By A. Avogadro. Olivet College.
Correction of the deforming force by correcting the planovalgus foot and external and tibial torsion is not enough to cause spontaneous correction of the valgus ankle joint in children with growth remaining discount 600 mg ibuprofen visa. Diagnostic Evaluations The correct radiographs are centered on the ankle joint with a long enough image of the tibia above to measure the long axis of the tibia purchase 600 mg ibuprofen with visa. The rotational position of the ankle should be to produce an anteroposterior mortise view showing the profile of the talus. Indications and Treatments Because the ankle valgus is almost always a secondary deformity, there is no role for correction of only the ankle valgus. This correction should be part of a reconstruction of a whole problem, which usually includes the planoval- gus foot, equinus ankle, and external tibial torsion. Indications for correc- tion are more than 10° of ankle joint valgus relative to the long axis of the tibia. If the external tibial torsion is being corrected as well, no more than 5° of valgus should be tolerated at the ankle joint. If more valgus is present on the postoperative radiograph, the cast should be wedged to correct the deformity (Case 11. The presence of the ankle valgus must be recognized when correcting the hindfoot because it is important to avoid overcorrection of the hindfoot valgus. If no tibial derotation is required, then correction of the ankle valgus can usually be done with a screw epiphyseodesis of the me- dial malleolars if there is adequate growth remaining. The ankle has to be monitored with radiographs every 4 to 6 months, and when the valgus has corrected, the screw should be removed (Case 11. For individuals with a closed growth plate, up to 15° of valgus can be accepted if the foot is cor- rected close to a neutral position below the ankle. This residual ankle valgus causes the foot to fall into external rotation and valgus with increased dor- siflexion, but tends to be less of a problem in individuals who are dependent on orthotics for ankle stability. Having the ankle valgus corrected is more important in individuals who are high-functioning community ambulators without orthotics or assistive devices. Outcome of Treatment There are no reports of the outcome of treating valgus deformity in spastic feet. Our experience has been that it is important not to overcorrect the de- formity because a little valgus is better tolerated than a little varus. Also, there does not seem to be much loss of correction, although we have not had enough children corrected by the screw epiphyseodesis who have completed growth to be confident of this fact. A stable correction has been reported in several series with a wide variety of other diagnoses. She and her family desired goal should be to have 0° to 5° of valgus at the ankle joint. A percutaneous If after the cast is applied and there is more than 10° of val- osteotomy was performed with the application of a short- gus or more than 5° of varus, the cast should be wedged leg cast and a proximal tibial pin. The radiograph in the op- and the angulation corrected. The technique for doing the erating room showed a significant valgus deformity of the wedge is to make two lines down the middle of the frag- ankle (Figure C11. This tech- kle to neutral alignment nique will correct both displacement and angulation. In gen- by measuring the width of the cast on the X-ray at level A eral, a little valgus is bet- (Figure C11. He had significant amount of growth remain- deformities. On ing so a medial malleolar epiphyseodesis screw was placed physical examination, he was hypotonic but could walk (Figure C11. He was then monitored carefully, and without assistance. He had severe planovalgus feet but no by the 24-month follow-up, he had acquired approxi- muscle contractures. In the operating room his feet were mately 20° of correction, (Figure C11. Under fluoroscopy, he was thought to when he had slight overcorrection and the foot appeared have mild instability of the ankle joint and approximately in a good position. Equinus As noted previously, ankle equinus was the first deformity of individuals with spastic CP that gained the attention of surgeons, namely Dr. Strohmeyer’s tenotomy of the tendon Achilles, and the promotion of this operation by Dr. Little, marked the beginning of modern medical and surgi- cal management of CP. The concept of the difference between contractures of the gastrocnemius and the soleus was considered very important in the middle half of the 1900s, as defined by the Silfverskiold test (Figure 11. This understanding spawned the development of gastrocnemius neurectomies and many different procedures to differentially lengthen the gastrocnemius versus soleus at the level where the gastrocnemius and soleus tendons join. Procedures were described by Vulpius in 1913 and 1920, by Strayer in 1950 and 1958, and by Baker in 1954 and 1956. However, by the late 1980s and 1990s, with the widespread use of improved kinematics and kinetic measures, the significant difference in the contracture patterns of the gastrocnemius and soleus was again recognized, even though there is minimal difference in the muscle activation times. This historical context is important in interpreting the various discussions at meetings and in published papers of the subject 11. A very important physical ex- amination test to obtain at the ankle is to de- of equinus ankle contractures in spastic children.
