cerebral palsy treatment - kellymeliasblog...hip in cerebral palsy •all hips should be considered...
TRANSCRIPT
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CEREBRAL PALSY TREATMENT
By
Dr.Tejaswi Dussa
Pg In Ms Ortho
Gmc , Sec-bad
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TREATMENT PRINCIPLES
• Though CNS insult is non progressive- deformities caused by abnormal muscle forces and cotracturesare progressive
• Treatment is not aimed at primary cause but to correct secondary deformities
• Deformities worse during time of growth it is better to delay few definitive surgeries to decrease the risk of recurrence
• Combined approaches (operative, non operative) are benificial
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OBJECTIVES
• Stabilization of joints for wieght bearing
• Prevent deformity
• Overcome deformity
• Establish muscle balance
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• Commonly used as primary treatment or in conjuction with surgery
Medication
Splinting
bracing
Physical therapy
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MEDICAL MANAGEMENT
• Common agents - diazepam- baclofen- dantrolene- botulinum toxin
Oral agents:• Diazepam increases inhibitory
neurotransmitter activity (GABA)• Baclofen inhibit abnormal monosynaptic
extensor activity and poly synaptic flexor activity and decrease substance P levels
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• -oral baclofen
• -intrathecal baclofen injection
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• Intramuscular–Phenol–BTX
– Intra muscular botulinum toxin for 2-6 months
– Safe maximal dose 36-50 U/kg
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Botox Indications contraindication
• Pre op Evaluation
• Improve Muscle balance for ROM
• Improve function (ADLs).
• Reduce spasticity (discomfort)
• Post op analgesia
• Fixed contractures
• Serious weakness
• Aminoglycosides
• Previous failure
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• Support the jonts
• assists the range of movements
• Correct deformities
• During physical therapy
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Ankle foot orthosis
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Floor reaction AFO
• Uses floor reaction force through toe aspect of foot plate to prevent forward tibial progression & subsequent knee collapse
• May be articulated
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Knee brace
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Ankle-foot-knee orthrosis
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Abduction spint
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SWASH orthosis
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GAIT TRAINING
• Adequate base of support
• Appropriate foot clearance
• Adequate step length
• Conservation of energy
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Gait trainer
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Assisted Gait Trainer
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Walking aids
• Axillary crutches
• Elbow crutches
• Walking sticks
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• In management of CP patient
how to do a procedure is not a big dealbut
what procedure to do is most important
• Without prior gait analysis the chance of faltydiagnosis and choice of treatment in experience hands is almost 50%
• Choice treatment as per clinical diagnosis will be definitely altered after gait analysis
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GAIT ANALYSIS
• To diagnose mechanisms responcible for gait disorders
• To assess the degree of disability
• To evaluate the improvement resulting from treatment
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APPROACHES
• Obeservational gait analysis
• Gait parameters
• Kinematic data
• Force plate data
• Kinesiological data
• energetics
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MANNERISMS
• No abnormalities
• They are only individual characteristics
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OBSERVATIONAL GAIT ANALYSIS
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OBSERVATIONAL GAIT ANALYSIS
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GAIT PARAMETERS
• Gait parameters - cadence (90 steps/min)
- step length(0.7-0.9 m)
- walking velocity(60-90 m/min)
- single limb support (0.5-2 sec)
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Kinesiological analysis
• Combined motion ,forces, muscle function
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Kinematic analysis
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Force plate analysis
ground reaction force
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Aims of operative management
• Evaluate muscle tone and determine type.• Evaluate degree of deformity / contracture at
each joint.• Assess linear, angular and torsional deformities
of spine, long bones, hands and feet.• Appraise balance, equilibrium and standing /
walking posture.• Correct static or dynamic deformities• balance muscle power across the joint• reduce spasticity• Stabilize uncontrollable joints
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with
• Early regular stretching of tightened structure
• Reeducation and exercising weak antagonists
• Proper bracing
• Traning of balance and posture
• Locomotion and relaxation
• Speech therapy
“ MOST PATIENTS NEVER REQUIRE SURGERY”
And achieve good balance and independent gait
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OPERATIVE MENAGEMENT
• Indications
• contracture or deformities causing
pain
Decrease function
Interfere with ADL
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PREREQUISITES FOR EFFECTIVE SURGERY
• spastic• hemiplegics / diplegics : good results
quadriplegics : minimal improvement• Age : 3- 12 years• IQ : good• Good upper limb function : for walking• Underlying muscle power should be good
surgery hardly changes status in walkers/nonwalker, but improves gait
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PROCEDURE
• Neurosurgical procedures
• Tendon release
• Muscle tendon lengthening
• Capsulotomies
• Osteotomies
• Resection and replacement procedures
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NEUROSURGICAL • SELECTIVE DORSAL ROOT RHIZOTOMY
• 30 – 50 % of abnormal dorsal rootlets L2 - S1• Pt selection:child 3-8 yrs with spastic diplegia
voluntory motor and thrunk control pure spastic andno fixed contracture
• With physical therapy continued improvement can be expected for 6-12 months
• Not recommonded in -spastic quadriplegia
-spastic hemiplegia
• Complication: hip subluxation/dislocation
lumbar hyperlardosis
spondylolysis/listhesis
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HIP IN CEREBRAL PALSY
• All hips should be considered abnormal unless proved otherwise
• Deformities ranges from mild painless subluxation to complete dislocation
