Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Physical Medicine and Rehabilitation 8 Cerebral Palsy Rehabilitation PPT-Powerpoint Presentations and lecture notes
Cerebral Palsy
Rehabilitation
Department Of PMR
Team approach
Associate manifestations
& complications
Mental Retardation
Epilepsy
Feeding, Nutrition, and Growth
Bladder Dysfunction
Bowel Dysfunction
Sleep Disturbances
Drooling
Hearing Loss
Visual Abnormalities
Orthopaedic Abnormalities
Goals of Rehabilitation
Improve mobility level of child
Prevent deformity and contractures
Educate parents regarding home management of child
To train child in activities of daily living (ADL)
To improve social participation of affected child.
Rehabilitation plan
There is no single blue print
Each patient and his or her family provides
a separate chal enge
Prognosis
Bleck(1987) has described tests for prognosis of walking
in children over 1 year
Neck righting reflex, asymmetrical and symmetrical tonic
neck reflex, Moro reflex ? all should disappear by 1 yr
Children who retain more than two primitive reflexes after
1 year.
Cannot sit unsupported by 4 year.
Cannot walk unaided by 8 years are unlikely to ever walk
independently.
NON-PHARMACOLOGICAL
MANAGEMENT
Basic needs
9
Ability to communicate with others
Ability to cope with ADLs
Independent mobility
Basic needs for a non walking child is straight
spine with level pelvis, painless hip and knee and
plantigrade feet
Physical therapy
10
Passive ROM exercises
Stretching exercises
Strength training
Neurodevelopmental therapy (NDT)/ Bobath technique:
aims to improve gross motor function and postural control
by facilitating muscle activity through key points of control
assisted by the therapist.
Physical therapy
11
Constraint-induced movement therapy holds promise in
improvements of upper limb dysfunction
Involved placing a full arm cast on the unimpaired upper
limb for 21 consecutive days, accompanied by intensive
training of impaired hand for 6 hours each day.
Functional electrical stimulation and biofeedback can
be helpful in training specific muscles
Occupational therapy
12
The primary goal is to help patient gain more
independence
Children work on fine motor skills by grasping and releasing
toys
Practice handwriting skills and hand-eye coordination
Basic tasks such as bathing, dressing, brushing teeth, and
eating are also addressed
They also work on fitting the child for special devices that
help them function. This may include utensils, dressing
devices, wheelchairs, bathing seats
Orthosis
13
Goals include reduction of abnormal tone, avoidance of
deformity, and facilitation of normal movement patterns
AFOs are used in case of dynamic equinus setting the
ankle in neutral to slight dorsiflexion promotes heel strike
and limits knee recurvatum.
Hinged AFOs can be used with plantar flexion stop
Ankle Foot Orthosis
14
FLOOR REACTION
15
ORTHOSIS
Ankle set at neutral
dorsiflexion and molded
anteriorly to just below
the patella this limit
crouch gait secondary to
hamstring spasticity by
creating an extension
moment at knee
Orthosis
16
Posterior leaf spring orthoses are thinned posteriorly to
simulate push-off at the end of stance phase
KAFO & HKAFO do not improve gait and they add
weight to already weak muscles
But they prevent deformity and facilitate standing
Long leg Tone inhibiting orthosis (with abduction
mechanism in c/o adductor spasticity) and serial
casting help in cases of correctable deformities
Assistive technology
17
Power wheelchairs ? as young as 20 to 36 months can
learn to use
Posterior postural walkers
Ultrasonic detectors can be incorporated for cortical
blindness
Augmentative communication devices
NON-SURGICAL
MANAGEMENT OF
CEREBRAL PALSY
General consideration
Factors to be considered before spasticity treatment:
1.
Whether to treat at all
2.
Distribution (focal/ regional/global)
3.
Degree of spasticity
4.
Family support & ability
5.
Physical access to medical care
Treatment options
Oral antispasticity medications
Nerve & motor point block
Botulinum toxin
Intrathecal baclofen
Oral medications
Baclofen
Diazepam
Clonazepam
Dantrolene
Tizanidine
Baclofen
MOA: Activates GABA-B & decreases excitatory
neurotransmitter release.
Dose:- starting dose 1 mg/kg/d (bid). 2 to 7 yr: max 40
mg, 8 to 11: max 60 mg, >12 yr: max 80 mg (divided
doses).
S/E: sedation, confusion, paraesthesia, weakness.
Rapid withdrawal: rebound spasticity, fever,
hallucination, seizure.
Caution: renal& hepatic compromise.
