Skip to main content
SpringerLink
Log in

Bilaterale spastische Parese mit Gehfähigkeit (Diparese)

Pathophysiologie, State of the Art konservativer und operativer Behandlung und Rehabilitation

Bilateral spastic cerebral palsy with ambulatory ability (diplegia)

Pathophysiology, state of the art of conservative and surgical treatment and rehabilitation

  • Leitthema
  • Published:
Der Orthopäde Aims and scope Submit manuscript

Zusammenfassung

Hintergrund

Die infantile Zerebralparese ist eine der häufigsten Erkrankungen mit der Folge einer chronischen Behinderung, die meist mit einer Beeinträchtigung der Gehfähigkeit einhergeht.

Erkrankungsmuster

Typischerweise entwickeln sich während des Wachstums Muskelverkürzungen mit nachfolgenden Gelenkkontrakturen und -instabilitäten sowie knöcherne Deformitäten in unterschiedlicher Ausprägung. Aus biomechanischer Sicht liegt der Gehbehinderung eine Hebelarmdysfunktion zugrunde.

Therapiestrategien

Das Therapiekonzept ist multimodal und umfasst konservative sowie operative Maßnahmen. Ziel ist es, den Muskeltonus zu senken, Muskel- und Gelenkkontrakturen sowie knöcherne Deformitäten zu vermeiden bzw. bereits fixierte Fehlstellungen zu korrigieren, um eine bestmögliche Funktion für den Patienten zu erzielen; dazu sind häufig aufwendige Multilevel-Operationen notwendig.

Schlussfolgerung

Für die Durchführung der Operationen sind fundierte Kenntnisse über die Biomechanik des Gehens sowie die Pathobiomechanik der spastischen bilateralen Zerebralparese erforderlich. Mithilfe der instrumentellen Ganganalyse können die biomechanischen Verhältnisse besser analysiert und aufwendige Operationen mit einer höheren Präzision geplant werden.

Abstract

Background

Infantile cerebral palsy is one of the most common diseases resulting in chronic disability and is mostly concomitant with impairment in the ability to walk.

Disease pattern

Muscle contractions typically develop during the growth phase with subsequent joint contracture and instability as well as bone deformities to various extents. From a biomechanical viewpoint the gait impairment is due to a lever arm dysfunction.

Therapeutic strategies

The therapy concept is multimodal and involves conservative as well as operative measures. The objectives are to lower the muscle tonus, to avoid muscle and joint contractures and bone deformities and to correct already fixed malformations in order to achieve the best possible function for the patient. Complicated multilevel operations are often necessary to achieve this aim.

Conclusion

Extensive knowledge on the biomechanics of gait and the pathobiomechanics of spastic bilateral cerebral palsy are necessary to carry out surgery. Using instrumental gait analyses the biomechanical relationships can be analyzed better and complicated operations can be planned with greater precision.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4
Abb. 5

Literatur

  1. Ackman JD, Russman BS, Thomas SS et al (2005) Comparing botulinum toxin A with casting for treatment of dynamic equinus in children with cerebral palsy. Dev Med Child Neurol 47:620–627

    Article  PubMed  Google Scholar 

  2. Beckung E, Hagberg G, Uldall P et al (2008) Probability of walking in children with cerebral palsy in Europe. Pediatrics 121:e187–e192

    Article  PubMed  Google Scholar 

  3. Delp SL, Zajac FE (1992) Force- and moment-generating capacity of lower-extremity muscles before and after tendon lengthening. Clin Orthop Relat Res 284:247–259

    PubMed  Google Scholar 

  4. Desloovere K, Molenaers G, De Cat J et al (2007) Motor function following multilevel botulinum toxin type A treatment in children with cerebral palsy. Dev Med Child Neurol 49:56–61

    Article  PubMed  Google Scholar 

  5. Döderlein L (2007) Infantile Zerebralparese, Diagnostik, konservative und operative Therapie. Steinkopff, Darmstadt

  6. Dudley RW, Parolin M, Gagnon B et al (2013) Long-term functional benefits of selective dorsal rhizotomy for spastic cerebral palsy. J Neurosurg Pediatr 12:142–150

    Article  PubMed  Google Scholar 

  7. Filho MC, Yoshida R, Carvalho Wda S et al (2008) Are the recommendations from three-dimensional gait analysis associated with better postoperative outcomes in patients with cerebral palsy? Gait Posture 28:316–322

