1. Therapeutic Considerations in Cerebral Palsy Travis Edmiston R1, UW General Surgery

2. RJ  16 y/o male  Hemiplegic Spastic CP -GMFCS IV  PMHx -FTT at young age -Aspiration PNA as a infant -Multiple Fractures  PSHx -Gastrostomy age 5 months  Rx -Scopolamine -Baclofen -BTX -SSI  SocHx -10 th grade -Basketball -Gadgets -Good access to Healthcare -Part-time job

3. Heterogeneity in Etiology and Features A heterogeneous group of disorders -Present at birth although not easily detected -Motor and Postural Dysfunction -Uncoordinated, Stereotypic and/or Limited Movements

4. Heterogeneity in Etiology and Features 3 Main Classifications  Spastic (Most Common Dx) -Diplegic: LE>UE and bilateral 2/2 Periventricular Luekomalacia, term/preterm Prenatal Infection or Ischemia -Hemiplegic: Asymmetric 2/2 Cortical Injury, term Intrauterine Stroke or Vascular Issue -Quadriplegic: Most Severe Form 2/2 Developmental abnormality Infection or Underdevelopment  Dystonic: 2 nd most common, hypoxic injury, brain stem/BG/thalamus  Ataxic: Heterogeneous group

6. Clinical Features Spastic: Upper Motor Neuron Disorder -Spasticity is velocity dependent -Pos Signs: Hypertonic, Hypereflexive, Clonus -Neg Signs: Slow, Fine Motor, Poor movement isolation -Not the same as adult onset LMN signs Dystonic: Defect in Motor Processing -Repetitive spontaneous movements, Athetosis -Dyskinesias Ataxia: Ataxia

7. Natural History  Present at birth  Dx often after age 2  5-10% die in childhood  Aspiration is number one COD  Severity of motor dysfunction and associated disorder  2/3 Walk, 1/3 wheel chair dependent  Adult life expectancy not significantly different  Progressive disability but not due to disease progression

8. Associated Disorders  CNS: Other dysfunctions  Developmental -50% Intellectual disability -Epilepsy -Behavioral  Functional -30% unable to walk -25% unable to talk (Motor vs speech center)  Physical -75% with significant pain -Hip disorders -Bladder dysfunction

10. Diagnosis  No biomarkers  Generally 12-24 months of age  Various predictive motor-based assessment tools

12. Gross Motor Function Classification System  I Walks without limitation  II Walks with some limitation  III Uses Hand-held ambulatory device  IV Self Mobilization  V Transport dependent

13. Treatment  Treatment is life-long  Disability progression not disease progression  Goals: Maintain or improve function -Prevention of GSFCS Advancement -Social development -Communication -Education -Nutrition (caloric demands, oromotor dysfunction, growth charts) -Mobility -Independence

14. Medications  Anticholinergics  Antispasmodics (BDZ, dantrolene, baclofen)  Botox  Intrathecal Baclofen

15. Surgery  Gastrostomy  Salivary  Selective Dorsal Rhizotomy  DBS?

16. Orthopedic  Hip interventions  Casting  Splints/AFOs/PFOs  Tendon Release

17. Physical Therapy  Moderate level of evidence -Gross motor task training -Hippotherapy -Non-supported treadmill -Postural training -Reactive balance training  Weak or Conflicting -Functional Electrical Stim -Hippotherapy simulation -Supported treadmill -Neurodevelopmental therapy -Virtual Reality -Visual Feedback -Strength training (Ineffective) -Most Upper extremity interventions

18. High Tech Gadgets ?

19. Evidence-Based Approaches  Child Active (Vs Child Passive) -Task-based -Neuroplasticity Model -Considered “Best Practice”  Compensatory Environmental Adaptation -Adapting skills for novel tasks/obstacles -Avoids adapting environment to child  Health and Secondary Prevention -Aging, comorbidities -Preventing Disability progression (Contractures)

22. Stigma  Historical -Most/Considered to have MR -Institutionalized -Locked in syndrome?  Modern -Identity constructs (with CP or CP identity) -Needing help, feeling different, decreased healthcare usage -Need for individualized care (practitioner burden) -Perceived disability often > actual disability -Feeling need to mimic stereotypical behavior to HC professionals -Support with associated groups

23. RJ  16 y/o male  Hemiplegic Spastic CP -GMFCS IV  PMHx -FTT at young age -Aspiration PNA as a infant -Multiple Fractures  PSHx -Gastrostomy age 5 months  Rx -Scopolamine -Baclofen -BTX -SSI  SocHx -10 th grade -Basketball -Gadgets -Good access to Healthcare -Part-time job

25. Questions

26. Citations  Centers for Disease Control and Prevention. Data & Statistics for Cerebral Palsy. 2015, January. http://www.cdc.gov/ncbddd/cp/data.html  Novak I. Evidence-Based Diagnosis, Health Care, and Rehabilitation for Children With Cerebral Palsy. Journal Of Child Neurology [serial online]. August 2014;29(8):1141-1156.  Rosalee Dewar, Sarah Love, Leanne Marie Johnston. Exercise interventions improve postural control in children with cerebral palsy: a systematic review. Journal Of Child Neurology [serial online]. DOI: 10.1111/dmcn.12660  Stuart A. Read, Thomas A. Morton, Michelle K. Ryan Negotiating identity: a qualitative analysis of stigma and support seeking for individuals with cerebral palsy. Disability and Rehabilitation 2015 37:13, 1162-1169