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


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

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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


Evaluation: First Steps Post Cast Removal

Scar/Incision: Debride and clean incision

Remove sutures

Measure: length, width

Note open areas

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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


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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• 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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• 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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• 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


Treatment: E-stim

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Treatment: Fine Motor

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• 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


Remove sutures


Note open areas

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Edema:



Sensation:


• New sensation

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Range of motion: Elbow extension/flexion


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


Treatment: Scar Management:

• Scar massage

Manual


• Silicone Gel

• Scar pump

• Elastomer

• Compression

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• Compression

• Elevation

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Treatment 4-6 weeks post-operatively

• Goal:

– Increase passive/active elbow extension

• Splint:


• 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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Range of motion with air

splint

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Home Program:


• Active/Passive range of motion exercises

• Scar massage


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• 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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Weight bearing

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Treatment Activities: Postural Stretching

• Towel Stretching

• Retraining Scapular Positioning

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Home Program:

• Nightly splint wear


• Scar massage


• Strengthening activities as provided

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Discharge Planning



home program






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


Remove sutures


Note open areas

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Edema:



Sensation:


• New sensation

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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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• Goal:

– Increase active thumb motions

• Splint:


• 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


• Silicone Gel

• Scar pump

• Elastomer

• Compression

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• 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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https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjbqsjg98XWAhWLwiYKHW5JBxoQjRwIBw&url=https://colibribookstore.com/piramidki-schet-shary.html&psig=AFQjCNE2i7dk2USbrlgrWwOGE7rEF0vReA&ust=1506621184274974

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https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiGvp7_-MXWAhXJWCYKHfYSC-8QjRwIBw&url=https://firsthandschoolresources.co.uk/Chubby-Egg-Crayons&psig=AFQjCNFxg2ch3aDUENtNxruQ5J0rJ56YWg&ust=1506621594207718



Home Program:



• Scar massage


85



• 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

86


Treatment

Kinesiotape for thumb abduction assist

Splinting for thumb stabilization during day as needed

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https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwi10rvAoJPVAhVBYiYKHRoUBaIQjRwIBw&url=https://mckiesplints.com/products/thumb-splint-pediatric&psig=AFQjCNGxXDQ3zpPfiZ_sqX6FnbSNo6eXDA&ust=1500481814654075


Treatment: E-Stim

88


Treatment activities

89


Strengthening activities

90

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Home Program:

• Nightly splint wear


• Scar massage


• Strengthening activities as provided

91


Discharge Planning



home program







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.

93

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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.

94

Children’s Healthcare of Atlanta 95

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