Cerebral palsy

Our approach to cerebral palsy

Cerebral palsy is not one disease — it is a heterogeneous clinical picture. My first job as a paediatric neurologist is to classify it precisely: the motor pattern (spastic unilateral or bilateral, dyskinetic, ataxic, or mixed), the severity, and the function. We use the shared international scales — GMFCS for gross motor function, MACS for manual ability, CFCS for communication, EDACS for eating and drinking, and the FMS where useful — because they are the common language between the family, the school, the physiotherapist, the orthopaedic surgeon and any second opinion you may seek.

But carrying a CP label does not mean we stop asking why. In the last decade, the proportion of children labelled with CP who turn out to have a genetic, metabolic or other underlying cause has risen substantially — by some estimates, between 10 and 30 per cent in series where modern genomic work-up is offered. That matters, because some of those children have conditions with targeted treatments, and almost all of them have prognostic and recurrence-risk information that the family deserves to know. Our approach is to re-examine the MRI, the perinatal history and the clinical pattern with fresh eyes, and extend the work-up where the picture does not fit a clean perinatal injury.

Once the diagnosis and the function are mapped, we look at what travels with CP — epilepsy, sleep, feeding and gastrointestinal problems, drooling, pain, vision and hearing, cognition, communication, mood and behaviour. Each of these strands needs its own attention, and each interacts with the others. The therapy plan, the orthopaedic surveillance, the cross-specialty referrals and any consideration of regenerative options all sit on top of this integrated picture, coordinated under one paediatric neurologist rather than split across separate clinics.

What the in-person evaluation looks like

A first visit starts with a detailed perinatal, developmental and medical history, with parents and — where possible — the previous treating team. From there I work through the picture in five overlapping passes.

The first pass confirms and classifies the diagnosis. Tone is assessed with the modified Ashworth and Tardieu scales; motor pattern is described carefully (spastic uni- or bilateral, dyskinetic — dystonic or choreoathetoid — ataxic, or mixed); and function is rated with GMFCS, MACS, CFCS and EDACS. These are not just labels — they are the baseline against which we will measure everything we do next.

The second pass re-examines the aetiology. We review all previous brain MRI with structured pattern interpretation (periventricular white-matter injury, cortical/subcortical injury, basal-ganglia and thalamic injury, focal vascular lesion, brain malformation, or normal imaging) and read it together with the perinatal history. Where the picture does not fit a clean perinatal injury — or where the MRI is normal, the family history is suggestive, or there are atypical features — we extend the work-up: chromosomal microarray, gene panel or whole-exome / whole-genome sequencing, and targeted metabolic testing. A meaningful proportion of children labelled with CP have a diagnosis hidden in the genome that changes the plan.

The third pass characterises what travels with CP. Epilepsy and EEG when indicated; sleep; feeding, swallowing and gastrointestinal function with input from a dietitian; drooling; pain; vision and hearing; cognition and communication; mood and behaviour. Each strand is mapped separately, because each needs its own plan.

The fourth pass reviews the therapy your child is already receiving. Physiotherapy — including the modern goal-directed and task-specific approaches such as constraint-induced movement therapy, bimanual training, treadmill and hippotherapy where relevant — alongside occupational therapy, speech and language therapy with augmentative and alternative communication where needed, special education, and the rehabilitation goals as a whole. We ask the same honest questions as in any other area: is the intensity right, is it the right model for this child, and is it actually working against the measures we set at baseline?

Where the picture needs another set of eyes, I bring in the colleagues we work with regularly — paediatric orthopaedics (hip surveillance, gait analysis, single-event multilevel surgery, scoliosis), ophthalmology, audiology, paediatric gastroenterology and a dietitian, sleep medicine, child and adolescent psychiatry, clinical genetics and metabolism, and paediatric neurosurgery (for selective dorsal rhizotomy or intrathecal baclofen pump in selected children). The consultations are fast and focused, the findings come back to me, and the plan stays single and integrated rather than split across separate clinics.

