Stimați colegi,

Vă invităm să participați la Cel de-al XXIV-lea Congres SNPCAR şi a 46-a Conferinţă Naţională de Neurologie-Psihiatrie a Copilului şi Adolescentului şi Profesiuni Asociate din România cu participare internaţională

25-28 septembrie 2024 – CRAIOVA, Hotel Ramada

Pentru a vă înscrie la congres, vă rugăm să apăsați aici.

Vă așteptăm cu drag!

Asist. Univ. Dr. Cojocaru Adriana – Președinte SNPCAR

Informații şi înregistrări: vezi primul anunț 


OPPORTUNITY OF SURGERY TREATMENT OF SPASTICITY IN CHILDREN WITH CEREBRAL PALSY

Autor: Liliana Padure
Distribuie pe:

ABSTRACT: 

Scope. Background. Walking initiative corresponds to a “fall” due to posture inhibition. First, the centre-of mass-is-moving on one leg, allowing the other leg to leave the fl oor. Th e centre-of-mass is in anterior position and the body switches the support onto the advanced leg. Muscular contractions are permanently redistributed on the postural muscles, which re-establish the balance at any time. Locomotion is possible: just because the postural activity and walking coalesce on the motoneurons that are centrally coordinated in their interaction; when alpha activity is suffi cient; due to the inter-dependence between cortex and sub-cortex; under the strong infl uence of gravity.
All these mechanisms, which suff er disorders in spasticity through hypertonia on the extensors of the lower limbs (anti-gravitational muscles), generate walking diffi culties and joints modifi cations in cerebral palsy (CP) aff ected children.
Material & Methods. By this paper, we proposed to monitor the spastic hip joint modifi cations in the child who acquired gait, because surgery interventions on this joint in early childhood, when the chronologic and motor age are inappropriate for this level, block the correct continuity of the rehabilitation program.
Our follow up lot with CP aff ected children comprises 52 inpatients, with acquired gait, between February 2009 and May 2010.
Results. Th e observed modifi cations had showed that, at walking age, the spastic patient can have a normal hip or the following (unilateral / bilateral) defi ciencies: Hip abarticulation – 1, Coxa magna breva – 1, Surgery treated abarticulation – 2, Bilateral hip dysplasia – 4, Unilateral coxa recta – 7, Bilateral coxa recta – 4, Unilateral coxa valga – 10, Bilateral coxa valga – 12, Normal hip – 13.
One of the patients presented bilateral coxa valga in association with sub-contortion.
Discussions & Conclusions. Insuffi cient and too concise examination by the surgeon of a complex pathology of central origin – which demands consistent and direct observation – generates errors, worsening the anterior condition of the patient. The child must be assessed by means of clinical methods, video recordings, and complex gait analysis, in order to decide on the most appropriate moment for surgery (when cerebral maturation is complete and the brain is ready for the anaesthetic shock) and to take the best decision.

 


 

At the onset of autonomous walking, the normal child is not able to adjust to postural disorders caused by the unfriendly ground or by visible obstacles. Usually, the 2 year-old child anticipates the problems generated by an obstacle. Sutherland considers that only in 6-7 year-old children, walking reveals the kinematic and kinetic electro-myographic characteristics found in adults.

Around 1 year of age, before his first independent steps, the child bears his body bent to the fore; the lower limbs (LL) in triple flexion, the arms in abduction and variable flexion, and the elbows flexed. Alternating movements of the upper (UL) and lower (LL) limbs are absent. The fore foot establishes the initial contact with the ground, the lower part of the leg being in plantar fl exion. Th e hips are rotated externally. The child props himself on heels for a short moment, while being in anterior unbalance, as if he would attempt to catch at his own centre-of-mass [1].

During the wavering phase, the fl exion of the hip, the anteversion of the pelvic girdle and its left – right rotation are important. Around 1 ½ years of age, the plantar fl exion decreases and, when the child stops wavering, his foot assumes the position to make the initial contact with the ground with his heel: he starts to “attack” with his heel. Around the age of two years and a half, the hip goes in internal rotation and in adduction during the unipodal support. The pelvic girdle is less bent forward and, consequently, its fl exion is reduced when the support ceases. The length and speed of the steps are suffi cient to provoke an alternative rotation of the girdles, inducing the swinging of the UL in about 75% of infants. For the rest of 25%, the alternating rotation and UL swinging will be acquired around 3 ½ years of age [1].

