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Cerebral Palsy: Defining the Common Terms

Cerebral Palsy: Defining the Common Terms

by | Mar 23, 2022 | Neurology

Cerebral palsy (CP) is a condition that affects posture, movement and balance associated with an injury to the developing brain. The injury is static (does not worsen) and occurs before or during infancy. Scottish Rite for Children provides a multidisciplinary approach to care for children diagnosed with CP. Below are the most common terms used when our team is talking with patients and families about the condition. 

Motor Difference

  • Hypertonia – Increased muscle tone or a tendency for muscle to be tight.
  • Hypotonia – Low muscle tone, or a tendency for muscles to be excessively relaxed.
  • Dyskinesia – Excessive muscle movements.
  • Spasticity – Muscle tightness that manifests as a catch and release when a limb is moved quickly about a joint. This type of muscle tightness is constant and consistent throughout the day.
  • Dystonia – Muscle tightness that occurs because of unintended muscle activation. This type of muscle tightness can occur when an individual is trying to move other body parts or with certain emotions.
  • Ataxia – Motor pattern that describes difficulties with balance and difficulty with performing smooth limb movements.

Anatomic Involvement

  • Diplegic cerebral palsy – This term describes a motor difference that involves both legs.
  • Hemiplegic cerebral palsy – This term describes a motor difference that involves one side of the body and including the leg and arm on the same side.
  • Quadriplegic cerebral palsy – This term describes a motor difference that involves all four limbs.
  • Triplegic cerebral palsy – This term describes a motor difference involves both legs, and one arm.

Motor Classification

  • Gross Motor Functional Classification System (GMFCS) – This is a system used by clinicians to categorize how a person with CP moves and functions in different environments. It helps clinicians come up with treatment plans and anticipate changes that can occur in the body as the individual ages.
  • GMFCS I – Individuals in this category of mobility are able to go walk around their environment with little to no help. They can go up and down stairs without holding on to a handrail.
  • GMFCS II – Individuals in this category of mobility may need more help when walking on uneven surfaces or inclines and can go up and down stairs by using a handrail.
  • GMFCS III – Individuals in this category of mobility use an assistive device to walk community distances, such as a walker or crutches. They may use a wheelchair for longer community distances
  • GMFCS IV – Individuals in this category of mobility use a wheelchair for most of their mobility. They may be able to propel manual wheelchairs without any help, and they require little to no head and trunk support when sitting.
  • GMFCS V – Individuals in this category of mobility use the wheelchair for all of their mobility. They may be able to drive a motorized wheelchair and typically need head and trunk support when sitting.

Related Neurologic Findings

  • Periventricular Leukomalacia – This is a pattern that is seen on brain imaging that indicates scarring around the ventricles (the area of the brain that hold spinal fluid). It is usually associated with injury to the vessels around the ventricles in premature infants and affects both sides of the brain.
  • Hydrocephalus – This is a finding on imaging that indicates that the ventricles are enlarged.
  • Porencephaly – This is a pattern on brain imaging that indicates a local injury to a specific area of the brain. It usually affects only one side of the brain.

Related Orthopedic Diagnoses

  • Contracture – This describes a limitation in range of motion at a joint. There are multiple factors that contribute to contractures.
  • Hip migration – Tendency for the femur bone to become uncovered by the hip bone. This can occur in individuals with weakness or increased tone.
  • Neuromuscular scoliosis – A curvature of the spine that is related to weak or spastic muscles.
Orthopedic Manifestations of Cerebral Palsy

Orthopedic Manifestations of Cerebral Palsy

by | Jun 22, 2021 | Neurology

Content included below was presented at the 2021 Pediatric Orthopedic Education Symposium by pediatric orthopedic surgeon Lane Wimberly, M.D.

Watch the full lecture or download this summary.

At Scottish Rite for Children, we have a multidisciplinary team dedicated to providing excellent care to children with cerebral palsy (CP) through an interdisciplinary approach with evaluation, treatment, and support of the families throughout their childhood. We provide services grounded in evidence-based interventions, employing standardized practices to best demonstrate treatment outcomes for orthopedic and neuro-developmental conditions, including neuromuscular scoliosis, hip subluxation, spasticity, and associated co-morbidities.

