Good Luck
Bertil Romanus MD, PhD Ortop
dpt
Univ or Göteborg
Sweden
First I would like to state that I have limited practice experience
in pediatrics, as I primarily involved in orthopedics and sports
rehabilitation. But I would like to throw some ideas out after
viewing the videos.
I do not think the equinus is that severe to warrant a z-plasty. When
advancing the contralateral LE, stance time on the LLE is
abbreviated secondary to triceps surae length/tone. You could
see premature heel rise during terminal stance. I am curious if the
parents have been offered the option of serial casting as an alternative
to surgery.
Something of interest though. . . I would like to know his hip abductor
strength on the paretic side. The ER of the LLE during heel
strike and throughout stance could be a compensatory motion to optimize
length-tension of the gluteus medius during stance. If it is
weak, this is something that should be addressed in physical therapy.
John Fraser’s Physical Therapy
http://www.geocities.com/johnjfraser
The video will not tell us if there is any fixed plantarflexion. What
are the ankle dorsiflexion
ranges with the knees extended and flexed (Sylverskiold test), ie.
is the Soleus and/or
Gastrocnemius contractured? If the Soleus is not short then the Achilles
tendon lengthening is
contraindicated. In most cases a Gastrocnemius lengthening is the answer
(using various techniques,
avoiding the Achilles tendon).
I would postpone the final decision and get more data about the child.
Ideally a full gait analysis
would be needed but given the constraints at least a physical examination
would be essential.
Chris, you must be provoking us with such a question. Is your message
that even though we know how
to make a decision about a CP child we do not always have all the info?
--
Dr Gabor Barton (Mr)
Senior Lecturer in Biomechanics
Research Institute for Sport and Exercise Sciences
Liverpool John Moores University
http://www.livjm.ac.uk
tel: +44 (0)151 231 4333 / 4321
fax: +44 (0)151 231 4353
Nipun Seth
India
I am Sandeep Bhagwat from (Maharashtra) India. I would suggest OSSCS (orthopaedic selective spasticity controlling surgery) after a thorough evaluation by the surgeon instead of TA lengthening. we have operated a number of patients and have good collection of data. If you need further help please feel free to write me.
Sandeep Bhagwat (physiotherapist)
He does look fairly mild to be considering TA lengthening, although
as everyone has said it is
difficult to assess with slightly out-of-plane videos and no clinical
exam.
Just thought I would throw the suggestion of either serial casting
or Botox into the pot -
especially if he is fairly mild?? or as someone else suggested (I think)
- gastroc fascial type
release to reduce spasticity without lengthening muscle excessively.
Does he have any orthoses? That could control the rearfoot and
provide a dynamic stretch to the
tricpes surae whilst permitting a more normal gait pattern (could also
be moulded to correct any
forefoot problem suggested too) - I would definitely try this
first (being a physio) to assess the
effect of correct positioning on gait and triceps length over a period
of time, before considering
surgery.
I guess this all shows how subjective the decision making process is?!
Thanks
Helen Evans
I'm interested in what you specifically mean by OSSCS--it sounds as
if ii applies to
spasticity-controlling surgery at many possible levels; what specifically
do you do for the
gastro-soleus complex shortening/contracture?
I'm a pediatric orthopedic surgeon, rather 'old', and have been doing
percutaneous Achilles
lengthenings for most of my CP patients who have a gs contracture,
regardless of the source of the
contracture. The lengthenings are controlled [no more than 10-12
degrees of dorsiflexion at the
time of surgery], and they wear a solid-ankle AFO for a full 6 months
to avoid over-lengthening.
[With some PT to maintain ROM and strength, but no weightbearing out
of braces; they can swim, and
walk in chest-deep water w/out braces.] It has worked well
for me and I have not seen subsequent
significant weakness of the calf.
I agree with Helen Evans about the need for us to know about
the foot position [can he passively get to neutral, including subtalar
neutral?], and for a trial
of AFO [especially hinged with plantar-flexion stop, or the "DAFO #3"
type, with solid ankle,
posterior upright without a proximal strap to allow DF with gait].
