Download 6 Ajuncts to physiotherapytherapy

The Management of the children with spastic
Cerebral Palsy:
Adjuncts to Physiotherapy Intervention
Robyn Smith
Department of Physiotherapy
UFS
2012
Spasticity : a complex problem
• Spasticity is a complex problem and can
have a significant influence on:
– a child’s quality of life,
– negatively impact the rehabilitation process,
– achievement of functional goals
• In some cases however a child may use
spasticity for function
What is spasticity?
• Spasticity is a physiological consequence
of damage to the central nervous system
or spinal cord
• Overactive stretch reflex
How to we measure spasticity
objectively
• Objective Scales available:
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Ashworth scale
Modified Ashworth (Scale 1-5)
Tardieu (includes some neurological aspects, speed of PM)
PENN spasm scale: self report on f, severity
? Reliable and valid
? Effect of velocity on spasticity
Scales do not look at the effect of spasticity on function
Ineffective management of
spasticity
The impact of spasticity can be devastating if not
managed early and appropriately it can result in:
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muscle contractures,
severe postural and/or limb deformities ,
pressure sores which may even,
make basic nursing care a challenge,
Pain resulting from spasticity is also a significant
concern.
Aggravation of spasticity
• Spasticity may be aggravated by factors
such as:
– emotional distress
– illness
– hypothermia
– poor positioning
– Pressure sores
The effective management of
spasticity is fundamental in the
successful management of
neurological disabilities and the
prevention of secondary
complications.
Physiotherapy remains the
most common first line
treatment option for patients
with spasticity
Physiotherapy in the management
of spasticty
Physiotherapists make use of :
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physical activities
tone influencing techniques and/or positions,
passive movements,
muscle stretching,
orthotics and serial casting,
therapeutic standing,
hydrotherapy,
electrotherapeutic modalities such as (TENS) and Functional
Electrical Stimualtion (FESS)
Dealing with severe spasticity
in a child with neurological
dysfunction a huge problem
especially when it limits
functional abilities.
?
If physiotherapy is not in itself effective
enough to manage/ influence the child’s
tone,
What alternative therapies are available?
Alternative Management strategies for
spasticity
Pharmacological
treatments
Intramuscular agents
• BOTOX (BoNT)
• Intrathecal Baclofen
• Oral agents e.g.
benzodiazepines and
baclofen
Injectable agents/nerve
blocks
• Phenol
NeuroSurgical intervention
• Selective Dorsal Rhizotomy
(SDR)
• Orthopaedic surgery
• Tendon transfer
• Osteotomy
Pharmaceutical Agents
Oral medications
Oral Baclofen
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Muscle relaxant and antispasmodic agent
Can also be used
Not always available in public sector
Not specific
Results in a general decrease in muscle
tone
Valium /Diazepam
(Benzodiazepine)
• Can also be used as a last resort to relieve
spasticity
• Antipsychotic agent with muscle relaxation
properties
• Not a drug of choice to manage spasticity
• CNS suppression –resulting in drowsiness,
over-sedation, respiratory function
impairment.
• Cannot then continue with therapy as child is
often non responsive and drowsy
Intrathecal Baclofen
Intrathecal Baclofen
Intrathecal Baclofen
• Use of implantable, programmable pump
• To deliver precise amounts of Baclofen
directly to the site of action at the spinal
cord via the CSF
• Precise action of Baclofen as a muscle
relaxant and antispasmodic agent is not
fully understood.
• Baclofen inhibits both monosynaptic and
polysynaptic reflexes at the spinal level.
Negative aspects of using a intrathecal
Baclofen pump
• Side effects
– Dislodging
– mechanical malfunctioning of the pump
– Infection
• Should not suddenly be discontinued as
the patient will go into withdrawal.
Intrathecal Baclofen
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Expensive
Central nervous system effects
Used with good success in Europe
Not currently available as a treatment
option in in SA
Intramuscular agents:
BOTOX
BOTOX
BOTOX
• = BoNT
• Botilium type A toxin (BOTOX) is a poison
that is injected in small amounts locally
• into a specific spastic muscle
• used to reduce spasticity
• No benefit if muscle is already contractured
• Not licensed to be used in children under 2
years.
