**2.17 Orthopedic procedures**

Orthopedic procedures are the most frequently performed operations for spasticity. The targets of these operations are muscles, tendons, or bones. Muscles may be denervated and tendons and muscles may be released, lengthened, or transferred. The goals of surgery may include reducing spasticity, increasing range of motion, improving access for hygiene, improving the ability to tolerate braces, or reducing pain. Orthopedic problems that may result from a spastic limb include cubital or carpal tunnel syndrome, spontaneous fracture, dislocation of the hip or knee, and heterotopic ossification.

The most common orthopedic procedure for the treatment of spasticity is a *contracture release*. In this procedure, the tendon of a muscle that has a contracture is partially or completely cut. The joint is then positioned at a more normal angle, and a cast is applied. Regrowth of the tendon to a new length occurs over several weeks. Serial casting may be used to gradually extend the joint. Following cast removal, physical therapy is used to strengthen the muscles and improve range of motion.

Spastic muscles in the shoulder, elbow, forearm, hands, and legs may all be treated with tendon or muscle lengthening. Spasticity in the shoulder muscles may cause abduction or adduction and internal rotation of the shoulder. Abduction results in difficulties with balance, which then affects walking and transferring, and adduction causes problems when reaching for an object or with hygiene and personal care. An operation known as a slide procedure may be used to lengthen the supraspinatus muscle in an abducted spastic shoulder. With adducted shoulders, the surgeon can perform a release of all four muscles that typically cause this deformity.

In an operation known as a tendon transfer, the orthopedic surgeon moves a tendon from the spot at which it attaches to the spastic muscle. With the tendon transferred to a different site, the muscle can no longer pull the joint into a deformed position. In some situations, the transfer allows improved function. In others, the

joint retains passive but not active function. Ankle-balancing procedures are among the most effective interventions.

The goal of surgical-orthopedic treatment, which is basically symptomatic, improve, or facilitate the movement to solve the functional or fixed contractures preventing further rehabilitation, to solve the deformation that reduces or prevents movement, sitting, causing pain as in the cases of hip luxation, or threaten respiration as in cases of severe scoliosis. Subluxation and dislocations of the hip in children with CP are most common in children and adolescents who do not walk. We must bear in mind the saying that every child and adolescent with CP has a hip disorder until proven otherwise. The occurrence of dislocation of the hips makes furniture, hygiene and often causes pain. Requires regular radiological studies to the hips once or twice a year during growth, to discover any hip dislocation at an early stage. Subluxation and luxation of the hips are treated surgically. The decision about surgery should bring those involved in the treatment of patients, carefully weighing hopper performs coarse benefits, and harms of surgery. Surgery is necessary to balance the muscle forces around the hip and normalize abnormal anatomic relationships [54].

Osteotomy and arthrodesis involve operations on the bones and are usually accompanied by operations to lengthen or split tendons to allow for fuller correction of the joint deformity. Osteotomy can be used to correct a deformity that cannot be fixed with other procedures. In an osteotomy, a small wedge is removed from a bone to allow it to be repositioned or reshaped. A cast is applied, while the bone heals in a more natural position. Osteotomy procedures are most used to correct hip displacements and foot deformities. Arthrodesis is a fusing together of bones that normally move independently. This fusion limits the ability of a spastic muscle to pull the joint into an abnormal position. Arthrodesis procedures are performed most often on the bones in the ankle and foot. In triple arthrodesis, the three joints of the foot are exposed, the cartilage is removed, and screws are inserted into the bones, fixing the joints into position. With a short walking cast in place for 6 weeks or until the bones have fully healed, the patient may bear weight immediately after the operation (http://wemove.org/spa/spa\_oss.html, 2007).

The risks of developing a structural spinal deformity ranges from 24% to 36% for scoliosis and 50% for lordosis for an average of 4–11 years after selective dorsal rhizotomy [55].

Other principles include single event, multilevel surgery; surgery is delayed if possible (more than 6 years). Spasticity management is used as an adjunct to surgical intervention.

#### **2.18 Intensive suit therapy**

Intensive suit therapy is a new and experimental treatment for CP children helping them to improve muscle tone, posture, and movement. Despite more studies being needed to confirm its treatment effectiveness, some therapists offer it to their patients because they feel it is useful as a treatment option. It consists of an orthotic suit that includes a hat, knee pads, and specially designed therapeutic shoes. It also has rings that allow bungee cord-like ropes to be inserted and adjusted according to the child's height.

The child goes through a group of specific exercises in a therapeutic setting, and the suit brings the body into proper alignment and helps to improve abnormal muscle tone, while the suit is on and the elastic ropes are adjusted. Simply, it retrains the brain to recognize the new, corrected body movements. It reduces ataxia, spasticity, and other symptoms that are typically associated with cerebral palsy.

