By Q. Vasco. Grand Canyon University.

The importance of family does not provide an excuse for medical care providers or educators to become pes- simistic if they do not perceive the family is doing its part cheap 200mcg cytotec mastercard. In this circum- stance generic cytotec 200 mcg with mastercard, professional care providers still must give as much as possible to each child but recognize their place and limits in the care of these children order 100 mcg cytotec otc. Med- ical care providers who fail to recognize their own limits in the ability to pro- vide care often will become overwhelmed by their sense of failure and will burn out quickly order cytotec 200 mcg visa. Family Impacts of the Child with CP A healthy liaison should be developed between children with CP discount cytotec 200mcg with amex, the family unit, and the medical care providers. Cerebral palsy is a condition that varies extremely from very mild motor effects to very severe motor disabilities with many comorbidities. In addition, there are great variations among families. To provide proper care for children with CP, physicians need to have some understanding of the family structure in which the children are living. Be- cause of time pressures, this insight is often difficult to develop. Families vary from young, teenage mothers who may have the support of their families, to single parent families, to families with two wage earners and other children. All the pressures of caring for a child with a disability are added onto the other pressures that families of normal children have. Because most children with CP develop problems in infancy and early childhood, families grow and develop within the context of these disabilities. Often, the father and mother will react differently or come to different levels of acceptance. It is our impression that these different reactions may cause marital stress leading to high levels of divorce, most frequently when the children are 1 to 4 years old. Although this is our impression, there is no clear objective evidence that the divorce rate for these families is higher than in the normal population. Another high time of family stress is during the teenage or young adult years for those individuals with severe motor dis- abilities. Often, as these individuals are growing to full adult size and the parents are aging, it becomes very apparent to the parents that this is not a problem that is going away, nor are these young individuals capable of go- ing off to college and making a life of their own. The response of an individual family varies greatly with the wide vari- ability of severity of CP. Many families develop a stable and very supportive structure for their disabled child. Physicians and other medical care pro- viders may be amazed at how well these families deal with very complex medical problems. For many of these families, however, the medical com- 1. The Child, the Parent, and the Goal 5 plexities have accumulated slowly and are themselves a part of the growth and development phenomena. With multiple medical treatments often pro- vided by many different medical specialists, a high level of stress develops in almost every family. For the medical professional, continuing to be aware of this stress and listening for it during contact with families is important. Families with less education and limited financial resources may do remarkably well, whereas a family with more education and more financial resources may not be able to cope with the stresses of a child with a severe disability. It is extremely dif- ficult to judge which family can manage and which family will develop dif- ficulty, so it is important not to become prejudiced either for or against spe- cific families. Medical care providers should continue to be sensitive to how the family unit is managing to deal with their stresses. Some families will be seen to be doing well and then suddenly will become overwhelmed in the face of other family stress. This stress may be illness in other family members, financial pressures, job changes, marital stress, and, most commonly, the effects of aging on the parents, siblings, and individuals with CP. Care-Providing Community Children with CP develop in supporting communities, which vary with each individual child. There are four general segments of these caring commu- nities, with the family or direct caregivers being the primary relationship. This primary relationship is surrounded by community support services, the medical care system, and the educational system (Figure 1.

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This pro- cedure should accomplish the task of creating a peroneal longitudinal arch on the lateral side of the foot generic cytotec 200 mcg amex. Triple Arthrodesis Palliative treatment of severe valgus deformities purchase 100 mcg cytotec fast delivery, usually in children who are nonambulators or are marginal ambulators discount cytotec 100 mcg line, requires a major series of fu- sions cytotec 100 mcg visa. This operation is also indicated in a few ambulators who have devel- oped severe foot deformities after previous surgeries generic cytotec 100 mcg with amex. A severe foot deformity is the indication for a triple arthrodesis, with extensive correction of the medial column supination by distal extension of the fusion, as discussed in the section on forefoot supination. This triple arthrodesis can be a challeng- ing operation, and it requires a careful reduction and fixation of each bone into its anatomically correct location. First, the calcaneus is reduced to the talus and then fixed with a screw across the anterior facet. The cuboid is then reduced to the calcaneus by excision of the calcaneocuboid joint and insertion of a graft, which will lengthen the lateral column and reestablish the peroneal arch. Next, the navicular should be reduced to the talus and an excision of the medial cuneonavicular joint performed with the goal of at least fusing the talonavicular and cuneonavicular joints. Each of these joints has to be rigidly immobilized with either a plate, typically used on the calcaneocuboid joint, or internal fixation with strong K-wires, usually used on the medial column. Tendon Achilles lengthening and other tertiary deformities as indi- cated are corrected at the same time. Physical examination demonstrated severe but flexible This error caused him to develop high lateral foot weight planovalgus deformities of the feet. There were no toe bearing, as the medial column would not bear weight. Be- deformities, and torsional alignment was external foot cause of poor knee control and tendency for back-kneeing, progression of 30°. He was very crutch use dependent and he used AFOs, which were of some help; however, due to he was a functional community ambulator. Radiographs the crutch use, he would still back-knee with the AFOs. He had a subtalar fusion ing any of the deformities that are present at the time of with a lateral column lengthening (Figure C11. There are many case series reports, especially of subtalar fusion for planovalgus feet in children with CP. Most of these reports focus on nonunion rates, or the need for additional surgery as an outcome assessment. Many publications also report different technical methods for doing the procedure; however, the end result tends to be similar. In general, using different evaluation criteria for subtalar fusions, which are by far the most commonly reviewed proce- dures for planovalgus feet in children with CP, 70% to 90% of the children with subtalar fusions are reported to do well. The outcome of triple arthrodesis has shown a high rate of developing degenerative arthritic changes in the ankle joint on long-term follow-up. Another short-term study demonstrated that children do better if the triple arthrodesis is done before the deformity is so severe that they stop walking. The ex- traarticular osteotomy, in which the osteotomy is made at the level of the calcaneal tuberosity, is similar to the Dwyer osteotomy for varus deformity; however, in the planovalgus foot, the osteotomy is displaced medially. This osteotomy shifts the force medially and decreases the pathologic force that tends to cause the planovalgus to progress. This osteotomy has been reported to provide good correction with functional improvement in the foot. This approach leaves the subluxated and dislocated joints in the ab- normal positions but creates compensatory deformities. Reasonable correc- tion can be obtained, but there are no long-term data to suggest that this approach is better than correcting the deformity at the location where it oc- curs through the joint, which also requires fusing the joints. The feet with these extensive osteotomies do not have a large amount of joint motion, and the motion that is present is occurring through subluxated or dislocated joints, which in other parts of the body have a tendency to develop arthritis much quicker and more severely as patients age. Long-term follow-up of these patients has not been reported. Another popular approach is to insert some device in the sinus tarsi to create a subtalar joint arthroereisis. This technique appears to address the dys- plasia that has occurred in the posterior facet by causing a mechanical block of the calcaneus, preventing the posterior subluxation and collapse into dor- siflexion relative to the talus. Reported devices include staples,128 plastic plugs,129, 130 and screws placed into the calcaneus. The object of all these procedures is to reduce the primary deformity of planovalgus, then introduce 11.

