Standard Treatment Guidelines For Cerebral Palsy

Cerebral palsy is defined as the non-progressive motor impairment (motor neurological deficit) due to the insult to the developing brain; affecting the movements and posture, however, no sensory impairment.

The involvement of the brain most commonly occurs between the time of conception and the age 2 years (the time of major motor development). After 8 years of the age, the development of the immature brain is almost complete; its affection is just like adults. This is very common disorder in the child hood and its incidence is on rise.

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Cerebral Palsy. Following are the major recommendations :

Types:

As per the time of affection of the brain this is categorized as prenatal, perinatal and post natal. Most common is prenatal and only less than 10% cases are affected during the delivery time i.e. perinatal.

Management

For the management, the complete and proper evaluation of the individual as whole and the affected part is mandatory. Some times in the situation of spasticity it is difficult to judge the muscle power and the treatment can be worsening rather than improving the functions and there can also be recurrence of the deformity. Therefore, whenever in doubt, the peripheral surgeon can refer the patient to the medical institute or to the metro hospital for the treatment after evaluation.

These patients apart from motor power evaluation may require the gait analysis; MRI of the brain and electromyography. The treatment of the some rare types of cerebral palsy is really difficult and very much demanding even at the level of the medical institute or the metro hospital. At the metro hospital the team approach involving the peaediatrician, the orthopedic surgeon, psychiatrist, physiotherapist and psycho-social workers is required for the better outcome in such patients.

Situation 1

No surgical intervention is expected at this level. One should refer the patient to the higher centre.

1. CHC/Civil Hospital level: At the non-metro hospital only simple surgeries like tendo-achillis tenotomy and adductor tenotomy for equines and the scissoring gait respectively can be tried and that too if the operating surgeon has the confidence and has reasonable experience. Otherwise it is better to refer the patient.


2. The goal of the treatment at the non metro clinic or small hospital is: Evaluation of the motor weakness by muscle power charting by Medical Research Council (MRC) grading system (Grade 0 to5).

Following can be done at this level:

Prescription of orthosis/calipers and its fitting;

-corrective cast application;

-Simple corrective procedures like- tenotmy for the tight tendo-achillis; lengthening of tendon and adductor tenotomy etc.

3. Arrangement of camps for providing orthosis and walking aids-Additionally at the district level hospital the patients can be provided the walking aids (like sticks, crutches, walkers etc), and wheel chair from the district level charitable agencies (Governmental/Non-governmental). They can be issued the disability certificates for their financial benefits from various schemes run by the Government.

Criteria for referral: The cases that need special investigations like nerve conduction studies, electromyographies and MRI/CT scans. Those who need tendon transfers, correction of deformity at multiple joints and in different planes; and need care of multiple specialists under one roof. Any case where the non metro level surgeon is in doubt in decision making of the type of surgery should be referred.

Situation 2

At the metro or the medical college level hospital the goal of management of these cases include: In addition to the situation 1- If required the elctromyographic studies, nerve conduction studies, MRI and CT scan of brain as per indication.

The non surgical treatment like botulinum injection can be given to relieve the spasticity.

Then all surgeries for the correction of deformity

-by tendon transfer

-the osteotomies/tenodesis,

-tendon lengthening,

-tenotomies, capsulotomies and arthrodesis as per the indication and after the careful evaluation of the individual. The goal of the treatment is focused on the independent walking (for lower limb) or the proper use of the upper extremity with/without orthosis. The lower extremity should be with planti-grade foot with no or minimal residual deformity at various joints and the limb should suitable for fitting of the orthosis/calipers and if feasible for independent walking. The upper extremity should be made suitable for fitting of orthosis and for the use in daily day to day routine like self eating, bathing; cleansing after toilet etc.

Various common surgical procedures include:

Tendo-achillis lengthening-for equinus correction,

Adductor tenotomy – to correct scissoring gait

Split tibialis anterior transfer -for inversion foot

Tibialis posterior tendon transfer- for foot drop,

Egger’s operation/Fractional release of hamstrings (Tendon lengthening/tenotomies and capsulotomies)-for knee contracture release.

Tripple arthrodesis for talipes equino-varus correction in mature feet.

Flexor pronator release and transfer of flexor carpi ulnaris to the wrist dorsiflexors for contracture of flexor and pronator muscle group.

Sever’s and Fairbank operation and derotation osteotomy of humerus- for internal rotation contracture at shoulder etc.

All the surgeries should be performed by the experienced surgeon and standard text book on the subject should be available in the operation theatre for the reference.

Resources required for patient and procedure

Situation	Human Resources	Investigations	Drugs and consumables	Equipment
1.	Doctor, Nurse and other paramedics	None	None	No surgical intervention except first aid
2.	Doctor, Nurse, and technicians	X-rays, Complete Haemogram, Bleeding time, Clotting time, Complete urine examination for for pre-anaesthetic check up	Plaster bandages PVC splints and Braces, Calipers	Theatre set up for Surgeries with all Basic equipments
3.	Doctor, Physiotherapist, Nurse, orthotist, Prosthetist, and technicians	As situation 1	As situation 1 and tricycle, wheel chair etc	As situation 1 and major physiotherapy set up for rehabilitation

Guidelines by The Ministry of Health and Family Welfare :

Dr. P.K. DAVE, Rockland Hospital, New Delhi, Dr. P.S. Maini, Fortis Jessa Ram Hospital, New Delhi

Reviewed By

Dr. V.K. SHARMA Professor Central Instiute of Orthopaedics Safdarjung Hospital New Delhi