Medical Management in CP

Question 1

Pain in Adolescents with CP: Have you experienced physical pain in the past month?

Answer 1

64% girls and 50% boys, avg age 15 yrs (N = 230) have had pain

Pain most frequent in feet, ankles, knees and low back (Levels I-IV)

Question 2

CP in Adulthood - Secondary Pathology

Answer 2

Pain (67-82%)

Walking dysfunction

Orthopedic injury

Falls (often resulting from falls or osteopenia)

Fracture

Fatigue

Question 3

Neurological
Procedures: 4 neuro medical interventions

Answer 3

oral baclofen
baclofen pump
botox injection
selective dorsal rhizotomy

Question 4

Baclofen description and side effects:

Answer 4

centrally acting muscle relaxant that works by inhibiting neurotransmitter release in the spinal cord, reducing muscle spasticity

drowsiness, dizziness, weakness, fatigue, and gastrointestinal disturbances

abrupt withdrawal may cause seizures or increased spasticity

Question 5

Baclofen Pump description and side effects:

Answer 5

delivers medication directly into the cerebrospinal fluid (CSF), allowing for lower doses and reduced side effects compared to oral administration

recommended for patients with severe spasticity who do not respond adequately to oral baclofen or experience intolerable side effects

pump malfunction, infection, or complications from surgery

Question 6

Botox Injection description and side effects:

Answer 6

Botulinum toxin (Botox) injections temporarily weaken specific muscles by blocking the release of acetylcholine at the neuromuscular junction

pain at the injection site, temporary weakness of surrounding muscles, and flu-like symptoms

Question 7

Selective Dorsal Rhizotomy (SDR) description and side effects:

Answer 7

surgical procedure that involves cutting specific nerve rootlets in the spinal cord to reduce spasticity

weakness, sensory changes, bladder dysfunction, and surgical complications

Question 8

Baclofen:

Answer 8

Synthetic GABA

Stimulates GABA receptors in SC-GABAB

Decrease excitation of alpha motor neuron

Can be administered:
Orally (PO)
Intrathecal (ITB)

Question 9

Oral Baclofen Advantages:

Answer 9

Decreases muscle tone/spasticity

Question 10

Oral Baclofen Disadvantages:

Answer 10

Adequate dose to decrease spasticity

Drowsiness

Question 11

How old do you have to be to get a Backofen pump?

Answer 11

about 4 years old before you have enough space between your pelvis and ribcage to get a Baclofen pump - it has a whole body effect (children who are more involved, quadriplegia)

Question 12

Intrathecal Baclofen Pump Advantages:

Answer 12

Muscle tone decreases in LE’s

Decreased “overflow”

Some improved function

Simplified seating and postioning

Continuous delivery of medication

Question 13

Intrathecal Baclofen Pump Disadvantages:

Answer 13

Size

Refills (every 2-6 months depending on the dose)

Catheter pulling out of intrathecal space

Infections

Reserved for those who need total body spasticity management Botox

Question 14

Botulinum Toxin (Botox):

Answer 14

Injected into selected muscles

Relaxation 3-7 days

longevity 4-6 months

Localized and selective effect

Usually after about a week you’ll see an effect that might last up to 6 months

Works by blocking the release of acetylcholine = reduces the activity of muscles that are injected

Provides targeted relief of muscle spasticity, improves function, and can enhance participation in therapy and daily activities

Question 15

Botulinum Toxin (Botox) complications:

Answer 15

Local irritation

Potential for antibody production - Means they need to be injected with more next time

Muscle weakness/atrophy

Cost - Increased tolerance - can be cost prohibitive for some families

Question 16

Selected Dorsal Rhizotomy:

Answer 16

Electrical stimulation to afferent dorsal rootlets (L2 - L5) to identify which rootlets elicit a spastic response (ie, uninhibition of the stretch reflex)

Selected rootlet neurectomy to uninhibited rootlets

Spasticity permanently alleviated without loss of other posterior root functions

often allows for better outcomes from physical therapy post-surgery

Question 17

Selected Dorsal Rhizotomy procedure:

Answer 17

Open and remove part of the vertebrae in order to access the posterior rootlets


They stimulate each rootlet to identify which ones actually will elicit a response - and then they cut those

Question 18

Selective Dorsal Rhizotomy : indications

Answer 18

Velocity-dependent spasticity
Overactive EMGs
> Continuous activity
> Out-of-phase activity
Spastic diplegia 4+ years
Good cognitive function
Ambulatory potential
Therapy resources

Question 19

Selective Dorsal Rhizotomy : relative contraindications

Answer 19

Weakness
Poor motor control
Dyskinesia
Ataxia

Question 20

Selective Dorsal Rhizotomy : best candidates

Answer 20

those with spastic diplegia, who are at least 4yrs old - you want them to be able to participate fully in the intensive therapies following surgery w/o major behavioral issues that younger children might have

Question 21

SEMLS =

Answer 21

single event multi-level surgery

2+ joints and 3+ bony/soft tissue procedures

Reduce the number of times that a child may need to go through procedures and recovery

Can be positive results - especially when treating contractures and bony malalignment
*they can take a year or more of recovery in rehab

> important to make sure family and child are truly committed before going into something like this

Question 22

SEMLS: types

Answer 22

tendon or fascia release/lengthening

muscle transfer

distal femoral extension osteotomy

acetabular/femoral osteotomies (varus derotation osteotomy- VDRO)

hemi-epiphysiodesis

Question 23

Tendon-Achilles 
Lengthening - Subcutaneous (Open Surgery)

