EARLY INTERVENTION IN
CEREBRAL PALSY
HOW EARLY CAN WE INTERVENE ?
Dr. Pradeep Dubey
MD (Ped.), DCH.
Cons. Developmental Ped.
“DEVCHHAYA”
Early Intervention Centre
Prem Mandir Chowk, Wright Town
Dr. Pradeep Dubey - Consultant Pediatrician
Dr. Pradeep Dubey - Consultant Pediatrician
Dr. Pradeep Dubey - Consultant Pediatrician
FOLIC
ACID
400 mcg. Start before conception
Birth defects  by 30%
Mandatory food fortification in US & Chile
Dr. Pradeep Dubey - Consultant Pediatrician
MATERNAL BLOOD GROUP
Mother – Rh negative
Precautions for Rh incompatibility
Dr. Pradeep Dubey - Consultant Pediatrician
DYSKINETIC - C.P.
Dr. Pradeep Dubey - Consultant Pediatrician
STAGES OF BRAIN DEVELOPMENT
Formation of Medula, pones & fore brain
Differentiation of Neurons in to various nuclie
Hypothalamus, Thalamus etc.
Neo cortical layer & formation of Gyrie & Sulcie.
Establishment of synapses & Myelination of brain stem.
Functional development of mid brain & fore brain.
Dr. Pradeep Dubey - Consultant Pediatrician
MATURITY vs NEUROLOGICAL OUTCOME
NEURO. INSULT
(Hypoxia / Infection / Hypothermia)
nNOS + Free Radicals
Neuronal Necrosis
Pre Term Babies
Term Babies
Periventricular infarction
Cortical Necrosis
Periventricular Hem.
Status marmoratum
Subcortical Necrosis
Focal & Parasag.
Necrosis
 eNOS – ER2 receptors
Dr. Pradeep Dubey - Consultant Pediatrician
PREMATURITY & LBW
Anatomical Peculiarities
Intracranial Hemorrhage & periventricular
Leukomalacia .
NEURO. DEFICIT :
Birth wt. 800 – 1000 gms.
6 – 8%
Birth wt. 800 gms. & less
20 – 40%
US spending 26 billion $ (120,000 Crores Rs.) annually on
Preterm babies and their related problems
Dr. Pradeep Dubey - Consultant Pediatrician
OUTCOME OF H. I. E.
Normal population 1-5 – 2/1000 L.B.
Asphyxia 50 – 100/1000 L.B.
Mild Asphyxia all are normal.
Mod. Asphyxia – about 1/5 develop CP.
Severe asphyxia – most of the survivors
develop CP.
Dr. Pradeep Dubey - Consultant Pediatrician
HIGH RISK CONDITIONS
Low birth weight babies.
Severe H.I.E.
Severe neonatal jaundice
Persistence of Abn. Neuro signs after 2 wks.
Hypodensisties in Ct. even after 4 wks.
Oliguria (<1ml./kg./ hr.) for 24 hrs.
associated with H.I.E.
Low apgar (0-3) after 20 mts.
Late seizures in a depressed NB
Background abnormalities in interictal EEG.
Dr. Pradeep Dubey - Consultant Pediatrician
ALARMING SIGNS
Responsiveness / Alertness
Spontaneous motility
Persistant hyper excitability
Feeding difficulty
Constant fisting
Abnormal movements / convulsions.
Abnormal postures
Abnormal Head circumerence
Abnormalities of tone
Ocular abnormalities
Lack of response to sound.
Dr. Pradeep Dubey - Consultant Pediatrician
NEUROPLASTICITY
Brain tissues are plastic and responsive .
Adequate and repeated stimuli can modify
brain physiology as well as morphology
Brain port in patient with Vestibular
damage – Secondary pathways unmasked.
Grey matter mass of Med. Students brain
increase in months of exam.
“DO WE MAKE THE ROAD BY WALKING.”
Dr. Pradeep Dubey - Consultant Pediatrician
CRITICAL PERIOD IN BRAIN MATURATION
Kitten blind folded after birth for 3 months
developed acquired amblyopia, Visual Cortex
start processing auditory information.
Strabismus in infants leads to acquired
amblyopia
Congenital deafness – auditory area process
visual information.
