Presentation of Hypertonia in Children

An international working group has defined CP as “a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain” (19).

Symptoms

• Motor: CP invariably involves impairments in movement and posture. While the CNS injury is regarded as static, the clinical presentation can be expected to change in response to the development of the nervous system, therapies being given, and complications that arise. Commonly found are abnormal muscle tone, limitation in passive range of motion, and impaired motor function.
• Sensory: The CNS injury may also result in sensory dysfunction.
• Cognition: More than 40% of children with CP exhibit an intellectual disability, and 25% of children with CP have both an intellectual disability and epilepsy (20).

Patterns of evolution

• Hypertonia: Typically, the hypertonia in the legs involves flexor muscles more than extensors, and the hip adductors more than abductors. The hypertonia may be generalized, affecting both upper and lower extremities (quadriplegic); it may affect just the legs symmetrically (diplegia); it may affect only one side of the body (hemiplegic); or it may be focal, affecting only one limb or even only one muscle group in a limb.
• Muscle contracture: Chronic untreated spasticity may result in contractures from permanent shortening of the spastic muscle and its tendon and dislocations of joints. This problem appears in subluxations of the femoral head in the hip joint. These patients often require hip surgery to help with their ambulation once spasticity has been controlled.

Time for evolution

• Appearance of hypertonia: Hypertonia will develop during the first year of life to a varying degree. Severe forms of hypertonia commonly develop earlier.
• Appearance of contracture: Secondary contracture develops as the child begins to develop motor function. Significant range limitations do not commonly develop until the third year of life.

Intervention at Presentation

Stabilization

• Early intervention: Therapy in the form of passive range of motion and assisted play to foster motor development is commonly used for the first two years of life. This is largely passive therapy.
• Physical therapy: Physical therapy to foster motor development is instituted during the third year of life, taking advantage of the child’s ability to follow instructions. Intensive and consistent physical therapy remains the cornerstone of spasticity treatment.
• BOTOX: Botulinum toxin injections can be used to treat developing limitations in passive range of motion due to spasticity and developing contractures. This treatment is not usually needed until the third year of life.

Preparation for definitive intervention, nonemergent

• Discussion with treating therapists: Surgical interventions are designed to assist in fostering motor development. Physical therapy is typically the primary treatment for advancing motor development, so the child’s disability and functional goals should be discussed with the therapists prior to entertaining any surgical interventions to insure that the planned surgery will have a desired result.

Admission Orders

• Routine