Originally Posted by Nikki
Having discussed this with a Physio collegue we came up with the following.
First let me say
there is nothing more annoying than having a fellow clinician use the phrase 'too mentally impaired to have a primary diagnosis'. Surely this is a key part of the treatment, if you don't look at all the reasons for the presentation then nothing is likely to work long term.
What is the underlying diagnosis - this could affect the choice of solutions. Could it be CP or Rett?- Is the 'neurological impairment' from birth or an acquired brain injury?
Does the child want to walk? What is the quality of the walking? Is it so energy expensive that she spends an hour recovering and cannot function once she arrives at her goal?
Surgery will only work in the long term if it includes something to stop the spasticity which caused the problem in the first place. In our experience even a triple osteotomy does not work in the long term if nothing is done with the muscle.
Botox may only useful if there is intensive (ie daily physio input) for the first 2-14 days post injection to optimise the effectiveness with splinting added as soon as there is improvement in range. Not sure if botox is even done on gastroc. You can only botox a fusiform or the occasional bipennate muscle owing to the need to inject the motor end plates. Also there is leakage to surrounding structures, which limits which muscles are possible to botox.
Since the calcaneus is inverted it will be impossible (in our opinion) to hold it with an orthotic or shoe or ankle foot orthosis. We have yet to find something which can hold the calcaneus effectively once the spasticity kicks in. Especially if you then want the child to walk which is the aim.
Daily stretches should enable the calcaneus to be brought to neutral and then a TA stretch to follow. We have had experience where we have been able to achieve this over a two year period! If the calcaneus is not brought to a neutral position before the stretch, then it will be ineffective
Ultimately it should be the best interests of the child which is considered- not the parents!
Thank you for your comments. I’m sorry my clumsy expression annoyed you.
I am in a third world country with limited access to inter-disciplinary medical services one ordinarily relies on in a first world country. My client, despite consulting amongst other local health professionals an eminent professor of neurology, as well as seeking medical advice in Singapore, does not actually have a primary ‘diagnosis’, nor does she have a ‘primary complaint’ which is what I actually said in my reply to Lucky Lisfranc.
The parents report her neurological condition is congenital although they were told she was ‘normal’ but has a low IQ. Brain scans are not normal according to the parents. I am not able to converse with the child directly because I don’t speak Bahasa Indonesia and even if I did, neurological disorders are not my specialty. I’m just trying to get an idea of what avenues might be available to the client.
In my opinion, other than mental retardation and gait abnormalities, she doesn’t fit the criteria for Rett Syndrome. She doesn’t appear to have spasticity as there are no signs of involuntary muscle control. She doesn’t really fit the progressive nature of CP which, if it were the case, one would expect a neurologist to diagnose.
The child wants to walk; she seeks assistance from parents and siblings bilaterally during ambulation. She has a transverse type gait with a lot of upper body torsional movement and can pick up quite a bit of speed, but sweats profusely with the exersion. She has hyperkeratosis on the plantar metatarsal area and lateral malleoli especially on the left.
Stretching along the lines of your suggestions had already been implemented, but I can see according to your experience, it’s going to be a long road.
Interestingly, while assisting the family with appropriate footwear, the client tried on her sister’s 3cm heel sandals. Despite the complete lack of ankle support, I was interested to see that her gait improved marginally.
Has anyone prescribed a higher heel boot to such a client with success?