Spastic diplegia refers to a type of cerebral palsy that is a neuromuscular condition of hypertonia and spasticity in the muscles of the lower extremities, usually those of the legs, hips, and pelvis.
It results from brain damage at birth that prevents proper development of the pyramidal tract, meaning that certain nerve receptors in the spine are unable to properly absorb the gamma amino butyric acid which would otherwise properly regulate tone in the affected areas.
Above the hips, the body typically retains normal muscle tone and range of motion, but some lesser spasticity may also affect the upper body, such as the trunk, depending on the severity of the condition in the individual. Depending on the severity of the hypertonia in the legs, people with spastic diplegia may or may not be ambulatory.
Diplegia is a form of CP primarily affecting the legs. Most children with CP have some problems with their arms but with Diplegia they are less involved. Most children with diplegia have spasticity and have difficulty with balance and coordination.
Delayed muscle growth and spasticity cause their leg muscles to be short, and as a result, the joints become stiff and the range of motion can decrease as a child grows. The feet and ankles present more problems than the knees, and the hips may become dislocated.
Many diplegic children were born prematurely and have had respiratory problems. Most have normal or near-normal learning abilities. Most diplegic children are eventually able to walk, though many begin walking late.
Diplegia, like other forms of CP, is hard to detect early on. Warning signs may include stiff lower extremities or floppiness of the limbs that turn stiff later. There are no tests or scans that can detect CP, and it has to be diagnosed based on motor movement.
Before the age of 1, if your child appears to have leg problems or tightness, gentle stretching and exercise are healthy, though never too much to discomfort the child. Your infant may also benefit from an infant stimulation program.
Between ages one to three, diplegia is usually noticed and can be diagnosed because the child is not walking. Parents tend to focus on this but it is important to remember that most diplegic children will eventually walk and that the other milestones are more important; that the child is fairly healthy, eating well, growing normal, gaining weight, and developing hand function.
It is appropriate to environmentally stimulate your child to have the desire to walk, but you should never try to force her or make her feel bad for not being able to.
Many children with diplegia do not walk until between the ages of 2 and 4. As they start to move around the floor, they may start using a commando-type of a crawl, or may skip crawling all together but eventually learn how to work.
Some do not start walking until as late as age 8, but between 8 and 10 they will have set up a pattern of mobility they will continue for life.
Between 1 and 3 years of age, diplegic children tend to like sitting in a W position with their legs bent. This is a very comfortable sitting position and frees up the hands for play.
Most therapists recommend letting children sit in any position comfortable for them, but some think that this position causes hip and gait problems, or causes them to walk toeing in. Therapists may recommend tailor-style positions and size-appropriate chairs to develop good sitting posture.
If by age two and a half your child is not pulling to a stand, he may have severe involvement and a standing program should be initiated. Ankle-foot braces (AFOs) and prone type standers may be helpful.
If he tolerates it, standing for one or two hours a day can help him have a sense of being upright, encourages balance, and stimulates the normal development of bones and joints in the legs. Standing programs are only recommended for children with severe involvement.
If your child is walking on her toes or if the foot tends to roll in, ankle braces work well. For rolling-in feet, braces should extend to the tips of the toes to prevent toe curling and gripping and should not have hinges.
Generally, children prefer plastic braces that can be concealed by clothes and shoes rather than orthopedic shoes. Long leg braces and knee braces are almost never needed for children with diplegia. Surgery is also not usually recommended at this age.
At age 2, close and regular examination of the hips of children with diplegia is needed for possible spastic hip disease. This disease puts the child at risk for hip dislocation.
This can eventually cause arthritis and pain as the child grows. The process of gradual dislocation is called subluxation of the hip. X-rays can help detect spastic hip disease.
It is generally agreed that the period between age 4 to 6 is the best time to focus on therapy. Most children will not tolerate more than five half-hour sessions a week, some even less.
The experience should be pleasant both for parent and child, and it is important not to push the child too far. By age 6, by the time your child reaches kindergarten or first grade, cognitive issues should be emphasized, and therapy should be de-emphasized or even discontinued.
For the 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.
For severely involved children, the question of if they will ever walk cannot be answered until the age of 7 or 8. It is also not an either-or issue; many children are able to walk short distances but do not walk for longer distances.
Some factors that may inhibit walking include ataxia, or difficulty with balance, lack of muscle coordination, spasticity, and muscles working against each other. Stretching and physical therapy can be helpful for lack of muscle coordination and to some extent spasticity. Surgery can be helpful in improving the balance between opposing muscles.
If muscles prevent each other from operating properly, and your doctor recommends surgery, the time before first grade may be a good opportunity to do surgery, preparing him for school in the best possible condition.
Minimizing the number of surgeries a child has is essential because it may prevent the child from seeing himself as “sick.” Operating on a child at an age when he can understand some of his experience and cooperate is a good idea.
Cultural usage of the term “spastic” The term “spastic” describes the attribute of spasticity in spastic cerebral palsy. In 1952 a UK charity called The Spastics Society was formed. The term “spastic” was used by the charity as a term for people with cerebral palsy.
The word has since been used extensively as a general insult to disabled people, which some see as extremely offensive. It is also frequently used to insult able-bodied people when they seem overly anxious or unskilled in sports. The charity changed its name to Scope in 1994.