    Article  PubMed  Google Scholar 

  8. Glanzman AM, Kim H, Swaminathan K et al (2004) Efficacy of botulinum toxin A, serial casting, and combined treatment for spastic equinus: a retrospective analysis. Dev Med Child Neurol 46:807–811

    Article  PubMed  Google Scholar 

  9. Godwin EM, Spero CR, Nof L et al (2009) The gross motor function classification system for cerebral palsy and single-event multilevel surgery: is there a relationship between level of function and intervention over time? J Pediatr Orthop 29:910–915

    Article  PubMed  Google Scholar 

  10. Gough M, Eve LC, Robinson RO et al (2004) Short-term outcome of multilevel surgical intervention in spastic diplegic cerebral palsy compared with the natural history. Dev Med Child Neurol 46:91–97

    Article  PubMed  Google Scholar 

  11. Grunt S, Becher JG, Vermeulen RJ (2011) Long-term outcome and adverse effects of selective dorsal rhizotomy in children with cerebral palsy: a systematic review. Dev Med Child Neurol 53:490–498

    Article  PubMed  Google Scholar 

  12. Grunt S, Fieggen AG, Vermeulen RJ et al (2013) Selection criteria for selective dorsal rhizotomy in children with spastic cerebral palsy: a systematic review of the literature. Dev Med Child Neurol 56:302–312

    Article  PubMed  Google Scholar 

  13. Harvey A, Rosenbaum P, Hanna S et al (2012) Longitudinal changes in mobility following single-event multilevel surgery in ambulatory children with cerebral palsy. J Rehabil Med 44:137–143

    Article  PubMed  Google Scholar 

  14. Healy MT, Schwartz MH, Stout JL et al (2011) Is simultaneous hamstring lengthening necessary when performing distal femoral extension osteotomy and patellar tendon advancement? Gait Posture 33:1–5

    Article  PubMed  Google Scholar 

  15. Joseph B, Reddy K, Varghese RA et al (2010) Management of severe crouch gait in children and adolescents with cerebral palsy. J Pediatr Orthop 30:832–839

    Article  PubMed  Google Scholar 

  16. Kay RM, Dennis S, Rethlefsen S et al (2000) The effect of preoperative gait analysis on orthopaedic decision making. Clin Orthop Relat Res 372:217–222

    Article  PubMed  Google Scholar 

  17. Kay RM, Dennis S, Rethlefsen S et al (2000) Impact of postoperative gait analysis on orthopaedic care. Clin Orthop Relat Res 372:259–264

    Article  Google Scholar 

  18. Kay RM, Rethlefsen SA, Fern-Buneo A et al (2004) Botulinum toxin as an adjunct to serial casting treatment in children with cerebral palsy. J Bone Joint Surg [Am] 86-A:2377–2384

  19. Lucareli PR, Lima Mde O, Lucarelli JG et al (2007) Changes in joint kinematics in children with cerebral palsy while walking with and without a floor reaction ankle-foot orthosis. Clinics 62:63–68

    Article  PubMed  Google Scholar 

  20. Mclaughlin J, Bjornson K, Temkin N et al (2002) Selective dorsal rhizotomy: meta-analysis of three randomized controlled trials. Dev Med Child Neurol 44:17–25

    Article  PubMed  Google Scholar 

  21. Molenaers G, Desloovere K, Fabry G et al (2006) The effects of quantitative gait assessment and botulinum toxin a on musculoskeletal surgery in children with cerebral palsy. J Bone Joint Surg [Am] 88:161–170

  22. Narayanan UG (2012) Management of children with ambulatory cerebral palsy: an evidence-based review. J Pediatr Orthop 32(Suppl 2):S172–S181

    Article  PubMed  Google Scholar 

  23. Novacheck TF, Stout JL, Gage JR et al (2009) Distal femoral extension osteotomy and patellar tendon advancement to treat persistent crouch gait in cerebral palsy. Surgical technique. J Bone Joint Surg [Am] 91(Suppl 2):271–286

  24. Novak I, Mcintyre S, Morgan C et al (2013) A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev Med Child Neurol 55:885–910

    Article  PubMed  Google Scholar 

  25. Palisano R, Rosenbaum P, Walter S et al (1997) Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol 39:214–223

    Article  CAS  PubMed  Google Scholar 

  26. Radtka SA, Skinner SR, Dixon DM et al (1997) A comparison of gait with solid, dynamic, and no ankle-foot orthoses in children with spastic cerebral palsy. Phys Ther 77:395–409

