Title: LATEST ADVANCEMENT IN MANAGEMENT OF CEREBRAL PALSY
1 LATEST ADVANCEMENT IN MANAGEMENT OF CEREBRAL PALSY
DR JITENDRA KUMAR JAIN
MS ORTHO (PGI CHANDIGARH) DNB MNAMS
CONSULTANT ORTHOPAEDIC SURGEON
TRISHLA ORTHOPAEDIC SPINAL CLINIC
SECRETARYSAMVEDNA TRUST ALLAHABAD UP
VISITING CONSULTANT ICDNEW DELHI
Email- jjain99_at_rediffmail.com
www.samvednatrust.org
2 CEREBRAL PALSY
Also known as static encephalopathy
It is a group of disorders that affect the control of movement and posture caused by a static defect in immature brain by any insult from prenatal period to 2.5 years of postnatal period.
3 CONT.
Commonest cause of severe physical disability in childhood.
Incidence- 0.6-4 /1000 live birth.
It is 27 times more common in child of lt1.5 Kg as compared to 2.5 Kg.
4 Clinical Classification
1.Spasticity-Commonest(70-80)
2. Dyskinesia a) Athetosis
b) Chorea c) Ballismus
d) Tremor e) Dystonia
3. Hypotonic
4. Ataxia
4. Mixed
5 Topographical Classification
Hemiplegia
2) Monoplegia
3) Diplegia
4) Triplegia
5) Quadriparesis
6 Spectrum of child with CP
Every child with cerebral palsy is different.
In some children the problem may be so slight that he or she is only a little clumsy with certain movements.
In other children the problem can be severe.
7 Cont.
Their disabilities stayed relatively the same but presentation can change with age.
8 Motor Disabilities
Hyper-tonicity - spasticity rigidity and athetosis (involuntary movement)
Paralysis (weakness) of the propulsive and antigravity muscles
Abnormal movements and postures
Difficulty in coordinated and alternative movements
Difficulty in keeping the body in antigravity postures
10 Criteria For Gross Motor Function Classification System (GMFCS)
Level I Walks without restrictions limitations in more advanced gross motor skills
Level II Walk without assistive devices limitations in walking outdoors and in the community
Level III Walks with assistive mobility devices limitations in walking outdoors and in the community
Level IV Self-mobility with limitations children are transported by use of power mobility for outdoors and in the community
Level V Self-mobility is severely limited even with the use of assistive technology.
11 Matsua Gross motor level
Non rolling
Turn over from the supine to the side
Turn over from side to the prone
Mermoid crawl symmetrical
Mermoid crawl unilateral cross pattern
Mermoid crawl alternate crossed pattern
Coming to the W sitting
Coming to on hands and knee posture
Crawling on hands knee symmetrical
Crawling on hands knee crossed pattern
Coming to knee standing
Coming up to standing parallel bar
Walker or parallel bar gait
Crutch walking
Crouched gait
Upright bipedal gait
12 Type Of Gait Crouch Gait Jump Gait Stiff knee Gait Scissoring Gait 13 Normal Developmental Stages Of The Child 14 Diagnosis
Diagnosis of cerebral palsy is based on detail history and clinical examination.
Gait analysis and detail examination of musculoskeletal systems is important for planning of management.
MRI and genetic analysis required
in certain cases to rule out other
causes of neurological deterioration
15 Evaluation of child with CP
History is key in getting full diagnosis
General condition of child should be assed in detail before embarking on other evaluation
16 Goals Of Evaluation
Establish an accurate diagnosis
Classify the type and severity of involvement
Define the musculoskeletal impairment ( spasticity balance weakness contractures and deformities) and decide on ways of treatment
Evaluate associated impairments and get appropriate treatment
17 Cont.
Determine functional prognosis
Set treatment goals
Devise a treatment plan
Evaluate the outcome of previous treatment procedures
Assess the changes that occur with Tt as well as with growth development
18 History
Personal historyName age social background social status.
History of treatment --Any history of rehab. intervention like therapy bracing and assistive device and surgical intervention
Detail History of associative problem and treatment taken
Family resource and Attitude of family member and their expectation.