If posture and locomotion are separate “systems”, they converge simultaneously on motoneurons, being coordinated by the central interactions necessary to bipedalism.

The coordination between posture and locomotion appears since the initiation of walking.

The locomotion balance is more complex because it associates more divergent obstacles: the dynamic control of posture stability while the body is pushed forwards with variable uni- or bipodal support, according to the phase in the locomotion cycle. The locomotion begins when the cortical activity has reached an appropriate level and it depends both on cortical activity and on the sub-cortical one, under the strong infl uence of gravity. Walking initiation corresponds to a real fall due to the inhibition of posture. At first, the centre-of-mass moves laterally on one foot, which enables the other foot to go up. Then, the centre-of-mass moves again, allowing the body to prop on the anterior foot. Finally, the contraction is redistributed to the postural muscles, which re-establish the balance. I have presented here some concise data on the sequence of elements that contribute to the acquisition of gait because the specialist is obliged to take into consideration the subtlety of these phases in the child with CP.

All the Central Nervous System (CNS) lesions determine a reorganization of the partially de-nerved subadjacent structures where architectural alterations of the Peripheral Nervous System appear, such as collateral conglomerations of the intact fi bres, or the emergence of new motor end plates and neural synapses.

The reorganization of the spinal segmental refl exes that get involved in the somatic motor function explains the emergence of spasticity. The myotatic and reverse myotatic refl exes are disinhibited and there is a loss in muscle tone and an alteration of the balance between agonist and antagonist muscles due to the decrease in reciprocal inhibition. Spasticity may become excessive, disturbing the posture or the residual motor function. Besides the defi cit, in diff erent degrees, of voluntary muscular strength, (paresis, paralysis), spasticity combines with the motor function defi ciency because they have close neurologic pathways [2].

Spasticity predominates on the postural muscles, on LL extensor muscles (UL fl exions). Here are some of its characteristics:

1. It is dependent on lengthening velocity. In spasticity, the refl ex activity weakens, while the muscle is in repose, contrary to other causes of hypotonia.

2. Spasticity weakens at prolonged stretching (the “clasp knife” effect). While the amplitude of the stretch increases, the refl ex contraction decreases on the extensor muscle, a phenomenon due to: Golgi receptors, activation of secondary fusal aff erents, inhibiting eff ect of the aff erents of the fl exion refl ex (It has recently been concluded that the fl exion refl ex is absent in the UL).

3. Fatigue –the refl ex activity decreases while muscle stretching is repeated at a time interval incompatible with the initiation of the presynaptic inhibition – this is interpreted as a progressive exhaustion of myotatic hyperexcitability, connected with the synaptic depletion in the neuromediator.

4. Spasticity varies in time with the same child, but also according to certain parameters like: temperature, the environment, which is considered unfriendly by the child, vigilance state, position, cutaneous stimulation, vegetative aff erents, constipation.

It is regrettable that many clinicians do not know or ignore these physiopathological mechanisms, as well as the diff erent possibilities of therapeutic approach of CP and they look upon the lower limbs of motor and neurologically impaired children – from a strictly anatomical point of view.

We, who care for these children and consider that the lesions in CP are non-evolutive, are conscious that, unfortunately, we face a progressive pathology on its developing phase when we strive that our little patients should not collapse in “triple fl exion”. Th rough direct monitoring, in a multidisciplinary team, we must analyse the problem of the motor function and of clinic in children with CP:

— The primary expression of the neuronal lesions (evidenced on the Computerised Tomography and cranial Magnetic Resonance Imagery) and perturbations in muscle tone, balance and segment muscle strength.

— The clinic consequences following growth that takes place faster in bones, then the primary problems generated by muscular retractions and bone deformities.

— The tertiary problems represented by gait compensatory postural mechanisms.

