Serebral Palside Spastisite Tedavisi

Yıl 2016, , 136 - 141, 01.12.2016

Gül Mete Civelek Ayçe Atalay

https://doi.org/10.4274/jcp.74755

Öz

Serebral palsi tanısı klinik bir tanıdır ve motor gelişimde gerilik, anormal kas tonusu ve hiperrefleksiyi içerir. Serebral palsili çocuklarda kas güçsüzlüğü, spastisite, koordinasyon kaybı, primitif reflekslerin devam etmesi ve normal motor kontrolün gelişememesi sıklıkla görülür. Spastisite hıza bağımlı olarak, pasif kas gerilmesine karşı artan dirençtir. Spastisite derecesi ve etkileri açısından ayrıntılı olarak değerlendirildikten sonra bir tedavi programı oluşturulmalıdır. Optimal kas tonusuna ulaşabilmek için yapılacak tedaviler genel olarak fizik tedavi ve rehabilitasyon programını, oral ve enjekte edilen ilaçları ve cerrahi tedavileri kapsar. Serebral palside spastisite tedavisinde özellikle germe egzersizlerini içeren kişiselleştirilmiş bir fizik tedavi ve rehabilitasyon programı tedavi planlarında mutlaka yer almalıdır. Serebral palside spastisite tedavisi için verilen farmakoterapinin optimal uygulaması ile ilgili bir konsensus yoktur. Generalize spastisite tedavisinde baklofen, benzodiazepin, tizanidin ve dantrolen gibi oral ilaçlar kullanılabilir. Ağızdan alınan ilaçların sedasyon ve kognitif defisit gibi önemli yan etkileri vardır. Lokalize spastisite tedavisi için perinöral fenol ya da etil alkol enjeksiyonuyla kemodenervasyon ya da intramusküler botulinum nörotoksin A enjeksiyonu kullanılabilir. Botulinum nörotoksin tip A’nın çocuklarda spastisiteyi azaltmada güvenilir ve etkili olduğu gösterilmiştir. Serebral palside spastisite tedavisinde kullanılan cerrahi teknikler arasında en sık kullanılanı selektif dorsal rizotomidir ve seçili olgularda uygulanabilir. Bu derlemede serebral palside spastisite tedavisinde kullanılan tedavi seçenekleri yer almaktadır

Anahtar Kelimeler

Serebral palsi, kas spastisitesi, tedavi, ilaç tedavisi, rehabilitasyon

Treatment of Spasticity in Cerebral Palsy

Öz

The cerebral palsy diagnosis is a clinical one and it includes motor development delay, abnormal muscle tone and hyperreflexia. Muscle weakness, spasticity, loss of coordination, the continuation of the primitive reflexes and non-developed normal motor control are often seen in children with cerebral palsy. Spasticity is the velocity dependent increase in the resistance against passive muscle stretching. Spasticity treatment program should be established after detailed evaluation of degree and effects.Treatments to achieve optimal muscle tone include physical therapy and rehabilitation program, oral and injectable medications and surgical treatments. In the treatment of spasticity, a personalized physical therapy and rehabilitation program including stretching exercises should be in the treatment plans, absolutely. There is no consensus regarding the optimal application of pharmacotherapy for the treatment of spasticity in cerebral palsy. Oral medications such as baclofen, benzodiazepine, tizanidine and dantrolene can be used for the treatment of generalized spasticity. Oral drugs have significant side effects such as sedation and cognitive deficits. Chemodenervation with perineural phenol or ethanol injection or intramuscular injection of botulinum neurotoxin A can be used as treatment of localized spasticity. It is shown that botulinum neurotoxin type A is safe and effective in reducing spasticity in children. Most commonly used surgical technique for the treatment of spasticity in cerebral palsy is selective dorsal rhizotomy and it can be applied to selected cases. Treatment options that are used in the treatment of spasticity in cerebral palsy are discussed in this review

