Cerebral Palsy Centre

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Hand & Arm Spasticity

The United Kingdom did not have a dedicated treatment centre for the surgical treatment of spasticity in the upper limb despite an increasing and weighty body of evidence supporting its benefits.

This was in contrast to established units in the USA, Europe and Australia. I had gained experience in the treatment of such patients in Louisville in the United States and had made an in depth survey of the current literature on surgical techniques and the results of these techniques. My conclusions were that certain surgical techniques had been shown clearly to be beneficial in these patients.

Hand and arm spasticity develops as a result of damage to that part of the brain that controls the limb. This may be apparent at or shortly after birth as in cerebral palsy, or be the devastating consequence of a severe head injury, brain mass or stroke.

Despite these conditions being common, the provision of integrated surgical care for these patients has not been widely available. It was disturbing to me that many patients had been actively discouraged from surgical intervention or told, frequently by specialists, that there was none. Many of these patients suffered and continue to suffer from avoidable disability throughout their lives.

In 2000 I set up a multidisciplinary team with senior occupational and physiotherapists to treat patients afflicted with spasticity of the arms. This is called the CP Clinic although all causes of upper limb spasticity are treated. Colleagues in paediatric and adult neurology, rehabilitation medicine and paediatric orthopaedics to are also available to provide an overall strategy of care.

A New Approach

My approach to patients suffering from spasticity preventing hand use – whether an infant born with cerebral palsy or an elderly stroke-victim, challenges some of the preconceived ideas that have lead to patients being denied surgical intervention over the years.

I have introduced surgical modifications based on biomechanical studies that exist in the peer-reviewed, hand surgery literature and simply do not accept the (unsupported) view that the brain cannot adapt and learn new ways of using the hand into adulthood. Some of my own patients have clearly demonstrated this adaptation.

It was clear to me from my work on tendons that the traditional view of immobilising patients following surgery for cerebral palsy had little scientific support. In contrast the advantages of early movement in terms of less scarring and stronger tendons was established.

As a result I incorporated early movement into the post-operative protocol for the patients that I treat. This has been successful and at the time of writing is a unique post-operative protocol for this condition.

I have carefully recorded all aspects of patient’s’ function in a multidisciplinary clinic, using validated assessment and outcome measures prior to surgery and at intervals after surgery.

In 2003, I presented my early results at the annual meeting of The Federation of European Societies for Surgery of the Hand in Lisbon – a meeting attended by hand specialists from around the world. The work was received well (appendix 2).

3 years later the extended work was presented at the International Federation of Societies for Surgery of the Hand Meeting in Sidney 2007.

I have started to train the next generation of hand surgeons in the techniques involved and increased awareness through presentations to primary and secondary care physicians, trainees and therapists.The work continues at currently the only unit in the UK dedicated to the treatment of upper limb spasticity in a multi-disciplinary setting. Patients are referred on a national and regional level.