He may need surgery in the future but he is going to go through a couple
of growth spurs and if
you can delay the surgery through Botox injections may reduce
the number of surgeries. Good
luck.
Alberto Esquenazi, MD
MossRehab and Albert Einstein Med. Center
Director Gait & Motion Analysis Laboratory and
Regional Amputee Center
MossRehab a Member of the Jefferson Health Network
One of U.S. News & World Report "Americas Best Hospitals"
1200 West Tabor Rd.
Philadelphia, PA 19141 USA
Voice: 215 456 9470 Fax: 215 456 9631
Email: Aesquena@einstein.edu
http://www.einstein.edu/phl/1214p2.html
Seems to be a combination of weakness and spasticity (especially psoas muscle leading to a hyperlordosis and right internal rotation in gait activity).
I also would suggest another 2-3 trials of Botox into psoas muscle (right > left) in order to reduce internal rotation and hyperlordosis during gait) and a little dose to right medial gastrocnemius (in order to reduce toe walking and improve heel contact in stance phase). Botox-injections should be repeated every 4-6 months (not earlier in order to allow development of central inhibition patterns).
Work on strengthening hip external rotation and extension after
chemodenervation of psoas muscles and strenghtening of
anterior tibial and peroneal muscles after chemodenervation
of gastrocnemius.
Probably right tendon-achilles-lenghtening may be helpful in the next one or two years.
Dr. Klemens Fheodoroff
Gailtal-Klinik Hermagor
Abt. f .Neurologische Rehabilitation
Radniger Straße 12
A-9620 Hermagor
Austria
On the grounds that it will probably take me a lot longer than the two
weeks
available to interpret all the gait analysis data supplied by our colleagues
in Tel Aviv I won't attempt this as I expect that there will be others
in a
better position than I who will do so over the next few days.
However I do have some experience in the use of AFOs in cerebral
palsy which
may be of some use to the mother and the clinical team looking after this
wee boy.
I would agree with Alberto when he suggests using an AFO. However from
our
experience here we would suggest a rigid polypropylene AFO cast
in
sufficient dorsiflexion to maintain the shank at about 10 degrees anterior
to the vertical during stance phase, taking into consideration the
additional effect of any footwear. In this attitude (or thereabouts) the
aim
is to align the ground reaction force in mid to late stance in front
of the
knee and behind the hip joint to create extension moments (the hip
being
extremely critical). If contractures prevent this then it is imperative
that
these are reduced sufficiently to enable the establishment of the
appropriate external moments described above if the AFO is to work properly.
The good news is that clinical experience suggests that if you are able
to
reduce the contractures conservatively to enable the initial successful
fitting and biomechanical functioning of the AFO, the continual stretching
of the muscles during each step during walking prevents recurrence
(other
than sometimes when there is a quick growth spurt). I would think from
looking at the data supplied that this boy should do quite well.
I appreciate however that I am looking only at sagittal plane circumstances
and that this is really a three dimensional problem with other aspects
to be
addressed.
The subject of how you achieve the critical biomechanical alignment and
joint moments is a bit more complicated than I have described above. 10
degrees anterior lean of the shank is just a starting point to enable tuning
of the orthosis and associated footwear to optimise the moments and ground
reaction forces. It varies from child to child (and depending on how you
choose to measure it as well!) and the outcome is sensitive to very small
changes eg one or two degree by altering the heel wedge. If anyone is
interested in finding out some more, some of this is published in the ISPO
Consensus Conference Report on CP orthotics (1994) or, if you suffer from
insomnia, my PhD thesis (University of Strathclyde, 1984). If anyone wants
further info please email me and I would be happy to help.
Barry
Dr C B Meadows
Head of Neurobiomechanics
WESTMARC
Southern General Hospital
Glasgow
G51 4TF
Scotland
email: barry.meadows@sgh.scot.nhs.uk
Bill Ogard
William K. Ogard, P.T., Ph.D.
Department of Physical Therapy
University of Alabama at Birmingham
RMSB 337
1530 3rd Ave South
Birmingham, AL. 35294-1212
205-934-5972
bogard@uab.edu
I would suggest obtaining EMG from hip adductors/abductors in the future. Treating the left hip adductors may need to be considered as well.
