By T. Bram. Christopher Newport University. 2018.

A stable and correctly aligned foot is mandatory in the correction of 364 Cerebral Palsy Management Case 7 buy 50 mg pristiq otc treatment pneumonia. According to her parents 100mg pristiq visa medications names and uses, she did not even own a wheelchair when she was in grade school, as she was able to walk every- where using a walker. They were concerned that she would completely lose her ability to walk. She had no previous surgeries and currently received no physical therapy. She had grown rapidly in the past 2 years, and in the past year, as she had spent more time in the wheelchair, she had gained a lot of weight. A physical examination demon- strated hip abduction to 20°, almost symmetric hip rota- tion with 40° internal and 30° external rotation; popliteal angles were 70°, the knees had 10° fixed knee flexion con- tractures, and the feet had severely fixed planovalgus de- formities. The kinematics showed high knee flexion at foot contact and decreased knee flexion in swing phase, with a severely reduced knee range of motion (Figure C7. The pedobarograph showed severe planovalgus with ex- ternal foot progression of 34° on the right and 19° on the left (Figure C7. Most weight bearing was in the medial midfoot (Figure C7. The main cause of the loss of ambulation appeared to be the crouch gait caused Figure C7. Gait 365 formities, which prevented the foot from functioning as valgus with a triple arthrodesis both stabilized the foot a rigid moment arm, with the majority of the weight bear- and corrected the malalignment. Hamstrings were length- ing on the medial midfoot (Figure C7. This lever arm ened, and after a 1-year rehabilitation period, she was disease needed to be corrected by stabilizing the foot so again doing most of her ambulation as a community am- it was a stiff and stable structure, and it had to be aligned bulator using crutches. The foot pressure showed a dra- with the axis of the knee joint. Correction of the plano- matic improvement although there was still more weight Figure C7. The kinematics demonstrate a good indicating some mild residual valgus (Figure C7. Elizabeth would have become a perma- cating continued weakness in the gastrocsoleus (Figures nent wheelchair user if her feet had not been corrected. Gait 367 crouch because the ground reaction force has to be controlled through the foot as a functional moment arm. Poor moment arm function of the foot causing the ground reaction force to be ineffective in producing knee extension is often one of the primary pathologies of a crouched gait pattern. The foot has to come to within neu- tral dorsiflexion in midstance so it can be placed in an orthosis, or the gas- trocsoleus must provide the force needed to control the ground reaction force. If the gastrocnemius or soleus is contracted, it must be lengthened, but only to neutral dorsiflexion at the end range. Never do uncontrolled, percutaneous tendon Achilles lengthenings in adolescent crouching individuals. These individuals will likely never be able to stand again without using a fixed AFO. Tibial torsion must be assessed next, and if it is contributing to the malalignment of the foot causing the foot to be out of line with the knee joint axis, a tibial derotation is required. Physical examination of passive range of motion of the knee should allow extension to within 10° of full extension. If the fixed knee flexion con- tracture is between 10° and 30°, a posterior knee capsulotomy is required. If the fixed knee flexion contracture is greater than 30°, a distal femoral extension osteotomy is required. Distal hamstring lengthening is always indicated with crouched gait unless the procedure has been done in the pre- ceding year. The indication to do a hamstring lengthening is a popliteal an- gle of more than 50° with an initial contact knee flexion of more than 25°, and knee flexion in midstance phase of more than 25°. If individuals have decreased knee flexion in swing phase or late knee flexion in swing phase with toe drag, a rectus transfer should be performed. Many clinicians are hesitant about doing rectus transfers in individuals with crouched posture; however, they must remember that the rectus is only 15% of the strength of the quadriceps and the muscle is not even active, except in pathologic cases in midstance phase. If children are very slow walkers in the quadriplegic cat- egory, rectus transfer has less benefit.