I am only an undergraduate student(Engineering and P&O) so aplogies
if my
suggestion is weak. A suggestion has been made for an AFO for during
the
day, but also maybe a night splint so as to strech the muscle during
the
night?
regards,
The CP patient shows signs of a short calf on video
I maintain my first opinion that surgery should be avoided until further
information is available
(at least physical exam including ROM and measures of spasticity).
Gabor
--
Dr Gabor Barton (Mr)
Senior Lecturer in Biomechanics
Research Institute for Sport and Exercise Sciences
Liverpool John Moores University
http://www.livjm.ac.uk
tel: +44 (0)151 231 4333 / 4321
fax: +44 (0)151 231 4353
Excuse me for the honesty
Paulo Lucareli - AACD Gait Lab
Your mail was forwarded to me by Sandeep. Well, I am a Paed. Ortho Surgeon
from India. I have been
practicing OSSCS for the last couple of years & have found
excellent results. We all beleive that the
fundamental abnormality in Cerebral Palsy is Hypertonicity
(Spasticity,
Rigidity & Athetosis) .
Thus it is necessary to reduce this hypertonicity & as well
correct deformities to acheive a good results.
OSSCS is based on the concept that monoarticular muscles
are antigravity muscles thus, responsible
for erect posture in human being. The multiarticular muscles
are spastic & responsible for various
deformities & gait abnormalities in Cerebral Palsy Thus
multiple surgeries on these multiarticular muscles
at multiple levels will reduce hypertonicity & activate
the monoarticular muscles & antagonist muscles
(monoarticular & multiarticular) for various function of
the Limb. This is true if there are no contractures
or fixed deformities.If these are present then OSSCS has to
be combined with conventional orthopedic
surgeries.
Right now we are doing CP upper limb, hand, lower limb, neck
etc & are quite happy with the results.
We have done about 250 - 300 cases till date. If you need any
further information please feel free to
contact me.
Sincerely yours
Dr. Girish Datar
MB.,D.Orth.,MS.Orth
Pediatric orthopedic specialist
Sushruta Hospital For Orthopedics & Traumatology
Hospital Road, Behind Hotel Arafa,
Miraj. 416410
Dist: Sangli
Maharashtra, INDIA
+91-233-3103402.
Adam
Adam Shortland PhD, MIPEM,
SRCS
One Small Step Gait Laboratory,
Guy's Hospital
London
UK
We have used Btx in case of equinus on plegic children for three years.
We
evaluate our treatment with gait analysis and surface EMG. The
evaluation is made at 1, 3, 6, and 12 month after the injection.
Moreover, we evaluate our patient at least every 1 year after
this first
observation. I don't know if this match with your concept of
long term
effects. Well, we have observed in some cases a temporary modification
of gait pattern, and in others a permanent modification with
a evident
equinus reduction. We never observed a long-term weakening
of principal
support muscles with loss of function with maturity.
Besides, the child
object of discussion, has already reach gait maturity. In this
sense, in
cases like this, Btx can be considered a try. On contrary, we
have
observed some cases of weakening of principal support muscles
with loss
of function with maturity after surgery treatment, that
requires a more
careful evaluation.
Maurizio Petrarca
Movement Analysis Laboratory
Children Hospital Bambino Gesù, Rome
Italy
An evaluation at 12 months is not long enough in most instances
to determine
the long-term effects of injection (it is just about long enough
to decide
that they need another injection). As you know in children with
spastic CP
the positive symptoms of their condition are strong and their
bodyweight is
light - no immediate problem! But repeated injection and weight
gain is a
dangerous recipe. Children with spastic CP are often injected
when they are
young and on the positive slope of any functional curve. So
they would get
better without injection! Fewer children are injected when they
are older
perhaps because they are on the negative slope and would deteriorate.
We need to understand the natural history of function in this
group, before
we make to strong claims for our interventions. We also need
to understand,
at the level of the organ, the natural history of deformity
and its
correction. We are far from this objective. Until then we should
veer on the
side of caution when considering a "new" treatment without a
long history
but with potentially damaging effects..
Adam
Adam Shortland PhD, MIPEM,
SRCS
One Small Step Gait Laboratory,
Guy's Hospital
London
UK
I agree with your point of view regarding offering treatment
comments under the current scenario.
