pediatric electrodiagnostic for cerebral palsy,
A diagnosis of CP is often made based on MRI, delay of motor milestones and the presence of gait abnormalities in young children
Although the initial brain injury is non-progressive, the musculoskeletal impairments and functional limitations associated with CP are progressive
Three main classes of CP include spastic, dyskinetic and ataxic
2. Introduction
Cerebral Palsy is a term
referring to a non progressive
disease of the brain
originating during antenatal,
neonatal, or early post natal
periode when brain neuronal
connections are still evolving
Secondary effects of
spasticity on growth may
progressive, additional
disturbances of sensation,
cognition, communication and
behaviour
Zwaini, 2018, Cerebral Palsy : Clinical and
Therapeutic Aspect
3. Diagnosis
A diagnosis of CP is often made based on MRI, delay
of motor milestones and the presence of gait
abnormalities in young children
Although the initial brain injury is non-progressive, the
musculoskeletal impairments and functional
limitations associated with CP are progressive
Three main classes of CP include spastic, dyskinetic
and ataxic
Zhou et al, 2019, Influence of Impaired Selective Motor Control on
4. Spastic Cerebral Palsy
Spastic CP is often
linked to damage to
the periventricular
WM due to hypoxia-
ischemia
four interrelated
neuromuscular
deficits: muscle
weakness, short
muscle-tendon unit,
spasticity and
impaired selective
motor control (SMC)
Spastic CP, which
involves injury to
the corticospinal
tract (CST) as well
as other brain
regions, affects
approximately 87%
of children with CP
Zhou et al, 2017, Neurologic Correlates of Gait Abnormalities in
Cerebral Palsy : Implication for Treatment
5. Dyskinetic and Ataxic
Dyskinetic CP is the
second most common
type of CP, affecting
approximately 7.5% of
children with CP
It is often linked to
damage of the
subcortical GM, i.e.,
basal ganglia and
thalamus
Ataxic CP is the least
common type of CP
and is associated with
cerebellar vermis
injury, cerebellar
malformations, and or
genetic mutations
Ataxic CP is
characterized by
impaired limb
coordination during
voluntary movements,
as well as balance,
stability, and speech
impairments
6. early appearance and persistence of
spasticity in cerebral palsy is
considered a leading cause of
disruption of the growth and
development of the musculoskeletal
system
The formation of secondary
orthopedic complications
such as contractures and
dislocations in the joints
Klochkova et al, 2017, Development of Contractures in
Spastic Forms of Cerebral Palsy : Pathogenesis and
Prevention
7. Muscle changes in cerebral palsy
histological and
histochemical changes in
the muscles
(changes in the cell
characteristics, types of
myocytes, connective
tissue content, and gene
expression)
morphological changes
(myocyte diameter,
length of muscle fibers,
length and cross section
of the entire muscle,
angle of attachment of
muscle fibers to the
tendon, as well as number
and length of sarcomeres)
biomechanical changes
(disorders in the
development of muscular
effort, tension, and
moment of force)
Limitation of function
Blemker SS, et al, 2017, Skeletal muscle mechanics, energetics and plasticity
8. Changes in muscle with spasticity
as well as structural
anomalies of muscle
spindles and
acetylcholine receptors
(dysgenesis)
Disorder in the
differentiation of
muscle fibers and
neuromuscular
transmission
Expression and
transformation of
myosin are exposed to
hormonal regulation
and modulation due to
muscle activity and
various external
influences, especially
mechanical stretching
Changes in the level of
motor activity in cases
of CNS damage and
lack of weight loading
disrupt the maturation
of the “adult” forms of
myosin
Abnormal
suprasegmental
influences of the
brainstem and
cerebellum on the
developing motor unit
during the
histochemical stage of
muscle development
Klochkova et al, 2017, Development of Contractures in
Spastic Forms of Cerebral Palsy : Pathogenesis and
Prevention
9. Muscle properties
A summary of experimental results on the relative difference in collagen
content between spastic CP-affected and TD muscle, data for lower
extremity muscles indicate that the collagen content is elevated in
10. Summary of results on the relative difference in fiber diameter,
fascicle diameter, and cross-sectional area for spastic CP-affected
and TD muscles, there is not agreement as to whether or not there is
11. A summary of experimental results on the difference in sarcomere length
(SL) between spastic CP-affected and TD muscles.
