Young Adult Cerebral Palsy Fictional Case Study

Original Editor - Michelle Pratola Top Contributors - Sandra Zigic, Michelle Pratola, Alyssa Neville, Jordyn Sjerven, Emma Peters, Lauren Ianni, Chloé Devine, Kim Jackson and Carina Therese Magtibay

Abstract

This is a fictional case study of a 21 year old female living with Cerebral Palsy (CP). The purpose is to identify out-patient musculoskeletal and neurological rehabilitation in adults living with CP. Blake was born premature and diagnosed with diplegic spastic CP at the age of 4 which affects her bilateral lower extremities and was classified as a level II on the Gross Motor Function Classification System (GMFCS). She has a medical history of depression and osteoarthritis (OA) and is currently experiencing increased bilateral knee pain, increased difficulty walking, causing her to skip her usual classes at university. She has increased spasticity within her calf and hip flexor muscles as well as diffuse weakness within her lower extremities. This case study documents the process from the initial assessment to discharge outlining the patient's goals and treatment plan. This case aims to discuss the limitations and provide evidence for rehabilitation and outcomes for adults living with CP.

Introduction

Cerebral palsy (CP) arises from damage or malformations to the brain during development and is one of the most common paediatric onset physical disabilities. CP can lead to a variety of neurological and neuromuscular alterations which prevent optimal motor function capacity and mechanical loading. CP is a non-progressive disorder of posture and movement pathology. It is typically associated with an impairment of the developing fetal brain or infant brain, typically up until 2 years of age. This is typically the age where these malformations occur as the brain is rapidly growing during this time which increases the risk for damage. The prevalence of CP is approximately 2-3 individuals per every 1000, most affecting children but continues into adulthood.

There are many different types of CP, which are often classified in terms of whether it is a unilateral or bilateral disorder, the motor subtype (spastic, dystonia, dyskinesia, etc.), and the severity. Spastic diplegia affects 35% of children diagnosed with CP, making it one of the most common types of CP. This form of CP typically involves muscle stiffness bilaterally in the lower limbs, however, individuals will have normal cognitive function and a good prognosis for independent ambulation. The severity can be categorized by the Gross Motor Function Classification System (GMFCS), which has been approved and validated for individuals with CP ages 0-18 years at the time of diagnosis. Although it is not validated in adults, it can provide a good indication of what an individual's functional mobility will be like into adulthood. This classification system describes the gross motor function based on self-initiated movement abilities, with level I representing individuals who are most able and level V representing individuals who are most dependent on others for all mobility needs.

There is a lack of research and evidence on CP once individuals reach adulthood. Adults with CP may experience decreased mobility because of a number of factors, including muscle tone, weakness, and pain. Adults with CP have a wide range of abilities from full independence to 24-hour care needed. Although CP is a non-progressive disorder, adults may experience new symptoms and difficulties due to progression of musculoskeletal disorders and comorbidities that are associated with their CP diagnosis. Additionally, young adults with CP, ages 18-30 years old, have been shown to have approximately ten times more of a risk for musculoskeletal conditions than young adults without CP. Some common comorbidities that have been identified in adults with CP are hypertension, depression, epilepsy, osteoarthritis, and many more. There is also a variability in the services for adults with CP and how they are provided, and there is a reduced focus in the healthcare system on the long-term needs of adults with CP.

The purpose of this case presentation is to explore the effects of CP on a young adult who is independent, but is experiencing new musculoskeletal symptoms with her CP in adulthood. The case presentation will take place in an outpatient setting and will discuss all necessary components of a comprehensive physiotherapy exam. This case presentation will then discuss the analysis and plan for this individual and will also cover some newer technologies available for CP treatment, and how an interdisciplinary team can be beneficial to treating adults with CP. The overall goal of this case presentation is to bring awareness to CP in adulthood. It will focus on maintaining function while creating new management and treatment strategies for new symptoms that may arise in adulthood.