I do like to correct you on the fact that long term effects
and safety
of botulinum toxin in CP has not been studied. It is imperative
to keep
the content distributed to the members as accurate as possible,
I would
not like to discredit one technique over another based on personal
impressions. I just happened to find these two recent references
on the
issue and want to make the scientific information available
to all.
The references with abstracts follow
Respectfully
Alberto Esquenazi, MD
Chair Department of PM&R & Chief Medical Officer.
MossRehab & Albert Einstein Med. Center
Director Gait & Motion Analysis Lab. and
Regional Amputee Center
MossRehab a Member of the Jefferson Health Network
1200 West Tabor Rd.
Philadelphia, PA 19141 USA
Voice: 215 456 9470 Fax: 215 456 9631
www.einstein.edu/gaitlab
Ianieri G; Santamato A; Saponieri F; Di Cillo P; Megna G.
Safety and efficacy of botulinum toxin in cerebral palsy: Four-year
study.
Mov Disord 2002;17(Suppl 5):S337 ABS P1116.
Objectives: The authors review the long-term effectiveness and safety
of BT treatment in patients with cerebral palsy (CP) who had received
botulinum toxin (BT) injections regularly for at least 4 years.
Background: CP is a medical condition that affects control of the
muscles (palsy refers to anything wrong with control of the muscles
or
joints in the body). Children who have CP may not be able to walk,
talk,
eat or play in the same ways as most other kids. Methods: A total of
9
patients (mean age: 9.1 +/- 4.5, 3 M, 6 W) received a diagnosis of
spasticity and began treatment with BTX (Dysport Ipsen, London, UK)
during the four-year period 1998 to 2001. The mean time at first
symptoms and first treatment was 27.3 +/- 15 months. Of the total cohort
of 9 subjects initially available for study, any patient has been
considered dropouts. At each session BT (20 U/0.1 ml) was injected
into
various sites in the in the following muscular regions: foot, leg,
thigh, hip joint. The anatomical identification of the spastic muscles
was done with kinesiologic maneuvers, or in patients with serious
neurological condition, with common electrodiagnostic procedures of
electromyography. Data were analyzed for statistical significance with
Student's paired t-test. Results: The evaluation of the middle total
dosing of BT injected has emphasized a statistically significant
reduction of the amount of drug used (T = 1: 1,898.3 +/- 500; T = 12:
1,013.9 +/- 280 P < 0.001). The evaluation of the middle dosing
for
single muscle has underlined a statistical significant reduction the
quantity of drug used. The evaluation of the spasticity with the
Ashworth's scale has underlined an improvement of the ipertony of the
upper limb with statistically significant reduction of the middle score
between the beginning and the end of study (T=1: 2.55 +/- 0.72; T =
12:
1.22 +/- 0.66 P < 0.001). Data are summarized in the Table. (Table
omitted) Conclusion: Their study confirms that the infiltration
of BT
in a spastic muscle is a sure and strong treatment for the symptoms
of
spasticity.
Diffazio Mark D; Coll Edward; Menachi William; Latimer Elizabeth;
Pesin
Elena; Jabbari Bahman
Long-term effects and safety of botulinum toxin A in children with
cerebral palsy.
Neurology 2003 Mar;60(5 Suppl 1):A466 ABS P06.070.
OBJECTIVE: To report on longterm efficacy and side effects of botulinum
toxin A treatment in a large number of children with cerebral palsy
BACKGROUND: Over the past decade, several investigators reported
amelioration of spasticity and functional improvement of children with
cerebral palsy after treatment with botulinum toxin A. However, except
one report (Koman et al 1998), no other described efficacy and safety
issues in a large number of CP children over a long period of time.
The
authors have previously described a preliminary, short term observation
in 56 children with cerebral palsy treated with this agent. In this
communication, they report their experience in a large number of CP
children. In many of these children efficacy and side effects of
botulinum toxin A were monitored closely over several years.
DESIGN/METHODS: They have reviewed the results of treatment with Botox
in 250 children , age 1-16 years with Cerebral palsy. Of this cohort
206
had repeated treatment and 148 were followed beyond one year (mean
38
months -1-8 years). Baseline dystonia was rated by Ashworth scale.
