Treatment of the Child with Cerebral Palsy Post Surgical...
Transcript of Treatment of the Child with Cerebral Palsy Post Surgical...
Treatment of the Child with
Cerebral Palsy
Post Surgical Rehabilitation
Sheelah Cochran OTR/L, CPAM, CKTP
Children’s Healthcare of Atlanta
Objectives
• Perform an initial evaluation of post-surgical
conditions
• Identify appropriate splinting per surgical intervention
• Demonstrate knowledge of therapeutic interventions
and home programs
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Cerebral Palsy: General Information
• Non-progressive neurological disorder of movement
that is related to an insult to the developing brain
• Can result in abnormal sensation, dyskinesia, athetosis,
ataxia or most commonly spasticity
• Classic presentation of child with spastic U/E is
shoulder adduction with internal rotation, elbow
flexion, forearm pronation, wrist flexion with ulnar
deviation and thumb adducted in palm
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Typical Presentation
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Considerations
• Pediatric patients with cerebral palsy present unique
challenges.
• Any treatment regimen must take into account
potential growth, possible sequelae of surgery, and
behavioral issues.
• Careful evaluation of motor and sensory function of
the extremity and also use patterns is critical in
determining the ultimate success of any intervention.
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Considerations
• Every patient is addressed independently and
treatment individualized.
• The patient and parents must understand that surgery
can address only the function or position of the
anatomic area that the surgeon will work on.
• Surgery will not correct the underlying problem.
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General Evaluation
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Evaluation: General
Parent/Patient interview:
History:
• Medical history/birth history
• Medications
• Interventions: medical, surgical, therapeutic
• Pain
• Functional deficits/current level of function
– Parent report, PEDI, UEFI
• Current concerns
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Evaluation: Parent Report
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Evaluation: Functional Deficits
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Evaluation: General
Pain: use of numeric/faces pain scale
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Initial Evaluation: General
AROM/PROM measurements ( as allowed per protocol)
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Initial Evaluation: General
Strength measurements (per protocol)
Functional skills assessment (per protocol)
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Evaluation: General QUEST
Quality of Upper Extremity Skills Test (QUEST): an
outcome measure designed to evaluate movement
patterns and hand function in children with cerebral
palsy.
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Evaluation: General MACS
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Evaluation: Clinical observations
Measurement of incisions and scar tissue formation using
the Vancouver or Manchester Scar Scale
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Evaluation: Clinical Observations
Edema Measurements
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Specific Procedures
Evaluation and Treatment
Green Transfer
Evaluation and Treatment
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Green Transfer
The Green Procedure:
• Transfer of the Flexor Carpi Ulnaris to the Extensor Carpi
Radialis Brevis and/or the Extensor Carpi Radialis Longus
This procedure was developed from
• Clinical work by Dr. Green in 1942
• To treat children with limited wrist extension due to spastic,
infantile, or obstetrical paralysis
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Green Transfer:
Candidates:
• Children with weak wrist extension
• Children with ulnar deviation of the wrist
• Children with flexion posturing of the wrist
Benefits:
• Improved wrist extension
• Improved grasping
• Improved functional use of hand for bilateral tasks
and ADLs
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Post Operative Phase
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The patient is casted up to four weeks
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Evaluation: First Steps Post Cast Removal
Scar/Incision: Debride and clean incision
Remove sutures
Measure: length, width
Note open areas
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Evaluation: Clinical Observations
Edema:
• Circumferential measurements
• Pitting/non-pitting
Sensation:
• Changes in sensation
• New sensation
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Clinical Observations
Range of motion measurements: Passive measurements
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Clinical Observations:
AROM measurements
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Clinical Observations
How is the Activation of Transfer?
Can the patient get the transfer to fire?
In what planes can the patient get the transfer to fire?
How much cueing is needed?
