NEW RECENT CHANGES IN 2017

1. Cerebral Palsy: Management
Guide: Dr. N. Bajaj
Presented By: Dr. Harshit
Dr. Mukesh
Dr. Akhilendra

2. INVESTIGATIONS

3. Radiology
 The primary indication for a radiography is monitoring
hip instability.
 Obtain baseline spine and hip radiographs in every child
and follow the hip at risk with hip radiographs. Measure
the Reimer’s index which is the percentage of femoral
head coverage by the acetabulum. Three-dimensional
CT is useful when planning hip reconstruction.
 Clinical examination is sufficient to diagnose and follow-
up scoliosis.
 Obtain radiographs of the extremities for patients if you
plan osteotomies.
 Standing radiographs of the feet help if there are
varus/valgus deformities.

4. Cranial Imaging Studies
 Neuroimaging studies can help to
evaluate brain damage and to identify
persons who are at risk for cerebral
palsy.
 Cranial ultrasonography performed in
the early neonatal period can be helpful
in medically unstable infants until they
are able to tolerate transport for more
detailed neuroimaging. Ultrasonography
can delineate clear-cut structural
abnormalities and show evidence of
hemorrhage or hypoxic-ischemic injury.

5.  In infants, computed tomography (CT) scanning
of the brain helps to identify congenital
malformations, intracranial hemorrhage, and
periventricular leukomalacia more clearly than
ultrasonography.
 Magnetic resonance imaging (MRI) of the brain
is most useful after 2-3 weeks of life and is the
diagnostic neuroimaging study of choice for older
children, because this modality defines cortical
and white matter structures and abnormalities
more clearly than any other method. MRI also
allows for the determination of appropriate
myelination for a given age.
 In children with spasticity of the legs and
worsening of bowel and bladder function, a spine
MRI may help identify a tethered spinal cord.

6. Magnetic resonance
image (MRI) of a 1-year-
old boy who was born at
gestational week 27. The
clinical examination was
consistent with spastic
diplegic cerebral palsy.
Pseudocolpocephaly and
decreased volume of the
white matter posteriorly
were consistent with
periventricular
leukomalacia. Evidence of
diffuse polymicrogyria and
thinning of the corpus
callosum is noted in this
image.

7. Magnetic resonance image
(MRI) of a 16-month-old boy
who was born at term but had
an anoxic event at delivery.
Examination findings were
consistent with a spastic
quadriplegic cerebral palsy with
asymmetry (more prominent
right-sided deficits). Cystic
encephalomalacia in the left
temporal and parietal regions,
delayed myelination,
decreased white matter
volume, and enlarged
ventricles can be seen in this
image. These findings are most
likely the sequelae of a
neonatal insult (eg,
periventricular leukomalacia
with a superimposed left-sided
cerebral infarct).

8. Electroencephalography
 Electroencephalography (EEG) is useful
in evaluating severe hypoxic-ischemic
injury.
 This study is important in the diagnosis
of seizure disorders; findings initially
show marked suppression of amplitude
and slowing, followed by a discontinuous
pattern of voltage suppression, with
bursts of high-voltage sharp and slow
waves at 24-48 hours.
 However, EEG is not indicated if
seizures are not suspected along with
cerebral palsy.

9. EMG and Nerve Conduction
Studies
 Electromyography (EMG) and nerve
conduction studies are helpful when a
muscle or nerve disorder is suspected
(eg, a hereditary motor or sensory
neuropathy as a basis for equinus foot
deformities and toe walking).
 Evoked potentials are used to
evaluate the anatomic pathways of the
auditory and visual systems.

10. LAB INVESTIGATIONS
 The 2003 American Academy of Neurology
(AAN) practice parameter on cerebral palsy
suggests laboratory studies if [24] : (1) the
clinical history or findings from
neuroimaging do not indicate a specific
structural abnormality, (2) additional and
atypical features are present in the history
or clinical examination, or (3) a brain
malformation is detected in a child with
cerebral palsy.
 In addition, diagnostic testing for
coagulation disorders is recommended if a
cerebral infarction is seen

11. Potentially Helpful Laboratory
Tests
 There are no definitive laboratory
studies for diagnosing cerebral palsy,
only studies to rule out other symptom
causes, such as metabolic or genetic
abnormalities, as deemed necessary
based on clinical examination.

