Management of the Knee Problems in Spastic Cerebral Palsy

Effect of the Dynamic Orthotic Garment on Postural Control, and Endurance in Children with Spastic Diplegic Cerebral Palsy: A Randomized Controlled Trial

Purpose

To investigate the effect of dynamic orthotic garments (Thera togs) on foot pressure distribution, postural control, and endurance in children with spastic diplegic CP.

Patients and Methods

This is a single-blind randomized controlled clinical trial involving 34 (8-10 years) with spastic diplegic CP. The control group received conventional physical therapy (CPT), whereas the study group received CPT in addition to wearing TheraTogs. We recorded foot pressure distribution, trunk control measurement scale, trunk position sense, Pediatric Berg Balance Scale (PBS), and six-minute walking distance (6MWD).

Results

Both groups showed improvement. The study group had significant improvement in foot pressure distribution (p-value 0.003, 0.001, <0.001 for forefoot, midfoot, and rearfoot mean pressures respectively, and 0.005, <0.001, and 0.005 for forefoot, midfoot, and rearfoot peak pressures respectively), Pediatric balance scale, The trunk control measurement scale, and Trunk position sense (p-value < 0.001) and six-minute walking distance (p-value 0.029). Our data suggest that adding TheraTogs to conventional physiotherapy improves foot pressure, postural control, and endurance in children with spastic diplegic cerebral palsy.

Conclusion

Both TheraTogs and conventional physical therapy corrected foot pressure distribution, trunk control, improved balance, and increased 6MWD in children with spastic diplegic CP but the improvement was more significant in TheraTogs group.

Clinical Trial Registration

NCT05271149.

Hyper-selective neurectomy for knee flexion spasticity: anatomic bases and surgical technique

PURPOSE

Spasticity may result from damage to neurons of the corticospinal tracts and loss of inhibitory supraspinal influences following head trauma. Traditionally, peripheral nerve surgeries for spasticity in lower limbs were limited to selective neurectomies. Here we used hyper-selective neurectomy (HSN) to release hamstring spasticity at the muscle spindle level.

METHODS

This study describes anatomic bases and surgical technique of HSN and its results in treating spastic knee flexion in a 23-year-old male who developed severe spasticity following severe brain injury. The spasticity was prominent in the left knee. The surgical technique including resection of over one centimeter of three-quarters of the overstimulated nerve rami at the entry point of the nerve into the muscle is shown in the video 1.

RESULTS

After the surgery Visual Analog Scale and Modified Ashworth Score reduced from 7 to 3 and 4 to 1, respectively. Popliteal angle improved from 118° to 73° at the second months after the surgery.

CONCLUSION

Hyper-selective neurectomy is a safe and reliable therapeutic option for the treatment of permanent trauma induced spasticity in the lower limb.

Incorporation of Torsion Springs in a Knee Exoskeleton for Stance Phase Correction of Crouch Gait

Crouch gait is a motor complication that is commonly associated with cerebral palsy, spastic diplegia, stroke, and motor-neurological pathologies, broadly defined as knee flexion in excess of 20° in the gait cycle. Uncorrected crouch gait results in fatigue, joint degradation, and loss of ambulation. Torsion springs have been used in cycling to store energy in the knee flexion to reduce fatigue in the quadriceps during knee extension. SolidWorks was used to design a passive exoskeleton for the knee, incorporating torsion springs of stiffnesses 20,000 N/mm and 30,000 N/mm at the knee joint, to correct four different crouch gaits. OpenSim was used to gather data from the moments produced, and knee angles from each crouch gait and the normal gait. Motion analysis of the exoskeleton was simulated using knee angles for each crouch gait and compared with the moments produced with the normal gait moments in the stance phase of the gait cycle. All crouch gait moments were significantly reduced, and the correction of peak crouch moments was achieved, corresponding to the normal gait cycle during the stance phase. These results offer significant potential for nonsurgical and less invasive options for wearable exoskeletons in crouch gait correction.

Functional and Clinical Outcomes of Combined Simultaneous Bilateral Anterior Distal Femoral Plate Hemiepiphysiodesis and Hamstrings Release in Management of Knee Flexion Contractures in Children With Neuromuscular Disorders

BACKGROUND

We examined the clinical and functional outcomes of the simultaneous anterior distal femoral 8-plate hemiepiphysiodesis (ADF8PH) and hamstring release, for fixed knee flexion deformity in children with neuromuscular disease. To our knowledge, no published evidence is available that reports the outcomes of this combined techniques.

METHODS

Electronic medical records were retrospectively reviewed for 19 consecutive children who underwent bilateral ADF8PH and concomitant hamstrings release in our institution from 2012 to 2019. Relevant demographics, Gross Motor Functional Classification Score and preoperative and postoperative knee flexion contractures and popliteal angles were documented.

