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9.1 Cerebral Palsy Classification & GMFCS

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ABPMR Physical Medicine and Rehabilitation Board Exam Study Guide Exam

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1 Chapter 1: Introduction & Exam Overview

1.1 ABPMR Part I Exam Overview & Format 1.2 Board Review Strategy & Content Blueprint Breakdown

2 Chapter 2: Musculoskeletal Medicine

2.1 Shoulder & Upper Extremity Diagnostics 2.2 Knee, Hip & Lower Extremity Conditions 2.3 Spine Pathology, Radiculopathy & Myelopathy 2.4 Inflammatory Arthritis, Tendinopathies & Concussion 2.5 Bone Health, Osteoporosis & Metabolic Bone Disease 2.6 Thoracic Outlet Syndrome & Peripheral Nerve Entrapment 2.7 Fracture Rehabilitation & Immobilization Complications 2.8 Overuse Tendinopathies & Regenerative Medicine 2.9 Gait Analysis & Abnormal Gait Patterns

3 Chapter 3: Spinal Cord Injury Rehabilitation

3.1 ASIA Examination & Impairment Scale 3.2 Spinal Cord Injury Syndromes 3.3 Autonomic Dysreflexia & Acute Complications 3.4 Neurogenic Bladder, Bowel & Secondary Complications

4 Chapter 4: Stroke & Neuromuscular Rehabilitation

4.1 Stroke Vascular Syndromes & Acute Assessment 4.2 Stroke Motor Recovery & Hemiplegic Complications 4.3 Spasticity Assessment & Multimodal Management 4.4 ALS, GBS, CIDP & Neuromuscular Disease Rehab 4.5 Multiple Sclerosis & Demyelinating Disease Rehabilitation 4.6 Parkinsonism, Movement Disorders & Functional Neurologic Disorder

5 Chapter 5: Electrodiagnostics (EMG/NCS)

5.1 Nerve Conduction Studies Principles & Physics 5.2 Needle Electromyography & MUAP Analysis 5.3 Mononeuropathies & Radiculopathy Patterns 5.4 Neuromuscular Junction Disorders & Myopathies

6 Chapter 6: Traumatic Brain Injury

6.1 TBI Severity Classification, Glasgow Coma Scale, and Pathophysiology 6.2 Rancho Los Amigos Levels of Cognitive Functioning and Disability Rating Scale 6.3 Neurobehavioral Sequelae and Agitation Management 6.4 Concussion Evaluation, Vestibular-Ocular Dysfunction, and Return-to-Play/Work Protocols

7 Chapter 7: Chronic Pain & Interventional Spine

7.1 Fluoroscopic Spine Interventions 7.2 Opioid Stewardship & Controlled Substance Compliance 7.3 Complex Regional Pain Syndrome, Fibromyalgia & Myofascial Pain 7.4 Spinal Cord Stimulation & Intrathecal Therapy

8 Chapter 8: Amputee Rehabilitation & Prosthetics

8.1 Amputation Surgical Levels & Medicare K-Levels 8.2 Socket Designs & Suspension Systems 8.3 Prosthetic Feet & Microprocessor Knee Mechanisms 8.4 Post-Amputation Care, Residual Limb & Phantom Pain

9 Chapter 9: Pediatric Rehabilitation

9.1 Cerebral Palsy Classification & GMFCS 9.2 Spina Bifida & Myelomeningocele Management 9.3 Muscular Dystrophies & Neuromuscular Disease in Children 9.4 Pediatric Brachial Plexopathy & Congenital Disorders

10 Chapter 10: Prosthetics, Orthotics & Assistive Technology

10.1 Lower Limb Orthoses — AFOs & KAFOs 10.2 Spinal & Upper Extremity Orthoses 10.3 Upper Limb Prosthetics — Body-Powered vs Myoelectric 10.4 Wheelchairs, Seating Systems & Pressure Mapping

11 Chapter 11: Medical Rehabilitation & Outcomes

11.1 Dysphagia Assessment & Management 11.2 Neurogenic Bladder & Bowel Management 11.3 Pressure Injuries & Wound Management 11.4 Outcome Measures & Medical Complications 11.5 Cancer Rehabilitation & Oncologic Rehabilitation 11.6 Burns, Endocrine/Metabolic & Medical Complications Rehabilitation