12.  Thyroid function studies - Abnormal thyroid function
may be related to abnormalities in muscle tone or deep
tendon reflexes or to movement disorders.
 Lactate and pyruvate levels - Abnormalities may
indicate an abnormality of energy metabolism (ie,
mitochondrial cytopathy).
 Ammonia levels - Elevated ammonia levels may
indicate liver dysfunction or urea cycle defect.
 Organic and amino acids - Serum quantitative amino
acid and urine quantitative organic acid values may
reveal inherited metabolic disorders.
 Chromosomal analysis - Chromosomal analysis,
including karyotype analysis and specific DNA testing
may be indicated to rule out a genetic syndrome, if
dysmorphic features or abnormalities of various organ
systems are present.
 Cerebrospinal Fluid protein - levels may assist in
determining asphyxia in the neonatal period. Protein
levels can be elevated, as can the lactate-to-pyruvate
ratio.

13. TREATMENT
 A multidisciplinary approach is most
helpful in the assessment and
treatment of such children.
 A team of physicians from various
specialties, as well as occupational
and physical therapists, speech
pathologists, social workers,
educators, and developmental
psychologists provide important
contributions to the treatment of these
children.
13

14.  Parents should be taught how to work
with their child in daily activities such as
feeding, carrying, dressing, bathing, and
playing in ways that limit the effects of
abnormal muscle tone.
 Series of exercises designed to prevent
the development of contractures,
especially a tight achilles tendon.
14

15. Essentials of Spasticity
Treatment
 Indications for treatment
 Consider treating spasticity when it
causes loss of function or produces
contractures, deformities, pressure sores,
or pain
 Additional indications include difficulty in
positioning or caring for the total body
involved child.
 children do not respond to any of the
antispasticity measures.
 The success of treatment depends on
having specific goals in treatment,
choosing the correct method according to
the child’s

16. Goals of spasticity treatment
• To perform better in activities
of daily living
 To walk better
 Increase sitting ability and balance
 Prevent deformity & decrease
contractures
 Pain relief
 Improve hygiene and patient care

17. Treatment methods
Physiotherap
y
Positioning
Exercises
Stretching
Neurofacilitation
Electrostimulatio
n
Splinting &
Casting
Oral medications
Baclofen
Diazepam
Clonazepam
Dantrolene
Tizanidine
Intrathecal
medications
Baclofen
Morphine
Clonidine
Neuromuscular
blocks
Local anesthetics
Phenol
Botulinum toxin
Orthopedi
c surgery
Selective
dorsal
rhizotom
y

18. Oral medications
 Any age ( 2-5year most common)
 Patient group total body involved
 Indication severe spasticity
 Follo up Rehabilitation
 Mild reduction of spasticity
 A/E- Sedation, weakness

19. Oral antispastic agents in CP
Baclofen Diazepam Dantrolene
Mechanism of
action
GABA analogue Postsynaptic
GABA-mimetic
Inhibits Ca++
release from
sarcoplasmic
reticulum
Dose 2.5 mg/day
increased to 30
mg for
2 - 7 years 60 mg
for 8 and above
0.12 - 0.8
mg/kg/day divided
doses
0.5 mg/kg twice
daily to 3 mg/kg
q.i.d.
Duration 2 - 6 hours 20 - 80 hours 4 - 15 hours
Side Effect Seizure activity Cognitive Hepatotoxicity

20. Intrathecal baclofen
 Above age 3 year Abdomen large
enough for pump insertion
 Patient group Total body involved spastic
or dystonic
 Indication - Severe spasticity interfering
with function or patient care
 Folloup care Range of motion exercises
 Less need for orthopaedic surgery easier
care better sitting
 A/E-Infection ,Cerebrovascular ,fluid leak

21. Neuromuscular Blocking Agents
 Indications for local anesthetic
blocks
 Differentiate spasticity from
contracture
 Predict functional changes
 Distinguish the muscles that contribute
to spasticity
 Evaluate the presence of selective
motor control

22.  Advantages of local anesthetic blocks
 Reversible short duration effect
 Relatively painless
 Helps differentiate contracture from spasticity
 Unmasks activity in the antagonists by
relaxing the spastic muscles.
 Side effects and precautions
 Hypersensitivity reaction
 Hematoma at injection site
 Sudden weakness may cause injuries in the
unprepared patient
 Systemic toxicity (dose related)

23. Local anesthetics
block the Na+ channels
and stop nerve
conduction. Injection into
the mixed nerve causes
a total nerve block for a
few hours.
Injection of
phenol into the
motor branch of the
nerve as it penetrates
the muscle causes a
motor nerve block.
Phenol denaturates the
protein in the myelin and the
axon.
Injection into a mixed
peripheral nerve causes a
total nerve
block for 2 - 12 months.
Botulinum toxin
injected into the muscle
inhibits acetylcholine
release at the
neuromuscular junction
and causes a chemical
denervation for 3 - 6
months.
Botulinum toxin