Anahtar Kelimeler

Cerebral palsy, muscle spasticity, treatment, drug treatment, rehabilitation

Kaynakça

• 1. Zarrinkalam R, Russo RN, Gibson CS, van Essen P, Peek AK, Haan EA. CP or not CP? A review of diagnoses in a cerebral palsy register. Pediatr Neurol 2010;42:177-80.
• 2. Dodge NN. Cerebral palsy: medical aspects. Pediatr Clin North Am 2008;55:1189-207.
• 3. Berker AN, Yalcin MS. Cerebral palsy: orthopedic aspects and rehabilitation. Pediatr Clin North Am 2008;55:1209-25.
• 4. Tilton AH. Management of spasticity in children with cerebral palsy. Semin Pediatr Neurol 2004;11:58-65.
• 5. Sanger TD, Delgado MR, Gaebler-Spira D, Hallett M, Mink JW, Task Force on Childhood Motor D. Classification and definition of disorders causing hypertonia in childhood. Pediatrics 2003;111:e89-97.
• 6. Verrotti A, Greco R, Spalice A, Chiarelli F, Iannetti P. Pharmacotherapy of spasticity in children with cerebral palsy. Pediatr Neurol 2006;34:1-6.
• 7. Koman LA, Smith BP, Shilt JS. Cerebral palsy. Lancet 2004;363:1619-31.
• 8. Rekand T. Clinical assessment and management of spasticity: a review. Acta Neurol Scand Suppl 2010:62-6.
• 9. Erkin G, Aybay C. Pediatrik rehabilitasyonda kullanılan fonksiyonel değerlendirme metodları. Türkiye Fiziksel Tıp ve Rehabilitasyon Dergisi 2001;47:16-38.
• 10. Başarır M, Özek MM. Spastisite ve Tedavisi. Türk Nöroşirürji Dergisi 2013;23:158-73.
• 11. Verschuren O, Ketelaar M, Gorter JW, Helders PJ, Uiterwaal CS, Takken T. Exercise training program in children and adolescents with cerebral palsy: a randomized controlled trial. Arch Pediatr Adolesc Med 2007;161:1075-81.
• 12. Sterba JA. Does horseback riding therapy or therapist-directed hippotherapy rehabilitate children with cerebral palsy? Dev Med Child Neurol 2007;49:68-73.
• 13. van Dijk H, Jannink MJ, Hermens HJ. Effect of augmented feedback on motor function of the affected upper extremity in rehabilitation patients: a systematic review of randomized controlled trials. J Rehabil Med 2005;37:202-11.
• 14. Ozer K, Chesher SP, Scheker LR. Neuromuscular electrical stimulation and dynamic bracing for the management of upperextremity spasticity in children with cerebral palsy. Dev Med Child Neurol 2006;48:559-63.
• 15. van der Linden ML, Hazlewood ME, Aitchison AM, Hillman SJ, Robb JE. Electrical stimulation of gluteus maximus in children with cerebral palsy: effects on gait characteristics and muscle strength. Dev Med Child Neurol 2003;45:385-90.
• 16. van der Linden ML, Hazlewood ME, Hillman SJ, Robb JE. Functional electrical stimulation to the dorsiflexors and quadriceps in children with cerebral palsy. Pediatr Phys Ther 2008;20:23-9.
• 17. Khalili MA, Hajihassanie A. Electrical simulation in addition to passive stretch has a small effect on spasticity and contracture in children with cerebral palsy: a randomised within-participant controlled trial. Aust J Physiother 2008;54:185-9.
• 18. Dodd KJ, Taylor NF, Graham HK. A randomized clinical trial of strength training in young people with cerebral palsy. Dev Med Child Neurol 2003;45:652-7.
• 19. Patikas D, Wolf SI, Mund K, Armbrust P, Schuster W, Doderlein L. Effects of a postoperative strength-training program on the walking ability of children with cerebral palsy: a randomized controlled trial. Arch Phys Med Rehabil 2006;87:619-26.
• 20. Unger M, Faure M, Frieg A. Strength training in adolescent learners with cerebral palsy: a randomized controlled trial. Clin Rehabil 2006;20:469-77.
• 21. Scholtes VA, Dallmeijer AJ, Rameckers EA, et al. Lower limb strength training in children with cerebral palsy--a randomized controlled trial protocol for functional strength training based on progressive resistance exercise principles. BMC Pediatr 2008;8:41.
