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8/22/2019 Comorbidities in Cerebr
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Comorbidities in cerebral palsy and theirrelationship to neurologic subtype andGMFCS level
Michael I. Shevell, MD,
CM, FRCPC
Lynn Dagenais, BSc
Nicholas Hall, BSc
On behalf of the
REPACQConsortium*
ABSTRACT
Objective: Utilizing a population-based registry, the burden of comorbidity was ascertained in a
sample of children with cerebral palsy and stratified according to both neurologic subtype and
functional capability with respect to gross motor skills.
Methods: The Quebec Cerebral Palsy Registry was utilized to identify children over a 4-year birth
interval (1999–2002 inclusive) with cerebral palsy. Information on neurologic subtype classified
according to the qualitative nature and topographic distribution of the motor impairment on neu-
rologic examination, Gross Motor Function Classification System (GMFCS) categorization of mo-
tor skills, and the presence of certain comorbidities (cortical blindness, auditory limitations,
nonverbal communication skills, gavage feeding status, and coexisting afebrile seizures in the
prior 12 months) was obtained.
Results: The frequency of individual comorbidities, their proportional distribution, and mean num-
ber of occurrences basically falls into a significant dichotomous distribution. Across the spectrum
of comorbidities considered, these comorbidities are relatively infrequently encountered in those
with spastic hemiplegic or spastic diplegic variants or ambulatory GMFCS status (levels I–III),
while these entities occur at a frequent level for those with spastic quadriplegic, dyskinetic, or
ataxic-hypotonic variants or nonambulatory GMFCS status (levels IV and V).
Conclusion: The enhanced burdens of comorbidity are unevenly distributed in children with cere-
bral palsy in a manner that can be associated with either a specific neurologic subtype (spastic
quadriplegic, dyskinetic, ataxic-hypotonic) or nonambulatory motor status (Gross Motor Function
Classification System levels IV and V). This provides enhanced value to the utilization of these
classification approaches. Neurology ® 2009;72:2090–2096
GLOSSARY
GMFCSϭGross Motor Function Classification System; REPACQϭQuebec Cerebral Palsy Registry.
The sine qua non of cerebral palsy is early onset objective signs of motor impairment that isboth cerebral in origin and the product of a nonprogressive lesion to the developing CNS. 1 It
has been well recognized that this can occur in conjunction with a variety of comorbid condi-tions.2 The co-occurrence of these conditions are explicitly recognized in the most recentconsensus definition for cerebral palsy.3 Several complementary classification schemes for cate-
gorizing cerebral palsy have emerged over time. The most common in clinical use are a classifi-cation scheme based on neurologic subtype and another based on functional skills in the gross
motor domain.4-8
For many children with cerebral palsy, it is these co-occurring conditionsthat may often have the greatest impact on the child and family from varying perspectives. 1
Ideally, systematic programmatic follow-up of children with cerebral palsy will permit therecognition of these coexisting entities.9-12
Address correspondence and
reprint requests to Dr. Michael
Shevell, Room A-514, Montreal
Children’s Hospital, 2300
Tupper, Montreal, Quebec,
Canada, H3H [email protected]
*Members of the REPACQ Consortium are listed in the appendix.
From the Departments of Neurology/Neurosurgery and Pediatrics (M.I.S., N.H.), McGill University; Division of Pediatric Neurology (M.I.S.,
N.H.), Centre de Readaptation Marie-Enfant du CHU Ste Justine (L.D.); and Montreal Children’s Hospital–McGill University Health Center
(M.I.S., N.H.), Montreal, Quebec, Canada.
Disclosure: The MCH Foundation provided salary support for Dr. Shevell and the RSDBE of the FRSQ and the CP Research Chair of Laval
University provided operational funding of REPACQ.
2090 Copyright © 2009 by AAN Enterprises, Inc.
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Population-based cerebral palsy registries
provide an opportunity to capture the entire
spectrum of cerebral palsy in a community in
a relatively unbiased way.13 Identification of
readily available predictor variables will assist
us in such domains as counseling, prognosti-
cation, and selective program emphasis on
particular subgroups.
The objective of this study was to utilize a population-based registry to classify cerebral
palsy by both subtype and functional level
and identify the burden of certain comorbidi-
ties across the stratifications of each of these
classification schemes. As a corollary, associa-
tions between particular cerebral palsy sub-
types, either neurologic or functional, and
individual comorbidities were sought.
