Quote: "Most children with diplegia are eventually able to walk, although many start walking late."
Detail: Spastic diplegia refers to a form of cerebral palsy that is a neuromuscular condition of hypertonia and spasticity in the muscles of a person’s lower extremities, often the ones of the hips, pelvis and lower legs. The condition results from brain damage at the time of the person’s birth that prevents proper development of the, ‘pyramidal tract,’ meaning certain nerve receptors in the person’s spine are unable to properly absorb the gamma amino butyric acid which would otherwise properly regulate tone in the areas affected.
Above the person’s hips, their body commonly retains average muscle tone and range of motion, yet some lesser spasticity might also affect their upper body such as their trunk, depending on the severity of the condition in the individual. Depending on the severity of the hypertonia in their legs, people with spastic diplegia may or may not be ambulatory.
Diplegia is a form of cerebral palsy primarily affecting a person’s legs. The majority of children with cerebral palsy experience some issues with their arms but with diplegia they are less involved. Most children with diplegia have spasticity and difficulties with coordination and balance. Delayed muscle growth and spasticity cause their leg muscles to be short and because of this their joints become stiff and their range of motion may decrease as they grow. Their feet and ankles present more issues than their knees and their hips might become dislocated.
Many children with diplegia were born prematurely and have experienced respiratory issues. The majority have average or near average learning abilities. Most children with diplegia are eventually able to walk, although many start walking late.
Diplegia, like other forms of cerebral palsy, is difficult to detect early on. Warning signs may include stiff lower extremities or floppiness of the limbs that become stiff later on. There are no tests or scans that can detect cerebral palsy and it has to be diagnosed based on the person’s motor movement. Before the age of 1 if your child appears to have leg tightness or problems, gentle stretching and exercise is healthy, although never too much to cause discomfort for your child. Your child might also benefit from an infant stimulation program.
Ages 1 to 3
Between the ages of 1 and 3, diplegia is usually noticed and may be diagnosed because the child is not walking. Parents often focus on this but it is important to remember that most children with diplegia will eventually walk and that other milestones are more important such as:
- Eating well
- Weight gain
- Overall health
- Average growth
- Development of hand function
It is appropriate to environmentally stimulate your child to have the desire to walk, but you should not try to force them, or make them feel bad for not being able to.
Between the ages of 1 and 3, children with diplegia tend to like sitting in a, ‘W,’ position with their legs bent. The position is a very comfortable one and frees their hands for play. The majority of therapists recommend allowing children to sit in any position that is comfortable for them, although some think this position causes hip and gait issues, or causes them to walk, ‘toeing-in.’ Therapists might recommend tailor-style positions and size-appropriate chairs to develop good sitting posture.
Ages 2 to 4
If by the age of 2 ½ your child is not pulling to a stand they might have severe involvement and a standing program should be initiated. Ankle-foot orthotics (AFO’s) and prone type standers may be helpful. If your child tolerates it, standing for one or two hours each day may help them to have a sense of being upright, encourage balance, as well as stimulate the average development of bones and joints in their legs. Standing programs are only recommended for children with severe involvement.
If your child is walking on their toes, or if their foot tends to roll in, ankle braces work well. If their feet roll in, braces should extend to the tips of their toes to prevent toe curling and gripping and should not have hinges. In general, children prefer plastic braces that can be hidden by clothes and shoes instead of orthopedic shoes. Long leg braces and knee braces are almost never needed for children with diplegia. Surgery is not usually recommended for children of this age.
At age 2, close and regular examination of the hips of children with diplegia is needed for potential spastic hip disease. The disease places the child at risk for hip dislocation, which may eventually cause arthritis and pain as the child grows. The process of gradual dislocation is called, ‘subluxation,’ of the hip. X-rays might help to detect spastic hip disease.
A number of children with diplegia do not walk until between the ages of 2 and 4. As they begin to move around the floor they might start crawling, or they may skip crawling entirely but eventually learn how to walk. Some children do not start walking until as late as 8 years of age, but between the ages of 8 and 10 they will have set up a pattern of mobility they will continue for the rest of their life.
Ages 4 and Above
It is generally agreed that the period between the ages of 4 and 6 is the best time to concentrate on therapy. The majority of children will not tolerate more than five half-hour sessions a week, sometimes even less. The experience should be pleasant for both the parent and the child and it is important not to push the child too far. By age 6, cognitive issues should be emphasized and therapy should be de-emphasized or even discontinued. For children with mild diplegia, replacing therapy with other physical activities such as dance class, swimming, horseback riding, or karate is a good idea because the child’s interest will keep them active in developing their motor skills.
For severely involved children the question of if they will ever walk is something that cannot be answered until they reach the age of 7 or 8. It is also not an either-or issue; a number of children are able to walk short distances, yet do not walk for longer ones. Some factors that might inhibit walking include:
- Lack of muscle coordination
- Muscles working against each other
Stretching and physical therapy can be helpful for lack of muscle coordination and to some extent spasticity. Surgery might be helpful in improving the balance between opposing muscles. If muscles prevent each other from operating as they should and a doctor recommends surgery, the time before first grade might be a good opportunity to pursue surgery, preparing your child for school in the best possible condition. Minimizing the numbers of surgeries a child experiences is essential because it might prevent them from seeing themselves as being, ‘sick.’ Operating on a child at an age when they can understand some of their experiences and cooperate is a good idea.