Surgery

Upper extremity surgery can improve hand function in a few selected cases. The ideal surgical candidate must be a motivated, intelligent child who has good sensation in the handand uses the extremity. Those children with satisfactory handeye coordination can benefit from surgery even when hand sensation is poor.

The surgeon must be careful in patient selection because some children develop adaptive mechanisms to compensate for lost hand movements as they grow. Functional loss occurs after surgery in such patients because surgery prevents the adaptive movements they developed over the years. Consider surgery between 6- 12 years of age when the child will cooperate with postoperative rehabilitation. Set goals that fit with the expectations of the child and the parents.

Before surgery should be considered the followings

• Voluntary hand use
• Sensation
• Intelligence
• Athetosis

The shoulder Adduction – internal rotation contracture is the most common problem. Provide a program of stretching exercises. Consider surgical lengthening of the muscles if the deformity is severe.

The elbow Flexion contractures of more than 45 are functionally disabling. Try botulinum toxin injection to elbow flexors and stretching exercises in dynamic deformities and even for cosmetic reasons. Consider surgery for elbow only if the hand is functional, if there is skin breakdown at the elbow or if hygiene in the antecubital fossa is poor. Deformities greater than 60o require surgical lengthening of the biceps tendon, be aware of the fact that this procedure worsens the forearm pronation deformity. Maximum range of motion is gained 3 months postoperatively.

Forearm The main problem is a pronation contracture because of spasticity in the pronator teres and pronator quadratus muscles [B]. Activities that require supination like grasping a walker or a cane, balancing objects in the palm, washing the face are impossible. Severe pronation causes radial head dislocation but it is generally painless and does not cause functional problems. Consider pronator teres transfer to the supinator if the child can voluntarily pronate the forearm. Pronator release gives satisfactory results if the child has active supination. Longstanding pronation contracture of the forearm leads to relative shortening of the biceps aponeurosis. Release this structure to allow the biceps to be a more effective supinator.

Wrist The wrist usually is held in a position of flexion and ulnar deviation because of flexor carpi radialis and flexor carpi ulnaris spasticity [D, E]. The digital flexors also contribute to wrist flexion. Finger flexors are inefficient and the grasp is weak when the wrist is flexed [F]. Grasping is essential for function. Correct flexion contractures of wrist and fingers and adduction of thumb if they interfere with grasp. Macerations and mycotic infections are common in severe flexion contractures of the hand. Surgery becomes necessary for hygienic purposes. Options for surgery [G] include wrist flexor lengthening, flexor origin slide, tendon transfer to improve wrist extension, proximal row carpectomy, and wrist fusion with or without carpal shortening [H]. Avoid wrist arthrodesis because the patient loses the tenodesis effect of wrist extension that results in finger flexion and facilitates grasp and release. Consider wrist arthrodesis only to relieve the pain and improve the cosmesis of the hand when there is no or limited hand function. Wrist and digital flexor muscles can be selectively lengtheneddistally. Do not release or transfer both flexor carpi ulnaris and radialis as this eliminates active wrist flexion.Consider tendon transfers to augment wrist extension when it is weak or absent. Transfer the flexor carpi ulnaris to extensor digitorum communis when both finger and wrist extension is weak. This transfer improves wrist extension and does not impair finger extension and release.

Fingers Finger flexion deformity is a result of spasticity and contracture in the flexor digitorum superficialis and profundus muscles [1]. It becomes more obvious when the wrist and metacarpophalangeal joints are held in neutral position. Consider surgical intervention when flexion deformity is severe [2]. The flexor-pronator origin release effectively lengthens the flexor digitorum superficialis, pronator teres and flexor carpi radialis. Correct finger flexion deformity by direct Z-lengthening of involved tendons. If there is spasticity of intrinsic hand muscles, releasing the finger flexors will increase the deformity. Excessive lengthening weakens flexor power, impairs grasp, and can produce swan neck deformities. In this case, transfer the flexor digitorum superficialis tendon to augment wrist, finger or thumb extension instead of lengthening. Swan-neck deformity [3] is hyperextension deformity of the proximal interphalangeal joints. It is because of over-activity of the intrinsic muscles, and increases with the pull of the extensor digitorum communis when the wrist is in flexion. Consider surgical intervention if there is severe hyperextension, or when the proximal interphalangeal joints lock in extension. The thumb The thumb-in-palm deformity [4] is characterized by metacarpal flexion and adduction, metacarpophalangeal joint flexion or hyperextension and usually interphalangeal joint flexion. The causes are spasticity and contracture of the adductor pollicis, first dorsal interosseous, flexor pollicis brevis, and flexor pollicis longus . The extensor pollicis longus, extensor pollicis brevis, and/or abductor pollicis longus are often weak or ineffective. The thumb-in-palm deformity impairs the ability of the hand to accept, grasp, and release objects. The goals of surgery  are to release the spastic muscles to position the thumb, to create a balance in the muscles around the thumb, and to provide articular stability for grasp and pinch.

Rehabilitation aims to prevent disability by minimizing the effects of impairments, preventing secondary disabilities and maximizing motor function throughout the child’s life. The focus of treatment shifts over the years but the principles remain the same. Functional goals change as the baby becomes a child and the child matures into an adult. Younger children focus mainly on mobility whereas adults shift their focus to communication and activities of daily living. The first four years are spent in physiotherapy and bracing, orthopaedic surgical procedures are performed between 5 to 7 years of age, education and psychosocial integration become main issues in the school age (7-18 years). Reach mobilization goals by the time the child is ready to go  to school. The child needs aggressive physiotherapy in the growth  spurt period and after orthopaedic surgery. Communicate with the school physiotherapist or the physical education teacher to help with the child’s exercise program to enable an active life for the child at school.

Early intervention
Early intervention is the general name given to many therapy modalities including exercise and caregiver education. Early intervention programs involving infant stimulation and caregiver education may retard or reverse the central nervous system lesion  causing the clinical picture of CP and thus prevent or minimize neuromotor delay. There is no established routine and no proven  value of these programs, however until we know which babies  are going to be normal on their own, it is better to let them have the benefit of early treatment so that any improvement potential is not lost. Despite the controversies early treatment benefits the parents. They receive a great deal of practical advice and support this way. The child’s functional status may improve with parental support. Early treatment creates more opportunity for the potential to develop any normal abilities and for decreasing the defects.

