Topic map

1. Definition and epidemiology
2. Etiology and risk factors
3. Classification
   • By motor type: spastic, dyskinetic, ataxic, mixed
   • By distribution: hemiplegia, diplegia, quadriplegia
   • Functional: GMFCS I-V
4. Clinical features and associated comorbidities
5. Diagnosis, investigations, and differential diagnosis
6. Management: multidisciplinary rehabilitation, spasticity treatment, orthopedic care
7. Prognosis and prevention

High-yield overview

• Spastic CP is most common. Spastic diplegia commonly affects the legs more than arms and is classically associated with prematurity and periventricular white-matter injury.
• Diagnosis is principally clinical: delayed motor milestones, abnormal tone/posture, persistence of primitive reflexes, hyperreflexia, and characteristic gait patterns. Brain MRI helps define timing and pattern of injury and identify alternative diagnoses.
• Screen actively for epilepsy, intellectual/developmental impairment, visual or hearing difficulty, speech and feeding problems, pain, hip displacement, constipation, sleep and behavioral problems.
• Management is individualized and multidisciplinary: physiotherapy, occupational and speech therapy, nutrition and education support, orthoses and assistive devices, treatment of spasticity such as botulinum toxin for focal spasticity and baclofen for generalized spasticity, plus selective orthopedic or neurosurgical interventions in selected children. Current NICE guidance emphasizes assessment and management of associated developmental and clinical comorbidities, alongside maximizing activity and independence through coordinated care (NICE CP guideline).
• Diagnosis remains clinical, supported by history, examination, and selected investigations, as described in Bradley and Daroff's Neurology in Clinical Practice and Campbell's Operative Orthopaedics. The library did not contain Ghai Essential Pediatrics, so I cannot give page-specific Ghai citations.
• Recent reviews support structured rehabilitation approaches but do not replace core multidisciplinary care. Examples include upper-limb cognitive rehabilitation (PMID: 38512713) and rehabilitation after upper-limb botulinum toxin A (PMID: 39593559).

1. Full long answer
2. Classification and clinical features
3. Diagnosis and differential diagnosis
4. Management
5. Short note with viva questions

Cerebral Palsy

Definition

• The brain lesion itself is non-progressive.
• Clinical manifestations such as contractures, deformities, hip displacement, and functional limitation can worsen as the child grows.

Epidemiology

• CP is the commonest cause of chronic motor disability in childhood.
• Prevalence is approximately 2-3 per 1,000 live births in many populations.
• Most cases are congenital, occurring before or around birth.
• Perinatal asphyxia accounts for only a minority of cases. Bradley and Daroff's Neurology in Clinical Practice notes it is responsible for less than about 12% of cases.

Etiology and Risk Factors

1. Prenatal causes

• Prematurity and low birth weight
• Intrauterine growth restriction
• Multiple pregnancy
• Congenital CNS malformations
• Maternal infections: TORCH infections, especially cytomegalovirus
• Chorioamnionitis
• Placental insufficiency or placental thrombosis
• Maternal diabetes, thyroid disease, severe anemia
• Genetic and metabolic disorders

2. Perinatal causes

• Hypoxic-ischemic encephalopathy
• Birth trauma
• Severe neonatal jaundice causing kernicterus
• Neonatal sepsis or meningitis
• Intracranial hemorrhage, particularly intraventricular hemorrhage in preterm infants
• Periventricular leukomalacia, a common lesion in premature infants

3. Postnatal causes

• CNS infection: meningitis, encephalitis
• Severe head injury
• Hypoxic events: drowning, aspiration, severe status epilepticus
• Stroke
• Severe untreated hyperbilirubinemia
• Neurotoxic exposure

Pathology and Important Brain Lesions

Classification

A. According to motor abnormality

1. Spastic CP

• Spastic hemiplegia: one side of body affected, upper limb often more affected than lower limb.
• Spastic diplegia: both lower limbs more affected than upper limbs. Common in preterm children.
• Spastic quadriplegia: all four limbs involved, usually severe; associated with epilepsy, intellectual disability, visual impairment, feeding difficulty, and scoliosis.

2. Dyskinetic CP

• Dystonic CP: sustained twisting postures, often worsened by voluntary activity or emotion.
• Choreoathetoid CP: irregular, jerky chorea with slow writhing athetoid movements.

3. Ataxic CP

• Hypotonia initially
• Incoordination
• Intention tremor
• Broad-based gait
• Dysmetria and poor balance

4. Mixed CP

B. According to distribution

• Monoplegia
• Hemiplegia
• Diplegia/paraplegia
• Triplegia
• Quadriplegia

C. Functional classification: GMFCS

Clinical Features

General features

• Delayed motor milestones
• Abnormal spontaneous movements or posture
• Abnormal muscle tone: usually spasticity, sometimes hypotonia or fluctuating tone
• Persistence of primitive reflexes
• Delayed disappearance of neonatal reflexes
• Early hand preference before 12 months may suggest hemiplegic CP
• Delayed rolling, sitting, crawling, standing, or walking

Features of spastic CP

• Increased tone, often velocity-dependent
• Hyperreflexia
• Ankle clonus
• Extensor plantar response
• Contractures
• Scissoring of lower limbs due to hip adductor spasticity
• Toe walking/equinus due to gastrocnemius-soleus spasticity
• Crouch gait due to hamstring and hip-flexor involvement
• Hip subluxation/dislocation, especially in nonambulant children

