An interdisciplinary approach to intensive rehabilitation post Selective Dorsal Rhizothomy / Une approche interdisciplinaire de réadaptation ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
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
i000
SDR journey • Spasticity Clinic • Surgery • Intensive in-patient Rehabilitation – 6 weeks in- patient 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
Ambulators dependent on Improve quality of walking and
2 assistive devices (canes, walkers) decrease amount of assistance
required for ambulation and
transfers
4-points crawlers (either reciprocal or Improve ability to move through
3 non-reciprocal; eg.: bunny hopping) 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 needsSéjour 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 • 9 protocoles
Établissements • Canada & USA
• Interne – réadaptation intensive: 2 à 12 semaines
Réadaptation • Externe – jusqu’à 12 mois post-opératoire
• 1 à 2 x/jour
Physio • 5x/semaine
• Au besoin
Ergo • 4 x/semaineRéférences
• 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, Marie-
Andrée; 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.Merci!
Site web
hopitauxshrinerspourenfants.org/Canada
Facebook
Facebook.com/HopitalShrinersMontreal
Twitter
Twitter.com/ShrinersCanada
Instagram
@SHCCanadaYou can also read