Infancy
Rehabilitation goals are to educate the family about the child’s problem, to improve parental bonding, to help the mother care for the baby and to promote optimal sensorimotor development through positioning, stimulation and exercises  if possible. Increase mobility and help the baby explore his surroundings. Use positioning, carrying, feeding and dressing techniques which promote bodily symmetry in the infant. These limit abnormal posture and movements and make functional activity possible. Provide sensory stimulation using various movements and postures. Some positions lengthen the spastic muscles and make voluntary movement easier. Add weight shifting, weight bearing, trunk rotation and isolated movements into the exercise regimen.  Customized seating or seating supports are necessary. Visual attention, upper extremity use and social interaction improve in the child who is supported in sitting. When the child is sitting comfortably without fear of falling he sees his hands, practices midline play, reaches for his or her feet and sucks on his fingers. All of these movements provide sensory stimulation and promote a voluntary motor response to that stimulation. Active movements encourage the infant to develop flexor control and symmetry. Use toys that require two hands, facilitate the use of neck and trunk muscles and anteroposterior control of the head. Educate the parents to help them accept their child’s problems and raise their child in the best possible way.

Childhood
The needs of the children are different starting at age one depending on the type and severity of involvement. Redefine goals of treatment at this stage. Limitations in motor function create disabilities in learning and socialization. The child cannot become independent. The major goal of rehabilitation in the
preschool period is achieving independent mobility. At this age child’s maximum level of motor function can be predicted with greater accuracy. Choose a method of mobilisation and teach the child how to use it so that he will be free to explore his environment. Bring every child to an erect position regardless of prognosis for walking. Encourage the use of standers. Focus on independent mobility in every child. The total body involved child needs sitting supports and wheeled mobility. The diplegic and the hemiplegic must be supplied with appropriate bracing to begin to work on ambulation. As the child matures physically by the age of four he must be involved in self care activities and activities of daily living at home. Always aim for functional tasks in the limits of the child’s capacity. Address educational issues with help from  special educators if necessary. Plan and complete all surgical procedures directed towards better ambulation by school age if
possible.

School age and adolescence
Children in mainstream schools regress because of a lack of exercise. Physiotherapy done in clinics in contrast, takes too much time, causes separation of the child from his peers and prevents socialization. Physiotherapy should be performed at school if possible with the help of a community physiotherapist or the physical education teacher. Coordinate school with play and exercise. Handle social and vocational issues during school years for a better state of independence. Efforts to improve the
psychological well being of the child are necessary especially in adolescence. Children with CP have a significantly lower level of physical activity and cardiovascular fitness compared to their healthy peers even if they are only mildly impaired. Keep in mind the fact that cardiovascular issues continue to be a problem for the CP patient in adulthood, increase the activity levels of these children at school by sports and play.

The family
Physical impairments that create lifelong disability for the child cause psychological disturbance in the family. The parents are  in need of constant support, have problems understanding and accepting the situation and tend to blame themselves or the physicians. Explain the nature of the problem to the family and include them in the treatment plan. Remember that families may need to hear the same information many times before they can fully comprehend the problems they will encounter. The concept of management rather than cure forms the basis of intervention. Long term aggressive therapy programs cause social isolation and delay normal psychological development. Integrate therapy programs into summer camps,  home activities and school. Let the child live like a child, as close to normal as possible. Do not raise false hopes. Successful rehabilitation includes the prevention of additional problems, reduction of disability and community integration. Rehabilitation is successful if the child is a happy child and if the parents are well adjusted, happy people.

Hemiplegia
Hemiplegic children have involvement of the arm and leg on  one side of the body. The upper extremity is more severely involved than the lower. Spastic hemiplegia constitutes 20% of cases with spastic CP. These children generally have very few associated problems. Communication is unimpaired most of the time. They may have seizures, learning and behavioural problems. Functional prognosis is good compared to other types because one side of the body is normal. All hemiplegic children learn to walk by the age of three. They become independent in the activities of daily living. Seizures, mild mental retardation,  learning difficulties and behavioural disturbances may complicate the management and integration into the society.

Common musculoskeletal problems

The shoulder is adducted and internally rotated, the elbow is flexed and pronated, the wrist and fingers are flexed, the thumb is in the palm. The hip is flexed and internally rotated, the knee is flexed or extended, the ankle is in plantar flexion. The foot is generally in varus, although valgus deformity may also be  seen. The hemiplegic side is short and atrophic depending on the severity of involvement.

Musculoskeletal problems in hemiplegia

Upper extremity

• Shoulder -  Internal rotation, Adduction
• Elbow -  Pronation, Flexion
• Wrist – Flexion
• Hand – Flexion , Thumb-in-palm

Lower extremity

• Hip – Flexion, Internal rotation
• Knee – Flexion, Extension
• Ankle – Plantar flexion
• Foot – Varus

Treatment consists of physiotherapy, occupational therapy, bracing, botulinum toxin injections and orthopaedic surgery. Some children may need speech therapy and antiepileptic medication.

