factors can be incorporated into clinical practice to facilitate early, accurate, and reliable classification of CP subtype, and may lead to individually tailored neonatal care and other (early) intervention options.
... Seven hundred seventy-five children with CP were screened based on the following inclusion criteria: age between 12 and 18 years, severe DDs diagnosed by a pediatric neurologist, being spastic, dystonic, or having mixed spastic/dystonic or hypotonic CP classified using the Surveillance of Cerebral Palsy in Europe system [ 32 ], and having at least 3 years of follow-up data. The exclusion criteria were progressive encephalopathy or spinal neuropathology [ 32 ]. ...
... Seven hundred seventy-five children with CP were screened based on the following inclusion criteria: age between 12 and 18 years, severe DDs diagnosed by a pediatric neurologist, being spastic, dystonic, or having mixed spastic/dystonic or hypotonic CP classified using the Surveillance of Cerebral Palsy in Europe system [ 32 ], and having at least 3 years of follow-up data. The exclusion criteria were progressive encephalopathy or spinal neuropathology [ 32 ]. ...
Epileptic seizures are associated with a higher incidence of Developmental Disabilities and Cerebral Palsy. Early evaluation and management of epilepsy is strongly recommended. We propose and discuss an application to predict epilespy (PredictMed-Epilepsy) and seizures via a deep-learning module (PredictMed-Seizures) encompassed within a multi-agent based healthcare system (PredictMed-MHS); this system is meant, in perspective, to be integrated into a clinical decision support system (PredictMed-CDSS). PredictMed-Epilespy, in particular, aims to identify factors associated with epilepsy in children with Developmental Disabilities and Cerebral Palsy by using a prediction-learning model named PredictMed. PredictMed-epilespy methods: We performed a longitudinal, multicenter, double-blinded, descriptive study of one hundred and two children with Developmental Disabilities and Cerebral Palsy (58 males, 44 females; 65 inpatients, 37 outpatients; 72 had epilepsy - 22 of intractable epilepsy, age: 16.6±1.2y, range: 12-18y). Data from 2005 to 2021 on Cerebral Palsy etiology, diagnosis, type of epilepsy and spasticity, clinical history, communication abilities, behaviors, intellectual disability, motor skills, and eating and drinking abilities were collected. The machine-learning model PredictMed was exploited to identify factors associated with epilepsy. The guidelines of the "Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis" Statement (TRIPOD) were followed. PredictMed-epilepsy results: Cerebral Palsy etiology [(prenatal > perinatal > postnatal causes) p=0.036], scoliosis (p=0.048), communication (p=0.018) and feeding disorders (p=0.002), poor motor function (p<0.001), intellectual disabilities (p=0.007), and type of spasticity [(quadriplegia/triplegia > diplegia > hemiplegia), p=0.002)] were associated with having epilepsy. The prediction model scored an average of 82% of accuracy, sensitivity, and specificity. Thus, PredictMed defined the computational phenotype of children with Developmental Disabilities/Cerebral Palsy at risk of epilepsy. Novel contribution of the work: We have been developing and we have prototypically implemented a Multi-Agent Systems (MAS) that encapsulates the PredictMed-Epilepsy module. More specifically, we have implemented the Patient Observing MAS (PoMAS), which, as a novelty w.r.t. the existing literature, includes a complex event processing module that provides real-time detention of short- and long-term events related to the patient's condition.
... Four hundred eighty-six teenagers with cerebral palsy were screened based on the following inclusion criteria: age between 12 and 18 years, being spastic, dystonic, having mixed spastic/dystonic or hypotonic cerebral palsy classified using the Surveillance of Cerebral Palsy in Europe system, 16 and having at least 3 years of follow-up. The exclusion criteria were progressive encephalopathy or spinal neuropathology. ...
... Ninety-one (53 male, 38 female; 62% whites, 32% Arabs, 4% blacks, 2% Asians) teenagers met the inclusion criteria ( Figure 1). The mean age was 17 + 1 years (range: [12][13][14][15][16][17][18]. Mean follow-up was 6 + 1 years (range: 3-12). ...
Background:
Intellectual disability and impaired adaptive functioning are common in children with cerebral palsy, but there is a lack of studies assessing these issues in teenagers with cerebral palsy. Therefore, the aim of this study was to develop and test a predictive machine learning model to identify factors associated with intellectual disability in teenagers with cerebral palsy.
Methods:
This was a multicenter controlled cohort study of 91 teenagers with cerebral palsy (53 males, 38 females; mean age ± SD = 17 ± 1 y; range: 12-18 y). Data on etiology, diagnosis, spasticity, epilepsy, clinical history, communication abilities, behaviors, motor skills, eating, and drinking abilities were collected between 2005 and 2015. Intellectual disability was classified as "mild," "moderate," "severe," or "profound" based on adaptive functioning, and according to the DSM-5 after 2013 and DSM-IV before 2013, the Wechsler Intelligence Scale for Children for patients up to ages 16 years, 11 months, and the Wechsler Adult Intelligence Scale for patients ages 17-18. Statistical analysis included Fisher's exact test and multiple logistic regressions to identify factors associated with intellectual disability. A predictive machine learning model was developed to identify factors associated with having profound intellectual disability. The guidelines of the "Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis Statement" were followed.
Results:
Poor manual abilities (P ≤ .001), gross motor function (P ≤ .001), and type of epilepsy (intractable: P = .04; well controlled: P = .01) were significantly associated with profound intellectual disability. The average model accuracy, specificity, and sensitivity was 78%.
Conclusion:
Poor motor skills and epilepsy were associated with profound intellectual disability. The machine learning prediction model was able to adequately identify high likelihood of severe intellectual disability in teenagers with cerebral palsy.
... CP clinical subtypes were classified according to Surveillance of Cerebral Palsy in Europe and classified as spastic, dyskinetic, ataxic, and non-classifiable [22]. In the initial assessment, parents of participants completed the PEDI-Mobility. ...
Background: The gross motor function measurement is considered as the gold standard for the motor assessment of children with cerebral palsy. The aim was to carry out the cross-cultural adaptation and investigate psychometric properties. Methods: A total of 150 children with cerebral palsy aged 2–16 (mean 8.82 ± 3.78 years; 54.7% male) included. The Gross Motor Function Measurement was adapted into Turkish. Two physiotherapies independently administered the gross motor function measurement. Internal consistency and intra/inter-rater reliability were assessed using Cronbach’s alpha, intraclass-correlation-coefficient. Standard-error-of-measurement, minimal-detectible-change calculated. The Bland–Altman method was applied to estimate the measurement bias in reliability analysis. Construct validity assessed with Spearman’s correlation coefficient between the gross motor function measurement and the gross motor function classification system, pediatric-evaluation-of-disability-inventory—mobility; confirmatory-factor-analysis was carried. Results: Internal-consistency (α: 0.997–1.00); reliability indices were excellent for total scale (intraclass-correlation-coefficient for intra-rater reliability 0.994–0.999, inter-rater reliability 0.997–0.999) and for each sub-dimension and total score. Standard-error-of-measurement was ranging 1.044–1.677, minimal-detectible-change was 2.435–5.520. Construct validity was supported by strong to excellent negative significant correlations (p < 0.05).
... Cerebral palsy (CP) is the most common cause of disability in children and has a high prevalence of 2 to 2.5 per 1,000 live births. 1 CP is classified based on tone pattern as spastic, dyskinetic, hypotonic or mixed and based on limb involvement as diplegia (lower limbs affected more than upper limbs), hemiplegia (upper limb frequently more affected than lower limb), and quadriplegia. 2 Most children with CP face limitation in ambulation which hinders participation in physical, recreational, and social activities thus considerably affecting the quality of life. The ambulatory potential varies significantly among different subtypes of CP. ...
