When Protocols Don’t Apply in Outpatient Ortho

1. When Protocols Don’t Apply in Outpatient Ortho PT for a Child with CP Following Bilateral Hamstring Release/Gastroc Lengthening Jenn Zambito, PT, DPT Maximum Fitness: Physical Therapy and Sports Medicine February 5, 2010

2. Background • Hamstring tightness is a common problem in the management of CP • Deformities • Muscle Imbalance • Ultimately Affects Gait

3. What can be done to manage hamstring tightness in children with Cerebral Palsy?

4. What can be done to manage hamstring tightness in children with Cerebral Palsy? • PT/OT- Flexibility, Strength, Gait Training • Drug Therapies- Baclofen and Botox • Bracing- Fix and Prevent Deformities • Can lead to secondary deformities and muscle imbalances • Surgery- Tenotomy and/or Tendon Lengthening

5. Question # 1 • Which of the following is true of Baclofen and NOT Botox in the treatment of CP? • Administered through injection to target specific muscles or muscle groups • Effects typically last for up to six months • Diffused throughout the body, often orally or through a pump • Effectiveness decreases over time

6. Initial Evaluation (11/4/08) • 9 y.o. girl • 1 week s/p Bilateral HS Release/Gastroc Lengthening • Diagnosed with mild Quadriplegic Cerebral Palsy • Presents to PT in W/C w/ bilateral ankle and lower leg casts, knee immobilizers, and cast boots

7. History • What pertinent past medical history do I want to know?

8. Past Medical History • Birth History • Born at 25 weeks (1lb, 7oz) • 3 ½ mos. in hospital • Heart, lung, and eye problems since birth • Progressive muscle tightening • Crawled until the age of 3

9. Question # 2 • What percentage of cerebral palsy occurs prenatally (before birth)? • 70% • 20% • 50% • 10%

10. Past Medical History • 3 Years Old- Diagnosed with CP • Started with Cascade DAFO braces and a posterior rolling walker • Progressed to Loftstrand crutches quickly • Able to ambulate in school with ADs • Increasing foot deformities → skin breakdown • Ambulatory abilities progressively worsened

11. Past Medical History • Began repeat Botox injections (July 2002) • Gastrocnemius • Soleus • Peroneus longus • Hip adductors • Ultimately chose surgery • Distal Hamstring Release • Distal Gastroc Lengthening • Precautions/Contraindications?

12. PLOF • Prior to surgery • Ambulating with posterior rolling walker • Significant hamstring and gastroctightness • Popliteal angle: Right 40°, Left 30° • Dorsiflexion: Right lacking 2°, Left lacking 5° • Activities • Enjoys playing with brother • Singing and dancing, especially to Hannah Montana and Miley Cyrus

13. What Do You Want to Measure?

14. Objective Measures • Pain: “only a little when I’m standing” • Patient wearing bilateral hard casts from toes to tibialtuberosities • ROM: • Hamstrings R 55°, L 60° • Hip IR/ER R 90°, L 90° • Strength: • Hip Flexion (SLR) R 2+/5, L 2+/5 • Knee Flexion R 3/5, L 3/5 • Knee Extension R 2+/5, L 2+/5

15. Objective Measures • Balance: • Seated: Patient able to sit without support, however significant forward flexion at the waist noted • Standing Patient required bilateral upper extremity support (RW or HH) • Gait: Posterior RW with cast boots • Hip IR R>L noted • Mother reports gait slowed since surgery, but pt. standing much more upright • Forward flexed posture still noted with ambulation

16. Impairments and Goals?

17. Goals • Increase hamstring flexibility to >80º B to increase upright standing with gait • Ambulate with rolling walker in both school and community • 0/10 Pain with all activities to play with brother

18. Prognosis???

19. Given the impairments, what do you want to work on during treatment?

20. Initial Treatments • Treatment Goals: Increase ambulatory and standing tolerance and balance, and MAKE IT FUN • Exercises: • Standing TEs (bouncing ball, kicking ball, stacking clothespins and moving cones on the table) • Gait Training w/ Rolling Walker • 1st Month: Consistent verbal cues required to decrease step length, which resulted in increased ambulatory stability

21. 12/6/08- Cast Removal! • Re-Eval • Pain: 3/10 over incision sites • Incisions: tightness noted over bilateral popliteal and distal posterior calf incisions • ROM: • Hamstrings R 73°, L 71° • Dorsiflexion R 3°, L 4° • Hip IR and ER 90° Bilaterally • Strength: • Hip Flexion (SLR), Knee Flexion, and Knee Extension R 3/5, L 3/5 • Back and arm extensor strength limited- unable to raise arms above head

22. Re-Eval Post Cast Removal • Balance: • Seated: Able to sit without back support with limited sway • Standing: Unable to stand without upper extremity support • Gait: Posterior RW • Using old DAFO braces • Step length decreased • Hip IR R>L still noted • Forward flexed posture still noted • Patient reported fatigue after 150’, with incision soreness also noted

23. Question #3 • A child with cerebral palsy demonstrates forward leaning with gait. Which rolling walker would be more advantageous? • Anterior • Posterior