Treatment in hemiplegia

• Physiotherapy – Prevent contractures, Strengthen weak muscles, Establish a better walking pattern
• Occupational therapy – Functional use of upper extremity, Activities of daily living
• Bracing
  Lower extremity  –>  Solid or hinged AFOs
  Upper extremity  –>   Functional or resting hand splints
• Botulinum toxin A
  Lower extremity – Rectus femoris and gastroc spasticity
  Upper extremity – Pronator flexor spasticity
• Orthopaedic surgery – Correction of Pes equinovarus, Stiff knee, Femoral anteversion

Physiotherapy & occupational therapy

Motor problems of the hemiplegic child are usually mild. Physiotherapy is prescribed to prevent contractures of the involved side, to strengthen the weak muscles, to enable functional use of the upper extremity and to establish a better walking pattern. The basic program for the lower extremity consists of hip, knee, ankle range of motion exercises; rectus femoris, hamstring and gastrocnemius muscle stretching and agonist muscle strengthening. Do not neglect the back extensors and pelvic girdle muscles. Prescribe occupational therapy to gain hand function. Activities that involve both hands may improve the use of the involved side. Inhibiting the sound extremity and forcing the involved one to work is a novel method called constraint induced therapy. This method has certain beneficial effects but it is frustrating for most children. Children with hemiplegia do not need physiotherapy for ambulation. Prognosis for independent walking is very good. Physiotherapy is beneficial to prevent contractures of the ankle. In most of the cases the physiotherapy and occupational therapy can be accomplished on an outpatient basis or home program.

Botulinum toxin A

Botulinum toxin injections are used for upper and lower extremity spasticity in the young child. The toxin reduces gastrocnemius-soleus and rectus femoris spasticity in the lower extremity. The child uses his braces more efficiently and may develop a better walking pattern. Early relief of spasticity may prevent shortening of the gastrocnemius muscle and delay or eliminate the need for surgical intervention. In the upper extremity, inject botulinum toxin to relax wrist, finger and thumb flexors so that the child may gain forearm supination and wrist stabilization. Relaxing the spastic muscles with botulinum toxin injections may aid the treatment team to visualize how the child will function when his spastic muscles are surgically lengthened. However, the toxin cannot show its real effect in some older children with already shortened muscles. Botulinum toxin may be combined with surgery in the older child. Inject muscles which have mild spasticity and no shortening with Botulinum toxin and surgically lengthen the severely spastic short muscles. This combination approach adopted in the recent years enables a swifter return of function, less complications and less muscle weakness because of less extensive orthopaedic surgery.

Bracing

Upper extremity bracing
There are two indications for hand splints in hemiplegia. One is to prevent deformity and the other is to improve function. Night splints help stretch muscles and maintain range of motion.Tone usually decreases at night, therefore the use of resting splints at night to prevent deformity is questionable. The child’s compliance with night splints is generally poor. Use day splints to increase function by either supporting the wrist in 10o extension, the thumb in opposition or both. Keep in mindthat day splints prevent sensory input in the already compromised hand.

Lower extremity bracing
AFOs stabilize the ankle and foot and keep it in the plantigrade position for weight bearing. They are set in 5o dorsiflexion to avoid genu recurvatum or at neutral to prevent knee flexion. If the foot remains fixed the child has to extend the knee. Correct all fixed contractures before giving braces. Use hinged AFOs for mono and hemiplegic patients especially when they have active dorsiflexion.

Type of brace   <–>  Indication

• Solid AFO                        <–> Equinus and equinovarus
• AFO in 5 dorsiflexion <–> Equinus & genu recurvatum
• Hinged AFOs                  <–> Equinus and equinovarus if the child:
  a.     can tolerate the hinge
  b.     has varus-valgus control
  c.     has 5o passive dorsiflexion
• Supramallleolar orthoses (SMO)  <–> Mild varus – valgus deformity
  without equinus

Braces are devices which hold the extremities in a stable position. The goals of bracing are to increase function, prevent deformity, keep the joint in the functional position, stabilize the trunk and extremities, facilitate selective motor control, decrease spasticity and protect the extremity from injury in the postoperative phase. Their design and use requires an understanding of human biomechanics. Indications differ according to the age, selective motor control level, type of deformity and functional prognosis of the child. The physician writes the prescription and the orthotist manufactures the brace. A close communication is necessary between them. Braces are custom-made from a plaster model of the child’s extremity and fabricated with plastic materials. Evaluate the child for the first time together if possible. When the brace is ready, teach the child and the family how to put it on, take it off and how to look after it together with the therapist and the orthotist. Consider any modifications for better fit during this period. Evaluate the child once again after he begins to use the brace. The brace should be simple, light but strong. It should be easy to use. Most importantly it should provide and increase functional independence. The child will easily accept and use a brace which carries the above characteristics. Children will resist braces if the brace interferes with function. Do not insist if the child does not want to use the brace. The child quickly outgrows the brace in the growth spurt period. Indications change as the child’s functional status changes. Evaluate the child at 3-6 month intervals and renew all braces regularly as the child grows.

Lower extremity bracing
Orthotics are usually named according to the body parts they cover.

Braces in CP

Ankle foot orthoses: AFOs
Knee-ankle foot orthoses: Plastic KAFOs and knee immobilizers
Hip abduction orthoses
Thoracolumbosacral orthoses: TLSOs
Supramalleolar orthoses: SMOs
Foot orthoses: FOs
Hand splints

Various kinds of ankle foot orthoses called AFOs are the most common braces used in CP. Static braces immobilize the joint while flexible or hinged ones use bodyweight to stretch the muscles of the leg and ankle. AFOs provide appropriate contact with the ground during stance and foot clearance during swing. Knee immobilizing splints and hip abduction splints are prescribed both for nonambulatory and ambulatory children. Compliance with night splints to prevent deformity is low. KAFOs work in children who use them. AFOs are not very useful as night splints because they do not prevent knee flexion.

Ankle foot orthoses (AFO)

The AFO is the basic orthosis in CP and is a crucial piece of equipment for many children with spastic diplegia. The main function of the AFO is to maintain the foot in a plantigrade position. This provides a stable base of support that facilitates function and also reduces tone in the stance phase of gait. The AFO supports the foot and prevents drop foot during swing phase. When worn at night, a rigid AFO may prevent contracture. AFOs provide a more energy efficient gait but do not prevent foot deformities such as pes valgus, equinus or varus. It is better to use the AFOs part time in most children. They may cause sensory deprivation and muscle atrophy if used continuously. Adolescents generally outgrow their braces and adults do not comply with them.

There are various types of the AFO.