“WE USE IT OR WE LOSE IT”
Dr. Pradeep Dubey - Consultant Pediatrician
STRABISMUS IN C.P.
Dr. Pradeep Dubey - Consultant Pediatrician
HEMIPLEGIC
C.P.
Dr. Pradeep Dubey - Consultant Pediatrician
FOLLOWUP OF HIGH RISK INFANTS
NICU SURVIVORS – LONG TERM FOLLOWUP
Cerebral Palsy
-
4%
Mental Retardation
-
5%
Seizure Disorder
-
3.9%
Hearing Impairment
-
1.5%
Learning Problems
-
14%
ROP in VLBW babies
-
24%
Majority of these babies were LBW & Preterm.
Dr. Pradeep Dubey - Consultant Pediatrician
EARLY INTERVENTION - AIMS
THE PRINCIPLE OF NEUROPLASTICITY FORMS
THE BASIS OF EARLY INTERVENTION
1. Early identification of neuro developmental disorders.
2. Minimisation of persistant abnormalities & detection of
transient neurological abnormalities
3. Prevention
of
asymmetries
&
abnormalities
of
development.
4. Stimulation along channel of normal development
Dr. Pradeep Dubey - Consultant Pediatrician
PRIORITIES OF MANAGEMENT
Communication
Socioemotional Development
Maximal independence in ADL
As near normal appearance as possible
Mobility
Dr. Pradeep Dubey - Consultant Pediatrician
AGE FOR ASSESSMENT
AMIEL TISON - 2 MTHS, 7 MTHS, 12 MTHS
P.G. I. CHANDIGRAH – 9 MTHS.
OTHERS
- 8 MONTHS
Dr. Pradeep Dubey - Consultant Pediatrician
NEURO DEVELOPMENTAL EXAMINATION METHODS
AMEIL TISON’S METHOD
VOJTA’S TECHNIQUE
CAPUTE AND ASSOCIATES
INFANT NEUROLOGICAL INTERNATION
BATTERY (INFANIB)
Dr. Pradeep Dubey - Consultant Pediatrician
AMIEL TISON’S METHOD
A. GENERAL DISCRIPTION
Head – size shape, fontanell sutures
Eyes – Setting sun, Strabismus, nystagmus
Skin abnormalities – Cafeaulet, Nevi etc.
Cranial nerves
Altered mental status
Spine
Dr. Pradeep Dubey - Consultant Pediatrician
AMIEL TISON’S METHOD
1. Tone
- Scarf sign heel to ear
leg abduction, Popliteal angel
- dorsoflexion of foot Pull to sit.
prone, sitting position
- atnr,
2. Vestibular
- Side ways sparachute, backward &
Function
forward parachute, body rotative
3. Lethargy/Hyper excitability
4. Vision & Hearing
5. Developmental delay
Dr. Pradeep Dubey - Consultant Pediatrician
PROGNOSIS FOR WALKING IN CP
Hemiplegia
100%
Diplegia (Paraplegic)
90%
Ataxia/ Dyskinesia
80%
Quadriplegia
18%
Dr. Pradeep Dubey - Consultant Pediatrician
INTERVENTION - MODALITIES
Vestibulo Kinesthetic stimulation
Tactile stimulation
Auditory & Visual stimulation
Cognitive stimulation
Management of associated medical,
neurological & behavioral problems
Dr. Pradeep Dubey - Consultant Pediatrician
WE ARE GUILTY OF MANY ERRORS AND FAULTS, BUT OUR WORST CRIME IS
ABANDONING OUR CHILDREN, NEGLECTING FOUNTAIN OF LIFE.
MANY THINGS WE NEED IN LIFE CAN WAIT, THE CHILD CAN NOT.
RIGHT NOW IS THE TIME – HIS BRAIN IS GROWING ,
HIS BLOOD IS BEING MADE. HIS SENSES ARE BEING DEVELOPED.
TO HIM WE CAN NOT ANSWER TOMORROW
HIS NAME IS “TODAY”
GABRIELA MISTRAL (NOBEL LAURIET FROM CHILE)
Dr. Pradeep Dubey - Consultant Pediatrician
“DEVCHHAYA”
Early Intervention Centre
Prem Mandir Chowk, Wright Town
www.healthychildindia.com
Dr. Pradeep Dubey - Consultant Pediatrician