Abstract
Since the 1800s, there have been calls in the literature for the early diagnosis of cerebral palsy (CP). However, diagnosis still often occurs late, from 12 to 24 months in high income countries and as late as 5 years in low resource settings. This is after the optimal timeframe for applying interventions which could harness neuroplastic potential in the developing brain. Multiple barriers exist which affect clinicians’ confidence in diagnosing CP early. These range from the lack of definitive biomarkers to a lack of curative treatments for CP. Further barriers to diagnosis are proposed including; (a) difficulty finding a congruent fit with the definition of CP in an infant, where expected activity limitations might not yet be apparent; and (b) differences in the presentation of motor type and topography classifications between infants and children. These barriers may affect a clinicians’ confidence using “pattern recognition” in the differential diagnosis process. One of the central tenets of this paper is that diagnosis and classification are different, involving different instruments, and are more accurately conducted separately in infants, whereas they are fundamentally interconnected in older children and inform therapeutic decisions. Furthermore, we need to be careful not to delay early diagnosis because of the low reliability of early classification, but instead uncouple these two processes. Ongoing implementation of best practice for early detection requires creative solutions which might include universal screening for CP. Implementation and accompanying knowledge translation studies are underway to decrease the average age of diagnosis in CP.
Highlights
Definitions of cerebral palsy (CP) have been the subject of debate throughout history
The process of diagnosis and classification should be uncoupled, the earliest possible accurate classification of motor type and topography is recommended in the international guideline [9]
The use of Hammersmith Infant Neurological Examination (HINE) cut off scores and magnetic resonance imaging (MRI) are recommended for use with infants to predict motor severity [9], the strength of these recommendations is only conditional based on low quality evidence
Summary
Definitions of cerebral palsy (CP) have been the subject of debate throughout history. William Little, credited for first describing the condition that is CP in 1861 [1,2], described birth asphyxia as the cause of neurological disturbance in an infant. The term ‘cerebral palsies’ was first coined by William Osler [3], who recognized a heterogeneous group of disorders. In the 2007 consensus definition, the term ‘cerebral palsy’ was defined as “a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain” [4]. Recognized barriers include: (a) a lack of definitive biomarkers; (b) uneasiness about false positives; (c) the difficult conversation of giving the diagnosis and the resultant grief and perceived stigma; (d) the desire to rule out the differential diagnosis of every treatable condition first; (e) the lack of curative treatments and evidence for early interventions; and (f) making a diagnosis when faced with a lack of definitive signs on traditional clinical examination
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