MANAGEMENT OF INFANTS AT RISK FOR CEREBRAL PALSY MANAGEMENT OF INFANTS AT RISK FOR CEREBRAL PALSY MANAGEMENT OF INFANTS AT RISK FOR CEREBRAL PALSY

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1 MIAMI CHILDREN S NEUROLOGY Oscar Papazian, MD, FAAP Clinical Associate Professor Department of Pediatrics Herbert Wertheim College of Medicine Florida International University Miami, Florida, USA Risk Factors Early Treatment Physical Therapy Neurodevelopmental Reciprocal Inhibition Botulinum toxin A Medications Risk Factors % Perinatal asphyxia 35 None 25 Emergency c section 14 Prematurity 14 Prenatal disorder 12

2 Risk Factors Total Sex % Male 71 Female 29 Hypertonia Hypotonia central Dystonia Athetosis Primitive reflexes Motor developmental skills delay Behaviour disorder Sleep disorder Hypertonia Increase resistance to stretching the hypertonic muscles Voluntary movements are impaired Static increased Dynamic Postural increased MSR increased Hypotonia (central) Decrease resistance to stretching the hypotonic muscles Voluntary movements are impaired Static decreased Dynamic Postural increased MSR increased

3 Dystonia Static (postures) Dynamic (movements) Resistance to stretching the dystonic muscles Voluntary movements are affected Athetosis Resistance to stop the distal involuntary movements Voluntary movements are impaired Primitive Reflex Resistance to stop muscles action Voluntary movements abnormal Static increased Dynamic Postural increased MSR increased Motor developmental skills adquisition Head up Roll over Crawling Seating-up Pull to stand Stand-up Walk with and withouth support

4 Motor developmental skills adquisition Pincer grasp Transfering Visuomotor coordination for pacifier Hold the bottle in the mouth Clap Behavior disorder Low tolerance Easy frustration Poor self-control Temper tantrums Colic-like pain Sleep disorders Difficult to fall sleep crying Frequent awakenings crying Early Treatment Physical Therapy Neurodevelopmental Reciprocal inhibition Diving/swimming therapy Occupational Therapy Speech / oral therapy

5 Early Treatment Botolinum toxin A Medications Hypertonia Baclofen Zanitidine Clonazepan Early Treatment Botolinum toxin A Medications Dystonia Baclofen Athetosis Trihexyphenidyl REHABILATION GOALS To achieve independent walking and use of the hands by age 2 years old. NEURODEVELOPMENTAL THERAPY Inhibition Hypertonia Abnormal Postures and Movements

6 Objectives To increase the muscle tone and strenght of antagonist muscles To decrease the muscle tone and improve the strenght of the protagonistic muscles To avoid any activity that it may increase the abnormal postures and movements. Methods To evoke primitive reflexes continously Placing reflex Crawling reflex Diving reflex Lower extremities placing reflexes To apply during sleep subliminal electical current to the antagonistic muscles

7 Upper extremities placing reflex Crawling Reflex Instructions to parents To evoke the upper and lower extyremities placing and crawling reflexes 10 times each three times a day To strech the muscles 10 minutes three times a day 1. Orthotics during sleep at ankles, toes, wrist and fingers 2. PT/OT 1 hour 3/week.

8 RESULTS Independent Ambulation at age 2 years old NDT/RIT NDT N 40 N (60 %) * 12 (35 %) 21 months 15 (62.5%) * 7 (58 %) 12 months 9 (37.5%) 5 (42 %) * p = RESULTS Independent use of the hands at age 2 years old NDT/RIT NDT N=40 N=34 28 (70 %) * 17 (50 %) 21 months 19 (68 %) * 10 (53 %) 12 months 9 (32 %) 7 (47 %) * p = RESULTS Cerebral Palsy Incidence at age 2 years old NDT/RIT NDT N=40 N=34 16/40 (40 %) 22/34 (65 %) * 23 months 3 (19 %) 9 (41%) 12 months 13 ( 81 %) * 13 (59 %) *p = RESULTS FTA/NDT 40 NDT m 12 m Total 23 m 12 m Total I/II N42 Initial Final A * III N23 Initial Final A 1 2 4* IV N9 Initial Final A 0 0 0* 0 0 0* * p = 0.013

9 TREATMENT BOTOX Transient decrease muscle tone by distal motor axonal neurolysis Doses 10 units/kg BW every 3 months times 4 Target muscles : gastronecmius, hamstring, hip adductors, abductor pollicis brevis, wrist and finger flexors, biceps and brachialis. Side effects rare Efficacy transient for 3 months TREATMENT Medications NONE in the first 2 years of life. Surgery NONE in the first 2 years of life. CONCLUSIONS The incidence of CP at age 24 months old was signicantly higher in the infants treated for 12 months with RIT /NDT (81%) than NDT (59%). The incidence of CP at the age of 24 months old was significanlty higher in the infants treated for 21 months with NDT alone (41%) than in the group treated with NDT and RIT (19%). p = MANAGEMENT OF THE INFANTS AT RISK OF CEREBRAL PALSY CONCLUSION Infants with dynamic and static hypertonia with or without abnormal postures and/or involuntary movements must be treated with NDT 3 times a week with therapist RIT 2 times a day with parents Duration: until age 2 years old

10 MANAGEMENT OF THE INFANTS AT RISK OF CEREBRAL PALSY CONCLUSION We do not recommend Diving Reflex MANAGEMENT OF THE INFANTS AT RISK OF CEREBRAL PALSY BOTOX MEDICATIONS SURGERY MANAGEMENT OF THE INFANTS AT RISK OF CEREBRAL PALSY MANAGEMENT OF THE INFANTS AT RISK OF CEREBRAL PALSY Placing Reflex THANK YOU