• Has been used very successfully in
hemiplegic, and diplegic children
BOTOX
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Effect is temporary and lasts for 3-4 months
Expensive (R2000 -4000/injection)
Repeated administration is often required
Not available on code for public sector patients
Safety ? FDA has it under investigation has
resulted in deaths in adults when used in high
doses causing inability to swallow and
respiratory failure
• Needs to be administered by an experienced
paediatrician/neurologist
How does BOTOX work?
Benefit of using BOTOX (BoNT)
• Effect temporary/reversible
• Can be used before something more
permanent such as surgery is considered
• Injections however need to be followed up
with intensive physiotherapy and
appropriate orthoses
Surgical Intervention:
Selective Dorsal
Rhizotomy
Selective dorsal rhizotomy (SDR)
What is SDR?
• “Myelonotomy”
• Is a neurosurgical procedure where the
dorsal nerve roots are severed
• Used management of spasticity
• Mainly in case spastic diplegic child
• Permanent effect or relief of spasticity
Dorsal Rhizotomy
Dorsal laminectomy L2-S2
Electric stimulation nerve roots
Reflex arch broken by severing dorsal nerve root
Sensation & motor function preserved
Important to assess if the child
spasticity useful or harmful?
• Harmful : impedes function
• Useful: aids in antigravity movement and
functioning
Consideration is that if spasticity is useful
removing the child’s spasticity via a SDR
may result in deterioration of function
Considerations before doing SDR:
• Main problem must be spasticity
• Adequate underlying muscle strength (lower limbs,
pelvis and trunk)
• Child must have received intensive surgery for at
least 2 years prior to the surgery
• Family and child must be motivated
• Cognitive ability of the child to participate actively in
intensive rehabilitation programme
Surgery best between 6-8 years of age (but no age
limit)
Considerations before doing SDR:
• Will not prevent hip dislocations due to poor
biomechanics
Need to reconsider in the following cases:
• Previous orthopaedic surgery .
Usually decide to do SDR. Orthopaedic surgery
then only done afterwards if indicated to correct
remaining shortenings or deformities.
• Contractures or spinal deformities present ?
Orthopaedic surgery first
Physiotherapy Assessment before SDR
• NB!!!
• Evaluate child’s underlying
muscle strength in trunk and legs
• Evaluate functional activities
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sitting up from supine
standing up from chair
Walking
running.
• Functional abilities and potential
• Computerised/video gait analysis
widely now used to measure
before and after changes
(objective measure)
Complications SDR
Early:
• Dysasthesia (loss sensation)
• CSF leak (severe spinal
headache)
• Neurogenic bladder
Late:
• Back pain
• Spondilolisthesis
Complications in the case of a
competent neurosurgeon are
however very rare
Post operative management
• Strict bed rest 5 days
Precautionary measures:
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No passive or active trunk rotation 4/52
No lumber flexion 4-6/52
70 ◦ degrees hip flexion 4-6/52
Intensive physiotherapy essential after
surgery once child can mobilize more
freely
Other therapy intervention for motor problems related to
neurological pathology and spasticity
• Orthopaedic surgery
• Hyperbaric Oxygen Therapy (HBOT)
• Constraint Induced Therapy (CIT)
• Compression Suit therapy
• Static weight bearing therapy
• Strength training
• Orthoses and assistive devices
• Hippotherapy
• Virtual Reality Training (VRT)
:
Other Management
Approaches
Orthopaedic Surgery
Why consult an Orthopaedic surgeon?
SPASTICITY
• Often severe spasticity, poor biomechanics and muscle
imbalances lead to contracturing of the soft tissue and
muscles
• Can also lead to postural and joint deformities.
• Contractures can and do limit function
• Especially limiting in terms of mobility in diplegic and
hemiplegic patients
.
Why consult an Orthopaedic
surgeon?
• Severe spastic quadruplegic patients
adductor muscle contracturing can make
nursing care difficult e.g. bathing, dressing,
changing diaper
• Muscles most often effected in the LL are:
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m. iliopsoas
m. Hamstrings
m. adductors
m. Gastrognemius and souleus (TA)
Why consult an Orthopaedic
surgeon?
