Spastic Diplegia in Children With Cerebral Palsy

The form of cerebral palsy known as “spastic diplegia” is one of five categories of spastic CP that help indicate what parts of the body are primarily affected. In the case of diplegia, the lower extremities (legs, hips and pelvis) show spasticity abnormalities while the upper extremities function at a normal or near-normal capacity. Children born with this form of cerebral palsy exhibit near-normal cognitive development and performance, but are frequently delayed in their ability to walk. Once they are able to walk, they commonly have a pronounced scissoring gait, with legs crossing over each other in a stiff, scissor-like pattern.

Even though spastic diplegia is generally considered one of the lesser forms of cerebral palsy, people who suffer from it can expect lifelong difficulty with all voluntary and passive leg movement, as well as pain associated with muscle and joint breakdown that can lead to arthritis and tendinitis. Some forms of spastic diplegia are mild enough to result in barely noticeably abnormalities in balance and gait.

The cause of spastic diplegia, as with many forms of cerebral palsy, is from neonatal asphyxia, a sudden depravation of the oxygenated blood that passes to the fetus through the umbilical cord. This is sometimes combined with a pre-term birth. Spastic diplegia can also be the result of bladder, kidney, urinary tract, STD’s, yeast infections or bacterial vaginosis in the mother during pregnancy. These conditions can lead to infant hypoxia, which inhibits proper development of upper motor neuron function associated with movement.

Dr. William John Little’s first recorded encounter with cerebral palsy during the 1860’s is reported to have been among children displaying signs of spastic diplegia. For this reason, spastic diplegia is sometimes referred to as “Little’s Disease.” Diagnosis of spastic diplegia usually can’t be made until a child is several months or even several years old, but a child can be labeled “high risk” if they experienced birth trauma before, during or shortly after delivery. This includes prematurity of more than 3 weeks. If a child does not meet standard developmental milestones regarding movement of the legs (usually around 18 months), a preliminary diagnosis of spastic diplegia may be made. Around this time, a parent may observe a child’s legs as unusually stiff or floppy (which will gradually lead to stiffness). The cause of this is the failure of the motor neurons to properly develop muscle tone. Normal muscles function in pairs-one contracting while the companion muscle relaxes. When this function is compromised, both muscles contract simultaneously. Hypertonia is the result of too much muscle tone. Hypotonia is too little muscle tone.

Some of the indicators of spastic diplegia include:

1) Children often prefer sitting in a “W” position. Physical therapists will encourage sitting cross-legged or chair sitting.

2) Children may fail in early attempts to crawl, or begin crawling by pulling themselves forward with the use of their forearms, letting their legs drag behind.

3) Children who have failed to pull themselves to a standing position by age 2 and a half may require devices, such as braces, to assist with standing. Standing puts important stress on leg bones and joints, thus promoting healthy growth.

4) Toe walking or feet-rolling–can be improved with low profile/low impact leg braces.

5) Spastic diplegia can lead to gradual hip dislocation, a condition that promotes arthritis and pain. For this reason, regular hip x-rays and exams are needed to monitor the disease.

Physical therapy, including massage therapy, is the most important treatment for any form of spasticity, aimed at training and strengthening muscles to promote healthy bone growth, balance and motor functions. There are medication that can be taken to relax tight muscles and minimize spasms. Injecting Botox into overly tight muscles has proven to provide at least temporary relief. In more extreme cases, surgery can be performed to lengthen muscles. Other treatments include electrical muscle stimulation, hyperbaric oxygen therapy and hippotherapy.

If pain and spasticity are severe enough to inhibit walking, orthopedic surgery can become an option. First, it must be determined which of the 30 major muscles are causing the problem. Gait analysis, a computerized diagnostic technique, is used as a guide in making

Before surgery occurs, doctors must determine which among the 30 major muscles involved in walking are causing the problem. Doctors today use a computerized diagnostic technique known as gait analysis to guide them in making surgical decisions. Gait analysis uses:

1) cameras that record how an individual walks

2) force plates that detect how the feet land

3) a test called electromyography that records muscle activity

4) a computer program that gathers and analyzes the data.

Using this information, doctors can precisely locate which muscles would benefit from surgery and how much improvement in gait can be expected. The timing of such surgeries is based on the child with cerebral palsy’ s motor development and age. Surgery to correct spasticity in upper leg muscles is likely to occur between ages 2 and 4, while surgery to correct spasticity in the lower muscles (hamstring, Achilles tendon) would likely occur around age 7 to 8. Orthopedic surgery had evolved into a relatively simple procedure, often being done on an outpatient basis.

In cases of extreme spasticity and associated pain, SDR (selective dorsal rhizotomy) surgery may be required. SDR surgery involves severing specific nerves at the base of the spinal column to release stress on the targeted muscles.