Neuromuscular Disorders Approach


 

CEREBRAL PALSY

More than any other condition, treatment of the child or adult with Cerebral Palsy (CP) must be individualized for that patient. Cerebral Palsy impacts each person differently. Some people suffer from severe spasticity or severe weakness while others have rigidity or movement disorders such as dystonia and athetosis.  Each of these patients must be treated differently. In order to achieve an optimal functional life and minimize chronic pain, all options from physical and occupational therapy to oral medications, injections of Botox and Dysport, a baclofen pump, percutaneous muscle lengthening, Rhizotomy to osteotomies etc. must be available and understood. Choosing between these options and creating a life plan with expectations and outcomes to match, is the key to my approach. No age is too young or too old to improve one’s quality of life.


Cerebral Palsy treatment needs to be the most individualized treatment protocol based on the child or adult’s symptoms and features of the condition.


I will briefly outline from non-invasive to more invasive treatments that are tailored to the patient.


  •  Physical therapy (PT):

Appropriate and intensive PT is the first line of treatment for most CP conditions.  Stretching, serial casting, gait training, strengthening, re-training neuromuscular pathways, constraint therapy, Medec, Feldenkrais method and many others are utilized to aid the patient in development  and achieving goals.


  • Chemodenervation:

Botox injections, and more recently Dysport, can be utilized to help loosen spastic muscles and aid the therapist in working with a patient.  Often this needs to be repeated every six months.


  •  Soft tissue releases (STML):

In most instances this can be done with percutaneous releases (PERCS).  This is a minimally invasive method to loosen contractures, most commonly of the lower extremities. Performed correctly and for the appropriate patient, PERCS can often be effective in helping the patient achieve new goals. Performed for the incorrect patient it can cause severe weakness and asymmetry. Larger soft tissue releases should often be combined with decompressing nerves to prevent severe pain and nerve dysfunction.


  • Dorsal Rhizotomy:

Most often performed by neurosurgeons specializing in Rhizotomy, it is most often utilized for children with good underlying strength but spasticity that is hampering them.  Best results are obtained if performed before the age of 7. Indications for the dorsal rhizotomy procedure have been expanded and it is being performed in adults and more severely involved children. I would be very careful about this as it can cause a great deal of weakness and rebound spasticity.


  • Baclofen pump:

Most commonly performed by specialized neurosurgeons, the pump is a reversible device implanted to administer Baclofen into the spinal fluid. It is quite effective in decreasing spasticity in those severely involved children and adults.


  • Osteotomies: 

Breaking of the bone and aligning the hips and lower extremities is often an essential part of treatment in CP.  Both to achieve the correct rotation of the limbs so individuals may walk better and more efficiently as well as to prevent hips from dislocating, this becomes crucial in the overall management of CP. Creating symmetry is the most important factor in treating these patients. I have spent many years performing these operations and successfully managing these problems.


FAMILIAL SPASTIC PARAPARESIS

FSP is variable in its presentation of age from childhood to adulthood, and its severity from mild to quite severe. For this reason, making the diagnosis is important and creating symmetry is essential. Balancing the muscles and utilizing all modalities carefully is often effective in maintaining ambulation in this patient population.


The most important factor distinguishing FSP from standard CP is that is often progressive and because all the muscles of the extremity may be involved, doing simple lengthening of the muscles may be quite detrimental and lead to imbalance. Symmetry is key. Utilizing a Baclofen pump and perhaps Rhizotomy may be effective.


RETT SYNDROME

Rett Syndrome often requires scoliosis treatment and surgical management.


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