PHYSIOTHERAPY IN RELATION TO .ORTHOPAEDIC SURGERY IN THE TREATMENT OF CEREBRAL PALSY

Physiotherapy in relation to Orthopaedic Surgery in the treatment of Cerebral Palsy. Orthopaedic Surgery is an integral part o f the treat­ ment of cerebral palsy; the success o f such surgery being largely dependent on the preand post-operative therapy which the patient receives. A format of physiotherapy which decreases post-operative disturbance and enhances the results of surgery has been developed a t the Forest Town School for Cerebral Palsied Children and is described as it pertains to surgery o f th e lower extremities.


The Integration of the Orthopaedic Approach with other techniques used in the Treatment of Cerebral Palsy.
Physiotherapy has been used in the treatm ent of Cere bral Palsy since the time that treatm ent was directed towards it as a specific condition. T h e role o f physiotnerapy has varied with the passage o f time. A t first, it was considered to be the only treatm ent indicated, albeit used in conjunction with braces, by W inthrop Phelps, who also advocated the "Team A pproach" (Keats, "C ere bral Palsy"- Thomas 1965).
Different techniques or approaches to the physio therapeutic treatment of Cerebral Palsy became estab lished and are fully described in the literature. (American Journal of Physical Medicine, Vol. 46, N o. 1, February 1967).
Orthopaedic surgery, when it first entered the field, was used as a substitute treatment, disregarding physio therapy, with disastrous results from the orthopaedic angle. It is now appreciated that the success of surgery is largely dependent on the quality of therapy which the patient receives, and orthopaedic surgery and bracing is now an integral part of the treatm ent of the cerebral palsied. The physiotherapist shares the responsibility for the state of the patient.
However, there still exists a great deal of confusion and doubt as to the role of orthopaedic surgery, among therapists working in the field. This is mainly due to the fact that some exponents of accepted treatm ent tech-

