Can you dislocate your leg: The request could not be satisfied
Dislocated kneecap – NHS
A dislocated kneecap is a common injury that normally takes about 6 weeks to heal.
It’s often caused by a blow or a sudden change in direction when the leg is planted on the ground, such as during sports or dancing.
The kneecap (patella) normally sits over the front of the knee. It glides over a groove in the joint when you bend or straighten your leg.
When the kneecap dislocates, it comes out of this groove and the supporting tissues can be stretched or torn.
Symptoms of a dislocated kneecap
When a kneecap dislocates, it’ll usually look out of place or at an odd angle. But in many cases it’ll pop back into place soon afterwards.
Other symptoms can include:
- a “popping” sensation
- severe knee pain
- being unable to straighten the knee
- sudden swelling of the knee
- being unable to walk
What to do if you dislocate your kneecap
A dislocated kneecap is not usually serious and will often pop back into place by itself.
But it’s still a good idea to get it checked by a health professional:
- if your kneecap has gone back into place by itself – go to your nearest urgent treatment centre or A&E
- if you cannot get to hospital without being in severe pain, you should call an ambulance – do not try to put the cap back in place yourself
While you’re on your way to hospital or waiting for an ambulance, sit still with your leg in the most comfortable position.
Treatment for a dislocated kneecap
If your kneecap has not corrected itself by the time you get to hospital, a doctor will manipulate it back into place. This is known as a reduction.
You may be given medicine to ensure you’re relaxed and free from pain while this is done.
Once the kneecap is back in place, you may have an X-ray to check the bones are in the correct position and there’s no other damage.
You’ll be sent home with painkillers and your leg will normally be immobilised in a removable splint to begin with.
A few weeks of physiotherapy will be recommended to aid your recovery.
Surgery is usually only necessary if there was a fracture or another associated injury, such as a ligament tear.
It may also be done if you have dislocated your kneecap at least once before.
Recovering from a dislocated kneecap
Your knee may hurt at first and you’ll probably need to take painkillers, such as paracetamol or ibuprofen. See a GP if this does not control the pain.
During the first few days, you can help reduce any swelling by keeping your leg elevated when sitting and holding an ice pack to your knee for 10 to 15 minutes every few hours.
A physiotherapist will teach you some exercises to do at home to strengthen the muscles that stabilise your kneecap and improve the movement of your knee.
The splint should only be kept on for comfort and should be removed to do these exercises as soon as you’re able to move your leg.
It usually takes about 6 weeks to fully recover from a dislocated kneecap, although sometimes it can take a bit longer to return to sports or other strenuous activities.
Ask your GP, consultant or physiotherapist for advice about returning to your normal activities.
If you keep dislocating your kneecap
Most people who dislocate their kneecap will not dislocate it again. But in some people it can keep happening.
This often happens if the tissues that support the kneecap are weak or loose, such as in people with hypermobile joints, or because the groove in the bone beneath the kneecap is too shallow or uneven.
Regularly doing the exercises your physiotherapist recommends can help strengthen the tissues that hold the kneecap in place and reduce the risk of dislocating it again.
Surgery may occasionally be needed if the kneecap keeps dislocating. A common procedure is a medial patellofemoral ligament (MPFL) repair.
This is where the connective tissue (ligament) that helps hold the kneecap in place is repaired and strengthened.
Page last reviewed: 20 May 2019
Next review due: 20 May 2022
Signs of subluxation and dislocation of the hip
What is subluxation and dislocation of the hip?
Dislocation of the hip refers to a state in which the head of the thigh bone (the femur) is brought out of the socket of the hip joint (the acetabulum) and the two joint surfaces are separated.
The injured hip is usually painful and it may not be possible to bear weight on the leg. A hip dislocation should be reviewed urgently by a doctor, and the bones should be relocated as quickly as possible. Once the joint is repositioned, most people recover well.
A hip dislocation occurs when the thigh bone is knocked out of the hip joint socket. Hip dislocations are more common in old age. People who have had a hip replacement are at special risk of developing a hip dislocation, and this is one of the more common causes. Other causes are injuries to the pelvis or leg, especially injuries involving extreme force, such as those incurred during a car accident. This injury can occur during some high-impact sports, such as downhill skiing, gymnastics, rugby and American football. Children born with hip dysplasia (faulty hip development before birth) are at increased risk of developing this condition.
What are hip dislocation symptoms?
The most common symptoms of a hip dislocation are hip pain and difficulty bearing weight on the affected leg.
The hip can not be moved normally, and the leg on the affected side may appear shorter and turned inwards or outwards. Some people may have numbness and weakness on the side of the hip dislocation.
The Ada app can help you check your symptoms. Download the free app or find out more about how it works.
The diagnosis is usually based on the physical examination and on an x-ray of the hip. If there are any broken bones, a CT (computed tomography) scan may be needed to fully investigate damage to the joint and to plan treatment.
Hip Subluxation Treatment
- Repositioning the thigh bone into the joint.
This is done as soon as possible to reduce the chances of complications.
If there are no complicating factors, such as broken bones, this can be done by pulling the bone back into place. This should be done by a doctor, and often requires pain relief and sedation. If there are broken bones, the bones are usually repositioned in surgery.
Children who have hip dysplasia should be treated for their condition. Avoiding high-impact sports may help to prevent some cases of hip dislocation.
Other names for subluxation and dislocation of the hip
- Hip dislocation
- Hip subluxation
What Is Knee Dislocation?
What Is Knee Dislocation?
A dislocated knee is when the three bones of your knee are out of place and aren’t aligned the way they should be. It can happen if the structures in your knee are abnormal. Some people are born with a knee dislocation (congenital dislocation of the knee). Most of the time, knee dislocations happen when a traumatic event thrusts the bones in your knee joint out of place with great force. It’s an emergency, and it’s very painful.
If your knee is dislocated, your thigh and shin bones may be completely or partially out of place. A dislocated knee is different from a dislocated kneecap. That’s when your kneecap (patella) slips out of place. Doctors sometimes call this a patellar subluxation.
Dislocated knees are rare, but serious. Other parts of your knee might also have been damaged at the same time. You need to see a doctor right away.
Knee Dislocation Symptoms
When you dislocate your knee, you may hear a popping sound. Common symptoms include:
- It hurts a lot. Your knee is in so much pain that you can’t move or straighten it.
- Your knee feels unstable.
- It’s swollen and severely bruised.
- Parts of the knee look like they’ve been knocked out of place.
- You aren’t able to do activities or sports you normally do.
Knee Dislocation Causes
If it’s not something you were born with (congenital dislocation), knee dislocation happens as the result of serious trauma such as:
- Car accidents. If you bang your knee against a hard surface like your dashboard, the force of the blow may be strong enough to dislocate your knee.
- Sports injuries. This is less common than car accidents, but it’s possible to dislocate your knee if you collide with great force with another player or with the ground when your knee is bent, or if you overextend your knee (bend it backward farther than it’s supposed to go).
- Hard falls. It may happen to skiers or runners who lose control and fall on a bent or overextended knee. You may even dislocate your knee if you fall after stepping into a hole in the ground by mistake.
Knee Dislocation Diagnosis
You should go to your doctor at once so they can see your knee from many angles to confirm the injury.
Examination. Your doctor will look at your knee, and they’ll want to hear how you injured it. They’ll note whether or not your knee is misshapen and swollen, and whether or not you can move it.
Your doctor may push on different parts of your leg to see if you’ve also damaged any ligaments, which are bands of tissue that help to hold the knee in place. It’s common to tear ligaments when you dislocate your knee.
They’ll also note what your skin looks and feels like below your knee, all the way to your foot. Dislocating your knee may cause damage to nerves or blood vessels, which may change the color and temperature of your skin. This could affect blood flow or your sense of touch below the knee. In extreme cases, you could lose your limb (amputation) if these severe complications aren’t addressed.
Ankle-brachial index test. To look for changes in blood flow, they may do this test. It compares your blood pressure measured at your ankle to your blood pressure measured at the usual place on your arm. If your ankle-brachial index number is low, it may mean the dislocation has caused a problem with the blood flow to your legs.
Electromyography. Your doctor may use this procedure to check your muscles and nerves. They’ll insert a needle into your muscle to record electrical activity. Electrodes on the surface can measure the speed and strength of signals from your nerves.
Imaging. Your doctor likely will want to see what’s going on inside your knee.
An X-ray can confirm that your bone has been knocked out of the joint. It can also show if there are broken bones from your accident.
An MRI can show whether any of the ligaments or other soft tissues in the knee have been damaged. It can also help a surgeon prepare to rebuild your knee. An MRI or ultrasound also can show whether there’s nerve injury.
Your doctor may order an arteriogram, an X-ray outlining blood flow in your arteries and veins. It’s another way to see if the knee dislocation damaged blood vessels.
Knee Dislocation Treatment
Your treatment will depend on how badly you’ve been injured.
No-surgery option. If the damage to your knee isn’t too severe, your doctor may try to pop your bone back into place by pressing and moving your leg in certain ways. This will be very painful, probably. Your doctor will offer to give you medicine so that you won’t feel what’s happening. After your bone is back in the joint, you’ll likely need to wear a splint for a few weeks to allow your knee to heal without moving or bearing any weight.
Surgery. Your doctor may need to do surgery to correct the dislocation and other damage from your injury, including:
- Broken bones
- Torn ligaments
- Damaged nerves
- Damaged blood vessels
You might not have surgery until 1 to 3 weeks after you’re hurt, to allow time for the swelling to go down. While you wait, you’ll need to wear a splint, keep your leg raised, and put ice on the injury.
Your surgeon may do arthroscopic knee surgery. This is done through small cuts made around your knee.
You might need “open” surgery, with bigger cuts. The type you need depends on the damage to the rest of your knee.
Knee Dislocation Recovery
After surgery, you may wear different knee braces as you heal. Some let you bend your knee — to ease stiffness.
After you’re finished wearing splints or braces, your doctor should send you to a physical therapist to rehab your knee. You’ll do exercises to strengthen the leg muscles around your knee and work to bring a full range of motion back to your joint.
Your recovery will depend on how serious your injury is and whether you had damage to your blood vessels and nerves. If you got treatment quickly, you will likely heal well. Recovery from a knee dislocation can take a long time. You may need to rehab your knee for up to a year. You’ll recover faster if you stick to your doctor’s advice. Athletes who dislocate their knees may be able to return to their sports, but they might not be able to perform at the same level as before.
Knee Dislocation Complications
Knee dislocation is a serious injury that can have major complications if it isn’t treated right away. If the dislocation causes a big loss of blood flow to your legs, your doctor may have to amputate. Knee dislocations also can lead to blood clots in deep veins of your legs (deep venous thrombosis).
Acute compartment syndrome is another common complication. This happens when the swelling in the muscles causes pressure to build up in the blood vessel, nerves, and muscles. If this happens, it’s painful. You’ll need to see a doctor right away.
Symptoms, Causes, Treatment & Prevention
What is a dislocation?
The place where two or more bones in the body come together is called a joint. A dislocation occurs when the bones in a joint become separated or knocked out of their usual positions. Any joint in the body can become dislocated. If the joint is partially dislocated, it is called a subluxation.
Dislocations can be very painful and cause the affected joint area to be unsteady or immobile (unable to move). They can also strain or tear the surrounding muscles, nerves, and tendons (tissue that connects the bones at a joint). You should seek medical treatment for a dislocation.
How common is a dislocation?
Dislocations are very common. They can happen to any joint in the body, but they most often affect these joints:
Symptoms and Causes
What causes a dislocation?
Trauma that forces a joint out of place causes a dislocation. Car accidents, falls, and contact sports such as football are common causes of this injury.
Dislocations also occur during regular activities when the muscles and tendons surrounding the joint are weak. These injuries happen more often in older people who have weaker muscles and balance issues.
What are the symptoms of a dislocation?
Symptoms of a dislocation vary depending on the severity and location of the injury. The symptoms of a dislocated joint include:
- Instability of the joint
- Loss of ability to move the joint
- Visibly deformed joint (bone looks out of place)
Diagnosis and Tests
How is a dislocation diagnosed?
Your doctor may diagnose a dislocation by looking at and moving the joint and asking about what caused the injury.
In some cases, a doctor will use an imaging test called an X-ray to take a picture of your bones. This test allows the doctor to see the exact location and severity of the dislocation.
Management and Treatment
How is a dislocation managed or treated?
Treatment can vary based on the severity of the injury and which joint is dislocated. Applying ice and keeping the joint elevated can help reduce pain while you wait to see a doctor. Treatments for dislocations include:
- Medication: Your doctor may recommend medication to reduce pain from a dislocation
- Manipulation: A doctor returns the bones to their proper places.
- Rest: Once the joint is back in place, you may need to protect it and keep it immobile. Using a sling or splint can help the area heal fully.
- Rehabilitation: Physical therapy exercises strengthen the muscles and ligaments around the joint to help support it.
- Surgery: Your doctor may recommend surgery if:
- Manipulation does not work to put the bones back in place.
- The dislocation damaged blood vessels or nerves.
- The dislocation damaged bones, tore muscles or ligaments that need repair.
What complications are associated with dislocation?
Most dislocations don’t have serious or lasting complications. When the bones that make up a joint slide out of place, it can cause the tendons, ligaments, and muscles around the joint to tear. It may also sometimes cause bones to break. Your doctor may recommend surgery to repair these injuries.
Some severely dislocated joints can damage nerves and blood vessels around the joint. When blood is unable to flow to the affected area, the surrounding tissue may die. To minimize the likelihood of damage, it is important to have severely dislocated joints put back in place promptly by a doctor.
What are the risk factors for dislocation?
Anyone can suffer a dislocation. People at higher risk include those:
- Over age 65, because they are more prone to falls
- Involved in contact sports
- With inherited joint diseases such as Ehlers-Danlos Syndrome
Can a dislocation be prevented?
You can take several steps to reduce the risk of a dislocation. They include:
- Being cautious on stairs to help avoid falls
- Wearing protective gear during contact sports
- Staying physically active to keep the muscles and tendons around the joints strong
- Maintaining a healthy weight to avoid increased pressure on the bones
Outlook / Prognosis
What is the prognosis (outlook) for people with dislocations?
Most dislocations heal completely. They start to feel better as soon as a doctor puts the joint back in place.
Recovery times vary based on the severity of the dislocation and the joint affected. A dislocated finger may feel back to normal in three weeks. However, a hip dislocation could take several months or longer to heal.
People who dislocate their knee or shoulder are more likely to dislocate those joints again because the surrounding tissues have stretched. Wearing protective gear such as a brace during physical activity can reduce the risk of another dislocation.
When should I call the doctor?
Contact your doctor right away if you think you have a dislocated joint. Do not try to push a dislocation back into place yourself. This effort could damage the muscles and tissue around the joint and lead to complications.
What questions should I ask my doctor?
If you have a dislocated joint, you may want to ask your doctor:
- How serious is the dislocation?
- What signs of complications should I look out for?
- Is there anything I should avoid during recovery?
- Do I need a follow-up visit and if so, when?
When can I go back to work? When can my child go back to school?
Healing times for dislocations vary depending on the joint affected and the severity of the injury. Most people can return to work or school once a doctor has returned the dislocated joint to its proper location.
A splint or sling can help protect the joint so you can get back to day-to-day activities while the joint heals fully. Your doctor will advise you when you can return to more physical activities such as sports, chores, or heavy work.
