History: Referrals regarding the question of CP are based on a history of gross motor developmental delay in the first year of life.

• Motor dysfunction is most evident as infants mature; they may display delayed early gross motor milestones (e.g., head control, rolling, reaching unilaterally, sitting without support) or show an early hand preference when younger than 1.5 years, suggesting relative weakness of 1 side.

• Children may have a history of initial delayed gross motor milestones with early hypotonia followed by spasticity.

• A prenatal history should include information on pregnancy, such as prenatal exposure to illicit drugs, toxins, or infections; maternal diabetes; acute maternal illness; trauma; radiation exposure; prenatal care; and fetal movements. A history of early fetal loss or miscarriage (eg, frequent spontaneous abortions), parental consanguinity, and a family history of neurological disease (eg, hereditary neurodegenerative disease) are important.

• Perinatal history should include presentation of the child and delivery type, birth weight, American Pediatric Gross Assessment Record (APGAR) score, and complications in the neonatal period (eg, intubation time, use of surfactant, presence of ischemia or hemorrhage on neonatal ultrasound, feeding difficulties, apnea, bradycardia, infection, hyperbilirubinemia).

• Developmental history should review gross motor, fine motor, and verbal milestones from birth until the time of evaluation.

• The presence of an unexplained regression would be more suggestive of a hereditary neurodegenerative disease than of CP.

• Current social skills, academic performance, and participation in an early intervention program (if aged <3 y) or school support (if aged >3 y) should be reviewed, including resource room assistance; physical, occupational, and speech and language therapy; and adaptive physical education.

• Standardized cognitive and educational testing and a current individualized education plan (IEP) can be informative.

• Review the patient's equipment or need for equipment such as the following:

• Adaptive and communication devices

• Orthotics

• Walkers

• Wheelchair

• Seating

• General medical history should include a review of systems that screens for the multiple complications that can occur with CP

Physical: The neurological evaluation includes close observation and a formal neurological examination.

• Prior to the formal physical examination, observation may reveal abnormal neck or truncal tone; asymmetric posture, strength, or gait; or abnormal coordination.

• Spasticity may be evident in a tendency to keep elbow in a flexed position or hips flexed and adducted with knees flexed and the valgus and ankles in equinus (resulting in toe walking).

• Patients with dyskinetic or extrapyramidal CP may have decreased head and truncal tone and defects in postural control and motor dysfunction such as the following:

• Athetosis (ie, slow, writhing, involuntary movements, particularly in the distal extremities)

• Chorea (ie, abrupt, irregular, jerky movements), choreoathetosis (ie, combination of athetosis and choreiform movements)

• Dystonia (ie, slow rhythmic movements with muscle tone abnormalities and abnormal postures)

• Patients with CP may show the persistence of primitive reflexes (eg, the Moro or asymmetric tonic neck reflexes) or the underdevelopment or absence of postural or protective reflexes.

• Many classifications of CP have been proposed, based on either the body distribution or the functionality or severity of the involvement. A modification of the system proposed by Crothers and Paine in 1959 divides patients into spastic (pyramidal) cerebral palsy, dyskinetic (extrapyramidal) cerebral palsy, and mixed types.

• Functional classification systems generally divide patients into mild, moderate, and severe types (depending on functional limitations). Alternatively, patients may be categorized more comprehensively by their abilities and limitations.

• Classic presentations of CP include the following:

• Spastic hemiplegic

  • One-sided upper motor neuron deficit

  • Arm generally affected more than the leg; possible early hand preference or relative weakness on 1 side

  • Oromotor dysfunction

  • Specific learning disabilities

  • Possible unilateral sensory deficits

  • Visual field deficits (eg, homonymous hemianopsia) and strabismus

  • Seizures

• Spastic diplegic

  • Upper motor neuron findings in the legs more than the arms

  • Scissoring gait pattern with hips flexed and adducted, knees flexed with valgus and ankles in equinus (resulting in toe-walking)

  • Learning disabilities and seizures less commonly than in spastic hemiplegia

• Dyskinetic (extrapyramidal)

  • Early hypotonia with movement disorder emerging when aged 1-3 years

  • Arms more affected than legs

  • Deep tendon reflexes usually normal to slightly increased

  • Some spasticity

  • Oromotor dysfunction

  • Gait difficulties

  • Truncal instability

  • Risk of deafness in those affected by kernicterus

• Spastic quadriplegic

  • All limbs affected, either truncal hypotonia with appendicular hypertonia or full-body hypertonia

  • Oromotor dysfunction

  • Increased risk of cognitive difficulties

  • Multiple medical complications

  • Seizures

  • Legs generally affected equally or more than arms

  • Categorized as double hemiplegic if arms more involved than legs