Treatment of the Child with Cerebral Palsy Post Surgical Rehabilitation

Treatment of the Child with Cerebral Palsy Post Surgical Rehabilitation Sheelah Cochran OTR/L, CPAM, CKTP Objectives Perform an initial evaluation of post-surgical conditions Identify appropriate splinting per surgical intervention Demonstrate knowledge of therapeutic interventions and home programs 2 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 3

Typical Presentation 4 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. 5 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. 6

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 8 Evaluation: Parent Report 9

Evaluation: Functional Deficits 10 Evaluation: General Pain: use of numeric/faces pain scale 11 Initial Evaluation: General AROM/PROM measurements ( as allowed per protocol) 12

Initial Evaluation: General Strength measurements (per protocol) Functional skills assessment (per protocol) 13 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. 14 Evaluation: General MACS 15

Evaluation: Clinical observations Measurement of incisions and scar tissue formation using the Vancouver or Manchester Scar Scale 16 Evaluation: Clinical Observations Edema Measurements 17 Specific Procedures Evaluation and Treatment

Green Transfer Evaluation and Treatment 19 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 20 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 21

Post Operative Phase The patient is casted up to four weeks 22 Evaluation: First Steps Post Cast Removal Scar/Incision: Debride and clean incision Remove sutures Measure: length, width Note open areas 23 Evaluation: Clinical Observations Edema: Circumferential measurements Pitting/non-pitting Sensation: Changes in sensation New sensation 24

Clinical Observations Range of motion measurements: Passive measurements 25 Clinical Observations: AROM measurements 26 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? 27

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 28 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 29 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 30

Treatment Scar Management: Initiate scar management two to three times daily Use silicone gel or elastomer as indicated 31 Scar Management: Scar massage Manual Use of Mini massager Silicone Gel Scar pump Elastomer Compression 32 Treatment: Edema Control Retrograde massage Compression Elevation 33

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 34 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 35 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 36

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 37 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 38 Treatment: Kinesiotaping Assisted wrist extension 39

Treatment: E-stim 40 Treatment: Fine Motor 41 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 42

Treatment: Strengthening 43 Treatment: Strengthening 44 Treatment: Weight bearing 45

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 47 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 48

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 49 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 50 Evaluation: Initial Steps Post Cast Removal Scar/Incision: Debride and clean incision Remove sutures Measure: length, width Note open areas 51

Evaluation: Clinical Observations Edema: Circumferential measurements Pitting/non-pitting Sensation: Changes in sensation New sensation 52 Evaluation: Clinical Observations Range of motion: Elbow extension/flexion 53 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 54

Treatment Scar Management: Initiate scar management two to three times daily Use silicone gel or elastomer as indicated 55 Treatment: Scar Management: Scar massage Manual Use of Mini massager Silicone Gel Scar pump Elastomer Compression 56 Treatment: Edema Control Retrograde massage Compression Elevation 57

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 58 Treatment Range of motion 59 Treatment Activities Range of motion with air splint 60

Treatment Activities Range of motion with air splint 61 Treatment Activities 62 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 63

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 64 Treatment: Kinesio taping 65 Treatment: E-Stim Triceps activation 66

Treatment Activities 67 Treatment Activities Weight bearing 68 Treatment Activities: Postural Stretching Towel Stretching Retraining Scapular Positioning

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 70 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 72

EPL reroutement Reroutement tendon transfer of EPL from the 3 rd compartment through the 1 st compartment Typically combined with adductor pollicis, flexor pollicis brevis, and first dorsal interosseous release at the muscle origins. 73 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 74 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 75

Evaluation: Initial Steps Post Cast Removal Scar/Incision: Debride and clean incision Remove sutures Measure: length, width Note open areas 76 Evaluation: Clinical Observations Edema: Circumferential measurements Pitting/non-pitting Sensation: Changes in sensation New sensation 77 Evaluation: Clinical Observations Range of motion: Active thumb extension/abduction, no passive thumb flexion until 6 weeks post-op 78

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 79 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 80 Treatment: Scar Management: Scar massage Manual Use of Mini massager Silicone Gel Scar pump Elastomer Compression 81

Treatment: Edema Control Retrograde massage Compression Elevation 82 Treatment: 4-6 weeks post-op Range of motion 83 Treatment 4-6 weeks 84

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 85 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 86 Treatment Kinesiotape for thumb abduction assist Splinting for thumb stabilization during day as needed 87

Treatment: E-Stim 88 Treatment activities 89 Strengthening activities 90

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 91 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 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

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 95