12 Chapter 12: Cardiopulmonary Rehabilitation

12.1 Cardiac Rehabilitation Phases & Metabolic Equivalents 12.2 Pulmonary Rehabilitation & COPD Management

13 Chapter 13: Foundational Rehabilitation Concepts

13.1 Kinesiology, Biomechanics & Functional Anatomy 13.2 Rehabilitation Pharmacology & Medication Management 13.3 Research Methodology, Biostatistics & Evidence-Based Practice 13.4 Nutrition, Metabolism & Energy Expenditure in Rehabilitation 13.5 Diagnostic Procedures: Imaging, MSK Ultrasound, Urodynamics & Neuropsych Assessment

9.1 Cerebral Palsy Classification & GMFCS

Key Takeaways Explain This Topic AI

Cerebral Palsy (CP) is a non-progressive encephalopathy affecting the developing fetal or infant brain, characterized by motor impairment, muscle tone abnormalities, and postural dysfunction.

The Gross Motor Function Classification System (GMFCS I-V) categorizes gross motor function from independent ambulation without limitations (Level I) to total dependence for mobility in a manual wheelchair (Level V).

Hip surveillance is guided by GMFCS level; children in GMFCS Levels III-V require frequent radiographic screening (every 6-12 months) due to high risk of progressive hip subluxation (Migration Percentage >30%).

Selective Dorsal Rhizotomy (SDR) is indicated for a select subset of children aged 3-8 years with pure spastic diplegia, GMFCS Levels I-III, good selective motor control, and absence of fixed contractures or dystonia.

Dyskinetic CP (choreoathetosis/dystonia) results from basal ganglia lesions (intrapartum asphyxia, kernicterus), whereas Ataxic CP reflects cerebellar injury and Spastic Diplegia classically stems from periventricular leukomalacia.

Last updated: July 2026

Overview of Cerebral Palsy Definition & Etiology

Cerebral Palsy (CP) represents a group of permanent, non-progressive disorders of movement and posture development causing activity limitation. The motor disturbances are attributed to non-progressive brain lesions occurring in the developing fetal or infant brain. Although the primary brain lesion is static, secondary musculoskeletal manifestations (muscle contractures, bony deformities, and joint subluxations) evolve dynamically with growth.

In premature infants (gestational age <32 weeks), the predominant neuropathological mechanism is periventricular leukomalacia (PVL) —ischemic necrosis of white matter surrounding the lateral ventricles, affecting descending pyramidal fibers supplying the lower extremities. In term infants, mechanisms include hypoxic-ischemic encephalopathy (HIE), middle cerebral artery stroke, and intrauterine infections.

Motor Classification and Topographic Distribution

Cerebral palsy is classified by abnormal tone pattern (spastic, dyskinetic, ataxic, mixed) and anatomical distribution (diplegia, hemiplegia, quadriplegia).

Spastic Cerebral Palsy

Spastic CP accounts for ~80% of cases, presenting with velocity-dependent hypertonia, hyperreflexia, and clonus.

Spastic Diplegia : Lower extremities are affected significantly more than upper extremities. Classically associated with prematurity and PVL. Demonstrates a scissoring gait (hip adductor spasticity) and crouch gait (hamstring/hip flexor tightness paired with weak plantarflexors). Cognition is frequently preserved.

Spastic Hemiplegia : Unilateral motor impairment (arm > leg). Caused by focal cortical/subcortical stroke. Early handedness (preference before 12 months) is a primary red flag. Independent ambulation (GMFCS I-II) is typical.

Spastic Quadriplegia : All four limbs and trunk are severely involved. Caused by diffuse cerebral insult (severe HIE). High incidence of intellectual disability, epilepsy, dysphagia, and severe hip dislocation.

Dyskinetic and Ataxic Cerebral Palsy

Dyskinetic CP : Accounts for 10-15% of cases, caused by basal ganglia lesions secondary to kernicterus or severe asphyxia. Manifests as dystonia (sustained twisting postures) or choreoathetosis (involuntary writhing movements). Cognition is often preserved.

Ataxic CP : Caused by cerebellar injury , manifesting with hypotonia, wide-based gait, intention tremor, and dysmetria.