• Muscles most often effected in the UL are:
– m. biceps brachii
– m. long flexors over the wrist and fingers
– m.flexor pollicis brevis, longus and opponens
pollicis at the thumb
Soft Tissue Releases
Soft Tissue Releases
• Before sending child for surgery:
– Evaluate underlying muscle length (shortening vs.
contracture) and which specific joints are affected
– Evaluate underlying muscle strength carefully
– Evaluate how tone influences function
– Evaluate the child’s functional abilities and potential
• Physiotherapists input essential prior to surgery to
ensure optimal functional outcome post operatively
• Z-plasty for lengthening of shortened/contractured muscle
• “Full house” release is when in the LL they release:
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m. iliopsoas,
M. adductors magnus
Hamstrings
TA
• ??? Often too aggressive and results in “over-releasing with
subsequent:
– Loss of function
– Joint hyper-mobility
– Loss muscle tone
Soft Tissue Releases
• Usually only done after 5 years of age
– Make sure that procedure does not have to be
repeated over and over again at short intervals
• Releases of arm contractures not often done
and not very successful
• Post operative intensive physiotherapy must be
available
Physiotherapy after Soft Tissue
Releases
• POP spika with cross bar for 6/52
• S Therapeutic standing commenced from day 2
• Stretch m.iliopsoas in standing/prone lying
• Positioning:
– no pillow under legs
– Lie in prone least 30 min./day
– No extended periods sitting
• Keep POP dry and clean
• Daily therapeutic standing until POP removed
Physiotherapy after Soft Tissue
Releases
Once the POP removed 6 weeks:
• KAFO(knee and ankle foot orthosis)/AFO
(ankle foot orthosis) worn 3 months full time
• Intensive physiotherapy (remove KAFO/AFO if
needed during therapy)
• Sleep with KAFO/AFO 6 months to prevent
shortening of the lengthened muscles
• Include a ROM and stretching programme
Rehabilitation following Soft tissue
surgery
Muscle or Tendon
Transfers
Muscle or Tendon Transfers
• Careful selection for procedure
• Tendon or muscle transfers can be done in
cases where it may result in improved
function
• UL and LL transfers are done
• Followed up by intensive physiotherapy, reeducate the muscles new function
Muscle/tendon transfer
Other orthopaedic surgery
Hip Dislocations
Why consult an Orthopaedic surgeon?
HIP DISLOCATION:
• Severe spasticity/hypotonicity and constant abnormal
biomechanics do result in dislocations
• Posterior dislocation more common, anterior dislocation
can also occur
• Important to remember that the acetabulum does not
develop its normal shape and depth in children that do
not weightbear
– contributing further to the risk of dislocation
Why consult an Orthopaedic
surgeon?
HIP DISLOCATION:
• Common in severe spastic quadruplegia
– posterior dislocation due to spastic pattern
• Can contribute to o severe postural deformities as well
Orthopaedic management of hip
dislocations
• Femoral osteotomy is done to:
– relieve pain
– and to aid nursing care
– improve posture
– Improve function
• At times arthroplasty may also be done.
Femoral osteotomy
Derotation Femoral Osteotomy
Physiotherapy following a femoral
osteotomy
• Rehabilitation commences on day 2
• May be in a spika (same STR)
• Mobilisation for ROM
• Can start weightbearing mobilisation as pain
allows
• Arthoplasty of the hip NWB for up to 6 weeks
Foot Abnormalities
Club-foot Deformities
Club-foot deformity
Club-foot deformity
• “Tallipes equinovarus”
• Causes often unknown
• Club foot causes may be iodiopathic or arise in
conjunction with other neuromuscular deformities.
• Deformity is structural and is fixed or rigid requires may
require surgery depending on degree.
• A positional clubfoot occurs when an otherwise normal
foot is held in a deformed position in utero.
Management of a Club–foot deformity
Positional Clubfoot
Management commences 2-3 days after birth
• POP –repeat weekly
• Strapping/ splinting –every few days
• Until correct positioning attained
• Orthoses may be useful
Management of a Club–foot
deformity
Structural Clubfoot
• Management started as soon as is possible.
• Ponseti method
– manipulation funder anaesthesia, followed by
POP
– Dennis Brown boots to be worn 6-12 months.
– Careful not cause Rocker-bottom foot (mid
foot fracture).
Dennis Brown Boot
Management of a Club–foot
deformity
• When conservative management fails
The club foot will require surgical management:
– Child Younger 5 years only soft tissue surgery.