#### *Management of Spasticity and Cerebral Palsy Update DOI: http://dx.doi.org/10.5772/intechopen.106351*

Different types of suits are available, and each one comes with a specific exercise program and training method, but all work in a similar therapeutic concept. The most common suits are Adeli Suit, NeuroSuit, Polish Suit, and TheraSuit. Some suits, such as the NeuroSuit and TheraSuit, offer elbow pads and gloves, which help to increase the function and strength of the arms. In1971, Russia's space program, the first suit was used, allowed cosmonauts to keep their normal muscle tone while in a weightless environment. In the late 1960s, the Penguin Suit was invented by the Russian Center for Aeronautical and Space Medicine, and it was reliable and fully functional in helping astronauts to prevent disabilities. In the early 1990s, a similar suit was invented by the Pediatric Institute of the Russian Academy of Medical Sciences for CP children and other neuromuscular disorders. This suit was patented in 1994 and became available for therapeutic use. Other suits were invented later for the same purpose.

School of Physical Therapy at the Pacific University reported some improvement in standing ability in the patients who underwent intensive suit therapy from their program [56]. The same conclusion came from a published study by the National Institutes of Health (NIH) [57]. More research is needed to understand the effectiveness of this therapy. Professor Siemionowa, who was member of the team that invented the "Adeli Suit," concluded that, after the second or third exercise session, children showed a decrease in their spasticity and diminished hyperkinesis in a study done by his institute. The conclusion of the stay was that the suit has a positive effect on the vestibular system, leading to improvements in balance and spatial awareness. The use of the intensive suit therapy in conjunction with the traditional therapy has proven to be the most beneficial effect. In research published in 2011 by the Online Journal of Health and Allied Sciences, 30 spastic diplegic CP children, ranging from ages 4 to 12 years, were studied by a team of physicians [14]. Children were in a combined program of traditional PT and intensive suit therapy for 2 hours a day, for 3 weeks. Significant improvement in gross motor function was achieved by all the children.

Sessions usually are under the supervision of licensed certified physical therapists, who had hands-on training in intensive suit therapy. The typical day routine consists of tissue massage and warm-ups, sensory integration techniques, proper movement patterns and body alignment, development of motor skills, strengthening exercises, and flexibility, balance, and coordination exercises, but each program may be different according to the therapist. Different rehabilitation techniques can be facilitated by using cables, pulleys, and weights. Children often exercise in safe exercise units, known as "monkey cages" or "spider cages," in which the pulleys and weights help to isolate movements, thereby strengthening the muscles.

Children with certain medical conditions, such as high blood pressure, heart and circulatory conditions, diabetes, kidney problems, severe scoliosis, hydrocephalus (VP shunt), and uncontrolled seizures, must take their doctor and therapist approval before using the suit therapy.

The cost of intensive suit therapy is an important factor to be considered [58]. It is not covered by most insurance companies, and unfortunately, families have to pay out of pocket to pay it. Because the treatment is still considered experimental, it is not covered by some insurance companies.

#### **2.19 Hyperbaric oxygen therapy**

Hyperbaric oxygen therapy gained a lot of interest in the medical community. Despite it is not approved as a treatment option for CP, some private offices offer it to their patients. Hyperbaric oxygen therapy (HBOT) is a chamber that supplies the bloodstream with 100% oxygen, while the patient is inside a pressurized chamber. When the patient is inside the chamber, the air pressure will be increased three times higher than the normal air pressure, allowing the lungs to hold on more oxygen [59]. Oxygen is carried by the blood into the body tissues, the extra oxygen can fight infection, and at the same time, the body will stimulate and release stem cells and growth factors. Extra blood oxygen will restore and correct the tissue function and blood gas levels temporarily.

Currently, results are mixed regarding the benefits of HBOT therapy in CP children. There is a feeling that it will be the future of CP treatment. There is a consensus that HBOT works best in CP cases secondary to a brain injury caused by a lack of oxygen, rather than a genetic or developmental cause [60].

Not everyone agrees about the benefits of HBOT. In fact, some doctors believe that HBOT may do more harm than good to CP children. Published studies for clinical trials of HBOT by the National Institutes of Health (NIH) indicated that despite a minimal decrease in children mortality with traumatic brain injuries, it also increased the chances of a poor functional outcome [61]. There was no significant difference between CP children who received HBOT and a placebo group in published research in the modern drug discovery and NHI. Two clinical trials for CP children, 3–12 years of age. One group received hyperbaric oxygen at 1.75 ATA of 100% oxygen. The second group received slightly pressurized room air. They had daily sessions for 40 days. Both groups showed significant improvements in the following areas: attention, memory, gross motor function, speech, and functional skills. The treatment is not covered by most insurance companies, which does not cover the treatment because it is not considered current, valid treatment for CP.
