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

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 prob-
lems, 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, oste-
oporosis, 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 chorioamnionitis), intrauterine growth restriction, use of
defines cerebral palsy as a group of disorders that affects an preterm antibiotics before rupture of membranes, acidosis
individual’s movement, posture, and balance.1 The clinical or asphyxia, and multiple gestation, any of which can lead
findings, which are due to an injury to the developing brain, to brain injury.4,5 Fewer than 10% of cases are attributable to
are permanent and nonprogressive, but they can change intrapartum hypoxia.6 Cerebral palsy occurs at an older age
over time. in about 8% of patients, often from head injury or infection.3
Cerebral palsy is the most common physical disability Despite identification of risk factors, 80% of cases have no
of childhood, occurring in one out of 323 children in the clear cause and are considered idiopathic.7
United States, a figure that has been relatively stable over Further research is needed to delineate pathophysiologic
decades.1,2 factors, such as the maximum age at which a postnatal injury

Etiology
Cerebral palsy has multiple etiologies that can affect dif- WHAT’S NEW ON THIS TOPIC
ferent parts of the brain, thus contributing to the broad
range of clinical findings. Approximately 92% of cases of Cerebral Palsy
cerebral palsy are traced to the perinatal period.3 Risk fac-
Although selective dorsal rhizotomy is typically used for
tors include preterm birth, perinatal infection (particularly
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
CME This clinical content conforms to AAFP criteria for
more severe cases.
continuing medical education (CME). See CME Quiz on
page 199. Assessment using a spasticity-related hip surveillance
Author disclosure:​ No relevant financial affiliations. program combined with early, preventive surgical release
Patient information:​ A handout on this topic is available at has been demonstrated to reduce hip pain, hip disloca-
https://​family​doctor.org/condition/cerebral-palsy. tion, and the need for orthopedic salvage surgery.

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 CEREBRAL PALSY

SORT:​KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating Comments

Neuroimaging, preferably magnetic resonance imaging, may be obtained in C Guidelines from the American
a child with a permanent, nonprogressive disorder of motor function con- Academy of Neurology and the
sistent with cerebral palsy if no cause is shown on perinatal imaging.9 Child Neurology Society, which
are based on a systematic review
and meta-analysis

After establishing the diagnosis of cerebral palsy, severity of disease and C Expert opinion
response to treatment can be assessed using an evidence-based tool, such
as the GMFCS.10,14

Intramuscular onabotulinumtoxinA (Botox) injections can be used to reduce B Randomized controlled trial and
spasticity and deformity and improve mobility and pain control in children European consensus guidelines
with cerebral palsy of any severity. 25,26

Routine hip surveillance in patients with cerebral palsy can help identify C Standard-of-care guidelines used
developing problems earlier and prevent poor outcomes, such as hip pain in Europe, Australia, and Canada;​
and dislocation. Hip surveillance consists of periodic examinations and radi- no formal guidelines have been
ography, the frequency of which is determined by GMFCS classification. 34,35 developed in the United States

In patients 18 years or older with cerebral palsy, the Fracture Risk Assess- C Consensus guidelines
ment 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

Administration of magnesium sulfate should be considered before preterm B Meta-analysis of five randomized
birth to reduce the risk of cerebral palsy.48 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://​w ww.aafp.
org/afpsort.

