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Rehabilitation of a Child with Cerebral Palsy

Presentation · March 2022

DOI: 10.13140/RG.2.2.34704.07687

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Muhammad Tawab Khalil

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HOPE is but a waking
man’s DREAM
Aristotle
TRINA
PhD and a proud
mum
MAXIM
Dancer
NATHAN
Musician
JUDITH
Type writer Artist
MARIA
Adventurist &
Book Writer
 Cerebral Palsy:
Every Child Matters
Capt M. Tawab Khalil
Resident Physical Medicine & Rehabilitation
(Grd Batch 2020)

Supervisor
Lt Col M. Farooq Azam Rathore
MBBS, FCPS, MSc (Pain Med),
Classified Rehab Med Specialist
AFIRM Rawalpindi
 Cerebral Palsy: Every Child Matters
Objective

To Highlight the Importance of Comprehensive Rehabilitation in

Management of a Child with Cerebral Palsy

12
 Cerebral Palsy: Every Child Matters
Sequence

Case Presentation

Case Discussion

Literature Review

Conclusion 13
Cerebral Palsy: Every Child Matters
Case Presentation

14
 Cerebral Palsy: Every Child Matters
History

1.5 years Rawalpindi 15 April 2019

CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW

 Cerebral Palsy: Every Child Matters
Presenting Complaints

• Delayed milestones since birth

16
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Antenatal History

Conception Spontaneous

Gestational history 39 weeks

Antenatal Visits Regular

Anomaly Scan Normal

Maternal Vaccination Completed

17
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Natal History

• Failed Induction of Labor at Term

• Emergency Lower Segment

Cesarian Section

18
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Postnatal History

• Delayed Cry
• Admitted in NICU
• Multiple Episodes of Convulsions
• Did not pass Stool for 7 Days
• Colostomy done at age of 7days-
Hirshprung Disease
19
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Past History
• Surgical History:
• Colostomy done at Age of 7days - Hirshprung Disease
• Colostomy Reversal Performed at 3 Months of Age

• Medical History:
• Epilepsy
• On and off Chest Infections

20
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Past History
• Feeding History:
• Bottle Fed - Formula Milk
• Weaning Started at the age of 6.5months

• Immunization History:
• First dose was given at the 27th Day after Birth
• Then Proceeded as per EPI

21
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Developmental History

• No Neck • Reaches
Holding for Toys
Gross Fine
Motor Motor

Speech Social

• Babbles • Smiles

22
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Drug History

• Syp Valproic acid – 3ml BD

• Syp Sodium Picosulfate – 2.5ml HS

• Vit D drops – 800 IU x OD

• Syp Calcium-P – 1 Teaspoon OD

• No History of Drug Allergy

23
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Family History

26 yr 30 yr

24
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Functional History

• Gross Motor Function Measure (GMFM) Score – 10.8%

25
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Socioeconomic History

• Middle Socioeconomic Class

• Double Storey House

• Earners and Caregivers

26
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
General Physical Examination

85/ min < 2 sec

HR CRT

Afebrile 25/ min

Temp RR

27
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Anthropometry
WHO GROWTH CHART GIRLS
• Height: 78cm (38th Centile)

• Weight: 9.9Kg (40th Centile)

• Occipito-frontal Head

Circumference: 45cm

(15thcentile) at 18 months of Age

28
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
General Physical Examination
• Anterior Drooling- Present
• Pallor
• Cyanosis
• Jaundice
• Clubbing WNL
• Edema
• Lymphadenopathy

29
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Systemic Examination
• Respiratory Exam

• Cardiovascular Exam

• Abdominal Exam
• Laparotomy Scar- 10cm
• Colostomy Scar- 3cm
30
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Systemic Examination
Neurological Exam
Hammersmith Infant Neurological Evaluation (HINE)- 49/78
Right Left
Power Proximal -5/5 Proximal- 3/5
Distal – 5/5 Distal- 2/5
Reflexes ++ Clonus
Spasticity (MAS) 0 2
Plantars
31
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Investigations

• Blood Complete Picture

• Serum Vit D3 Levels

• Serum Calcium Levels

32
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Imaging Investigations

• CT Scan Brain:
• Brain Atrophy

33
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Diagnosis

Left Hemiplegic Cerebral Palsy GMFCS V

34
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
Cerebral Palsy: Every Child Matters
Multidisciplinary Approach

Rehab
Physician

Psychologist
Paediatrician

Parents
Physical Prosthetist
Therapist

Occupational
Therapist 35
 Cerebral Palsy: Every Child Matters
Problem List
Medical Problems Seizures
Sialorrhea