Client Characteristics

Blake Parker (she/her) is a 21 year old female who has been diagnosed with CP. She was diagnosed at the age of 4 with diplegic spastic CP affecting her bilateral lower extremities. At the time of her diagnosis, she was classified as a level II on the GMFCS Score. She was born premature and has a past medical history of depression and OA. She was previously able to ambulate without a gait aid and complete all activities of daily living (ADLs) independently. The patient is seeking outpatient physiotherapy as she has been experiencing increased bilateral diffuse knee pain, increased difficulty walking, and has not been attending her university classes due to the pain for the past four weeks. The pain has progressively gotten worse over the last 4 weeks reaching an 8/10 on the Visual Analogue Scale (VAS) when walking for more than 10 minutes and takes about 20 minutes to come back down to a 2/10 at rest. The patient lives in her two-storey family home with her parents and three sisters in Kingston, Ontario. She is a general arts student at Queen's University and enjoys volunteering at a horse range, exercising with friends, and reading in her free time.

Examination Findings

Subjective

History of Present Complaint

• Increased bilateral diffuse knee pain:
  • At rest 2/10, with activity 8/10 (after 10 minutes of walking)
  • Pain comes back down to a 2/10 after 20 minutes of rest
  • Reports pain as a dull achey pain but with activity becomes tight and sharp
  • If standing for long periods time, knee will start to ache
• No MOI, started 4 weeks ago
• Increased difficulty walking distances of more than 10 mins
• Unable to attend school currently due to issues with walking and stairs - currently doing virtual school instead

Past Medical History

• Born premature at 30 weeks
• Diagnosed with CP at the age of 4, level 2 on GMFCS score
• Depression (diagnosed in 2019)
• OA (diagnosed in 2021)
• Minor attention span and memory issues but pt noted it doesn’t affect her daily activities
• Attended physiotherapy regularly from age of 4-16 to develop a good regime to keep her symptoms of CP managed (has been self managing since age 16)

Current Functional Status

• Ambulates without gait aid but pain becomes severe after 10 minutes of walking
• Can perform ADLs independently
• Able to horseback ride currently, but unable to volunteer at hippotherapy events due to long periods of standing and walking
• Feels fatigued by the end of the day

Past Functional Status

• Able to ambulate independently without gait aid and without pain for 30 minutes
• Has forearm crutches but only brings them with her on walks of more than 1 hour and will not use until she absolutely needs them
• Able to perform ADLs independently
• Able to attend school and walk around campus independently

Social History

• Supportive family (lives with parents and 3 sisters in Kingston)
• Has many supportive friends who enjoy helping her
• Undergraduate student in general arts at Queen’s University
• Leisure: enjoys hanging out with friends, reading books, and painting
• Enjoys horseback riding on the weekends with her friends and volunteers with events at their range
• Exercises 2-3 x/ week but has not been consistent lately
• Has occasional drinks socially with friends (1-2 on the weekends)

Medications

• Citalopram (20 mg, 1 x per day)

Home/ Work

• Lives in two-storey home with family (4 stairs to get into house and 1 staircase in home)
• School/work: most buildings are accessible but fair distances between
• Volunteers at horseback riding range

Sleep/ Stress

• Trouble sleeping at night due to staying up late to study and finish assignments
• Stress levels are elevated due to not being able to attend school in person and not having her volunteering as an outlet
• Sleep is increasingly affected due to new knee pain

Objective

Observations

• Slight left side lean
• Tendency to weight bear more on the left side
• Right knee swollen and red compared to left

Gait Analysis

• Slight toe walking pattern (bilateral)
• Not fully getting heel strike at initial contact  (bilateral)
• Walks with hips slightly internally rotated (bilateral)
• Compensatory hip flexion to clear foot during swing phases (bilateral)
• Slower walking speed

Vitals

• HR: 62 BPM

• BP: 122/84 mmHg

• RR: 14 breaths/min

AROM

All UE and LE ROM are Within Normal Limits (WNL), except:

• Bilateral (B) hip extension = 10 degrees
• B hip ER = 15 degrees
• B knee flexion = 100 degree with ERP (End Range Pain)
• B ankle dorsiflexion = -10 degrees

PROM

All UE and LE ROM are Within Normal Limits (WNL), except:

