HemiHelp Conference for Professionals, Newcastle, 27 June 2005
The day started early on a bright summer’s morning; people gathering in the Sir James Spence Institute to collect name tags and glug coffee in preparation for the intensive schedule of lectures that lay ahead. A quick glance around at the occupations printed beneath names on the tags indicated that today’s was a varied crowd comprised of all sorts of physicians and physios who had travelled from across the country to attend. There was a definite air of anticipation surrounding the proceeding talks to be given by renowned and respected individuals and all were eager to get things underway.
First to present was Dr. Anil Gholkar, Consultant Neuroradiologist at Newcastle General Hospital. He began by naming the four main systems of neuro-imaging as being Computed Tomography, Magnetic Resonance Imaging, Angiography and Trans-cranial Ultrasound. At the moment Computed Tomography (or CT or CAT scanning) is the investigation of choice and is most widely used particularly for cranial trauma and haemorrhaging. However, there are some limitations to this technique, particularly in its ability to show the detail of soft tissue, i.e. the brain.
Magnetic Resonance Imaging (MRI), a field in which new advances have been made, is both far more sensitive as well as being able to produce images far faster than CT. Dr Gholkar wishes to see far more widespread use of MRI, especially as it can be used on the prenatal brain as early as the second trimester. This will make it far easier to determine whether a child will have hemiplegia as well as being able to trace more precisely how the condition develops. There are severe problems regarding the availability of this method, as there is huge demand for scanners in both paediatrics and geriatrics, and the number of both scanners and personnel qualified to operate them falls well short of that demand.
Neurophysiology of early unilateral brain lesions
Dr. Mary Gibson, Consultant Neurodevelopmental Paediatrician at the Royal Victoria Infirmary, presented on behalf of Professor Janet Eyre with a lecture on ‘Neurophysiology of early unilateral brain lesions’. Her profile of children with hemiplegia at school entry has included studies into Corticospinal Tract Development and she began by explaining the effects neonatal strokes can have on the corticospinal tract. The tract is divided into two: the controlateral and ipsilateral tracts. With normal development the ipsilateral tract will withdraw. If a stroke occurs it is preserved, and this is a causal factor in the development of hemiplegia.
Professor Eyre's profile of children at school entry is primarily and largely based on the ability to perform upper limb functions of varying complexity, both bilaterally and unilaterally. These are divided into categories: simple synergies, including thumb and forefinger pinching movement and the dynamic tripod such as holding a pen; reciprocal synergies, as in a rolling movement between thumb and forefinger; and sequential patterns involving repositioning of digits such as unscrewing a jar. There is also the question of judging size in relation to the hand and grip. She also describes the four point scales used to assess the level of dysfunction in both the upper limbs and with walking, which is used to determine a ‘lifestyle assessment score’. Children with lower scores are those most severely affected, and this score can be used to measure any progress made.
Early diagnosis and management of childhood hemiplegia
A well deserved coffee break was followed by another lecture from Dr Gibson, this time concerning early diagnosis and management of childhood hemiplegia. This started with a video of a baby about six months old, lying down and apparently just doing what babies do. The audience was asked to offer any observations they may have made that could suggest any problems. While it was acknowledged that some of the observations made may imply hemiplegia, abnormalities perceived at this early stage could not definitely be used to form a positive diagnosis.
She then went on to talk of the use of Constraint Therapy, a technique developed for adult stroke patients that had been advocated by some in the field for use with children. She questioned whether the same principles could be used with children. Is it developmentally appropriate, considering it may involve the restraining of a non affected limb at a developmentally sensitive time? It could also lead to the exchange of the dominant hand for the poorly functioning hand. Milder versions of the therapy were suggested, perhaps using restraints for a limited time, or restraining the dominant hand with only the physician’s hand.
Therapy Needs to be Fun
The afternoon session was opened by Janice Pearse, Paediatric Occupational Therapist at the Sir James Spence Institute. Her presentation entitled Therapy Needs to be Fun, was rested on the hypothesis that the use of Botulinum toxin to reduce spasticity combined with appropriately motivating therapy, will lead to a sustained improvement in the function of the upper limb. She stressed the importance of motivation, saying that children are naturally motivated to learn but are inclined to choose the easiest way of achieving any goal. With relation to hemiplegia, choosing the easiest way of achieving a goal usually results in learnt misuse of the affected arm.
Mrs Pearse believes children learn best through play, and suggests the use of certain games as therapy, particularly those that can provide some immediate satisfaction. Such games should not demand speed or accuracy to win, and should encourage bilateral activity where possible. In relation to home therapy, Mrs Pearse advises limited use of Activities of Daily Living (ADLs), and says that exercises should be kept short (10-30 minutes), done every day, be varied but always fun and be challenging but always achievable. It is also vital to praise a child’s effort rather than their success at a particular task. She then went on to discuss splints, and certain regimes for their use. She is in favour of their use, using results from certain trials to illustrate how they can aid dexterity and strength. Any splinting programme must be monitored and regularly reviewed in order to be most effective.
Therapeutic intervention in the hemiplegic gait
Next up were Pat Clements, Extended Scope Practitioner and Sue Kelly, Senior Physiotherapist, both of the Newcastle Upon Tyne Hospitals’ NHS Trust. They spoke of therapeutic intervention in the hemiplegic gait. They began by illustrating different gait patterns seen with hemiplegia and suggested different ways in which botox could be administered. Range of motion in the knee is represented by the Tardieu score, and it is asserted that the use of botox can reduce this. They then went on to discuss orthotics, and gave examples of the many different types of orthotics that can be used to help correct the many different abnormalities observed with the hemiplegic gait.
Surgical management of the lower limb in children with hemiplegia
Following this was Janice Quimby, Consultant Orthopaedic Surgeon at the Freeman Road Hospital, Newcastle upon Tyne. She talked about the surgical management of the lower limb in children with hemiplegia. Indications that operative treatment should be used include failure of conservative treatment and functional problems. There was previously a tendency to intervene and lengthen tendons, which has proved disastrous. Now botox is given before any surgery takes place. Before surgery can go ahead, there is a full assessment of the patient including a full medical history; a discussion of the child and parents’ desires and expectations; a full clinical examination; a gait analysis; a physio’s report; and a look into the rehab facilities available post surgery.
Mrs Quimby made it clear that the patient’s desires and expectations must be achievable and that surgery cannot ‘make them like everyone else’. Any surgical procedure will be in two parts: the bone surgery being done first and then the soft tissue operation roughly six weeks later. She then demonstrated some of the conditions treatable with surgery, and despite all the latin names and technical terminology she insisted that it is all just ‘anatomy and common sense’. It was stressed that the post operative rehabilitation is the most crucial part, and there must be full cooperation from the patient before any surgery is attempted.
A long day of lectures had come to an end and it seemed everyone there had learned something very useful to take away with them.