Asia Pacific Childhood Disability UpdateDecember 4, 2005

Recent Advances in Managing Cerebral Palsy

Barry S. Russman, MDProfessor Pediatrics and NeurologyOregon Health Sciences and UniversityPediatric NeurologistShriners Hospital for Children-Portland

Approach To Patient With CP

1. History and Physical Exam Leads to Dx

2. Evaluate for Etiology

3. Classify The Pt by Anatomy, Physiology and Gross Motor Function Measure Classification (Prognostic Value)

4. Identify Associated Problems

5. Develop Treatment Program

Treatment of Pt with CP

• The menu of options for treatment are extensive– Agreement among experts as how one might

approach the child with cerebral palsy is lacking

Important Caveats

Treatment Program will change over time

Ages 0-2 yrs: PT; Infant Stimulation; emphasis on positioning and parent education

Ages 2-5 yrs: Tone becomes a problem; dyskinesias manifest themselves

Ages > 5 yrs: Orthopedic interventions are considered

Teen yrs: Issues of hygiene and seating in the nonambulator; pain secondary to spasticity of concern

Loss of selective motor control and dependence on primitive reflex patterns for ambulation

• A remedy does not exist that can significantly alter selective motor loss, such as lack of control of lower extremity muscle.

• Physical and occupational therapy programs can provide help.

• The primary goals of a physical therapy (PT) program are to minimize the impairment, reduce the disability and optimize function.

• Various schools of therapy promote programs that superficially vary greatly, but nevertheless have certain common principles:– including development of sequence learning– normalization of tone– training of normal movement patterns– inhibition of abnormal patterns– prevention of deformity

• Help the Patient Compensate and Present Alternative Methods of Accomplishing the task

• FUTURE: Brain Plasticity exists: How can rehabilitation programs capitalize on this knowledge???

Type of Therapy

• Infant Stimulation

• NDT

• Sensory Motor Integration

• Adeli Suit

• Constraint Therapy

Complementary and Alternative Therapy (CAM)

• Hyperbaric Oxygen Therapy (HBOT)

• Adeli Suit• Constraint Therapy• Patterning• Electrial Stimulation

• Equine-Assisted Therapy

• Craniosacral Therapy• Feldenkrais Therapy• Acupuncture• Conductive Education

Important Caveats

Treatment Program will change over time

Ages 0-2 yrs: PT; Infant Stimulation; emphasis on positioning and parent education

Ages 2-5 yrs: Tone becomes a problem; dyskinesias manifest themselves

Ages > 5 yrs: Orthopedic interventions are considered

Teen yrs: Issues of hygiene and seating in the nonambulator; pain secondary to spasticity of concern

Methods of Intervening with Abnormal Tone in Cerebral Palsy

1.Oral Medication2.Serial casting/orthoses3.Chemodenervation: Phenol, Botulinum

toxin injections (Bta or b)4.Selective Dorsal Rhizotomy5.Intrathecal baclofen (ITB)6.Orthopedic surgery7.Electrical stimulation???8.NOT physical therapy

Personal use of Oral Antispasmodic Agents

• Diplegic or Hemiplegic Child– Very unhelpful

• Quadriplegic Child– Use when sleeping is difficult– Sitting in chair is unpleasant

Methods of Intervening with Abnormal Tone in Cerebral Palsy

1.Oral Medication2.Serial casting/orthoses3.Chemodenervation: Phenol and Botulinum

toxin injections (Bta or b)4.Selective Dorsal Rhizotomy5.Intrathecal baclofen (ITB)6.Orthopedic surgery7.Electrical stimulation???8.NOT physical therapy

Chemical Neurolysis

• Use of Phenol or Alcohol– Requires general anesthesia– Limited to only a few nerves such as the

obturator and musculcutaneous nerves– Side effects in ~10%; painful dysesthesias

Mechanism of Action Of Botulinum Toxin

Methods of Intervening with Abnormal Tone in Cerebral Palsy

1.Oral Medication2.Serial casting/orthoses3.Chemodenervation: Phenol, Botulinum

toxin injections (Bta or b)4.Selective Dorsal Rhizotomy5.Intrathecal baclofen (ITB)6.Orthopedic surgery7.Electrical stimulation???8.NOT physical therapy

Selective Dorsal Rhizotomy

Selective Dorsal Rhizotomy

• 3 randomized trails comparing SDR with physical therapy (PT)

• A significant decrease in muscle tone

• Significant improvement in motor skills as measured by the Gross Motor Function Measure

• Wright et al also noted improved gait velocity and stride length was also noted in the rhizotomy group compared to the PT group.

Baclofen

• GABA-B receptor agonist

• Not rapidly removed from spinal tissue by the GABA uptake system

• Only slightly lipophilic

• Densest GABA-B binding in the spinal cord is relatively superficial (lamina II and III in the dorsal horn}

Penn and Kroin, 1984

• "By administering baclofen intrathecally it was hoped that severe spasticity arising from the spinal cord could be controlled without CNS side effects"

Ambulatory 5 year old Diplegic Child

• We are treating symptoms, not disease

• Realistic expectations must be carefully articulated

• Natural course of disease must be understood

Conclusions (1)

• If 2 or 3 muscles are the problem, consider botulinum toxin injection

• If dysfunction mainly in the lower extremities, consider SDR

• If many muscles are involved, consider ITB

Conclusions (2)