Movement Disorders: Cerebral Palsy

Question 1

What are the characteristics of quadriplegia?

Answer 1

• Whole body distribution of varying degrees
• Usually 1 side is more effected, leading to asymmetry
• Poor head control, impaired speech, impaired hand-eye coordination
• Can present with spasticity, athetosis, ataxia, hypotonia

Question 2

Describe the distribution of a patient who has spastic quadriplegia?

Answer 2

Whole body (top and bottom) effected fairly equally, may see some asymmetry between L and R

Question 3

Describe the distribution of a patient who has athetoid quadriplegia?

Answer 3

UE and trunk will likely be more effected than LE

Question 4

What are the characteristics of diplegia?

Answer 4

• Whole body involved, but LE are more effected than UE
• Symmetrical or asymmetrical presentation
• Good head control with min/mod UE involvement
• Speech usually unaffected, may have strabismus (misalignment of eyes)
• All individuals have spasticity

Question 5

What are the characteristics of hemiplegia?

Answer 5

• Only one side of the body is involved (face, UE, trunk, LE)
• UE more involved than LE, most common presentation is flexion bias in UE and extension bias in LE
• Typically spastic with some developing athetosis late on

Question 6

What is the difference between diplegia and paraplegia?

Answer 6

Paraplegia refers to involvement of only LEs and trunk, while diplegia has some involvement of UE and increased involvement in LEs

Paraplegia is rare in cerebral palsy because there is not usually pure LE involvement

Question 7

What are some ways to assess the degree/severity of the patient’s presentation?

Answer 7

• Standardized outcome measures (GMFM, Early Clinical Assessment of Balance, etc.)
• Gross Motor Function Classification System for Cerebral Palsy
• Functional Mobility Scale

Question 8

What is the Gross Motor Function Classification System (GMFCS)?

Answer 8

• A standardized gross motor classification for children with cerebral palsy up to 18 years of age
• 5 levels in the classification based on self-initiated movement abilities in positions/movements such as sitting, walking, wheeled mobility

Question 9

What are the determinants that differentiate one level from another level in the GMFCS?

Answer 9

Abilities of the child and the need for AT/AD in home, school, and community settings

Question 10

How does the GMFCS Family Report Questionnaire supplement the GMFCS?

Answer 10

Allows for parent input about the child’s ability

Question 11

What are the general headings for each classification level of the GMFCS (1-5)?

Answer 11

Level 1: Walks without limitations, may have quality issues
Level 2: Walks with limitations
Level 3: Walks using a hand-held mobility device
Level 4: Self-mobility with limitations, may use powered mobility
Level 5: Transported in a manual wheelchair

(Will have higher and lower levels of assistance within levels due to environmental demands)

Question 12

What differentiates level 1 from level 2?

Answer 12

Children in level 2 have limitations in walking long distances as well as balance. They may need to use hand-held devices when first learning how to walk and wheeled-mobility with very long distances, outdoors, or in the community. They will need a railing to negotiate stairs and will have more difficulty running and jumping.

Question 13

What differentiates level 2 from level 3?

Answer 13

Children in level 2 are able to discard their hand-held device when they become more efficient in walking around age 4, though they may choose to use it again at times. Children in level 3 will always need a hand-held device and will need wheeled mobility when outdoors or in the community.They will also require supervision/assistance when negotiating stairs.

Question 14

What differentiates level 3 from level 4?

Answer 14

Children in level 3 can sit on their own or require minimal external support. They are also more independent in transfers and can walk with a hand-held device independently. Children in level 4 can function in sitting while supported but self-mobility is limited. They are more limited in using a hand-held device independently and are more likely to be transported in manual wheelchair or using powered mobility.

Question 15

What differentiates level 4 from level 5?

Answer 15

Children in level 5 have severe limitations in head and trunk control and require extensive assisted technology and physical assistance. Self mobility is achieved only if child can learn how to operate a powered wheelchair with extensive adaptations.

Question 16

What is the Functional Mobility Scale?

Answer 16

• Short, standardized mobility assessment for children aged 4-18 with cerebral palsy
• Allows use of ADs or orthoses
• Parent reports on child’s ability to ambulate at three distance to represent “natural environments”
• Rated on a scale of 1-6 with higher scores indicating improved functional ambulation skills

Question 17

What level of function is represented by each rating (1-6) on the Functional Mobility Scale?

Answer 17

1: Uses a wheelchair. May stand for transfers, may do some stepping when supported by another person or walker
2: Uses a walker without the help from another person
3: Uses crutches without the help from another person
4: Uses straight canes without help from another person
5: Independent on level surfaces. Does not use walking aids or physical help. Requires railing for stair negotiation
6: Independent on all surfaces. Does not use any ADs or help from another person.

Question 18

What body structures and functions must be considered in a child with cerebral palsy?