Dislocated Hip: The Symptoms – Central Orthopedic Group
As a leading Long Island orthopedist, we’re no strangers to hip questions. Very often, our patients complain of hip pain. This includes swelling, aches or feeling “out of place.” Have you been experiencing any of these issues? If so, you might be feeling the symptoms of a dislocated hip.
In this post, we’ll discuss hip dislocations and their corresponding symptoms. In addition, we’ll explore treatment and how an orthopedist can guide you to recovery. Keep reading to find out more.
What Causes a Dislocated Hip?
Basically, a hip dislocation occurs when an impact forces the femoral head of the thighbone out of the hip bone socket. As a result, there may be damage to the nerves, muscles, ligaments and other soft tissues.
Usually, car accidents are the primary cause of hip dislocations. Typically, in the impact of an accident, the knee hits the dashboard. This force drives the thigh backward and drive the femur head out of the socket. Also, a fall from a certain height can cause the hip to dislocate. And of course, contact sports can lead to hip dislocations, as well.
Usually, much like strains, patients with dislocated hips are in severe pain. Also, they’re unable to move their legs. If there’s nerve damage, you may experience loss of feeling in your ankle or foot.
Some additional symptoms include difficulty sleeping on your hip, abnormal warmth around the area, limping and groin pain.
Assessment & Treatment
If a hip dislocation is diagnosed early enough, it can be treated without any long-term complications. Usually, an orthopedist can maneuver a hip back in place while the patient is sedated. This non-invasive procedure is called a “reduction.” Afterwards, x-rays or CAT scans will confirm that the bones are in the right place.
If the surrounding tissues have damage as a result of the dislocation, additional treatment may be necessary. Usually, this requires a hip arthroscopy. This is a treatment that employs small instruments and a miniature camera to examine the hip joint. Then, your doctor can make the repairs to the soft tissue or ligaments as needed.
Healing & Recovery
Very often, it takes a few months for a hip to heal at home after this injury. If there are more fractures, then the recovery time will take longer. Your doctor will most likely advise reducing hip motion for a few weeks to limit the chance of your hip dislocating again. In order to speed up healing, physical therapy is always advisable. In addition, aids like canes, walkers and crutches can help reduce strain on your hips.
Conclusion – Central Orthopedic Group
Are you feeling any dislocation symptoms? These can often be one of the more painful and inconvenient injuries. Therefore, if you suspect you might have a dislocated hip, you should make an appointment with our specialists at Central Orthopedic Group today.
Kneecap dislocation | UF Health, University of Florida Health
Kneecap dislocation occurs when the round-shaped bone covering the knee (patella) moves or slides out of place. The dislocation often occurs toward the outside of the leg.
Dislocation – kneecap; Patellar dislocation or instability
Kneecap (patella) often occurs after a sudden change in direction when your leg is planted. This puts your kneecap under stress. This can occur when playing certain sports, such as basketball.
Dislocation may also occur as result of direct trauma. When the kneecap is dislocated, it can slip sideways to the outside of the knee.
Symptoms of kneecap dislocation include:
- Knee appears to be deformed
- Knee is bent and cannot be straightened out
- Kneecap (patella) dislocates to the outside of the knee
- Knee pain and tenderness
- Knee swelling
- “Sloppy” kneecap — you can move the kneecap too much from right to left (hypermobile patella)
The first few times this occurs, you will feel pain and be unable to walk. If you continue to have dislocations, your knee may not hurt as much and you may not be as disabled. This is not a reason to avoid treatment. Kneecap dislocation damages your knee joint. It can lead to cartilage injuries and increase the risk of developing osteoarthritis at a younger age. Repeat dislocations will make the condition worse and harder to treat.
If you can, straighten out your knee. If it is stuck and painful to move, stabilize (splint) the knee and get medical attention.
Your health care provider will examine your knee. This may confirm that the kneecap is dislocated.
Your provider may order a knee x-ray or an MRI. These tests can show if the dislocation caused a broken bone or cartilage damage. If tests show that you have no damage, your knee will be placed into an immobilizer or cast to prevent you from moving it. You will need to wear this for about 3 weeks.
Once you are no longer in a cast, physical therapy can help build back your muscle strength and improve the knee’s range of motion.
If there is damage to the bone and cartilage, or if the kneecap continues to be unstable, you may need surgery to stabilize the kneecap. This may be done using arthroscopic or open surgery.
When to Contact a Medical Professional
Call your provider if you injure your knee and have symptoms of dislocation.
Call your provider if you are being treated for a dislocated knee and you notice:
Also call your provider if you re-injure your knee.
Use proper techniques when exercising or playing sports. Keep your knees strong and flexible.
Some cases of knee dislocation may not be preventable, especially if physical factors make you more likely to dislocate your knee.
Mascioli AA. Acute dislocations. In: Azar FM, Beaty JH, eds. Campbell’s Operative Orthopaedics. 14th ed. Philadelphia, PA: Elsevier; 2021:chap 60.
Naples RM, Ufberg JW. Management of common dislocations. In: Roberts JR, Custalow CB, Thomsen TW, eds. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th ed. Philadelphia, PA: Elsevier; 2019:chap 49.
Sherman SL, Hinckel BB, Farr J. Patellar instability. In: Miller MD, Thompson SR, eds. DeLee, Drez, & Miller’s Orthopaedic Sports Medicine. 5th ed. Philadelphia, PA: Elsevier; 2020:chap 105.
Traumatic Patellar Dislocation – Hughston Clinic
During a traumatic event, such as a fall, auto accident, or sports injury, the patella (kneecap) can completely or partially dislocate. A patellar dislocation occurs when the patella “jumps” out of the trochlear groove (a groove that holds the patella in line) and usually moves toward the outside of the knee. With patellar dislocations, often the most recognized damage is to the medial patellofemoral ligament (MPFL). A MPFL tear allows the patella to move out of place; and then, when it returns to its normal position, the patella damages the trochlea, causing bone bruising or fractures. Three bones form the knee joint—the tibia (shinbone), the femur (thighbone), and the patella, and these bones are held in place by a group of ligaments (tissues connecting bone to bone) and tendon (connects muscle to bone). These include the patellar ligament, medial and lateral patellotibial ligaments, medial patellofemoral ligament, and quadriceps tendon. As you move your leg, the patella glides up and down on top of the femur inside the trochlea (Fig.1).
Normal knee anatomy
Patellar dislocations occur most commonly in young athletes and can be a result of a direct blow to the knee or patella. After a kneecap dislocation, a patient often experiences pain, swelling, and hemarthrosis (a collection of blood) in the joint. The kneecap usually is displaced toward the outside, but the appearance of the knee may lead the untrained eye to think the patella moved toward the inside because the shape of the large medial femoral condyle, the bony projection at the end of the femur (Fig.2). It may be painful to walk or to bear weight and the range of motion of the knee may be limited. The patella may need to be reduced, or put back in place, or it may spontaneously reduce (return on its own). The doctor can perform the
reduction by gently straightening the knee and placing a side-directed force to the patella. After reduction, an immobilizer or hinged knee brace is worn to keep the knee in full extension (straight) to protect it from dislocating again while it heals. This injury can have long-term consequences, such as instability of the patella, pain, recurrent dislocation, and patellofemoral osteoarthritis.
Fig. 2. Visibly displaced patella
Diagnosing the injury
An orthopedist should examine your knee after a patellar dislocation. During the doctor’s visit, the physician will take a medical history and perform a physical exam, which helps evaluate the nature of your injury. Your physician will order x-rays and may elect to order a magnetic resonance imaging (MRI, a scan that shows the bones, muscles, tendons, and ligaments). Not all first-time patellar dislocations require an MRI, but based on the severity of your injury and the results of your physical exam the test can help determine the extent of other damaged structures within your knee. During the visit, the orthopedist will likely ask questions to help determine the course of treatment. For example, is this the first time you have injured your knee or have you had other problems with your knee before. The information can help determine if the injury is due to trauma, if it is the result of malalignment of the patella, or if you have a history of patellar instability.
Your orthopedist will decide on a course of treatment based on information ascertained about your knee and the history of your injury. Initially, your physician may elect to have you wear a brace that allows minimal weight-bearing, control pain with medications, and have you transition to a physical therapy program. During physical therapy, range of motion will be the focus for the first 4 weeks. Then, strengthening exercises start around 4 to 6 weeks and sports-specific training between 6 and 10 weeks. Often, you can return to sport at 10 to 12 weeks as long as there are no other dislocations.
After a course of therapy, if your patella continues to dislocate or feels unstable your surgeon may offer surgical intervention. Surgery would include knee arthroscopy, to look at the inside of the knee for damage, and an open procedure to stabilize the patella. This can be done with a procedure called proximal extensor mechanism realignment. This procedure takes tissue available in the knee and tightens the stretched-out structures. It also loosens tighter structures to balance the forces of the patella, and the trochlea groove it slides in. After the arthroscopic portion of the procedure, a 3 to 4 cm vertical incision is made over the upper portion of the patella to gain access to the vastus medialis oblique (VMO) and vastus lateralis (VL) tendons. While the knee is bent at 30 degrees the VMO attachment is removed from the upper inside pole of the patella. It is then advanced (pulled) over the superior medial body of the patella, essentially tightening it, and reestablishing stability as this is the loose side. With the knee still bent, the VL is also released in a similar fashion; however, it is reattached to the center of the patellar ligament; thereby loosening the more contracted side. This surgery is usually an outpatient procedure or a short 23-hour hospital stay. Risks include infections, blood clots in legs, problems with anesthesia, stiffness of the knee, and damage to nerves, arteries or veins.
Returning to your sport
After surgery, rehabilitation is similar to early conservative treatments, such as physical therapy that first concentrates on range of motion, then strength training, followed by sports-specific training. Your physician will not recommend returning to your sport until you have reached the strength and agility levels you had before injury. You should not be surprised if it takes you a little more than 3 to 6 months to return to your pre-injury level.
Author: George B. Sutherland, MD | Savannah, Georgia
Vol. 30, Number 2, Spring 2018
Last edited on May 13, 2021
What to do if you twisted your leg
First, let’s define the terms. In medicine, there is no concept of “twisted a leg”, but there is an “ankle injury”.
Further rehabilitation depends on what kind of damage the joint and surrounding tissues have received. Therefore, it is important to understand what exactly you got sick after the awkward step.
What hurts when the leg is twisted
The ankle joint is one of the most vulnerable mechanisms in the human body.As the name implies, it connects the bones of the lower leg and foot. The bones, in turn, are fixed with elastic ligaments.
The problem is that the ankle has conflicting functions. On the one hand, in order for us to walk and run, it must provide high mobility of the foot. Therefore, the ankle consists of a heap of medium-sized bones that form a complex and rather fragile system.
On the other hand, the ankle carries the weight of the whole body. And when we walk or run, this load only increases.Ligaments help cushion pressure. Often – at the cost of their own integrity.
So, you twisted your leg – inadvertently put your foot on the edge and loaded it with your own weight. Depending on how strong this load was, the following can occur:
- Sprain . The ligaments withstood the load and saved the ankle from destruction, but micro tears formed in the tissue. And they won’t hurt very much until they heal.
- Tear or rupture of ligaments .The ligaments could not stand, their tissue was torn, but the bones remained intact. As a rule, such an injury is accompanied by a click, and the pain is greater than with a sprain.
- Dislocation or fracture of the ankle . The ligaments, even when they were torn (however, a rupture is not necessary), could not save the bones. The ankle joint has shifted, and some of the bones may have been broken. This injury is accompanied by a characteristic crunch and other fracture symptoms. The pain is so severe that it is impossible to stand on the injured leg.
When you need to see a doctor urgently
As it is already clear, the consequences of an injury can be very different – from mild to quite serious. Contact an emergency room or a surgeon as soon as possible if:
- You cannot stand on your injured leg.
- The joint is “walking”, there is a feeling of instability.
- You feel severe numbness or tingling in the ankle that does not go away even after a few hours.
- Severe pain does not go away for an hour or longer.
- The site of the injury continues to hurt a day after the injury, while severe edema and hematomas are visible.
- The skin at the site of the injury is reddened and hot to the touch. This may indicate an infection.
- Your ankle has already suffered from sprains, fractures or severe sprains and you are now seeing similar symptoms.
Don’t waste time. If we are talking about a fracture or dislocation, delay can lead to the fact that your ankle will lose stability for a long time, and you will acquire chronic pain.
What to do if you twisted your leg
But if you are lucky and there are no frightening symptoms, most likely, we are talking only about a sprain. This condition does not need any specific treatment and, as a rule, goes away by itself.
To speed up recovery, doctors advise using the so-called RICE therapy.
- R – Rest – rest. Rest your injured leg. For the first day or two after the injury, try to walk less, and ideally lie at home at all.
- I – Ice – ice. To relieve pain and swelling, apply something cold to the affected joint. This can be a bag of ice or frozen vegetables wrapped in a thin towel, or a heating pad filled with ice water.
- C – Compress – compression. Wear something tight over your leg, such as compression socks, or a tight bandage around the joint. This will help relieve swelling. Just make sure that the blood flow is not disturbed.
- E – Elevate – lifting. Immediately after the injury, try to lie on your back for at least half an hour (better – more), lifting the injured foot above the level of the heart.To do this, place a pillow under the heel. This procedure will also help relieve swelling and speed up recovery.
For pain relief, take ibuprofen, paracetamol, or aspirin.
What not to do if you twisted your leg
For faster recovery of ligaments, remember a few “not” :
- Do not play sports that load the ankle while the leg hurts.
- Do not take warm baths and do not try to “cure” the ankle with hot compresses or going to the bath in the first 2-3 days after the injury.Fever can increase the swelling.
- Do not massage the ankle for the first 2-3 days after injury. There is a risk of bruising yourself and provoking inflammation.
- Don’t get stuck. If the leg is even shown to be at rest during the first 1-2 days after the injury, then it is necessary to start moving again (of course, not in the case of dislocation and fracture). By gently and gradually increasing the stress on the joint, you will speed up its recovery.
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What to do if your leg is twisted and the ankle is swollen
Causes of pain and swelling in the ankle of the foot
Rapid rhythm of life, active sports, significant physical activity, excess weight – these are factors that put the joint at risk of injury.In the case of the ankle, uncomfortable ladies’ shoes are added.
If the leg has turned up, then there is a great danger of getting a number of unpleasant consequences in the form:
90,017 bone subluxation;
If a person twists his leg and his ankle is swollen, it is necessary to find out what kind of injury affected the condition of the limb.
- Sprain – the injury is closed, while the fibers that make up the ligament are torn, the patient feels pain and discomfort, but can walk with difficulty.It will take two weeks for the ligaments to heal
- Ligament tear and rupture is a more serious and painful injury. You can’t walk, the ankle is swollen. You cannot touch, let alone step on a limb. If a rupture occurs, a person hears a clap, followed by a sharp pain syndrome. These injuries cannot be cured on their own, therapeutic and surgical measures are required, wearing a fixing bandage for up to one and a half months
- Ankle contusion is the easiest to get around.She also swells, but everyone knows what to do from childhood. It is necessary to give the leg rest and apply a cold compress. If you suspect a more serious injury, consult a doctor
- If there is a subluxation of the bone, then the ankle is slightly displaced and the ligamentous apparatus is injured. It is likely that conservative methods will not work, and operation
- Dislocation of the joint is characterized by strong displacement (up to 40 degrees) of the bone and trauma to the joint capsule.The pain is unbearable, it swells up very much, the limb fails until it is adjusted. This can only be done after anesthesia, and not at home. In case of significant damage, the capsules resort to the help of a surgeon
- Ankle fracture can be with or without displacement of the bone, open and closed. Treatment will take from a month or more
will be required
Due to the fact that the injuries of this joint are quite numerous, the answer to the question: dislocated leg, swollen ankle, what to do, will not be treated independently and not let things go by themselves.Chronic injuries, even minor ones, eventually become the cause of arthritis and arthrosis, and these ailments are practically incurable and dangerous with disability.