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Splinting: 4 weeks Post-Op
Splint: fabricated in position of pronation with the wrist
in neutral or slight extension determined by the position
of casting
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Treatment Goals: 4 weeks Post-Op
1. Fire transfer in gravity eliminated plane
2. Grasp and release of objects
3. Pain free
4. Follow through with home program
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Treatment
AROM: shoulder, elbow, fingers and thumb, initiate firing
of transfer with flexion block
PROM: shoulder, elbow, fingers
Precautions: no forced wrist motions, splint at all
times, no weight bearing, no sports
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Treatment
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Scar Management:
• Initiate scar management two to three times
daily
• Use silicone gel or elastomer as indicated
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Scar Management:
• Scar massage
Manual
Use of Mini massager
• Silicone Gel
• Scar pump
• Elastomer
• Compression
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Treatment: Edema Control
• Retrograde massage
• Compression
• Elevation
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Four weeks post-operatively
Home Program:
• Daily/nightly splint wear
• Active range of motion exercises
• Practice firing of transfer
• Scar massage
• Use of silicone gel or elastomer as indicated
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4-6 weeks post-operatively
• Goal:
– fire transfer against gravity consistently
• Splint:
– at all times except for bathing, therapy and home program
• AROM:
– continue with active range as in week 4
– Firing of transfer in gravity eliminated without splint
– Firing of transfer against gravity
– Light activities that encourage pronation, wrist extension and
grasp and release
– Cleared to use NMES for muscle transfer re-training
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4-6 weeks post-operatively
• PROM:
– shoulder, elbow, fingers
• Precautions:
– no resistive activities,
splint at all times, no
weight bearing
• Scar Management:
– as noted previously
• Home program:
– Splint for day and night
– Firing of transfer/light
activities
– Scar massage
• use of silicone gel or
elastomer
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7-8 weeks post-operatively
• Goal:
– Fire transfer consistently in all planes
• Splint:
– Night time only
• AROM:
– Continue with active range
– Firing of transfer in all planes and in multiple positions
– Light activities that encourage pronation, wrist extension and
grasp and release
– NMES for muscle transfer re-training
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7-8 weeks post-operatively
• PROM:
– full passive range of
motion allowed
• Strengthening:
– light weight bearing
• Scar Management:
– as noted previously
• Home program:
– Splint for night
– Firing of transfer/light
activities
– Scar massage
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Treatment: Kinesiotaping
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Assisted wrist extension
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Treatment: E-stim
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Treatment: Fine Motor
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9-12 weeks post-operatively
• Goal:
– Fire transfer consistently
in all planes
• Splint:
– Wean splint
• AROM:
– Firing of transfer in all
planes and in multiple
positions
– NMES for muscle transfer
re-training
• Strengthening:
– Progress weight bearing
activities
– Progress strengthening
• Grasp
• Pinch
• Wrist extension
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Treatment: Strengthening
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Treatment: Strengthening
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Treatment: Weight bearing
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Discharge Planning
• The child should be ready for discharge after 12
weeks of consistent therapy and active participation in
home program
• Home program of continued strengthening, range of
motion and scar massage
• A follow up appointment in one month may be
recommended to ensure continued progress and to
adjust home program as needed
Elbow release
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Anterior Elbow Release
• Release of the soft tissues of the anterior elbow
• Lengthening of the Brachialis at the muscle tendon
junction
• Lengthening of the Biceps
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Anterior Elbow Release
