Effect of Cast Application in Spastic Cerebral Palsy* Hasan Izharul ** Faiyaz Ahmed*PG Scholar, Dept. of Preventive and Social MedicineNIUM Bangalore, IndiaCorresponding Address: Dr Izharul Hasan, NIUM CampusKottigepalya Bangalore, Karnataka 560091 India.Mob: 9379559363Email: drizharnium@gmail.comABSTRACTObjective: Cerebral palsy (CP) is the term for a range of non progressive syndromes of posture and motor impairments that results from an insult to the developing central nervous system. Spasticity and in coordination are major causes of disability in these children which can be managed by different modalities like casting, surgery, and botulinum toxin etc.Methods: This study is conducted on 22 children of spastic CP in age range of 3-12 years with bilateral involvement of hip, knee and ankle in 20 cases, hip and ankle in one case. Sixty eight % children were spastic diplegics. Serial weekly cast with (11 cases) or without abductor bar (11 cases) was applied for four weeks. They were followed up patchily with an average period of 7 months.Results: considerable enhancement was noticed in range of motion around hip, knee and ankle which as maintained over hip and knee after average follow up. Spasticity was also reduced as precise by Modified Ashworth Scale (MAS). This ultimately improved the ambulatory status and efficient ability of these children.Conclusion: Serial casting is very simple, safe and cost effective procedure which can be applied even in children with mental sub normality having all three major joints involved bilaterally.Key words: Cerebral Palsy; Serial castingCerebral palsy (CP) is a range of non progressive syndromes of posture and motor impairment due to an insult to developing brain.1 It may be associated with mental impairments. 2,3 seizures, sensory abnormalities, hydrocephalus, autonomic dysfunction, defects of visual perception 4,5 and learning disabilities.6A form of cerebral palsy, calledspastic cerebral palsy, is caused when the brain damage occurs in the outer layer of the brain, the cerebral cortex. Spastic cerebral palsy is the most common form of cerebral palsy, affecting 70 to 80 percent of patients. Spastic cerebral palsy symptoms include increased tone, or tension, in a muscle. Normal muscles work in pairs; when one group of muscles contract, the other group relaxes. This allows uninhibited movement in the desired direction. Due to complications in brain-to-nerve-to-muscle communication, the normal degree of muscle tension is disrupted.Spasticity presents with various positive (increased tone, increased deep tendon reflexes, clonus, extensor plantar responses, discordant mass activation of muscles) and negative elements (decreased coordination strength and endurance).7 It poses detrimental effect on activities of daily living, ambulation and overall development of these children. Spastic form of the disorder is the commonest.8 Short leg casts were found to be useful in increasing range of motion,9-18 tone reduction, 9-11,17-20 decreasing static and dynamic stretch21, reducing resistance to passive stretch and dynamic reflex excitability,12 , improving stride length and functional abilities10 along with providing stability while allowing mobility, initiating weight bearing activities and improving motor skills. Stastically significant changes in muscle tone 11 and functional improvement were not found by others. Tone reducing cast was found to b e better option than standard one in gait improvement but, maintenance of improvement after cast removal was found difficult in CP children.9,13,14 Physiotherapy along with casting was found to be superior to physiotherapy alone.In spastic hemiplegia, the child experiences stiffness on only one side of his body and at times it is the arms and hands that are more affected then the legs. The arms and legs, which are on the affected side, have no normal growth and need the help of leg braces to enable him o her to walk. In spastic quadriplegia, which is the most severe of the three a child who is affected by this disorder will be mentally, retarded in addition to having their limbs also affected. Not only will the child experience seizures it will also be difficult for the child to speak, eat and move with ease. Spastic cerebral palsy can be treated with the help of therapy, medications and even surgery. Children with this disorder would do well to learn music and dance therapy, yoga, physical therapy so that they become better.Many authors studied impact of Botulinum toxin in CP children. It was found more effective than casting15 while similar efficacy with both modalities was proved later but Botulinum toxin was rated better by treating physician and parents. Recent studies reveal