Upper Limb Problems in Children with Cerebral Palsy
The decision regarding the management of upper limb spasticity in cerebral palsy is multifactorial. Intervention ranges from therapy and splinting through to multilevel surgery utilising tendon transfers and arthrodesis procedures. This article presents t
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Jonathan A. Baxter and Matthew F. Nixon
Abstract
The decision regarding the management of upper limb spasticity in cerebral palsy is multifactorial. Intervention ranges from therapy and splinting through to multilevel surgery utilising tendon transfers and arthrodesis procedures. This article presents the current evidence behind treatment choice. A literature search has been conducted on each topic with a subsequent summary of the evidence. The use of Botulinum toxin type A in cerebral palsy has been the focus of several randomised trials. There exists good evidence of efficacy when used in conjunction with therapy however currently there is no clear consensus on optimal dose, frequency and post injection therapy regime. There exists good evidence that the surgical treatment of thumb in palm deformity has beneficial outcomes. The efficacy of surgical intervention for other upper limb deformities is less well understood. Each patient should be thoroughly assessed and surgical plans tailored to their specific needs. Surgical intervention should be delayed until the appropriate age to avoid recurrence with growth and the child should have voluntary motor control of the limb and reasonable cognition in order to comply with post-operative therapy. Keywords
Upper limb • cerebral palsy • Botox • BoNT-A • Botulinum • Tendon transfer
Introduction Cerebral palsy (CP) is a non-progressive upper motor neuron disease due to injury to the immature brain. It is the commonest cause of neurological disability in children and a common condition seen by the paediatric orthopaedic surgeon. Upper limb involvement, particularly in those patients with spastic hemiplegic CP, can have a significant impact on function. Generally, flexors exhibit increased tone over extensors. Pectoralis major, biceps brachii, forearm flexors and pronator teres are often hypertonic leading to shoulder flexion, adduction and internal rotation with elbow flexion, forearm pronation, wrist flexion with ulnar deviation. In the hand, finger and thumb flexion is seen along with thumb adduction giving the J.A. Baxter • M.F. Nixon (*) Royal Manchester Children’s Hospital, Manchester, UK e-mail: [email protected]; [email protected]
classic thumb-in-palm deformity. MCPJ dislocations and swan neck deformities can significantly affect opposition and therefore grasp. Patient factors such as cognitive capacity and limb sensation will significantly affect the management and therefore intervention must be tailored to each individual. Non-invasive management strategies include physiotherapy and occupational therapy aimed at maximising function. Newer modalities are subject to extensive investigation and include bimanual therapy, constraint-induced movement therapy, action observation therapy, virtual reality and robotassisted therapy. Functional splinting aims to improve motor function by supporting joints in the optimal position during use. There is however a paucity of evidence to support their efficacy. Non-functional splinting provides prolonged stretch w
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