can be considered a cause of cerebral palsy and genetic fac- hearing loss, blindness, and progression of scoliosis due to
tors that might contribute to the development of cerebral muscle spasm.10,11
palsy.8,9
Diagnosis
Clinical Features The diagnosis of cerebral palsy is clinical, based on iden-
The clinical features of cerebral palsy are varied and encom- tification of the defining features.10 The diagnosis can be
pass a broad range of abnormalities. They are predomi- further classified based on the nature of the movement
nantly disorders of movement but also include a spectrum disorder:​stiff muscles (spasticity), uncontrollable move-
of abnormalities such as poor balance and sensory defi- ments (dyskinesia), poor coordination (ataxia), or other/
cits.1,10 A number of comorbidities that are not part of the mixed.1,7,8,10 Spasticity is the most common movement dis-
core definition of cerebral palsy also occur, most commonly order, affecting approximately 80% of children with cere-
pain (75%), intellectual disability (50%), inability to walk bral palsy.1 A video demonstrating spasticity and the other
(33%), hip displacement (33%), inability to speak (25%), movement disorders of cerebral palsy is available at https://​
epilepsy (25%), incontinence (25%), and behavioral or sleep www.youtube.com/watch?v=cOfUGUNxEqU. Spasticity
disorders (20% to 25%).11 These clinical findings occur out- in cerebral palsy can be characterized as diplegia, hemi-
side of the expected age-based developmental stages. Other plegia, or quadriplegia, depending on which limbs are
studies have shown additional clinical findings such as affected.

214  American Family Physician www.aafp.org/afp Volume 101, Number 4 ◆ February 15, 2020
 CEREBRAL PALSY

In the past, the diagnosis of cerebral palsy was usually Treatment

made between 12 and 24 months of age when there were GENERAL APPROACH
clinical findings of impaired movement, posture, or balance, Treatment of patients with cerebral palsy varies depending
and it was evident that the impairment was permanent and on the specific symptoms. However, discussing expecta-
nonprogressive. However, now that perinatal ultrasonogra- tions with families to help them develop realistic goals is
phy and postbirth magnetic resonance imaging (MRI) can important in all cases. Involving a multidisciplinary team
identify brain injury, the diagnosis may be made as early as (Table 116) to address the various aspects of care is also
six months of age (corrected for prematurity).7,9 important for tailoring the treatment plan to the patient’s
The American Academy of Neurology recommends a individual needs.
stepwise workup to aid in the diagnosis of cerebral palsy.9 By five years of age, most children with cerebral palsy
The first step is recognition of a permanent, nonprogressive have about 90% of their eventual total motor development,
disorder of motor function in a child through a history and even with aggressive and ongoing therapy.17 In addition to
physical examination. Next, the clinician should screen for focusing on motor skills, however, physicians should assist
the comorbidities that often accompany cerebral palsy. families in coping with development of their child’s com-
If perinatal imaging studies, such as fetal anatomy sur- munication, social, academic, and eventually professional
veys or newborn transcranial ultrasonography, do not skills as the child grows into adulthood.17 The treatment
show a cause for the clinical findings, neuroimaging may
be obtained. MRI is the recommended imaging modality
TABLE 1
and is preferable to computed tomography given its higher
specificity (approximately 89%) for identifying intracranial Multispecialty Management Team
abnormalities.9 A broad range of abnormalities may be seen for Patients with Cerebral Palsy
on brain imaging in patients with cerebral palsy, includ-
ing schizencephaly (clefts in cerebral tissue), hydroceph- Team member Role
alus, and periventricular leukomalacia. In one study, only Physician* Team leader;​synthesizes long-term,
5% of imaging studies demonstrated findings specific to comprehensive plans and treatments
hypoxic-ischemic injury.12
Surgical specialist Focuses on preventing contractures,
If imaging results are normal or nondiagnostic, the final hip dislocations, and spinal curva-
step is to consider screening for inborn errors of metabolism tures in addition to treatment of pain
and carrier states for genetic disorders that might explain
Physical therapist Develops and implements care plans
the patient’s symptoms.9 However, there is limited evidence
to improve movement and strength,
to support such testing. and administers formal gait analyses

