Barry S. Russman, MD Professor Pediatrics and Neurology Oregon Health Sciences and University

1. Asia Pacific Childhood Disability UpdateDecember 4, 2005Recent Advances in Managing Cerebral Palsy Barry S. Russman, MD Professor Pediatrics and Neurology Oregon Health Sciences and University Pediatric Neurologist Shriners Hospital for Children-Portland

2. Approach To Patient With CP • History and Physical Exam Leads to Dx • Evaluate for Etiology • Classify The Pt by Anatomy, Physiology and Gross Motor Function Measure Classification (Prognostic Value) • Identify Associated Problems • Develop Treatment Program

3. 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

4. Important CaveatsTreatment 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

5. 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.

6. 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???

7. Type of Therapy • Infant Stimulation • NDT • Sensory Motor Integration • Adeli Suit • Constraint Therapy

8. Hyperbaric Oxygen Therapy (HBOT) Adeli Suit Constraint Therapy Patterning Electrial Stimulation Equine-Assisted Therapy Craniosacral Therapy Feldenkrais Therapy Acupuncture Conductive Education Complementary and Alternative Therapy (CAM)

9. Important CaveatsTreatment 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

10. Methods of Intervening with Abnormal Tone in Cerebral Palsy 1. Oral Medication 2. Serial casting/orthoses 3.Chemodenervation: Phenol, Botulinum toxin injections (Bta or b) 4. Selective Dorsal Rhizotomy 5. Intrathecal baclofen (ITB) 6. Orthopedic surgery 7. Electrical stimulation??? 8. NOT physical therapy

12. Personal use of Oral Antispasmodic Agents • Diplegic or Hemiplegic Child • Very unhelpful • Quadriplegic Child • Use when sleeping is difficult • Sitting in chair is unpleasant

13. Methods of Intervening with Abnormal Tone in Cerebral Palsy 1. Oral Medication 2. Serial casting/orthoses 3.Chemodenervation: Phenol and Botulinum toxin injections (Bta or b) 4. Selective Dorsal Rhizotomy 5. Intrathecal baclofen (ITB) 6. Orthopedic surgery 7. Electrical stimulation??? 8. NOT physical therapy

14. 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

15. Mechanism of Action Of Botulinum Toxin

18. Methods of Intervening with Abnormal Tone in Cerebral Palsy 1.Oral Medication 2. Serial casting/orthoses 3.Chemodenervation: Phenol, Botulinum toxin injections (Bta or b) 4. Selective Dorsal Rhizotomy 5. Intrathecal baclofen (ITB) 6. Orthopedic surgery 7. Electrical stimulation??? 8. NOT physical therapy

19. Selective Dorsal Rhizotomy

20. 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.

23. 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}

24. 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"

26. Ambulatory 5 year old Diplegic Child

27. Conclusions (1) • We are treating symptoms, not disease • Realistic expectations must be carefully articulated • Natural course of disease must be understood

28. Conclusions (2) • 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