O PSO M M IN G Fisioterapie m et betrekking to t O rtopediese Chirurgie in die behandeling van Serebrale Verlamming.
Ortopediese Chirurgie is 'n integrate deel van die be handeling van serebrale-verlamming; en die sukses van sulke chirurgie is grootendeels afhanklik van die meegaande terapie w at die pasient ontvang. 'n V orm aat van fisioterapie wat die navolgende steum is van chirurgie verm inder en die voordele daarvan verbreed is ontwikkel op Forest Townskool vir Serebraal V erlam de Kinders en word beskry met betrekking to t chirurgie van die onderste ledemate. niques have, in the past, condemned the use of ortho paedic measures in this regard. In addition, there are certain difficulties in treating post-operative cases which may prove hazardous to the inexperienced therapist.
There is as yet, very little in the literature to guide the therapist in this aspect of treatm ent.
(] D uring the past fifteen years we have developed^form at o f physiotherapy which is used in the treatment of cerebral palsied children and adults undergoing sur gery, which largely eliminates perm anent post-operative complications and ensures maximal success. A t Forest Town Sdhool an eclectic appirolaeih to therapy is employed, rath er than strict adherence to any one technique. The type o f treatm ent used is dependent on the particular requirem ent of the child at any neurodevelopmental stage and on the type o f disability (i.e. the patho-physiology). Some children respond best to a specific technique while others require a com bination of techniques to achieve the best results.
Thus a baby w ithout head control and uninhibited ab norm al reflexes would respond best to the Bobath tech nique using reflex inhibiting patterns and facilitation of norm al responses, while in th e same child arm weight bearing might be achieved by using techniques o f sensory stim ulation to the extensors of the arm as advocated by Rood.
In an older child, however, where co-operation may be enlisted, Proprioceptive N eurom uscular Facilitation could play an im portant p art in the breaking down of , nrmal synergies provided th at due regard is given to h n e u ro lo g ic a l aspect o f the child's condition-and [[jus careful positioning is im portant when using thiŝ TrTthe^am e way as physiotherapy has been adapted to pet the needs of the cerebral palsied child, so has the thopaedic approach been tem pered to suit their par-? pillar problems. T hus orthopaedic assessment m ust ntnrally take into account the general neurological con dition of the child and the effect th a t surgery o r splintage anil have upon this.
. , . , , The integration of the orthopaedic approach with other seeds of therapy presents minim al problems when all members of the team are aw are of all aspects o f the child's condition. This includes not only the orthopaedic and neurological facets, but also educational and emo tional problems which present themselves in the cerebral palsied child.
One o f the basic principles in the treatm ent o f cerebral "aisy is the understanding and accurate assessment of the abnorm al synergic patterns and therapy is directed towards m odifying or changing these patterns in order \ achieve as norm al o r as functional a pattern as ossible. However, due to intractable spasm, o r where an abnormal synergy cannot be inhibited in a functional position (e.g. as in a persistent exaggerated positive sup porting reflex producing equinus o f the foot), norm al development is even further im paired. H ere the ortho paedic approach, whether it be conservative (i.e. bracing, "New Concepts in Bracing in C erebral Palsy" by Alice L. G arrett, M .D. et al. Physical Therapy, July 1966, Vol. 46 No. 7) or operative, is often the m ost dynamic method of facilitating norm al development.
By way of example, a child w ho is unable to develop standing balance due to a persistent exaggerated Positive Supporting Reaction producing equinus could be consider ably helped by wearing the Forest Town Boot, which will enable him to stand on a plantigrade foot. e.g. Case I.
'Carel, spastic quadriplegic, is m ore affected on the Right than on the Left. H e was pulling u p to standing at 15 months, but he was unable to learn to stand alone because o f bilateral equinus feet. A fter wearing Forest Town Boots, he walked at 20 m onths, for the following six months, he could stand and walk while wearing the Forest Town Boots, but not w ithout them .' In addition the effect of the Positive Supporting Reflex could be overcom e by putting the triceps surae muscles at a mechanical disadvantage as is achieved by a gastrocnemius recession and T.A.Z-lengthening opera-%n. 7 The correction o f deformities and contractures may enable a sedentary child to become upright and mobile and the psychological im portance o f this achievement cannot be over-estimated. M oreover, the educational aspect of the child's development is also enhanced as the experience of the upright position plays an im portant part in the aw am ess of spatial orientation and hence in perceptual development. The im provem ent in body image and the subsequent perceptual concepts brought about by the attainm ent o f the upright position has been repeatedly observed.
A particular example is of a child who, in the " Drawa-man" test would produce a picture of a man either lying down or with no particular relationship to the upright while the limbs showed n o constant orientation. Post-operatively and following mobilization, she drew a man standing upright and on his feet.
In addition, increased m obility attained by surgery enables the child to explore his environm ent and thus learn new spatial concepts which h e was unable to grasp beforehand.
Successful integration of the orthopaedic approach with other techniques used depends m ainly on a close IVIAART 1974 3 co-operation between surgeon an d therapists. Surgery is never performed in isolation-all members of the team including the teachers are aware o f the aims, purposes and possible problems o f surgery. Post-operatively, a change of positioning in the classroom may be indicated as well as an adaption to classroom furniture. Tlie emphasis in therapy may be changed by surgery. Changes in pattern produced by surgery, if not antici pated, could cause alarm . However, with the therapist well aware of this, the opposite pattern which may be produced can be immediately counteracted before it has a chance to take over or cause any kind of stress.
In the use of the R ood technique therapists have realised 'the need for carefully thought out methods of splintage. It is im portant to be aw are of certain neurophysiological principles in order to know which muscles are being facilitated and which are being inhibited by the splint used; and thus methods of sensory stim ulation as advocated by Rood may be achieved by the splintage itself or superimposed o n the particular m ethod of splintage used.
The orthopaedic technician participates as a valuable member o f the team and his awareness of th e special problems of the C erebral Palsied child along with his close co-operation with the surgeon and therapist enables him to adapt and modify orthopaedic appliances in such a way that the optimal support, correction and mobility can be achieved.
It has been shown th a t the orthopaedic approach to th e treatm ent of the cerebral palsied child is, in our experience at F orest Town, an essential modality to supplem ent and com plem ent the overall treatm ent and management of the child.

Preparation for Hospitalisation
Outline o f the procedure which has evolved at Forest Tow n At Forest Tow n all staff members co-operate and p ar ticipate in the preparation o f a child for surgery. It is appreciated that there can be a great deal of em otional traum a to both parents and child unless this aspect is carefully and frankly handled. Basic to the success o f any methods which may be employed is th e general attitude towards surgery (on the p art of the staff) which is inevitably comm unicated to the parents and children. A t Forest Town, in m any cases, surgery is regarded as an indispensable m odality which contributes to the child's general progress, rather than a m ethod which is con sidered a last resort in th e case of failure of therapy. Thus parents understand, right from the beginning, th at should surgery be recommended it would benefit the child, w hether th e aim was limited to cosmesis or to increased function.

