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Bee stings for treatment of cerebral palsy

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  • 1. Bee venom by stings for treatment of cerebral palsy Prof. Mohamed Nagib El-Bassiony; Prof. of Economic Entomology and Apiculture. Faculty of Agriculture& Environmental sciences,ElArish branch, Suez Canal University Prof. Nabil Khalil; Professor and head of Neurosurgical department, Faculty of Medicine, Suez Canal University Summary Background: Bee venom sting therapy is the part of apitherapy which utilizes bee venom in the treatment of health conditions. It has been used since ancient times and in this modern age as an alternative therapy to treat multiple sclerosis, Lyme disease, and chronic fatigue syndrome. Objective: This study aims to evaluate the benefit of using Bee venom sting in treatment of cerebral palsy Material and Method: Between 2004 and 2007, 6 children with cerebral palsy (4 males and 2 females) continued their medical treatment, rehabilitation, assisted devices, and speech therapy, beside weekly Bee venom sting treatment according to the center program. The child was evaluated by clinical sheet proposed by department of neurosurgery, Faculty of medicine, Suez Canal University (Khalil cerebral palsy scale, table 1). Khalil scale was 15 points where the child had evaluated with the maximum score of 15. This scale evaluated the clinical status and improvement every six months for the next three years Result: All cerebral palsy children during follow up had variable degree of improvement that was recorded using Khalil scale during research study period. Notably, those children with spastic or mild cerebral palsy showed much more improvement than those with ataxia and Dyskinesia (score of 8-13 comparative to 6-9 respectively). Not only motor function but also speech, occupational, and intellectual function had variable degree of improvement. Conclusion: Use of Bee Venom stings in treatment of cerebral palsy children may improve the motor, occupational and intellectual function in those patients beside other standard medical treatment. Key words: Cerebral palsy Bee venom sting Scale record system outcome
  • 2. Introduction Bee venom therapy is the part of apitherapy which utilizes bee venom in the treatment of health conditions. Apitherapy is the use of beehive products, including honey, pollen, propolis, royal jelly, bee venom. It has been used since ancient times and in this modern age as an alternative therapy to treat multiple sclerosis, Lyme disease, and chronic fatigue syndrome. Bee venom is a rich source of enzymes, peptides and biogenic amines. There are at least 18 active components in the venom. But the effect mechanism of the venom is not entirely known yet. It was believed that it can modify the immune system in body and contribute to increase cortisol production. It also can improves blood circulation, increases physical strength, reduces pain and inflammation, has anti-oxidant effect, and helps converts chronic conditions to acute, thus facilitate the healing of chronic inflammatory conditions. When administered, there may be discomfort in the form of itching, swelling, redness, and pain. Cerebral palsy is a term refers to a number of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination but not worsen overtime. It is caused by abnormalities in parts of the brain that control muscle movements (1) . The overall incidence of cerebral palsy ranges from 1.5 to 3 per 1000 live births (2) . The early signs of cerebral palsy usually appear before a child reaches 3 years of age. The common are ataxia, spasticity, scissored gait, and muscle tone either too stiff or too floppy. A small number of children have cerebral palsy as the result of brain damage in the first few months or years of life, brain infection, and head injury (3) . Treatment of cerebral palsy including speech therapy, drugs to control seizures, relax muscle spasm, surgery to control anatomical abnormalities, and physical and occupational therapy and rehabilitation (3) . In this study we proposed a trial for treatment of cerebral palsy with bee stings in addition to medical therapy.
  • 3. Material and methods Six children with cerebral palsy (2 with diplegia, one with hemiplegia, one with extrapyramidal athetosis, one with ataxia, and one with mild cerebral palsy) were involved in the study. The inclusion criteria include a) child with age less than 12 years, b) diagnosed with any type of cerebral palsy, c) permission of the patient family for treatment with Bee stings and for follow up. Patients who missed in follow up were excluded. The mean age of the total group was 7 years with a range of 4-8 years. Each child on first visit was subjected to assessment with scale pattern system proposed by department of neurosurgery, Faculty of medicine, Suez Canal University. Table 1(Khalil scale). Furthermore, the child had a series of laboratory and radiological investigation for proper diagnosis of cerebral palsy from other infantile motor neuron disease) Table 3 .( Each child evolved in a program treatment continued his medical treatment (anticonvulsant and muscle relaxant, and neurotonic therapy) rehabilitation, assisted devices, and speech therapy. Multidisciplinary team therapists including pediatrician, neurosurgeon, physiotherapist, orthopedic surgeon, and staff member of bee venom therapy research center were involved in the treatment of each child. After permission and consent from families, each child was subjected to stings according to the center program. The child, then, had subsequent score every six months in the first year and then annually in the next three years using the same score system. SCU Bee Venom therapy research center program for the treatment of cerebral palsy by stings (M-Nagib program) The duration of program ranges between six months to two years. It is scheduled for five days weekly (Saturday till Wednesday) 1- First week : (Test dose as for any foreign antigen) One sting on the right hand (for adults) or at the lower back area (for infants) 2- Second week : (and for three successive months) A- Saturday (Day one) Three stings on the right upper limb which may be chosen alternatively from the 12 locations which are shown in figure 1.
