Interrater reliability study of cerebral palsy diagnosis, neurological subtype, and gross motor function

Prevalence, Clinical Features, Neuroimaging, and Genetic Findings in Children With Ataxic Cerebral Palsy in Europe

BACKGROUND AND OBJECTIVES

To report on prevalence, associated impairments, severity, and neuroimaging findings in children with ataxic cerebral palsy (CP).

METHODS

In children coded as having ataxic CP in the Central database of Joint Research Center-Surveillance of Cerebral Palsy in Europe (JRC-SCPE) and born during 1980-2010, birth characteristics, severity profiles including associated impairments, neuroimaging patterns, and the presence of syndromes were analyzed. Definitions were according to validated SCPE guidelines. Prevalence over time was estimated using Poisson regression.

RESULTS

In total, 679 children with ataxic CP were identified in 20 European CP registers. The proportion with ataxic CP was 3.8% and varied from 0% to 12.9%. Prevalence over time showed no significant trend. Approximately 70% of children with ataxic CP were able to walk, and 40% had severe intellectual impairment and a high impairment index. Children with ataxic CP were mostly born at term (79%) and with normal birth weight (77%). Neuroimaging patterns revealed normal findings in 29%, brain maldevelopments in 28.5%, miscellaneous findings in 23.5%, and brain injuries in 19%, according to the SCPE classification. Genetic syndromes were described in 9%.

DISCUSSION

This register-based multicenter study on children with ataxic CP provides a large sample size for the analysis of prevalence, severity, and origin of this rare CP subtype. Even with strict inclusion and classification criteria, there is variation between registers on how to deal with this subtype, and diagnosis of ataxic CP remains a challenge. Ataxic cerebral palsy differs from other CP subtypes: children with ataxic CP have a disability profile that is more pronounced in terms of cognitive than gross motor dysfunction. They are mostly term born and the origin rarely suggests acquired injuries. In addition to neuroimaging, a comprehensive genetic workup is particularly recommended for children with this CP type.

Prevalence of cerebral palsy and factors associated with cerebral palsy subtype: A population-based study in Belgium

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.

Public health indicators for cerebral palsy: A European collaborative study of the Surveillance of Cerebral Palsy in Europe network

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.

Muscle architecture, growth, and biological Remodelling in cerebral palsy: a narrative review

Cerebral palsy (CP) is caused by a static lesion to the brain occurring in utero or up to the first 2 years of life; it often manifests as musculoskeletal impairments and movement disorders including spasticity and contractures. Variable manifestation of the pathology across individuals, coupled with differing mechanics and treatments, leads to a heterogeneous collection of clinical phenotypes that affect muscles and individuals differently. Growth of muscles in CP deviates from typical development, evident as early as 15 months of age. Muscles in CP may be reduced in volume by as much as 40%, may be shorter in length, present longer tendons, and may have fewer sarcomeres in series that are overstretched compared to typical. Macroscale and functional deficits are likely mediated by dysfunction at the cellular level, which manifests as impaired growth. Within muscle fibres, satellite cells are decreased by as much as 40–70% and the regenerative capacity of remaining satellite cells appears compromised. Impaired muscle regeneration in CP is coupled with extracellular matrix expansion and increased pro-inflammatory gene expression; resultant muscles are smaller, stiffer, and weaker than typical muscle. These differences may contribute to individuals with CP participating in less physical activity, thus decreasing opportunities for mechanical loading, commencing a vicious cycle of muscle disuse and secondary sarcopenia. This narrative review describes the effects of CP on skeletal muscles encompassing substantive changes from whole muscle function to cell-level effects and the effects of common treatments. We discuss growth and mechanics of skeletal muscles in CP and propose areas where future work is needed to understand these interactions, particularly the link between neural insult and cell-level manifestation of CP.

Trends in Prevalence and Severity of Pre/Perinatal Cerebral Palsy Among Children Born Preterm From 2004 to 2010: A SCPE Collaboration Study

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.