The
condition of dystonia or spasticity after treatment was recorded by
parents, physicians and physiatrists as improved, unchanged or worsened.
More detailed evaluations (modified gait/motor UPDRS, physiatric rating
and videotapes) was available in 102 patients. The prepared Botox
solution contained 100 units/cc. Botulinum toxin A was injected
intramuscularly through a 27 gauge needle. The dose per muscle varied
from 10-100 units. The total dose per session ranged from 8-14mg/Kg.
RESULTS: Worthwhile improvement was noted in 86% of the children. In
the
lower limbs, improvement of spasticity or dystonia (or both) resulted
in
longer periods of standing, assisted and non-assisted gait, hygiene,
better use of FAO's and better orthopedic adjustment (delay in surgery,
ease of serial casting, etc). In the upper limbs, treatment improved
dressing and passive limb movements, prevented finger and palm skin
sores, and in some children resulted in first time appearance of
voluntary movements (videotape). Favorable response persisted in the
majority of children (92%) beyond 1-2 years. Among whom followed beyond
two years, > 80% displayed improvement over baseline (pretreatment)
symptoms, often extending beyond four months after treatment. Five
children (2%) demonstrated transient side effects (4 flu-like reaction,
1 mild weakess of both legs). No Clinical immuno-resistence was noted
with new botox introduced in 1998. CONCLUSIONS: 1- Efficacy of Botulinum
toxin A in children with cerebral palsy continues over years with
repeated treatment 2- Longterm Botulinum toxin A treatment in cerebral
palsy is safe, side effects are mild and occur rarely 3- The incidence
of clinical immuno-resistence to new Botox formulation appears to be
very low.
When I wrote that we began to investigate Botox three years ago and
we
evaluate our children at least every one year, I mean that we made
observations at three years. I agree that 12 months are not a long
enough time. Our study on this issue is not yet concluded and
consequently not published. I also agree with you that we don't know
the
natural history of function development in CP and that this is a crucial
information for a complete understanding on the effects of every
treatment. I think that many of us are engaged on this and that it
will
be a long and hard work. But, this way to consider, freezes every
possibility to discuss what we should do on a specific case, and this
was the context of discussion. I never asserted that Btx could be
considered a new treatment, but our experience, supported by structured
observation, led us to made same reflections on the case proposed,
from
the only video information: 12 years old CP is with poor probability
on
positive slope of recovery; the proposed surgical intervention is surely
an irreversible treatment that needs of a very carefully evaluation
not
possible by the video data available; it is hoped a more detailed
clinical investigation; an evaluation made by a physiotherapist can
investigate the capacity of equinus modification; the use of an AFO
can
provide information on this management; if you want just to consider
surgery, try before the btx, if there are no contraindication (i.e.
fixed muscle shortening), like a partial experiment of muscle
lengthening. Is if true that the long term effect of Botox on CP is
not
documented, is also true that it is not documented a functional damage
for one injection of Botox. I think that this assertion is not the
proposal of a new treatment, but a suggestion on more prudent path.
Unfortunately the story of CP rehabilitation is full of mistakes often
made on the basis of personal convincement without any evidence, but
this
is another question.
Maurizio Petrarca
Movement Analysis Laboratory
Children Hospital Bambino Gesù, Rome
Italy
Thanks very much to everyone for the contributions so far. I appreciate
that this is an especially tricky case on which to comment
because of the paucity of data. As usual, though, it does seem to have
raised some interesting issues for debate. Of course, it is not
our job here to advise the treating physician/surgeon/therapist on
the course of treatment. In my view, the chief role of this list is to
open up the clinical-decision making process to peer scrutiny, so that
we can all learn from each other's perpective.
The child's grandfather (his guardian) comments:
I've actually learned some new things from skimming over all responses appeared on the web last weak. It appears as the surgical operation would be the only real and permanent solution in the Tino's case. It's clear that it might be a complex surgery with number of different procedures.
