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 Table of Contents  
LETTER TO THE EDITOR
Year : 2022  |  Volume : 36  |  Issue : 1  |  Page : 65-67

Management of spasticity in cerebral palsy children with early intervention and functional physical therapy


1 District Early Intervention Centre of Excellence, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
2 Department of Orthopaedic Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Web Publication25-Apr-2022

Correspondence Address:
Dr. Nusrat Jahan
District Early Intervention Centre of Excellence, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh - 202 002, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_85_21

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How to cite this article:
Jahan N, Ateeq A. Management of spasticity in cerebral palsy children with early intervention and functional physical therapy. Indian J Pain 2022;36:65-7

How to cite this URL:
Jahan N, Ateeq A. Management of spasticity in cerebral palsy children with early intervention and functional physical therapy. Indian J Pain [serial online] 2022 [cited 2022 Jul 1];36:65-7. Available from: https://www.indianjpain.org/text.asp?2022/36/1/65/343831



Sir,

Early intervention and functional physical therapy is an important key for the initial treatment and prevention of contracture in cerebral palsy children. It also reduces further complications in the management of spasticity. The interdisciplinary approach is needed to counter spasticity and early motor development. It should be initiated as early as possible, around 3 months when the age where the child holds his neck stability or as weight-bearing starts in children by 6 months to 1 year.

Spasticity in cerebral palsy causes due to damage of the motor cortex of the brain before, during, or after birth. Commonly in birth asphyxia, any prenatal or postnatal brain injury which hinders blood supply to the functional brain in children. The definition of spasticity by Lance (1980) is “a velocity dependent increase in stretch reflex.”[1] The North American Task Force for Childhood Motor Disorders suggested that spasticity should be redefined as “a velocity dependent increase in hypertonia with a catch when a threshold is exceeded” in 2003. Standardized Measures of Spasticity (the SPASM consortium) suggested spasticity as “disordered sensory-motor control, resulting from an upper motor neuron lesion, presenting as intermittent or sustained involuntary activation of muscles.” Cerebral palsy can be divided into three main subtypes based on the main motor disorder: spastic, dyskinetic, and ataxic. Spastic cerebral palsy can again divided into: (a) spastic diplegia (where muscle stiffness is mainly in the legs, with the arms less affected or not affected at all), (b) spastic hemiplegia/hemiparesis (affects only one side of a person's body; usually the arm is more affected than the leg), and (c) spastic quadriplegia/quadriparesis (most severe form of spastic CP and affects all four limbs, the trunk, and the face). Spastic cerebral palsy can be assessed with neural and physical examination, which includes tone, posture, and movement of the child. Spasticity can assess with the length of the muscles involved in thigh muscles as hamstring, iliopsoas muscle, adductors, primarily resulting in scissoring and tendo achilles, which results in toe standing. W-sitting [Figure 1] occasionally seen in spastic children with scissoring [Figure 2] and equines gait due to spasticity in leg muscles. Modified Ashworth scale assess for objective value of spasticity in CP children. A thorough neural examination is important, including primitive reflexes and deep tendon reflex to classify for upper motor neuron lesion. In the case of a child is < 1 year, Amiel-tison examination can be performed to evaluate hypertonicity in the upper and lower limb. In the case of a child older than 1 year, Hammersmith Infant Neurological Examination (HINE) can be performed to evaluate the motor development and prognosis of the child. These scores of the HINE were used for the detection of high risk of cerebral palsy at an early age and prediction of independent sitting and walking in children with CP.
Figure 1: Scissoring of legs