Staff and Parents
Preparation of the child for hospitalisation starts with the members of staff handling the child and then with the parents, then staff and parents together, prepare the child.
1. It is imperative th at all members of the team are fully acquainted with the type of procedure to be under taken and the reasons for its being selected as p art o f the treatm ent programme.
2. The teaching staff who, will forfeit a certain am ount of valuable time in the classroom, are aware th at surgery aims to benefit the child as a whole and thus consider the time lost in the classroom is justified by the overall benefit gained. (Parents, too, understand that a t this particular stage surgery takes precedence over schooling.) 3. Staff members and parents m ust be aware of the possible post-operative disturbances, the reasons for them and how to counieract them. These may include changes in: (e) there will be a change in the physical condition and the child's abilities-this may initially appear to be negative, or retrogressive. It is im portant to note, however, th at the duration and intensity o f these disturbances vary trem endously and in our experience the disturbances are inversely pro p o r tional to the thoroughness o f the preparation for hos pitalisation and not dependent on other factors, e.g. the severity o f the operation. (Reynell 1965) It has been repeatedly observed th at children who have to be adm itted for a second o r even third procedure react with less disturbance than they did the first time.
4. The surgeon interviews the parents personally and explains as fully and simply as possible to them and the child, what will be achieved by the operation, what period of hospitalisation to expect and what post-opera tive care will be necessary at home. The im portance o f intensive post-operative therapy is also stressed and the fact that they must be prepared fo r the child to wear an orthopaedic appliance for some time after the opera tion. It is also pointed out that with the rem oval o f the m ore obvious deform ity or disability, other already present but less obvious problems may become more apparent and need further correction. There is no promise of a cure.

Approach to the Child
Preparation fo r hospitalisation varies with the age of the child and the emotional disposition.
T he pre-verbal child (up to 21 years) needs the su p port of its m other during hospitalisation and, ideally, the m other should accom pany th e child. However, few children are subjected to surgery at this age. W ith the guidance of the psychologist, it is determined whether the child can cope em otionally with hospitalisation. Should there be doubt in this respect, the operation is postponed, until conditions are m ore favourable.

Preparation through play
In the N ursery School, preparation takes the form of "H ospital Play". T here is a "hospital corner" in which the dolls are dressed as nurses, patients and doctors and plastic hospital utensils are at hand. T he teacher tells a story around this them e and the children participate in lively discussion and play. T hroughout the school this is reinforced and the children often indulge in spon taneous "hospital play" in the playground.

T he School-Treatm ent Centre Environm ent
C hildren see and know o th er children w ho have under gone surgery and benefited from it. T hey learn to accept therapists, doctors and the clinical atm osphere as much as p art of life as teachers and classrooms. O thers wearing and walking in plaster o f paris are a fam iliar sight! A prospective patient is also shown the plaster saw and cutters and thus the rem oval of his own plaster (usually done at school) is not a completely new and frightening experience.
Clinics are held at school and the surgeons are fam iliar and friendly figures w ho inspire confidence. Older children are given opportunities to talk to the surgeon and to discuss any aspect which may be causing con cern. Fam iliarity with the surgeon and therapists obvi ates (the necessity for play therapy with the psychologist; however, should there be any indications o f alarm , the psychologist is asked to help the parents and child and advises the surgeon and therapists in his respect.
The therapist shows the child some o f the exercises he will have to do at hospital or at hom e and explains th the aim o f the operation-" to make it easier fo r you walk"-will not necessarily be immediately achiev but will surely follow on prelim inary mobilization, t v same physiotherapist is responsible for the child do operatively and thus the child is secure in the know le/1' that he will be back with someone he knows and th^ continuity of treatm ent is maintained.

Liaison with H ospital Staff
Because o f a good liaison with the hospital staff th nurses are aware of the special problem s of the cereh^ palsied child. 151 It is particularly im portant fo r the nurses to know W much the child can understand and communicate t have an indication of his I.Q. and to be aware of'th° fact th at a non-verbal child might well comprehend more than one realises.
The senior physiotherapist attends the ward round the day after the child is admitted, im m ediately prior to surgery. It has been found that the presence o f a known doctor and fam iliar therapist makes a tremendous dij, ference to the security o f the child in th e strange hospiP surroundings. Should the child be unduly nervous the therapists will be present when he is taken to the theatre and stays until he is anaesthetised. T he parents are present when he comes round.
The period of hospitalisation is naturally reduced to a minimum and the parents, w ho are well instructed as to how to care for him a t home, know that he may go hom e as soon as his condition permits.

