3/9/2018 Disclosures Cerebral Palsy: Personal Disclosures : A View from Both Sides Consultant: Allergan Corporation, Orthopediatrics, 3D4Medical Corp. Institutional Research Support : NIH, Orthopedic Research and Education Foundation, Major League Baseball, Rady Children ’ s Hospital, DePuy Spine, Allergan, Axial Hank Chambers, MD Biotech, Ellipse, Alphatec Spine, KFx, Magellan David H Sutherland Chair of Cerebral Palsy Program Spine, Zimmer, KCI, Synthes, Syntaxin, K2M, Rady Children ’ s Hospital San Diego Professor of Clinical Orthopedic Surgery Institutional Education Support : University of California at San Diego Rady Children ’ s Hospital, DePuy Spine Off-Label Use What Is Cerebral Palsy? Is it brain damage due to obstetrical trauma? Was the baby too big or too small? Botulinum Toxin (Botox, Myobloc, Xeomin, etc) Occurs before the age of 3 are not approved for use in children for spasticity by the FDA. Dysport has recently received Cerebral palsy (CP) describes a group of approval for lower extremity spasticity in children permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive Intrathecal Baclofen is not approved for use in disturbances that occurred in the developing dystonia fetal or infant brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, However, 50% of all drugs that are used in communication, behavior, by epilepsy and by children are not specifically indicated secondary musculoskeletal problems Modified after Bax et al. DMCN 2005 1
3/9/2018 Epidemiology: The Cerebral Palsies Some Statistics Risk is 25-30 times in neonates < 1500g 1 in 3 children with VLBW will have CP 54 million Americans have a disability Most children with CP were not premature 10% of <28 week premature patients will have CP 72 percent of unemployed adults with Prevalence in 8 year olds: 3-4 patients/1000 disabilities would like to work (1 in 278) 10,000 new diagnoses each year Lifetime cost of child born today with Prevalence: ~950,000 Americans with CP CP: 87% 30-year survival rate $1 million Much higher prevalence in black population There are now more adults with CP than children Etiology of Cerebral Palsies Prematurity Multiple Births: Assistive Reproduction, older mothers, teen pregnancy Chromosomal and Brain Abnormalities Genetic Influences Metabolic Influences Hormonal Heat Inflammation Hemostatic Disorders Infection: bacterial, viral Trauma Epigenetic factors such as maternal deparession Remember: Correlation does not imply causation 2
3/9/2018 Tractography Preventive Strategies Career Choices Magnesium Sulfate United Cerebral Palsy Telethon Infant and brain cooling Pediatric Rotation EPO Antiinflammatories Birth of my son, Sean in 1982 while I was an intern Thyroid Hormone Erythropoiesis Stimulating Agents Avoidance of toxic substances: nicotine, drugs, alcohol Question Assistive Reproduction Technology Prevention of Non accidental Trauma, automobile accidents, near drowning 3
3/9/2018 Orthopedic Education Fellowship in San Diego Introduction to Gait Analysis by Dr. David Sutherland Residency taught me the “ fundamentals ” of Other teachers included forward thinkers cerebral palsy care, which essentially was heel such as Scott Mubarak and Dennis cord lengthening, percutaneous adductor and Wenger who encouraged me to work in hamstring lengthening and prolonged casting the field Therefore these were the procedures that I Meeting other great thinkers like Freeman learned and these were the procedures that my Miller, Mike Sussman, Mike Aiona, Jim son had. Gage, Kerr Graham, etc Gait Analysis Classification Systems The diplegia, quadriplegia, hemiplegia system has poor intra and interobserver What is gait analysis? reliability Why is it important for the individual patient and Unilateral vs Bilateral (Surveillance of the overall care of children with cerebral palsy? Cerebral Palsy in Europe) Why is there a controversy? Levels of ambulation: household, therapy, community also has limitations Gross Motor Functional Classification System (GMFCS) 4