METHODS Subjects were recruited through the Quebec Ce-
rebral Palsy Registry (REPACQ). This Registry was established
in 1998 by a multidisciplinary consortium of clinicians and re-
searchers with an interest in cerebral palsy. After an initial effort
over 4 years in conjunction with international experts and then
existing cerebral palsy registries (i.e., Western Australia,14
SPCE15) to reach a consensus on the definition and diagnosis of
cerebral palsy, mechanisms of case ascertainment, data variables
to be collected, and mechanisms of data collection, the Registry
became operational in 2004 in 6 of 17 geographically defined
administrative health and social service regions of the province of
Quebec, representing roughly half of the province’s population
and annual births. Cases were ascertained through systematic
surveys of regionalized pediatric rehabilitation and medical ser-
vice providers. Quebec has a universal third party (i.e., govern-ment funded) program of medical and rehabilitation service
provision available to all provincial residents. Regionalization re-
quires that those children requiring rehabilitation service provi-
sion for their needs are serviced through local specialized centers
responsible for a specific defined geographic region. Once cases
were identified, parents (or guardians where necessary) were ap-
proached for consent to participate in the Registry. Once con-
sent was obtained, over 120 variables pertaining to each case
were sought through a combination of direct review of maternal
and child medical and rehabilitation records and parental (pref-
erably maternal) interview.
Cases were ascertained only once a child was beyond the age
of 2 years and where possible confirmed at 5 years of age. Cere-
bral palsy was defined as per recent consensus statements as a
nonprogressive motor impairment of early onset, that is presum-
ably cerebral in origin, which may or may not be associated with
developmental delays, cognitive disability, language impairment,
epilepsy, sensory (auditory or visual) loss, orthopedic abnormali-
ties, or behavioral difficulties.3,16,17 A recognized motor impair-
ment required objective changes in tone, muscle strength,
posture, reflexes, and motor skills on examination for diagnosis.
Nonprogressive referred to the underlying pathologic process
and not apparent clinical manifestations. Genetic and metabolic
disorders considered as per Badawi et al.18 were excluded from
consideration. Early onset meant signs and symptoms were evi-
dent prior to 1 year of age. By definition, neuromuscular disor-
ders and myelodysplasias were excluded from diagnosis. Data
were obtained in a systematic fashion by duly trained research
assistants according to established written procedures and train-
ing protocols and a subset was checked for accuracy prior to
registry inscription. Data were obtained on demographic fea-
tures, maternal medical and obstetric history, labor and delivery
of the affected child, neonatal course, age at onset, diagnostic
investigations and their results, type of cerebral palsy, gross mo-
tor functional status, various coexisting medical and comorbid
conditions, and medical and rehabilitation service provision
(both previously and at the time of inscription). Data extraction was conducted by trained local research assistants according to
standardized policies and procedures supervised consistently by a
single individual. A subset was randomly selected for indepen-
dent validation of accuracy. Ethical permission was obtained at
the local host institution (McGill University Health Center) and
each participating pediatric rehabilitation center.
For this study, subjects were children born in 1999–2002 (a
4-year inclusive birth cohort). When both were recorded the sub-
type of cerebral palsy and gross motor functional status was ex-
tracted. The subtype of cerebral palsy was classified according to the
quality and topographic pattern of motor impairment last docu-
mented by an objective assessment employing the following well-
utilized clinical scheme: 1) spastic-quadriplegic (spasticity
[symmetric or asymmetric] in all four limbs with equivalent or
greater spasticity in the upper extremities), spastic-hemiplegic (spas-
ticityrestricted to oneside of the body with relative variable involve-
ment of the upper and lower extremity), spastic-diplegic (spasticity
in the lower extremities far in excess of any discernable in the upper
extremities which or may not be relatively asymmetric), or spastic-
other (spasticityin onelimb or in alllimbsexceptone); 2) dyskinetic
(i.e., athetosis, chorea, or dystonia in the absence of objective weak-
ness or tone changes); 3) ataxic-hypotonic. Those with a mixed pro-
file of dyskinetic and spastic features were counted as dyskinetic.
