Cerebral palsy - PG lecture for Orthopaedic Assessment and Management Guidelines by Dr Shobha S. Arora

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Cerebral palsy - PG lecture for Orthopaedic Assessment and Management Guidelines by Dr Shobha S. Arora

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Cerebral palsy - PG lecture for Orthopaedic Assessment and Management Guidelines by Dr Shobha S. Arora

  1. 1. CEREBRAL PALSY ORTHOPAEDIC ASSESSMENT AND MANAGEMENT GUIDELINES Dr shobha S. Arora Prof. Orthopedics, UCMS and GTB Hospital, Delhi )
  2. 2. statistics <ul><li>Worldwide-2 to 3 cases /1000 live births </li></ul><ul><li>More than 15 million people suffer from CP </li></ul><ul><li>Asia 2000- </li></ul><ul><li>93,00,000 CP patients </li></ul>
  3. 3. Definition <ul><li>Sequel of anoxic damage to the developing brain in the perinatal period </li></ul><ul><li>No active lesion at the time of presentation </li></ul>
  4. 4. Classification of CP <ul><li>A. Areas involved- </li></ul><ul><ul><ul><li>Hemiplegia </li></ul></ul></ul><ul><ul><ul><li>Diplegia </li></ul></ul></ul><ul><ul><ul><li>Triplegia </li></ul></ul></ul><ul><ul><ul><li>Double hemiplegia/tetraplegia </li></ul></ul></ul><ul><ul><ul><li>Crossed hemoplegia </li></ul></ul></ul><ul><ul><ul><li>Monoplegia </li></ul></ul></ul>
  5. 5. Classification by movement disorder <ul><li>Spastic </li></ul><ul><li>Athetoid </li></ul><ul><li>ataxic </li></ul>
  6. 6. Etiological causes <ul><li>1.multiple births (e.g. twins, triplets) </li></ul><ul><li>2. a damaged placenta which may interfere with fetal growth   </li></ul><ul><li>3.sexually transmitted infectious diseases, e.g. AIDS, herpes, syphilis, gonorrhea  </li></ul><ul><li>4. poor nutrition  </li></ul><ul><li>5. exposure to toxic substances, including nicotine, alcohol and drugs   </li></ul><ul><li>6.Rh or A-B-O blood type incompatibility between mother and infant   </li></ul><ul><li>7.chromosome abnormalities   </li></ul>
  7. 7. Causes contd. <ul><li>8. biochemical genetic disorders   </li></ul><ul><li>9. congenital malformations of brain  </li></ul><ul><li>microcephaly/cranial synostosis </li></ul><ul><li>10. Prolonged labour with </li></ul><ul><li>perinatal anoxia </li></ul><ul><li>small pelvic structure </li></ul><ul><li>premature delivery </li></ul><ul><li>caesarian or breech delivery </li></ul><ul><li>11. German measles during pregnacy </li></ul><ul><li>12. effects of anesthetics, analgesics </li></ul>
  8. 8. ‘ Acquired’ or Post natal C P <ul><li>Sequel of Anoxic / Traumatic/ chemical/ infective damage to a growing brain. </li></ul><ul><li>Post- head injury </li></ul><ul><li>Post- meningitis/ Encephalitis </li></ul><ul><li>Post- drowning </li></ul><ul><li>Following critical illness </li></ul>
  9. 9. Mobility- the Orthopedic concern <ul><li>First cause of concern to the parents (mostly detected by the Pediatrician) </li></ul><ul><li>Delayed milestones </li></ul><ul><li>Less than average activity </li></ul><ul><li>less than normal IQ </li></ul>
  10. 10. Which one is a C P child ? <ul><li>Difficult to say in a child less than six months old , unless gross signs are present. </li></ul><ul><li>Also difficult to diagnose in a chronically sick child </li></ul><ul><li>Too young babies should not be diagnosed as C. P. </li></ul>
  11. 11. History- Almost pointing to the diagnosis <ul><li>Premature babies </li></ul><ul><li>H/o cyanosis immediately after birth </li></ul><ul><li>Prolonged hospitalization in neonatal period </li></ul><ul><li>Neonatal jaundice </li></ul><ul><li>Maternal illness during pregnancy </li></ul>
