Spastic Hand - CHU Sainte-Justine - SAAC

Upper Extremity in Cerebral
Palsy: Indications for
Treatment
Susan Thompson, MD, FRCSC
Assistant Professor
University of Manitoba
Winnipeg, Manitoba

Cerebral Palsy
‣ Definition:
• Static, non-progressive disturbance of the
cerebral cortex occurring before the age of
two
• Results in altered motor, sensory and often
intellectual function

‣ Remember:
• While the brain lesion may be permanent and
non-progressive, the natural history of
cerebral palsy is NOT static
• Growth and maturation of the central nervous
system, and the whole child will cause
changing musculoskeletal problems

‣ According to Manske (1990):
• Only 20% of all CP surgery involves the upper
extremity

‣ “traditional criteria” for surgery
‣ Aimed to select those patients who will
show functional improvement

Traditional Criteria
‣ Assessment of:
1. Voluntary hand use
2. Motor function
3. Sensibility
4. Intelligence/ability to comply
5. Athetosis/movement disorders

Voluntary Hand Use
‣ Very difficult to quantify
‣ Hoffer – estimated it by assessing the
ability to place the hand from the head to
the knee in an alternating fashion every 5
seconds
‣ Dependent on good shoulder and elbow
control
‣ Very difficult if a movement disorder is
present (athetosis, ataxia, dyskinesia)

Voluntary Hand Use
‣ Examine wrist and digits for voluntary
flexion and extension
‣ Contracture may limit movement of digits
with respect to wrist position (ie wrist
flexion may allow digital extension )

Grading of Hand Function
‣ Green & Banks (mod: Samilson & Morris)
• Poor – paperweight, poor or absent grasp &
release, poor control
• Fair – helping hand, no effectual use of hand,
moderate grasp & release, fair control
• Good – use in dressing & general activities,
effectual grasp & release, good control
• Excellent – good use of hand, excellent
control

House Grading
‣ 0 – does not use
‣ 1 – poor passive
assist
‣ 2 – fair passive assist
‣ 3 - good passive
assist
‣ 4 – poor active assist
‣ 5 – fair active assist
‣ 6 – good active assist
‣ 7 – spontaneous use,
partial
‣ 8 spontaneous use,
complete

Sensibility
‣ Very difficult and unreliable
‣ Need cooperative child, a certain level of
intellectual capacity, and language ability

Sensibility
‣ Impairment is seen in 50-90%
‣ Decreased 2-point discrimination,
stereognosis, and proprioception
‣ Must consider the age of the child
• If

Sensibility
‣ Improved functional results are more likely
in patients with less than 10mm 2-point
discrimination, 3 of 5 object identification,
or number discrimination in the palm
‣ Impaired sensibility should not prevent
reconstructive surgery

IQ
‣ Reconstructive surgery - Contraindicated
If IQ < 70
‣ Is IQ testing accurate in CP
‣ Is IQ important if re-education is not
necessary

Athetosis/Movement disorder
‣ Fluctuations in tone
‣ Results of surgery are unpredictable
‣ Consider fusions

Other Considerations

Timing
‣ Delay surgery until a clear evaluation of
functional use is possible – age 6-12 years
‣ Functional improvement can be seen in
older individuals after surgery

Goals & Expectations
‣ Discuss expectations with patient and
caregivers
• Will not achieve a “normal” limb
‣ Team approach
• Therapists, physiatrists, pediatricians can all
help determine the goals of surgery
‣ Usefulness of patient questionnaire

‣ Improving function is not the only objective
of surgery
‣ Consider Three goals:
• Improved function
• Improved cosmesis
• Improved hygiene

Guidelines
‣ If IQ less than 50, hand placement greater than 5
seconds, and poor sensibility – primary goal should be
hygiene
‣ If IQ greater than 50, but poor hand placement and poor
sensibility – procedures to improve contracted
appearance of the limb as well as hygiene should be
considered
‣ If IQ greater than 50, hand placement less than 5
seconds, good sensibility – ideal candidate for functional
improvement

Physical Examination
Just a few tips!