Similarly, the last objective assessment was utilized to assign func-
tional mobility according to the Gross Motor Function Classifica-
tion System (GMFCS).19 This relativelyrecently developed measure
provides an assessment of a child’s gross motor function andabilitiesin early life emphasizing the stratification of function into categories
that capture meaningful differences for child and family from most
able (level I) to most limited (level V).8 Content validity, reliability,
consistency, and predictive validity have been established for this
now widely employed measure.20-22 Independent ambulation, with-
out(level I andlevel II) andwith assistance (level III),can be reliably
distinguished and inferred in this approach from nonambulation
(level IV and level V).
Several different comorbidities are the focus of this article;
cortical blindness, substantial auditory impairment, nonverbal
communication skills, gavage feeding status, and coexisting sei-
zures. The age of the children (between 2 and 5 years) precluded
reliable assessment of possible cognitive disability. Lack of accessto psychiatric information precluded data collection regarding
behavioral disorders. Information pertaining to these comorbidi-
ties was specifically sought for in the medical records reviewed
and in the parental interview conducted at the time of obtaining
data for Registry inscription. Cortical blindness required diagno-
sis by an ophthalmologist. Substantial auditory impairment was
defined as a 70 dB or greater hearing loss (bilateral) on audio-
metric testing. Nonverbal referred to the absence of specific
words or recognizable vocabulary in the child’s maternal lan-
guage irregardless of possible etiology (i.e., motor or cognitive
limitations). Gavage feeding referred to the use of a temporary or
permanent artificial tube to administer the bulk of a child’s nu-
trition internally. Coexisting seizures was defined as the occur-
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rence of afebrile seizures in the 12 months preceding Registry
inscription.
Individual comorbidities noted were tabulated across cere-
bral palsy subtype and GMFCS level. The proportions of chil-
dren with each comorbidity were compared dichotomously
between spastic quadriplegia or dyskinetic subtypes (grouped to-
gether) and all other subtypes by Pearson 2analysis. Similarly,
the proportion of children with each comorbidity was comparedbetween GMFCS levels grouped dichotomously into ambula-
tory (levels I–III) and nonambulatory (levels IV and V) subsets.
Similarly, the mean number of comorbidities was tabulated
across cerebral palsy subtypes and GMFCS levels separately with
Student t test of means used to compare the means obtained for
the dichotomous groupings of neurologic subtype and GMFCS
levels outlined previously. A p value of 0.05 or less was chosen a
priori to denote significance.
RESULTS In all, 301 children were identified in the
six administrative regions comprising REPACQ over
the 4-year inclusive birth interval (1999–2002).
Given roughly 144,000 live births in these same re-gions over this interval, this yields a crude prevalence
of 2.09 per 1,000 live births, in the middle of the
1.5–2.5/1,000 live births range quoted in the litera-
ture for developed regions analogous to Quebec.23
Concurrent information on cerebral palsy subtype
and GMFCS level was available on 243 of these chil-
dren and it is this group which comprises the study
cohort. The children were a mean age of 44 months
(SD 14 months, range 24–79 months) at the time of
registry inscription. The individual comorbidity fre-
quency distribution by neurologic subtype and
GMFCS level are reported in tables 1 and 2. The
mean number of comorbidities experienced by a sin-
gle child is reported by stratification by neurologic
subtype and GMFCS level in table 3. The results of
Pearson 2
analysis for the proportional distributionof individual comorbidity dichotomously grouped
into either spastic quadriplegic/dyskinetic or other
cerebral palsy subtypes and ambulatory (levels I–III)
or nonambulatory (levels IV and V) GMFCS status
are reported in table 4. The results of Student t tests
of the means of the total number of comorbidities
experienced for each child for these same dichoto-
mous groupings are reported in table 5.
For all comorbidities considered, the difference in
proportional distribution between the spastic quadri-
plegic/dyskinetic and all other cerebral palsy subtypes
was significant. Similarly, the difference in propor-
tional distribution of all individual comorbidities was
significant between the ambulatory (levels I–III) and
nonambulatory (levels IV and V) GMFCS group-
Table 2 Frequency of comorbidities distributed by GMFCS level
GMFCSlevel
Severe visualimpairment(n 23)
Severeauditoryimpairment(n 28)
Nonverbal(n 54)
Gavagefeeding(n 19)
Seizureslast 12mo(n 41)
I ( n 108) 4 (4) 6 (6) 1 (1) 4 (4) 7 (6)
I I (n 23) Ϫ (Ϫ) 3 (13) Ϫ (Ϫ) Ϫ (Ϫ) 3 (13)
I II (n 30) 1 (3) 4 (13) 6 (20) Ϫ (Ϫ) 5 (17)
I V (n 43) 5 (12) 7 (16) 15 (35) 3 (7) 9 (21)
V ( n 39) 13 (33) 8 (21) 32 (82) 12 (31) 17 (44)
Valuesare n (%).
