Cerebral Palsy: An Overview


Am Fam Physician. 2020 Feb 15;101(4):213-220.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/cerebral-palsy.

Author disclosure: No relevant financial affiliations.

Cerebral palsy, which occurs in two to three out of 1,000 live births, has multiple etiologies resulting in brain injury that affects movement, posture, and balance. The movement disorders associated with cerebral palsy are categorized as spasticity, dyskinesia, ataxia, or mixed/other. Spasticity is the most common movement disorder, occurring in 80% of children with cerebral palsy. Movement disorders of cerebral palsy can result in secondary problems, including hip pain or dislocation, balance problems, hand dysfunction, and equinus deformity. Diagnosis of cerebral palsy is primarily clinical, but magnetic resonance imaging can be helpful to confirm brain injury if there is no clear cause for the patient’s symptoms. Once cerebral palsy has been diagnosed, an instrument such as the Gross Motor Function Classification System can be used to evaluate severity and treatment response. Treatments for the movement disorders associated with cerebral palsy include intramuscular onabotulinumtoxinA, systemic and intrathecal muscle relaxants, selective dorsal rhizotomy, and physical and occupational therapies. Patients with cerebral palsy often also experience problems unrelated to movement that need to be managed into adulthood, including cognitive dysfunction, seizures, pressure ulcers, osteoporosis, behavioral or emotional problems, and speech and hearing impairment. (Am Fam Physician. 2020;101(4):213–220. Copyright © 2020 American Academy of Family Physicians.)

The Centers for Disease Control and Prevention defines cerebral palsy as a group of disorders that affects an individual’s movement, posture, and balance.1 The clinical findings, which are due to an injury to the developing brain, are permanent and nonprogressive, but they can change over time.


Cerebral Palsy

Although selective dorsal rhizotomy is typically used for ambulatory spastic diplegia in children with Gross Motor Function Classification System level II or III cerebral palsy, more recent data suggest that it may also be helpful for more severe cases.

Assessment using a spasticity-related hip surveillance program combined with early, preventive surgical release has been demonstrated to reduce hip pain, hip dislocation, and the need for orthopedic salvage surgery.

 Enlarge     Print


Clinical recommendationEvidence ratingComments

Neuroimaging, preferably magnetic resonance imaging, may be obtained in a child with a permanent, nonprogressive disorder of motor function consistent with cerebral palsy if no cause is shown on perinatal imaging.9


Guidelines from the American Academy of Neurology and the Child Neurology Society, which are based on a systematic review and meta-analysis

After establishing the diagnosis of cerebral palsy, severity of disease and response to treatment can be assessed using an evidence-based tool, such as the GMFCS.10,14


Expert opinion

Intramuscular onabotulinumtoxinA (Botox) injections can be used to reduce spasticity and deformity and improve mobility and pain control in children with cerebral palsy of any severity.25,26


Randomized controlled trial and European consensus guidelines

Routine hip surveillance in patients with cerebral palsy can help identify developing problems earlier and prevent poor outcomes, such as hip pain and dislocation. Hip surveillance consists of periodic examinations and radiography, the frequency of which is determined by GMFCS classification.34,35


Standard-of-care guidelines used in Europe, Australia, and Canada; no formal guidelines have been developed in the United States

In patients 18 years or older with cerebral palsy, the Fracture Risk Assessment Tool or the QFracture tool can be used to determine if the patient’s risk of osteoporosis merits treatment. If the patient is at high risk, dual energy x-ray absorptiometry can confirm the diagnosis before starting treatment. Calcium and vitamin D supplements and bisphosphonates have been shown to improve bone density and reduce fracture rates.19,20


Consensus guidelines

Administration of magnesium sulfate should be considered before preterm birth to reduce the risk of cerebral palsy.48


Meta-analysis of five randomized controlled trials

GMFCS = Gross Motor Function Classification System.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

show all author info

KIRSTEN VITRIKAS, MD, is program director of the David Grant USAF Medical Center Family Medicine Residency, Travis Air Force Base, Calif., and is an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

HEATHER DALTON, MD, is a faculty physician at the David Grant USAF Medical Center Family Medicine Residency and is an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

DAKOTA BREISH, MD, is a staff physician at the Mountain Home Air Force Base medical treatment facility in Idaho.

Address correspondence to Kirsten Vitrikas, MD, David Grant USAF Medical Center Family Medicine Residency, 101 Bodin Cir., Travis AFB, CA 94535 (email: kirsten.r.vitrikas.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Centers for Disease Control and Prevention. Cerebral palsy. Accessed May 22, 2019. https://www.cdc.gov/ncbddd/cp/facts.html...

