The foot in the child with cerebral palsy: Physiotherapy thoughts and perspective

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1 The foot in the child with cerebral palsy: Physiotherapy thoughts and perspective Margaret Mockford, MSc, MCSP 2 nd November 2016 West Midlands Cerebral Palsy day

2 But there s nothing wrong with his feet...yet

3 What s on our children s wish list? Pain-free feet Feet I can walk on Feet I can stand on Feet that I can put my shoes on Feet that will help me do the things I want to do.. Play football, ride a trike, ride a horse, use the bathroom, keep up with my friends, look normal, dance

4 The bolting horses Subtalar and midfoot joints Bone growth Muscle tissue growth

5 Subtalar and midfoot joints

7 Inversion / eversion occurs at sub-talar joint and talocalcaneonavicular joint Isolated motion of the STJ was the most difficult movement sequence for participants with CP to understand and perform Fowler et al 2010

8 Motor fibres controlling the foot and ankle pass closest to the ventricle: highest risk of damage Ventricle

9 What do physios do to influence control of the foot and ankle? Alignment and posture Strengthening muscle Educating disordered muscle Gait training Implementing interventions around orthoses Implementing interventions around orthopaedic events Teaching good practice to parents, school staff and other carers

10 What happens to bone and joint development? Infantile talus has a shorter neck, and angled more medially than in adult Ossification of talus: early in neck; later around STJ (Hubbard et al 1993) Ossification of calcaneus: begins aged 5-7yrs; finished aged 13-15yrs. Variations in internal architecture of seven bones of tarsus due to different functional stresses on each bone (Grays 38 th 1995)

12 What might influence early bone growth and development? Bone. is exquisitely sensitive to the loads imposed upon it or to the lack of such loads (Seeman 2003) Weight-bearing (compression) Muscle pull (tension) Heel strike posture of whole leg

Muscle growth The most significant muscle impairment [in children with CP] may be lack of muscle growth Shortland (2009) Muscles need excursion, loading, active use, bone

13 Muscle growth The most significant muscle impairment [in children with CP] may be lack of muscle growth Shortland (2009) Muscles need excursion, loading, active use, bone growth and intense activation to stimulate their growth in length and width Muscle activity in response to sensory bombardment Progressive deterioration of this MSK aspect of CP

Changes in non-contractile tissue Changes in passive muscle stiffness, by the age of 3 years (Willerslev-Olsen et al 2013) Possible changes to titin,

14 Changes in non-contractile tissue Changes in passive muscle stiffness, by the age of 3 years (Willerslev-Olsen et al 2013) Possible changes to titin, affecting stiffness. Are there other changes in the extracellular matrix, making muscle tissue stiffer? Are there changes to the elastic properties of the tendon?

15 Titin is important in determining muscle extensibility

16 What can we do? Progressive strength training NICE guideline 2014 re management of person under 19 with spasticity Treadmill training? Inclined treadmill, 30 minutes per day for one month: increased heel strike, increased activation of dorsi- and plantar-flexors; increased incline of treadmill (Willerslev-Olsen et al 2014) Standing frame to use body weight to elongate hamstrings and gastro-soleus (Gibson et al 2009)

17 Summary: Can we stabilise the STJ and TCNJ early on? Can we promote more normal growth of tarsal bones? Can we build length and strength into the ankle muscles?

18 Key references Allard et al 2014 Key health outcomes for children and young people with neurodisability. BMJ Open 2014;4:e Barrett and Lichtwark 2010 Gross muscle morphology and structure in CP: systematic review. Dev Med Child Neuro 52: Bernhardt 1988 Prenatal and postnatal growth and development of the foot and ankle. Physical Therapy 68912): Biewener and Bertram 1994 Structural response of growing bone to exercise and disuse. J Appl Physiol 76(2): Biewener et al 1996 Adaptive changes in trabecular bone architecture in relation to functional strain patterns and disuse. Bone 19(1):1-8 Doralp and Bartlett 2010 The prevalence, distribution and effect of pain among adolescents with CP. J MSK Pain 18(1):26-33 Caulton et al 2004 RCT effects of standing programme on bone density in non-ambulant children with CP. Arch Dis Childhood 89(2):131-5 Fowler et al 2010 Lower extremity selective voluntary motor control in patients with CP. Dev Med Ch Neuro 52:264-9

19 Gibson et al 2009 the use of standing frames for contracture management for nonmobile children with CP. Int J Rehab Res 32(4): Hubbard et al 1993 Relationship between the ossification centre and cartilaginous anlage in the normal hindfoot in children. Am J Roentgenology 161(4): NICE draft guideline on cerebral palsy 2016 NICE guideline on spasticity management in under 19s 2014 Nsenga-Leunkeu et al 2014 Gait cycle and plantar pressure distribution in children with CP. Neurorehab 35: Seeman 2003 Periosteal bone formation a neglected determinant of bone strength. New England J Med 349(4):320-3 Shortland 2009 Muscle deficits in CP and early loss of mobility. Dev Med Child Neuro 51(suppl 4):59-63 Shortland 2013 Muscle deformity in the lower limbs of children and young adults with CP. Ass Paed Chartered Physio 4(2):7-12 Willerslev-Olsen et al 2013 Willerslev-Olsen 2014 Gait training reduces ankle joint stiffness and facilitates heel strike in children with CP. Neurorehab 35:643-55

Progressive strength-training in ambulant children and teenagers with cerebral palsy: a retrospective service evaluation

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