Young Adult Cerebral Palsy Fictional Case Study

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 (Whitney et al., 2019). CP can lead to a variety of neurological and neuromuscular alterations which prevent optimal motor function capacity and mechanical loading (Whitney et al., 2019). CP is a non-progressive disorder of posture and movement pathology (Bromham et al., 2019). It is typically associated with an impairment of the developing fetal brain or an infant brain, typically up till 2 years old (Bromham et al., 2019). This is typically the age where these malformations occur as the brain is rapidly growing during this time which increases the risk for damage (Bromham et al., 2019). The prevalence of CP is approximately 2-3 individuals per every 1000, most affecting children but continues into adulthood (Bromham et al., 2019).

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 (Bromham et al., 2019). Spastic diplegia affects 35% of children diagnosed with CP, making it one of the most common types of CP (Patel et al., 2020). 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 (Patel et al., 2020). 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 (Bromham et al., 2019). 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 (Bromham et al., 2019).

Gross Motor Function Classification System (GMFCS)

(Bromham et al., 2019)

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

See the link below for additional Information on the GMFCS:

Gross Motor Function Classification System - Expanded and Revised (GMFCS-ER)

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 (Bromham et al., 2019). Adults with CP have a wide range of abilities from full independence to 24 care needed (Bromham et al., 2019). 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 (Bromham et al., 2019). 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 (Whitney et al., 2019). Some common comorbidities that have been identified in adults with CP are hypertension, depression, epilepsy, osteoarthritis, and many more (Whitney & Kamdar, 2021). 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 (Bromham et al., 2019).

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 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

Analysis Statement/Clinical Impression

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 mins
• 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 1 month
• Ambulate for 20 minutes consecutively with a 4/10 pain or less in 1 month
• 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 (Krautwurst et al., 2016).
• 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 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 (Singleton et al., 2019). 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) (Prosser et al., 2012). 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