• Pain and joint distruction
• Impaired mobility
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HIP AT RISK
• Quadriplegia, Nonambulator• Age 2-6 yr.• < 30O abduction in flex or ext.• > 20O flexion contracture• valgus and anteversion• Shallow acetabulum AI > 40*• Abnormal migration index
Film Pelvis Every 12 Mo. For Nonambulator
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A B C
AB/AC= MIGRATION INDEX (MI)
ACETABULAR INDEX
33%subluxation100%dislocation
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DEFORMITIES• DEFORMITIES OF HIP:• Flexion deformities• adduction• Subluxation and dislocation
• SECODARY DEFORMITIES:• Knee Flexion • Version deformities of tibia• Equinus foot• Pelvic tilt• Scoliosis• lordosis
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Causes of hip deformities
• Causes:• Muscle imbalance• Retained primitive reflexes• Abnormal positioning• Pelvic obliquity
• Structural changes• Acetabular dysplasia
• Excessive femoral anteversion• Increased neck shaft angle
• osteopenia
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• Pseudoadductiondeformity
Flexion internal rotation of hip
Incresed femoral anteversion
External tibial torsion
Planovalgus feet
Pt sit in the ‘W’ position
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Hip flexion deformity
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Indication for surgery
• Hip flexion deformity never decrease by physiotherapy – orthoses – sleeping prone …
• Hip flexion deformity > 20 needs surgery
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Hip flexion contracture hip , knee & ankle contractures
single stage 15-30 deg flexion >30 deg flexion multi level correction
ilioPsoas lengthening more release of -rectus femoris-sartorius-TFL-anterior fibers of Gl.minimus
Gl.medius
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•Iliopsoas recession is most commonly used than complete tenotomy to avoid excessive
flexion weakness
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•Lengthening (z plasty) : best / easy satisfactory in ambulating patients. no risk of too much weakening of flexion power
keats
ILIOPSOAS RELEASE
• Better in non ambulatory patients
• Release at insertion of iliopsoas
• Causes risk of excessive weakness of hip flexon
• Often done with adductor release and varusderotational osteotomy
ILIOPSOAS RECESSION
• M.c used
• Preferred in ambulatory patients
• good for subluxated hip
• Adviced when hip internally rotated during walking
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• After treatment
• Co-operative pt immediate physiotherapy started with hip extension and external rotation
• Non co-operative ptpt are placed prone at bed
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What not to do !• Yount’s fasciotomy of Tensor F. Lata – not
enough
• Souter’s muscle sliding of Sartorius, Rectus Femoris, and Tensor Fascia Lata – 66% recurrence
• Proximal Rectus Femoris tenotomy
• Myotomy of ant. Fibers of Gluteus Medius
very important pelvic stabilizer in stance phase
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ADDUCTION DEFORMITY
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ADDUCTION DEFORMITY
• AGE < 4 YR
<45o abduction in ext, 60o in flex soft tissue release
• AGE 4-8 YR.
MI 25%-60%,
abduction <30o soft tissue release
MI > 60%, not improve in 1 yr soft tissue release+ capsulorraphy+ bony
reconstruction
• AGE > 8 YR
MI soft tissue release &
bone reconstruction
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• Mild contracture severe contracturesEarly hip subluxation
• Adductor tenotomy more release of -gracilis-anterior half of adductor bevis
• Leave adductor brevis ( the major hip stabilizer )• No anterior branch obturator neurectomy
(Nerve to adductor brevis)• Release brevis if can not abduct 45*
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Banks and green procedure
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After treatment:Abduction bar for 1month
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HIP SUBLUXATION
• MI > 30 %Soft tissue release for very young
Flexion adduction deformities
• MI > 50% open reduction + femoral osteotomy
Correction of femoral valgus and anteversion
• AI > 25O pelvic osteotomy
(Correction of acetabular deformities)
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• Femoral varus and derotational(external rotation) osteotomy
• Acetabular osteotomies:
• Salter osteotomyredirection of the acetabulum anterioly and laterally
• Postero-superior deficiencyshelfsosteotomy
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Neck shaft angle < 115O
Anteversion10-20O (30-45O
passive IR)
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HIP DISLOCATION
• MI=100%Types:• Posterior dislocation (m.c)• Anterior dislocationSeen in
-spastic diplegics-spastic quadriplegics
• Significant acetabular changes present
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Spastic Diplegia Spastic quadriplegia
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hip dislocation :
if detected early: surgery
if detected late : no pain – leave
pain – proximal resection
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• Criteria for open reduction of a dislocated hip:
• Moderate intellectual
• Should have atleast sitting potential
• Pelvic obliquity should be minimaldislocationideally unilateral
• No longer duration of dislocation
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TRETMENT OPTIONS IN HIP DISLOCATION
• Observation
• Relocation procedure on femur and acetabulum
• Proximal femoral resection
• Hip arthrodesis proposed for
• Total hip arthroplasty painful
unreducible
dislocated hip
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Combined one stage correction of spastic dislocated hip
1. Soft tissue release
2. Open reduction
3. femoral osteotomy
4. Pericapsular pelvic osteotomy
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Varus derotational shortening femoral osteotomy
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Pericapsular acetabuloplasty
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PROXIMAL FEMORAL RESECTION
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NON AMBULATORY CP HIP DISLOCATION
• Resection
• Valgus Osteotomy
• Arthrodesis
• Arthroplasty
• Femoral & Pelvic osteotomy
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Proximal Femoral Resection
Leet et al JPO 2005
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Valgus Osteotomy
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Arthroplasty
Miller et al JPO 1999
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Arthrodesis
40* flexion,15*abduction and neutral rtation
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Femoral & Pelvic Osteotomy
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