Best results at 3-4 months of age.
– Older 5 years also often also involves bony
reconstruction of the foo
• Surgery followed by POP 6 weeks
• FWB mobilization in POP/boot
• Orthotics once POP removed
• 25 % chance of reoccurrence
Management of a other
common foot deformities
Pes Planus (Flat feet)
Pes Planus (Flat feet)
• All babies' feet look flat because an arch hasn't
formed yet.
– Arches only start to form once the child is weight
bearing;
– and the intrinsic foot muscles are activated.
– Foot arches should form by the time child is 2 or 3
years old.
• In CP children flat feet may be caused by:
– hypotonia,
– spastic everters
– biomechanical issues of the LL
Rocker bottom foot
(mid foot hypermobility/ or fracture)
Types of foot deformities common in
children with CP?
• Equinous foot (downwards)
• Equinovarus foot (down and in)
• Equinovalgus foot (down and out)
When to refer to orthopaedic surgeon?
• Earliest age possible !!!
• As soon as abnormalities are observed, severe
spasticity is noted and shortening has started so
that the orthopaedic surgeon can follow up the
child regularly at his clinic until surgery is
deemed necessary
• Usually do not operate before 3-4 years of age
of age
• Must give corrective foot wear and orthotics on
e.g. inner soles, AFO, orthopaedic boots to limit
deformities as far as soon as is possible
Physiotherapy after foot surgery
Mobilisation post-operatively:
• Child to mobilize FWB with below knee POP cast
6/52
• Foot surgery often combined with TA lengthening
• Appropriate orthotics
• Continued rehabilitation
The Toolbox....alternative
therapy approaches
Hyperbaric Oxygen
Therapy
Hyperbaric Oxygen Therapy (HBOT)
What is HBOT?
• 100% Oxygen administered at a controlled
pressure using a hyperbaric chamber
• The use is HBOT remains controversial
• Has been used in management of children
with CP, traumatic and anoxic brain
injuries
Hyperbaric Oxygen Chambers
Suggested benefits HBOT
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Hyper-oxygenation
Neurovascularization
Vasoconstriction
Antibacterial activity
How is HBOT supposed to work ?
• Brain injuries result in neuronal death
• Also forms “ idling” neurons suggesting
recoverable brain tissue
• HBOT postulated to re-activate “idling”
neurons
• Suggest more beneficial when done
shortly after neuronal injury (CP??? vs.
hypoxic or traumatic brain injury)
What do I tell a parent who wants to try
it ?
• Current research about HBOT efficacy in
the management of neuronal injury is
inconclusive Research studies results are
very contradictive.
• Not widely used any more as adjunct to
therapy. Not as fashionable any more.
• Expensive (R150- 350/per session, and
several sessions in a course).
Constraint Induced
Therapy
Constraint Induced Therapy
Constraint induced therapy (CIT)
• Used in hemiplegia and assymetircal
diplegia
• Involves the physical constraint of the
unaffected upper limb
• Aim is to improve awareness of , and the
physical activity and function of the affected
arm and hand
• Based on the learn- not use concept
• Combined with intensive PT/OT
What do I tell a parent who wants to try
it ?
• Definitely give it a try !
• Use a bandage/immobi-sling/neoprene splint
• Labour intensive for parent/therapist got to be followed
up with task or goal directed activity for hand
• Have been some controlled clinical trial done on CIT
• Research results have been promising – research has
shown improved use of the arm and hand to lesser
extent
• More clinical trial research indicated
• Concerns :Often difficult to implement with a child with
little active use of arm or even in cases severe hemineglect. Use your clinical judgement here.
