Case of the Week 7/1/2004: What people said...

I agree to the tendoachilles lengthening but he might also need a split anterior tibialis tendon transfer to the lateral part of the foot to
improve on his tendency to turn the foott inwards. I preferr to have frontal standing X-ray films of both feet on the same film. There
seems to be a forefoot adduction.

Good Luck

Bertil Romanus MD, PhD Ortop dpt
Univ or Göteborg

Dear Group,

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 J Fraser, PT, MS

John Fraser’s Physical Therapy

This child can easily drift into the well wknown "Birthday syndrome" (Rang, 1980?) if a premature
decision is made on the basis of limited information. Tele-medicine can work but not without access
to the appropriate information.

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
tel: +44 (0)151 231 4333 / 4321
fax: +44 (0)151 231 4353

I think as the boy age is only 12 years and the epiphyseal growth still there he should hold the surgery for a while. Is TendoAchilles is
tight and if it is stretchable then it is better to use the soft tissue to make it straight by splints.

Nipun Seth

I got your request for information. Was his hemiparesis from birth? Are you
aware of Cranial Osteopathy

John Marsden RMT

Hi everybody

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)

Hello all,

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

I guess this all shows how subjective the decision making process is?!

Helen Evans

Hello, Mr. Bhagwat/Sandeep--

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].

Mary Williams Clark MD

Hello all,

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


Nicholas Gallogly

I'm completely agree with Helen Evans.
It's impossible to answer without clinical evaluation, and without
trying botox or AFO before.
However, from video it doesn't seem the worst equinus that I ever seen,
and the management seems possible without surgery.
But the final decision can be affected by social and individual aspect
too. i.e. Your expertise with the techniques or the difficulty to
realize it in the patient's living territory.

Maurizio Petrarca

It appears that some of the responders believe that spasticity of the calf can be treated by
surgery. Someone used an analogy to CP in that the CNS/muscle link can be modelled by a
computer/printer analogy. If the computer's CPU is faulty then the printer will not work but we
shouldn't really fiddle with the printer. Unfortunately we are far from repairing the damaged brain
but there are some means of treating spasticity more directly.

The CP patient shows signs of a short calf on video

  1. is there a Gastroc + Soleus contracture? yes: TA lenghtening; no: continue
  2. is there an isolated Gastrocnemius contracture (without Soleus contr.)? yes: intramuscular lengthening of Gastrocnemii; no: continue
  3. spasticity reduction techniques
Obviously this is very crude and qualitative (amount of contracture is not considered) and does not
cover the wide spectrum of combined abnormalities, use of splints, etc.

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).

Dr Gabor Barton (Mr)
Senior Lecturer in Biomechanics
Research Institute for Sport and Exercise Sciences
Liverpool John Moores University
tel: +44 (0)151 231 4333 / 4321
fax: +44 (0)151 231 4353

I am totally in agreement with Mr Garbor, it is not possible to admit in 2004 that a child with CP is operated without gait analysis. In
my country ( Brazil ) we have a great rehabilitation center (AACD - and a gait lab that works since 1996 and
already did more than 3000 gait analysis. Now our engineer Mr Godoy and I tried to implant other lab in Brazil with help of
industries and If I speak here in Brazil that people indicate and make orthopedical surgeries without gait analysis we won't get to set
up a new lab and the one that I work now will close.

Excuse me for the honesty

Paulo Lucareli - AACD Gait Lab

Hello Mary Clark,

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
  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
  Pediatric orthopedic specialist
  Sushruta Hospital For Orthopedics & Traumatology
  Hospital Road, Behind Hotel Arafa,
  Miraj. 416410
  Dist: Sangli
  Maharashtra, INDIA

Dear list members,
I agree with a number of others who subscribe to this list that it is impossible to comment on this case from the scant information that is
available. Even if we did have clinical examination and cga data, I think it would be wrong to influence a prospective treatment on this child.
We do not know the child, his circumstances and would not take responsibility for an unsuccessful intervention here. This situation is
different to previous "case of the week" examples when there has been no request for our input to direct treatment.
Still, I am intrigued by the various comments made about different treaments and the assumption that some treatments do no harm and
that, therefore, we should give them a try. The long term effects of the injection of Botulinum toxin has not been evaluated. The two pieces
of work I know of indicate structural disruption of injected muscles. While injection may have a desirable short term effect, we do not know
if the muscle recovers its former integrity. If it does not, the child injected may suffer the consequences of long-term weakening of principal
support muscles with loss of function with maturity. It is worrying that Btx injection appears to have become a ubiquitous, "conservative"
treatment, particularly in Europe, without the support of longer term studies.


