Is High Muscle Tone related to Cerebral Palsy?

High muscle tone, or hypertonia, is a condition that causes tight muscles and stiff or rigid movements. It is especially common in cerebral palsy patients. Symptoms of high muscle tone include loss of function and limited range of motion, causing a child to have issues properly sitting or standing up. However, cerebral palsy is not the only cause of hypertonia. Read more to learn about what to do if you think your child has hypertonia possibly caused by cerebral palsy. Cerebral Palsy & High Muscle Tone Cerebral palsy is caused by damage to the parts of the brain that control motor functions, such as muscle tone. This is especially true in the most common form of CP that accounts for 70% of all cases — spastic cerebral palsy. Muscle tone in cerebral palsy patients can be low, high, or a combination of both. The type of muscle tone abnormality a person experiences is based on the severity and location of damage to the brain. High muscle tone is called hypertonia and is often seen within the first 18 months of life. Hypertonia causes too much muscle tone which causes arms or legs to be stiff and, therefore, difficult to move. Hypertonia doesn’t mean anything is wrong with the muscles, but rather that the brain cannot voluntarily control them. This causes the muscles to over- or under-develop, leading to high or low muscle tone. Since their muscles are constantly contracting, cerebral palsy patients with hypertonia tend to have stiff or rigid movements. What Causes High Muscle Tone? Although hypertonia in cerebral palsy patients is common, high muscle tone does not always mean your child has developed cerebral palsy. Other conditions that are linked with high muscle tone are: • Brain bleeds • In-utero strokes • Multiple sclerosis • Parkinson’s disease • Toxins in the brain Traumatic birth injuries or injury to the spinal cord can also cause hypertonia to occur. Birth trauma may be preventable with proper care during childbirth. Treatment for High Muscle Tone If high muscle tone is not managed correctly, it can limit a child’s range of motion and overall independence. This is the result of consistently pulling the body into abnormal positions due to muscle spasticity. Severe cases of hypertonia may cause joints to become frozen (joint contractures). Very high muscle tone can also cause secondary conditions such as scoliosis or hip displacement. One of the most common types of treatment for high muscle tone is physical therapy. Physical therapy for high muscle tone includes: • Exercises to relax tight muscles • Muscle stretching for pain and tightness • Strength training • Weight training Another option for treating high muscle tone includes managing the patient’s posture by relaxing them, which can help the body naturally fall into more comfortable positions. Your child’s doctor may also prescribe muscle-relaxing medications such as baclofen, diazepam, and dantrolene. These drugs can be used to reduce muscle tightness and spastic movements. Orthotics — medical devices that help correct musculoskeletal abnormalities — may also be beneficial for children with high muscle tone. Orthotics can hold limbs in place to ensure the correct muscles are stretched. Another important treatment for high muscle tone is practicing daily activities with your child under guidance from their healthcare provider. Helping your child practice movement involved in daily living can allow them to complete these activities on their own. Diagnosing The Cause of Your Child’s Hypertonia Hypertonia is usually noticeable within the child’s first 18 months of life as their bodies start to develop. One of the tell-tale signs of high muscle tone is developmental delays with fine and gross motor skills. Hypertonia signs and symptoms may include: • Crossed or scissored legs • Fisted hand after 6 months of age • Joint and muscle pain • Lack of flexibility • Moving slowly and rigidly • Musculoskeletal deformities • Spasms/involuntary movements • Walking in abnormal patterns Since the symptoms of hypertonia are different for each patient, it is essential to talk with your child’s doctor. This is the best and only way to diagnose the cause of your child’s high muscle tone. You can expect your child’s doctor to examine their symptoms. If the doctor believes your child suffered from trauma during birth, they will conduct brain imaging tests such as MRI (magnetic resonance imaging) and CT (computer tomography) scans to diagnose cerebral palsy. From there, your doctor can determine the cause of your child’s symptoms and start treatment.