• Right dorsiflexion = 5 degrees

Tone

• Increased tone and spasticity in bilateral calves and hip flexors
  • Worse in R side but present in both L and R
  • Modified Ashworth Score:
    • Right Calf: 3
    • Right Hip Flexors: 2
    • Left Calf: 1+
    • Left Hip Flexors: 1+

Global Strength Testing

Muscle Group	Right	Left
Hip Abductors	3+	3+
Hip Flexors	4	4
Hip Extensors	3+	3+
Hip Adductors	4	4
Knee Flexors	4	4
Knee Extensors	4	4
Ankle Plantar Flexors	4	4
Ankle Dorsiflexors	3	3+
Ankle Invertors	4	4
Ankle Evertors	3	3+

Neuro Scan

• All dermatomes and myotomes → WNL
• All reflexes and UMN → WNL
• Somatosensory (superficial, deep, and cortical) intact

Special Tests

• (+) Brush test
• (+) Thomas test on hip flexors & adductors
• (-) Clarke’s and (-) McConnell for Patellofemoral Pain Syndrome (PFPS)
• (-) Noble compression test for iliotibial band friction syndrome
• (-) Hoffa’s test for fat pad impingement

Palpation

• Both knees tender on palpation around the joint line - R knee worse
• Swelling felt around patella on both knees - R knee worse

Outcome Measures at Baseline

Pain Assessment: Visual Analog Scale (VAS)

The VAS as an outcome measure has the strongest reliability and validity for measurement of knee pain caused by OA. Since pain has been shown to be linked to spasticity caused by CP, it is also beneficial to determine the degree of spasticity. It has been shown that the Penn Spasm Frequency Scale (PSFS) has the best association with spasticity-induced pain. It is a self-reported measure that indicates the perception of spasticity for a number of different neurological disorders including CP in adults . The measure looks at the severity and frequency of spasticity.

Case Study:

	VAS	PSFS: Spasm Frequency	PSFS: Spasm Severity
At Rest	2/10	1/4	1/3
After 10 minutes of Walking	8/10	3/4	2/3

Walking Assessment: 6-Minute Walk Test

This outcome measure is commonly used to assess an individual’s walking ability in several cardiovascular and neurological disorders. It is shown to have good reliability and concurrent validity of functional mobility and endurance in adults with CP.

Case Study: 410m

Quality of Life: Pediatric Evaluation of Disability Inventory Computer Adaptive Test (PEDI-CAT)

The PEDI was revised to a computer adaptive test (CAT) that is intended to be used for adolescents and young adults (up to 21 years old) to assess function and quality of life in a variety of different populations including individuals with CP. The outcome measure looks at daily activities, mobility, social/cognitive abilities, and responsibility and it has a high validity for the daily activity and mobility categories for young adults.

Case Study: Daily Activities = 83, Mobility = 81, Social/Cognition = 89

Analysis Statement/Clinical Impression

Patient is a 21 y/o female diagnosed with CP presenting with right knee pain that began 4 weeks ago due to OA. Patient has increased tone in bilateral hip flexors and calves that results in decreased dorsiflexion during gait and internal rotation of the ankles. The patient was previously active participating in horseback riding and going to the gym 2-3 times a week. Previously was fully independent in ADLs and ambulated well without a gait aid. Patient is currently able to perform ADLs independently, however, needs to take a break when walking more than 10 minutes due to pain increasing to an 8/10 with activity which takes 20 minutes to come back down to a resting 2/10. The patient is an excellent candidate for physiotherapy treatment aimed at gait training, strengthening, stretching, tone reduction, and education to help decrease pain and increase functional mobility. The patient shows signs for a good prognosis as she was was previously active and independent, is in the acute/sub-acute phase of this exacerbation of her CP symptoms, and has a good support system from friends and family. The patient may also benefit from gait aid use and from referrals for a multidisciplinary team to tackle all of her needs, including returning to school. The patient is at risk of the knee OA continuing to progress, but will benefit from exercises and self management strategies.