Physical Problems Spasticity

Delayed Motor Milestones

Delayed Speech Milestones

Cognitive Problems
Delayed Social Milestones

36
 Cerebral Palsy: Every Child Matters
Rehabilitation Goals
SHORT-TERM GOALS
Management of Spasticity and Sialorrhea
Upper and Lower Limb Motor Training
Prevention of Musculoskeletal Complications
Family Education and Counselling
Provision of Appropriate Assistive Devices
Management of Speech Delay
LONG-TERM GOALS
Community Re-integration
Schooling as per Patient’s Potential 37
 Cerebral Palsy: Every Child Matters
Management of Spasticity

• Non Pharmacological Management

 Active and Passive ROM Exercises
 Sustained Stretching
 Rigid AFO- Night Splint

• Medications
 Tab Baclofen 10mg - ½ Tablet BD

38
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW *All photos and videos shown with parent’s consent
 Cerebral Palsy: Every Kid Matters
Management of Sialorrhea

Non-Pharmacological
Oromotor and Orosensory Exercises
Behavioral Interventions

Pharmacological
Oral Glycopyrollate Solution 200mcg
TDS
Chewy tubes

39
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Speech Therapy

• Oromotor Exercises

• Babbling Exercises

• Vocal Drills

40
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Management of Delayed Motor Milestones
Paraspinal Strengthening

Balance Trg on CP Ball

CP Stand

Barrel Standing

41
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Management of Delayed Motor Milestones
Paraspinal Strengthening

Balance Trg on CP Ball

CP Stand

Barrel Standing

42
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Management of Delayed Motor Milestones
Paraspinal Strengthening

Balance Trg on CP Ball

CP Stand

Barrel Standing

43
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Management of Delayed Motor Milestones
Paraspinal Strengthening

Balance Trg on CP Ball

CP Stand

Barrel Standing

44
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Management of Delayed Motor Milestones
Sit to Stand

PBWSTT

Gait Trg with Walker

GMFM

45
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Management of Delayed Motor Milestones
Sit to Stand

PBWSTT

Gait Trg with Walker

GMFM

46
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Management of Delayed Motor Milestones
Sit to Stand

PBWSTT

Gait Trg with Walker

GMFM 74.5%
GMFM

47
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Impact of COVID-19 Pandemic on Patient

48
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Impact of COVID-19 Pandemic on Patient

• In-accessability to Care because of COVID-19 Restrictions for 10 Months

• Regression of Progress:
• Stopped Walking
• GMFM Score Decreased to 63.9%
• Spasticity Increased to MAS Gd III In Left Adductors
• Behavioral Problems

49
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Management of Spasticity

• Modiefied Heckmet Scale- Grade 2

GRACILIS
 Evaluation of Echogenic Changes

• Therapeutic Intervention ADDUCTOR

MAGNUS
 Ultrasound Guided Left Adductor Motor Point
FEMUR
Block With 6% Phenol

50
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW *All photos and videos shown with parents’s consent
 Cerebral Palsy: Every Child Matters
Psychological Management
• Behavioural Problems:

• Decreased attention and concentration

• Throwing behaviour and aggression

• Sessions:

• Blue room - attention enhancement

• BBHT for attention enhancement

• Sessions on TOBI
51
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Motor Training Lower limb

Sit to Stand

PBWST

Independent Walking

52
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Motor Training Lower limb

Sit to Stand

PBWST

Independent Walking

53
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Motor Training Lower limb

Sit to Stand

PBWST

Independent Walking

54
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Gross and Fine Motor Training Upper limb

Arm Ergometry

Therapy Cones

Thѐrapeute

55
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Gross and Fine Motor Training Upper limb

Arm Ergometry

Therapy Cones

Thѐrapeute

56
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Gross and Fine Motor Training Upper limb

Arm Ergometry

Therapy Cones

Thѐrapeute

57
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Sensory Motor Re-integration

58
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Summary

Apr 2019
GMFCS V
G GMFM
M 10.8%
G
C
S

PATIENT’S PROGRESS
59
 Cerebral Palsy: Every Child Matters
Summary

GMFCS III
GMFM
G 74.5%
M
G
C
S

PATIENT’S PROGRESS
60
 Cerebral Palsy: Every Child Matters
Summary

GMFCS IV
GMFM
G
63.9%
M
G
C
S

PATIENT’S PROGRESS
61
 Cerebral Palsy: Every Child Matters
Summary

GMFCS II
GMFM
G 82.1%
M
G
C
S

PATIENT’S PROGRESS
62
 Cerebral Palsy: Every Child Matters
Case Discussion

63
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
History of Cerebral Palsy

• Dr John Little Started Working- 1830

• “On the Nature and Treatment of the
Deformities of the Human Frame”-1843

• First ever Definition of CP-1861

64
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
History of Cerebral Palsy

