Cerebral Palsy Ppt.pptx clinical features,and treatment

Cerebral palsy

1. CEREBRAL PALSY PRESENTER-DR.C.YASHOVARDHAN MODERATOR-DR.K.SAI KRISHNA

2. International definition of CP is as follows: Cerebral palsy is a group of permanent disorders of movement and posture, causing activity limitation, that are attributed to non progressive disturbances that occurred in the developing fetal or immature brain. The motor disorders are often accompanied by disturbances of sensation, perception, cognition, communication, and behavior, by epilepsy, and by secondary musculoskeletal problems .

3. ETIOLOGY PRENATAL PERINATAL POSTNATAL

4. CLASSIFICATION ANATOMICAL Pyramidal system damage Movement disorder of spasticity Extra pyramidal system damage Hypotonia floppy or hypotonic infan ts

5. PHYSIOLOGICAL Spastic Dyskinetic Ataxic Mixed form

6. GEOGRAPHIC Based on part of the body is affected by CP. Hemiplegia Diplegia Triplegia Quadriplegia

7. The Gross Motor and Functional Classification System (GMFCL)

8. EVALUATION History complete birth history. Birth weight, gestational age, complications, and whether the child required ventilator assistance or hospitalization in the neonatal intensive care unit Motor milestones Head control by 3 to 6 months, sitting by 6 to 9 months, crawling by 9 months standing and cruising by 10 to 12 months, walking between 12 and 18 months

9. PHYSICAL EXAMINATION INFANTILE REFLEXES disappear in normal children by 3 to 6 months of age but retained in children with CP The startle reflex Disappears by 5 months The parachute reflex Appears after 5 months The tonic neck reflex Disappears by 10-12 months

10. 6 POINTS ON CLINICAL EVALUATION Tone /Power. Selective Control. Joint Contractures. Torsional Deformities. Balance, Posture, equilibrium, ambulation. Gait

11. TONE EVALUATION Evaluate the patient in comfortable surroundings. On two or more occasions to know exact muscle tone. Spastic-clasp knife. Dystonic-cogwheel rigidity. Deep tendon reflexes.

12. MODIFIED ASHWORTH SCALE No increase in muscle tone. Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half)of the rom. More marked increase in muscle tone through most of the rom, but the affected part is easily moved. Considerable increase in muscle tone, passive movement is difficult Affected part is rigid in flexion or extension (abduction or adduction)

13. TRADIEU SCALE R2-R1=window of opportunity

14. SELECTIVE MOTOR CONTROL Clinical evaluation of power is not very reliable as the problem is more of loss of voluntary control and not of motor paralysis A typical scale reports three grades of control 0 no ability Partial ability Complete ability to isolate movement Confusion test in equinovarus

15. JOINT CONTRACTURE OF HIP Thomas’s Test Staheli’s Test Duncan-Ely Test

16. JOINT CONTRACTURE OF KNEE Knee joint contracture is identified if knee extension is limited with the hip in extension(to relax the hamstrings) and the ankle relaxed in a position of equinus (to relax the gastrocnemius) Hamstring contracture is identified if knee extension is limited when the hip is flexed 90 (the popliteal angle) The bilateral popliteal angle measurement is performed with the contra lateral hip flexed until the ASIS and PSIS are aligned vertically –hamstring shift test

17. Phelp’s Test ANKLE Silverskiold Test

18. TORSIONAL DEFORMITY Femoral anti version Estimated in the prone position by rotating the hip internally and externally until the greater trochanter is felt to be maximally prominent laterally Femoral anti version is reported as the difference between the tibia and the vertical .

19. Tibial extorsion Thigh foot axis Bimalleloar angle

20. Gait Clinical gait analysis (CGA) Is needed to identify and understand gait deviations in CP Provides identification of gait deviations as in diplegics and hemiplegics Helps in selection of treatment options to manage gait deviations in cp This helps in limiting secondary deformations, and re-establish the lever arm function

21. GAIT In spastic diplegics

22. GAIT In spastic hemiple gics

23. PROGNOSIS FOR AMBULATION Poor prognostic indicators Inability to sit by 2 years of age Persistence of two or more infantile reflexes beyond 12 to 15 months Lack of head control by 20 months 4. Spastic diplegics who fail to ambulate by 4 years 5. Spastic hemiplegics who fail to ambulate by18 to 22 months