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Figure 2: W-sitting

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Early intervention in spasticity and motor functions is the prime aspect at the initial stage of treatment. Scissoring in legs, standing on toes, and flexed contracture in the knee are some of the obstacles to walking and functional mobility due to spasticity. The role of physiotherapists play an important role in assessing function, defining disability, and providing appropriate treatment with mobility aids/casting/orthoses and motor training with stretching exercises for the success of medical and surgical interventions in spasticity management. Managing spasticity could have a variety of treatments based on severity, including myofascial release, acupressure, and physical therapy treatment including BOBATH and ROODS approach, mirror therapy, constrained induced movement therapy (CIMT), manual therapy, and specific stretching exercises. CIMT includes not only for hemiparesis CP treatment but also involves fine motor activity to engage in hand motor functional activity to increase motor function in hand. Passive stretching programs, splintage, and positioning are essential to prevent deterioration of body alignment. Facilitation of active control in the limbs and strengthening exercises for the trunk muscles are essential in promoting functional movement in children with CP. If physical treatment alone is not sufficient to overcome spasticity, intramuscular botulinum toxin injection or nerve block with phenol is also a treatment of choice for focal spasticity.[2] Its effect lasts for 4–6 months during which, better motor control can obtain and it also allows intensive physical therapy to maintain the results for long-lasting. Botulinum treatment can be used followed by physical therapy methods to get better results that last longer in children.[3] Once children acquire their milestones in the form of weight-bearing like quadrapod, crawling and standing with good alignment of body positioning, then the activity of daily life can be trained to the child with minimal support.

Modulation of tone by weight-bearing [Figure 3] and [Figure 4] is an important part after weight-bearing phase has been achieved. Weight-bearing promotes the influence of gravity within the optimum alignment.[4] Standing, quadrapod position, sitting with hand support is vital tool for therapists in the treatment of spasticity with weight-bearing phenomena. However, it must be dynamic and not static to have access influence from the vestibular system. Weight-bearing on joints of the upper and lower limb not only gives freedom to explore better, but it also promotes the facilitation of movements, muscle tone normalization, and trunk control strengthening. The ideal position is the hip should be maintained at an angle of slightly more than 90°, which is often facilitated by a seat cushion with a slight backward slope. Knees and ankles should be at 90°. In severe spasticity, this posture may not be possible or may require a variety of seating adjustments such as foot straps, knee blocks, adductor pommels, lumbar supports, lateral trunk supports, and a variety of head-and-neck support systems. A spastic child also can be advised for modified supportive chairs support to enhance correct poisoning as well as trunk control.
Figure 3: Functional physical therapy

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Figure 4: Functional physical therapy

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Crawling exercise builds up both core and girdle muscles in preparing for better development of the gross motor function.[5] Crawling is better for reducing spasticity, milestone development, and preparing the body for the next goal to achieve in proper alignment. Sitting is also an area that we need to emphasize for those with spastic diplegia. Spasticity of lower limb muscles-hamstrings, hip adductors, and iliopsoas-hampers sitting posture. These kids either sit with a round back because of the pull from the hamstrings muscle or they compensate with “W” sitting posture [Figure 2] to alleviate the pull from the spastic muscles. Children with spastic diplegia always have increased muscle tone over both calf muscles, which causes equinus gait with toe standing pattern with the collapse of medial foot arches. Ankle foot orthosis (AFO) are typically designed to limit unwanted ankle movements, specifically ankle plantar flexion.[6] AFO is used to prevent or correct deformities in the spastic limb and help cerebral palsy children to conquer activity limitations, such as difficulties in standing and walking. Serial casting can also improve the range of movement in a contracted joint.

Financial support and scholarship

Nil

Conflict of interest

There is no conflict of interest



 
  References Top

1.
Bar-On L, Molenaers G, Aertbeliën E, Van Campenhout A, Feys H, Nuttin B, et al. Spasticity and its contribution to hypertonia in cerebral palsy. Biomed Res Int 2015;2015:317047.  Back to cited text no. 1
    
2.
Barnes MP. Management of spasticity. Age Ageing 1998;27:239-45.  Back to cited text no. 2
    
3.
Shamsoddini A, Amirsalari S, Hollisaz MT, Rahimnia A, Khatibi-Aghda A. Management of spasticity in children with cerebral palsy. Iran J Pediatr 2014;24:345-51.  Back to cited text no. 3
    
4.
Kilbride C, McDonnel A. Spasticity: The role of physiotherapy. Br J Ther Rehabil 2000;7:61-4.  Back to cited text no. 4
    
5.
Chan N. Physiotherapy in spasticity management for children with cerebral palsy. The Hong kong Medical diary, 2011;16:24-6.  Back to cited text no. 5
    
6.
Flett P. Rehabilitation of spasticity and related problems in childhood cerebral palsy. J Paediatr Child Health 2003;39:6-14.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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