Introduction: Cerebral Palsy (CP) is the most common disorder causing disability in children resulting from injury to the developing brain. Neurological imaging techniques like magnetic resonance imaging (MRI) facilitates identification of location and extent of brain injury in CP and helps to correlate with motor function, type of cerebral palsy and functional outcome. Aim: To correlate the brain MRI abnormality with clinical feature. Methodology: Cross sectional study was done on cerebral palsy diagnosed children aged 2-12 years, MRI of brain was performed to determine the type of lesion and assigned a grade based on the scoring system by expert radiologist. Results: In children with Cerebral Palsy abnormal neuroanatomical findings was found in 46 of the 50 cases with help of MRI. Type E (Periventricular leukomalacia) brain lesion was most common seen in all types of CP. Type D (Enlargement of lateral ventricle), type H (Thin corpus callosum) and type G (Border zone infarction) were next most common. Eleven (100%) patients in GMFCS level 1 had brain MRI grade 1(normal) (p=0.003). In GMFCS level 2 and 3 predominant MRI grade was 1. In GMFCS 4 and 5 predominant MRI grade was 2 (mild) (p=0.013) and (p=0.147) respectively. Conclusion: Majority of CP cases have neuroimaging finding on MRI and very few have no MRI finding. There was correlation between motor function and type of CP with severity of lesion in MRI and type of brain lesion.
... The rehabilitation of children with CP requires long-term and continuous rehabilitative medical services that are intertwined with their growth and development, along with appropriate treatments at various life stages, community living, and phased education. To enhance the all-encompassing development of children with CP and provide comprehensive services across medical, educational, and social domains throughout their lifespan from infancy, certain countries have established CP registry systems, such as the Surveillance of Cerebral Palsy in Europe (SCPE) [5] or Australian Cerebral Palsy Register (ACPR). [2] Over the decades, these registries have systematically collected and analysed data on CP, establishing a foundation for identifying causes and developing policies for prevention, medical care, and educational services. ...
Background
Cerebral palsy (CP) is a leading cause of motor developmental disability in children. Generating epidemiological data on CP could enable early diagnosis, intervention, and translational research. We aim to establish a Korean network and online data repository for CP called the Korean Cerebral Palsy Registry (KCPR).
Methods
The KCPR is a nationwide, multicentre, prospective cohort study designed as a 20-year longitudinal follow-up of approximately 800 children with CP. Institution-based surveillance mechanisms will be adopted for the registration of children with CP aged less than 7 years to participate in KCPR. The data collection form of the KCPR will comprise diagnostic information, risk factors, extent of disability, genetic data, quality of life, socioeconomic status, functional levels according to life cycle stages, and patterns of healthcare utilisation, including rehabilitation. The study objectives include (1) identifying the pathological characteristics of CP along with their medical, social, economic, and psychological needs and challenges; (2) using data accumulated from prospective tracking of the function and quality of life of children with CP to develop comprehensive service plans and policies that integrate medical care, special education, and welfare; and (3) conducting intervention cohort studies to establish guidelines for the provision of standardised rehabilitative medical services.
Discussion
The establishment of KCPR is crucial to delivering systematic and comprehensive services in the medical, educational, and social sectors throughout the lifecycle of children with CP. KCPR aims to enhance the diagnostic, rehabilitative, and educational approaches for children with CP. Ultimately, this initiative will contribute to advancements in the health and welfare of children with CP.
... We have collected data from two cohorts: long-term patients living in institutional care and others treated in day hospitals. Among 486 children with CP in the Nice region (France), 102 subjects, 60 from Lenval University Children's Hospital and 42 from Nice Day Hospital (age 16.5 ± 1.2 years, 60 males, 42 females) (Figure 1), met the following inclusion criteria: age 12 to 18 years at last follow-up, spastic, dystonic, with mixed spastic/dystonic or hypotonic CP, classified according to the European Cerebral Palsy Surveillance System [23], and had at least three years of follow-up (6.4 ± 1.2 years, range [3][4][5][6][7][8][9][10][11][12]. Spinal cord neuropathology and progressive encephalopathy were the exclusion criteria. ...
Insufficient postural control and trunk instability are serious concerns in children with cerebral palsy (CP). We implemented a predictive model to identify factors associated with postural impairments such as spastic or hypotonic truncal tone (TT) in children with CP. We conducted a longitudinal, double-blinded, multicenter, descriptive study of 102 teenagers with CP with cognitive impairment and severe motor disorders with and without truncal tone impairments treated in two specialized hospitals (60 inpatients and 42 outpatients; 60 males, mean age 16.5 ± 1.2 years, range 12 to 18 yrs). Clinical and functional data were collected between 2006 and 2021. TT-PredictMed, a multiple logistic regression prediction model, was developed to identify factors associated with hypotonic or spastic TT following the guidelines of “Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis”. Predictors of hypotonic TT were hip dysplasia (p = 0.01), type of etiology (postnatal > perinatal > prenatal causes; p = 0.05), male gender, and poor manual (p = 0.01) and gross motor function (p = 0.05). Predictors of spastic TT were neuromuscular scoliosis (p = 0.03), type of etiology (prenatal > perinatal > postnatal causes; p < 0.001), spasticity (quadri/triplegia > diplegia > hemiplegia; p = 0.05), presence of dystonia (p = 0.001), and epilepsy (refractory > controlled, p = 0.009). The predictive model’s average accuracy, sensitivity, and specificity reached 82%. The model’s accuracy aligns with recent studies on applying machine learning models in the clinical field.
... Ce handicap a plusieurs origines. La plus répandue est le manque d'oxygène à la naissance [8]. Il provoque des mouvements involontaires accentués durant des périodes d'émotion. ...
Abstract. Disability comes in different forms such as physical or mental disability. It is a question of taking into account finely any form in the definition of disabled user profiles for the design of suitable interactive systems. This paper focuses on physical handicap, and more precisely on that called cerebral palsy of the athetoid type. With the aim of designing interactive communication aid systems, an ontology is under development for the detailed modeling of the characteristics of the handicap. This serves as an entry point for the definition of one or more personas, to be made available to designers of interactive communication aid systems. A first case study illustrates the approach and is discussed.
Résumé. Le handicap se décline sous différentes formes, comme le handicap physique ou mental. Il s’agit de prendre en compte finement toute forme de handicap dans la définition des profils utilisateurs pour la conception de systèmes interactifs adaptés. Dans cet article, nous nous intéressons au handicap physique, et plus précisément à celui nommé paralysie cérébrale de type athétosique. Avec une visée de conception de système interactif d’aide à la communication, une ontologie est en cours de développement pour la modélisation fine des caractéristiques de ce handicap. Celle-ci peut servir de point d’entrée pour la définition d’un ou plusieurs personas, à mettre à la disposition de concepteurs de système interactif d’aide à la communication. Une première étude de cas permet d’illustrer l’approche, et est discutée.
... For participants to be included in the study, they had to be Egyptians with CP that met the Surveillance of Cerebral Palsy of Europe (SCPE) inclusion and exclusion criteria and have their parents provide written informed consent for them to participate in the study. 29,30 We only included participants who were 4 years and older according to the SCPE criteria. Participants older than 18 years were excluded, as the GMFCS (one of the two measurement tools used in this study) has been validated for those with CP younger than 18 years. ...
Background:
An adaptive seating system is a basic rehabilitation need for children and youth with cerebral palsy (CP) as it supports the structure and function of the musculoskeletal system and can positively affect their activities and participation. Despite the importance of adaptive seating systems, there is limited access to such systems in low-income countries.
Objectives:
To determine the percentage of children and youth between 4 and 18 years of age with CP in Egypt whose activity level and sitting ability suggest the need for an adaptive seating system.
Study design:
Observational cross-sectional study.
Methods:
One hundred ninety-three participants were included after fulfilling the criteria of the Surveillance of Cerebral Palsy of Europe. Their level of activity was assessed by a physical therapist using the Gross Motor Function Classification System (GMFCS), and their sitting ability was evaluated using the Level of Sitting Scale (LSS). Participants were considered to require an adaptive seating system if they scored GMFCS level IV or V and LSS level 1-5 concurrently.
Results:
Approximately 44% of the study participants were classified as GMFCS level IV or V and LSS level 1-5, suggesting that they were in need of an adaptive seating system.
Conclusions:
There is a large percentage of children and youth with CP in Egypt who need an adaptive seating system to be integrated into their rehabilitation.
