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## Complete Summary

#### GUIDELINE 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.

#### BIBLIOGRAPHIC SOURCE(S)

Ashwal S, Russman BS, Blasco PA, Miller G, Sandler A, Shevell M,
Stevenson R. 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. Neurology 2004 Mar 23;62(6):851-63. \[77 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15037681)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Cerebral palsy (CP)

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Screening

#### CLINICAL SPECIALTY

Neurology\
Pediatrics

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

-   To review data regarding the value and role of diagnostic tests used
    to evaluate children diagnosed with cerebral palsy (CP)

-   To review evidence regarding the prevalence of associated problems
    such as epilepsy, mental retardation, speech and language disorders,
    and ophthalmologic and hearing impairments, and the need for their
    systematic evaluation

#### TARGET POPULATION

Children suspected of having cerebral palsy (CP)

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Neuroimaging including magnetic resonance imaging (MRI) and computed
    tomography (CT)

2.  Metabolic and genetic testing

3.  Coagulation studies

4.  Evaluations for associated conditions including
    electroencephalography (EEG) for epilepsy and screening for mental
    retardation, ophthalmologic and hearing impairments, and speech and
    language disorders

#### MAJOR OUTCOMES CONSIDERED

Predictive value of diagnostic tests

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Literature searches were conducted with the assistance of the University
of Minnesota Biomedical Information Services for relevant articles
published from 1980 to March 2002. Medline, CINAHL, and Healthstar
databases were searched for relevant articles published from 1966 to
2002, in the English language, using the following key words: cerebral
palsy (CP), magnetic resonance imaging, MRI, computed axial tomography,
CT scan, single photon emission tomography, SPECT, metabolic disease,
thrombophilia, brain stem evoked potentials, sensory evoked potentials,
visual evoked potentials, electroencephalography (EEG), seizures,
epilepsy, vision loss, hearing loss, developmental delay, and speech and
language delay.

Articles were excluded if the tests were ordered for reasons other than
to establish the etiology. Only studies that contained more than 20
patients were included; smaller case series were excluded. The ages of
infants and children included in these studies were similar to the ages
of children typically seen for diagnostic evaluation so it was believed
that the evidence-based recommendations included in this parameter were
appropriate. It was also believed that as CP is usually due to a static
process, it was unlikely for neuroimaging studies to change over time so
that data from studies done in older children with CP were valid
regarding etiologic yield.

#### NUMBER OF SOURCE DOCUMENTS

Approximately 350 titles and abstracts were reviewed for content
regarding the establishment of the etiology of cerebral palsy (CP)

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Classification Scheme for Determining the Yield of Established
Diagnostic and Screening Tests**

**Class I**: A statistical, population-based sample of patients studied
at a uniform point in time (usually early) during the course of the
condition. All patients undergo the intervention of interest. The
outcome, if not objective, is determined in an evaluation that is masked
to the patients´ clinical presentations.

**Class II**: A statistical, non-referral-clinic-based sample of
patients studied at a uniform point in time (usually early) during the
course of the condition. Most (\>80%) patients undergo the intervention
of interest. The outcome, if not objective, is determined in an
evaluation that is masked to the patients\' clinical presentations.

**Class III**: A selected, referral-clinic-based sample of patients
studied during the course of the condition. Some patients undergo the
intervention of interest. The outcome, if not objective, is determined
in an evaluation by someone other than the treating physician.

**Class IV**: Expert opinion, case reports, or any study not meeting
criteria for class I to III.

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Each article was reviewed, abstracted, and classified by a committee
member. Data extracted include first author, year, study population,
study design, number of patients, types of cerebral palsy (CP), results
of testing, and outcomes measured. A new four-tiered classification
scheme for determining the yield of established diagnostic and screening
tests developed by the Quality Standards Subcommittee was utilized as
part of this assessment (see \"Rating Scheme for the Strength of the
Evidence\" above). This classification scheme is different from the one
currently used in recently published practice parameters that evaluate
diagnostic, prognostic, or therapeutic articles. Depending on the
strength of this evidence, it was decided whether specific
recommendations could be made, and if so, the level of strength of these
recommendations (see \"Rating Scheme for the Strength of the
Recommendations\" below).

