9.2 Pediatric Neurologic Conditions and Cerebral Palsy
Key Takeaways
CP reflects a nonprogressive disturbance in the developing brain. Motor presentation, activity and musculoskeletal needs can change over time.
Describe the motor pattern and usual functional mobility separately. Use the age-specific GMFCS for classification and an appropriate measure such as GMFM to track change.
Coordinate tone management with functional goals and monitor the response. Suspected intrathecal baclofen withdrawal requires emergency assessment.
Select and tune an AFO with its footwear using gait, passive range, motor control and activity goals.
AACPDM hip surveillance uses clinical assessment and standardized radiographs. Refer to pediatric orthopaedics when MP exceeds 30% or passive hip abduction is below 30 degrees. Hip pain also warrants specialist referral.
Pediatric Neurologic Conditions and Cerebral Palsy
Cerebral palsy (CP) describes permanent disorders of movement and posture that limit activity and are attributed to a nonprogressive disturbance in the developing brain. Function and musculoskeletal findings can change with growth and experience. Assess associated needs, including feeding, communication, pain, vision and hearing, with the multidisciplinary team.
Etiology and Pathogenesis
Risk factors and mechanisms can act before, around or after birth. Examples include fetal or perinatal stroke, white matter injury associated with prematurity, neonatal encephalopathy and early brain infection or trauma. Injury patterns can support etiologic reasoning. For example, bilateral spastic involvement with the legs more affected can occur after preterm white matter injury. Dyskinetic findings can occur after basal ganglia injury or kernicterus. The history, examination and investigations guide the differential diagnosis.
For high-risk infants before about 5 months corrected age, the AACPDM pathway uses the General Movements Assessment with neuroimaging when indicated and available. Later in infancy, a structured neurological examination such as the Hammersmith Infant Neurological Examination helps assess risk. Hand asymmetry, delayed sitting and caregiver concerns merit attention. Loss of an acquired skill warrants evaluation for other causes. Arrange timely specialist assessment and early intervention when risk is identified.
Set a meaningful activity goal with the family and measure it at baseline. For example, practice a supported transfer used at home, adjust the support and number of repetitions to safe performance, and reassess how much assistance the child needs. Whole-task practice, equipment and environmental adaptation can support participation.
Classification of Cerebral Palsy
Describe the predominant motor finding and the distribution. Report everyday mobility separately.
| Motor pattern | Examination features |
|---|---|
| Spastic | Increased resistance to faster passive stretch can occur with brisk reflexes and other upper motor neuron signs. Describe unilateral or bilateral involvement. |
| Dyskinetic | Involuntary movements or postures. Dystonia involves patterned, sustained or intermittent contractions. Choreoathetosis may include irregular rapid movements and slower writhing movements. |
| Ataxic | Impaired coordination, timing and accuracy of movement. Balance difficulty and dysmetria can be prominent. |
| Mixed features | Describe the findings present, such as spasticity together with dystonia, and their effects on activity. |
Older clinical descriptions include hemiplegia for one-sided involvement, diplegia for bilateral involvement with the legs more affected and quadriplegia for all four limbs. Motor type and limb distribution help describe the presentation. Use a functional classification to document mobility.
Gross Motor Function Classification System (GMFCS)
The Gross Motor Function Classification System, Expanded and Revised (GMFCS E&R) describes usual self-initiated gross motor function, including sitting, transfers, walking and wheeled mobility. Use the relevant age band and the child's performance across everyday settings.
| Level | Examples for the 6th to 12th birthday age band |
|---|---|
| I | Walks across settings and uses stairs without a railing. Running and jumping are possible, with possible limits in speed, balance and coordination. |
| II | Walks in most settings and usually uses a rail on stairs. Uneven terrain, crowds or distance may call for help, a hand-held device or wheeled mobility. |
| III | Uses a hand-held device to walk in most indoor settings and wheeled mobility for longer distances. Stairs can require a rail and supervision or assistance. |
| IV | Uses physical assistance or powered mobility in most settings. May walk short distances with physical assistance or use a body-support walker in selected settings. |
| V | Usually transported in a manual wheelchair with substantial limitations in antigravity head and trunk control and complete assistance for transfers. Some children use extensively adapted powered mobility. |
Document the age band, usual equipment and environment. Use the GMFM or another appropriate outcome measure to track change in gross motor capacity. Use the GMFCS to communicate the functional classification and plan support.
Medical and Surgical Spasticity Management
Identify a problem such as pain, difficulty with care, orthosis intolerance or a mobility limitation. Evaluate strength, motor control, dystonia and passive restriction. Some children use increased tone to help complete a task, so measure the effect of any treatment on the actual goal.
1. Botulinum Toxin Type A (BoNT-A)
BoNT-A cleaves SNAP-25 and temporarily reduces acetylcholine release at the neuromuscular junction. A specialist may consider injections for focal spasticity that interferes with a meaningful goal. Use product-specific prescribing information and coordinate therapy, orthoses or casting with the treating team. NICE CG145 recommends reassessment of tone, range and motor function at 6–12 weeks after treatment and again at 12–26 weeks to inform repeat treatment. When casting is indicated after injection, that guideline advises considering a delay of 2–4 weeks. The dates are follow-up and casting guidance for that pathway. Select practice based on the child's response and the treatment plan.
Warning
The Saudi Food and Drug Authority identifies swallowing or breathing difficulty from toxin spread as potentially life-threatening. New difficulty swallowing or breathing after injection requires immediate medical assessment.
