Severe Spasticity in Cerebral Palsy Should Not Simply Be Accepted: When Specialist Assessment Can Help

What Is Cerebral Palsy?

Cerebral palsy is a lifelong disorder of movement and posture caused by disturbances
in the developing brain. Its clinical presentation can vary considerably from one
child to another.

Some children have predominantly spasticity, while others may have
dystonia, weakness, impaired coordination, or a combination of
these problems.

This difference is important because the same treatment is not appropriate for every
child with cerebral palsy.

The first step should therefore be to understand what is actually limiting the
child’s function and whether any part of that limitation may be modifiable.

What Is Spasticity in Cerebral Palsy?

Spasticity refers to abnormal muscle tone that can make movement stiff or difficult.
In a child with cerebral palsy, significant spasticity may restrict movement that
the child otherwise has the potential to perform.

The important clinical question is not simply whether a child has cerebral palsy.
It is whether abnormal muscle tone is preventing the child from using voluntary
movement that is already present.

The key question is whether spasticity is limiting movement already present and,
if so, whether reducing that spasticity could improve movement, daily activities
and rehabilitation.

 

Severe Spasticity Should Not Automatically Be Considered “Just Part of CP”

A diagnosis of cerebral palsy does not mean that every functional limitation should
automatically be attributed to the underlying condition.

When increasing stiffness begins interfering with a child’s function, specialist
assessment may help determine whether spasticity, dystonia, weakness or another
neurological problem is the dominant limitation.

The goal is not to promise that surgery will make a child “normal.” The goal is to
identify potentially modifiable problems, reduce barriers to movement where
appropriate, and give the child the best possible opportunity to use the function
they have.

When Should a Child With Cerebral Palsy Be Reassessed?

Earlier specialist assessment does not necessarily mean earlier surgery.
It means identifying potentially treatable problems before they become accepted as
an unavoidable explanation for every functional limitation.

A specialist assessment may be particularly relevant when:

• Increasing stiffness interferes with walking or mobility
• Sitting becomes increasingly difficult
• Transfers become more difficult
• Dressing or personal hygiene becomes difficult because of abnormal tone
• Functional progress has plateaued despite appropriate rehabilitation
• Repeated focal treatments provide only temporary benefit
• It is unclear whether spasticity, dystonia, weakness or another neurological
  problem is the main functional limitation

The objective is to identify the child’s modifiable problems and establish
realistic functional goals.

Cerebral Palsy Treatment Is Multidisciplinary

Cerebral palsy management should not be viewed as a choice between rehabilitation
and neurosurgery.

Depending on the individual child, treatment may involve a combination of:

• Physiotherapy
• Occupational therapy
• Antispastic medications
• Botulinum toxin injections
• Intrathecal baclofen
• Orthopaedic procedures
• Selected neurosurgical procedures

Neurosurgery, when appropriate, should be considered as one component of a much
longer rehabilitation pathway rather than as the end of treatment.

Reducing abnormal muscle tone may, in carefully selected children, create a better
environment in which rehabilitation can help the child make use of the movement
that remains.

What Is Selective Dorsal Rhizotomy (SDR)?

Selective dorsal rhizotomy (SDR) is a neurosurgical procedure
used in carefully selected children with significant lower-limb spasticity.

During SDR, selected sensory nerve rootlets contributing to lower-limb spasticity
are divided with the aim of reducing abnormal muscle tone.

Because SDR is an irreversible procedure, the decision to perform
it should never be based on the diagnosis of cerebral palsy alone.

Appropriate patient selection, detailed neurological assessment, functional goals,
multidisciplinary evaluation and discussion of potential complications and
uncertainties are essential.

Who May Be Considered for Selective Dorsal Rhizotomy?

Not every child with cerebral palsy and spasticity is a candidate for SDR.

The press release cites NICE guidance that recommends consideration of selective
dorsal rhizotomy for appropriately selected children and young people with
spasticity affecting the lower limbs, particularly those at GMFCS levels II or III,
following multidisciplinary assessment.

The decision should also take into account the irreversible nature of the procedure,
known complications, uncertainty surrounding some long-term outcomes, and the
availability of intensive rehabilitation after treatment.

What Does the Evidence Say About Selective Dorsal Rhizotomy?

The evidence surrounding SDR supports a careful and selective approach rather than
offering the procedure to every child with cerebral palsy.

A 2025 systematic review and meta-analysis cited in the release found significant
improvements in measures of lower-limb spasticity and gross motor function following
SDR in children with cerebral palsy, while also noting limitations in the available
evidence and follow-up.

