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Cerebral palsy

About

What is covered

This NICE Pathway covers:
  • diagnosing and assessing cerebral palsy in children and young people from birth up to their 25th birthday
  • managing cerebral palsy, including common complications and comorbidities, in people of all ages, and
  • service organisation.
It aims to improve the health and wellbeing of people with cerebral palsy, so that they can be as active and independent as possible.

Updates

Updates to this NICE Pathway

30 January 2020 Cerebral palsy in adults (NICE quality standard 191) added.
8 October 2019 Xeomin (botulinum neurotoxin type A) for treating chronic sialorrhoea (NICE technology appraisal guidance 605) added to saliva control in people under 25 and saliva control in people 25 and over.
14 January 2019 Amended to include cerebral palsy in adults (NICE guideline NG119).
9 October 2017 Cerebral palsy in children and young people (NICE quality standard 162) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on cerebral palsy in an interactive flowchart

What is covered

This NICE Pathway covers:
  • diagnosing and assessing cerebral palsy in children and young people from birth up to their 25th birthday
  • managing cerebral palsy, including common complications and comorbidities, in people of all ages, and
  • service organisation.
It aims to improve the health and wellbeing of people with cerebral palsy, so that they can be as active and independent as possible.

Updates

Updates to this NICE Pathway

30 January 2020 Cerebral palsy in adults (NICE quality standard 191) added.
8 October 2019 Xeomin (botulinum neurotoxin type A) for treating chronic sialorrhoea (NICE technology appraisal guidance 605) added to saliva control in people under 25 and saliva control in people 25 and over.
14 January 2019 Amended to include cerebral palsy in adults (NICE guideline NG119).
9 October 2017 Cerebral palsy in children and young people (NICE quality standard 162) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Cerebral palsy in adults (2019) NICE guideline NG119
Xeomin (botulinum neurotoxin type A) for treating chronic sialorrhoea (2019) NICE technology appraisal guidance 605
Cerebral palsy in adults (2020) NICE quality standard 191
Cerebral palsy in children and young people (2017) NICE quality standard 162

Quality standards

Cerebral palsy in children and young people

These quality statements are taken from the cerebral palsy in children and young people quality standard. The quality standard defines clinical best practice for cerebral palsy in children and young people under 25 and should be read in full.

Cerebral palsy in adults

These quality statements are taken from the cerebral palsy in adults quality standard. The quality standard defines clinical best practice for cerebral palsy in adults and should be read in full.

Quality statements

Follow-up for children with major risk factors for cerebral palsy

This quality statement is taken from the cerebral palsy in children and young people quality standard. The quality standard defines clinical best practice in diagnosing, assessing and managing cerebral palsy in children and young people and should be read in full.

Quality statement

Children with any major risk factor for cerebral palsy have enhanced clinical and developmental follow-up from birth to 2 years.

Rationale

The signs of cerebral palsy might not be apparent at birth. Following up children with any major risk factor for cerebral palsy for the first 2 years of life will help to identify and diagnose cerebral palsy as early as possible. Early diagnosis can guide interventions, inform prognosis and let family members know what to expect.

Quality measures

Structure
Evidence of local arrangements to provide enhanced clinical and developmental follow-up from birth to 2 years for children with any major risk factor for cerebral palsy.
Data source: Local data collection, for example, service protocols.
Process
a) Proportion of children with any major risk factor for cerebral palsy attending a routine appointment up to 3 months of age who had movement and development checked.
Numerator – the number in the denominator who had movement and development checked.
Denominator – the number of children with any major risk factor for cerebral palsy attending a routine appointment up to 3 months of age.
Data source: Local data collection, such as the Royal College of Paediatrics and Child Health personal child health record (‘red book’).
b) Proportion of children with any major risk factor for cerebral palsy and older than 3 months who have a planned schedule of developmental follow-ups.
Numerator – the number in the denominator who have a planned schedule of developmental follow-ups.
Denominator – the number of children with any major risk factor for cerebral palsy and older than 3 months.
Data source: Local data collection, such as the Royal College of Paediatrics and Child Health personal child health record (‘red book’).
Outcome
Number of children and young people with cerebral palsy who were diagnosed by age 2 years.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as secondary care services) work together to ensure the provision of enhanced clinical and developmental follow‑up for children from birth to 2 years (corrected for gestational age) who have any major risk factor for cerebral palsy.
Healthcare professionals (such as midwives and neonatologists) identify major risk factors for cerebral palsy and refer children who have a risk factor for cerebral palsy for enhanced clinical and developmental follow‑up from birth to 2 years (corrected for gestational age).
Commissioners (such as clinical commissioning groups) ensure that they commission services that support children with any major risk factor for cerebral palsy by providing enhanced clinical and developmental follow-up from birth to 2 years.
Babies who have problems that might cause cerebral palsy have their movement and development closely checked until they are 2 years old, because cerebral palsy is not always obvious at birth. Some common causes of cerebral palsy are problems in the way the baby’s brain develops before birth, an infection in the baby before or shortly after birth, or a difficult or early (preterm) birth.

