Adult Spastic Cerebral Palsy: A Case Study with Anterior Knee Pain
Original Editor -
Top Contributors - Mackenzie Peters, Gillian Plummer
Abstract[edit | edit source]
The purpose of this fictional case study is to outline the out-patient management of a 38-year-old female with CP whose primary complaint is of bilateral anterior knee pain. Early on in her CP diagnosis, she was given a level II rank on the Gross Motor Function Classification System (GMFCS) indicating that she can ambulate but has difficulties with uneven surfaces. Upon objective assessment, it was found that she has some indications of spasticity within the hamstrings and quadriceps according to the Modified Ashworth Scale. She also demonstrated a crouch gait pattern and reduced strength bilaterally in hip extensors, knee extensors, and ankle plantar flexors. Since quality of life has been shown to increase following improvements in walking, the focus of the program implemented in this case study is on gait training. Taken together, the information outlined in this fictional case can provide some evidence to guide decision-makers in the future and to highlight the importance of further research in adults that have CP.
Introduction[edit | edit source]
Cerebral palsy (CP) is an umbrella term used to describe a group of non-progressive motor impairment disorders (Amankwah et al., 2020; van Gorp et al., 2020). It is the result of neurodevelopmental disturbances, such as premature birth or stroke, that occurred at any time from conception to when the child was two years of age (Amankwah et al., 2020; Physiopedia, 2022). It is one of the most common causes of motor disability in children, with approximately 2 to 2.5 in 1000 Canadian children meeting the criteria for diagnosis (Amankwah et al., 2020; Physiopedia, 2022; van Gorp et al., 2020). The disease’s severity is classified using the Gross Motor Function Classification System (GMFCS)(Palisano et al., 2007; Physiopedia, 2022).
Despite occurring in early childhood, approximately 75 percent of individuals currently living with CP are older than 18 years of age (van Gorp et al., 2020). This number is expected to significantly increase by 2031 (Amankwah et al., 2020). As individuals with CP age, the clinical presentation of the condition changes. Adults with CP are roughly 7 to 10 times more likely than the general population to have a musculoskeletal morbidity (French et al., 2019; Whitney et al., 2018; van Gorp et al., 2020). Furthermore, nearly one-third of adults with CP report musculoskeletal pain that is associated with deteriorating physical function, such as inability to ambulate, and reduced participation in daily life (Booth et al., 2018; Ganjwala & Shah, 2019; O’Connell et al., 2019; Rethlefsen et al., 2015).
Musculoskeletal impairments and pain may be caused by altered gait patterns (Ganjwala & Shah, 2019; Miller, 2020; Rethlefsen et al., 2015). Specifically, the crouch (i.e., knee flexion) gait pattern commonly seen in individuals with CP has been significantly associated with knee pain (Ganjwala & Shah, 2019; Rethlefsen et al., 2015). Crouch gait is used to describe the two common knee patterns seen in CP gait: (1) increased knee flexion during the stance phase and (2) reduced knee flexion during the swing phase (Ganjwala & Shah, 2019). Increased knee flexion during stance may be caused by hamstring spasticity, quadriceps weakness, soleus weakness, and/or lever-arm dysfunction, whereas decreased knee flexion during swing may be due to rectus spasticity (Ganjwala & Shah, 2019). As a result of the crouch gait pattern, there is also an increase in patellofemoral forces in individuals with CP (Pelrine et al., 2020; Rethlefsen et al., 2015). Furthermore, in a CP patient population, the patella is often located proximally to its typical anatomical location (i.e., patella alta) and is therefore more susceptible to dysfunction or subluxation that contributes to knee pain (Miller, 2020). Improvements in independence, participation in activities of daily living, and overall quality of life can be seen following improvements in gait patterns (Booth et al., 2018).
Client Characteristics[edit | edit source]
The patient is a 38-year-old female diagnosed with bilateral spastic CP. She was diagnosed at the age of 5 due to observable mild developmental delays, abnormal posture and high muscle tone. It was later discovered that she fell into the Level II category of the GMFCS (Palisano et al., 2007). The patient reports that their forearm crutches are used during ambulation and provide increased stability and support. The patient presents with several health complications including type II diabetes, epilepsy, obesity (BMI of 32), chronic pain, and fatigue. The patient is seeking outpatient physiotherapy care for her bilateral anterior knee pain as a result of spasticity and altered gait (Yi et al., 2019). The patient explains that the pain has progressively gotten worse over the last three months, rating it 7/10 on the numeric pain rating scale when walking and reports that it takes over an hour for her pain to come down to 3/10 when resting. The patient lives in a single -level community home where she has her own bedroom and bathroom. She reports being independent in most activities of daily living (ADLs) but relies on the support personnel for her meals and medication.