Recommendations for the design of therapeutic trials for neonatal seizures

Although seizures have a higher incidence in neonates than any other age group and are associated with significant mortality and neurodevelopmental disability, treatment is largely guided by physician preference and tradition, due to a lack of data from well-designed clinical trials. There is increasing interest in conducting trials of novel drugs to treat neonatal seizures, but the unique characteristics of this disorder and patient population require special consideration with regard to trial design. The Critical Path Institute formed a global working group of experts and key stakeholders from academia, the pharmaceutical industry, regulatory agencies, neonatal nurse associations, and patient advocacy groups to develop consensus recommendations for design of clinical trials to treat neonatal seizures. The broad expertise and perspectives of this group were invaluable in developing recommendations addressing: (1) use of neonate-specific adaptive trial designs, (2) inclusion/exclusion criteria, (3) stratification and randomization, (4) statistical analysis, (5) safety monitoring, and (6) definitions of important outcomes. The guidelines are based on available literature and expert consensus, pharmacokinetic analyses, ethical considerations, and parental concerns. These recommendations will ultimately facilitate development of a Master Protocol and design of efficient and successful drug trials to improve the treatment and outcome for this highly vulnerable population.

Socioeconomic Status Influences Functional Severity of Untreated Cerebral Palsy in Nepal: A Prospective Analysis and Systematic Review

BACKGROUND

Cerebral palsy (CP) comprises a heterogeneous group of disorders whose clinical manifestations and epidemiologic characteristics vary across socioeconomic and geographic contexts. The functional severity of untreated CP in low-income countries has been insufficiently studied; a better understanding of how these children present for care in resource-constrained environments is important because it will better characterize the natural history of CP, guide clinical decision-making, and aid in the prognostication of children with untreated CP.

QUESTIONS/PURPOSES

The purposes of this study were (1) to determine the etiologies, motor subtypes, topographic distributions, and functional classifications of a large cohort of Nepali children with untreated CP presenting to a large pediatric rehabilitation center in Nepal; and (2) to compare the Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MACS), and the Communication Function Classification System (CFCS) scores of a subset of patients with spastic CP in the Nepali cohort with control subjects from high-income countries.

METHODS

A cross-sectional study was conducted at the Hospital and Rehabilitation Centre for Disabled Children in Nepal. Two hundred six consecutive Nepali children (76 girls; median age 4.0 years [interquartile range {IQR}, 2.5-9.0 years]) were evaluated to determine the demographic, clinical, and functional characteristics of a cohort of Nepali children with untreated CP. A systematic review of the Medline and Cochrane databases was then performed to obtain reference classification scores from high-income countries. Cross-sectional, noninterventional studies reporting at least one functional classification system with a sample size of at least 50 participants were included. Only studies of patients with spastic CP were included to allow for compatible comparisons with a subset of our study sample with spastic CP. A random-effects analysis was used to pool functional scores from participants in the included studies. Among the 206 children in our sample, 102 had spastic CP (35 girls; median age 5.5 years [IQR, 3.5-9.0 years]). Functional scores from these children were compared with pooled scores obtained from the systematic review by assessing the proportions of children in each sample with GMFCS, MACS, and CFCS score categories of I or II versus III to V.

RESULTS

Children with spastic hemiplegia from high-income countries were more likely to have a GMFCS score of I or II (96% [95% confidence interval {CI}, 92%-99%] versus 78% [95% CI, 62%-89%]) and a MACS score of I or II (83% [95% CI, 77%-88%] versus 50% [95% CI, 32%-68%]) relative to those from Nepal, but they were less likely to have a CFCS score of I or II (67% [95% CI, 51%-80%] versus 97% [95% CI, 87%-99%]). No differences were seen in children with spastic diplegia or quadriplegia.

CONCLUSIONS

Children in Nepal with hemiplegic CP display less difficulty in communicating and social engagement (CFCS) despite more-severe upper- and lower-extremity impairments in gross motor function (GMFCS) and manual ability (MACS) than do children with hemiplegic CP from high-income countries. Targeted interventions, including perhaps simple orthopaedic interventions to treat soft-tissue contractures, may therefore provide more-substantial improvements in function and quality of life to Nepali children than could be achieved for the same deployment of resources in more-affluent settings.

LEVEL OF EVIDENCE

Level II, prognostic study.

Cerebral palsy in Moldova: subtypes, severity and associated impairments

BACKGROUND

Moldova is ranked as one of the countries in Europe with the lowest income per capita and with a relatively high infant and maternal mortality rate. Information on neurodisabilities in general is limited, and regarding cerebral palsy (CP) in particular, it is completely lacking. The aim of this study was therefore to make a crude estimate of the prevalence of CP and to describe subtypes and the severity of motor impairments and associated problems in this country.

