Panelists present "Case Presentations – Spasticity Management (Baclofen Pumps, Rhizotomies, and Inpatient Rehabilitation)" at the UCSF Pediatric Musculoskeletal and Sports Medicine Conference 2023 in Berkeley, CA.
OK, final stretch. Um I think Selena and Rhonda asked me to do this because I was the only person who could get the neurosurgeon into the building. So this is our panel talk and we're focusing on case presentations for um rhizotomies. Oh, sorry. Before I do that, I have three more introductions for the new people on our panel whom you don't know. So, um let's start with Dr Peter. So he is our pes neurosurgeon. Uh went to med school at Columbia University, did his neurosurgery training at Yale, then did his P S neurosurgery fellowship at Children's Hospital in Philadelphia. And one of the cool things on his profile is that he uh was named the John and Sherry Chen and Dow chair five years ago, which I thought was a figurative thing. But actually, it's literal, like if you walk to his office, there's a wooden chair in his office. Um and he's been doing rhizotomies since 2004. And then we have our therapist here are also hard to get a hold of them because they're always treating patients. We have Lucy Tomlinson. She is um she's been our P T for the last 10 years, starting off with inpatient rehab and now doing acutes in-house, she did her training at Boston University to get her doctorate of physical therapy. Um And for the last four years, she has had the special board certification of being a pediatric clinical specialist. And then we have Fiona Dunbar, our news member to our inpatient rehab team. She's our O T. She did her training at San Jose State and I think at some point she was considering working with CCS, but we were able to get her full time with us competitions. Um Anyhow, OK, so back to the presentation, we're talking about rhizotomies. I'm sorry, the agenda mentioned pumps, but we're just gonna focus on rhizotomies. It's this cool thing that's like kind of a jewel in our crown that not many people know about. It's kind of in the backyard of the East Bay and um it's a differentiator for other programs around the area. So we wanted to try to showcase it a little bit. So Peter, you're up. All right. Um I'm Peter Sun. Thank you for that introduction. Um I think I know some of you um or um thank you for uh referring your patients to us. So that has helped take care of them. I just wanna say one word about Tortola from the neurosurgery perspective. I think whenever you do have a new onset Tortola that needs to be worked up, you know, what brings them ophthalmological disorders and for congenital Tortola often, um, it's, of course, um, you know, um, in neural positioning, it gets better when they try to get up and walk and they try to pull up the sand and starts to cruise and they still have a Tortola. Then that's when I think about, you know, musculoskeletal um issues or if it's just, you know, if it's just like, you know, off to the side rather than, you know, turned, but that's just um some general observations um from the neurosurgical side. All right. So um um talking about um uh selective dorsal rhizotomy and um cerebral palsy, we all know that cerebral palsy is loss of impairment, motor function is one of the most common um pediatric conditions up to 2.5 out of the 1000 live births. It's typically caused by brain injury prenatally or perinatal and it typically manifests by three years of age. Uh we know there are different types, there's spastic, there's a toxic and mixed um purpose of this talk. We're gonna concentrate more on the spastic uh cerebral palsy, the spastic diplegia or even the spastic quadriplegia. We all remember um that uh you know, the spinal reflex on its own is hyper active. So we need the inhibitory influences from the brain to keep it in check to modulate it for normal motor function. And when we do have um um brain injury, we typically lose that inhibitory modulation. So we have increased resistance, spasticity, hypertonia and spasticity is of course, uh classic, classically defined by um increased resistance to externally um imposed movement, you know, hyper clonus or hyperlexia. So, this hypertonicity along with um the associated motor weakness, lack of motor control, uh leads to we all know deformity and loss of function. Um This um also, you know, patients have decreased strength, uh they have decreased mobility, this can lead to chronic pain over a lifetime. Um um There's orthopedic morbidity from it. And then, you know, we're taking medicine or having repeated orthopedic surgery, we can have, you know, morbidities from dad. And typically, um um I, you know, Bob isn't here, but one of the most experienced we have uh physicians is by 50 Children with any sort of spasticity from C P typically lose their mobility and just go into a wheelchair. Um because these things add up over time. So, while the brain lesion is static, right, the clinical presentation and the morbidity um and the interference with daily function is dynamic, it goes on, it gets worse and worse throughout the lifetime. And certainly for the most um affected patients, um we have also um uh the burden of care and their orthopedic complications um increase over time. So what is selective dorsal rhizotomy, selective dorsal rhizotomy is an operation where we go and um interfere or we interrupt the hyper