Source guidance

Cerebral palsy in under 25s: assessment and management (2017) NICE guideline NG62, recommendations 1.1.2 and 1.3.1

Definitions of terms used in this quality statement

Major risk factors for developing cerebral palsy
The following are major risk factors for developing cerebral palsy:
  • birth before 28 weeks
  • neonatal encephalopathy
  • neonatal sepsis (particularly with a birth weight below 1.5 kg).
[NICE’s guideline on cerebral palsy in under 25s, recommendation 1.1.1 and expert consensus]
Enhanced clinical and developmental follow-up
Enhanced clinical and developmental follow-up ensures that a child has their movement and development closely checked. This should happen at their routine appointments up to age 3 months. They should then have extra follow‑up appointments to check for problems until they are 2 years old. However, these should be tailored to the needs of the child or young person. Follow-up should be provided by an expert who can draw on the following expertise from a multidisciplinary team:
  • paediatric medicine
  • nursing care
  • physiotherapy
  • occupational therapy
  • speech and language therapy
  • dietetics
  • psychology.
[Adapted from NICE’s guideline on cerebral palsy in under 25s, recommendation 1.5.3 and expert opinion]

Referral for children with delayed motor milestones

This quality statement is taken from the cerebral palsy in children and young people quality standard. The quality standard defines clinical best practice in diagnosing, assessing and managing cerebral palsy in children and young people and should be read in full.

Quality statement

Children with delayed motor milestones are referred to a child development service.

Rationale

The diagnosis of cerebral palsy is typically based on observations and parental reports on the attainment and quality of motor milestones. Referral to a child development service will enable early diagnosis of cerebral palsy, guide interventions, inform prognosis and let family members know what to expect.

Quality measures

Structure
Evidence of local arrangements to provide child development services for children with delayed motor milestones.
Data source: Local data collection, for example, service protocols.
Process
Proportion of children with delayed motor milestones who are referred to a child development service.
Numerator – the number in the denominator who are referred to a child development service.
Denominator – the number of children with delayed motor milestones.
Data source: Local data collection, such as the Royal College of Paediatrics and Child Health personal child health record (‘red book’).
Outcome
Number of children and young people with cerebral palsy who were diagnosed by age 2 years.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as primary care services) ensure that they provide healthcare professionals with training to enable them to identify delayed motor milestones in children.
Healthcare professionals (such as GPs, practice nurses and health visitors) are aware of motor milestones in children and refer children with delayed motor milestones to a child development service for multidisciplinary assessment.
Commissioners (such as clinical commissioning groups and local authorities) ensure that child development services are available to provide an assessment of motor milestones to help early diagnosis and intervention in children with delayed motor milestones.
Children with unusual signs that suggest possible cerebral palsy are referred to a specialist team at the local child development service for more checks to find out whether they have cerebral palsy. Examples of unusual signs are not sitting by 8 months, not walking by 18 months, or using one hand more than the other before 12 months.

Source guidance

Cerebral palsy in under 25s: assessment and management (2017) NICE guideline NG62, recommendation 1.3.6

Definitions of terms used in this quality statement

Delayed motor milestones
The following are the most common delayed motor milestones in children with cerebral palsy:
  • not sitting by 8 months (corrected for gestational age)
  • not walking by 18 months (corrected for gestational age)
  • early asymmetry of hand function (hand preference) before 1 year (corrected for gestational age).
[NICE’s guideline on cerebral palsy in under 25s, recommendation 1.3.5]
Child development service
A service that offers multidisciplinary assessment for children and that:
  • provides the following expertise, as appropriate, though a local network of care:
    • paediatric or adult medicine
    • nursing care
    • physiotherapy
    • occupational therapy
    • speech and language therapy
    • dietetics
    • psychology
  • can enable access to other services within their local or regional network as appropriate, including:
    • paediatric or adult neurodisability, neurology, neurorehabilitation, respiratory, gastroenterology and surgical specialist care
    • orthopaedics
    • orthotics and rehabilitation services
    • social care
    • visual and hearing specialist services
    • teaching support for preschool and school-age children, including portage (home teaching services for preschool children).
[Adapted from NICE’s guideline on cerebral palsy in under 25s, recommendation 1.5.3]

Information for parents and carers of children and young people with cerebral palsy

This quality statement is taken from the cerebral palsy in children and young people quality standard. The quality standard defines clinical best practice in diagnosing, assessing and managing cerebral palsy in children and young people and should be read in full.

Quality statement

Parents and carers of children and young people with cerebral palsy are given information about the diagnosis and management of cerebral palsy.

Rationale

Providing information is essential in enabling parents and carers to help children and young people with cerebral palsy to manage their condition and in reducing the chance of complications. It also helps to reduce the anxiety associated with a cerebral palsy diagnosis and improve satisfaction with the care process for the person diagnosed and their parents or carers. Parents should be given information from diagnosis and throughout the person’s care.

Quality measures

Structure
Evidence of local arrangements to ensure that parents and carers of children and young people with cerebral palsy are provided with up-to-date information on the diagnosis and management of cerebral palsy that is tailored to their needs.
Data source: Local data collection, for example, service protocols.
Process
Proportion of parents and carers of children and young people with cerebral palsy who are given information about the diagnosis and management of cerebral palsy at the point of diagnosis.
Numerator – the number in the denominator whose parents or carers are given information about the diagnosis and management of cerebral palsy.
Denominator – the number of children and young people with cerebral palsy.
Data source: Local data collection, such as the child or young person’s personal folder.
Outcome
Level of parent and carer satisfaction with information they are given about the diagnosis and management of cerebral palsy.
Data source: Local data collection based on feedback from parents and carers of children and young people with cerebral palsy.