Examination Goals
‣ Evaluate spasticity
‣ Evaluate motor and sensory deficit
‣ Evaluate existing function and functional
needs
‣ Perform complete general examination to
seek associated neurologic disorders and
contraindications to surgery

Physical examination
‣ Often difficult
‣ Patient & parents can identify specific
tasks that are problematic
‣ Observe routine activities – note functional
deficits and patterned hand movements
‣ Videotaping
‣ Multiple visits

Physical examination
‣ Note resting position
‣ Posturing
‣ Strength of muscles
‣ Inspect for potential
hygiene problems

Spasticity
‣ Velocity dependent increase in muscle
tone
‣ Selective – predominant in flexor and
adductor muscles
‣ Usually more severe in distal part of limb

Fibrous Contracture
‣ Permanent and cannot be overcome
‣ In cases of severe spasticity, clinical
distinction between contracture and
spasticity may be extremely difficult
• Consider motor block

Range of motion
‣ Assess both active and passive range of
motion
‣ Useful to ask patient to do purposeful
tasks
‣ Need a range of toys, games to better see
arm function
‣ Therapist can be very helpful with this part
of evaluation

Shoulder
‣ If resting position is
internal rotation
• Spasticity and possibly
contracture exist
• Determine if this
interferes with use of
UE
• Usually involves
adductor and internal
rotator muscles

Elbow
‣ Resting position – usually flexion
‣ Spasticity of biceps and brachialis
‣ Possibly also brachioradialis

Forearm
‣ Position at rest – usually pronation
‣ Spasticity of muscles originating from medial
epicondyle
‣ Active supination & pronation
‣ Palpation of pronator teres during passive
supination

Forearm
‣ Unable to oppose hands;
difficult to oppose small
objects
‣ Reverse grasp
‣ Rarely associated with radial
head dislocation – does not
need to be addressed
surgically

Wrists & Digits
‣ Observe flexion & extension
• If UD with flexion – spasticity of
FCU
• If UD with extension – spasticity
of ECU
‣ Palpate FCR to ensure it is
firing (especially if considering
transfer)
‣ Note: UD may passively
increase thumb abduction

‣ Volkman’s angle
Flexor tightness

‣ FDS vs FDP tightness
• When passive PIP joint extension is limited -
suspect FDS spasticity
• If PIP joints have full extension, but the DIP
joints do not – FDP spasticity is suspected

Grasp and Release
‣ Evaluate grasp and release
with wrist in flexion and in
extension
‣ Poor grasp = weak wrist
extensors
• May be unable to actively
extend wrist
• May flex wrist when making a
fist
• Consider transfer to increase
wrist extensor power

‣ Poor release = weak
digital extensors
• Unable to actively
extend digits, or able to
extend digits only with
the wrist flexed
• A transfer to extend the
wrist may leave the
patient unable to extend
the digits
• May benefit from a
transfer to augment
digital extension

‣ Curled or clenched
into a fist
‣ Swan neck or clawtype
deformity
‣ Occasionally
Boutonniere
deformity
Fingers

Intrinsic tightness
‣ At rest: flexion of MP
joints and extension
at IP joints
‣ Bunnell test

Thumb
‣ Thumb-in-palm deformity
1. Web space contracture
2. Spasticity or contracture of
APB, FPB, 1 st dorsal
interosseous, spasticity of FPL
with wrist flexed and extended
3. Strength of APL, EPB, EPL
4. Hypermobility of thumb MP
joint

Additional studies
‣ EMG
• Surface and fine needle electrodes
• Determine spastic & flaccid muscles
• Determine phase of firing
• Muscles found to be in phase with the
recipient muscle tend to do better than those
that are nonphasic

Additional studies
‣ Motion laboratory analysis
• Patterned movement
• Efficiency (oxygen consumption)

1. FCU EDC
2. BR ECRB
3. EPL reroute
4. Pronator rerouting
5. Adductor release
6. Web plasty
7. Flexor lengthening
8. Thumb MP fusion