Valeri: Thank you very much. When I started to get my talk together, I realized there was a lot of information out there. Please downloaded the handout, so if I go rather quickly through some of this information, you can always refer back to that. At the end, I will also include my email so that you are more than welcome to get a hold of me with any further questions. Today's topic is really specific, but I feel very exciting. I am going to focus on the surgical interventions that are provided to these individuals, some of them more common, and therapy's role in that. Although we are not surgeons, we are very implementable in helping to decide who is the good candidate for these surgeries, because not all children with CP are appropriate. We can also help to enhance the outcomes following the surgery. Surgery is only the first step, and the therapy afterwards is what creates the changes. It is definitely a team approach. I am very fortunate that I get to work with a team of very talented surgeons that do a lot of this type of surgery.
Cerebral Palsy
Cerebral palsy is a non-progressive neurological disorder of movement and posture that is related to an insult in the developing brain; cerebral anoxia in the perinatal period or acquired postnatally (O’Reilly DE, Walentynowicz JE : Dev Med Child Neurol 23:633,1981). The true definition of cerebral palsy is anything that occurs within the first two years of life. There are children who have neurological insults following birth that also have CP. It is a broad category of descriptions. I am assuming that you already know about CP and the causes, because due to time constraints, I am not going to be able to go over all of that information.
There are two types of classifications. One is based on muscle tone and the other is based on body involvement.
Classification-Muscle Tone
There are two types of classifications. The first one is based on muscle tone.
- Spastic
- Dystonia
- Athetoid
- Mixed
- Ataxic
You can have spastic, dystonia, athetoid, mixed and ataxic. Most of these surgeries that I am going to talk about are geared for the spastic individual, and as we go through those surgical protocols, you will find out why. For example, an individual with the fluctuating tone from extensors to flexors (athetoid) do not really benefit when you change the muscle pull or when you transfer the tendon; it is still going to look like athetoid CP. There is also classification then based on body part.
Classification- Body Part
This classification describes how many limbs are involved.
- Monoplegia
- Hemiplegia
- Diplegia
- Double Hemiplegia
- Quadriplegia
- Pentaplegia
Monoplegia is one limb involvement. Hemiplegia is two limbs (arm and leg) on one side. Diplegia is two limbs, either upper or lower. A double hemi is what I think a lot of people call quadriplegia. If they have one side that is affected differently, at a different level than the other side, then it is more than likely a double hemiplegic patient rather than quadriplegic, which should have this same level of effect on all four extremities. Pentaplegia has been used at times, and that just includes the trunk as the fifth extremity. One thing you need to know is how much spasticity there is because this is going to affect whether they are a good candidate for surgical intervention or not.
Measures of Severe Spasticity
I am not going to go over the specifics of each of this, but give you a quick overview.
The scale that is most commonly used for the upper extremity is the Ashworth Scale of Spasticity. The Ashworth scale is a descriptive scale. As you know, spasticity is based on velocity and reverse of motion. This scale uses a quick stretch on a muscle to see how much spasticity is there.
Figure 1. Overview of the grading for Ashworth Scale.
Hopefully if you are working with the cerebral palsy population, you use this Ashworth scale so that you can determine how much spasticity is involved. Is it rigid, is it significant enough that it makes it really challenging for them to use, or is it just something that postures when they are running across the room or when they are doing more gross motor activities?
The Tardieu Scale is a scale that you will see used on a lot on lower extremities.
Cerebral Palsy Upper Extremity
Spastic CP
What problems do we see in the upper extremity when a child has hemiplegic spastic CP?
- Elbow flexed
- Forearm pronated/or reverse pronated
- Wrist flexed and/or ulnarly deviated
- Fingers flexed
- Thumb in palm
Elbow flexed.
Figure 2. CP at the elbow.
The elbow is flexed and the forearm is pronated (or what we call reverse pronated) (Figure 3). The fingers are flexed and the thumb is positioned in the palm, whether it is under the index finger or completely between the next two fingers into the second web space.
