What are Mixed Motor Types of Cerebral Palsy?

We know that people with cerebral palsy usually have a mixed type, meaning that they have spasticity and some sort of dyskinesia.

In the cerebral palsy world, we talk a lot about spasticity, but we're not always as good at identifying dyskinesia. If somebody does have dyskinesia, either dystonia, chorea, or athetosis, some of the things that they might notice are the following:

• They may notice extra movements or postures that come and go that they don't have control of.
• They may notice that when they move one part of their body, another part of their body develops an extra movement or a posture.
• They may notice that when they're trying to do a task, for example, reaching for something that suddenly, that hand develops a posture or a movement that makes the task harder and that they don't have control over. 

We oftentimes like to say that spasticity is more common when you have injury in the areas around the ventricles, something called periventricular leukomalacia, and that dystonia and other forms of dyskinesia are more common when you have injury to the basal ganglia. We now know that most people have more than one motor type, meaning that they have spasticity and some sort of dyskinesia, usually dystonia, and people who have dystonia oftentimes can have some degree of chorea or athetosis as well. There are a few different reasons for this:

1) People with cerebral palsy may have injury in multiple parts of the brain.

2) Even if the injury is isolated to one part of the brain, that part of the brain may also have connections that are going to other parts of the brain that are involved in a different type of motor process. 

For people who have more than one motor symptom as part of their cerebral palsy, there are a few ways that we can help distinguish what's going on. There are some characteristics that clearly separate spasticity from different types of dyskinesia. For example, spasticity has a velocity dependent catch. There are also additional tools like the Hypertonia Assessment Tool that is used to help detect subtle dystonia from spasticity in patients who have cerebral palsy.

One of the challenges that we face when somebody has more than one motor symptom is deciding what medications to use or what symptom to treat first. Unfortunately, sometimes the medication that's used for one motor symptom may not help or may actually worsen another. In general, the best way to approach this is to find the motor type that is having the biggest impact on function and it is most prevalent, and start by treating that first. Sometimes even subtle dyskinesia can have profound effects on daily life, so recognizing that dyskinesia and treating it can have important implications on function and thus quality of life.

It's very important to recognize the dyskinesia so that they can have access to the best medications for them, as well as have early access to things to help them explore their world. These can include things like communication devices, powered mobility, and other adaptive equipment.