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Muscle tone : intra fusal fibre of muscle tension. Cerebral palsy

Muscle power: extra fusal fibre of muscle tension / contraction.
Upper motor neuron lesion
Cerebral palsy
Pathology
a) Group of disorders which are prenatal, perinatal or postnatal in origin.
b) Major causes include hemorrhage below lining of ventricles, hypoxic encephalopathy,
malformations and traumas of CNS.
c) Pattern birth associated with CP.

Classification of CP:
a) By area of body showing impairment
1. One limb/monoplegia
2. Two lower limbs/paraplegia
3. Two upper limbs/ diplegia
4. Upper limb & lower limb of one side of the body/ hemiplegia
5. All four limbs/ quadriplegia.
b) Types of most obvious impairment:
a. Spastic: increased tone, lesion of motor cortex or projections from motor cortex.
b. Athetosis: fluctuating muscle tone, lesion of basal ganglia.
c. Ataxia: instability of movement, lesion of cerebellum.
c) Gross motor function classification system for CP:
a. Level l: walking without restrictions, limitations in more advanced gross motor skills.
b. Level ll: walking without assistive devices, limitations walking outdoors and in
community.
c. Level lll: walk with assistive mobility devises, limitations walking outdoors and in the
community.
d. Level lV: self-mobility with limitations, children are transported or use power mobility
outdoors and in the community.
e. Level V: self-mobility is severely limited, even with the use of assistive technologies.

Impairments for all classification of CP:

- Insufficient force generation.
- Tone abnormality.
- Power selective control of muscle activity.
- Power regulation of muscle activity in anticipation of postural changes.
- Decreased ability to learn unique movements e.g. swimming, cycling, jogging and sports.
- Abnormal patterns of movements in total flexion and extension.
- Persistence of primitive reflexes:
o Interfere with normal posture and movement
o May cause contractures and deformities.

Impairments by classifications of CP:

a) Spastic CP:
- Increased muscle tone in antigravity muscles.
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Cerebral palsy

- Abnormal postures and movements with mass patterns of flexion and extension.
- Visual, auditory, cognitive and oral motor deficits may be associated with spastic CP.
- Imbalance of tone across joints may cause contractures and deformities, especially of hip
flexors, adductors, internal rotators and knee flexors, ankle planter flexors in lower extremity,
scapular retractors, shoulder extensors and adductors, elbow flexors, forearm pronators.
b) Athetoid CP:
- Generalized decreased muscle tone, floppy baby syndrome.
- Poor functional stability especially in proximal joints.
- Ataxia and incoordination when child assume upright position, with decreased base of support
and muscle tone fluctuations.
- Poor visual tracking, speech delay and oral motor problems.
- Tonic reflexes may be persistent, blocking functional postures and movement e.g. asymmetrical
tonic neck reflex (ATNR), symmetrical tonic neck reflex (STNR) and tonic labyrinthine reflex
(TLR).
c) Ataxic CP:
- Low postural tone with poor balance.
- Stance and gait are wide based.
- Intention tremors of hand.
- Uncoordinated movements.
- Ataxia follows initial hypotonia.
- Poor visual tracking, nystagmus
- Speech articulation problems.
- May occur with spastic or athetoid CP.

Functional limitations:

- Dependent on classification of CP.

- Spasticity may lead to decrease ROM, which may limit mobility.
- Ambulation:
o Without use if assistive devices may be attained by children with hemiplegia and by
some with diplegia and ataxia.
o May be attained birth use of rollator walkers or crutches by some children with diplegia,
athetosis and few with mild quadriplegia.