Clubfoot: Risks, Diagnosis, & Treatment Options

What is clubfoot? Clubfoot is a birth defect that causes your baby's foot to point down and be turned inward. One or both feet may be affected. Your baby's foot bones, muscles, tendons, and blood vessels may also be affected. Clubfoot can range from mild to severe. Clubfoot develops because the tendons in your baby's leg and foot are shorter and tighter than normal. This causes the foot to be pulled into an incorrect position. What increases my baby's risk for clubfoot? • A family history of clubfoot • Being male • Having another birth defect, such as spina bifida • Not enough amniotic fluid during pregnancy • Cigarette smoking or drug use by his or her mother during pregnancy What are the signs of clubfoot? • Toes point down or toward the opposite foot • Foot turned upside down (severe clubfoot) • A deep crease on the bottom of the foot • Foot stiffness • Foot joints that do not move correctly • Smaller foot, heel, or calf muscles than normal How is clubfoot diagnosed and treated? Your baby's healthcare provider may be able to see the clubfoot on an ultrasound before your baby is born. He or she will be able to see the clubfoot after your baby is born if it is not found before birth. X-rays may be used to find specific bone problems and help plan treatment. Your baby may need any of the following depending on how severe the clubfoot is: • Stretching and casting means stretching the foot toward the correct position and applying a cast to hold the position. The cast will go from your baby's foot to his or her upper thigh. One or 2 times a week, the cast will be removed so the foot can be moved closer to the correct position. A new cast will be applied each time. This will continue for 6 to 8 weeks. Your baby's provider may cut the Achilles tendon, or heel cord, before the final cast is applied. This helps the tendon grow longer before the cast comes off. Ask for information on cast care and safety. • Stretching, taping, and splinting may start soon after your baby is born. Your baby's provider will stretch your baby's foot toward the correct position. He or she will tape and splint the foot to hold it in the correct position. This will continue each day for 2 months. Then it will be done less often until your baby is 6 months old. Stretching and splinting at night will continue until your baby starts to walk. • Surgery may be needed if other treatments do not work or if your baby's clubfoot is severe. Surgery is used to make the heel cord longer, and to fix other foot problems. Your baby will be in a cast for 6 to 8 weeks after surgery. Surgery may not fix clubfoot completely, but it can help improve your child's ability to walk. What are the risks of clubfoot? • Your child may have trouble walking, even after treatment. If only 1 foot was affected, it may be about 1½ shoe sizes smaller than the other foot. The affected leg may be slightly shorter than the other leg. Even after treatment, your child may get leg cramps or become tired when he or she plays sports. Clubfoot can come back, even with treatment. Your child will need more treatment if clubfoot returns. • Left untreated, clubfoot may lead to arthritis. Your child may walk on the balls of his or her feet or on the outer edge. This may prevent his or her calf muscles from developing normally. It may also cause sores or calluses to form on his or her feet. What can I do to manage clubfoot? Help your child do stretching exercises provided by his or her provider. After casting, splinting, or surgery, he or she may also need to wear a brace for 3 to 4 years. A brace is a pair of shoes connected to a metal bar. He or she will wear the brace for 23 hours every day for 3 months. The hour it is off is for when you bathe your child. Your child's provider may also recommend other activities he or she can do while the brace is off. Your child will transition to wearing the brace when he or she sleeps at night and during naps. It can be difficult to make sure your child wears the brace, but it is important so clubfoot does not return. The following can help make it easier to stay with the routine: • Encourage your child to walk and play in the brace. The way your child walks will depend on the kind of brace he or she has. Some braces have bars that bend as the baby walks. You may be able to move his or her legs up and down to help him or her get used to the motion. Other braces have solid bars that do not move. You may be able to help by pushing and pulling on the bar to make his or her legs bend and straighten. Your child may adjust to wearing a brace more easily if you play with him or her while he or she wears it. • Create a brace wearing routine. Tell your child when it is time to put on the brace. Make it a normal part of getting ready for overnight sleep and naps. The brace may prevent your child from sleeping well. Talk to his or her provider if you notice your child is fussy or irritable from not getting enough sleep. • Make your child's foot comfortable. Check that his or her heel is all the