  • 4. B- Sunday (Day two) Three stings on the left upper limb which may be chosen alternatively from the same 12 locations shown on the right in figure 1. C- Monday (Day three) Three stings on the right lower limb which may be chosen alternatively from the 16 locations shown in figure 1. D- Tuesday (Day four) Three stings on the left lower limb which may be chosen alternatively from the same16 locations shown on the right in figure 1. E- Wednesday (Day five) Three stings along the back as shown in figure 1. Additional Consideration 1- The dose may be increased or decreased each 3 months according to the progress of the status with the previous program. 2- Addition of some locations on the head is done if required after the first 3 months especially in cases of troubles with speech, vision or swallowing. (Figure1) Figure 1: Sites of stings in the upper limb (12 dots), in the lower limb (16 squares), in the back (3 dots) and additional sites on the head in certain cases (white squares&black dots).
  • 5. Table 1- Scale record system for cerebral palsy children (Khalil scale) Examination Intact(1) Affected(0) 1- Orientation: Know his mother or father 2- memory: Remember what he eat 3- Intelligence: Know mother and type of food 4- Speech and comprehension: - Dysarthria, dysphonia, dysphasia (expressive, or receptive). - Reading and writing. 5- Cranial nerves 6- Muscle status: - atrophic -wasted - fasciculation - twitching 7- Muscle tone: - spastic - flaccid 8- Muscle power: - grade 0 I II III IV 9- Abnormal movement, Nystagmus 10- Coordination: - Arm finger nose test - Leg: Heel knee test - Ataxia 11- Gait: Scissor 12- Primitive reflexes: Glabeller and grasp reflex 13- Superficial reflexes: Abdominal and planter - Deep reflexes: biceps, supinator and knee jerk 14- Sensory - Superficial sensations: pinprick and touch. - Deep sensations: sense of position - Cortical sensation: tactile localization, discrimination 15-Spine and cranium: Scoliosis, kyphosis, microcephaly, macrocephaly. Total score : /15
  • 6. Table 2 Type of cerebral palsy children in the study No Type of cerebral palsy Number of children 1 Spastic diplegia 2 2 Spastic hemiplegia 1 3 Spastic quadriparesis 0 4 Dyskinesia 1 5 Ataxia 1 6 Minimal cerebral palsy 1 Total 6 Table 3 Investigation for each child Laboratory 1- The Erythrocyte sedimentation rate (ESR):1st hour using Westergren's Method. mm/hour). 2- The C-reactive protein (CRP) level (in mg/liter). 3- Complete blood picture. 4- Liver function tests (AST, ALT). 5- Kidney function tests (creatinine). 6- Complete urine analysis. 7- TSH, T3, T4 Radiology 1- Plain roentgenogram skull and lumbosacral spine, with antero-posterior, and lateral view. 2- Magnetic Resonance Image (MRI) axial, coronal and sagittal cuts, including T1 and T2 phase images without contrast. 3- Computed Tomography (CT) without contrast. Other special tests: 1- Electroencephalography (EEG). 2- Intelligent quotient (IQ).