I can understand that majority of the participants were not able to make any final decision without receiving more data. The limitation of videotape is that three-dimensional motion is confined to two dimensions, which may mislead a clinician. I guess that Gait Analyses and perhaps electromyography would be an essential guideline for decision of an eventual orthopaedic surgery, perhaps SEMLS (single event multi-level surgery).
Now, after getting through all suggestions gathered last week, I will appreciate your opinion what should we do as next step.
Assuming this is the direction followed, I would now like to address
the question of the relative merits of a subcutaneous (Z-type)
heel-cord lengethening versus a Baker or Strayer type proximal (gastrocnemius
origin) recession. I just found this excellent summary
of the various surgical approaches to equinus by Takashi Matsuo, Chief
of Staff at Minamitama Orthopaedic Hospital, which you
might be interested to read:
http://hb3.seikyou.ne.jp/home/t-matsu2/E.p2.ch3.4-3-1.html
Once again, let me stress that I am not implying that the decision to
opt for surgery has been made. I am merely interested in moving
on the discussion!
Chris
--
Dr. Chris Kirtley MD PhD
Associate Professor
Dept. of Biomedical Engineering
Catholic University of America
620 Michigan Ave NE, Washington, DC 20064
Tel. 202-319-6134, fax 202-319-4287
Email: kirtleymd@yahoo.com
http://faculty.cua.edu/kirtley
Gabor
--
Dr Gabor Barton (Mr)
Senior Lecturer in Biomechanics
Research Institute for Sport and Exercise Sciences
Liverpool John Moores University
http://www.livjm.ac.uk
tel: +44 (0)151 231 4333 / 4321
fax: +44 (0)151 231 4353
I subscribe from home so I always seem to be 12 hours behind the pace.
I'm
aware that the discussion has moved on from Botulinum toxin but I have
to
respond to some of the comments Alberto (Esquenzi) has made.
Alberto, I'm sorry that you feel I've misrepresented Botox. I pride
myself on
the accuracy with which I make written statements, so I'm glad to report
that the abstracts you quote do little to dent my confidence!
Let's get to the critical detail.
Firstly, I did not suggest that there was an issue with the systemic
safety
of Botox. Its safety has been demonstrated in a number of studies/reviews.
Of
course, this does not mean that Botox is innocent of the charge
of "harm". It
is a local injection and it is harm at the local level that I am concerned
with.
The only other outcome measure from the first abstract (I could not
find
full articles associated with these abstracts) was an Ashworth scale
rating.
I have no doubt that Botox reduces the spastic response of muscles:
it is one
of the most potent neurotoxins known to man, it should.
The second abstract is more interesting though still less than convincing.
The authors quote a large number of patients but there are several
significant weaknesses, namely:
I did not suggest in my original e-mail that medics should not use Botox.
Rather, my complaint was that it was a ubiquitous treatment that demanded
more respect because of potential long-term damaging effects. Greater
consideration needs to be given to its use. Many of the arguments that
we
employ against surgery could well be applied to Botox. We need controlled
studies of the effects of injections on the integrity of the local
musculature and to correlate those with functional changes.
Best regards,
Adam
Adam Shortland PhD, MIPEM,
SRCS
One Small Step Gait Laboratory,
Guy's Hospital
London
UK
I agree we should continue this discussion outside the list but would
not like to walk away from the opportunity to address your concern
of
effects of Botulinum toxin A at the local muscle level. I will encourage
all interested to learn from the work by Alderson published in Botulinum
and Tetanus Neurotoxins: Neurotransmision and Biomedical Aspects
Dasgupta (edt) 1993 .
In her chapter Motor Nerve Terminal Morphology Following Botulinum
A
Toxin Injections in Humans she painstakingly explores the effects of
botulinum toxin on the neuromuscular junction. She reports no loss
of
motor axons and normal muscle histochemistry.
Hope this helps
Alberto Esquenazi, MD
Chair Department of PM&R & Chief Medical Officer.