3/9/2018 Gross Motor Function GMFCS Measure (GMFM) Series of tests given to ascertain the level of gross motor involvement in children with cerebral palsy. GMFCS and Musculoskeletal Problems 1. Hip displacement: incidence, type Functional Mobility Scale 2. Success of hip surgery: STR vs VDROs 3. Mortality & Morbidity Function at 5, 50 4. Contracture and bony deformity and 500 meters 5. Success of Gait Correction Surgery 6. Choice of procedures: Rectus Femoris Transfer, Varus foot surgery 5
3/9/2018 Dimensions of Disability Other Classifications International Classification of Functioning, Manual Ability Classification System For Upper Extremity Problems Disability and Health (ICF) WHO Body Functions Body Structures Activities and Participation Environmental Factors Communication Functional Classification System I Effective Sender and Receiver with unfamiliar and familiar partners II Effective but slower paced Sender and/or Receiver with unfamiliar partners III Effective Sender and Receiver with familiar partners IV Inconsistent Sender or Receiver with familiar partners V Seldom Effective Sender and Receiver even with familiar partners The NCMRR Model of Participation Disablement The Person with a Disability and the Rehabilitation Process Societal Limitation National Center for Medical Rehabilitation Research. Bethesda, MD. 6
3/9/2018 Treatment Paradigms First We Must Set Goals Goal Setting Independence Team Approach Working Management of Movement Disorders Therapies: Physical, Occupational, Speech Communication Role of Technology Activities of Daily Living Timing of Orthopedic Surgery Mobility Bony and Soft Tissue Surgery Walking Integrated Treatment Approach Therapies in the Child with Cerebral Palsy Alternative Treatment Orthopedic Occupational PT Surgery Intrathecal OT Baclofen Pump Speech and Language Casting Child With Rhizotomy Management of Drooling Spasticity Bracing Alcohol Injection Visual Impairment Orthotics Botulinum Toxin Oral Phenol Medications Injection 7
3/9/2018 Physical Therapy Technology Neurodevelopmental Therapy Hippotherapy Promise and Challenges Equipment Challenges Robotics Cost Training Upkeep Specificity for each child 8
3/9/2018 Speech Therapy Mobility Getting from Point A-Point B Communication Devices May mean walking, using assistive devices, wheelchairs or the means of accessing private or public transportation Simple Computer Role of Standing Wheelchairs Simple sling chairs Custom Manual Chairs Custom Powered Chairs 9
3/9/2018 Mobility: Wheelchairs and Transportation Seating Systems Medical Management of Movement Disorders Cerebral Palsy Spasticity Growth Retardation Seizure Disorders Choreo- Management of Reflux Athetosis Management of other GI issues such as Gall stones, constipation, dumping after bowel surgery Ataxia Kidney Stones Skin ulceration Dystonia Oral Health Intellectual Disability Etc. Etc, Etc 10
3/9/2018 Ataxia Dystonia and Choreoathetosis Choreoathetosis 11
3/9/2018 Spasticity vs Dystonia New understandings of the definitions and therefore the natural history of children with cerebral palsy. Other Important Problems Current Spasticity Treatment Options: General Loss of Selective Motor Exercise and physical modalities Control Systemic drugs Sensory Deficits Diazepam (Valium) Weakness Baclofen (Lioresal) Trihexyphenidyl (Artane) Etc. 12
3/9/2018 Orthopedic and Neurosurgical Methods Anesthetic and neurolytic injections Tendon lengthenings altering the muscle receptors Phenol Alcohol Osteotomies Chemodenervation Lever Arm Syndrome injections Neurotomies Botulinum Toxin A, B Cannibis CBD Oil Fusion especially spinal fusion stabilizes the trunk Intrathecal drugs Intrathecal Baclofen Selective Dorsal Rhizotomy 13
3/9/2018 Deep Brain Stimulation Principles of Orthopedic Surgery Single event, multilevel surgery Delay surgery as long as possible (> 6 years) Use spasticity management as adjunct to surgery Timing of Orthopedic GMFCS Level 1 GMFCS Level 1 Surgical Interventions Relative frequency of treatment type in cerebral palsy management program BTX-A + motor Surgery training and (SEMLS) orthoses Casting Casting Casting and + BTX-A surgery Casting Isolated use with Isolated soft tissue after repeated surgery, and/or bony surgery surgery where indicated for hip stability 0 5 7.5 10 15 Years Boyd, et al. Eur J Neur 1999;6:S37-43. 14
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