Answer 18

• Muscle tone and extensibility
• Muscle strength
• Skeletal structure
• Selective control
• Postural control
• Pain
• Fatigue

Question 18

Describe the movement quality of a patient with spastic/hypertonic cerebral palsy

Answer 18

• Labored movement, small/limited motions, move in midrange rather than end-range
• Stereotypic and limited patterns of active movement
• Inaccurate muscle recruitment and co-contraction
• Difficulty with initiation, sustaining, and terminating movement (will use primitive reflexes to initiate movement, lacking variability)
• Poor balance of flexion and extension (lack rotation and frontal plane movements)
• Appears to dislike movement
• Diminished balance

Question 19

Describe the characteristics for a patient with spastic quadriplegia

Answer 19

Movement quality: spastic qualities in the entire body
Health: seizures and cognitive impairments
Sensory: vision deficits (acuity, depth, fields, control, asymmetrical upward gaze), auditory deficits
Cardiopulmonary: poor respiratory capacity, altered breathing patterns, stridor
Oral motor/Speech: poor motor control (weak suck, poor mouth closure, poor swallow, tonic bite reflex, jaw or tongue thrust/retraction, hyperactive gag reflex, reflux, aspiration, drool, poor phonation, labored speech)
Musculoskeletal: contractures that may cause scoliosis/kyphosis, hip dislocation, wrist/thumb dislocation, overuse/disuse disorders

Question 20

Describe the characteristics for a patient with spastic diplegia

Answer 20

Movement quality: Spastic characteristics that are greater in LE and trunk than UE, good head control, LE “stuck in symmetry”, increased effort to move/transition
Health: learning disability and perceptual deficits
Sensory: vision (acuity depth, fields, fields, control, bilateral esotropia)
Cardiopulmonary: mildly limited respiratory capacity, altered breathing patterns
Oral motor/Speech: early oral motor difficulties, speech characterized by a burst of words and quiet vocalization which fades at the end of sentences
Musculoskeletal: contracture and deformity of LE joints leading to hip/patella dislocation

Question 21

Describe the characteristics for a patient with spastic hemiplegia

Answer 21

Movement quality: spastic characteristics (UE>LE), lack of integration of L and R side of body, “new midline” is created in the center of the uninvolved side, lack development of controlled symmetry in order to integrate top and bottom of body, diminished motor planning
Health: learning problems, attention deficits, increased frustration, seizures begin around 7-8 yrs old
Sensory: significant impairment, vision (acuity, depth, fields, control, hemianopsia, strabismus)
Cardiopulmonary: asymmetrical breathing patterns, asymmetrical rib deformity
Oral motor/Speech: facial asymmetry affecting motor control (cry, nursing, drool) and speech
Musculoskeletal: contracture and deformity due to asymmetry (scoliosis, leg length discrepancy)

Question 22

Describe the characteristics of a patient with dyskinetic cerebral palsy

Answer 22

Movement quality: latency but can initiate movement, difficulty with control at midrange and sustaining posture, problems with termination due to lack of eccentric control and proper timing, fixes for stability (may grimace), appears fearless during movement, impaired balance
Health: seizures and cognitive impairments
Sensory: poor integration, vision (acuity, depth, fields, control, upward fixing gaze, athetosis), high frequency hearing loss
Cardiopulmonary: fluctuations in rate and rhythm of respiration due to fluctuations in truncal tone
Oral motor/Speech: difficulty sustaining activity of the tongue, jaw, and oral muscles for feeding and speech
Musculoskeletal: hypermobility, shoulder and finger subluxation due to prolonged fixing

Question 23

Describe the characteristics of a patient with hypotonic cerebral palsy

Answer 23

Movement quality: difficulty intiating, sustaining, and terminating movement and postures with ecentric control, fearful of movemnt, uses phasic bursts for activity, lock out ligaments and joints for stability, poor balance
Sensory: significant impairment, vision (acuity, depth, fields, control, limited convergence)
Cardiopulmonary: difficulty sustaining deep respirations due to decreased strength in intercostals
Oral motor/Speech: poor sustained oral muscle activity and head control for feeding, speech, and drooling
Musculoskeletal: contracture and deformity due to abnormal compensatory holding that can cause hip dislocation, scoliosis, AA subluxation

Question 24

Describe the characteristics for a patient with ataxic cerebral palsy

Answer 24

Movement quality: difficulty with initiation, and termination, fixation required for sustained postural control, poor timing/sequencing, fear/dislike of movement, use joint structures and vision for fixing, poor motor planning, uncoordinated balance
Sensory: significant impairment, vision (acuity, depth, fields, control, poor tracking, nystagmus, rely on visual fixing)
Cardiopulmonary: difficult respiratory control for activity and speech
Oral motor/Speech: impaired articulation causing slow/monotone/arrhythmic voice quality and ranges of dysarthria
Musculoskeletal: hip abduction contracture possible (due to wide BOS) with hyperextensibility in other areas

Question 25

Describe the characteristics of a patient with mixed cerebral palsy

Answer 25

Classified according to dominant degree or severity/type/distribution or extent presentation and add description of other characteristics seen