All data confirm that the sarcomere length in spastic Cp affected muscle
13. Selective Motor Control
• Selective motor control (SMC) is an essential element of normal
human movement that enables agile, independent control of
joint motion
• Impaired SMC is one of four interrelated neuromuscular deficits
in spastic cerebral palsy (muscle weakness, spasticity, short
muscle-tendon length)
• Impaired SMC is defined as ‘impaired ability to isolate the
activation of muscles in a selected pattern in response to
demands of a voluntary posture or movement (Zhou et al, 2019
DOI: 10.1302/1863-2548.13.180013)
14. Impaired of selective motor control
More recent definitions of impaired SMC are based on visual observation and
electromyographic (EMG) evaluation of muscle activation patterns
Characterized reduced SMC as abnormal ‘obligatory co-activation of synergist
muscles
During isometric activation of knee extensors, participants with idiopathic toe
walking had no overlap in activation timing between the quadriceps and
gastrocnemius muscles, whereas participants with CP had 84.2% overlap
During resisted knee extension, participants with idiopathic toe walking had 3.8%
overlap of activation between the two muscles, compared with 93.4% overlap in
participants with CP (Rose et al, 1999)
16. Modeling of Muscle Activation from Electromyography Recordings in Patients with Cerebral
Palsy
fourteen adult patients with CP (nine with diplegia and five with hemiplegia) with
ages between 23 to 60 years and a group of ten healthy adults aged between 25
and 55 years
A patient’s degree of mobility according to the Gross Motor Function Classfication
Scale (GMFCS) varied from Level I to Level IV
Ranged from 0 to 3, the degree of lower leg muscle spasticity classfied according to
the Modfied Ashworth Spasticity (MAS) scale
Participants were asked to cycle as regularly as possible on their own (e.g., without
external help) with an average speed of 60 revolutions per minute (shown in the
ergometer display) and for a period of 5 min
Before starting a recording, the distance of the participant to the ergometer was
adjusted such that, when the crank angle was 90 degree, the leg stretched to make
an “upper leg-to-lower leg” angle of 170 degree (Roy et al, 2018)
19. • Participants in this study included 20 children with CP, 12 were
Gross Motor Function Classification System (GMFCS) level I,
and 8 were level II (All participants were able to walk
independently) and 8 with TD (Tipically Developed)
• Our results show that children with CP exhibit more variability in
muscle synergies deployed during walking than those with TD
• We found that children with CP utilize the same synergies as
those with TD in some strides, whereas at other times, they
exhibit distinct synergies not present in those with TD
20.
21. https://doi.org/10.1016/j.gaitpost.2006.10.012
The results : showed that the EMG pattern of
the soleus, lateral gastrocnemius and tibialis
anterior muscles became closer to normal after
the surgery
Subject : Children with diplegia (n = 18) and
hemiplegia (n = 16) aging from 6 to 16 years
participated in the study, twenty healthy children
within the same age span are presented as
reference
The purpose : was to investigate the changes
in electromyographic (EMG) patterns after
multilevel surgical treatment in children with
spastic cerebral palsy (equinus correction, distal
rectus femoris transfer, femoral derotation
osteotomy and hamstrings lengthening)
Electromyographic patterns in children with
cerebral palsy: Do they change after surgery?
22. Interpretation of Surface EMGs in Children with Cerebral
Palsy: An Initial Study Using a Fuzzy Expert System
Surface EMG detected simultaneously at
different muscles has become an
important tool for analysing the gait of
children with cerebral palsy (CP), as it
offers essential information about muscular
coordination (Rohlfing et al, 2006)
The investigations were performed on 19
children with cerebral palsy, ages ranged
from 3 to 12 years, the majority of patients
were diplegic and four children were
hemiplegic
23. Clinical stage I included
patients who could walk safely
without external support from
orthoses or a helping hand
Clinical stage II comprised
patients whose gait showed at
least intermittent contact of
the heels with the ground
In Clinical stage III, patients
required intermittent support
while walking. The heels did
not reach the ground and the
ROMs were severely limited
24. NEW INTERPRETATION ON EMG CHARATERISTICS OF
SPASTIC CEREBRAL PALSY DURING A REHABILITATIVE
WALKING EXERCISE
In addition, the CP
produced significantly
smaller root mean square
value in tibialis anterior
muscle than the normal
It was found that our CP
participants ha:d
significantly longer firing
duration and higher
median frequency within
a gait cycle for all the
muscle groups, these
indicated of the EMG
characteristics of in the
spastic muscles
The EMG signal of 16
cerebral palsy patients
(GP) and 18 age
matched control (Normal)
were collected during
several walking trial
The purpose of this study
is to interpret the EMG
characteristics of spastic
cerebral palsy children
during walking
https://ojs.ub.uni-
konstanz.de/cpa/article/view/1022
25.
26. Abnormal coactivation of knee and ankle extensors is related to
changes in heteronymous spinal pathways after stroke
• doi: 10.1186/1743-0003-8-41