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The results of this procedure have demonstrated good pain relief that is more quickly acquired than with the femoral resection generic pristiq 100mg fast delivery medicine list. The cost of these custom prostheses is two to three times higher than the off-the-shelf shoulder prostheses because they are custom made purchase pristiq 50 mg on line medicine park cabins, and they do not work any better or worse. Resection Arthroplasty If children are very small, weighing less than 20 or 25 kg, and especially if they have open decubitus ulcers or are otherwise in very poor health, the primary procedure to consider is a subtrochanteric resection or Castle pro- cedure. A sleeve of the rectus femoris and vastis lateralis is then sewn over the end of the proximal femur to provide a cover and to try to make a soft-tissue 10. After consider- because he had developed a severe painful dislocated hip. Although he seemed to get some pain relief af- within 4 weeks and has remained pain free for 10 years ter the initial surgical pain decreased, as soon as his ac- (Figure C10. Generally, it is recommended that these individuals be main- tained in distraction traction for 6 weeks to allow the soft-tissue interposition to heal and stabilize this resection. We have also performed this procedure in a very small child using short-leg casts with broomsticks. There have also been reports using external fixators to hold these resections. It is important to notify the parents or caretakers that this procedure takes 6 to 9 months to obtain relief of pain. In the long term, not all these chil- dren will become pain free. In a review of 12 hips, 3 failed, requiring further 572 Cerebral Palsy Management Case 10. She had severe scoliosis; however, the main problem were told that the scoliosis had to be addressed first with her parents were concerned about was severe bilateral a correction of the pelvic obliquity, which was performed hip pain with almost any motion. A custom-molded prosthesis was then had a proximal femoral resection 2 years previously, and made for interposition arthroplasty, which provided al- 9 months previously she had a left femoral resection and most immediate pain relief (Figure C10. The right femur was very 8-year follow-up, she has continued to do well. A bilateral resection arthroplasty, which over the greater trochanter on the right side. Her aunt, allowed primary closure of the decubitus, was performed. Following the fused to lie in any position except on her right side. On traction, she was mobilized back into her wheelchair, and physical examination she was noted to have a 2-cm-wide by 6 months postoperatively, she had reduced pain with decubitus ulcer extending to the greater trochanter with no skin breakdown. By 1 year postoperatively, she was a dislocated hip with significant degenerative changes. Using a radiation treatment to prevent heterotopic ossifica- tion is not routinely recommended; however, if individuals had previous hip surgery and have developed heterotopic ossification, it should be considered because most of these children, even with primary resections, develop a sig- nificant amount of heterotopic ossification. Sometimes, almost the essence of a new femoral head may emerge, and in some children, the proximal mi- gration and heterotopic ossification becomes so painful that further resection or revision to an interposition arthroplasty are the salvage procedures. Other Treatments There have been many other treatment options discussed for the palliative treatment of the subluxated, dislocated, and painful spastic hip. The use of proximal femoral osteotomy is discussed frequently at meetings; however, there are no published reports reviewing the outcome of this procedure. Our experience primarily has been seeing children after someone else has done this procedure and having to take down these valgus osteotomies and do another palliative procedure (Case 10. Clearly, there are some children and young adults who develop relatively pain-free hips with this procedure, but it is unclear how often it is successful. From personal experience in fol- lowing children, there is a 50% to 75% failure rate, but this is somewhat biased because we have not done this procedure as a palliative procedure. The subtrochanteric valgus osteotomy is an excellent procedure for the hip that is pain free but fixed in a poor position. This osteotomy is also an ex- cellent operation to reposition the leg (Case 10. Another option in doing a valgus osteotomy, as defined by McHale and associates,83is combining the valgus osteotomy with a femoral head resection or Girdlestone resection. They have reported good motion and pain resolution in five children using this procedure. We have no experience with this procedure; however, it does seem to be a reasonable option for some children although it is not clear what specific advantage it provides over doing interposition arthroplasty.

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The wide-base position forces excessive side-to-side movement of the body to keep the center of mass over the weightbearing limb cheap 50 mg pristiq mastercard medicine in the middle ages. If chil- dren have increased abduction with a wide-based gait but have no abduc- tion contracture on physical examination cheap 100 mg pristiq mastercard treatment programs, the cause of the wide-based gait is weakness of the adductor muscles. Usually, the cause is incompetent ad- ductors secondary to excessive adductor lengthening, or the addition of an obturator neurectomy to an adductor lengthening (Case 7. The best treatment of this problem is to prevent it from happening by not doing this type of surgery on a functional ambulator. However, if presented with the problem, working on strengthening the remaining adductor strength and allowing the children to grow often slowly corrects the problems. The wide-based gait may also be due to an abduction contracture, usually of the gluteus medius or fascia latae. The eti- ology of wide-based gait due to a contracture requires identifying the source of the contracture, and the kinematic measure should show increased ab- duction, especially in midstance phase. Once the specific source of the abduction contracture is identified, the treatment is surgical lengthening of the contracted muscle. Fixed contractures of the hip joint may also cause the same effect as muscle contractures. His hip radiographs were spastic hip disease at age 3 years. His gait was characterized by a wide- efficiently with a walker; however, his parents were con- based gait with foot drag and knee stiffness in swing cerned about his wide-based gait and foot drag. Based on these data, Sean had bilateral rectus ical examination, he was not able to get into the walker transfers because the knee stiffness was believed to be without assistance, but had functional gait once he was adding to the tendency to have a wide-based gait. His hip abduction was 50° on each side, initiating a circumduction maneuver because of adductor full hip flexion and extension was present, the popliteal weakness to assist with foot clearance. After the rectus angle was 40°, and he had grade 2 spasticity in the rec- transfers, his base of support narrowed and knee flexion tus, with a positive Ely test at 40°. Transverse Plane Deformity Transverse plane deformity in children is common and is often confused with coronal plane deformity. The difference between scissoring, which is excessive hip adduction, and hip internal rotation gait is often missed. Scis- soring is a completely different motion requiring a different treatment (Fig- ure 7. Hip rotation is defined as a rotation of the knee joint axis relative to the center of hip motion in the pelvis. In normal gait, this rotation around the mechanical axis of the femur allows the feet to stay in the midline and allows the pelvis to turn on top of the femur, which are both motions that work to decrease movement of the HAT segment and therefore conserve energy. At initial contact, the normal hip has slight external rotation of ap- proximately 10°, then it slowly internally rotates, reaching a maximum at terminal stance or initial swing phase. If the hip is positioned in internal ro- tation at initial contact, then during stance phase as the knee flexes, there is an obligatory hip adduction and the knee may impact the opposite limb (Case 7. If the internal rotation is present during midstance, such as in a crouched gait pattern, the knees often rub during swing phase of the con- tralateral limb. Internal rotation positioning in terminal swing also causes the knee to cross the midline, a problem that continues into initial swing. Another primary effect of this internal rotation is placing the knee axis out of line with the forward line of motion. This position causes significant alter- ation in mechanical efficiency of the push-off power that the ankles gener- ate. Secondary adaptation to the internal rotation of the hip includes de- creased knee flexion in weight acceptance in swing phase, decreased ankle push-off power burst, and requires the use of more hip power. If the inter- nal rotation is unilateral, the pelvis may rotate posteriorly on the side of the internal hip rotation, then the contralateral hip compensates with external rotation. The amount of internal rotation is assessed by physical examination with children prone and the hips extended (Case 7. There are two problems with the kinematic measure of which clinicians must always be aware.