Types of AFO

• Solid AFO
• Posterior leafspring AFO (PLSO)
• Ground Reaction AFO (GRAFO)
• Antirecurvatum AFO
• Hinged AFO
• Hinged GRAFO
• Hinged antirecurvatum AFO

Solid AFO: The solid or rigid AFO [B, C] allows no ankle motion, covers the back of the leg completely and extends from just below the fibular head to metatarsal heads. Raise the sides for better varus-valgus control. The solid AFO enables heel strike in the stance phase and toe clearance in the swing phase. It can improve knee stability in ambulatory children. It also provides control of varus/valgus deformity. Advise solid AFOs to prevent contractures and to provide ankle stability in the standing frame in nonambulatory children. Because they are more comfortable compared to a short leg cast, consider using them in the early postoperative period for protection of the operated extremity.

Posterior leaf spring AFO: A PLSO is a rigid AFO trimmed aggressively posterolaterally and posteromedially at the supramalleolar area [D]. This provides flexibility at the ankle [E] and allows passive ankle dorsiflexion during the stance phase. A PLSO provides smoother knee-ankle motion during walking while preventing excessive ankle dorsiflexion, particularly in larger children who have the strength to deform the material. However it also increases knee flexion in stance. Varus-valgus control is also poor because it is repeatedly deformed during weight bearing. The brace breaks when it is repeatedly deformed. These AFOs are frequently renewed because of material failure. A PLSO is an ideal choice in mild spastic equinus. Do not use in patients who have crouch gait and pes valgus.

GRAFO or FRO (Ground reaction or floor reaction AFO): This AFO is made with a solid ankle at neutral [F]. The upper portion wraps around the anterior part of the tibia proximally with a solid front over the tibia. The posterior opening extends to the malleoli level. The rigid front starts just below the tuberositas tibia with a band at the back to create a three point pressure distribution and provide strong ground reaction support for patients with weak triceps surae [G]. The foot plate extends to the toes. The ankle may be set in slight plantar flexion of 2-3o if more corrective force at the knee is necessary. Use the GRAFO in patients with quadriceps weakness or crouch gait. It is an excellent brace for patients with weak triceps surae following hamstring lengthening. Use an anterior strap in children below 15 kg. Above that, use a rigid GRAFO if the foot alignment is poor and a hinged GRAFO if it is satisfactory. The benefit depends also on the work quality of the orthotist. Children with static or dynamic knee flexion contractures do not tolerate the GRAFO. Surgically release the knee flexion contracture before prescribing the GRAFO.

GRAFO as seen from posterior, lateral and anterior. The characteristic
of a GRAFO is the tibia restraint in front. This restraint prevents the tibia from moving forward as the person starts to put his weight on his extremity in stance (the second rocker phase of stance) It prevents excessive ankle dorsiflexion and crouch gait.

Anti-recurvatum AFO: This special AFO is molded in slight dorsiflexion or has the heel built up slightly to push the tibia forward to prevent hyperextension during stance phase. Consider prescribing this AFO for the treatment of genu recurvatum in hemiplegic or diplegic children. Anti-recurvatum AFOs may be solid or hinged depending on the child’s tolerance.

The mechanism of antirecurvatum AFOs: The AFO is built in 5o dorsiflexion. Therefore initial contact occurs with the ankle in dorsiflexion. Equinus is prevented. The back of the AFO pushes the tibia forward and the ground reaction force vector slides behind the knee joint creating a flexion moment at the knee.

Hinged AFO
Hinged AFOs have a mechanical ankle joint preventing plantar flexion, but allowing relatively full dorsiflexion during the stance phase of gait [B,C]. They provide a more normal gait because they permit dorsiflexion in stance, thus making it easier to walk on uneven surfaces and stairs. This is the best AFO for most ambulatory patients. Adjust the plantar flexion stop in 3-7o dorsiflexion [D] to control knee hyperextension in stance in children with genu recurvatum. The hinged AFO is contraindicated in children who do not
have passive dorsiflexion of the ankle because it may force the midfoot joints into dorsiflexion and cause midfoot break deformity. Knee flexion contractures and triceps weakness are other contraindications where a hinged AFO may increase crouch gait [E].

Knee orthoses
Knee orthoses are used as resting splints in the early postoperative period and during therapeutic ambulation. There are two types of knee orthoses, the knee immobiliser and the plastic knee-anklefoot-orthosis (KAFO). The use of such splints protects the knee joint, prevents recurrence after multilevel lengthening and enables a safer start to weight bearing and ambulation after surgery.

Knee immobilisers: Knee immobilisers are made of soft elastic material and holds only the knee joint in extension, leaving the ankle joint free. Consider using them in the early postoperative period after hamstring surgery and rectus transfers.

Plastic KAFOs: Plastic resting KAFOs extend from below the hips to the toes and stabilize the ankle joint as well as the knee. They are more rigid and provide better support to the ankle and the knee in the early postoperative phase. Knee-ankle-foot orthoses with metal uprights and hinged joints (KAFOs) were developed and used extensively in the 1950s and 60s for children with poliomyelitis. Though KAFOs are still used for ambulation in poliomyelitis and myelomeningocele where there is a need to lock the knee joint, they are not useful for the child with CP because they disturb the gait pattern by locking the knee in extension in the swing phase. Donning the KAFOs on and off takes a lot of time and they are difficult to wear. For these reasons, KAFOs for functional ambulation have disappeared from use in children with CP. Use anti recurvatum AFOs or GRAFOs for knee problems in ambulatory children.

Foot orthoses (FO)
Foot orthotics do not prevent deformity. They provide a better contact of the sole of the foot with the ground.

Supramalleoler orthosis (SMO): Extends to just above the malleoli and to the toes [A,B]. Consider in mild dynamic equinus, varus and valgus instability.

University of California Biomechanics Laboratory Orthosis (UCBL): Medial side is higher than the lateral, holds the calcaneus more firmly, supports the longitudinal arch [C]. Prescribe in hind and midfoot instability.

Heel cup Holds the calcaneus and the surrounding soft tissue, ends laterally underneath (trim lines are below) the malleoli and proximally ends at the metatarsals. Use in cases of mild subtalar instability causing varus or valgus deformity.