Conclusion.
The success of surgery is la rg ely ' dependent on the thorough preparation o f the child beforehand. T0 achieve this, all members o f the team and the parents must be thoroughly acquainted with the purpose and nature of the hospital treatm ent to be undertaken. The child's em otional disposition is taken into account and handled with the utm ost care. It is im portant to recog nise the child's feelings about the situation-th a t he may be frightened or angry. The child must know that his feelings are understood and accepted and that his prob lems are very real. R ather than belittling his problems, he must be given support to cope with them.

Physiotherapy in Relation to Orthopaedic Surgery of the Lower Extremities in Cerebral Palsy
General pre-operative measures, to be follow ed in <L cases.
These are generally the same as those used in con servative therapy when surgery is not indicated, and include the following;

1.
Facilitation and training of postural reactions (bal ance and equilibrium ) in all developm ental sequences. *1 The following secondary responses are desirable for good results post-operatively: i. Head control in all positions.
ii. H and support.
iii. Protective reactions of arms. iv. Equilibrium reactions in lying and sitting, possibly in supported standing. v. Reciprocal stepping movements o f legs.
The presence of primitive reflexes is a deterrent to surgery b u t does not necessarily preclude satisfactory suits. In actual fact, surgery may be an aid to the inhibi tion of a primitive reflex by facilitating m ore normal _ f e.g. a persistent M oro reflex may be triggered fHQvem > • terior movement of the head which results by i j t i c h t hamstrings pulling a sitting child into exten-• L e n g th e n in g of hamstrings with release of adduc-sl0n' results in a wider sitting base with resultant imtors d balance and the ability to inhibit the M oro P!flex e g-Case 2. . rnh'an severely involved spastic quadriplegic a t six rs old was un ab le to sit in any p o sitio n due to yLntinual M oro reaction. H e 'had th re a te n e d disloca-C°n of the hips as a resu lt o f c o n tra ctu re s o f add u cto r "nH psoas m uscles a n d had surgical co rrectio n o f these Hpformities. P ost-operatively h e could sit, lea rn t to • Libit the M oro-reflex a ctio n and lea rn t to h old on with his hands, even p ushing a w alker.
following surgery, e.g. (i) Pre-operative adductor spasm may mask lesser degree of spasticity in abductors of hip, with consequent over-action of abductors following adductor transfer, (ii) Pre-operative pattern o f hip and knee extension, adduction and equinus of feet caused by positive supporting reflex, may change to complete flexion after lengthening of triceps surae, due to weak spastic extensors of knee and 'breaking u p ' of total extensor pattern. Therefore pre-operatively, strengthen voluntary exten sion, even though extensor spasticity is present.
7. Preparation of appliances which are to be used post-operatively.
8. The therapist should have a good understanding of the indications, aims and procedures of surgical treat ment of the cerebral palsied. *3 9. An appreciation, on the part o f the therapist, of any changes occurring in the patient's condition which may necessitate early consultation with the surgeon, e.g. (i) a complaint of pain in the hips, which may indicate threatening subluxation, or (ii) the development of a ' Rocker-bottom" foot, (iii) development of pelvic obliity with possible development of scoliosis.

General Post-operative Measures
/. Immediate post-operative period (a) During this time the patient is sedated; to relieve pain and spasm. A fter the first few days spasm only may need to be prevented; and valium is usually prescribed for this purpose. of movement, and it is advisable to use valium (prescribed by doctor) at the beginning; decreas ing and discontinuing its use as soon as possible during the day. Many children have spasm at night, and as rest is necessary fo r child and parent, it is often necessary to take measures to ensure this.
Re-assurance, support, if necessary total bodily sup port, are very often needed until a child becomes used to being w ithout the support of the plaster.
Physiotherapy in Relation to the Hips, e.g. Adductor Transfer, Psoas Release, with or without Release o f Rectus Femoris.

