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

Introduction

Cerebral palsy (CP) arises from damage or malformations to the brain during development and is one of the most common paediatric onset physical disability. 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 an infant brain, typically up till 2 years old. 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 a the Gross Motor Function Classification System (GMFCS) which has been approved and validated for individuals with CP ages 0-18 at the time of diagnosis. Although it is not validated in adults, it can provide a good indication of what their 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 most dependent on others for all mobility needs.

Gross Motor Function Classification System (GMFCS)

Level	Limitation
Level I	Walks without restrictions; limitations in more advanced gross motor skills
Level II	Walks without assistive devices; limitations walking outdoors and in the community
Level III	Walks with assistive devices; limitations walking outdoors and in the community
Level IV	Self-mobility with limitations; the person is transported or uses power mobility outdoors and in the community
Level V	Self-mobility is severely limited even with the use of assistive technology

There is a lack of research and evidence behind CP once individuals reach adulthood. However, 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 care needed. Although CP is a non-progressive disorder, adults may experience new symptoms and difficulties due to progressions of musculoskeletal disorders and comorbidities that are associated with their CP diagnosis. Additionally, young adults, ages 18-30 years old, with CP have been shown to have approximately ten times more of a risk for musculoskeletal conditions compared to 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 not as much focus in the health care system on 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 experiencing new 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 touch on 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 as there is not a lot of evidence and information out there for how to care for these individuals. As CP is a non-progressive disease this case study will focus on maintaining function while creating new management and treatment strategies for new symptoms that may arise in adulthood.

Bellow is a brief video with additional information about cerebral palsy:

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 Gross Motor Function Classification System (CMFCS) Score. She was born premature and has a past medical history of depression and osteoarthritis. 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 numeric pain rating scale 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-story 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 achy pain but with activity but become 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, 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)
• Osteoarthritis (diagnosed in 2021)
• Minor attention span and memory issues but pt noted it doesn’t affect her daily activities
• Attended physiotherapy from age of 4-16 regularly 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 events due to long periods of standing and walking
  • Hippotherapy
• 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 distances 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 (6/10) 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

• Bilateral (B) hip extension = WNL

• B hip flexion = WNL

• B hip adduction = WNL

• B hip abduction = WNL

• B hip ER = 15 degrees

• B hip IR = WNL

• B knee flexion = 100 degree with ERP

• B knee extension = WNL

• B ankle dorsiflexion = -10 degrees

• B ankle plantar flexion = WNL

• B ankle inversion = WNL

• B ankle eversion = WNL

PROM

• Right dorsiflexion 5 degrees
• All other ranges WNL for right and left

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

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

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)

This outcome measure had the strongest reliability and validity for a measurement of knee pain caused by osteoarthritis. Since pain has been shown to be linked to spasticity caused by cerebral palsy, it would also be beneficial to determine the degree of spasticity. It has been shown that Penn Spasm Frequency Scale (PSFS) has the best association with spasticity-induced pain. It is a self-reported measure indicating the perception of spasticity following a number of different neurological disorders including Cerebral Palsy 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 cerebral palsy.

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 cerebral palsy. The outcome measure looks at daily activities, mobility, social/cognitive abilities, and responsibility and showed high validity for the daily activity and mobilities categories towards 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 cerebral palsy presenting with right knee pain that began 4 weeks ago due to osteoarthritis. 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 ADL's and ambulated well without a gait aid. Patient is currently able to perform ADL’s 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 for activities aimed at gait training, strengthening, stretching, tone reduction, and education to all help decrease pain and increase her functional mobility. The patient shows signs for a good prognosis as she was was previously active, 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. Patient is at risk of continuing to progress OA in her knees 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, decrease R knee pain from 8/10 to 6/10 when walking for periods of 10 minutes
• Ambulate for 10 minutes consecutively outside using gait aid in 2 weeks
• Complete 10 stairs consecutively using gait aid in 2 weeks

Long-Term Goals

• Increase strength of hip extensors, abductors, and dorsiflexors to MMT grade 4- in 6 weeks
• Ambulate for 20 minutes consecutively with a 4/10 pain or less in 6 weeks
• Return to attending school 3 days/week in-person in 6 weeks

Treatment

This treatment plan uses the International Classification of Functioning, Disability and Health (ICF) model by targeting different aspects 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 cerebral palsy that 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 when ambulating longer distances, feeling fatigued, or experiencing knee pain.
  