Interventions & Goals in CP:

a) Very individualized, depending on abilities, age, type of CP. Incorporate child and family.
b) Focus on prevention of disability by minimizing effects of impairments, preventing to limiting
secondary impairments such as contractures, scoliosis.
- Utilize static positioning and dynamic patterns of movement opposite to habitual abnormal
spastic patterns.
- Facilitates symmetry in postures (verbal cues).
- Elongates spastic hamstrings and heel cords.
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Cerebral palsy

- Serial casting may be used to increase length of muscle and decreased tone.
c) Maximize the gross motor functional level.
- Use principles of motor learning and motor control; facilitate functional motor skills, including
voluntary movements, anticipatory and reactive postural adjustments.
- Use toys, fun activities, balls and bolsters to facilitate postural control and developmental
activities.
- Use weight bearing and postural challenge to increased muscle tone and strength.
- Incorporate orthosis as necessary:
o AFO rigid or with articulated ankle
o Submalleolar orthosis for forefoot and midfoot
E.g. pronated foot; arches
ankle weight relieving calipers, boot cast or air cast brace for foot and ankle or ankle air
cast brace.
- Utilize adaptive equipment as necessary:
a. Seating should maintain head in neutral position, trunk upright, hips, knees and ankles
at 900 flexion (hips in abduction if spastic adductors). Wheelchair or seat may be tilted
posteriorly to decrease extensor tone and maintain hip flexion.
b. Prone or supine standards and Para podium will promote weight bearing through lower
extremities and encourage bone mineralization, GIT function tone, strengthening of
lower extremity muscles and social interaction.
Tonic labyrinthine reflex (TLR) will elicit more extensor tone in supine, more flexor tone
in prone.
c. Side lying will help decrease effect of TLR.
d. Rollator walkers often used. Posterior rollator walker helps child maintain upright
position and arm position helps decrease extensor tone.

Prognosis for CP:

a) Prognosis depends on severity of brain lesion.

Mcqs b) Most children with spastic hemiplegia, mild to moderate spastic CPand mild ataxia will be able
to ambulate.

Medical, surgical and pharmaceutical interventions

Management of spasticity:

a) Oral medications – presynaptic inhibition of acetylcholine release.

- Benzodiazepines; diazepam (valium).
- Baclofen (Lioresal).
b) Intrathecal baclofen pump (ITB) : delivers drug directly to spinal cords, producing muscle
relaxation with less medications and decreased side effects.
c) Selective dorsal rhizotomy (SDR):
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Cerebral palsy

- Surgical transection electromyography (EMG) –selected dorsal sensory rootlets with the goals of
facilitating or maintaining ambulation or improving ease of caregiving.
- Intensive strengthening program after surgery when the ambulation is goal
d) Peripheral nerve block:
- Injection of phenol or alcohol into peripheral nervous system from nerve root to motor
endplate.
- Lasts 3-6 months.
e) Botox injections – minute amounts of botulinum toxin injected into muscle, paralyzing it for 4-6
months.

Orthopedic management:

a) Lengthening procedures:
I. Muscle or tendon lengthening to correct deformity or weak muscle prevents hip
subluxation / dislocation.
II. Muscles most often lengthened include Achilles tendon, hamstrings, iliopsoas, and hip
adductors.
b) Muscle transfer:
o Muscle attachments moved to change direction of force in order to increase function
and decrease spasticity.
o Most often hip adductors transferred to hip abductors.
c) Osteotomies:
o Cutting, removing or repositioning bone to facilitate normal alignment, prevent
subluxations / dislocations.
o Most often performed at hip (femoral or pelvic osteotomy).
o E.g. lateral wedge osteotomy, medial wedge osteotomy.

Abnormal synergy patterns of the extremities seen in patients following stroke:

Upper extremity:

 Flexion synergy components:

Scapular retraction/elevation, shoulder abduction & external rotation, elbow flexion, forearm
supination, wrist and finger flexion.
 Extension synergy components:
Scapular protraction, shoulder adduction and internal rotation, elbow extension, forearm
pronation, wrist and finger flexion.

Lower extremity:

 Flexion synergy components:

Hip flexion, abduction, external rotation, knee flexion, ankle dorsiflexion and inversion.
 Extension synergy components:
Hip extension, adduction, internal rotation, knee extension, ankle plantar flexion and inversion.