19 History Of Risk Factor
Prenatal - Prematurity Low birth weight Maternal epilepsy Hyperthyroidism Infections (TORCH) Bleeding in the third trimester Incompetent cervix Severe toxemia eclampsia Drug abuse Trauma Multiple pregnancies Placental insufficiency.
Perinatal- Prolonged and difficult labor Premature rupture of membranes Presentation anomalies Vaginal bleeding at the time of admission for labor Hypoxia.
Postnatal - CNS infection Hypoxia Seizures Neonatal hyper-bilirubinemia Head injury.
20 Examination
More than 30 muscles are involved in taking a single step so meticulous assessment is required.
Thorough examination of child as whole in different position such as supine prone sitting standing walking and running.
The surgeon needs to identify exactly which muscle are causing functional problem because lengthening of wrong muscle will make the child much worse.
21 Neurological Examination
Motor---
Muscle tone power Muscle bulk Degree of voluntary control deep reflex primitive and advanced reflexes involuntary movement and coordination of movement developmental milestones
Sensory
Propioceptive fine tactile sensation and two point discrimination
22 Orthopaedic Evaluation
Detailed examination at each joint Active and passive Range of movement spasticity and contracture of each muscle separately muscle strength and coordination
Orthopedic complication -- deformity bony torsion joint subluxation and dislocation.
Gait analysis---Detail analysis of gait and postural tone and control of head and trunk
Functional achievement Hand function
23 Differential Diagnosis
Familial spastic Para paresis
Autism
Neurodegenerative disorder- primary and metabolic
Intracranial lesion
Metabolic disorder
24 Management
No Permanent cure for cerebral palsy as Brain damage can not be repaired.
Aim of treatment is to increase the patients ability up to maximum level minimize his disability.
25 Concept Of Integrated Approach
Multidisciplinary approach.
All Available Proven Modality Of Tt Combined Together To treat a child for getting Maximum response.
Prevent permanent consequences like bony torsion dislocation and de-compensated changes in joint and if it happen then it should be treated early.
Training of parents for home based therapy programme .
Proper coordination between developmental therapists and Pediatric orthopedic surgeon.
26 Criteria For Treatment Modality
AGE
DEVELOPMENTAL MILE STONES
ASSOCIATED SENSORY AND PROPIOCEPTIVE PROBLEMS
DEGREE OF SPASTICITY
DEGREE OF CONTRACTURE AND DEFORMITY
IQ
AFFORDABILITY
27 Good Prognostic Value
Mild mental retardation to good IQ
Spastic variety
Diplegic and hemiplegic
Good family support
Early identification and early intervention from 3 month to 6month.
Good neck holding and spinal balance.
28 Poor Prognostic Value
Moderate to sever mental retardation
Abnormal behavioral pattern
Athetotic and mixed cerebral palsy
Quadriplegic with sever contracture in early age
Absent neck holding after 4 year age
Absent Sitting and standing capability even with support after 6 year of age
29 Primary Modality Of Treatment In Cerebral Palsy
THERAPY---
SENSORY INTEGRATION
NEURO-DEVELOPMENTAL THERAPY
STRETCHING STRENGTH TRAINING EXERCISE
HIPPOTHERAPY HYDROTHERAPY
GAIT TRAINING BALANCING EXERCISE
BRACES AND MOBILITY AIDS
30 Main Basic Foundation Of Treatment Plan In Cerebral Palsy
Therapy
therapy
therapy
31 Braces Night Splint And Mobility Aid
BRACES( AFO Gaiter Spinal frame)- helps in balancing ex. And gait training
NIGHT SPLINT-To keep muscle in maximum stretched position.
