뇌성마비 아동의 운동점차단에 관한 임상적 연구

Abstract

[한글]

Phenol Motor Point Block in Cerebral Palsied Children

Dae Yong Han, M.D.

Department of Medical Science, The Graduate School, Yonsei University

(Directed by Prof. In Hee Chung, M.D.)

The relative incidence of cerebral palsy is increasing in comparison with the

incidence of poliomyelitis. Spasticity of the muscle in cerebral palsy is a common

obstacle to rehabilitation.

At present the most useful clinical method to provide persistent and reliable

reduction of spasticity is peripheral muscle release, which has the disadvantage of

causing associated motor weakness and of offering a varying degree of postoperative

morbidity, depending on the soft tissue destruction at surgery. The ideal method of

controlling spasticity would decrease excessive muscle tone permanently without

associated less of motor control ant strength, and without loss of sensation. Such

a method is not available.

Recently several authors haute made efforts to find a better method of spasticity

control without surgery. Maher(1957) first described the use of intrathecal phenols

to relieve spasticity. This method was further developed by Nathan (1959) and Kelly

and Gautier-Smith(1959).

Peripheral nerve block with dilute phenol in the management of spastic patients

was reported by Khalili et al. (1964), Khalili and Benton(1966), Khalili and

Betts(1967), Katz et al. (1967), Meelhuysen et al. (1968), Mooney et al. (1969),

Awad(1972), and Braun et al. (1972, 1973). They observed relief of spasticity from

weeks to months with occasional complications.

Rushworth (1960) reported the effects of procaine intramuscularly applied motor

points, and described diminution of stretch reflexes and other phenomena related to

spasticity. Tardieu and Hariga (1964) made an attempt to obtain a greater

prolongation of the effect from injection of dilute alcohol solutions into motor

points by the conventionally described method using electrical stimulation

equipment.

Cain et al. (1966) have done phenol motor point block for spasticity with

satisfactory results and have not observed denervation potentials on

electromyographic study after the phenol block. Halpern and Meelhuysen(1966)

reported phenol motor point block in the management of muscular hypertonia and they

observed satisfactory reduction of spasticity, but they found denervation patterns

on electromyography after the phenol block. DeLateur(1972) described a new

technique of end-plate block and small intramuscular nerve block with dilute

phenol. There is no report concerning the relationship between quality and duration

of effects and the number of blocked motor points, and between quality and duration

of effects and amount of phenol used.

Therefore we studied the clinical effect of phenol motor paint block, made a

comparison between phenol motor point block and phenol peripheral nerve block, and

attempted to clarify electromyographic findings in spastic cerebral palsied

children.

In this studs twenty spastic cerebral palsied children who had no soft tissue

contracture and bony deformity were selected from Severance Hospital and Sam Yook

Rehabilitation Center. Motor point block with 5% phenol was done in 48 muscles of

14 patients and 12 obturator nerve block in mix patients. Blocked muscles were 28

triceps surge, nine hip adductors, eight hamstrings, and three posterior tibials.

All patients were examined to grade the degree of spasticity before and after the

block by the author and the same physiotherapist, who then observed the effect of

the block and analysed the quality of reduction of spasticity compared with time

interval, weekly up to two months and then every month, for one year.

Electromyographic study accompanied these clinical observations each time to show

any changes In pre-and postblock stages. Instruments used in this study were the

Hewlett Packard Model 1510 A Electromyographic Machine, Hewlett Packard Model 197 A

Scope Camera, Variable Pulse Generator & Chronaxie Meter, TECA Model CH-3, and

Hypodermic Needle Elextrode, TECA HY 75P.

Results were classified as "good" when relaxation was considered to be moderate

to complete, and function was improved to permit walking better than in the

preblock stage or to enable the effective application of brace or training

procedures. A result was classified as "fair" if relaxation of tone was mild to

moderate and/or function partially improved. The grade "poor" was applied to those

results in which diminution of tone was minimal to absent and/or functional

improvement was not significant.

Results of analysis were as fellows:

1. Phenol motor point block.

1) Quality of effect:

Effect immediately after block was good in 18 muscles (37.5%), fair in 16

(33.3%), and poor in 14(29.2%), Thus an overall satisfactory result was obtained in

34 muscles(70.8%).

2) Duration of effect of good or fair results:

(Effects terminated within three months in 16 muscles(47.0%), three to six months

in nine (26.5%), six to nine months in seven(20.6%), and over nine months in

two(5.9%). Effects have persisted over six months in nine muscles(26.5%) among 34.

3) Relationship between quality and duration of effect of good or fair results:

Effects terminated within mix months in ten muscles(55.6%) and have persisted

over six months in eight(44.4%) among 18 of the good results. Effect terminated

within three months in 11 muscles(68.8%) and persisted from three months to six

months in five(31.2%) among 16 of the fair results.

