1. Types of Cerebral Palsy
Robyn Smith
Department of Physiotherapy
UFS
2012

2. 1. Spastic Group

4. Spastic Quadriplegia

5. Distribution All four limbs similarly involved
UL sometimes to a greater degree than LL
Distribution of tone may be assymetrical with one side more involved
or with one side in flexion and the other in extension
Trunk often hypotonic or with increased extensor tone

6. Etiology Asphyxia Anoxia Abruptio placenta Merconium aspiration
Usually indicative of severe cortical damage

7. Development Supine Asymmetrical ATNR Uses retraction of head roll side
No segmental rotation
Spasticity with IR hip may lead dislocation
Sitting
Flexed posture
Strengthens TLR
Grasp weak due IR pronation arm
Lifts head extension and retraction shoulders “chin poke”

8. Development Standing & walking Very mild cases –seldom realistic
Prone
Due to TLR battles lift head
STNR with neck flexion and UL flexion with LL in extension
Often don’t tolerate prone
Mild – learns to lift head with extension and may even creep.
Uses TLR and STNR constantly
TLR/STNR used to get into M-sitting in mild cases
Standing & walking
Very mild cases –seldom realistic
Uses extension spasticity LL - ??? No true active WB
No rotation or dissociation
AP weight shifts
Shuffling gait
As body weight increases loose ability to walk

9. Additional characteristics
Associated with significant associated problems.
Microcephaly & cerebral atrophy
Mental retardation
Cortical blindness
Epilepsy
Feeding problems

10. Spastic Diplegia

11. Distribution All four limbs involved UL to a lesser degree than LL
???? Terminology you will aslo hear refering to assymetrical diplegia or a hemiplegia superimposed on diplegia

12. Etiology Lesion lies near the para-ventricular region
Forms part sub-cortical group lesions
Prematurity (PVL/ IVH)
Hydrocephalus

13. Development Supine Sitting Far better head and trunk control than quad
Uses extension of head and retraction of head to roll
Later as flexion improves uses arm and upper body to roll over
No segmental rotation
Kicking may notice scissoring legs
Sitting
No segmental rotation cannot come up into sitting through side lying
Used STNR to get into M-sitting
Pattern hip flexion and anterior pelvic tilt –becomes fixed deformity
Often shortening hamstrings, long sitting difficult with poor balance and child uses arm support

14. Development Prone Creeps using arms to pull forward
STNR to get into M-sitting
“Bunny hops” or crawls asymmetrically due to poor rotation and dissociation
On floor requires arm support in sitting
Often sitting chair more comfortable and stable
To get into kneeling pull up with arms, LL inactive
Standing & walking
Lumbar lordosis & hip flexion
No segmental rotation or dissociation
Lateral weight shifts
Often up on toes
High guard and poor balance
Tries get foot flat
Extension LL with scissoring
Walking aid –swing through gait

15. Characteristics
Near normal IQ
Epilepsy
Feeding problems may occur

16. Spastic Hemiplegia

17. Distribution Arm and leg on the same side of body involved
Arm usually to greater extent than leg
BUT:
Arm more leg middle cerebral artery
Arm =leg anterior cerebral artery
“dense”(arm, leg and face) capsula interna

18. Etiology
Emboli
Thrombi
Artery malformations
Prematurity with anoxia

19. Development Initially may not appear asymmetric
Start to become evident 6/12
Starts only using unaffected arm
Orientate themselves only to unaffected side
Retraction of hemi side
Difficulty in rolling to unaffected side
Dislikes prone
Does not crawl
Sitting falls over hemi-side to compensate shifts weight to normal side
Associated reactions common
Unable do bilateral hand activities
Locomotes by bum shuffling

20. Development Standing no weight taken on hemi-leg
Pelvis and hip in retraction, LL flexion up on toe
Walk by 18/12
Under-development of hemi leg
Postural deformities common e.g. scoliosis

21. Characteristics Microcephaly Sensory involvement Epilepsy
Intelligence varies –left cerebral hemisphere poor prognosis
Left vs. right hemiplegia:
Left hemi has speech, language and feeding problems
Right hemi has visual perceptual problems

23. Children with spasticity divided into 2 groups:
Severe spasticty
Moderate spsticity

24. Severe spasticity

25. Features In a state of hypertonus The hypertonia does not change
Little or no movement ability due to tone.
Only small movements are
Contractures tend to be more toward the mid- position
Balance reactions are absent
Problems e.g. respiration, feeding and speech
Emotionally child is fearful and cannot adjust to movement.
Children are often very passive