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Other

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

When formulating the recommendations the guideline developers considered
the *magnitude* of the effect (benefit or harm of therapy, accuracy of
tests, yield of studies) and the relative *value* of various outcomes.
Under most circumstances, there is a direct link between the level of
evidence used to formulate conclusions and the strength of the
recommendation. This linkage is illustrated in Appendix 9 of the 2004
AAN Guideline Process Manual (see Companion Documents field). Thus, an
\"established as\" (two class I) conclusion supports a \"should be
done\" (level A) recommendation; a \"probably effective\" (two class II)
conclusion supports a \"should be considered\" (level B) recommendation;
a \"possibly effective\" (two class III) conclusion supports a \"may be
considered\" recommendation. In those circumstances where the evidence
indicates that the intervention is not effective or useful, wording was
modified. For example, if multiple adequately powered class I studies
demonstrated that an intervention is not effective, the recommendation
read, \"should not be done.\"

There are important exceptions to the rule of having a direct linkage
between the level of evidence and the strength of recommendations. Some
situations where it may be necessary to break this linkage are listed
below:

-   A statistically significant but marginally important benefit of the
    intervention is observed

-   The intervention is exorbitantly costly

-   Superior and established alternative interventions are available

-   There are competing outcomes (both beneficial and harmful) that
    cannot be reconciled

Under such circumstances the guideline developers may have downgraded
the level of the recommendation.

Edlund W, Gronseth G, So Y, Franklin G. Clinical practice guideline
process manual. St. Paul (MN): American Academy of Neurology (AAN);
2004. 49 p.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Translation of Evidence to Recommendations**

**Level A** rating requires at least one convincing class I study or at
least two consistent, convincing class II studies.

**Level B** rating requires at least one convincing class II study or
overwhelming class III evidence.

**Level C** rating requires at least two convincing class III studies.

**Rating of Recommendations**

**A** = Established as useful/predictive or not useful/predictive for
the given condition in the specified population.

**B** = Probably useful/predictive or not useful/predictive for the
given condition in the specified population.

**C** = Possibly useful/predictive or not useful/predictive for the
given condition in the specified population.

**U** = Data inadequate or conflicting. Given current knowledge, test,
predictor is unproven.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Guidelines were approved by the Quality Standards Subcommittee in March
2003, the American Academy of Neurology (AAN) Practice Committee on
August 9, 2003, and the AAN Board of Directors on October 18, 2003.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions of the strength of the recommendations (A, B, C, U) and
classification of the evidence (Class I through Class IV) are provided
at the end of the \"Major Recommendations\" field.

**Neuroimaging**

1.  Neuroimaging is recommended in the evaluation of a child with
    cerebral palsy (CP) if the etiology has not been established; for
    example, by perinatal imaging (**Level A, class I and II
    evidence**).

2.  Magnetic resonance imaging (MRI), when available, is preferred to
    computed tomography (CT) scanning because of the higher yield of
    suggesting an etiology and timing of insult leading to CP (**Level
    A, class I--III evidence**).

**Metabolic and Genetic Testing**

1.  Metabolic and genetic studies should not be routinely obtained in
    the evaluation of the child with CP (**Level B, class II and III
    evidence**).

2.  If the clinical history or findings on neuroimaging do not determine
    a specific structural abnormality or if there are additional and
    atypical features in the history or clinical examination, metabolic
    and genetic testing should be considered (**Level C, class III and
    IV**).

3.  Detection of a brain malformation in a child with CP warrants
    consideration of an underlying genetic or metabolic etiology
    (**Level C, class III and IV evidence**).

**Coagulopathies**

1.  Because the incidence of unexplained cerebral infarction seen with
    neuroimaging is high in children with hemiplegic CP, diagnostic
    testing for a coagulation disorder should be considered (**Level B,
    class II--III evidence**). There is insufficient evidence to be
    precise as to what studies should be ordered.

