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 and was classified as a level 3 on the GMFCS. The interventions used were based on the ICF model to address the body structure, activity and participation components.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

Objective Assessment

The patient appeared to be underweight, have mild dysarthria and difficulty managing saliva (8). Objectively, the patient presents with right arm resting posture of shoulder adduction, elbow, wrist and finger flexion, and forearm pronation (8). Resting right leg posture showed slight hip and knee flexion, and significant plantarflexion of the ankle (8). The patient had increased tone and spasticity in the right upper limb and lower limb as well as decreased passive range of motion with hip and knee extension, hip abduction, elbow and wrist extension, shoulder abduction and forearm supination (8). There was also a notable contracture of the gastroc-soleus complex (8). The patient had reduced strength in both the right upper and lower extremities (8). Left side strength and range of motion was within normal limits.  The patient had impaired sensation in the right upper and lower extremities, with decreased 2 point discrimination, proprioception, and astereognosis. Deep tendon reflexes were brisk with clonus and the Babinski sign was present. The presentation of decreased sensation and hyperreflexia are common in people with spastic cerebral palsy (6). During gait, the patient used his posterior posture four wheeled walker. The patient demonstrated circumduction and adduction of the right hip during the swing phase. Initial contact was made on metatarsal heads, demonstrating foot equinus. The patient had a flexed and stiff right knee and hip throughout the gait cycle, and anterior pelvic tilt. The patient's gait was slow and he demonstrated shortened stride length, decreased stance time on the right side and minimal trunk movement. The patient’s gait pattern was similar to those previously described in cerebral palsy (9). Please see the pPhysiopediapage on the classification of gait patterns in CP for more information on common gait patterns and how to classify them. [Classification of Gait Patterns in Cerebral Palsy: https://www.physio-pedia.com/Classification_of_Gait_Patterns_in_Cerebral_Palsy].  There is a severe lack of information regarding tools validated to use to assess gait in this population, which is why we chose to assess the patient via observation.

Clinical Impression

Physiotherapy Diagnosis:

Functional motor impairments affecting right side and resulting in decreased ability to ambulate and engage in activities of daily living.

Problem list:

• Weakness from impaired voluntary motor control due to lack of coordinated agonist and antagonist muscle contraction

• Constant plantar flexion causing difficulties with gait due to high tone and contracture in plantar flexors
• High spasticity in right arm leading to decreased ROM and inability to participate in ADLs
• Decreased ability to ambulate independently and thus decreased ability to engage in activities of daily living due to impaired voluntary movements, balance, and spasticity (18).

Intervention

Patient-centred treatment goals

Short term (0-8 weeks)

• Ability to have less mobile joints with high spaciticy passively moved with enough range to allow for skin hygiene by the end of 4 weeks
• Ability to remain upright after small internal perturbations with moderate support by the end of 4 weeks
• Able to stand independently and walk with the use of a gait aid by the end of 8 weeks
• Able to manipulate larger, lighter objects such as an empty cup with spastic right side by the end of 8 weeks

Long term goals (9-24 weeks)

• Able to remain upright after moderate internal perturbations to increase independence with ambulation after 16 weeks
• Maintain available ROM in joints affected by spasticity in 24 weeks to facilitate ambulation and prevent contractures
• Able to perform and regain ability to perform certain BADLs, such those in the SF-36, in 24 weeks by increasing strength and endurance
• Take 5 steps between parallel bars without use of hands on the bars and without loss of balance, in 16 weeks
• Able to ambulate for 20min without experiencing fatigue and with limited assistance from caregivers to increase ability to do ADLs in 24 weeks time
• Manipulate both smaller and heavier objects such as utensils and/or pots with spastic right side by the end of 24 weeks
• Able to use technological devices such as a video game remote and smart phone to participate in social events by the end of 24 weeks

Intervention approach: body, structure, and function, ICF Domain

For more information on the ICF domains please see https://physio-pedia.com/ICF_and_RPS_within_Cerebral_Palsy

To reach his body, structure, and function goals that are the basis for more functional goals presented in the next section we targeted three main areas with interventions:

1. Strengthening

- With the goal increasing gait and ADL abilities

2. Range of motion

- With the goal of caring for skin and easing contractures

3. Balance

- With the goal increasing gait and ADL abilities

Techniques used:

Strengthening

• Strengthening was incorporated from 0-24 weeks
• Weight and resistance were increased as needed when the exercises no longer challenged the patient.