reflexic cycle or uh circuitry by cutting some of the dorsal nerves. It's called selective because we select the dorsal nerves that's most responsible for the um um specificity by neurophysiology criteria. We also target the muscle groups that we're looking for. And of course, the dorsal means, uh of course, we're cutting the dorsal nerve roots, we're not cutting the ventral nerve roots. And the rhizotomy is of course cutting the root nerve roots. So this is the only um treatment amongst our arm terrarium that permanently um reduces specificity. So this is the set up. Uh We do a one level laminoplasty. When I first started this, actually, the operation was popularized in uh North America by Dr Peacock. Uh I learned it from him back then. We actually did a five level exposure, which is a big exposure. Now, we just go directly to the um we um um ascertain where the Conus is with a quick MRI and I'll show that. And then um we have um uh we would anatomically separate the ventral nerve roots from the dorsal nerve roots by anatomy and also by neurophysiology because the simulation threshold for the dorsal nerve roots typically are, are 100 to 10 times higher than the ventral nerve roots. And then we put um uh um electrodes in the major muscle groups when we, and we know which muscles we're targeting. Um we give the nerve roots a chain of stimulation and we observe their response and the worst response are when it goes contralateral to the other side showing total lack of inhibition or they have sustained uh responses such as what you would see with clonus or when you have agony antagonate muscles, both go off at the same time. And you know, of those muscles uh are in a faulty uh working pattern. So sorry about that. So, um yeah, so in terms of classification, um we all know this classification uh for um patients with um G M F CS scores 2 to 4 with who needs assistance with. We offer a functional selective rhizome which improves their gait and mobility, you know, and this is one of my favorite operations because as it turns out when you can make people walk better, they're just over the moon, parents are over the moon, like if you take out a brain tumor or take out an ep Hema and save their lives just like, ok, thanks doc have a good life, you know, because I was entitled to that. I mean, I my brain tumor needed to be treated, my human tumor needed to be evacuated. Um Not that people aren't grateful. Of course, they're happy, but when you make them walk better, it's like my best cards that I get are from families that are from patients who get to walk better. And certainly we, we also can uh uh patients who are severely affected can also benefit from reduction in tone either by back with the pump or this operation uh to uh reduce uh orthopedic uh or um reduce orthopedic morbidity and also increase ease of care. So, uh this of course, is a team approach you heard today, how we have a team and this is, you know, uh patients go through a multi um um um specialty uh evaluation and our therapists are super important in helping us select the patients. Um Our approach with this is that the S C R program, the surgery is only a very small part of it. We keep the patients in house for 4 to 6 weeks to learn how to use our looser legs. So I tell families this is neuroplasticity, right? So we're taking away the spasticity um to allow better mobil mo mo mobility and better gate pattern. But it takes time for that to be ingrained. And these days it's very hard to get outpatient therapy or even if you can get outpatient therapy, you certainly can't get it three times a day, six days a week. So our program incorporates a 4 to 6 week stay, which I think is one of the you in the country that actually does that. Um optimal age is seven. Um for so for us, um you know, you have to be able to uh cooperate in the inpatient therapy program. Um some centers do it much younger. But by seven or eight, you know, your adult gate pattern is starting to be ingrained. So if we can get to these patients before seven. That would be great. Um, so this is, uh, this is what a quick MRI looks like. So everybody's, as it turns out, um, medical school tells us is at two. Right. Well, it's not at L two for everybody and because we're doing a one level, a small exposure, we have to know exactly where to make the incision. So, um, we do a quick MRI. So this does not need sedation. This is actually also the study I would do if I have an atypical depo that I don't really want to pull the trigger on getting a full sedated. MRI on someone who has a low chance of having a te corresponds. So you can see it's a pretty good picture. So, so we know where to go. The incision is pretty small, um such as that. And then uh once we um we don't do a laminectomy, most places do a laminectomy, we actually do what's called a Lano plasty. We lift up the bone like we open the door and we tracked the side over there. And these are other roots that we see. Uh And then uh anatomically, we would separate the dorsal nerve roots from the spinal cord and the ventral nerve roots are down there. And then now the fun starts. So we would take that big bundle of dorsal nerve roots and we would stimulate each root lit and then um for uh patients who we want to improve function. R we cut 60 to 65% for functional rhizotomies. And then we stimulate each one of these nerves to look for those