As a rule, the ankle reacts to injuries with sharp pain, swelling of the ankle or the entire foot, hematomas are possible, due to which the foot is enlarged several times. If the foot has acquired an unnatural position, you cannot try to correct it yourself. This can only be done by a qualified technician. It is forbidden to apply heat, heat the injured place.
However significant the injury, first aid may include:
- Fixing the foot with a splint – real or homemade
- You should not step on this foot, so as not to cause even more harm
- Apply ice for pain relief. It will also reduce swelling. Such a compress can be kept without harm to health for up to 20 minutes. Reapply – only after an hour
- If possible, apply a tight bandage
- It is better if the leg is raised.
After first aid, it is imperative to consult a doctor and determine the condition of the ankle and the entire foot.
Diagnosis of trauma
In the case when the bone on the ankle is swollen from the outside, you need to find out what kind of injury the person received and prescribe the necessary treatment. As a rule, the symptoms are expressive enough for the traumatologist or surgeon to determine the nature of the injury. However, for one hundred percent certainty, doctors send a person to an x-ray, which shows the damage to the ankle.This is the cheapest and most informative way. True, it does not give a result if you need to know the state of soft tissues. It also happens that the leg is so swollen that the X-ray is blurry. In such cases, a tomogram is done.
Treatment of external and internal ankle pain
If no fracture is detected, then the patient is prescribed anesthetic and anti-inflammatory, the fluid is removed from the joint, and a splint is applied. After the ligaments are restored, the limb is developed with exercise and physical therapy.In case of fractures, the leg is fixed with a plaster cast; you can only move with the help of crutches. All parts of the joint must be immobilized, a cast is excellent for this purpose.
It is clear that it is impossible to protect yourself one hundred percent from any injuries. But it is quite possible to try to prevent a situation when the leg in the ankle area hurts and treatment is necessary.
- Strong lower leg muscles are able to withstand somewhat dislocations and subluxations, they nourish the joint tissues well and they will not be fragile
- It is easy for women to protect themselves with comfortable shoes, in which the heel is no higher than 5 centimeters
- It is better to dose physical activity and not “go for a record”, if you are not a world sports star
- If any damage does occur, it will not hurt to go to check the condition of the ankle, because it is extremely important for movement.
Caring for a child with cerebral palsy: a multidisciplinary team, monitoring the condition
The MERCY Portal published a recording and transcript of the webinar by Vera Zmanovskaya, chief freelance specialist in pediatric medical rehabilitation of the Tyumen Region Health Department
Good afternoon, colleagues! We are broadcasting our webinar from the city of Chusovoy. Wonderful city! This is our first time in this city, and since yesterday I have fallen in love with it.It’s very peaceful here. Today, let’s talk more about the problems of cerebral palsy, but we will touch on various motor problems, because when we talk about cerebral palsy, we will first of all raise the problems of spasticity, impaired motor activity, impaired communication, impaired self-service. And, of course, if the first part of our webinar is devoted specifically to the monitoring program for children with cerebral palsy, then in the second part we will talk directly about rehabilitation.
What is cerebral palsy?
Cerebral palsy is a group of developmental movement disorders.But the main syndrome, the clinical syndrome of this disease is the syndrome of movement disorders. In 2004, in the United States, such a definition was given by the International Workshop on the Definition of the Classification of Infantile Cerebral Palsy.
What is this disease? What problems does this ailment bring with it? Unfortunately, this disease is incurable, and we must understand that no one today has invented such methods of treatment that could heal a person from this disease.
Today in general there are many discussions – is cerebral palsy a disease at all? Maybe this is some kind of physical disability of childhood, which continues in a person at an older age.Accordingly, they are already arguing about whether this is a disease and whether it should be treated? But, pay attention, even today we see how many severe medical complications of cerebral palsy. It turns out that all the same it needs to be treated, all the same it is necessary to intervene. But the question arises: when to start interfering and when to stop? Can’t the treatment last for a lifetime?
This is probably one of the few diseases when we do not see any abrupt onset of this disease and do not see its end.That is, it turns out that it gradually develops in a child in the process of life and continues throughout his life, to a ripe old age, no matter how long this person has lived.
The main problems in cerebral palsy
We have published a systematic review of 2012, made by an Australian group of scientists led by Iona Novak, who is the director of the analytical center of a medical clinic. You see it on the slide. Iona Novak with a group of doctors analyzed a large number of works and showed how many complications of concomitant pathologies are cerebral palsy.
Three out of four children with cerebral palsy – 75% – experience pain.
You can imagine how much it can complicate us in general to carry out any rehabilitation measures, especially when it comes to motor rehabilitation, when we conduct physiotherapy exercises, when we simply even massage or try to put these children in some kind of styling, stretching some commit. Pain, in itself, can still provoke an increase in tone, the child’s natural reactions can themselves increase this muscle tone or weaken the muscle rehabilitative effect.
Every second child has an intellectual disability. Today it is impossible at all to talk about a child fully integrating into society if his intellectual deficit is uncompensated. After all, the most important thing is that these children do not just have intellectual problems, they also have physical problems. Therefore, our center, which is 99% concerned with this problem, pays special attention to this.
And today, for example, it has been proven that the mortality rate of people with cerebral palsy is much higher at
within a certain age period than in the normal population of people.
Here are the very recent studies of the British have proved that it is people with cerebral palsy who experience a state of anxiety and depression to a much greater extent.
When they began to analyze the mortality of people with cerebral palsy, from what they die – and they die mainly from cardiovascular and cardiovascular diseases and from bronchopulmonary pathologies – and so a special status
was given to depression, which provokes the development of these diseases in people with cerebral palsy … Naturally, they therefore die early.
That is, how important it is already at an early age, even in preschool, school age to identify such problems – anxiety and depression of children with cerebral palsy so that we can prevent these cardiovascular diseases, depressive conditions, so that children have a better quality of life and long duration. Today you, as teachers, are creating a very important step in the struggle for the life expectancy of such children.
Every third child has a hip displacement.
It is the displacement of the hip that is today a serious urgent problem that causes severe pain syndromes and which can seriously disrupt the quality of life and, again, the life expectancy of children with cerebral palsy.
Every fourth person cannot talk.
But if the child cannot speak, in any case, we must teach him to communicate. Maybe this child, in fact, will never speak with cerebral palsy. Because if, for example, he does not have the opportunity to acquire the skill of independent communication, he will never speak, but some alternative methods of communication definitely exist, and we must master this technique, because it is very important.
Every fourth child suffers from epilepsy, that is, almost 25% of children, due to their seizures, are limited in carrying out rehabilitation measures.
Especially when it comes to some very active rehabilitation.
Every fourth child has urinary disorders. Moreover, he may simply not feel this signal, and the child may be with absolutely normal intelligence, but due to the spasticity of the motor structures, he cannot feel this signal.
Every fourth child has a conduct disorder. Every fifth child has a sleep disorder.
We understand perfectly well that if a child has something painful, then he does not sleep well. A child with cerebral palsy can get sick anything. Many have a headache, many have muscle spasms. He may have an elementary stomach or intestinal pain. A child who is in reduced physical activity has an abnormal gastrointestinal tract. Chronic constipation, gastroreflux disease, all this can create severe pain symptoms that interfere with children not only sleep, but generally worsen the quality of life.
Every fifth child has a drooling problem. It would seem such a small problem, but how cosmetically even the appearance of a child can worsen. We also have to fight this.
Every tenth person is blind. Every fifteenth eats through a tube is a huge problem.
Today we will talk about nutritional problems, because it is impossible to carry out active rehabilitation measures with children if we have not fed the child, if the child is experiencing some kind of protein or energy deficiency in weight.
Every twenty-fifth child is deaf.
How much does cerebral palsy cost?
In Russia, no one at all considered how much this problem costs. But, you know that in the West they like to count money very well. For example, the National Institute of Medicine of the United States, there is data, of course, long-standing, for 2015 – it calculated that the financial burden of cerebral palsy in the United States is approximately estimated at $ 11.5 billion.
In 2004, the same institute wrote that each new case of cerebral palsy carries an average lifetime cost of $ 500,000 and that only 30% of people with this ailment live to 30 years.It was practically a courtyard study, bypassing all families with children with cerebral palsy in America, people conducted a very serious statistical study. I’ll tell you about it a little later, it’s very interesting.
Why do people with cerebral palsy die?
Do you see this graph here? This is the mortality rate of children, people with cerebral palsy. These yellow cubes are adults with cerebral palsy, the blue ones are the general population. But this is the statistics of France. This is France, moreover, this is 2008.
In France in 2008, life expectancy was 84 years.We assume that we have not reached such a life expectancy in Russia. And then, look, in France, mostly people with cerebral palsy die at 35 to 65 years. If you apply just rough mathematics for our Russian Federation, then you can subtract immediately, you can subtract 15 years and we get it, patients with cerebral palsy approximately – no one counted – they die, somewhere it turns out, from 20 to 50 years old.
Imagine, this is the most able-bodied population. In principle, these are the people who can be useful.That is, these are people with cerebral palsy who can master the profession, but nevertheless, they develop a lot of complications of various diseases.
And look further, from what do they die? Here they are. These are respiratory problems, these are bronchopulmonary problems, and these are cardiovascular diseases. See, the blue bars are when the entire population dies, and the yellow bars are when people with cerebral palsy die. This is a serious problem.
Cerebral palsy and childbirth: who is to blame?
It is interesting, for example, how much the prevalence of cerebral palsy is growing in our country.Because everywhere and always everyone says that the incidence is growing. You hear about it?
And for how many years there have been statistics practically since the fifties of the last century, the disease with cerebral palsy is not growing. This is how it was, approximately, then 2-2.5 per thousand newborns, and it remained that way.
At one time, when we entered the new live birth registration from April 1, 2012, at the same time a child was considered a live birth, an infant of about 26 weeks and 500 grams. If the child has already shown at least some signs of life, then, of course, this child needed to be provided with all kinds of medical assistance in order to revive him.So we have always been afraid that just this group of patients will bring us a large influx of children with cerebral palsy.
The Americans spoke about the same in their time. 50% of babies who are born prematurely with extremely low body weight have a risk of developing cerebral palsy of about 50%.
Many countries for many decades, when they started to analyze the situation, how can the incidence of cerebral palsy be influenced? – we began to look for preventive measures: how can we prevent this disease, and attached great importance to asphyxiation in childbirth.Even when at one time the ancestor and descriptor of this pathology was Little, an Englishman, a scientist whose name is named one of the forms of cerebral palsy – Little’s disease, there is one. When he wrote a treatise in 1862, he wrote that the main problem of cerebral palsy is asphyxia during childbirth.
So, at that time Sigmund Freud, also known to you surname, did not agree with him, who wrote in 1897 – “No, the whole problem of cerebral palsy is not only in childbirth, it goes far into the prenatal period.”
Imagine, back in those days at the end of the 19th century, people were already thinking that not the whole problem is in childbirth. After all, do you understand what common opinion exists in our country? Here comes to us for an appointment, for example, a mother with a child who already has cerebral palsy. You understand that in any case, we cannot blame anyone for the situation that a child with cerebral palsy was born. Why did it happen – you still need to discuss with these parents. But this did not happen, for example, because the child’s neck was broken during childbirth, as is often said about it.The first phrase that patients say when they come to see you.
“Is something bothering you?” The first thing they say to you: “My baby’s neck was broken during childbirth.” Then you begin to unwind this tangle, this complex tangle, you ask your mother – who could tell you that, how did this happen? She says – yes, everyone is talking about it. And you ask – well, who was the first to tell you about this? She replies – well, here is a masseur who comes to our home and gives a massage to a child, he said that your neck is curled, that is, you have a cervical spine injury.
It hurts when we ourselves, in our medical community, say such things, absolutely non-proof, inadmissible things! Therefore, I definitely left this slide “Genetic nature of the disease”. At one time, the Australians, a very rich country, decided to set the task, nevertheless, to somehow develop a plan of measures for the prevention of this disease. And given, nevertheless, that there was such a concept – then, a very large percentage of children with cerebral palsy are obtained from asphyxia in childbirth – they decided to increase the frequency of caesarean section in 50 years from 5 to 34% in childbirth.
See, huh? Imagine, every third mother began to give birth only with a cesarean section. Here is any risk factor – and immediately a cesarean section.
In 2015, the American journal Obstetrics and Gynecology practically detonated a bomb. That is, these data were published, where they wrote that the number of children with cerebral palsy did not change. That is, it would seem, they removed this risk factor, but nothing changes.
And now scientists are on a different path. Now they are trying to prove that the nature of this disease is genetic.It has already been proven that up to 45% of cases of cerebral palsy are of a genetic nature. It has not been proven that this is some kind of monogenic disease, when the gene responsible for the pathology is inherited. Cerebral palsy is not a monogenic disease; more than one gene is responsible for it. This is a polygenic problem. And therefore, of course, it is very difficult to detect it.
There are predisposition factors for this disease.
And then, unfortunately, here are two pregnant women walking around, carrying a child in absolutely identical conditions, eating the same food in the same time zone and living in the same city.But one mother gives birth to a child with cerebral palsy, and the other mother gives birth to a healthy child, because after all, even with some factors, the risk during childbirth, which was made with both mothers, one child has some factors of struggle with these negative factors, while the other child, unfortunately, did not have such resources.
Improving birth care – preserving the brain
The next slide I wanted to show today is not even a decrease in the prevalence of children with cerebral palsy in the world, but a decrease in the resource intensity of the disease.What is resource intensity? Today we looked at children with level I and level II according to the GMFCS system – and you are watching a child with level IV.
Which child do you think will cost more? Of course, with IV, huh? Do you remember how many technical aids we prescribed for a child with II level, and how many for a child with IV?
Of course, it is much more serious for society to bear the burden of a heavier child with cerebral palsy, so today, if something needs to be worked on, it is to reduce the number of births of children with severe forms of cerebral palsy.
And the second big problem is the prevention of the development of secondary complications and timely assistance. If you remember a 15-year-old child with already severe contractures. Do you think it will be easier to rehabilitate him in the postoperative period than the child brought by his mother at the age of six? Harder, naturally. And still no one has given a guarantee that after the operation the child is at the age of fifteen, who has the hardest and contractures, that we will be able to restore him to the level that he had 2-3 years ago.It is important to provide normal assistance to a child with cerebral palsy on time.
As for the first of this block – reducing the resource intensity of the disease, obstetricians-gynecologists today must improve their care to such an extent that when such a risky child is born, neuroprotection and protection of the brain occurs as soon as possible and as powerful as possible.
This article, which was published by the Americans, also caused a great resonance in the world. There is a dispute everywhere. Europeans show – one of the tables of the journal “Pediatric Neurology.Development medicine ”- that the number of children with cerebral palsy is increasing depending on how the gestational age decreases. But in 2007, Europeans published a great article in the Lancet magazine, in which they write what they have for 17 years, that’s just the management of premature babies, the number of children with cerebral palsy has dropped tremendously!