GMFCSϭGross Motor Function Classification System.
Table 1 Frequency of comorbidities distributed by neurologic subtype
Neurologic subtype
Corticalblindness(n 23)
Severeauditoryimpairment(n 28)
Nonverbal*(n 54)
Gavagefeeding(n 19)
Seizureslast 12mo*(n 41)
Spastic quadriplegia(n 85) 18 (21) 12 (14) 38 (45) 14 (17) 26 (31)
Spastic hemiplegia (n 77) 2 (3) 4 (5) 2 (3) 1 (1) 6 (8)
Spastic diplegia (n 52) 1 (4) 3 (6) 1 (4) 2 (4) 3 (6)
Dyskinetic (n 16) 1 (7) 6 (38) 8 (50) 2 (13) 1 (7)
Ataxic-hypotonic (n 9) 1 (11) 3 (33) 4 (44) Ϫ (Ϫ) 4 (44)
Values are n (%).
*Four children with spastic triplegia or monoplegia were excluded from analysis. One child with spastic triplegia was non-
verbaland another had seizures in the prior 12 months.
Table 3 Mean ( SD)number of comorbidities
(range 0 –5) stratifiedby neurologic
subtype andGMFCS level
Neurologic subtype Mean SD
Spastic hemiplegia 0.19 Ϯ 0.91
Spastic diplegia 0.19 Ϯ 0.89
Dyskinetic 1.13 Ϯ 0.77
Spastic quadriplegia 1.27 Ϯ 1.10
Ataxic-hypotonic 1.33 Ϯ 1.00
GMFCS level
I 0.20 Ϯ 0.92
II 0.26 Ϯ 0.97
III 0.53 Ϯ 0.95
IV 0.91 Ϯ 1.03
V 2.10 Ϯ 0.97
GMFCSϭGross Motor Function Classification System.
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ings. The mean number of comorbidities experi-
enced between those in the spastic quadriplegic/
dyskinetic and the other subtypes and the ambulatory
(levels I–III) and nonambulatory (levels IV and V)
groupings were also different at a significant level.
For each individual comorbidity and for the bur-den of comorbidity taken collectively, a higher
proportion and a higher mean number were evi-
dent in either the spastic quadriplegic/dyskinetic
or nonambulatory (levels IV and V) subgroups
compared to the other dichotomous group within
each respective classification scheme.
DISCUSSION The results from our population-
based registry indicate that each of the comorbidities
evaluated occurred in less than a quarter of the group
of children with cerebral palsy as a whole with the
following decreasing frequency distribution docu-
mented: nonverbal 22.2% (54/243), active afebrile
seizure disorder 16.9% (41/243), severe auditory im-
pairment 11.5% (28/243), cortical blindness 9.5%
(23/243), and gavage feeding requirement 7.8% (19/
243). Clustering of comorbidities, both individually
and collectively, was readily apparent when consider-
ing the classification of cerebral palsy from either a
neurologic or functional perspective. Children with
ataxic-hypotonic (1.33 Ϯ 1.00), spastic quadriplegic
(1.27Ϯ 1.10), and dyskinetic (1.13Ϯ 0.77) cerebral
palsy variants experienced at a mean level roughly
five times the numerical burden (i.e., frequency) of comorbidities compared to children with the spastic
diplegic (0.19 Ϯ 0.89) or hemiplegic (0.19 Ϯ 0.91)
variants. Similarly, there was a marked elevation in
comorbidity burden with each increment above a
GMFCS level II, with a 10-fold difference noted be-
tween those at level I (0.20Ϯ 0.92) and level V (2.10Ϯ
0.97). Furthermore, of 165 separate comorbidities
documented among the 243 subjects, 138 (84%) oc-
curred among children with the spastic quadriplegic,
dyskinetic, and ataxic-hypotonic variants and 121
(73%) occurred among nonambulatory (GMFCS
Table 4 Pearson 2 analysis of proportional distribution of comorbidity: Spastic quadriplegic/dyskinetic
subtypes vs other cerebral palsy subtypes;GMFCS levelsI–III (ambulatory)vs GMFCS levelsIV
and V (nonambulatory)
Spasticquad/dyskinetic(n 101 )
Othercerebralpalsysubtype(n 142 )
2 p Value
GMFCSlevelsI–III(n 161)
GMFCSlevelsIVand V(n 82)
2 p Value
Severe visual
Yes 19 4 17.62 Ͻ0.001 5 18 22.52 Ͻ0.001
No 82 138 156 64
Severe auditoryimpairment
Yes 18 10 9.56 0.003 13 15 8.27 0.007
No 83 132 148 67
Nonverbal
Yes 46 8 31.28 Ͻ0.001 7 47 55.04 Ͻ0.001
No 55 134 154 35
Gavage feeding
Yes 16 3 15.02 Ͻ0.001 4 15 18.4 Ͻ0.001
No 85 139 157 67
Seizureslast12 mo
Yes 27 14 11.46 0.001 15 26 18.81 Ͻ0.001
No 74 128 146 56
GMFCSϭGross Motor FunctionClassification System.