Clinical Assessment Instruments Occupational Develops and implements care plans

therapist focused on activities of daily living
After establishing the diagnosis, various instruments can be
used to evaluate the severity of cerebral palsy and response to Speech-language Develops and implements care plans
treatment. The most widely used evidence-based tool is the pathologist to optimize the patient’s capacity for
Gross Motor Function Classification System (GMFCS).10,14 communication
Other cerebral palsy assessment tools are available, but Social worker Assists the patient’s family in
studies show no major advantages of one over another.15 identifying community assistance
The GMFCS (available at https://​bit.ly/2KtnrCr) is an age- programs
based tool that evaluates gross motor function in different Psychologist Assists the patient and patient’s
realms, including mobility, posture, and balance, and clas- family in coping with the stress and
sifies the severity of each of those realms into one of five demands of the disability
levels. Level I indicates few limitations (e.g., walks without Educator Develops strategies to address cog-
limitations), whereas level V indicates severe limitations nitive or learning disabilities
(e.g., requires a wheelchair).
*—Family physician or pediatrician, with support or direction from
After classification with the GMFCS, patients may be a neurologist or psychiatrist trained to help children with develop-
monitored as they age to see if treatments result in improved mental disabilities, if available.
GMFCS levels.14 Additional scoring systems such as the Adapted with permission from Krigger KW. Cerebral palsy:​an over-
Wong-Baker FACES Pain Rating Scale can also be used to view. Am Fam Physician. 2006;​73(1):​98.
assess response to treatment.

February 15, 2020 ◆ Volume 101, Number 4 www.aafp.org/afp American Family Physician 215
 CEREBRAL PALSY
TABLE 2

Management of Common Complications from Cerebral Palsy Comorbidities

Condition Complications Care

Abnormal sensa- Some children have impaired sensations to Mittens may be needed during teething to prevent dam-
tion and perception touch and pain age to fingers and hands

Communication People with cerebral palsy may struggle Consider referral for speech therapy
difficulties with communication or may be nonverbal

Gastrointestinal Caused by delayed gastric emptying, Use stool softeners, especially if patient is taking opioid
problems (e.g., abnormal autonomic control of gas- pain medications
vomiting, con- trointestinal mobility, immobilization, Perform bowel hygiene
stipation, bowel inadequate oral intake, and prolonged
Increase fluids and fiber with or without laxatives
obstruction) colonic transit

Hearing and vision Children with cerebral palsy may present Vision screening is recommended at 12 months and four
abnormalities with strabismus or hemianopia;​25% to 29% years of age, then periodically as needed
of adults with cerebral palsy have visual Hearing screening is recommended at birth and every six
defects, 8% to 18% have hearing problems months until three years of age

Impaired oral- May cause hypoxemia, temporomandibu- Special diets, different positioning or feeding techniques,
motor function lar joint contractures, vomiting, aspiration gastrostomy, or nasogastric tube feeding may be needed
pneumonia (associated with gastro- for feeding difficulties
esophageal reflux), poor nutrition, failure Medications (anticholinergics and onabotulinumtoxinA
to thrive, drooling, and communication [Botox] injections into salivary glands), surgery on sali-
difficulties vary ducts and glands, and biofeedback have been used
to control drooling
Speech therapy and the use of computer voice synthe-
sizers can help improve communication

Mental health Up to one in four children with cerebral Encourage functionality and independence with living
issues palsy have behavioral or emotional issues;​ accommodations, transportation, exercise, mechanical
psychiatric comorbidities and cognitive aids, and employment opportunities
impairment also occur Provide counseling;​consider therapies, such as cogni-
tive behavior therapy, for emotional and psychological
challenges
Monitor for needed medications

Osteoporosis Up to 90% of patients with cerebral palsy Use risk screening tools to stratify those who would
have low bone density and are at risk of likely benefit from treatment, then perform dual energy
fracture x-ray absorptiometry in high-risk patients to confirm the
diagnosis;​calcium, vitamin D, and/or bisphosphonates

Pressure ulcers Patients with limited mobility are at Consider different positioning strategies, support
increased risk of pressure ulcers and asso- surfaces, and prophylactic dressings;​wound care con-
ciated complications sultation for those with recurrent/persistent ulcers

Seizures One-half of children with cerebral palsy Monitor and control with medication
have seizure activity

Urinary Impaired control of bladder muscles Physical therapy, biofeedback, medications, surgery,
incontinence surgically implanted devices to replace or aid muscles,
or specially designed undergarments may be beneficial

