CURRENT CONCEPTS

Management of the Spastic Wrist and Hand in

Cerebral Palsy
Nels D. Leafblad, BS, Ann E. Van Heest, MD

CME INFORMATION AND DISCLOSURES

The Review Section of JHS will contain at least 2 clinically relevant articles selected by the
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”.
Physicians should claim only the credit commensurate with the extent of their participation
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Editors
Ghazi M. Rayan, MD, has no relevant conflicts of interest to disclose.
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Learning Objectives
 Clarify the concept of neuroplasticity.
 Elucidate the clinical presentation of the wrist and hand among cerebral palsy patients.
 List classifications of upper extremity cerebral palsy.
 Examine the nonsurgical treatment including therapy for wrist and hand cerebral palsy.
 Discuss the surgical treatment and outcomes for the wrist and hand among cerebral
palsy patients.
Deadline: Each examination purchased in 2015 must be completed by January 31, 2016, to
be eligible for CME. A certificate will be issued upon completion of the activity. Estimated
time to complete each JHS CME activity is up to 1 hour.
Copyright ª 2015 by the American Society for Surgery of the Hand. All rights reserved.

Research from the last 5 years on the pathophysiology and treatment of upper extremity
sequelae of cerebral palsy (CP) is presented. The development of new treatments of CP-
affected limbs, utilizing the brain’s inherent neuroplasticity, remains an area of promising
and active research. Functional magnetic resonance imaging scans have evaluated the role of
neuroplasticity in adapting to the initial central nervous system insult. Children with CP
appear to have greater recruitment of the ipsilateral brain for motor and sensory functions of
the affected upper limb. Studies have also shown that constraint-induced movement therapy
Current Concepts

From the Department of Orthopaedic Surgery and the Medical School, University of Minnesota, Corresponding author: Ann E. Van Heest, MD, Department of Orthopaedic Surgery,
Minneapolis, MN. University of Minnesota, 2450 Riverside Ave., Ste. R200, Minneapolis, MN 55454; e-mail:
Received for publication November 10, 2014; accepted in revised form November 20, 2014. vanhe003@umn.edu.

No benefits in any form have been received or will be received related directly or indirectly 0363-5023/15/4005-0032$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2014.11.025
to the subject of this article.

 2015 ASSH r Published by Elsevier, Inc. All rights reserved. r 1035

 1036 STEREOGNOSIS CHANGE IN CEREBRAL PALSY

results in localized increase in gray matter volume of the sensorimotor cortex contralateral to
the affected arm targeted during rehabilitation. Recent therapy interventions have emphasized
the role of home therapy programs, the transient effects of splinting, and the promise of
constraint-induced movement therapy and bimanual hand training. The use of motion labo-
ratory analysis to characterize the movement pattern disturbances in children with CP con-
tinues to expand. Classification systems for CP upper limb continue to expand and improve
their reliability, including use of the House Classification, the Manual Ability Classification
System, and the Shriner’s Hospital Upper Extremity Evaluation. Surgical outcomes have
greater patients’ satisfaction when they address functional limitations, also in addition to
aesthetics, which may improve patients’ self-esteem. Surgical techniques for elbow, wrist,
fingers, and thumb continue to be refined. Research into each of these areas continues to
expand our understanding of the nervous system insults that cause CP, how they may be
modified, and how hand surgeons can continue to serve patients by improving their upper
limb function and aesthetics. (J Hand Surg Am. 2015;40(5):1035e1040. Copyright  2015
by the American Society for Surgery of the Hand. All rights reserved.)
Key words Cerebral palsy, stereognosis.