24. Selective dorsal rhizotomy
 Age group 3-7 years
 Patient group diplegic patient with
pure spasticity
 Indication-Spasticity interfering with
walking
 Intensive physiotherapy in followup
care
 A/E-Increasing scoliosis, hip instability,
risk of incontinence

25. RHIZOTOMY PROCEDURE
25

26. Orthopaedic surgery
 Age gruop 5-15 years
 All spastic types
 Indication- Contractures & deformities
 In folloup care to check Strengthening
 Results mostly Better walking
 A/E-Recurrence,

27. Rehabilitation &
Physiotherapy

28. Rehabilitation
 Rehabilitation is the name given to all
diagnostic and therapeutic procedures
which aim to develop maximum
physical, social and vocational
function in a diseased or injured
person.
 The goal of rehabilitation is to gain
independence in activities of daily
living, school or work and social life.

29. Goals of Rehabilitation
Improve
mobility
• Teach the
child to use
his remaining
potential
• Teach the
child
functional
movement
• Gain muscle
strength
Prevent
deformity
• Decrease
spasticity
• Improve joint
alignment
Educate the
parents
• To set
reasonable
expectations
• Do the
exercises at
home
Teach daily
living skills
• Have the
child
participate in
daily living
activities
Social
integration
• Provide
community
and social
support

30. Planning rehabilitation
 The child begins to receive
physiotherapy when he is a baby.
 Occupational therapy starts towards
age two to teach daily life activities.

31. Factors influencing rehabilitation
outcome
Treatment team Productive interaction
Basic understanding
Medical problems Respiratory
Convulsions
Dysphagia
Depression
Gastroesophageal reflux
Sleep disorders
Visual and hearing deficits
Mental retardation
Sensation
Communication
Child’s character Motivation to move
Temperament
Behaviour/cooperation
Willingness to take risks
The family Resources
Quality of home environment
Support
Expectations

32. Physiotherapy
 Physiotherapy helps improve mobility.
 It is the basic treatment in all children
with CP.
 It consists of exercises, bracing and
activities towards reaching specific
functional goals.
 It aims to bring the child to an erect
position, give the child independent
mobility and prevent deformity.

33.  The ‘dose’ of physiotherapy
intervention (e.g., frequency, duration,
etc.) is often decided empirically,
following tradition and modified by
economic considerations.

34. Physiotherapy tries to
improve
 Postural control
 Muscle strength
 Range of motion
 Decreasing spasticity and contracture
 Increasing muscle elasticity and joint laxity
 Joint alignment
 Motor control
 Muscular/cardiovascular endurance and mobility
skills
 Increasing coordination / agility
 Balance
 Transitions
 Use of assistive devices

35. General principles of
physiotherapy
 The primary purpose is to facilitate
normal neuromotor development
Support the development of multiple systems such
as cognitive, visual, sensory and musculoskeletal
Involve play activities to ensure compliance
Enhance social integration
Involve the family
Have fun

36. Therapy program
• Stimulating advanced postural,
equilibrium and balance
reactions to provide head and
trunk control
Infant
• Stretching the spastic muscles,
strengthening the weak ones,
and promoting mobility
Toddler &
preschooler
• Improving cardiovascular status
Adolescent

37. Basic problems in the
neuromotor development of
children with CP
Difficulty with flexing and extending
the body against gravity
Sitting
Functional ambulation

38. Forfunctionalambulation
achildneeds
Motivation to move
Enough muscle
strength and control
Able to shift his body
weight (balance)
Awareness of body
position and movement
(deep sensation)
Sufficient visual and
vestibular system
No deformities
interfering with joint
function

39. Therapy methods
Conventional exercises
Active and passive range of motion
Stretching
Strengthening
Fitness
Neurofacilitation
techniques
Vojta method of therapy
Bobath neurodevelopmental therapy

40. Neurofacilitation techniques
Vojta method of therapy
• Vojta used the positions of
reflex crawling and reflex
rolling
• He proposed that placing the
child in these positions and
stimulation of the key points
in the body would enhance
CNS development.
• In this way the child is
presumed to learn normal
movement patterns in place
of abnormal motion.
Bobath neurodevelopmental
therapy
• This is the most commonly
used therapy method in CP
worldwide.
• It aims to normalize muscle
tone, inhibit abnormal
primitive reflexes and
stimulate normal movement.
• It uses the idea of reflex
inhibitory positions to
decrease spasticity and
stimulation of key points of
control to promote the
development of advanced
postural reactions

41. How can we help?
 First, with the help of parents and
family we observe the child carefully to
see:
what the child can do.
what he looks like when he moves
and when he is in different positions.
what he cannot do, and what prevents
him from doing it.