4) Relationship between effect and number of blocked motor points:

Number of blocked motor points per muscle was 6.35±0.39 in the good results,

4.38±0.25 in the fair, and 6.00±0.44 in the poor. Average number of blocked motor

point per muscle was 5.70±0.25. There is no significant relationship between the

effect and number of blocked motor points.

5) Relationship between effect and amount of phenol used:

Amount of phenol used per muscle was 0.75±0.05m1. in the good results,

0.61±0.04 in the fair, and 0.72±0.06 in the poor. Average amount of phenol used

per muscle was 0.70±0.03ml. There is no significant relationship between effect

and amount of phenol used.

2. Phenol obturator nerve block.

1) Quality of effect:

Immediately after block results in airs nerves(50.0%) were good, five(41.7%) were

fair, and one(8.3%) was poor. Satisfactory results were obtained in 91.7% of twelve

obturator nerves.

2) Duration of effect:

Effect terminated within one months in four nerves(36%), one to three months in

four nerves(36%), and three to six months in three nerves(24%) among eleven nerves

of good or fair results.

3) Amount of phenol used:

0.1 to 0.2ml. of 5% phenol was sufficient to block the obturator nerves.

3. Electromyographic findings.

1) Phenol motor point block:

There was evidence of partial denervation in blocked muscle, which appeared from

two to four weeks after block. No more denervation potentials were found six months

after block. Many polyphasic potentials suggesting reinnervation of blocked muscle

began to be noted two months after block. After eight months, polyphasic potentials

could not be found.

2) Phenol obturator nerve block:

Electromyographic findings were very similar to those of the phenol motor point

block.

The results are summarized as fellows:

1. Satisfactory reduction of spasticity was obtained in 34(70.8%) out of 48

muscles by phenol motor point block. The effects have persisted over six months in

nine muscles(26.5%).

2. An average of 5.6 motor points was blocked in muscle, using an average of

0.70ml. of 5% phenol in each muscle. There is no significant relationship between

effect and number of motor point blocks, or between effect and amount of phenol

used.

3. When the immediate results were better, the effects lasted longer. In the

group of good results, effects have persisted over six months in eight out of ten

muscles, but the effects terminated within six months in all muscles with fair

results.

4. Satisfactory reduction of spasticity was obtained in 11 out of 12 obturator

nerve block. The effects of nerve block have lasted up to six months in all and

duration of effects was shorter than that of motor point block.

5. Electromyographic studies have revealed partial denervation after the phenol

motor point block and nerve block.

On the basis of these results, it may be valuable to perform the phenol block

prior to tendon transference in spastic patients, since planning how to balance

spastic muscles is difficult because the strength of individual muscles are hard to

determine. The relief of spasticity may also be valuable to retard contracture

formation, facilitate nursing care and allow self-ranging exercise and training

programs to be taught.

[영문]

The relative incidence of cerebral palsy is increasing in comparison with the incidence of poliomyelitis. Spasticity of the muscle in cerebral palsy is a common obstacle to rehabilitation.

At present the most useful clinical method to provide persistent and reliable reduction of spasticity is peripheral muscle release, which has the disadvantage of causing associated motor weakness and of offering a varying degree of postoperative

morbidity, depending on the soft tissue destruction at surgery. The ideal method of controlling spasticity would decrease excessive muscle tone permanently without associated less of motor control ant strength, and without loss of sensation. Such

a method is not available.

Recently several authors haute made efforts to find a better method of spasticity control without surgery. Maher(1957) first described the use of intrathecal phenols to relieve spasticity. This method was further developed by Nathan (1959) and Kelly

and Gautier-Smith(1959).

Peripheral nerve block with dilute phenol in the management of spastic patients was reported by Khalili et al. (1964), Khalili and Benton(1966), Khalili and Betts(1967), Katz et al. (1967), Meelhuysen et al. (1968), Mooney et al. (1969), Awad(1972), and Braun et al. (1972, 1973). They observed relief of spasticity from weeks to months with occasional complications.

Rushworth (1960) reported the effects of procaine intramuscularly applied motor points, and described diminution of stretch reflexes and other phenomena related to spasticity. Tardieu and Hariga (1964) made an attempt to obtain a greater

prolongation of the effect from injection of dilute alcohol solutions into motor points by the conventionally described method using electrical stimulation equipment.

Cain et al. (1966) have done phenol motor point block for spasticity with satisfactory results and have not observed denervation potentials on electromyographic study after the phenol block. Halpern and Meelhuysen(1966) reported phenol motor point block in the management of muscular hypertonia and they

observed satisfactory reduction of spasticity, but they found denervation patterns on electromyography after the phenol block. DeLateur(1972) described a new technique of end-plate block and small intramuscular nerve block with dilute phenol. There is no report concerning the relationship between quality and duration

of effects and the number of blocked motor points, and between quality and duration of effects and amount of phenol used.

Therefore we studied the clinical effect of phenol motor paint block, made a comparison between phenol motor point block and phenol peripheral nerve block, and attempted to clarify electromyographic findings in spastic cerebral palsied

children.