... Participants are classified according to the distribution (unilateral or bilateral) and tone presentation (hypertonia will be identified as predominantly spastic, dystonic or mixed in type) as identified by the guidelines of the surveillance of cerebral palsy in Europe network (SCPE). 67 ...
Introduction
Botulinum neurotoxin-A (BoNT-A) is an accepted treatment modality for the management of hypertonia in children and young people with cerebral palsy (CYPwCP). Nevertheless, there are concerns about the long-term effects of BoNT-A, with a lack of consensus regarding the most meaningful outcome measures to guide its use. Most evidence to date is based on short-term outcomes, related to changes at impairment level (restrictions of body functions and structures), rather than changes in adaptive skills (enabling both activity and participation). The proposed study aims to evaluate clinical and patient reported outcomes in ambulant CYPwCP receiving lower limb BoNT-A injections over a 12-month period within all domains of the WHO’s International Classification of Functioning, Disability and Health and health-related quality of life (HRQoL).
Methods and analysis
This pragmatic prospective longitudinal observational study will use a one-group repeated measures design. Sixty CYPwCP, classified as Gross Motor Function Classification System (GMFCS) levels I–III, aged between 4 and 18 years, will be recruited from an established movement disorder service in London, UK. Standardised clinical and patient reported outcome measures within all ICF domains; body structures and function, activity (including quality of movement), goal attainment, participation and HRQoL, will be collected preinjection and at 6 weeks, 6 months and up to 12 months postinjection. A representative subgroup of children and carers will participate in a qualitative component of the study, exploring how their experience of BoNT-A treatment relates to clinical outcome measures.
Ethics and dissemination
Central London Research Ethics Committee has granted ethics approval (#IRAS 211617 #REC 17/LO/0579). Findings will be disseminated in peer-reviewed publications, conferences and via networks to participants and relevant stakeholders using a variety of accessible formats including social media.
... Neurological examinations were performed by experienced pediatric neurologists or by neonatologists with expertise in neonatal follow-up. CP was diagnosed according to the European guidelines and severity was classified using the Gross Motor Function Classification System (GMFCS) [20,21]. Motor outcomes were collected between 12 and 36 months PTA. ...
Background:
Unilateral spastic cerebral palsy (USCP) occurs in 30%-68% of infants with perinatal stroke. Early detection of USCP is essential for referring infants to early intervention. The aims of this study were to report motor outcomes after perinatal stroke, and to determine the predictive value of the General Movements Assessment (GMA) and Hand Assessment for Infants (HAI) for detection of USCP.
Materials and methods:
This was a prospective observational study involving infants with perinatal stroke. GMA was conducted between 10 and 15 weeks post term-age (PTA). The HAI was performed between 3 and 5 months PTA. Motor outcome was collected between 12 and 36 months PTA.
Results:
The sample consisted of 46 infants. Fifteen children (32.6%) were diagnosed with CP, two children with bilateral CP and 13 with USCP. Abnormal GMA had a sensitivity of 85% (95% confidence interval [CI] 55-98%) and a specificity of 52% (95% CI 33-71%) to predict USCP. When asymmetrically presented FMs were also considered as abnormal, sensitivity increased to 100%, hence the specificity declined to 43%. A HAI asymmetry index cut-off of 23, had both a sensitivity and a specificity of 100% to detect USCP.
Conclusion:
Using GMA and HAI can enable prediction of USCP before the age of 5 months in infants with perinatal stroke. Nevertheless, GMA must be interpreted with caution in this particular population. The HAI was found to be a very accurate screening tool for early detection of asymmetry and prediction of USCP.
... In 2000, the Surveillance of CP in Europe (SCPE) investigators specifically created diagnostic and classification guidelines that would provide uniformity across populations, clinicians, and investigators. 1 They achieved that to a considerable extent, but variation in assignment of CP subtype remained a problem. 2 Recent advances in molecular genetics have allowed the identification of treatable metabolic disorders associated with CP (e.g. glutaric aciduria type 1 arginanse deficiency). ...
This commentary is on the systematic review by Pham et al. on pages 1024–1030 of this issue.
... Binary dependent variable "gastrostomy placement" versus independent variables. NS TT ET SP DY EP SE MACS GMFCS EDACS 1 0 1 0 1 2 0 1 1 1 3 3 2 0 1 0 1 1 0 1 1 2 3 2 3 1 1 0 3 3 0 2 1 4 5 4 4 0 0 1 1 3 1 1 0 4 5 Europe" system; 11 and were followed for at least 3 years after initial diagnosis. Patients with progressive encephalopathy or spinal neuropathology, well-developed gross motor functional capacities (defined by Gross Motor Function Measure-88 > 70), 12 and good manual abilities (Manual Ability Classification System (MACS) < 2) 12 were not included. ...
Logistic regression–based predictive models are widely used in the healthcare field but just recently are used to predict comorbidities in children with cerebral palsy. This article presents a logistic regression approach to predict health conditions in children with cerebral palsy and a few examples from recent research. The model named PredictMed was trained, tested, and validated for predicting the development of scoliosis, intellectual disabilities, autistic features, and in the present study, feeding disorders needing gastrostomy. This was a multinational, cross-sectional descriptive study. Data of 130 children (aged 12–18 years) with cerebral palsy were collected between June 2005 and June 2015. The logistic regression–based model uses an algorithm implemented in R programming language. After splitting the patients in training and testing sets, logistic regressions are performed on every possible subset (tuple) of independent variables. The tuple that shows the best predictive performance in terms of accuracy, sensitivity, and specificity is chosen as a set of independent variables in another logistic regression to calculate the probability to develop the specific health condition (e.g. the need for gastrostomy). The average of accuracy, sensitivity, and specificity score was 90%. Our model represents a novelty in the field of some cerebral palsy–related health outcomes treatment, and it should significantly help doctors’ decision-making process regarding patient prognosis.
... Its prevalence is between 1.5 and 3 per 1,000 born alive. It is generally classified as congenital or acquired, according to the time when the brain damage occurred [3][4][5][6][7]. ...
Objective. The aim of this study was to determine the usefulness of ozone therapy in the treatment of Infantile Cerebral Palsy (ICP). Patients and methods. A non-controlled clinical assay was made in the Ozone Research Center (CIO), Havana, Cuba from January 2013 to January 2014. The sample was constituted by patients remitted to pediatrics consultation of CIO, to whom inclusion and exclusion criteria were applied. The study group involved 45 patients, from 1 month of birth to 8 years, with cerebral palsy of hypoxic-ischemic cause. The evaluation criteria were: evolution of the motor disorder according to the Gross Motor Function Classification System (GMFCS) scale, modification of muscle tone (Ashworth modified scale) and response to treatment (O’Brien modified scale). The way of administration was rectal insufflation; concentrations between 15, 20, 25 and 30 mg/L were used, volumes varied according to age, making calculation of the dose of ozone according to kilograms of weight. Cycles of 20 sessions, every 3 months were indicated, until completing 4 in 16 months. Patients were clinically evaluated, according to the scales used, before and after each cycle. Results and Discussion. The best answer to treatment was obtained in the group aged ? 4 years. The variables analyzed showed a significant improvement when the ozone treatment concluded. With respect to the evolution of the motor disorder, in 65 % of cases it improved. In the group of children below 4 years, the response was better in relation to the muscle tone. Response to treatment, according to the relatives’ criteria, was of 70 % of the children with marked improvement in the tone and muscle function. Conclusions. The greatest percentage of patients improved in the evolution of the motor disorder; when the Manual Ability Classification System (MACS) scale was applied, more than half the patients showed an improvement. A high percentage of children get a satisfactory result regarding muscle tone and motor function. No side effects were present in any of the cases during the study.
... It could be explained by the fact that seven of the eight children with GMFCS II were bilaterally affected, having higher lower limb spasticity compared to upper limb. 43 Looking at the values of the HHD and the FSM-CP, we see a reversed pattern. Here, we see higher scores on isometric strength items (only one was significant) in the GMFCS II group consisting of the older children. ...