If nighttime orthoses are used to prevent recurrent equi- nus generic 600mg ibuprofen with visa, these orthoses must include a knee extension splint ibuprofen 400mg lowest price. Using the nighttime ankle splint will only tend to make the contracture of the gastrocnemius rel- ative to the soleus worse, because the ankle splint will usually encourage the knee to position in flexion so all tension is removed from the gastrocnemius. The most feared and worst complication of equinus surgery is over- lengthening, leading to insufficiency of the plantar flexors (Case 11. He had used AFOs for most of his childhood but now complained of knee pain and problems tolerat- ing AFO wear, as he had had progressive collapse of his feet. On physical examination he had popliteal angles of 50°, knee flexed ankle dorsiflexion on the left of 40°, and on the right of 30°. There was no difference with ex- tended knee dorsiflexion. Both feet were noted to have a flexible cavovalgus deformity with calluses over the first metatarsal phalangeal joint area and the heel (Figures C11. Not only was there a significant medial cavus, he also had a significant increase in the lateral arch, which is typical of the foot whose Achilles tendon has been functionally removed (Figure C11. No tendon Achilles could be palpated; however, there was some resistance at the end of dorsiflexion. Both tibias had 50° external transmalleolar-to-thigh axis. The foot pres- sures showed bilateral cavovarus feet (Figure C11. He had good balance and walked with a normal walking speed of 115 cm/sec and 138 steps per minute cadence. On gait analysis, he was noted to have low variability with nor- mal timing of ankle motion, although it was slightly in- creased in dorsiflexion. The knee demonstrated increased knee flexion at foot contact with a weight acceptance knee Figure C11. Knee flexion in swing phase was slightly low and slightly late. Ankle moment was normal; however, the knee moment showed very high Figure C11. Knee, Leg, and Foot 719 extension moment in both early and late stance. In terminal ments also showed increased extension moment in early stance, the knee absorbs power because it continues with stance and increased flexion moments in late stance. Power an eccentric contraction of quadriceps to guide knee flex- evaluation showed mild decreased ankle power genera- ion. The hip, on the other hand, has normal motion but tion at push-off, increased generation at the knee in early greatly increased demands from its normal moment force stance, and very high absorption in late stance. The hip and power generation, showing that it is the main power showed significant increase in generation in both early generator in this boy. This case is an excellent example of the de- great success of Achilles tendon lengthening. We can now formity occurring from insufficiency of the gastrocsoleus see that this is a far worse outcome than anything caused muscle. The foot collapses into cavovalgus because all the by a contracted gastrocsoleus. The foot deformity and mal- plantar flexors are now the long toe flexors, including the rotation can be corrected; however, the lack of gastroc- tibialis posterior, peroneus longus, and brevis. Most of the moment of these muscles allows the calcaneus to dorsiflex but generated in this ankle comes from a combination of the causes plantar flexion of the forefoot. The cavovalgus is out-plane stiffness and the small muscle plantar flexors never seen with a spastic or contracted gastrocsoleus. After correction of these de- ankle has normal motion and moments; however, the mo- formities, this boy will have to wear an AFO with plan- ment and motion is at 20° to 40° external to the knee axis tar flexion resistance for the rest of his life. With even a causing the ground reaction force vector in the plane of the shortened muscle and a contracture, the gastrocnemius knee axis to be significantly less. This requires a second- tendon could be lengthened to provide ankle stability so ary response at the knee, which is to use knee extensors a child with this level of neurologic involvement would not to control the knee position. The knee tends to stay in an likely need an AFO as an adult. The cavovarus foot defor- increased flexed position, requiring a high knee extension mity, though, is somewhat easier to correct than a severe moment. In midstance, the knee generates power as it helps planovalgus deformity due to a spastic contracture. The incompetent ankle plantar flexion–knee extension couple can be treated with ground reaction AFOs. An articulated ground reaction AFO is especially useful in children who have active but weak plantar flexion, active dorsiflexion, and corrected foot deformities. This allows the plantar flexors to strengthen during gait but main- tains good knee extension. This orthotic of- ten can be weaned away over 1 to 2 years as the plantar flexors strengthen. Overlengthening based on full evaluations of gait has been defined in as many as 30% of children. This limit is set because almost all children with spasticity have de- creased range of motion at the ankle joint; therefore, if more dorsiflexion oc- curs, more plantar flexion will be lost. Any spastic child with more than 20° to 30° of dorsiflexion on physical examination with the knee extended after equinus surgery has overlengthened plantar flexors. These individuals with overlengthened plantar flexors need to be braced with a solid-ankle AFO with the hope that growth and shortening of the muscle fibers will slowly tighten the plantar flexors (Figure 11. This overlengthening is usually, but not always, a direct result of surgical overlengthening of the plantar flexors.