• 22. Taub E, Ramey SL, DeLuca S, Echols K. Efficacy of constraintinduced movement therapy for children with cerebral palsy with asymmetric motor impairment. Pediatrics 2004;113:305-12.
• 23. Charles JR, Wolf SL, Schneider JA, Gordon AM. Efficacy of a child-friendly form of constraint-induced movement therapy in hemiplegic cerebral palsy: a randomized control trial. Dev Med Child Neurol 2006;48:635-42.
• 24. Deluca SC, Echols K, Law CR, Ramey SL. Intensive pediatric constraint-induced therapy for children with cerebral palsy: randomized, controlled, crossover trial. J Child Neurol 2006;21:931-8.
• 25. Gordon AM, Chinnan A, Gill S, Petra E, Hung YC, Charles J. Both constraint-induced movement therapy and bimanual training lead to improved performance of upper extremity function in children with hemiplegia. Dev Med Child Neurol 2008;50:957-8.
• 26. Sung IY, Ryu JS, Pyun SB, Yoo SD, Song WH, Park MJ. Efficacy of forced-use therapy in hemiplegic cerebral palsy. Arch Phys Med Rehabil 2005;86:2195-8.
• 27. Carlson WE, Vaughan CL, Damiano DL, Abel MF. Orthotic management of gait in spastic diplegia. Am J Phys Med Rehabil 1997;76:219-25.
• 28. Wilson H, Haideri N, Song K, Telford D. Ankle-foot orthoses for preambulatory children with spastic diplegia. J Pediatr Orthop 1997;17:370-6.
• 29. Bjornson KF, Schmale GA, Adamczyk-Foster A, McLaughlin J. The effect of dynamic ankle foot orthoses on function in children with cerebral palsy. J Pediatr Orthop 2006;26:773-6.
• 30. Chung CY, Chen CL, Wong AM. Pharmacotherapy of spasticity in children with cerebral palsy. J Formos Med Assoc 2011;110:215- 22.
• 31. Quality Standards Subcommittee of the American Academy of N, the Practice Committee of the Child Neurology S, Delgado MR, et al. Practice parameter: pharmacologic treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2010;74:336-43.
• 32. Benini R, Shevell MI. Updates in the treatment of spasticity associated with cerebral palsy. Curr Treat Options Neurol 2012;14:650-9.
• 33. Hoving MA, van Raak EP, Spincemaille GH, et al. Efficacy of intrathecal baclofen therapy in children with intractable spastic cerebral palsy: a randomised controlled trial. Eur J Paediatr Neurol 2009;13:240-6.
• 34. Yadav SL, Singh U, Dureja GP, Singh KK, Chaturvedi S. Phenol block in the management of spastic cerebral palsy. Indian J Pediatr 1994;61:249-55.
• 35. Lowe K, Novak I, Cusick A. Repeat injection of botulinum toxin A is safe and effective for upper limb movement and function in children with cerebral palsy. Dev Med Child Neurol 2007;49:823- 9.
• 36. Hoare BJ1, Wallen MA, Imms C, Villanueva E, Rawicki HB, Carey L. Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy (UPDATE). Cochrane Database Syst Rev. 2010 Jan 20;CD003469.
• 37. Tedroff K, Granath F, Forssberg H, Haglund-Akerlind Y. Longterm effects of botulinum toxin A in children with cerebral palsy. Dev Med Child Neurol 2009;51:120-7.
• 38. Lynn AK, Turner M, Chambers HG. Surgical management of spasticity in persons with cerebral palsy. PM R. 2009;1:834-8.
• 39. Engsberg JR, Ross SA, Wagner JM, Park TS. Changes in hip spasticity and strength following selective dorsal rhizotomy and physical therapy for spastic cerebral palsy. Dev Med Child Neurol 2002;44:220-6.
• 40. McLaughlin J, Bjornson K, Temkin N, et al. Selective dorsal rhizotomy: meta-analysis of three randomized controlled trials. Dev Med Child Neurol 2002;44:17-25.
• 41. Josenby AL, Wagner P, Jarnlo GB, Westbom L, Nordmark E. Motor function after selective dorsal rhizotomy: a 10- year practice-based follow-up study. Dev Med Child Neurol 2012;54:429-35.