  • 7. Results All children were subjected to stings in the buttock and the skeletal muscle of the back twice time/week for along the study period. The child, then, had subsequent follow up for 3 years from January 2004 till January 2007. The mean age of the total group was 7 years with a range of 4-8 years. Four children were male and two were female. The average body weight was 14 ±6 KG. Pyramidal spasticity was found in 3 children; two of them had diplegia, and one presented with hemiplegia. One patient presented with extrapyramidal dyskinesia in the form of athetosis, another one with cerebellar ataxia, and the last one had mild cerebral palsy (Table 2). Variant degree of language delay was presented in all children and all children at the beginning had bowel and urinary incontinence. Epilepsy was presented on two patients and one of them was controlled with sodium valproate and carbamazepin while the second child had infrequent epileptic fits in spite of treatment. All patients with spasticity were on physiotherapy management and oral baclofen therapy. Speech therapy were used to all patients and intelligent quotient (IQ) for all were ranged from 50% - 80%. After treatment the IQ raised after 3 years to reach 60%-90%. No surgical intervention were done for all patient especially those with spasticity, and one patient had refractory to anticonvulsive therapy that needed blood analysis for anticonvulsant drug serum level and two drugs regime. No significant data was found in laboratory investigation, only two patients had mild brain atrophy on CT and one patient had demyelination finding on MRI with FLAIR and T2 images.
  • 8. All cerebral palsy children during follow up had variable degree of improvement; these improvements were recorded using our scale record during research study period (Table 4). We noticed these children with spastic or mild cerebral palsy showed much more improvement than those with ataxia and Dyskinesia (score of 8-13 comparative to 6-9). Not only motor function but also speech, occupational, and intellectual function had variable degree of improvement. Of 6 children on Bee venom stings treatment; two patients developed moderate itching and redness on skin during follow up sessions; and these local reaction improved on local treatment with steroid cream. Table 4: The outcome on (Khalil scale) after treatment of cerebral palsy children on different follow up periods Patients Type of Cerebral palsy Score on Khalil scale 6 month One year 1.5 years 2 years 2.5 years 3 years 1 Diplegia 8 8 9 10 10 12 2 Diplegia 8 9 9 10 11 12 3 Hemiplegia 9 10 11 11 12 13 4 Dyskinesia 6 7 7 9 9 9 5 Cerebellar ataxia 6 7 8 8 8 9 6 Mild CP 10 10 12 12 12 13
  • 9. Discussion Cerebral palsy is a diagnosis that represents a diverse collection of clinical syndromes. These disorders are non-progressive and are characterized by alterations in movement and posture, which occur as a result of injury to the immature brain (3) . This immaturity is caused by migrational defects, infarction, intracranial hemorrhage, infection, chemical injury, and hypoxia, and traumatic brain ischemic injury. There are six primary clinical syndromes that constitute the diagnosis of cerebral palsy and four forms of cerebral palsy; one type with pyramidal cerebral palsy (spastic quadriplegia, diplegia, hemiplegia, other type with extrapyramidal dyskinetic cerebral palsy(, plus two types of cerebellar or ataxic cerebral palsy and mild cerebral palsy rigidity (3-5) . Varieties of special tests had been used for assessment of cerebral palsy, the most commonly one used is Levine test which assesses the major motor categories including posture and movement pattern, primitive reflexes, muscle tone and reflex patterns (deep reflexes and plantar reflexes) (6) . Cognitive function is another categories that usually and simply assessed by intelligent quotient IQ (7) . In this study we use a special scale that collectively and simply assesses both motor and intellectual function of the cerebral palsy child and uses a score system for tracing improvement after treatment during follow up (Khalil cerebral palsy scale). Treatment of cerebral palsy is concerning with quality of life of cerebral palsy child through a means of functional communication and independence in daily living skills followed by mobility and ambulation. Usually patient passes through a series of physical, social, and cognitive function assessment and rehabilitation to come through this independence (8) . Speech therapy which enable the child to communicate for basic needs, and occupational therapy where the child able to perform self care activities including feeding, grooming, dressing are a basic treatments categories beside physical therapy (3) . Physical therapy is a standard treatment for the impairments of cerebral palsy.