Adapted with permission from Krigger KW. Cerebral palsy:​an overview. Am Fam Physician. 2006;​73(1):​94, with additional information from refer-
ences 17-23.

of children with cerebral palsy also involves managing the SPASTICITY

common complications of the condition Table 2.16-23 Treatment of spasticity is important for preventing and
Most treatments for cerebral palsy are supported by weak, correcting spasticity-induced bone and joint deforma-
short-term evidence. This is largely because of difficulty tion, in addition to controlling pain and maintaining
studying this vulnerable population. function. Primary care physicians often refer patients to a

216  American Family Physician www.aafp.org/afp Volume 101, Number 4 ◆ February 15, 2020
 CEREBRAL PALSY

surgical specialist to aid in selection of appropriate treat- its use, but it appears to improve quality of life and ease of
ments, including nerve blocks, soft tissue lengthening, care in the short term. However, it is expensive, requires
tendon transfers, and joint stabilization.24 The timing of refills, is intrusive, and increases risk of infection and surgi-
referral depends on severity. For GMFCS level V cerebral cal complications compared with other treatment options.33
palsy, initial referral should be considered between one and
four years of age.25 For GMFCS level I cerebral palsy, initial HIP DISORDERS
referral should be considered at around five years of age.25 Hip disorders are among the most common musculoskel-
OnabotulinumtoxinA. Intramuscular onabotulinum­ etal issues in children with cerebral palsy. Approximately
toxinA (Botox) has been used for decades to reduce spas- 36% of children with cerebral palsy have a hip disorder, and
ticity and deformity and improve mobility and pain control the incidence increases with higher GMFCS level.34 Spastic-
in children with cerebral palsy of any severity.26 A 2019 ity can lead to hip pain and hip dislocation and can make
Cochrane review indicated mixed outcomes for intramus- it difficult for families to care for nonambulatory children.
cular onabotulinumtoxinA with low-quality evidence.27 Routine hip surveillance, including periodic examina-
The optimal age at which to initiate onabotulinumtoxinA tions and radiography, can help identify developing prob-
injections is controversial, but the first injections typically lems earlier and prevent poor outcomes. The frequency of
occur between 18 and 24 months of age.26 European con- hip surveillance is determined by GMFCS level. Although
sensus guidelines provide recommendations for the use of no formal hip surveillance program has been developed
onabotulinumtoxinA injections in children with cerebral in the United States, standard-of-care guidelines have
palsy, including indications, dosing, and techniques.25 been adopted in Europe, Australia, and Canada.35 Assess-
Systemic Antispasticity Medications. Medications such as ment using a spasticity-related hip surveillance program
baclofen (Lioresal) and diazepam (Valium) are short-acting combined with early, preventive surgical release has been
drugs that help relax muscle groups, but they come with demonstrated to reduce hip pain, hip dislocation, and the
many adverse effects (e.g., sedation, dizziness, confusion, need for orthopedic salvage surgery.34
nausea, lowered seizure threshold, central nervous system
depression).28 Although these medications may be neces- IMPROVING MOVEMENT AND BALANCE
sary in severe cases of cerebral palsy (typically GMFCS level Formal physical and occupational therapies have been
IV or V), there is limited evidence to support their long- the cornerstones of treatment for movement and bal-
term use given the adverse effects.28 ance problems in children and adults with cerebral palsy.
Selective Dorsal Rhizotomy. In this neurosurgical proce- There are many different modalities and approaches to
dure, selective nerve roots are severed to reduce spasticity therapy, including stretching; massage;​strengthening,
and maximize motor control. Although the procedure is weight-bearing, and balance exercises;​electrical stimula-
typically used for ambulatory spastic diplegia in children tion;​treadmill use;​and endurance training.
with GMFCS level II or III cerebral palsy, more recent data Studies show that physical and occupational therapies
suggest that it may also be helpful in more severe cases.29 improve gait and motor function;​however, there is minimal
Evaluation for this procedure should be done between four data to support one therapeutic modality over another or to
and five years of age.25 guide the optimal intensity, frequency, or duration of treat-
Many studies show short-term improvement in gait and ment.36,37 Referral for physical and occupational therapies is
range of motion following selective dorsal rhizotomy.30 recommended as soon as cerebral palsy is diagnosed.25 Aug-
Long-term studies demonstrate reduced spasticity with the menting therapy with onabotulinumtoxinA injections can
procedure, but functional motor improvement at 10 years further improve motor function in appropriate patients.38
is variable.31 Nevertheless, those treated with selective dor- Home therapy programs implemented by parents after a
sal rhizotomy required significantly less orthopedic surgery formal instructional session can successfully improve the
and onabotulinumtoxinA injections over 10 or more years patient’s function and parent satisfaction.39 Web-based pro-
of follow-up compared with a matched control group that grams that train families on using therapy techniques, with
did not undergo the treatment, along with small improve- progress monitored by a trained therapist, have also been
ments in gait outcomes.32 shown to improve motor skills, although these improve-
Intrathecal Baclofen. Administration of intrathecal ments were limited to the dominant upper limb.40
baclofen via an implantable pump is an option that reduces
adverse effects by limiting systemic exposure to the drug. It IMPROVING HAND FUNCTION
is usually reserved for nonambulatory children with GMFCS Constraint-induced movement therapy and hand-arm
level IV or V cerebral palsy. There are few studies to support intensive bimanual therapy are designed to improve

