CEREBRAL PALSY

Prof. V.P.Sharma M.S.,(Ortho), DNB(PMR), .FACS, FICS, FIMSA, MAMS, PG (Spine-Aus.)

Professor

Deptt. of Physical Medicine & Rehabilitation

K.G. Medical University, Lucknow

16-10-2014

CEREBRAL PALSY

• C.P. refers to a disorder of motor function

resulting from a non progressive brain lesion

occurring before the brain is fully mature.

C.P. refers exclusive to the motor dysfunction

May also have – Cognitive dysfunction or

seizures

• Lesion is static, symptoms often change with time.

• Eg. Hypotonia to hypertonia

• increasing dystonia with age

• Bony deformities

• Contractures

Classification

1. Limbs involved - Monoplegia

Diplegia

Triplegia

Quadriplegia

Hemiplegia

2 Tone - Hypotomia

Spasticity

3 Associated Movement Disorders -

Dystonia

Chorea

Athetosis

Ataxia

Assessment of spasticity

• Evaluation of muscle tone • R.O.M.• Associated movements disorders• Psycho Social Assessment

Physical and occupational therapy

1. Spastic

– Passive ROM

– Active ROM

– Spinal mobility

– Use of varied and differential movement pattern incorporating varied speed and directions

– Equipment to aid with weight bearing movement and position transitions.

– Promotive muscle Elongation as well as joint mobility & stability

Athetoid

• Postural tone and balance • Promoting midline & Symmetrical muscle control• Small graded movements

Hypotonic

• Antigravity positioning of head• Trunk control• Promoting automatic reactions• Stabilization of joins

Treatment According to age

Infancy and toddler• Optimal movement patterns and postures during daily

care activities such as feeding, playing , carrying, toileting and movement.

• Adaptive equipments• Special strollers• Bath chairs• Feeding equipments• Fist, hand or limbs splints

Pre-school-

• Promote skill acquisition for independent function.

• Therapy promotes strength, endurance and

movement patterns.

Mobility issues wheel chairs crutches, walkers, strollers, car seats school chairs, splints and orthotics

Schooling

• Architecture adaptations

• Home modifications• Installing wheel chair

lifts• Classroom

accommodations

Ambulation

Sports

Formal Evaluation tools

• Modified ashworth scale (MAS)• Measure resistance to passive movements in

upper/lower limbs• Goniometer measurements PROM / AROM• Gross motor functional measure• Assess current level of function and provides goal for

treatment.• Paediatric evaluations of disability inventory.• Functional skills in the areas of mobility• Self care• Social functions• Strength measurements by dynamometers

Facilitation of movement patterns

• Neuro developmental training NDT/ Bobath• Inhitit abnormal muscle tone and primitive reflaxes• Facilitate normal movement patterns via postioning and

handling techniques that promote sensation of normal movement

• Emphasis is on acquiring functional skills• Weight bearing • Weight shifting• Normalizing tone

Electrical stimulation

• FES• Other Therapies• Strengthening / Stretching• Serial casting• Functional Activities• Dynamic approach repetition of activities by the patient • Adaptive equipments• Sealing system• Walker• Canes• Splinting low temperature thermoplastics

Oral Pharmacotherapy

• AIM Spasticity• Associated movement eg. Dystomia• CNS acting • Benzodia zepines Diazepam• Clonazepam• Lorazepam• Tizanidine• Baclofen• Peripheral - Dantrolene

Benzodiazepines

• Acts via inhibitory neuro transmitter GABA in spinal cord

• Effect - relief in painful muscular spasm

- Improvement in sleep

- Long term muscle tone

- Anticonvulsiant property• Side effect - Habituation

- Sedation

- Secrctions

- Rebound seizures with abrupt

withdranwal

Baclofen

Action on GABA receptor in spinal cord

• Effect Toletrated long term • Muscle tone / Active Passive• Side effect - Sedation

- Truncal hypotomia

- Change in bladder habits

Clonidine quanfacine Tizanidine

• Effect - Aplha 2 adrenergic effects

- Anti hypertensive

- Treat movement disorder & eg tics

Dantrolene

• works directly on the sarcoplasmic reticulum of

muscle and is effective in decreasing muscle tone

• Side effect - Muscle weakness

- GI upset, fatigue

- Hepato Toxicity

Intrathecal Baclofen

• In patients with

spasticity of cerebral

origin

• Continuous infusion of

baclofen in intrathecal

space

Surgery

• Maintain mobility & Stability of joints

– Surgery at hip when subluxation or abduction less

them 300

Bracing

• Improves function

– prevent worsening of

contractures

– Prevents recurrence of

deformities after surgical

correction

Future Direction

• Treatment for CP with focus on prevention of CP as

well as effective and permanent at the level of brain.

Treatment occurs most effectively with a

multidisciplinary approach to assessment and

treatment.

1. The commonest etiologies for cerebral palsy include all

of the following except,

I. Prematurity

II. Cerebral hypoxemia

III. Vitamin C deficiency

IV. Hyperbilirubinemia

2. Which of the following is not a Pre-natal cause of C.P.,

I. Prolonged and difficult labor

II. Premature rupture of membranes

III. CNS infection (encephalitis, meningitis)

IV. Multiple pregnancies

3. Which of the following scale is used for assessment of

spasticity-

I. GCS

II. MAS

III. AS

IV. AIS

4. Which of the following is not a centrally acting anti

spastic medication,

I. Diazepam

II. Tizanidine

III. Dantrolene

IV. Baclofen

5. Among the following which is not used for spasticity

management in C.P.,

I. Stretching Exercises.

II. Bracing.

III. Baclofen

IV. Anti spasmodic drugs.