Joint	Muscles	Exercises
Shoulder (19)* *Article specifies muscle groups and parameters but not specific exercises. Exercises were thus chosen by us editors as appropriate for patient.	Biceps brachii	Biceps curls with light dumbells secured to hands as needed 10 reps, 3 sets, 3 times a week, to an intensity of light fatigue by the end of the day
	Triceps brachii	Triceps brachii extensions with light resistance theraband, secured to hands as needed. 10 reps, 3 sets, 3 times a week, to an intensity of light fatigue by the end of the day
	Pectoralis major	Seated chest press with light resistance therabands, secured to hands as needed. 10 reps, 3 sets, 3 times a week, to an intensity of light fatigue by the end of the day
	Deltoid	Seated arm abduction with light resistance therabands, secured to hands as needed. 10 reps, 3 sets, 3 times a week, to an intensity of light fatigue by the end of the day
Hip	Flexors	Seated hip flexion with progression including resistance band as needed 10reps, 3 sets, 3 times a day, 3 days a week, to an intensity of light fatigue by end of the day
Ankle	Dorsiflexors	Seated dorsiflexion strengthening with light resistance theraband 10reps, 3 sets, 3 times a day, 3 days a week, to an intensity of light fatigue by end of the day

Stretching

• Stretching was incorporated from 0-24 weeks.
• Stretches were done to maintain range.
• Held for 20s done 3 times and repeated 3 times a day to an intensity of a light stretch unless otherwise specified.

Joint	Muscle Group	Stretch
Shoulder	Adductors	Passive shoulder abduction by therapist or caregiver
Wrist and hand	Wrist flexors	Passive wrist flexion by therapist or caregiver or his unaffected arm
	Finger flexors	Passive finger flexion by therapist or caregiver  or his unaffected arm
	Forearm pronators	Passive forearm pronation by therapist or caregiver or his unaffected arm
Hip	Adductors	Lying supine with knees out to the sides
	Flexors	Lying prone
Knee	Flexors	Lying prone with very light weight on ankles to extend knees
Ankle	Plantar flexors	Treadmill walking on an incline for 30min everyday to decrease joint contractures. Progression included increasing the incline weekly(20).

Balance

• Balance training was incorporated from 0 to 24 weeks
• Exercise:  Balance via APA training as per the Su and Chow (21) study with parameters determined by implementing therapists in this case study
  • Trunk rotation tasks standing supported such as reaching across the body to increase ability to maintain balance while doing tasks.
  • 10 reps, 3 sets, 3 times a day, 3 days a week, to an intensity of a mild challenge to support himself
  • Balance exercises were progressed by increasing perturbations when the previous ones no longer challenged the patient.

References

(1) Peterson, M., Lukasik, L., Muth, T., Esposito, P., Haapala, H., Gordon, P.,... & Hurvitz, E. (2013). REcumbent Cross-Training is a Feasible and Safe Mode of Physical Activity for Significantly Motor Impaired Adults with Cerebral Palsy. Archive of Physical Medicine and Rehabilitaiton, (94), 401-407.

(2) Struass, D., Brooks, J., Rosenbloom, L. & Shavelle, R. (2008). Life expectancy in cerebral palsy: an update. Developmental Medicine and Child Neurology, 50(7).

(3) Bottos, M., Feliciangeli, A., Sciuto, L., Gericke, C., & Vianello, A. (2001). Functional status of adults with cerebral palsy and implications for treatment of children. Developmental Medicine and Child Neurology, 43(8), 516–528.

(4) Slaman, J., Roebroeck, M., van der Slot, W., Twisk, J., Wensink, A., Stam, H., van den Berg-Emons, R., and Learn 2 Move Research Group.  (2014). Can a Lifestyle Intervention Improve Physical Fitness in Adolescents and Young Adults with Spastic Cerebral Palsy? A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation, 95, 1646-1655.

(5) Reddihough DS, Collins KJ. The epidemiology and causes of cerebral palsy. Australian Journal of physiotherapy. 2003 Jan 1;49(1):7-12.

(6) Odding E, Roebroeck ME, Stam HJ. The epidemiology of cerebral palsy: incidence, impairments and risk factors. Disability and rehabilitation. 2006 Jan 1;28(4):183-91.

(7) National Institute for Health and Care Excellence. Cerebral palsy in adults, NICE guideline [Internet]. London: National Institute for Health and Care Excellence; 2009 Jan [cited 2019 May]. Availible from: https://www.nice.org.uk/guidance/ng119/resources/cerebral-palsy-in-adults-pdf-66141606816709

(8) Rapp CE, Torres MM. The adult with cerebral palsy. Archives of family medicine. 2000 May 1;9(5):466.

