Spasticity

Cerebral Palsy: Patient Assessment and Treatment Planning

Cerebral Palsy: Patient Assessment and Treatment Planning
Barry S. Russman, MD; Ann Tilton, MD; Mark E. Gormley, Jr, MD
MF Brin, MD, editor
Muscle Nerve 1997; 20 (suppl 6):S181-S193.

Abstract: Cerebral palsy (CP) is characterized by aberrant control of movement or posture and appears early in life secondary to central nervous system damage. The symptoms of CP fall into four groups: symptoms due to loss of selective motor control; symptoms due to abnormal muscle tone; symptoms due to imbalance between muscle agonists and antagonists; and symptoms due to impaired balance. The goals of treatment are to maximize function and minimize the development of joint contracture and other secondary problems. Development of a treatment plan begins with the definition of objectives and consideration of the effects of growth and development on the patient's abilities. The role of botulinum toxin in CP treatment has grown in recent years. The patient who could benefit most from botulinum toxin treatment is one who is hypertonic and whose abnormal muscle tone is interfering with function, or who is expected to develop joint contracture with growth because of this abnormal tone. By altering this muscle tone, function can be enhanced or additional therapeutic modalities can be employed. Assessing treatment outcomes for BTX injection involves the same set of questions and measurements as for other types of treatments and depends on the careful definition of treatment objectives beforehand.

©1997 John Wiley and Sons, Inc.

Key Points:

• Cerebral palsy is:
  –secondary to early CNS damage
  –marked by postural or movement dyscontrol
  –not progressive


• Other manifestations may accompany CP, but are not implied by the diagnosis


• The definitive diagnosis must be established through evaluation over a period of months


• A progression from hypotonia to hypertonia is consistent with CP; the reverse is not


• The goal of treatment is to maximize function, minimize contracture and other complications, and delay surgery


• Family support is paramount to the effectiveness of any treatment plan


• The treatment plan must account for the effects of growth and development, and should be adjusted with age


• Continued dependence for help with ADLs is a major source of caregiver stress; one goal of therapy is to reduce that source of stress


• Compensation is a more realistic goal than correction of motor dysfunction


• Reducing abnormal tone minimizes contracture and promotes muscle growth


• Tone reduction may require a multifaceted approach


• Simultaneous surgeries for all contractures lessens morbidity and improves function


• Balance abnormalities are common. Compensation may require physical therapy, contracture surgery, and assistive devices


• BTX can be an effective tool for reducing muscle tone in the appropriately selected patient


• The "ideal" patient has hypertonia interfering with function, is expected to develop fixed contracture, and has few muscles needing treatment at any one time


• Children may benefit from sedation before injection


• BTX rarely causes complications or significant adverse effects in the pediatric patient


• The effects of BTX are seen within several days and last for 3-8 months


• Meaningful assessment of treatment outcome depends on careful definition of objectives beforehand

Table 2: Cerebral Palsy Classifications

• Etiologic Groups
• Obvious prenatal
• Simple inheritance
• Defined prenatal syndromes
• Unequivocal prenatal infections
• Cerebral malformations
• Potential pre- or perinatal
• Presence of one or more risk factors
• Obvious postnatal
• Unknown

• Physiologic and Anatomic Groups
• Spastic
• Diplegia - legs more than arms
• Quadriplegia - all four extremities equally involved
• Hemiplegia - one-sided involvement, usually arm more than leg
• Double Hemiplegia - arms involved more than legs, usually asymmetrical
• Dyskinetic
• Hyperkinetic or choreoathetoid
• Dystonic
• Ataxic
• Mixed

Table 3: Assessment Scales for Gross and Fine Motor Abilities

• Alberta Infant Motor Scale
• Miller First Step
• Denver II
• Bayley Infant Neurodevelopmental Screen
• Test of Infant Motor Performance
• Peabody Developmental Motor Scales
• Toddler and Infant Motor Evaluation
• Bruininks Oseretsky Test of Motor Proficiency
• Gross Motor Function Measure
• Gesell Revised Developmental Schedules
• Bayley Scales of Infant Development