Access to verticality for children with cerebral palsy

doi:10.15406/jnsk.2025.15.00615

Journal of

eISSN: 2373-6410

Neurology & Stroke

Mini Review Volume 15 Issue 1

Access to verticality for children with cerebral palsy

Valérie Hernandes

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Physiotherapist and Psychomotricist, Trainer in Neuromotor Physiotherapy, France

Correspondence: Valérie Hernandes, Physiotherapist and Psychomotricist, Trainer in Neuromotor Physiotherapy, France

Received: March 11, 2025 | Published: March 27, 2025

Citation: Hernandes V. Access to verticality for children with cerebral palsy. J Neurol Stroke. 2025;15(1):19-20. DOI: 10.15406/jnsk.2025.15.00615

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Summary

In the course of its development, the baby will itself gradually against gravity, erect thus achieving verticality. This is not the case for children with cerebral palsy, for various reasons related to their motor problem. Cerebral Palsy (CP) is a group of disorders activity-limiting motor development (movements and postures) attributed to non-progressive disturbances in brain development fetal or infant. Motor disorders are often accompanied by sensory, cognitive, communication, perceptual and/or behavioral disorders, and/or seizures.¹ For each type of CP there will be different problems accessing verticality, which we will detail below.

Verticality in typical development

Dr. K. Bobath has described the normal reflex underlying postural mechanism typical development: On the basis of normal postural tone, optimal reciprocal innervation and numerous and varied coordination patterns, the baby will itself gradually against gravity erect through the development of righting reactions, balancing reactions and protective reactions.² Righting reactions enable the controlled head to be against gravity, aligning the trunk with the head and the limbs with the trunk, and introduce rotation around the body's axis. Balance are reactions triggered when the center of gravity leaves the support base, providing mobility and stability in antigravity positions. Lastly, protective reactions are triggered when is lost balance, providing protection from falling. They thus secure the baby's motor experiences and are present throughout life. These protective reactions develop through sensations already known at the level of hand and support foot support all around the body.³ Postural is essential for control stability and mobility.⁴ Gradually, the baby will discover the sequence of positions from lying down to standing up, and vice-versa, with the ability to graduate movements, and to have great mobility thanks to optimal reciprocal innervation. Reciprocal innervation includes the possibility of having the antagonist release during the contraction of the agonist, allowing movement throughout the course. When agonists and antagonists contract simultaneously (co-contraction), they can stabilize a joint or slow down rapid movement to avoid bone-surface contact. When reciprocal innervation is disrupted full, amplitude stability in a held position and fluidity of movement are not possible, as braking is also impaired.⁵

Typically-developed can children access the sitting position in various ways, but most often from the prone by leaning on their arms, lifting pelvis as if to get position their on all fours, and finally transferring their body weight behind their legs to sit up. He will move into the standing position most often from the 4-legged position, by kneeling upright in front of a support, then as a knight in shining armor or by pushing on the toes of both feet, and finally by pulling himself up to a standing before position learning to stand up from the ground. In these 2 transitions, the importance of support on the arms, dynamic transfer of body weight (forward, backward, laterally, possibly in rotation), stability of position (the position upright kneeling must be stable to enable be weight to transferred onto one knee to pass the foot and arrive in a knight-in-shining position), muscular strength (sufficient strength is needed in the muscles of the limb lower to push on the foot and arrive in a standing position), dissociation in the lower limb, etc....

Verticality in children with cerebral palsy

For a variety of reasons, it is difficult for CP children to: from their achieve verticality outset, motor repertoire is less extensive than that of typically developing, and they have greater children difficulty selecting the best strategy for a motor task.⁶ Furthermore, we observe frequently that these children have difficulty in the prone position, which allows them to develop support on their upper limb. PC children often have spasticity, which impedes movement and reduces strategies for changing position, weakness in certain muscle groups, possibly involuntary movements that disrupt stability, inefficient balance, reactions etc....When we analyze sitting, standing and walking in PC children we observe 2 phenomena that disrupt the optimality posture and movement: lack of alignment, and difficulty in being stable statically, dynamically, or both. However, PC children are all different and present a variety of problems in accessing verticality, which we will list by referring to the SCPE (Surveillance of Cerebral Palsy in Europe) below classification.

We will therefore describe the problems of access to verticality encountered in the spastic child, the dyskinetic child and the ataxic child.

The child with CP spastic

The problems posed in spastic CP are: a too high tonus, excessive co-contraction resulting in reduced mobility, inadequate righting, balancing and protective reactions, abnormal motor patterns (most often in the case of the patterns diplegic: flexion-adduction and endorotation of the hips, more or less flexion of the knees and equinus or talus), weakness of certain muscle groups (maximus and medius gluteus, quadriceps, foot lifters). This often results in a sitting position with a pelvis retroverted, support on the sacrum rather than on the ischium, knees bent due to hamstring , and often spasticity difficulty in freeing the hands from the support for manipulation, which often leads these children to find a more stable position in the W sitting position that gives them greater stability (hips in endorotation +++ sitting between the heels).

In the static standing position there is anterior flexion of the trunk due to deficits of the maximus muscles gluteus and dorsalis, spasticity of the hip flexors, equinus and sometimes flexion of the knees (disturbance of alignment in the sagittal plane), and in the frontal and horizontal planes, adduction and endorotation caused by spasticity of the muscles concerned.⁷ These elements disrupt posture, reduce the base of support and prevent good static stability. In addition, we often observe in children with walking a diplegia difficulty in stopping on command: the center of gravity is carried forward by trunk, flexion braking and stopping are not functional, and balance reactions are ineffective.

The child with CP

We describe the problems posed by 2 types of dyskinesia: dystonia and choreoathetosis. In dystonia, tone is fluctuating (either very low or very high during activity), patterns are total and abnormal, encompassing the whole body and often dependent on position head; righting, reactions balancing and protective are poor or non-existent. This is a child who will have greater difficulty accessing antigravity positions, mainly because of tonus fluctuations and total patterns in the case of dystonia, and involuntary movements in the case of choreoathetosis.

Sitting will be made more difficult by trunk hypotonia, and involuntary movements or total patterns that destabilize posture. Regarding standing: in dystonia, wide tonus fluctuations may prevent standing, while involuntary movements in choreoathetosis may unbalance the posture.

The child with PC ataxia

Problems include tone moderately low, excessive and uncoordinated balance reactions, lack of proximal co-contraction, and excessive, and reciprocal innervation impairment are reflected in dysmetria. Children with ataxia may choose to sit in a W position, to be more stable and have fewer balance reactions to manage. These reactions, however, are too large in amplitude and poorly coordinated, and therefore inefficient. Standing up will be done with a large base of support, balance is precarious and walking will be done with an of exaggeration step length.

Conclusion

Access to verticality for PC children poses different problems, depending on the type of PC. Nevertheless, there are solutions to help them. It is important to adopt a treatment specific for each type of problem often depending on the classification, which will help them gain access to the antigravity positions that are important for their development and social participation, as well as for the development of instrumental behaviours.