In assessing the child with PC, one must always take into consideration:

1. The functional level of the neuropsychomotor development.

2. The rather fast physical development, especially between 1 and 7 years of age, when the child’s waist doubles.

3. The acquisition of “mature” gait (autonomous, confi dent, as gracious as possible).

After these considerations, the therapeutic protocol should be coherent, in agreement with the ensemble of the above mentioned elements. The intervention against hypotonia should be precocious, in order to prevent the emergence of secondary disorders (retractions, vicious postures, bone deformities).

At the level of LL, we are attentive to each patient’s particular details in connection to an inactive or less active muscle, when it is in a voluntary contraction, but which is excessively active in a synergic movement. For example, tibialis anterior may be inactive in the analytical dorsal flexion of the leg, but very active in the hip flexion, as well as having a single activity phase during normal walking, while being permanently active during more accelerated walking.

In paraplegics, with apparently symmetrical motor defi cit, the schemes right – left are often slightly diff erent, with a more accentuated hypertonia on a hemibody.

The hip adductors are unjustly considered the only responsible for the adduction of the thighs. The attitude in adduction is a kinematic consequence of combining flexion with the internal rotation of the hip.

Attention should be paid to internal rectus muscle, which, in contrast to the internal hamstrings, may participate in knee flexion and adduction – internal rotation of the hip. Taking into consideration the issues presented above, intelligent surgery avoids the adductors and the intervention with botulinum toxin is no longer performed on the adductors, but on the internal rectus.

When the internal rotation is combined with the flexion of the hip, the legs in deviated laterally. During the support flexion on the laterally deviated leg, the lateral swing of the shoulders on the support side does not mean that the muscles of lateral hip stabilization are weak, but that it is a necessary adjustment in order to bring the centre-of-mass to the nearest possible point from the support foot.

The dynamic equine foot (without the retraction of the triceps surae components) is the consequence of an activity shortened by the muscles that lift the leg, followed by a premature activity of the gastrocnemius (the most often) and of the soleus)

The propulsion phase is concealed because the triceps is less active. Our insistence on the intimacy of the muscular activity reveals the necessity to adapt the treatment to each child’s peculiarities. We mean by this, the kinetic sequences and the electrical, thermal, or biochemical (with the botulinum toxin) interventions. More than that, it is necessary to make a detailed assessment with a view to correct surgery decisions concerning the spastic child, be they tendon transpositions or muscle lengthening. In order to reduce hypertonia, the therapy should be:

— selective, because more hypertone muscles disturb the child’s motor function.

— reversible, in order not to damage a muscle, a group of muscles and, implicitly, the bone segments that constitute a joint where growth cartilage is present.

— secure, correct doses of electric stimulation, wave shocks, botulinum toxin.

For our team at the “Dr. Nicolae Robănescu” National Child Neurorehabilitation Centre, the botulinum toxin, by its reversible and durable (between 3 and 6 months) action focused locally, and by its eff ect of chemical neuroectomy, is considered to be the most requested treatment for the plurifocal spasticity, especially in a small child up to 5 – 6 years of age.

Our practice involves:

— a clinic multidimensional rigorous assessment (Asworth Scale and video analysis)

— multi-site injections within the frame of a judicious sagittal realignment

— sustained kinesiotherapy, adapted and adapted to the patient’s needs, whose functional benefi ts are further preserved in specifi c orthoses.

A short memento- Type A Botulinum toxin acts at the level of neuromuscular junction where it inhibits the secretion of acetylcholine, thus generating local hypotonia; the muscle recuperates its force at a distance of 8 to 24 weeks, recuperating morphologically in totality. Today, it is well known the fact that the obstruction of the neuromuscular junction is not irreversible, that a new neuromuscular junction appears in support of the obstructed one, and that this new junction declines when the formerly obstructed one becomes functional again. The therapeutic intervention of selecting the muscles to be injected is done collectively, within the multidisciplinary team (physician, kinesiologist, ergotherapist, and psychologist) in good knowledge of the biomechanics of hip, knee and leg (and of gait, too, when it is acquired). The team also analyses the child in totality: his trunk in relation to the pelvic girdle, hip, knee and leg. We target only the muscles really involved by the therapeutic aims, according to the following principles:

— the necessity of maintaining continuity in the action of neurupsychomotor development, in order to ameliorate the kinesthetic image, the motor scheme of the child with CP.

