1. Classification of Cerebral Motor Disturbances Robyn Smith Department of Physiotherapy UFS 2012

2. Classification Systems for CMD Many classification systems have been developed over the years. Important that clinicians working with children with CMD use a common language when communicating with each other. Provides tools for physiotherapists to make their own clinical diagnosis & confirm or question diagnoses already made by another healthcare provider. Remember clinical picture can change over time!!!....but the lesion/damage sustained to the brain cannot

3. As clinicians we make use of 2 key classification systems in children with CMD Tonal & Quality of movement Limb involvement

4. What are we talking about if we are talking about “tone”? Muscle tone refers to the resting tension in a muscle or the amount of tension or resistance to movement in a muscle. Muscle tone is what enables us to keep our bodies in a certain position or posture against gravity. Changes in muscle tone are what enables us to move to smoothly and in a coordinated manner

5. What are they talking about hypertonicity, spasticity and rigidity

6. Refers to increased resistance to passive lengthening of a muscle or muscle group. Not velocity dependent. Can have neural (spasticity) or non-neural causes (changes in the musculotendinous unit contractility) Hypertonicity Is velocity dependent increased resistance to passive lengthening of the muscle. The faster you stretch the muscle the greater the resistance. Spasticity is neural in nature and is a associated with the UMN lesions and hyper-reflexia Spasticity Constantly increased neural activity throughout the range of muscle excursion and is not velocity dependent. Neural in nature Rigidity is present in both agonist and antagonist Rigidity

7. Classification 5 main groups of CMD Hypertonic Hypotonic DyskineticAtaxic Mixed

8. So what does above the classification system provide us with information about the child? Type of muscle tone Quality of the movement

9. Modified Ashworth Scale 0 No increase in tone 1 Slight increase in tone Catch/release at end ROM 1+ Slight increase in tone Catch/release and resistance through rest ROM (1/2 ROM) 2 More marked increase in tone through ROM, but affected part moved easily 3 Considerable increase in tone, passive movement difficult 4 Affected part in rigid flexion and extension

10. classification Increased muscle tone 1. Hypertonic Athetosis Fluctuating muscle tone 2. Dyskinetic Generally low underlying tone 3. Ataxic ٭ Low underlying muscle tone 4. Hypotonic ٭ 5. Mixed group Spastic with ataxia,or dyskinesia * Pure ataxia or hypotonia is very rare

11. Hypertonic group Mild Tone usually not very high “catch” 1 or 1+ on MAS Moderate Tone moderate to high through ROM 2 on MAS Severe Tone constantly very high (rigidity) 3 0r 4 MAS

12. Hypotonic group Temporary Permanent (rare) Postural tone remains very low

13. Dyskinetic group Pure athetosis Tone varies low to high Involuntary movements distal Choreoathetosis Tone varies low to normal Involuntary movements proximal Athetosis with dystonic spasms Sudden variation in tone from very low to high Appears as tonic spasm= dystonia

14. Ataxic Postural tone generally low Incoordinated movement

15. Mixed Spastic with athetosis Spastic with ataxia Spastic with athetosis and ataxia Most common type of CMD

16. Classification system using limb involvement Triplegia Monoplegia Diplegia Hemiplegia Quadruplegia

17. Equally involved All 4 limbs

18. Diplegia LL > UL involvement All 4 limbs Asymmetrical diplegia both LL and only one UL

19. Hemiplegia UL> LL involvement UL and LL on same side Double Hemiplegia All 4 limbs with bilaterally UL>LL involvement

20. Triplegia Usually both UL and a lower limb 3 limbs are involved

21. Monoplegia Usually UL Only one limb involved Rare Don’t confuse with brachial plexus injury = LMN

22. REMEMBER MOST Children with CMD have hypotonic trunks

23. Use of the classification in combination Common practice to refer to patients as a spastic quadriplegic, or a spastic diplegic or an athetoid with dystonia. FAR MORE DESCRITIVE VALUE Everyone on same page

24. References Paediatric dictate (2009) Images courtesy Google (2011) Rosenbaum et al. Proposed definition and classification of cerebral palsy, April 2005 in Developmental Medicine and & child neurology 2005:(47)571-576