A quick course on cerebral palsy

Join me in my rabbit hole for a moment, SLP friends. Bring coffee. Last month, Developmental Medicine & Child Neurology had a whole issue on cerebral palsy (CP).

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Our search takes us back to 2017, when a HUGE group of researchers lead by Iona Novak described diagnosis and treatment options based on their systematic review (note: this research team also included SLPs and people with CP/parents of people with CP as authors, so we have the FULL EBP triangle going on here!). Cerebral palsy is a huge umbrella diagnosis; but in general, CP is defined as a non-progressive disorder of posture and movement related to an injury or some problem in the developing brain. It can be diagnosed between 1 and 2 years, and sometimes a provisional diagnosis is given until CP can be confirmed or ruled-out after a period of development, around 5 years. For a diagnosis of CP, a child has to demonstrate motor dysfunction and either abnormal neuroimaging or a risky clinical history (genetics, stroke, maternal health risks, etc.). Table 1 in Novak et al. will give you a thorough overview of identification and diagnosis.

Last month, Msall published a commentary on a recent paper by Boychuck et al., who surveyed international experts on CP to compile a list of red flags clinicians should keep in mind (see Table 3 or read the Msall’s one-page commentary for more information):

  • Children should be referred for evaluation if they demonstrate things like:

    • Holding hands in fists, asymmetry, or head lag after 4 months

    • Tightness in legs between 6–12 months

    • Requiring support to sit after 9 months

    • Hand preference before 12 months

  • Children should be referred for monitoring if they demonstrate:

    • A persistent startle after 6 months

    • Consistent toe-walking or asymmetric walking after 12 months

  • Children should be referred to SLPs any time there are feeding or communication delays or concerns

    • Speyer et al. reported a high prevalence of feeding (53.5%), drooling (44%), and swallowing (50.3%) problems in children with CP.

Thinking about the diagnostic process and transition to treatment, EI SLPs should be pretty well-versed in interacting with parents, but it’s always nice to have a reminder of parent priorities as they begin to plan for their child’s interventions. Byrne et al. conducted focus groups of parents and providers and found that overall, parents of children with CP want:

  • Honesty and directness from providers, with information specific to their child (not just a general prognosis)

  • Explanations of the assessments and tools used to make the diagnosis (including the names of the assessments)

  • Written material (it helps to be able to refer back)

  • Support from providers and assistance in securing services 

In terms of treatment in CP, EI is critical for development. We have to help build those brain connections and take advantage of early neuroplasticity. While CP is a motor disorder (so you will probably need involvement from PT and OT in some capacity), many children with CP have feeding and communication difficulties, so SLPs are likely to be involved on intervention teams. For communication, Novak et al. recommended supporting parent–child interaction, and considering AAC. If feeding is a concern, the team should assess swallowing safety because pneumonia is particularly risky for people with CP. For those of you providing family-centered services in natural environments, you’re already on the right track for service delivery for this population. McCoy et al. measured gross motor outcomes in children with CP, but their message is powerful for all EI providers. The number of therapy visits (including PT, OT, AND Speech) did not predict outcomes, but family-centered services and the focus of sessions (e.g., incorporating overall health and well-being and engaging in structured play activities) did. So keep coaching those parents on how to implement interventions in enjoyable and contextualized settings.

 

Boychuck, Z., Andersen, J., Bussieres, A., Fehlings, D., Kirton, A., Li, P., …, & Majnemer, A. (2019). International expert recommendations of clinical features to prompt referral for diagnostic assessment of cerebral palsy. Developmental Medicine & Child Neurology. doi: 10.1111/dmcn.14252.

Byrne, R., Duncan, A., Pickar, T., Burkhardt, S., Boyd, R., Neel, M. L., & Maitre, N. L. (2019). Comparing parent and provider priorities in discussions of early detection and intervention for infants with and at risk of cerebral palsy. Child: Care, Health, and Development. doi: 10.1111/cch.12707.

McCoy, S. W., Palisano, R., Avery, L., Jeffries, L., Fiss, A. L., Chiarello, L., & Hanna, S. (2019). Physical, occupational, and speech therapy for children with cerebral palsy. Developmental Medicine & Child Neurology. doi: 10.1111/dmcn.14325.

Msall, M. E. (2019). Establishing community pathways for the early recognition of cerebral palsy: Red flags, enablement, and family support. Developmental Medicine & Child Neurology. doi: 10.1111/dmcn.14314.

Novak, I., Morgan, C., Adde, L., Blackman, J., Boyd, R. N., Hernandez-Brunstrom, J., …, & Badawi, N. (2017). Early, accurate diagnosis and early intervention in cerebral palsy: Advances in diagnosis and treatment. JAMA Pediatrics. doi:10.1001/jamapediatrics.2017.1689.

Speyer, R., Cordier, R., Kim, J., Cocks, N., Michou, E., Wilkes-Gillan, S. (2019). Prevalence of drooling, swallowing, and feeding problems in cerebral palsy across the lifespan: A systematic review and meta-analyses. Developmental Medicine & Child Neurology. doi: 10.1111/dmcn.14316.