Cerebral Palsy Case Studies

Cerebral palsy Treatment protocol in cerebral palsy affected individuals is decided on the basis of careful evaluation taking into consideration of clinical presentation (type), topography (extent of problem), age of individual, associated medical problem, GMFCS level, severity of disability etc. Every affected individual needs different set of treatment modality. Standard treatment protocol includes multimodal therapy program, brace, walking aid, botulinum toxin, surgery etc. All these techniques are being utilised in different combination based on the requirement of child. Advanced therapeutic modality is the primary modality of treatment in these children and this should be continued for long duration. No one can decide exact treatment modality without detail evaluation. Treatment protocol given below is only a guideline but final decision has to be taken only after detailed evaluation of every individual child including static physical examination, gait analysis and lastly examination under anaesthesia. Treatment required in similar looking children can differ from guideline given below. The medical technology in cerebral palsy treatment is evolving and new researches are coming up frequently, so all this general information can change with new research guidelines in future.


According to clinical & topographical presentation:


Spastic Cerebral Palsy


Hemiplegic spastic cerebral palsy


Hemiplegic spastic cerebral palsy typically affects upper & lower limb on one side. Children can have weakness in muscle group along with contracture & deformity. It may be only mild impairment in functional activity or sever disability. If left for long duration there can be shortening of limb. Most common presentation is Equinus deformity in lower limb with pronation deformity in upper limb.

Cerebral PalsyProblem: Most of the time heels do not touch ground during walking and running. They can be present in variety of ways based on involvement of foot, knee & hip joint. This non-touching of ground can be due to real equinus which is due to gastrocnemius contracture or may be one of the apparent equinus because of deformity proximaly. shortening of limb can also occur in late age.

Management Protocol: In early age this problem can be easily managed by therapy, AFO & botulinum toxin but in later age they may need surgical intervention followed by therapy & brace. Associated problem at knee & hip also need correction in same setting.

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Hand Deformity
Hand deformity Cerebral PalsyProblem: Common problem in upper limb is pronation deformity, spasticity of finger & wrist flexor, weakness of wrist / finger extensor, flexor spasticity at elbow.

Management Protocol: Hand affection in early age is managed by physiotherapy, training in fine motor activity, sensory modulation & brace. Most of the time persistent sensory problem interferes in getting good outcome. Botulinum toxin is required in severe spasticity. But when the deformity becomes fixed, then they need surgical intervention in the form of aponeurotic release of long musculo-tendinous unit. Tendon transfer is used to supplement function of weaker muscle. Common tendon transfer for pronation deformity is rerouting of pronater teres & transfer of Flexor Carpi Ulnaris to Extensor Carpi Radialis Brevis for weak wrist extensor & Flexor Carpi Ulnaris to Extensor digitorum Commines for finger extension. Functional deficit in the hands requires good therapeutic modality including CIMT, Mirror therapy, Fine motor activity and sensory modulation.


Diplegic Spastic Cerebral Palsy

Diplegic spastic cerebral palsy affects both lower limbs . It also features some functional problems in upper limb. Lower limb affection is more than upper limb. In initial age most commonly they are present in jump knee (toe walking) & scissor gait but after growth spurt in adolescent their gait presentation may change to crouch gait. They can present in variety of manner.


1. Crouch Gait:

Problem: Crouch gait cerebral palsyCrouch gait can occur because of many factors like overstretched / over lengthened calf muscle, tight knee flexor & rotational deformity of leg & foot. This gait pattern is very much cumbersome and need lot of energy. With increase in weight & height crouching can also increase.

Management Protocol: This gait pattern should be prevented at all costs and if it happens then it should be managed at earliest to prevent rapid deterioration in gait pattern. In early childhood (< 6 year) physiotherapy, proper brace & botulinum toxin helps lot in controlling this problem. During pubertal growth spurt, rapid progression of crouching can occur. This rapid progression occurs because of increasing weight, contracture of hamstring muscle & overstretching of gastrocnemius. Then these children need urgent attention and can be managed by hamstring lengthening with strengthening of knee extensor & calf muscle followed. Later on they may need osteotomy in distal thigh and transfer of tibial tuberosity. Rotational deformity of leg & feet also need correction in same stage. These Children also need Floor reaction orthosis (FRO) & strength training exercise of quadriceps & gastroc-soleus muscle for long duration even after surgery.