MossRehab & Albert Einstein Med. Center
I wonder if any of you read that review of equinus surgery by Takashi Matsuo?
http://hb3.seikyou.ne.jp/home/t-matsu2/E.p2.ch3.4-3-1.html
To summarize, he says that tendo-Achilles lengthening (by sliding or
z-plasty) is complicated by collapse of the ankle (calcaneal gait) post-op
because the support (plantarflexor-knee extensor couple) function of
the soleus is compromised. On the other hand, selective procedures (such
as
Vulpius, Strayer, Baker, Hoke, proximal recession) in which only the
gastrocnemius is lengthened, suffer from a high recurrence rate. He suggests
that
TAL might be the procedure of choice in hemiplegia (where the contralateral
limb can provide support) and selective procedures reserved for diplegia,
and speculates that a combination of the two procedures might give
better results than either procedure alone.
I also came across a study by Bruce McWilliams (who I know subscribes to CGA):
with results summarized here:
This study found very little difference in efficacy of the two approaches.
I would be interested in your views, and any other comparison studies that have been done.
Chris
--
Dr. Chris Kirtley MD PhD
Associate Professor
Dept. of Biomedical Engineering
Catholic University of America
620 Michigan Ave NE, Washington, DC 20064
Tel. 202-319-6134, fax 202-319-4287
Email: kirtleymd@yahoo.com
http://faculty.cua.edu/kirtley
I'm not suprised that Bruce McWilliams found little difference between
the
groups. There may be two reasons:
Adam
Adam Shortland PhD, MIPEM,
SRCS
One Small Step Gait Laboratory,
Guy's Hospital
London
UK
Kepler was assigned the task by Tycho Brahe to analyze the observations that Tycho had made of Mars. Of all the planets, the predicted position of Mars had the largest errors and therefore posed the greatest problem. Tycho's data were the best available before the invention of the telescope and the accuracy was good enough for Kepler to show that Mars' orbit would precisely fit an ellipse. In 1605 he announced The First Law:
Planets move in ellipses with the Sun at one focus
Johannes Kepler (1571-1630)
by http://www.kepler.arc.nasa.gov/johannes.html
The Science is amoral: annihilates beliefs just with mathematical equations.
Wagner de Godoy
Laboratório de Marcha - Gait Laboratory
labmarcha@aacd.org.br
AACD - Associação de Assistência à
Criança Deficiente
Disabled Children Care Association
Brazil
Nice analogy, but...
We have a limited grasp of many issues in CP/GA. In spite of the limitations
it all works quite
well around the world (see all the papers which prove the usefulness
of GA). So far the analogy is
fine. But probably gait analysts should adjust the focus a bit and
surgeons should grind a new
mirror so that we don't get stuck in the present.
Surgeons on the list, how accurate can you get? Is it important at all
to be accurate? One of the
best surgeons around told me that he lengthens the Gastrocnemius (Baker
slide) so that the foot can
be dorsiflexed to neutral during the operation.
Dr Gabor Barton (Mr)
Senior Lecturer in Biomechanics
Research Institute for Sport and Exercise Sciences
Liverpool John Moores University
http://www.livjm.ac.uk
tel: +44 (0)151 231 4333 / 4321
fax: +44 (0)151 231 4353
Dear CGA readers,
Here is a short list of some useful reading on the
application of Botulinum Toxin to children with CP:
Keeping Current In... The Use of Botulinum Toxin
in Children with Cerebral Palsy
A detailed document written by the Director of the Neurodevelopment
Program
at Bloorview-MacMillan Centre that provides the reader with
an introduction
and subsequent sections including "How Does It Work?", "Are
There Any Side
Effects?", "What Do We Know About the Use of Botulinum Toxin
in the Lower
Extremity in Children with Cerebral Palsy?", "What Do We Know
about the Use
of Botulinum Toxin in the Upper Extremity?", "Clinical Implications:
What We
Know..." and "What We Don't Know...".
References included.
http://www-fhs.mcmaster.ca/canchild/publications/keepcurrent/kc_intro_98-1.html
Spasticity: Etiology, Evaluation, Management,
and the Role of Botulinum Toxin Type A
An entire journal supplement on botox therapy.
**Readers will have to register for free access to the document.
Journal: Muscle & Nerve, Supplement 6/1997
A Wiley-Interscience Publication
John Wiley & Sons, Inc.
http://www3.interscience.wiley.com/cgi-bin/jhome/32891
Allergan Botox Website
The makers of Botox provide extensive information for consumers
and health
care professionals.