One study of 14 nondepressed PD patients treated with 20 mg daily of ﬂuoxetine showed that scores on the Montgomery-Asburg Depression Rating Scale fell signiﬁcantly after one month of treatment (42) buy ibuprofen 600mg low cost. Sertraline was evaluated in an open-label study of 15 depressed PD patients at a dose of 50 mg per day and was found to produce a signiﬁcant improvement in the BDI without affecting motor scores (43) buy ibuprofen 600 mg online. While several case reports have suggested a potential for SSRI antidepressants to worsen parkinsonism (44,45), these events are considered to be quite uncommon (46). When data from controlled clinical trials are lacking, expert opinion may be of some use. Richard and Kurlan surveyed 71 members of the Parkinson Study Group (who together followed over 23,000 patients with PD) regarding antidepressant use in depressed PD patients (47). The results were that SSRIs were selected as ﬁrst-line agents most frequently, with tricyclics being less popular choices. Those who favored initiation with SSRIs considered these drugs more effective and less likely to produce side effects compared to tricyclic antidepressants. In cases where depression does not remit following appropriate drug trials, electroconvulsive therapy (ECT) should be considered. ECT has long been considered to be effective in drug-refractory cases of depression, and several reports have found an antidepressant effect in depressed PD patients. Additionally, signiﬁcant improvement in parkinsonian motor function was seen in 5 of 7 patients after only two treatments. Other reports have appeared conﬁrming this ﬁnding but have emphasized a particular sensitivity of these patients to ECT-induced delirium (49,50). Most authors noted that this delirium resolves within 2–3 weeks, though they offered varying explanations for this phenomenon ranging from structural changes in the caudate nucleus (49) to dopaminergic psychosis owing to increased permeability of the blood-brain barrier resulting from ECT (51,52). Those advocating the latter hypothesis reported that post-ECT delirium was largely prevented by reducing the dose of dopaminergic drugs by one third to one half of the typical dosage before starting ECT. In light of the powerful antidepressant effects of ECT together with the beneﬁcial effect on parkinsonian motor function, clinicians should consider this treatment modality if several drug trials for depression prove ineffective or poorly tolerated. ANXIETY Prevalence Anxiety is common in PD, occurring about as frequently as depression. A comparison of the frequency of anxiety in PD with that seen in other disabling medical conditions showed that anxiety occurred in 29% of PD patients and in only 5% of disabled osteoarthritis patient controls (55). This ﬁnding was interpreted as indicating that the anxiety seen in PD is not merely a reaction to the disability inherent in this condition but is more likely related to the underlying neuropathology of the disease. Pathophysiology The causes of the various anxiety disorders associated with PD are unknown. While dopaminergic drug therapy could potentially cause anxiety, the observations that anxiety occurs most commonly in the off state (54) and is reversible following a dose of levodopa (37) argue for the opposite conclusion that the dopaminergic deﬁciency state of PD is in part responsible for anxiety. Several lines of research support the view that the intrinsic dopaminergic deﬁciency in PD may be causally related to anxiety. Since it is known that dopaminergic projections inhibit the ﬁring of noradrenergic neurons of the LC, and since excess noradrenergic tone correlates with anxiety, Iruela et al. This observation supports the notion that PD is associated with a state of increased noradrenergic sensitivity that could be related to anxiety. Another possible contributing cause to anxiety seen in PD is autonomic dysfunction. They also noted a signiﬁcant correlation between autonomic complaints and anxiety within the PD group. They concluded that anxiety and depression in some PD patients may represent a ‘‘behavioral phenocopy’’ caused by autonomic failure. Clinical Features In their review of anxiety in PD, Richard et al. No adequate studies exist of sufﬁciently large populations to establish the relative frequencies of the various anxiety disorders in PD. Treatment There have been no randomized controlled clinical trials of pharmacother- apy for the anxiety of PD. Thus, treatment recommendations are based on anecdotal reports and expert opinion. When panic attacks occur coincident with off states, the most rational treatment approach is to modify dopaminergic drugs to reduce the number and duration of off states. This can be accomplished by shortening the interdose interval of levodopa, adding a dopamine agonist, initiating therapy with a COMT inhibitor, or utilizing subcutaneous injections of apomorphine (61). In those patients with generalized anxiety disorder or panic attacks unrelated to motor ﬂuctuations, benzodiazepines such as alprazolam, lorazepam, or clonazepam are recommended (62). Others have been careful to point out that elderly patients are particularly sensitive to benzodiaze- pines with regard to sedation and risk of falls and that therefore these agents should be used for short periods only (63). Buspirone at doses of 5–20 mg per day can also be useful (62), but high-dose therapy (100 mg/day) is not recommended due to a worsening of the motor features of PD (64). Patients who do not respond to benzodiazepines may beneﬁt from low-dose tricyclic antidepressant therapy with agents such as nortriptyline, desipramine, and imipramine (62). Psychological therapies using strategies including cognitive therapy, behavioral training, and relaxation techniques are recommended to help patients cope with stressful elements of the disease (63). One study showed that scores on the Beck Anxiety Inventory diminished signiﬁcantly following surgery for PD (pallidotomy, thalamotomy, and pallidal deep brain stimulation), indicating that those patients who are candidates for brain surgery on the basis of their motor dysfunction might experience amelioration of their anxiety disorder postoperatively as well (65). AUTONOMIC DYSFUNCTION Prevalence Determining the prevalence of autonomic dysfunction in idiopathic PD is difﬁcult because early in the clinical course, PD can be easily mistaken for multiple systems atrophy (MSA, Shy-Drager syndrome) in which autonomic failure is universal. Generally, as the diseases progress, MSA patients Copyright 2003 by Marcel Dekker, Inc. By contrast, PD patients continue to respond favorably to levodopa throughout their lifetime and autonomic failure is relatively less severe when compared to MSA. They found that clinically signiﬁcant orthostatic hypotension was present in 30% of patients with PD and 88% of those with MSA. Other autonomic problems were also less common in PD than in MSA, respectively: bladder dysfunction 32% vs.
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