(9) Dobson F, Morris ME, Baker R, Graham HK. Gait classification in children with cerebral palsy: a systematic review. Gait & posture. 2007 Jan 1;25(1):140-52.

(10) Palisano RJ, Rosenbaum P, Bartlett D, Livingston MH. Content validity of the expanded and revised Gross Motor Function Classification System. Developmental Medicine & Child Neurology. 2008;50:744-50.

(11) Morgan PE, Soh SE, McGinley JL. Health-related quality of life of ambulant adults with cerebral palsy and its association with falls and mobility decline: a preliminary cross sectional study. Health and quality of life outcomes. 2014 Dec;12(1):132.

(12)

(13) Gannotti ME, Gorton III GE, Nahorniak MT, Masso PD. Gait and participation outcomes in adults with cerebral palsy: A series of case studies using mixed methods. Disability and health journal. 2013 Jul 1;6(3):244-52.

(14) Sandström K. Adults with cerebral palsy: living with a lifelong disability (Doctoral dissertation, Linköping University Electronic Press).2009.

(15) Andersson C, Asztalos L, Mattsson E. Six-minute walk test in adults with cerebral palsy. A study of reliability. Clinical rehabilitation. 2006 Jun;20(6):488-95.

(16) Brien M, Sveistrup H. An intensive virtual reality program improves functional balance and mobility of adolescents with cerebral palsy. Pediatric Physical Therapy. 2011 Oct 1;23(3):258-66.

(17) Opheim A, Jahnsen R, Olsson E, Stanghelle JK. Balance in relation to walking deterioration in adults with spastic bilateral cerebral palsy. Physical Therapy. 2012 Feb 1;92(2):279-88.

(18) Opheim, Arve, Jahnsen, Reidun, Olsson, Elisabeth, et al. Walking function, pain, and fatigue in adults with cerebral palsy: a 7-year follow-up study. 2009;51(5):381-8.

(19)Hutzler Y, Rodrıguez BL, Mendoza Laiz N, Dıez I, Barak S. The effects of an exercise training program on hand and wrist strength, and function, and activities of daily living, in adults with severe Cerebral Palsy. 2013;34(12):4343-54.

(20) Lorentzen J, Kirk H, Fernandez-Lago H, Frisk R, Scharff Nielsen N, Jorsal M, et al. Treadmill training with an incline reduces ankle joint stiffness and improves active range of movement during gait in adults with cerebral palsy. Disability & Rehabilitation. 2017;39(10):987-93.

(21) Su IYW, Chow DHK. Anticipatory Postural Adjustments in Standing Reach Tasks Among Middle-Aged Adults With Diplegic Cerebral Palsy. Journal of Motor Behavior. 2016;48(4):309-18.

(22) Hesse S., Bertelt C., Jahnke M. T., Schaffrin A., Baake P., Malezic M., et al. Treadmill Training With Partial Body Weight Support Compared With Physiotherapy in Nonambulatory Hemiparetic Patients. Stroke. 1995 Jun 1;26(6):976–81.

(23) Schindl MR, Forstner C, Kern H, Hesse S. Treadmill Training With Partial Body Weight Support in Nonambulatory Patients With Cerebral Palsy. 2000;81:6.

(24) Kim SJ, Kwak EE, Park ES, Cho S-R. Differential effects of rhythmic auditory stimulation and neurodevelopmental treatment/Bobath on gait patterns in adults with cerebral palsy: a randomized controlled trial. Clinical Rehabilitation. 2012 Oct;26(10):904–14.

(25) Steenbergen B, Crajé C, Nilsen DM, Gordon AM. Motor imagery training in hemiplegic cerebral palsy: a potentially useful therapeutic tool for rehabilitation. Developmental Medicine & Child Neurology. 2009;51(9):690–6.

(26) Szturm T, Peters JF, Otto C, Kapadia N, Desai A. Task-specific rehabilitation of finger-hand function using interactive computer gaming. Archives of Physical Medicine & Rehabilitation. 2008 Nov;89(11):2213–7.

(27) Brown SH, Lewis CA, McCarthy JM, Doyle ST, Hurvitz EA. The Effects of Internet-Based Home Training on Upper Limb Function in Adults With Cerebral Palsy. Neurorehabilitation and Neural Repair. 2010 Jul;24(6):575–83.