An interdisciplinary approach to intensive rehabilitation post Selective Dorsal Rhizothomy / Une approche interdisciplinaire de réadaptation intensive suivant la Radicellectomie Sélective Postérieure. Nikita Gandhi PT Marie-Elaine Lafrance OT

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SDR journey • Spasticity Clinic • Surgery • Intensive in-patient Rehabilitation – 6 weeks inpatient stay – PT 2x/day – 5 days/week – OT 4x/week • Out-patient Rehabilitation • Clinical follow up

Indications for surgery • Indications from a medical perspective – – – –

Dx of cerebral palsy (spastic diplegia, spastic triplegia and spastic quadriplegia) Age 3-7y.o. Good underlying muscle strength in trunk and Lower extremities Developmental milestones, ambulation and function limited by spasticity of the lower extremities – Available physiotherapy follow-up locally 3 times per week for 6 months – Maturity of child

• PT and OT input to determine candidacy: – Assessment muscle strength, muscle tone, sitting and standing equilibrium and protective reactions, ability to maintain trunk alignment, gait pattern, participation in transfers, overall gross motor skills

Contraindications • • • • •

Neurological diagnosis which is not felt to be stable Child with severe inherent weakness Non-spastic cerebral palsy ex.: athetosis, ataxia Severe fixed contractures Hips which are: subluxed more than 50%, progressive subluxations or dislocated • Prior orthopedic surgery (relative contraindication)

Goals of Selective Dorsal Rhizotomy PRE-SURGERY FUNCTION

POST-SURGERY GOALS

1

Independent ambulators

Improve appearance and efficiency of ambulation

2

Ambulators dependent on assistive devices (canes, walkers)

Improve quality of walking and decrease amount of assistance required for ambulation and transfers

3

4-points crawlers (either reciprocal or non-reciprocal; eg.: bunny hopping)

Improve ability to move through developmental sequence; possible ambulation with assistive devices; increase independence in self-care activities

Évaluation pré-opératoire • Évaluation ergo et physio pré-opératoire combinée – Physiothérapeute: • Révision du positionnement et des précautions concernant la mobilisation (transferts, lit, etc.); • Mesure pour planche à station debout et tricycle adapté • Orthèse – type AFO

– Ergothérapeute: • • • •

Fauteuil roulant (personnel ou en prêt) ajustement – incluant appui-tête; AVQ (PEDI); QUEST; Habiletés de motricité fine – un aperçu

Visite pré-opératoire - suite • Autres rendez-vous à l’hôpital Shriners – Milieu de l’enfance: • Enseignement fait avec l’enfant • Stratégies gestion de l’anxiété

– Urodynamie – Travail social • Support à la famille + Organisation du séjour • Processus: pré-opératoire, chirurgie, transfert et séjour à l’hôpital

• Évaluation de pré-admission à l’hôpital de Montréal pour enfants – – – –

Radiologie Prise de sang Enseignement – fait par l’infirmière Physiothérapie

Réadaptation – Jour 1 • Ergo et physio – de pair – Révision des précautions – Pratique des transferts; déplacements au lit – Endurance à la station assise – Fauteuil roulant – Siège de toilette adapté

Precautions • No passive straight leg raising beyond 45 degree • Place a roll under his knees if the head of bed raised at 45deg • No passive hip flexion beyond 90 degree • No long leg sitting, side sitting, sitting on heels, crossed legged sitting or W-sitting • No passive trunk rotation • No lifting under axilla • Bed flat when positioned in prone and in sidelying • * Any active movement done by the child is permitted*

Precautions • 6 pictures of transfers from booklet (p.21) – Guylaine will send them to us

Precautions

Precautions

Rehab - Week 1 • Interdisciplinary meeting with family • Provide schedule • Set up specific rehabilitation goals

Week 1 - Physio • Assessment (ex. Tone, ROM, flexibility, strength, sensation, etc…)

• Treatment (ex. Stretches, strengthening, functional activities, etc…)