Problem List

• Increased bilateral diffuse knee pain on anterior aspect of knee - worse on R knee
• Increased difficulty walking distances of more than 10 mins because of pain
• Unable to attend school currently due to decreased tolerance for walking distances >1 km and climbing 10+ stairs
• Increased tone and spasticity in bilateral calves and hip flexors
• Decreased bilateral strength of hip extensors, abductors, dorsiflexors, and evertors

Short-Term Goals

• In 2 weeks, the patient's R knee pain will decrease from 8/10 to 6/10 when walking for periods of 10 minutes
• In 2 weeks, the patient will be able to ambulate for 10 minutes consecutively outside using gait aid
• In 2 weeks, the patient will be able to complete 10 stairs consecutively using gait aid

Long-Term Goals

• In 6 weeks, the patient will increase strength of hip extensors, hip abductors, and ankle dorsiflexors to a MMT grade of 4/5
• In 6 weeks, the patient will be able to ambulate for 20 minutes consecutively with a 4/10 pain or less, without a gait aid
• In 6 weeks, the patient will be able to return to attending school 3 days/week in-person

Treatment

This treatment plan uses the International Classification of Functioning, Disability and Health (ICF) model by targeting different aspects of her condition that will allow the patient to reach their functional and meaningful goals. It is important to note that there is no single template for CP physiotherapy intervention, as every individual with CP may present differently and needs a personalized approach.

Education

Educate patient on techniques for using forearm crutches and the importance of using them when needed.

• Studies have found that patients with CP who use forearm crutches have increased efficiency of gait due to adapting a longer stride length and decreased cadence.
• Since Blake already owns forearm crutches, our main focus is to re-educate her on the proper use and benefits to using them. This includes using the crutches when ambulating longer distances, feeling fatigued, or experiencing knee pain.
  

Education on performing additional hip flexor stretches after sitting for long periods of time such as after a day of classes or after increased physical activity in addition to the home exercise program (HEP).

Education on the importance of monitoring fatigue and regressing the HEP if needed.

• Examples:
  • Reduce reps
  • Reduce sets
  • Increase rest times
  • Reduce resistance/weight if applicable
    

Referral to occupational therapy will assist in determining modifications that can be made to her environment to decrease barriers in participation and activity.

Stretching

Spasticity of hip flexors and plantar flexors to be targeted with gentle stretching of these muscle groups.

• Hip flexors: 2x30 second hold, completed on each side
  • Half Kneel Hip Flexor Stretch: should feel a stretch along the front hip area of the knee-down side
  • Hip Flexor/Quad Stretch With Strap - Thomas Stretch: gently pull on strap until stretch is felt in front hip area
• Plantar flexors: 2x30 second hold, completed on each side
  • Calf Stretch with Towel - Gastrocnemius: pull your ankle back until a stretch is felt on your calf area
  • Standing Calf Stretch - Soleus: gentle stretch is felt along the back of your leg that is farther behind you

Strengthening

Exercises to strengthen hip extensors, hip abductors, and ankle dorsiflexors to counteract spasticity in opposing muscle groups.

Each exercise to be completed for 10 repetitions, 3 sets, with a 5 second hold. Exercises to be completed daily, or as tolerated.

• Glute Bridges: lying supine, elevate the hips to make a straight line with your shoulders → should feel the exercise in the glute muscles
• Hamstring Curl: seated hamstring curl with elastic bands  
• Hip Abduction: side-lying straight leg raise → should feel the glutes and outside (lateral) aspect of the leg working
• Dorsiflexion: long sitting or seated dorsiflexion with elastic band

Functional Electrical Stimulation (FES)

Recent research demonstrates that FES can facilitate safe walking and exercise of ‘normal’ movement patterns, increase joint ROM, stimulate muscle strengthening, improve proprioception, and reduce the effects of spasticity in children and young adults with CP. Additionally, research suggests that FES is a more functional way to improve dorsiflexion than using ankle foot orthoses (AFO), because it addresses issues with foot clearance during the swing phase. This is due to the restrictive nature of AFOs, which hold the joint in place rather than working on the strength and movement patterns at the ankle.    