Purpose: No instrument exists that measures functional strength in both lower and upper extremities in children with cerebral palsy (CP). Therefore, the functional strength measurement (FSM) was tested for feasibility, test–retest reliability and validity in CP.
Methods: Thirty-seven children with CP (aged 4–10 years, Gross Motor Function Classification System I and II) participated. The most common compensations for CP were described; new item descriptions were standardized, and one item was removed. Test–retest reliability was examined. To measure convergent validity, correlations between the FSM-CP and isometric muscle strength measured with the handheld dynamometer (HHD) were determined.
Results: Test–retest reliability was considered high for all items (intra-class correlation coefficient 0.79–0.95). Significant correlations between the HHD and FSM-CP ranged from r = 0.36 to 0.75.
Conclusion: The FSM-CP is feasible, reliable, and valid to use in children with CP. The FSM-CP can be considered as a helpful tool in clinical practice of physical examination of children with CP.
... b. Classification of CP Participants will be classified by motor type (spasticity, dyskinesia, ataxia or unclassifiable) and distribution (unilateral or bilateral) [34,35]. ...
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Background:
Modified sport interventions run by physiotherapists have shown potential as cost-effective, engaging, and effective interventions to improve gross motor skills and support transition to real-world sports participation for children with cerebral palsy. At present, this population demonstrates decreased participation in physical activities and sport compared to peers due to barriers ranging from body function to accessibility challenges. Sport provides culturally relevant opportunities for social integration, community participation and physical activity and has been shown to improve the fitness, self-esteem, confidence and quality of life of children with disabilities. The Sports Stars physiotherapy group has been designed to support the development of a range of fundamental movement and sports skills through activity skill practice and participation in modified popular Australian sports.
Methods:
This randomised, waitlist controlled, assessor blinded, superiority trial with two parallel groups will aim to compare the effectiveness of Sports Stars to standard care across all ICF domains. Children in the Sports Stars group are expected to demonstrate greater improvement in their individually-selected, sports related goals measured by the Canadian Occupational Performance Measure. This study will aim to assess sixty ambulant children aged six to 12 years with a diagnosis of cerebral palsy. Children will be excluded if they have had recent Botox or neurological/orthopaedic surgery. The Sports Stars intervention includes eight, one-hour, weekly physiotherapy group sessions with four to six participants and one lead physiotherapist. Outcome measures will be collected pre, post and 12 weeks post the immediate Sports Stars group to assess change immediately after, and at follow up time points.
Discussion:
This will be the first study of its kind to investigate a culturally relevant sports-focussed fundamental movement skills physiotherapy group for ambulant children with cerebral palsy. The findings will add to a growing pool of evidence supporting group physiotherapy for children with cerebral palsy and the Sports Stars group will provide an avenue for children to transition from individual physiotherapy to mainstream and modified recreational and competitive sports.
Trial registration:
Australian New Zealand Clinical Trials Registry: ACTRN12617000313336 Registered 28, February 2017. WHO Universal Trial Number: U1111-1189-3355 Registered 1, November 2016.
... There is no consensus on the operational definitions for HMD (Gainsborough, Surman, Maestri, Colver, & Cans, 2008;Graham et al., 2016), making it difficult to know the incidence of HMD in childhood. However, one can speculate that it is over 0.5 per 1,000 of the population, given that the incidence of dyskinetic CP, the largest subgroup of HMD, is about 10% to 15% of all cases with CP (3.6 per 1,000; Himmelmann et al., 2009). ...
Background:
Hyperkinetic movement disorders (HMD) are a heterogeneous group of neurological conditions among which dystonia is the predominant disorder and dyskinetic cerebral palsy the largest secondary dystonia group. Currently, there are no evidence-based, non-medical management options for childhood HMD. The Cognitive Orientation to daily Occupational Performance (CO-OP) Approach is a task-oriented, performance-based intervention that focuses on participation.
Purpose:
This paper reports the protocol for a proof-of-concept study to assess feasibility and preliminary evidence regarding efficacy of CO-OP for HMD following deep brain stimulation (DBS).
Method:
A series of N-of-1 trials with replications will be conducted with children, ages 6 and 21 years with HMD and DBS as indicated by the Manual Ability Classification System. Ten individualized CO-OP sessions, with multiple baselines before, during, and after, will be completed. The primary outcome measures are the Performance Quality Rating Scale and the Assessment of Motor and Process Skills. Outcome data will be plotted over time for each participant and supplemented with graph statistical analysis and effect size estimates.
Implications:
A written protocol will be developed based on evidence and feedback incorporating any changes to the CO-OP intervention for children and young people with HMD, as per the Medical Research Council's Framework for Complex Interventions.
... However, an unambiguous classification and definition of CP remains difficult (Morris 2007). There is still high variability in register entries due to the lack of agreement between raters in the type and laterality of motor involvement (Gainsborough et al. 2008) and in the interpretation of clinical information (Reid et al. 2015), suggesting the need of more clear and reliable differentiation criteria. A clear difficulty in classifying CP patients is confirmed also by neuroimaging studies. ...
Cerebral palsy (CP) is a group of non-progressive developmental movement disorders inducing a strong brain reorganization in primary and secondary motor areas. Nevertheless, few studies have been dedicated to quantify brain pattern changes and correlate them with motor characteristics in CP children. In this context, it is very important to identify feasible and complementary tools able to enrich the description of motor impairments by considering their neural correlates. To this aim, we recorded the electroencephalographic activity and the corresponding event-related desynchronization (ERD) of a group of mild-to-moderate affected unilateral CP children while performing unilateral reach-to-grasp movements with both their paretic and non-paretic arms. During paretic arm movement execution, we found a reduced ERD in the upper µ band (10–12.5 Hz) over central electrodes, preceded by an increased fronto-central ERD in the lower µ band (7.5–10 Hz) during movement preparation. These changes positively correlated, respectively, with the Modified House Classification scale and the Manual Ability Classification System. The fronto-central activation likely represents an ipsilesional plastic compensatory reorganization, confirming that in not-severely affected CP, the lesioned hemisphere is able to compensate part of the damage effects. These results highlight the importance of analyzing different sub-bands within the classical mu band and suggest that in similar CP population, the lesioned hemisphere should be the target of specific intensive rehabilitation programs.
... During the second stage of screening, a mobile team of specially trained fieldworkers visited all households with a positive response to either question. The fieldworkers followed a protocol that included questions for the household head and assessments of mobility and fine motor control derived from Surveillance of Cerebral Palsy in Europe (SCPE) guidelines 18,19 and that had been adapted to the cultural context (appendix). All children with suspected motor impairment or other clinical signs of cerebral palsy were referred to the third stage of screening. ...
Background: Few population-based studies of cerebral palsy have been done in low-income and middle-income countries. We aimed to examine cerebral palsy prevalence and subtypes, functional impairments, and presumed time of injury in children in Uganda.
Methods: In this population-based study, we used a nested, three-stage, cross-sectional method (Iganga-Mayuge Health and Demographic Surveillance System [HDSS]) to screen for cerebral palsy in children aged 2–17 years in a rural eastern Uganda district. A specialist team confirmed the diagnosis and determined the subtype, motor function (according to the Gross Motor Function Classification System [GMFCS]), and possible time of brain injury for each child. Triangulation and interviews with key village informants were used to identify additional cases of suspected cerebral palsy. We estimated crude and adjusted cerebral palsy prevalence. We did χ2 analyses to examine differences between the group screened at stage 1 and the entire population and regression analyses to investigate associations between the number of cases and age, GMFCS level, subtype, and time of injury.