METHODS

Children with CP born 2009-2010, attending the National Hospital Institute of Mother and Child, the reference hospital for ~ 75% of children in Moldova with neurological disabilities, were identified from medical records.

RESULTS

Among 207 children with CP (estimated prevalence 3.4 per 1000 live births), 185 (mean age 7.3 years; 36% girls) had detailed information. Thirty seven (20%) children had spastic unilateral, 113 (61%) spastic bilateral, 22 (12%) dyskinetic and 9 (5%) children had ataxic CP. The subtype was unclassified in four children. Among all children, 93 (51%) had epilepsy, 109 (59%) intellectual disability, 42 (23%) severe vision and 10 (5%) hearing impairments while 84 (45%) children had severe speech impairments. Fifty-two (28%) children were born prematurely, and 46 (25%) had Apgar scores below 7 at five minutes.

CONCLUSION

Compared to other European studies, the distribution of CP subtypes was different in Moldova. Moreover, the estimated prevalence, the proportions with severe motor and associated impairments and of children born at term were higher in Moldova while the proportion with low Apgar did not differ. The findings may suggest different etiological pathways causing CP in Moldova than in other European countries. A national register is warranted for quality assurance and improvement.

Subgrouping children with cerebral palsy from a broader perspective using two methods

The purpose was to develop two versions of a body function index in cerebral palsy (BFI-CP I and BFI-CP II) using two methods to explore the relationship and differences among them and the Gross Motor Function Classification System (GMFCS) and to explore the differences among subsets of the classifications that do not correspond to the ordinal levels of the GMFCS. Data on various measures from 405 children with CP between 18 months and 5 years of age were extracted from the Move & PLAY Study. The BFI-CP I was developed using a summing technique and the BFI-CP II was developed using cluster analysis. There was a strong correlation between the BFI-CP I and the GMFCS (r = 0.92), between the BFI-CP II and the GMFCS (r = 0.93), and between the BFI-CP I and II (r = 0.92) all (p < 0.001). There was also a significant difference between the BFI-CP I and the GMFCS (χ² = 670.49, df = 16, p < 0.001) and between the BFI-CP II and the GMFCS (χ² = 685.57, df = 16, p < 0.001). The findings of this study indicate that the two versions of the BFI-CP could be used as complementary methods in describing children with CP.

Identification and measurement of dystonia in cerebral palsy

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.

WHAT THIS PAPER ADDS

Dystonia is readily identified in cerebral palsy (CP) using the Hypertonia Assessment Tool, regardless of the predominant motor type. Spasticity and dystonia frequently coexist in the CP population. Severity of dystonia is inversely related to motor function.

Spasticity, dyskinesia and ataxia in cerebral palsy: Are we sure we can differentiate them?

OBJECTIVE

Cerebral palsy (CP) can be classified as spastic, dyskinetic, ataxic or combined. Correct classification is essential for symptom-targeted treatment. This study aimed to investigate agreement among professionals on the phenotype of children with CP based on standardized videos.

METHODS

In a prospective, observational pilot study, videos of fifteen CP patients (8 boys, mean age 11 ± 5 y) were rated by three pediatric neurologists, three rehabilitation physicians and three movement disorder specialists. They scored the presence and severity of spasticity, ataxia or dyskinesias/dystonia. Inter- and intraobserver agreement were calculated using Cohen's and Fleiss' kappa.

RESULTS

We found a fair inter-observer (κ = 0.36) and moderate intra-observer agreement (κ = 0.51) for the predominant motor symptom. This only slightly differed within the three groups of specialists (κ = 0.33-0.55).

CONCLUSION

A large variability in the phenotyping of CP children was detected, not only between but also within clinicians, calling for a discussing on the operational definitions of spasticity, dystonia and ataxia. In addition, the low agreement found in our study questions the reliability of use of videos to measure intervention outcomes, such as deep brain stimulation in dystonic CP. Future studies should include functional domains to assess the true impact of management options in this highly challenging patient population.

Perspectives on classification of selected childhood neurodisabilities based on a review of literature

PURPOSE

Classifying children with heterogeneous health conditions is challenging. The purposes of this perspective are to explore the prevailing classifications in children with the three selected neurodisabilities using the underlying framework of ICF/ICF-CY, explore the utility of the identified classifications, and make recommendations aimed at improving classifications.

