What is Spastic Diplegic Cerebral Palsy, Gross Motor Function Classification System (GMFCS) II?

Spastic Diplegic Cerebral Palsy, GMFCS II: Definition and Characteristics

Spastic diplegic cerebral palsy with GMFCS level II is a form of cerebral palsy characterized by increased muscle tone primarily affecting the lower limbs more than the upper limbs, with moderate functional limitations that allow independent mobility with possible need for assistive devices after age 4. 1, 2

Definition and Classification

• Cerebral palsy (CP) is defined as "a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain" 1
• Spastic diplegia is a topographical classification affecting approximately 37% of CP cases, where the lower limbs are affected more than the upper limbs 3, 1
• Spasticity is the most common motor type in CP (85-91% of cases), characterized by increased muscle tone and velocity-dependent resistance to passive movement 1
• The Gross Motor Function Classification System (GMFCS) is a standardized 5-level system that classifies the gross motor function of children with CP based on self-initiated movement abilities 4

GMFCS Level II Characteristics

• Children with GMFCS II can walk in most settings without assistive mobility devices 2
• They may experience difficulty with balance when walking on uneven surfaces or inclines 4
• They may require physical assistance or handheld mobility devices when learning to walk, or over long distances 4
• They have limitations in performing gross motor skills such as running and jumping compared to typically developing peers 4
• They can climb stairs holding onto a railing but have limitations walking outdoors and in the community 4

Clinical Presentation

• Reduced hamstring length, with popliteal angle averaging -59.2° ± 10.6° (compared to -38.8° ± 13.4° in typically developing children) 5
• Limited straight leg raise, averaging 52.7° ± 10.2° (compared to 75.8° ± 11.1° in typically developing children) 5
• Reduced ankle dorsiflexion with knee extension, averaging -2.5° ± 8.4° (compared to 8.6° ± 6.8° in typically developing children) 5
• Minimal hip extension loss compared to typically developing children 5
• Significantly reduced muscle volume, cross-sectional area, and muscle length in the lower limbs compared to typically developing children 6
• Increased subcutaneous fat in the lower limbs compared to typically developing children 6

Functional Implications

• Selective motor control deficits correlate with poorer gross motor function, balance control, and gait performance 7
• Children with GMFCS II show increasing popliteal angle (hamstring tightness) during childhood, reaching above 40° by age 14 8
• Hamstring spasticity tends to increase in the first four years of life and then slightly increases until age 15 8
• Despite limitations, these children have good functional prognosis: in high-income countries, 2 in 3 individuals with CP will walk, 3 in 4 will talk, and 1 in 2 will have normal intelligence 3, 2

Associated Comorbidities

• Chronic pain (75% of CP cases) 1
• Epilepsy (35%) 1
• Intellectual disability (49%) 1
• Musculoskeletal problems like hip displacement (28%) 1
• Behavioral disorders (26%) 1
• Sleep disorders (23%) 1
• Visual impairment (11%) 1
• Hearing impairment (4%) 1

Management Considerations

• Early diagnosis and intervention are essential to optimize motor and cognitive plasticity 1
• Physical therapy should include interventions that promote selective motor control to improve overall functional ability 7
• Regular monitoring of popliteal angle and hamstring spasticity is important as these tend to increase with age 8
• Early referral to diagnostic-specific intervention is crucial to prevent secondary complications and enhance caregiver well-being 1

Prognosis

• Children with GMFCS II have a good prognosis for independent mobility, though they may require assistive devices for longer distances 4
• Motor function classification may change during the first 2 years of life, with approximately half of infants having their GMFCS level reclassified 3
• Early intervention can help maximize neuroplasticity and minimize deleterious modifications to muscle and bone growth 1