serial casting more suitable than toxin whereas serial casting alone or with toxin was found to be better option for dynamic equines in CP.Present study was conducted to evaluate the impact of serial casting in spastic children in terms of increase in range of motion, reduction of spasticity and improvement in ambulation in whom all three major joints.MATERIAL AND METHODS: Those children who fulfilled the given criteria were included in the study:Convulsive diplegia, paraplegia or quadriplegiaAge group between 3- 12 yearsIntellectual status normal or below normal but able to follow instructionsCapable to sit or stand with supportGrade 2/3 spasticity on MASWith conversant permission of parents, twenty two children were given weekly cast for four weeks using custom made plaster of paris bandages. Groin to toe cast (20 cases), cylindrical cast (1 case) and short leg casts ( 1 case) were applied with (11 cases) or without abductor ba r (11 cases) according to joints involved maintaining neutral position over knee, mild dorsiflexion over ankle and extension over toe with extra padding done over pressure points. On the second day of cast application, child was made ambulatory with the help of custom made assistive devices ( reciprocal walker or wooden tripod). Similar exercises were taught to every child and their parents. Once casting protocol was completed, joints were mobilized gently and every child was provided with customized static splints in the form of knee immobilizers and poly propylene ankle foot orthoses. Knee and ankle exercises were added in the previous schedule and the child was discharged. Follow ups were planned after one month and then every three monthly.Precast, postcast and on successive follow ups, range of motion (ROM) around hip, knee and ankle were measured using goniometer and measuring tape. Children were evaluated after dividing them into five categories according to their abilities:Standing with supportStanding without supportWalking with supportWalking without supportSittingPaired t' test was employed to test difference in ROM at various joints in lower extremities between precast, postcast and average follow up values.RESULTS: Majority of children were males (77.27%), between age group 3- 7 years (72.72%) and spastic diplegics (68.18%). Mental status of half of the children could not be evaluated; in rest, 72.72% had mild mental retardation. Only thirteen children came for follow up with an average follow up of 7 months 5 days.Table 1. Type of Cerebral Palsy in the ChildrenTypeNumber of patientsSpastic DiplegiaSpastic ParaplegiaSpastic TetraplegiaTotal15 (68.18%)5 (22.73%)2 (9.09%)22 (100%)Range of motion: Enhancement in Thomas test after cast removal from precast status was found to b e highly significant (p<0.001) while after average follow up it deteriorated to significant value (p<0.01). Abduction with hip and knee extension improved after cast removal and was maintained in follow up to highly significant level. Highly significant improvement was noted after cast removal and in follow up in popliteal angle.Spasticity: Mainstream of the children presented with MAS grade 2 and grade 3 spasticity over knee and ankle, respectively. 100% and 90.91% children showed improvement over knee and ankle respectively, after cast removal. After average follow up period, 41.67% and 33.33% children over knee and 38.46% and 46.15% over ankle were able to maintain the improvement on right and left side correspondingly.Ambulatory status: Thirteen out of twenty two children came fo r follow up and all of them showed improvement in ambulation. Out of ten children who were in grade A precast, 10% children showed improvement of one or two grades each. Three and four grade improvement was observed in 60% and 20% children respectively. One child of grade B showed two grade improvements. Two children who belonged to grade E that is independent walkers remained in grade E but they attained cosmetically and functionally a better gait. Dcissoring, previously a big problem in these children resolved to an extent that they could ambulate easily.During the process, two complications were encountered- pain and pressure sore. Pain was present immediately post cast and on mobilization after final removal of cast. Once they started ambulating, the pain subsided.Table 2. Mean change + SD in Various Parameters from Pretest to Various joints in Right LegClinical TestsRightLeftMean change + SDp-valueMean change + SDp- valueThomas testPopliteal AngleDorsiflexion with knee extensionDorsiflexion with knee flexionPost castFollow upPost castFollow upPost castFollow upPost castFollow up12.22 + 9.5814.30 + 10.8245.71 + 11.7537.08 + 18.2712.22 + 8.784.50 + 9.2610.55 + 