Pre-operative therapy
Conservative therapy aims at establishment of postural control in all basic m otor developm ental sequences. M obility and stability of the hips is very often impaired due to muscle instability caused by spasticity or contrac ture of the hip flexors, adductors and internal rotators. Long-standing muscle im balance may lead to subluxation and anteversion of the fem oral necks with eventual dislocation. Surgery aims to correct muscle imbalance, and prevent bony deformity, or to correct deformity when such has developed. *4 E arly physiotherapeutic measures to prevent deformity include:

M obilisation o f the hips
From infancy this is done with the baby in supine in flexion, bringing the toes to the mouth. This activity ensures spinal mobilisation as well as full external ro ta tion and flexion/abduction of the hips. It also helps to prevent the contracted, stiff hips sometimes seen in older children, where hip flexion contracture may be decreased by surgery, but the inability to fully flex the hips persists, with resultant flexion o f the spine instead. The use of a Frejka pillow prevents adduction and effectively breaks up a total extensor pattern.

Weight-bearing with corrected alignment
In norm al development, a baby starts taking weight from about five months of age onwards. W eight-bearing with the head of the fem ur located in the acetabulum is necessary for the development of a norm al acetabulum and this process is completed by the age of fo u r years.
In the presence of spastic adductors and psoas muscles, there is a tendency for the development of anteversion of the fem oral neck, coxa valga and subluxation of the hip, with failure o f acetabular development. It is there fore im portant that weight-bearing is encouraged even though the child is not neurologically m atured. Measures used to correct alignment and prevent abnorm al patterns when standing include: 1. Use of Forest Town Boot (or below-knee iron, with backstop) to provide plantigrade feet. In spite of heels riding u p in boots with irons, the boot provides a plantigrade surface.
2. Roller between legs to ensure abduction and a wide standing base.  Abduction brac^ ^ abduction (m anual, springs or 6. Use of r . ,the older child. . . . dental ' gth of rectus fem ons by using posi--Maintain leng h extension an d knee flexion. s ami moyem hould be improved as fa r as de-Pelvic staBimy^ ^ js dependent on: forming f. orc.esm,' cie' strength, extensors, abductors and Abdominal musuc ,jdudiirs in eaia • interfere with postural control wl'e,c, tlg DeM c control is often better in kneelin "p ro v id in g there is no rectus fem ons contraclurc)' < -" " CPnce of psoas contracture or rectus femoris In the Presehj D0Sture will increase lum bar lordosis, ^ be le s s e n e d by having the patient support •^s o l f with his arms straight out in front of him.

