FEATURED ARTICLE • NEURO REHABILITATION
Cerebral Palsy: Assessment, Classification and Physiotherapy Rehabilitation
Introduction
Cerebral palsy (CP) describes a group of permanent disorders of movement and posture causing activity limitation, attributed to disturbances in the developing fetal or infant brain. The neurological disturbance itself is non-progressive, but the child's functional presentation may change with growth, development, secondary musculoskeletal problems, pain, fatigue and changing environmental demands.
Modern management emphasizes early recognition, individualized goals, participation, family involvement and coordinated multidisciplinary care. NICE recommends focusing on functional abilities as well as impairments, while AACPDM care pathways emphasize evidence-informed clinical decision-making and surveillance of important complications.
Causes and Risk Factors
- Premature birth and very low birth weight.
- Perinatal stroke or neonatal brain injury.
- Hypoxic-ischaemic injury.
- Congenital brain abnormalities.
- Central nervous system infection.
- Severe neonatal jaundice with neurological injury.
- Genetic, metabolic or developmental conditions.
- Acquired brain injury during infancy or early childhood.
In many children, a single definite cause cannot be identified. Risk factors should not be treated as proof of causation.
Pathophysiology
Damage or abnormal development in the immature brain can disrupt descending motor pathways, sensory-motor integration, postural control and selective movement. The resulting motor phenotype may include spasticity, dystonia, dyskinesia, weakness, impaired coordination or combinations of these. Over time, altered muscle activity and reduced movement can contribute to contracture, bony deformity, gait changes, pain and reduced participation.
Flow: Developing brain disturbance → impaired motor control → abnormal tone/selective control → altered posture and movement → activity limitations → risk of secondary musculoskeletal complications.
Classification
| Type | Typical Characteristics |
|---|---|
| Spastic | Velocity-dependent increased resistance, abnormal muscle activation, stiffness and reduced selective motor control. |
| Dyskinetic | Involuntary movement and fluctuating tone; dystonia and choreoathetoid patterns may occur. |
| Ataxic | Predominantly impaired coordination, balance and movement accuracy. |
| Mixed | Features of more than one movement disorder. |
Topographical Patterns in Spastic CP
| Pattern | Distribution | Common Functional Presentation |
|---|---|---|
| Hemiplegia | One side predominantly affected | Asymmetry, reduced affected-hand use and gait deviations. |
| Diplegia | Lower limbs more affected than upper limbs | Lower-limb stiffness, altered gait, balance limitations. |
| Quadriplegia | Four limbs and trunk substantially affected | Major limitations in posture, transfers, mobility and self-care. |
Clinical Features
- Delayed or abnormal motor milestones.
- Abnormal muscle tone.
- Weakness and reduced endurance.
- Poor selective motor control.
- Balance and postural-control impairment.
- Abnormal gait or reduced walking efficiency.
- Upper-limb and hand-function difficulties.
- Contractures or loss of joint range.
- Pain, fatigue and reduced participation.
- Associated visual, communication, feeding, cognitive or seizure-related problems in some individuals.
Red Flags for Reconsidering the Diagnosis
| Loss of previously acquired developmental skills, unexpected focal neurological signs, a progressive clinical course, or other findings inconsistent with the expected pattern of CP require specialist neurological assessment. |
|---|
NICE specifically recommends reviewing the diagnosis when clinical signs or development do not follow the expected pattern and identifies developmental regression and unexpected focal neurological signs as important red flags.
Physiotherapy Assessment
| Domain | Key Components |
|---|---|
| History | Birth/developmental history, medical history, seizures, pain, fatigue, previous treatment, family goals. |
| Tone | Distribution and severity of spasticity/dystonia; response to movement and position. |
| ROM | Active/passive hip, knee, ankle and upper-limb range. |
| Strength | Functional strength, selective activation and endurance. |
| Motor control | Dissociation, coordination, motor planning and task performance. |
| Posture | Head, trunk, pelvis and limb alignment. |
| Balance | Static/dynamic balance and protective reactions. |
| Gait | Speed, symmetry, step length, foot position, knee/hip control and device use. |
| Function | Floor mobility, transfers, standing, walking, stairs and self-care. |
| Participation | School, play, family and community activities. |
Functional Classification: GMFCS
The Gross Motor Function Classification System (GMFCS) describes usual gross motor performance using five levels. It is a classification system, not a treatment outcome measure.
| Level | General Description |
|---|---|
| I | Walks independently with relatively few gross-motor limitations; advanced activities may be affected. |
| II | Walks independently but has limitations with speed, distance, uneven surfaces or advanced motor skills. |
| III | Usually walks with a hand-held mobility device and may use wheeled mobility for longer distances. |
| IV | Self-mobility is limited; powered mobility or substantial assistance is often needed. |
| V | Severe limitations in voluntary movement, head/trunk control and independent mobility. |
Physiotherapy Goals
- Maximize functional mobility and independence.