Hip abduction orthoses. Consider using hip abduction orthoses in children with hip adductor tightness to protect hip range of motion and prevent the development of subluxation. It is easier and cheaper to use a simple abduction pillow. Use mainly at night or during periods of rest. There is no scientific evidence to support the belief that they prevent subluxation. One clear indication for hip abduction orthoses is the early period after adductor lengthtening.

Spinal orthoses
There are various types of braces used for spinal deformity [D]. None of them alter the natural history of scoliosis in children with CP. Do not aim to stop the progression of scoliosis by prescribing a brace. Contrary to idiopathic scoliosis, the deformity continues to progress even after skeletal maturity in CP. Therefore, most children with scoliosis need spinal surgery to establish and maintain sitting balance in the long run. Prescribe a brace for the time period until surgery to enable the child to grow as much as possible. An important indication for using a brace in a spinal deformity is to provide better sitting balance [E]. A thoracolumbosacral brace helps the child sit better during the growth spurt period when spinal deformity becomes apparent, progresses fast and the child outgrows custom molded seating devices quickly. Children who are not candidates for surgery for different reasons may use spinal braces instead of seating devices for better sitting. Patients with mild and early scoliosis tolerate brace without difficulty. The brace should not be too difficult for the child to put on and take off should not compress the chest too tight and should be properly ventilated for comfortable use.

Upper extremity bracing
The indications of bracing in the shoulder and elbow are very limited. An example of a resting splint is a thermoplasticresting elbow, wrist and hand splint which keeps the wrist in 10o extension, the metacarpophalangeal joints in 60o flexion and the interphalangeal joints in extension. This type of splint is used at night and during periods of inactivity with the hope of preventing deformity. An example of a functional splint is an opponens splint [B] to bring the thumb out of the palm of the hand, allowing for better grasp. This type of splint is used in every day activities. Hand orthoses may inhibit the active use of the extremity. They also effect sensation of the hand in a negative way. Use them only in the therapy setting or at school and take off during other times in the day.

Stretching, range of motion and strengthening exercises are essential in all children. In addition, neurofacilitation techniques stimulate the central nervous system to establish normal patterns of movement. These neurofacilitation techniques were developed over the years to minimise the neurological impairment and help the healing CNS to reorganize. This has not been possible and the focus of therapy shifted from trying to heal the neurological lesion to increasing motor function. There is no treatment method that can heal the lesion in the CNS. The intact neurons in the brain may substitute for lost function, new synapses may form and reorganisation of neurons take place so that the child gains function as he grows. This process is termed neuronal plasticity. The present neurofacilitation methods stimulate the CNS and accelerate neuromotor maturation through the process of neuronal plasticity. The Vojta method is common in Eastern Europe whereas the neurodevelopmental training technique established by B. Bobath and named after her is widely used in the Western world. Both because of difficulties in diagnosing CP in infancy, and the inherent potential of the CNS to heal, it is extremely difficult to judge the actual success of such procedures. Plan the exercises according to the mobility needs of the child. It is not enough to have a therapy session only once during the day with the therapist. Children with CP need to exercise at home to gain maximum function. The success of the techniques used in physical therapy depends on repeated practice. The parents must repeat the exercises with their children every day and observe children for improvement or changes that may be needed.

Conventional exercises
Conventional exercises consist of active and passive range of motion exercises, stretching, strengthening and fitness to improve the cardiovascular condition. Range of motion  and strengthening exercises continue for a lifetime in CP, but are especially important in the recovery stage following orthopaedic surgery and in the growth spurt period when risk of contracture formation is maximal. Teach the stretching exercises to the caregiver to prevent contractures. Physiotherapists and parents should be careful with stretching exercises so as not to tear muscle fibers and cause pain, otherwise they will have the opposite effect. Night splints and stretching are not by themselves sufficient to prevent contractures. Strengthening exercises to the antagonist muscles are always necessary because spastic muscles are also weak. Sports activities are helpful in decreasing stiffness and contractures in adolescents using the wheelchair. Cardiovascular conditioning is crucial for the total body involved individual in the wheelchair. Balance is a prerequisite for independent walking, balance training is one of the key reasons for physiotherapy. Strengthening does not affect muscle tone, it does not increase spasticity. On the contrary, the importance of strengthening the spastic muscles and their antagonists cannot be over emphasized for efficient motor function. Do not prevent sitting in the W-position for fear of hip subluxation. W-sitting does not increase femoral anteversion or cause hip subluxation. Children with femoral anteversion sit in a W-shaped position because it is comfortable. When forced to change position for fear of contracture, the child needs to use his hands for balance which interferes with hand function.

Occupational therapy and play

OT aims to improve hand and upper extremity function in the child through play and purposeful activity. There are defined systematic treatment methods for occupational therapy. Ayres sensory integration therapy aims to enhance the child’s ability to organize and integrate sensory information. In response to sensory feedback, CNS perception and execution functions may improve and the motor planning capacity of the child may increase. Begin therapy toward one year of age when the child can feed himself using a spoon and play with toys. Teach the child age-appropriate self care activities such as dressing, bathing and brushing teeth. Encourage the child to help with part of these activities even if he is unable to perform them independently. Always include play activities in the rehabilitation program. Play improves mental capacity and provides psychological satisfaction. Organized play can address specific gross and fine motor problems in the child and take the place of boring exercise protocols. This increases the child’s compliance with therapy. For example, riding a toy horse may
improve weight shift over the pelvis, swinging may improve sensation of movement.