Allergan, Inc.
2525 Dupont Drive
Irvine, CA 92715
Allergan Botox Information Line: 1-800-668-6424 ext. 2003
http://www.botox.com/site/
United Cerebral Palsy Research Fact Sheet
A short document providing an introduction to Botox therapy.
http://ucp.org/ucp_generaldoc.cfm/1/4/24/24-6608/153
DIY Medical Knowledge
http://www.diy-medical-knowledge.com/botox/botox-for-cp-children.htm
Botulinum Toxin Injection in CP:
The Experience at All India Institute of Medical Sciences
New Delhi, India
http://www.udaan.org/botulinum/aiimsbtx.html
Regards,
Alan Morris,
M.A.Sc., P.Eng.
Research Engineer - Biomechanics Group
Bloorview MacMillan Children's Centre
350 Rumsey Road
Toronto, Ontario
CANADA
M4G-1R8
Tel (416) 425-6220 x3509
Fax (416) 425-1634
http://www.bloorviewmacmillan.on.ca
To summarise, much of the discussion has focussed on the
treatment of spasticity and associated clinical efficacy. However,
none of the debates or discussions addressed the issue of
measurement of the phenomenon that was described as "being
treated".
If one were to accept Lance's definition of spasticity, then none of
the exiting clinically available measurement techniques measure
spasticity. If this is the case, how then can we discuss the
management of the phenomenon of spasticity?
Kind regards
a
Paraphrasing Lord Kelvin - You need to measure to know!
umm .. Shall I now dive for cover.
end of message.............--
(Dr) Anand David Pandyan
Department of Physiotherapy Studies
Keele University, Staffs ST5 5BG
Tel: +44 (0)1782 584252 / Fax +44 (0)1782 584255
Mobile: +44 (0)797 009 3877
I think it's very important to control and maintain the length over
the healing
period--specifically for the Achilles, with the extreme lever arm of
the leg, a solid-ankle AFO for 6 months
post-op. [yes, they get weak, but they don't over-lengthen---and
I get them going on strengthening
after a month or so]. Hamstrings are a lot less likely
to over stretch, in my experience,and they
begin strengthening within the first few weeks post-op.
[I realize there's no 'Level II, or even III" to this---just 'my experience'].
ps---I've so far not ever had a gait analysis suggest to me the amount
of lengthening that would
be ideal. ["7 mm"--??---really , could you determine that, do you
think? :) ]
A clinical gait analysis is not the equivalent of a highly accurate muscle
modelling study and so
it will not aim to tell the surgeon how much to lengthen but I guess that
the ultimate use of the
dynamic muscle length charts attached to gait analysis reports will be
to direct the surgeon. Many
of the cases from Gillette Children's Hospital at the ESMAC course in 2001
used such muscle length
charts (beside all other data) in the decision making process.
Gabor
--
Dr Gabor Barton (Mr)
Senior Lecturer in Biomechanics
Research Institute for Sport and Exercise Sciences
Liverpool John Moores University
http://www.livjm.ac.uk
tel: +44 (0)151 231 4333 / 4321
fax: +44 (0)151 231 4353
Dr. Bernard Zwick has kindly performed a 3D analysis at his lab in Graz,
Austria. I have put the results on the page and I think it
would be interesting to review the case again with this data:
Kinematics:
Walks with right hemipelvis rotated forward and elevated
Left hip abducted and externally rotated
Left knee flexed at contact
Plantarflexion limited bilaterally
Kinetics:
Increased ankle plantarflexor moment during loading on left.
Reduced A2 power generation bilatterally, with increased H1 compensation
on left.
Increased abductor power on right during left swing - suggests circumduction
pattern.
Points for Discussion:
-What is the reason for the limitation in plantarflexion on the right (normal)
side?
-Why is the pelvis thrust forward on the right?
-What is the reason for the pelvic obliquity?
-What would be your management now, and has it changed after seeing the
data?
mailto:[n/a] as usual with your comments!
Chris
--
Dr. Chris Kirtley MD PhD
Associate Professor
Dept. of Biomedical Engineering
Catholic University of America
