Cerebral palsy

==Diagnosis==
The diagnosis of cerebral palsy has historically rested on the person's history and physical examination and is generally assessed at a young age. A [[general movements assessment]], which involves measuring movements that occur spontaneously among those less than four months of age, appears most accurate.<ref name="McI2011" /><ref name="bosanquet_2013" /> Children who are more severely affected are more likely to be noticed and diagnosed earlier. Abnormal muscle tone, delayed motor development and persistence of [[primitive reflexes]] are the main early symptoms of CP.<ref name="oxfordnutritionchapter" /> Symptoms and diagnosis typically occur by the age of two,<ref name="research gaps 2016" /> although depending on factors like malformations and congenital issues,<ref name=":1">{{Cite web|title=Cerebral Palsy from Birth Injury|url=https://www.birthinjuryguide.org/birth-injury-types/cerebral-palsy/|access-date=2022-01-04|website=Birth Injury Guide|date=3 January 2022 |language=en-US}}</ref> persons with milder forms of cerebral palsy may be over the age of five, if not in adulthood, when finally diagnosed.<ref name="autogenerated1" /> 

Cognitive assessments and medical observations are also useful to help confirm a diagnosis. Additionally, evaluations of the child's mobility, speech and language, hearing, vision, gait, feeding and digestion are also useful to determine the extent of the disorder.<ref name=":1" /> Early diagnosis and intervention are seen as being a key part of managing cerebral palsy.<ref>{{cite journal | vauthors = Graham D, Paget SP, Wimalasundera N | title = Current thinking in the health care management of children with cerebral palsy | journal = The Medical Journal of Australia | volume = 210 | issue = 3 | pages = 129–135 | date = February 2019 | pmid = 30739332 | doi = 10.5694/mja2.12106 | s2cid = 73424991 }}</ref> Machine learning algorithms facilitate automatic early diagnosis, with methods such as deep neural network<ref>{{cite journal | vauthors = McCay KD, Ho ES, Shum HP, Fehringer G, Marcroft C, Embleton ND |title=Unifying Person and Vehicle Re-identification |journal=IEEE Access |volume=8 |issue=1 |page=2169-3536 |year=2020 |doi=10.1109/ACCESS.2020.2980269|s2cid=214623895 |doi-access=free }}</ref> and geometric feature fusion<ref>{{cite journal | vauthors = McCay KD, Hu P, Shum HP, Woo WL, Marcroft C, Embleton ND, Munteanu A, Ho ES | title = A Pose-Based Feature Fusion and Classification Framework for the Early Prediction of Cerebral Palsy in Infants | journal = IEEE Transactions on Neural Systems and Rehabilitation Engineering | volume = 30 | pages = 8–19 | year = 2022 | pmid = 34941512 | doi = 10.1109/TNSRE.2021.3138185 | s2cid = 245457921 | doi-access = free }}</ref> producing high accuracy in predicting cerebral palsy from short videos.  It is a [[developmental disability]].<ref name="McI2011" />

Once a person is diagnosed with cerebral palsy, further diagnostic tests are optional. [[Neuroimaging]] with [[CT scan|CT]] or [[MRI]] is warranted when the cause of a person's cerebral palsy has not been established. An MRI is preferred over CT, due to diagnostic yield and safety. When abnormal, evidence from neuroimaging may suggest the timing of the initial damage. The CT or MRI is also capable of revealing treatable conditions, such as [[hydrocephalus]], [[porencephaly]], [[arteriovenous malformation]], [[subdural hematoma]]s and [[subdural hygroma|hygromas]], and a vermian tumour<ref name="pmid2602010" /> (which a few studies suggest are present 5–22% of the time). Furthermore, abnormalities detected by neuroimaging may indicate a high likelihood of associated conditions, such as [[epilepsy]] and intellectual disability.<ref>{{cite journal | vauthors = Ashwal S, Russman BS, Blasco PA, Miller G, Sandler A, Shevell M, Stevenson R | title = Practice parameter: diagnostic assessment of the child with cerebral palsy: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society | journal = Neurology | volume = 62 | issue = 6 | pages = 851–863 | date = March 2004 | pmid = 15037681 | doi = 10.1212/01.WNL.0000117981.35364.1B | doi-access = free | collaboration = Quality Standards Subcommittee of the American Academy of Neurology; Practice Committee of the Child Neurology Society }}</ref> There is a small risk associated with sedating children to facilitate a clear MRI.<ref name="autogenerated1" />