Look, they directly write what they had, for example, in children who were born with a weight, weighing less than 1000 g, their total prevalence of children with cerebral palsy decreased from 50 to 39. And those who were born up to 1,500 – from 64 to 29.And most importantly, their mortality is falling.
That is, the Europeans prove that if we begin to intensify our medical effects, especially immediately after childbirth, we can get, in general, not so many children with severe cerebral palsy. See how they show on the graph how the number of children with cerebral palsy and fragile premature babies is falling.
What is this talking about? This suggests that we need to improve the health care system, we need these magnificent perinatal centers that are developing in the Russian Federation today.These perinatal centers today are just taking care of and are committed to providing all premature babies with high-quality rehabilitation immediately after birth, preserving their brain.
How to observe a child with cerebral palsy: making a functional diagnosis
So, a little later, maybe we’ll talk about how many forms of cerebral palsy we have in childhood. But our task is now to talk about how to observe a child with cerebral palsy.
Yes, it so happened that a child with cerebral palsy was born.It is very important to make a professional diagnosis in this program. There are more of you in the classroom of teachers here. Now, in a very short time
I will try to teach you how to use these international rating scales so that you understand what GMFCS is, what MAKS is. Now it is not yet clear what I am talking about. Well, let’s try to get used to it and, well, probably in 15 minutes you will tell me what you did.
So, the formulation of a functional diagnosis.There is no need to make a clinical diagnosis, the doctors will make it. According to the international classification, there are only three forms of cerebral palsy. This applies, for example, to the pathology of muscle tone.
There is spastic cerebral palsy, understandably, increased tone, right? There is dyskinetic cerebral palsy and there is ataxic. It’s very simple – there are three forms of cerebral palsy. We will not dwell on clinical forms, that is, here there is spastic, look, hemiplegia, when half of the body is only affected.There is spastic quadriplegia when 4 limbs of the body are affected. There is diplegia, when the two lower limbs are more affected than the arms. There is asymmetrical diplegia, you see, when there is one side, but the other is also, in general. There is a triplegia. There are different forms. We will not dwell on dyskinetic forms.
And so, for example, I am asking you a question. Come on, you will be my doctor. For example, I am telling you – a child has cerebral palsy, spastic diplegia, a child is 5 years old.I didn’t tell you anything else. Can you tell me something about this child?
(I’ll tell you right away what spastic diplegia is. This is a child who has four limbs affected, but his legs are more affected than his arms). Can you tell me something about this child? Here, look. There is a clinical diagnosis, but it has absolutely nothing to do with functionality.
And for many years the world medical community has been trying to come up with something like that, so to put some kind of abbreviation, some kind of figure, so that we can say for sure about the child what he can do.
Tell me, please, if, for example, I ask you a question, a question from the audience – if you know what a child can do at two years of age (we are talking about cerebral palsy), can you predict what a child will be able to do at 18? Raise your hands, who can say what he can do at 2 years old, what a child will learn to do at 18 years old? Raise your hands who believe you can say this. Nobody believes?
Then let’s ask another question: do you believe that in 10 minutes you can do it? Don’t you believe it too? Then let’s study it.All the same, literally in 10 minutes you will understand some tendencies.
45 physical therapists, who are physical therapists, I guess you already know? These are not physiotherapists who are engaged in physiotherapy in our country. These are physical movement therapists. So 45 physical therapists from all over the world created a classification system for global motor forms. There has been a very long heated debate about the creation of this classification system, and it was created in 1997.
It was a system of 4 age periods and 5 functional classes. The first three functional classes are walking children. The first functional level is those who can walk without restrictions. The second functional level is the walkers with limitations. The third level is a walking one, but with technical means and rehabilitation. The fourth level is non-ambulatory patients, those who move in wheelchairs. And the V level is only bedridden children who do not hold their heads well.
There are five functional levels, and all of these children have been divided into age periods: 1.5 to 2 years, 2 to 4, 4 to 6, and 6 to 12.
In 2007, the authors of this classification system considered that we still need to add one more age period – this is the period from 12 to 18 years old, and we now have a classification system of two fives: five functional classes and five age periods.
So, look, the first functional level. Unfortunately, I will not show you the video now, for ethical reasons, but I will practically show it myself.
The first level is children who can perfectly learn to walk on their own.And children should be able to walk on their own by the age of two. A patient comes to your appointment, a 2-year-old child. He officially has cerebral palsy, such as spastic diplegia. He is two years old and can walk on his own. If a child up to two years old has mastered the skill of independent walking, it means that he belongs to the first level of development according to the Function Classification System GMFCS, and it means that by the age of 5-6 this child must learn to run and jump, walk up stairs without support, respectively, he will participate in all sports activities, he will be functionally motor active until the age of 18.If a child starts at 2 years old, it means that the regularity of his motor development will lead to the fact that he practically learns everything. The only thing that this child will be bad for is that he may not be able to put one leg and the other so well. It all depends on what form of cerebral palsy he has. Well, he twists his leg, so something like that could be. But if he went to two years, then he has GMFCS I.
Now look what II is. The second level is children who will also learn to walk on their own, but will walk with restrictions.The end point of starting independent walking is 4 years of age. Well, there are different opinions. He can study up to 4 years old, maybe up to 5 years old, but we understand that at 5 years old a child who has not learned to walk on his own is a bad level II. But, nevertheless, it still has very good opportunities.
What do you think a child with level II cerebral palsy can do at 2 years old? Level I has already gone. Level II, we agreed with you – he must go on his own up to 4 years old. Well, what do you think he must do at the age of 2 to get into this two? He has to get up and walk to the balcony.If a child comes to you who has an official diagnosis of cerebral palsy, but at 2 years old he walks only along the couch and cannot break away from the support, but moves, then the child is clearly not level I, he did not go on his own, but he got up and went in 2 years, which means that he has II level and look, what is the prognosis. This means that you did not believe that you can predict its further development. From the age of 4, he will necessarily go independently, this is a pattern of development. But this is the functional level of movement in which he cannot learn to jump and run.Here, the second level – it can no longer tear the body away from the support like you. For example, I’ll ask you to jump. A real jump is when you jump many, many times, pulling the bodies off the support. If a person tears himself off the support only once, then this is not a real jump, incomplete. So a level II child can only jump once, but he will not jump many times. So, look, in order to go up the stairs, he always needs some kind of handrail, must be. There may be some serious weather situation – for example, an ice path, heavy clothes – he will also need a handrail or a crutch.That is, look, children of the II level begin to walk on their own until they are 4 years old. But these are children who do not tear themselves away from the support. And up to 18 years old – how do you describe his motor level? Yes, he will walk on his own, and in principle, good, but he will always need some kind of support. He obviously will not be able to run in competitions, he will not be able to jump too much, but he will probably be able to go to school with a crutch himself. This is the law of the development of movements – children cannot move from one level to another. That is, it is, you know, like the color of the eyes, the shape of the ears, it is just a characteristic of the body.These are the regularities of the development of the motor path, this is the scheme for constructing the movement.
Transitional can be. Sometimes it happens, he is either good II level, or bad 1. But this is only a transitional period. He, of course, can move back and forth, but he will still remain at one level of movement. Sometimes such questions arise. Orthopedists are looking at a patient, for example, today you and I saw a patient who is 15 years old. What can he do? He could only sit in a wheelchair and crawl on all fours, but he could not get up and could not walk along the support.But my mother says that 2 years ago he does it perfectly. That is, we immediately have a logical question – aha, now it looks like it is in level IV, but it was in level III. That’s impossible? However, it happens that in children, secondary orthopedic problems impair motor status. But when we do a good operation on him, do a good post-operative recovery, he will return to his level again.
That is, his level, initially given, he will remain with him for life.As we work with him, so he will live.
So we agreed that the second level – the child can get up and walk along the support, and he will definitely go at the age of four, well, from the age of four.
Third level. Unfortunately, children of level III, they already have very little hope for their walking. The largest is 5% of Level III children can learn to walk short distances on their own. They can simply break away and run forward and it is difficult for them to stop; due to the inertia of movement, they cannot stop on their own.
What do level III children at 2 years old do, what do you think? If the I level went, the II began to walk with a support, then the III level can only sit. Now, if a child at 2 years old cannot crawl on his bellies in any way and cannot stand at the support in any way, but only sits. You will sit him down, and he sits. Then, of course, you should already have thoughts that this is already a child of the 3rd level
of the movement according to the GMFCS system. And what is the prognosis for these children? These babies can learn to crawl on all fours by age 4. Now, if, for example, you ask your mother if your child is crawling and the mother says – yes, he crawls the whole apartment well – then put the child on the floor, ask him to crawl.If he crawls on all fours for four strokes, then this means a real III level of movement. And if he crawls, you know, like a frog, that is, crawls, and pulls his legs a little like this, that is, he seems to be crawling on all fours, but there is no such even four-stroke movement, then this, of course, is no longer level III … So, the maximum ceiling of the III level of movement, the fact that our child himself
learned to crawl on four limbs up to 4 years old, naturally, he will not be able to get up and walk along the support and walk with technical means.
That is, this child, unfortunately, will not master the skills of independent walking to the extent that they have the first and second levels. Therefore, our task, as rehabilitators, is to develop in this child the skills of being active with technical means of rehabilitation. And sometimes it takes a lot of energy to fight with parents who tell me – I will never give my child a walker and never put my child in a stroller, because this way he will never learn to walk on his own.But, unfortunately, this is how it happens, well, it may be unfair in this life – this is the third level of movement. But these children could be mobile, active, socially integrated much better if they were in the same speed and in the same direction of movement with their peers. That is, if we put him in an active type stroller and the child went to play football with the children on the playground, with the same peers, not hobble around, but in a good technical facility, he would probably be more integrated into society …Or, for example, go to school with a good walker.
Therefore, colleagues, the 3rd level of movement is a very difficult category of patients, when they require a large resource intensity, nevertheless, because they require large expenditures, technical means. But this is that promising group of children who can be integrated into society very fully.
Fourth level. Do you understand that we are going to difficult levels? Level IV and V are non-ambulatory patients, but they sound like that in terminology because they are considered bedridden patients.These are very resource intensive patients. The fourth level is children who can only sit in a support. That is, these are children who cannot maintain a posture while sitting without some kind of special device, without a support for sitting – a special orthopedic chair. So, children of level IV at 2 years old can only roll over from back to stomach. That is, if the children of the I level went at 2 years old, the II level – got up and began to walk along the support, the III level – began to sit, then the IV level – only turn over from the back to the stomach and the ceiling of their movement is maximum – these are only turns from the back to the stomach …
They themselves cannot sit down on their own, we can only sit them down, they can sit in a chair, we can move them with the help of a special chair, and these children can crawl, but only like a frog, pulling up their legs. This is the IV level of movement. Verticalization is very difficult for these children – it is very difficult for such children to rise.
Well, the fifth level. This is the most difficult level, when in children practically only head control can be developed vertically. They can neither sit nor crawl.And the biggest, by the age of 2-2.5, what do they achieve? This is just vertical head control.
So I told you the whole system of classification of global motor functions. It is clear, I told it in a very general way, without details. If you want to study it in more detail, then there is information in many different medical literary sources. Today it is unacceptable for doctors not to take into account the functional level of movement for a child with cerebral palsy, because this is included as a mandatory standard for assessing the quality of work with a patient with cerebral palsy by order of the Ministry of Health of the Russian Federation.
And now, colleagues, I am asking you a question now: a 5-year-old child, spastic diplegia of cerebral palsy, GMFCS III. Look, – 5 years, and I mention only one number of GMFCS III. Do you understand what I’m talking about now? If a child is 5 years old and has GMFCS III – what can you tell me about this? Can the child walk on their own? Here, to a greater extent, most likely not, if only for a small some distance. That is, this is a child who walks perfectly with technical means of rehabilitation and can crawl with four strokes.And, most importantly, if you know even further what is typical for each category of patients with a functional level of movement, that is, what is the risk of developing a dislocation of the hip joint? In general, you create a rehabilitation program right away!
The problem of the hip joint and rehabilitation
We talked about this: Level 1 – 0% of this risk, Level 2 – 15%, Level 3 – 40% motor. That is, 40% of the dislocations of the hip joint. That is, it already becomes much more interesting for you if this abbreviation appears.Five levels of movement, and we can already track the functionality of each patient with this figure. You don’t even need to write what kind of contractures he has, in what joints, what tone, but if we say according to GMFCS, it will become clear what can be expected from a child.
So I will still return to the topic of the webinar, and then we will talk about the details. That is, today we will talk more about the problem of the hip joint and, in general, today it has been proven that almost 1/3 to 2/3 of children have problems of the hip joint.Now I will popularly show in my hands how this problem is called. Let the orthopedists forgive me, who are now watching us on the webinar. I will tell you very popular for the audience, which, in general, is even far from medicine.
Suppose a child is born with a hip joint – this depression, it is not yet formed, it is not round, it is so sloping, and here it is the head of the femur, here, it turns out, the hip, and this is the neck of the femur – and that’s when it is born a child, unfortunately, he has not yet formed the top of this joint, he still has a very sloping acetabulum, which is not completely formed, he still has this very large cervical angle, sometimes up to 170 degrees.
And this is what happens in the process of a child’s life? A child is born. First, he is born with high muscle tone. He needs to be born with this high tone of spasticity. In such a position, because if he does not have such a position, then he is injured in childbirth. And now, the first six months, nature begins to relieve the child, if everything turned out to be absolutely normal in childbirth and everything is normal in the head, and childbirth begins to rid him of the vexor dominant. And this vexor tone begins to fade away.And the first symptom that tells us that the vexor tone is fading away is holding the head. When you put a newborn baby on his stomach, he immediately begins to raise his head, that is, he is already overcoming this flexion hypertonicity.
And watch what happens next. This tone begins to fade in all absolutely muscles. And the child begins to move his legs very actively in a horizontal position, which is the most important thing that our parents do not like. They come to the doctor’s office and complain: “The child moves his legs very much.He kicks heavily, moves a lot. This is probably not good. ” That is, many parents believe that this is a pathology. But this is the opposite, very cool. The more the child moves his legs spontaneously, the better he develops all his muscle joints. He forms, prepares himself for verticalization. And so he twirls, twists. Sometimes it is even recommended at the first visits to prevent hip dysplasia with circular movements, up to 200 movements per day, in order to form the prerequisites for a normal ratio in the hip joint.
Then what does a child do at 6 months? We plant him, he sits. These subcutaneous bones begin to somehow surround the femoral head, and already press, that is, axial loads go to the femoral head. And the cervico-diaphyseal angle begins to decrease. And then the child kneels, then stands upright. What’s happening? He twisted and twisted, he formed such a round acetabulum, he reduced this cervico-diaphyseal angle and formed a normal hip joint. Tell me, what will happen to a child’s joint if a child, for example, is only lying up to one year old and has spastic hypertonicity in both hips? Flexor joints, such as knee joints.What will happen? It will not move as many times, it will not form a good femoral head and acetabulum, and the cervico-shaft angle will not decrease. What’s going to happen? The tone will begin to push the femoral head out of the acetabulum. And, look, the more severe the child has a motor disorder, the faster and in a higher frequency of cases this problem will occur.
I will now dictate the world statistics to you, and you will analyze it. Children of the first level of movement – there is a zero risk of dislocation of the hip joint.Clear? Because he went to two years old. Children of the second level of movement – in 15% of cases, these are those who went closer to 4 years. Children of the third level – in 40% of cases, the hip joint is dislocated, children of the fourth level – in 70% of cases, the joint is dislocated, and children of the fifth level – in 90% of cases.