M E D IC A L D IS T R IB U T O R S E D M S BPK X A P E Y O R K ' I 252 JE P P E ST. | J O H A N N E S B U R G | D e W a a l H o u se , 172 V ic to r ia Road_
9 Sec g e n e ra l pre-operative measures.
l<ost-»ln'rat've Therapy (Sec (5 plaster.) (Sec General Post-operative M easures, also removal of After hip surgery, the patient m ay or m ay not be n, h Used in a hip-spica. In any event sitting up, will bc sl'atcd after three weeks or after rem oval of plaster. Therapy now comprises: i General mobilisation. Passive movements (well within the limits of spasm or pain), assisted active and active movements, using developm ental sequences, ■ijving the child an opportunity to adapt to altered muscle action and post-operative weakness, so in creasing confidence and strength w ithout undue anxiety and strain. W hatever the child's pre-operative motor level, it is advisable to start again at the be ginning. This progression through the developmental slaves may take children only a day or two in some cases, while others may take several weeks to regain I he pre-operative development level. The time taken depends on the reaction to surgery and hospitalisalion. Once this period of apparent retrogression has passed, one begins to see the benefits of surgery. Support of the patient and parents during this time is an important part o f therapy. It is very often necessary to use a mild muscle relaxant/seda tive for a while as well as counselling. (b) Hollowing hip surgery, pelvic stability m ay initially seem to be very poor, as mobility is usually greatly increased. With the removal of contractures, muscle balance becomes a more realistic goal, although this may, in some instances, take as long as three or four years to achieve.
Abdominal muscles are m ore easily facilitated in mrter ran^e, i.e. in positions of total flexion at first. nnn?* :itltluctors of the hip which pre-operatively may ti rr. »u parcsed must be assessed fo r spasticity and 'iniin^A?CuCtl-' Adduction and hip flexion are brought in •"HI emphasised in mid-position.
are S^ven. w ithout long calipers. H ow-CilliPers or nth'ne tl^le> while the child is wearing long <i> S .a n d ? n , w ith^ , 7 tS' th e f o l l°w in ® is s ta r t e d : >-• ith full support when necessary. In most cases the ability to stand erect, even fully supported, w ithout the spasm or contracture which was present pre-operatively, gives the child and his parents a great deal o f pleasure and encouragement.
Postural training begins on the day after rem oval o f plaster, and is given concomm itantly with m obilisa tion and strengthening exercises. (ii) Assisted walking (in calipers when necessary). This activity acts as an incentive to most children. All the measures described under pre-operative therapy are used. Increased post-operative mobility will facilitate rotation which is given at first, in rolling, with or w ithout resistance at h ip or shoulder, then in the m ovem ent from four-foot kneeling to side-sitting and up to kneel-standing. If arm support is used, the hands should be in a flat supportive position, instead of grasping and pulling with the arms.
Half-kneeling may be a progression from step-stand ing, as the adductors, hamstrings and hip flexors are stretched. This position should be achieved as soon as possible after surgery, and the lengthening maintained. Resistance to the pelvis anteriorly on the weight-bearing side, and laterally to the non weight-bearing knee, facili tates full extension o f the weight-bearing hip and external rotation of the non weight-bearing knee.
Standing. It is easier to start standing up from sitting on a high stool, with hand support. The stool is lowered, to increase muscle work and postural control. Give approxim ation through the knees to facilitate quadriceps, and prevent the head from leading into total extension.
A great deal of sensory training (proprioceptive, kinaesthetic) is given with a great variety of slight postural changes and adjustm ents to acpustom the patient to the altered centre o f gravity and skeletal alignment. T his is essentially sensori-motor learning. *6 Standing at first in parallel bars, using hands for sup port, in different positions. W eight transference, laterally as well as antero-posteriorly, and reciprocal arm m ove m ent precedes walking. W alking starts in the parallel bars with hand support. This is progressed to walking with a rollator, crutches and sticks, or independent walking.
T runk rotation is an im portant com ponent of the walking pattern and is facilitated by resisted walking, the therapist resisting at the hips either anteriorly to increase flexion, or posteriorly to increase extension and external rotation of the leg. Give downward approxim ation of the pelvis to increase extension. *7 If there is a tendency to walk with flexed knees, the use of a gaiter or similar splint on the one leg ensures weight-bearing and extension o f the hip on th at side, while on the other leg one achieves hip extension in the inner range and knee extension in order to enable the gaitered leg to clear the ground.
The above measures apply to treatm ent in cases where locom otion is aimed for. In those cases where hip sur gery is performed to facilitate nursing, treatm ent includes mobilisation, but n o t necessarily exercises in weight bearing positions.
W hen surgery is done to facilitate sitting, as in wheel chair cases, the programme is followed as far as is possible; a certain am ount of pelvic stability is needed for sitting balance. Patients are often able to long-sit for the first time while in plaster after a hamstring release or lengthening. This may lead to excessive sitting and possible hip flexion contracture with weakening of hip extensors.

Physiotherapy in Relation to Surgery o f the Knee
2. Prone-lying should be enforced for at least h alt a day.
,. , 3. Postural reactions are stimulated in standing be tween bars, also in assisted walking.
4. Posterior arm balance reactions and weight-bearing. 5. Back extension to correct kyphosis produced by previously tight hamstrings.
F or R em oval o f Plaster -See General Post-operative page.
Post-operative Therapy follows the post-operative pro gramme used while plaster casts are worn, including the following after removal of plaster of paris: (a) M obilisation, using passive, assisted active, active and resisted movements progressing through the developmental sequences. In the older child knee flexion may be somewhat pain ful. G radual flexion, using gravity over a pillow or over the edge of the bed, with voluntary extension of the knee, and prevention of flexor spasm in the unoperated hamstrings is a safe way of ensuring mobilisation. It is im portant to get flexion, as there may be spasm of the rectus femoris, which, if not alleviated or relaxed, rapidly leads to shortening and inability to flex the knees.
Four-foot kneeling, with roller supporting under abdom en and slow rocking, allows patient to mobilise (b) Bilateral calipers are worn initially until strength and control of muscles around the knee is sufficient to enable only one caliper to be worn. This is done on alternate legs until it can be discarded, or a lesser splint, e.g. gaiter, can be worn. (c) Nightsplints should be used to maintain correction of deformity. (d) Strengthening of (i) hip musculature. . . . . (ii)knee extensors, using sensory stimulation, resisted exercises, first in non weight-bearing, then in weight-bearing positions. (e) Spasm of the rectus femoris may be aggravated by the release of the hamstrings and the wearing of long calipers. Prone lying with knee flexion an d ( hip extension is useful to counteract this. As soon as the knees permit, weight-bearing exercises are given in half-kneeling and upright-kneeling. During the same period that m obilisa tion and strengthening exercises are given w ithout cali pers, the following is carried out while the patient is wearing calipers. (i) Standing, supported or assisted. This is started on the first day, (ii) Postural training, i.e. decreasing support to one hand, turning, reaching, bending etc. (iii) Walking with calipers.
The essence of post-hamstring surgery treatm ent is the attainm ent of a balance between mobility of the knee, and controlled stability o f the knee, w ithout tight quad riceps muscles. (i) Slow stepping on and off a stool, slow getting up and sitting down on a low stool are two practical home exercises. Hyperextension of the knee is to be avoided, or corrected. (ii) Re-education of the hamstrings is done if there is a tendency to rectus femoris spasm, or when laxity of knee ligaments predisposes to hyperextension of the knee. Physiotherapy: Programme following Surgery to the