Findings: We used data from the March 1, 2015, to June 30, 2015, surveillance round of the Iganga-Mayuge HDSS. 31 756 children were screened for cerebral palsy, which was confirmed in 86 (19%) of 442 children who screened positive in the first screening stage. The crude cerebral palsy prevalence was 2·7 (95% CI 2·2–3·3) per 1000 children, and prevalence increased to 2·9 (2·4–3·6) per 1000 children after adjustment for attrition. The prevalence was lower in older (8–17 years) than in younger (
... Cerebral palsy (CP) is an umbrella term for a group of nonprogressive motor disorders caused by damage to the immature brain, resulting in abnormal development of movement and posture. 1 Dystonic CP is less well understood than hemiplegic CP or the more widely recognised bilateral spastic CP phenotypes. 2 Dystonia presents specific motor challenges but it is now recognised that non-motor symptoms occur in 95% of adults with dystonia and these are independent of motor severity or dystonia duration. 3 A range of non-motor problems have been identified, including communication difficulties, 4 problems with emotion regulation, theory of mind (ToM) and peer relation difficulties. ...
Aims:
This cross-sectional study aimed to investigate whether children and adolescents with dystonic cerebral palsy (CP) present with emotional and social difficulties along side motor limitations.
Participants/measures:
Twenty-two verbal and nonverbal children and adolescents with dystonic CP were compared with a normative sample of twenty children and adolescents on measures of theory of mind (ToM), emotion regulation (ER), and social difficulties (SD).
Results:
Higher social and emotional difficulties were found in the dystonic CP group compared to the control group. Nonverbal participants with dystonic CP were found to present with greater social impairment and lower ToM ability than their verbal counterparts. Emotional regulation and hyperactivity and attentional difficulties (HAD) significantly predicted ToM ability and social difficulties. Lower Gross Motor Function Classification System (GMFCS) level and IQ also contributed to differences in ToM ability.
Interpretation:
Findings support the need for greater attention to the emotional health and social development of children/adolescents with dystonic CP, along with assessments of motor difficulties in the planning and implementation of interventions and individual care plans. Further research is needed to explore links between motor disorder and mental state understanding in this clinical group.
... By contrast, reliability between current observers is the guiding principle of the more recent multicenter surveillance system in Europe, which adopted a flowchart to decision inclusion or exclusion of cases of cerebral palsy on registration [20]. However, the reality of barriers to achieving interobserver agreement of classification is demonstrated by the relatively poor agreement achieved with this flowchart [21]. Diagnosis of CP is not easy. ...
CP is not a diagnosis but an " umbrella term for many clinical descriptions. It refers to a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain. The motor disorerders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition. First description was made in 19th century by William Little. CP prevalence is generally reported around 2-3 per 1000 live births in both developed and developing countries (even if for very different reasons). Additionally for term children CP prevalence is 1 per 1000 live births. This rates are 6-10 times higher in preterm birth. The etiology of CP has been reported very diverse and multifactorial as prenatal, perinatal and postnatal. The causes and risk factors are congenital, genetic, inflammatory, infectious, anoxic, traumatic and metabolic. Knowledge of the epidemiology and etiology of cerebral palsy is impor‐ tant. Thus, at least in some cases, early diagnosis and prevention can be achieved.
Background & Objective: This study aimed to investigate the relationship between the Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MACS), the Eating and Drinking Ability Classification System (EDACS), the Communication Function Classification System (CFCS), dyskinetic movements and participation levels in children with dyskinetic cerebral palsy (DCP) to attain a comprehensive functional profile of DCP. Methods: Forty children with DCP aged between 5-18 years were included. Functional classification systems: GMFCS, MACS, CFCS, EDACS levels investigated. The Dyskinesia Impairment Scale (DIS) was used for evaluate dyskinetic movements: dystonia and choreoathetosis. Assessment of Life-Habits-Questionnaire (LIFE-H) was used for evaluate participation. Spearman’s correlation test was used to evaluate the relationship among functional classification levels, DIS subscales and LIFE-H subdomains. Multivariate simple linear regression, backward model was used to explain relations between LIFE-H subdomains, DIS subscales, GMFCS, MACS, EDACS and CFCS. Results: The mean age was 12.88±4.57 years. Correlations were found between GMFCS-MACS, GMFCS-EDACS, MACS-EDACS, CFCS-MACS, GMFCS-CFCS and EDACS-CFCS (p<0.05); between GMFCS and dystonia upper extremity, dystonia lower extremity total score, dystonia total score (p<0.05); between MACS and dystonia upper extremity, dystonia lower extremity total score, dystonia total score, and dystonia mouth total score (p<0.05). LIFE-H Social-Roles Total Score, Daily-Living-Activities Total Score, LIFE-H-Total-Score were correlated with GMFCS, MACS, EDACS and CFCS (p<0.05). The results of regression analysis showed GMFCS and MACS levels are strong predictors of participations (p<0.05). Conclusions: To plan participatory intervention programs, it is important to understand the levels of participation and differences among children with DCP subtypes according to the ICF framework.
Aims
To determine the quality of prospectively collected data from the highly specialized Danish Cerebral Palsy Follow-up Program (CPOP), and to establish the validity of a reported cerebral palsy (CP) diagnosis in the Danish National Patient Registry (NPR), regularly used as a proxy for neurodevelopmental disorders in epidemiological research.
Methods
We compared data from the two registries on children with registered CP, born in Denmark between 2008 and 2009, with information from medical records verified by two experienced physicians specializing in pediatric neurology. Data accuracy was estimated by completeness, correctness, and reliability. Completeness was calculated as the number of cases with correctly registered CP diagnoses divided by the total number of true CP diagnoses (similar to sensitivity). Correctness was calculated as the number of cases with correct registrations divided by the total number of cases (similar to positive predictive value). Reliability was estimated using kappa statistics.
Results
Registered CP diagnoses in the CPOP had high accuracy, with 94% correctness and 91% completeness. Furthermore, most key variables in the CPOP showed excellent reliability, especially variables defining the severity of the condition. In the Danish NPR, only 225 of 348 children with a noted CP diagnosis fulfilled the diagnostic criteria for CP, resulting in 65% correctness.
Conclusions
Danish CPOP data are a valid source for epidemiological research. Conversely, a noted CP diagnosis in the Danish NPR was, at best, correct in only two out of three patients.
Background
Public health indicators (PHIs) play an increasingly important role in health policy decision‐making. Although cerebral palsy (CP) is the commonest physical disability in children, its impact at population level has not been systematically measured so far.
Objectives
We aimed to propose six PHIs for CP designed to annually document the extent of CP and effectiveness of perinatal organisation, the burden of this condition, access to health services and preventive health strategies in the post‐neonatal period and to report on the latest updated estimations using population‐based data routinely collected by European CP registries.
Methods
The study included children with CP born between 2002 and 2011. Harmonised data (number of cases, functional profile, imaging) were extracted from the Surveillance of Cerebral Palsy in Europe (SCPE) database. Eligibility criteria for analyses were applied separately for each indicator by selecting registries, birth years and CP cases. Current estimates were based on the last 3 birth years, while trends were reported over a 10‐year period. All analyses were descriptive. Sensitivity analyses were carried out to examine the stability of the results using various thresholds of percentages of missing values.
Results
Analyses were performed on a total of 8621 children with CP from 12 to 17 SCPE registries. A decreasing prevalence of pre/perinatal CP overall, as well as in preterm and full‐term‐born children, was observed. The burden of the condition was strongly dependent on CP subtype and the presence of associated impairments. Access to brain imaging ranged from 80% to 100% depending on registries. The overall prevalence of post‐neonatally acquired CP was approximately 0.8 per 10,000 live births over the study period.
Conclusions
Population‐based CP registries can provide data that are relevant for generating key outcomes of interest at the population level, thus potentially contributing to improving public health policies for children with disabilities.