February 15, 2020 ◆ Volume 101, Number 4 www.aafp.org/afp American Family Physician 217
 CEREBRAL PALSY

functionality of the hands. In constraint-induced movement In patients 18 years or older, the Fracture Risk Assess-
therapy, the dominant hand is constrained to encourage ment Tool or the QFracture tool can be used to determine
development and use of the nondominant hand in children whether a patient’s risk of osteoporosis merits treatment. If
with hemiplegia. Hand-arm intensive bimanual therapy has the patient is at high risk, dual energy x-ray absorptiome-
similar goals and tasks but encourages use of both hands. try can confirm the diagnosis of osteoporosis before start-
In a trial of children with hemiplegic cerebral palsy, both ing treatment.19 Calcium and vitamin D supplements and
of these strategies have been shown to improve function, bisphosphonates have been shown to improve bone density
which was sustained six months after completion of ther- and reduce fracture rates.20
apy.41 Hand-arm intensive bimanual therapy may be more
tolerable in children who are frustrated with constraint- BEHAVIORAL, EMOTIONAL, AND PSYCHIATRIC ISSUES
induced movement therapy. Up to one in four children with cerebral palsy have behavioral
or emotional issues. Many also meet criteria for comorbid
EQUINUS DEFORMITY psychiatric diagnoses, such as attention-deficit/hyperactivity
Equinus deformity causes the classic hyper-plantar flexion disorder, conduct disorders, anxiety, and depression.45 Eval-
of the ankle in people with cerebral palsy. See https://​bit. uation for these conditions is recommended to assure early
ly/35bIAYe for a photo of equinus deformity. Small gains in access to resources and associated treatments.45 One treat-
dorsiflexion could theoretically improve gait. Some stud- ment, cognitive behavior therapy, is designed to help patients
ies show that ankle orthotics can help increase lower-limb identify and restructure negative thoughts and behaviors.
motion and strength, resulting in improved walking func- Cognitive behavior therapy has been shown to be helpful
tion and parent satisfaction.42 There is insufficient evidence in modifying behavior and managing emotions for a wide
to support upper-limb orthotics.43 range of physical and mental conditions, although studies of
patients with cerebral palsy are limited.
IMPROVING RANGE OF MOTION
Serial casting (casting to progressively stretch against con- Continuing Care
tracture) has historically been used in patients with cere- Much of the research on cerebral palsy focuses on children
bral palsy to improve range of motion. However, evidence and adolescents. However, most individuals with mild to
demonstrating functional improvement from these short- moderate cases have near-normal life expectancies. For
term, small increases in range of motion is limited.34,44 adults with cerebral palsy, it is important to consider the
Therefore, this previously routine treatment should be con- increased risk of secondary conditions as a result of a seden-
sidered only after other therapies fail. tary lifestyle, such as obesity, lower fitness, decreased bone
density, and generally reduced functional reserve.46 Unless
Managing Associated Conditions cerebral palsy–specific screening guidance is available, ado-
PRESSURE ULCERS lescents and adults with cerebral palsy should be assessed
Preventing pressure ulcers is necessary for any patient for chronic diseases, offered guidance on reproductive
with limited mobility, including those with cerebral palsy. health, and screened for malignancies as indicated by the
Different positioning strategies, support surfaces, and U.S. Preventive Services Task Force.
prophylactic dressings should be used for at-risk individ- All members of the care team should address barri-
uals. Use of alternating pressure mattresses, wheelchair ers to care, such as ensuring accessibility of buildings and
cushions, or medical-grade sheepskins for areas of pres- availability of appropriate equipment (wheelchairs, hoists,
sure or friction should also be considered.18 Wound care bathroom items), facilitating transportation, addressing
consultation is recommended for recurrent or persistent communication difficulties, offering longer appointments,
pressure ulcers. and assisting patients in finding an advocate or support for
social and emotional barriers to care. An annual evaluation
OSTEOPOROSIS with a neurodisability specialist is recommended for adults
Osteoporosis is common in patients with cerebral palsy, with GMFCS levels IV and V cerebral palsy.47
likely a result of poor growth and nutrition, non–weight
bearing status, limited exposure to sunlight, late-onset Prevention
puberty, and use of anticonvulsants. It is estimated that Other than prevention of risk factors, there are few interven-
80% to 90% of children with cerebral palsy have low bone tions known to reduce the risk of cerebral palsy. Although
density and are at increased risk of fractures, most com- magnesium sulfate is not the standard initial treatment
monly in the femur.20 for premature labor, it has been shown to reduce the risk

