Effect of Cast Application in Spastic Cerebral Palsy

Effect of Cast Application in Spastic Cerebral Palsy				Once they started ambulating, the pain
* Hasan Izharul ** Faiyaz Ahmed				subsided.
*PG Scholar, Dept. of Preventive and Social Medicine
NIUM Bangalore, India
				Table 2. Mean change + SD in Various
Corresponding Address: Dr Izharul Hasan, NIUM				Parameters from Pretest to Various joints
Campus				in Right Leg
Kottigepalya Bangalore, Karnataka 560091 India.				Clinical Tests
Mob: 9379559363
Email:
ABSTRACT				Right
Objective: Cerebral palsy (CP) is the term
for a range of non progressive				Left
syndromes of posture and motor
impairments that results from an insult to
the developing central nervous system.				Mean change + SDp-value
Spasticity and in coordination are major				Mean change + SDp- value
causes of disability in these children which				Thomas test
can be managed by different modalities like
casting, surgery, and botulinum toxin etc.				Popliteal Angle
Methods: This study is conducted on 22
children of spastic CP in age range of				Dorsiflexion with knee extension
3-12 years with bilateral involvement of hip,				Dorsiflexion with knee flexion
knee and ankle in 20 cases, hip and				Post cast
ankle in one case. Sixty eight % children				Follow up
were spastic diplegics. Serial weekly cast				Post cast
with (11 cases) or without abductor bar (11				Follow up
cases) was applied for four weeks. They				Post cast
were followed up patchily with an				Follow up
average period of 7 months.				Post cast
Results: considerable enhancement was noticed				Follow up
in range of motion around hip, knee and				12.22 + 9.58
ankle which as maintained over hip and				14.30 + 10.82
knee after average follow up. Spasticity				45.71 + 11.75
was also reduced as precise by Modified				37.08 + 18.27
Ashworth Scale (MAS). This ultimately				12.22 + 8.78
improved the ambulatory status and				4.50 + 9.26
efficient ability of these children.				10.55 + 11.74
Conclusion: Serial casting is very simple, safe				0.00 + 20.54
and cost effective procedure which can				<0.001
be applied even in children with mental				<0.01
sub normality having all three major joints				<0.001
involved bilaterally.				<0.001
Key words: Cerebral Palsy; Serial casting				<0.001
Cerebral palsy (CP) is a range of non				>0.05
progressive syndromes of posture and motor				<0.001
impairment due to an insult to developing				>0.05
brain.1 It may be associated with mental				12.78 + 8.78
impairments. 2,3 seizures, sensory abnormalities,				10.30 + 10.79
hydrocephalus, autonomic dysfunction, defects				46.90 + 14.36
of visual perception 4,5 and learning				34.17 + 13.45
disabilities.6				12.78 + 6.00
A form of cerebral palsy, called spastic cerebral				3.50 + 7.09
palsy, is caused when the brain damage occurs in the				9.72 + 9.62
outer layer of the brain, the cerebral cortex. Spastic				2.00 + 18.74
cerebral palsy is the most common form of cerebral				<0.001
palsy, affecting 70 to 80 percent of patients. Spastic				<0.05
cerebral palsy symptoms include increased tone, or				<0.001
tension, in a muscle. Normal muscles work in pairs;				<0.001
when one group of muscles contract, the other group				<0.001
relaxes. This allows uninhibited movement in the				>0.05
desired direction. Due to complications in				<0.001
brain-to-nerve-to-muscle communication, the normal				>0.05
degree of muscle tension is disrupted.
Spasticity presents with various positive				Table 3. Mean Change + SD in Abduction
(increased tone, increased deep tendon				Positions of Limbs
reflexes, clonus, extensor plantar responses,				Stage
discordant mass activation of muscles) and				Mean change + SD Postp- value
negative elements (decreased coordination				Abduction with hip and knee extension
strength and endurance).7 It poses detrimental
effect on activities of daily living,				Abduction with hip and knee flexion
ambulation and overall development of				Post cast
these children. Spastic form of the disorder				Follow up
is the commonest.8 Short leg casts were				Post cast
found to be useful in increasing range of				Follow up
motion,9-18 tone reduction, 9-11,17-20 decreasing				9.12 + 5.30
static and dynamic stretch21, reducing				9.44 + 4.64
resistance to passive stretch and dynamic				0.81 + 3.69
reflex excitability,12 , improving stride length				0.89 + 4.17
and functional abilities10 along with providing				<0.001
stability while allowing mobility, initiating				<0.001
weight bearing activities and improving				>0.05
motor skills. Stastically significant changes in				>0.05
muscle tone 11 and functional improvement
were not found by others. Tone reducing				Discussion: In developing countries where
cast was found to b e better option than				scarcity, illiteracy and paucity of health
standard one in gait improvement but,				services are big problems; cast application
maintenance of improvement after cast				is safe, simple and effective procedure
removal was found difficult in CP				for children with CP which can be
children.9,13,14 Physiotherapy along with casting				applied at remote places with minimal
was found to be superior to				facilities available. This can be applied
physiotherapy alone.				simultaneously for all joint inexpensively.