**Associated Conditions**

*Epilepsy*

1.  An electroencephalogram (EEG) should not be obtained for the purpose
    of determining the etiology of CP (**Level A; class I and II
    evidence**).

2.  An EEG should be obtained when a child with CP has a history or
    examination features suggesting the presence of epilepsy or an
    epileptic syndrome (**Level A; class I and II evidence**).

*Mental Retardation, Ophthalmologic Impairments, Speech and Language
Disorders, Hearing Impairments*

1.  Because of the high incidence of associated conditions, children
    with CP should be screened for mental retardation, ophthalmologic
    and hearing impairments, and speech and language disorders (**Level
    A, class I and II evidence**). Nutrition, growth, and other aspects
    of swallowing dysfunction should be monitored. Further specific
    evaluations are warranted if screening suggests areas of impairment.

**[Definitions]{.underline}**:

**Rating of Recommendation**

**A** = Established as useful/predictive or not useful/predictive for
the given condition in the specified population.

**B** = Probably useful/predictive or not useful/predictive for the
given condition in the specified population.

**C** = Possibly useful/predictive or not useful/predictive for the
given condition in the specified population.

**U** = Data inadequate or conflicting. Given current knowledge, test,
predictor is unproven.

**Translation of Evidence to Recommendations**

**Level A** rating requires at least one convincing class I study or at
least two consistent, convincing class II studies.

**Level B** rating requires at least one convincing class II study or
overwhelming class III evidence.

**Level C** rating requires at least two convincing class III studies.

**Classification Scheme for Determining the Yield of Established
Diagnostic and Screening Tests**

**Class I**: A statistical, population-based sample of patients studied
at a uniform point in time (usually early) during the course of the
condition. All patients undergo the intervention of interest. The
outcome, if not objective, is determined in an evaluation that is masked
to the patients´ clinical presentations.

**Class II**: A statistical, non-referral-clinic-based sample of
patients studied at a uniform point in time (usually early) during the
course of the condition. Most (\>80%) patients undergo the intervention
of interest. The outcome, if not objective, is determined in an
evaluation that is masked to the patients\' clinical presentations.

**Class III**: A selected, referral-clinic-based sample of patients
studied during the course of the condition. Some patients undergo the
intervention of interest. The outcome, if not objective, is determined
in an evaluation by someone other than the treating physician.

**Class IV**: Expert opinion, case reports, or any study not meeting
criteria for class I to III.

#### CLINICAL ALGORITHM(S)

A clinical algorithm was provided for the evaluation of the child with
cerebral palsy (CP).

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Accurate determination of the etiology of cerebral palsy (CP) has
    specific implications regarding treatment, prognosis, and ongoing
    medical management of associated conditions.

-   The importance of determining whether there is a malformation,
    genetic etiology, or injury and whether the injury is due to an
    acquired pre-, peri-, or postnatal process has obvious significance
    from the point of view of assessment of recurrence risk, counseling
    of families, and implementation of prevention programs, and when
    medicolegal issues arise.

-   Determining causality also helps limit further unnecessary testing.

-   Finally, understanding the etiology of CP has implications for
    prevention and intervention strategies.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This statement is provided as an educational service of the American
Academy of Neurology (AAN) and the Child Neurology Society (CNS). It is
based on an assessment of current scientific and clinical information.
It is not intended to include all possible proper methods of care for a
particular neurologic problem or all legitimate criteria for choosing to
use a specific procedure. Neither is it intended to exclude any
reasonable alternative methodologies. The AAN and the CNS recognize that
specific patient care decisions are the prerogative of the patient and
the physician caring for the patient, based on all of the circumstances
involved.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Patient Resources\
Quick Reference Guides/Physician Guides\
Slide Presentation

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Ashwal S, Russman BS, Blasco PA, Miller G, Sandler A, Shevell M,
Stevenson R. 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. Neurology 2004 Mar 23;62(6):851-63. \[77 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15037681)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 Mar 23