Sports and recreation

Disabled children need to be involved in sports and recreational activities just like their able bodied peers. Sports and recreational activities also form part of the rehabilitation program. Physical activity plays an important role in physical development, general fitness and health. It provides fun and recreation. Physical and occupational therapy combined with recreational activities or adapted physical education increases efficiency of rehabilitation and assist the disabled child to use his potential. It is difficult and time consuming for a child to continue physiotherapy once he is in school. If he does, he will be alienated from his friends. Sports and recreation benefit the child because they save him from going to long hours of physiotherapy and being apart from his friends, from loss of valuable time for lessons and play. In the meantime sports provides the only means of improving the child’s neuromotor abilities and preventing deformities when he is at school. Through sports and recreational activities, the child has the ability to participate in the world of normal children, will not feel left out because of hours of physiotherapy and will improve his neuromuscular functional status. There are a variety of summer and wintertime sports that the disabled child can participate in. The competitive aspects of involvement in sports and games is basic to human nature, however many physically handicapped individuals frequently do not have the physical attributes to participate fully in different sport activities. Therefore most of the modern games and sports are modified for handicapped persons. The rules of the sport or the game are modified to meet the needs of disabled person (wheelchair tennis), or specially designed adapted devices are used for physically disabled to compensate or substitute the loss of muscle strength or function (downhill skiing). Some modern sports require very high-technology equipment, but most adapted equipment and devices can be easily made or adjusted locally. Sports scientifically shown to have significant therapeutic effects in CP are swimming and horseback riding. They help to increase muscle strength and range of motion in the joints, improve sitting balance and body control and provide fun.

Most children love to swim, or at least be in the water. The buoyancy of water helps movement and inhibits muscle tone. Splashing about is a lot of fun. Prescribe aquatic exercises as therapy in the less severely involved child.

Advantages of swimming
Normalizes muscle tone
Decreases rate of contracture
Strengthens muscles
Improves cardiovascular fitness
Improves walking

Swimming  starts with basic pool exercises. In the whole body involved child, it helps normalize muscle tone and decreases rate of contracture. In hemiplegic and diplegic children, it can strengthen muscles, improve cardiovascular fitness and efficiency of gait. Horseback riding improves head control and trunk balance, normalizing muscle tone. It creates a lot of positive emotions in interaction with the horse. It also improves self esteem in the child. Even vigorous sports activities do not cause or increase orthopedic deformity. In developed countries adapted physical education and sport are included in public school programs. It is also a part of rehabilitation treatment at the rehabilitation centers. In developing countries adapted sport and recreation is organized by special NGO’s (non-government organizations) or sport organizations.

Rehabilitation strategy and goals according to age

Rehabilitation aims to prevent disability by minimizing the effects of impairments, preventing secondary disabilities and maximizing motor function throughout the child’s life. The focus of treatment shifts over the years but the principles remain the same. Functional goals change as the baby becomes a child and the
child matures into an adult. Younger children focus mainly on mobility whereas adults shift their focus to communication and activities of daily living. The first four years are spent in physiotherapy and bracing, orthopedic surgical procedures are performed between 5 to 7 years of age, education and psychosocial integration become main issues in the school age (7-18 years). Reach mobilization goals by the time the child is ready to go to school. The child needs aggressive physiotherapy in the growth spurt period and after orthopedic surgery. Communicate with the school physiotherapist or the physical education teacher to help
with the child’s exercise program to enable an active life for the child at school.

Early intervention

Early intervention is the general name given to many therapy modalities including exercise and caregiver education. Early intervention programs involving infant stimulation and caregiver education may retard or reverse the central nervous system lesion causing the clinical picture of CP and thus prevent or minimize neuromotor delay. There is no established routine and no proven value of these programs, however until we know which babies are going to be normal on their own, it is better to let them have the benefit of early treatment so that any improvement potential is not lost. Despite the controversies early treatment benefits the parents. They receive a great deal of practical advice and support this way. The child’s functional status may improve with arental support. Early treatment creates more opportunity for the potential to develop any normal abilities and for decreasing the defects.
Infancy

Rehabilitation goals are to educate the family about the child’s problem, to improve parental bonding, to help the mother care for the baby and to promote optimal sensorimotor development through positioning, stimulation and exercises if possible. Increase mobility and help the baby explore his surroundings.
Use positioning, carrying, feeding and dressing techniques which promote bodily symmetry in the infant. These limit abnormal posture and movements and make functional activity possible. Provide sensory stimulation using various movements and postures. Some positions lengthen the spastic muscles and make voluntary movement easier. Add weight shifting, weight bearing, trunk rotation and isolated movements into the exercise regimen. Customized seating or seating supports are necessary. Visual attention, upper extremity use and social interaction improve in the child who is supported in sitting. When the child is sitting comfortably without fear of falling he sees his hands, practices midline play, reaches for his or her feet and sucks on his fingers. All of these movements provide sensory stimulation and promote a voluntary motor response to that stimulation. Active movements encourage the infant to develop flexor control and
symmetry. Use toys that require two hands, facilitate the use of neck and trunk muscles and anteroposterior control of the head. Educate the parents to help them accept their child’s problems and raise their child in the best possible way.

Childhood

The needs of the children are different starting at age one depending on the type and severity of involvement. Redefine goals of treatment at this stage. Limitations in motor function create disabilities in learning and socialization. The child cannot become independent. The major goal of rehabilitation in the
preschool period is achieving independent mobility. At this age child’s maximum level of motor function can be predicted with greater accuracy. Choose a method of mobilization and teach the child how to use it so that he will be free to explore his environment. Bring every child to an erect position regardless of prognosis for walking. Encourage the use of standers. Focus on independent mobility in every child. The total body involved child needs sitting supports and wheeled mobility. The diplegic and the hemiplegic must be supplied with appropriate bracing to begin to work on ambulation. As the child matures physically by the age of four he must be involved in self care activities and activities of daily living at home. Always aim for functional tasks in the limits of the child’s capacity. Address educational issues with help from special educators if necessary. Plan and complete all surgical procedures directed towards better ambulation by school age if possible.