The question logically arises – what is the most important factor, the most important factor in the formation of the hip joint? It is clear that the muscle tone is increased. But the most important thing for us is the gravitational load.That is, if we do not create gravitational loads for a child at an early age, accordingly, we will not create the prerequisites for the development of a normal hip joint.
What am I just talking about? Early verticalization. There are two opinions of parents, two prejudices. Some parents say that if a child is put on a walker early or given some kind of technical means, then he will never develop the skills of independent movement. Is this correct or not? No, of course, you and I have proven that there are patterns in the development of movement.And no matter how we try to change these patterns, we can never do it. That is, if a child is in the 3rd level of movement, and we put him in two years, then, accordingly, no manipulations of ours, I mean, giving or not giving a technical means, we will not change the level of movement. We can only slow down its development.
There is a second prejudice that “children with cerebral palsy must go through all stages of vegetative development.” Is that what I just said? That if the child has not yet held his head, then he does not need to be taught to roll over.If the child does not know how to roll over, he cannot be seated. If the child is not sitting, it cannot be placed. Am I right or wrong? Of course not.
Here, look. Let’s take children with 4 and 5 levels of movement. Will these children sit on their own or will they walk on their own? No. And what is the risk of developing a dislocation of the hip joint? 70% vs. 90%. Can we,
in general, somehow logically connect these things? We ourselves push children towards a secondary orthopedic complication with our own hands. We ourselves, practicing with him a skill that by the nature of the pattern of movement development will never appear on his own, for example, independent landing, we do not verticalize him, thereby we do not give axial loads, and the child develops a serious complication – dislocation of the hip joint, which will lead to pain.Can you imagine what it is – when it is impossible to carry out even hygienic measures for the child, it is impossible to change the diaper, when the child is screaming day and night?
And constantly experiencing chronic pain syndrome … Imagine that you have something in pain from day to day for weeks. Your general feeling of pain dulls, a person loses, this has already been proven, intellectual abilities if he constantly has chronic pain syndrome. If children experience chronic pain syndrome, no rehabilitation, no correction, no social integration is possible.When a child even undergoes palliative surgery, there are such methods of treatment when time has already been lost and it is necessary to do the maximum resection of the femoral head and some other operations – the child is relieved of the pain syndrome, the child becomes different, he becomes contact, he begins to develop. And his parents, even those who have been with him for many years, are beginning to see positive changes in his psyche.
So, hip displacement is probably the main most formidable complication that visits our children with cerebral palsy.When my parents ask me – what are you doing there, rehabilitating children with cerebral palsy, have you never cured anything? Well, we naturally cannot cure him. But the most important thing we are fighting with is that we are fighting its formidable complications. The first is with dislocation of the hip joint.
And, therefore, when we consulted patients today, you probably noticed that the first thing we asked for was an X-ray of the hip joint. Because in different categories of children it should be done a little differently.I’ll try to tell you about it now. These are the statistics on the slide that I told you about, these are 40%, 70% and 90%. We’ll skip a bit here, and I’ll tell you about the program.
At one time in 1994, I will now talk about the Swedish program, Gunnar Hagglund – there is such an orthopedic surgeon with his group of doctors invented such a program. This is a long-term work. They tried to show that certain research protocols can prevent the appearance of not only hip dislocation, but also various physical complications in children with cerebral palsy, and early preventive measures can reduce the percentage of complications.So, it is important that if we are now talking about dislocations of the hip joint, I will tell you about the Reimers index.
The Reimers index is such a thing that it would be better, of course, to be measured in an X-ray room, but unfortunately, even many radiologists in our country do not do this. This can, in principle, be measured by any doctor – both a neurologist and an orthopedist, even a pediatrician can do it. Well, you just need to own certain things. Please note that it is very important to get a correct picture of the hip joint.A picture is taken in direct projection. And it is necessary, in general, to draw only one horizontal line and three vertical ones. One line is drawn, a horizontal line. This is the line that connects the lowest points of the ilium and, look, three vertical lines – one line goes along the roof of the acetabulum – this is the Keller line, and two lines, they are not drawn here, which are along the inner surface of the femoral head and along the outer surface … And look, this is a small distance that has already emigrated behind the roof of the acetabulum.This is measured in millimeters and divided by the entire width of the femoral head. And so it turns out that if we get an index of 33% with you, no less.
Can you imagine 33% of the head emigrated? This is still considered normal. That is, up to 33% it is considered normal. Today one mother said to me, I don’t remember who: we took a long time ago an X-ray of the hip joint, and everything was fine with us, many years ago. And so they stopped doing it, because everything was fine. So, this situation can change every year.And everything goes like this due to the fact that the child is growing, that the child’s muscle tone increases in the first years. Migration of the head from the acetabulum increases, and we can get such indicators of the traffic light zone.
See, these three colored mugs? So this whole observation program, it is just based on traffic light scales. That is, if, for example, the indicators fall into the green traffic light zone, then this is all right and good. This means that we are on the right track, we are acting correctly in relation to the child, and we should not undertake any surgical tactics.
If the child is already in the yellow zone, here it is already necessary to sound the alarm, then we are not working on something. Maybe we do not sufficiently reduce muscle tone, insufficient verticalization in a child with abduction of the hips, maybe in a child, of course, some kind of growth spurt has happened, sometimes we see such a situation. But we must already take measures. And I liked that it is very cool that you have it in the Perm Territory, they immediately recommend an operation on the muscles. That is, in principle, if conservative therapy, which can be carried out with the help of type A botulinum toxin preparations, no longer works, then, yes, it is necessary to carry out preventive surgery on muscle tissue.
And, if the indicator already goes into the red zone – more than 40%, then all conservative measures must be stopped. We must take steps to carry out an operative surgical treatment.
This is the same program that is schematically indicated in this way. That if we observe a child according to some unified protocol, we identify the problem early and begin to fight it early.
This program, it is called CPUP, is a Swedish program, it has its own website.This program started in 1994 only in the southern part of Sweden. Marked in green on the slide – these were two counties with a population of 1.5 million people. And all children with cerebral palsy born in 1990 are 4 years old and younger, all of them were taken under supervision in this program. And when Gunnar Hagglund and their doctors looked at what they had achieved, they themselves came, in general, after 10 years of monitoring children, they were delighted – the number of hip joint contractures decreased from 18% to 8%, the number of children who were operated on for contracture decreased from 26% to 4%.Moreover, not because they were more operated on. The number of children who had a frequency of deformity by the type of a gust of wind – here, please note, this is such a severe deformity, if you see such patients, these are patients, most often 4 and 5 levels according to the GMFCS system, who have been in the wrong posture for a long time, in the supine position due to the fact that their tendon, knee flexors, hip flexors are shortened, and this posture is formed – it seems to have been blown away by the wind, that is, the legs fall to one side and the pelvis is deformed, that is, it goes misalignment of the pelvis.On the one hand, we see an application contracture of the hip joint. And even such a deformation, Gunnar Hagglund with his doctors – physical therapists were able to reduce. Reduce the number of scoliosis with a Cob angle from 12% to 8%.
You will see what our colleagues from Sweden have achieved the most revolutionary. If before the introduction of the program 11% of children with cerebral palsy in Sweden had problems of the hip joint, then after the introduction of the program, only 0.4% have it.
3300 children with cerebral palsy in Sweden today are observed in the register.Of these, only 13 children have hip problems. Today we watched ten children. Of these, exactly half had hip problems. When Gunnar Hagglund published these results with a group of specialists, they hit the whole of Sweden, and in 2005 this program becomes the National Program of Sweden. In 2009, other countries joined the program. Norway in 2009, Denmark in 2013, Iceland and part of England in 2014, Ireland joins the program.And, look, even part of Australia. There is a different program in Australia. There is a program under the direction of Kengrem, but, nevertheless, the Swedish program is starting to exist. And today, 9000 patients with cerebral palsy are already observed, and 800 new children are added to it every year.
Risk Factors for Hip Displacement
I still want to show you again those risk factors for hip displacement, so that you are deeply oriented, that is, aimed at this problem. So, the first risk factor for hip displacement is GMFCS, which we talked about, that is, this is exactly the level of motor development.The more difficult the child is in motor development, the greater the risk of developing a dislocation of the hip joint. Remember, a recumbent child almost 90% has a dislocation of the hip joint?
Now look at another graph. The second risk factor for hip displacement is age. When should children be afraid of hip dislocation? Pay attention, there is such a risk age factor – this is 3-4 years and about 7 years. Why do you think 3, 4 and 7 years? You, a teacher, should also be close to this.Height. A child makes a leap in growth, mainly at this age, and we ourselves see it at 3-4 years old, and the second growth leap occurs at about 7 years old. We see exactly what the problem is.
Therefore, when we had children 12-13 years old today for consultation, and when we saw the Reverse index of 33%, then, in general, we have everything with you … Firstly, 33% – it is in green zone, the risk age of 4 years and 7 years has already passed, that is, we should, in principle, reassure parents about the problem of dislocation of the hip joint.There are other problems, remember, yes, they were growing – knee and ankle joints? The most important thing is, look, the spasticity does not grow all the time. Here, look, in red – this is just an increase in muscle tone, this is a high muscle tone.
So, in children with cerebral palsy, muscle tone grows only for the first 4 years, and then it begins to fall. So, the whole problem happens, at first the child walks on tiptoe. Well, few children, some walk right on the foot. First, they walk on tiptoe, then they still fall on their heels, but their knees bend due to the fact that they are 01:08:00 calf muscles.
So, if we are still trying to aggravate this change with our medical manipulations. How? If we overextend the Achilles tendon with an operation, if, for example, we do all sorts of surgeries like, well, I don’t want to give my surname, neurofibromias, yes, then these surgeries, they can all significantly weaken the muscle link, lead to overextension of the tendons, levers of movement, etc. in this way we develop pathological crouch gait types. Crouch means “hide” from English.They walk like hidden children.
The next risk factor for hip displacement is the Reimers Migration Index. I just talked about it. If, for example, the Reimers index is already beyond 40%, then this is a red zone that requires an operation. cervico-shaft angle – HSA. Here, look at the slide. If it is more than 40 degrees, then this is, of course, the red zone.
Mobile application for risk assessment
And I want to tell you about the application that is available and you can download it to your phones, if technical capabilities allow you.If you enter these four letters in the AppStore or PlayMarket, then you immediately have an application that you can download for free. And what can you add to this application, for example?
Firstly, even some parents download this application from us, because it is very useful to speak the same language with parents. Take a look. Here it is necessary to note only the level of GMFCS, here it is at the top. Now you can even determine the GMFCS level yourself. For your child, you can definitely determine this.Now, definitely HSA. If you find it difficult to test, your doctor can do it.
Reimers index. The doctor can also calculate it – he will draw only a horizontal line, three vertical ones, he will calculate the migration index. And put the age. And look, if we have a child of level 4 and these are the indicators, we immediately have a risk of dislocation of the hip joint in the calculation of 10% – 20%. Now look, I only changed the level of development, only put an A. And with the same indicators, the risk of developing a dislocation of the hip joint increases to 50% – 60%.Now look, I only changed HSA, set 180 degrees and already the risk is 70% – 80%. And now, look, I have reduced my age. The child has not yet passed the risky age – three years. In a child, the risk of dislocation reaches 90% – 100%.
This program is very simple. It is available in applications on every phone. Parents who are serious about hip misalignment want to be actively involved in preventing these things.
A patient comes to us today for an appointment, and together we calculate the risk of dislocation 50% – 60%.Six months pass, mom comes, we score new indicators and the risk of dislocation is already 70% – 80%. And we have another dialogue with our parents. First, something is wrong. Or we give recommendations, and mom does not follow them so carefully. Either everything turns out so difficult for the child, urgent measures must be taken to prevent the risk from occurring, this is not a dislocation, it is only a risk. But, unfortunately, it happens like this, well, not a dislocation, but the displacement of the hip reaches critical indicators and we still reach that day of surgical treatment.Unfortunately, this often happens today.
Practically, we have 26 children of level 5 under the GMFCS system, half of them have been operated on. Unfortunately, we cannot yet keep this situation on the green level with preventive measures. We still have to operate a lot. But, most importantly, the operated joint is a painless joint, they do not hurt in children.
How often you need to observe
Now look how often you need to observe in this program.Children under 8 years old should be seen every six months. That is, I understand that it may be difficult to go to a doctor in a polyclinic, but if, for example, there is a rehabilitation center on the territory, and the doctor has the skills to lead a child according to this protocol, then do it must be sure. Every six months, a child under 8 years old should be examined by a doctor or physical therapist.
The protocol, of course, is very complex. I will not dwell on it in great detail, because today we do not have a medical audience.But for the listeners of the webinar, I will show. These are the main 14 dimensions. Those where we will measure two indicators – R1 and R2, a mandatory measurement of spasticity, are highlighted in red. And now I will show pictures of what we are doing. We are sure to watch the flexion of the hip joint, extension of the hip joint. As you can see, different indicators have different color characteristics. That is, if we get an indicator of the green zone, then everything is fine. If the indicator of the yellow zone, then – “Attention, danger”, then we are not finalizing.If the indicator is the red zone, then urgent measures must be taken to organize operative surgical treatment.
This is a mandatory definition of the Thomas test for contracture – flexion of the hip joint. This is the norm, and this is a pathology, we have already seen this today. This is the Duncan-Ely test. You see, we put the child on the stomach and bend the leg at the knee joint. Thus, we stretch the rectus femoris muscle and show its state, a minimum of spasticity. And then the pelvis rose and the lumbar lordosis intensified, this indicated that not everything was calm here.But if this is, for example, a normal situation, then look, not everything is good here. That is, this is the same rectus femoris test. We certainly did, if you saw, I watched the abduction of the hip joints with extended knee hip joints in all children, first of all we are talking about the state of the tender muscle. If her condition is problematic, then it was recommended, for example, to carry out preventive therapy. It was imperative that the hip joints were carried out with the hip joint bent at the knee, when we turned off this delicate muscle and already talked about the state of the hip adductor – the oblique muscles that encircle the thigh in the hip joint.It is imperative to measure the internal and external rotation. We certainly measure the flexion of the knee joint, the extension of the knee joint, the Harmstring test, we said, remember, when we looked, we extended the knee joint and looked exactly the tension of these internal muscles of the knee joint extensor. Many of them are tense. If they become less than 140 degrees, this, of course, means that in
this case some additional measures are required.
And remember, when we put the child on the couch, we asked to straighten each leg separately and looked exactly at the deficit of active extension of the knee joint.Remember, there were children who could not fully straighten the knee joint due to the fact that, nevertheless, the muscles, despite the fact that it was in good shape, it already lost its lever activity, this tendon lengthened, the patella rises up and does not allows the knee to completely unbend. If in this case we already see such an angle – a deficit in extension of the knee joint – then we must definitely take measures for surgical intervention to bring it down to the knee. We definitely looked at the ankle joints, remember, with the knee bent, because we turned off the bicarticular muscles.Be sure to include two heads of the gastrocnemius muscles with the knee extended. And thus, all indicators were entered into the green or red zone.