responses. That I was mentioning whether it goes contralateral, whether it has sustained uh reactivity or whether it has multiple muscle groups. And then we also tailor it to the patient's gate. So if there's a lot of scissoring, we would cut more abductors. If we're on our toes, we would cut more gastro. And for the therapeutic ones, we want to um cut up to 70% of uh the dorsal nerve roots uh to achieve reduction in tone. And of course, uh I didn't mention, but we all remember that uh sensation is very overlapped. So you can uh uh cut uh up to this amount of dorsal nerve roots and still have full proprioception and uh sensation. Patients do get a little numb after surgery, but that generally goes away very quickly. So, and then we tabulate, of course, um what we're doing. Um And um um the setup also allows us to uh we have clear drapes uh and in the lower extremities. And then, so we can immediately test for Clonus. I don't know if this is a, this is a Yeah. So, um after we, we, we're doing our omy, we go in and we, we test for Clonus and uh this is supposed to show that we have Clonus on the right, but no more Clonus on the left. All right. Thank you so much. And I think uh we're following this with uh some clinical examples with uh uh doctor. Thank you so much. Oh Did you wanna talk? Oh, yeah. So this, this, this picture of the, the blue is um it does go away, don't worry. OK. Um So we mark the spin process uh before we uh put it aside and then we put it back on, you can see everything is put back on. So this really uh when it heals, it's like it really has no impact on spine health down the line. You one more slide. No, that's not. That's the last one. OK. Great. Thanks so much. All right. So we're gonna um go over some cases spending the most time on the first patient. Uh Our CCS Alameda County crew will probably recognize this patient. Um All right. So patient A he is the first time he presents to our Spasticity Clinic. He is 6.5 years old. He's an ex full term male with a spastic diplegic C P G M F CS 23. He has developmental delay and was uh referred for consideration of a selective dorsal rhizotomy past medical history. He was born in Guatemala. Um full term C section mom reports. She wasn't really told the details, but that uh prenatal period was uh unhealthy. He already had an MRI actually work up and that showed increased paraventricular signal like leos or A K scarring from uh some sort of prenatal slash perinatal circulatory issue. And then he had some genetic testing, further genetic testing when he came to the states, which revealed a likely diagnosis of Shorin Larson syndrome. So, it's an aal recessive um inborn error of lipid metabolism, which consists of skin findings, um developmental delay and spasticity. And he had already gone through four rounds of chemo denervation. Prior to seeing us in city clinic, the last two did consist of serial casting developmentally. He was sitting unsupported at 18 months. So it's just kind of before that cut off that we talked about at two years, he was crawling um and doing some supported standing at two years, nine months. Then his current functional status consisted of him crawling for his main floor mobility. Um He's able to climb in and out of bed, but he couldn't stand on his own and sometimes you would use a walker. He can sort of help with AD L S and mostly non-verbal but could have pretty good receptive language. And he was already plugged in with the CCS medical therapy program and was getting monitored by P T and O T. His equipment included a walker, um an adaptive stroller bilateral turb A F OS which is are solid A F Os and knee extension orthosis to try to keep his knees straighter. So the team met him and thought that he the impression was he had good partial support but very spastic bilateral lower extremities. So the team had recommended getting going moving forward with the selective door on me to help mostly with caregiver ease. Um and maybe get some functional benefit too given that he's a G M F C s3 slash four. We didn't know how much function we could get out of him. Um But we're hoping to like kind of get him better from a four to a three, not using, you know, the full on gate trainer and getting to use just a reverse walker more functionally. But the problem is the family wanted him to walk independently. So that's when um our social worker is really helpful. We have a social worker in our clinic and then the rehab, the whoever the Pyschiatrist is, who's seeing the um patient and family spend a lot of time, kind of going over expectations. Um He, when you see the video, you'll see that he has really severe plan reflection contractures to the point where we thought like, oh, we may have to intervene with some soft tissue releases even during his hospital stay. And then, you know, given that he has this underlying um Shogren Larsen syndrome, we weren't sure how that would, how that would evolve over time. So the nice thing is we have a neuromuscular neurologist in our spasticity clinic and he was able to do some research on the syndrome and reassure, reassured us that it wouldn't progress very quickly. So that's why we felt confident in recommending the rhizotomy. Unfortunately, he was lost to follow up for a year and a half. And then it was his pediatrician who finally got him back in to see us. And by then he was almost eight years