T
HE PURPOSE OF THIS ARTICLE IS TO review litera-
ture from the last 5 years to update hand
surgeons regarding the pathophysiology and
treatment of upper extremity sequelae secondary to
cerebral palsy (CP). By definition, CP is “a group of
disorders of development of movement and posture
causing activity limitations that are attributed to non-
progressive disturbances that occurred in the devel-
oping fetal or infant brain.”1
Etiologies can include fetal stroke, brain anoxia,
central nervous system (CNS) infections, maternal in-
fections, or CNS congenital malformations. Population-
based studies report prevalence estimates of CP ranging
from 1.5 to 4 per 1,000 live births, which makes it the
most common motor disability in childhood.2 Tradi-
tionally, the hand surgeon has treated the secondary
peripheral manifestations of the primary CNS insult,
because few CNS treatments exist. However, future
treatments of upper extremity pathology due to CP
may evolve by gaining a greater understanding of the
primary CNS insults and CNS plasticity from such in-
sults. Considerable work has been done in the last
5 years in attempt to better understand these processes
regarding upper extremity use and function.
Current Concepts
timing of the insult during development. Structural
neuroplasticity has already been demonstrated in
adult stroke patients undergoing neurorehabilitation.
Several interventions are now being employed to
increase upper limb function in children with uni-
lateral CP. Inguaggiato et al3 found that successful
noninvasive rehabilitative strategies, including
constraint-induced movement therapy (CIMT) and
virtual reality therapy, result in enlargement of the
primary hand motor area contralateral to the paretic
hand. Increased activation was also found in the
contralateral sensory cortex, supplementary motor
area, premotor cortex, and cerebellum. These plastic
changes correlate with the enhancement of motor
skills of the paretic upper limb.
Eyre et al4 examined brain plasticity utilizing
transcranial magnetic stimulation to characterize
corticospinal tract development in healthy children,
children with perinatal stroke with hemiplegia, and
bilateral lesions. Magnetic resonance imaging (MRI)
and anatomical studies showed that ipsilateral corti-
cospinal axons from the noninfarcted hemisphere to
the paretic side undergo compensatory hypertrophy.
Such hypertrophy predicts severe impairment in the

upper limb after 2 years. Similar to amblyopia, it

NEUROPLASTICITY
The functional and structural changes that take place
after insult to the CNS are part of a process referred
to as adaptive plasticity. These changes occur in an
attempt to offset or improve functions compromised
by the pathological insult, whether they arise from
malformations, ischemia, or parenchymal lesions.
Mechanisms of plasticity differ depending on the
appears that the increased projections from the ipsi-
lateral cortex actually competitively displace the
remaining projections from the contralateral (injured)
cortex. Krageloh-Mann and Cans5 state that the
healthy hemisphere plays an important role after
unilateral insults. They confirm that, in the motor
system, there is compensatory recruitment of ipsilat-
eral tracts with limited functionality in the affected
limb.

