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types and presentations of cerebral palsy

Types and Presentations of Cerebral Palsy

In last month’s blog about cerebral palsy (CP), I talked about the neurological condition and what can be improved by working with a physical therapist. This week, I am going to delve deeper into the condition and explain why some kids with CP are so different from one another.

Cerebral palsy has many classification systems. Medical professionals use these systems to understand and manage a child’s symptoms and help plan their treatment.

As stated previously, cerebral palsy describes a brain lesion that occurred in utero or around the time of birth.   Much like a brain injury, CP can be classified based on severity level, location of lesion, body part affected, change in motor control, and how gross motor function is affected.

Classification of CP Based on Level of Severity:

This is a common method of categorizing children with CP, used by doctors and parents alike, though it provides relatively little information. Parents and doctors use this classification system as a simplified communication tool to describe the exact level of impairment.

  • Mild: Having mild CP means a child can move independently and without assistance from people or equipment. He can complete his daily activities without any limitations.
  • Moderate: A child with moderate cerebral palsy will need braces, medical interventions, and adaptive equipment to do functional things, such as walking and keeping up with peers.
  • Severe: A child who will require a wheelchair and who will need quite a bit of assistance to accomplish daily activities is said to have severe CP. Often times, severe cases have multiple equipment needs, and simple things such as eating or sitting alone can be a challenge.
  • No CP:  Some children display cerebral palsy signs though the brain injury occurred after the time of birth, and therefore is classified under traumatic brain injury or encephalopathy.

Classification Based on Topographical Distribution (Body Part Affected):

When trying to plan treatment protocol for a child newly diagnosed with CP, many therapist and pediatricians like to know which body parts are affected and how they are affected. Is one limb weakened (paresis) or paralyzed (plegia)? How many limbs are affected that way?

  • Monoplegia/monoparesis – Only one limb is affected.
  • Diplegia/diparesis – When the legs and the lower body are more affected than the arms
  • Hemiplegia/hemiparesis – The arm and leg on one side of the body are affected.
  • Paraplegia/paraparesis – Only the legs are affected.
  • Triplegia/triparesis – When 3 limbs are affected, or 2 limbs and the face
  • Double hemiplegia/double hemiparesis – All four limbs are affected, but one side of the body is more affected than the other.
  • Tetraplegia/tetraparesis – All 4 limbs are affected, but three limbs are more affected than the fourth.
  • Quadriplegia/quadriparesis – All four limbs are impacted.
  • Pentaplegia/pentaparesis – All four limbs involved, as well as the neck and head.

Classification Based on Motor Control:

What is motor control? It is the body’s ability to voluntarily control limb and joint motion.  Muscles are controlled by the nervous system and abnormal contractions (too much or too little) often occur with brain lesions. Cerebral palsy is often a complex condition. It is possible to have variable muscle tone or a mixture of motor control presentations.

Spastic CP – indicates increased muscle tone, the most common type of cerebral palsy.
Non-Spastic Cerebral Palsy – characterized by low muscle tone or fluctuating muscle tone, or involuntary movements.

When muscle tone is affected, the movements and power needed to move the joints are often affected as well.

Hypertonia/hypertonic – describes increased muscle tone and is often associated with spastic cerebral palsy.  The child may present with stiff limbs, muscles that seem tight, or decreased ability to open his hands or straighten a limb.
Hypotonia/Hypotonic – often used to describe low muscle tone, and can be seen in diagnoses outside of CP. A child’s limbs or trunk may seem hard to control and “floppy.”

Some children’s cerebral palsy can actually be mixed in presentation, where some limbs are affected by spasticity and others are non-spastic.

Classification Based on the Gross Motor Function Classification System (GMFCS):

The last system of categorizing CP is a five-level system that describes the severity of impairment and limitations a child experiences with the condition.  Higher numbers mean a child is able to achieve less activities on his own.

GMFCS Level I – the individual walks without limitations
GMFCS Level II – walks with some limitations, including long distances, running, jumping, and balancing.  They may need devices when first learning to walk, up to age 4, and may need wheeled mobility when travelling long community distances.
GMFCS Level III – walks with an adaptive device.  Assistance is needed to walk indoors and wheeled mobility needed outdoors.  The individual can sit independently or with some external support.
GMFCS Level IV – the child is independent with powered mobility (motorized wheelchair) though need support when sitting. He may be unable to push himself in manual wheelchair.
GMFCS Level V – the individual shows significantly limited head and trunk control. Much of his mobility will need assistive technology or physical assistance.

A more expansive copy of the GMFCS system can be viewed here.

Why so many classification systems?

Most cerebral palsy specialists, health professionals, and parents will need guidance and direction when approaching a child with cerebral palsy. Knowing whether or not a child has low or high tone will determine equipment needs. Knowing the severity level will help physicians plan out need for future treatments and care options.  Understanding whether a child has spastic or non-spastic CP will help tell neurologists and neurosurgeons which part of the nervous system is affected. Having a better grasp on the type and location of lesion will help the medical team prepare for long term associated conditions of cerebral palsy, such as hip dislocation, scoliosis, joint contractures, or seizures.   It is important for therapists to know whether a child with CP has difficulties with muscle tone, muscle control, hand-eye coordination, balance, stiffness, or muscle strength.

The Gross Motor Function Classification System (GMFCS) is used by researchers and clinicians alike and is applicable to all types of cerebral palsy. While other classification systems describe what a child is limited by, the GMFCS places more emphasis on what a child can accomplish. Therefore, parents can use this system to understand how their children will progress over time.

Classification is very important in the treatment of the young child with cerebral palsy, and multiple classification systems help therapists and specialists create individualized plan of care for those children and families impacted by the condition.

Reference:
Types and Forms of Cerebral Palsy. MyChildTM at The Cerebral Palsy Organization website. Available from: http://cerebralpalsy.org/about-cerebral-palsy/types/; 2014 [accessed 18 March 2014]