old. And, um, so did the whole you'll see video from that clinic as well. He went to the O R just shortly after turning eight and doctor so did his surgery and you'll see he got about 50% cut on both sides and then he spent six weeks on her rehab unit. All righty. Sure. Let me just try to pull up the slides. Hold on, hold on, hold on. Ok. It's just gonna play. Let's see if this works. I can talk all this, talk about um in clinic when we're seeing him. Uh uh One thing we're always doing is test taking MA S scores and range motion scores. So this will all make sense when you see the video. But um uh his modified dashboard for his hips were like one and it need flexors, two need sensors too. But most notably, you'll see that his hip, there we go. His a actors or at a three and his line flexors at a four. So they are very, very, very fixed. Um We'll see in the video it's very cute. Um That uh as he's walking, his four ft is the only thing hitting the ground. He's got that huge fine skate, the toes dragging. And he's, even if you look at his right, even in that much reflection on his right side, you'll see his mid foot collapsing in his terminal stands because he can't even take that much to build progression. Even with his like 35 40 degrees of minor reflection, his mid foot is completely um collapsing on right. Um When you stay. Uh And um, yeah, I'll wait till we get along. So, yeah, so you'll see the for going the point gate dragging his toes has no clearance. His knees and hips are staying flashed throughout the whole game patter and they absolutely have to, even though he had these contractors additionally, you think of just the ground reaction that this is causing on this very, very narrow, effective looks that he has hitting the ground, everything is causing everything flex and it's just gonna promote this fluing pattern forever and ever and ever. Um, he has some mild scissoring and this is that first video before he was lost to file the follow up. And um I think the only reason not seeing even more scissoring is because it was a three and he's um, he's not getting much of a catch, it's just constantly pulling. So there's not an additional, it just come staying right there. Um Yes. Uh So his fringe with his Dorsey collection with his knees relatively extended as extended as they go is negative 35 is the maximum stretch that we can get. His, the extension is negative 40 on both sides. Um His angle is like, you know, 90 if that and his, his um uh a direct and he only is at 20 degrees. Um So from a therapist standpoint, if you're seeing him and, and you, you're thinking how you're trying to work with your artist and you're like, let's try to brace this guy. I mean, you thought, think about the wedging and the shoes, the modify things you have to put in there. You would need like a 40 degree at least wedge um in there to get any sort of relative shaft, vertical angle that's above neutral to get anything. Um So the therapist amazing ccs people, we're only seeing him about like 11 time a month because what, what can I do? What, what can I do here? Um This is his second time through our Asbestos City 20 follow up when you see his, he's only got worse after seeing him that one time among them. He's just, he's getting worse as he grows up from. The first video was when he was six and now he's feet. I believe so, he's just getting effectively worse. Um And I think if you're big on this pattern, uh, that I don't, I don't think we would be past this kind of work today. Um That's my personal opinion. There's no study with that. That's just, um, my own thoughts. Um, so, yes. Um, oh, this is our attempt. I think, I think like, anyway, yes, I think therapist will all agree. If this poor child walked in and this whole independent walking and this child walked in to your clinic, you would be like, there's only so much we can do. His body is breaking down with every step you take. There's nothing the amount of racing. I don't think we, yeah, we have to be very creative, very, very creative. Um especially, I don't know, I don't know how if you guys need specialty shoes, I have a very hard time with it. So let me know all your resources for special shoes or your so that you can tune them appropriately because yeah, you would definitely need them. Yeah. So next is moving into the post op videos. I just wanted to preface by saying that. So after kids spend their like 4 to 8 weeks on rehab, then um they go home and continue with outpatient therapies, we usually try to ask for 2 to 3 times a week and um the M T us try to fill that for at least six months, if not 12 months. Um then I'll see them in like for a one month out hospital discharge, follow up, make sure that they're already, you know, plugged into the resources that they need. And then we bring them back to our Spasticity Clinic at the six month mark and the 12 month mark. And if they look good after that, then we say, ok, you're done. But sometimes we will still bring them in. Um, like at the two year mark, we usually counsel families that they're gonna, they may look a lot worse right after the s well, they do look a lot worse right after the surgery. And, um, we don't really gauge success until the one year out mark. So this is him eight months out and give him his braces with this one. So we have a bare foot out there. But you'll see if this kid walked into your clinic. He would