Transcript Recent Advances in Managing Cerebral Palsy

Asia Pacific Childhood Disability Update
December 4, 2005
Recent Advances in Managing
Cerebral Palsy
Barry S. Russman, MD
Professor Pediatrics and Neurology
Oregon Health Sciences and University
Pediatric Neurologist
Shriners Hospital for Children-Portland
Approach To Patient With CP
1. History and Physical Exam Leads to Dx
2. Evaluate for Etiology
3. Classify The Pt by Anatomy, Physiology
and Gross Motor Function Measure
Classification (Prognostic Value)
4. Identify Associated Problems
5. Develop Treatment Program
Treatment of Pt with CP
• The menu of options for treatment are
extensive
– Agreement among experts as how one might
approach the child with cerebral palsy is
lacking
Important Caveats
Treatment Program will change over time
Ages 0-2 yrs: PT; Infant Stimulation;
emphasis on positioning and parent
education
Ages 2-5 yrs: Tone becomes a problem;
dyskinesias manifest themselves
Ages > 5 yrs: Orthopedic interventions are
considered
Teen yrs: Issues of hygiene and seating in the
nonambulator; pain secondary to spasticity of
concern
Loss of selective motor control and dependence
on primitive reflex patterns for ambulation
• A remedy does not exist that can significantly alter
selective motor loss, such as lack of control of
lower extremity muscle.
• Physical and occupational therapy programs can
provide help.
• The primary goals of a physical therapy (PT)
program are to minimize the impairment, reduce
the disability and optimize function.
• Various schools of therapy promote programs that
superficially vary greatly, but nevertheless have
certain common principles:
– including development of sequence learning
– normalization of tone
– training of normal movement patterns
– inhibition of abnormal patterns
– prevention of deformity
• Help the Patient Compensate and Present Alternative
Methods of Accomplishing the task
• FUTURE: Brain Plasticity exists: How can
rehabilitation programs capitalize on this
knowledge???
Type of Therapy
•
•
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•
Infant Stimulation
NDT
Sensory Motor Integration
Adeli Suit
Constraint Therapy
Complementary and Alternative Therapy
(CAM)
• Hyperbaric Oxygen
Therapy (HBOT)
• Adeli Suit
• Constraint Therapy
• Patterning
• Electrial Stimulation
• Equine-Assisted
Therapy
• Craniosacral Therapy
• Feldenkrais Therapy
• Acupuncture
• Conductive Education
Important Caveats
Treatment Program will change over time
Ages 0-2 yrs: PT; Infant Stimulation; emphasis
on positioning and parent education
Ages 2-5 yrs: Tone becomes a problem;
dyskinesias manifest themselves
Ages > 5 yrs: Orthopedic interventions are
considered
Teen yrs: Issues of hygiene and seating in the
nonambulator; pain secondary to spasticity of
concern
Methods of Intervening with Abnormal
Tone in Cerebral Palsy
1.Oral Medication
2.Serial casting/orthoses
3.Chemodenervation: Phenol, Botulinum
toxin injections (Bta or b)
4.Selective Dorsal Rhizotomy
5.Intrathecal baclofen (ITB)
6.Orthopedic surgery
7.Electrical stimulation???
8.NOT physical therapy
Personal use of Oral Antispasmodic Agents
• Diplegic or Hemiplegic Child
– Very unhelpful
• Quadriplegic Child
– Use when sleeping is difficult
– Sitting in chair is unpleasant
Methods of Intervening with Abnormal
Tone in Cerebral Palsy
1.Oral Medication
2.Serial casting/orthoses
3.Chemodenervation: Phenol and Botulinum
toxin injections (Bta or b)
4.Selective Dorsal Rhizotomy
5.Intrathecal baclofen (ITB)
6.Orthopedic surgery
7.Electrical stimulation???
8.NOT physical therapy
Chemical Neurolysis
• Use of Phenol or Alcohol
– Requires general anesthesia
– Limited to only a few nerves such as the
obturator and musculcutaneous nerves
– Side effects in ~10%; painful dysesthesias
Mechanism of Action Of Botulinum Toxin
Methods of Intervening with Abnormal
Tone in Cerebral Palsy
1.Oral Medication
2.Serial casting/orthoses
3.Chemodenervation: Phenol, Botulinum
toxin injections (Bta or b)
4.Selective Dorsal Rhizotomy
5.Intrathecal baclofen (ITB)
6.Orthopedic surgery
7.Electrical stimulation???
8.NOT physical therapy
Selective Dorsal Rhizotomy
Selective Dorsal Rhizotomy
• 3 randomized trails comparing SDR with
physical therapy (PT)
• A significant decrease in muscle tone
• Significant improvement in motor skills as
measured by the Gross Motor Function
Measure
• Wright et al also noted improved gait velocity
and stride length was also noted in the
rhizotomy group compared to the PT group.
Baclofen
• GABA-B receptor agonist
• Not rapidly removed from spinal tissue
by the GABA uptake system
• Only slightly lipophilic
• Densest GABA-B binding in the spinal
cord is relatively superficial (lamina II
and III in the dorsal horn}
Penn and Kroin, 1984
• "By administering baclofen intrathecally
it was hoped that severe spasticity
arising from the spinal cord could be
controlled without CNS side effects"
Ambulatory 5 year old Diplegic Child
Conclusions (1)
• We are treating symptoms, not disease
• Realistic expectations must be carefully
articulated
• Natural course of disease must be
understood
Conclusions (2)
• If 2 or 3 muscles are the problem, consider
botulinum toxin injection
• If dysfunction mainly in the lower
extremities, consider SDR
• If many muscles are involved, consider ITB