Longer-term reviews have highlighted uncertainties regarding functional outcomes
and the quality and consistency of the available evidence.

Potential complications also need to be considered. Reviews of SDR complications
have reported structural and neurological complications, reinforcing the importance
of careful patient selection and long-term surveillance during growth.

Therefore, the evidence does not support treating SDR as a procedure that should be
automatically offered to every child with cerebral palsy.

Why Specialist Assessment Matters More Than Simply Choosing Surgery

The important question for a child with cerebral palsy is not simply:

“Does my child need surgery?”

 

A more useful starting question is:

“What is actually limiting my child’s function, and is any part of it treatable?”

 

This approach helps distinguish between spasticity, dystonia, weakness and other
factors that may affect function.

It also allows the treatment plan to be built around the child’s actual functional
goals rather than around a procedure.

Dr. Rao’s Hospital Reports Surgical Treatment of 104 Patients With Cerebral Palsy

Dr. Rao’s Hospital – International Institute of Neurosciences (IIN), Guntur,
reports surgical treatment of 104 patients with cerebral palsy.

According to the institutional experience described in the World Cerebral Palsy Day
release, this experience has reinforced the importance of individualized treatment
rather than applying one procedure to every child.

The hospital evaluates and provides a range of approaches for clinically significant
spasticity, including medical management, botulinum toxin therapy, intrathecal
baclofen and selected neurosurgical procedures.

Decisions regarding surgery are based on the individual child’s neurological
examination, functional limitations, pattern of tone, treatment goals,
rehabilitation potential and multidisciplinary assessment.

Three Questions Every Family Should Ask During a Specialist Assessment

Families considering treatment for significant spasticity may find it useful to
discuss these three questions with the treating team:

1. 
   Is the main problem spasticity, dystonia, weakness or a combination of these?
   

1. 
   What voluntary movement does my child already have that may be hidden or
   restricted by abnormal muscle tone?
   

1. 
   If treatment reduces the abnormal tone, what specific rehabilitation programme
   will help my child use the movement that remains?
   

These questions shift the conversation away from simply asking how to reduce muscle
stiffness. They bring the discussion back to the real goal: improving the child’s
function and independence.

What Is the Goal of Cerebral Palsy Surgery?

The purpose of cerebral palsy surgery is not to “cure” cerebral palsy or to make a
child normal.

The purpose is to identify what may be modifiable, reduce barriers to movement where
appropriate, and provide the child with the best possible opportunity to use their
existing functional potential.

For appropriately selected children, treatment of significant spasticity may become
one component of a broader rehabilitation programme.

This is why postoperative rehabilitation is not an optional afterthought. It is an
important part of the overall treatment pathway.

World Cerebral Palsy Day: A Different Conversation About Spasticity

World Cerebral Palsy Day provides an opportunity to recognize people living with
cerebral palsy and the families and professionals supporting them.

It is also an opportunity to look beyond the diagnosis itself and consider potentially
modifiable factors that influence function throughout childhood.

Severe, function-limiting spasticity should not automatically be accepted as an
unavoidable part of cerebral palsy.

At the same time, this does not mean that every child with cerebral palsy needs
neurosurgery. The appropriate approach is individualized assessment followed by
treatment that matches the child’s neurological findings, functional goals,
rehabilitation potential and overall needs.

When Should Parents Seek a Specialist Opinion?

Parents may consider specialist assessment when their child’s increasing stiffness
begins to interfere with function or when progress has stopped despite appropriate
rehabilitation.

A specialist assessment can help determine:

• What type of abnormal muscle tone is present
• Which movements are being restricted
• Whether spasticity is the principal functional limitation
• What treatment options are available
• Whether rehabilitation alone may be appropriate
• Whether medication, injections, intrathecal therapy, orthopaedic treatment or neurosurgery should be considered
• What functional goals should guide treatment

Cerebral Palsy Treatment Should Be Built Around the Child

Every child with cerebral palsy is different. The pattern of spasticity, dystonia,
weakness, coordination problems, existing voluntary movement, functional goals and
rehabilitation potential can vary substantially.

Therefore, treatment should not begin with a procedure. It should begin with a
careful assessment of the child and a clear understanding of what is limiting
function.

For selected children, reducing severe spasticity may create an opportunity for
more effective rehabilitation and improved use of existing movement. For others,
non-surgical management may remain the most appropriate strategy.

The goal is always individualized care rather than a one-size-fits-all approach.