say I can work with that, that I can raise that. I can get that. I can keep walking for a longer, much more longevity of his life. I mean, he's getting that flap so he's not getting tricky. He's getting a flat foot, at least initial contact. His mid foot is, you'll see he's still collapsing and, um, when he's barefoot, but with racing, uh, like solid, you can totally control that. He still has a knee selection. Um And so he still has like 15 degree knee flexion contractors, but that's a lot better than the 40 it was before. Um, and now his ankle Dorsey collection um with knee flexion and he's getting like positive ranges into about a positive 15. Um So all of that is great, but he goes through so that can include proper product management that's something that we can much better work with. Um And then you guys at the N T U, we now see him twice a week because this is something you said we, this is something you could much more have uh effective therapy session. So I think that speaks a lot too that you guys aren't able to uh um keep going with therapy and his longevity for his walking is looking much more promising and it's just just one case. Um uh And I, I think I was supposed to talk about what we look at in those pre-op videos as well from a therapy standpoint and beyond just the ma s and range scores. Um uh We look at single egg stands and squat uh like swat recover if they can or if they can't. And for this particular kid, he couldn't um do a single egg at all in the pre-op and post. Now he can somehow, but you can actually do it. And that's mostly just in your way, you have to have a little bit of tibial progression, a little bit of nosy collection in order to have your, you know, blood line come down effectively. He's now able to do that which just transfers over to all the other functions. Um The other things you look at in a clinic are behaviors. We don't like to take anyone. We take a wide range of behaviors. Everyone in uh the, all of our CCS friends here will know all of that we love and we get to work with. Um But there's some things that we will not recommend a Razo tour because if they can't minimally participate in a rehab program, we don't see the benefits uh as much. So one thing we do, we as a behavior, the goals of the patient, the goals of the um uh and the most of the family because it has to be everyone's buying into it. Um, because it is a lot of work afterwards. It's not, uh, you know, after so does the big, but then they have to do a lot of, a lot of work after in order to make it um, more functional. Yeah. Yeah. It's not uncommon for us to evaluate them the first time and, you know, take into con really true consideration of where their cognitive maturity level is at and just say, oh, they're not ready yet, let's bring them back in six months or a year. Ok. Is this anything? Ok. Let me pull. So those are the eight months out and here's his kind of one year check back in, there's Lucy. Oh, ok, let me forward this. Um So I would say in this video he's not scissoring as significantly, although he still has some of that dynamic tone that we see persist after surgery. Yeah. Yeah, I wouldn't. Doctor Sun always does a great job of getting rid of like there's never any clonus, no reflexes um afterwards. So during this clinic, mom was expressing how happy she was that he, you know, she did see some of the benefits from getting better caregiver, ease with diapering and hygiene and grooming. And I mentioned in the beginning, we weren't really sure how much function we would get out of him. Um Since there were many layers of like how tight he was and his behavior as well. Um Surprisingly, I was looking back at the back at the old notes when he was in the hospital on rehab and he didn't even need serial casting. Somehow his ankles just melted back down like his heels just came down on their own after the surgery, which is amazing. So that's just him showing off how much he was using his arms before to get around in his walker. Let's see if there's anything. If I had more technical skills, I would have been able to edit these videos better for you all. So in this check in, he still wasn't really confident enough to stand on his own and take some independent steps. But then I got some video from his CCS therapist out in at the M T U. Impressive and that's what brace is and the last one is him without Yeah. So I think that's more than we were expecting. Honestly, it doesn't look beautiful, but we didn't even think he would be able to take independent steps, not fixing everything but it's definitely increasing the longevity of his walking and giving you guys to work with them a very uh you know, on a weekly basis, something more to work with. And then I think um Fiona, you wanna come talk about the rehab, stay. Um If I talk from here, can you all hear me? Fine, great, excellent. Um So, as has been mentioned, the um kids come to us and C clinic and we do an evaluation at that stage, both O T and P T as well as the rest of the team. Um because as, as you mentioned, it's really important that kids uh have enough cognition to work with us as therapists can manage behaviorally because the expectation when they come to us is not just a six week stay but that they be able to do three hours of therapy a day um and very consistently and that we will see progress. So there needs to be um cognitive capacity