Adam Shortland PhD, MIPEM, SRCS
One Small Step Gait Laboratory,
Guy's Hospital

Dear Adam,

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

Dear Maurizio,

  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 Shortland PhD, MIPEM, SRCS
One Small Step Gait Laboratory,
Guy's Hospital

Dear Adam

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

  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

Ianieri G; Santamato A; Saponieri F; Di Cillo P; Megna G.
Safety and efficacy of botulinum toxin in cerebral palsy: Four-year
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

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.

Dear Adam,

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

Dear all,

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:

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!

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

I am not sure if surgery is the only "real solution". It would certainly be "permanent" which is one of its dangers. There is a long list of options such as conservative treatment (including orthotics, stretching, serial casting, etc.), Botullinum, and various orthopaedic techniques controlling foot position. Each of these treatment options are attached to well(?) defined problems but at present we do not know if any of these conditions are met. The grandfather's educated guess (SEMLS) is an important one. The careful re-balancing of bones, muscles, static and dynamic functions is not something that can be done on the basis of a home-video.

Dr Gabor Barton (Mr)
Senior Lecturer in Biomechanics
Research Institute for Sport and Exercise Sciences
Liverpool John Moores University
tel: +44 (0)151 231 4333 / 4321
fax: +44 (0)151 231 4353

Dear List,

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

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:

Neither of these abstracts deal with long-term function.

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 Shortland PhD, MIPEM, SRCS
One Small Step Gait Laboratory,
Guy's Hospital

Adam thanks for your response.

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

Dear all,

I wonder if any of you read that review of equinus surgery by Takashi Matsuo?

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.

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

Dear Chris,

I'm not suprised that Bruce McWilliams found little difference between the
groups. There may be two reasons:


Adam Shortland PhD, MIPEM, SRCS
One Small Step Gait Laboratory,
Guy's Hospital

Dear all,

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)

The Science is amoral: annihilates beliefs just with mathematical equations.

  Wagner de Godoy
  Laboratório de Marcha - Gait Laboratory
  AACD - Associação de Assistência à Criança Deficiente
  Disabled Children Care Association


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
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.

  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.

  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

  United Cerebral Palsy Research Fact Sheet
  A short document providing an introduction to Botox therapy.

  DIY Medical Knowledge

  Botulinum Toxin Injection in CP:
  The Experience at All India Institute of Medical Sciences
  New Delhi, India


  Alan Morris, M.A.Sc., P.Eng.
  Research Engineer - Biomechanics Group
  Bloorview MacMillan Children's Centre
  350 Rumsey Road
  Toronto, Ontario
  Tel (416) 425-6220 x3509
  Fax (416) 425-1634

I have been monitoring the various postings related to spastic
hemiparesis and would like to open the discussion up further...

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

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

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

Hello All,
                          In response to the questions from Gabor and Chris, I can say that I was not taught any special
                      technique for muscle lengthenings, but over the years [>30] I have evolved the following [from
                      observations & discussions with others and, more so, from observations of 'what seems to work' in my
                      own patients]:   Fractional lengthenings [e.g. percutaneous Achilles lengthenings, or open
                      'fractional' [cutting tendons within large muscles twice or thrice, biceps or semimembranosus]
                      allow stretching of the joint after the tendon is cut, and I stretch until I have a 'good' range of
                      motion. This is usually something between 5 to 10 degrees of dorsiflexion of the ankle, after a TAL
                      [Achilles}--- I think anything more than 10 deg. invites weakness;  in other joints, usually knees,
                      I get as much stretch as I can, without 'snapping' the tendon in two.

                      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'].

                     Mary Clark

                      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.

                     Dr Gabor Barton (Mr)
                      Senior Lecturer in Biomechanics
                      Research Institute for Sport and Exercise Sciences
                      Liverpool John Moores University
                      tel: +44 (0)151 231 4333 / 4321
                      fax: +44 (0)151 231 4353

Dear all,

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:

To remind you, these were your suggestions before we had a 3D analysis performed:                  Here's my short summary of the data:


                 Walks with right hemipelvis rotated forward and elevated
                 Left hip abducted and externally rotated
                 Left knee flexed at contact
                 Plantarflexion limited bilaterally


                 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!

                 Dr. Chris Kirtley MD PhD
                 Associate Professor
                 Dept. of Biomedical Engineering
                 Catholic University of America


Back to Case