SPASTIC CEREBRAL PALSY

Spastic cerebral palsy is a specific type of cerebral palsy where there is spasticity (Stiffness) or high muscle tone which result stiff and jerky movements. Spastic cerebral palsy is further classified according to the affected part(s) of the body. They are spastic hemiplegia, spastic diplegia, Spastic triplegia, and spastic monoplegia.

Identification of Children with CP Spastic Hemiplegia

• There will be defect / impairment of one side of the body either right or left.
• The upper limb will be more affected than the lower limb.
• There is often little abnormality of hip movements and adductor spasm (Scissoring) is not usually noted.
• There is severe spasticity of the calf muscles and the foot is held in plantar flexion (on Toes).
• When the child makes a movement with his non - affected limb, the affected side partially or completely assumes the typical hemiplegic position.
• Contracture or deformity can be seen at hip, knee, ankle, elbow and wrist joint

Identification of Children with CP Spastic Diplegia

• They show symmetrical or near symmetrical involvement
• The legs are more involved than the arms.
• The hips, knees and ankles may flex and the child can sit in the tailor position (W Position) on the base of his spine.
• The arms may be mildly, moderately or severely affected.
• Very mild cases of spastic diplegia may involve the legs and feet only.
• There may be a tendency to walk on toes only.

 Identification of Children with CP Spastic Quadriplegia / Spastic Triplegia

• All four limbs and usually the trunk and muscles that control the mouth, tongue and pharynx are affected.
• These children show symmetrical or near symmetrical involvement
• The arms are more involved than the legs.
• If the arms are moderately affected, one hand is better than the other because the child will use one hand for play.
• In triplegia, one arm is better than the other one, both lower limbs are more or less equally involved

  
Causes of Spastic Cerebral Palsy
If your child has been diagnosed, Spastic Hemiplegia, it can be due to

• Birth Abnormalities
• Childhood infective illness such as pertussis, measles, mumps or chickenpox
• Hemiplegia may be due to a cerebral venous thrombosis during pneumonia, meningitis, following surgery such as appendectomy and tubercular meningitis.
• It can occur after severe dehydration in gastroenteritis.
• Hemiplegia has followed arterial thrombosis in a congenital heart defect such as Fallot's tetra logy, or in sickle cell anemia.
• Hemiplegia may follow injury such as a road accident or baby battering.
• Sturge-Weber Syndrome
• Absent Corpus Callosum

If your child has been diagnosed Spastic Diplegia, it can due to

• Prematurely born
• Many have very low birth weight
• In some cases the child is a twin or one of a triple.
• There may be a maternal history of previous miscarriages or premature births and the birth suggests some form of maternal inadequacy.
• Antenatal hemorrhages in early pregnancy and also pre-eclampsia. .

If your child has been diagnosed Spastic Quadriplegia, it can be due to

• Developmental brain abnormalities
• Genetic or chromosomal abnormalities
• Radiation exposure
• Prenatal infections
• Illicit drug use and fetal alcohol syndrome
• Birth asphyxia (Hypoxic ischemic encephalopathy)
• Birth trauma, Meningitis, traumatic brain injury, encephalitis, etc
  

Associated Problems / Factors with Spastic Cerebral Palsy
Your child with Cerebral Palsy Spastic Hemiplegia may have

• visual defects
• sensory Loss (Astereognosis of the affected hand)
• poor growth
• Speech Problems
• Epilepsy
• Poor Intelligence
• Behavior Problems, etc

 Your child with Cerebral Palsy Spastic Diplegia may have

• Speech problem
• hearing deficit
• vision disorder
• Perceptual disorder
• Epilepsy
• poor intelligence, etc

 Your child with Cerebral Palsy Spastic Quadriplegia may have

• impaired Speech
• hearing deficit
• visual disorder
• Perceptual disorder
• Epilepsy
• poor cognition
• Pain
• poor bladder and bowel control
• Sleep disorder
• behavioral issues, etc

Treatments and Management Techniques used for Children with Spastic Cerebral Palsy
Your child with Spastic Cerebral Palsy will be treated with our unique multimode treatment approach which is considered the best. All children with Spastic Cerebral Palsy are helped with combination of the following treatment systems based on proper assessments and case selection.  