11.740.00 + 20.54<0.001<0.01<0.001<0.001<0.001>0.05<0.001>0.0512.78 + 8.7810.30 + 10.7946.90 + 14.3634.17 + 13.4512.78 + 6.003.50 + 7.099.72 + 9.622.00 + 18.74<0.001<0.05<0.001<0.001<0.001>0.05<0.001>0.05Table 3. Mean Change + SD in AbductionPositions of LimbsStageMean change + SD Postp- valueAbduction with hip and knee extensionAbduction with hip and knee flexionPost castFollow upPost castFollow up9.12 + 5.309.44 + 4.640.81 + 3.690.89 + 4.17<0.001<0.001>0.05>0.05Discussion: In developing countries where scarcity, illiteracy and paucity of health services are big problems; cast application is safe, simple and effective procedure for children with CP which can be applied at remote places with minimal facilities available. This can be applied simultaneously for all joint inexpensively.Serial casting for progressive correction was applied for all three major joints simultaneously in most of the children in our study. Except for one case report of knee flexion contracture, all other studies included children with either r equinus9, 11 or equines deformity with mild involvement of hip and knee.10 Conservative managements of scissoring was also not considered in these studies. We were able to achieve highly significant improvement in range of motion around hip, knee and ankle immediately post cast except for abduction with hip and knee flexion. This high statistical significance was maintained in popliteal angle and abduction with hip and knee extension even after average follow up. Thomas test improvement became significant (<0.05), while changes in abduction with hip and knee flexion on both occasions remained non significant (<0.05). Various other studies also showed increase in passive range of ankle dorsiflexion immediately after cast application.9,10,12,13,15Current study showed decrease in grades of spasticity as measured by MA S around knee and ankle joints. Though there was deterioration in follow up period from immediate post cast status, still > 50% children maintained their improvement. This is an correlation with other studies10,11,15 but no statistical significance was proved.11Compliance of the children, dedication of parents and proper exercises are must for the success of any treatment in cerebral palsy. Even orthoses and assistive devices play an important role in the attainment of set goals. We found that children with dedicated parents who regularly followed their exercises schedule and used orthoses and assistive devices were able to maintain correction for a longe r period of time.With increase in range of motion and reduction of spasticity we could improve ambulatory status of our children to a great extent which was different from most of the other studies.9,14 In the present study, around 76% children were unable to stand even with support while the above mentioned studies included children with independent o r assisted walking. Only few authors considered those children who were not able to stand or attained standing with support.10,11For certification of efficacy of any management modality, a good sample size, regular and long follow-up are required. The shortest follow up of 6 weeks12 and longest of average 3.08 years14 were described in literature. Because of larger drop out and variable follow up period we could not find out the time when deterioration started after casting.Conclusion: The effect of casting in cerebral palsy in children with all three major joints involvement has never been studied. With all its drawbacks like small number of patients, irregular and short follow up, more drop outs in follow up, absence of sophisticated measures and more; it is rather premature stage to draw a firm conclusion. Still, we think if properly applied, serial casting is very effective, safe and simple procedure which can be applied at remote places with minimum cost in children with mild to moderate sub normality and having all three major joints I nvolved bilaterally.References:Koman LA, Smith BP, Shilt JS. Cerebral Palsy. Lancet 2004; 363: 1619-1631.Rumeau- Rouquette C, Grandjean H, Cans C et al. Prevalence and time trends of disabilities in school- age children. Int J Epidemiol 1997; 26: 137-145.Rumeau- Rouquette C, du MC, Mlika A et al. Motor disability in children in three birth cohorts. Int J Epidemiol 1992; 21: 359- 366.Beckung E, Hagberg G. Neuroimpairments, activity limitations and participations restrictions in children with cerebral palsy. Dev Med Child Neurol 2002; 44: 309-316.Stiers P, Vanderkelen R, Vanneste G et al. Visual perceptual impairment in a random sample of children with cerebral palsy. Dev Med Child Neurol 2002: 44: 370-382.Evans P, Elliott M, Alberman E at al. 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