What the quality statement means for different audiences

Service providers (such as child development services) ensure that systems are in place to provide up-to-date and tailored information about the diagnosis and management of cerebral palsy to the parents and carers of children and young people with cerebral palsy.
Healthcare professionals (such as paediatricians, nurses, physiotherapists, occupational therapists, ophthalmologists, speech and language therapists, dietitians and psychologists) provide information about the diagnosis and management of cerebral palsy to the parents and carers of children and young people with cerebral palsy.
Commissioners (such as clinical commissioning groups) ensure that services are in place to provide information on the diagnosis and management of cerebral palsy and associated comorbidities to the parents and carers of children and young people with cerebral palsy, and that the information is tailored to their individual needs and learning styles.
Parents and carers of children and young people children with cerebral palsy are given information about the child or young person’s diagnosis, the treatment they will receive and other conditions associated with cerebral palsy.

Source guidance

Cerebral palsy in under 25s: assessment and management (2017) NICE guideline NG62, recommendation 1.6.2

Definition of terms used in this quality statement

Information on diagnosis and management of cerebral palsy
The information provided should cover:
  • diagnosis
  • aetiology
  • prognosis
  • expected developmental progress
  • comorbidities
  • availability of specialist equipment
  • resources available and access to financial advice, respite care, social care and other support for children and young people, and their parents, carers and siblings
  • educational placement (including specialist preschool and early years settings)
  • transition.
[NICE guideline on cerebral palsy in under 25s, recommendation 1.6.2]

Equality and diversity considerations

Parents and carers of children and young people with cerebral palsy should be provided with information that they can easily read and understand themselves, or with support, so they can communicate effectively with health and social care services. The information should be in a format that suits their needs and preferences. It should be accessible to people who do not speak or read English, and should be culturally and age appropriate. Children and young people with cerebral palsy should have access to an interpreter or advocate if needed.
For children and young people with cerebral palsy who have additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's accessible information standard.

Personal folders for children and young people with cerebral palsy

This quality statement is taken from the cerebral palsy in children and young people quality standard. The quality standard defines clinical best practice in diagnosing, assessing and managing cerebral palsy in children and young people and should be read in full.

Quality statement

Children and young people with cerebral palsy have a personal folder to help them make decisions about how their condition is managed.

Rationale

A personal folder will hold information about the child or young person with cerebral palsy that can be shared with health, social care and education providers to ensure good communication. Having a personal folder can help children and young people with cerebral palsy, their families and carers to take control and make informed decisions about their lives and how their condition is managed. Children and young people should be involved in creating their own folder, which is tailored to their needs and evolves throughout the patient pathway. The personal folder should remain with the child or young person.

Quality measures

Structure
Evidence of a locally defined approach to the development of personal folders for children and young people with cerebral palsy to help them make decisions about how their condition is managed, and systems in place to make staff aware of the approach.
Data source: Local data collection, for example, service protocols.
Process
Proportion of children and young people with cerebral palsy who have a personal folder to help them make decisions about how their condition is managed.
Numerator – the number in the denominator who have a personal folder to help them make decisions about how their condition is managed.
Denominator – the number of children and young people with cerebral palsy.
Data source: Local data collection based on audits of patient care records.
Outcome
Levels of satisfaction of children and young people with cerebral palsy with control over care and daily life.
Data source: Local data collection based on feedback from children and young people with cerebral palsy.

What the quality statement means for different audiences

Service providers (such as health, social care and educational providers) ensure that systems are in place for children and young people with cerebral palsy to have a personal folder that can be shared with family members and carers, and used in health, social care and educational settings.
Health and social care practitioners help children and young people with cerebral palsy and their parents or carers to develop and update a personal folder to help them make decisions about how their condition is managed.
Commissioners (such as clinical commissioning groups) ensure that they commission services that support children and young people with cerebral palsy to be involved in developing a personal folder that is updated throughout the entire care pathway to help them to make decisions about how their condition is managed.
Children and young people with cerebral palsy have a personal file with information that is unique to them. Their care team helps them to put the information together and keep it up to date. The personal file can help children and young people make decisions about the care they would like to have. It can be in an electronic or paper format, and can be shared with everyone who supports the family, including friends, other family members, health professionals, social workers and teachers.

Source guidance

Cerebral palsy in under 25s: assessment and management (2017) NICE guideline NG62, recommendation 1.6.5

Definition of terms used in this quality statement

Personal folder
A personal folder is a file that contains information about the child or young person with cerebral palsy that can be shared with family members and friends, and used in health, social care and education. The file can be in an electronic format, or on paper, whichever is preferred by the child or young person and their family or carers. It could include:
  • early history
  • motor subtype and limb involvement
  • functional abilities
  • interventions
  • medication
  • comorbidities
  • preferred methods of communication
  • any specialist equipment that is used or needed
  • care plans
  • emergency contact details.
[NICE’s guideline on cerebral palsy in under 25s, recommendation 1.6.5]

Equality and diversity considerations

Children and young people with cerebral palsy should be provided with information that they can easily read and understand themselves, or with support, so they can communicate effectively with health and social care services. Information should be in a format that suits their needs and preferences. It should accessible to people who do not speak or read English, and should be culturally and age appropriate. Children and young people with cerebral palsy should have access to an interpreter or advocate if needed.
For children and young people with cerebral palsy who have additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's accessible information standard.

Referral to a specialist multidisciplinary team

This quality statement is taken from the cerebral palsy in adults quality standard. The quality standard defines clinical best practice for cerebral palsy in adults should be read in full.

Quality statement

Adults with cerebral palsy are referred to a specialist multidisciplinary team if their ability to carry out usual daily activities deteriorates or is expected to deteriorate.

