Latest concept in management of Cerebral Palsy Treatment
In our society there are lots of myths about cerebral palsy, like these CP children can’t have good quality of life, they will remain disable for whole life and most of them are mentally retarded and can’t do much in their life and so on… But this is not the whole truth. It is proven fact that with early intervention more than 80% children can be given fully acceptable life in society.
Quality of life & survival in Cerebral Palsy affected children with ambulatory capability with or without walking aid is roughly equal to normal population. More than 70% children with mild to moderate affection have nearly normal IQ. They can be active, productive members of their communities. They can have jobs, live independently, marry, have children & retire. They can even excel in the activity given to them. But this can happen only when every parent and other members of society know about different aspects of cerebral palsy and give them a chance of good quality of cerebral palsy treatment.
Cerebral palsy is not a diseases but it is group of Neuro-motor disorder which occurs because of Non-progressive disturbances in the developing brain from fetus to 3 years of early life. This insult to brain occurs because of variety of reason start from in-utero to 3 year of age. Genetic & brain anomaly, intrauterine infection, post delivery birth-asphyxia, sever jaundice; encephalitis and birth trauma are common causes of brain insult that causes cerebral palsy. Low birth weight & premature babies are at highest risk for development of cerebral palsy.
It is comprises of physical disability in the form of sensory motor dysfunction along with problem in other function like problem in perception, cognition, communication, speech, hearing, vision, loss of immunity, epilepsy and lots more. It is a lifelong condition that affects individuals, their families and society. More than 50% patients can have one or more associated medical problems along with motor dysfunction. The brain injury is static; it is not progressive. However, the dysfunctions or disabilities associated with cerebral palsy can be static, progressive or regressive depending upon quality of cerebral palsy treatment and intervention. Cerebral palsy can present in variety of manner. Presentation is based on extent and site of lesion in brain.
Variety of cerebral palsy
Spastic cerebral palsy is the commonest and most amenable to treatment. Second variety is Dyskinetic in which child can be choreo-athetotic variety or dystonic one. In athetoid variety child cannot control movements of his body part and thus can have bizarre movement but in dystonic, they have abnormal posture with rigidity in extremity. Third variety is ataxic with unbalanced gait pattern and last one is mixed pattern in which there can be combination of spastic and Dyskinetic variety. Dyskinetic and ataxic variety usually affects whole body but spastic cerebral palsy can present in variety of manner depending upon extent of lesion in brain. This affection can be monoplegic affecting single extremity, one side of body in hemiplegic cerebral palsy, both lower limb in diplegic spastic cerebral palsy and two lower and one upper limb in triplegic and all four limbs can be affected in quadriplegic cerebral palsy. This classification is not sufficient to describe every problem in these Cerebral Palsy children since they can have lots of other motor problems like lack of postural control, problem in fine motor control and activity of daily living. Spectrum of problem can range from clumsiness in gait to sever disability.
Incidence of cerebral palsy is .6 to 4 per 1000 live birth and but high incidence (27 time more) in low birth weight (<1.5 kg) and pre term born babies (< 7 month of pregnancy). Worldwide about 15 million and in India about 3 million are affected with cerebral palsy. Now with the elimination of polio from many parts of world cerebral palsy has become the commonest cause of severe physical disability in childhood.
Brain damage is not repairable so we can’t cure this problem but our goal is to allow these people live with least impact of disability. Our aim of management is to rehabilitate the children to their maximum ability & diminish their disability & impairment by all means so that they can be integrated to the main stream of society. Children affected with CP not only need treatment of physical disability but they also need treatment of every associated medical problem along with treatment of physical disability to give best outcome. Children with speech problem should be managed with speech therapy, problem with hearing deficit should be assessed for hearing aid, and epilepsy should be managed by anti epileptic management. All these children should be given early education and practice in hand writing so that they can be given admission in main stream school. Problem arises when child comes in very late stages with sever disability neglected for long duration and not able to perform any activity. In cerebral palsy children even small degrees of improvement makes a great difference. Getting a child to walk, be it in crutches, in braces or with a walker, is much better than having him in a wheelchair
Developmental Physiotherapy along with judicious use of light wt polypropylene brace & walking aid is the mainstay of treatment. In last few decades many therapeutic techniques have shown good out come in these children but use of single therapeutic technique are not so much helpful. Neuro Development Therapy, Sensory integration, CIMT, Strength training, Mirror therapy, FES, Hydrotherapy, Horse riding etc are few examples. These therapeutic techniques are used in different combinations based on specific requirement. Apart from these therapeutic technique our focus are toward training in activity of daily living along with activity oriented exercises. All these therapeutic modality should be supplemented with walking aid & light weight AFO made of polypropylene. Parents should be trained in home based therapy program & activity of daily living so that they can give therapy to their child at home. These children should continue physical therapy for whole life and should be under direct follow-up of consulting physician & therapist till the maturity. All these therapeutic modality is not so much useful in Dyskinetic cerebral palsy and they need some relaxation exercise, pelvic balancing and correction of posture by tone reducing posture (TRP) & muscle relearning process (MRP). Yoga, meditation are great help to these children. Different posture of yoga are very helpful in cases with cerebral palsy specially dystonic & athetoid type. We have started using this different posture & yoga position for these problem and find excellent outcome in most of our children. But it require lots of training and gentleness in utilizing this yoga posture.Stretching exercise & joint mobilization are not helpful in this variety and even some time it harm to children. This is indicated in patient with associated spasticity, contracture but it should be managed with caution in these children and usually should be avoided and if really need then should be very gentle.Despite of all therapeutic modality, few of the children with spastic & mixed cerebral palsy do not show much progress due to persistence of sever spasticity. These children need some antispasic measure to control them. Few medicines like baclofen & other muscle relaxant are being prescribed for management of spasticity but not much helpful. Trihexiphenydil hydrochloride is being used in management of abnormal movement in athetoid & dystonic cerebral palsy. These medicines are very useful to control abnormal movement up-to some extent if it is used with good relaxing exercise technique.
