Cerebral Palsy an Overview of the Disease and Its Management

8/11/2019 Cerebral Palsy an Overview of the Disease and Its Management

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J.L. Pons et al. (Eds.): Converging Clinical & Engi. Research on NR, BIOSYSROB 1, pp. 11171121.

DOI: 10.1007/978-3-642-34546-3_183 Springer-Verlag Berlin Heidelberg 2013

Cerebral Palsy: An Overview of the Disease andIts Management

Ignacio Martnez Caballero1,4, Sergio Lerma Lara2,4,

and Maria Antonia Linares Lpez3,4

1Medical Coordinator of the Neuro-Orthopedic Unit,

Pediatric Orthopedic [email protected] in Charge of the Motion Analysis Laboratory of the Neuro-Orthopedic Unit.

Pediatric [email protected]

3Chief of the Pediatric Rehabilitation Department

4

Hospital Infantil Nio Jess. Madrid. Spain

Abstract. How a neurologic disease affects to the muscles, bones is introduced.

Classifications systems and treatments according functional levels and ages are

already established. How to improve treatment outcomes is an important task.

1 Introduction

Cerebral palsy is a static encephalopathy presented in a patient with a growing

skeleton. Due to that, the orthopaedic symptoms are getting worse until the

skeletal maturity.

Associated cognitive, sensorial and neurological problems are common. [1] [2] [3].

The incidence of the disease, 2-3/1.000 new born babies, makes necessary a

great effort of management. [3]

2 Pathogenesis

The upper motor neuron lesion creates spasticity, lack of selective motor control

and the predominance of some agonists over their antagonists produces joint

deformities.

Symptoms with excess of features, such us Hypertonia, Clonus or Co-

contraction and others with deficit of them, like weakness or poor balance, will

cause muscle, and joint problems. [1]The initially flexible joint deformities will become rigid, because the muscle

shortening related to its lower growth speed compared to bone. The growth


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1118 I.M. Caballero, S.L. Lara, and M.A.L. Lpez

Fig. 1 Pathogenesis of musculo-skeletal problems according to Bache

hormone increase the bone length and the lack of muscle stimulus for growing,

like stretching, justify the lower muscle fiber length.

Weight bearing introduces Biomechanics in the skeletal deformity

pathogenesis. Bone will grow guided partially by torque forces, and together with

the ground reaction vectors axis deviations may appear. The muscle will work

with inefficient lever arms around the joints because the bone has bad transverse,

sagittal or frontal axis. This will lead to the bone lever arm dysfunction that needsto be corrected. [2]

3 Classifications Systems

Topographic criteria are commonly used. Tetraplegic, triplegic, diplegic, or

hemiplegic refers to the number or extremities affected, four, three, two or one

respectively.

The motor control with will give us the movement disorders of spasticity,

dystonia, mixed problems or less frequently ataxia and athetosis, being the first thecommonest. Dystonia or extrapyramidal diseases are the worse scenarios.

The functional classification based on functional walking abilities, GMFCS

(Gross Motor Function System) with 5 levels, offers the possibility of setting goal

treatments.

For GMCS Levels IV and V the spine and hips are clinically followed from an

early age, because the greater incidence of scoliosis and hip subluxation. These

will finally affect the body posture on a wheelchair. Functional weight bearing can

be a goal in some of these patients. For Levels III and II, the ability of walking

makes the gait disorders a priority of treatment.


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Cerebral Palsy: An Overview of the Disease and Its Management 1119

6-12 Years 12-16 Years

Fig. 2 GMFCS functional Levels according to Palisano. [2] [3]

4 Treatment

All the treatments are complementary. Physiotherapy, orthotics, Botulinum Toxin

have the goal of improving the diminished joint range of motion and used at the

beginning. The spasticity can be handle first globally with oral drugs, with

Intrathecal Baclofen or Dorsal Rhizotomy, and ideally would cause a positive

effect preventing orthopedic deformities. However the patients still need

orthopedic surgery after the general spasticity treatment.

The frequency of type of treatment is different according the age of the patient.

[1].

Fig. 3Frequency of type of treatment related to age. (From Bache and Graham).

A good treatment guide, according GMFCS levels and ages has been

established in recent literature. [3]

Level I

Level II

Level III

Level IV

Level V


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1120 I.M. Caballero, S.L. Lara, and M.A.L. Lpez

Fig. 3Treatment according ages and Functional GMFCS Level. Each color is a different

type of treatment. The hexagon represent the time for orthopedic surgery. In levels V, IV,

III appears sooner because the possible need of profilactic hip subluxation surgery. (From

the Updated European consensus in Botulinum Toxin Therapy 2009).

Despite the lack of studies, according the medicine based on evidence criteria,

some therapies such us Bobath, Vjta o Therasuit, still claim to have a role in the

general management. Better design studies will clarify this point.

A realistic goal, the patient selection, and an adequate surgical plan are basic

conditions for reaching a successful treatment. For better treatment decisions therole of motion analysis laboratories has been extensively debated. [2]

Fig. 4 The evaluation process for orthopedic surgery includes clinical and functional

evaluation, radiology and motion laboratory studies. FMS and FAQ are functional scales.

(From Young and Graham)

LermaLara,S.PT,MSc.

NEURO-ORTOPEDIA INFANTIL


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Cerebral Palsy: An Overview of the Disease and Its Management 1121

Observational gait studies are not enough for quantifying and detect deeply the

disorders that occur while we walk.

This tool has showed the ability of changing surgical planning and even

reducing costs related. [6]

For pre-treatment evaluation, some scales like the FMS (Functional Mobility

Scale) or the FAQ (Functional Ambulatory Questionnaire) offer a reference. [2][4] [5]

The long recovery period needs a close follow up, checking physiotherapy, the

orthotic devices and even taking care of psychological aspects. The Single Event

Multilevel Surgery achieves the best of the lower limb alignment in the sagittal,

transversal and frontal planes, but this is not always enough for cerebral palsy

patients. The trunk position, and muscle strength remains challenging in some of

them.

5 Conclusions

A road map of treatment is already set for cerebral palsy patients following

Functional Levels and ages. However improving outcomes is a necessary task for

all of us.

References

[1]

Bache, C., Selber, P., Graham, H.K.: Themanagement of spasticdiplegia. CurrentOrthopaedics 17, 88104 (2003)

[2] Gage, S., Koop, N.: The Identification and Treatment of Gait Problems in Cerebral

Palsy, 3rd edn. Mc Keith University Press (2009)

[3] Heinen, F., et al.: The updated European consensus 2009 on the use of Botulinum

Toxin for children with cerebral palsy. Eur. J. Paediatric Neurol. 14(1), 4566 (2010)

[4] Young, J.L., et al.: Management of the Knee in Spastic diplegia: What is the dose?

Orthop. Clin. North Am. 41, 561577 (2010)

[5] Freeman, M.: Physical Therapy in Cerebral Palsy. Springer (2005)

[6] Wren, T.: The effect of preoperative gait analysis on costs and amount of surgery. J.

Pediatr. Orthop. 29(6), 558563 (2009)

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Cerebral Palsy an Overview of the Disease and Its Management