METHODS

A literature search on six databases and Google was conducted. Articles published between the years 2000 and 2013 were included if they provided information on classification of cerebral palsy (CP), and/or developmental coordination disorder (DCD) and/or autism spectrum disorders (ASD).

RESULTS

Children with DCD and ASD are classified using combinations of multiple measures. The classifications in CP meet more of the proposed criteria for utility than those in DCD and ASD.

CONCLUSION

None of the existing classifications addressed all the criteria. The heterogeneity associated with the selected neurodisabilities poses major challenges. Further work is required to establish improved classifications.

MRI classification system (MRICS) for children with cerebral palsy: development, reliability, and recommendations

AIM

To develop and evaluate a classification system for magnetic resonance imaging (MRI) findings of children with cerebral palsy (CP) that can be used in CP registers.

METHOD

The classification system was based on pathogenic patterns occurring in different periods of brain development. The MRI classification system (MRICS) consists of five main groups: maldevelopments, predominant white matter injury, predominant grey matter injury, miscellaneous, and normal findings. A detailed manual for the descriptions of these patterns was developed, including test cases (www.scpenetwork.eu/en/my-scpe/rtm/neuroimaging/cp-neuroimaging/). A literature review was performed and MRICS was compared with other classification systems. An exercise was carried out to check applicability and interrater reliability. Professionals working with children with CP or in CP registers were invited to participate in the exercise and chose to classify either 18 MRIs or MRI reports of children with CP.

RESULTS

Classification systems in the literature were compatible with MRICS and harmonization possible. Interrater reliability was found to be good overall (k=0.69; 0.54-0.82) among the 41 participants and very good (k=0.81; 0.74-0.92) using the classification based on imaging reports.

INTERPRETATION

Surveillance of Cerebral Palsy in Europe (SCPE) proposes the MRICS as a reliable tool. Together with its manual it is simple to apply for CP registers.

Classifying cerebral palsy: are we nearly there?

BACKGROUND

Cerebral palsy (CP) is the most common cause of physical disability in childhood in developed countries and encompasses a wide range of clinical phenotypes. Classification of CP according to movement disorder or topographical distribution is widely used. However, these classifications are not reliable nor do they accurately predict musculoskeletal pathology. More recently, the Gross Motor Function Classification System (GMFCS) has been introduced and its validity, reliability, and clinical utility have been confirmed. In 2005 it was suggested that children should be described and classified according to the GMFCS in all outcome studies involving children with CP, in the Journal of Pediatric Orthopaedics (JPO). This study aimed to describe utilization of the GMFCS in 3 journals: Journal of Bone and Joint Surgery (JBJS Am), JPO, and Developmental Medicine and Child Neurology (DMCN), over a 7-year period (2005 to 2011), and any relationship to the journal's impact factor. A secondary aim was to establish if differences in methodological quality existed between those studies utilizing GMFCS and those that did not.

METHODS

A targeted literature search of the 3 selected journals using the term "cerebral palsy" was conducted using the Medline database. Utilization of the GMFCS was assessed using report of these data in the methods or results section of the retrieved papers. The Methodological Index for Non-Randomized Studies (MINORS) was employed to evaluate the quality of papers published in JPO.

RESULTS

One hundred and fifty-four studies met the inclusion criteria and in 85 (68%) the GMFCS was used. Of these, 112 were published in JPO, of which 51 (46%) utilized the GMFCS, compared with 72% for JBJS Am, and 88% for DMCN. In the JPO, utilization of the GMFCS improved from 13% to 80%, over the 7-year study period.

CONCLUSIONS

Utilization of the GMFCS has increased rapidly over the past 7 years in the JPO but there is room for further improvement.

LEVEL OF EVIDENCE

Not applicable.

MRI-based radiologic scoring system for extent of brain injury in children with hemiplegia

BACKGROUND AND PURPOSE

Brain MR imaging is recommended in children with cerebral palsy. Descriptions of MR imaging findings lack uniformity, due to the absence of a validated quantitative approach. We developed a quantitative scoring method for brain injury based on anatomic MR imaging and examined the reliability and validity in correlation to motor function in children with hemiplegia.