<!-- timing and differential diagnosis -->
The age when CP is diagnosed is important, but medical professionals disagree over the best age to make the diagnosis.<ref name="bosanquet_2013" /> The earlier CP is diagnosed correctly, the better the opportunities are to provide the child with physical and educational help, but there might be a greater chance of confusing CP with another problem, especially if the child is 18 months of age or younger.<ref name="bosanquet_2013" /> Infants may have temporary problems with muscle tone or control that can be confused with CP, which is permanent.<ref name="bosanquet_2013" /> A metabolism disorder or tumors in the nervous system may appear to be CP; metabolic disorders, in particular, can produce brain problems that look like CP on an MRI.<ref name="NINDS2013" /> Disorders that deteriorate the [[white matter]] in the brain and problems that cause spasms and weakness in the legs, may be mistaken for CP if they first appear early in life.<ref name="bosanquet_2013" /> However, these disorders get worse over time, and CP does not<ref name="bosanquet_2013" /> (although it may change in character).<ref name="NINDS2013" /> In infancy it may not be possible to tell the difference between them.<ref name="bosanquet_2013" /> In the UK, not being able to sit independently by the age of 8 months is regarded as a clinical sign for further monitoring.<ref name="autogenerated1" /> [[Fragile X syndrome]] (a cause of autism and intellectual disability) and general intellectual disability must also be ruled out.<ref name="bosanquet_2013" /> Cerebral palsy specialist John McLaughlin recommends waiting until the child is 36 months of age before making a diagnosis because, by that age, motor capacity is easier to assess.<ref name="bosanquet_2013" />

===Classification===
CP is classified by the types of motor impairment of the limbs or organs, and by restrictions to the activities an affected person may perform.<ref name="rethlefsen_2010" /> The [[Gross Motor Function Classification System]]-Expanded and Revised and the [[Manual Ability Classification System]] are used to describe mobility and manual dexterity in people with cerebral palsy, and recently the [[Communication Function Classification System]], and the Eating and Drinking Ability Classification System have been proposed to describe those functions.<ref name="multidisciplinary455" /> There are three main CP classifications by motor impairment: spastic, ataxic, and dyskinetic. Additionally, there is a mixed type that shows a combination of features of the other types. These classifications reflect the areas of the brain that are damaged.<ref>{{cite book | vauthors = Ogoke C |title=Clinical Classification of Cerebral Palsy |date=2018 |url=https://www.researchgate.net/publication/329785522 |access-date=21 March 2021}}</ref>

Cerebral palsy is also classified according to the topographic distribution of muscle spasticity.<ref name="Becher" /> This method classifies children as [[spastic diplegia|diplegic]], (bilateral involvement with leg involvement greater than arm involvement), [[spastic hemiplegia|hemiplegic]] (unilateral involvement), or [[spastic quadriplegia|quadriplegic]] (bilateral involvement with arm involvement equal to or greater than leg involvement).<ref name="O'Shea" /><ref name="Becher" />

====Spastic====
{{main|Spastic cerebral palsy}}
Spastic cerebral palsy is the type of cerebral palsy characterized by [[spasticity]] or high muscle tone often resulting in stiff, jerky movements.<ref name=":0:" /> Itself an [[umbrella term]] encompassing [[spastic hemiplegia]], [[spastic diplegia]], [[spastic quadriplegia]] and – where solely one limb or one specific area of the body is affected – spastic monoplegia. Spastic cerebral palsy affects the [[motor cortex]]<ref name=":0:" /> of the brain, a specific portion of the [[cerebral cortex]] responsible for the planning and completion of voluntary movement.<ref>{{Cite web|url=https://nba.uth.tmc.edu/neuroscience/m/s3/chapter03.html|title=Chapter 3: The motor cortex| vauthors = Knierim J |date=2020|website=Neuroscience online: An electronic textbook of the neurosciences from the University of Texas at Houston|url-status=dead|archive-url=https://web.archive.org/web/20191217070517/https://nba.uth.tmc.edu/neuroscience/m/s3/chapter03.html|archive-date=17 December 2019|access-date=4 March 2020}}</ref>  Spastic CP is the most common type of overall cerebral palsy, representing about 80% of cases.<ref>{{Cite web|url=https://www.cdc.gov/ncbddd/cp/facts.html|title=What is Cerebral Palsy? {{!}} CDC|last=CDC|date=2018-04-18|website=Centers for Disease Control and Prevention|language=en-us|access-date=2020-03-05}}</ref> [[Botulinum toxin]] is effective in decreasing [[spasticity]].<ref name=Farag2020/> It can help increase range of motion which could help mitigate CPs effects on the growing bones of children.<ref name=Farag2020/> There may be an improvement in motor functions in the children and ability to walk. however, the main benefit derived from botulinum toxin A comes from its ability to reduce muscle tone and spasticity and thus prevent or delay the development of fixed muscle contractures.<ref name=Farag2020/><ref>{{cite journal | vauthors = Nolan KW, Cole LL, Liptak GS | title = Use of botulinum toxin type A in children with cerebral palsy | journal = Physical Therapy | volume = 86 | issue = 4 | pages = 573–584 | date = April 2006 | pmid = 16579673 | doi = 10.1093/ptj/86.4.573 | doi-access = free }}</ref>