— obtaining precise functional benefits, expected by a clinically logic common sense concerning the evolution of the child (we do not have divine powers to decide the form and angle of the joint segments at a certain age!).

— the design of a multi-site strategy for the injections with the aim of obtaining the expected functional gain by judicious dosage on zones placed in a kinematic chain so as to give the muscle the adequate quantity of toxin (avoiding to waste too many small doses, in many places – focus on too many muscles).

Our major objectives in the perspective of the CP treatment are:

I. Realignment in saggital plane, in order to ameliorate the stability on the ground (support on the whole sole, by bringing down the heel) – in cases of distally predominant motor deficit.

The objective to stabilize the heel on the ground and to allow the child to rest on the whole sole has the role of limiting the superadjacent (compensations, of off ering a proximal motor function and a reduction of knee, hip deformities so as to escape the spastic patient’s logic of collapse in flexion (hip, knee). It is a relatively often-fulfi lled objective. The soleus muscle is weak, the heel descent on the ground and the stabilization on the sole reduce the child’s frequent falls. The early, that is, on time, use of a leg orthosis and suitable kinesiotherapy make this objective a success from a short time perspective. On medium and long time perspective, the knee and hip are more and more diffi cult to ameliorate (hypertonia). The uncomfortable orthoses make this objective hard to attain. Applied after 9 months, if the sitting posture has not been acquired in order to prevent vertebral rotation, the orthopedic brace has the role to sustain the frontal balance.

II. Frontal balance – may be achieved only by preventing rotation disorders, trying to preserve the symmetrical support by means of injecting botulinum toxin in the internal rectus and tibialis posterior and by preserving the functional gain by means of correctly built orthoses. It is a continuous struggle of the physician, of the kinesiotherapist and of the mother to limit, as much as possible, the structuring of the rotation disorders, which are aggravating factors for the child’s functional level.

The amelioration will be progressive, implemented by the multidisciplinary team that has been briefed on the previous outcome of the treatment applied to the spastic child and it will be notable by far through:

— the child’s functional stability in all his acquisitions

— the diminution of surgical interventions on tendons in the child until 5 – 6 years of age

— a limitation of surgery at bone level.

We exemplify with the observation of a lot made up of 52 children with CP who acquired gait. We chose to assess only one joint, the hip, because in our experience we have lived the drama of some children who suff ered hasty surgery at this level. For all the 52 children who walk we have:

— their video recordings before and after injections with botulinic toxin

— records of clinical assessments.

Results: We found modifi cations, which showed that, at age of gait acquisition, the spastic patient can have the hip unmodifi ed or with the following defi ciencies present unilaterally or bilaterally (even 2 types of modifi cations):

— Hip abarticulation – 1

— Coxa magna breva – 1

— Surgery treated abarticulation – 2

— Bilateral hip dysplasia – 4

— Unilateral coxa recta – 7

— Bilateral coxa recta – 4

— Unilateral coxa valga – 10

— Bilateral coxa valga – 12

— Normal hip – 13

Certain patients presented in association diff erent anomalies on both hips.

Conclusions: The insufficient, too concise examination by the surgeon of a complex neuromuscular pathology with central origin that implies continuous and meticulous assessment generates errors, which worsen the initial condition of the spastic child.

Clinical methods, video recordings, and complex analyses of gait should document the child’s assessment, in order to enable the specialists to take adequate decisions and to make sure that surgery is performed only when cerebral maturation is attained, the brain is able to resist to the shock of total anaesthesia and THE MOTOR POTENTIAL OF THE PATIENT REQUIRES SURGERY.

Our team (at National Child Neurorehabilitation Centre “Dr. Nicolae Robănescu”, Bucharest) has been working together for three years, since we have in our staff positions for physicians at all specialties necessary for PLURIDISCIPLINARITY (rehabilitation, neu-rology, orthopaedics, paediatrics, intensive care).

BIBLIOGRAFIE/ BIBLIOGRAPHY

1. Viel, E., La marche humaine, Elsevier Massons, 2008.

2. Padure, L., Managementul spasticitatii la copil, Ed. Universitară, 2007.

3. Onose, G., Padure, L., Our experience concerning the use of extracorcoporeal shockwave therapy for the spasticity management , in children with cerebral palsy- preliminary results.