26. Moderate spasticity

27. Features Tone moderate at rest increases activity
More able to move due to changeability in tone
Inconsistent performance during execution task
Contractures more dangerous in this group
Associated reactions
Balance reactions present but underdeveloped
Emotionally these children are often frustrated and insecure

28. Principles to use when treating a spastic child
Reducing the spasticity in itself will not make the child more functional
Therapist should always have a functional goal in mind.
Analyse the patterns of hypertonia and the way in which it interferes with postural control and the performance of functional tasks.
Asses the degree of compensation

29. Principles to use when treating a spastic child
Use of tone influencing patterns, postures and techniques
Facilitate large range movements, free and rhythmical
Dissociation/ rotation
Mobile weight bearing in elongation
Elongation of muscles
Correct biomechanical alignment
Reciprocal patterns
Shaking and vibrating

30. Principles to use when treating a spastic child
Use patterns of activity that lead to function.
Facilitate active movements 
Facilitate balance reactions
Prevent and minimize contracturing
Grade stimulation

31. 2. Hypotonic Group

32. Aetiology Most children with CP start out hypotonic
Premature babies are hypotonic
Hypotonia usually transient
True hypotonia is rare

33. Complex differential diagnosis
The following other possible conditions need to be excluded:
PNL e.g. GBS
SC lesion
Neuromuscular junction diseases e.g. Myasthenia Gravis
Muscle diseases e.g. SMA, DMD
UMN = CP
NB: valuable clinical tool is to test reflexes as hypotonic CP reflexes will still be present

34. Long term outcome for intial hypotonia
45 % Hypertonic
10% Diplegia
45% Dyskinetic
? % Ataxic
?? % True hypotonia

35. Features Little or no postural control against gravity
Body takes up all the available support
Move with difficulty
Uses limbs as post of postural control i.e. Wide base
Hyper mobility of all joints
Apathetic/ passive. Reduced state of alertness. Possible lack of motivation due to their inability to respond . Placid, often describes as “good” baby
Delayed intellectual development
Usually problems with breathing, feeding and drinking
Respiration often shallow with recession of the chest wall evident. Aspiration common. Children also usually have a depressed cough reflex with ineffective cough

36. Principles to use when treating a hypotonic child
Be careful of how stimulate child often hard to arouse
Increase postural tone by stimulation techniques:
Compression
Symmetrical patterns
Static weight bearing
Rhythmical stabilization
All forms of tapping
Movements to be fast and resisted
Work for head and trunk control and alignment
Address associated problems of breathing, eating and drinking
Maximize positioning and handling to ensure the preservation of joint integrity and to prevent aspiration.
Prevent contractures especially postural deformities

37. 3. Athetoid Group

38. Athetoid group Characterised by: Involuntary movements
Abnormal or fluctuating postural tone

39. Athetoid group
Classified according to type of involuntary movement into 4 groups
Pure athetosis
Choreoathetosis
Athetosis with dystonic spasms
Athetosis with spasticity

40. Distribution tone

41. Pure athetosis Tone varies very low normal Distal > proximal
Slow wreathing movements

42. Choreoathetoid Tone varies very low high Proximal > distal
Large wreathing movements
Poor grading of movement

43. Athetoid with dystonic spasms
Hypotonic OR hypertonic

44. Athetoid with spasticity
Moderate spasticity
Proximal > distal
Poor grading of movement

45. Etiology Kericterus hyperbilirubinaemia (severe jaundice)
Rh incompatability
Prematurity
Asphyxia
Metabolic disorders
Encephalitis/ meningitis
Heavy metal poisoning
Rhumatic fever
Degenerative disorders brain

46. Management of jaundice

47. Etiology = damage to the basal ganglia Basal ganglia are NB for:
Control of movement
Scale and amplitude determination of movement
Important in the control of eye movements

48. Characteristics High IQ –cortex not involved
However usually severely disabled
Abnormal fluctuating tone
Lack of proximal stability
Poor grading movement
Poor balance
Contracturing usually not a concern
Repetitive assymetrical movement patterns may lead to deformities
Joint hypermobility
Emotionally volatile
Often frustrated –temper tantrums

49. Associated problems Speech
Vocalization & speech problem –speech poor and indistinct
Hearing loss
Can hear but does not listen
Feeding
Difficulty in swallowing
Battle especially with liquids

50. Associated problems Vision Battle to focus May have nystagmus
= rapid, rhythmic, involuntary eye movements caused by damage brain
Eyes unable move independently head
Lack of stability of head affects vision