Rationale

A specialist multidisciplinary team, experienced in the management of neurological impairments, can work with people with cerebral palsy to identify their needs and understand how these may change over time. The team can also advise on specialist treatment options (such as neurosurgical or orthopaedic procedures for dystonia and spasticity) and the possible impact these might have on the person’s abilities. The team will know what specialist and local services are available and how they can be accessed. Access to specialist multidisciplinary teams is particularly important when a person with cerebral palsy is having difficulty carrying out their usual daily tasks, or if their ability to do so is expected to become more difficult, for example, as a result of an operation that is being planned. Referral to a specialist multidisciplinary team can reduce delays in management or unplanned visits to hospital.

Quality measures

Structure
a) Evidence of local pathways to allow adults with cerebral palsy to be referred to a specialist multidisciplinary team.
Data source: Local data collection, for example, from service specifications, NHS trust directories of services and clinical commissioning group pathways.
b) Evidence of local networks of care providing access to specialists in adult rehabilitation medicine, neurodisability, physiotherapy, occupational therapy, and speech and language therapy.
Data source: Local data collection, for example, from service specifications, NHS trust directories of services and clinical commissioning group pathways.
c) Evidence of local services with specialist multidisciplinary teams.
Data source: Local data collection, for example, from service specifications, NHS trust directories of services and clinical commissioning group pathways.
Process
a) Proportion of adults with cerebral palsy whose ability to carry out their usual daily activities deteriorates who are referred to a specialist multidisciplinary team.
Numerator – the number in the denominator who are referred to a specialist multidisciplinary team.
Denominator – the number of adults with cerebral palsy whose ability to carry out their usual daily activities deteriorates.
Data source: Local data collection, for example, local audit of patient records.
b) Proportion of adults with cerebral palsy scheduled for neurosurgical or orthopaedic procedures who are referred to a specialist multidisciplinary team.
Numerator – the number in the denominator who are referred to a specialist multidisciplinary team.
Denominator – the number of adults with cerebral palsy scheduled for neurological or orthopaedic procedures.
Data source: Local data collection, for example, local audit of patient records.
Outcome
Rate of unplanned hospital admissions of adults with cerebral palsy.
Data source: Local data collection, for example, local audit of patient records. NHS Digital’s Hospital Admitted Patient Care Activity includes the number of admissions by primary diagnosis and admission type.

What the quality statement means for different audiences

Service providers (such as community neurorehabilitation services, neurology services and rehabilitation services) ensure that they have a specialist multidisciplinary team with expertise in neurodisabilities, and referral pathways so adults with cerebral palsy can be referred to the team to coordinate care. They have systems in place to ensure that specialist multidisciplinary teams can assess the needs of adults with cerebral palsy and their ability to carry out daily activities. They establish networks, which may be virtual, to allow teams to work across organisations including community, hospital and tertiary services.
Health and social care practitioners (such as GPs, doctors, therapists, social workers and home care workers) ask adults with cerebral palsy about any changes in their ability to carry out daily activities and discuss any possible future changes. They refer them to a specialist multidisciplinary team if the person’s abilities have worsened. Surgeons and anaesthetists considering orthopaedic or neurological procedures for adults with cerebral palsy who anticipate an impact on daily living skills communicate with and refer the person to a specialist multidisciplinary team. Members of the specialist multidisciplinary team assess the person’s needs, anticipate changes and adjust their care and support, as needed.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they develop pathways that allow adults with cerebral palsy to be referred to a specialist multidisciplinary team experienced in the management of neurological impairments.
Adults with cerebral palsy are asked if they find it harder to carry out their usual daily activities by the people who provide their care. If they do, or if an operation is being considered, they are referred to a specialist team to talk about whether they need any extra or different support.

Source guidance

Cerebral palsy in adults (2019) NICE guideline NG119, recommendation 1.1.1

Definitions of terms used in this quality statement

Adults
For this quality standard, adults are defined as people aged 25 and over, in line with the source guidance. The NICE quality standard for cerebral palsy in children and young people covers people under 25.
Expected to deteriorate
Ability to carry out usual daily activities is anticipated to be affected by any neurosurgical or orthopaedic procedure being considered.
[Adapted from NICE’s guideline on cerebral palsy in adults, recommendation 1.1.1]
Specialist multidisciplinary team
A team experienced in managing neurological impairments. The composition of the team varies with the severity of cerebral palsy, and the level of the person’s impairment and disability. The input from each team member will also vary with time, but access to specialist medical input must be maintained. This team could include the following members:
  • medical consultant (such as a rehabilitation, neurology or respiratory specialist)
  • specialist nurse
  • allied health professionals (such as a speech and language therapist, physiotherapist, occupational therapist, dietitian or orthotist)
  • others (such as a psychologist, learning disability psychiatric nurse or social worker).
The team provides access to:
  • advocacy support
  • learning disability services
  • mental health services
  • orthopaedic surgery (and post-surgery rehabilitation)
  • rehabilitation engineering services
  • rehabilitation medicine or specialist neurology services
  • secondary care expertise for managing comorbidities (for example, respiratory, gastrointestinal and urology services)
  • social care
  • specialist therapy services (for example, physiotherapy, occupational therapy, speech and language therapy, and dietetics)
  • wheelchair services.

Annual review

This quality statement is taken from the cerebral palsy in adults quality standard. The quality standard defines clinical best practice for cerebral palsy in adults should be read in full.

Quality statement

Adults with cerebral palsy who have complex needs have an annual review with a healthcare professional with expertise in neurodisabilities.

Rationale

Care and support needs for adults with cerebral palsy may change. An annual review is an opportunity to identify changes; assess clinical and functional needs; check for problems and comorbidities; and make sure that the person’s needs are being met. People with complex needs, including multiple medical comorbidities, or cognitive or communication impairments, would benefit most from an annual review. Annual reviews may help reduce unplanned admissions to hospital and improve the person’s quality of life. Information about the review and any changes to the person's needs should be shared, with the person’s permission, to ensure integrated care between the different healthcare professionals providing care and support. A main point of contact should also be provided to ensure that people can access advice and services between reviews.