Flexible and stabilising orthotics:
Compression Suit Therapy
Adeli Compression Suit Therapy
Adeli compression Suit Therapy
• “Wearable therapy clothes” = Adeli suit
• Originated in Poland and being used worldwide
• Compression and support orthotics used in
attempt to improve muscular and motor control,
as well as resistance to some movement in
individuals suffering from neurological
dysfunctions
• ??? Use in cases low tone, ataxia
• Cases where you feel you do not “have enough
hands’’during therapy
• Increased sensory feedback and bodily
awareness
Electrical Stimulation
Electrical muscle stimulation
Electrical Stimulation (FES)
• ??? Use in muscle specific re-education &
strengthening programs
• Used in strengthening quadriceps in
ambulant diplegic children who find
resisted exercises' difficult
• Lack of scientific evidence at this therapy
• Use remains controversial
• Not widely implemented
Static Weight bearing
Exercises
Static Weight bearing
Static Weight bearing Exercises
• “therapeutic standing”
• Widely used e.g. standing frame or tilting table
• Used to
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stimulate antigravity muscle strength,
prevent hip dislocations,
improve bone density,
reduce spasticity and
improve bowel and bladder function
• ??? Little scientific evidence to support its use
• Deemed to be motivating to child and family
Strength Training
Strengthening exercises
Strength Training
• Increase the power and strength of muscles –
very important in neurological re-education
• Treadmill training. Partial body weight supported
walking on a treadmill. Initial studies show
benefits e.g. walking speed, endurance and
strength
• General strength training “ functional
strengthening” also improves child’s functional
abilities in the long run
• Scientific evidence to support its use widespread
Virtual Reality Training
(VRT)
Virtual Reality Training (VRT)
Virtual Reality Training (VRT)
Orthotics & Assistive
Devices
Orthotics & Assistive Devices
Orthoses & Assitive Devices
• Devices that by an application of an external force
attempt to correct the alignment of a body segment
– Help to prevent or correct deformities
• Static s. dynamic orthoses avaiable. Decided on in
consultation with orthotist.
• Plaster of fiberglass or plastic
• Serial casting (management of spasticity as well)
• Research about use of orthoses is more favourable in
terms of LL than UL. Effect however deemed to be short
term
• Assistive devices including walking frames, rolators
Serial casting
Hippotherapy
Hippotherapy
Hippotherapy
• Therapeutic horse-back riding under the supervision of a
trained and licensed therapist
• Often deemed recreational
• Studies have shown the therapy to be beneficial in
reducing spasticity and improving central control, muscle
symmetry in hips and trunk and improving gross motor
function
• ??? Expensive
• ??? Availability
• Becoming more popular in SA, more widely used in USA
and in Europe
In Conclusion …….
Weighing up available treatment options extremely
important in the management of a child with
spasticity and motor dysfunction
Sometimes need to think outside the NDT box !!!!!
In NDT we apply principles of motor learning but also
need to include aspects like:
– strength and endurance
– CVS fitness training
In Conclusion …….
The following needs to be taken into consideration
when making decisions regarding therapy and
adjuntive modalities:
• Clinical picture and diagnosis of the child
• Interdisciplinary approach essential – parent/child must
be involved in the decision making.
• Cost vs. proven effectivness of therapies (evidence
based practice)
• Treatment must be individualised –there are no recipes
In Conclusion …….
• We also need to make use of appropriate
orthotics and assistive devices where indicated
• Ultimate aim is improving the child’s functional
ability and participation
• Need to accurately assess the impact tone and
especially spasticty has on a child’s functional
abilities
In conclusion ……
• Collaborative effort to decide on which
approaches and interventions are right for each
child considering:
• Financial resources of the parent
• Availability of quality, intensive physiotherapy
treatment
• Commitment and parent/caregiver/child
participation in therapy
• Preference of child and their family. It ultimately
remains their choice.
References
• Images Courtesy of GOOGLE (2009)
• Alternative approaches to managing spasticity
(2008) PANDA course provided Prof. Fieggen &
Prof. Peter (UCT, Dept. Neurosurgery)
• Brown, E. 2001. Neurodevelopmental Therapy
(NDT) Course notes. (Unpublished)
Bloemfontein.
• Coovadia, H.M. & Wittenberg, D.F. 2006.
Paediatrics & Child health. A manual for health
professionals in developing countires. 5th ed.
Cape Town: Oxford University Press
References
• Downie, P. A. 1986. Cash’s Text book of
Neurology for Physiotherapists. 4th ed. London:
Faber and Faber
• Fieggen, G. 2005.Selective dorsal rhizotomy.
Who should be considered for the procedure..
(lecture) University of Cape Town
• Stokes, M. 1998. Neurological physiotherapy.
London: Mosby International Ltd.
• Papavasiliou, A.S. 2008. Management of motor
problems in cerebral palsy: a critical update for
the clinician