Spastic Diplegia – Overview and Considerations for Children
Spastic diplegia is a form of cerebral palsy that primarily affects the legs, hips, and pelvis. Arms can also be affected, but to a lesser degree. Considered a less severe form of cerebral palsy, children born with spastic diplegia usually have average to slightly below average intelligence and language skills. Most also learn to walk, although it may come late, but usually by age 8.
People with this form of cerebral palsy will have a distinct scissoring gait, in which the legs cross over each other in a stiff, scissoring pattern.
Causes of Spastic Diplegia
Overall, the most common cause of spastic diplegia is periventricular leukomalacia, more commonly known as neonatal asphyxia, a sudden shortage of oxygen delivered through the umbilical cord, combined with premature birth. The presence of certain maternal infections during pregnancy can also lead to spastic diplegia, since such infections can have similar effects to infant hypoxia. This lack of oxygen damages areas of the brain associated with movement.
Since the disorder is frequently associated with birth trauma before, during, or shortly after delivery or prematurity, an infant can be assessed at birth as high risk. The type or severity of cerebral palsy may not be known for some months or even years depending on extent of the brain damage.
Because spastic diplegic cerebral palsy is primarily associated with movement of the legs, a diagnosis frequently comes when a child starts showing signs of not meeting developmental milestones for walking. This occurs usually between the ages of 18 months and three years.
Before this time, an infant’s legs may seem stiff, or may start out unusually floppy and gradually stiffen. The cause of this stiffness or floppiness is muscle tone, which has to do with the ability of muscle groups to lengthen and contract to produce movement. Too much muscle tone is called hypertonia, and too little is called hypotonia.
Some spastic diplegic cerebral palsy is so mild that people with the disorder report only minor problems with balance and gait.
Treatments for Spastic Diplegia
Treatment for spastic diplegia focuses on physical therapy to strengthen and retain range of motion; braces or other devices to direct bone development; and surgery, for older children, to lengthen muscles and ease muscle contractures. Massage can begin in infancy to help relax stiff muscles. Medications, such as intrathecal baclofen, are also available to help relax muscles and ease pain associated with contractures. For more information about treatments for spastic cerebral palsy, visit Cerebral Palsy Family Network.
Orthopedic surgery is often recommended when spasticity and stiffness are severe enough to make walking and moving difficult or painful, and to smooth an awkward gait.
Before surgery occurs, doctors must determine which among the 30 major muscles involved in walking are causing the problem. Doctors today use a computerized diagnostic technique known as gait analysis to guide them in making surgical decisions. Gait analysis uses cameras that record how an individual walks, force plates that detect how the feet land, a test called electromyography that records muscle activity, and a computer program that gathers and analyzes the data. Using this information, doctors can precisely locate which muscles would benefit from surgery and how much improvement in gait can be expected.
According to the National Institute of Neurological Disorders and Stroke, the timing of orthopedic surgery is now based on the child’s age and motor development. For example, spasticity in the upper leg muscles (the adductors), which causes the “scissor pattern” walk, is a major obstacle to normal gait. The optimal age to correct this spasticity with adduction release surgery is between 2 and 4 years of age. However, the best time to perform surgery to lengthen the hamstrings or Achilles tendon is between 7 and 8 years of age. Today, most of these surgical procedures can be done on an outpatient basis or with a short inpatient stay. Children usually return to their normal activities within a week.
Selective dorsal rhizotomy (SDR) is a surgical procedure recommended only for cases of severe spasticity when all other standard treatments have failed to reduce spasticity or chronic pain. In the procedure, a surgeon locates and selectively severs nerves at the base of the spinal column.
The Child with Spastic Diplegia
According to Living with Cerebral Palsy, children with spastic diplegia may:
- Crawl using a commando-type movement (pulling themselves around by their forearms with legs dragging behind), or may skip crawling altogether.
- Prefer sitting in a W position between 1 and 3 years of age. Therapists may recommend other positions, such as sitting cross-legged, and child-size chairs, to help develop good sitting postures and avoid hip and gait problems.
- Need a program to promote standing postures, if, by age 2 ½ the child is not pulling to a stand. This may include ankle-foot braces (AFOs) and prone type standers. Regularly standing an hour or two a day can improve balance, and stimulate the normal development of bones and joints in the legs. Standing programs are only recommended for children with severe involvement.
- Require ankle braces to prevent toe-walking or rolling in of the feet. These can be low profile braces that can be hidden by clothes or shoes. Long leg braces and knee braces are almost never needed for children with diplegia.
- Need regular hip exams and x-rays at age 2 for spastic hip disease, which can lead to hip dislocation. This condition can cause arthritis and pain as the child grows. The process of gradual dislocation is called subluxation of the hip.
- Need to concentrate on regular physical therapy between the ages of 4 and 6, and then switch the focus to cognitive issues when the child starts school. For a child with mild diplegia, replacing therapy with other physical activities, such as swimming, dance class, karate, or horseback riding, is a good idea because the child’s interest will keep her active in developing her motor skills.
- Be able to walk only short distances.