(1) Background: Cerebral palsy (CP) is associated with a higher incidence of epileptic seizures. This study uses a prediction model to identify the factors associated with epilepsy in children with CP. (2) Methods: This is a retrospective longitudinal study of the clinical characteristics of 102 children with CP. In the study, there were 58 males and 44 females, 65 inpatients and 37 outpatients, 72 had epilepsy, and 22 had intractable epilepsy. The mean age was 16.6 ± 1.2 years, and the age range for this study was 12–18 years. Data were collected on the CP etiology, diagnosis, type of epilepsy and spasticity, clinical history, communication abilities, behaviors, intellectual disability, motor function, and feeding abilities from 2005 to 2020. A prediction model, Epi-PredictMed, was implemented to forecast the factors associated with epilepsy. We used the guidelines of “Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis” (TRIPOD). (3) Results: CP etiology [(prenatal > perinatal > postnatal causes) p = 0.036], scoliosis (p = 0.048), communication (p = 0.018), feeding disorders (p = 0.002), poor motor function (p < 0.001), intellectual disabilities (p = 0.007), and the type of spasticity [(quadriplegia/triplegia > diplegia > hemiplegia), p = 0.002)] were associated with having epilepsy. The model scored an average of 82% for accuracy, sensitivity, and specificity. (4) Conclusion: Prenatal CP etiology, spasticity, scoliosis, severe intellectual disabilities, poor motor skills, and communication and feeding disorders were associated with epilepsy in children with CP. To implement preventive and/or management measures, caregivers and families of children with CP and epilepsy should be aware of the likelihood that these children will develop these conditions.
Accumulating evidence from clinical and neuropathological study has identified a number of seemingly disparate associations carrying a predisposition for cerebral palsy (CP). We narratively reviewed clinical studies reporting associations between prenatal and perinatal environmental factors and the risk of developing CP. As expected, some processes with direct central nervous system involvement (e.g. perinatal hypoxic-ischemic encephalopathy or infectious encephalomalacia) carry >10% absolute risk of CP. Other acute perinatal processes including placental abruption, uterine rupture, and neonatal sepsis are also associated with increased risk of CP but carry <3% absolute risk of CP. Indirect markers of chronic placental insufficiency such as fetal and placental growth patterns are associated with increased risk of CP, and risk of CP in infants with growth abnormalities born extremely preterm exceeds 10%.
We synthesize these findings within a framework of risk accumulating across several defined pre- and perinatal developmental windows. Causal links remain incompletely understood, but genetic background, the intrauterine environment, general fetal health, and fetal neurologic health all appear to contribute.
Aim: To report on prevalence of cerebral palsy (CP), severity rates, and types of brain lesions in children born preterm 2004 to 2010 by gestational age groups.
Methods: Data from 12 population-based registries of the Surveillance of Cerebral Palsy in Europe network were used. Children with CP were eligible if they were born preterm (<37 weeks of gestational age) between 2004 and 2010, and were at least 4 years at time of registration. Severity was assessed using the impairment index. The findings of postnatal brain imaging were classified according to the predominant pathogenic pattern. Prevalences were estimated per 1,000 live births with exact 95% confidence intervals within each stratum of gestational age: ≤27, 28–31, 32–36 weeks. Time trends of both overall prevalence and prevalence of severe CP were investigated using multilevel negative binomial regression models.
Results: The sample comprised 2,273 children. 25.8% were born from multiple pregnancies. About 2-thirds had a bilateral spastic CP. 43.5% of children born ≤27 weeks had a high impairment index compared to 37.0 and 38.5% in the two other groups. Overall prevalence significantly decreased (incidence rate ratio per year: 0.96 [0.92–1.00[) in children born 32–36 weeks. We showed a decrease until 2009 for children born 28–31 weeks but an increase in 2010 again, and a steady prevalence (incidence rate ratio per year = 0.97 [0.92–1.02] for those born ≤27 weeks. The prevalence of the most severely affected children with CP revealed a similar but not significant trend to the overall prevalence in the corresponding GA groups. Predominant white matter injuries were more frequent in children born <32 weeks: 81.5% (≤27 weeks) and 86.4% (28–31 weeks), compared to 63.6% for children born 32–36 weeks.
Conclusion: Prevalence of CP in preterm born children continues to decrease in Europe excepting the extremely immature children, with the most severely affected children showing a similar trend.
Neuromuscular hip dysplasia (NHD) is a common and severe problem in patients with cerebral palsy (CP). Previous studies have so far identified only spasticity (SP) and high levels of Gross Motor Function Classification System as factors associated with NHD. The aim of this study is to develop a machine learning model to identify additional risk factors of NHD. This was a cross-sectional multicenter descriptive study of 102 teenagers with CP (60 males, 42 females; 60 inpatients, 42 outpatients; mean age 16.5 ± 1.2 years, range 12–18 years). Data on etiology, diagnosis, SP, epilepsy (E), clinical history, and functional assessments were collected between 2007 and 2017. Hip dysplasia was defined as femoral head lateral migration percentage > 33% on pelvic radiogram. A logistic regression-prediction model named PredictMed was developed to identify risk factors of NHD. Twenty-eight (27%) teenagers with CP had NHD, of which 18 (67%) had dislocated hips. Logistic regression model identified poor walking abilities (p < 0.001; odds ratio [OR] infinity; 95% confidence interval [CI] infinity), scoliosis (p = 0.01; OR 3.22; 95% CI 1.30–7.92), trunk muscles' tone disorder (p = 0.002; OR 4.81; 95% CI 1.75–13.25), SP (p = 0.006; OR 6.6; 95% CI 1.46–30.23), poor motor function (p = 0.02; OR 5.5; 95% CI 1.2–25.2), and E (p = 0.03; OR 2.6; standard error 0.44) as risk factors of NHD. The accuracy of the model was 77%. PredictMed identified trunk muscles' tone disorder, severe scoliosis, E, and SP as risk factors of NHD in teenagers with CP.
Classification systems are intended to reduce the complexity of heterogeneous conditions by grouping people with similar clinical manifestations together. Classifications are intended to improve communication among clinicians, researchers, patients, and caregivers. They may guide clinical diagnosis, prediction of prognoses, goal setting, treatment decisions, and determinations for service eligibility. They are used for population surveillance and for identifying and/or describing research participants. Classification systems categorize people with cerebral palsy (CP) on the basis of type and topography of neuromotor impairment, neuroanatomical disturbances, gait patterns, and functioning. The systems differ in their coverage of body structure, body function, and activity levels as specified in the International Classification of Functioning, Disability, and Health framework. This chapter reviews commonly used classification systems for people with CP, including their reliability, validity, and utility for specific uses.
Cerebral palsy is not a disease, but a collection of disorders of the brain resulting from a malformation or injury as the final common pathway. A strict definition of CP is a difficult task to determine. This chapter overviews the history of the “cerebral palsies” and discuss a practical use of the current classification systems to benefit the provider caring for patients with CP.
Background:
Orthopedic surgery in children with cerebral palsy (CP) aims to improve function and prevent deformities. Each child's condition in CP is unique and many co-variables influence surgical decision-making including a patient's age and their functional level. Little is known about the frequency of different types of orthopedic surgery in children with CP who have varied functional levels, particularly in countries from Latin America.
Aim:
To assess the type of orthopedic surgical procedures in relation to age and gross motor function in children with CP.
Methods:
This retrospective study included all children with CP (n = 245) treated with elective orthopedic surgery at a Uruguayan university hospital between October 2010 and May 2016 identified from a surgical database. Eighteen children (7%) were lost to follow-up due to missing medical charts. Demographics, gross motor function classification (GMFCS), and orthopedic surgeries were obtained from the medical records of 227 children. Chi-squared tests and analysis of variance were used to assess the frequency of surgery, accounting for GMFCS levels. Mean age for soft tissue vs bone surgery was compared with the independent samples t-test.
Results:
A total of 711 surgical procedures were performed between 1998 and 2016. On average, children had 3.1 surgical procedures and the mean age at first surgery was 8.0 years. There were no significant differences in age at first surgery among GMFCS levels (P = 0.47). The most common procedures were lower leg soft tissue surgery (n = 189, 27%), hip tenotomy (n = 135, 19%), and hamstring tenotomy (n = 104, 14%). For children with GMFCS level I, the mean number of surgeries per child [1.8 (range 1-9)] differed significantly at P < 0.05 in children with GMFCS levels II [3.2 (1-12)], III [3.2 (1-8)], IV [3.3 (1-13)], and V [3.6 (1-11)]. Within II, III, IV, and V, there was no significant difference in mean number of surgeries per child when comparing across the groups. The proportion of soft tissue surgery vs bone surgery was higher in GMFCS levels I-III (80%-85%) compared to levels IV (68%) and V (55%) (P < 0.05).