even if there are delays and it is challenging and difficult at baseline um to, to be able to motor plan and to sequence and to progress in learning. Um And that's really different for every patient. We're also from an O T perspective looking to see does this kid participate in any way in their self-care in their dressing and toilet and bathing? We do see variable levels in that. Um But we are hoping to be able to help to progress those skills as well in addition to the gate and the walking. Um so when the, the child has had the surgery and they come to us on rehab, we reevaluate them, we find out what their prior levels were, what kind of equipment they have in terms of mobility activity equipment? Is it still appropriate for them? Does it fit them? Um and then evaluate that during their stage. Does that equipment need progressing? Also, I think as my mentioned in her talk earlier, um these kids are usually kind of at a developmental age where they're bodies are physically growing. So they're physically more um to manage for their caregivers. But also in a stage where with a more typically developing child, we'd probably expect them to be participating more in their care, but the family may well have developed the routine of caring for their child. Um So something that I think is kind of unique for us um as occupational therapists particularly, is this very intense rehab, say where life is put on hold and terms of like how long you have to get dressed every day or practicing, getting to the toilet. And so we really can work with the child and the family. They may have, you know, new mobility, they have changes in their ability to sit unsupported um that were progressing during their stay. But we can also say what's some adaptive equipment that might be appropriate and we now have six weeks to work on teaching you to use it. Um So, so that's something that we do as well. Um You can go to the next slide. Uh So in terms of our therapy, what it looks like there's a lot of crossover between O T and P T. Um because of course, uh some of these kids, as you've seen in the video have been using their spasticity and their tone in a functional manner for how they sit, how they get around. Um So this has changed their body, their sense center of gravity. Um We'll have Children who now feel very insecure, sitting somewhere unsupported, don't want to reach for objects. And so there's a lot of relearning, just play, setting things up for them to build strength where in the past their phone has um helped them stable. Um So lots of motor uh yeah, neuroplasticity, lots of retraining sequencing, a lot of repetition in what we do. Um We spend time with kids, we get them in a standard. So they're weight bearing into their legs and have freedom of movement with their arms and they work with fine motor skills as well. Um We spend a lot of time in prone in different positions to gain strength in all of the posterior muscles. A lot of extension get the stretch to the lower extremities where there may have been um pip collection before for the Chrome. The main reason we um are doing a lot and a lot of so, um we all function as our everyone's therapist. Main goal or everyone's main goal is to focus on function. But this is a unique situation where we actually can't usually start and function right away because we do need to build a little groundwork, unlike um traumatic brain injury or stroke or other types of things where even then like it show like high intensity train, like just go for it. That's gonna be crazy. You know, uh this one that you really do have to take a step back. Um And the pro we need to be able to uh strengthen the extensors and get them to learn to fire when extended, uh which is very, very different than most of our crouch walkers because you think we're gonna go back. I know it's like five PM and no one wants to think about school for a second, but I feel like Mildrid Ros and there's like the acting and the, and they're overlapping a little bit. Ring some bells, right? Um And then if they've always been kind of stretched out and they're never closing that little gap, even when they're firing, they're not contracting to that close extent. So now we're are able to get that range and so we wanna be able to fire or do a consentual contraption in that more end range. So in order to fire your glutes and an end range position for someone that can't yet stand or do any of those more functional things, like our most favorite position is prone superman. So we spend a lot of time and that our modification of that in some sort. Um And that's kind of the reasoning as to get those things going. Um And not, uh if people are carrying it over outside because it's good for life like um uh it not, not trying to get these types of Crown Supermans. This is like my least favorite thing to see is people, oh, they're beautiful prone and then they just like scared of their chap and come to this fixation period. But actually doing the law trying to get your multi everything in the long chain forming and from a neutral hip of now that we're getting at zero hip, zero degrees like hip extension from there trying to activate the boots to get that glut extension. And that's kind of the foundation we need before are getting up and standing and walking. And um also like and sitting the same things. Um when we're sitting with our feet on the