Roughly 50% of children with CP have a defined perinatal risk factor and roughly 40% of the total number have Hemiplegia.1 Children with hemiplegia have damage on one side of the brain that produces the signs of cerebral palsy on the opposite side of the body. However, the risk factors that cause brain damage produces different patterns of cerebral palsy in babies born early when compared to babies at or near their expected date of delivery. The image shows the different patterns of hemiplegic cerebral palsy in premature compared to full-term babies.
In the baby born early, this damage affects the periventricular white matter of the brain. Either Periventricular Leukomalacia (PVL) or a Grade IV hemorrhage can produce a hemiplegic pattern. Both lesions affect the fiber tracts that control the foot and leg in an ascending pattern. In simple terms, in a preterm infant with hemiplegia, the leg is always more affected than the arm and hand. Speech and cognition are not affected by this localized brain damage.
In the full-term infant, there are two types of unilateral brain lesions. The most common is a Hypoxic-Ischemic Encephalopathy or HIE in a watershed area of the gray matter between the anterior and middle cerebral arteries. The second most common type of damage is a middle cerebral artery stroke.
In both these situations, the site of damage primarily affects the upper limb girdle, hand and face. Speech can also be affected. The pattern of hemiplegia produced by either of these full-term lesions is a descending one with the upper limb and hand more affected than the leg.
Children with either type of hemiplegia will walk. In the CP registry studies reported by Iona Novak1, 99% of children with hemiplegia were walking independently or with an aid. They were scored at GMFCS Levels I to III. The data was not analyzed by birth weight or gestational age, but in my experience, the children with preterm pattern hemiplegia have to work harder to get up and moving and it is really important to keep the foot, ankle and leg in alignment as they grow. The full term child has fewer problems with the leg.
The situation is reversed for functional hand use. The preterm child has fewer problems, especially if the wrist and thumb are maintained in good position. The full term infant tends to have a tighter hand that is less useful and a hand that is not useful becomes a neglected hand. In my experience, most of the full term children will need a wrist and thumb splint early and until they either stop growing or develop functional use. This study demonstrates the importance of a stable wrist and thumb for functional use.
In spite of this reality, most children with hemiplegia either do not have a splint or they do not use them consistently. In my opinion, this is a big mistake. As the study above demonstrates, using an appropriate splint results in instantaneous improvement.
What about the other types of CP? Diplegia is a preterm problem and they all have an ascending pattern of involvement.
Quadriplegia can be either preterm pattern or full term pattern and the same rules apply. Preterm quadriplegia pattern is ascending and full term pattern is descending.
Why is this important?
If you know the pattern, you can focus your attention where it is most needed. Parents of a child with cerebral palsy have a lot of competing demands and only a finite amount of time. The good news is that there are now a large number of evidence based and promising best practice interventions that may help. The bad news is that you and your therapy team will have to make choices.1,2 Setting priorities helps. Putting on an AFO and a Wrist/Thumb splint takes 10 minutes at most, but the child benefits from these 10 minutes all day long.
Constraint Induced Movement Therapy (CIMT) is one of the “Gold Standard”, proven interventions that work to improve hand use in children with Hemiplegia. 2
Now that this technique has passed the single intervention randomized controlled trial phase, it should be obvious that CIMT will work even better if the hand is held in proper alignment. Obvious, but hard to find! I spent half a day looking for an image of a child doing CIMT with good hand alignment.
There are lots of images on the Internet of hands in poor alignment with the wrist held in flexion. Human Body Biomechanics 101…When the wrist is in flexion, the grasp strength is weak.
It is time to maximize the results from our interventions and that means we HAVE TO pay attention to alignment and start from the basic biomechanical realities that apply equally to world-class athletes and to children with cerebral palsy. Stabilize the most affected joints first.
As ever, your comments and questions are welcome.
- Iona Novak. Evidence-Based Diagnosis, Health Care and Rehabilitation for Children With Cerebral Palsy. Journal of Child Neurology 2014, 29:1141-1156
- Iona Novak, Sarah McIntyre, Catherine Morgan, Lanie Campbell, Leigha Dark, Natalie Morton, Elise Stumbles, Salli-Ann Wilson, Shona Goldsmith. A systematic review of interventions for children with cerebral palsy: state of the evidence. Developmental Medicine & Child Neurology 2013, 55: 885–910