• Sir William Osler Coined the Term Cerebral

Palsy, wrote Book “Cerebral Palsies of
Children”-1887

65
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Definition

• An Umbrella Term Covering a Group of NON-PROGRESSIVE,

but Evolving MOTOR Impairment Syndromes Secondary to
Lesions or Anomalies of Brain at The EARLY Stage of
Development

66
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Etiology

Pre-Natal Risk Factors

Before Conception During Pregnancy

Prior Loss of Newborn TORCH Infection
Maternal Thyroid Disorder Gestational DM
Maternal Seizure Disorder Toxin Exposure
Irregular Menstrual Cycles Bleeding in 3rd Trimester

67
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Etiology

Peri-Natal Risk Factors Post-Natal Risk Factors

Premature Birth Seizures with in 48 hours

Infection Sepsis
Asphyxia Kernicterus
Placental Abruption Cerebral Infarction
Abnormal Fetal Position Respiratory Distress Syndrome

68
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Classification of CP

Functional Level

Part of Body Involved

Type of Movement

69
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Classification of CP

Gross Motor Functional Classification System

GMFCS I GMFCS II GMFCS III GMFCS IV GMFCS V

INCREASED DEPENDENCE

70
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Classification of CP
Part of Body Involved

Monoplegic Hemiplegic Diplegic Quadriplegic

71
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Classification

Type of Movement

Spastic 75% Dyskinetic 10%

Ataxic
Mixed

Hypotonic

72
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Diagnosis

• No Lab Biomarker- Clinical Diagnosis

• Why Early Detection is Necessary?

• Early Intervention Improves Neuroplasticity
• Monitoring and Treatment of Known Complications of CP
• Parents Experience more Stress if Dissatisfied by Diagnosis

73
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Diagnosis
Pathways for Diagnosis

Infants < 5 Months of Age Infants > 5 Months Of Age

Abnormal Motor Function Hammersmith Infant
Detected as “Absent Fidgety” Neurological Evaluation
On Prechtl’s General (HINE) Score less than 73
Movements Assessment
And Abnormal MRI- 95% And Abnormal MRI- 90%
Specifity Specifity
74
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Associated Conditions

Visual Impairment – 28% Intellectual Disability – 52%

Hearing Impairment – 12% Epilepsy – 42%

Speech & Language – 38% Gastrointestinal

75
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Visual Impairments

• Strabismus

• Retinopathy of Prematurity

• Homonymous Hemianopsia

• At Risk for:
• High Myopia, Gaze Dysfunction

76
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Spasticity Compass
Intrathecal
Generalized Baclofen
Baclofen
Pump
Traditional
Selective
Dorsal Root Diazepam Tizanidine
Rhizotomy
Permanent
Reversible

Orthopedic
Botulinum
Surgery Focal Inj
Selective
Dorsal Root Phenol Inj
Rhizotomy
Focal
77
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Hip Surveillance
Child with CP

Initiate Hip Surveillance

Complete Clinical Assessment X-Rays (if Indicated)

Assess GMFCS Level

Pain AP Pelvis View
Gait Type Measure Migration Percentage
Hip PROM
78
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Hip Surveillance

If one of the following?

•Pain at Hip Joint
•Pain on Physical Examination
•Migration Percentage > 30%
•Hip Abduction < 30
Yes No

Refer to Physician (Paediatric

Orthopedic Specialist, Paediatric Continue Surveillance
PM&R Specialist)
79
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Management of Osteoporosis
Child with CP at Risk for Osteoporosis
PREVENTION

Calcium Intake:
Vitamin D: Promote
•1-3 yrs= 700mg elem Ca
•800-1000IU starting Weight
•4-8 yrs= 1000mg elem Ca
dose Bearing
•9-18 yrs= 1300mg elem Ca

Investigations:
Vit D Level at Baseline and at 6 Months after Supplementation
80
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Management of Osteoporosis
Child with Osteoporosis

Lab Tests:
TREATMENT

•Calcium DXA Scans:

X-rays:
•Phosphate •Consider Z-
If needed
•PTH score
•Vit D3

•Ensure Adequate Vit D & Calcium

•Consider Bisphosphonates
81
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Hemiplegic CP Gait Classification

82
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Orthotics used in CP
Ankle Foot Orthoses

Articulated Non- Articulated

AFO Rigid PLSO FRO SMO

83
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Orthopedic Management

Soft Tissue Transfers Osteotomies

Lengthening
•Gastrocnemius •Spilt Posterior •Hip
Recession Tibialis Transfer Reconstruction –
•Adductor •Rectus Femorus VDRO +/- Pelvic
Recession Transfer Osteotomies
•Derotational
Osteotomies