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When this role works well discount pristiq 100 mg line 714x treatment, it is the best therapeutic relationship a family has 100mg pristiq with mastercard treatment plan for anxiety. The positive aspects of this role are providing the parents with insight and expectations of their child, reassuring the family that they are providing excellent care, and being readily available to answer the family’s questions. The “grandmothering” role of the therapist has associated risks. One of the greatest risks in our current, very unstable medical environment is that a change in funding or insurance coverage may abruptly end the relation- ship. The therapist must be careful not to be overly demanding of the family, but to help the family find what works for them. Occasionally, a therapist may be fixated on a spe- cific treatment program and believe that it is best for the child; however, the parents may not be in a situation to follow through with all this treatment. The parents feel guilty, and the therapist may try to use this guilt to get them to do more. The physical therapist in this role as a therapeutic “grandmother” can help parents sort out what medical care and choices are available. The ther- apist can help parents by attending physician appointments and making the parent ask the right questions, which is often not possible because of fund- ing restrictions. The physical therapist must not give specific medical advice beyond helping parents get the correct information. Therapists with exten- sive experience should recognize that they have great, detailed, and deep experience with a few children and that generalizing from the experience of one child is dangerous. We have heard therapists tell parents on many occa- sions that their child should never have a certain operation because the therapist once saw a child who did poorly with that surgery. This type of ad- vice is inappropriate because one child’s experience may have been a rare complication of the operation. Also, there are many different ways of doing surgery. This would be like telling someone to never get in a car again after seeing a car accident. A more appropriate response to the family would be giving them questions to ask the doctor specifically about the circumstance with which the therapist is concerned and has experience. Another physical therapist therapeutic relationship pattern is the purely clinical relationship in which the therapist thinks the family is incompetent, unreliable, or irresponsible and only wants to deal with the child. Almost invariably, this same therapist next will complain that the family and child never do the home exercise program or that the child is not brought to ther- apy regularly. This relationship may work for a school-based therapist or a therapist doing inpatient therapy, but it leads to great frustration for both the therapist and family when it is applied to an outpatient-based, ongoing developmental therapy. In this environment, the therapist must try to under- stand and work within the family’s available resources. The Physician Relationship Families of children with CP often have a series of physician relationships and tend to choose the physician with whom they are comfortable, who re- sponds to their needs, and who is able to help them with their child’s prob- lems. As pediatric orthopaedists, many of our patients will report to their schools and emergency rooms that we are their child’s doctors. We strongly 14 Cerebral Palsy Management encourage families to have family doctors or general pediatricians to care for well child care needs and minor illnesses. With the changing healthcare pay- ers, some families have changed family doctors every year or two and the physician who cares primarily for the musculoskeletal disabilities of a child often becomes defined as the child’s doctor. The musculoskeletal problems of CP are well known and are relatively predictable; therefore, a major part of the treatment is educating the family of what to expect. For example, a nonambulatory 2-year-old child who is very spastic has a high risk of developing spastic hip disease. This risk needs to be explained to parents so they know that routine follow-up is important and that, if spastic hip disease is found, there is a specific treatment program. Diligent attention to this individ- ual education process gives parents a sense of confidence about the future and helps prevent the development of a nihilistic family approach that noth- ing can be done for their child. Because families usually start to see the CP doctor when the children are about age 2 years, and in our clinic stay until age 21 years, a long-term relationship is developed. Keeping a healthy therapeutic relationship, under- standing and taking into consideration the family’s strengths and limits, is important. In addition to helping the family understand what to expect with their child, continuing to support the family as much as possible is very im- portant.

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