2. Wimalasundera N, Stevenson VL. Cerebral palsy. Pract Neurol. 2016;16(3):184–194.

3. Morgan C, Fahey M, Roy B, et al. Diagnosing cerebral palsy in full-term infants. J Paediatr Child Health. 2018;54(10):1159–1164.

4. O'Callaghan ME, MacLennan AH, Gibson CS, et al.; Australian Collaborative Cerebral Palsy Research Group. Epidemiologic associations with cerebral palsy. Obstet Gynecol. 2011;118(3):576–582.

5. Shi Z, Ma L, Luo K, et al. Chorioamnionitis in the development of cerebral palsy: a meta-analysis and systematic review. Pediatrics. 2017;139(6):e20163781.

6. Blair E, Stanley FJ. Intrapartum asphyxia: a rare cause of cerebral palsy [published correction appears in J Pediatr. 1988;113(2):420]. J Pediatr. 1988;112(4):515–519.

7. Novak I, Morgan C, Adde L, et al. Early, accurate diagnosis and early intervention in cerebral palsy: advances in diagnosis and treatment [published correction appears in JAMA Pediatr. 2017;171(9):919]. JAMA Pediatr. 2017;171(9):897–907.

8. Smithers-Sheedy H, Badawi N, Blair E, et al. What constitutes cerebral palsy in the twenty-first century? Dev Med Child Neurol. 2014;56(4):323–328.

9. Ashwal S, Russman BS, Blasco PA, et al. Practice parameter: diagnostic assessment of the child with cerebral palsy: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2004;62(6):851–863.

10. O'Shea TM. Diagnosis, treatment, and prevention of cerebral palsy. Clin Obstet Gynecol. 2008;51(4):816–828.

11. Novak I, Hines M, Goldsmith S, et al. Clinical prognostic messages from a systematic review on cerebral palsy. Pediatrics. 2012;130(5):e1285–e1312.

12. Wu YW, Croen LA, Shah SJ, et al. Cerebral palsy in a term population: risk factors and neuroimaging findings. Pediatrics. 2006;118(2):690–697.

13. Barrington KJ. The adverse neuro-developmental effects of postnatal steroids in the preterm infant: a systematic review of RCTs. BMC Pediatr. 2001;1:1.

14. Palisano R, Rosenbaum P, Walter S, et al. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997;39(4):214–223.

15. Compagnone E, Maniglio J, Camposeo S, et al. Functional classifications for cerebral palsy: correlations between the Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MACS) and the Communication Function Classification System (CFCS). Res Dev Disabil. 2014;35(11):2651–2657.

16. Krigger KW. Cerebral palsy: an overview. Am Fam Physician. 2006;73(1):91–100. https://www.aafp.org/afp/2006/0101/p91.html

17. Novak I. Evidence-based diagnosis, health care, and rehabilitation for children with cerebral palsy. J Child Neurol. 2014;29(8):1141–1156.

18. Novak I, McIntyre S, Morgan C, et al. A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev Med Child Neurol. 2013;55(10):885–910.

19. National Institute for Health and Care Excellence. Osteoporosis: assessing the risk of fragility fracture. Accessed June 26, 2019. https://www.nice.org.uk/guidance/cg146

20. Simm PJ, Biggin A, Zacharin MR, et al.; APEG Bone Mineral Working Group. Consensus guidelines on the use of bisphosphonate therapy in children and adolescents. J Paediatr Child Health. 2018;54(3):223–233.

21. Evenhuis H, Van Der Graaf G, Walinga M, et al. Detection of childhood visual impairment in at-risk groups. JPPID. 2007;4(3):165–169.

22. Joint Committee on Infant Hearing; American Academy of Audiology; American Academy of Pediatrics; American Speech-Language-Hearing Association; Directors of Speech and Hearing Programs in State Health and Welfare Agencies. Year 2000 position statement: principles and guidelines for early hearing detection and intervention programs. Pediatrics. 2000;106(4):798–817.

23. Greensmith AL, Johnstone BR, Reid SM, et al. Prospective analysis of the outcome of surgical management of drooling in the pediatric population: a 10-year experience. Plast Reconstr Surg. 2005;116(5):1233–1242.

24. Tranchida GV, Van Heest A. Preferred options and evidence for upper limb surgery for spasticity in cerebral palsy, stroke, and brain injury [published online October 9, 2019]. J Hand Surg Eur. Accessed November 5, 2019. https://journals.sagepub.com/doi/abs/10.1177/1753193419878973

25. Heinen F, Desloovere K, Schroeder AS, et al. The updated European consensus 2009 on the use of botulinum toxin for children with cerebral palsy. Eur J Paediatr Neurol. 2010;14(1):45–66.

26. Copeland L, Edwards P, Thorley M, et al. Botulinum toxin A for nonambulatory children with cerebral palsy: a double blind randomized controlled trial. JPediatr. 2014;165(1):140–146.

