Interesting Findings and Reflections

14 April 2010

Today I was fortunate enough to treat a patient who has Bells Palsy. I had not seen this condition before and I decided to readup on Bells Palsy to gain a better understanding of the condition.

Bells palsy:
Studies have shown that men and women are equally affected by Bells Palsy and there is a higher incidence in pregnant women.
The main cause of Bells Palsy are the Herpes Simplex viruses: Herpes Simplex virus type 1 and Herpes Zoster virus (This presents with more severe symptoms).

Symptoms are:
- Decreased production of tears
- Altered taste Otalgia (earache)
- Fascial / Retroauricular pain Fascial Paresis - Patients usually think that they have had a stroke or have a tumour).
- Bells Phenomenon - The upward diversion of the eye when attempting to close the lid (incomplete closure) is a obvious clinical feature of Bells Palsy.

It is interesting to note that Bells Palsy causes periperal lower motor neurone palsy which presents as follows:
Unilateral impaired movement of the fascial and platysma muscles, drooping of the brow and the corner of the mouth and impaired closure of the eye and mouth. A central upper motor neuron lesion as seen in stroke, causes weakness of the lower face only. This is a useful way of differentiating the two conditions.

Treatment of Bells Palsy:
- Medical intervention should begin immediately to stop viral replication which results in inflammation of the fascial nerve (Reversible neuropraxia). Medication includes - Antivirals such asaciclovir and coricosteriods (prednisone).
- Psychological support Eye care - To protect the cornea from drying and gettin abrasions (Eye drops should be applied hourly).
- Surgery (middle fossa craniotomy) involves decompression of the fascial nerve. The operation has several risks such as seizures, deafness, leakage of cerebral spinal fluid and fascial nerve damage and this is why surgical intervention is not routinely done.
- Physiotherapy - Massage, fascial exercises and mime therapy have been useful treatment options. TENS (transcutaneous electrical stimulation) has uncertaian effects.

Reference: N Julian Holland, Graeme M Weiner. Clinical review: Recent developments in Bell’s palsy. BMJ 2004;329


30 April 2010

Today I observed the physiotherapy management of a 1 day old baby with Talipes Equinovarus (Clubfoot). I got consent from the mother to take photo's of the baby's feet before and after strapping. The baby has unilateral clubfoot of her left foot.

Talipes Equinovarus seems to be a common condition seen at Elim Hopital. I feel that the management of clubfoot is poor and ineffective and I've decided to read-up on this condition to get an overview and find out about other management options.

There are 4 variations of clubfoot:

1) Talipes Varus - foot turned inwards resembling the letter J (Inversion and adduction).

2) Talipes Valgus - foot turned outwardly resembling the letter L (Eversion and Abduction).

3) Talipes Equines - Foot points downwards (Plantarflexion).

4) Talipes Calcaneus - Foot points upwards (Dorsiflexion).

* Clubfoot usually resembles a combination of the 4 variants. As the name indicates (Talipes Equinovarus)the foot deformity is commonly in Inversion, Adduction and Plantarflexion (Seen in above Picture).

The causes of clubfoot is speculative. Some authors mention abnormal intrauterine positioning of the fetus and there is evidence of genetic predispostion for Talipes equinovarus.

Surgical treatment of clubfoot seems to have many risks, complications and poorer outcomes. Patients develop weak, stiff and scarred feet. Studies Have revealed high success rates for the Ponseti Method (92 - 98%). The Ponseti method is a conservative treatment method that was developed by Ignacio V. Ponseti in the 1940's and was based on his observations in the clinic nad operation room. The goal of the Ponseti method is to impose simultaneous supination and abduction of the foot. There are 2 phases to this technique:

1) Treatment phase

This involves gentle manipulation of the foot and serial casting. Each cast holds the foot in the correct postion so that the foot is gradually 're-shaped'. Most infants will require a percutaneous tenotomy after the last cast (Usually 5- 6 cast are done, 1 cast per week) to gain adequate lenghtening of the archilles tendon.

2) Maintenance phase

An orthosis is used to prevent relapse of the deformity. A denis-browne splint is usually used which the infant wears for 23 hours a day for 3 - 4 months an then at night (12 hours) for the next 3 years.

I feel that the strapping seen in the above pictures is not effective (poorly done) and other medical intervention should be done. It would be interesting to know the long term outcomes of these patients and whether or not the Ponseti method could be implemented at Elim hospital. This may not be feasible due to the lack of resources available at district level but I do think that it would be very benificial and have high success rates in this community.

Reference: R Kamper, K Binks, M Dunkley, C Coats. Multidisciplinary management of clubfoot using the Ponseti method in a district general hopsital setting. Journal of Child Orthopaedics, 2008;2: 463-467 RA Agrawal, MS Suresh, R Agrawal. Treatment of congenital clubfoot with Ponseti method. Indian Journal of Orthopaedics, 2005; 39(4):244-247

4 May 2010

During my community outreach vistits, I came across a 3 year old Child with Clubfoot. According to the mother, the child has orthotic shoes that she is suppose to wear but is unwilling to wear them due to the fact that other children laugh at her when she puts them on. I am not sure what sort of medical management can be done for her at this stage but this goes to show, in my opinion, that Elim is not offering appropriate treatment for patients with clubfoot.
Please see attached video to observe how clubfoot has affected the childs gait.