  • 10. In physical therapy, there are numerous treatment techniques concerned with neuro- developmental treatment including Vojta, Rood, techniques (9-10) . Pharmacological treatment plays a significant role in the management of convulsions, spasticity, and dyskinesia. The mainstay treatment of spasticity including baclofen, dantrolene, diazepam, tizanidine, and gabapentin, while for dystonia carbidopa-levodopa and clonazepam are usually effective in controlling such motor deficit (11) . Bowel and bladder incontinence is another major issue that usually controlled through stool softeners, bulking agent for bowel and anticholinergic agents such as oxybutynin, hyoscyamine, and propantheline for hyperactive bladder (3) . In this research we used bee venom stings to treatment varies symptoms of cerebral palsy patient. It may have some role in improvement of motor neuron function. We found gross improvement in growth cognitive, motor, bowel and bladder incontinence. We didn’t stop other medical treatment and speech therapy for patient through the duration of treatment and follow up which extend to 3 years. According to this fact and due to small number of patients, the role of this new modality of treatment is still not conclusive in treatment modalities although some improvement was noticed in those cerebral palsy children who took the Bee venom stings. However, a larger number of patients and use of control group are much recommended for another study trial due to these promising results. Conclusion Cerebral palsy is the result of a non-progressive lesion of the immature brain. Optimizing independence in communication, self care, and mobility, and thereby reducing dependence on caregiver, is the primary goal of patient management. This needs a multidisciplinary team of pediatrician, neurosurgeon, physiotherapist, orthopedic surgeon, and staff member of bee venom therapy research center psychiatry, and orthopedic surgeon. Beside speech, occupational, and physical therapies treatments, medical treatment still had much higher role for treatment and control of disease. In this study, we found that Bee venom sting showed some improvement in intellectual and motor function for patient with cerebral palsy. Due to some research limitation, further study is recommended.
  • 11. References 1- Kuban K, Leviton A: cerebral palsy review article. N Engl J Med 330:188-195, 1994 2- Goodlin R: Do concepts of causes and prevention of cerebral palsy require revision? Am J Obstet Gynecol 172: 1830-1836, 1995 3-Doty CJ: cerebral palsy: an overview; in Winn H R (ed): Youmans Neurological surgery. Saunders, Elservier Inc, Phyladelphia, USA, 5th ed. pp 3723-3735, 2004 4- Khaw C, Tidemann A, Stern L: Study of hemiplegic cerebral palsy with a review of the literature. J Paediatr Child Health 30: 224-229, 1994. 