Table 5 Student t tests of mean numberof
comorbidities:Spastic quadriplegic/
dyskinetic subtypesvs othercerebral
palsysubtypes and GMFCSlevelsI–III(ambulatory)vs GMFCSlevels IV
and V (nonambulatory)
Mea n SDStudentt test
Spastic quadriplegic/dyskinetic
1.25Ϯ 1.05 pϽ 0.001
Other cerebral palsysubtype
0.27Ϯ 0.97
Levels I–III 0.27Ϯ 0.97 pϽ 0.001
LevelsIV andV 1.48Ϯ 1.05
GMFCSϭGross Motor FunctionClassification System.
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levels IV and V) children, though these groupings
represented respectively 45% and 34% of the sample
population as a whole.
Within some subgroupings, a particular comor-
bidity was a common (greater than 25% frequency)
occurrence. For children with spastic quadriplegia,
this was represented by nonverbal status (38/85,
45%) and coexisting seizures (26/85, 31%). For dys-
kinetic children, nonverbal skills (8/16, 50%) and
auditory impairment (6/16, 38%) occurred espe-
cially frequently. For level IV GMFCS stratified chil-
dren, being nonverbal was especially evident (15/43,
35%). All comorbidities, with the relative exception
of severe auditory impairment, occurred particularly
frequently (nonverbal [32/39, 82%], coexisting sei-
zures [17/39, 44%], cortical blindness [13/39, 33%],
and gavage feeding requirement [12/39, 31%])
among level V GMFCS children. Across the spec-
trum of specific comorbidities evaluated, for children
with spastic hemiplegic or spastic diplegic variants,
the comorbidities were infrequent (Ͻ10%) occur-rences and similarly for level I GMFCS children.
2
analysis through contrasting dichotomous groupings
of subtypes (spastic quadriplegic/dyskinetic vs other
cerebral palsy subtypes and levels I–III GMFCS vs
levels IV and V GMFCS) confirmed that these dif-
ferences in the proportional distributions docu-
mented were indeed significant.
Thus from varying approaches, it is readily appar-
ent that the varying comorbidities encountered in ce-
rebral palsy are not equally distributed across the
population of children afflicted with this neurodevel-
opmental disability. Whether utilizing a system
based on neurologic observation and examination4-6
or one employing meaningful functional differences
in gross motor skills,8 particular subtypes are espe-
cially associated with the occurrence of one or more
comorbidities. This suggests a burden beyond that
captured inherently by either classification itself that
will challenge the child, family, and health service
providers.
Though not part of their conceptualization and
formulation,23 both classification schemes go beyond
simply describing in their complementary ways neu-rologic deficits or motor limitations. They also ap-
pear to impart a profile of expectations (i.e., risks)
with respect to the occurrence of various comorbidi-
ties that can inform and guide clinical approach,
counseling and programmatic efforts, and prognosti-
cation. Clearly, identification and intervention ef-
forts targeting these various comorbidities would best
be directed toward children with spastic quadriple-
gic, dyskinetic, and ataxic-hypotonic variants or level
IV and V GMFCS status assignment. Since both of
these classification schemes can be applied at an early
age with measurable (though not complete) stability
and confidence,17-24 this provides for the clinician a
simple mechanism for rendering a child at risk for
sequelae that have the potential to limit participation
and quality of life and are also possibly amenable to
intervention that are best served by early detection.