way down in the shoe. Tighten the straps to make sure the heel does not slide. It is normal to have some redness at first from the shoes. Do not put lotion on your child's feet. Lotion will make your child's foot slide in the shoe. Check his or her foot a few times every day for blisters, sores, and redness. These may mean his or her heel is sliding in the shoe. • Prevent your child from getting out of the brace. Check that the straps and laces are tightly secured. It may help to have your child wear 2 pairs of socks or to use socks with nonslip soles. You can also try removing the tongue of the shoe. You can make the laces harder to loosen by lacing the shoe from top to bottom. • Make the brace safe. Put a pad on the metal bar. This will help protect your child and anyone who is caring for him or her. It will also help protect furniture as your child walks. Ask your child's provider how to pad the bar and what to use for padding. How can I prevent clubfoot in a future pregnancy? Clubfoot often has no clear cause to prevent, but you can lower your baby's risk. Do not smoke cigarettes or take drugs while you are pregnant. To prevent other birth defects that may lead to clubfoot treatment, take a prenatal vitamin. Start taking it at least 1 month before you get pregnant. Continue as directed through the first trimester. Look for prenatal vitamins that have at least 400 micrograms of folic acid. Folic acid helps prevent birth defects. When should I contact my baby's healthcare provider? • You have questions or concerns about your baby's condition or care. Care Agreement You have the right to help plan your baby's care. Learn about your baby's health condition and how it may be treated. Discuss treatment options with your baby's healthcare providers to decide what care you want for your baby. The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you. © Copyright IBM Corporation 2022 Information is for End User's use only and may not be sold, redistributed or otherwise used for commercial purposes. All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or IBM Watson Health

A Guide to The Ponseti Method for Clubfoot Correction

Introduction: A Brief History of the Ponseti Method Ignacio V. Ponseti can be credited with developing a comprehensive technique for treating congenital clubfoot in the 1940s. One of the major principles of this technique is the concept that the tissues of a newborn's foot, including tendons, ligaments, joint capsules, and certain bones, will yield to gentle manipulation and casting of the feet at weekly intervals. By applying this technique to clubfeet within the first few weeks of life, most clubfeet can be successfully corrected without the need for major reconstructive surgery. This technique is based upon Ponseti's experiences with the wide variety of treatments being applied at that time and his observations in the clinic and operating room, as well as his anatomic dissections and analysis by using a movie camera to produce radiographic images. Utilizing these principles and his understanding of clubfoot anatomy, Dr. Ponseti began employing this technique in 1948 at the University of Iowa. Recently, his observations have been confirmed using modern techniques, including Magnetic Resonance Imaging (MRI). The Ponseti technique has become the most widely practiced method for initial treatment of infants born with clubfeet. It is an easy technique to learn and, when applied accurately, it yields excellent results. The Ponseti Technique The corrective process utilizing the Ponseti technique can be divided into two phases: The Treatment Phase - during which time the deformity is corrected completely The Maintenance Phase - during which time a brace is utilized to prevent recurrence During each of these phases, attention to the details of the technique is essential to minimize the possibility of incomplete correction and recurrences. The Treatment Phase The treatment phase should begin as early as possible, optimally within the first week of life. Gentle manipulation and casting are performed on a weekly basis. Each cast holds the foot in the corrected position, allowing it to gradually re-shape. Generally, five to six casts are required to fully correct the alignment of the foot and ankle. At the time of the final cast, the majority of infants (70% or higher) will require a percutaneous surgical procedure (with a small incision through the skin) to gain adequate length of their Achilles tendon. The Maintenance Phase The final cast remains in place for three weeks, after which the infant's foot is placed into a removable orthotic device. The orthosis is worn 23 hours per day for three months and then during the night-time until 5 years of age. Failure to use the orthosis correctly may result in recurrence of the clubfoot deformity. Good results have been demonstrated at multiple centers, and long-term results indicate that foot function is comparable with that of normal feet. Manipulation and Casting - Distinct Elements of the Ponseti Method The unique manipulation and