2. Oral Antispasticity Medication
Oral baclofen acts at GABA-B receptors and can be considered for selected children with troublesome spasticity. Sedation and weakness can affect function. Other agents such as tizanidine or dantrolene require individualized specialist selection and monitoring. Check the child’s alertness, mobility and response after medication changes. Use the prescriber’s plan for dose changes or withdrawal.
3. Intrathecal Baclofen (ITB)
A pump delivers baclofen into cerebrospinal fluid. A specialist team can consider it when severe generalized spasticity or dystonia causes significant pain, difficulty with care or functional limitations despite less invasive management.
Warning
Abrupt interruption of intrathecal baclofen can cause life-threatening withdrawal. Sudden return of marked spasticity, fever or altered mental status after a pump alarm or missed refill requires emergency assessment and contact with the pump team. Restoring intrathecal delivery is a specialist emergency treatment.
4. Selective Dorsal Rhizotomy (SDR)
SDR sections selected sensory rootlets to reduce spinal stretch reflex activity. NICE recommends considering it to improve walking for selected children at GMFCS levels II or III. A specialist multidisciplinary team considers the motor pattern, strength, control, contractures, family goals and ability to participate in postoperative rehabilitation. Discuss that the intervention is irreversible. Set individualized postoperative goals and progress functional practice and strengthening according to healing and ability.
Orthotic Management and Pathological Gait
Choose the orthosis by gait, passive range, strength, motor control and the child’s task goals. Assess it with the footwear, because alignment affects how the tibia and knee move during stance.
| Sagittal gait pattern | Typical observations in bilateral spastic CP |
|---|---|
| True equinus | The ankle remains plantarflexed in stance, with relatively extended hips and knees. |
| Jump gait | Equinus occurs with increased knee and hip flexion, particularly in early stance. |
| Apparent equinus | Excessive hip and knee flexion makes the child appear to walk on the toes despite an ankle angle nearer the expected range. |
| Crouch gait | Increased ankle dorsiflexion, knee flexion and hip flexion during stance. |
- A solid AFO limits ankle motion and can provide stance stability. A hinged AFO with a plantarflexion stop can allow dorsiflexion when suitable knee and hip extension control is present.
- A ground-reaction AFO can limit excessive forward tibial progression. An orthosis–footwear setup can alter the external knee moment toward extension in stance. A comparison of solid and ground-reaction designs found similar crouch correction across groups. Fit and alignment, passive hip and knee range, and the child’s gait affect the result.
- A supramalleolar orthosis can support foot alignment when little sagittal ankle control is needed. Check fit, skin, comfort and function with any design.
Adaptive Equipment and Positioning
Select a stander or seating system to meet a specific goal such as access to play, supported alignment or comfortable participation. Fit pelvic, trunk and head supports to the child and check skin, comfort, transfers and tolerance. For example, use supported standing during a short classroom activity and adjust duration and position according to response and the team’s recommendations. A standing trial in nonambulant children found a benefit at the vertebrae after increasing existing standing time, with no corresponding proximal tibial benefit. Set the plan by the child’s goal and precautions.
Hip Surveillance for Displacement
Hip displacement can develop without obvious symptoms. The AACPDM care pathway recommends beginning surveillance when CP is identified or suspected, ideally by age 2. Determine frequency using age, GMFCS level, relevant gait pattern, previous imaging and change in migration percentage. Check hip pain and passive abduction.
Reimers Migration Percentage (MP)
On a standardized supine AP pelvis radiograph, measure the width of the ossified femoral head lateral to Perkins’ line and divide by the total ossified head width. Perkins’ line is perpendicular to the horizontal pelvic reference and passes through the lateral acetabular margin.
Hip pain on history or examination warrants referral to a specialist experienced in hip displacement in CP. Referral thresholds identify children who need assessment. Orthopaedic decisions use the trend, age, symptoms and the complete clinical picture.
Worked example: In a 4-year-old at GMFCS level IV, 10.5 mm of the ossified head lies lateral to Perkins’ line and its full width is 25 mm. The migration percentage is . Refer to pediatric orthopaedics and communicate the current result, previous images if available, pain and passive abduction.
A 9-year-old with bilateral spastic cerebral palsy usually walks indoors using a posterior walker and uses a wheelchair for longer distances at school and outdoors. With supervision the child uses a rail on stairs. Which GMFCS E&R level best matches this usual mobility?
Level II
Level III
Level IV
Level V
An 8-year-old with bilateral spastic cerebral palsy shows excessive ankle dorsiflexion and persistent knee and hip flexion in stance. The team is trialing a ground-reaction AFO with appropriately aligned footwear. Which effect is the team trying to achieve?
Increase forward tibial progression during stance
Support the midfoot while allowing unrestricted sagittal ankle motion
Limit excessive forward tibial progression and improve the external knee extension moment in stance
Increase knee flexion by moving the ground reaction force posterior to the knee
A standardized pelvis radiograph for a 4-year-old at GMFCS level IV shows a Reimers migration percentage of 42% on the left. Under the AACPDM hip surveillance pathway, what is the appropriate next step?
Discharge the child from surveillance because the value is expected at level IV
Arrange emergency open reduction based on the percentage alone
Stop all supported standing until avascular necrosis is excluded
Refer to pediatric orthopaedics and communicate the imaging trend and examination findings
Which child best fits a specialist evaluation for selective dorsal rhizotomy when the proposed goal is improved walking under NICE CG145?
A 5-year-old with bilateral spastic cerebral palsy at GMFCS level II, adequate strength and trunk control, and a family able to participate in follow-up therapy
A child whose main walking limitation is a fixed bony deformity
A child whose predominant motor finding is severe generalized dystonia
A child whose standing currently depends on tone because of severe weakness
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