Quality measures

Structure
Evidence of local systems and pathways to identify adults with cerebral palsy who have complex needs and invite them to have annual reviews.
Data source: Local data collection, for example, from service specifications.
Process
a) Proportion of adults with cerebral palsy and complex needs who have had an annual review within the last 12 months carried out by a healthcare professional with expertise in neurodisabilities.
Numerator – the number in the denominator who have had an annual review within the last 12 months carried out by a healthcare professional with expertise in neurodisabilities.
Denominator – the number of adults with cerebral palsy and complex needs.
Data source: Local data collection, for example, local audit of patient records.
b) Proportion of adults with cerebral palsy and complex needs who are given details of a main contact for support at their annual review.
Numerator – the number in the denominator given details of a main contact for support at their annual review.
Denominator – the number of adults with cerebral palsy and complex needs who had an annual review.
Data source: Local data collection, for example, audit of patient records.
Outcome
a) Rate of unplanned hospital admissions of adults with cerebral palsy.
Data source: Local data collection, for example, local audit of patient records. NHS Digital’s Hospital Admitted Patient Care Activity includes number of admissions by primary diagnosis and admission type.
b) Health-related quality of life of adults with cerebral palsy and complex needs.
Data source: Local data collection, for example, survey of adults with cerebral palsy.

What the quality statement means for different audiences

Service providers (neurology services and rehabilitation medicine services) ensure that systems are in place to identify adults with cerebral palsy who have complex needs and offer them annual reviews with a healthcare professional with expertise in neurodisabilities. They ensure that reviews include information from a range of health and social care professionals, including assessments carried out by specialist multidisciplinary teams in the past year. They have systems in place to document the reviews, share the results and provide a main point of contact to the person with cerebral palsy.
Healthcare professionals (with expertise in neurodisabilities) offer an annual review of clinical and functional needs to adults with cerebral palsy who have complex needs. They discuss what information should inform the review and who should receive clinical information following the review. They also identify who will be the main point of contact between reviews and provide information on how to contact them.
Commissioners (such as clinical commissioning groups and NHS England) ensure that service specifications for neurodisability and rehabilitation medicine include annual reviews for adults with cerebral palsy who have complex needs with a healthcare professional with expertise in neurodisabilities.
Adults with cerebral palsy who have complex needs are asked if they would like to have a regular review of their needs with a healthcare professional with expertise in neurodisability. The review will be done at least every year and means that the specialist can see how well the person's care and support are working and discuss whether any changes are needed. The results and any changes to treatment or care will be shared with others providing care and treatment, with the person’s permission. The person will also be given details of a main point of contact for advice and support between reviews.

Source guidance

Cerebral palsy in adults (2019) NICE guideline NG119, recommendation 1.1.13

Definitions of terms used in this quality statement

Adults
For this quality standard, adults are defined as people aged 25 and over, in line with the source guidance. The NICE quality standard for cerebral palsy in children and young people covers people under 25.
Complex needs
Gross Motor Function Classification System levels 4 and 5 and any of the following:
  • communication difficulties
  • learning disabilities
  • living in long-term care settings
  • living in the community without sufficient practical and social support (for example, being cared for by elderly, frail parents)
  • multiple comorbidities.
The Gross Motor Function Classification System is a 5‑level clinical classification system that describes the gross motor function of people with cerebral palsy based on self-initiated movement abilities. People assessed as level 1 are the most able and people assessed as level 5 are dependent on others for all their mobility needs.
[NICE’s guideline on cerebral palsy in adults, recommendation 1.1.13 and terms used in this guideline]
Annual review
A planned clinical appointment between an adult with cerebral palsy and a healthcare professional, or group of healthcare professionals, with expertise in neurodisability. They may explore common concerns, physical symptoms, mental health, pain, nutrition, communication and barriers to participation in everyday life to ensure an individualised approach to care. This also allows the opportunity to address general health issues that affect people as they grow older.
This review is distinct from, and in addition to, other reviews that an adult with cerebral palsy may have, such as an annual health check in primary care for adults with learning disabilities and reviews of care and support plans of people using social care services.
[Adapted from NICE’s guideline on cerebral palsy in adults, terms used in this guideline, and expert opinion]

Equality and diversity considerations

Adults with cerebral palsy who have complex needs have limited mobility and may find it difficult to attend an appointment. Arrangements should be made to:
  • offer an accessible location for the review within a reasonable travelling distance for the person
  • provide accessible transport services
  • ensure that appropriate equipment (for example, hoists and wheelchair weighing scales) and adequate changing and toilet facilities are available
  • offer an alternative to clinic-based review, such as home visits.

Independent living referral

This quality statement is taken from the cerebral palsy in adults quality standard. The quality standard defines clinical best practice for cerebral palsy in adults should be read in full.

Quality statement

Adults with cerebral palsy who want support to live independently are referred to a professional with expertise in independent living.

Rationale

Adults with cerebral palsy should be able to live as independently as possible. They should be able to participate in activities they like and fully take part in life and the wider community. A professional with expertise in independent living, usually an occupational therapist, can work with people with cerebral palsy to assess their abilities and goals, identify any barriers, provide advice and tailor support to their aspirations and needs. This may include using assistive technologies or making modifications to their home or personal care assistance.