This is such a protocol, but not a simple protocol, right? The question is always asked – how much time can it take for a specialist doctor to carry out such a research protocol? Now, if everything is brought to automatism, then this protocol can be carried out in 10 minutes. In principle, 10 minutes can be allowed during working hours to conduct such a research protocol.The only thing is that it is very difficult for one doctor to do it. A system is absolutely necessary here – one does it, the other measures it. Of course, it is better for an assistant to work with us.
When to take pictures of the hip joint
Now look. This is to make it clear to you when to take pictures of the hip joint. This is where you must be competent. You’ll tell me now what is the risk of dislocation of the hip joint in children of the 1st level of motion.Null. Accordingly, everyone does not need to take pictures of the hip joint.
It should be done only for clinical indications. When they took measurements and saw that the organs of movement are suffering, there is a difference in the lengths of the limbs and, in general, there are some alarming symptoms, it is imperative to take a picture in direct projection.
Level 2 children must do them at 2 and 6 years old. You don’t have to do it all the time. There the risk of development is 20%. And look how red the field is.Children at levels 3, 4, and 5 should have a hip X-ray every year. And therefore, it is correct in general for any specialist involved in the rehabilitation of children to ask – did you forget to take a picture of the hip joint? You just need to determine the child’s level of motor development. It’s all very simple. The most important thing is how early we can identify the problem. You will not read
yourself, but you will send the child to a specialist with this problem.
Now look, I want to show you how the Swedish system differs from the Australian system.Swedish, it irradiates children a little less and takes pictures of the hip joints a little less. See, 100%? And the Australian system is 162%. And all this is due to the fact that in the Swedish system there is an emphasis on this particular clinical examination. What we did with our own hands today. We looked a lot today, the pictures – that was already the second case, right? But in the Australian system – it is clear that an orthopedic surgeon is looking at a child – but the main thing is, of course, an X-ray examination of the hip joint.And look, when, nevertheless, without a clinical protocol, it is more often necessary to teach children, look, it is highlighted in red – twice a year, studies of the hip joints in children of level 3, 4 and 5 until they reach 4 years of age. Remember, we said that the first risk age period is 4 years. And therefore, children who are not walking – level 3, 4, 5 – take pictures twice a year, even. And children of the 5th level are examined 2 times a year up to 8 years of age.
Generally, this program includes various studies.And knee joints. Today we requested some pictures from children. And the ankle under stress. And necessarily – the spine. A big problem for children who cannot walk on their own, that is, it is 3,4,5 level according to the GMFCS system, then an X-ray examination of the spine. Here is the COBA angle measurement. I will not tell you the details now.
So this is the program. Why exactly the Tyumen Region and why am I now talking about this program? In 2014, we first got acquainted with this protocol, we got to know Hebard.He very kindly addressed us to his site, which was open, they gave us information, we went to this site, read it carefully, it is true, it is all in Swedish, but it is not difficult for doctors in Sweden and Russia to find a common language.
And we were able to translate this program and from 2014 start observing children under this program. It was organized by one system. Of course, we have many computers working in one system. And I want to show you what statistics we have achieved.
Sweden and Russia: Comparative Statistics
So, as of January 1, 2018, we have 958 children with cerebral palsy.Of these, 318 children are children born in 2010 and younger. We set ourselves the task just as once in 1994 Gunnar Hagglund took birth in 1990, in 2014 we took children with cerebral palsy born in 2010.
We could not take all children with cerebral palsy for one simple reason, we were able to take only 55% into this program. It turned out to be very difficult. First, the program means that every six months the child must be in the office.
It is advisable that he constantly comes, does not go anywhere, and does not engage in any other activities.Considering that this program is new for Russia, and some parents do not yet have confidence in it. Many do not even know that such a program exists, and doctors can observe children under this program. We were able to take only 55% of young children under this program, because they lived in Tyumen. We do not have an exit form of work, so we did not have the opportunity to travel to other territories to watch. Most of them lived in Tobolsk, so we could come and watch the children. And 10% came to us.
Now look, we decided to analyze our children with cerebral palsy and compare them with children in Sweden. Here, the blue bars are the children of Sweden. Burgundy columns – children with cerebral palsy from the Tyumen region. But these here 1, 2, 3, 4, 5 – this is already clear to you – these are children who are walking, few walking, non-walking, sedentary and lying. And the first thing that we saw that we have a large number of children, of course … Well, firstly, the almost equal proportion of all functional levels of movement and we have walking children in the Tyumen region turned out to be much less than in Sweden.
Recently we analyzed the statistics of many European countries, and such statistics are available not only in our Tyumen region. I think the story is the same in Chusovoy. In general, I believe that the picture is the same in the Russian Federation.
We have roughly the same records. Still, I would like to see more walking children with cerebral palsy, functionally active. But this is probably still a big, big work in our country to improve the obstetric and gynecological service and the neonatal service so that we can still preserve and protect the child’s brain in the first hours, in the first day of birth in order to we still had more functionally active children.
Here is Sweden in 1994, when they first entered the follow-up program – 11% of children had hip problems. And after joining, they led children in the program for 10 years – 0.4%. When we analyzed all children in 2014, 43.4% had hip problems. And when we look at children in the regions today, the situation is about the same there. That is, imagine, we are doing something, we are not sitting idly by. We do massage, we do gymnastics, electrophoresis, stimulation, cerebrolysin injections.I can also name a lot of different procedures that we do with these children, but unfortunately we cannot effectively influence the problem of the hip joint. See what the situation is?
Because for the prevention of problems of the hip joint there is a certain set of measures, there must be a certain algorithm. When we had children in this program for 4 years, look at what indicators we have achieved – 8%. After entering the observation program, the number of children with hip displacement with a Reimers index of 40% or more – we have only 14 children out of 176 children.But I honestly say that we have not always achieved this only through preventive measures.
Almost half of our children have been operated on. We operated on, we got rid of this problem, and we have a painless hip joint that never hurts in a child, and we can actively verticalize the child and work with him actively. But nevertheless, look what indicators were – 43.4%, and what we have achieved today. And look at the bars, what level we had.It did not differ from world indicators. We have children of 3rd level – 41% had a problem, 4th level – 67%, 5th level – 90%. See what indicators we have now.
I always encourage the medical community, podiatrists and neurologists to study this program. Yes, it is not easy, it requires a certain skill, it is not always, in general, that you can quickly master it. But this is actually a real program that can significantly reduce the incidence of complications in children with cerebral palsy.And this may be what we generally worked for, rehabilitologists, that is, I am talking today about the medical component. Not to reap the benefits of pain syndrome of chronic, difficult palliative operations, which will practically not give the child the opportunity to verticalize. This should be done at an early age. Of course, I may not be entirely correct in comparing these groups, because these are children with an average age of 6.5 years already, these children, who in our middle group have just passed through 3.5 years, and we have not passed the second growth leap 7-8 years and nevertheless, have achieved such results.Therefore, when we talk about how we were able to achieve such results, it is probably worth talking about rehabilitation now.
Assessing hand function: MACS scale
In the rehabilitation of children with cerebral palsy, there are three main directions, as it were, three global things that we must solve. Note. This is a solution to the problem of physical activity, a solution to the problem of communication and independence in service.
Now let me ask you, colleagues, questions.First question. Now, if I, for example, say – a 5-year-old child, cerebral palsy, spastic diplegia. And you can already tell me about his functional motor development. Can you tell me something about the function of the hand? What can a child do with his hand? You, all the same, only assume so far that something is difficult, but you cannot say for sure, right? Until you see, right? And if I come up with some classification system again, and if, for example, cerebral palsy sounds in the functional diagnosis, spastic diplegia according to GMFCS 3 and, for example, there will be MACS3 – a classification system that was first developed for children from 4 to 18 years old, and now it even exists from 1 to 4 years of age.So this classification system allows us to define the function of the hand in the same way. It’s all very simple.
Here, for example, I’ll just show you. What is MACS1? This is in direct correlation with GMFCS. If GMFCS 1, then this is a beautiful walking child. What is MACS1? This is also a child who perfectly owns the function of the hand. Well, it is clear that he will not do all this as a healthy child, because a child with cerebral palsy of the 1st level, he also has certain violations of the quality of movement, but the child can do everything.He can write, paint, he can eat and drink. He can thread a needle. That is, he will do all this, but not so well. But this is MACS 1.
But imagine what is MACS2? Remember GMFCS2. This also the child walks independently, but walks with restrictions. What do you think MACS2 will be? Evaluates two-handed activity. This is when help is needed. A child, in principle, can do everything that a child with MACS1 will do, but support is needed. Now, if, for example, I could do everything by weight with MACS1, even thread a needle by weight, then with MACS2 I have to put my hands on the surface.It will certainly be much slower execution. It will be of less quality. But everything,
absolutely, manual skills are available to a child with MACS2.
What do you think is MACS3? Remember GMFCS3? The child already, in general, walks only with technical means, adaptations are needed. That is, MACS3 – this is also some help needed. First, you need some kind of technical means. For example, a spoon with a special twist. It should be a handle with holes so you can insert your fingers.That is, the repetition rate suffers, this child’s strength decreases, naturally, it is not that, the speed decreases and, of course, not all, absolutely, already subtle movements are not subject to him.
What is MACS4? Imagine, GMFCS4 are children who just sit and sit only in the support. Only certain activities are available to a child with MACS4. What can they do? They can push a button of some kind. They can take a large cap on the felt-tip pen and put it on, that is, if you put it in his hands, he can do it.He can show some hand gestures. That is, everything is subject to MACS4. But for MACS5 it is practically not subject to some complex movements. And only simple movements, only in an adaptive situation.
Look at the correlation between GMFCS and MACS. Here are GMFCS – these are blue bars. The yellow bars are MACS. That is, look at how, nevertheless, violations of the global function and violations of the manual function, hands, go side by side. That is, of course, if a child has a severe movement disorder, then his fine motor skills of the hand can also be impaired.
Now tell me, please, if I say now – cerebral palsy, GMFCS3, MACS3, 5 years. It is clear who I am already talking about, what is their functionality? That is, the child does not walk on his own, he walks with technical means very actively. In principle, he can perform a lot of manipulations with his hands, but they must be modified, right? He needs some help. But can you tell me something about his communication with others? You can not. You can’t even guess if he can communicate with us.I’m not talking about some kind of verbal, non-verbal contact.
Evaluating Communication: CFCS
So, there is another classification system. There are only four of them, but I will only introduce you to three. See CFCS – Communication Function Classification System. You will have all these presentations, you can work with them, study them in more detail, because after all, this is a global approach to establishing a functional diagnosis. And today, in general, you see such diagnoses in any statements of children who come to you for rehabilitation.
So, look, what is this classification system? I’ll just open this slide, and you will already understand that P is a patient. Here everything is in Swedish: “okando och” is “outsiders”, and “kando och” is “relatives, acquaintances.”
Look, what is level 1? Here comes a child to your office, and you say: – What is your name? – My name is Vasya. – How are you? – Everything is fine, I study at school, I have excellent grades. I don’t want to go to school because the teacher comes to my house.I love it all so much.
Children came to us today, they all told the truth about the city of Chusovoy. And now this is a real CFCS1, great, the children are very communicative. They communicate, they easily go to communicate.
Or, for example, we had such a child. He sat down on the couch, we ask him a question, and he thinks first – to say or not to say? Thought, answer, not answer? I looked at my mother and asked my mother. So, he looks, he is looking for some kind of support from his mother. But, nevertheless, some time passes, the child still comes into contact.It took time to establish contact with the child. Delayed contact. But nevertheless, the child is in communication. This is CFCS2 (you cannot immediately put CFCS on the move, you need to communicate with the child, gain confidence in him).
Now look at slide CFCS3 – the child completely ignores communication with the doctor or with the teacher. I don’t want to call it autism, when a child communicates only with relatives, and does not communicate with strangers, and this can be. But these can be different types of non-communication with outsiders.Clear? That is, CFCS3 is a complete disregard for communication with strangers.
Continue CFCS4. Look, the already dashed line. That is, a minimum of communication even with relatives. That is, in practice, even the mother does not have a common language with him, that is, the child already reacts badly to some requests from his parents and relatives.
And the fifth level of CFCS5 is just a reflex reaction. That is, the mother, in fact, only guesses what the child wants. Moreover, one should not confuse CFCS with verbal contact. Verbal, you get the idea – through speech.There are children who absolutely do not say a single word, but they are ready to communicate through any active communication. They are ready through cards, through different albums, through pictures, through a computer to communicate with you, with your eyes. They understand everything, they want to communicate with you. There are children who don’t really say anything. But they are actively willing to communicate.
And, look, how the diagnosis of cerebral palsy, spastic diplegia, 5 years, GMFCS3, MACS3, CFCS3 is transformed. Do you understand who I’m talking about? See how important it is to make a functional diagnosis.For example, in a rehabilitation center, it may even make no difference to have asymmetrical diplegia, or, I don’t know, even there, hemiparesis. You don’t need that.
If you even put down GMFCS, MACS and CFCS for yourself, you generally understand what to do with this child. And, look, we are closing three main problems that you must definitely work out with a patient with cerebral palsy. This is, look, the global motor skill according to GMFCS, the child’s self-care is the manipulative function of the hand, MACS.And communication, its ability to integrate in society – CFCS.
It would seem that these are the three main problems. No matter what you do, you need to solve the child’s cerebral palsy … Well, let’s talk about the motor problem in general, if we talk not only about cerebral palsy – we need to close three main problems – global motor skills, self-care and communication. And each center, they, in general, perform their specific function. Your center, as I understand it, performs the function of adapting the communicative function, right? Now look at the correlation between GMFCS and CFCS.This is what I’m talking about – communication and motor functions.
Look, this is the register of Norway 2015, and they show in their register how communication and global functions stand side by side, because this is also a function of the brain. If the brain is very strongly affected in terms of movement, then, unfortunately, it can also be affected in terms of the emotional, in terms of the communicative properties of the individual. Although there are certain deviations.
It is very difficult to listen to a lecture for two hours, and I will tell a story.
We had a consultation. And we selected children for surgical treatment. And now they bring a child in a stroller. In practice, it was level 5 according to the GMFCS system. We have been working for many years and we understand perfectly well that a child with the 5th GMFCS level with what level of communication can already be? With the weakest, huh? And when they have a dialogue with their parents, there is little time, they say – yes, there is not much time, it is necessary to do such and such an operation.
Well, the doctor is already moving away from the couch, and suddenly the boy says: – Wait, doctor, tell me what kind of operation you want me to perform.
Can you imagine? This is the kind of discrepancy when you see a child with a severe motor effect and at the same time with such very intact communicative functions.
We know with you difficult children with cerebral palsy who receive higher education, who draw great, reaching heights in their artistic skills, write songs, write poetry and music. Today, there is generally a technique available to develop these skills.
Well, colleagues, we just talked about the surveillance program.Let it be schematic, but I think that I have nevertheless conveyed to you the meaning of observing a child with cerebral palsy, that he does not need to carry out a set of formal medical procedures. You must first approach the assessment of its
functional capabilities, and already based on what you have, build the correct rehabilitation program.
International classification of functioning
Colleagues, now, perhaps, we will summarize our webinar. And I would like to dwell on the issues of tools that we use to achieve successful results of our work.
In 2001, the entire world community that deals with the rehabilitation of people with disabilities leaves the International Classification of Disabilities, Disabilities, Social Disability and adopts a new classification – this is the International Classification of the Functioning of Disabilities and Health, which is abbreviated as ICF. I understand that these three letters are familiar to you.
