Functional assessment aided by motion laboratory studies.
The physician needs to integrate the results of the assessment of overall patterns of functional use (Table 1), static contractures, dynamic deformities of motor imbalance for multiple levels of involvement (shoulder, elbow, wrist, and hand), and sensory deficiencies. This information is combined with a general assessment of the child's mentation, motivation, and generalized medical condition. Certain patients benefit most from surgical intervention in cerebral palsy. Patients with spastic deformities or flaccid control of specific movements can be helped significantly. In patients with flaccid control of certain movements, such as absent ability to extend the wrist or abduct the thumb, surgery is centered on tendon transfers to augment the patient's ability to perform that movement. In patients with excessive spasticity or musculotendinous contracture, surgery is centered on muscle lengthening. In general, patients with athetosis are not treated surgically; the only surgical treatment considered for the athetotic patient is fusion, as this helps preposition the limb in a desired position and "simplifies" the system for the patient to control. Sensibility deficiencies do not preclude effective tendon transfer but do limit the overall use of the limb; patients with sensibility deficiencies need to be coached to use visual input as their afferent information. Motor deficiencies can be assessed by observation, examination, functional testing, and motion laboratory analysis. Combining an assessment of shoulder, elbow, forearm, wrist, thumb, and finger abilities and disabilities helps provide the physician with an overall plan of upper limb reconstruction using soft tissue releases, tendon transfers, and joint stabilization procedures to address the upper limb functional deficiencies. The ideal candidate for tendon transfer surgery is 7 years of age or older so they can be cooperative with postoperative rehabilitation and motivated to improve the use of their limb. Children with passive use of their limb (Functional Use Classification levels 1-3) can be improved most, on average 2.7 levels to active use of their limb (Functional Use Classification levels 4-6). An overall treatment plan is synthesized, taking into account the child's capabilities, disabilities, and potential, in the context of the child's age and expectations. The assessment techniques discussed in this article are the first step to appropriate treatment.