Management of the upper limb in cerebral palsy

Abstract

The management of the upper limb in children with cerebral palsy (CP) is complex and challenging, requiring a co-ordinated, multidisciplinary approach. The management team may include developmental paediatricians, occupational therapists, physiotherapists, orthotists and upper extremity surgeons from an orthopaedic or plastic surgery background. Interventions are generally aimed at improving function and cosmesis by various combinations of motor training, strengthening, spasticity management, movement disorder management and the prevention of contractures and other fixed deformities by effective splinting and positioning. Movement disorders may respond to oral medications but when severe, may require neurosurgical approaches such as intrathecal baclofen (ITB) or deep brain stimulation (DBS). The correction of fixed musculoskeletal deformities requires various combinations of muscle-tendon lengthenings, tendon transfers, osteotomies, arthrodeses and joint stabilizing procedures. These can be performed as individual surgical procedures or as multiple procedures, in a single session of upper limb surgery, single-event multilevel surgery (SEMLS). Occupational therapy and physiotherapy have small treatment effects in isolation but are essential adjuncts to medical and surgical management. The therapy with botulinum toxin A has small effects and short-lived. Surgery is also effective but requires careful patient selection, as many children with CP are not candidates for upper limb surgery. Surgery management varies according to the needs and goals of each child and family. Children with severe involvement (MACS IV and V) may benefit from simple surgery to relieve pain and to make care and activities of daily living easier. Procedures include correction of severe fixed deformities around the shoulder, elbow and wrist by soft tissue releases or in the case of the severely flexed wrist, by arthrodesis. Children with higher levels of function (MACS I-III) may benefit from various combinations of muscle-tendon lengthenings, for flexion deformities and tendon transfers and for muscle imbalance, joint stabilization and correction of "thumb-in-palm" deformity. SEMLS for the upper limb can improve both cosmesis and function. The outcomes of surgical management are greater than those obtained from therapy or botulinum toxin A injections in the domains of joint range of motion, function and quality of life.