52. Development
Fluctuating tone present sometimes birth
Initially seem hypotonic
Develop extension head, neck, retraction shoulders
Persistent ATNR
Due to involuntary movements fail to develop adequate head and trunk control
Athetoid very intelligent and quickly learn to use pathological reflexes for function

53. Development Prone ATNR get up on one arm
TLR and STNR to get into M-sitting
Sitting
Like to M-sit as is stable position
Uses ATNR for hand function
Chair –stabilises using arm around backrest or hooks foot around leg chair
Promotes further asymmetry

54. Development
Gait
Struggle to learn to walk due to fluctuating tone, poor central control and involuntary movement
Asymmetry may be noted
Lumbar lordosis and anterior tilt due to poor central control
Knees locked together
Arm held together or against leg for stability
Often appears in-coordinated

55. Principles to use when treating a child with athetosis
Try stabilizing postural tone !!!! Remember underlying muscle tone is LOW
Compression
Tapping
Rhythmical stabilization
Use of small ROM
Weight bearing in good alignment
Try and promote symmetry
Children with dystonic spasms
Try and inhibit spasms
Work slowly, small ROM and in a graded manner
Counteract development of joint and postural deformities
For the child with spasticity
apply the same principles you would use for a spastic child

56. 4. ATAXIA

57. Characterised by:
In-coordinated
movement
Usually noted
proximally

58. Etiology Damage to the Cerebellum Cerebellar malformations
Cerebellitis
Trauma
Asphyxia
Poisoning/overdose e.g. Tegretol and epilum toxicity
Metabolic disorders
Neoplastic (tumor)
Infective
Genetic

59. Importance of Cerebellum
Responsible for ensuring smooth, coordinated movement
Important role in the execution of the motor plan

60. Clinical features Generally Low tone. Spasticity may be present
Intension tremor absent co-contraction around joint. Cannot give stability to moving part
Overshoot/ Dysmetria poor grading of movement
Use eyes to “fixate” and may have nystagmus
Truncal sway when walking
Uneven stride length and staggering gait, wide base
Appear to be clumsy. Tend to fall frequently due inadequate balance reactions

61. Associated problems Visual problems Speech problems
Problems with swallowing
Perceptual and motor planning problems

62. Principles to use when treating a child with ataxia
Physiotherapy treatment aims to:
Improve postural control
Improve balance and coordination
Improve their movement possibilities in a safe environment
Prevent stiffness, deformities and contractures

63. Principles to use when treating a child with ataxia
Increase postural tone
Work with activities incorporating rotation to improve flexion rotation control
Improve balance and movement abilities e.g. obstacle course
Activities requiring limbs to move separately from body
Resisted activities e.g. walking pushing a box/chair
Work on placement, grading, direction and timing movement
Frenkel exercises
Address thoracic and neck stiffness if present
Propriocetive re-education

64. Principles to use when treating a child with vestibular dysfunction
The vestibular system is the part of the body responsible for balance
Located in the inner ear
Important part of the sensory system as it co-ordinates information from the vestibular organ, eyes, receptors in muscles and joints, palms and soles of the feet and the proprioceptors
Results in the adjustment of muscle tone, limb position, arousal and balance
Sensory systems involved in balance:
Vision
Vestibular system
Somato-sensory system

65. Symptoms of a vestibular dysfunction
Nausea
Nystagmus
Developmental delays
Visual spatial problems
Poor hand eye and hand foot co-ordination

66. Causes of vestibular dysfunctions:
Chronic ear infections
Infarcts and vascular insufficiencies
Neurological disorders including cerebellar degeneration, CP, hydrocephalus
Head and neck trauma
Immune deficiency syndromes e.g. HIV
Tumors of the brain (posterior fossa) and inner ear (acoustic neuromas)

67. Vestibular Rehabilitation Therapy VRT
Can we incorporate
principles in our
Treatment children
with ATAXIA ????
Sensory weighting- selection occurs between visual, vestibular and somatosensory inputs when attempting to balance
VRT programme may include:
Cawthorne-Cooksey exercises
Balance re-education
Gaze stabilizing exercises
Visual dependance exercises
Somatosensory dependence exercises
Otholithic recalibration exercises
Start with eyes open progress to eyes closed

68. 5. Mixed group

69. Most common type of Cerebral Palsy

70. Etiology
Asphyxia with diffuse cerebral damage

71. Most common types mixed CP are:
Spastic with dystonic movements
Spastic with ataxia

72. References Brown, E. 2001. NDT basic course material (unpublished)
Smith, R Paediatric dictate, UFS (unpublished)
Smith, R role of physiotherapy in vestibular rehabilitation, PowerPoint presentation
Images courtesy of Google images (2009)