- Improve strength, balance, endurance and motor control.
- Maintain available joint range and muscle length.
- Improve safe and efficient gait or alternative mobility.
- Reduce secondary musculoskeletal complications.
- Improve participation in school, play and community life.
- Educate caregivers and promote practical home practice.
Evidence-Informed Physiotherapy Management
Task-specific training
Repeated practice of meaningful tasks such as reaching, transfers, sit-to-stand, standing, walking, stairs and play should be integrated into daily routines.
Strength training
Progressive strengthening can be used to address weakness and improve functional capacity. Technique, fatigue, recovery and the child's goals should guide dosage.
Balance and postural control
Progress from supported sitting/standing and weight shifts to reaching, stepping, obstacle negotiation and dynamic functional activities.
Gait training
Use overground practice and, where appropriate, treadmill or other structured stepping practice. Goals should focus on safe, efficient and meaningful mobility rather than appearance alone.
Aerobic activity
Age-appropriate active play, cycling, swimming or adapted sports can support fitness and participation.
ROM and positioning
Use individualized active movement, gentle ROM, positioning and functional practice to maintain available movement and comfort.
Orthoses and assistive technology
AFOs, standing systems, walkers, wheelchairs and other devices may support alignment, mobility and participation when appropriately prescribed.
Upper-limb rehabilitation
For unilateral involvement, task-specific upper-limb practice, including bimanual activities or constraint-induced approaches when appropriate, may be incorporated.
Family-centered care
Goals should be agreed with the child and family and embedded into meaningful daily activities.
Secondary Complications
| Problem | Clinical Consideration |
|---|---|
| Hip displacement | Requires systematic surveillance; pain or loss of hip movement warrants assessment. AACPDM recommends a systematic surveillance approach using clinical and radiographic assessment according to risk. |
| Contracture | Monitor ROM over time; combine positioning, active movement, strengthening and appropriate referral. |
| Scoliosis | Monitor posture and spinal alignment, especially with increasing motor impairment. |
| Pain | Look for musculoskeletal, tone-related, fatigue, gastrointestinal or other causes rather than assuming pain is 'part of CP'. |
| Low bone density | Weight-bearing activity may be part of an individualized plan; children with risk factors need appropriate medical assessment. |
| Fatigue | Balance activity and recovery and consider mobility efficiency and energy-conservation strategies. |
Hip Surveillance
Hip displacement is an important preventable source of pain and functional decline. AACPDM describes hip surveillance as systematic monitoring to identify early indicators of hip displacement. Surveillance incorporates clinical examination and radiographic assessment at intervals determined by risk, including age and GMFCS level.
Home Program
- Use short, repeatable activities rather than an unrealistic exercise schedule.
- Practice functional tasks through play.
- Include strengthening, balance, mobility and active range according to the child's goals.
- Teach safe transfers and positioning to caregivers.
- Monitor pain, fatigue, falls and changes in function.
- Review orthoses and equipment as the child grows.
Clinical Case Study
A 7-year-old child with spastic diplegic CP, GMFCS II, walks independently but has reduced ankle dorsiflexion, weak hip extensors, reduced dynamic balance and difficulty keeping pace with classmates.
Assessment Findings
- Reduced selective lower-limb control.
- Limited ankle dorsiflexion.
- Reduced hip-extensor strength.
- Reduced single-leg and dynamic balance.
- Reduced walking speed and difficulty on uneven surfaces.
Rehabilitation Plan
- Task-specific sit-to-stand and step-up practice.
- Progressive hip and knee strengthening.
- Dynamic balance and stepping tasks.
- Gait practice across safe varied surfaces.
- Individualized ankle ROM/positioning program.
- Review orthotic and footwear needs.
- Home activities incorporated into play and school routines.
Multidisciplinary Management
Depending on individual needs, the team may include physiotherapy, occupational therapy, speech and language therapy, pediatric medicine/neurology, orthotics, orthopedics, rehabilitation medicine, dietetics, psychology, nursing and educational support. Coordinated management is especially important when pain, swallowing, communication, epilepsy, vision, respiratory problems or orthopedic complications are present.
Key Takeaways
- CP is non-progressive at the level of the original brain disturbance, but function and secondary complications can change over time.
- Classification and functional assessment guide individualized rehabilitation.
- Task-specific activity, strengthening, balance, gait and fitness are important rehabilitation domains.
- Hip surveillance and monitoring of pain and musculoskeletal changes are important.
- Family-centered, participation-focused care is central to long-term management.
References
- NICE. Cerebral palsy in under 25s: assessment and management (NG62). Published 2017; guideline reviewed 2024.
- American Academy for Cerebral Palsy and Developmental Medicine (AACPDM). Hip Surveillance in Cerebral Palsy. Care Pathway.
- AACPDM. Care Pathways: evidence-informed clinical recommendations for childhood-onset disabilities.