5. Scissor Gaits
Crouch gait cerebral palsyProblem: Scissoring Gait occur because of medial hamstring & adductor contracture.

Management Protocol: They need therapy with or without botulinum toxin in early age and surgical intervention in late age. In surgical intervention they need detail evaluation and all deformity has to be corrected in single stage surgery followed by intensive therapy for few months.


6. Jump knee gait / Toe walking

Scissor gaits cerebral palsyProblem: In toe walking child walks on toes of both feet, knee joint is flexed. Some time they may have rotational deformity of leg.

Management Protocol:In early age they are being managed by therapy, brace & botulinum toxin but in later age they need surgical intervention (SEMLOS) followed by therapy & brace.


7. In Toeing

Problem:cerebral palsy Jump knee gait Toe walkingmost of the time this intoeing occur because of increased femoral anteversion but some time they can occur because of spastic tibialis posterior muscle/ internal tibial torsion

Management Protocol: Most of time intoeing occur because of bony torsion and need surgical correction. This problem can not be managed conservatively. Increase femoral anteversion / internal tibial torsion can be managed by derotational osteotomy of respective bone and tibial posterior contracture will be managed by lengthening or partial transfer.


8. Genu-recurvatum

Problem: Genu Recurvatum gait can occur because of tendoachillis contracture or hamstring over lengthening

Management Protocol: Tendoachillis contracture is managed by surgery but in cases with over-lengthening of hamstring only brace can help up to some extent



Triplegic spastic Cerebral palsy

In triplegic spastic cerebral palsies both lower limbs and one of upper limb are affected. Treatment is similar to management of diplegic spastic cerebral palsy and management of hand problem.


9. Quadriplegic Cerebral Palsy

Problem: In Quadriplegic spastic cerebral palsy all four extremities are affected. Most of the time, they are also affected with some other medical problem. Prognosis is poor in some of the cases due to profound brain damage but in some cases they have only physical impairment.

Management Protocol: In early age they need intensive therapy protocol with brace along with treatment of other associated medical problem but in late age with mild to moderate affection they may need surgery. Children with severe disability need good nursing care, physiotherapy with wheel chair training. Sever deformity, contracture need surgery followed by intensive therapy.


10. Athetoid / Dystonic

Problem: Athetoid cerebral palsy occurs because of basal ganglia lesion and presents abnormal involuntary movement. Dystonic cerebral palsy presents as persistent & uncontrollable increase in tone during all activity but disappears during rest.

Management Protocol: It is very difficult to manage athetoid/dystonic cerebral palsy by all means but we can correct many abnormal postures by careful analysis and with the utilisation of newer technique of therapy like Tone Reducing Posture, Muscle Relearning Posture and different yoga postures. With this concept they can have much control on them. With continuous practice these children can also develop some ambulatory capability. Joint mobilization & stretching exercises are not advised in these children.


11. Mixed Cerebral Palsy

Problem: Most important/common combination is the combination of athetoid or dystonic variety with spastic cerebral palsy.

Management protocol: In early age, we utilise the concept of management as in athetoid cerebral palsy with therapy, brace and some time with botulinum toxin and oral drugs. In late age when child develop some contracture and deformity they may need surgical intervention followed by therapy.


12. Ataxic cerebral palsy

Ataxic cerebral palsy occur because of lesion in cerebellum. The child has very shaky & unstable gait. These children need intensive therapy to improve balance, pelvic control & posture. Some time they also need Brace & walking aid . Rarely do they need surgery to correct associated contracture.


13. Hypotonic Cerebral palsy

In this variety tone in body are too less so they cannot maintain posture and balance. Most of the time presentation can change into other variety like athetoid / spastic variety. Outcomes are not satisfactory in persistent hypotonia. These children need good therapy, brace and supportive measure. In these children hypothyroidism should be ruled out.

