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ImportanceCerebral palsy (CP) is the most common childhood physical disability. Early intervention for children younger than 2 years with or at risk of CP is critical. Now that an evidence-based guideline for early accurate diagnosis of CP exists, there is a need to summarize effective, CP-specific early intervention and conduct new trials that harness plasticity to improve function and increase participation. Our recommendations apply primarily to children at high risk of CP or with a diagnosis of CP, aged 0 to 2 years.ObjectiveTo systematically review the best available evidence about CP-specific early interventions across 9 domains promoting motor function, cognitive skills, communication, eating and drinking, vision, sleep, managing muscle tone, musculoskeletal health, and parental support.Evidence reviewThe literature was systematically searched for the best available evidence for intervention for children aged 0 to 2 years at high risk of or with CP. Databases included CINAHL, Cochrane, Embase, MEDLINE, PsycInfo, and Scopus. Systematic reviews and randomized clinical trials (RCTs) were appraised by A Measurement Tool to Assess Systematic Reviews (AMSTAR) or Cochrane Risk of Bias tools. Recommendations were formed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and reported according to the Appraisal of Guidelines, Research, and Evaluation (AGREE) II instrument.FindingsSixteen systematic reviews and 27 RCTs met inclusion criteria. Quality varied. Three best-practice principles were supported for the 9 domains: (1) immediate referral for intervention after a diagnosis of high risk of CP, (2) building parental capacity for attachment, and (3) parental goal-setting at the commencement of intervention. Twenty-eight recommendations (24 for and 4 against) specific to the 9 domains are supported with key evidence: motor function (4 recommendations), cognitive skills (2), communication (7), eating and drinking (2), vision (4), sleep (7), tone (1), musculoskeletal health (2), and parent support (5).Conclusions and relevanceWhen a child meets the criteria of high risk of CP, intervention should start as soon as possible. Parents want an early diagnosis and treatment and support implementation as soon as possible. Early intervention builds on a critical developmental time for plasticity of developing systems. Referrals for intervention across the 9 domains should be specific as per recommendations in this guideline.

Background/Objectives: Early interventions for infants at high risk of cerebral palsy (CP) are recommended, but limited evidence exists. Our objective was, therefore, to evaluate the effects of the family-centered and interprofessional Small Step early intervention program on motor development in infants at high risk of CP (ClinicalTrials.gov: NCT03264339). Methods: A single-subject research design was employed to investigate participant characteristics (motor dysfunction severity measured using the Hammersmith Infant Neurological Examination (HINE) and Alberta Infant Motor Scale (AIMS) at three months of corrected age (3mCA) related to intervention response. The repeated measures Peabody Developmental Motor Scales-2 fine and gross motor composite (PDMS2-FMC and -GMC) and Hand Assessment for Infants (HAI) were analyzed visually by cumulative line graphs, while the Gross Motor Function Measure-66 (GMFM-66) was plotted against reference percentiles for various Gross Motor Function Classification System (GMFCS) levels. Results: All infants (n = 12) received the Small Step program, and eight completed all five training steps. At two years of corrected age (2yCA), nine children were diagnosed with CP. The children with the lowest HINE < 25 and/or AIMS ≤ 6 at 3mCA (n = 4) showed minor improvements during the program and were classified at GMFCS V 2yCA. Children with HINE = 25–40 (n = 5) improved their fine motor skills during the program, and four children had larger GMFM-66 improvements than expected according to the reference curves but that did not always happen during the mobility training steps. Three children with HINE = 41–50 and AIMS > 7 showed the largest improvements and were not diagnosed with CP 2yCA. Conclusions: Our results indicate that the Small Step program contributed to the children's motor development, with better results for those with an initial higher HINE (>25). The specificity of training could not be confirmed. [ABSTRACT FROM AUTHOR]