5- Menkes J, Curran J: Clinical and MR correlates in chidren with extrapyramidal cerebral palsy. AJNR Am J Neuroradiol 15: 451-457, 1994. 6- Levine M: cerebral palsy diagnosis in children over age 1 year: standard criteria. Arch Phys Med Rehabil 61: 385-389, 1980. 7- Kudrjavcev T, Schoenberg B, kurland L, Groover R: Survival rates: associated handicaps, and distribution by clinical subtype. Neurology 35: 900-903, 1985. 8- Bulter C: effects of powered mobility on self-intiated behavior of very young children with locomotor disability. Dev Med Child Neurol 28: 325-332: 1986. 9- Graves P: Therapy methods for cerebral palsy. J Paediatr Child Health 31: 24-28, 1995 10- Rood M: Neurophysiological mechanisms utilized in the treatment of neuromuscular dysfunction. Am J Occup ther 10: 220-224, 1956. 11- Massagli T: Spasticity and its management in children. Clin Phys Med Rehabil 2: 867-884, 1991.
  • 12. ‫الدماغي‬ ‫الشلل‬ ‫عالج‬ ‫في‬ ‫بالنحل‬ ‫الوخز‬ ‫يثم‬ ‫األيزاض‬ ‫تعط‬ ‫عالج‬ ً‫ف‬ ‫انُحم‬ ‫سى‬ ‫اسرخذاو‬ ‫ٌرى‬ ٍّ‫ٔف‬ ‫انثذٌم‬ ‫انطة‬ ٍ‫ي‬ ‫جشء‬ ًْ ‫انُحم‬ ‫تٕخش‬ ‫انعالج‬ ‫غزٌقح‬ ٌ‫إ‬ ‫انًشيُح‬ ‫انععف‬ ‫أيزاض‬ ٔ ‫انًرعذد‬ ‫انًزكشي‬ ً‫انعصث‬ ‫انجٓاس‬ ‫ذهٍف‬ ‫يزض‬.ٍ‫ي‬ ‫انفائذج‬ ‫ذقٍٍى‬ ‫إنى‬ ‫انذراسح‬ ِ‫ْذ‬ ‫ذٓذف‬ ‫انشهم‬ ‫عالج‬ ً‫ف‬ ‫انُحم‬ ‫ٔخذ‬ ‫اسرخذاو‬‫األغفال‬ ‫عُذ‬ ً‫انذياغ‬.‫تانشهم‬ ٍٍ‫يصات‬ ‫أغفال‬ ‫سرح‬ ‫عالج‬ ‫ذى‬ ‫انذراسح‬ ِ‫ْذ‬ ‫ٔفى‬ ً‫انذياغ‬(‫انثُاخ‬ ٍ‫ي‬ ٌ‫ٔاثُا‬ ‫األٔالد‬ ٍ‫ي‬ ‫أرتعح‬)ٍ‫ي‬ ‫انفرزج‬ ً‫ف‬2004‫إنى‬2007‫تٕاسطح‬‫أسثٕعٍا‬ ‫تانُحم‬ ‫انٕخش‬ ً‫انذٔائ‬ ‫انعالج‬ ‫إنى‬ ‫تاإلظافح‬,‫انرأٍْهى‬,‫انرخاغة‬ ‫ٔغزق‬.‫جزاحح‬ ‫نقسى‬ ‫ذاتع‬ ً‫غث‬ ٌ‫تثٍا‬ ‫انطفم‬ ‫ذقٍٍى‬ ‫ذى‬ ‫انعالج‬ ‫ٔتعذ‬ ‫ٔاألعصاب‬ ‫انًخ‬,‫انطة‬ ‫كهٍح‬,‫انسٌٕس‬ ‫قُاج‬ ‫جايعح‬(‫نهشم‬ ‫خهٍم‬ ‫ذقٍٍى‬‫ل‬‫األغفال‬ ‫عُذ‬ ً‫انذياغ‬).‫انرقذو‬ ‫نرٕظٍح‬ ‫انرقٍٍى‬ ‫ْذا‬ ‫سُٕاخ‬ ‫ثالثح‬ ‫نًذج‬ ‫شٕٓر‬ ‫سرح‬ ‫كم‬ ‫انعالج‬ ً‫ف‬.‫انشهم‬ ‫حاالخ‬ ‫كم‬ ً‫ف‬ ‫يهحٕظ‬ ٍ‫ذحس‬ ‫ٔجٕد‬ ‫انُرٍجح‬ ‫ٔكاَد‬‫عُذ‬ ً‫انذياغ‬ ‫انذراسح‬ ‫فرزج‬ ‫أثُاء‬ ‫خهٍم‬ ‫نرقٍٍى‬ َََ‫ا‬‫غثق‬ ‫ذسجم‬ ‫كاَد‬ ً‫ٔانر‬ ‫انًراتعح‬ ‫أثُاء‬ ‫األغفال‬.‫شهم‬ ‫نذٌٓا‬ ً‫انر‬ ‫انحاالخ‬ ٌ‫أ‬ ‫ٔٔجذ‬ ‫يصحٕب‬ ٔ‫أ‬ ًَ‫اذشا‬ ‫غٍز‬ ً‫دياغ‬ ‫شهم‬ ‫نذٌٓى‬ ٌٍ‫انذ‬ ‫ْؤالء‬ ٍ‫ع‬ َََ‫ا‬‫يهحٕظ‬ َََ‫ا‬ُ‫ذحس‬ ‫اظٓزٔا‬ ً‫ذصهث‬ ٔ‫أ‬ ‫يرٕسػ‬ ً‫دياغ‬ ‫إرادٌح‬ ‫ال‬ ‫تحزكاخ‬(8-13‫ب‬ ‫يقارَح‬6-9‫انرزذٍة‬ ‫عهى‬)‫انحزكٍح‬ ‫انٕظائف‬ ً‫ف‬ ‫فقػ‬ ‫نٍس‬ ٍ‫ٔانرحس‬,ً‫ف‬ ‫أٌعا‬ ٍ‫ٔنك‬ ‫يرفأذح‬ ‫تذرجاخ‬ ‫ٔانذقٍقح‬ ‫انًٍُٓح‬ ‫انٕظائف‬.ٌ‫أ‬ ‫ٔجذ‬ ‫انذراسح‬ ِ‫ْذ‬ ٍ‫ٔي‬ٕ‫ت‬ ‫انعالج‬ ‫غزٌقح‬‫انٕخش‬ ‫اسطح‬‫ب‬‫انُحم‬‫نحاالخ‬ ‫انشهم‬ً‫انذياغ‬‫عُذ‬‫األغفال‬‫ٌك‬ ٌ‫أ‬ ٍ‫ًٌك‬ًٔ‫ف‬ ‫يهحٕظ‬ ‫دٔر‬ ‫نٓا‬ ٌٍ‫ذحس‬‫انًٍُٓح‬ ‫انحزكٍح‬ ‫انٕظائف‬,‫انذقٍقح‬ ‫ٔانٕظائف‬ ‫انرأٍْهى‬ ٔ ً‫انذٔائ‬ ‫انعالج‬ ‫إنى‬ ‫تاإلظافح‬ ‫انًزظى‬ ‫نٓؤالء‬.

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