Conclusion:
The frequency of surgical procedures per child did not increase with higher GMFCS level after level I. However, the proportion of bone surgery was higher in GMFCS levels IV-V compared to I-III.
Introducción:
la luxación de cadera es una complicación severa en pacientes con parálisis cerebral (PC), sobre todo en pacientes incluidos en el sistema de clasificación de la función motora gruesa (GMFCS, por su sigla en inglés) III-V. Para su identificación son necesarias radiografías de pelvis.
Objetivos:
evaluar el seguimiento radiográfico en estos pacientes y la detección precoz de esta complicación en nuestro hospital.
Material y método:
se revisaron historias clínicas y radiografías de 17 pacientes GMFCS III-V, entre 2 y 8 años de edad al momento de la radiografía de pelvis índice, midiendo el porcentaje de migración (PM) de cadera de acuerdo al índice de Reimer, el ángulo cérvico-diafisiario y calculando el CPUP Score de cada cadera. Evaluamos el control radiográfico al año o posteriormente a esa fecha, y de no haber sido así, se citaría a los pacientes a control radiológico para detectar las caderas con riesgo migratorio elevado.
Resultados:
de los 17 pacientes evaluados, 3 (18%) tuvieron una nueva radiografía de pelvis al año; 6 (35%) pacientes la tuvieron posteriormente al año, y antes de la fecha de control designada, 7 (41%) pacientes nunca fueron controlados, citándose para nueva radiografía en 2018. Un paciente (6%) se perdió en el seguimiento. Un paciente presentó una cadera con riesgo alto (CPUP Score 50%-60%), el resto tuvo PM dentro de rangos normales.
Conclusiones:
pocos pacientes con PC GMFCS III-V tuvieron un seguimiento radiográfico anual. Los monitoreados posteriormente no mostraron progresión de esta condición. El resultado de este estudio y la literatura respaldan la introducción de un programa de vigilancia en nuestro hospital.
Aim
The application of current, best evidence into clinical practice is problematic. This article describes a knowledge translation (KT) project aimed at improving clinician identification, classification and measurement of dyskinesia in children with cerebral palsy (CP).
Method
A 2‐year KT fellowship investigated clinicians' understanding of dyskinetic CP, identified knowledge gaps, determined educational needs and implemented a multifaceted KT strategy and dissemination framework to address those needs.
Results
Australian and New Zealand medical and allied health clinicians identified significant gaps in their clinical knowledge regarding dyskinetic CP, particularly confidence in identifying and measuring dyskinesia and poor knowledge of available identification and measurement tools. Following a targeted implementation strategy, there was a definite shift towards increased awareness of dyskinetic CP, a significant improvement in identification and measurement confidence (mean change from 47 to 66% confidence, P < 0.0001), and the embedding of the knowledge and skills into everyday clinical practice.
Conclusions
This targeted and well‐resourced KT project in dyskinetic CP improved clinician knowledge and led to meaningful change in clinical practice. The strategy utilised would be appropriate across a range of health‐care settings.
The Surveillance of Cerebral Palsy in Europe (SCPE) 20th Anniversary Scientific Report 1998-2018.
Cambridge Core - Neurology and Clinical Neuroscience - Treatment of Dystonia - edited by Dirk Dressler
Purpose: To investigate the relationship between trunk control in sitting and functionality in children with spastic cerebral palsy (CP).
Methods: Fifty-eight children with spastic CP were included in the study. Functional abilities were evaluated with the Gross Motor Function Measurement-88 (GMFM-88) and the Pediatric Evaluation of Disability Inventory Functional Skills domain (PEDI-FSD). Trunk control in sitting was tested with the Trunk Control Measurement Scale (TCMS) and the Trunk Impairment Scale (TIS). The scores of the TCMS and TIS were compared with GMFM-88 and PEDI-FSD with Spearman correlation analysis.
Results: The total score of GMFM-88 was significantly correlated with the total score of TCMS (rho = 0.90, p < 0.01) and TIS (rho = 0.78, p < 0.01). The total score of PEDI-FSD was also significantly correlated with the total score of TCMS (rho = 0.76, p < 0.01) and TIS (rho = 0.72, p < 0.01).
Conclusions: The evaluation of trunk control can provide valuable information for functional abilities of children with spastic CP.
Objetivo: Determinar la correlación de la función motriz básica y las destrezas manuales con la capacidad para manejar una silla de ruedas en niños con PC.Metodología: Se evaluaron 33 niños con diagnóstico de PC espástica de distribución bilateral en estados funcionales III y IV. A todos se les aplicó como prueba de función motriz gruesa el Gross Motor Function Measure (GMFM-66) y como prueba de destrezas manuales, la prueba de caja y cubos. Se establecieron las correlaciones de estas pruebas con la prueba de los 6 minutos en silla de ruedas.Resultados: Se encontró una correlación estadísticamente significativa entre el puntaje del GMFM-66 y la prueba de los 6 minutos (p=0,001; r=0,53). La función motriz gruesa explicó el resultado de la prueba de los 6 minutos en un 28%. Así mismo se encontró una correlación estadísticamente significativa entre el resultado de la prueba de caja y cubos y la prueba de los 6 minutos (p=0,004; r=0,48). La prueba de caja y cubos explicó el resultado de la prueba de los 6 minutos en un 23%.Conclusión: Aunque la función motriz gruesa y las destrezas manuales sirven para predecir la capacidad para autopropulsar la silla de ruedas en el niño con parálisis cerebral, otros factores deben influir en el rendimiento final. Estas pruebas sirven de guía para definir las metas de rehabilitación y proponer planes de tratamiento en los niños con parálisis cerebral en estados III y IV.
Aim:
The aims of this study were to investigate clinicians' knowledge, and barriers they perceive exist, relating to the identification and measurement of dyskinesia (dystonia/choreoathetosis) in children with cerebral palsy (CP) and to explore educational needs regarding improving identification and assessment of dyskinesia.
Methods:
This was a cross-sectional online survey of clinicians working with children with CP. Data analysis was descriptive, with qualitative analysis of unstructured questions.
Results:
In total, 163 completed surveys from Australian clinicians were analysed. Respondents were allied health (n = 140) followed by medical doctors (n = 18) working mainly in tertiary hospitals and not-for-profit organisations. Hypertonia subtypes and movement disorders seen in children with CP appear to be identified by clinicians, although limited knowledge about dyskinesia and access to training were reported as significant barriers to accurate identification. Despite knowledge of available measurement scales, only a small percentage were used clinically and reported to be only somewhat useful or not useful at all. Barriers identified for use of scales included limited training opportunities and knowledge of scales and lack of confidence in their use.
Conclusion:
A lack of confidence in identifying and measuring movement disorders in children with CP was reported by Australian clinicians. It was identified that a greater understanding of dyskinetic CP and the tools available to identify and measure it would be valuable in clinical practice. The results of this survey will inform the development of a 'Toolbox' to help identify, classify and measure dyskinetic CP and its impact on activity and participation using the framework of the International Classification of Functioning, Disability and Health.
Purpose of review:
In childhood, movement disorders are generated by a very large number of disorders of the nervous system, and the very different developmental ages at which these occur make studies of pharmacotherapy efficacy extremely difficult. In most clinical practices, medication used in management is by trial and error, and limited by lack of efficacy and/or adverse drug reactions leading to drug intolerance. Nevertheless, symptom reduction using polypharmacy must be balanced against any accompanying comorbidities such as poor attention and concentration, constipation, ileus, urinary retention, blurred vision sedation and respiratory depression.
Recent findings:
A 'personalised medicine' approach may lead to specific management breakthroughs that are beneficial to a wider number of children. At present, neuromodulation with implantable devices offers greater proven efficacy for dystonia, myoclonus and dystonic-choreoathetosis, but enteral, intravenous and, more recently, transdermal medication strategies with clonidine patches and enteral gabapentin may provide important relief for both home management and critical care settings.
Summary:
The current review brings the clinician up-to-date with the latest, albeit limited, thinking on the pharmacological management of movement disorders in children by focussing on goal-directed outcome measures to improve clinical decision-making in an evidence-light clinical setting.
