Summary

Cerebral palsy (CP) is a group of permanent disorders of movement and posture, attributed to non-progressive disturbances in the developing fetal or infant brain. It is the most common cause of physical disability in childhood, affecting approximately 2-3 per 1,000 live births. The motor disorders are often accompanied by disturbances of sensation, perception, cognition, communication, behaviour, and epilepsy. CP is classified by motor type (spastic, dyskinetic, ataxic, mixed), anatomical distribution (hemiplegia, diplegia, quadriplegia), and functional severity (GMFCS levels I-V). The underlying brain lesion is non-progressive, but secondary musculoskeletal complications develop over time. Management is multidisciplinary, focusing on maximising function, preventing complications, and improving quality of life.

Key Facts

• Prevalence: 2-3 per 1,000 live births; stable despite improved neonatal care (improved preterm survival)
• Causes: Prematurity (major risk factor), hypoxic-ischaemic encephalopathy (HIE), intrauterine infection, kernicterus
• Key pathology: Periventricular leukomalacia (PVL) in preterm; watershed infarcts in term
• Classification: Spastic (70-80%), Dyskinetic (10-15%), Ataxic (5%), Mixed
• Distribution: Hemiplegia (one side), Diplegia (legs > arms), Quadriplegia (all four limbs)
• Functional classification: GMFCS levels I (walks without limitations) to V (severe limitations, wheelchair)
• Non-progressive brain injury: But secondary musculoskeletal problems develop over time
• Comorbidities: Epilepsy (25-50%), intellectual disability, visual/hearing impairment, feeding difficulties
• Life expectancy: Varies by severity; many live into adulthood

Clinical Pearls

"Non-progressive Brain, Progressive Musculoskeletal": The brain injury in CP is static, but the musculoskeletal consequences (contractures, scoliosis, hip dysplasia) are progressive. This distinction is essential for prognosis discussions.

"Regression = Not CP": If a child loses previously acquired skills, this is NOT CP. Investigate for metabolic or degenerative neurological conditions. CP is characterised by motor delay, not regression.

"Premature + White Matter = PVL": Periventricular leukomalacia (injury to white matter around ventricles) is the classic lesion in preterm infants, leading to spastic diplegia (legs affected more than arms).

"The Stiff Baby Becomes Floppy First": Some children with spastic CP initially present with hypotonia before spasticity develops. The motor pattern may not be fully apparent until 12-24 months.

"Scissoring Gait = Spastic Diplegia": The classic scissoring gait (knees crossing midline) with toe-walking is pathognomonic of spastic diplegia from bilateral periventricular injury.

Why This Matters Clinically

Cerebral palsy is the most common childhood physical disability and requires lifelong multidisciplinary care. Early recognition enables timely intervention, which improves developmental outcomes. Understanding the classification helps predict functional trajectory and guide management. Distinguishing CP from progressive neurological conditions is critical — regression of milestones mandates urgent investigation.[1,2]

Structured Examination

General Observation:

• Posture at rest
• Spontaneous movement pattern
• Asymmetry
• Involuntary movements
• Alertness and interaction

Motor Examination:

• Tone: Spasticity (velocity-dependent), rigidity, hypotonia
• Power: Weakness pattern (pyramidal = extensors in arms, flexors in legs)
• Reflexes: Hyperreflexia, clonus, Babinski sign
• Primitive reflexes: Persistence of Moro, ATNR, grasp

Gait Assessment:

• Scissoring (spastic diplegia)
• Circumduction (hemiplegia)
• Toe-walking
• Crouch gait (hip and knee flexion in older children)
• Ataxic gait (wide-based, unsteady)

Oromotor Assessment:

• Drooling
• Jaw thrust
• Tongue thrust
• Swallowing coordination

Special Tests

Functional Classification (GMFCS)

Ambulatory Prognosis

Life Expectancy

Prognostic Factors

Key Guidelines

Landmark Studies

GMFCS Development (Palisano et al. 1997)

• Developed 5-level classification system
• Validated, reliable, widely used globally
• Predicts motor prognosis
• PMID: 9161656

SDR Evidence (McLaughlin et al. 2002)

• RCT of Selective Dorsal Rhizotomy
• Showed improvements in spasticity and function in selected children
• PMID: 11872903

Swedish Hip Surveillance Programme

• Population-based hip surveillance reduced dislocation rate from 8% to <0.5%
• Model for preventive orthopaedic care
• PMID: 15580352

Evidence Strength

What is Cerebral Palsy?