School age and adolescence

Children in mainstream schools regress because of a lack of exercise. Physiotherapy done in clinics in contrast, takes too much time, causes separation of the child from his peers and prevents socialization. Physiotherapy should be performed at school if possible with the help of a community physiotherapist or
the physical education teacher. Coordinate school with play and exercise. Handle social and vocational issues during school years for a better state of independence. Efforts to improve the psychological well being of the child are necessary especially in adolescence. Children with CP have a significantly lower level of physical activity and cardiovascular fitness compared to their healthy peers even if they are only mildly impaired. Keep in mind the fact that cardiovascular issues continue to be a problem for the CP patient in adulthood, increase the activity levels of these children at school by sports and play. The family Physical impairments that create lifelong disability for the child cause psychological disturbance in the family. The parents are in need of constant support, have problems understanding and accepting the situation and tend to blame themselves or the physicians. Explain the nature of the problem to the family and include them in the treatment plan. Remember that families may need to hear the same information many times before they can fully comprehend the problems they will encounter. The concept of management rather than cure forms the basis of intervention. Long term aggressive therapy programs cause social
isolation and delay normal psychological development. Integrate therapy programs into summer camps  home activities and school. Let the child live like a child, as close to normal as possible. Do not raise false hopes. Successful rehabilitation includes the prevention of additional problems, reduction of disability and community integration. Rehabilitation is successful if the child is a happy child and if the parents are well adjusted,happy people.

General principles of physiotherapy

Physiotherapy begins in early infancy and continues throughout adolescence. The primary purpose is to facilitate normal neuromotor development. With the help of correct positioning, appropriate stimulation and intensive exercise the therapist tries to gain head control, postural stability and good mobility in the child. This is possible only to the extent of the child’s neurological capacity. Even with vigorous physiotherapy many children remain functionally impaired in varying degrees. There are different methods of therapy for children with neurological impairments. Even though they differ in the techniques they use, basic principles remain the same. The problems of neuromotor development are difficulty flexing and extending the body against gravity, difficulty sitting and functional ambulation.

Basic problems in the neuromotor development of children with CP

• Difficulty with flexing and extending the body against gravity
• Sitting
• Functional ambulation

For functional ambulation a child needs motivation to move and explore the world around him.

For functional ambulation a child needs

• Motivation to move
• Enough muscle strength and control
• Able to shift his body weight (balance)
• Awareness of body position and movement (deep sensation)
• Sufficient visual and vestibular system
• No deformities interfering with joint function

He must have enough muscle strength and control. He must be able to shift his body weight and have an awareness of body position in space at rest and during movement. Visual and vestibular systems must be sufficient. There must not be any deformities interfering with joint function. In physiotherapy sessions the therapist works with the child in supine and prone  positions to improve head and trunk control. She supports the child in the sitting position to develop weight shifting and unilateral balance, ability to rotate the body and the ability to respond to sudden changes in position. The rehabilitation team strives for longterm, functional mobility in a variety of environments so that the child will integrate into the community and social life in a healthy way.

Indications for treatment
Consider treating spasticity when it causes loss of function or produces contractures, deformities, pressure sores, or pain. Additional indications include difficulty in positioning or caring for the total body involved child. Even though a wide range of treatments exist, none of them is fully satisfactory. Unwanted side effects limit the use of certain modalities. Some children do not respond to any of the antispasticity measures. The success of treatment depends on having specific goals in treatment, choosing the correct method according to the child’s problem and monitoring for side effects and complications.

• Goals of spasticity treatment
  • Increase function
  • to perform better in activities
  • of daily living
• to walk better
• Increase sitting ability and balance
• Prevent deformity & decrease contractures
• Pain relief
• Improve hygiene and patient care

Treatment methods
Treatment options are divided into reversible and permanent (surgical) procedures.

• Physiotherapy
  • Positioning
  • Exercises (Stretching, Neurofacilitation)
  • Electrostimulation
• Splinting & Casting
• Oral medications
  • Baclofen
  • Diazepam
  • Clonazepam
  • Dantrolene
  • Tizanidine
• Intrathecal medications
  • Baclofen
  • Morphine
  • Clonidine
• Neuromuscular blocks
  • Local anesthetics
  • Phenol
  • Botulinum toxin
• Orthopedic surgery
• Selective dorsal rhizotomy

They can also be classified as systemic or local treatments. All treatment procedures aim to modulate the stretch reflex. In mild spasticity, basic measures such as positioning, exercises and bracing may be sufficient whereas in more severe cases, interventions can be more invasive. Often, treatments are combined to decrease side effects and to improve outcome.

Physiotherapy
Physiotherapy is a fundamental part of spasticity management. Muscle overactivity produces muscle shortening and muscle shortening increases spindle sensitivity. Muscle contracture and stretch sensitive muscle overactivity are intertwined. Therefore physical treatments aimed at lengthening the overactive muscles are fundamental. Address both shortening and overactivity. Consider applying various techniques such as positioning, ice, and exercises for these purposes. Positioning Position the child to stretch the spastic muscles and decrease the sensitivity of the stretch reflex and the brain stem reflexes that trigger spasticity. The therapists should teach these positions to the family so that the child lies and sits this way most of the time at home. Head supports may improve tone in the trunk muscles by providing a sense of safety and inhibiting the tonic neck reflexes. Advise use of the tailor-sitting position to reduce adductor spasticity. Good seating provides a stable platform and facilitates good upper extremity function. Stretching exercises Stretching muscles may prevent contractures and promote muscle growth. Spasticity decreases with slow and continuous stretching. This effect lasts from 30 minutes to 2 hours. Use stretching exercises before bracing and serial casting to obtain the necessary joint position.

Neurofacilitation techniques Most neurofacilitation techniques are used to reduce muscle tone. With the Bobath method, the therapist positions the child in reflex inhibitor positions and provides kinesthetic stimulation to inhibit the primitive reflexes and elicit advanced postural reactions to normalize muscle tone. With the Vojta method, different positions and proprioceptive stimulation are used for the same effect. Tone reduction lasts for a relatively short period of time with both methods.

Inhibitive (Tone Reducing) Casting and Bracing
Muscle relaxation after stretching exercises lasts for a short period of time. For longer duration the stretch on the muscle should be maintained for several hours every day. This is possible with the use of rigid splints or serial casting. The effects are maximal if the cast or the splint is applied after the muscle is relaxed. The tone-reducing effect of casts and splints is controversial. Some think that casts decrease muscle tone by creating atrophy in the already weak spastic muscle. Casts also cause pressure sores in children who are malnourished and have severe spasticity. Patient compliance may be poor because of difficulties of living with the cast. Consider casting as an adjunct to treatment with local antispastic medications in the young diplegic or hemiplegic child with severe spasticity interfering with ambulation to delay orthopaedic surgery. At present, the most common methods of spasticity management in cases of CP are oral medications, botulinum toxin, phenol or orthopaedic surgery.