Aim:
To establish the prevalence and severity of dystonia in a population of children with cerebral palsy (CP) with hypertonia assessment and measurement tools.
Method:
A cross-sectional study of 151 children (84 males, 67 females) with CP who were assessed with the Hypertonia Assessment Tool (HAT) and Barry-Albright Dystonia scale (BAD) for identification and measurement of severity of dystonia. HAT dystonia items were assessed for construct and convergent validity.
Results:
Distribution by predominant motor type (PMT) was: 85% spastic, 14% dyskinetic, and 1% ataxic. Spastic and dyskinetic groups showed widespread evidence of dystonia according to HAT profiles and BAD scores. The dyskinetic PMT group had a higher mean BAD score than the spastic group (difference of 13 units, 95% CI 9.1-16.4). Dystonia severity (BAD score) increased linearly across gross motor (p<0.001), manual ability (p<0.001) and communication functional levels (p<0.001). Divergence was noted in how HAT item six identified dystonia compared to items one and two.
Interpretation:
The HAT provided an estimate of the prevalence of both spasticity and dystonia in a large CP population, beyond predominant motor type. Dystonia is a common finding in the spastic PMT group, and its severity increases as motor function worsens.
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 (k) 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.
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.
Children with cerebral palsy (CP) experience a change in motor function with age and development. It is important to consider this expected change in offering a prognosis, or in assessing differences in motor function after an intervention. The Gross Motor Function Classification System for CP (GMFCS) has been developed for these purposes. This study was based on a retrospective chart review of 85 children with CP followed from < or =2 to > or =12 years of age. The GMFCS was applied to clinical notes by two blinded raters four times throughout the study. Interrater reliability was high (G=0.93). Test-retest reliability was high (G=0.79). The positive predictive value of the GMFCS at 1 to 2 years of age to predict walking by age 12 years was 0.74. The negative predictive value was 0.90. The GMFCS can validly predict motor function for children with CP. The results are discussed in terms of their implications for clinical practice and future research.
To determine the reliability of family assessment for the Gross Motor Function Classification System (GMFCS) for children with cerebral palsy in the UK.
Families of a complete geographically defined population of children with cerebral palsy between 6 and 12 years old were identified from the 4Child epidemiological database. Postal surveys were conducted with the families and any of the child's health professionals that were nominated by the families.
Families of 129/314 eligible children took part in the study (41%). The indices of agreement and reliability between families and professionals were also equivalent to those observed between the professionals (kappa = 0.5, ICC > or = 0.9). Reliability coefficients were higher when more of the professionals classified children using direct observation rather than only reviewing their clinical records.
Despite excellent reliability, families and professionals did not always agree exactly on a child's GMFCS level. Classifications may differ due to children's varying performance in different environments, in which case families will almost certainly know their children's ability in a broader range of settings. The indices of reliability of family assessment for the GMFCS meet the recommended criteria for use with individuals and groups, indicating that the method is suitable for use in research studies and clinical practice.
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.
The Gross Motor Function Classification System (GMFCS) for cerebral palsy has been widely used internationally for clinical, research, and administrative purposes. This paper recounts the ideas and work behind the creation of the GMFCS, reports on the lessons learned, and identifies some philosophical challenges inherent in trying to develop an ordered, valid, and consistent system to describe function in children and adolescents with developmental differences. It is hoped that these ideas will be useful to others who choose to expand the field with additional systems in other areas of childhood neurodisability.
Although cerebral palsy (CP) is the most common cause of motor deficiency in young children, it occurs in only a 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 GP surveys and registers was formed in 14 centres in eight countries across Europe. Differences in prevalence rates of GP 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.
Introduction: Cerebral Palsy (CP) is the commenest cause of physical disability in early childhood. Overall, the CP rate is between 2 and 3 per 1000 live births. SCPE is a network of CP surveys and registers, which extends across Europe. SCPE members have agreed on definition of CP and inclusion/exlusion criteria. To promote a shared understanding of the words and phrases used to describe the clinical, functional and neurological features of CP, a Reference and Training Manual (R&tm) has been developed.
Methods and Results: Text and video material illustrates neurological features: All CP subtypes have in common an abnormal pattern of movement and/or posture.
*Spastic CP is characterized in addition by increased tone, pathological reflexes (hyperreflexia and pyramydal signs).
*Dyskinetic CP by involuntary, uncontrolled, recurring, occasionally stereotyped movements; primitive reflex patterns predominate, muscle tone is varying.
*Ataxic CP by loss of orderly muscular coordination, so that movements are performed with abnormal force, rhythm and accuracy.
SCPE has also agreed on functional criteria (uses GMFCS, BFMF).
Examples of children with different subtypes of CP and children without CP are given.
Conclusion: The R&tm is an instrument of the SCPE to illustrate the definitions, agreed on within SCPE. It will be available also for health professionals outside the SCPE (e.g. for training purposes).
Keywords: cerebral palsy
Following agreement on definitions and classification, a central database was set up to include information on over 6000 children with cerebral palsy (CP) from 13 geographically defined populations in Europe. The overall rate for the period 1980 to 1990 was 2.08/1000 live births (95% CI 2.02 to 2.14). One in five children with CP (20.2%) was found to have a severe intellectual deficit and was unable to walk. Among babies born weighing less than 1500g, the rate of CP was more than 70 times higher compared with those weighing 2500g or more at birth. The rate of CP rose during the 1970s, but remained constant during the late 1980s. Future analyses will include data from children born in the 1990s. This collaborative work provides a powerful means of monitoring trends in birthweight-specific rates of CP and an infrastructure for research and service planning.
Interobserver reliability of the Surveillance of Cerebral Palsy in Europe algorithm for classification of cerebral palsy
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- C Van Der Kraats
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Gorter J, Van der Kraats C, Bulten R, Ketelaar M. Interobserver
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at the annual meeting of the European Academy of Childhood
Disability Oslo, Norway 2003.
The Reference and Training Manual (RTM) of the Surveillance of Cerebral Palsy in Europe (SCPE) – a video and text-based interactive CD-ROM. Invited speaker presentation at the annual meeting of the European Academy of Childhood Disability Oslo
- I Krageloh-Mann
- U Petruch
- M Gainsborough
Krageloh-Mann I, Petruch U, Gainsborough M, Cans C. The Reference and Training Manual (RTM) of the Surveillance of Cerebral Palsy in Europe (SCPE) – a video and text-based interactive CD-ROM. Invited speaker presentation at the annual meeting of the European Academy of Childhood Disability Oslo, Norway 2003. Validity of the SCPE Guidelines Mary Gainsborough et al. 831
Surveillance of Cerebral Palsy in Europe. Prevalence and characteristics of children with cerebral palsy in Europe
Surveillance of Cerebral Palsy in Europe. Prevalence and
characteristics of children with cerebral palsy in Europe. Dev
Med Child Neurol 2002; 44: 633-40.
The Reference and Training Manual (RTM) of the Surveillance of Cerebral Palsy in Europe (SCPE) -a video and text-based interactive CD-ROM
- I Krageloh-Mann
- U Petruch
- M Gainsborough
- C Cans
Krageloh-Mann I, Petruch U, Gainsborough M, Cans C. The
Reference and Training Manual (RTM) of the Surveillance
of Cerebral Palsy in Europe (SCPE) -a video and text-based
interactive CD-ROM. Invited speaker presentation at the annual
meeting of the European Academy of Childhood Disability
Oslo, Norway 2003.
Prevalence and characteristics of children with cerebral palsy in Europe
- Surveillance of Cerebral Palsy in Europe
Interobserver reliability of the Surveillance of Cerebral Palsy in Europe algorithm for classification of cerebral palsy. Poster presented at the annual meeting of the European Academy of Childhood Disability Oslo Norway
- Gorterj Van Der Kraatsc Bultenr Ketelaarm
The Reference and Training Manual (RTM) of the Surveillance of Cerebral Palsy in Europe (SCPE) - a video and text-based interactive CD-ROM
- Krageloh-Manni Petruchu Gainsboroughm Cansc