  12. 12. Acquired C P <ul><li>H/o head injury of significant severity </li></ul><ul><li>Saved from drowning </li></ul><ul><li>H/o meningitis or Encephalitis </li></ul><ul><li>Any other prolonged, severe illness- Diarrhea-dehydration, Hyperpyrexia, jaundice etc </li></ul>
  13. 13. H/o motor milestones <ul><li>Does not match the chronological age- not diagnostic of CP </li></ul><ul><li>Normal milestones with asymmetrical motor development- can be CP </li></ul><ul><li>Undetected local pathology - the cause of delayed motor milestone? </li></ul>
  14. 14. Asymmetric motor activity
  15. 15. I Q - the better pointer ? <ul><li>Basic Pointers of I Q of a small child- </li></ul><ul><ul><li>Recognizes mother and family members </li></ul></ul><ul><ul><li>Asks for favorite food, indicates hunger </li></ul></ul><ul><ul><li>Tells about toilet before or after voiding </li></ul></ul>
  16. 16. Why know the IQ ? <ul><li>A child with not even the basic IQ is not a candidate for enthusiastic Orthopedic treatment </li></ul><ul><li>Orthopedic management remains restricted to comfortable positioning of the child, prevention of injuries and nursing care </li></ul>
  17. 17. Pitfalls in I Q assessment <ul><li>Hemiplegics always have a normal I Q. </li></ul><ul><li>Dysphasia can mask the IQ, the mother is the best assessor of the child’s IQ </li></ul><ul><li>Diplegics need individual assessment </li></ul>
  18. 18. Will a CP child ever walk independently? <ul><li>YES, if </li></ul><ul><li>the child has attained standing with support by 4 years of age, </li></ul><ul><li>walking is established by 8 years -final adult gait pattern. </li></ul><ul><li>NO, if this is not achieved. </li></ul>
  19. 19. What is the basic effect of CP on locomotors mechanism? <ul><li>Damages the automatic myelination process in a developing brain </li></ul><ul><li>Damages the control mechanism of the muscle tone from the motor cortex, including the balance center and proprioception </li></ul>
  20. 20. The Damaged HUMAN components of locomotion <ul><li>Phylogenetically latest acquired modalities are lost first. </li></ul><ul><li>The Human child is converted to the baby of a lower primate and stays so. </li></ul><ul><li>Treatment aims at bringing him closer to the human stance as much as possible. </li></ul>
  21. 21. What is lost from the Human? <ul><li>A. The IQ </li></ul><ul><li>Ranges from a slightly dull child to drooling child </li></ul><ul><li>loss of intelligent human thought process to loosing the basic survival instincts- food/toilet/pain response </li></ul>
  22. 22. B. The locomotor apparatus <ul><li>Normal myelination </li></ul><ul><li>Development of the extensor muscles of the weight bearing areas to attain the ultimate vertical posture and bipedal human locomotion. </li></ul><ul><li>Lack of myelination- Leaves an individual only with flexors and adductors i.e. the fetal muscles with spasticity </li></ul>
  23. 23. Spasticity- the surgeon’s enemy <ul><li>Exaggeration of flexor muscle tone </li></ul><ul><li>Adding insult to injury - abnormal movements, sensory deficit. </li></ul><ul><li>Does not respond to the surgeon’s knife favorably. </li></ul>
  24. 24. What is spasticity? <ul><li>AN ABNORMAL, </li></ul><ul><li>velocity-dependent (i.e., how fast the joint is moved through its range) </li></ul><ul><li>increase in muscle tone </li></ul><ul><li>Due to interruption of the neural circuitry regulating the muscles. </li></ul>
  25. 25. Spasticity- <ul><li>characterized by </li></ul><ul><li>increase in the tonic stretch reflexes (muscle tone) </li></ul><ul><li>exaggerated tendon jerks. </li></ul>
  26. 26. Clinical examination <ul><li>Try talking to the child as per his age, see the response. </li></ul><ul><li>Establish the IQ for orthopaedic purposes- Will the child understand your commands of mobilization? </li></ul><ul><li>Leave him alone and see his natural ambulating </li></ul>
