MANAGEMENT OF CEREBRAL PALSY
Definition
Cerebral palsy is a group of disorder of the development of movement and posture, causing activity limitation, that are attributed to non progressive disturbance that occurred in the developing brain . The motor disorder of CP is often accompanied by disturbance of sensation , cognition communication perception and/or by a seizure disorder.
(American academy of Cerebral palsy and development medicine)
Diagnosis
1.Delayed motor milestones
2.Abnormal muscle tone
3.Hyperreflexia
4.Absence of regression or evidence of a more specific diagnosis
1.Intervention never should be delayed awaiting diagnosis or etiological assessment
2 families do the best when informed up front that cerebral palsy is the possibility
Spasticity Vs dystonia
Spasticity: Spasticity- velocity dependent increase in tonic stretch reflex with exaggerated tendon jerks.
Other motor phenomena of upper motor neuron: phasic stretch reflex (clonus and hyperreflexia),
flexor and extensor spasms, co-contraction, dystonia
Dystonia: involuntary muscles contraction that cause twisting ,repetitive movements and abnormal postures
SPASTICITY
Present in most patient with Cerebral palsy (65 % )
When reduced patients may :
– perform integrated muscle movement
– develop muscle strength
– function at a higher level
Measurement of spasticity
Modified Ashworth scale
GMFCS
1.Ambulatory in all settings
2.Walks without aides but has limitations in community settings
3.Walks with aides
4.Mobility requires wheelchair or adult assist
5.Dependant for mobility
GMFCS
GMFCS
Motor impairment
1.primary: muscle tone, balance, strength and selectivity problems that are directly related to damage in the CNS
2.Secondary:muscle contractures and deformity that develop over time in response to primary problem and musculoskeletal growth
3.tertiary:adaptive mechanism and coping responses that the child develops to adapt to the primary and secondary impairment.
Goals of Spasticity: Management
Decrease spasticity
Improve functional ability and independence
Decrease pain associated with spasticity
Prevent or decrease incidence of contractures
Improve ambulation
Facilitate hygiene
Ease rehabilitation procedures
Save caregivers’ time
Near full participitation in society
Treatment of spasticity and motor tone
Physical therapy
Orthotics
Assistive devices
Control of spasticity
Orthopedic surgery
Timing of rehabilitative measures
PHYSIOTHERAPY
Conventional PT :
goal: bring child to erect posture, give independent mobility and prevent deformity
works peripheral on muscles, tendons, and ligaments
– Active exercises,
– Passive ROM exercises
– Passive stretching
– Bracing
CNS modifications :
applying external stimuli / effectiveness not proven
e.g. – Neuro-developmental therapy
– Sensory integration therapy
– Patterning
– Conductive education
– Pressure point stimulation
NDT(NeuroDevelopment therapy)
According to the Bobaths – the motor problems of cerebral palsy arise fundamentally from central nervous system (CNS) dysfunction which interferes with the development of normal postural control against gravity and impedes normal motor development.
Their goal was the establishment of normal motor development and function and/or the prevention of contractures and deformities.
Effects of physiotherapy
Maintenance Physical Therapy
Goals :
– balance and gait training
– maximize voluntary muscle usage
– prevent joint contractures
-essential after orthopedic procedures
and pubertal spurts.
ORTHOTICS
to hold extremity in stable and functional position.
1.Ankle foot orthosis :provide ankle stability, put foot I more functional position for gait & slow down contracture at ankles
2.Spinal orthosis: slow progression of scoliosis
PHARMACOTHERAPY
Baclofen
Diazepam
Dantrolene Sodium
Tizanidine
Other
MECHANISM OF ACTION
Drug
Baclofen:
Diazepam:
Dantrolene Sodium:
Tizanidine:
Site of action
GABAb receptors in spinal cord
Central nervous system
Skeletal muscles beyond the myoneural junction
Central acting (spinal and supraspinal) at alpha2 – adrenergic receptor sites
BACLOFEN
GABA agonist – inhibits release of excitatory neurotransmitter at level of spinal cord
Oral : mixed reports/ side effects/ not selective
Continuous intrathecal – implantable pump
Good results in releasing spasticity, and improving function
Complications of pump and catheter
Needs specialized centers
Botulinum-A toxin
Acts at myo-neural junctions
Inhibits exo cytosis of Acetylcholine
Inject selected muscles at multiple sites
Spasticity reduction may last up to 6 months
Reversible , painless , minimal side effects
Most patients still require lengthening for permanent correction
Role : – Facilitates physiotherapy and mobilization
– Delays surgical management
– Trial to determine effects of specific
proposed surgical treatment
SELECTIVE DORSAL RIHZOTOMY[SRD]
Cut 30 – 50 % of abnormal dorsal rootlets L2 – S1
Followed by intensive physiotherapy
Results encouraging
May cause hyperlordosis / hip subluxation
Best for : spastic diplegia, 4-8 yrs, no previous surgery, no contractures, no extra pyramidal signs
? Not enough alone
Orthopedic procedures obtain similar results
Orthopedic procedures
Goal:
ambulatory: straight spine, stable hip and horizontal pelvis and extended knee
non ambulatory: facilitate sitting ,prevent pain and improve hygiene
Depending on CNS maturation ,ambulation potential and rate of deformity development
SOFT TISSUE PROCEDURES
Reduce muscle tone by lengthing the spastic muscle and reducing stretch reflex
Tenotomy
Tendon lengthening
Myotomy
Tendon transfers
Orthopedic procedures
1)Contracture management: soft tissue procedures
2)Joint dislocations: osteotomies , arthrodeses
3)Bony deformities
Timings:
Soft tisses procedures-4-7 yrs
Hand surgeries- 6-12yrs
Bony procedures-aft 8 yrs
Hip surveillance
Non ambulatory and who can walk fewer than 10 steps hip xray 30 month
Repeat every 6-12 month until 7 yrs
Spinal radiographs 5 and 10 yrs
(dev med child neruo 2004)
Oromotor Dysfunction
Especially common in persons with Extrapyramidal Cerebral palsy and Spastic quadriplegia
Language delay/Speech delays
Drooling
Dysphagia
Aspiration
Gastrointestinal Dysmotility
Delayed gastric emptying
Gastroesophageal reflux
Pain
Chronic aspiration
Constipation
These disorders are interrelated and compound one another.
Associated problems
Mental Retardation
Communication Disorders
Neurobehavioral
Seizures
Vision Disorders
Hearing loss
Somatosensation (skin sensation, body awareness)
pain
Temperature instability
Nutrition
Drooling
Dentition problems
Gastroesophageal reflux
Dysphagia
Autonomic dysfunctio