Week 1 - Physio • Adapted tricycle and/or standing frame • Establish goals

Ergothérapie - 1ère semaine • Buts spécifiques et fonctionnels

Ergothérapie - 1ère semaine • Buts spécifiques et fonctionnels • Motricité fine / habiletés pré-académiques – PDMS-II

• Station assise – Alignement – Équilibre – Endurance

Weeks 2-5 (PT) • Treatment is progressed as per patient's own functional and endurance level  Stretching  Strengthening  Trunk and pelvic control  Weight bearing/standing  Ambulation  Stairs when indicated  Hydrotherapy (post-op day #14)  *Pet therapy

Weeks 2-5 (PT) Examples of equipment used by child Adapted tricycle Standing frame Kaye walker Quad canes

Ergo – semaine 2 à 6 • Equipment

Ergo – semaine 2 à 6 • Équilibre assis

Ergo – semaine 2 à 6 • AVQ

Ergo – semaine 2 à 6 • Activités de motricité fine / pré-académiques

• 3e semaine: Équipe de réadaptation se rencontre afin de discuter du progrès de l’enfant et mettre à jour les buts • 4e et 5e semaine: week-end pass: Pause!

Week 6 - PT • Hamstring stretches- SLR > 45deg • Start hip flexors stretches (Thomas) in supine, if necessary • Sitting on mat (Cross-leg sit, long sitting) • Squats

Week 6 • • • • •

Reassessment Gait filming Prep for returning home Communication with local therapists Provide home exercise program

Discharge • All post-operative contraindications are discontinued, except for lifting under the axilla • Teaching to parents: transfer as done past 6 weeks. Avoid activities with vibrations (ex: snowmobile, all-terrain vehicle) and avoid high impact risk activities (horseback riding, trampoline, tobogganing…etc…)

Discharge • Five-point harness car seat for any travelling up to 6 months post-surgery • Continue wearing solid AFOs 23 out of the 24hrs

Local Rehab • PT 3x/week for 6 months • OT based on child needs

• Follow up in spasticity clinic – 6 months post-op – Rehab frequency modified depending on child`s needs

Séjour 6 semaines • Réadaptation intensive patient admis • Projets Étudiants OT-PT Université McGill 20176 & 2018 • Étude impacts – Long terme (10 + 15 ans) – Court terme (18 mois à 3 ans)

17 Établissements Réadaptation

• 9 protocoles • Canada & USA • Interne – réadaptation intensive: 2 à 12 semaines • Externe – jusqu’à 12 mois post-opératoire

Physio

• 1 à 2 x/jour • 5x/semaine

Ergo

• Au besoin • 4 x/semaine

Références •

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Functional performance in self-care and mobility after selective dorsal rhizotomy: a 10-year practice-based follow-up study. Developmental Medicine & Child Neurology, March 2015; 57(3): 286-293. Long-term functional benefits of selective dorsal rhizotomy for spastic cerebral palsy. Dudley, Roy W R; Parolin, Michele; Gagnon, Bruno; Saluja, Rajeet; Yap, Rita; Montpetit, Kathleen; Ruck, Joanne; Poulin, Chantal; Cantin, MarieAndrée; Benaroch, Thierry E; Farmer, Jean-Pierre; Journal of Neurosurgery: Pediatrics, Aug 2013; 12(2): 142-150. Reduction in upper-extremity tone after lumbar selective dorsal rhizotomy in children with spastic cerebral palsy. Gigante, Paul; Journal of Neurosurgery: Pediatrics, Dec 2013; 12(6): 588-594. Bilodeau, N and Montpetit, K Impact of Selective Dorsal Rhizotomy on Reach, Grasp and Weight Bearing of the Upper Extremity, Scientific Poster American Academy of Cerebral Palsy and Developmental Medicine, Supplement October 2007, No 111 Vol. 49 Comprehensive short-term outcome assessment of selective dorsal rhizotomoy. Trost JP; Schwartz MH; Krach LE; Dunn ME; Novacheck TF; Developmental Medicine & Child Neurology, Oct 2008; 50(10): 765-771.

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