Candidates:
• Primarily children with CP/spasticity causing flexion
contractures of the elbow
Benefits:
• Increased active and passive elbow extension
• Improved ability to perform bilateral tasks
• Improved ability to weight bear
• Improved posture for ambulation/mobility
• Ease of caregiving for dressing/bathing/transfers
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Post Operative Phase: 4 weeks
Placed in long arm cast for 4 weeks with elbow in 25 to
30 degrees of flexion, forearm and wrist in neutral
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Evaluation: Initial Steps Post Cast Removal
Scar/Incision: Debride and clean incision
Remove sutures
Measure: length, width
Note open areas
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Evaluation: Clinical Observations
Edema:
• Circumferential measurements
• Pitting/non-pitting
Sensation:
• Changes in sensation
• New sensation
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Evaluation: Clinical Observations
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Range of motion: Elbow extension/flexion
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Splinting: 4 weeks Post-Op
Long Arm elbow extension splint: wrist neutral, forearm
in pronation or neutral for 3 weeks full time than
transition to night time use
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Treatment
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Scar Management:
• Initiate scar management two to three times daily
• Use silicone gel or elastomer as indicated
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Treatment: Scar Management:
• Scar massage
Manual
Use of Mini massager
• Silicone Gel
• Scar pump
• Elastomer
• Compression
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Treatment: Edema Control
• Retrograde massage
• Compression
• Elevation
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Treatment 4-6 weeks post-operatively
• Goal:
– Increase passive/active elbow extension
• Splint:
– at all times except for bathing, therapy and home program
• AROM/PROM:
– active/passive range of motion for extension, flexion and
supination, reaching activities that encourage elbow
extension
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Treatment
Range of motion
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Treatment Activities
Range of motion with air
splint
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Treatment Activities
Range of motion with air
splint
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Treatment Activities
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4-6 weeks post-operatively
Home Program:
• Daily/nightly splint wear
• Active/Passive range of motion exercises
• Scar massage
• Use of silicone gel or elastomer as indicated
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Treatment 6-12 weeks post-operatively
• Goal:
– Increase passive/active elbow extension
– Increase triceps strength
• Splint:
– At night time only
• AROM/PROM:
– active/passive range of motion for extension, flexion and
supination, reaching activities that encourage elbow
extension
– Triceps strengthening
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Treatment: Kinesio taping
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Treatment: E-Stim
Triceps activation
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Treatment Activities
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Treatment Activities
Weight bearing
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Treatment Activities: Postural Stretching
• Towel Stretching
• Retraining Scapular Positioning
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6-12 weeks post-operatively
Home Program:
• Nightly splint wear
• Active/Passive range of motion exercises
• Scar massage
• Use of silicone gel or elastomer as indicated
• Strengthening activities as provided
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Discharge Planning
• The child should be ready for discharge after 12
weeks of consistent therapy and active participation in
home program
• Home program of continued strengthening, range of
motion and scar massage
• A follow up appointment in one month may be
recommended to ensure continued progress and to
adjust home program as needed
Thumb in Palm Deformity
EPL reroutement surgery
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EPL reroutement
• Reroutement tendon transfer of EPL from the 3rd
compartment through the 1st compartment
• Typically combined with adductor pollicis, flexor
pollicis brevis, and first dorsal interosseous release at
the muscle origins.