Cerebral palsy (CP) is a condition that affects movement and posture. It is caused by damage to the developing brain, usually before or around birth. "Cerebral" refers to the brain, and "palsy" means problems with movement.

Why does it happen?

The brain injury that causes CP can happen:

• Before birth (most common) — often related to premature birth
• During birth — lack of oxygen (rare)
• After birth — infections like meningitis, or head injury (rare)

In many cases, the exact cause is not known.

What are the symptoms?

CP affects children differently. Some have mild difficulties, while others have more significant challenges:

• Stiff or floppy muscles
• Difficulty with walking, balance, or coordination
• Problems with fine movements (writing, dressing)
• Speech difficulties
• Some children may also have learning difficulties, epilepsy, or vision problems

How is it treated?

There is no cure for CP, but many treatments help:

• Physiotherapy — to improve movement and prevent stiffness
• Occupational therapy — to help with everyday tasks
• Speech therapy — to improve communication and swallowing
• Medicines — to reduce muscle stiffness (spasticity)
• Botox injections — to relax specific muscles
• Surgery — sometimes needed for tight muscles or hip problems

What to expect?

CP is a lifelong condition, but it is NOT progressive — the brain injury does not get worse. Many children with CP live happy, fulfilling lives. Early intervention and ongoing support make a big difference.

When to seek help

See a doctor if you notice:

• Your child losing skills they previously had (this is NOT typical of CP)
• Worsening seizures
• Difficulty breathing or frequent chest infections
• Signs of hip pain or worsening walking

High-Yield Exam Topics

Sample Viva Questions

Q1: A 2-year-old presents with motor delay, spasticity, and scissoring gait. What is the likely diagnosis and what investigations would you perform?

Model Answer: The presentation suggests spastic diplegic cerebral palsy. I would take a detailed history including pregnancy, prematurity, neonatal course, and developmental history. Key investigation is MRI brain, which would likely show periventricular leukomalacia (PVL) in a previously preterm infant. I would also screen for associated conditions: vision and hearing assessment, developmental assessment. I would classify using GMFCS and establish multidisciplinary follow-up with physiotherapy, orthopaedics (hip surveillance), and speech therapy.

Q2: Why is it important to distinguish CP from progressive neurological conditions?

Model Answer: CP is characterised by a non-progressive brain injury. The clinical presentation may evolve as the child develops, but there should be no regression of skills. If a child loses previously acquired skills or shows progressive deterioration, this suggests a different diagnosis such as:

• Metabolic disorders (leukodystrophies, mitochondrial diseases)
• Neurodegenerative conditions (Rett syndrome, Batten disease)
• Structural lesions (tumours)

This distinction is critical because progressive conditions require specific investigation (metabolic screen, genetic testing) and may have different treatments or implications for prognosis and genetic counselling.

Q3: What is the evidence for Selective Dorsal Rhizotomy (SDR)?

Model Answer: SDR is a neurosurgical procedure that selectively cuts sensory nerve rootlets in the lumbar spine to reduce spasticity. Evidence supports its use in carefully selected ambulant children with spastic diplegia (typically GMFCS II-III). McLaughlin et al.'s meta-analysis of three RCTs showed improvements in spasticity and gross motor function. Selection criteria include: pure spasticity (not dystonia), adequate strength, reasonable cognition for rehab, and clear evidence of spasticity limiting function. SDR requires intensive post-operative rehabilitation. It is not suitable for all children and requires specialist assessment.

Common Exam Errors

Last Reviewed: 2025-12-24 | MedVellum Editorial Team

Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.