27. Blumetti FC, Belloti JC, Tamaoki MJ, et al. Botulinum toxin type A in the treatment of lower limb spasticity in children with cerebral palsy. Cochrane Database Syst Rev. 2019;(10):CD001408.

28. Pavone V, Testa G, Restivo DA, et al. Botulinum toxin treatment for limb spasticity in childhood cerebral palsy. Front Pharmacol. 2016;7:29.

29. Ingale H, Ughratdar I, Muquit S, et al. Selective dorsal rhizotomy as an alternative to intrathecal baclofen pump replacement in GMFCS grades 4 and 5 children. Childs Nerv Syst. 2016;32(2):321–325.

30. Wang KK, Munger ME, Chen BP, et al. Selective dorsal rhizotomy in ambulant children with cerebral palsy. J Child Orthop. 2018;12(5):413–427.

31. Ailon T, Beauchamp R, Miller S, et al. Long-term outcome after selective dorsal rhizotomy in children with spastic cerebral palsy. Childs Nerv Syst. 2015;31(3):415–423.

32. Munger ME, Aldahondo N, Krach LE, et al. Long-term outcomes after selective dorsal rhizotomy: a retrospective matched cohort study. Dev Med Child Neurol. 2017;59(11):1196–1203.

33. Hasnat MJ, Rice JE. Intrathecal baclofen for treating spasticity in children with cerebral palsy. Cochrane Database Syst Rev. 2015;(11):CD004552.

34. Huser A, Mo M, Hosseinzadeh P. Hip surveillance in children with cerebral palsy. Orthop Clin North Am. 2018;49(2):181–190.

35. Shrader MW, Wimberly L, Thompson R. Hip surveillance in children with cerebral palsy 2019;27(20):760–768.

36. Franki I, Desloovere K, De Cat J, et al. The evidence-base for basic physical therapy techniques targeting lower limb function in children with cerebral palsy: a systematic review using the International Classification of Functioning, Disability and Health as a conceptual framework. J Rehabil Med. 2012;44(5):385–395.

37. Branjerdporn N, Ziviani J, Sakzewski L. Goal-directed occupational therapy for children with unilateral cerebral palsy: categorising and quantifying session content. Br J Occup Ther. 2018;81(3):138–146.

38. Flemban A, Elsayed W. Effect of combined rehabilitation program with botulinum toxin type A injections on gross motor function scores in children with spastic cerebral palsy. J Phys Ther Sci. 2018;30(7):902–905.

39. Novak I, Cusick A, Lannin N. Occupational therapy home programs for cerebral palsy: double-blind, randomized, controlled trial. Pediatrics. 2009;124(4):e606–e614.

40. James S, Ziviani J, Ware RS, et al. Randomized controlled trial of web-based multimodal therapy for unilateral cerebral palsy to improve occupational performance. Dev Med Child Neurol. 2015;57(6):530–538.

41. Gordon AM, Hung YC, Brandao M, et al. Bimanual training and constraint-induced movement therapy in children with hemiplegic cerebral palsy: a randomized trial. Neurorehabil Neural Repair. 2011;25(8):692–702.

42. Wren TA, Dryden JW, Mueske NM, et al. Comparison of 2 orthotic approaches in children with cerebral palsy. Pediatr Phys Ther. 2015;27(3):218–226.

43. Garbellini S, Robert Y, Randall M, et al. Rationale for prescription, and effectiveness of, upper limb orthotic intervention for children with cerebral palsy: a systematic review. Disabil Rehabil. 2018;40(12):1361–1371.

44. Tustin K, Patel A. A critical evaluation of the updated evidence for casting for equinus deformity in children with cerebral palsy. Physiother Res Int. 2017;22(1):e1646.

45. Bjorgaas HM, Hysing M, Elgen I. Psychiatric disorders among children with cerebral palsy at school starting age. Res Dev Disabil. 2012;33(4):1287–1293.

46. Cremer N, Hurvitz EA, Peterson MD. Multimorbidity in middle-aged adults with cerebral palsy. Am J Med. 2017;130(6):744.e9–744.e15.

47. Bromham N, Dworzynski K, Eunson P, et al.; Guideline Committee. Cerebral palsy in adults: summary of NICE guidance. BMJ. 2019;364:l806.

48. Crowther CA, Middleton PF, Voysey M, et al.; AMICABLE Group. Assessing the neuroprotective benefits for babies of antenatal magnesium sulphate: an individual participant data meta-analysis. PLoS Med. 2017;14(10):e1002398.

49. Wapner RJ, Sorokin Y, Mele L, et al.; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Long-term outcomes after repeat doses of antenatal corticosteroids. N Engl J Med. 2007;357(12):1190–1198.



Copyright © 2020 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP

Related Content

More in Pubmed

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article