1. Definition and Core Concepts
Definition: A group of nonprogressive disturbances that occurred in the developing fetal or infant brain, resulting in permanent disorders of movement and posture.
Core Truths: The brain lesion is fixed, the spinal cord and muscles are structurally normal at birth, but motor impairment is primary.
Dynamic Progression: Although the brain lesion is static, the musculoskeletal manifestations (contractures and deformities) are dynamic and change as the child grows.
2. Gross Motor Function Classification System (GMFCS)
The GMFCS is the standard for functional classification, describing a child’s self-initiated movement and need for assistive technology.
Level I: Children walk without limitations at home, school, and outdoors. They can run and jump, though speed and balance are reduced. They climb stairs without using a railing.
Level II: Children walk in most settings but have difficulty with long distances, uneven terrain, or crowded spaces. They climb stairs holding onto a railing and have minimal ability to run or jump.
Level III: Children walk using hand-held mobility devices (walkers, crutches, or canes) for most indoor settings. They use wheeled mobility for long distances and may self-propel for short distances.
Level IV: Children use methods of mobility that require physical assistance or powered mobility. They are transported in a manual wheelchair or use powered mobility in the community. They may take a few steps at home with body-support walkers.
Level V: Children are transported in a manual wheelchair in all settings. They have severely limited head and trunk control and lack independent mobility.
3. Orthopaedic Surgery and the Spastic Type
Predictability: The results of orthopaedic surgical treatment are most predictable and successful in purely spastic patients.
Contraindications: Results are highly unpredictable in patients with large athetoid, dystonic, or ataxic components.
Surgical Goals: For spastic patients, surgery aims to correct dynamic or static deformities, balance muscle power across joints, and stabilize uncontrollable joints.
SEMLS: Single-Event Multilevel Surgery (SEMLS) is preferred to minimize repeated hospitalizations and maximize rehabilitation efficiency.
4. Physiologic and Anatomic Classification
Spastic (Pyramidal): Most common (80%); characterized by velocity-dependent increased muscle tone due to motor cortex or corticospinal tract injury.
Athetoid (Extrapyramidal): Purposeless, involuntary movements; often involves the entire body.
Ataxic: Clumsy gait and balance disturbances due to cerebellar lesions.
Anatomic Distribution:
Hemiplegia: One side involved; upper limb usually worse than lower.
Diplegia: Lower extremities more involved than upper extremities.
Quadriplegia: All four limbs equally involved; often associated with cognitive deficits.
5. Milestones and Prognosis
Walking Predictors: Independent sitting by age 2 is a strong predictor of walking. If a child has not learned to walk by age 8, they will likely never be ambulatory.
Primitive Reflexes: Persistence of the asymmetric tonic neck reflex or Moro reflex beyond the normal time frame (e.g., after 11 months) indicates a poor prognosis for independent ambulation.
Survival: Survival is linked to GMFCS level; level I and II have near-normal life spans, while level V has a higher risk of early mortality due to medical fragility.
6. Associated Conditions
Hip Displacement: Risk is directly correlated with GMFCS level. Level V has a 90% risk of hip subluxation/dislocation.
Scoliosis: Affects 25%–68% of patients, with the highest incidence in GMFCS IV and V quadriplegics.
Sensory/Cognitive: Sensory changes (stereognosis, proprioception) are common, especially in hemiplegics, and can predict poor functional surgical outcomes.
Cerebral Palsy: General
1. Definition and Core Concepts
Definition: A group of nonprogressive disturbances that occurred in the developing fetal or infant brain, resulting in permanent disorders of movement and posture.
Core Truths: The brain lesion is fixed, the spinal cord and muscles are structurally normal at birth, but motor impairment is primary.
Dynamic Progression: Although the brain lesion is static, the musculoskeletal manifestations (contractures and deformities) are dynamic and change as the child grows.
2. Gross Motor Function Classification System (GMFCS)
The GMFCS is the standard for functional classification, describing a child’s self-initiated movement and need for assistive technology.
Level I: Children walk without limitations at home, school, and outdoors. They can run and jump, though speed and balance are reduced. They climb stairs without using a railing.
Level II: Children walk in most settings but have difficulty with long distances, uneven terrain, or crowded spaces. They climb stairs holding onto a railing and have minimal ability to run or jump.
Level III: Children walk using hand-held mobility devices (walkers, crutches, or canes) for most indoor settings. They use wheeled mobility for long distances and may self-propel for short distances.
Level IV: Children use methods of mobility that require physical assistance or powered mobility. They are transported in a manual wheelchair or use powered mobility in the community. They may take a few steps at home with body-support walkers.
Level V: Children are transported in a manual wheelchair in all settings. They have severely limited head and trunk control and lack independent mobility.
3. Orthopaedic Surgery and the Spastic Type
Predictability: The results of orthopaedic surgical treatment are most predictable and successful in purely spastic patients.
Contraindications: Results are highly unpredictable in patients with large athetoid, dystonic, or ataxic components.
Surgical Goals: For spastic patients, surgery aims to correct dynamic or static deformities, balance muscle power across joints, and stabilize uncontrollable joints.
SEMLS: Single-Event Multilevel Surgery (SEMLS) is preferred to minimize repeated hospitalizations and maximize rehabilitation efficiency.
4. Physiologic and Anatomic Classification
Spastic (Pyramidal): Most common (80%); characterized by velocity-dependent increased muscle tone due to motor cortex or corticospinal tract injury.
Athetoid (Extrapyramidal): Purposeless, involuntary movements; often involves the entire body.
Ataxic: Clumsy gait and balance disturbances due to cerebellar lesions.
Anatomic Distribution:
Hemiplegia: One side involved; upper limb usually worse than lower.
Diplegia: Lower extremities more involved than upper extremities.
Quadriplegia: All four limbs equally involved; often associated with cognitive deficits.
5. Milestones and Prognosis
Walking Predictors: Independent sitting by age 2 is a strong predictor of walking. If a child has not learned to walk by age 8, they will likely never be ambulatory.
Primitive Reflexes: Persistence of the asymmetric tonic neck reflex or Moro reflex beyond the normal time frame (e.g., after 11 months) indicates a poor prognosis for independent ambulation.
Survival: Survival is linked to GMFCS level; level I and II have near-normal life spans, while level V has a higher risk of early mortality due to medical fragility.
6. Associated Conditions
Hip Displacement: Risk is directly correlated with GMFCS level. Level V has a 90% risk of hip subluxation/dislocation.
Scoliosis: Affects 25%–68% of patients, with the highest incidence in GMFCS IV and V quadriplegics.
Sensory/Cognitive: Sensory changes (stereognosis, proprioception) are common, especially in hemiplegics, and can predict poor functional surgical outcomes.