# Upper Limb Orthotics/Cerebral Palsy with flexion contracture

The patient is a nine year old female who presents with flexion contractures of the wrist. The contracture is only evident on her right side and is a secondary effect of the patients’ unilateral spastic hemiplegic cerebral palsy. At this stage the contracture appears to be limited to the wrist and has not noticeably affected the digits. Measurements taken during the initial appointment stated that the patients resting position of the wrist is thirty five degrees of flexion. This can be corrected to 0 degrees on manipulation. The patient was assessed based on The Manual Ability Classification System and rated as being at level III. Functional assessments of patient performing activities of daily living (i.e. getting dressed, tying shoes, eating etc. indicated that she required help or is very slow when performing these tasks. While current using botulinum toxin injections to manage the contractures, the patient would like to discuss orthotic options. The patients’ goals include independently completing activities of daily living and being able to write and draw more efficiently.

## Written information

This piece will consider and explore various treatment options regarding the case study of a nine year old female with spastic cerebral palsy. The focus will be on her right wrist as it has presented with flexion contractures and must be managed. The contracture appears to be due to the prolonged spasticity in her right flexi carpi ulnaris and right flexor carpi radialis muscles. The patient has been assessed according to The Manual Ability Classification System and is considered a level III (Ohrvall, Krumlinde-Sundholm, and Eliasson, 2013). While currently requiring support and environmental adjustments to complete activities of daily living, the patient is highly motivated to become more independent. When deciding on what treatment to provide, it is important to consider the client goals, physiological state and support available.

### Evidence

Cerebral Palsy, or ‘the cerebral palsies’, is a non-progressive neurological condition which arises as a result of a legion in an immature or developing brain of a child or foetus and affects both posture and movement (Kerr Graham, and Selber, 2003; Dekker, and Bouter, 2004; Hoare et al. 2010). Cerebral palsy is irreversible and while the legion which causes the condition does not change or progress over time, the symptoms generally do (Koman, Smith, and Shilt, 2004). The patient being studied in this case has spastic hemiplegic cerebral palsy and it has been noted that those in this group, while constituting one of the most common of the groups, are the ones most likely to function and assimilate with other ‘typically developing’ children (Kerr Graham, and Selber, 2003; Russo, Atkins, Haan, and Crotty, 2009). Despite this, spasticity is often present and, when in the upper limb, can lead to issues such as decreased force production, control and range of motion (Burtner et al., 2008). This loss of dexterity can in turn significantly affect an individual’s quality of life by resulting in a loss of independence and a decreased ability to continue with activities of daily living. The spasticity associated with this condition, if ongoing and not stretched, can lead to the formation of contractures (Gracies et al., 1997). Fattal-Valevski, Sagi, and Domenievitz, (2010) state that muscle groups such as the wrist flexors are likely to advance to a state of contracture from spasticity at a faster rate than other upper limb muscles, which is consistent with the patient having contractures in her right flexor carpi ulnaris and flexor carpi radialis. The flexor carpi ulnaris is a muscle of the forearm responsible for flexion of the wrist and, if working in conjunction with the extensor carpi ulnaris, it will also adduct the hand by functioning over the wrist joint. The origins of the flexor carpi ulnaris are the medial epicondyle of the humerus and the olecranon and the insertion sites are the pisiform bone, the hook of hamate and the fifth metacarpal bone. Likewise, the flexor carpi radialis is also responsible for flexion of the wrist and works with the flexor carpi ulnaris to produce this action. The attachment sites for the flexor carpi radialis are the medial epicondyle of the humerus and the base of the second metacarpal bone (Moore, Dalley, & Agur, 2010).

