Cerebral Palsy: An Overview

Kirsten Vitrikas; Heather Dalton; Dakota Breish

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Feb 15, 2020 Issue

Cerebral Palsy: An Overview

KIRSTEN VITRIKAS, MD, and HEATHER DALTON, MD, David Grant USAF Medical Center, Travis Air Force Base, California

DAKOTA BREISH, MD, Mountain Home Air Force Base, Idaho

Am Fam Physician. 2020 Feb 15;101(4):213-220.

Patient information: A handout on this topic is available at https://familydoctor.org/condition/cerebral-palsy.

Author disclosure: No relevant financial affiliations.

Cerebral palsy, which occurs in two to three out of 1,000 live births, has multiple etiologies resulting in brain injury that affects movement, posture, and balance. The movement disorders associated with cerebral palsy are categorized as spasticity, dyskinesia, ataxia, or mixed/other. Spasticity is the most common movement disorder, occurring in 80% of children with cerebral palsy. Movement disorders of cerebral palsy can result in secondary problems, including hip pain or dislocation, balance problems, hand dysfunction, and equinus deformity. Diagnosis of cerebral palsy is primarily clinical, but magnetic resonance imaging can be helpful to confirm brain injury if there is no clear cause for the patient’s symptoms. Once cerebral palsy has been diagnosed, an instrument such as the Gross Motor Function Classification System can be used to evaluate severity and treatment response. Treatments for the movement disorders associated with cerebral palsy include intramuscular onabotulinumtoxinA, systemic and intrathecal muscle relaxants, selective dorsal rhizotomy, and physical and occupational therapies. Patients with cerebral palsy often also experience problems unrelated to movement that need to be managed into adulthood, including cognitive dysfunction, seizures, pressure ulcers, osteoporosis, behavioral or emotional problems, and speech and hearing impairment. (Am Fam Physician. 2020;101(4):213–220. Copyright © 2020 American Academy of Family Physicians.)

The Centers for Disease Control and Prevention defines cerebral palsy as a group of disorders that affects an individual’s movement, posture, and balance.1 The clinical findings, which are due to an injury to the developing brain, are permanent and nonprogressive, but they can change over time.

WHAT’S NEW ON THIS TOPIC

Cerebral Palsy

Although selective dorsal rhizotomy is typically used for ambulatory spastic diplegia in children with Gross Motor Function Classification System level II or III cerebral palsy, more recent data suggest that it may also be helpful for more severe cases.

Assessment using a spasticity-related hip surveillance program combined with early, preventive surgical release has been demonstrated to reduce hip pain, hip dislocation, and the need for orthopedic salvage surgery.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	Comments
Neuroimaging, preferably magnetic resonance imaging, may be obtained in a child with a permanent, nonprogressive disorder of motor function consistent with cerebral palsy if no cause is shown on perinatal imaging.⁹	C	Guidelines from the American Academy of Neurology and the Child Neurology Society, which are based on a systematic review and meta-analysis
After establishing the diagnosis of cerebral palsy, severity of disease and response to treatment can be assessed using an evidence-based tool, such as the GMFCS.^10,14	C	Expert opinion
Intramuscular onabotulinumtoxinA (Botox) injections can be used to reduce spasticity and deformity and improve mobility and pain control in children with cerebral palsy of any severity.^25,26	B	Randomized controlled trial and European consensus guidelines
Routine hip surveillance in patients with cerebral palsy can help identify developing problems earlier and prevent poor outcomes, such as hip pain and dislocation. Hip surveillance consists of periodic examinations and radiography, the frequency of which is determined by GMFCS classification.^34,35	C	Standard-of-care guidelines used in Europe, Australia, and Canada; no formal guidelines have been developed in the United States
In patients 18 years or older with cerebral palsy, the Fracture Risk Assessment Tool or the QFracture tool can be used to determine if the patient’s risk of osteoporosis merits treatment. If the patient is at high risk, dual energy x-ray absorptiometry can confirm the diagnosis before starting treatment. Calcium and vitamin D supplements and bisphosphonates have been shown to improve bone density and reduce fracture rates.^19,20	C	Consensus guidelines
Administration of magnesium sulfate should be considered before preterm birth to reduce the risk of cerebral palsy.⁴⁸	B	Meta-analysis of five randomized controlled trials

GMFCS = Gross Motor Function Classification System.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	Comments
Neuroimaging, preferably magnetic resonance imaging, may be obtained in a child with a permanent, nonprogressive disorder of motor function consistent with cerebral palsy if no cause is shown on perinatal imaging.⁹	C	Guidelines from the American Academy of N

The Authors

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KIRSTEN VITRIKAS, MD, is program director of the David Grant USAF Medical Center Family Medicine Residency, Travis Air Force Base, Calif., and is an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

HEATHER DALTON, MD, is a faculty physician at the David Grant USAF Medical Center Family Medicine Residency and is an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

DAKOTA BREISH, MD, is a staff physician at the Mountain Home Air Force Base medical treatment facility in Idaho.

Address correspondence to Kirsten Vitrikas, MD, David Grant USAF Medical Center Family Medicine Residency, 101 Bodin Cir., Travis AFB, CA 94535 (email: kirsten.r.vitrikas.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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