Cerebral Palsy Treatment

CEREBRAL PALSY TREATMENT

Aims & Principles of Management—  Since brain damage is permanent we cannot offer definite cure for Cerebral palsy. Only thing which we can do is to increase patient’s asset as much as possible. This can be done by retraining of the muscles by proper management. This improves functional capability to a great extent. Every child can be made self dependent by training them about self-care, mobility and communication whatever may be their mental capability. For doing this we have to utilize the remaining capacity of the child’s brain and enhance this ability by giving correct therapy. Although we have to focus on  all the problems simultaneously.

Although we can not do much in these children by managing one problem at a time, but by multimodal approach, in which their physical disability along with other associated problem can be tackled, they can be given maximum benefit. It has been seen that with improvement in their physical condition, children also improve a lot in their cognition and their personality.

Multimodal  Approach– In this approach we use all available proven  inter-ventional modality in a suitable combination to prevent permanent consequences in body and decompensated changes in joint and if it happen then it should be treated early so that child can be given a good chance of recovery without loosing important phase of life. It requires multidisciplinary approach & training of parents in ADL & home based therapy programme.   

Early intervention –  More than 80% children with cerebral palsy can have nearly normal life with early intervention despite different grade of severity. Treatment can be started from NICU itself in high risk children with proper handling and sensory motor Mx. During discharge from NICU, counseling of parents can be done so that proper therapy can be started from three months onwards.

Physiotherapy – Therapy is the main stay of treatment in cerebral palsy. Traditional methods are stretching exercise, joint mobilization, electric stimulation etc. Advanced modality includes SI, NDT, TRP, CIMT, context therapy, Strength training exercise Etc. With advance modality of therapy and early intervention, child can be given maximum benefits. Light weight polypropylene braces and walking aid is the essential part of multimodal approach & it makes the activity of daily living easier for children with cerebral palsy. Heavy weight caliper have no role in management of cerebral palsy.

Botulinum Toxin–– It causes temporary and reversible blockade of cholinergic transmission at NM junction. Its effect last for only 3 to 4 months but the duration of response can be prolonged up to some extent by use of serial cast, day night splint & good physiotherapy. It is effective only in children with spastic CP and best response is seen between 2-6 years age group. It is not very effective in elder children with contracture.

Orthopedic surgical intervention – Contracture and bony deformities are almost inevitable in a growing child with spastic CP & need surgical intervention at proper time to prevent joint de-compensation & over-lengthening of tendon. Now surgery is being considered an important incident in total mx of patient with spastic cerebral palsy.

Routine Orthopedic surgery — Orthopedic surgery is typically recommended when fixed deformities results in stalled motor progress,  orthotic intolerance & difficulties with care. Orthopedic surgery primarily involves fractional lengthening &  tenotomy, muscle transfers, joint reconstruction, bone fusions, or bone realignment. Routinely surgery is being performed at single or two levels (eq. TA lengthening &/or adductor tenotomy) at a time and patients require repeated surgery. Routine orthopedic surgery is advised after 10-12 year age, when permanent damage to extremity is already fixed.

Problem with routine concept – Selective control of spasticity is not possible with routine orthopedic concept & child is always left out with deformity despite repeated surgeries. this type of surgical intervention is not helpful in severely affected patient. Some times child develop reveres deformity (Genu Recurvatum & Crouch Gait) and ambulatory children become non-ambulatory leading to psychological upset to parents & children.

RECENT ADVANCEMENT

Single Event Multilevel Surgery (SEMLS)

 in this concept all the deformity and affected muscle are being operated in single setting anesthesia so that child can be saved from repeated surgical intervention . Result is always better if every deformity in the body is corrected simultaneously which should be followed by well planed physiotherapy

Early Surgical Intervention

Ideal age for the surgical intervention is 6-10 years because gait matured in children at age of 5-6 years. surgery can also be perfomrd in elder age children but results are not so excellent as in early age group. When surgical intervention is delayed child can develop non correctable deformity like genu recurvatum, crouch gait, bony torsion, joint dislocation, mid foot break & plano-valgus feet & some time they develop early degenerative changes in joint and neglect of hand function. all these problem can be prevented by the use of early intervention but not before the age gait maturity. 

Orthopedic Selective Spasticity Control Surgery (OSSCS)

Basic Concept of OSSCS

Concept of OSSCS is given by Dr takashi matsua. Muscle groups in human body  crosses either single joint or as well as more than two joints. Multiarticular muscles are culprit for the spasticity in cerebral palsy. On the other hand monoarticular muscles are antigravity and provide balance to the body. If selective lengthening of multi-articular muscles & preservation of mono-articular muscles (Selective Spasticity control) in all affected body parts  is done in single setting anesthesia  lead to well balanced  muscle tone in the body.With the concept of selective Spasticity control, children with cerebral palsy are more balanced and can perform All their physical activities in much better way. In this concept usually we do lengthening by aponeurotic release so that child never develop any weakness in respective muscle and therapy is being start with in 2 week and child start getting results with in 4-6 week. 

BASIC DIFFERENCE BETWEEN ROUTINE ORTHOPAEDIC SURGERY AND OSSCS

ROUTINE ORTHOPAEDIC SURGERY

OSSCS

Complete section of tendon (no consideration of muscle behavior)

Selective lengthening of biarticular muscle and sparing of mono articular muscle

Tendon transfer

Not done

Not able to balance muscle power of antagonist

Possible with this procedure

Some time patient deteriorate

No deterioration

Usually delayed & done at the age of 9-10 year

Early intervention from 6 year onward to prevent Joint malfunctioning

Advantage of New Technique –

Permanent correction of deformity can be achieved with this concept & recurrence is very –very rare so most of time child do not require second surgical intervention. Earlier thought was that, result of surgery in cerebral palsy is unpredictable, some feel better and some worse following surgery. Now with the advance technique and well planned surgery, child always get good outcome. Well performed surgery on properly selected patient give good result provided the rehabilitation after surgery is carefully managed. Gait pattern become much more normal with properly performed Single event multilevel surgery. Successful surgery give all round acceleration of other function like learning, speech, behavior along with motor function recovery .

SEMLOSSS-

Concept of SEMLOSSS is given by DR J K Jain . In this concept he utilized various well proven concept of surgical intervention like concept of OSSCS, SEMLS,  tendon transfer & Lever arm restoration with some modification. We are getting excellent result in most of the children with cerebral palsy at all age group (link to https://www.youtube.com/watch?v=iaANyS6xTsk ). Tendon transfer are being used only in certain patient of selected muscular weakness like hand  ( link to https://www.youtube.com/watch?v=TYmRjlsM0rM ) & foot to balance the muscle power in affected extremity. lever arm restoration is being used only in certain patient with sever bony torsion because bony surgery usually delayed rehab program and most of the it is required in elder age only.