The fifth pass is the plan itself — a family-centred, written plan that names the highest-yield next steps, integrates orthopaedic surveillance and any cross-specialty actions, and is explicit about which regenerative options (if any) fit this particular child.

Regenerative and neuromodulation options — our position

Regenerative therapies are the area where families most often arrive with hope, pressure, and conflicting information. My principle here is the same as everywhere else: precision-first. If a treatable underlying cause is identified by the genetic or metabolic work-up, that comes first. If conventional, evidence-based rehabilitation has not yet been optimised, we optimise that first — because the literature is clear that intensive, goal-directed rehabilitation done well outperforms anything we add on top of generic care. Only then do we ask whether regenerative and neuromodulation options have a real, child-specific place.

Stem-cell therapies in cerebral palsy draw from a number of different sources — umbilical-cord blood, umbilical-cord-derived mesenchymal stem cells, adipose-derived and bone-marrow-derived mesenchymal stem cells, among others — each with its own biology, evidence profile and indication picture. The choice of source is not neutral; the right product for a given child depends on the clinical picture, the age, the imaging pattern and what is available within appropriate regulatory frameworks. We discuss every case individually, share our own clinical experience and the current literature honestly, and proceed only with full informed consent and the Republic of Türkiye Ministry of Health authorisation that any such treatment legally requires.

Exosome therapies — extracellular vesicles derived from stem cells — are one of the most actively studied frontiers in regenerative neurology. Different cellular sources produce exosomes with intrinsically different molecular cargoes, and that opens up the possibility of tailoring the content to the child's clinical picture. In practical terms, exosomes have a favourable side-effect profile, are relatively straightforward to administer, can produce a fast clinical signal, and allow individualised content selection. The honest counterweight is that their scientific efficacy in cerebral palsy is still in the research phase — we apply exosome therapies in the framework of structured scientific studies and not as proven treatment, with very explicit honesty about what is known and what is not.

Photobiomodulation — transcranial and intranasal — is an area where the basic-science rationale is strong (mitochondrial cytochrome-c-oxidase enhancement, modulation of neuroinflammation) and small but encouraging clinical signals are emerging, particularly for cognitive and motor function in selected children. In our practice, we use photobiomodulation as part of an integrated plan in selected children, with realistic expectations and objective response measurement.

None of these techniques are stand-alone. The picture we emphasise — and what we believe makes the most clinical difference — is the combined approach: cell or exosome therapy alongside neuromodulation methods (photobiomodulation and other appropriate modalities) and intensive, goal-directed rehabilitation in the days and weeks around the intervention. The biology of brain plasticity argues for combining these together, not isolating them; in our own experience, the response is meaningfully better when they are delivered as one integrated package rather than as separate, unsynchronised efforts.

We also keep an open, evidence-led eye beyond Western biomedicine. Selected elements from Russian neurorehabilitation schools, Indian Ayurvedic medicine and Traditional Chinese Medicine have, in specific situations, a research base that justifies considering them alongside the conventional plan — particular acupuncture techniques in motor recovery, defined herbal preparations with reproducible pharmacology, structured rehabilitation methodologies developed outside North American and European centres. We do not adopt any of these by tradition or popularity alone; we incorporate the elements that have credible evidence behind them, alongside the rest of the plan, and we are explicit with families about which strands sit on stronger evidence and which sit on emerging or weaker evidence.

And we say no when we should. There are children, families and presentations where regenerative therapy is not the right step — severe global brain involvement with no realistic target, an unresolved orthopaedic or epilepsy problem that should come first, or expectations that the current evidence cannot support. Saying "not yet" or "not for this child" with honest reasoning is part of the same care.

Follow-up matters as much as the first decision. We measure response with the same scales we used at baseline — GMFCS, MACS, gait analysis, functional measures — at structured intervals. We do not call something working on impression; we call it working when the numbers move and the family's lived experience confirms it. The plan evolves with the child.