Motor Subtype Brain Lesion Site Common Etiology Primary Clinical Features

Spastic Diplegia Periventricular white matter (PVL) Prematurity (<32 weeks) Leg spasticity > arm; scissoring gait

Spastic Hemiplegia Unilateral cortical/subcortical Focal MCA stroke Arm/leg affected; early handedness

Spastic Quadriplegia Diffuse cerebral cortex Severe HIE, CNS infection All 4 limbs involved; seizures, dysphagia

  • Dyskinetic Basal ganglia & thalamus Kernicterus, severe asphyxia Involuntary writhing/twisting movements
  • Ataxic Cerebellum & tracts Congenital malformation Wide-based gait, dysmetria, tremor
  • Gross Motor Function Classification System (GMFCS)

The Gross Motor Function Classification System (GMFCS) categorizes gross motor function in children with CP across 5 ordinal levels, focusing on self-initiated movement and assistive technology needs in daily life:

GMFCS Level I : Walks indoors and outdoors and climbs stairs without using a handrail. Gross motor skills (running, jumping) are limited in speed and balance.

GMFCS Level II : Walks indoors/outdoors and climbs stairs holding a railing. Experiences limitations on uneven terrain or inclines; cannot run or jump effectively.

GMFCS Level III : Walks using a hand-held mobility device (forearm crutches, rolling walker) indoors. Uses wheeled mobility for long distances outdoors.

GMFCS Level IV : Relies on wheeled mobility in most settings. May achieve self-mobility with a powered wheelchair or walk short distances at home with a body-support walker.

GMFCS Level V : Transported in a manual wheelchair in all settings. Severe head and trunk control limitations; requires complete physical assistance for positioning and transfers.

  • GMFCS Level Indoor Ambulation Outdoor/Community Mobility Assistive Device / Orthosis
  • Level I Independent without limitations Independent; limited running Optional SMOs/AFOs
  • Level II Independent; uses handrail on stairs Walks with limitations AFOs common; walker when learning
  • Level III Walks with hand-held device Wheeled mobility for long distances Forearm crutches, walker, AFOs
  • Level IV Short distances with support walker Powered wheelchair or assistance Powered mobility, custom seating
  • Level V Transported in manual wheelchair Transported in manual wheelchair Dependent; tilt-in-space wheelchair
  • Focal Spasticity Management & Serial Casting

Focal spasticity management integrates physical therapy, orthoses, serial casting, and chemodenervation. Botulinum toxin A injections target dynamic muscle overactivity (e.g., gastrocnemius, hamstrings, adductors), peaking at 2-4 weeks with effects lasting 3-4 months. When dynamic spasticity is complicated by early fixed soft-tissue tightness (such as Achilles tendon tightness), serial casting is performed by applying weekly below-knee casts for 3-6 weeks, progressively stretching the soft tissues into dorsiflexion.

Hip Surveillance Protocol by GMFCS Level

Progressive hip displacement affects up to 90% of children at GMFCS V due to muscle imbalance (hypertonic adductors/iliopsoas vs weak gluteals) and delayed weight-bearing. Surveillance uses AP pelvis radiographs to measure Migration Percentage (MP) . Normal MP is <20%; an MP >30% indicates hip displacement requiring orthopedic referral.

Radiographic Screening Schedule:

GMFCS I : Baseline AP pelvis radiograph at 12-24 months; annual clinical monitoring.

GMFCS II : Baseline radiograph at 12 months; repeat every 2 years until age 8.

GMFCS III-IV : Baseline radiograph at 12 months; repeat every 6-12 months until age 8-10, then annually until skeletal maturity.

GMFCS V : Baseline radiograph at 6-12 months; repeat every 6 months until age 8-10, then annually until skeletal maturity.

When MP >30%, interventions include soft tissue releases (adductor/psoas tenotomy) or Varus Derotation Osteotomy (VDRO) . Preventive bracing does not halt hip displacement.

Selective Dorsal Rhizotomy (SDR)

Selective Dorsal Rhizotomy (SDR) transects abnormal sensory nerve rootlets at L2-S1 to interrupt hyperactive stretch reflexes and reduce spasticity.

Candidate Selection Criteria

Ideal Candidate : Pure spastic diplegia due to PVL; age 3 to 8 years ; GMFCS Level II or III ; good underlying trunk strength and selective motor control; no fixed contractures or deformities.

Exclusion Criteria : Presence of dystonia, athetosis, or ataxia; severe trunk weakness; fixed structural contractures; lack of family support for intensive therapy.

Post-operatively, patients require 6-12 months of intensive physical therapy (4-5 days/week) to strengthen unmasked underlying muscle weakness and retrain gait.