Parameters:

• Place electrode over the tibialis anterior muscle belly
• Amplitude: low-medium, increasing until we generate a small visible contraction
  • We want to avoid a large stimulus that is painful or too fatiguing
• Ramp time of 4-8 seconds to avoid rapid stretch and thus more spasticity
• The electrical stimulation will be provided throughout the swing phase and heel strike phases of gait

Gait Training

• FES will be used to facilitate dorsiflexion as mentioned above
• Cueing will be provided during stance phase to decrease Trendelenburg gait
• Cueing will be provided to encourage knee flexion in order to minimize circumduction
• Cueing for proper sequencing of the gait cycle and forearm crutch use

Home Exercise Program

• Patient will be provided with a handout with explanations and images of the exercises to be done at home
• Patient will also be provided with videos of herself ambulating and doing the exercises with the physical therapists verbal cues audible in the video
• Patient will come in weekly for FES gait training and monitoring of symptoms and to ensure proper progression and regression of exercises when appropriate
• Patient is encouraged to walk 10 minutes daily with the use of her forearm crutches

Referrals

1. Occupational Therapists: Individual could benefit from a new gait aid, as well as any additional mobility devices and school adaptations that may be recommended.
2. Psychologist: Individual has been diagnosed with depression and could benefit from a therapy intervention to help with mental health challenges.
3. Massage Therapist: Patient displays muscle spasticity and could benefit from massage therapy to assist with pain and tone.

Technology-Based Treatment

Robotics Assisted Gait Training (RAGT) uses a robotic exoskeleton to help individuals normalize their gait pattern. It is a safe and effective option for improving motor performance when used with conventional therapies in a rehabilitation setting. RAGT benefits the CP population because it allows them to be physically active and maintain their physical performance to help prevent the development of comorbidities. However, the exoskeleton is a new technology and requires further investigations before conclusions can be drawn on its efficacy for gait training.

For additional information on robotic rehabilitation, head over to: Robotic Rehabilitation for the Lower Extremity

Outcome

Following the initial consult, the physiotherapy team continued to see Blake 2 times per week for 6 weeks to continue to help improve her symptoms and increase her functional status.

Blake has met all short and long-term goals. After the 6 weeks, Blake has increased strength in hip extensors, hip abductors, and ankle dorsiflexors. She has been able to consistently walk 20 minutes with decreased pain and is now attending her University classes 3 days a week.

In addition to meeting her goals, we saw a decrease in overall pain, reduced muscle tone, and increased ROM into dorsiflexion bilaterally. We have observed Blake using her forearm crutches efficiently, which has created a longer stride length and allowed her to offload her knee during long periods of walking. She has demonstrated a proper understanding of when to use her forearm crutches and the importance of using them when needed. Blake has also been following our recommendations to perform additional hip flexor stretches after an extended period of time sitting in class or after a day of increased physical activity.

Objective Findings/Outcome Measures at Discharge

AROM: Ankle dorsiflexion: neutral (0 degrees), Knee flexion: 110 degrees. All other ROM remained unchanged from her initial assessment.

MMT: Hip extensors, hip abductors, and ankle dorsiflexors all increased to a 4/5

Tone:

• Modified Ashworth Score:
  • Right Calf: 1+
  • Right Hip Flexors: 1+
  • Left Calf: 1
  • Left Hip Flexors: 1

Pain:

	VAS	PSFS: Spasm Frequency	PSFS: Spasm Severity
At Rest	1/10	1/4	1/3
After 10 minutes of Walking	3/10	1/4	1/3

6-Minute Walk Test: 550 m

PEDI-CAT: Daily Activities = 90, Mobility = 88, Social/Cognition = 89

Discharge Plan

Her discharge plan includes keeping up with her HEP for 2-3 additional months, as well as providing education and information for additional referrals. She has been referred to OT, massage therapy, and a psychologist. She has received accommodations for school that allow her to attend 3 days a week while doing the other 2 days online. Additionally, she has been granted additional time between classes so she does not have to rush when walking across campus. She has been advised to reach out to the physiotherapy team if she requires any additional questions or concerns. Patient has been discharged at this time.