  27. 27. The Ambulation <ul><li>1. Community ambulater without support. </li></ul><ul><li>2. Community ambulater with support. </li></ul><ul><li>3. Household ambulator with support. </li></ul><ul><li>4. Crawler. </li></ul><ul><li>5. Immobile. </li></ul>
  28. 28. Assessment of useful ambulation <ul><li>Vertical stance </li></ul><ul><li>Independent walking with gait abnormalities </li></ul><ul><li>Walks holding hands of parents </li></ul><ul><li>Stands with support </li></ul>
  29. 29. Not so useful ambulation <ul><li>No vertical stance even with support </li></ul><ul><li>crawler </li></ul><ul><li>dragger </li></ul><ul><li>Immobile </li></ul>
  30. 30. The target <ul><li>To help a crawler become a walker </li></ul><ul><li>To help a walker walk better </li></ul><ul><li>To continue walking for the rest of the life </li></ul>
  31. 31. Assess clinically - I <ul><li>No. of extremities involved-lesser the better </li></ul><ul><li>Pattern of involvement </li></ul><ul><li>Severity of involvement </li></ul><ul><li>Hemiplegia </li></ul><ul><li>Diplegia </li></ul><ul><li>Crossed Hemiplegia </li></ul><ul><li>Tetraplegia </li></ul><ul><li>Monoplegia </li></ul>
  32. 32. The better category? <ul><li>In the descending order </li></ul><ul><li>Hemiplegics </li></ul><ul><li>Monoplegics (lower limb) </li></ul><ul><li>Diplegics </li></ul><ul><li>Crossed Hemiplegics </li></ul><ul><li>Tetraplegics </li></ul>
  33. 33. Assess clinically - II <ul><li>The spinal balance- </li></ul><ul><ul><li>Independent sitting for prolonged periods </li></ul></ul><ul><ul><li>mandatory for standing </li></ul></ul><ul><ul><li>Anti-gravity, voluntary power in bilateral Gluteus maximus </li></ul></ul><ul><ul><li>Absence of fixed deformities in the lower limbs </li></ul></ul>
  34. 34. Other modalities <ul><li>Good hand control </li></ul><ul><li>No visual or other handicap </li></ul><ul><li>No abnormal movements (Chorea or Athetoid movements) </li></ul><ul><li>Intact sensations in the feet </li></ul>
  35. 35. The joint status <ul><li>Look for </li></ul><ul><li>Paralytic hip dislocations (x-ray analysis) </li></ul><ul><li>Status of contractures </li></ul><ul><li>Dominant spastic muscles </li></ul><ul><li>Week antigravity muscles </li></ul><ul><li>Upper limb function </li></ul><ul><li>Co-ordination </li></ul>
  36. 36. Hip in CP Coxa valga Paralytic hip dislocation
  37. 37. The Family <ul><li>Should be motivated </li></ul><ul><li>Not disgusted </li></ul><ul><li>More than one adult interested in the child </li></ul><ul><li>Financial support available for orthotic services </li></ul><ul><li>Compliant and persistent </li></ul>
  38. 38. The Muscles Chart of a spastic child <ul><li>Note the weak extensors from proximal to distal </li></ul><ul><li>Note the spastic flexors and other group of muscles </li></ul><ul><li>(weakness and spasticity can co-exist) </li></ul>
  39. 39. Difficulties of spastic muscle testing <ul><li>Not the same as a polio child </li></ul><ul><li>But some voluntary power is detectable. </li></ul><ul><li>The useful grade of power is antigravity. </li></ul><ul><li>If present, it will show its presence. </li></ul>
  40. 40. Categories of muscles in CP <ul><li>Weak </li></ul><ul><li>spastic </li></ul><ul><li>Spastic and weak </li></ul><ul><li>( Both not useful for voluntary action) </li></ul><ul><li>Contribute to contractures </li></ul>
  41. 41. Deformities <ul><li>The older the child and the severe is the involvement, the more are the deformities. </li></ul><ul><li>‘ Fetal’ position dominates- </li></ul><ul><ul><li>Flexion </li></ul></ul><ul><ul><li>Adduction </li></ul></ul><ul><ul><li>Internal rotation </li></ul></ul>