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Clear discount 200mcg cytotec with amex, plastic material is best because it is easy to clean buy generic cytotec 100mcg line, lightweight buy discount cytotec 200mcg on line, and the child’s position in the wheelchair can be monitored more easily while the tray is in place cytotec 100mcg without prescription. Attachments It is very important for the seating clinic to do a good medical and social his- tory to understand all the needs of caretakers and families for the use of the wheelchair buy 200 mcg cytotec free shipping. The wheelchair has to be adapted to carry all the things care- takers need when these children are taken out in the community because the caretakers cannot push a wheelchair and also carry a large bag of other things. This careful history should make sure that these things are not over- looked because commonly, when something is overlooked, it takes 6 to 12 months from the time the item is found to be missing until it is ordered, approved by the insurance company, and placed on the wheelchair. Crutch holders are often overlooked and should be added on the wheelchairs of all individuals who use crutches. Other overlooked items are augmentative communication attachment devices, feeding pump holders, and intravenous pump holders, which should be ordered when they are needed for the rou- tine care of these children. Also, suction machines should have a place to be carried if they are required when these children leave the house. Wheelchair frames with respirator supports have to be special ordered if these children use a respirator. This kind of careful medical evaluation is part of the stan- dard expected full seating evaluation. Cosmetic Appearance The major element in the choice of which automobile a person chooses to purchase is often based on cosmetic appearance. Likewise, in choosing a wheelchair, the cosmetic appearance is important to caretakers and to the individual wheelchair user. The ability to choose a color gives the user an important task in the process of selecting the system. Although function must not be compromised for the sake of cosmesis, it is important to consider the appearance of the system. Another area of cosmesis to consider is the dura- bility of the seating system, especially the material the seating cover is made of and ease of cleaning. Because this seat is expected to last for approxi- mately 3 years and will be used for long periods of time every day, high wear stress occurs. This high wear stress is an area where different manufacturers try to make improvements and experience gained by vendors, rehabilitation 6. Durable Medical Equipment 223 engineers, and families can help guide a selection. It is recommended to fam- ilies to be very suspicious of new materials with which no one has experi- ence, because these materials will occasionally be found to function poorly, and it is typical for manufacturers not to know this until the first group of patients has tried them. Making the Specific Wheelchair Prescription Most insurance companies require physicians to sign a prescription and to dictate a letter of medical necessity to document why each specific compo- nent of this wheelchair is needed. Physicians who sign these prescriptions should have examined the children and understand the appropriateness and need of each component. Although the full list is usually compiled by the seating team, it is still the physician’s responsibility to know that the system meets the needs of the individuals for whom it is ordered. Physicians who sign prescriptions for patients they have not seen or order things that they cannot evaluate because of insufficient knowledge of the equipment, disease process, or specific patient can be held liable for fraud. An example of the prescription and letter of medical necessity that we use for the evaluation team, which allows physicians to evaluate each component and the specific rationale for which it was ordered, is included. This worksheet is also very helpful when writing a letter of medical need (see algorithms). Seating Problems Related to Skeletal Deformities Individuals with CP often have specific deformities that are an added chal- lenge to the design of the seating system. Good communication with the treating physician is required when designing seating systems for specific sig- nificant deformities. If this communication is overlooked, great efforts will occasionally be made to develop complex seating systems to accommodate, for example, a scoliosis deformity only to find that by the time the system has been ordered, the child no longer has scoliosis because it subsequently has been corrected. This situation has occurred on several occasions in our patients, and there is no excuse for this kind of poor communication from an adaptive seating clinic. Also, it is important for the seating team to under- stand that some deformities are so severe that seating is impossible. This judgment is rarely made by wheelchair vendors who have some profit mo- tive to sell a wheelchair.

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