GUEST COLUMN
According to the 2011 census, 26.8 million population was disabled and 20.3 per cent had movement disability with the major causes being CTEV, CDH, CP, polio, scoliosis, myelomeningocele and rickets. In the past, polio was a major cause of orthopaedic disability. India has become polio-free with the help of the World Health Organization, Bill Gates Foundation, Rotary Club and millions of health workers of the country since 27 March 2014.
Cerebral Palsy (CP) is a common cause of orthopaedic disability. CP is a lifelong condition that affects the individual, family, society and nation. CP is caused due to lack of oxygen supply in the brain due to any reason. It causes paralysis of a certain part of the brain (cerebrum) resulting in motor disability, which is called CP in medical language. This lack of oxygen can happen at the time of delivery or after delivery. Whatever may be the reason, the result is the same, paralysis of the brain.
Nearly 15-20 per cent of physically disabled children are affected by CP. It is the most common motor disability in childhood. Because of the developing nature of Indian health care in semi-urban and rural areas and the lack of technology used in these areas, it is still a problem.
Diplegia is the commonest presentation at 30 – 40 per cent, hemiplegia 20 – 30 per cent, and quadriplegia 10-15 per cent. In an analysis of 1,000 cases of CP from India, it was found that spastic quadriplegia constituted 61 per cent of cases followed by diplegia 22 per cent. Spastic CP is the commonest and accounts for 70 – 75 per cent of all cases, dyskinetic for 10 to 15 per cent and ataxic for less than five per cent of cases.
Due to CP, the child faces difficulty to varying degrees in speaking, hearing, walking and doing any work with hands. Some children have slight stiffness in their hands and legs or some have so much stiffness that they are unable to even eat, sit, stand or walk. If any child’s milestones are delayed or there is difficulty in speaking, sitting or walking, the parents should consult a paediatrician, orthopaedic surgeon or neurologist.
CP is a lifelong problem that affects the individual, family and society. Therefore, the aim of its treatment is to try to make the child capable in every way. CP not only creates physical problems but it also creates mental problems for the child, social problems for the family and a huge economic problem for the country. As mentioned earlier, it is a complex problem, so sometimes dozens of specialists are required to treat it. The author’s experience is that if every expert pays even a little attention to these, the results are very beneficial and far-reaching.
Since we are the orthopaedic surgeon, we will limit ourself to orthopaedics problems caused by CP. The authors believe that no handicapped or disabled person can be equal to an able-bodied person. We believe that not only the experts but also the society and administration should try to reduce their disability because the human resource is the greatest on planet earth, which should be nurtured by all. Even disabled people should be enabled to make an important contribution in nation building in their own way.
We urge the parents and guardians of CP afflicted children that though the problem is serious, they should not despair because even small help from experts is very beneficial for the children. First of all, all CP children should be examined and investigated thoroughly by the specialist so that the disease can be confirmed and treated appropriately according to its severity. The development of an individual depends on the individual’s actions, which are important at every stage of life. Locomotion plays an important role in shaping life. In fact, the authors believe that the locomotion is as important as the heart and lungs for one’s day to day life. Locomotion depends on the strength of bones, joints and muscles which are controlled by various neuro-vascular structures. Deformity and disability caused by any reason affects not only the individual and family but also to the community and nation. Therefore, the goal of all stakeholders should be to enable the disabled person so that they can live a life with minimal disruption.
If we talk about orthopaedic problems then the children usually have stiffness in their hands and legs, which hampers their day to day activities particularly the scissoring gait and severe pronation deformity of the hand. The former hampers the walking and later hampers the feeding. The correction of these deformities requires manipulation of joints, balancing exercises of muscles, use of splints etc. If the stiffness of joints and muscles is not corrected with the above means, then surgery should be considered. The principle of surgery is to balance the power of opposite muscles. If one muscle is weak and the other is strong then either the strength of the weak muscle is increased or the strength of the strong muscle is decreased.
Flexible deformities can be corrected with soft tissue surgeries and rigid bony deformities with Ilizarov external fixator. If the angular deformity of the joints is excessive then the bone near the joint is cut, straightened and fixed with plaster or screw-plate. Nowadays, with the use of fixators, the joint or bone can be straightened without any incision and at the same time shortening of the bone, if any, can be corrected. If plates and screws are used, they should be removed after one or two years. Children should visit a specialist at least once a year for follow up so that if there is any recurrence of deformity or any new problem which can be checked and corrected in time.
Correction of deformities and disabilities requires a multidisciplinary approach. The needs of people with disabilities are the same as the needs of a non-disabled person. Deformities and disabilities caused by any reason should be corrected as soon as possible, because plants can be easily straightened, not the trees.
(The authors are orthopaedic surgeons based in Dehradun; views expressed are personal)