RESULTS

The average age at the time of operation was 12±2.1 years. There were 15 males and 4 females. Diagnoses included cerebral palsy (n=16), Cornelia de Lange syndrome (n=1), hereditary spastic paraplegia type 56 (n=1) and fructose-1,6 bisphosphonate aldose B deficiency (n=1). Mean length of follow-up was 3.8 years (range: 1.5 to 7 y). Mean fixed knee flexion deformity improved from 28.9 to 13.4 degrees (P<0.001) at an average correction rate of 0.94 degrees per month. Mean popliteal angle improved from 81.8 to 44.4 degrees (P<0.001) in the early postoperative phase and to 51.8 degrees (P<0.001) in latest clinic review. Mean time to correction was 18.9 months. The agreed treatment goals of maintaining or promoting the use of standing frame and spinal/postural symmetry was attained in 18 patients (94.7%). Postoperative knee pain was reported in 2 cases (10.5%). We report 2 complications; 1 case of neurapraxia and 1 case of sepsis because of respiratory infection.

CONCLUSION

Simultaneous bilateral ADF8PH with hamstrings release is a promising effective technique for correction of knee flexion contractures in skeletally immature individuals with neuromuscular disabilities. Our findings demonstrate improvement in clinical outcomes and maintaining functional outcomes, indicating the validity of this approach as a satisfactory, less invasive alternative in the management of this deformity.

LEVEL OF EVIDENCE

Level IV-therapeutic study.

Comparison of Surgical Outcomes for Distal Rectus Femoris Transfer and Resection Surgeries in Children With Cerebral Palsy With Stiff Knee Gait

BACKGROUND

Children with cerebral palsy (CP) often present with a stiff knee gait pattern because of rectus femoris (RF) spasticity and/or contracture. Rectus femoris transfers (RFTs) and resections are surgical procedures aimed at reducing muscle stiffness, thereby improving knee flexion during the swing phase of gait. Previous research has consistently demonstrated objective benefits of rectus transfer using instrumented gait analysis (IGA). Rectus femoris resection (RFR), a relatively simpler procedure, shows similar improvement in knee range of motion during gait. The objective of this study was to compare surgical outcomes between rectus transfers and resections using 3-dimensional IGA.

METHODS

Children with spastic CP who had RFTs or resections were retrospectively matched by walking speed and preoperative knee kinematics from 3-dimensional IGA (peak and timing of peak knee flexion in swing). Secondary outcomes included knee range of motion and maximum knee extension during gait.

RESULTS

Twenty-eight children were included in both the transfer group [age 9.4±2 y; Gross Motor Function Classification System (GMFCS) I (3 children), II (15 children), III (8 children), and IV (2 children)] and the resection group [age 10.6±2.5 y; GMFCS I (1 child), II (14 children), and III (13 children)]. Both surgical groups showed statistically significant short-term postsurgical improvements in peak knee flexion during swing (P<0.001 for the transfer group and P=0.003 for the resection group) and Duncan-Ely test (P=0.004 for the transfer group and P<0.001 for the resection group). Further analysis by GMFCS level showed children at GMFCS levels III/IV had a greater tendency to crouch after RFT when compared with children at GMFCS levels I/II. This tendency was not observed in the RFR group.

CONCLUSIONS

Both transfer and resection surgeries significantly improved gait kinematics short-term outcomes in children with spastic CP who present with stiff knee gait pattern. Further studies are required to compare long-term outcomes of both surgeries.

LEVEL OF EVIDENCE

Level III-retrospective matched-cohort study.

Quadriceps muscle strength in Duchenne muscular dystrophy and effect of corticosteroid treatment

Objectives

In Duchenne muscular dystrophy, quadriceps weakness is recognized as a key factor in gait deterioration. The objective of this work was three-fold: first, to document the strength of the quadriceps in corticosteroid-naïve DMD boys; second, to measure the effect of corticosteroids on quadriceps strength; and third, to evaluate the correlation between baseline quadriceps strength and the age when starting corticosteroids with the loss of ambulation.

Methods

Quadriceps muscle strength using hand-held dynamometry was measured in 12 ambulant DMD boys who had never taken corticosteroids and during corticosteroid treatment until the loss of ambulation.

Results

Baseline quadriceps muscle strength at 6 years of age was 28% that of normal children of the same age; it decreased to 15% at 8 years and to 6% at 10 years. The increase in quadriceps muscle strength obtained after 1 year of corticosteroid treatment had a strong direct correlation with the baseline strength (R = 0.96). With corticosteroid treatment, the age of ambulation loss showed a very strong direct relationship (R = 0.92) with baseline quadriceps muscle strength but only a very weak inverse relationship (R = -0.73) with the age of starting treatment. Age of loss of ambulation was 10.3 ± 0.5 vs 19.1 ± 4.7 (P < 0.05) in children with baseline quadriceps muscle strength less than or greater than 40 N, respectively.

Conclusions

Corticosteroid-naïve DMD boys have a quantifiable severe progressive quadriceps weakness. This long-term study, for the first time, shows that both of the positive effects obtained with CS treatment, i.e. increasing quadriceps strength and delaying the loss of ambulation, have a strong and direct correlation with baseline quadriceps muscle strength. As such, hand-held dynamometry may be a useful tool in the routine physical examination and during clinical trial assessment.