ground, we all know our kids when you reach forward or do anything, their, their legs just flex under them because everything's used to just coming here. So now even in that if we're feet are flat and now we're reaching forward. Are we staying in that position and activating it there? Um So those are kind of the ground works on rehab that we spent a month, at least we usually don't get people on their feet until, like, besides outside of the standard until like that six week mark, at least after their surgery. Um, there's a lot of ground work that needs to be laid and I think that's a little bit different than most other rehab mentalities, especially that come out now. So, yeah, that's one keep going. All right. Um, so something else that we do is we fabricate the extensions ones. Um The picture on the left here is one that's sort of in the midst of being fabricated. It's not yet cut down and then is our patient in the wheelchair with those on. We do make them over their A F O si would say almost all the kids have A F Os coming to us already. Um And those are modifiable. So it's a thermoplastic um that the uh form fit to the child where they are at that point, we try and maximize the popal angle, uh create that splint and then a week later go back and increase the stretch to it. So they'll be wearing it when they're up in their wheelchair seated like this snugged in really tightly. Um It doesn't show as much on this picture, but oftentimes we make sure that the foot rests uh are at like a 90 degree and that the legs are fully extended to maximize the stretch all the time. If kids will tolerate them overnight. That's great too. So just kind of constantly stretching the muscles out to gain that angle over a gradual period of time. Uh And then this is just some of the equipment probably familiar to therapists out there. Uh But we spend lots of time, as we said in Superman in Chrome. Um having kids engage in stuff that they really enjoy uh increasing the demand of the tap, the, the objects they need is outside their region. And so they really have to stretch forward or they might be in tall meal um uh reaching for things and we'll have them tuck their chin and reach overhead because that engages the core muscles so much more as well as um the glutes, lots of like sideways to meal, walking to go and get toys along the way. Also, many of these Children have had tightly abduct or excuse me, abducted um hips. And so if they can, we'll straddle over a red bolster like in that third top picture there while engaged in play and really just be in these uh more functional positions while gaining the strength very progressively over time. Um We might get on a scooter board and go finding things down the hallway um and the standard as well. Um So most people try to avoid me and I understand that unfortunately, you know, um so you, you think like if you're able to remove the spasticity, then hopefully the um the effects on the joint, um will be negated. But, you know, as this kid was eight years old, he already had a lot of his hip development. And so I think there's been a lot of literature to show that though S D R does not necessarily prevent orthopedics from needing to do their hip reconstructive surgeries to better like fix that bony anatomy. I think it does decrease the orthopedic surgical burden, um where you're not having to go and continuously like release different muscles and weaken different muscles and tendons. And so, um he is now on my surgical uh wait list for um bilateral V D R OS and likely like and likely um uh PCIO um often depending on their age that we might stage. Um we'll do bilateral the arrows that stage their pelvis. The thing is when again, I know I said this earlier, but when I do the surgery, I do weaken them. And so when I watch him walk, you can see the scissoring. Um So that will be improved. We put him in on the hips and better bars. Um But then his abductors are pretty weak and he circumduct a lot on the right. What worries me if a kid is too old um is that they're just gonna, you know, after I make a nonwaiver 4 to 6 weeks that they're not gonna have the motivation to stand back up again and to try hard again. So if we can um admit to rehab after the six weeks and there's enough phony consolidation that the plates can handle it. We'll do that to, to do physical therapy and O T and something intensive to get them back and motivated. Typically after S er, especially in um, a functional S C R, uh we will wait like six months or a year before I do my portion because they're weakened after S D R, but they gain that strength back in the um rehabilitation afterwards. As everyone's been saying to is focusing on them if I come in and do my work and that's a double hit and um we don't want to weaken someone that much. Uh So we will wait about a year as long as the hits can take it. If it hit, it's gonna dislocate, we just see it moving over. The speed decrease is unlikely to progress very fast so often we can wait. Um So what you see on the left is when he was six years old, migration percent on the right with 20% on the left, um was 30% and then at nine years old, I mean, it's pretty good at 40%. Um And so you can, you know it, it progress um but it's, it's not bad. Um But I do see Obor when I walk in, I want to make that better. Um And then the other things I look at too are the indices or angles. Um and