  42. 42. Modifying factors <ul><li>Posture and Weight bearing alters the deformities </li></ul><ul><li>Surgical intervention also alters the deformities (reverse deformities) </li></ul>
  43. 43. Other negative factors <ul><li>Prolonged antiepileptic therapy leading to Osteomalacia and its consequences </li></ul><ul><li>pathological fractures and dislocations </li></ul><ul><li>General health- respiratory and diarrheal diseases </li></ul>
  44. 44. Planning the treatment <ul><li>Target - </li></ul><ul><li>Independent ambulation with near normal gait </li></ul><ul><li>Hand function sufficient for self care </li></ul><ul><li>Useful IQ </li></ul>
  45. 45. Assessment of a CP child <ul><li>Gait analysis- Gait labs </li></ul><ul><li>Radiological assessment- hip dislocation subluxation </li></ul><ul><li>coverage </li></ul><ul><li>coxa valga </li></ul><ul><li>EMG of specific muscles </li></ul><ul><li>Other handicap- visual, auditory </li></ul><ul><li>X ray foot/elbow/ spine </li></ul>
  46. 46. Gait lab analysis
  47. 47. Surface electrode EMG
  48. 48. Where to begin? <ul><li>Golden rules- </li></ul><ul><li>Refrain from using the knife straight away </li></ul><ul><li>Stretch the contracted muscles by serial plaster casts </li></ul><ul><li>Support the weak muscles by orthoses </li></ul><ul><li>Simultaneous ambulation should be the aim </li></ul>
  49. 49. Orthoses in CP <ul><li>Splints </li></ul><ul><li>Gaiters </li></ul><ul><li>CP strollers </li></ul><ul><li>CP chairs </li></ul><ul><li>Elbow crutches </li></ul><ul><li>Hand splints </li></ul><ul><li>Spinal orthoses </li></ul><ul><li>Neck supports </li></ul>
  50. 50. Orthoses in CP
  51. 51. Postures and gaits <ul><li>Crouch- </li></ul><ul><li>-flexion adduction at hip </li></ul><ul><li>- flexion at knee </li></ul><ul><li>-variable foot deformities </li></ul><ul><li>Hemiplegic- </li></ul><ul><ul><ul><li>Internal rotation at shoulder </li></ul></ul></ul><ul><ul><ul><li>Flexion-pronation at elbow </li></ul></ul></ul><ul><ul><ul><li>Wrist variable </li></ul></ul></ul><ul><ul><ul><li>Adduction-internal rotation at hip </li></ul></ul></ul><ul><ul><ul><li>Flexion at knee </li></ul></ul></ul><ul><ul><ul><li>Foot variable </li></ul></ul></ul>
  52. 52. Crouching gait and orthosis
  53. 53. Orthotic supports contd.
  54. 54. Joints in CP <ul><li>Stability- most difficult to achieve by surgery </li></ul><ul><li>(Therefore need splintage) </li></ul><ul><li>Mobility- also compromised </li></ul><ul><li>Painless- initially, may become painful later due to deformities </li></ul>
  55. 55. Specific deformities <ul><li>Hip- flexion-adduction </li></ul><ul><li>Knee- flexion/recurvatum </li></ul><ul><li>Foot- equinovarus/calcaneovalgus </li></ul><ul><li>Elbow - flexion-pronation </li></ul><ul><li>Hand- wrist flexion/thumb in palm </li></ul><ul><li>Spine- scoiliosis </li></ul>
  56. 56. Conservative t/t of deformities <ul><li>POP cast under anaesthesia, </li></ul><ul><li>change every 15 days, till a significant correction is achieved, or a static level is reached </li></ul><ul><li>Dynamic Splintage after correction </li></ul>
  57. 57. Therapeutic modalities to control spasticity <ul><li>Local nerve blocks- </li></ul><ul><ul><ul><li>Phenol- severe local site reaction </li></ul></ul></ul><ul><ul><ul><li>Botox A- careful injection at local sites </li></ul></ul></ul><ul><ul><ul><li>Intrathecal baclofen pumps </li></ul></ul></ul>
  58. 58. Surgical modalities to control spasticity <ul><li>Cortical level- </li></ul><ul><ul><li>selective cryosurgery techniques </li></ul></ul><ul><li>Spinal level- </li></ul><ul><ul><li>Selective posterior rhizotomy </li></ul></ul><ul><li>Peripheral nerve level- </li></ul><ul><ul><li>Neurectomies- obturator, soleal </li></ul></ul>