casting maneuvers used in the Ponseti technique are just two examples of several elements which make it quite distinct from other casting methods. First Cast: Prior to casting, the position of the forefoot (front of the foot) in relation to the heel creates cavus (abnormally high arch) of the foot. The first cast application addresses the foot deformity, aligning the forefoot with the hindfoot (back of the foot). In doing so, the cavus (Figure 1) is corrected (Figure 2), typically after one cast. It is usually easiest to apply the cast in two stages: first a short-leg cast to just below the knee, which is then extended above the knee up to the groin once the plaster sets. This is preferable in older children (beyond 2 to 3 months) who are stronger and less easily consoled during the casting. Ponseti emphasizes the importance of long-leg casts, which are essential to maintain adequate stretching of tendons and ligaments. Second Cast: One week later, the first cast is removed and, after a short period of manipulation, the next toe-to-groin plaster cast is applied. This phase in the manipulation and casting process is focused on straightening the foot, aligning the forefoot with the heel. Care is taken to maintain the downward tilt of the foot; correction of this downward tilt - due to tightness of the ankle - will occur in subsequent casts. Before casting, the physician manipulates the forefoot according to Ponseti's carefully described technique in order to stretch the foot, determining the amount of correction that can be maintained when the plaster cast is applied. Another crucial point in the Ponseti technique, which is radically different than other techniques, is that the heel is never directly manipulated. The gradual correction of the hindfoot and midfoot are such that the heel will naturally move into a correct position. Further Casting: Manipulation and casting are continued on a weekly basis for the next two to three weeks in order to gradually straighten the forefoot, allowing the forefoot to move in line with the heel. After four or five casts have been applied, normal position of the foot will begin to be observed. The Achilles tendon: The Achilles tendon is the cord behind the ankle that allows the ankle to move up and down. In children with clubfoot this tendon is shortened, which prevents the ankle from bending up properly. In the majority of these children the tendon must be lengthened in order to allow sufficient ankle motion. In the Ponseti technique, this is accomplished with a percutaneous surgical release of the tendon, which allows the ankle to be positioned at a right angle with the leg. The percutaneous release is a quick, sterile procedure that is typically done through a small puncture, under local anesthesia. The final cast: The foot and ankle are then casted in the final, corrected position. A total of five or six casts are typically needed to correct the foot and ankle. More are needed in the most severe cases of clubfoot treatment. Maintenance and Recurrence Prevention Upon removal of the final cast, the infant is placed into an orthosis, or brace, which maintains the foot in its corrected position. The purpose of this splinting, after the casting phase in the Ponseti method, is to maintain the foot in the proper position, with the forefeet set apart and pointed upward. This is accomplished with a brace consisting of shoes mounted to a bar. The brace is worn 23 hours per day for the first three months following casting and then while sleeping for several years to follow, usually until around age five. Multiple studies have demonstrated the high risk for recurrence if the brace is not worn according to these guidelines. The reasons for recurrence in feet that appear to be corrected fully have not yet been clearly proven, but regardless of the cause, recurrence appears to be close to zero when the bracing regimen is followed accurately. In one study, researchers reported no recurrences among patients compliant with the foot abduction orthosis compared with 57% recurrence among non-compliant patients when studied at short-term follow-up. (Thacker MM, Scher DM, Sala DA, et al: Use of the foot abduction orthosis following Ponseti casts: Is it essential? Management of Recurrence The risk of recurrence persists for several years after the casting is completed. Ponseti reported a recurrence rate of approximately 50% in his early series, but noted a decrease with greater emphasis placed on the use of the foot orthotic. Early recurrences are best treated with several long-leg plaster casts applied at two-week intervals. The first cast may require correction of recurrent foot deformity, with subsequent casts to correct ankle tightness. An Achilles tendon lengthening may be necessary if there is insufficient correction at the ankle, and a tendon transfer (of the tibialis anterior tendon) may be performed in older children to help maintain the correction. Following this additional surgery, the child is then placed in a long-leg cast for four weeks with the foot in neutral position.