you can see their elevator at nine years old. And that's why he said he probably needs to really contain those hips bone wise. And the thing is when you do the hip reconstructions, while young, if the spasticity is unchecked and the, um, neuromuscular forces are unchecked, then if you do them while young, there's so much growth and development, you're at risk for needing to redo the surgery, um, in the future. And so when that tone is addressed, it makes the like likelihood of my surgery, um like it increases the likelihood of the success of my surgery. So I think for this. Oh, yeah, sorry. The circles are for Chen's lines. You should be a nice arc from the operator brain along the neck and you could see it grown bilaterally, um starting at six years old, but then worse at nine years old. Um, they don't even like form a nice arch. And so, um, my plan if I can remember correctly, um his bilateral video videos on the right of public. Um, and then the stage on the left later and then probably gastro recessions not doing T A L like things but the gas rocks will still allow like power. Um And so it won't weaken him too much. Um Yeah. Ok. So I think in the interest of time since we're supposed to end in five minutes, I'll just do one more case and just mostly show the video we have patient B So when he came through our S C clinic, he was five years old uh known X 29 week prey with spastic diplegic C P G M F CS one slash two uh mild learning delay, remote history of seizures. And he was also being um considered for a functional rhizotomy. This is when we were in our old rehab area for asbestos clinic. So, Lucy, you wanna OK, I'll go really quick but you can see he's got the uh very poor foot clearing more so on the right. He's got in to, um, and you can see the kind of sweet bearing bilaterally. And then you also notice everything works up the chain as he's snapping back into extension in his knees and stands and he has that increased hip internal rotation. Um And he's just dragging a little baby toes all throughout the ground. Um So this is someone that is a much higher level and you might look at and say, um, isn't he too good for me? And I think that's one of the things we're finding is that we make a lot of kids better or it, it's not going to, I don't mind it, but we're not finding that it makes people worse, even if we're functionally not changing levels, we're not making people worse, even the good ones relatively. Sorry, I'm gonna try to forward. I think that right, because I feel like a lot of people like I don't do S D R s. Right? And in training, I wasn't exposed to S D R s and I've learned so much work in this team here. Um And people's concerns. Look at that hell to though. I mean, come on, sorry, sorry, I don't want people's concerns. Ask me is, and I, I'm like, I'm not the neurosurgeon but it, they're like, is my kid gonna be too weak afterwards? Don't they need to tell me what this is? I think what you're saying is showing is, um, you know, they, yeah, um and I, I think we noticed in the pre gate video too that, um, he was able to squat. I don't know if anyone saw that. Um A a and it looked like, oh, so he, he did, in fact, this kid was before our electronic medical records. Actually finding his ranges was tough because I was actually rehab therapist and that saves me a little bit too. But um, I couldn't find his actual ranges but if I noticed when he um, squatted when he was being to squat, it looks like he had pretty a decent range that was just over burdened and by the tone in his walking and we uh doctor so, you know, beautifully took most of that away and it makes it, um just even, uh, so that he's so that he doesn't have as bad of a foot drag and everything and something that can very nicely take and this is even many years later. Three years later, there you go. No one here is from Merced County ccs. I mean, I think no, this is Bob's patient. So when you see him from the back, I think you notice that his right side ankle looks a little tighter once we get him in view. So he's doing some low toe walking, especially when he starts to walk faster. You can see it there, that heel coming up. Then this is him 10 years out and this was recently taken out at his M T U by our senior doc doctor who goes out to those further locations. So I don't know, I mean, I think that it's pretty obvious even to a layperson, I would say um a few things not anyone can refer into our clinic. Well, the official title is, let's see, Multidisciplinary Hypertonicity Clinic. I think that's what the CCS specialty Care Center name is, but colloquially, we call it our speciality clinic. Um There are people who outside of the system who refer to spasticity clinic and our nurses will triage and just make sure like if they've some people think, oh, it's just for spasticity management. So then they'll get triage into the Pyschiatrist clinic. Usually it's neurosurgery Petes Ortho um rehab referring in specifically into spasticity clinic because it's like a two hour long visit. And it's mostly for the kids who have tried everything else and need more surgical intervention and then just so, you know, if you wanted to show a family more about it, if you go to our general web page, um, you have children's, there's a story on another patient in the past. That's pretty nice, that's developed there and I think I'll end there. Thank you.