====Ataxic====
{{main|Ataxic cerebral palsy}}
Ataxic cerebral palsy is observed in approximately 5–10% of all cases of cerebral palsy, making it the least frequent form of cerebral palsy.<ref>{{cite journal | vauthors = McHale DP, Jackson AP, Levene MI, Corry P, Woods CG, Lench NJ, Mueller RF, Markham AF | title = A gene for ataxic cerebral palsy maps to chromosome 9p12-q12 | journal = European Journal of Human Genetics | volume = 8 | issue = 4 | pages = 267–272 | date = April 2000 | pmid = 10854109 | doi = 10.1038/sj.ejhg.5200445 | doi-access = free }}</ref> Ataxic cerebral palsy is caused by damage to cerebellar structures.<ref>{{cite journal | vauthors = Cheney PD |title=Pathophysiology of the corticospinal system and basal ganglia in cerebral palsy |journal= Mental Retardation and Developmental Disabilities Research Reviews |volume=3 |pages=153–167 |year=1997 |doi=10.1002/(SICI)1098-2779(1997)3:2<153::AID-MRDD7>3.0.CO;2-S |issue=2}}</ref> Because of the damage to the [[cerebellum]], which is essential for coordinating muscle movements and balance, patients with ataxic cerebral palsy experience problems in coordination, specifically in their arms, legs, and trunk. Ataxic cerebral palsy is known to decrease muscle tone.<ref>{{cite journal | vauthors = Straub K, Obrzut JE |title=Effects of cerebral palsy on neurophsyological function |journal=Journal of Developmental and Physical Disabilities |volume=21 |pages=153–167 |year=2009 |doi=10.1007/s10882-009-9130-3 |issue=2|s2cid=144152618 }}</ref> The most common manifestation of ataxic cerebral palsy is intention (action) [[tremor]], which is especially apparent when carrying out precise movements, such as tying shoe laces or writing with a pencil. This symptom gets progressively worse as the movement persists, making the hand shake. As the hand gets closer to accomplishing the intended task, the trembling intensifies, which makes it even more difficult to complete.<ref name="O'Shea" />

====Dyskinetic====
{{main|Dyskinetic cerebral palsy}}
Dyskinetic cerebral palsy (sometimes abbreviated DCP) is primarily associated with damage to the [[basal ganglia]] and the [[substantia nigra]] in the form of [[lesions]] that occur during brain development due to [[bilirubin]] [[encephalopathy]] and hypoxic-ischemic [[brain]] injury.<ref name="Hou et al" /> DCP is characterized by both [[hypertonia]] and [[hypotonia]], due to the affected individual's inability to control muscle tone.<ref name="O'Shea" /> Clinical diagnosis of DCP typically occurs within 18 months of birth and is primarily based upon motor function and [[neuroimaging]] techniques.<ref name="ADCP" /><ref name="Mann" />
Dyskinetic cerebral palsy is an [[extrapyramidal system|extrapyramidal]] form of cerebral palsy.<ref name="Jones" /> Dyskinetic cerebral palsy can be divided into two different groups; [[choreoathetosis]] and [[dystonia]].<ref name="O'Shea" /> Choreo-athetotic CP is characterized by involuntary movements, whereas dystonic CP is characterized by slow, strong contractions, which may occur locally or encompass the whole body.<ref name="Becher" />