MATERIALS AND METHODS

Twenty-seven children with hemiplegia underwent MR imaging (T1, T2-weighted sequences, DTI) and motor assessment (Manual Ability Classification System, Gross Motor Functional Classification System, Assisting Hand Assessment, Jebsen Taylor Test of Hand Function, and Children's Hand Experience Questionnaire). A scoring system devised in our center was applied to all scans. Radiologic score covered 4 domains: number of affected lobes, volume and type of white matter injury, extent of gray matter damage, and major white matter tract injury. Inter- and intrarater reliability was evaluated and the relationship between radiologic score and motor assessments determined.

RESULTS

Mean total radiologic score was 11.3 ± 4.5 (range 4-18). Good inter- (ρ = 0.909, P < .001) and intrarater (ρ = 0.926, P = < .001) reliability was demonstrated. Radiologic score correlated significantly with manual ability classification systems (ρ = 0.708, P < .001), and with motor assessments (assisting hand assessment [ρ = -0.753, P < .001]; Jebsen Taylor test of hand function [ρ = 0. 766, P < .001]; children's hand experience questionnaire [ρ = -0. 716, P < .001]), as well as with DTI parameters.

CONCLUSIONS

We present a novel MR imaging-based scoring system that demonstrated high inter- and intrarater reliability and significant associations with manual ability classification systems and motor evaluations. This score provides a standardized radiologic assessment of brain injury extent in hemiplegic patients with predominantly unilateral injury, allowing comparison between groups, and providing an additional tool for counseling families.

Determinants of Developmental Gain in Daily Activities in Young Children with Cerebral Palsy

ABSTRACT The aim of this study was to examine which child and family characteristics at the child's age of 2 years are determinants of development of self-care and mobility activities over a period of 2 years in young children with cerebral palsy (CP). Longitudinal data of 92 children, representing all levels of the Gross Motor Function Classification System (GMFCS), were analyzed. Children's self-care and mobility activities were assessed with the Functional Skills Scale of the Pediatric Evaluation of Disability Inventory. Development of self-care and mobility activities was related to several child determinants but no family determinants. GMFCS, type of CP, intellectual capacity, and epilepsy were related to the development of self-care and mobility activities, while manual ability and spasticity were related to development of mobility activities. Multivariate analysis indicated that GMFCS and intellectual capacity were the strongest determinants of development of self-care activities, and GMFCS was the strongest determinant of development of mobility activities. The change in self-care and mobility activities was less favorable in severely affected children with severe disability. Knowledge of GMFCS level and intellectual capacity is important in anticipating change over time and goal setting in young children with CP.

The cerebral palsy transition clinic: administrative chore, clinical responsibility, or opportunity for audit and clinical research?

PURPOSE

The majority of children with orthopaedic conditions in childhood survive to adult life, and there is a need for many of them to transition to adult services. This includes children with disorders such as club foot or developmental dislocation of the hip as well as those with complex syndromic conditions, bone dysplasias or neuromuscular disorders such as cerebral palsy and myelomeningocele. In many tertiary paediatric centres, transition has become a formal process in which clinicians document and communicate the status of patients who have been under their care to ensure a smooth transfer to adult services. The purpose of this report is to support the need for clear communication when children with cerebral palsy transition to adult services and to suggest that this transition represents a significant opportunity for audit and clinical research.

METHODS

Some of the factors to be considered in developing a minimum data sheet for the transfer or transition of children with cerebral palsy to adult services are described.

CONCLUSION

Using the model of adolescents with cerebral palsy transitioning to adult services, orthopaedic surgeons can be encouraged to develop similar methodology and documentation for many other conditions for the purposes of communication, facilitation of transition, audit and clinical research.

What constitutes cerebral palsy in the twenty-first century?

AIM

Determining inclusion/exclusion criteria for cerebral palsy (CP) surveillance is challenging. The aims of this paper were to (1) define inclusion/exclusion criteria that have been adopted uniformly by surveillance programmes and identify where consensus is still elusive, and (2) provide an updated list of the consensus concerning CP inclusion/exclusion when a syndrome/disorder is diagnosed.