MOBILITY AID (Walker Rolator Tripod etc) - helps in mobilization
Traditional metal and leather caliper (HKAFO)
has no place in management of cerebral palsy
32 Cont. Polypropylene AFO Walker Gaitor tripod 33 Modality Of Intervention
DEFORMITY CORRECTIVE SURGERY ( single stage multilevel surgery)-
ROUTINE ORTHOPAEDIC SURGERY
ORTHOPEDIC SELECTIVE SPASTICITY CONTROL SURGERY (OSSCS)
SIMULTANEOUS CORRECTION OF LEVER ARM DYSFUNCTION
34 Cont.
Contracture and bony deformities are almost inevitable in a growing child with spastic diplegia
So intervention at proper time is being considered an important incident in life of child with cerebral palsy
to prevent joint de-compensation and over-lengthening of tendon.
35 CONT.
Good intervention modality at proper time in properly selected patient give good result provided post intervention therapeutic protocol is carefully managed
36 Anti-Spastic Treatment
Orally- Baclofen and Tizanidine (drowsiness and generalized muscle weakness)
Intrathecal Baclofen- Invasive very costly
Nerve block- Phenol and alcohol (sensory loss and disasthesia)
Botulinum Toxin- Effective in only early age spastic CP (2-5 year age). Effect last for only 4-6 month. Only minor side effect.
37 Botulinum toxin
Botulinum toxin is being given at most probable site of condensed neuromuscular junction in affected muscles
It causes focal dose dependent chemo-denervation of muscle.
38 Repeated Corrective Plaster Application
Aim--
Correct Static Muscular Contracture. Indication--
Mild to moderate contracture
Useful only in foot ankle and knee deformity
To enhance effect of Botulinum toxin.
Problem--
Incomplete correction and short lasting effect.
39 Neurosurgical Procedure
All type of neurosurgical procedure has its own permanent complication which is irreversible and some time it causes sever weakness in child and walker children can became non-walker.
40 Indication of Orthopedic surgical intervention
No further progress despite continuation of therapy programme/ presented first time for treatment in more than 5 year age group with--
Sever spasticity
Development of contracture
Development of torsional deformity
Dislocation of joint
41 CONT.
Now orthopedic deformity corrective surgery is being considered an important incident in total management of patient with cerebral palsy.
Successful surgery give all round acceleration of other function like learning speech behavior along with motor function recovery.
42 BASIC CONCEPT OF ROUTINE ORTHOPAEDIC SURGERY
Treat the problem what we are able to see and under stand
Treat the contracture by lengthening and sectioning affected tendon
Tendon transfer
Concept based more on anatomical finding lesser on selective muscle spasticity
Surgery usually postpone till age of 9-10 year (joint disintegration and malfunctioning ) and most of time being done in staged manner so child require multiple surgery in different phase of life
Eq. adductor tenotomy iliopsoas lengthening TA lengthening distal hamstring lengthening
43 Problem Arises From Routine Orthopedic Surgery
Some time ambulatory patient became nonambulatory d/t loss of antigravity action
Reverse deformity develop (genu recurvatum and weakness of tendoachilis windblown deformity)
May require repeated surgery
Not able to correct spasticity athetosis
torsional deformity and Lever arm dysfunction
Not based on concept of functional approach
Not helpful in severely affected patient
44
All this problem can be tackle by OSSCS in a better ways
( Functional Orthopedic Surgery ).
45 RECENT CONCEPT
Orthopedic selective spasticity control surgery (OSSCS)
Simultaneous correction of lever arm dysfunction
Single event multilevel surgery
46 BASIC DIFFERENCE BETWEEN ROUTINE ORTHOPAEDIC SURGERY AND OSSCS 47 OSSCS
Orthopedic Selective Spasticity Control Surgery (OSSCS) is an Orthopedic procedure designed to control or reduce all kinds of hypertonicity such as spasticity rigidity and athetosis in cerebral palsy.
48 BASIC CONCEPT OF OSSCS
The goal is not to remove muscle tone
Muscle tone is good however
Too much of a good thing is bad
Selective spasticity control may allow many patient with CP to use motor control in more effectively and functionally.
49 Cont.
Muscles Of The Vertebrate Body Divide Into Two Groups according to spanning number of joint Multi-articular Mono-articular muscles
Their functional nature differ according to their representation
These muscle are distributed side by side in body
50 CONT.
Hypertonicity of the multi-articular muscles
Hypertonic postures and deformities
Weakens the antigravity and voluntary activity of antagonistic mono-articular muscles.