24. TREATMENT Physical therapy Strength training of weak muscles Stretching to prevent joint contractures Training for orthoses utilisation Gait, using ambulatory aids and wheelchair training For postoperative muscle stregnthening and preventing joint stiffness

25. ORTHOSES Helpful in improving gait in ambulatory patients Indications for bracing are 1. To obtain a plantigrade foot position and reduce genu recurvatum in patients with dynamic equinus 2. To support the foot in dorsiflexion during swing phase when footdrop is present 3. To assist the foot, knee, hip postoperatively for tissue healing and while weakness is being treated by physical therapy 4. To improve mild crouch

26. MEDICAL TREATMENT OF SPASTICITY Oral medication diazepam tizanidine and baclofen Intrathecal baclofen small doses Botulinum toxin injection - dynamic equinus deformity , before SEMLS procedure, for better care of non ambulatory cripple children

27. SURGICAL INTERVENTIONS single-event multilevel surgery ( SEMLS ) Will be done at an appropriate age multilevel surgeries will correct the deformities at different levels in one sitting Example hip flexion deformity causes anterior pelvic tilt, hamstrings lengthening without correction of the pelvic tilt results in hamstrings weakness causing worsening of pelvic tilt

28. single-event multilevel surgery ( SEMLS ) SEMLS followed by intense physio therapy helps in maintaining the pt GMFCS level or lower GMFCS level at follow-up SEMLS exceptions Young children with hip subluxation . Adductor release for scissoring gait to improve their ambulation Around 12 years postural and ambulation starts worsening SEMLS should be done before this age

29. SURGERY FOR EQUINUS DEFORMITY Equinus is defined as increased plantar flexion In dynamic equinus where there is passive dorsiflexion no surgical treatment is needed Surgical techniques are 1 Gastrocnemius/soleus Recession Baumann Strayer, Baker, Vulpius . 2 Open tendo achilles lengthening

30. EQUINOVARUS Equinovarus deformity of the foot results from muscle imbalance in which the invertors of the foot, posterior and anterior tibialis muscles, overpower the peroneals The gastrocnemius contributes equinus to the deformity If the foot can be passively corrected to a neutral position, tendon surgery can be performed If the deformity is stiff and the foot cannot be manipulated into a plantigrade position, bone surgery will be necessary

31. Surgeries for equinovarus Posterior Tibialis Tendon Lengthening. 1. The tendon lengthened distally z plastiy 2. Intramuscular lengthening can be performed in the distal third of the calf Achilles tendon lengthening procedure is added for equinus deformity The patient is placed in a short-leg cast postoperatively for approximately 6 weeks.

32. Equinovarus Tendon transfers surgeries Transfer of the posterior tibialis tendon to the dorsum. Split Posterior Tibialis Tendon Transfer.. Kaufer and Green procedure posterior half of the posterior tibialis tendon detached from its insertion,rerouted posterior to the tibia and fibula attached to peroneus brevis Split tendons are balanced as an evertor and invertor .

33. EQUINOVARUS Bone Surgery If the varus deformity of the foot is fixed bone surgery is needed Heel varus will respond to calcaneal osteotomy . Rigid midfoot supination, triple arthrodesis performed Bone procedures needs muscle imbalance correction as the fusion or osteotomy will get deformed causing reccurence

34. PES VALGUS common in older diplegic caused by spastic peroneal muscles, weakness of the posterior tibialis, or a tight gastrocsoleus Midfoot break valgus will mask equinus , foot may appear flat in the standing Plantar flexion of the talus and calcaneus, a collapsed longitudinal arch, and dorsiflexion and pronation of the forefoot.

35. Weight bearing radiographs reveal plantar flexion of the talus conservative treatment if the foot is not rigid –orthotics Peroneal tendon lengthening or transfers aren't useful Bone surgical procedure (1) Grice extraarticular arthrodesis, (2) Lateral column lengthening of the calcaneal neck (3) Calcaneal osteotomy (4) Triple arthrodesis

36. Grice extraarticular arthrodesis Bone graft is placed in the sinus tarsi laterally to elevate the plantar-flexed talus and correct the valgus of the subtalar joint Joint is not fused, tarsal bones growth is not affected

