NRF’s second webinar, focused on “Rehabilitation in Cerebral Palsy” was held successfully on June 29th 2020. With an impressive participation of 539 attendees, with 284 remaining engaged until the session’s conclusion, the talks were most insightful and well appreciated. Dr Seema Grover, Head of Physiotherapy at Apollo Hospitals Delhi, moderated the 90-minute session.
The distinguished panel included experts from Apollo Hospitals Delhi: Dr Vineet Bhushan Gupta, Paediatric Neurologist and Dr Ramani Narasimhan, Paediatric Orthopaedician; and Dr Amruta Paranjape from NeuroGen Brain and Spine Institute, Mumbai who is an Aquatic Therapy specialist.
Dr Gupta spoke on the clinical presentation of cerebral palsy (CP), stressing the importance of early diagnosis and outlining its signs, symptoms, and associated comorbidities. Dr Narasimhan discussed the
broader impact of CP on families and detailed the rationale and criteria for surgical intervention in affected children. He underscored the necessity of a focused multidisciplinary approach to CP management.
The session concluded with an insightful video presentation by Dr Amruta Paranjape, elaborating on the benefits of aquatic therapy alongside physical therapy for CP. She emphasised its positive effects on children’s mental well-being, respiratory and cardiovascular systems, and overall quality of life.
Despite the overwhelming response with over 34 questions, time constraints allowed for only a partial response during the session. However, all queries were addressed comprehensively afterward and are accessible on the NRF website.
Dr Seema Grover expressed gratitude to the guest speakers for their excellent presentations and thanked NRF for organizing such a valuable educational webinar as part of their effort, during the pandemic period when physical meetings seemed a thing of the past.
NRF's 2nd Webinar | Rehab in CP | 29 June 2020 | 6 to 7:30 pm | Questions posted on chatbox / Q&A by participants
It won’t be correct to name ‘a’ type of therapy as most useful. The therapist needs to choose different approaches based on child’s impairments and goals. A combination of different approaches, interdisciplinary team work and making sure that multisystem impairments are addressed, are of essence to provide good clinical outcomes.
Yes. Active infections, contagious infections, Fever, Dysphagia are absolute contraindications. Open wounds, lack of oromotor control, uncontrolled seizures, lack of bowel and bladder control, limited ability to follow instructions, tube feeding are some of the relative contraindications.
Yes, parents can be trained to give some of the passive aspects of this therapy like Watsu ® stretches etc. at home. They can also be trained to supervise certain active aspects. However, they need to be in constant communication with the therapists and should not practise this therapy on their own without seeking advice from a trained Aquatic Therapist. Unlike land based therapy, parents first need to get trained on how to move in the water and how to manage themselves and the child. Therefore, it is essential to train parents before advising home programs.
Aquatic therapy is an adjunct to land based therapy. It cannot replace physiotherapy, but it can reduce the need or frequency of physiotherapy. Children need to do both the therapies for maximum outcomes.
Diplegia is a condition that causes stiffness, weakness, or lack of mobility in muscle groups on both sides of the body. This predominantly involves the legs, but does not exclude involvement of the upper limbs and face. Diplegia exhibits hypertonicity. It is a movement disorder and not complete lack of movement. Paraplegia on the other hand is inability to perform any movement with lower limbs. It is flacid/spastic paralysis as observed in spinal cord injury.
Aquatic therapy can be started in children as young as 6 months of age as well; however, it requires a good infrastructure and therapeutic pool as opposed to public pools which are usually used / are available in India. By stage, if you mean stage of motor development, we can start the therapy even before the child has achieved any motor milestones.
I would suggest for such a child, Aquatic Therapy should be done under supervision of an expert therapist. The reason for aggression needs to be identified. Many a times in my practice, I have noticed that the children may have some underlying sensory processing disorders, impaired communication ( inability to express) or behavioral issues that cause aggressive behavior. Once the reason is identified, we need to address that first. The child should not be forced to undergo therapy sessions; it should happen more organically. Some medications may also help to reduce the aggression and a pediatric neurologist or pediatrician can be consulted to a} reduce aggressive behaviour b} reduce seizures.
Aquatic therapy is an adjunct to land based therapy. It cannot replace physiotherapy, but it can reduce the need or frequency of physiotherapy. Children need to do both the therapies for maximum outcome. No therapy is better than the other. However, both the therapies have their advantages e.g. aquatic therapy reduces joint compression and therefore protects the ligaments and soft tissues when the child is weight-bearing, while activities like walking etc. on the other hand (land based therapy) provide better ground reaction force and therefore more sensory input. There are a lot of differences between land based and aquatic therapy – the below mentioned features, in my opinion, are the most relevant for cerebral palsy rehabilitation –
1. Aquatic Therapy reduces the influence of gravity which facilitates performing certain movements that are otherwise not possible on land. It also reduces the speed at which children fall down and accommodates greater reaction time, observed in these children.
2. Helps to normalize tone.
3. Improves cardio-respiratory endurance.
4. Facilitates better motor control.
For poor bowel and bladder control following precautions can be taken –
1. Make sure that the child empties bowel and bladder not more than half and hour before the session, plan the session accordingly.
2. Keep the sessions short, not more than 30 min duration
3. There are water proof diapers available in the market which can prevent pool contamination even if the child urinates / defecates. However, in such an event, pool evacuation and decontamination procedures need to be followed
4. Pool water should be warm of therapeutic temperature and not cold
5. Know the signs when the child wants to urinate or defecate; usually, although they can’t express in words, the parents know the signs. There are certain signs that are suggestive; parents or caretakers must get well versed with those, so that you can prevent any accident in the pool.