ImportanceCerebral palsy describes the most common physical disability in childhood and occurs in 1 in 500 live births. Historically, the diagnosis has been made between age 12 and 24 months but now can be made before 6 months' corrected age.ObjectivesTo systematically review best available evidence for early, accurate diagnosis of cerebral palsy and to summarize best available evidence about cerebral palsy-specific early intervention that should follow early diagnosis to optimize neuroplasticity and function.Evidence reviewThis study systematically searched the literature about early diagnosis of cerebral palsy in MEDLINE (1956-2016), EMBASE (1980-2016), CINAHL (1983-2016), and the Cochrane Library (1988-2016) and by hand searching. Search terms included cerebral palsy, diagnosis, detection, prediction, identification, predictive validity, accuracy, sensitivity, and specificity. The study included systematic reviews with or without meta-analyses, criteria of diagnostic accuracy, and evidence-based clinical guidelines. Findings are reported according to the PRISMA statement, and recommendations are reported according to the Appraisal of Guidelines, Research and Evaluation (AGREE) II instrument.FindingsSix systematic reviews and 2 evidence-based clinical guidelines met inclusion criteria. All included articles had high methodological Quality Assessment of Diagnostic Accuracy Studies (QUADAS) ratings. In infants, clinical signs and symptoms of cerebral palsy emerge and evolve before age 2 years; therefore, a combination of standardized tools should be used to predict risk in conjunction with clinical history. Before 5 months' corrected age, the most predictive tools for detecting risk are term-age magnetic resonance imaging (86%-89% sensitivity), the Prechtl Qualitative Assessment of General Movements (98% sensitivity), and the Hammersmith Infant Neurological Examination (90% sensitivity). After 5 months' corrected age, the most predictive tools for detecting risk are magnetic resonance imaging (86%-89% sensitivity) (where safe and feasible), the Hammersmith Infant Neurological Examination (90% sensitivity), and the Developmental Assessment of Young Children (83% C index). Topography and severity of cerebral palsy are more difficult to ascertain in infancy, and magnetic resonance imaging and the Hammersmith Infant Neurological Examination may be helpful in assisting clinical decisions. In high-income countries, 2 in 3 individuals with cerebral palsy will walk, 3 in 4 will talk, and 1 in 2 will have normal intelligence.Conclusions and relevanceEarly diagnosis begins with a medical history and involves using neuroimaging, standardized neurological, and standardized motor assessments that indicate congruent abnormal findings indicative of cerebral palsy. Clinicians should understand the importance of prompt referral to diagnostic-specific early intervention to optimize infant motor and cognitive plasticity, prevent secondary complications, and enhance caregiver well-being.

Background/Objectives: Recent guidelines on early intervention in children at high risk of cerebral palsy (CP) recommend parental involvement and family-centered home-based interventions with parents as primary trainers. Therapist coaching by home visitation is resource demanding, and telerehabilitation is a viable option for remote intervention and coaching. This study aims to describe parents' experiences of engaging in Baby-mCIMT coached remotely. Their infants are at high risk of unilateral cerebral palsy and the parents have been the primary trainers in regard to home-based intervention, optimizing the use of the affected hand. Methods: A qualitative approach involving semi-structured interviews with eight parents was employed. Data were analyzed using qualitative content analysis. Results: The overarching theme "Parents in the driver's seat—learning through remote coaching to create conditions to enhance the child's motor skills" describes parents' experiences as primary training providers. The following three underlying categories with subcategories were identified: (1) Baby-mCIMT coached remotely in an everyday context—practical and technical prerequisites; (2) the child's response and the therapists' coaching supports active parental learning; (3) capability and sense of control—strengthening and demanding aspects. Conclusions: Our findings revealed that Baby-mCIMT coached remotely empowered the parents as primary trainers, which provided them with opportunities for understanding and learning about their child and their development. The findings underscore the importance of responsive professional guidance and a strong therapist–parent relationship to succeed with the Baby-mCIMT program coached remotely and to manage the digital coaching format. [ABSTRACT FROM AUTHOR]

The aim was to evaluate the effect of Eco-CIMT in young children with unilateral cerebral palsy in a randomized controlled crossover design. The training was implemented within the regular pediatric services, provided by the child's parents and/or preschool teacher and supervised by the child's regular therapist. Methods: Twenty-five children (mean age 28.8 months [SD 11.2], 72% male) participated. Assisting Hand Assessment (AHA) was used as the outcome measure. The Eco-CIMT was provided for 2 h a day over a period of two months. Children were randomized into two groups and started either with Eco-CIMT or as controls with a four-month washout period before crossing over. Result: A significant effect of Eco-CIMT was found when compared to the control period, and the estimated treatment effect was 5.47 (95% C.I. 2.93-8.02) (including both Group 1 and Group 2) (p less than 0.001). The non-significant estimated carryover effect allowed us to collapse the two groups based on estimates from the ANOVA model. No clear relationship to hours of training, age or general attitudes of mastery was found. Conclusion: Eco-CIMT influenced development more than ordinary treatment at this age when Eco-CIMT was performed by parents and preschool teachers supervised by the child's ordinary therapist. (Contains 3 figures and 3 tables.)