This unexpected and unintended profiling utility for
these classification schemes is an added value and
benefit that reinforces their known strengths.7,8 It is
not surprising that both of these classification
schemes impart such profiling as they have been
shown to covary.25,26
Under the influence of the International Classifi-
cation of Functioning, Health & Disability model,
our emphasis in the neurodevelopmental disabilities
has shifted to a focus on overall health, and especially
participation, which are predicates for an individual’s
quality of life.27 Comorbidities are likely to be impor-
tant determinants of health, participation, and qual-
ity of life, which are under both intrinsic and
extrinsic influences.28,29
It appears from this study that the actual categorical type of cerebral palsy may
be one of these intrinsic factors. An additional ave-
nue of future study suggested by our results are what
factors, both intrinsic and extrinsic, are the determi-
nants of comorbidity occurrence among each of the
high frequency subtypes identified? At present, what
such factors are remains open to speculation though
a recent study has highlighted clinical (i.e., neonatal
encephalopathy, microcephaly, GMFCS IV or V
level) and radiologic (i.e., periventricular leukomala-
cia) features among children with spastic quadriple-
gic cerebral palsy.9
Our study represents the first report from a North
American population-based cerebral palsy registry re-
garding varying comorbidities in this particular neuro-
developmental disability. It most resembles a recent
study from western Sweden that focused on intellectual
impairment, epilepsy, and severe visual impairment co-
morbidities.30 As in our study, a relationship between
particular CP neurologic subtype, GMFCS level, and
comorbidity occurrence was documented. No informa-
tion was provided on verbal skills, severe auditory im-
pairment, or feeding status. A higher frequency of severevisual impairment was noted in the Swedish study,
likely due to their additional consideration or inclusion
of severe myopia. A recent first report from a Norwe-
gian CP registry reported comorbidity occurrence, but
omitted information pertaining to the child’s functional
motor status in this context.31 With respect to neuro-
logic subtype, this report grouped together classically
distinguished spastic quadriplegic and diplegic variants,
which have vastly different functional motor and co-
morbidity status, into a single bilateral spastic CP
grouping. Another report from southern Sweden on a
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smaller cohort of children (n ϭ 167) focused on three
comorbidities (intellectual impairment, epilepsy, severe
visual impairment), but omitted analysis of a relation-
ship to CP subtype or the important discriminator of
ambulant vs nonambulant motor status.32 A final recent
study from the United Kingdom combined data from
five different registries utilizing different methods of
data collection, without the context of either neurologic
subtyping or GMFCS stratification.33
This population-based study has documented the
frequency of selected comorbidities evident before
the age of 5 years in children with cerebral palsy.
Timing of Registry inscription and available data
precluded consistent reliable determination of intel-
lectual and behavioral comorbidity, thus our study
inherently underestimates the overall comorbidity
burden. The burden of comorbidities falls dispropor-
tionately on those children with spastic quadriplegic,
dyskinetic, or ataxic-hypotonic variants and GMFCS
level IV or V functional limitations. This illustrates
an added benefit for utilization of both of these clas-sification approaches and has clear clinical implica-
tions with regards to our programmatic efforts,
counseling, and prognostication in this neurodevel-
opmental disability. The facility of use and the
potential near-universal application of these classifi-
cation schemes provides an opportunity to endeavor
to attain early identification of varying comorbidities
among at-risk subgroups that may ultimately lead to
a more optimal outcome for these children.
ACKNOWLEDGMENT
The authors thank Alba Rinaldi for s ecretarial assistance and Anna Radzi-och for creating the tables.
APPENDIX
REPACQ Consortium (Contributors): Marie-Danielle Boucher, MD
(Quebec City); Claude Desjardins, MD (Hull); Josee Fortier, MD (Trois-
Rivieres); Louise Koclas, MD (Montreal); Celine Lamarre, MD (Mon-
treal); Francine Malouin, PT, PhD (Quebec City); Jean Mathieu, MD,
MSc (Chicoutimi); Diane Munz, MD (Montreal); Nicole Pigeon, MD
(Sherbrooke); Carol L. Richards, PT, PhD (Quebec City).
ReceivedNovember18,2008. Accepted in final formMarch31,2009.
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DOI 10.1212/WNL.0b013e3181aa537b2009;72;2090 Neurology
Michael I. Shevell, Lynn Dagenais and Nicholas HallGMFCS level
Comorbidities in cerebral palsy and their relationship to neurologic subtype and
October 27, 2012This information is current as of
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