LATEST ADVANCEMENT IN MANAGEMENT OF CEREBRAL PALSY

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LATEST ADVANCEMENT IN MANAGEMENT OF CEREBRAL PALSY

• DR JITENDRA KUMAR JAIN
• MS ORTHO (PGI CHANDIGARH), DNB, MNAMS
• CONSULTANT ORTHOPAEDIC SURGEON
• TRISHLA ORTHOPAEDIC SPINAL CLINIC
• SECRETARY,SAMVEDNA TRUST, ALLAHABAD, UP
• VISITING CONSULTANT ,ICD,NEW DELHI
• Email- jjain99_at_rediffmail.com
• www.samvednatrust.org

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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.

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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.

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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

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Topographical Classification

• Hemiplegia
• 2) Monoplegia
• 3) Diplegia
• 4) Triplegia
• 5) Quadriparesis

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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.

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Cont.

• Their disabilities stayed relatively the same but
  presentation can change with age. 

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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

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Associated Disabilities

• Speech impairment (82) 11.
  Feeding problems
• Mental retardation (19) 12.
  Constipation
• Visual defects (34) 13.
  Dental defects
• Hearing defects (15 ) 14. Chest
  congestion
• Convulsive disorders (25) 15. Sleeping
  disorder
• Sensory defects 16. Poor immunity
• Growth retardation 17.
  Obesity
• Behavior problems 18.
  Malnourishment
• Spinal defects 19.
  Atrophy
• Perceptual problems 20.
  Micro-cephaly Hydrocephaly

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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.

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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

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Type Of Gait
Crouch Gait
Jump Gait
Stiff knee Gait
Scissoring Gait
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Normal Developmental Stages Of The Child
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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

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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

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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

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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

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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.

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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.

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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.

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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

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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

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Differential Diagnosis

• Familial spastic Para paresis
• Autism
• Neurodegenerative disorder- primary and metabolic
• Intracranial lesion
• Metabolic disorder

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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.

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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.

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Criteria For Treatment Modality

• AGE
• DEVELOPMENTAL MILE STONES
• ASSOCIATED SENSORY AND PROPIOCEPTIVE PROBLEMS
• DEGREE OF SPASTICITY
• DEGREE OF CONTRACTURE AND DEFORMITY
• IQ
• AFFORDABILITY

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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.

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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

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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

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Main Basic Foundation Of Treatment Plan In
Cerebral Palsy

• Therapy
• therapy
• therapy

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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

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Cont.
Polypropylene AFO
Walker
Gaitor tripod
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Modality Of Intervention

• ANTISPASTIC TREATMENT
• ORAL DRUGS, INTRATHECAL BACLOFEN,
  NERVE BLOCK, BOTULINUM TOXIN
• REPEATED CORRECTIVE PLASTER APPLICATION
• NEUROSURGICAL PROCEDURE -
• SELECTIVE RHIZOTOMY
• SELECTIVE NEURECTOMY
• DEFORMITY CORRECTIVE SURGERY ( single stage
  multilevel surgery)-
• ROUTINE ORTHOPAEDIC SURGERY
• ORTHOPEDIC SELECTIVE SPASTICITY
  CONTROL SURGERY (OSSCS)
• SIMULTANEOUS CORRECTION OF LEVER ARM
  DYSFUNCTION

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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.

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CONT.

• Good intervention modality at proper time in
  properly selected patient give good result
  provided post intervention therapeutic protocol
  is carefully managed

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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.

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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.

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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.

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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.

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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

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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.

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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

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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

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• All this problem can be tackle by OSSCS in a
  better ways
• ( Functional Orthopedic Surgery ).

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RECENT CONCEPT

• Orthopedic selective spasticity control surgery
  (OSSCS)
• Simultaneous correction of lever arm dysfunction
• Single event multilevel surgery

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BASIC DIFFERENCE BETWEEN ROUTINE ORTHOPAEDIC
SURGERY AND OSSCS
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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.

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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.

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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

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CONT.

• Hypertonicity of the multi-articular muscles
• Hypertonic postures and deformities
• Weakens the antigravity and voluntary
  activity of antagonistic mono-articular muscles.

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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.
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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.

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Cont.

• Single event multi level OSSCS avoid multiple
  surgery in different phase of life ( birthday
  syndrome)

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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.

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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

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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.

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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

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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

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CONT.
POWER
LEVER ARM
CENTER
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LOWER LIMB LEVER ARM IMBALANCE

• Femoral Anteversion
• Hip joint subluxation / dislocation
• Tibial torsion
• Hind foot Valgus / Eversion

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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

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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

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SURGICAL TECHNIQUE IN LEVER ARM RESTORATION
SURGERY

• DEROTATIONAL
• DISPLACEMENT OSTEOTOMY

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SURGERY AT WHAT TIME ?

• Lower limb 5-6 year
• Upper limb6-8 year

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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

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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.

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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.

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THANK YOU