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EPL reroutement
Candidates:
• Child with spastic thumb adduction posturing or thumb
in palm deformity
Benefits:
• Improved thumb function
• Improved functional grasping
• Improved finger flexion
• Improved bilateral skills
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Post Operative Phase: 4 weeks
Placed in a short arm thumb spica cast with the wrist in
neutral deviation and flexion/extension. Thumb placed
in midpalmar and radial abduction. Avoidance of
metacarpal phalangeal hyperextension in cast
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Evaluation: Initial Steps Post Cast Removal
Scar/Incision: Debride and clean incision
Remove sutures
Measure: length, width
Note open areas
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Evaluation: Clinical Observations
Edema:
• Circumferential measurements
• Pitting/non-pitting
Sensation:
• Changes in sensation
• New sensation
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Evaluation: Clinical Observations
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Range of motion: Active thumb extension/abduction, no
passive thumb flexion until 6 weeks post-op
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Splinting 4 weeks post-op
Fabricate volar forearm thumb spica splint with wrist in
15 degrees extension and thumb in radial abduction
Worn full time for a minimum of 2 weeks depending on
tone
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Treatment 4-6 weeks post-operatively
• Goal:
– Increase active thumb motions
• Splint:
– at all times except for bathing, therapy and home program
• AROM/PROM:
– Active range of motion for thumb extension, abduction
– Progress to passive range of motion for thumb extension,
abduction as tolerated
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Treatment: Scar Management:
• Scar massage
Manual
Use of Mini massager
• Silicone Gel
• Scar pump
• Elastomer
• Compression
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Treatment: Edema Control
• Retrograde massage
• Compression
• Elevation
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Treatment: 4-6 weeks post-op
Range of motion
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Treatment 4-6 weeks
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4-6 weeks post-operatively
Home Program:
• Daily/nightly splint wear
• Active/Passive range of motion exercises
• Scar massage
• Use of silicone gel or elastomer as indicated
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Treatment 6-12 weeks post-operatively
• Goal:
– Increase active thumb motions
• Splint:
– At night
• AROM/PROM:
– Active range of motion for thumb extension, abduction
– Passive range of motion for thumb extension, abduction,
adduction, and flexion
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Treatment
Kinesiotape for thumb abduction assist
Splinting for thumb stabilization during day as needed
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Treatment: E-Stim
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Treatment activities
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Strengthening activities
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6-12 weeks post-operatively
Home Program:
• Nightly splint wear
• Active/Passive range of motion exercises
• Scar massage
• Use of silicone gel or elastomer as indicated
• Strengthening activities as provided
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Discharge Planning
• The child should be ready for discharge after 12
weeks of consistent therapy and active participation in
home program
• Home program of continued strengthening, range of
motion and scar massage
• A follow up appointment in one month may be
recommended to ensure continued progress and to
adjust home program as needed
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References
• Burn, Matthew B., and Gloria R. Gogola. “Flexor Carpi Ulnaris Myotendinous
Lengthening Improves Function in Children with Spastic Hemiplegic Cerebral Palsy.”
The Journal of Hand Surgery, vol. 40, no. 9, 2015, doi:10.1016/j.jhsa.2015.06.095.
• DeMatteo, C., Law, M., Russell, D., Pollock, N., Rosenbaum, P., & Walter, S. (1992).
QUEST: Quality of Upper Extremity Skills Test. Hamilton, ON: McMaster University,
CanChild Centre for Childhood Disability Research.
• Goldfarb, Charles A., et al. Hand and upper extremity therapy: congenital, pediatric
and adolescent patients: Saint Louis protocols. St. Louis, MO, Charles A. Goldfarb,
2012.
• Gong, Hyun Sik, et al. “Early Results of Anterior Elbow Release With and Without
Biceps Lengthening in Patients With Cerebral Palsy.” The Journal of Hand Surgery,
vol. 39, no. 5, 2014, pp. 902–909., doi:10.1016/j.jhsa.2014.02.012.
• Heest, Ann E Van, et al. “Tendon Transfer Surgery in Upper-Extremity Cerebral Palsy
Is More Effective Than Botulinum Toxin Injections or Regular, Ongoing Therapy.” The
Journal of Bone and Joint Surgery-American Volume, vol. 97, no. 7, 2015, pp. 529–
536., doi:10.2106/jbjs.m.01577.
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References
• Koman, L. Andrew, and Beth Paterson Smith. “Surgical Management of the Wrist in
Children with Cerebral Palsy and Traumatic Brain Injury.” Hand, vol. 9, no. 4, 2014,
pp. 471–477., doi:10.1007/s11552-014-9636-8.
• Roode, Carolien P. De, et al. “Tendon Transfers and Releases for the Forearm, Wrist,
and Hand in Spastic Hemiplegic Cerebral Palsy.” Techniques in Hand & Upper
Extremity Surgery, vol. 14, no. 2, 2010, pp. 129–134.,
doi:10.1097/bth.0b013e3181e3d785.
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