In spastic hemiplegia, the child experiences				Serial casting for progressive correction was
stiffness on only one side of his body				applied for all three major joints
and at times it is the arms and hands				simultaneously in most of the children in
that are more affected then the legs. The				our study. Except for one case report
arms and legs, which are on the				of knee flexion contracture, all other
affected side, have no normal growth and				studies included children with either r equinus9,
need the help of leg braces to enable				11 or equines deformity with mild involvement
him o her to walk. In spastic				of hip and knee.10 Conservative
quadriplegia, which is the most severe of				managements of scissoring was also not
the three a child who is affected by				considered in these studies. We were able
this disorder will be mentally, retarded in				to achieve highly significant improvement in
addition to having their limbs also affected.				range of motion around hip, knee and
Not only will the child experience seizures				ankle immediately post cast except for
it will also be difficult for the child to				abduction with hip and knee flexion. This
speak, eat and move with ease. Spastic				high statistical significance was maintained in
cerebral palsy can be treated with the				popliteal angle and abduction with hip and
help of therapy, medications and even				knee extension even after average follow
surgery. Children with this disorder would				up. Thomas test improvement became
do well to learn music and dance				significant (<0.05), while changes in
therapy, yoga, physical therapy so that				abduction with hip and knee flexion on
they become better.				both occasions remained non significant
Many authors studied impact of Botulinum				(<0.05). Various other studies also showed
toxin in CP children. It was found more				increase in passive range of ankle
effective than casting15 while similar efficacy				dorsiflexion immediately after cast
with both modalities was proved later but				application.9,10,12,13,15
Botulinum toxin was rated better by				Current study showed decrease in grades
treating physician and parents. Recent				of spasticity as measured by MA S around
studies reveal serial casting more suitable				knee and ankle joints. Though there was
than toxin whereas serial casting alone or				deterioration in follow up period from
with toxin was found to be better option				immediate post cast status, still > 50%
for dynamic equines in CP.				children maintained their improvement. This is
Present study was conducted to evaluate				an correlation with other studies10,11,15 but
the impact of serial casting in spastic				no statistical significance was proved.11
children in terms of increase in range of				Compliance of the children, dedication of
motion, reduction of spasticity and				parents and proper exercises are must for
improvement in ambulation in whom all				the success of any treatment in cerebral
three major joints.				palsy. Even orthoses and assistive devices
MATERIAL AND METHODS: Those children who				play an important role in the attainment
fulfilled the given criteria were included in				of set goals. We found that children with
the study:				dedicated parents who regularly followed
- Convulsive diplegia, paraplegia or quadriplegia				their exercises schedule and used orthoses
- Age group between 3- 12 years				and assistive devices were able to maintain
- Intellectual status normal or below normal				correction for a longe r period of time.
but able to follow instructions				With increase in range of motion and
- Capable to sit or stand with support				reduction of spasticity we could improve
- Grade 2/3 spasticity on MAS				ambulatory status of our children to a
With conversant permission of parents,				great extent which was different from
twenty two children were given weekly				most of the other studies.9,14 In the
cast for four weeks using custom made				present study, around 76% children were
plaster of paris bandages. Groin to toe				unable to stand even with support while
cast (20 cases), cylindrical cast (1 case) and				the above mentioned studies included
short leg casts ( 1 case) were applied with				children with independent o r assisted walking.
(11 cases) or without abductor ba r (11 cases)				Only few authors considered those children
according to joints involved maintaining				who were not able to stand or attained
neutral position over knee, mild dorsiflexion				standing with support.10,11
over ankle and extension over toe with				For certification of efficacy of any
extra padding done over pressure points.				management modality, a good sample size,
On the second day of cast application,				regular and long follow-up are required.
child was made ambulatory with the help				The shortest follow up of 6 weeks12 and
of custom made assistive devices (				longest of average 3.08 years14 were
reciprocal walker or wooden tripod). Similar				described in literature. Because of larger
exercises were taught to every child and				drop out and variable follow up period we
their parents. Once casting protocol was				could not find out the time when
completed, joints were mobilized gently and				deterioration started after casting.
