J.L. Pons et al. (Eds.): Converging Clinical & Engi. Research on NR, BIOSYSROB 1, pp. 11171121.

DOI: 10.1007/978-3-642-34546-3_183 Springer-Verlag Berlin Heidelberg 2013

Cerebral Palsy: An Overview of the Disease and
Its Management
Ignacio Martnez Caballero
1,4
, Sergio Lerma Lara
2,4
,
and Maria Antonia Linares Lpez
3,4

1
Medical Coordinator of the Neuro-Orthopedic Unit,
Pediatric Orthopedic Department
manatina@hotmail.com
2
PT in Charge of the Motion Analysis Laboratory of the Neuro-Orthopedic Unit.
Pediatric Orthopedic
slermalara@yahoo.com
3
Chief of the Pediatric Rehabilitation Department
4
Hospital Infantil Nio Jess. Madrid. Spain
Abstract. How a neurologic disease affects to the muscles, bones is introduced.
Classifications systems and treatments according functional levels and ages are
already established. How to improve treatment outcomes is an important task.
1 Introduction
Cerebral palsy is a static encephalopathy presented in a patient with a growing
skeleton. Due to that, the orthopaedic symptoms are getting worse until the
skeletal maturity.
Associated cognitive, sensorial and neurological problems are common. [1] [2] [3].
The incidence of the disease, 2-3/1.000 new born babies, makes necessary a
great effort of management. [3]
2 Pathogenesis
The upper motor neuron lesion creates spasticity, lack of selective motor control
and the predominance of some agonists over their antagonists produces joint
deformities.
Symptoms with excess of features, such us Hypertonia, Clonus or Co-
contraction and others with deficit of them, like weakness or poor balance, will
cause muscle, and joint problems. [1]
The initially flexible joint deformities will become rigid, because the muscle
shortening related to its lower growth speed compared to bone. The growth

1118 I.M. Caballero, S.L. Lara, and M.A.L. Lpez


Fig. 1 Pathogenesis of musculo-skeletal problems according to Bache
hormone increase the bone length and the lack of muscle stimulus for growing,
like stretching, justify the lower muscle fiber length.
Weight bearing introduces Biomechanics in the skeletal deformity
pathogenesis. Bone will grow guided partially by torque forces, and together with
the ground reaction vectors axis deviations may appear. The muscle will work
with inefficient lever arms around the joints because the bone has bad transverse,
sagittal or frontal axis. This will lead to the bone lever arm dysfunction that needs
to be corrected. [2]
3 Classifications Systems
Topographic criteria are commonly used. Tetraplegic, triplegic, diplegic, or
hemiplegic refers to the number or extremities affected, four, three, two or one
respectively.
The motor control with will give us the movement disorders of spasticity,
dystonia, mixed problems or less frequently ataxia and athetosis, being the first the
commonest. Dystonia or extrapyramidal diseases are the worse scenarios.
The functional classification based on functional walking abilities, GMFCS
(Gross Motor Function System) with 5 levels, offers the possibility of setting goal
treatments.
For GMCS Levels IV and V the spine and hips are clinically followed from an
early age, because the greater incidence of scoliosis and hip subluxation. These
will finally affect the body posture on a wheelchair. Functional weight bearing can
be a goal in some of these patients. For Levels III and II, the ability of walking
makes the gait disorders a priority of treatment.



Cerebral Palsy: An Overview of the Disease and Its Management 1119


6-12 Years 12-16 Years

Fig. 2 GMFCS functional Levels according to Palisano. [2] [3]
4 Treatment
All the treatments are complementary. Physiotherapy, orthotics, Botulinum Toxin
have the goal of improving the diminished joint range of motion and used at the
beginning. The spasticity can be handle first globally with oral drugs, with
Intrathecal Baclofen or Dorsal Rhizotomy, and ideally would cause a positive
effect preventing orthopedic deformities. However the patients still need
orthopedic surgery after the general spasticity treatment.
The frequency of type of treatment is different according the age of the patient.
[1].


Fig. 3 Frequency of type of treatment related to age. (From Bache and Graham).
A good treatment guide, according GMFCS levels and ages has been
established in recent literature. [3]

Level I


Level II



Level III


Level IV


Level V

1120 I.M. Caballero, S.L. Lara, and M.A.L. Lpez


Fig. 3 Treatment according ages and Functional GMFCS Level. Each color is a different
type of treatment. The hexagon represent the time for orthopedic surgery. In levels V, IV,
III appears sooner because the possible need of profilactic hip subluxation surgery. (From
the Updated European consensus in Botulinum Toxin Therapy 2009).
Despite the lack of studies, according the medicine based on evidence criteria,
some therapies such us Bobath, Vjta o Therasuit, still claim to have a role in the
general management. Better design studies will clarify this point.
A realistic goal, the patient selection, and an adequate surgical plan are basic
conditions for reaching a successful treatment. For better treatment decisions the
role of motion analysis laboratories has been extensively debated. [2]

Fig. 4 The evaluation process for orthopedic surgery includes clinical and functional
evaluation, radiology and motion laboratory studies. FMS and FAQ are functional scales.
(From Young and Graham)

LermaLara,S.PT,MSc.
NEURO-ORTOPEDIA INFANTIL

Cerebral Palsy: An Overview of the Disease and Its Management 1121

Observational gait studies are not enough for quantifying and detect deeply the
disorders that occur while we walk.
This tool has showed the ability of changing surgical planning and even
reducing costs related. [6]
For pre-treatment evaluation, some scales like the FMS (Functional Mobility
Scale) or the FAQ (Functional Ambulatory Questionnaire) offer a reference. [2]
[4] [5]
The long recovery period needs a close follow up, checking physiotherapy, the
orthotic devices and even taking care of psychological aspects. The Single Event
Multilevel Surgery achieves the best of the lower limb alignment in the sagittal,
transversal and frontal planes, but this is not always enough for cerebral palsy
patients. The trunk position, and muscle strength remains challenging in some of
them.
5 Conclusions
A road map of treatment is already set for cerebral palsy patients following
Functional Levels and ages. However improving outcomes is a necessary task for
all of us.
References
[1] Bache, C., Selber, P., Graham, H.K.: Themanagement of spasticdiplegia. Current
Orthopaedics 17, 88104 (2003)
[2] Gage, S., Koop, N.: The Identification and Treatment of Gait Problems in Cerebral
Palsy, 3rd edn. Mc Keith University Press (2009)
[3] Heinen, F., et al.: The updated European consensus 2009 on the use of Botulinum
Toxin for children with cerebral palsy. Eur. J. Paediatric Neurol. 14(1), 4566 (2010)
[4] Young, J.L., et al.: Management of the Knee in Spastic diplegia: What is the dose?
Orthop. Clin. North Am. 41, 561577 (2010)
[5] Freeman, M.: Physical Therapy in Cerebral Palsy. Springer (2005)
[6] Wren, T.: The effect of preoperative gait analysis on costs and amount of surgery. J.
Pediatr. Orthop. 29(6), 558563 (2009)