Diazepam
MOA: Acts centrally on GABA-A & facilitates GABA
mediated inhibition.
Dose:- <12 yr: 0.1--0.8 mg/kg/d,
>12 yr: 6--30 mg/d. (divided tid or qid)
S/E: sedation, memory loss.
Rapid withdrawal: anxiety, insomnia, seizures.
Caution: Hepatic compromise
Clonazepam
MOA: Same as Diazepam
Dose:- <10 yr: 0.1--0.2 mg/kg/d,
>10 yr: max 20 mg/d. (divided bid/tid)
S/E: more sedation than Diazepam.
Tizanidine
MOA: Alpha 2 agonist, facilitates action of glycine
spinally & supraspinally.
Dose: 0.2--0.3 mg/kg/d (tid/qid).
Advantage: Reduces spasm at night, helpful for sleep
S/E: hypotension, drowsiness.
Caution: Ciprofloxacin, hepatic compromise.
Nerve & motor point block
Nerve block: Peri-neural injection targeting a
motor/mixed nerve to impair its function.
Motor point block: Intramuscular injection lower down
the nerve trunk (below sensory branches) to create a
motor block with minimum sensory involvement.
Chemical denervation
agents
Phenol (5-7%): Denature protein of nerve tissue.
Alcohol (45-100%): Dehydrates nerve tissue & causes
sclerosis of myelin sheath.
Site: Motor nerve/point located by electrical nerve
stimulator.
Disadvantage of
phenol/alcohol
Needs precise location of injection.
Pain & dysesthesia very common.
Overdose & accidental i.v injection may lead to
depression, convulsion, cardiovascular collapse.
Botulinum toxin
A protein and neurotoxin produced by the anaerobic
bacteria Clostridium botulinum.
MOA: Blocks neurotransmitter (Ach) release at the
peripheral cholinergic nerve terminals
Reduction in muscle tension improved passive and active
range of motion, facilitates stretching techniques (casting
and splinting).
Dosing is based on amount of tone present, patient's prior
response to injections, residual function of the spastic
muscles, and potential impact of excessive tonal reduction
Intrathecal baclofen
ITB therapy significantly reduced severe spasticity which
did not respond to oral medications and botulinum
toxin treatment.
It might have reversible adverse effects or catheter-
related complications and spasticity reduction did not
always induce functional improvements.
SURGICAL MANAGEMENT
Four basic principles
Although the central nervous system injury, by definition, is non-
progressive, the deformities caused by abnormal muscle forces
and contractures are progressive.
The treatments currently available correct the secondary
deformities only and not the primary problem.
The deformities typically become worse during times of rapid
growth. For some patients, it may be beneficial to delay surgery
until after a significant growth spurt to decrease the risk of
recurrence.
Operative or non-operative treatment should be done to
minimize the impact it has on the patient's socialization and
education.
Operative Treatment
Operative treatment of deformities:
(1) correct static or dynamic deformity
(2) balance muscle power across a joint
(3) reduce spasticity (neurectomy)
(4) stabilize uncontrollable joints
Often, procedures can be combined--an adductor tendon
release can be done at the time of pelvic osteotomy for hip
subluxation.
Procedure
Indication
Possible
complications
Hip
Z-lengthening of
Flexion deformity
1. Decrease in hip
Psoas tendon
of the hip over 20
flexion pull
degree, shifting
the centre of
2. Compensatory
gravity forwards if
caliper gait with
primarily due to
increased pelvic
Psoas
rotation
Adductor
Scissoring gait
Asymmetrical
tenotomy
causing instability
abduction deformity
with pelvic tilt
Adductor tenotomy
---- do ---
---- do ----
with Obturator
neurectomy
Procedure
Indication
Possible
complications
Knee surgery
Medial hamstring
Flexion deformity
Patella alta, Knee
lengthenig
of the hip over 30
recurvatum and
degree during the
Secondary rotation of
gait
tibia
Lateral hamstring
Insufficient correction Patella alta & Knee
lengthening
after medial release
recurvatum
(Biceps)
(over 30 degree)
Distal rectus
Caliper gait (lack
Decrease of
release
of flexion at swing
extension pull
phase)
inducing relapse of
flexion at stance
phase
Procedure
Indication
Possible
complications
Ankle & Foot
Surgery
Tendo Achilles (Z-
Equinus Deformity
Progressive crouch
lengthening)
gait
Selective
------ do -------
gastrocnemius
fascial lengthening
using the Strayer or
Baker surgical
techniques
Thank you
This post was last modified on 08 April 2022