Cerebral Palsy
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Direct answer
Cerebral palsy is a group of non-progressive disorders of movement and posture caused by a permanent insult to the developing fetal or infant brain, with a prevalence of about 2 to 3 per 1,000 live births. The motor phenotype is spastic — diplegia, hemiplegia or quadriplegia, the large majority — dyskinetic, ataxic, hypotonic or mixed, with severity graded on the Gross Motor Function Classification System from level I, walking without limitation, to level V, transported in a wheelchair. Management is multidisciplinary for life: physiotherapy and occupational therapy as the backbone, botulinum toxin and baclofen for spasticity, surgery for contractures and bony deformity, and systematic surveillance of comorbidities — epilepsy, intellectual disability, feeding difficulty, sensory deficits and drooling.
What you must remember
- Topographical patterns: diplegia predominantly affects the legs and tracks with prematurity and periventricular leukomalacia; hemiplegia follows unilateral infarct or malformation with the arm usually worse than the leg; quadriplegia is the most severe, with high epilepsy and dysphagia rates.
- Dyskinetic cerebral palsy — dystonia and choreoathetosis — is the classic kernicterus phenotype; in Indian practice it remains over-represented because neonatal hyperbilirubinaemia is still inadequately treated, and it pairs with sensorineural hearing loss and upward-gaze palsy.
- Magnetic resonance imaging is abnormal in the great majority: periventricular white matter injury in the preterm, basal ganglia and thalamic lesions after term asphyxia, focal infarcts in hemiplegia.
- The clinical diagnosis rests on delayed motor milestones, abnormal tone, persistence of primitive reflexes and early hand preference before one year of age — an asymmetric reach in a young infant is a red flag, not a personality trait.
- GMFCS I–V grades mobility; MACS grades hand function and CFCS communication — a structured answer names the level, not just "severe".
- Spasticity ladder: physiotherapy with stretching and casting; botulinum toxin A injected focally into spastic muscle groups every few months; oral baclofen, tizanidine or diazepam; intrathecal baclofen pump for severe generalised spasticity; selective dorsal rhizotomy for selected diplegias; single-event multilevel surgery for contractures and bony torsion.
- Comorbidity screening at every visit: epilepsy in 30 to 40 per cent, intellectual disability in about half of quadriplegics, visual and hearing impairment, growth, reflux and aspiration-driven respiratory health.
- Under India's Rashtriya Bal Swasthya Karyakram, cerebral palsy is a screened condition with District Early Intervention Centres as referral hubs — national-programme framing examiners increasingly expect.
From tone to type: a worked assessment
An 18-month-old referred for "not walking yet": the assessment decides the next decade. Watch before touching — a child who commando-crawls with scissoring legs and sits with a rounded back is declaring a spastic diplegia; one who is hypotonic at rest but arches into extension with dystonic postures on handling, with a history of neonatal jaundice peaking above 20 mg/dL, is declaring dyskinetic cerebral palsy from kernicterus. Examine systematically: tone and clonus at each joint; reflexes; persistence of primitive reflexes past their window; and hand function with midline crossing and symmetry. Grade the GMFCS honestly by asking what the child actually does at home and school, not what they manage for the examiner. Then complete the aetiological work-up: MRI, hearing and vision assessment, and epilepsy enquiry. The plan falls from the pattern: for the diplegic child, goal-based physiotherapy, ankle-foot orthoses and botulinum toxin for dynamic equinus; for the dyskinetic child, trihexyphenidyl or baclofen trials, hearing amplification and communication aids, speech often disproportionately affected. For both, the family leaves with comorbidity actions — an EEG for suspicious events, a feeding and swallow assessment, growth plotting, and referral into the district early intervention system.
How the exam frames it
The stem either gives a movement pattern and asks the type — scissoring diplegia in an ex-preterm, dystonia with deafness after jaundice — or gives the type and asks the cause or the complication. The kernicterus pairing is the most treasured: dyskinetic cerebral palsy plus sensorineural hearing loss plus impaired upgaze, asking the single best aetiology, neonatal hyperbilirubinaemia. The second recurring format is therapeutic sequencing: a child with focal spastic calf interfering with gait — answer botulinum toxin with physiotherapy, not oral antispasticity drugs, whose CNS adverse effects outweigh local benefit. The third is prognosis, answered with the GMFCS level at two years — the single best predictor of adult ambulation.
Frequently asked questions
What are the main types of cerebral palsy?
Spastic (diplegia, hemiplegia, quadriplegia), dyskinetic, ataxic, hypotonic and mixed phenotypes, with spastic forms the most common.
What is the GMFCS?
The Gross Motor Function Classification System, levels I to V, grading real-world mobility and strongly predicting long-term ambulation.
Which cerebral palsy phenotype follows kernicterus?
Dyskinetic cerebral palsy with dystonia and choreoathetosis, classically with sensorineural hearing loss and impaired upgaze.
What is the first intervention for focal spasticity affecting gait?
Chemodenervation with botulinum toxin A into the targeted muscle group combined with a physiotherapy and casting programme.
Which comorbidities must be screened at every cerebral palsy review?
Epilepsy, intellectual and communication difficulties, visual and hearing impairment, feeding and swallowing with aspiration risk, growth, drooling and bowel-bladder function.