### Orthotic treatment options

Upper limb orthoses may be used in this circumstance to aid in the stretching and lengthening of the patients’ wrist flexor tendons to endeavour to manage the flexion contracture. Katalinic, Harvey, and Herbert, (2011) suggest that this could possibly be done by keeping the muscles in a stretched position for a sustained amount of time. Types of non-functional orthoses, such as resting hand orthoses and other removable devices are commonly used to stretch muscles involved in contractures as well as to decrease muscle tone (Jackman, Novak, and Lannin, 2013). The devices used may be either static orthoses or dynamic orthoses. The appropriate materials as well as position of the wrist and digits must be carefully considered before a decision can be finalised. Varying preferences will be seen depending on the clinician or researcher inclination and depending on the different circumstances of the patients involved. In this specific case, the wrist would have to be in slight extension to allow for stretch throughout the wrist flexor muscles in the anterior compartment of the forearm. Louwers, Meester-Delver, Folmer, Nollet, and Beelen, (2011) conclude that if in the correct functional hand position, improvements can be seen through bracing. Gillen, Goldberg, Muller, and Straus, (2008) state that while wrists are conventionally immobilised in thirty degrees of extension when in an orthotic device, the most appropriate degree of extension is dependent on the individual patient and the activities they are most required to perform during the time of treatment. There is little conclusive evidence available indicating with confidence that orthoses are statistically beneficial for managing contractures in cerebral palsy (Exner, and Bonder, 1983; Jackman, Novak, and Lannin, 2013). Katalinic, Harvey, and Herbert, (2011) come to the conclusion that there is no clinically relevant or long term improvements in spasticity or joint mobility when treated with stretch, however it is still a common and widely used form of treatment
Exner, and Bonder, (1983) suggests that, in children with spastic hemiplegic cerebral palsy, bilateral hand use and grasp are both improved with the use of a MacKinnon splint. This splint may be appropriate for contracture management as wrist flexion is decreased by placing pressure on the metacarpal heads, leading to a decrease in flexor tone. However Burtner et al. (2008) warn that while static splints may decrease the tone of the flexor muscles present in the forearm, shoulder muscles may be used in activities as compensation when requiring grip and dexterity. Fayer, and Sayed, (2013) recommend dynamic orthoses over static ones. The dynamic splints allow movement of the wrist while holding it in alignment and their study showed that this improved passive and active range of motion compared to the static splints which caused immobilization. An example of a possible dynamic orthoses is the Lycra arm splint which, in a study by Elliott, Raid, Hamer, Alderson, and Elliott, (2011) was shown to improve functional performance and efficiency of movement.

### Comparison of orthotic treatment options

Alternative treatment modalities can be used to treat contractures. The use of botulinum toxin injections and surgery are both popular options and are widely used. These options can be used alone, or on conjunction with other methods such as orthotic treatment, occupation therapy or physiotherapy. Botulinum toxin injections are used to decrease the tone of the muscles injected, and lead to improvements in grasp, increased functional scores and increased range of motion. The improvements last an average of seven months before the effects diminish (Hoare et al., 2010; Fattal-Valevski, Sagi, and Domenievitz, 2010). Fattal-Valevski, Sagi, and Domenievitz, (2010) report that the use of these injections resulted in improvements in Manual Ability Classification scores for some of the participants in their study. Surgery is also used successfully to manage wrist contractures. Wenner, and Johnson, (1988) state that post-operative improvements can be seen in grasp and range of motion of the wrist joint. The surgery is performed by transferring the spastic, hypertonic flexor carpi ulnaris muscle from the anterior compartment of the forearm to the posterior compartments’ extensor carpi radialis longus or extensor carpi radialis brevis.
As discussed, multiple treatment options are available when dealing with contractures relating to spastic hemiplegic cerebral palsy. Orthotic interventions appear to be widely used clinically, despite the lack of data supporting its effectiveness. These orthoses range in type, material, and positioning of the wrist and decisions on which device to use are dependent on the clinician preference as well as the patient requirements. Aside from orthoses, surgery and botulinum toxin injections are also used in the management of contractures. While botulinum is a temporary treatment method, its effectiveness is documented. Surgery has the most permanent positive effect and can be used in conjuncture with orthotic treatment to provide maximum benefit to the patient.

### Search Strategy

Databases such as Medline, Cinahl, and Cochrane Library were used when researching this case study. Terms such as cerebral, palsy, hemiplegic, contracture, spasticity, muscle tone, orthoses, splint, brace, botox, and wrist flexors were used to complete the search. Once articles were found, the reference lists of those articles were also used as a source of more information.