84
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Assistive Devices

CP Chair CP Chair CP Chair

85
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Recent Advances

Robotic Rehabilitation

Lokomat Pediatric Armeo Spring Pediatric

86
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Recent Advances

• Neuromuscular Electrical Stimulation

• Walkaide

87
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Literature Review

88
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Epidemiology
Prevalence of Cerebral Palsy
4
3.4
3.5
3 2.9
3
2.5 USA
2 India
1.5 1.1
Pakistan
1 Bangladesh
0.5
0
Prevalence per 1000 children
89
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
CP Patients 2017-2021 AFIRM

Gender Distribution

42%

58% Male
Female

90
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
CP Patients 2017-2021AFIRM

Diplegic 1996

Quadriplegic 1901

Patients
Hemiplegic 740

Other 366

0 500 1000 1500 2000 2500

Ref: Ayaz, S Khan, S., Saeed, F.. (2021). severity of depression and anxiety among caregivers of children with cerebral palsy and their correlation with functional
capabilities of the children.
91
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Literature Review
Mild Moderate Severe
74.2
67.2
• Severity of Depression and
Anxiety among Caregivers
of Children with Cerebral 25
17.2
Palsy 7.5 8.6

Anxiety Depression
Ref: Khan, S., Saeed, F., & Ayaz, S. (2021). severity of depression and anxiety among caregivers of children with cerebral palsy and their correlation with functional
capabilities of the children.
92
CASE PRESENTATION CASE DISCUSSION LITERATURE REVIEW
 Cerebral Palsy: Every Child Matters
Conclusion
• Early involvement of PM&R specialist for Comprehensive
Rehabilitation of Child with CP is ESSENTIAL

• Cerebral palsy is a life long diagnosis with challenges as the child

enters puberty / adulthood - requires regular monitoring

80
Cerebral Palsy: Every Child Matters
References
 Cerebral Palsy: Every Child Matters
References
• Novak, I., Morgan, C., Fahey, M. et al. State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for
Preventing and Treating Children with Cerebral Palsy. Curr Neurol Neurosci Rep 20, 3 (2020). https://doi.org/10.1007/s11910-
020-1022-z
• Gallagher C, Sheedy M, Graham HK. Integrated management with botulinum neurotoxin A. In: Panteliadis CP, ed. Cerebral palsy.
A multidisciplinary approach. Munchen, Germany: Dustri-Verlag; 2011:213-236
• Fehlings D, Brown L, Harvey A, Himmelmann K, Lin JP, Macintosh A, Mink JW, Monbaliu E, Rice J, Silver J, Switzer L, Walters I.
Pharmacological and neurosurgical interventions for managing dystonia in cerebral palsy: a systematic review. Dev Med Child
Neurol. 2018 Apr;60(4):356-366. doi: 10.1111/dmcn.13652. Epub 2018 Feb 6. PMID: 29405267.
• Novak I, Morgan C, Adde L, Blackman J, Boyd RN, Brunstrom-Hernandez J, Cioni G, Damiano D, Darrah J, Eliasson AC, de Vries LS,
Einspieler C, Fahey M, Fehlings D, Ferriero DM, Fetters L, Fiori S, Forssberg H, Gordon AM, Greaves S, Guzzetta A, Hadders-Algra
M, Harbourne R, Kakooza-Mwesige A, Karlsson P, Krumlinde-Sundholm L, Latal B, Loughran-Fowlds A, Maitre N, McIntyre S,
Noritz G, Pennington L, Romeo DM, Shepherd R, Spittle AJ, Thornton M, Valentine J, Walker K, White R, Badawi N. Early,
Accurate Diagnosis and Early Intervention in Cerebral Palsy: Advances in Diagnosis and Treatment. JAMA Pediatr. 2017 Sep
1;171(9):897-907. doi: 10.1001/jamapediatrics.2017.1689. Erratum in: JAMA Pediatr. 2017 Sep 1;171(9):919. PMID: 28715518.
• Gordon GS & Simkiss DE . A systematic review of the evidence for hip surveillance in children with cerebral palsy. J Bone Joint
Surg - Br 2006; 88 - B : 1492 - 6. doi:10.1302/0301 - 620X.88B. 18114.
• Walshe M, Smith M, Pennington L. Interventions for drooling in children with cerebral palsy. Cochrane Database Syst Rev. 2012
Feb 15;(2):CD008624. doi: 10.1002/14651858.CD008624.pub2. Update in: Cochrane Database Syst Rev. 2012;11:CD008624.
PMID: 22336850.
 “
"A hero is an ordinary
individual who finds the
strength to persevere and
endure in spite of
overwhelming obstacles."
-Christopher Reeve
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