J Hand Surg Am. r Vol. 40, May 2015

 STEREOGNOSIS CHANGE IN CEREBRAL PALSY
Holmström et al6 have reported that, of the various
lesions responsible for CP, the lesion associated with
the most favorable hand function is white matter
damage of immaturity, in which there is mild white
matter loss and the presence of contralateral motor
projections to the paretic hand. The most impaired
hand function was observed in children with ipsilat-
eral motor projections, regardless of the type of
damage. In addition, van de Winckel et al7 examined
brain activation patterns in children with unilateral
CP compared to normally developing children dur-
ing active and passive movement as well as tactile
stimulation. They concluded that, in children with
CP, there is an increased reliance on the ipsilateral
brain for motor and sensory function to the paretic
limb.
Using MRI and transcranial magnetic stimulation,
Mackey et al8 found decreased intracortical and in-
terhemispherical inhibitory mechanisms in children
with CP. More intact inhibition correlates with
higher limb function. Hopefully, interventions can be
developed that would enhance intracortical and
interhemispherical inhibition in order to restore the
excitatory balance in the brain in patients with CP.
Such interventions are already being explored in the
adult stroke population.
Role of therapy based on neuroplasticity
CIMT, a rehabilitative modality rooted in neuro-
plasticity, has been used for years in the adult pop-
ulation and has more recently been shown to improve
upper extremity functionality in children with CP.
Sterling et al9 found that CIMT resulted in localized
increase in contralateral gray matter volume of the
sensorimotor cortex during rehabilitation. In addition,
increased gray matter volumes were observed in the
ipsilateral sensorimotor cortex and contralateral hip-
pocampus. There was a significant improvement in
spontaneous use of the upper extremities in daily
activities following CIMT. Although not yet proven,
there seems to be a causal relationship between in-
creases in gray matter volume and the magnitude of
motor improvement.
Gordon et al10 have suggested that there may be
limitations to the utility of CIMT, particularly when
there is early-onset damage. When ipsilateral pro-
jections from the unaffected hemisphere reorganize
and are strengthened to the paretic hand, and con-
tralateral projections are weakened, the patients
typically have more adversely affected hand function.
The earlier the onset of the damage, the greater the
reorganization that occurs. In children with sub-
stantial ipsilateral corticospinal tract reorganization,
J Hand Surg Am.
1037
constraining the less-affected upper limb with CIMT
may lessen primary motor cortex activity controlling
both upper limbs—a suboptimal therapy. Specula-
tively, bimanual training may be a more appropriate
therapy for these children, but its efficacy may depend
on interhemispherical connections.
PATIENT EVALUATION
Several studies in the last 5 years describe advances in
motion laboratory assessment for evaluation of chil-
dren with upper extremity CP. By definition, CP is a
movement disorder, but the type of movement im-
pairment may clinically manifest as spastic, flaccid,
dystonic, or a combination thereof. In addition, the
manifestations of CP may vary in the different seg-
ments of the limb: shoulder, elbow, forearm, wrist,
fingers, and thumb.
Fitoussi et al11 report using a specific kinematic
protocol to measure the ability of hemiplegic patients
with CP to carry out simple daily tasks before and
after therapy with either botulinum toxin injection or
surgery. The study found that, as problems in the
forearm, wrist, and thumb were addressed and im-
proved with therapy, so did the proximal kinematic
problems. This suggests that proximal deficits could
be related to compensatory movement strategies and/
or cocontractions and should be addressed second-
arily after treatment of distal issues.
Klotz et al12 report that motion analysis is a useful
clinical tool for evaluating both coordination and
range of motion limitations. They describe use of a
fingertip reach task, in which the child touches the
top of a bottle with the index fingertip followed
immediately by touching the nose tip. This analysis
shows movement deviations due to lack of coordi-
nation very clearly for children with CP.
Jaspers et al’s study13 of spatiotemporal and ki-
nematic parameters in 3-dimensional motion anal-
ysis revealed that children with hemiplegic CP have
longer movement durations and less straight tra-
jectories in upper extremity movements. Compa-
red with normally developing children, children
with CP also have more wrist flexion and less
Current Concepts
elbow extension and forearm supination during
reach, reach to grasp, and gross motor tasks. In
addition, children with CP have increased trunk
movements and reduced shoulder elevation during
reach activities.
Motion laboratory analysis coupled with dynamic
electromyography testing was used in tendon transfer
surgery.14 Van Heest et al14 compared the preoper-
ative and postoperative firing pattern of the flexor
r Vol. 40, May 2015
 1038 STEREOGNOSIS CHANGE IN CEREBRAL PALSY
carpi ulnaris (FCU) in children treated with an FCUe
toeextensor carpi radialis brevis tendon transfer.
Before surgery, the most common pattern seen was
activation of the FCU during grasp and relaxation of
