The missed stages of the journey as possible treatments for the functional recovery of the lower limbs after an early injury to the central nervous system?

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What possible treatments for functional recovery of the lower limbs after an early injury to the central nervous system?

Curated by Dr. Luigi Piccinini-Medical surgeon

Specialist in physical medicine and rehabilitation

At the Scientific Institute "E. Medea"-Bosisio Parini (LC)

The Infantile Cerebral palsy (PCI) is a multisystemic pathology and the journey is one of many functions that can be included in the child's rehabilitation project. The lack of acquisition of the path or its alterations depend on various factors classified as primary problems (alteration of the muscular tone, deficiency of selective motor control, deficit of the equilibrium, sensory/sensorial disorders), problems Secondary (muscle-tendon retractions, skeletal deformities) and tertiary problems (compensation mechanisms that the child puts in place to remedy these problems).

The rehabilitation treatment should therefore aim to minimize the primary problems in order to avoid incurring the secondary or, at least, to slow down the worsening evolution that very often occurs with the child's stature-ponderal growth. In fact, while skeletal growth is genetically determined and happens even if the child does not perform any motor activity, muscle growth is mainly for stretching. Therefore, in the child with delayed acquisition of motor stages, one could create a discrepancy between the growth of the bone and that of the muscle, resulting in muscular retractions.

The reduction of spasticity facilitates therefore a more suitable muscular growth, allowing an improvement both postural and functional.

Rehabilitative treatments to facilitate the motor evolution of the child with PCI can predict the Physiotherapy, but, considering the multisystemic nature of the pathology, must necessarily be integrated into a project that takes into account aspects, visual, linguistic, visuo-spatial, cognitive, etc.

Classic rehabilitation treatments have been added in recent years High Technology equipment To facilitate the process of learning some functions. These include the Lokomat for the rehabilitation of the path and some instruments for the treatment of the upper extremity such as the Armeo, the Wrist and the You-Grabber. However, the new technologies will not have to replace the classic rehabilitation path, but only to integrate it.

The packaging of Orthosis It plays a very important role in the rehabilitation process: immobilization of a body segment with a brace will allow the muscle to be adequately ' stretchated ' and aligned the limb.

In some cases the packaging of Chalk That ensure proper alignment of the articulation 24h to 24.

The Aids such as static tables, Ambulatories, Quadripodi, Canadians, etc. They are a valuable aid to facilitate posture and motor function.

Many methods have always been proposed, considered innovative, but, in order to be applied, they must have a scientific validation.

A review has recently been carried out (Dev Med Child Neurol. 2013 Oct; 55 (10): 885-910. DOI: 10.1111/DMCN. 12246. Epub 2013 Aug 21.

A systematic review of interventions for children with cerebral palsy: state of the evidence. Novak I, Mcintvre S et al.) On existing rehabilitative methods, classing them in surely effective, probably effective, unknown efficacy, probably ineffective, certainly ineffective. We present the following:

These include the Fibrotomy: It is a functional surgical technique that is usually practiced with the aid of particular microbisturis called Microfibrotomes. Basically it consists in the elimination, which occurs by percutaneous way, of those contractures present at the level of muscle band or fiber that prevent or make difficult the joint movement. The technique is currently used in many Italian orthopaical surgeries. The gradual multiple fibrotomy, performed by orthopedic of other nationalities, consists in performing this step-tripping, involving several muscular districts even in corporeal areas apparently not very influential on the motor problem present (e.g. limb Upper, neck musculature, etc.). There is currently no scientific evidence in the literature of the latter technique.

THE Suggested treatments to reduce spasticity in the lower limbs They are distinguished in focal and generalised, in reversible and irreversible.

Among the focal and reversible treatments, we recall the botulinum toxin that is administered in the spastic muscle, inhibiting the release of a neurotransmitter, thus releasing the muscle. It is a safe therapy and with very rare side effects, if properly administered. The duration of action is between 3 and 6 months and, once the effect has vanished, it is possible to repeat the treatment. The objectives of this therapy can be functional (improve the way, the prension etc.), postural (to facilitate the positioning on a table by static, the use of a brace etc.) or analgesic (if the spasticity is cause of pain).

In the case of a Widespread spasticity, in addition to muscle relaxants, the implantation of an intrathecal baclofen infusion pump may be conceivable, an electronic system that allows the antispastic drug to be spread in the medullary canal at a given dosage set From the outside by telemetry. The treatment is very effective and has the advantage of being reversible; Therefore, in the case of undesirable effects or poor tolerance by the patient of the device, the device may be switched off or removed, thus returning to the pre-implantation situation.

The Selective Dorsal rhizotomy It is part of general and irreversible treatment.

It is a neurosurgical intervention that interrupts the reflex arc that causes an excess of input from the periphery to the marrow with consequent increase of the excitatory response of the musculature. In this way, it avoids a flow of excessive and erroneous information to the central nervous system, which would lead to alterations of the equilibrium, erroneous motor programs and dispercective phenomena.

The intervention consists in cutting exclusively (selective) the nerve fibers that lead an altered signal to the marrow, leaving intact those non-pathological.

Being the effects of this irreversible intervention, you have to pay close attention to the patient selection. If we have functional objectives (improving the way), the ideal candidate should have the following characteristics:

-Age between 6 and 10 years

– Purely spastic form (absence of dystonic elements)

– prematurity

-Good trunk control

– Good muscular Stenia

– Autonomous ambulation without AIDS

There are several surgical techniques more or less invasive on the lumbar vertebrae: Of course a greater invasiveness will allow to be more selective on the radicole to dissect and therefore to have better functional results.  

The Orthopedic Surgery It is very often part of the treatment of children with cerebral palsy. It is reserved for patients presenting structured muscle-tendon retractions or skeletal deformities, secondary to tone alteration, muscle retractions or postural defects.

The objectives of the surgery can also be postural (improving the seated posture, allowing the positioning on the table by static, facilitating the use of a orthosis etc.), functional (improving the pattern of the walk, the functionality of the limbs Superiors etc.) or analgesic (in case a skeletal deformity causes pain to the patient).

Interventions on soft parts provide The tenotomies, the fasciotomies, the muscular transfer, etc., while interventions on the bony parts are aimed at correcting deformities such as lever arm dysfunctions in the lower limbs, dislocations of the Also, correction of the column deformities (scoliosis, kyphosis).

While interventions on soft parts imply a fairly fast rehabilitative process (granting immediate load), skeletal surgery of the lower limb may include periods of non-load of variable duration depending on the intervention.

In some cases, after surgery of the soft parts it is necessary to place a plaster to immobilize the segment subjected to intervention that, after removal, will be replaced with a brace.

If the musculo-skeletal deformity is a consequence of an alteration of the tone, it would be preferable to treat the primary problem first (spasticity) and at a later time to correct residual retraction.

In General, we can conclude that a Taking charge of your child with PCI implies the following principles:

• Define the final product in terms of long-term treatment objectives

• Identify immediate and future child problems

• Analyse the effect of growth on problems (with and without the proposed treatment)

• Consider valid alternatives of treatment, including non-treatment

• Treat your child as a whole

• Use rehabilitative, medical and surgical methods that have proven efficacy, as described in the international literature.