I.

DEFINITION OF TERMS
CLASSIFICATION
SPASTIC CP
Spasticity is defined as an increase in the physiological resistance of muscle to
passive motion. It is part of the upper motor neuron syndrome characterized by
hyperreflexia, clonus, extensor plantar responses and primitive reflexes. Spastic
CP is the most common form of CP. Approximately 70% to 80% of children with
CP are spastic. Spastic CP is anatomically distributed into three types.

Children with spastic CP exhibit significant UMN signs, such as muscle spasticity
and hyperreflexia/clonus. Extensor Babinski response (abnormal at > 2 years
old) may be present in addition to other persistent primitive reflexes. The spastic
group is divided into 5 subtypes that are named by the part(s) of the body
involved:

Spastic Monoplegia
Rarely seen. The child has isolated upper or lower extremity involvement and
usually with a mild clinical presentation.
Spastic Diplegia (Most Common Type of CP)
With diplegia, the lower extremities are severely involved and the arms are
mildly involved [E,F]. Intelligence usually is normal, and epilepsy is less
common. Fifty per cent of children with spastic CP have diplegia. A history of
prematurity is usual. Diplegia is becoming more common as more low- birthweight babies survive. MRI reveals mild periventricular leukomalacia (PVL).

Of premature infants that develop CP, 75% are spastic diplegics.

Primarily LE >> UE involvement with a history of prematurity
Infants clinically present with a history of early hypotonia followed by
development of spasticity. Developmental delays, commonly in the area of
gross motor function, are also noted.
History of intraventricular hemorrhage is also typical, especially at 2832
weeks of gestation.
MRI
may
show
periventricular
leukomalacia
or
posthemorrhagic
porencephaly.
LE spasticity is caused by damage to pyramidal fibers within the internal
capsule. Muscles
that are affected typically include hip flexors, adductors, and gastrocnemius
muscles.
Contractures result secondary to long-term spasticity.
Diplegic gait pattern includes classic scissoring gait with toe walking.
Mild coordination problems result in the upper extremities with UMN findings
in the lower extremities.
Ocular findings include strabismus in 50% and visual deficits in 63%.
Seizures occur in 2025% and cognitive impairment found in 30%.

Spastic Triplegia

Involves 3 extremities with bilateral lower extremities and 1 upper extremity

classically affected.
Spasticity results in the involved limbs with mild coordination deficits in the
uninvolved limb.
Characteristic scissoring and toe walking

Spastic Quadriplegia
Quadriplegia (Total body involvement - tetraplegia) With quadriplegia, all four
limbs, the trunk and muscles that control the mouth, tongue, and pharynx are
involved [A and B]. When one upper extremity is less involved, the term
triplegia is used. Thirty percent of children with spastic CP have quadriplegia.
More serious involvement of lower extremities is common in premature
babies. Some have perinatal hypoxic ischemic encephalopathy. MRI reveals
PVL.
All extremities are involved.
Pattern of truncal hypotonia with appendicular hypertonia or total body
hypertonia exists.
Often a history of difficult delivery with evidence of perinatal asphyxia
Approximately 50% have a prenatal origin, 30% perinatal, and 20% postnatal.
MRI in the preterm child shows a periventricular leukomalacia.
Opisthotonic posturing may begin in infancy, often persisting in the severely
involved.
Oromotor dysfunction, pseudobulbar involvement and risk of aspiration with
feeding difficulties occur and may require feeding tube placement.
Cognitive involvement results in a large percentage of mental retardation.
Seizures occur in 50% of affected children.
Spasticity and persistent primitive reflexes contribute to making these
children the most severely involved of those with cerebral palsy.
Spastic Hemiplegia
With hemiplegia, one side of the body is involved with the upper extremity
generally more affected than the lower [D]. Seizure disorders, visual field
deficits, astereognosis, and proprioceptive loss are likely. Twenty percent of
children with spastic CP have hemiplegia. A focal traumatic, vascular, or
infectious lesion is the cause in many cases. A unilateral brain infarct with
posthemorrhagic porencephaly can be seen on magnetic resonance imaging
(MRI).

One side of the body is involved, usually the arm more than the leg.
7090% are congenital.
1030% are acquired secondary to vascular, inflammatory, or traumatic
causes.
MRI reveals evidence of unilateral lesions in 66% of cases.
In term infants, the cause is usually secondary to prenatal events.
In premature infants, asymmetric periventricular leukomalacia is a common
cause.
Hemiparesis is usually evident by 46 months of age with hypotonia being
the first indicator;

other indicators include premature preferential hand dominance.

There is a slightly higher incidence of right-sided involvement.
Average age of walking is 24 months
Cranial nerves may be involved (facial weakness).
Growth retardation of the affected side often seen with associated spasticity.
Sensory deficits on the ipsilateral side occur in 68%.
Visual deficits occur in 25% of hemiplegics, cognitive impairment in 28%,
seizures in 33%.
Perceptual motor deficits are common, causing learning disabilities.

DYSKINETIC CP
Abnormal movements that occur when the patient initiates movement are
termed dyskinesias [C,D]. Dysarthria, dysphagia, and drooling accompany the
movement problem. Mental status is generally normal, however severe
dysarthria makes communication difficult and leads the observer to think that
the child has intellectual impairment. Sensorineural hearing dysfunction also
impairs communication. Dyskinetic CP accounts for approximately 10% to 15 %
of all cases of CP. Hyperbilirubinemia or severe anoxia causes basal ganglia
dysfunction and results in dyskinetic CP.

Dyskinesias are characterized by abnormal extrapyramidal movement patterns

secondary to dysregulation of tone, defects in postural control, and coordination
deficits.
1. Athetosis: slow writhing involuntary movements, particularly in the distal
extremities
2. Chorea: abrupt, irregular jerky movements, usually occurring in the head,
neck, and extremities
3. Choreoathetoid: combination of athetosis and choreiform movements.
Generally are largeamplitude involuntary movements. The dominating
pattern is the athetoid movement.
4. Dystonia: a slow rhythmic movement with tone changes generally found
in the trunk and extremities; associated with abnormal posturing.
5. Ataxia: uncoordinated movements often associated with nystagmus,
dysmetria, and a wide-based gait.
Classic movement patterns emerge sometime between 1 and 3 years of age.
Severely affected children have persistent hypotonia. Movement patterns
typically increase with stress or purposeful activity. During sleep, muscle tone is
normal, and involuntary movement stops.
Pseudobulbar involvement presents with dysarthria, dysphasia, drooling, and
oromotor dyskinesias. These children have normal intelligence 78% of the time.
There is a high incidence of sensorineural hearing loss which has been
associated with hyperbilirubinemia and neonatal jaundice.

ATAXIC CP
Ataxia is loss of balance, coordination, and fine motor control [E]. Ataxic
children cannot coordinate their movements. They are hypotonic during the first
2 years of life. Muscle tone becomes normal and ataxia becomes apparent
toward the age of 2 to 3 years. Children who can walk have a wide-based gait

and a mild intention tremor (dysmetria). Dexterity and fine motor control is
poor. Ataxia is associated with cerebellar lesions.
MIXED CP
Children with a mixed type of CP commonly have mild spasticity, dystonia,
and/or athetoid movements [F]. Ataxia may be a component of the motor
dysfunction in patients in this group. Ataxia and spasticity often occur together.
Spastic ataxic diplegia is a common mixed type that often is associated with
hydrocephalus.
Mixed types of CP exhibit patterns of both spastic and dyskinetic types of CP.
The most common mixed type is spastic athetoid (predominant dyskinetic
movement pattern with an underlying component of spasticity).