When a normal individual rises from sitting to standing, his/her base changes from the bottom/thighs/feet to just the feet. In order to keep from falling, he/she must bring the feet back and lean the trunk well forward (‘Nose over toes’) prior to rising. The cerebral palsied child often either fails to organize his/her feet and trunk correctly before attempting to rise and therefore pushes himself/herself over backward, or, in attempting to get his/her ‘Nose over his/her toes’, the child is unable to anchor his/her bottom and slides forward off the chair in a heap. Most children with cerebral palsy, if given assistance in organizing their bodies and given balance support (usually at the upper arms or shoulders), have some ability which can be a great help in the day–to–day management of the less able child, especially as he/she grows older and heavier, and should therefore be encouraged whenever practical.
Again, the cerebral palsied child’s common difficulty is bringing and maintaining his/her weight forward while he/she steps, and therefore the helper must assist the child to do this. It is probably best if the helper stands in front of the child facing him/her and supports him/her either at the hands (arm gaiters might be helpful), the upper arms, or shoulders depending on the child’s level of ability. The child should be encouraged to lean forward, not to pull. With the helper at the front, the child has less temptation to lean backward for support. For some small or heavy children it is often easier on the helper’s back if he stands behind the child. The important point is that the child is positioned so that his/her weight falls through or in front of his/her feet and not behind them. With a hemiplegic child, support should be given to the affected arm/hand in an attempt to increase the child’s awareness of it and to prevent the affected side of the body from lagging behind. In more able diplegic children, support at the hips only will reduce the child’s abnormal tendency to use his/her upper trunk for shifting his/her weight.
Surgery in Cerebral Palsy
Orthopedic Surgery in Cerebral Palsy
Orthopedic surgery in cerebral palsy has no effect on the central neurological problem, and can only affect the mechanics of movement dictated by it. It should not be viewed as an alternative to physiotherapy or as a final treatment after physiotherapy has failed, but should form part of the overall management of the child and be carried out when appropriate. General aims of surgery in cerebral palsy are to improve function, alleviate pain, improve cosmesis and/or ease of care and dressing. Any surgical procedure is disruptive and must not be undertaken lightly. There should be strong indications that a significant benefit will be achieved. The intermittent use of corrective plasters on children’s feet can often be very effective in maintaining the range of soft tissues, as well as providing a good base of support for improved sitting and standing activities. They can also delay the need for surgery, and give some indication as to the likely effectiveness of a proposed surgical procedure. For similar reasons long–leg cylinders applied with the knee in full extension can be useful.
The physiotherapist should provide input regarding pros and cons of surgery. Pre–operatively he/she should assess range of motion, both passively and in functional positions, strength of relevant muscle groups, and functional ability. Pre and post–operative management must be well planned and the parents must be prepared. Consideration must be given to positioning of the child postoperatively while in plaster, both while sleeping and for daily activities. If special splints, boots, orthoses, or seating will be needed post–operatively, they should be ordered and obtained at the appropriate time. There are generally two difficult periods of time post–operatively: immediately post–surgery when the child may be in pain and discomfort, and following removal of immobilization casts, when the limbs often spasm painfully. Mobilisation of the joints must be carried out gradually and carefully. Treatment will also aim to improve postural ability, maintain joint range, strengthen appropriate muscle groups, and support unstable joints.
Sitting is a position in which many children will spend a good deal of the time and appropriate support is important. Ideally, a number of seats should be available for one child. Seating should not be viewed as something separate from treatment, but should reinforce and reflect the child’s ability. A seat should be changed not only when the child physically outgrows it, but also when his/her level of ability changes. The therapist must, therefore, be involved in prescribing the type and amount of support required. As an example, a very disorganized and/or deformed child should have a seat which will intimately support him/her, such as a moulded seat or even a hammock seat. Modular or ply–and–padding seating systems are usually appropriate for more able children who are able to be easily placed in sitting but require full support in order to function effectively. In assessing seating needs, the relative height of floors, seats and working surfaces are important.
Various devices provide support in standing, they either support in an upright, vertical position, or are inclined forward or backward to varying degrees.
Prone crawlers and sit–on trucks
Some prone crawlers support only the child’s trunk in prone and leave the head, arms and legs free for weight–bearing, propulsion and play. They are often more effective if the support can be angled down at the back to prevent the child from falling forward onto his/her nose and to aid purchase between the knees and the floor. Other prone crawlers leave only the head and arms free and support the rest of the body in one horizontal plane with the legs held in abduction. Many of the sit–on toys on wheels which are propelled by the feet are useful for some cerebral palsied children.
Although the position in a buggy is not ideal, it is usually safe and easy for the parent to use. For children who extend and have difficulty anchoring their bottoms, a Cheyne insert which introduces additional hip flexion is often effective. With older and larger children, wheelchairs with appropriate support can be posturally effective and easier to push over rough ground than buggies. However, the hammock effect of the seat can aggravate problems of asymmetry and instability and should be removed by the use of a shaped cushion or a cushion on top of a flat baseboard. For children requiring total, intimate support, a moulded seat or a shapeable matrix seat can be made to fit into a wheelchair.
It is becoming evident that provision of powered mobility early on has dramatic benefits in terms of motivation, and socialization. With new technology, a variety of switches is being developed to allow access to powered chairs. Before switches are investigated for a particular child, it is essential that correct positioning and support are first provided.