There is a lot of talk about this now that we should build our rehabilitation programs only on the basis of the International Classification of the Functioning of Disabilities and Health.This is an independent classification, which is the basis for the construction of any rehabilitation program.
And even being not a doctor – a teacher, a speech therapist, any, absolutely, specialist in the field of rehabilitation – we must use this classification system. What it is? This is a unified standard language that allows us to determine, firstly, the level of the child’s initial functioning, this time. Defining the goals of rehabilitation is two. It is imperative to develop the right approaches in the choice of interventions that we will carry out with the child.And they must assess whether this intervention is applied correctly and the result is obtained. Understood, yes, what I said? That is, we must definitely determine the level of functioning – what we did in the first part of the webinar, then we must set adequate goals, then we must determine with you whether we have achieved these goals.
So this is the International Classification of Functioning, it has these two large parts. The first part is the functioning of the disability and what are the contextual factors.The functioning of the limitation of life is divided into two large parts – the structures of body functions and activity and participation. What it is? Now I will not dwell in detail, but I want to show you with a small clinical example.
Here is a child in the photograph with a dysfunction of the left limbs. The left limbs just do not work – the left arm and the left leg. Now, if you are not doctors here, then I will honestly tell you that this child can have three completely different diagnoses.
This may be a child with cerebral palsy with unilateral hemiparesis. It may be a child with the consequences of a traumatic brain injury. Or is it a child who may have, as it is no longer a case in life today, for example, a cerebral stroke, and the child may also have hemiparesis. Look, for you, as for the rehabilitation therapists it has some special meaning in general, what is the diagnosis of this child? Trauma, cerebral palsy or stroke. For you, as for rehabilitation therapists, this does not have any fundamental significance.Impairment of the functions of the left extremities matters to you. That is, the first thing you start working on.
For example, let’s take with you the first global problem – this is physical activity. Think back to the three parts we are working on. The first problem is motor function. That is, the child’s left limb function suffers. Accordingly, you will build a program to improve the function of your left arm and left leg. Improve balance, for example, on one leg, teach him to jump, suppose, correctly transfer body weight from one leg to another, and so on.That is, it makes no difference to you whether it was an injury or a stroke. The main thing for your child is to increase mobility. Accordingly, you need to improve its function.
If you code a child according to ICD-10, that is, put cerebral palsy, stroke or injury, you will have to, according to all our rules of work, if you are doctors, apply three different protocols. And if you encode a child according to the ICF and give him a code, for example, d45000.2 – there is such an encoding – then you, absolutely sure, can only work on improving the walking function.
So this classification system is very simple. For example, I have coded the child as d45000.2, where 2d is the activity and participation category. What is d to make it clear to you? d is section 4, mobility, d4. Then, for example, I will indicate what 50 is. D450 is exactly the section of walking and movement. What is 0? This is pure walking.
Look, I’m opening the browser further. I will no longer show you the slides, but there is such a website of the World Health Organization, it has such a browser.By clicking here on this ICF browser, you immediately find yourself in different versions, I mean, multilingual versions of the ICF, choose the Russian version and you can start to open each of these sections in the same way.
ICF – it is not very difficult. By expanding each section, you can code the child’s dysfunction and only work, for example, to improve gait function. What is – .2? This indicates the degree of impairment – moderate, mild, severe or absolute. That is, the ICF today is very important in order to move away from some nosological characteristic.Moreover, you, as a rehabilitation center, without having medical workers on the staff, can put a violation of the function according to the ICF. Of course, it is advisable to undergo training in the ICF. Today there are places where you can take advanced training on this topic, because the International Classification has a lot of nuances. We will not stop at this today, especially since I myself have not yet fully figured out these nuances, I myself still need training. But I understand that this is the future, and I urge all of you that you must make friends with the ICF and in the future build your work on the basis and depending on this classification.
Clinical guidelines for cerebral palsy
But if we talk about the rehabilitation of children with cerebral palsy in general, there is a strong consensus in 2009, which was published in 2010, in which more than 1000 patients with cerebral palsy participated and, thanks to which, such clinical guidelines were created – what methods of treatment and in what children in the age period and, depending on the classification of ICD, which methods of treatment should be applied.
Look, each of these lines in a different color denotes its effect. This dark green line here is functional or physical therapy. What would we have called “physiotherapy exercises” is designated here as “methods of functional therapy.”
And look how early you and I must begin functional impact, from the very birth. If a child falls into a risk group for the development of cerebral palsy, and we talked about who it could be, then from birth we should engage in physiotherapy exercises.We must fight with you this increased muscle tone, with all kinds of pathological reflexes, create verticalization, that is, everything that is aimed at activating movement.
Now look, this light green line is a conservative orthopedic treatment. Today, when we looked at the patients, in the second big block we described the technical means of rehabilitation and discussed the issues of orthosis. Because without these two methods of treatment, it is impossible to cope with either the developing contracture, or with the creation of patient mobility and the correct position in the segments of the limbs and the spine.And in general, it is impossible to talk about any kind of effective rehabilitation in general.
Next, look, this yellow dashed line is the tone-reducing measures of oral neuro-relaxants. That is, what is it? We say that spastic forms of cerebral palsy should be treated only with the obligatory use of any kind of tone-reducing methods. Well, that’s how it is impossible to treat bacterial pneumonia without antibacterial drugs, and so, we must understand for ourselves that it is simply impossible to treat spastic forms of cerebral palsy without some antispastic methods, it is unacceptable.
So, in all methods of treating spasticity there are three blocks – these are oral tablets, these are neurosurgical methods of treatment and local methods of exposure, when drugs are injected into the muscle that reduce muscle tone, which we talked about today. So, look, this yellow dashed line – these are the pills, these are oral neuro-relaxants. But when you take a pill that reduces muscle tone, it, of course, reduces the tone in all absolutely muscles – both flexor and extensor.And given that in children with cerebral palsy, the flexor dominant predominates, as we talked about at the beginning, then, of course, we relax the tone in the flexor, which, on the contrary, needs to be made strong, and it turns out that taking oral neurorelaxants, we get disorganized tone -decreasing effect, and some children become weakened and become less active.
See which children are recommended for oral relaxant therapy? Only 3, 4 and 5 levels of functional levels of movement according to the GMFCS system.It is absolutely unacceptable for children of levels 1 and 2 of the functional level of movement according to GMFCS to prescribe pills that reduce muscle tone. Because they develop well, have good physical activity, and naturally we will not be able to reduce the tone with tablets locally, we will only weaken their physical activity. Only for children who have such a poor level of movement, 4 and 5 levels.
Now, look, this red thin line – it covers only the 4th and 5th levels according to the GMFCS system.These are neurosurgical interventions, this is a pump. Maybe you heard? Such pumps are installed. Now parents are even more oriented in this. The pump is sutured to the lumbar region (formerly to the anterior abdominal wall). The pump contains a certain amount of the drug, baclafen, which is constantly refueled and through the manifold it enters the spinal space, at a certain period it is thrown in. What is baclafen? This is also a drug that generally reduces muscle tone. And, accordingly, when you and I use this technique, we also generalized reduce the muscle tone of the flexors and extensors.
Accordingly, there is a very high risk that children may also become weaker in terms of activity and loss of strength. But, nevertheless, this is an excellent method of treatment that relieves tone in generalized spasticity. It is recommended for children sitting and lying.
And, look, this orange line that crosses absolutely all levels of movement. This is botulinum therapy. This is the use of injections of preparations of botulinum neurotoxin type A. Of course, but nevertheless we work only with the diploma, but today there is a drug botox, which is also registered in childhood.Xelonin has been registered in Russia. These are three drugs for today that have indications for use in childhood. To date, it is the preparations of botulinum neurotoxin that have the highest level of evidence for use in children in the direction of reducing muscle tone. This is the most conclusive, the safest. And when should you make preparations of botulinum neurotoxin? Then, when persistent contractures had not yet appeared. This should be done in children, mainly in children under 7, 8, 9 years of age.If children have contractures at a later age, then we must continue to do this further. This does not mean that botulinum therapy is not indicated for children and at an older age. Even after the operations, we continue to provide children with botulinum therapy.
And look what a thin blue line. This is an orthopedic surgical correction. As much as we want with you, but, unfortunately, almost all children of all levels of movement will be subject to surgical interventions.This is a very important problem, which, unfortunately, is very difficult to prevent, because, nevertheless, the patterns of development of a child with cerebral palsy lead to the fact that, regardless of our influence with you, these orthopedic problems are formed and still have to be solved surgically. And the most important thing is to do it on time, this operation is not to do it early, do not do it late. And for this, of course, to carry out effective, timely good conservative therapy.
Evidence-based and non-evidence-based methods
Well, and already ending our seminar, I want to show you this slide, which displays the results of a systematic 2013 review.Again, Jonah Novak, as I said in the first part of the webinar, this is an Australian group of doctors who analyzed all the interventions that are performed in all children with cerebral palsy around the world.
And look at the metrics she publishes. Only 16% of interventions were characterized as “carry out”. That is, a high level of evidence. Please note – 2/3 of the methods – 58%, according to the study, they were effective, but did not receive a high level of evidence, and therefore they received the characteristic “rather to carry out than not to carry out.”
It is sad that every 5th method did not receive any level of evidence at all, that is, these methods of treating children with cerebral palsy are practically in vain, and it was recommended to stop them. And it is alarming that 6% of these methods were not only ineffective, but also unsafe.
I’m literally just a short distance away and show you which methods have received the highest level of evidence. For example, let’s take a model with the reflection of quadriplegia, diplegia, plus a child with cerebral palsy – these are focused workouts and home programs.
What is Oriented Workout? Already today it has been proven that there is no movement for the sake of movement. There is movement for the sake of a goal. That is, if you just put your child on the couch and he moves his hand a thousand times, then he will not develop motor control of this movement.
But if you take him into the game and play with him, and he strives, for example, to throw a ball somewhere or achieve some goal, and in the end, he wants to cut off a piece of sausage and make himself a sandwich, then he will succeed much faster, and he will achieve this result than if you just work out some kind of automatism of movement.There will be no motor control without motivation, without achieving the goal.
Now look. Home rehabilitation programs. This is not very profitable for the healthcare system today, because the whole rehabilitation should go home. That is, today we must, in principle, teach a child to live at home and learn how to do everything. Today, remember, we discussed in detail with you? You stay at home, child. You can crawl to the toilet. You can sit on the toilet yourself. After all, it is much more important not just to develop contracture in the knee joint.Why do we even need to do this with you? It is important for us that a 15-year-old child, remaining at home, can crawl to the toilet and perform a very important action. Or if he was hungry, somehow get to the refrigerator and somehow feed himself.
Here it is, goal-oriented rehabilitation. We achieve the goal precisely by adapting the child to society. And not just to achieve some incomprehensible virtual tasks. Home rehabilitation programs are very important. They need to be worked out, of course, taking into account the situation where the child lives.When we begin to fantasize ourselves in our head – let us prescribe a back-support walker for you, let us prescribe you a support for standing – there is such a base of 2 sq. meters, and the apartment, for example, is one-room and only 18 square meters.
Some parents say that we have all the technical means in sheds or on balconies and are not unpacked, because if we put all of them, we will simply have nowhere to live. And we must proceed from real situations. Sometimes those verticalizers, I now do not want to say to the whole country that we should not use high-quality good technical means, but sometimes sometimes the inventions of parents are much more interesting, well, in some low-functional area in a small apartment, even just against the wall some kind of nailed panel, yes, it is impossible to create a certain angle of inclination there, but nevertheless, it is possible to carry out some kind of verticalization.But in general it is impossible not to do this! It is imperative to do this, but all the same it is the home environment, the home environment where the child lives to be considered. Who should do it? Well, at least a rehabilitation therapist, no one else. This is home rehab.
See more. There is such therapy – bimanual training and therapy induced by restriction of movement. I think you also have children with hemiparesis, when one side of the child is affected, and the child, whether he wants it or not, begins to work with a healthier hand.So, in order to develop the sore side, the sore arm, there is such a therapy induced by restriction of movement. Do you know where it all came from, colleagues? If the child suddenly broke his healthy arm by accident, they would put it in a cast and it would, for example, be out of the movement zone, the child still had to work with the sore arm, and it would develop. And thus this technique was born today. You can even put on a boxing glove on this hand. Look, this is also the highest level of recommendation. Bimanual training, two-handed activity – with two hands, when the hands are working.See which workouts for 30-60 minutes for 6-8 weeks are very effective.
Unfortunately, I will probably upset someone now, but I will tell you that the massage technique itself is an excellent procedure, but, unfortunately, it does not solve the functional goals that we want to achieve, for example building rehabilitation programs. What, in essence, does massage do? Massage improves the biological properties of the body. It improves immunity, the properties of lymphocytes, it releases a huge amount of endorphins, pleasure hormones – dopamine, serotonin.That is, in general, massage can help us prepare the mood of the child, in general, for performing different tasks. But massage by itself will not teach a child to walk, to work with a hand. Nevertheless, it is very important to include it in the procedure, but, unfortunately, it is not very suitable for functional purposes.
Unfortunately, there are techniques that are very popular in Russia. This is Voight’s technique, Bobat’s technique. I am not expressing my thoughts, I am stating facts. To date, these techniques have not received a high level of evidence.They, in general, still require further improvement. Today they receive not the lowest, but the level of C recommendations, this is the penultimate one, which does not mean that this technique is more effective than, for example, conventional physical therapy.
There is evidence. These are studies of foreign colleagues, and studies that have already been carried out in 2007, who took a large group of children for physical therapy, were compared with children who received the method of Bobat and Voight, and showed that there was no big difference.This technique costs a lot of money, we learned that it has a serious cost per procedure. But we must understand that it does not heal the patient from cerebral palsy.
I want to show you a slide showing those techniques that are not registered at all. These are craniosacral therapy, fixation of the hip joint, hyperbaric oxygenation, Bobath’s technique, sensory integration.
We must not put an end to this question. We should just read the literature further, look at the research, because, probably, even Iona Novak herself, who created this systematic review, said that it’s a matter of time, we need to develop a good research protocol, which, perhaps, could prove the effectiveness of these methods. …Therefore, of course, when we talk about whether or not to conduct electrophoresis in children with cerebral palsy, some kind of stimulation or just hydrotherapy, we must understand that some achievements in the emotional sphere do not occur in these children when these methods are applied. Well, as a general framework, the application of revolutionary techniques will have a big place.
Well, as for orthoses to Kitaru, we have recommended them to many children today. This is very important for their use in children. Nevertheless, there are conflicting data.For example, if the Swedes have proven that a positive effect on hip displacement in patients with severe movement levels 3 and 5 according to the GMFCS system for more than an hour a day leads to the prevention of hip dislocation. For example, the Norwegians or the Dutch show that some have a negative result, while others have not yet achieved a positive result. This, of course, also suggests that there is little literature today, few studies that would fully prove the effectiveness of these methods. But, nevertheless, we have no other choice, we must apply what we have.And in the arsenal there are very few good and technical means that could be adapted for wearing by our children. And, nevertheless, we still have a lot of work in this direction.
Thank you very much.
Phrasal verb put. Part 1 ‹engblog.ru
First, let’s highlight the main meanings of the verb put .
- Place, place.
- Attach, fit.
We obtain other meanings of this verb by adding prepositions, forming phrasal verbs. Let’s look at the variants of the phrasal verb put .
- Put on – is the most frequently used, has several meanings:
- Put on (about clothes).
- Gain weight.
- To put on stage.
- Switch on, operate.