Rehabilitation and Physiotherapy
Factors influencing rehabilitation outcome

• Treatment team :   Productive interaction ,  Basic understanding
• Medical problems : Respiratory, Convulsions, Dysphagia, Depression, Gastroesophageal reflux, Sleep disorders, Visual and hearing deficits, Mental retardation, Sensation, Communication
• Child’s character :  Motivation to move, Temperament, Behaviour/cooperation, Willingness to take risks
• The family Resources : Quality of home environment, Support, Expectations

Treatment team

The pediatrician provides diagnosis and preventive health care. The orthopaedic surgeon tries to minimise static and dynamic contractures to improve mobility. The pediatric physiatrist evaluates the child’s overall medical, surgical and therapy options and helps the child and the family to set functional, achievable goals. Together, the rehabilitation team works to
assist the person with CP to achieve his place in the society. A productive interaction between the physicians and the therapists is essential for the maximum benefit of the child. All those involved with the child must have a basic understanding on the diagnosis, family expectations, degree of motor dysfunction, functional goals and the therapy program.

Medical problems of the child

The rehabilitation physician and the team must be prepared to anticipate certain acute and chronic problems during the rehabilitation of the child with CP.

Medical problems of the child which prevent rehabilitation

• Respiratory problems
• Epileptic seizures
• Dysphagia
• Depression
• Gastroesophageal reflux
• Sleep disorders
• Visual and hearing deficits
• Mental retardation
• Cortical sensory deficits
• Communication deficits

The disabled child is more prone than his able-bodied peers to respiratory problems, convulsions, dysphagia, depression, gastroesophageal reflux and sleep disorders. Total body and some severely involved diplegics have visual and hearing deficits, mental retardation, cortical sensory deficits and communication deficits that prevent the child from reaching his maximum potential.

The child’s character

The motivation to move, temperament, behavior/cooperation and the willingness to take risks are important determinants of rehabilitation outcome. These personality characteristics of the child are independent of impairment or disability.

The family

Some families provide their children with ample experiences and opportunities that enrich their environment and increase their ability to achieve new skills. Family resources, quality of home environment, family support and parent/caregiver expectations guide the plans of long-term care for the disabled child.

Physiotherapy

Physiotherapy helps improve mobility. It is the basic treatment in all children with CP. It consists of exercises, bracing and activities towards reaching specific functional goals. It aims to bring the child to an erect position, give the child independent mobility and prevent deformity. Organize physiotherapy to fit into the family’s lifestyle.

Rehabilitation and Physiotherapy
Rehabilitation is the name given to all diagnostic and therapeutic procedures which aim to develop maximum physical, social and vocational function in a diseased or injured person. The goal of rehabilitation is to gain independence in activities of daily living, school or work and social life. This is possible to the extent of the person’s impairments.

Components of child rehabilitation
Child rehabilitation consists of improving mobility, preventing deformity and educating the parents about the child’s problem.

Goals of rehabilitation

Improve mobility

• Teach the child to use his remaining potential
• Teach the child functional movement
• Gain muscle strength

Prevent deformity

• Decrease spasticity
• Improve joint alignment

Educate the parents

• To set reasonable expectations
• Do the exercises at home

Teach daily living skills

• Have the child participate in daily living activities

Social integration

• Provide community and social support

It also involves helping the child to learn the skills he will need in daily life, school and while playing with friends. Lastly, rehabilitation means decreasing the complications which arise as a result of the child’s neuromuscular impairments. Therapeutic exercises help the child learn how to sit, stand, walk and use his upper extremity for function. The child also learns how to use his remaining potential to compensate for the movements he cannot perform. Decreasing spasticity, gaining muscle strength and improving joint alignment decrease deformity. The education of caregivers involves gently coaching them to set reasonable expectations for their child, and teaching them to follow their child’s exercises at home. Parents should encourage their children to participate in daily living activities by using the functional skills they learned during therapy. Community and social support is another aspect of rehabilitation. There is no method which can decrease the neurological impairment. Explain to the parents not to spend valuable time and hope with alternative treatments. Aim to have the child fulfil his maximum physical, intellectual and psychological capacity and have a happy childhood as close to normal as possible. Focus on the child’s abilities and interests. Try to improve function by working on these. The child can easily improve in the activities he likes doing. This will enable him to have a happy childhood and a job in the future. CP rehabilitation consists of physiotherapy, occupational therapy, bracing, assistive devices, adaptive technology, sports and recreation.

Components of rehabilitation

• Physiotherapy
• Occupational therapy
• Bracing
• Assistive devices
• Adaptive technology
• Sports and recreation
• Environment modification

The main aim of rehabilitation is providing an education for the child, and to help him grow up to be a productive, independent adult. Various therapy procedures exist some of which do not really relate to real world situations. The skills that the child gains during therapy sessions should be useful within the community. Never ignore the child’s education throughout the various therapy procedures. Always aim to send the child to school for an education and prepare him for community integration.

Planning rehabilitation
The child begins to receive physiotherapy when he is a baby. Occupational therapy starts towards age two to teach daily life activities. The toddler uses assistive devices for mobility. Bracing may be necessary as the child begins to walk. Sports and recreation are crucial for the school aged child. Play is
important beginning in infancy throughout adolescence. Have short and long term goals depending on the child’s expected functional outcome. Evaluate the child, specify these short and long term functional goals and set a time limit in which you expect the child to achieve these goals. Review
the plan if the child cannot achieve the expected function in the predetermined time period.

Rehabilitation planning
Example: Independent standing
1- State the necessary time period to achieve this goal i.e. 12 weeks
2- Plan the methods to achieve this goal i.e. Stander, exercises to
improve trunk balance
3- Evaluate the end state.
4- Revise the treatment program or the goals if not successful.