Quality measures

Structure
a) Evidence of local pathways that allow adults with cerebral palsy to be referred to a professional with expertise in independent living.
Data source: Local data collection, for example, from service specifications, NHS trust directories of services and clinical commissioning group pathways.
b) Evidence of local networks of care providing occupational therapy services to adults with cerebral palsy.
Data source: Local data collection, for example, from service specifications.
Process
Proportion of adults with cerebral palsy who want support to live independently referred to a professional with expertise in independent living.
Numerator – the number in the denominator referred to a professional with expertise in independent living.
Denominator – the number of adults with cerebral palsy who want support to live independently.
Data source: Local data collection, for example, local audit of patient records.
Outcome
Proportion of adults with cerebral palsy who feel that they live independently.
Numerator – the number in the denominator who feel that they live independently.
Denominator – the number of adults with cerebral palsy.
Data source: Local data collection, for example, local survey of adults with cerebral palsy.

What the quality statement means for different audiences

Service providers (such as occupational therapy services) ensure that referral pathways are in place so that adults with cerebral palsy who want support to live independently can be referred to a healthcare professional with expertise in independent living.
Health and social care professionals (such as GPs, rehabilitation consultants, neurology consultants, allied health professionals and social workers) ask adults with cerebral palsy what they enjoy doing, if they find it difficult to participate in activities and what living independently means to them. They give information about assessments of independent living skills and refer people who would like support to live independently to a healthcare professional with expertise in independent living, usually an occupational therapist.
Commissioners (such as clinical commissioning groups) commission occupational therapy services for adults with cerebral palsy who want support to live independently, and ensure that referral pathways are in place.
Adults with cerebral palsy who want support to live independently are referred for support from a healthcare professional with expertise in independent living. They discuss how the person would like to live their life, and what activities are meaningful and important to them. They also discuss what activities the person finds difficult, problems they may face and how these can be overcome through special equipment and adaptions, or developing skills and new ways to perform tasks.

Source guidance

Cerebral palsy in adults (2019) NICE guideline NG119, recommendation 1.2.11

Definitions of terms used in this quality statement

Adults
For this quality standard, adults are defined as people aged 25 and over, in line with the source guidance. The NICE quality standard for cerebral palsy in children and young people covers people under 25.
Professional with expertise in independent living
A professional, usually an occupational therapist, who can assess the functional ability of adults with cerebral palsy, what their home situation is like, what support networks are in place and discuss their goals for independent living. They can identify activities that people have difficulty with, potential barriers to achieving goals, and interventions that will enable independent living.
[Adapted from NICE’s guideline on cerebral palsy in adults and expert opinion]

Support to work referral

This quality statement is taken from the cerebral palsy in adults quality standard. The quality standard defines clinical best practice for cerebral palsy in adults should be read in full.

Quality statement

Adults with cerebral palsy who want support to work are referred to a professional with expertise in vocational skills and independent living.

Rationale

Working can help people become more independent, socially active and integrated into the community. However, adults with cerebral palsy can face physical and organisational barriers to work, such as access to buildings and policies and situations that put them at a disadvantage. Specialist support for people who want to start work can include advice on and access to job seeking, training, work placements, voluntary work and vocational rehabilitation. For those already working, specialist support can include access to workplace and equipment assessment, workplace and job retention training, and support for a planned exit from the workforce should it become too difficult to continue working.

Quality measures

Structure
Evidence of local networks of care providing occupational therapy and vocational rehabilitation services to adults with cerebral palsy.
Data source: Local data collection, for example, from service specifications.
Process
a) Proportion of adults with cerebral palsy who want support to start work referred to a professional with expertise in vocational skills and independent living.
Numerator – the number in the denominator referred to a professional with expertise in vocational skills and independent living.
Denominator – the number of adults with cerebral palsy who want support to start work.
Data source: Local data collection, for example, local audit of patient records.
b) Proportion of adults with cerebral palsy who want support to continue working referred to a professional with expertise in vocational skills and independent living.
Numerator – the number in the denominator referred to a professional with expertise in vocational skills and independent living.
Denominator – the number of adults with cerebral palsy who want support to continue working.
Data source: Local data collection, for example, local audit of patient records.
Outcome
Employment rate of adults with cerebral palsy.
Data source: Local data collection, for example, local survey of adults with cerebral palsy.

What the quality statement means for different audiences

Service providers (such as occupational therapy services, vocational rehabilitation services and social services) ensure that referral pathways are in place so that adults with cerebral palsy can be referred to a professional with expertise in vocational skills and independent living.
Health and social care professionals (such as GPs, rehabilitation consultants, neurology consultants, allied health professionals and social workers) ask adults with cerebral palsy whether they work or would like to work, what they enjoy doing, if they find it difficult to participate in activities and what their work-related goals are. They give information and advice about education, securing work and employment support. They refer those who would like support to start work, or with existing work, to a professional with expertise in vocational skills and independent living.
Commissioners (such as clinical commissioning groups) commission occupational therapy and vocational rehabilitation services for adults with cerebral palsy who want support to start or continue to work and ensure that referral pathways are in place.
Adults with cerebral palsy who want support to start or continue to work are referred to a specialist (such as an occupational therapist) to discuss what their work-related goals are and receive support to reach these goals. This may include support with finding a job or staying in their current job.

