Are we overmedicalizing cerebral palsy? Re‐centering the child over the impairment

As an interventionalist (orthopedic surgeon) who has dedicated his career to providing therapeutic procedures for cerebral palsy (CP), I appreciate that we have entered an era of remarkable therapeutic capability. We can reduce spasticity with precision, optimize lever arms through surgery, and quantify gait with extraordinary detail. Yet an uncomfortable question lingers: are we improving the lives of children or simply refining their impairments? ¹ Consider the child who undergoes a sequence of interventions: botulinum toxin injections, orthopedic procedures, and orthotic adjustments. Their gait looks better on analysis. Their spasticity scores improve. But their participation on the playground, in school, and within their community remains stubbornly unchanged. In some cases, it narrows. This is not a failure of technique. It is a failure of focus.

Modern CP care has drifted toward an intervention‐heavy model, particularly in high‐resource settings. The expansion of available treatments has subtly shifted decision‐making from necessity to possibility. Selective dorsal rhizotomy, intrathecal baclofen, multi‐level surgery, intensive physical therapy, and robotics each have a role. But together they create a culture of ‘therapeutic stacking’, where the absence of intervention can feel like an omission rather than a judgment. The threshold to act has lowered, even when the functional gains are uncertain. With so many options, the onus to intervene is not only placed on the clinician but also on the parents or the individual with the disability. What if we miss the critical procedure at the critical time?

Part of the problem lies in what we choose to measure. Our field remains deeply anchored in impairment‐level outcomes: tone scales, radiographs, range of motion, and kinematic indices. These are quantifiable, publishable, and responsive to intervention. But they are, at best, proxies. Improvements in gait kinematics do not consistently translate into enhanced participation, independence, or quality of life. ² A more ‘normalized’ gait may satisfy the clinician and the motion lab yet offer little meaningful change to the child's lived experience.

This misalignment is not benign. It carries real costs. Physically, children endure repeated procedures, recovery periods, and the cumulative burden of care. Psychologically, a life organized around serial interventions risks reinforcing an identity centered on deficit and correction. ³ For families, the impact is equally profound: time, financial strain, and the quiet exhaustion of navigating endless decisions framed as opportunities.

None of this is an argument against intervention. On the contrary, many treatments in CP clearly reduce pain, prevent deformity, and improve function. Early, targeted care can alter trajectories in meaningful ways. ⁴ Families often seek these interventions with clear goals and informed intent. The problem is not that we intervene, but how we decide: when, why, and to what end.

The International Classification of Functioning, Disability and Health (ICF) has long urged us to prioritize activity and participation. ⁵ Yet in practice, body structure and function still dominate our thinking. We continue to equate technical success with clinical success. This is the quiet overmedicalization of CP: not an excess of care, but an excess of emphasis on what is easiest to treat and measure rather than what matters most.

A different model is needed, one that begins with participation as the primary outcome and uses intervention as a means rather than an endpoint. This requires a deliberate shift. Goals should be defined in terms of what children want and need to do: play, communicate, and move through their environments with autonomy. Interventions should be selected only when they demonstrably advance these aims. Variability in movement should be accepted, even embraced, rather than reflexively corrected toward an often arbitrary norm.

The next advance in CP care may not come from a new technology or technique. It may come from restraint, from the discipline to ask not, ‘Can we intervene?’ but ‘Should we?’. If we continue to define success by how closely a child approximates typical movement, we risk mistaking technical refinement for meaningful progress. The challenge ahead is not to do more, but to do what matters. I'm guilty as charged.

In this issue

• A narrative review examines recent advances in migraine in children and adolescents, highlighting its complex polygenic aetiology, current understanding of pathophysiology, and emerging mechanism‐based therapies.

• A scoping review of 30 qualitative studies explores how children and young people with childhood‐onset disabilities experience involvement in daily activities, highlighting factors that shape meaningful participation.

• A scoping review identifies clinical and instrumented tools used to assess trunk posture and movement in people with spastic and dyskinetic cerebral palsy (CP).

• A descriptive qualitative study exploring how clinical gait analysis is felt to inform decision‐making for children with CP finds that clinicians and caregivers value its role in improving care but key barriers limit its effective use.

• A descriptive–interpretive qualitative study finds that young people with neuromotor disabilities view shared digital portals as valuable tools for supporting self‐management and coordinated rehabilitation, provided they are flexible, personalized, accessible, and give users control over their information and care decisions.

• A descriptive qualitative study focusing on the Transition Readiness Assessment Questionnaire in adults with CP and caregivers documents that this tool captures some important skills for adulthood but does not adequately reflect the diverse cognitive, physical, and support needs of individuals with CP, highlighting the need for a CP‐specific assessment tool.

• A phenomenological qualitative study in rural Bangladesh finds that financial, logistical, and social barriers continue to limit rehabilitation engagement for children with CP, while caregiver education, local affordable services, and family and community support facilitate access and participation in therapy.

• A feasibility and knowledge translation study shows that implementing the Hammersmith Infant Neurological Examination in Ethiopia enabled earlier identification of infants with CP or a high probability of CP, with diagnosis and referral to rehabilitation occurring at a mean age of 10 months, demonstrating the tool's feasibility in a low‐resource setting.

• A concurrent validity study finds that an at‐home wearable system for assessing infant motor performance showed very strong agreement with the Alberta Infant Motor Scale, supporting its potential as an accurate and scalable tool for monitoring early motor development outside clinical settings.

• A descriptive qualitative study of parental perspectives found that heatwaves and high ambient temperatures were perceived to increase the frequency, intensity, and duration of seizures in children with Dravet syndrome, leading families to adopt extensive thermoregulation strategies that can restrict social participation and increase caregiver burden.

• My Editor’s Choice is a cohort study of 327 people with developmental stuttering that characterizes two distinct phenotypes associated with specific support needs.

• An observational cohort study of nearly 1500 children and adolescents with migraine documents that stress, loud noise, light, and inadequate fluid intake, were the most commonly reported triggers, with more than half of affected participants identifying school as the sole source of their migraine triggers.

DATA AVAILABILITY STATEMENT

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