Dr Ramani
Hip subluxations have consistently bad natural history if left untreated and invariably result in early osteoarthritis. Surgery is strongly indicated to reduce the joint and restore mechanics. There are no alternatives.
Dr Amruta
There is no evidence to conclusively say that Aquatic Therapy can prevent surgery, I wouldn’t say it can. Surgery is important to prevent secondary complications of hip subluxation.
Indications of Ortho surgery in CP in general, is most predictable in Spastic CP. There is a huge importance given currently to: 1. Timing– surgeries are not indicated before the mature gait pattern has been established ie before 7-8 years, or recurrances are very common. 2. Concept of SEMLS, single even multilevel surgeries in order to address all the existing deformities or joint imbalances at the same time so that any focussed PT/OT which would follow is more effective in bettering function eventually. 3. Case selection is very important. Type (spastic better), extent of involvement and pre-op functional status are important determinants. Compliance to the whole multidisciplinary treatment is also a pre-requisite.
Piece-meal surgeries as name suggests, were surgeries previously performed especially in Spastic CP, as and when the deformities appeared. It is akin to ‘birthday syndrome’ where roughly at each birthday, the child ended up getting a deformity corrected. Now we have realised, that this sort of approach was bad and definitely did not translate into eventual improvement of function. Sadly on the contrary, there was deterioration!. This was mainly because there was always recurrance and complex adaptive deformities and abnormal gait patterns which were impossible to treat in majority.
That is so true. There is no alternative to spending enough time in pre-operative counselling with that family who is usually distraught with their child’s condition. First the family should have this strong felling to improve their child’s condition. The concept of pathogenesis of CP, multidisciplinary approach towards management and importance of compliance to regular post-op follow-up with usage of appropriate orthosis and PT/OT, needs to be explained in clear simple understandable way. We need to show them the positive direction through surgery emphasizing on the aspect of improving function of their child but at the same time, discuss realistic goals post op. Most educated families do understand and respond favorably.
That is so true. There is no alternative to spending enough time in pre-operative counselling with that family who is usually distraught with their child’s condition. First the family should have this strong felling to improve their child’s condition. The concept of pathogenesis of CP, multidisciplinary approach towards management and importance of compliance to regular post-op follow-up with usage of appropriate orthosis and PT/OT, needs to be explained in clear simple understandable way. We need to show them the positive direction through surgery emphasizing on the aspect of improving function of their child but at the same time, discuss realistic goals post op. Most educated families do understand and respond favorably.
SEMLS is safe enough in a well equipped bigger set-ups with established anaesthesia department and Paediatric ICU back-up. Tertiary centers are the best bet.
Chances of recurrances after surgery are more: 1. when surgery is performed at a younger age ie <7 years of age 2. in other forms of CP (not spastic but extrapyramidal for instance) 3. Iatrogenic due to incomplete or improper surgeries. In general, properly planned SEMLS around age of 8 years in an ambulatory spastic CP with a GMFCS 3, would have relatively best outcome.
Kindly clarify your question Dr. Rathore. Do you want to ask how to differentiate?
NO, unless both suffered the same insult, for e.g. APH in mother or an underlying metabolic/ genetic cause
As you know all the structures in the body including brain are not formed completely in premature babies; they are babies, hence they are at higher risk of insult e.g. lack of O2 due to immature lungs, bleeding in the brain, etc.
Spastic diplegia and hemiplegia are the commonest types. However, the pattern varies according to the gestation of the baby and the time of insult to the brain.
Mainly brain and all related functions of it and musculo-skeletal systems are mainly affected. But eyes, hearing, speech and intelligence are more affected. In severe cases, gastrointestinal system also causes a lot of issues.
Not necessarily. May have axial hypotonia.
Intelligent CP children do suffer from mental illnesses, especially during school play time and at teenage.
There is no agreed definition on the time line. Most the children can definitely be labelled as CP around 2 years of age. However, as I have said in my talk, the soft signs are visible as early as 3-6 months; an experienced clinician can detect it at this stage also.
See the earlier answer for the age. No universal criteria to differentiate from other syndromes, but it is very important to differentiate from certain conditions for e.g. spastic paraplegia in HSP, certain metabolic conditions, HSMN, etc. as the treatment varies.
No definite tests to diagnose, but investigations may be required to differentiate from other conditions that mimics CP.
In this, the basal ganglia are mainly affected and child has more movement abnormalities than motor or cognitive problems.
Yes. For e.g. someone getting a head injury or meningo-encephalitis in later life will have features of CP.
CP is the commonest cause of physical disabilities in children, but not the only cause. A number of metabolic, genetic and some skeletal conditions can mimic CP.
Developmental delay can be in only one domain. If it is in 2 or more, then it is called GDD. Most of the CP children may have developmental delay but only small percentage of GDD children have CP. Differential diagnoses needs standard approach of medicine i.e. do the tests based on your clinical suspicion and rule out the condition. The basic principles of Rehabilitation do not change, but need of a particular domain may be more or less in an individual condition/ child.
Physiotherapy is for physical disability, while one needs Special Educator and psychologist’s input also for the management of ID. Both should go simultaneously.
If a specific muscle/ group of muscles is affected, then it is best to use Botox. To do it at the right age is important for the outcome.