Alberto Esquenazi, MD
MossRehab and Albert Einstein Med. Center
Director Gait & Motion Analysis Laboratory and
Regional Amputee Center
MossRehab a Member of the Jefferson Health Network
One of U.S. News & World Report "Americas Best Hospitals"
1200 West Tabor Rd.
Philadelphia, PA 19141 USA
Voice: 215 456 9470 Fax: 215 456 9631
Email: Aesquena@einstein.edu
http://www.einstein.edu/phl/1214p2.html
I notice that nobody has taken my bait of offering a classification for this child's hemiparesis. I was thinking of Jim Gage's 1987 paper (Winters, TF, Gage, JR, Hicks, R Gait Patterns in Spastic Hemiplegia in Children and Young Adults. Journal of Bone and Joint Surgery, 69-A(3):437-441), in which the authors describe 4 grades:
Grade I - drop foot in the swing phase
Grade II - tight heel cord in stance phase as well as a drop foot in
the swing
Grade III - stiff knee as well as an equinus
Grade IV - hip involvement
Seems to me this child would have to be Grade IV. I wonder what people think of this method of classification, whether it is of any help, or whether there is an alternative?
I also have a little more info from the child's mother about his previous treatment...
First of all I really want to thank you. The responses are all
so
informative - although there are a lot of terms I am unfamiliar with...
Luckily I have a wonderful team of PTs at the Childhood Development
Center
in Beer Sheva, and they are all looking and learning from his gait
analysis
and the comments - and then explaining to me.
The last Botox was September 5, 2002 - passive range in the hamstring
increased by 15* (pop test), active range was not affected. Gait
analysis
was Dec.3, 2002 - so three months after Botox. Dose was 90 iu
of Botoulium
Toxin A. There were four injections - 2 in each hamstring muscle
- at
different spots (don't know exactly where).
First Botox was March 2001, 70 iu, also to hamstring, also Botox A - one shot.
Full length casting was Dec. 2000 for hamstring stretch (3 weeks) -
he had
terrible atrophy and it took him a few days to walk - and a month to
regain
his strength and run - and this point all the range gained by casting
was gone.
Half leg serial casting (5* and 10*) was Nov-Dec 1999. Great gains in dorsiflexion.
Gait analysis was performed 3 December 2002.
Chris
--
Some of the comments have mentioned different AFO's and I wanted to
mention
that he has had three different kinds of AFO's - none of which improved
his
gait.
We have been told that he will probably need an osteotomy at
about age 8
- and that that will help with the foot turning in.
What is the opinion on a spiral type brace? Will this help?
We are pretty sure that he has antibodies and Botox will no longer
work -
as it had little effect last time - so if he needs surgery - what surgery
is
recommended? All of his PT's are worried that his gait is getting
worse and
he is developing bad gait habits - and don't want to delay things so
that it
is hard to get rid of these bad gait habits later.
Although you should see him ride his bike - he is as fast as anyone
- and
you can't tell he has hemiplegia at all...
Robert Meier
Director of Education
rmeier@camphealthcare.com
cell phone 734-604-0448
Nice case study. I have a few questions regarding video and plots. On
your transverse plane hip rotation plots, does positive correlate with
hip external rotation and negative correlate with hip internal rotation?
I would be interested to see pelvic plots saggital, coronal and
transverse plane?
On visual analysis(video) the right hemipelvis is trailing or in
external rotation and the right hip appears to be in relative hip
internal rotation. Your hip rotation plot indicates a relatively
neutral hip on the right. Also your knee valgus varus plots indicate
varus alignment which does not exactly concur with video. When we saw a
large knee valgus or varus shift that was not confirmed with our video
in our lab, it was at times associated with slight misplacement of the
knee alignment device. We found that this could introduce error into the
transverse plane plots. What is your experience with this?
Does this
lab use a knee alignment device?
I ask all of this because clinically this patient appears to have more
hip internal rotation and possibly more hip anteversion on the right.
The patient almost bumps his knees and has to at times circumduct the
right to prevent bumping it into the left. Was a CT scan or MRI of the
hips done to confirm amount of femoral anteversion? This patient
appears to have type IV hemiplegia based on Dr. Gage's classification
and often these patients have excessive femoral anteversion on the more
involved side. Just wondering about the need for a femoral derotation
osteotomy on the right along with soft tissue procedures? Also do you
have any strength and selectivity grades for tibialis anterior? I am a
little curious about the need for a gastrocnemius lengthening on right.
I appreciate your work in maintaining this web site and look forward to
your reply.
Thanks,
Mary Beth Moses, MS, PT, PCS
Children's Health System
Birmingham, Alabama
marybethmoses@chsys.org
Mary Beth is likely right about some structural issues about
the hip, but if the appropriate muscles are weakened enough strength
to abductors may be
gained to avoid the osteotomy.
We use electrical stimulation after botox during gait training
to teach appropriate timing of muscle use. A treadmill is a very
useful place to do this. A
SWASH may well be helpful during gait training. None of
these will be helpful unless sufficient tone management is gained to achieve
appropriate
alignment. If Botox is not sufficient certainly muscle
releases will be necessary. The major concern of muscle release would
be weakness post-surgery
and casting. We often see good alignment post surgery with
poor function due to weakness.