In this studs twenty spastic cerebral palsied children who had no soft tissue contracture and bony deformity were selected from Severance Hospital and Sam Yook Rehabilitation Center. Motor point block with 5% phenol was done in 48 muscles of 14 patients and 12 obturator nerve block in mix patients. Blocked muscles were 28 triceps surge, nine hip adductors, eight hamstrings, and three posterior tibials.

All patients were examined to grade the degree of spasticity before and after the block by the author and the same physiotherapist, who then observed the effect of the block and analysed the quality of reduction of spasticity compared with time interval, weekly up to two months and then every month, for one year. Electromyographic study accompanied these clinical observations each time to show any changes In pre-and postblock stages. Instruments used in this study were the Hewlett Packard Model 1510 A Electromyographic Machine, Hewlett Packard Model 197 A

Scope Camera, Variable Pulse Generator & Chronaxie Meter, TECA Model CH-3, and Hypodermic Needle Elextrode, TECA HY 75P.

Results were classified as "good" when relaxation was considered to be moderate to complete, and function was improved to permit walking better than in the preblock stage or to enable the effective application of brace or training procedures. A result was classified as "fair" if relaxation of tone was mild to

moderate and/or function partially improved. The grade "poor" was applied to those results in which diminution of tone was minimal to absent and/or functional improvement was not significant.

Results of analysis were as fellows:

1. Phenol motor point block.

1) Quality of effect:

Effect immediately after block was good in 18 muscles (37.5%), fair in 16(33.3%), and poor in 14(29.2%), Thus an overall satisfactory result was obtained in 34 muscles(70.8%).

2) Duration of effect of good or fair results:

(Effects terminated within three months in 16 muscles(47.0%), three to six months in nine (26.5%), six to nine months in seven(20.6%), and over nine months in two(5.9%). Effects have persisted over six months in nine muscles(26.5%) among 34.

3) Relationship between quality and duration of effect of good or fair results:

Effects terminated within mix months in ten muscles(55.6%) and have persisted over six months in eight(44.4%) among 18 of the good results. Effect terminated within three months in 11 muscles(68.8%) and persisted from three months to six months in five(31.2%) among 16 of the fair results.

4) Relationship between effect and number of blocked motor points:

Number of blocked motor points per muscle was 6.35±0.39 in the good results, 4.38±0.25 in the fair, and 6.00±0.44 in the poor. Average number of blocked motor point per muscle was 5.70±0.25. There is no significant relationship between the effect and number of blocked motor points.

5) Relationship between effect and amount of phenol used:

Amount of phenol used per muscle was 0.75±0.05m1. in the good results, 0.61±0.04 in the fair, and 0.72±0.06 in the poor. Average amount of phenol used per muscle was 0.70±0.03ml. There is no significant relationship between effect and amount of phenol used.

2. Phenol obturator nerve block.

1) Quality of effect:

Immediately after block results in airs nerves(50.0%) were good, five(41.7%) were fair, and one(8.3%) was poor. Satisfactory results were obtained in 91.7% of twelve obturator nerves.

2) Duration of effect:

Effect terminated within one months in four nerves(36%), one to three months in four nerves(36%), and three to six months in three nerves(24%) among eleven nerves of good or fair results.

3) Amount of phenol used:

0.1 to 0.2ml. of 5% phenol was sufficient to block the obturator nerves.

3. Electromyographic findings.

1) Phenol motor point block:

There was evidence of partial denervation in blocked muscle, which appeared from two to four weeks after block. No more denervation potentials were found six months after block. Many polyphasic potentials suggesting reinnervation of blocked muscle

began to be noted two months after block. After eight months, polyphasic potentials could not be found.

2) Phenol obturator nerve block:

Electromyographic findings were very similar to those of the phenol motor point block.

The results are summarized as fellows:

1. Satisfactory reduction of spasticity was obtained in 34(70.8%) out of 48 muscles by phenol motor point block. The effects have persisted over six months in nine muscles(26.5%).

2. An average of 5.6 motor points was blocked in muscle, using an average of 0.70ml. of 5% phenol in each muscle. There is no significant relationship between effect and number of motor point blocks, or between effect and amount of phenol used.

3. When the immediate results were better, the effects lasted longer. In the group of good results, effects have persisted over six months in eight out of ten muscles, but the effects terminated within six months in all muscles with fair results.

4. Satisfactory reduction of spasticity was obtained in 11 out of 12 obturator nerve block. The effects of nerve block have lasted up to six months in all and duration of effects was shorter than that of motor point block.

5. Electromyographic studies have revealed partial denervation after the phenol motor point block and nerve block.

On the basis of these results, it may be valuable to perform the phenol block prior to tendon transference in spastic patients, since planning how to balance spastic muscles is difficult because the strength of individual muscles are hard to

determine. The relief of spasticity may also be valuable to retard contracture formation, facilitate nursing care and allow self-ranging exercise and training programs to be taught.