• Habilitation / Rehabilitation Therapies
• Oral medicines / drugs
• Injection Therapies
• Orthopedic Surgeries
• Neurosurgeries
• Intrathecal baclofen pump therapy
• Hyperbaric Oxygen Therapy
• Stem Cell Therapy
• Alternative and Complementary Medicines

Role of Habilitation / Rehabilitation therapies in the management of Spastic Cerebral Palsy
Habilitation therapies are the mainstay treatment of children with Spastic Cerebral Palsy. No treatment can be completed without the support of habilitation therapies. Our habilitation therapy comprises of

• Scientific parenting: Where we teach and train parents proper handling / positioning, transferring / postural changes and carrying technique
• Use of Assistive technology: Where we prescribe Aids & Appliances such as Postural aids, Mobility aids, Braces / Orthotic aids, Adaptive aids, Assistive aids, visual aids, hearing aids, etc
• Play therapy: Where we guide parents to choose age appropriate play activities and toys for development and acquiring skills 
• Physiotherapy: Where we make a need based physiotherapy program to practice and train parents to follow the same at home regularly
• Occupational therapy: Where we make a need based occupational therapy program ( combination of fine motor issues and sensory issues)  to practice and train parents to follow the same at home regularly
• Speech  therapy: Where we make a need based speech therapy program(combination of oromotor exercises, language development and communication) to practice and train parents to follow the same at home regularly
• Special Education: Where we make a need based cognition enhancement program to practice and train parents to follow the same at home regularly
• Behavioral therapy: Where we help the child and parents both to cope with day to day issues
• Counseling, etc to support the child in case of need

Role of Oral Medicines in the management of Spastic Cerebral Palsy
Lot of children with Spastic forms of cerebral palsy require medicinal support. We prescribe to

• Manage spasticity
• Manage  Convulsion (epilepsy / seizure / jerks)
• Manage drooling
• Manage constipations
• Manage  poor immunity
• Manage GERD, etc.

Role of Injection Therapy (Chemodenervation) in the management of Spastic Cerebral Palsy
Injection therapy has a great role in the management of children with Spasticity. We do Injection therapy with Botulinum Toxin (BOTOX, NOBOTA, XIOMEN, DYSPORT, etc) and Nerve block (Phenol, Alcohol). Botox is considered better than phenol nerve block. Botox can be injected as young as 2 years old. The golden period for Botox is 2-8 years of age. Botox can be given after 8 years of age also, when the child is not a right candidate for orthopedic surgery and the child has mild contracture. Always remember, the result of Injection therapy (Chemodenervation) depends on Post Intensive Phenol / Botox therapy. Generally, we do Botox to manage

• Toe walking 
• Bent Knees ( Crouch posture)
• Over straight knees ( Hyper-extended knees / Genu Recurvatum)
• Crossing of legs / Scissoring Gait ( Adducted Hips)
• Pronated mid arm
• Thumb-in-palm
• Flexed wrist
• Adducted and internally rotated shoulders, etc   

Role of Orthopedic Surgery in the management of Spastic Cerebral Pals
Orthopedic surgery has definitive role in the management of deformities due to spasticity and poor postures. The timing of the surgery depends on the type of deformity and the specific joints. Surgeries can be Single Event Single Level (SESL), Single Event Multilevel (SEML), Single Event Multilevel with Lever Arm Restorations (SEMLLARS), etc.  All orthopedic surgeries require intensive post operative care and therapies to get optimal improvements. The result of the procedure depends mostly on the quality and duration of the post operative therapy. Mostly surgeries fail due to poor therapy protocol. Parents should find an experienced therapist before they approach an orthopedic surgeon for the surgery. Orthopedic Surgeries can be very helpful if the child has

• Subluxation / Dislocation of Hips
• Severe Scoliosis  / Kyphosis
• Crouch Posture and Gait ( Bend knees, hips and ankle dorsiflexion)
• Fixed deformities of upper limb such as bend elbow, bend or deviated wrist, etc. It should be done before the child start ignoring the hand completely.     