every child was provided with customized				Conclusion: The effect of casting in cerebral
static splints in the form of knee				palsy in children with all three major joints
immobilizers and poly propylene ankle foot				involvement has never been studied. With
orthoses. Knee and ankle exercises were				all its drawbacks like small number of
added in the previous schedule and the				patients, irregular and short follow up,
child was discharged. Follow ups were				more drop outs in follow up, absence of
planned after one month and then every				sophisticated measures and more; it is
three monthly.				rather premature stage to draw a firm
Precast, postcast and on successive follow				conclusion. Still, we think if properly applied,
ups, range of motion (ROM) around hip,				serial casting is very effective, safe and
knee and ankle were measured using				simple procedure which can be applied at
goniometer and measuring tape. Children				remote places with minimum cost in
were evaluated after dividing them into				children with mild to moderate sub
five categories according to their abilities:				normality and having all three major joints I
- Standing with support				nvolved bilaterally.
- Standing without support				References:
- Walking with support				1. Koman LA, Smith BP, Shilt JS. Cerebral Palsy.
- Walking without support				Lancet 2004; 363: 1619-1631.
- Sitting				2. Rumeau- Rouquette C, Grandjean H, Cans C et
Paired ‘t' test was employed to test				al. Prevalence and time trends of disabilities
difference in ROM at various joints in				in school- age children. Int J Epidemiol 1997; 26:
lower extremities between precast, postcast				137-145.
and average follow up values.				3. Rumeau- Rouquette C, du MC, Mlika A et al. Motor
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(77.27%), between age group 3- 7 years				1992; 21: 359- 366.
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mental retardation. Only thirteen children				309-316.
came for follow up with an average				5. Stiers P, Vanderkelen R, Vanneste G et al. Visual
follow up of 7 months 5 days.				perceptual impairment in a random sample of children
Table 1. Type of Cerebral Palsy in the				with cerebral palsy. Dev Med Child Neurol 2002: 44:
Children				370-382.
Type				6. Evans P, Elliott M, Alberman E at al. Prevalence
Number of patients				and disabilities in 4 to 8 years old with cerebral palsy.
Spastic Diplegia				Arch Dis Child 1985; 60: 940-945.
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22 (100%)				10. Watt J, Sims D, Harckham F et al. A prospective
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Range of motion: Enhancement in Thomas				physiotherapy for cerebral palsied children.
test after cast removal from precast				11. Brouwer B, Davidson LK, Olney S J. Serial casting
status was found to b e highly significant				in idiopathic toe walker and children with cerebral palsy.
(p<0.001) while after average follow up it				J Pediatr Orthop 2000; 20: 221-225
deteriorated to significant value (p<0.01).				12. Brouwer B, Wheeldon RK, Stradiotto Parker N et
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improved after cast removal and was				cerebral palsy; The effect of serial casting. Dev Med
maintained in follow up to highly significant				Child Neurol 1998; 40
level. Highly significant improvement was				13. Cottalorda J, Gautheron V, Metton G et al. Toe
noted after cast removal and in follow				walking in children younger than six years with cerebral
up in popliteal angle.				palsy. The contribution of serial corrective cass. J Bone
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with MAS grade 2 and grade 3				14. Tradieu G, Tradieu C, Colbeau- Justin P et al.
spasticity over knee and ankle, respectively.				Muscle hypoextensibility in children with cerebral palsy:
100% and 90.91% children showed				Therapeutic implications. Arch phys Med Rehabil 1982;
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average follow up period, 41.67% and				toxin A compared with stretching cast in the treatment
33.33% children over knee and 38.46% and				of spastic equines: A randomized propective trial. J
46.15% over ankle were able to maintain				Pediatr Orthop 1998; 19: 304-311.
the improvement on right and left side				16. Glanzman AM, Kim H, Swaminathan K et al.
correspondingly.				Efficacy of botulinum toxin A, Serial casting and
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two children came fo r follow up and all				retrospective analysis. Dev Med Child Neurol 2004; 46:
of them showed improvement in ambulation.				807-811.
Out of ten children who were in grade				17. Kay RM, Rethlefsen SA, Furn- Buneo A et al.
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improvement of one or two grades each.				treatment in children with cerebral palsy. J Bone Joint
Three and four grade improvement was				Surg Am 2004; 86: 2377-2384.
observed in 60% and 20% children				18. Ackman JD, Russman BS, Thomas SS et al.
respectively. One child of grade B				Comparing botulinum toxin A with casting for treatment
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children who belonged to grade E that is				Med Child Neurol 2005; 47: 620-627
independent walkers remained in grade E				19. Sussman MD. Casting as an adjunct to neuro
but they attained cosmetically and				developmental therapy for cerebral palsy. Dev Med
functionally a better gait. Dcissoring,				Child Neurol 1983; 25: 804-806.
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Effect of Cast Application in Spastic Cerebral Palsy