Aim: To relate visual field function to brain morphology in children with unilateral cerebral palsy (CP). Method: Visual field function was assessed using the confrontation technique and Goldmann perimetry in 29 children (15 males, 14 females; age range 7-17y, median age 11y) with unilateral CP classified at Gross Motor Function Classification System (GMFCS) level I and Manual Ability Classification System levels I to III. The type and extent of brain lesions were determined using cerebral imaging. Results: Eighteen children had subnormal visual field function. The visual fields were severely restricted in six. The underlying brain lesions were malformation (n=7), white matter damage of immaturity (WMDI; n=13), and cortical-subcortical lesions (n=9). Visual field function could be correlated with the pattern of brain damage in children with cortical-subcortical lesions or extensive lesions caused by malformation or WMDI. Total homonymous hemianopia was common in the cortical-subcortical group but rare in children with malformation or WMDI. Five children had normal visual field function despite having malformation or WMDI involving parts of the brain usually encompassing the visual system. Interpretation: Visual field function may be preserved by plasticity of the immature brain in children with malformation and WMDI. Severely restricted visual fields were more often associated with lesions occurring later in the developing brain. All children with severely restricted visual fields were identified by the confrontation technique. Goldmann perimetry was a suitable method to identify relative visual field defects.

Aim: To examine the stability of caregiver-reported classifications of function of children with cerebral palsy (CP) measured 12 months apart. Method: Participants were 86 children (50 males, 36 females) with CP of all motor types and severities who were recruited into a population-based longitudinal study. Children were aged 11 years 8 months (SD 6mo) on the first assessment and 12 years 8 months (SD 6mo) on the second assessment. Data were gathered through a postal survey. Caregivers reported on the Manual Ability Classification System (MACS), the Gross Motor Function Classification System (GMFCS), and other demographic characteristics. The percentage absolute agreement and the intraclass coefficient correlation (ICC) equivalent of the weighted kappa were calculated to assess consistency between assessments for the MACS and GMFCS. We also examined associations between changes in classification and background variables. Results: Fifty-eight caregivers (67%) classified their child at the same MACS level on both assessments (ICC 0.92; 95% confidence interval [CI] 0.87-0.95), whereas 79% did so with the GMFCS (ICC 0.95; 95% CI 0.92-0.96). The evidence suggests that caregivers who were not born in Australia or who spoke a language other than English in the home were more likely to classify their child differently on the MACS at the second assessment, although this was not evident for the GMFCS. Interpretation: Caregiver-reported MACS and GMFCS levels were generally stable over 12 months.

The objective of the study was to investigate the feasibility of modified constraint-induced (CI) therapy provided in a 2-week day-camp model with and without intramuscular botulinum toxin type A (BoNT-A) injections for children with congenital cerebral palsy. Sixteen children with congenital hemiplegia, Manual Ability Classification System (MACS) level I and II, aged 8-17 years, participated in a CI therapy day camp; of whom five participants (aged 11-16 years) received intramuscular BoNT-A prior to CI therapy. Assessments were conducted 4 months and 2 weeks before (baselines 1 and 2), immediately after, and 6 months after the day camp. For the children who received BoNT-A, no statistical analyses were conducted due to the small size of the sample. In this group, consistent improvement was only found according to the Melbourne Unilateral Limb Assessment. The children who received only the CI therapy demonstrated improvements in the Jebsen-Taylor Hand Function Test (p = 0.04) at posttest, but improvements were not sustained at 6-month follow-up. No significant improvement was obtained for the Melbourne Assessment or the Assisting Hand Assessment. Children in both groups improved on specially trained tasks: frisbee golf, stacking blocks, and in-hand manipulation. Feedback from the participants suggests that the day-camp model is a feasible intervention following intramuscular BoNT-A injections. The results suggest that children with congenital hemiplegia with varying severity of impairment in hand function may benefit from CI therapy, but not every child demonstrates improvements in hand function. The characteristics of children who respond the best to CI therapy are not clear. (Contains 3 tables and 5 figures.)

