MOJ Orthopedics & Rheumatology

Mini Review Open Access

Cerebral palsy: causes and treatment alternatives,

based on the evidence provided by gait analysis
Abstract Volume 11 Issue 3 - 2019

Cerebral palsy is a pathology whose origin is in the immature nervous system, its
Marcel Rupcich G,1 Ricardo J Bravo2,3
common denominator is the loss of selective motor control, accompanied by other 1
Pediatric Orthopaedic Service, Centro Médico Docente La
manifestations derived from the neurological injury, such as abnormal tone, balance
Trinidad,Venezuela
disorders, and proprioception, so which results in a central motor dysfunction, 2
Center for Assistive Technology, Universidad Simón Bolívar,
presenting alterations of muscles and skeleton during the development of the child. Venezuela
Current concepts on biomechanical mechanisms governing normal and pathological 3
Neurodevelopment Unit, Residencia Humana,Venezuela
gait, have been provided by a tool known as a gait lab, that allows us to obtain a series
of data and measurements objectively and accurately. The Gait analysis has allowed Correspondence: Marcel Rupcich G, Pediatrics Department,
us to understand how and why these alterations compromise the normal ambulation, Centro Médico Docente La Trinidad, Caracas,Venezuela, Tel
being able to present protocols of treatment much more effective and lasting +58-412-3327825, Email

Received: May 31, 2019 | Published: June 14, 2019

Introduction Treatments for the management of high tone

By definition Cerebral Palsy is a static brain injury or lesion in Injectable medications such as botulinum toxin A or phenol are
prenatal, perinatal, or postnatal period (up to 2 years).1 The natural injected directly into the muscle. Botulinum toxin A temporarily
history of patients who have cerebral palsy2 is one of decline in weakens the muscle and reduces high muscle tone. Phenol reduces
ambulatory function. high muscle tone by acting on the nerve, not the muscle. Botulinum
toxin A injections given at multiple levels (e.g., hips, knees and ankles
An international review3 of “The Definition and Classification at the same time) may require sedation or general anesthesia in the
of Cerebral Palsy” in 2006 defines CP as: “A group of permanent operating room (OR), but do not require overnight stays.
disorders of the development of movement and posture, causing
activity limitation, that are attributed to non-progressive disturbances An intrathecal baclofen pump (ITBP) delivers a medication
that occurred in the developing foetal or infant brain. The motor (baclofen) to the intrathecal space around the spinal cord via a
disorders of cerebral palsy are often accompanied by disturbances of thin catheter that extends from an implanted pump to the spine. A
sensation, perception, cognition, communication, and behaviour, by neurosurgeon implants the pump under the skin of the abdomen
epilepsy, and by secondary musculoskeletal problems.” during an inpatient stay.

As a result, without treatment, the gait of patients who have the Selective dorsal rhizotomy (SDR) is a procedure intended to
necessary motor skills to walk will deteriorate over time.4 For them, reduce spasticity,13,14 one type of high muscle tone. During an SDR,
walking may become more exhausting5 and/or painful, and they will sensory nerve rootlets at the lumbar and sacral levels of the spinal
require more assistance to remain mobile.4,6 cord are electri­cally stimulated to determine if they trigger a normal
or an abnormal response. Those producing an abnormal response are
Overview of treatments cut, thus reducing spasticity. An inpatient stay is required for this
For children who have cerebral palsy, treatments to improve or procedure. Primordial attention in the indication of the procedure is
maintain walking function typically include measures to reduce high the selection of the patient.
muscle tone and orthopedic surgery to correct bony deformities, Corrective orthopedic surgery of the lower extremities
balance muscles and improve joint function.7 Gait analysis helps
guide the specific types of intervention. One of the key benefits of Orthopedic surgery is often recommended to relieve contractures
gait and motion analysis is the ability to accurately and quantitatively and correct bone and joint misalignments.10 In children with cerebral
measure8 patients’ gait patterns.9–11 These data allow us to objectively palsy, tone management usually occurs first.
identify orthopedic and neuromuscular problems10 and then use
Single-event multilevel surgery (SEMLS) refers to multiple bone
clinical expertise and guidance from existing evidence to recommend
and soft-tissue orthopedic procedures performed at more than one
treatments.11 This assessment and review of results has enabled discard
level (hip, knee, ankle or foot) during one episode of anesthesia.
surgical procedures that were useless and even harmful; allowing to
The approach is based on the premise that for children who have
know much better the problem. Gait data are also useful as a tool for
cerebral palsy and other complex gait disorders, it is best to correct all
assessing outcomes.12 By measuring changes in the gait pattern after
deformities simultaneously to optimize and balance muscle and joint
treatment, we also can gauge the efficacy of treatments in an unbiased
function. SEMLS reduces the need for multiple isolated admissions
and precise manner.12
and repeated episodes of anesthesia. This type of procedure would not
be possible without tools such as gait analysis.10,11

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Acknowledgments 9. Dobson F, Morris M, Baker R, et al. Clinician agreement on gait pattern
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Conflicts of interest 10. Winters T, Gage J, Hicks R. Gait patterns in spastic hemiplegia in children
and young adults. J Bone Joint Surg Am. 1987;69(3): 437–441.
Authors have no conflict of interest to declare.
11. Gage J R, Schwartz M, Koop S, et al. The Identification and Treatment
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Citation: Marcel RG, Bravo RJ. Cerebral palsy: causes and treatment alternatives, based on the evidence provided by gait analysis. MOJ Orthop Rheumatol.
2019;11(3):141‒142. DOI: 10.15406/mojor.2019.11.00488