the FCU during release. This pattern did not change
in 6 out of 7 patients after surgery, suggesting that the
FCU does not change phase after its transfer.
Classification systems
Early detection and classification of hand abnormal-
ities in CP can guide operative and nonoperative
therapies. Various classification systems are available
for this process. The Manual Abilities Classification
System (MACS) (Table 1) is a commonly used tool
and evaluates the child’s ability to handle objects in
daily activities. The House functional classification15
is useful in describing grip function in each hand
separately. The Zancolli classification of active finger
and wrist extension, along with the spastic thumb-
in-palm deformity classification of House, estimates
dynamic spasticity of the hand. A recent article
evaluated hand function in 367 children using these
common classification systems.16 Gajewska et al17
used the MACS system and noted that the presence
of epilepsy in children with CP is associated with
worse manual function, limitations in conscious
motor functions, and increased mental impairment.
Compagnone et al18 compared the gross motor
function classification system, expanded and revised,
the MACS, and the Communication Function Clas-
sification System as 3 systems that are used to clas-
sify functional levels of children with CP. These
3 systems correlate strongly with one another and
complement each other in describing the complete
functional profile of CP. In addition, an intelligence
quotient test seems to influence the global functional
profile of CP patients. Another classification schedule
has been developed to allow clinicians to assess spon-
taneous function, dynamic positioning, and child’s
ability to perform grasp-release maneuvers. This is
known as the Shriners Hospital for Children Upper
Extremity Evaluation (SHUEE), a validated video-
based tool.19
Current Concepts
NONSURGICAL TREATMENT AND OUTCOMES
Nonsurgical treatment options for the upper extremity
in CP have primarily focused on physical therapy,
splinting, and botulinum toxin injections. Sakzewski
et al20 recently reported that the most effective
rehabilitative programs have several elements in
common: therapy is goal directed, measureable goals
are identifiable by children and caregivers, motor
training is focused on activities rather than individual
J Hand Surg Am.
TABLE 1. Manual Ability Classification System
(http://www.macs.nu/)
Level Description
I Handles objects easily
II Handles objects with reduced quality and speed
III Handles objects with difficulty requiring modification
IV Handles objects only in adapted situations
V Does not handle objects
movements, and a substantial amount of time is spent
in training. When considering the various noninva-
sive interventions for unilateral upper extremity CP,
Taub and Uswatte21 suggest that CIMT and bimanual
training have demonstrated the most efficacy and
clinical practicality for improving functionality. Both
papers advocate continuing at-home therapy to
maximize clinical improvement.
Jackman et al,22 in a systematic meta-analysis,
evaluated the effectiveness of hand orthoses in
children with CP. Although they found that the use
of hand orthoses in addition to therapy may offer a
small benefit for manual skill development, this ef-
fect diminishes 2 to 3 months after discontinuation
of orthosis use. Orthoses can create discomfort and
cosmetic problems. Consideration of these factors
should influence the clinical appropriateness of
orthosis use. Further methodical research is neces-
sary to determine the overall effectiveness of hand
orthoses to improve outcomes.
A randomized, double-blind, placebo-controlled
study by Koman et al23 evaluated the short-term
effects of botulinum toxin injections for treatment
of upper extremity spasticity in children with CP.
Study participants underwent an average of 3 in-
jections based on their individual spasticity patterns.
A higher percentage of children treated with botu-
linum toxin injections showed improvement in the
Melbourne assessment after 6 months when compared
with children receiving placebo. They concluded that,
when surgery is not indicated, repeated botulinum A
toxin injections are safe and efficacious in providing
short-term functional improvement of children’s upper
extremity spasticity.
SURGICAL TREATMENT AND OUTCOMES
Two treatment outcomes that have not often been
evaluated in surgical treatment of the CP upper ex-
tremity are self-esteem and aesthetics. Riad et al24 have
advocated that health care providers should take into
r Vol. 40, May 2015
 STEREOGNOSIS CHANGE IN CEREBRAL PALSY
account the mental health of patients with CP when
making treatment decisions. Although movement de-
viations in upper and lower extremities often occur
simultaneously in patients with unilateral CP, the au-
thors report that upper extremity deviations correlate
most with lower self-esteem. Even in high-functioning
patients with mild CP, self-esteem may be adversely
affected by such deviations. Elbow flexion deformity is
the main contributor to decreased self-esteem, when
compared with shoulder flexion, shoulder abduction,
and wrist flexion deformity.
Similarly, Makki et al25 have reported that co-
smetic appearance after surgical correction may have
a greater influence on patient’s satisfaction than
functional outcome. Older children (> 12 y) are more