  59. 59. Selective posterior rhizotomy
  60. 60. Management of specific deformities <ul><li>Interlinked and compensatory deformities- </li></ul><ul><ul><li>Best assessed by gait lab </li></ul></ul><ul><li>Simultaneously address </li></ul><ul><li>the posture rather than a foot, knee or hip. </li></ul><ul><li>spinal balance </li></ul><ul><li>upper limb function </li></ul>
  61. 61. Procedures used commonly <ul><li>Open reduction of dislocated joints </li></ul><ul><li>Contracture release </li></ul><ul><li>Tendon lengthenings </li></ul><ul><li>Osteotomies </li></ul><ul><li>Tendon transfers </li></ul><ul><li>Spinal fusion/instrumentation </li></ul>
  62. 62. Muscle level surgery <ul><li>Aims at </li></ul><ul><li>Weakening the spastic muscle by changing the muscle tendon length proportion i.e. tendon lengthening, V-Y plasties </li></ul><ul><li>Altering the leverage by advancement of the insertion </li></ul>
  63. 63. Tendon transfers? <ul><li>Limited use in CP </li></ul><ul><li>Power difficult to assess </li></ul><ul><li>Reverse deformities commoner than polio after surgery </li></ul><ul><li>Difficult to re-educate the transferred tendon </li></ul>
  64. 64. Physio and occupational therapy <ul><li>Pre op stretching of contracted muscles </li></ul><ul><li>Hand function training </li></ul><ul><li>Gait training </li></ul><ul><li>Orthosis management </li></ul><ul><li>Posture management </li></ul><ul><li>Counseling of the family </li></ul>
  65. 65. Post op. rehab planning <ul><li>Part of the total rehabilitation program only. </li></ul><ul><li>Do not call it the end of the treatment. </li></ul><ul><li>Continue prolonged gait training. </li></ul><ul><li>continue exercises for the antigravity muscles </li></ul><ul><li>monitor periodically for ever </li></ul>
  66. 66. Splintage and walking supports in CP <ul><li>PoP slabs </li></ul><ul><li>Fiber glass plaster slabs </li></ul><ul><li>Molded PVC Splints </li></ul><ul><li>CP Stroller- local and commercial </li></ul><ul><li>Dynamic spring loaded splints </li></ul><ul><li>Spinal supports </li></ul>
  67. 67. Palliative surgery <ul><li>For positioning of a bed ridden, immobile patient </li></ul><ul><li>To prevent bed sore formation, improve the hygiene of a local area like hand and perineum </li></ul><ul><li>Deformity correction for fitting of orthoses </li></ul>
  68. 68. Limitations that must be understood <ul><li>Never a normal gait </li></ul><ul><li>never a normal hand function </li></ul><ul><li>supports are almost always needed </li></ul><ul><li>may be for a life time </li></ul><ul><li>yet it is worth all the effort </li></ul>
  69. 69. Summary <ul><li>No cure for CP </li></ul><ul><li>Limited improvement in mobility possible </li></ul><ul><li>IQ the biggest factor in planning the treatment </li></ul><ul><li>Plan the total rehabilitation along with the expected mobility outcome. </li></ul><ul><li>Surgery is only a small part of the plan. </li></ul><ul><li>Follow up needs to be regular including general health. </li></ul><ul><li>Life time splintage needed. </li></ul>
  70. 70. Future needs <ul><li>Gait lab facility to exactly locate the misfiring muscles. </li></ul><ul><li>Specialized surgical unit for selective posterior rhizotomy. </li></ul><ul><li>Sophisticated electronic mobility aids like RGO, computerized wheelchairs. </li></ul>
  71. 71. YET…. <ul><li>It is worth treating a CP child. </li></ul><ul><li>After all, vets also help somebody’s pet because somebody loves them! </li></ul><ul><li>YOU are treating a human being who is always superior to a pet. </li></ul>

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