#### GUIDELINE DEVELOPER(S)

American Academy of Neurology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Academy of Neurology (AAN)

#### GUIDELINE COMMITTEE

Quality Standards Subcommittee of the American Academy of Neurology

Practice Committee of the Child Neurology Society

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*AAN Quality Standards Subcommittee Members*: Gary Franklin, MD, MPH
(Co-Chair); Gary Gronseth, MD (Co-Chair); Charles E. Argoff, MD; Stephen
Ashwal, MD (ex-officio); Christopher Bever, Jr., MD; Jody Corey-Bloom,
MD, PhD; John D. England, MD; Jacqueline French, MD (ex-officio); Gary
H. Friday, MD; Michael J. Glantz, MD; Deborah Hirtz, MD; Donald J.
Iverson, MD; David J. Thurman, MD; Samuel Wiebe, MD; William J. Weiner,
MD; Catherine Zahn, MD (ex-officio)

*Practice Committee of the Child Neurology Society Members*: Carmela
Tardo, MD (Chair); Bruce Cohen, MD (Vice-Chair); Elias Chalhub, MD; Roy
Elterman, MD; Murray Engel, MD; Bhuwan P. Garg, MD; Brian Grabert, MD;
Annette Grefe, MD; Michael Goldstein, MD; David Griesemer, MD; Betty
Koo, MD; Edward Kovnar, MD; Leslie Anne Morrison, MD; Colette Parker,
MD; Ben Renfroe, MD; Anthony Riela, MD; Michael Shevell, MD; Shlomo
Shinnar, MD; Herald Silverboard, MD; Russell Snyder, MD; Dean Timmons,
MD; Greg Yim, MD; Mary Anne Whelan, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: A list of American Academy of Neurology (AAN)
guidelines, along with a link to a Portable Document Format (PDF) file
for this guideline, is available at the [AAN Web
site](http://aan.com/go/practice/guidelines).

Print copies: Available from the AAN Member Services Center, (800)
879-1960, or from AAN, 1080 Montreal Avenue, St. Paul, MN 55116.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Practice parameter: diagnostic assessment of the child with cerebral
    palsy. AAN guideline summary for clinicians. St. Paul (MN): American
    Academy of Neurology. 2. p. Electronic copies available in Portable
    Document Format (PDF) from the [AAN Web
    site](http://aan.com/professionals/practice/guidelines/guideline_summaries/Child_Cerebral_Pasly_Guideline_for_Clinicians.pdf).

-   Slide presentation: practice parameter: diagnostic assessment of the
    child with cerebral palsy (CP). St. Paul (MN): American Academy of
    Neurology. 2004. Available in Power Point from the [AAN Web
    site](http://aan.com/professionals/practice/guidelines/pwr_pnt/CP_Educational_pres.ppt).

-   Edlund W, Gronseth G, So Y, Franklin G. Clinical practice guideline
    process manual. St. Paul (MN): American Academy of Neurology
    (AAN); 2004. 49 p. Electronic copies available in Portable Document
    Format (PDF) from the [AAN Web
    site](http://www.aan.com/globals/axon/assets/2535.pdf).

-   AAN guideline development process \[online\]. St. Paul (MN):
    American Academy of Neurology (AAN). Available from the [AAN Web
    site](http://www.aan.com/go/practice/guidelines/development).

#### PATIENT RESOURCES

The following is available:

Evaluating and diagnosing the child with cerebral palsy. AAN guideline
summary for parents and caregivers. St. Paul (MN): American Academy of
Neurology (AAN). 2 p.

Electronic copies: Available in Portable Document Format (PDF) from the
[AAN Web
site](http://aan.com/professionals/practice/guidelines/guideline_summaries/Child_Cerebral_Pasly_Guideline_for_Patient.pdf).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on August 17, 2004. The
information was verified by the guideline developer on September 9,
2004.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is
copyrighted by the American Academy of Neurology.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008