Ankle and Foot, with Particular Reference to: Gastro. cnemius Recession and-Tendoachilles Z-Lengthening
Pre-operative M easures see above for G eneral p re. operative aims. In particular: 1. Assess: (a) Action of the anterior tibial muscle, as well as dorsiflexors of toes. Check w hether extensor hallucis longue is being used as a dorsiflexor. Assess action of toe-flexors. Post-operative period. m This consists o f three stages: ™ 1. First three weeks in long or above-knee plaster-ofparis casts which are non-weightbearing.
2. The second three weeks, after rem oval of sutures, either long o r short, below-knee casts which are weight bearing.
3. Period after rem oval of plasters. 1. D uring this stage, the therapist should take care that the muscle balance around the hip joints does not deteriorate, but im prove it if possible. She should note any evidence of pain or pressure in the plaster.
2. D uring the second h alf of the wearing of a plaster cast, the cast may be above-knee in the presence of tight hamstrings o r weak quadriceps, or it may be belowknee in the absence o f the above-named. W e find it useful to start with an above-knee cast, which we cut down below the knee as soon as control of weight bearing is achieved, and before we rem ove the plaster com pletely.' This allows time to work on the knee while the foot is still immobilised.
. (a) W eight transference is taught; leg length being equalised by using tem porary raises under other foot. . . . . (b) Establish control of knee extension, in weight-bear ing. Re-education of vastus medialis in sitting with knee flexed over edge of bed, and foot held to dorsiflexion in plaster. In addition all other methc#j of muscle stim ulation and strengthening are usu ' (sensory stimulation and resistance) as well as the use of tem porary splintage. *10

A fte r R em oval o f Plaster Casts
(a) Tendon lengthening very often has a widespread effect on the whole limb or body, in addition to the predictable expected localised effect. . In this way the extension-adduction pattern which is produced by an exaggerated positive supporting reaction may be so altered by a gastrocnemius recession ana Tendo Achilles lengthening that abduction and knee flexion becomes possible, even in weight-bearing, m some cases a child may start to crawl post-operatively. whereas pre-operatively she could only creep, dragging extended legs, e.g. Case 3.
'Joanne, at two years old, was able to assume sittint position with knees flexed, not extended due to tight hamstrings. H er arm protective reactions were very slow-She could creep, dragging extended legs, but could n°' crawl, as she had no dissociation of the legs. She trie» to pull up standing, but could not take steps in tn parallel bars, as she had co-contraction o f the legs duc IV1AART 1974 FISIOTERAPIE a grossly exaggerated positive supporting reaction t,irh made her stand with rigidly extended, adducted "" and equinus feet Surgery performed: Bilateral Gastrocnemius Recession Xendo Achilles Z-lengthening. S ix months later J o a n n e was crawling, enjoying rolling, sitting much better, pulling up to standing and pushing a walker on uer own. There has been a m arked change in her e m o tio n a l state; from being an introverted, frustrated, unhappy infant, she has changed to an outgoing, happy y o u n g child, eager to explore around her.' R e-education o f balance and equilibrium is therefore done, progressing through the different stages o f develop ment. Even where the postural reactions are good in sta n d in g , the confidence gained by the child while per forming the basic gross m otor activities o f rolling, sitting, kneeling and crawling will enhance his progress in walk ing-