Lynne Logan
Program Manager
Tone Management and Mobility Program
Upstate Medical University
750 E Adams St
Syracuse NY 13210
315-464-5820
I would classify the child as a level IV due to the hip involvement.
His
strong Trendelenburg type of gait with internal rotation was
very surprising
since he walks more like level I in the lower leg. I wonder if
the Botox
injection for the hamstrings has detrimentally weakened hip extension
and
thus he had to compensate for that loss with the excessive trunk and
hip
movement. He must have had some good muscle function in the past
to develop
the skills that he had, before the Botox and serial casting that weakened
him
further.
The child has some brace history with unknown flexibility at the joints.
We
do not know what were the cut lines of the braces and if dorsiflexion
and/or
toe extension were limited. Even when only toe extension is blocked,
the
child needs to abduct and or rotate the leg in order to get the body
over the
blocked joint. It is not possible to weight shift appropriately
onto the
blocked foot orthoses. Often the child uses the one brace as an outrigger.
I
would assume that the child did have some blockage of the digits on
all the
braces he used, as that is, unfortunately, very common especially for
toe
extension. It takes only one-quarter inch of plastic distal to
the
metatarsal heads to block a young child from getting digit extension
or to
move the body over the stable foot. Without that mobility the child
needs to
make undesirable compensations (Carmick J. Managing equinus in
children with
cerebral palsy: merits of hinged ankle-foot orthoses. Dev Med
Child Neurol.
1995;37:1006-1010.)
I feel that this child should have a period of strengthening needed
muscles
about the hip and ankle, and wear an orthosis that holds the foot in
subtalar
neutral posted as needed so that he can stand on the right foot correctly
with stability and swing the left leg forward. The brace should allow
digit
extension so he would not need to pivot on the toes in order to move
the body
over the stance leg. Muscle normally becomes stronger with
normal use.
Strengthening muscles is very difficult in children with cerebral palsy
unless electrical stimulation is used to the child's tolerance during
task-specific activities. In this case the task would be walking
with the
use of a remote switch to stimulate muscles at the timing that they
would
normally be contracting. In my experience I have seen that it
is even
possible to correct the internal rotation of gait over time with muscle
strengthening to the hip extensor muscles. If the child is prevented
from
strengthening needed muscles the derotational osteotomies will be necessary
but one wonders if the child will be interested in walking if it is
too
difficult due to weak muscles.
Regarding this child:
It is a case of Spastic hemiperesis where bipedal locomotion is no
problem due to one normal limb & usually in such children there
is
no disturbance of equilibrium thus he can walk though the gait is
altered.
I think that the proposed surgical plan is not right as it will
cause severe weekness of hip flexors due to ilipsoas tenotomy
which will cause altered gait as he will have dificulty in hip
flexion & heal strike.
Percutaneous tenotomy of hamstrings is not a procedure of choice
in CP as it will weeken the muscles on the medial aspect &
can
cause an extermal rotation deformity of the knee due to un-opposed
action of the long head of biceps which is a multiarticular
muscle.
Repeated injections of Botox do not help as the body develops
antitoxin. In my experience Botox is indicated only in mild
spasticity of one limb involvement.
My plan would be
Thank you for sending the case. Your web site is very impressive.
When I
watch the AP video, I see persistent internal rotation on the right
side
and, to my eye, the knee is internally rotating as well as the foot.
I did
not see a kinematics of the pelvis, but most of these children retract
the
pelvis on the hemiplegic side and protract it on the left. Your
clinical
examination did not indicate anteversion, nor did I see much evidence
on the
transverse plane hip rotation graphs, but nevertheless he is turning
in from
some where, so I suspect that he either has anteversion or internal
tibial
torsion (the former being more likely). I do not think he has
diplegia
because the lateral videos show a nice heel strike on the left side
and his
kinetics are normal at the left ankle. If he were diplegic, that
would not
be the case. Furthermore, he rides a two-wheel bicycle, which
is unusual
for a diplegic.
His hip flexors are not tight on clinical examination nor are
the right hip
kinetics particularly abnormal. Consequently, I would not have
much
enthusiasm for operating on the right hip flexor. Similarly,
I would be
fairly conservative with hamstring lengthening, as the length
of the
hamstrings is very dependent on the position of the pelvis. We
actually
have a print out that gives us true hamstring length compared to normal,
and
I depend a lot on that graph when I'm trying to decide on whether or
not to
lengthen the hamstrings. One clinical way to do this is to compare
hamstring tightness with a without hip flexion on the contralateral
side,
since by flexing the contralateral hip, you reduce pelvic lordosis.
