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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.

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.

Aim: To create a shortened, more user‐friendly Second Edition of the Dyskinesia Impairment Scale (DIS‐II) to assess dystonia and choreoathetosis, and evaluate its construct validity and reliability. Method: Scale development included an online expert meeting (n = 21) and iterative discussions within the research group (n = 6). A Rasch measurement model analysis on DIS scores from individuals with dyskinetic cerebral palsy or inherited/idiopathic dystonia (n = 123, 74 males, mean age 14 years, SD 5 years) was performed to evaluate the construct validity and reliability of the DIS‐II. Results: The DIS‐II evaluates dystonia and choreoathetosis in action and rest in 11 body regions, with action items scored from 0 to 3 and rest items 0 to 2. The number of videos to record are reduced from 26 to 14 and the items to score are reduced from 144 to 88. Rating scale functioning, goodness‐of‐fit evaluation, principal component analysis, and targeting met the predefined quality criteria of the study and construct validity was therefore considered good. Furthermore, person reliability indicated that the DIS‐II can separate individuals into eight distinct ability levels. Interpretation: The DIS‐II provides valid and reliable measures for dystonia and choreoathetosis, and reduces the administration and scoring time compared with the DIS. The DIS‐II logit scores (interval level data) enhance comparison over time and between individuals in clinical practice and research. What this paper adds: Compared with the Dyskinesia Impairment Scale (DIS), the shortened edition (DIS‐II) requires half of the number of videos to be scored.The DIS‐II has a simplified rating scale, requiring scoring of 88 instead of 144 items.The DIS‐II has shown excellent reliability and good construct validity.The interval properties of the DIS‐II are superior to the ordinal level outcome measures of the DIS. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to describe how the usefulness of the hemiplegic hand develops in children with unilateral cerebral palsy (CP) aged between 18 months and 8 years. Method: A prospective longitudinal study of 43 children (22 males, 21 females) with unilateral CP was conducted. Inclusion age was 18 months to 5 years 4 months (mean 2y 8mo [SD 1y 1mo]). Children were assessed with the Assisting Hand Assessment (AHA) 3 to 11 times per child over a mean period of 4 years 6 months. Two models were used for grouping children: by AHA score at 18 months and by Manual Ability Classification System (MACS) levels. Estimated average motor development curves were fitted with a nonlinear mixed-effects model. Results: Children with a high AHA score (high ability level) at 18 months reached a significantly higher ability level and at a higher progression rate than children with a low 18-month AHA score. Limits of development differed between the three MACS levels. Interpretation: Results indicate that the AHA score at 18 months can be used to discuss future development of affected hand use in bimanual tasks in children with unilateral CP.

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.)

Aim: To describe the use of upper‐limb botulinum neurotoxin A (BoNT‐A) treatment in a population‐based sample of children with cerebral palsy (CP), by investigating whether factors may be related to a first upper‐limb BoNT‐A treatment and whether passive range of motion (ROM) is related to a first BoNT‐A treatment after adjustment for confounders. Method: Data from five regions in Sweden, in the national registry and follow‐up programme for CP (CPUP), were collected for children with spastic or dyskinetic CP assessed between 2000 and 2017. CP subtypes, functional classification levels, and traffic‐light‐based passive ROM categories were investigated. Data were analysed with logistic regression (odds ratios). Results: Of a total of 496 children (317 males, 179 females; median 2 years, interquartile range 1–5 years, range 1–15 years at first measurement occasion), 22% (n = 108) had received upper‐limb BoNT‐A treatment, 45% of whom by 1 to 3 years of age. Those classified in Manual Ability Classification System levels IV and V showed the highest crude odds ratio for a first upper‐limb BoNT‐A treatment. Children with full passive ROM with tightness at the end of the movement range were most likely to receive an upper‐limb BoNT‐A treatment, also after adjustment for confounders. Thumb and forearm muscles were the most targeted at the first upper‐limb BoNT‐A treatment. Interpretation: Full passive ROM with tightness at the end of the movement range increases the likelihood of a first upper‐limb BoNT‐A treatment. This new traffic‐light category is an aspect to consider in the dialogue about upper‐limb BoNT‐A. What this paper adds: Among children receiving upper‐limb botulinum neurotoxin A (BoNT‐A), 45% had their first treatment before the age of 4 years.Thumb and forearm muscles were the most treated with BoNT‐A, finger flexor muscles the least.Full passive range of motion with tightness was related to first upper‐limb BoNT‐A treatment. [ABSTRACT FROM AUTHOR]

Aim: To investigate the external validity of the Both Hands Assessment (BoHA), a new test evaluating bimanual performance in children with bilateral cerebral palsy (CP), by analysing its relationship to established measurements of hand function and self‐care skills. Method: In this cross‐sectional study, we recruited children with bilateral CP and manual ability corresponding to Manual Ability Classification System (MACS) levels I to III attending three habilitation units in Norway. All participants completed the BoHA. Unimanual capacity was assessed using the Bimanual Fine Motor Function (BFMF) classification, the Box and Block Test (BBT), and the Melbourne Assessment 2 (MA2). Self‐care skills were assessed with the Pediatric Evaluation of Disability Inventory (PEDI). Results: Thirty‐nine children (19 males, 20 females; mean age 8y 2mo, SD 2y 8mo; age range 2y 8mo–12y 6mo) were included. Spearman's correlation coefficient (ρ) suggested high correlation between the BoHA and MACS (p=0.89; 95% confidence interval [CI] 0.79–0.94), BFMF classification (p=0.84; 95% CI 0.71–0.91), and BBT for the non‐dominant (p=0.85; 95% CI 0.68–0.95) and dominant hand (p=0.72; 95% CI 0.53–0.85). The Spearman's ρ between the BoHA and the MA2 subscales varied between 0.48 and 0.83, while the PEDI's ρ was 0.51 (95% CI 0.33–0.67). Interpretation: The BoHA provides valid measures of hand use as suggested by its high correlation with other activity‐based measures of hand function. [ABSTRACT FROM AUTHOR]