According to GMFCS level: Gross motor functional classification system is a 5 level clinical classification system that predict prognosis on the basis of self initiating movement ability by child. GMFCS level is fixed for every child affected with cerebral palsy & not meant for outcome assessment but usually one level shift can be seen after treatment . Our protocol in these children is to give them maximum efficient gait as much as possible by intensive therapy, brace, walking aid and correction of torsion, deformity, contracture and muscular weakness by surgical intervention. It has been shown in last 10 years that by our protocol we were able change one level of GMFCS and increase their gait efficiency as measured by FMS score.




Management based on GMFCS scores


13. GMFCS 1 & 2

Problem: Children with GMFCS level 1 are fully independent but in GMFCS level 2 need same support during outdoor activity.

Management Protocol: In these stages our aim of management is to correct all the deformity / muscular imbalance with fine tuning of muscle tone balance so that their gait efficiency can improve up-to maximal as much as possible. In early age they need good exercise, brace +_ botulinum toxin but in late age they may need surgical intervention. With good evaluation and planning they can be given good quality of ambulation.


14. GMFCS 3

Problem: Children with GMFCS level 3 use some walking aid during indoor and wheel chair during outdoor activity.

Management Problem:In this stage our aim of management is to increase their ambulatory capability by all means so that they can be much comfortable with minimum support as much as they can do. In early age they need good therapeutic protocol so that they can increase strength of muscle & balance in body. In late age they may need surgical intervention along with intensive therapy to improve their balance & endurance so that they can use walking aid more efficiently both for outdoor and indoor activity.


15. GMFCS 4

Problem: In this stage our aim of management is to correct all the deformity, increase their strength by intensive therapy, judicious use of walking aid & brace and make them ambulatory so that they can use walking aid and can move around in the community more comfortably with assistance of some one .

Management Protocol: Walking ability is severely limited even with walking aid. They need wheel chair for most of activity


16. GMFCS 5

Problem: Severely impaired in all motor function.

Management Protocol: Our aim of management for these children is to manage all possible deformity, weakness so that their perennial care, wheel chair use & transfer from one place to other in a house can be easier.


According to age in spastic cerebral palsy


Management protocol in infancy (< 2year)

Problem: Diagnosis of cerebral palsy can be made easily at the age of 6 month.

Management Protocol: Our aim of management for these children is to manage all possible deformity, weakness so that their perennial care, wheel chair use & transfer from one place to other in a house can be easier.


Management protocol in 2-7 year age group

2-7 year age group is the most active part of childhood. Normal children start walking at the age 15 month and gets full confidence in independent walking around 2 year. Most of the developmental milestone achieves between 2-7 year ages. Gait of children mature between 5- 6 year age. So it is very important to intervene therapeutically to get best outcome

Therapeutic modalities along with braces are used judiciously in this age group. Botulinum toxin is required to manage spasticity. Botulinum toxin is used in early age spastic children from 2 to 5 years of age. Its effect last for 3-4 months but the effect can be prolonged by the application of plaster & continuation of good therapy protocol. Oral drugs for control of abnormal movement are also being used in athetoid & dystonic cerebral palsy but less use is needed in spastic variety.


Treatment protocol in 7-10 year age group

Child gets adult pattern of gait around the age of 6 year and starts developing contracture & fixes deformity after that age so to prevent deterioration, fasten the rehabilitation as it became imperative to intervene surgically to manage and fix the deformity, contracture & bony torsion before pre pubertal growth spurt comes . At around 9-10 year age and children deteriorate at very fast speed due to rapid increase in height & weight




Treatment protocol in adolescent (10-14 yr age)

Problem: Adolescent are more prone for deterioration because of rapid increase in height & weight. They can develop contracture, muscular insufficiency and overstretching of ligaments. Crouching and food deformity are very common problem in this age group.