Answer 23

Commonly indicated for patients with equinus, where the foot cannot be brought to a neutral position due to tightness of the Achilles tendon

Often performed in children with spastic cerebral palsy to improve gait and overall mobility

incision is made along the posterior aspect of the heel and calf, over the Achilles tendon

Z-plasty or by performing a V-Y lengthening technique

Children usually casted for 6-8 weeks in new lengthened position to maintain that length

Question 24

Tendon-Achilles 
Lengthening - Percutaneous (Closed surgery)

Answer 24

Most common way to lengthen now

a minimally invasive surgical technique aimed at treating equinus deformity (limited dorsiflexion of the ankle)

small skin incision (usually about 5 mm) is made over the Achilles tendon, typically on the lateral aspect of the tendon, just above the calcaneus

Question 25

Distal Rectus 
Femoris Transfer

Answer 25

Muscle transfer Typically for a child who has overactive quads and stays in that more stiff knee gait pattern Surgeon cuts rectus femoris and reattaches a little further behind - closer to where hamstring tendon is located = results in a muscle that is overactive but works more as a flexor rather than an extensor repositioning a muscle or tendon to improve function, often to compensate for weakness or spasticity in another muscle group

Question 26

Femoral Extension
Osteotomy

Answer 26

Children who have a significant knee flexion contracture Surgeon goes in and does a femoral extension osteotomy Child with crouch gait could be a candidate for this kind of surgery Involves cutting a wedge out of anterior distal part of femur and then realigning the bone into extension and holding it with the screw plate Lengthens the hamstring in the back and shortens quad in the front Often paired with a patellar tendon advancement to counteract secondary effect

Question 27

Varus Derotational Osteotomy (VDRO)

& Acetabular Osteotomy

Answer 27

Typically performed in children with hip dysplasia, subluxation, or dislocation due to spasticity femur is realigned to correct for excessive internal rotation and improve hip stability

Question 28

VDRO - hip dislocated If not treated:

Answer 28

Femur easily dislocated Probate arthritis Joint pain Limited ROM Problems with skin around groin Problems with sitting

Question 29

VDRO w/ possible pelvic osteotomy: goals

Answer 29

Reconstructive surgery Prevent future complications Improve ROM of hip joint Improve care of skin around groin Improve sitting machine NOT an expectation to improve waking ability

Question 30

VDRO procedure

Answer 30

patient is positioned supine on the operating table General anesthesia is administered posterior or lateral incision is made over the hip joint to access the femur and acetabulum femur is exposed, and an osteotomy (cutting of the bone) is performed at the proximal femur urgeon typically performs a varus cut (angling the femur inward) and a derotation cut (to correct excessive internal rotation) femoral head is repositioned in the acetabulum in a more optimal position, usually with the hip in slight flexion, abduction, and external rotation new position is maintained using internal fixation devices, such as plates, screws, or intramedullary nails

Question 31

Hemiepiphysiodesis

Answer 31

Surgeon staples one side of the epiphysis to stop the growth on that side and allow the other side to catch up with increased growth 
 Timing is critical = needs to be done when growth plates are still open Often done with children with excessive knee valgus ndicated in cases where a limb is significantly shorter or if there is a deformity that needs correction as the child grows Slows growth on one side of the joint, allowing for realignment of the limbs as the other side continues to grow

Question 32

Potential consequences of spinal asymmetry from neuromuscular conditions:

Answer 32

Scoliosis Pelvic obliquity Postural control limitations Pulmonary function GI function Pain

Question 33

Scoliosis:

Answer 33

Levels 4 and 5 on GMFCS lateral curvature of the spine, often accompanied by rotational deformity Increased curvature may lead to difficulties in mobility and balance can worsen over time, especially in growing children and adolescents

Question 34

Pelvic obliquity:

Answer 34

uneven positioning of the pelvis, often secondary to scoliosis or muscular imbalances May result in functional leg length discrepancy, affecting gait ead to asymmetric weight distribution and pressure on joints, potentially causing pain and discomfort challenges in maintaining a stable posture, affecting overall functional ability

Question 35

Postural control limitations:

Answer 35

Difficulty in maintaining a stable and upright posture due to muscle weakness or imbalance raises the risk of falls Limitations in postural control can hinder activities of daily living (ADLs) and overall independence may adopt maladaptive strategies to maintain balance, leading to further musculoskeletal issues

Question 36

Pulmonary function:

Answer 36

efficiency of the lungs and respiratory system can be compromised due to spinal asymmetry restrict lung expansion, leading to decreased vital capacity may lead to hypoventilation or shallow breathing patterns may be more susceptible to respiratory infections and complications due to compromised lung function

Question 37

GI function:

Answer 37

efficiency of the digestive system can be affected by postural and spinal alignment issues can affect the position and function of abdominal organs, potentially leading to issues like constipation or reflux may affect nutritional intake and overall health

Question 38

Pain:

Answer 38

Chronic pain can develop as a result of muscle imbalances, joint dysfunction, and postural abnormalities chronic pain in the back, neck, hips, or legs due to abnormal loading on joints and muscles Poor posture and muscle tension can lead to tension-type headaches or migraines can significantly affect an individual's quality of life, including mental health and social participation

Question 39

Children with CP commonly have medical procedures for ____ and ____

Answer 39

spasticity management joint/bony abnormalities

Question 40

Medical management can help ____ and ____

Answer 40

reduce pain improve motor function

Question 41

____ and ____ need to be carefully considered and reviewed with the family

Answer 41

Disadvantages risks