- To make fun of someone, to put in a funny position.
I put the sweater on in order not to catch a cold. – I put on a sweater so as not to catch a cold.
Monica put on the most beautiful dress that she had in her wardrobe. – Monica put on the most beautiful dress that was in her wardrobe.
Note that the place of the preposition can change:
- I put the sweater on.
- I put on the sweater.
- I put it on.
As a rule, the noun can be placed between the verb and the preposition, or after the entire phrasal verb. A pronoun can only stand between a verb and a preposition.
Oh my God, Clara put on 10 kilos! – My God, Clara gained 10 kilograms!
We decided to put on something new, we want to impress our audience. – We decided to stage something new, we want to impress the audience.
Put the light on, I can’t see anything.- Turn on the light, I can’t see anything.
I was such a fool, they simply had put me on. – I was such a fool, they just made fun of me.
- Put out – just like put on has many different meanings:
- Dislocate (shoulder, arm).
- Extinguish, extinguish.
- Drive out, delete, eliminate.
- Give it somewhere (laundry, repair, child to kindergarten, etc.).
- To release, to produce.
- Cause inconvenience.
I’ve put my leg out, I can’t go, I should stay at home. – I sprained my leg, I cannot go, I need to stay at home.
Tourists hadn’t put out all fires, that’s why the conflagration started. “The tourists didn’t put out all the fires, so the fire started.
Three members were put out of the club for failing to pay the fee. – Three members were expelled from the club for non-payment of the fee.
Don’t you forget to put out the washing? – Did you forget to give your laundry to the laundry?
The plant has put out the record number of their production.- The plant has produced a record number of products.
Tom was really put out by the unexpected arrival of his mother-in-law. – The unexpected arrival of his mother-in-law caused Tom a noticeable inconvenience.
- Put off :
- Defer to a later date.
- Interfere, distract.
Don’t forget to put off all the lights before you leave the house. – Remember to turn off all lights when you leave the house.
Never put off till tomorrow what you can do today. “Never put off until tomorrow what you can do today.
His self-assured smile puts me off. His cocky smile disgusts me.
Stop talking, you put me off! – Stop chatting, you’re bothering me!
- Put through :
- Execute, Finish (task).
- Connect by phone.
- Accept (law).
The director decided to put all the business deals through very quickly. – The director decided to complete all the cases very quickly.
Can you put me through to this number? – Can you connect me to this number?
In spite of all difficulties, the Parliament has put the new law through. – Despite all the difficulties, the parliament passed a new law.
- Put down :
- Postpone, interrupt (work).
- Drop off (passengers).
- Eat, drink.
- Deposit (part of the amount).
- Cut back (expenses).
Please, put down all deals, today is your birthday! – Put aside all the cases, please, today is your birthday!
Can you put me down at the next stop? – Drop me off at the next stop.
He is a monster, he put down everything we had in the fridge! – He is a monster, he ate everything we had in the refrigerator!
Put down his lectures, they will be very helpful one day.- Write down his lectures, one day they will be very useful to you.
You should put down 15% as a deposit. – You must pay a deposit of 15%.
The firm had to put down expenditures, it was on the verge of bankruptcy. – The firm had to cut costs, it was on the verge of bankruptcy.
- Put across / over :
- To deceive anyone.
You’ll never succeed in putting me over, I’m also very sly.- You will never be able to deceive me, I am also very cunning.
He simply put us over. – He just deceived us.
- Put ahead:
- Promote development.
- Transfer, change (date) to an earlier date.
The good weather has put the flowers ahead rather early. – Due to the warm weather, the flowers appeared early enough.
We have to put our meeting ahead, I’ll be busy next week.- We have to reschedule our meeting to an earlier date, I’ll be busy next week.
- Put about :
- Distribute (information).
- Worry, disturb.
It has been put about that the weather will be cold. – They say it will be cold.
I was really put about by that news. “I was really worried about that news.
- Put across :
- Successfully complete a task.
- Convincing of something.
He managed to put across the project in time. – He managed to successfully complete the project on time.
I don’t want you to put me across with such ugly methods. “I don’t want you to convince me with such terrible methods.
I suggest you fix the new material with a small test:
Phrasal Verb put
This topic is closely related to others described in the articles to which you need to pay attention:
After familiarizing yourself with them, we recommend passing the following test: “Test # 2 on the use of phrasal verbs in English”.
If you find an error, please select a piece of text and press Ctrl + Enter .
How to tell if a finger is broken
Step-by-step instructions on how to identify a broken finger:
1. Pay attention to pain and sensitivity. The first sign of a broken finger is pain. The intensity of the pain depends on the severity of the fracture. Be careful with your finger after injury and pay attention to the degree of pain first.
- At first, it can be difficult to determine if a finger is broken, since displacement and sprains are also accompanied by acute pain and increased sensitivity.
- Watch for other symptoms or seek medical attention if you are unsure of the seriousness of your injury.
2. Pay attention to swelling and bruising. A broken finger is accompanied by severe pain, followed by swelling or bruising. This is the body’s natural reaction to the injury.After a fracture, an inflammatory process turns on in the body, which leads to edema as a result of the release of fluid into the surrounding tissues.
- A bruise often develops after the swelling. This occurs when the small blood vessels surrounding the fracture swell or burst due to increased fluid pressure.
- It can be difficult to tell if your finger is broken at first if you can still move it. However, after you move your finger, the swelling and bruising will become more noticeable.The swelling can also spread to nearby fingers or to the palm of your hand.
- As a rule, swelling and bruising appear 5-10 minutes after the first attacks of pain in the finger.
- However, slight swelling may occur due to sprains. However, it is not accompanied by immediate bruising.
3. Look closely at the deformation of the finger and the inability to move it. At the same time, the phalanx of the finger cracks or breaks in one or more places.Bone deformities can manifest as unusual bumps on the toe or curvature of the toe.
- If the toe is unusually curved, this is a sign of a fracture.
- Usually a broken finger cannot be moved due to the broken connection between the phalanges.
- The swelling and bruising may be so severe that the fracture may be difficult to lift.
4. Know when to seek medical attention. If you suspect you have a broken finger, go to the nearest emergency room or emergency room.A bone fracture is a serious injury, the severity of which cannot always be assessed only by external symptoms. Some fractures require special measures for the bone to heal properly. If you suspect that you have a fracture, it is better to play it safe and see a doctor.
- Get medical attention if you experience severe pain, swelling, bruising, or any deformity of the toe.
- In case of finger injuries in children, see a doctor in any case.Young and growing children’s bones are more prone to injury and complications if fractures are not properly treated.
- In the absence of professional treatment for the fracture, the finger and palm may partially lose their mobility.
- Failure to properly align the broken bone may limit your ability to use the palm of your hand.
About horses, iron roses and the harmony of life
In my trips to the districts of the Vologda region, I often meet creative and enthusiastic people who revive the occupations that have been practiced in the countryside since ancient times.But they do it at a new level, meeting the requirements of the time. Today is my story about them.
“We are all a little bit of a horse”
More recently, in the vicinity of Ustyuzhna, the film “Golden Transit” was filmed – with chases on horses, a shootout, in general, a real detective story. I visited the set and among the people working on the picture, I noticed a beautiful girl who was with the horses all the time. Having seized a free moment, I approached the girl, met and found out that her name was Anna Zavodova, she is from Cherepovets and has been running a small stable in the village of Plotichye for several years.Then I was very interested in how she managed to organize everything and how difficult it is to keep the horses.
For the first time, Anna saw horses in childhood and then simply fired up with the desire to be closer to them. She came to the city hippodrome, where there was a riding section, and realized that horses are for her forever. Observing their behavior, I came to the conclusion that these animals have a lot in common with people. The horse also needs love and trust. She may have “human” diseases – she may have a cold and cough, dislocate her leg.She, like us, is seized by mosquitoes and horseflies, and it is necessary to lubricate the bite sites with a special cream to relieve itching and pain. It is necessary to monitor the diet (there are also unscrupulous manufacturers in the field of feed production).
The village of Plotichye is an ideal place for keeping horses. Large, with four streets facing the Mologa River, it is perfect for organizing ecological tourism. When I got to Anna’s farm, the horses were peacefully grazing in the paddock, only a few remained in the stall.She approached everyone, treated them to the stored sweets, talked about something. The appearance of horses had a positive effect on Plotichye. The village already makes a favorable impression – it is very clean, neat, and here you can also ride horses, comb and braid the mane, and provide food. Many girls who come here on vacation from Cherepovets, Vologda, Rybinsk, St. Petersburg, disappear almost all day in the stables. They have their favorites. They try to bring them an apple or sugar.And upon returning home, they are constantly interested in how their charges are. Children, vacationing at the tourist base “Fort Yantar”, often come here on excursions, and get acquainted with the life of not only horses, but also other village animals – geese, goats, etc. Some of them see chickens alive for the first time.
“In general, on the basis of this stable, I would like to make a center for both patriotic education of children and a rehabilitation center,” says Anna. – Because very often parents of children with health problems contact us, and as you know, riding horses and simply communicating with them helps with many diseases.As for patriotic education, it could be night trips, tourist outings. Many people are now fixated on computer games, sit on social networks and see nothing around. And when they come here, they realize that life can be different, more interesting. Here are the girls – they themselves come and help. You know how pleasant it is for a horse when it is polished, braided, in a clean stall. Of course, there is a lot of work behind all this – both mine and my assistants. It is necessary to procure feed now, and do repairs in the stable.And we ourselves earn money for everything, for example, renting horses for filming helped a lot: we bought some of the ammunition, bought medicines. The main thing for me is that my business develops, so that people see that we have horses. Last year we were at the bottom of the Vanskoye village. Themselves in a boat crossed, and the horses were swimming. You should have seen how happy people were, because for many, a horse is a childhood memory, an animal that was a helper and breadwinner for the family.
“Young blacksmiths in the smithy”
And what about a horse without a smithy, where they can shoe it so that it prances beautifully? So that you can hear a mile away that the beauty is galloping – disperse, scatter, onlookers !….
At the end of June, I happened to visit the village of Pustyn, which is thirty kilometers from the village of Chagoda. On that Sunday, a folklore festival was held in the village. Folk craftsmen, dancers, singers, and storytellers of epics presented their skills. And on the Alley of Craftsmen, my attention was attracted by two young people who offered forged products. After talking with them, I learned that they had created their own smithy in Chagoda.
Working with metal has always brought joy to Pavel Mikheev. In every piece of iron he finds, he can discern a future work of art.Sometimes he walks through the forest, sees – like just a rusty piece lies; and Paul will bring it home, cleanse it and think what can be created out of it. Sometimes the decision comes in a dream: you just need to add another detail – and please, as if beauty is born out of nothing. About three years ago Pavel and a friend came to Ustyuzhna for the festival “Iron Field”,
where, by tradition, blacksmiths masters from all over the North-West gather. He looked, admired – and realized that it was his. Then he came to the famous Ustyuzhsky blacksmith Sergei Verkeenko and hired him as an apprentice for a month.Sergei was delighted to the assistant: if there are students, then blacksmithing will develop. For a month Pavel almost never left the smithy, but there is a result, now he has his own smithy.
Thursday evening, the sun was sinking behind the pine trees, when Pavel’s partner Danila Yeletsky and I arrived at the smithy on the outskirts of Chagoda – former production workshops. Pavel and his partner chose this place because there was a good and working hammer here. While Pavel was away, Danila kindled the forge, prepared material for forging: he wanted to complete the work he had begun – forge a rose.
“I’m from a working family,” Danila told me, burning a rose. – Grandfather was a carpenter, father is a carpenter. But I went to the metal. I really like to feel how the metal in your hands begins to live, to see how openwork lace or curl after curl is obtained from a red-hot mass, which, connecting with each other, turn into such beauty that you cannot take your eyes off.
– Danila is right, – Pavel, who had arrived from the house, entered the conversation. – People began to think about what surrounds them, that beauty can be next to them.We need to move away from Chinese and Taiwanese crafts. Because the quality of these products raises doubts, people buy and then complain … I love metal very much, it always inspires me. You see how he, red-hot, becomes tender, like plasticine, and you can twist it, set the pattern that you endured in your soul. And how nice it is to see work that will bring joy to someone.
And I was pleased that blacksmithing in Chagoda is not done by experienced men, but by very young guys.Pavel is a little over twenty-five, Danila recently celebrated his nineteenth birthday. They are ambitious, they have many plans. For example, they really want children to come to their smithy – and they can see how a horseshoe or a rose is forged, how a small carnation can be made for a boot, and how to forge one that can hold a massive log.
– … Why did I start all this? – Pavel says to me in the end. – I want our Chagoda to flourish, to be better. We opened a gym for the guys so that they can work out.It is only an ignorant person who can say that we are bored. No, we are not bored, we have enough talents. Come back in a year – I will surprise you with masterpieces, but for now you have to work and study a lot.
How to break a leg without pain?
As it turns out, the question “How can you break your leg?” sincerely worries not only the traumatologist and radiologist who are involved in the elimination of such troubles, but also directly those who create these troubles.Looking, for example, on the forum of conscripts or any similar resource, it turns out that the topic is “How to break a leg without pain?” as a way to “skip” the army is regularly in the top and is very popular. But not only potential military personnel are interested in such self-mutilation. This option of painlessly breaking a leg is seen as a good way to justify to the boss for undone work or to a girl for a failed date.
However, before deciding on such a downright absurd step, think well – are your health problems worth it? After all, in fact, the answer to the question “How to break a leg correctly?” just doesn’t exist.Expecting to get yourself a little trouble in the form of a plaster cast for a couple of weeks, you can become a “happy” owner of a fracture with displacement, an improperly fused bone, blood poisoning and other “amenities”.
For the sake of interest, you can ask your friends who are professionally involved in sports how long a broken leg heals. As a result, you will most likely find out that the removed plaster cast is still far from recovery, but only the beginning. After that, you will have to undergo a long rehabilitation course in order to restore your limb to its former mobility.In some cases, the previous functionality is never returned! In support of this fact, again, for general development, read the biographies of some famous football players, for whom one unfortunate fracture put an end to their further sports career.
And, finally, the very formulation of the question “How to break a leg without pain?” initially sounds wrong, because it is simply impossible to completely painlessly break the bone of a physically healthy person. Some “experts” on how to break a leg at home, to facilitate the task, advise to cool the limb well, then hit it with some heavy object, or put your foot in a bucket of sand and hit the bucket with the same object.In this case, there really will be no pain. But, it will not be only the first seconds after the fracture, then it will appear with a vengeance. Moreover, this pain can subsequently haunt you throughout your life, in the form of unpleasant pulling sensations when the weather changes or with heavy loads on your legs.
Another “brilliant” piece of advice from those who know how to break a leg quickly is to jump from the second floor, from a tree or an attic. A small disclaimer. In this case, you can break not only a leg or an arm, but also the spine, as a result of which you get an excellent chance to spend the rest of your life in a wheelchair.
In a word, the thought of how to break a leg cannot occur to a sane person by default, but if a temporary clouding has come over you and you are sure that a fracture is your only way of salvation, think about what you are missing, dooming themselves to existence in a plaster cast for many months. You can believe me, in a week you will be madly tired of the forced bed rest and the need to move on crutches. And this is not to mention the fact that such entertainments as dancing, running, swimming will be banned for a long time.Note that there is an unambiguous set of rules that says “How easy is it to break a leg?” still does not exist, which only says that such rules simply do not have the right to life.