218  American Family Physician www.aafp.org/afp Volume 101, Number 4 ◆ February 15, 2020
 CEREBRAL PALSY

of cerebral palsy from 6.7% to 4.7% (relative risk = 0.68;​ 7. Novak I, Morgan C, Adde L, et al. Early, accurate diagnosis and early
intervention in cerebral palsy:​advances in diagnosis and treatment
number needed to treat = 48).48 There is some controversy [published correction appears in JAMA Pediatr. 2017;​171(9):​919]. JAMA
as to whether antenatal steroids to promote fetal lung mat- Pediatr. 2017;​171(9):​897-907.
uration in premature infants, particularly multiple courses, 8. Smithers-Sheedy H, Badawi N, Blair E, et al. What constitutes cerebral
palsy in the twenty-first century? Dev Med Child Neurol. 2014;​56(4):​
increase the risk of cerebral palsy. Therefore, the decision
323-328.
to initiate such therapy must be individualized based on 9. Ashwal S, Russman BS, Blasco PA, et al. Practice parameter:​diagnostic
potential benefits.13,49 assessment of the child with cerebral palsy:​report of the Quality Stan-
dards Subcommittee of the American Academy of Neurology and the
This article updates a previous article on this topic by Krigger.16 Practice Committee of the Child Neurology Society. Neurology. 2004;​
Data Sources:​ A PubMed search was completed in Clinical Que- 62(6):​851-863.
ries using the key terms cerebral palsy, motor function clinical 10. O’Shea TM. Diagnosis, treatment, and prevention of cerebral palsy. Clin
assessments, treatment, medications, therapy, and comorbidi- Obstet Gynecol. 2008;​51(4):​816-828.
ties. The search included meta-analyses, randomized controlled 1 1. Novak I, Hines M, Goldsmith S, et al. Clinical prognostic messages
trials, clinical trials, and reviews. Also searched were the Amer- from a systematic review on cerebral palsy. Pediatrics. 2012;​1 30(5):​
ican Academy of Neurology, National Institute for Health and e1285-e1312.
Care Excellence, the Cochrane database, and Ovid MEDLINE. 1 2. Wu YW, Croen LA, Shah SJ, et al. Cerebral palsy in a term population:​
Search dates:​December 8, 2018, and October 20, 2019. risk factors and neuroimaging findings. Pediatrics. 2006;​1 18(2):​690-697.
1 3. Barrington KJ. The adverse neuro-developmental effects of postnatal
The views expressed in this material are those of the authors
steroids in the preterm infant:​a systematic review of RCTs. BMC Pediatr.
and do not reflect the official policy or position of the U.S. gov- 2001;​1:​ 1 .
ernment, the Department of Defense, or the Department of the
14. Palisano R, Rosenbaum P, Walter S, et al. Development and reliability of
Air Force. a system to classify gross motor function in children with cerebral palsy.
