Diplegia is a form of CP primarily affecting the legs.
Most children with CP have some problems with their
arms but with Diplegia they are less involved. Most
children with diplegia have spaticity, and have difficulty
with balance and coordination. Delayed muscle growth
and spasticity cause their leg muscles to be short,
and as a result the joints become stiff and the range
of motion can decrease as a child grows.1
The feet and ankles present more problems than the knees,
and the hips may become dislocated.
Many diplegic children were born prematurely and have
had respiratory problems. Most have normal or near-normal
learning abilities. Most diplegic children are eventually
able to walk, though many begin walking late.
Diplegia, like other forms of CP, is hard to detect
early on. Warning sings may include stiff lower extremities
or floppiness of the limbs that turn stiff later. There
are no tests or scans that can detect CP, and it has
to be diagnosed based on motor movement. Before the
age of 1, if your child appears to have leg problems
or tightness, gentle stretching and exercise is healthy,
though never too much to discomfort the child. Your
infant may also benefit from an infant stimulation program.2
Between ages one to three, diplegia is usually noticed
and can be diagnosed because the child is not walking.
Parents tend to focus on this but it is important to
remember that most diplegic children will eventually
walk and that the other milestones are more important;
that the child be fairly healthy, eating well, growing
normal, gaining weight, and developing hand function.3
It is appropriate to environmentally stimulate your
child to have the desire to walk, but you should never
try to force her or make her feel bad for not being
able to.
Many children with diplegia do not walk until between
the ages of 2 and 4.4
As they start to move around the floor, they may start
using a commando-type of crawl, or may skip crawling
all together but eventually learn how to work. Some
do not start walking until as late as age 8, but between
8 and 10 they will have set up a pattern of mobility
they will continue for life.5
Between 1 and 3 years of age, diplegic children tend
to like sitting in a W position with their legs bent.
This is a very comfortable sitting position and frees
up the hands for play. Most therapists recommend letting
children sit in any position comfortable for them, but
some think that this position causes hip and gait problems,
or causes them to walk toeing in. Therapists may recommend
tailor-style positions and size-appropriate chairs to
develop good sitting posture.
If by age 2/12 your child is not pulling to a stand,
he may have severe involvement and a standing program
should be initiated. Ankle-foot braces (AFOs) and prone
type standers may be helpful. If he tolerates it, standing
for one or two hours a day can help him have a sense
of being upright, encourages balance, and stimulates
the normal development of bones and joints in the legs.6
Standing programs are only recommended for children
with severe involvement.
If your child is walking on her toes or if the foot
tends to roll in, ankle braces work well. For rolling-in
feet, braces should extend to the tips of the toes to
prevent toe curling and gripping and should not have
hinges.7 Generally
children prefer plastic braces that can be concealed
by clothes and shoes rather than orthopedic shoes. Long
leg braces and knee braces are almost never needed for
children with diplegia. Surgery is also not usually
recommended at this age.
At age 2, close and regular examination of the hips
of children with diplegia is needed for possible spastic
hip disease. This disease puts the child at risk for
hip dislocation. This can eventually cause arthritis
and pain as the child grows. The process of gradual
dislocation is called subluxation of the hip. X-rays
can help detect spastic hip disease.
It is generally agreed upon that the period between
age 4 to 6 is the best time to focus on therapy. Most
children will not tolerate more than five half-hour
sessions a week, some even less. The experience should
be pleasant both for parent and child, and it is important
not to push the child too far. By age 6, by the time
your child reaches kindergarten or first grade, cognitive
issues should be emphasized, and therapy should be deemphasized
or even discontinued.8
For the child with mild diplegia, replacing therapy
with other physical activities, such as swimming, dance
class, karate, or horseback riding, is a good idea because
the child’s interest will keep her active in developing
her motor skills.
For severely involved children, the question of if
they will ever walk cannot be answered until the age
of 7 or 8. It is also not an either-or issue; many children
are able to walk short distances but do not walk for
longer distances. Some factors that may inhibit walking
include ataxia, or difficulty with balance, lack of
muscle coordination, spasticity, and muscles working
against each other. Stretching and physical therapy
can be helpful for lack of muscle coordination and to
some extent spasticity. Surgery can be helpful in improving
the balance between opposing muscles. If muscles prevent
each other from operating properly, and your doctor
recommends surgery, the time before first grade may
be a good opportunity to do surgery, preparing him for
school in the best possible condition.
Minimizing the number of surgeries a child has is
essential because it may prefent the child from seeing
himself as “sick.” Operating on a child
at an age when he can understand some of his experience
and cooperate is a good idea.9
1. 1995. Miller, Freeman, and
Bachrach, Steven J. Cerebral Palsy: A Complete Guide
for Caregiving. Johns Hopkins University Press,
Baltimore, Maryland. p. 137.
2. Ibid. p. 139
3. Ibid. p. 140
4. Ibid. p. 140
5. Ibid. p. 140
6. Ibid. p. 141
7. Ibid. p. 141
8. Ibid. p. 143
9. Ibid. p. 149