Spasticity is better managed by botulinum toxin injection. Botulinum toxin is being given at condensed site of neuro-muscular junction of all affected muscle at multiple levels. It is indicated in early age child (2-6 year) with spasticity & dystonia. Usually its effect last for 4-5 month but effect can be prolong upto 1 year by the use of postinjection plaster & good quality of cerebral palsy therapy & brace. Usually with good therapy protocol & use of day & night brace we don’t need botulinum toxin at frequently. Best outcome by this injection when child still have spasticity but did not respond much when they develop fix contracture and deformity. There is no side effect in prescribed dose limit. Most of the children needs once rarely twice and very rare third time injection.most of time in spastic cerebral palsy, child starts developing fix contracture, bony deformity after the age of 7 year and stop showing any further improvement even with continuation of therapy. Sometime this deterioration can also occur because of Vit D deficiency & rapid increase in height & weight. These children may deteriorate at very fast rate with in 1 year if proper intervention is not given in time. So at this age we need an intervention modality which should have quality of selective control of spasticity without any negative effect on already weakened muscle and bad posture, multilevel problem can be managed in single setting with short hospitalization and early start of rehabilitation. With that intervention future progression of disability can be prevented. With this aim we should think twice in selection of intervention procedure before embarking on final planning. Varieties of intervention modalities are available for these children but only few modalities fit in criteria of ideal intervention and few of them have been proven in literature worldwide. Selective dorsal rhizotomy, a kind of selective nurectomy at spinal card nerve root level. this surgical intervention is only useful in certain category of patient (pure spastic with good selective motor control in early age child ) and in the hand of few expert in this field. this may cause irreversible weakness in the extremity. orthopedic surgery with latest concept is a proven modality of intervention for children with spastic & mixed cerebral palsy .
Orthopedic surgery is being used to correct fix contracture & bony mechanical mal-alignment. But most of the time traditional orthopedic surgery doesn’t help in these children, and there is high chance of recurrence & over-correction, development of reverse deformity and even some times child deteriorate and develop reverse deformity. Traditionally surgery was done in stages so children required repeated admission, usually advised at very late stage when child already develop some very sever fix deformity like bending of the knee, sever posture problem and very week muscle. Most of these deformities cannot be corrected at late age. Because of this fact orthopedic surgical intervention in cerebral palsy have given discredit.
In single event multilevel orthopedic surgery (SEMLOS), we try to correct every possible site of spasticity, contracture, deformity, bony torsion in single setting surgery. We have utilized the concept of OSSCS given by Dr Takshi Matsua in our surgical technique and this has changed whole concept in surgical management of cerebral palsy. This concept is based on spastic nature of long multi-articular muscle crossing more than 2 joint and antigravity posture balancing nature of short muscle crossing to single joint. So during surgery, we selectively lengthen all contracted & short long multi-articular muscles and spare all short mono-articular muscle. currently with new update, we are more focusing on correction of lever arm problem by rotational osteotomy of bone and very infrequently lengthening of tendon and if really it is required then we do myofascial aponeurotic release so very rare chance of getting weakness in muscle. Because of this new update in surgical concept, whole body get good balance of muscle tone and with in short time child start showing good improvement. Sometimes we also do tendon transfer for augmenting weak muscle . Dose & site of surgical intervention are being decided on the basis of observational video analysis, detail neuro-muskuloskeletal examination and reevaluation of finding under anesthesia. Surgical intervention are being done in only selected patient, where we have achieved certain milestone and further improvement is not being possible because of mechanical misalignment.Every child requires different set of surgical intervention and we modify our surgical technique according to need of child. Ideal age for this surgery is 7-10 year, because walking skill gets mature at 6 to 7 year and we can assess in much better way but this technique can also be utilized in elder age group with good outcome. Surgical intervention is required only in selected patient with spastic & mixed cerebral palsy but not in other variety. We utilized mini incision/per cutaneous technique so that scar is very small & look aesthetic. Surgery is usually performed in regional anesthesia. Most of time child require only 3 day of hospital admission, plaster for 12 days and therapy starts within 2 weeks. All contracture, muscle imbalance & bony deformity are corrected in single setting anesthesia. There is no loss of antigravity activity. This surgical intervention improves the appearance, speed & efficiency of gait by simultaneous realignment of the lower limbs, patho-mechanics of the hip, knee and ankle in single stage. It decreases recurrence & subsequent surgery drastically. Decrease psychological trauma to parents & children. It enhances speedy recovery, easy therapy & better cooperation from child & parents. We have developed this comprehensive approach in last 12 years with regular update according to new researches & our experience.Our aim of orthopedic management is to make them ambulatory so that they can be prevented from negative consequences of not weight bearing like osteoporosis and others. We also emphasize that every children with nearly normal IQ get education in main stream school after getting sufficient training in preschool education. In last 10 years, we have managed more than 2500 children with good outcome. More than 500 children have undergone SEMLOS with excellent recovery. We take SEMLOS not as a surgical tool but as a part of total rehabilitation. It should not to be the last resort. Now it is possible to have Permanent correction of deformity, good balance of muscle tone with rare possibility of deformity recurrence. Successful rehab surgery gives all round acceleration of other function like learning, personality development, behavior along with motor function recovery. Now advance orthopedic surgical intervention is considered an important incidence in total management of patient with spastic cerebral palsy.We should not leave any stone unturned in the management of these children and adult. We should try our best possible efforts to give their maximum ability and give them a chance to intermingling with main stream of society.