With the multidisciplinary approach at Scottish Rite, orthopedic surgery, neurology, pediatric development medicine, movement, orthotics, physical therapy, occupational therapy, science, neurosurgery, psychology, and nutrition experts all work together to determine each patient’s treatment plan.

Cerebral Palsy and Orthopedic Surgery
With this population, it is important to communicate realistic goals and expectations to the patient and family. Surgical recovery may be prolonged—6 to 12 months in some cases – before patients have regained their preoperative strength and functional abilities. Many patients will require new approaches to care and new equipment, like seating systems.

The Scottish Rite utilizes mutual decision making, meaning patients, parents, surgeons, and the rest of the care team work together to make decisions about an appropriate treatment plan for the child, especially when discussing surgery. With these medically complex patients, there are greater risks of surgical complications, which orthopedic surgeons discuss with the patient and the family as part of the decision-making process. Our team helps families cope with the best and less optimal outcomes to ensure the best care for the child.

Gross Motor Function Classification System (GMFCS)
The GMFCS allows physicians to guide treatment and expectations. This standardized tool helps to classify the function of the child on a scale of 1 to 5 depending on their functional level.

  • Level 1 = the child is physically active with a slightly noticeable difference.
  • Level 5 = the child is in a wheelchair and requires assistance with all activities and daily living.

There may be some subtle changes as the child grows and ages, but it is very hard for a child to change one level. Most children achieve their optimum level by age 5 or 6. Children with lesser functional abilities often have a decline in their functional abilities as they age. As the child grows and gets heavier, the inherent weakness with their muscular disorders becomes more apparent, and they may need more assistance.

GMFCS Guide to Surgery
Surgery is optimally offered between 7 and 11 years of age. At this age, recovery is typically easier on the patient and family, and it has shown to be the window to obtain maximum benefit. In addition, contractures at that point are usually becoming less amenable to non-operative treatments.

  • Surgical goals for patients at GMFCS levels 1,2 & 3
    • Maintain function
    • Maintain ambulation
    • Prevent contractures
    • Prevent pain
    • Maybe increase function
      • Not always possible
  • Surgical goals for patients at GMFCS levels 4 & 5
    • Prevent pain
    • Allow ease of care
    • Maintain range of motion
    • Improve sitting tolerance or balance
    • Improve foot positioning
    • Unlikely to improve ambulation
    • May prolong standing tolerance or transfers

Orthopedic and Neuro-developmental Conditions Associated with Cerebral Palsy
Neuromuscular Scoliosis
In periadolescent patients, neuromuscular scoliosis is usually managed with a spinal fusion and implants. The goal of this surgery is to prevent curve progression while improving sitting balance and providing a better seated position.

  • Refer for pediatric orthopedic care if the patient develops:
    • an obvious increase in stiffness of the back.
    • an altered seating posture.
    • a persistent leaning to one side.
    • pelvic asymmetry.

Neuromuscular Hip Dysplasia
Children with cerebral palsy are typically born with normally developed and positioned hips. Over time, excessive linear and rotational muscle forces affect the growth of the femur and pelvis  which may cause the hip to dislocate. The likelihood of neuromuscular hip dysplasia is directly related to the patient’s functional ability – a child with a higher GMFCS level has a higher risk. There is little documented benefit to bracing, Botox injections, or physical therapy for treating neuromuscular hip dysplasia. Surgery is recommended to treat this condition.

  • Early referral and close monitoring can improve surgical outcomes when it becomes necessary. Current guidelines include:
    • Initial assessment at age 2.
    • A supine pelvis X-ray for baseline.
    • Further imaging is based on the patient’s functional level, exam and prior radiographs.
    • Being seen relatively early is most important for non-ambulatory children.

Knee Contractures
Hamstring spasticity can cause knee contractures, which lead to a crouched gait position and challenges with transfers and other care. This can become very taxing as the child moves. Sometimes early muscle releases can prevent or reduce contractures.