METHOD

Data were drawn from an international survey of CP registers, the New South Wales CP Register (1993-2003), the Western Australian CP Register (1975-2008), and the Surveillance of CP in Europe (SCPE; 1976-1998). An expert panel used a consensus building technique, which utilized the SCPE 'decision tree' and the original 'What constitutes cerebral palsy?' paper as frameworks.

RESULTS

CP surveillance programmes agree on key clinical criteria pertaining to the type, severity, and origin of motor disorder in CP. Further work is warranted to reach agreement for (1) minimum age of survival and maximum age of postneonatal brain injury, and (2) metabolic disorders with highly variable clinical courses/responses to treatment. One hundred and ninety-seven syndromes/disorders were reviewed and advice on their inclusion/exclusion is provided.

INTERPRETATION

What constitutes CP will continue to evolve as diagnostics improve. Surveillance programmes throughout the world are committed to addressing their differences regarding inclusion/exclusion criteria for the umbrella term CP.

Reliable classification of functional profiles and movement disorders of children with cerebral palsy

OBJECTIVE

To examine the inter-rater reliability of the Communication Function Classification System (CFCS), Bimanual Fine Motor Function (BFMF), Surveillance of Cerebral Palsy in Europe (SCPE) classification tree, and Gross Motor Function Classification System (GMFCS) in children with cerebral palsy (CP) and periventricular white matter injury (PWMI) aged 4-11 years.

METHOD

Twenty children were assessed by two raters using the four tools, in addition parents undertook ratings on the Manual Ability Classification System (MACS). Kappa statistics were used to calculate the level of agreement between raters' classifications.

RESULTS

Participants comprised 12 males and 8 females with CP and PWMI, mean age 8 years 1 month (standard deviation 2 years 3 months). Inter-rater reliability across the four tools was 0.98 (CFCS, BFMF, and GMFCS) and 0.84 (SCPE).

IMPLICATIONS

These findings suggest that these four tools are reasonably robust to inter-rater variability supporting their routine use along with the MACS in clinical and research applications.

Sex differences in cerebral palsy incidence and functional ability: a total population study

AIM

To describe gender difference in a total population of children with cerebral palsy (CP), related to subtype, gross and fine motor function, and to compare CP incidence trends in girls and boys.

METHODS

All 590 children with CP born in southern Sweden 1990-2005 were included. CP subtype was classified according to the Surveillance of Cerebral Palsy in Europe, gross motor function according to Gross Motor Function Classification System (GMFCS) and manual ability according to Manual Ability Classification System (MACS). Trends in CP incidence by birth year were analysed using Poisson regression modelling.

RESULTS

There was a male predominance in all levels of GMFCS except level II, in all levels of MACS and in all CP subtypes except ataxic CP. There was no statistically significant difference between males and females regarding gross motor function or manual ability. The CP incidence trends in boys compared with girls did not change during the period 1990-2005.

CONCLUSION

No equalization was detected in the incidence of CP between girls and boys during recent years in this total population. We could not confirm any consistent sex difference in motor function levels. Male sex is a risk factor for CP.

Trends in prevalence and characteristics of post-neonatal cerebral palsy cases: a European registry-based study

The present paper aims to analyze trends over time in prevalence of cerebral palsy of post-neonatal origin, to investigate whether changes are similar according to severity and to describe the disability profile by etiology. Post-neonatal cases, birth years 1976 to 1998, were identified from the Surveillance of Cerebral Palsy in Europe collaboration (19 population-based registries). A recognized causal event occurring between 28 days and 24 months of age was considered to define the cases. Trends in prevalence were explored using graphical methods (Lowess and Cusum control chart) and modeled with negative binomial regressions. Over the study period, 404 cases were identified as post-neonatal cases (5.5% of the total). Mean prevalence rate was 1.20 per 10,000 live births (95% CI [1.08-1.31]). A significant downward trend was observed (p=0.001), with an accentuated decrease in the 1990 s. The prevalence of severe cases which account for around one third of the total also significantly decreased over time (p<0.001). In 46% of cases, an infectious aetiology was reported; the corresponding prevalence significantly decreased since 1989. No significant decrease was observed for the rate of cases due to a vascular episode or of traumatic origin. Our results emphasize the need of large population-based surveillance systems to reliably monitor trends in prevalence in rare subgroups of children like those with acquired cerebral palsy. The decrease of the overall prevalence as well as those of the most severe cases may be partly due to public health actions targeted to prevent such events.