24. Now that the casts have been removed, what new treatment goals can be added?

25. Treatment • New Treatment Goals: Increase static and dynamic stability, endurance, and ROM, and continue to MAKE IT FUN • Exercises: • Sitting TEs for core strength and balance, as well as overhead throwing activities to promote extension • Began seated due to decreased balance in standing without upper extremity support • Standing TEs (bouncing and kicking ball- requested favorites) • Gait Training w/ Rolling Walker • Verbal cues still required, but becoming less frequent • Positive motivation worked really well to reach goals (turning corners) • Patient currently wearing solid AFOs that she had before surgery

26. Question #4 • After surgery for hamstring release and gastroc lengthening – • Pre surgery AFO’s should be used • Pre surgery AFO’s are no longer viable • Pre surgery AFO’s must be re-evaluated by an orthotists to determine usability • External bracing is not needed , surgery solved the problem

27. Traditional Bracing • Skeletal immaturity → foot/ankle deformities • Hyper/hypotonic muscles also contribute • Traditionally managed with plastic AFOs • Immobilized foot/ankle in subtalar neutral with the ankle fixed at 90° • Lead to further deformities and the development of abnormal gait patterns • Articulating AFOs → allow mid-foot DF and slightly more functional gait • SupramalleolarOrthoses (SMOs) • Provide medial/lateral support but immobilize the subtalar joint in the process

28. Controlled Motion Orthoses • 2 devices working together for 1 functional unit • Outer thin, lightweight carbon shell • Anterior shell for proximal control, especially with crouched gait • Allows for a more normal heel strike to propulsive toe-off • Inner foot orthotic to control foot position • Depends on severity • Severe/tight achilles= SMO • Allows more normal development of joint surfaces • Allows for better stretch reflexes leads to more desirable muscle strategies

29. Treatment • 1/5/09- Received new braces • Continued to improve with ambulation with improved upright posture • Added mini-squats and lunges at the request of the orthotist in order to reinforce push-off with new braces • Gait progresses, with ability to ambulate with bilateral handheld support

30. Treatment • 1/21/09- Began ambulation with Loftstrand crutches • Required increased verbal cues for upright standing and proper crutch placement • Added side stepping and marches with bilateral upper extremity support to increase ambulatory abilities

31. Positive Feedback • Teachers and hairdresser commenting on improved upright sitting posture • Other therapists and patients commenting on how well she is doing • Able to walk down the hall with handheld assist at school • Won an award in school for gym participation!!

32. Treatment • Continued with functional strengthening exercises for upper and lower extremities • Gait • Able to take 6+ steps without any assistance or an assistive device • Quickly progressed to >80ft with close supervision and only mild upper extremity touchdown

33. Question #5 • What of the following can affect ambulatory stability? • Changing surfaces • Cognitive activities or distractions • Changing directions • All of the above • A and C only

34. Treatment • Gait Barriers • Distractions • Change of direction • Uneven surfaces • Steps • Decreased hip flexion limiting step clearance → circumduction • Using two hands on one railing initially • Verbal cues= improvement

35. Treatment • “I learned a dance” • Video

36. Where Are We Now? • Patient is ambulating around the clinic without an AD, and often independently • Exercises progressed to work on core and more difficult strengthening tasks now that ambulatory independence has progressed • Long kneeling • Walk-outs on all fours to a “push up” • Ball sitting without lower extremity support

37. “Ches Rides a Bike” Video

38. What Have We Learned? • About Cerebral Palsy • PLOF is not always the sole indicator of ability • A multidisciplinary approach is very important • In General • Motivation and positive reinforcement • Progression is different for every patient • Goals are dynamic

39. References Albritton, Jane. “Chesapeake Wood: ‘Full of Smiles’.” OandP.com. The Edge, September 2009. Web. 4 January 2010. <http://www.oandp.com/articles/2009-09_10.asp> Cascade DAFO. Cascade. Web. 4 February 2010. <http://www.cascadedafo.com/>. CHOP. Pediatric Rehabilitation Procedure Notes- Wood, Chesapeake. Print. Pediatric Class Notes. University of Delaware Department of Physical Therapy. January 2007. Evaluation and Daily Therapy Notes. Maximum Fitness. 2008-Present. Delgado, MR et al. “Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society.” Neurology (2010); 74:336-343. Dhawlikar, SH, L Root, and RL Mann. “Distal lengthening of the hamstrings in patients who have cerebral palsy. Long-term retrospective analysis.” J Bone Joint Surg Am (1992);74:1385-1391. Education. United Cerebral Palsy Association. Web. 4 February 2010. <http://www.ucp.org>. Information and photographs courtesy of Day Iseminger. KiddieGAIT and ToeOFF. AllardUSA. Web. 4 February 2010. <http://www.allardusa.com/index.html>. Nelson, Maureen. “Cerebral Palsy Equipment”. Disaboom. Web. 4 February 2010. <http://www.disaboom.com/cerebral-palsy-information/equipment>. Schwentker, Edwards P. “Toe Walking.” eMedicine.com. Medscape, 22 January 2009. Web. 3 February 2010.