  • Refer for pediatric orthopedic care if the patient develops:
    • Asymmetry in knee extension range of motion.
    • Contractures or intolerance to stretching or positioning to prevent knee flexion contractures.
    • Crouched gait or difficulty with ambulation or sitting.

Foot and Ankle Deformities
The foot and ankle are very flexible in children. When they are flexible, braces can be used. Over time, the foot tends to become more stiff, resulting in bony changes that make bracing difficult and less tolerated. Toe walking is the most common orthopedic manifestation of cerebral palsy, due to an Achilles tendon contracture.

When treating foot and ankle deformities, the goal is for the patient to have a flat, braceable, shoable, flexible, and pain-free foot. The goals may differ depending on the age, GMFCS level, and stiffness of the patient.

  • Refer for pediatric orthopedic care if:
    • bracing is not tolerated.
    • contractures develop.
    • foot position is changing.
    • shoe wear difficulties are apparent.

Are you interested in learning more? Visit our on-demand page for more educational opportunities available for medical professionals.

Get to Know our Staff: Steven Sparagana, M.D.

Get to Know our Staff: Steven Sparagana, M.D.

by | Mar 15, 2021 | Neurology

Where did you go to college? Medical school? 
I spent two years at Georgetown University in Washington, DC prior to trekking to Texas to attend Texas A&M University. For medical school, I trained at UT Health San Antonio. Given that I attended both A&M (thumb up sign) and UT (hook ‘em horns sign), I have comfortably joined them, and now use the hang loose sign!  One could also easily argue that I also have the right to use the “I love you sign”!

What role does the Neurology and Rehabilitation Medicine department play at Scottish Rite for Children?  
Many of the children with orthopedic problems have underlying neurological causes or complications. Our team is involved in diagnosing and treating these neurological and neuromuscular conditions.  

What are your specialties?
I serve as the director of neurophysiology, director of the Tuberous Sclerosis Complex Clinic and medical director of neurology and rehabilitation medicine. Some of my specialties include child neurology with subspecialty certification in clinical neurophysiology and in neurodevelopmental disabilities. I have a special interest in epilepsy, neurogenetic disorders (for example, tuberous sclerosis complex) and in clinical neurophysiology (EEG, nerve conduction studies with electromyography, and intraoperative neurophysiologic monitoring).

Why did you want to become a doctor? Have you always wanted to work in pediatrics?  
As a youth, I was intrigued by the brain and human behavior, and this interest persisted in college where I managed to study a lot of philosophy before becoming interested in neuroscience. Prior to medical school, I also took an interest in developmental biology (think metamorphosis of insects), which ultimately led me to pediatric neurology—merging development, the brain and kids.

What led you to Scottish Rite? How long have you been here?  
I first came to Scottish Rite as a child neurology resident during my training at Children’s Health (then known as Children’s Medical Center) and UT Southwestern. I have been employed here 26 year(s), 8 month(s), 0 day(s) —but who is counting when you’re having so much fun!

Is there a special referral process for patients to be seen by our experts in the Neurology and Rehabilitation Medicine department?
The vast majority of our patients are referred from the numerous orthopedists, and a few are referred from our colleagues in Pediatric Developmental Disabilities and Rheumatology. There are a couple of diagnoses where children come in by direct referral (for example, tuberous sclerosis complex, holoprosencephaly and hereditary spastic paraparesis).

How do you help your patients feel comfortable and confident?
Smiles, humor, being NICE to them and setting the parents/caregivers at ease.

What do you enjoy most about Scottish Rite?  
The culture of kid and family-centered care, and the “can do/will do” attitude of everyone from the medical teams, to all the support teams, to Mr. Bob Walker and his super team! 

What was your first job?
Slinging ice cream at Friendly’s in Webster, NY (Where Life is Worth Living!). 

What’s your favorite place to eat around here? 
In the Dallas area, my favorite restaurant is Chamberlain’s Fish Market Grill along with sister restaurant, Chamberlain’s Steak and Chop House—both in Addison. Wonderful food and service (for example, Copper River Salmon—when in season)! My family often celebrates major life events there.