Weight-bearing and Transference o f W eight
Gastrocnemius recession and Tendo Achilles Z-leng thening, by mechanically reducing plantarflexion and decreasing the effect of the positive supporting reaction, !%ifts the balance of power to the dorsiflexors o f the ankle, thereby predisposing towards the total flexor p at tern of the lower extremity.
To prevent post-operative 'folding u p ' or collapse into flexion with failure to weight-bear, pre-and post-opera tive therapy should establish control o f extension of the hip and knee.
Sensory stimulation (icing, brushing, vibration) o f the quadriceps, followed by active and restricted extension, is given alternatively with weight-bearing and assisted standing and walking in calipers. Initially, long calipers or gaiters are used bilaterally to assist extension. As soon as possible one caliper only is used on alternate legs, to give stability on that side with increased mobility on the other. G aiters or any other terrjporary splints may be used. W hen control of the knees is satisfactory, below-knee irons with a back-stop and T -strap where necessary (to correct valgus o r varus) is worn until dorsiflexor strength is adequate. H ere a Forest Town Boot may be used instead; this has the added advantage of stretching the long toe flexors. (a) Refusal to stand may be due to: (i) presence of a withdrawal reflex, which may pre viously have been masked by the positive sup porting reaction. Flexion should be prevented mechanically until this is overcome. Begin by standing u p (with hand support) from sitting and stepping up and down from a low stool, therapist m anually assisting ex tension.
(ii) Hyper-sensitivity of sole o f foot. The skin should be de-sensitised by brushing, hardening the skin etc. (iii) Painful heel. A child who has never walked with heelstrike may have no insulating layer of thick skin and subcutaneous tissue over the calcaneous to cushion the shock of weight bearing on the heel. A resilient heel-pad will overcome this problem.
(b) Establish m uscle -balance a ro u n d th e ankle, m ainly (i) increasing strength of dorsiflexors. Initially it may be possible only to get active con traction of the tibialis anterior by facilitation of aorsiflexion in a mass pattern of flexion (i.e. with knee and hip flexed). This should be changed to aorsiflexion of the ankle with extended knee (for heelstrike) as soon as possible.
F acilitation o f c o n tra ctio n is greatly im proved by sensory stim ulation using ice, brushing, vibration, tnction, follow ed by active and resisted active m ove ment.
(ii) Prevent dorsiflexion of ankle by excessive con traction of extensor hallucis longus; isolate action of Tibialis anterior by repeated contrac tions of anterior tibial in inner range holding the big toe in flexion while activating dorsi flexion. (iii) Extension of the toes with the foot in dorsi flexion to overcome any tendency of clawing. (iv) M aintenance of lum brical action, especially when a Forest Town Boot is worn for a long time.
(v) When dorsiflexor strength is adequate, plantar flexion is strengthened to allow push-off in walking. (vi) Balancing the action of the evertors and inver tors of the foot. The above exercises are done with resistance, in modified patterns using proprioceptive neurom uscu lar facilitation, and ideally also in the weight-bear-. ing position. (c) E arly weight-bearing, whether supported or assisted, is very im portant, as the upright position, with the head vertical, and compression of the joints, added to the positive supporting reaction, increases exten sor tone and postural reflex activity. If a child is allowed to be non weight-bearing for too long, especially if there is a tendency to flexor hypertonus, then there is a danger that the flexors of the hip, knee and ankle may become overactive and pre clude muscle-balance. Calcaneous deformity mav result. W eight-bearing in a corrected standing position is a good way of preventing this 'shift' of spasticity. (d) G ait-training; with emphasis on (i) transference of weight to equalize weight-bearing. (ii) establishing trunk rotation. (iii) prevention of hyperextension of knee.
Resisted (from behind and in front) rotational walking is effective.
Standing and walking progresses from the use of parallel bars to rollator walker, then elbow crutches or tripod sticks, which may later be discarded. (e) Balance reactions of the feet in standing and walk ing, e.g. (i) balancing on a roller, (ii) standing on one leg, using other foot to roll around a large ball; without losing contact with the ball.

NOTE o n t h e f o r e s t t o w n b o o t
This appliance evolved as a result of the combined efforts of the physiotherapy staff at Forest Town School, the C onsultant O rthopaedic Surgeon and the Orthopaedic T echnicians at th e Johannesburg G eneral H ospital.
The object of the boot is to prevent tightening a o f the '*%endo Achilles and lengthening o f the dorsiflexors ^rh-ile enabling a child with an over-active positive sup porting reaction to walk.
In the boot the ankle is held at an angle of 90°, the toes are in extreme dorsiflexion, there is no pressure on the metatarsal heads (the boot being recessed here) and the calcaneus is well down.