====Mixed====
Mixed cerebral palsy has symptoms of dyskinetic, ataxic and spastic CP appearing simultaneously, each to varying degrees, and both with and without symptoms of each. Mixed CP is the most difficult to treat as it is extremely heterogeneous and sometimes unpredictable in its symptoms and development over the lifespan.<ref>{{Cite news |date=2023-10-05 |title=World Cerebral Palsy Day 2023: What is it and how does it affect a person? |url=https://www.bbc.com/newsround/67018528 |access-date=2024-03-16 |work=BBC Newsround |language=en-GB}}</ref><ref>{{Cite journal |title=Multi-Organ Dysfunction in Cerebral Palsy |journal=NLM|date=2021 |pmc=8382237 |volume=9 |doi=10.3389/fped.2021.668544 |doi-access=free |pmid=34434904 | vauthors = Allen J, Zareen Z, Doyle S, Whitla L, Afzal Z, Stack M, Franklin O, Green A, James A, Leahy TR, Quinn S, Elnazir B, Russell J, Paran S, Kiely P, Roche EF, McDonnell C, Baker L, Hensey O, Gibson L, Kelly S, McDonald D, Molloy EJ }}</ref><ref>{{Cite web |last=Visco |first=Rory |date=2023-11-09 |title=Early detection, societal support needed to combat cerebral palsy in the PHL {{!}} Rory Visco |url=https://businessmirror.com.ph/2023/11/09/early-detection-societal-support-needed-to-combat-cerebral-palsy-in-the-phl/ |access-date=2024-03-16 |website=BusinessMirror |language=en-US}}</ref><ref>{{Cite web |title=Cerebral Palsy {{!}} National Institute of Neurological Disorders and Stroke |url=https://www.ninds.nih.gov/health-information/disorders/cerebral-palsy |access-date=2024-03-16 |website=www.ninds.nih.gov |language=en}}</ref>

=== Gait classification ===
[[File:Amsterdam Gait Classification gb.jpg|thumb|The [[Orthotics#Definition of the orthotic functions in cases of paralysis caused by cerebral palsy and traumatic brain injury|Amsterdam Gait Classification]] facilitates the assessment of the gait pattern in CP patients. It helps to facilitate communication in the interdisciplinary team between those affected, doctors, physiotherapists and orthotists.]]
In patients with spastic hemiplegia or diplegia, various gait patterns can be observed, the exact form of which can only be described with the help of complex gait analysis systems. In order to facilitate interdisciplinary communication in the interdisciplinary team between those affected, doctors, physiotherapists and orthotists, a simple description of the gait pattern is useful. J. Rodda and H. K. Graham already described in 2001 how gait patterns of CP patients can be more easily recognized and defined gait types which they compared in a classification. They also described that gait patterns can vary with age.<ref>{{cite journal | vauthors = Rodda J, Graham HK | title = Classification of gait patterns in spastic hemiplegia and spastic diplegia: a basis for a management algorithm | journal = European Journal of Neurology | volume = 8 | issue = Suppl 5 | pages = 98–108 | date = November 2001 | pmid = 11851738 | doi = 10.1046/j.1468-1331.2001.00042.x | s2cid = 45860264 }}</ref> Building on this, the [[Orthotics#Definition of the orthotic functions in cases of paralysis caused by cerebral palsy and traumatic brain injury|Amsterdam Gait Classification]] was developed at the free university in Amsterdam, the VU medisch centrum. 

A special feature of this classification is that it makes different gait patterns very easy to recognize and can be used in CP patients in whom only one leg and both legs are affected. According to the Amsterdam Gait Classification, five gait types are described. To assess the gait pattern, the patient is viewed visually or via a video recording from the side of the leg to be assessed. At the point in time at which the leg to be viewed is in mid stance and the leg not to be viewed is in mid swing, the knee angle and the contact of the foot with the ground are assessed on the one hand.<ref name=":0">{{Cite journal| vauthors = Grunt S |title=Geh-Orthesen bei Kindern mit Cerebralparese|journal=Pediatrica|volume=18|pages=30–34}}</ref>

Classification of the gait pattern according to the Amsterdam Gait Classification: In gait type 1, the knee angle is normal and the foot contact is complete. In gait type 2, the knee angle is hyperextended and the foot contact is complete. In gait type 3, the knee angle is hyperextended and foot contact is incomplete (only on the forefoot). In gait type 4, the knee angle is bent and foot contact is incomplete (only on the forefoot). With gait type 5, the knee angle is bent and the foot contact is complete.<ref name=":0" />

Gait types 5 is also known as crouch gait.<ref>{{Cite journal |last=Armand |first=Stephan |date=Dec 2016 |title=Gait analysis in children with cerebral palsy |journal=Paediatrics and Child Health |language=English |volume=18 |issue=9 |pages=405–409 |doi=10.1016/j.paed.2008.05.013 |pmid=28698802 |pmc=5489760 |issn=1751-7222}}</ref>