Background: Validity of the Ugandan version of the Pediatric Evaluation of Disability Inventory (PEDI‐UG) was previously investigated on typically developing children. This study aimed to investigate the validity, test–retest reliability and minimal detectable change (MDC) of the PEDI‐UG in children and youth (C&Y) with cerebral palsy (CP). Method: A cross‐sectional study design with 118 C&Y with CP (44.7% girls) aged 10 months–22.5 years were included in the study; 37 of them completed the PEDI‐UG twice to investigate test–retest reliability, determined by calculating the intraclass correlation coefficient (ICC). Additionally, data from 249 typically developing children were used for differential item functioning (DIF) analysis. The validity of the PEDI‐UG was investigated by Rasch analysis. The Kruskal–Wallis test and Spearman's correlation coefficient were calculated to investigate associations between PEDI‐UG scores and external classification systems. Results: The principal component analysis of residuals indicated unidimensionality in all domains. The ICC values were excellent (0.98–0.99), and the MDCs were less than 6 and 13 (on a 0–100 scale) for the functional skills and caregiver assistance parts, respectively. The four‐category caregiver assistance rating scale fulfilled the criteria for the analysis of rating scale functioning. In total, 78 of 189 items in the functional skills domain and two items in the caregiver assistance domain demonstrated DIF between C&Y with CP and TD children. The Kruskal–Wallis test (p < 0.05) and Spearman's correlation (coefficients of −0.93 to −0.78) supported the validity of PEDI‐UG. Conclusion: The current diagnose‐specific version of PEDI‐UG demonstrates evidence for validity as a measure of ability in C&Y with CP in Uganda and other similar settings, being a promising tool for use in clinical practice and research. Conversion tables and MDC values are provided to facilitate clinical adoption of the measure. [ABSTRACT FROM AUTHOR]

Aim: To describe the development of the use of the affected hand in bimanual tasks in children with unilateral cerebral palsy (CP) from 18 months to 18 years. Specifically, whether early development can be confirmed in a larger cohort and how development progresses during adolescence. Method: In total, 171 participants (95 males, 76 females; mean age 3 years 1 month [SD 3 years 8 months], range 18 months–16 years at inclusion) were classified in Manual Ability Classification System (MACS) levels I (n = 41), II (n = 91), and III (n = 39). Children were assessed repeatedly (median 7, range 2–16 times) with the Assisting Hand Assessment: in total 1197 assessments. Developmental trajectories were estimated using a nonlinear mixed effects model. To further analyse the adolescent period, a linear mixed model was applied. Results: The developmental trajectories were different between participants in MACS levels (MACS I–II, II–III) in both rate (0.019, 95% confidence interval [CI] 0.006–0.031, p = 0.034; 0.025, 95% CI 0.015–0.037, p < 0.001) and limit (19.9, 95% CI 16.6–23.3, p = 0.001; 7.2, 95% CI 3.3–11.2, p < 0.003). The individual variations were large within each level. The developmental trajectories were stable over time for all MACS levels between 7 and 18 years (p > 0.05). Interpretation: Children and adolescents with unilateral CP have considerable development at an early age and a stable ability to use their affected hand in bimanual activities from 7 to 18 years in all MACS levels. [ABSTRACT FROM AUTHOR]

Aim: To compare the participation attendance and involvement of children and young people with and without cerebral palsy (CP) in a low‐resource area of Uganda. Method: Eighty‐two children and young people with CP aged 6 to 22 years (49 males, 33 females) and 81 age‐ and sex‐matched peers without CP (6 to 22 years; 48 males, 33 females) participated in this population‐based, cross‐sectional study. Data on attendance and involvement in 20 home and community activities were obtained using Picture My Participation, an instrument intended to measure participation in children with disabilities, particularly in low‐ and middle‐income countries. Non‐parametric statistical methods were used to assess between‐group differences. Effect size estimates were calculated. Results: Pooled attendance across all activities was lower in children and young people with CP than in children and young people without CP (p < 0.001) and for each activity item (p = 0.004 to p < 0.001). The effect sizes for each activity were 0.2 to 0.7. Between‐group differences were larger for community activities than for home activities. Pooled involvement across all activities was less in the group with CP (p < 0.001) and for each activity (p = 0.014 to p < 0.001). The effect sizes for each activity were 0.2 to 0.5. Children and young people in Gross Motor Function Classification System (GMFCS) levels I and II had higher attendance (p < 0.001) and involvement (p = 0.023) than those in GMFCS levels III to V. Interpretation: Participation of young people living with CP in Uganda was restricted, especially for community activities. There is a need to identify context‐specific participation barriers and develop strategies to overcome them. What this paper adds: Children and young people with cerebral palsy (CP) attended all activities less than their peers without CP.Differences in attendance were larger for community‐based activities than home activities.When attending activities, children and young people with CP were less involved than their peers.Children and young people with milder impairments attended less frequently than their peers without CP.Children and young people with milder impairments attended more frequently than their peers with severe impairments. [ABSTRACT FROM AUTHOR]