Adult Spastic Cerebral Palsy: A Case Study Amidst A Lack of Evidence

Abstract

This fictional case is presented in order to share the impact that a physiotherapy intervention can have on the body structure, activity, and participation of an adult with spastic cerebral palsy. Additionally, this case adds to the limited evidence and case studies done to examine adults with cerebral palsy, a population that is severely underreported on. This fictional 24 year old patient with acquired right side hemiplegic spastic cerebral palsy was referred to physiotherapy due to a recent decline in his walking abilities and functional ability. He presented with physical impairments on his right side including spasticity, pain, and weakness. He had a resting posture of a flexed and adducted right arm, a flexed right hip and knee, and plantar flexed ankle. He presented with slow and irregular gait. He also had impaired sensation in his extremities bilaterally. He was classified as a level 3 on the GMFCS, and outcome measures indicated that he had decreased quality of life and independence with ADLs, decreased balance, and a low BMI. The interventions used were based on the ICF model. To address the ‘body structure’ component of the ICF model, the intervention included strengthening, range of motion, and balance exercises. In order to address the ‘activity’ and ‘participation’ components of the ICF model, the intervention included gait training, upper extremity fine motor training, and aerobic conditioning. This case demonstrates the importance of physiotherapy in chronic conditions such as cerebral palsy, and the changes that exercise based interventions can have for a adult who is deteriorating due to this condition.

Introduction

Cerebral palsy (CP) is a non-progressive permanent condition that is associated with a variety of movement, mobility and postural challenges as well as occasionally neurological changes. Despite CP being a lifelong condition the majority of research is based on children with little to no attention to those with CP whom are 18 years of age or older (1) despite a trend toward increased life expectancy (2). As individuals with CP age they are at risk for secondary impairments, including stiffness, pain, fatigue and decreased mobility. These challenges can lead to loss of mobility and participation in early adulthood and continues into one’s later years. According to Bottos et al. (2001), between 30% and 52% of adults with CP will experience deterioration in their ability to ambulate. This loss is most often seen in adults 20 and 40 years of age (3). Loss of mobility will often lead to a decrease in participation in activities of daily living (ADLs) as well as overall quality of life. There has been two systematic reviews regarding the effects of physical activity, fitness and participation of adults with CP (4) however there is little research regarding the effects of physiotherapy interventions and mobility/participation in adults with CP. There is much research regarding children and their physical therapy experience but the adult population remains understudied. This fictional case study follows a 24 year old male with acquired CP whom experienced a deterioration of his gait and ability to participate in ADLs when he entered young adulthood. He was ranked a level 3 on the Gross Motor Classification Scale. The physiotherapy program implemented in this case study hopes to share with physiotherapists the impact that physical therapy can have on the mobility, participation in ADLs and overall quality of life for young adults with CP in lieu of the lack of research in this area.

Subjective Assessment

During the subjective assessment, the patient’s parents were present to assist the patient in answering questions. The patient was referred to physiotherapy from his family doctor because of his difficulty in managing the physical symptoms of his cerebral palsy and recent functional decline as a result of a decline in walking ability. The patient was previously using forearm crutches for ambulation but has recently transitioned to using a posterior posture four wheeled walker due to his recent decline in walking ability. The patient has been experiencing symptoms of right sided hemiplegic spastic cerebral palsy since the age of one due to a bout of encephalitis, a common cause of postnatally acquired cerebral palsy (5). The condition has affected mostly his right arm and leg, leading to motor and sensory impairments, pain, and has led to secondary low back pain (6). Commonly associated with his condition, the patient has occasional seizures that are well managed by medication and a mild-moderate cognitive impairment that limits his ability to learn, comprehend and remember (6).  The patient lives with both parents in a one storey home. The patient graduated from high school at the age of 21 and now attends a day program a few days a week and works part time as an office assistant. Having this job is very important to the patient and a very important factor for adults with cerebral palsy (7). The patient is able to complete the majority of his ADLs, such as dressing, feeding, bathing and walking with assistive devices; however, he and his parents are noticing increasingly that he is limited by pain, physical limitations and fatigue. In his instrumental activities of daily living (IADLs), the patient requires assistance, which is common for many individuals with cerebral palsy (8) . Patient does not currently participate in any structured physical activity and walks only when needed due to increased fatigue and associated difficulty with movement. Patient appears to have very low motivation to be involved in the community and with physical activity. The patient and his parents would like to reverse his decline in walking function, returning to using his forearm crutches and hopefully improve to be able to perform ADLs more independently.

Medications: Baclofen and Diazepam