self-conscious about the appearance of their hand.
These authors suggest that it is important not to un-
derestimate the psychosocial implications of hand
deformity. Libberecht et al26 reported that patient
satisfaction is significantly higher in patients with
considerable cosmetic improvement after surgery. It
is not unreasonable to suspect that patients may be
seeking treatment primarily for cosmetic reasons. As
such, even if surgical intervention is not expected to
deliver considerable functional improvement, cor-
recting the deformity for cosmetic reasons can be a
worthwhile endeavor for the patient.
Gong et al27 have reported on the use of the
MACS to categorize outcomes after surgery. They
reported that, by dichotomizing the MACS into high
and low levels for baseline hand function prior to
surgery, one can effectively predict surgical outcome,
regardless of the specific type of surgery performed.
Although patients in both groups experience sub-
stantial improvement, patients with high MACS
levels have greater improvements in function (utiliz-
ing the House functional scale) and overall satisfac-
tion, but less improvement in hygiene status
compared with those with low MACS levels.
Using the SHUEE to assess therapeutic outcomes,
Smitherman et al28 found that single-event multilevel
surgery for children with hemiplegic CP can signifi-
cantly improve thumb, finger, wrist, and forearm
segmental positioning as well as spontaneous func-
tion, but does not significantly change grasp-release
ability. In addition, the single-event multilevel sur-
gical approach provides the patients and families with
the benefits of avoiding staged surgical interventions.
The SHUEE has been demonstrated to be reliable in
clinical decision making and in assessment of func-
tional outcomes after surgery.
Other specific surgical technique articles and their
results have been published regarding treatment of
J Hand Surg Am.
1039
elbow flexion contractures,29,30 swan neck de-
formities,31 and thumb-in-palm deformity.32 An al-
gorithm for treatment of elbow flexion contractures
has been outlined by Carlson and Carlson.31 The
amount of preoperative contracture must be accoun-
ted for when determining the extent of elbow muscle
lengthening. In this study, patients with fixed elbow
deformities less than 45 underwent partial length-
ening, whereas those with fixed deformities greater than
45 underwent full release. A direct correlation exists
between increasing age and the degree of preoperative
contracture; patients 12 years of age or older are 5.5
times as likely to have fixed contracture (passive
extension  45 ) than patients younger than 12 years
of age. The appropriate surgical treatment, based
on the degree of preoperative contracture, can
greatly improve elbow flexion posture angle at
ambulation, active and passive extension, and total
range of motion. Van Heest32 described use of thumb
adductor release, extensor pollicis longus rerouting
and metacarpophalangeal stabilization procedures
depending on the preoperative thumb-in-palm
deformity.
Research from the last 5 years on the pathophysiology
and treatment of CP upper extremity sequelae is pre-
sented in this update article. Functional MRI scans have
evaluated the role of neuroplasticity in adapting to the
initial CNS insult. Children with CP appear to have
greater recruitment of the ipsilateral brain for motor and
sensory function of the affected upper limb. Studies have
also shown that CIMT results in localized increases in
gray matter volume of the sensorimotor cortex contra-
lateral to the affected arm targeted during rehabilitation.
The development of new treatments of CP-affected
limbs, utilizing the brain’s inherent neuroplasticity, re-
mains an area of promising and active research.
Recent reviews of therapy interventions have
emphasized the role of therapy extending into home
programs, the transient effects of fabricating an
orthosis, and the promise of CIMT and bimanual
hand training. The use of motion laboratory analysis
to characterize the movement pattern disturbances
present in children with CP continues to expand.
Classification systems for upper limb involvement
Current Concepts
due to CP continue to expand and improve their
reliability, including use of the House classification,15
the MACS, and the SHUEE. Outcomes after surgery
have been reported to have greater patient satisfaction
when they address not only functional limitations but
also aesthetics, which may improve patients’ self-
esteem. Lastly, surgical techniques continue to be
refined for treatment of the elbow, wrist, fingers, and
thumb. Continued research into each of these areas
r Vol. 40, May 2015
 1040 STEREOGNOSIS CHANGE IN CEREBRAL PALSY
continues to expand our understanding of the CNS
insults that cause CP, how they may be modified, and
how we, as hand surgeons, can continue to serve
our patients to improve their upper limb function and
esthetics.
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Current Concepts
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28. Smitherman JA, Davids JR, Tanner S, et al. Functional outcomes
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2011;93(7):655e661.
29. Gong HS, Cho HE, Chung CY, Park MS, Lee HJ, Baek GH. Early
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902e909.
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