Management Protocol: Children in this age need intensive therapy for few weeks followed by maintenance therapy for long duration they also need supplement of Calcium & vitamin D. Few children need surgical intervention to manage contracture, bony torsion. All prevailing deformity are managed in single stage surgery SEMLOS


Treatment protocol in late adolescent & young adult

Problem: Young adults with spastic cerebral palsy who do not undergone surgery for persistent deformity feel lots of problems in ambulation. As their age increase their ambulatory condition further deteriorate with increase in weight & muscular weakness.

Management Protocol: Every child with cerebral palsy need long term follow-up to look after deterioration, new development of deformity and need of any further intervention. In infancy they require therapy, between 2-6 year age therapy with or without botulinum toxin and 6-10 year age SEMLS to correct all the deformities surgically and after puberty they may need final plan of any further surgical intervention & rehabilitation. With properly planed surgical intervention at their ideal age with brace & continuation of physical therapy, child may not need second stage surgical intervention.


Other specific problem in cerebral palsy

Foot problem

Problem:Stable, flexible & plantigrade foot is primary requirement for balanced gait pattern. In cerebral palsy, Equinus deformity is the commonest deformity followed by planovalgus feet, calcaneus foot, Hallux valgus & cavovarus foot deformity.

Management ProtocolIn early age, all these foot deformity can be managed easily by judicious use of brace and therapy but later on they need surgical intervention. Many procedures are being used for correction of these deformities. It include aponurotic release or tendon lengthening, tendon transfer, bony osteotomy, arthrodesis .


Hip dysplasia

Problem: Hip instability in cerebral palsy is very common problem and occurs because of muscular imbalance. It includes hip subluxation / dislocation, acetabular dysplasia with or without joint degeneration & femoral head deformity. Incidence of Hip dysplasia is high in quadriplegic & non ambulatory children. So it is very important to have high suspicion of hip dislocation in these children and can be identified at very early stage

Management Protocol:Spasticity of adductor longus is the primary cause of hip dysplasia. We can reduce chances of hip instability by doing adductor tenotomy. Patient with acetabular dysplasia need acetabular reorientation osteotomy. Hip dislocation need open reduction along with corrective osteotomy of femur & acetabulam. Correction of all contracture & deformity also needs to be done during this surgery (SEMLS).


Bony torsion

Problem: Muscular imbalance in cerebral palsy can result from muscular weakness, contracture & Lever arm problem. Lever arm problem arise due to bony torsion, short lever arm length & joint dislocation. Usual bony torsion in cerebral palsy is internal femoral torsion, external tibial torsion & planovalgus feet. All these bony torsion cause insufficiency of muscle and causes various gait abnormalities.

Management Protocol: It is very important to include correction of all bony torsion during single event surgical intervention. Femoral & tibial torsion can be corrected by doing bony derotation osteotomy & planovalgus feet need bony surgery in feet.


Revision surgery

Problem: Traditional surgery in cerebral palsy sometimes can harm in the place of benefit. In the traditional concept, surgical intervention is based on the static evaluation & usually done in stages. Now a days surgical intervention is based on detail analysis of child which include static physical examination, gait analysis & examination under-anaesthesia. We always try to correct all possible deformity during single stage surgery (SEMLS).


Management Protocol: Most of the time, it is not possible to correct the problems which arise as a result of traditional surgery in previously operated patient but still few patients can improve with revision surgery. Other children with cerebral palsy who have been managed with latest concept of SEMLS at early age (6-9 year) but left out with some residual deformity or develop new problem at later age, need surgery to prevent further deterioration. All these problems need detail physical examination, gait analysis & examination under anaesthesia.


Adult

ProblemWith the aging, cerebral palsy affected individual can develop many musculoskeletal problems which include increase in spasticity, decrease in flexibility and more energy expenditure while walking. They also fatigue easily & develop muscle sore. Most of these individuals also deficit in Vitamin D.

Management ProtocolSo it becomes imperative to continue physical therapy along with yoga & supplement of Vitamin D in this age group. As age advances, they need walking aid more frequently. Individuals with bony deformity, muscle contracture & joint dislocation need surgery. With proper planning & rehabilitation these persons also can be given good quality of life.




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