Source guidance

Cerebral palsy in adults (2019) NICE guideline NG119, recommendation 1.2.12

Definitions of terms used in this quality statement

Adults
For this quality standard, adults are defined as people aged 25 and over, in line with the source guidance. The NICE quality standard for cerebral palsy in children and young people covers people under 25.
Professional with expertise in vocational skills and independent living
A professional, often an occupational therapist, who can assess the vocational and independent living skills of adults with cerebral palsy and discuss their goals. They identify activities that people have difficulty with, potential barriers to achieving goals, and interventions to address these. This can include access to job seeking, work preparation, training, work placements, voluntary work and vocational rehabilitation. For those already working, this can include workplace and equipment assessment, workplace and job retention training, and support for a planned exit from the workforce should it become too difficult to continue working.
[Adapted from NICE’s guideline on cerebral palsy in adults and expert opinion]

Communication

This quality statement is taken from the cerebral palsy in adults quality standard. The quality standard defines clinical best practice for cerebral palsy in adults should be read in full.

Quality statement

Adults with cerebral palsy who have communication difficulties have their need for intervention assessed by speech and language therapy services.

Rationale

People need to be able to communicate to fully engage in decision making and participate in social, family and economic activities. Adults with cerebral palsy can have communication difficulties caused by their underlying motor disorder, learning difficulties or problems with equipment. Referral to speech and language therapy services enables people with cerebral palsy to have their communication difficulties assessed and to be offered suitable interventions. Interventions may include intensive speech therapy, to improve the intelligibility of their speech, and alternative and augmentative communication (AAC) systems. When AAC systems are provided, people with cerebral palsy, their families, carers and other key communication partners are given training to ensure they are used effectively.

Quality measures

Structure
a) Evidence of processes to identify adults with cerebral palsy who have communication difficulties.
Data source: Local data collection, for example, from service specifications or directories of services.
b) Evidence of local referral pathways to speech and language therapy services for adults with cerebral palsy who have communication difficulties.
Data source: Local data collection, for example, from service specifications.
Process
a) Proportion of adults with cerebral palsy who have communication difficulties referred to speech and language therapy services to have their need for intervention assessed.
Numerator – the number in the denominator referred to a speech and language therapy service to have their need for intervention assessed.
Denominator – the number of adults with cerebral palsy who have communication difficulties.
Data source: Local data collection, for example, local audit of patient records.
b) Proportion of adults with cerebral palsy who have communication difficulties referred to speech and language therapy services who have their need for intervention assessed.
Numerator – the number in the denominator who have their need for intervention assessed.
Denominator – the number of adults with cerebral palsy who have communication difficulties referred to speech and language therapy services.
Data source: Local data collection, for example, local audit of patient records.
Outcome
Change in therapy outcome measures (TOMs)TOMs are measures that describe the abilities of a person in 4 dimensions: impairment – the severity of the difficulty or condition; activity – the impact on the person’s independence; participation – the impact on social engagement and autonomy; wellbeing – the impact on mental and emotional wellbeing. following intervention.
Data source: Local data collection, for example, local audit of patient records. The Royal College of Speech and Language Therapists Online Outcome Tool supports speech and language therapists with collecting and collating TOMs data and generating reports.

What the quality statement means for different audiences

Service providers (speech and language therapy services) ensure that referral pathways are in place so that adults with cerebral palsy and communication difficulties can be assessed by speech and language services. They have systems in place to undertake assessments, provide intensive speech therapy and access to AAC systems. They provide training on AAC systems for adults with cerebral palsy, their families, carers and other key communication partners in home, care, social or work environments.
Healthcare professionals (such as GPs, rehabilitation consultants and neurology consultants) ask adults with cerebral palsy about any changes in, or problems with, their hearing, speech and communication at every clinical review. They refer people who have communication difficulties to speech and language therapy services. Speech and language therapists assess their need for intervention, which may include use of intensive speech therapy to improve the intelligibility of speech and AAC systems.
Commissioners (such as clinical commissioning groups and NHS England) ensure that they develop pathways that allow adults with cerebral palsy who have communication difficulties to be referred to speech and language therapy services for assessment and intervention. They also commission intensive speech therapy and specialised or local AAC services.
Adults with cerebral palsy are asked if they have problems with their hearing, speech and communication when they are reviewed by a healthcare professional. If they are having problems, they are referred to a speech and language therapist who will check for any problems and discuss ways in which their communication can be improved.

Source guidance

Cerebral palsy in adults (2019) NICE guideline NG119, recommendation 1.2.6

Definitions of terms used in this quality statement

Adults
For this quality standard, adults are defined as people aged 25 and over, in line with the source guidance. The NICE quality standard for cerebral palsy in children and young people covers people under 25.
Alternative and augmentative communication (AAC) systems
A variety of methods (for example, signing, use of visual symbols and eye gaze technology) that can be used to help people with disabilities communicate with others. These systems or methods of communication can be used as an alternative to speech or to supplement it.
[NICE’s guideline on cerebral palsy in adults, terms used in this guideline]
Communication difficulties
A range of problems that an adult may have with expression and understanding. This includes problems with speech and non-verbal forms of expression, understanding what is being said to them, understanding emotions, using words and grammar and speaking fluently.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Xeomin (botulinum neurotoxin type A) is recommended, within its marketing authorisation, as an option for treating chronic sialorrhoea caused by neurological conditions in adults. It is recommended only if the company provides it according to the commercial arrangement.
When considering continuous pump-administered intrathecal baclofen, give the person (and their family and carers, if agreed) information and discuss the procedure with them. This should include:
  • the need for an intrathecal baclofen test to ensure treatment is suitable
  • the surgical procedure for implanting the pump
  • the need for regular hospital follow-up visits to ensure optimal dosage and pump refill
  • the risks of implanting a pump and pump-related complications (for example, battery failure or catheter leakage), which can result in baclofen withdrawal or overdose
  • a review of 24-hour postural needs.
If continuous pump-administered intrathecal baclofen is being considered for an adult with cerebral palsy, perform an intrathecal baclofen test to assess if it is suitable before implanting a pump. This should involve a test dose or doses of intrathecal baclofen given to the person by lumbar puncture or through a spinal catheter.
Assess the effect of the test dose or doses of intrathecal baclofen on:
  • reducing increased muscle tone
  • reducing pain
  • reducing the frequency of muscle spasms
  • motor function, such as sitting, standing and walking.
Discuss with the adult with cerebral palsy (and their family and carers, if agreed) their views on the response to the intrathecal baclofen test and whether treatment is likely to achieve their treatment goals.
If people with cerebral palsy have problems participating in physical activities because of pain or joint problems that do not respond to any other treatments, consider referring them to a musculoskeletal specialist or an orthopaedic surgeon with experience and expertise in managing musculoskeletal problems in adults with cerebral palsy.
Refer adults with cerebral palsy to a relevant clinical specialist, such as a dietitian or speech and language therapist, if assessment suggests they have difficulties with eating or malnutrition.