Bellow is a video that provides additional tips for how to use forearm crutches, including how to adjust them and how to incorporate them into gait patterns.

Education on performing extra 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 the 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 most 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 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 cerebral palsy. Additionally, research suggests that FES is a more functional way to improve dorsiflexion, which addresses issues with foot clearance during the swing phase, than using ankle foot orthoses (AFO). This is due to the restrictive nature of AFO’s 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 on 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 video's that show themselves ambulating and doing the exercises with the physical therapists verbal cues audible in the video
• Patient will come in weekly for FES gait training, monitoring of symptoms and progress and to ensure proper progression and regression of exercises are done 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 gait aid as well as any additional mobility devices that may be recommended School modifications
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 could benefit from massage therapy to assist with pain and tone.

Example Referral for OT Services

To whom it may concern,

Blake Parker is a 21 year old female who has been diagnosed with CP at the age of 4. Blake has diplegia spastic CP affecting her bilateral lower extremities. Blake experiences difficulty walking for more than 10 minutes and has difficulty ascending stairs because of pain and increased spasticity in legs. Blake is unable to attend school due to her condition. Blake could benefit from occupational therapy through proper prescription of a gait aid and assistance with mobility in regard to ambulation and ascending and descending stairs at school. I look forward to working with you in the furture.

Thank you,

Physiotherapist

Technology-Based Treatment

Robotics assisted gait training (RAGT) uses a robotic exoskeleton to help individuals normalize their gait pattern. The Lokomat Nanos exoskeleton has orthoses that attach to an individual’s limbs and adjust their anthropometry. The Lokomat has linear devices in the knee and hip joints that help the orthoses move through the gait cycle by guiding the individual through a predetermined gait pattern similar to that of a healthy individual. The therapist also controls how much guidance the exoskeleton will provide the user.

Robotics Assisted Gait Training (RAGT) is a safe, effective option for improving motor performance when used with conventional therapies in a rehabilitation setting. Individuals who used an exoskeleton while training gait were found to have an increased stride length as well as speed. In addition, individuals had better outcome measure scores on the 6 Minute Walk Test and Gross Motor Function Classification System while using the exoskeleton for gait. RAGT shows significant improvements in gait while the individual is wearing the exoskeleton, but we do not see significant changes without wearing the device. Furthermore, RAGT benefits the cerebral palsy population because it allows them to be physically active and maintain their physical performance to 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.

The challenge to using RAGT is that for an individual to experience the immediate benefits of the technology, they need to wear the device. Most devices are fixed to an installation within a hospital or clinical setting. However, fixed exoskeletons can still be beneficial in a clinical setting for the prevention of comorbidities and to help individuals with cerebral palsy to remain physically active, which can help improve the overall quality of life. Furthermore, there has been the development of mobile exoskeletons such as the HAL, but it is still in the experimental phase and not available for regular use in a clinical setting. Another challenge to RAGT is that the exoskeleton can cause increased energy expenditure among individuals with cerebral palsy, which can be because the individual is not accustomed to autonomous locomotion. Some strategies can be implemented to avoid fatigue during RAGT, such as decreasing gait speed, taking breaks, and timing their rehabilitation regarding medication or other activities the individual has during their day.

See the below for additional information on Robotic Rehabilitation:

Robotic Rehabilitation for the Lower Extremity

Outcome

Following the initial consult, the physiotherapy team continued to see Blake 2 times a week for 6 weeks to continue to decrease 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 2o minutes with decreased pain and is now attending school 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.

Blake was approved for accommodation …..

Talk about whether she kept up on his activities or not

Objective Findings/Outcome Measures at Discharge

AROM:

MMT:

Tone:

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

VAS:

	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: 630 m

PEDI-CAT: Daily Activities = 83, Mobility = 81, Social/Cognition = 89

Her discharge plan includes keeping up with her HEP for 2-3 additional months, education, and information for additional referrals. She has been referred for OT, massage therapy, and to see a psychologist.

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 a 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