    CAS  PubMed  Google Scholar 

  27. Rang M (1990) Cerebral palsy. In: Lovell WW, Morrissy RT, Winter RB (Hrsg) Lovell and Winter’s pediatric orthopaedics. Lippincott Williams & Wilkins, Philadelphia

  28. Read HS, Hazlewood ME, Hillman SJ et al (2003) Edinburgh visual gait score for use in cerebral palsy. J Pediatr Orthop 23:296–301

    PubMed  Google Scholar 

  29. Rethlefsen S, Kay R, Dennis S et al (1999) The effects of fixed and articulated ankle-foot orthoses on gait patterns in subjects with cerebral palsy. J Pediatr Orthop 19:470–474

    Article  CAS  PubMed  Google Scholar 

  30. Rosenbaum PL, Walter SD, Hanna SE et al (2002) Prognosis for gross motor function in cerebral palsy: creation of motor development curves. JAMA 288:1357–1363

    Article  PubMed  Google Scholar 

  31. Rutz E, Baker R, Tirosh O et al (2011) Tibialis anterior tendon shortening in combination with Achilles tendon lengthening in spastic equinus in cerebral palsy. Gait Posture 33:152–157

    Article  PubMed  Google Scholar 

  32. Scholtes VA, Dallmeijer AJ, Knol DL et al (2006) The combined effect of lower-limb multilevel botulinum toxin type a and comprehensive rehabilitation on mobility in children with cerebral palsy: a randomized clinical trial. Arch Phys Med Rehabil 87:1551–1558

    Article  PubMed  Google Scholar 

  33. Scholtes VA, Dallmeijer AJ, Knol DL et al (2007) Effect of multilevel botulinum toxin a and comprehensive rehabilitation on gait in cerebral palsy. Pediatr Neurol 36:30–39

    Article  PubMed  Google Scholar 

  34. Seniorou M, Thompson N, Harrington M et al (2007) Recovery of muscle strength following multi-level orthopaedic surgery in diplegic cerebral palsy. Gait Posture 26:475–481

    Article  PubMed  Google Scholar 

  35. Steinbok P (2001) Outcomes after selective dorsal rhizotomy for spastic cerebral palsy. Childs Nerv Syst 17:1–18

    Article  CAS  PubMed  Google Scholar 

  36. Stout JL, Gage JR, Schwartz MH et al (2008) Distal femoral extension osteotomy and patellar tendon advancement to treat persistent crouch gait in cerebral palsy. J Bone Joint Surg [Am] 90:2470–2484

  37. Sung KH, Chung CY, Lee KM et al (2013) Long term outcome of single event multilevel surgery in spastic diplegia with flexed knee gait. Gait Posture 37:536–541

    Article  PubMed  Google Scholar 

  38. Svehlik M, Steinwender G, Kraus T et al (2011) The influence of age at single-event multilevel surgery on outcome in children with cerebral palsy who walk with flexed knee gait. Dev Med Child Neurol 53:730–735

    Article  PubMed  Google Scholar 

  39. Thomason P, Selber P, Graham HK (2013) Single event multilevel surgery in children with bilateral spastic cerebral palsy: a 5 year prospective cohort study. Gait Posture 37:23–28

    Article  PubMed  Google Scholar 

  40. Thompson N, Stebbins J, Seniorou M et al (2010) The use of minimally invasive techniques in multi-level surgery for children with cerebral palsy: preliminary results. J Bone Joint Surg [Br] 92:1442–1448

  41. Wood E, Rosenbaum P (2000) The gross motor function classification system for cerebral palsy: a study of reliability and stability over time. Dev Med Child Neurol 42:292–296

    Article  CAS  PubMed  Google Scholar 

Download references

Einhaltung ethischer Richtlinien

Interessenkonflikt. B. Westhoff weist auf folgende Beziehungen hin: Referententätigkeit für die Fa. Ipsen-Pharma GmbH, Beratertätigkeit für die Fa. Pharm-Allergan GmbH. D. Bittersohl und R. Krauspe geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

Author information

Authors and Affiliations

  1. Klinik für Orthopädie und Orthopädische Chirurgie, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland

    B. Westhoff, D. Bittersohl & R. Krauspe

Authors
  1. B. Westhoff
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. D. Bittersohl
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. R. Krauspe
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to B. Westhoff.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Westhoff, B., Bittersohl, D. & Krauspe, R. Bilaterale spastische Parese mit Gehfähigkeit (Diparese). Orthopäde 43, 656–664 (2014). https://doi.org/10.1007/s00132-013-2220-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00132-013-2220-z

Schlüsselwörter

Keywords

Search

Navigation