Associated problems

• Intellectual disability or learning difficulty
• Epilepsy
• Speech and language impairment
• Hearing impairment
• Visual impairment, including strabismus and cortical visual impairment
• Feeding and swallowing difficulty, aspiration, malnutrition
• Gastroesophageal reflux and constipation
• Drooling
• Dental caries
• Sleep disturbance
• Pain
• Behavioral, emotional, and autism-spectrum problems
• Bladder dysfunction
• Osteopenia and pathological fractures
• Scoliosis and other orthopedic deformities

Diagnosis

Clinical diagnosis

History

• Antenatal events: maternal infection, multiple gestation, reduced fetal movements
• Birth history: prematurity, low birth weight, difficult labor, resuscitation, neonatal seizures
• NICU stay, ventilation, neonatal jaundice, sepsis, meningitis
• Developmental milestones
• Regression of milestones
• Seizures
• Feeding, speech, hearing, vision, and behavior
• Family history of similar illness, genetic disease, or consanguinity

Examination

• Growth parameters and head circumference
• Development in all domains
• Tone, power, reflexes, clonus, plantar response
• Posture and involuntary movements
• Gait, balance, coordination
• Hand function
• Spine, hips, knees, ankles, and contractures
• Vision, hearing, speech, swallowing, and cognition

Investigations

1. MRI brain

• Preferred neuroimaging investigation where cause is uncertain or imaging will aid diagnosis/prognosis.
• May show periventricular leukomalacia, infarction, congenital malformation, or basal ganglia injury.
• MRI supports assessment but should not be used alone to predict prognosis. This is also emphasized by NICE recommendations.

2. Other investigations when indicated

• Hearing assessment
• Ophthalmological examination
• EEG if seizures are suspected
• Swallow assessment in children with choking, recurrent chest infection, or poor weight gain
• X-ray pelvis for hip surveillance
• Genetic testing/metabolic evaluation if atypical features or a progressive disorder is suspected

Red Flags Against Cerebral Palsy

• Loss of acquired milestones or developmental regression
• Progressive worsening of weakness or ataxia
• Family history of progressive neurological disease
• Isolated hypotonia without upper motor neuron signs
• Diurnal fluctuation, especially dopa-responsive dystonia
• Peripheral neuropathy or absent reflexes
• Unusual MRI findings or MRI not consistent with CP
• Progressive microcephaly or macrocephaly
• Hepatosplenomegaly, dysmorphism, or recurrent metabolic decompensation

Differential Diagnosis

• Global developmental delay without CP
• Muscular dystrophy
• Spinal muscular atrophy
• Hereditary spastic paraplegia
• Dopa-responsive dystonia
• Leukodystrophy
• Neurodegenerative/metabolic disorders
• Brain malformations
• Autism spectrum disorder with motor delay
• Acquired brain injury

Management

Principles

Multidisciplinary team

• Pediatrician/developmental pediatrician
• Pediatric neurologist
• Physiotherapist
• Occupational therapist
• Speech and language therapist
• Orthopedic surgeon
• Rehabilitation specialist
• Dietician
• Dentist
• Ophthalmologist and audiologist
• Psychologist/special educator
• Social worker and orthotist

1. Rehabilitation therapy

Physiotherapy

• Maintain range of movement
• Prevent contractures and deformity
• Improve posture, balance, gait, and transfers
• Strengthen weak muscle groups
• Train parents in positioning and home exercises

Occupational therapy

• Improves hand use and activities of daily living
• Seating and positioning
• Adaptive devices for feeding, dressing, writing, and play
• Constraint-induced movement therapy may benefit selected children with hemiplegic CP

Speech and language therapy

• Speech and communication training
• Augmentative and alternative communication when required
• Feeding and swallowing assessment
• Advice on texture modification and safe feeding

Orthoses and assistive devices

• Ankle-foot orthosis for equinus and gait support
• Splints to prevent deformity and improve function
• Standing frames, walkers, wheelchairs, adaptive seating
• Communication devices

2. Management of spasticity

Treat aggravating factors first

• Pain
• Constipation
• Urinary infection
• Pressure sores
• Poor positioning
• Hip dislocation
• Tight orthoses

Focal spasticity

• Useful for dynamic focal spasticity, such as gastrocnemius, hamstrings, hip adductors, or upper-limb muscles.
• Should always be combined with therapy, stretching, splinting, and goal-directed rehabilitation.
• Effects are temporary.

Generalized spasticity

• Oral baclofen
• Diazepam in selected short-term situations
• Other specialist-directed options may include tizanidine or dantrolene

Severe generalized spasticity/dystonia

• Intrathecal baclofen pump in selected cases
• Selective dorsal rhizotomy in carefully selected ambulant children with predominantly spastic diplegia

3. Orthopedic management

• Tendon lengthening or release: Achilles tendon, hamstrings, hip adductors
• Osteotomy for hip displacement or rotational deformity
• Spinal surgery for severe progressive scoliosis

4. Treatment of associated conditions

Prognosis

• Type and severity of CP
• GMFCS level
• Presence of intellectual disability and epilepsy
• Vision and hearing status
• Feeding and swallowing ability
• Degree of trunk and head control

Useful clinical prognostic indicators

• Head control by around 9 months and independent sitting by around 2 years suggest better ambulatory potential.
• Severe quadriplegic CP, uncontrolled epilepsy, severe dysphagia, and profound cognitive impairment indicate greater care needs and lower life expectancy.
• Many children with mild CP have normal or near-normal life expectancy.

Prevention

• Good antenatal care and maternal infection prevention
• Prevention of prematurity
• Skilled neonatal resuscitation and neonatal intensive care
• Early treatment of neonatal jaundice
• Prompt treatment of neonatal sepsis and meningitis
• Prevention of head injury
• Early identification and early intervention for high-risk infants

Exam Conclusion

One-line viva answer