Advance care plan

Defined by international consensus as 'A process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences about future medical care. The goal of an advance care plan is to help ensure that people receive medical care that is consistent with their values, goals and preferences during serious and chronic illness.' Sudore et al. (2017) Defining advance care planning for adults

Alternative and augmentative communication systems

A variety of methods (for example, signing, use of visual symbols and eye gaze technology) that can be used to help people with disabilities communicate with others. These systems or methods of communication can be used as an alternative to speech or to supplement it.

Comorbidities

In the context of cerebral palsy, comorbidities are health problems caused by the brain disorder that also caused the motor impairment that is the core problem of cerebral palsy, but are not a direct complication of the motor disorder. For example, visual impairment and epilepsy are described as comorbidities because they are caused by the brain disorder. Hip dislocation and scoliosis are complications of the motor disorder and would not be described as comorbidities.

Electronic assistive technology

Any piece of equipment or system that is used to increase, maintain or improve function in people with disabilities, and is electronically powered (mains electricity and/or battery). These may include communication aids, environmental controls and access to computers.

Escalation plan

A record of the interventions that a person would find acceptable, in line with their values, goals and preferences. It can be used to indicate that more intensive or invasive interventions would be unacceptable to the person. For example, an escalation plan of ward-based care only, indicates that the person would not want invasive monitoring, intubation and ventilation, which are undertaken as part of intensive care.

Executive functions

Cognitive processes that are important for the control of behaviour. These include planning, organising and monitoring behaviours leading to goal attainment, inhibitory control, working memory and cognitive flexibility. As a result of injuries to the frontal lobes of the brain, these processes can be disrupted.

Gross Motor Function Classification System

A 5-level clinical classification system that describes the gross motor function of people with cerebral palsy based on self-initiated movement abilities. People assessed as level I are the most able and people assessed as level V are dependent on others for all their mobility needs.
The GMFCS is not validated for use in adults. However, the GMFCS level at age 12 has been shown to be a good predictor of mobility into adulthood, especially at the milder and most severe levels. It is used here in the absence of a validated system for use in adults because it is readily understood by people with cerebral palsy, their families and carers, and health professionals involved in the care of adults with cerebral palsy.

Reviews

Planned clinical appointments between an adult with cerebral palsy and a healthcare professional or multidisciplinary team. They may explore common concerns, physical symptoms, mental health, pain, nutrition and communication to ensure an individualised approach to care. The healthcare professional may be a GP, specialist nurse, rehabilitation specialist or therapist. This also allows the opportunity to address general health issues that affect people as they grow older.

Review

A planned clinical appointment between an adult with cerebral palsy and a healthcare professional or multidisciplinary team. They may explore common concerns, physical symptoms, mental health, pain, nutrition and communication to ensure an individualised approach to care. The healthcare professional may be a GP, specialist nurse, rehabilitation specialist or therapist. This also allows the opportunity to address general health issues that affect people as they grow older.

Rehabilitation engineering services

Centres that design, develop and adapt technological solutions to overcome challenges to function, activity and participation for individuals with disability. This includes assessment and provision of assistive devices to help with posture, mobility and communication (for example, electronic assistive technology).

Review of 24-hour postural needs

Part of a 24-hour posture review that considers all the relevant postures that an individual has the ability to adopt over the 24 hours of any given day, including postures to allow for participation in daily activities. The 3 core postural orientations are lying, sitting and standing. An example of a postural need is support and positioning in bed.

Key communication partners

People who regularly interact with the person with cerebral palsy in any environment. Communication may be by speech, using communication aids, signing, facial expression or a combination of these.

Glossary

(body measurements that include weight, height, knee height, mid-upper arm circumference, waist circumference, head circumference and skinfold thickness measurements)
(body measurements that include weight, height, knee height, mid-upper arm circumference, waist circumference, head circumference and skinfold thickness measurements)
(focused on relieving symptoms caused by serious illnesses such as respiratory failure, supportive care can be given at any point during a person's illness to help them feel more comfortable and improve their quality of life)
(a person aged 11 years or younger)
(people aged 11 years or younger)
(moving from one surface to another (for example, from a bed to a wheelchair) independently or with assistance)
(the ability to walk independently in the community without the need for supportive devices such as a walking frame, tripod sticks or crutches)
(dual-energy X-ray absorptiometry)
(a person aged between 12 and 24 years of age)
(people aged between 12 and 24 years of age)

Paths in this pathway

Pathway created: January 2017 Last updated: October 2020

© NICE 2020. All rights reserved. Subject to Notice of rights.

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