Dev Med Child Neurol. 1997;​39(4):​214-223.
15. Compagnone E, Maniglio J, Camposeo S, et al. Functional classifica-
The Authors
tions for cerebral palsy:​correlations between the Gross Motor Function
KIRSTEN VITRIKAS, MD, is program director of the David Classification System (GMFCS), the Manual Ability Classification System
Grant USAF Medical Center Family Medicine Residency, Tra- (MACS) and the Communication Function Classification System (CFCS).
Res Dev Disabil. 2014;​35(11):​2651-2657.
vis Air Force Base, Calif., and is an assistant professor in the
Department of Family Medicine at the Uniformed Services 16. Krigger KW. Cerebral palsy:​an overview. Am Fam Physician. 2006;​73(1):​
91-100. https://​w ww.aafp.org/afp/2006/0101/p91.html
University of the Health Sciences, Bethesda, Md.
17. Novak I. Evidence-based diagnosis, health care, and rehabilitation for
HEATHER DALTON, MD, is a faculty physician at the David children with cerebral palsy. J Child Neurol. 2014;​29(8):​1 141-1156.
Grant USAF Medical Center Family Medicine Residency and is 18. Novak I, McIntyre S, Morgan C, et al. A systematic review of interven-
an assistant professor in the Department of Family Medicine tions for children with cerebral palsy:​state of the evidence. Dev Med
Child Neurol. 2013;​55(10):​885-910.
at the Uniformed Services University of the Health Sciences.
19. National Institute for Health and Care Excellence. Osteoporosis:​assess-
DAKOTA BREISH, MD, is a staff physician at the Mountain ing the risk of fragility fracture. Accessed June 26, 2019. https://​w ww.
nice.org.uk/guidance/cg146
Home Air Force Base medical treatment facility in Idaho.
20. Simm PJ, Biggin A, Zacharin MR, et al.;​APEG Bone Mineral Working
Address correspondence to Kirsten Vitrikas, MD, David Grant Group. Consensus guidelines on the use of bisphosphonate therapy in
children and adolescents. J Paediatr Child Health. 2018;​5 4(3):​223-233.
USAF Medical Center Family Medicine Residency, 101 Bodin
Cir., Travis AFB, CA 94535 (email:​kirsten.r.vitrikas.mil@​mail. 21. Evenhuis H, Van Der Graaf G, Walinga M, et al. Detection of childhood
visual impairment in at-risk groups. JPPID. 2007;​4(3):​165-169.
mil). Reprints are not available from the authors.
22. Joint Committee on Infant Hearing;​American Academy of Audiology;​
American Academy of Pediatrics;​American Speech-Language-Hearing
Association;​Directors of Speech and Hearing Programs in State Health
References and Welfare Agencies. Year 2000 position statement:​principles and
1. Centers for Disease Control and Prevention. Cerebral palsy. Accessed guidelines for early hearing detection and intervention programs. Pedi-
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