If he
has a lot of hamstring tightness with the contralateral hip extended
and
very little with the contralateral hip flexed, you are probably dealing
with
"hamstring shift", rather than "hamstring contracture".
I certainly would
agree with the gastrocnemius recession. He has 15 degrees of
dorsiflexion in
stance on the right, so the soleus is not tight.
Finally, as you know, I'm very big on correcting "lever-arm dysfunction"
(long bone torsions and/or foot deformity) if present. Furthermore,
when we
correct anteversion we do it with an A-O hip spline and make the osteotomy
proximal to the lesser trochanter so that the osteotomy itself
has the
effect of unwinding the psoas, which in turn functionally lengthens
it.
Tibial torsion is easily corrected with just a tibial osteotomy
proximal to
the distal tibial epiphysis (it isn't necessary to cut the fibula)
using a
straight four-hole A-O plate and short leg cast for fixation.
Consequently,
if he does prove to have anteversion and is walking with pelvic retraction
and/or tibial torsion on the hemiplegic side, I would certainly consider
intertrochanteric derotational femoral osteotomy with the A-O
hip spline
and/or tibial derotation to correct it. Post-operative casting
is not
necessary for femoral osteotomy and we only keep them non-weightbearing
for
three weeks post surgery and with crutches or a walker for three weeks
thereafter. With tibial osteotomy we use a short leg cast plus
the plate
and, again, allow weight bearing three weeks post surgery.
Finally, I doubt that you would get too much benefit from Botox.
However,
an AFO nightsplint overwrapped with a knee immobilizer on the
right to keep
the right gastrocnemius on tension during the hours of sleep will go
a long
way towards preventing the redevelopment of a gastrocnemius contracture
post-surgery.
I hope this is helpful.
With warm regards,
Jim
James R Gage" <gagex001@maroon.tc.umn.edu>
1. He seems happy and very active as he is - why operate at all?
2. There is an overuse of the non-affected leg (well, of course).
When he puts weight on his affected leg his hip drops and the non-affected
leg becomes "too long" which makes him compensate with an exaggerated
kneeflexion in his non-affected leg to make it possible to move
it forward. That is the easy and automatic solution to this problem
but it helps his affected leg to stay weak.. IF you put a stiff orthosis
on
his non-affected leg that prevents kneeflexion you might find that
he starts using his hip abductors on the affected side when he walks. It
may take a few minutes, but it will probably happen. It happens to
my adult stroke patients.
If it happens - would somebody please check, via for example an EMG,
if this intervention increases muscular activity in the affected leg to
the extent that it would be a meaningful and effecient strengthening
exercise for both children and adults with light to moderate
hemiplegia?
I need an excuse to ask my stroke patients to walk around with a stiff
brace on their good leg for hours! And a stiff knee on the
non-affected leg is a perfect way to force the patient to stand up
from sitting on his affected leg - each time. The same goes of course for
sitting down.
Please excuse my butting in, and a bit late for this paricular case
at that, but I so much would like some factual knowledge about this
particular exercise!
Yours sincerely,
Bodil Carle Smedley,PT
Sweden
Surgery went well - had all the surgeons that I wanted and first class
treatment from everyone. In the end he had his achilles tendon
released
percutaneously, and his medial and lateral hamstrings released.
In the
medial they released both the facia (fractional lengthening of
Semimembranosus) and a z lengthening of the semitendinous.
In the lateral,
just the facia was released, and to a lesser extent so that the lateral
and
medial hamstring are now equal tightness.
I have to tell you that I shared your web site with the children's
hemiplegia and stroke association list server (www.chasa.org)
- and told them
that it is a great site for learning about gait analysis (I hope you don't
mind....). There are 700 on the list - who followed my surgery questions,
second guessings, etc - so the emails from parents were probably from the
list. There are quite a few kids in similar situation as him.
Another funny side note - one of his fellow patients was taking a class
in
understanding and evaluating gait analysis - and they used his gait
analysis (from your web site) as one of the choices for the test!
He is doing great with his stretches and exercises - he has been so
cooperative - a real trouper - he understands that he needs to stretch
and
exersize for the operation to work so he will be able to run faster, etc.
He can't wait for the huge cast to come off!
Thank you for you concern and help through this ordeal - I am so happy
the
operation is behind me....
All his PTs have been impressed with his improvement. He is playing
soccer
in a club here, and floor hockey with his sibblings. His walking
speed has
improved, but is still slower than normal.
All in all, we are happy with the results, and I am grateful to your web
site for giving me a great deal of information going into the operation.