51 CONT. A Antigravity mono-articular muscles support the body to be upright. B Multi-articular muscles helps in progression . C Hypertonicity of the multi-articular muscles causes abnormal hypertonic posture . D When the multi-articular muscles are lengthened or sectioned selectively hypertonicity are reduced and the mono-articular muscles are preserved and facilitated. 52 CONT.
OSSCS
Treat a wide range of problems in motor activities of daily living
A new path for functional improvement and active life styles in most of the patients with cerebral palsy.
53 Cont.
Single event multi level OSSCS avoid multiple surgery in different phase of life ( birthday syndrome)
54 ADVANTAGE OF NEW TECHNIQUE
In upper extremity help to improve the ability to turn over to crawl and to use crutch
Can be carried out in severely paralyzed patient to facilitate voluntary movement that are depressed by spasticity
Help in acquiring rolling crawling sitting kneeling standing and independent gait.
55 CONT.
Abnormal postural reflexes can be relieved
Reciprocal and alternate movements will be better facilitated.
Can correct spasticity in whole body muscle imbalance athetosis Dystonia contracture and bony deformities. / lever arm dysfunction
No loss of antigravity activity
No loss of sensation and stereognosis
No increase in deformity
56 CONT.
Orthopaedic selective spasticity control surgery is quite a reliable and promising procedure for patients parents physiotherapists and occupational therapists and even for school teachers.
57 INDICATIONS FOR SURGERY
All kinds of hypertonicity such as spasticity Rigo-spasticity and athetosis in the whole body can be relieved.
Totally involved cerebral palsy patients with abnormal postural reflexes
This treatment is also effective for reduction of severe postural abnormalities such as tonic labyrinthine reflex and asymmetric tonic neck reflex
58 LEVER ARM DYSFUNCTION
Disruption in the moment generation of a muscle joint complex due to an ineffective lever arm moment despite normal muscle force
Results in
Functional weakness and decrease power generation
59 CONT. POWER LEVER ARM CENTER 60 LOWER LIMB LEVER ARM IMBALANCE
Femoral Anteversion
Hip joint subluxation / dislocation
Tibial torsion
Hind foot Valgus / Eversion
61 Indication of multi level lever arm restoration
There is only few indication of multi level lever arm restoration in children with cerebral palsy.
first we should try OSSCS (soft tissue surgery) to make non ambulatory child into ambulatory capability.
Indication
Subluxation (gt 40) and dislocation of hip joint
Moderate to sever tibial torsion
Plano valgus feet not correctible by soft tissue surgery
child with ambulatory capacity want to improve their gait pattern
62 Cont.
Problem
Bony surgery lead to delayed start of rehabilitation
Child condition may not be fit for long surgery
Contraindication
Non ambulatory child with mild to moderate lever arm defect
Uncooperative and medically unfit child
63 SURGICAL TECHNIQUE IN LEVER ARM RESTORATION SURGERY
DEROTATIONAL
DISPLACEMENT OSTEOTOMY
64 SURGERY AT WHAT TIME
Lower limb 5-6 year
Upper limb6-8 year
65 Treatment Plan According To Age Group
Birth to 3 month- Positioning and sensory stimulation in ICU and at home
3 month- 1 .5 Year age Sensory integration and Neuro-developmental therapy
1.5 - 5 year Continuation of above Tt stretching strength training exercise gait training - botulinum toxin and plaster with AFO and Gaitor
gt5 year- 12 year Continuation of above Tt with single event multilevel orthopedic surgery (OSSCS) with rehabilitation and starting of schooling
gt 12 year Reassessment of child as whole and further surgical intervention if required and rehabilitation
66 Massage
With proper evaluation and planning most of our children can be given a fruitful life and even they can be intergraded in main stream of society.
Early intervention always give good functional outcome.
Team of dedicated therapist required for good result.
There should be proper coordination between therapist and pediatric orthopedic surgeon.
67 Cont.
Before going for surgical intervention you should be ensure about good therapist in your team otherwise result of any surgical intervention will be fruitless.
68 THANK YOU
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