Discussion

This fictional case followed Blake Parker, who is 21 years of age and was diagnosed with diplegic spastic CP when she was 4 years old. She came to outpatient physiotherapy due to an acute bout of bilateral knee pain (worse on right) caused by OA. A subjective history revealed that her pain was exacerbated by prolonged standing and walking for more than 10 minutes consecutively, which was affecting her ability to attend her University classes in-person. The objective assessment revealed that Blake had reduced bilateral strength of the hip extensors, abductors, and dorsiflexors that all presented weaker on the right leg, as well as bilateral tone and spasticity in the calves and hip flexors.

Based on her presentation, the treatment approach was focused on treating and managing the acute knee pain and OA, while taking a holistic approach that considered how the CP diagnosis affected the function of her lower extremities and entire body. Studies show that adults with CP have an increased risk of developing osteoporosis and OA, so it is likely that young adults with CP may present with similar symptoms to Blake’s case . OA is a degenerative joint disease that has an increased prevalence in the adult CP population compared to adults without CP . OA can cause functional limitations because of joint pain, which can decrease an individual's ability to perform physical activity. A common treatment for OA is surgery. Individuals with CP who have had surgery to treat their OA were found to have a significant reduction in pain . Despite the effectiveness of surgery for OA in the CP population, surgeons are reluctant to operate due to the increased risk of dislocation and prosthetic failure . This and Blake's young age was the rationale for treating Blake's OA conservatively with physiotherapy that included gait and gait aid training, FES, and stretching and strengthening exercises. Although the prevalence of OA in the CP population is high, there remains a lack of evidence on the most effective forms of rehabilitative treatment. It is important that further research is conducted in individuals with CP and OA due to the high prevalence, and so healthcare professionals know how to modify treatments and assessments when considering coexisting conditions.

The physiotherapy treatment plan was based on Blake’s short-term and long-term goals of increasing strength, reducing pain when walking, and returning to in-person classes. One focus of the physiotherapy plan was teaching Blake how to ambulate with her forearm crutches, which have been shown to reduce the body load on the legs for individuals with CP . The crutches were introduced as a compensatory management strategy to reduce load on Blake’s knee joints and to help her achieve independence when walking on campus. Studies have also shown that functional gait training and FES can be effective to improve walking speed and gross motor function for young adults with CP. Incorporating FES during gait training in the exercise plan would likely help Blake to achieve her goals.

The life expectancy of individuals who are diagnosed with CP depends on the severity of the condition. In this case, Blake was diagnosed with level II on the CMFCS indicating mild impairments. Blake’s diagnosis should therefore not decrease her life expectancy. There are many resources and programs that can be found through Can Child and Cerebral Palsy Canada, but they are more focused towards children with CP, rather than adults. Individuals diagnosed with CP will require treatments and accommodations throughout their life. It is important to continue conducting research with adult CP populations, so that healthcare professionals can provide the best evidence-based treatment for concerns occurring later in these patients' lives. This fictional case highlighted the early onset of OA that individuals with CP often experience due to the abnormal joint movements, greater stress concentration at the joints, and the increased tone of muscles surrounding the joints. Each person with CP will require an individualized treatment plan, with physiotherapists, occupational therapists, and massage therapists being vital to help individuals with CP manage their condition and be as independent as possible for as long as possible.

Self-Study Questions

Which of the following statements about cerebral palsy is false?

A. CP is one of the most common paediatric onset physical disabilities

B. The severity can be categorized by the Gross Motor Function Classification System (GMFCS)

C. CP is a progressive disease

D. CP affects approximately 2-3 individuals for every 1000

Which of the Following Best Describes a Level 5 on the Gross Motor Function Classification System (GMFCS)?

A. Walks without restrictions

B. Self-Mobility is severely limited even with the use of assistive technology

C. Walks with assistive devices

D. Walks without assistive devices

Which of the following is not a typical treatment technique for CP in young adults?

A. Acupuncture

B. Stretching muscles involved

C. Gait training

D. Use of gait aids

Answers Below

1. C
2. B
3. A