42. Can the child:
Can the
child:
lift her head? hold it up? sit? roll over?
pull herself along the floor in any way possible?
crawl? walk?
How does
the child
use
her hands?
Can she grasp things and hold on; let go; use
both hands together (or only one at a time)?
Can she use her fingers to pick up small stones
or pieces of food?
How much
can the
child do for
herself?
Can she feed herself; wash herself; dress
herself? Is she 'toilet trained'?
What can the child do in the home or in the
fields to help the family?

43.  After observing and discussing what
the child can do, we must expect him
to do these things.

44. HELPING THE CHILD ACHIEVE
BETTER POSITIONS

45.  Whenever possible the child should be
in positions that prevent rather than
cause these problems. Whatever the
child is doing (lying, sitting, crawling,
standing) try to encourage positions
so that:Her head is straight up and down.
Her body is straight (not bent, bowed, or twisted).
Both arms are straight and kept away from the sides.
Both hands are in use, in front of her eyes.
She bears weight equally on both sides of her body -
through both hips, both knees, both feet or both arms.

46. WARNING: Do not leave a child in any one position for
many hours as his body may gradually stiffen into that posi

47. Show the child other ways to move in
order to correct some of the abnormal
positions that she repeats again and
again.
If her arm
repeatedly
bends up,
Encourage
her to
reach out
and hold
objects .
It she
bends
backward
a lot
She needs
actions
that bend
her head,
body, and
shoulders
forward,
like these.

48. Lying and sleeping
 Try to find ways for the child to be in
positions that correct or are opposite
to his abnormal ones:

49. If the
child's
body often
arches
backward
try
positioning
him to lie
and play
on his side
Look for
ways to
'break the
spasticity'
by bending
him
forward,
or over a
barrel (or
beach ball
or big
rock, etc.)

50. If the child does not
have enough control to
reach out in this position
help position him so he
can lift his head using
his arms

51. If the child's
head always
turns to the
same side
have him lie so
that he has to
turn his head to
the other side to
see the action

52. Sitting
If his legs push together and turn
in, and if his shoulders press down
and his arms turn in
sit him with his legs apart and
turned outward. Also lift his
shoulders up and turn his arms out.
Look for simple ways to help him
stay and play in the improved
position without your help.

53. For the child
with spasticity
who has
trouble sitting,
you can
control his
legs like this
Sit the child on
your belly with
his legs
spread and
feet flat. Give
support with
your knees as
needed.
MAKE IT FUN!
As the child
develops,
encourage her
to put her
arms and body
in more
normal
positions
through play
and imitation

54. Standing
When you help the
child keep her
balance, she is
less tense and can
stand straighter.
Look for ways to
provide similar
assistance during
play and other
activities.
Two sticks can
help the child once
she develops
some standing
balance. At first
you can hold the
tops of the sticks.
But let go as soon
as possible.

55. Sports and recreation
Advantages of swimming
Normalizes
muscle tone
Decreases
rate of
contracture
Strengthens
muscles
Improves
cardiovascular
fitness
Improves
walking

56. Advantages of Horseback
riding

57. Bracing
Decrease spasticity
Facilitate selective motor control
Stabilize the trunk and extremities
Keep joint in a functional position
Prevent deformity
Increase function
Goals

58. Ankle foot orthoses (AFO)
 The AFO is the basic orthosis in CP
 The main function of the AFO is to
maintain the foot in a plantigrade
position
Functions of the AFO
Main function Keep the foot in a plantigrade
position
Stance phase Stable base of support
Swing phase Prevent drop foot
At night Prevent contracture

59. Types of AFO
• Posterior leafspring AFO
(PLSO)
• Ground Reaction AFO
(GRAFO)
• Antirecurvatum AFO
Solid
AFO
• Hinged GRAFO
• Hinged antirecurvatum
AFO
Hinged
AFO

60. Mobility aids
Standers
Walkers
Crutches
Canes

61. Advantages of mobility aids
Develop balance
Improve posture
Decrease energy expenditure
Decrease loads on joints

62. Benefits of standers
Support erect posture
Enable weight bearing
Stretch muscles to prevent contractures
Decrease muscle tone
Improve head and trunk control

63. Walkers
Walkers provide the greatest support during
gait
There are two types of walkers
The anterior open (reverse) walker
provides the best gait pattern and is less
energy consuming
Standard forward walkers lead to increased
weight bearing on the walker and increased
hip flexion during gait.

64. Canes, crutches and gait
poles
 Canes or gait poles are necessary if
the child does not have sufficient
lateral balance.
 Gait poles or sticks provide sensory
input for gait and facilitate a normal
gait pattern, but sometimes are not
cosmetically acceptable to patients.