 
Role of Rhizotomy (SDR/ SPR) in the management of Spastic Cerebral Palsy
Selective Dorsal/ Posterior Rhizotomy is a neurosurgical procedure. Severe spasticity which is uncontrollable with conventional therapies gets eliminated/ reduced with this SDR / SPR. A good assessment and procedure can do miracle but a bad decision can make the child cripple also. Children with Quadriplegia with good cognition and communication are best suited for SDR. Need based SDR can be done for children with Diplegia and hemiplegia also

Role of Intra-thecal Baclofen Pump Therapy in the management of Spastic Cerebral Palsy
Quadriplegic children with good intelligence and severe spasticity are always benefited with Intrathecal Baclofen Therapy.  Very few children with diplegia and hemiplegia require the help of ITBP as spasticity can be easily managed with other available treatment systems / procedures.

Role of Hyperbaric Oxygen Therapy (HBOT) in the management of Spastic Cerebral Palsy
As HBOT is a generalized treatment for children with Cerebral Palsy; Children with all form of spastic CP are eligible for this treatment system. When HBOT is accompanied with good pediatric therapy, encouraging results have been observed. HBOT (Oxygen Therapy) is always considered better than HBAT (Air Therapy). Children less than 6 years of age are better candidate for HBOT. Older children show very poor result or no results

Role of Stem Cell Therapy (SCT) in the management of Spastic Cerebral Palsy
Stem cells are considered as repairing cell of the body. As the children with Spastic CP have insulted brain cells, stem cell can be judiciously used to revive these cells. Stem Cell Therapy requires meticulous screening and assessments to select a genuine candidate. We provide stem cell therapy to selected children where parents consciously opt for it. Stem cell therapy is followed with 9-12 months intensive pediatric therapy to harvest the results.  

Role of Exploratory Therapies in the management of Spastic Cerebral Palsy
Parents of children with spastic cerebral palsy have reported good results from these therapies so these can be incorporated in the total management program. Isolated use of these therapies has very little role. So whenever, you start any of therapies, please continue the standard therapies / rehabilitation therapies as usual. Hydrotherapy (Water Therapy) and Hippo therapy (Horse Therapy) have been considered the best alternative therapies to encourage Spinal / Truncal control and balance with spastic children. Ayurveda, Unani, Acupuncture, Acupressure, Homeopathy, etc are worthy to manage / control associated problems with Spastic CP  

Prognosis / employment opportunities of person (Adult / individual) with Spastic Cerebral Palsy

Hemiplegic CP:
With opportunity and stimulation all hemiplegic children should walk. The vast majority has speech, the majority at the normal time. The placement of adult hemiplegic possibly with more organized early help the results could be better. The majority of hemiplegics with / without supervision can work in open market.

Diplegic CP:
Eventual independent walking should be achieved in all cases where the use of hands is nearly normal. Other children with more severe involvement of hands should walk with the use of elbow crutches. If the child can walk independently early in school life, he should be able to manage in a normal class at school. Employment in later life is influenced by the presence of visuo-perceptual difficulties. Mostly they are able to work in open market

Quadriplegic CP:
Children with less severe involvement of hands and trunk should walk with the use of elbow crutches. They may later need to use a wheelchair or motorized vehicle. With supreme effort a large number of children can walk without any support and attend normal school. Others, due to the need for treatment and special chairs and appliances during school life, may need education in a special class. Employment in later life is influenced by the presence of associate factors. If the child has below average mental ability and poor form of mobility then the chances of open employment is very less. A large number of children can work in a shelter workshop under supervision. Only a few of spastic quadriplegic children can have the opportunity to work in open market, in a factory or a place where mobility is must.


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