37. Lateral column ( calcaneal ) lengthening. Evans- Mosca technique

38. Subtalar arthrodesis The articular surfaces of the subtalar joint are resected. Tricortical autograft from the iliac crest followed by screw fixation of the subtalar joint

39. Triple arthrodesis For severe rigid symptomatic pes valgus in an adolescent .the subtalar, calcaneocuboid, and talonavicular joints are fused screws or staples used for fixation

40. SURGICAL MANAGEMENT OF KNEE DEFORMITY Spasticity or contracture in the hamstrings is generally the cause of a crouch knee gait Hamstrings cross two joints, the hip and the knee. At the hip the hamstrings serve as hip extensors, whereas at the knee they serve as knee flexors. Hip and ankle examined for hip flexion and equinus contractures Hamstrings lengthening in hip flexion contractures worsens the hip flexion deformity

41. Hamstrings lengthening Is intramuscular aponeurotic lengthening of the semimembranosus, Z-lengthening of the semitendinosus, and either tenotomy or Z-lengthening of the gracilis proximal to the knee. Intramuscular aponeurotic lengthening of the biceps Two cuts are needed in the fascia of the semimembranosus and biceps femoris for adequate lengthening Complication is sciatic nerve stretch injury

42. Tendon transfers around the knee Semitendinosus to Adductor magnus , to preserve knee Extension strength Rectus femoris tendon to semitemdinosus in stiff knee

43. Bone surgical procedures Patellar tendon reefing gives good results In growing children with severe flexion deformity In young children anterior epiphysiodesis corrects the deformity as they grow Distal femoral shortening extention osteotomy with internal fixation

44. HIP DEFORMITIES Hip flexion contractures common in spastic diplegia and spastic quadriplegia It is one component of the patient’s overall crouched-gait pattern Flexion contracture is caused by spastic iliopsoas The contracture is identified during physical examination by performing Thomas and Staheli maneuvers

45. Surgical correction of Hip flexion Flexion deformity of hip should be corrected before hamstring lengthening is done Psoas tenotomy performed over the pelvic brim Tendon of the psoas is identified deep within the iliacus muscle, which is not lengthened Proximal rectus femoris release has been described for correction of hip flexion contracture in patients with CP

46. Adduction Contracture at Hip Spasticity in the adductor muscles in CP results in scissoring. the untreated adduction contractures, when combined with a hip flexion contracture, lead to progressive hip subluxation and dislocation. The muscles leading to the adduction contracture are the adductor longus , adductor brevis , adductor magnus , gracilis ,

47. Adductor Release Banks and Green procedure A short transverse incision is made in the groin crease. The adductor longus tendon is detached from its origin along with the adductor brevis and gracilis . The adductor magnus is not released Obturator nuerectomy is avoided as post operative abduction deformity development chances are high

48. Hip dysplasia/ dislocations Hip dysplasia and dislocation rare in spastic hemiplegia. Spastic diplegia are at increased risk. Spastic quadriplegia the highest rate of hip instability is seen to almost 50% Spasticity and contracture of the adductors and flexors of the hip are the deforming forces Hip subluxation or dislocation suspected when Loss of range of motion, abduction is limited, hip flexion contracture and increased internal and decreased external rotation of the hip In dislocation a positive galeazzi sign is obvious

49. Shenton's line coxa valgus Shallow acetabulam Reimers index

50. Surgical treatment for hip subluxation and dislocation Adductor and iliopsoas release for subluxation or in hip at risk, in young ambulatory children (2) Reduction and reconstruction of the subluxated or dislocated hip, soft tissues’ release plus varus derotation osteotomy and if necessary pelvic support osteotomies

51. Chiari osteotomy Dega peri acetabular osteotomy (3) Salvage surgery for long-standing painful dislocations Proximal Femoral Resection–Interposition Arthroplasty in non ambulatory patients

52. LATEST DEVELOPMENTS Stem Cell Therapy Peripheral blood cells are commonly used improvement was seen in younger children between 10 months and 10 years old. gross motor functions improved better than fine motor activities Mobile Apps these apps by produces an auditory signal during altered biomechanics in foot and evaluates risk assessment of hip dysplasia in CP children

53. LATEST DEVELOPMENTS Robot-Assisted Devices robot-assisted gait training in rehabilitation Lower limb robotic exoskeletons are improving the quality of life in CP children. Virtual Reality is used in neuro rehabilitation for improving the functional activities children

54. THANK YOU