CP Spastic Diplegia

Practice Case: CP Spastic Diplegia

Cheryl R. Peralta, MSPT, MHPEd

Brainstorming: What do you know about the case?

Write down anything and everything that you know about Cerebral Palsy Spastic Diplegia. Discuss with your group mates how each of the items written here are related to each other and, as a whole, explain the nature of Cerebral Palsy.

Diagnosis: CP Spastic Diplegia Informant: Mother This is a case of J.J., a 5 11/12 y/o , born at full term to a 27y/o G3P2 (2 -0-0-2) mother via normal delivery, cephalic presentation at East Avenue Medical Center assisted by a doctor. Maternal Hx: unremarkable Prenatal Hx: Mother had regular monthly prenatal check-ups & took unrecalled vitamins. She was not exposed to any radiation & was not infected by serious illnesses nor acquired trauma. At 2-3 months of gestation mother took Cytotech (4 tablets) d/t family problems. No bleeding or premature contractions occurred. Also stated she didnt tell her MD that she took Cytotech. Perinatal Hx: Mother underwent labor for 24 hours c no noted cx. States always has long labors in previous pregnancies. APGAR score was unrecalled but stated pt. was pinkish, cries and moves extremities. Both mother & pt. were D/C the day p.

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Post-natal Hx: When pt. was about 1 yr. old mother noticed pt. still cannot stand alone. Mother brought pt. to MD @ NCH. CT scan was requested but didnt continue d/t financial constraints. Pt. didnt have follow-up checkups. At 5 y/o, mother decided to have pt. checked @ PCMC (MD unrecalled) d/t pt. still unable to walk & to have brain checked. Pt. was then referred to rehab under Dr. Dungca d/t findings of GDD r/o muscular dystrophy; was requested to have EEG (results to follow) & was referred to PT eval & Mx to address walking & standing. Developmental Milestones: Skills Hold head Roll- over Transfer objects Sits alone Stands alone Walks alone S: > c/c: hindi siya makalakad ng mag-isa > caregivers goal: sana makalakad siya mag-isa O: VS> HR= 95bpm RR= 24cpm T= 37 C OI> Caregiver borne F/N, F/D Head Circumference: 53cm [+] Postural Deviations (see PA) [+] Gait Deviations (see GA) (+) Extension synergy (B) LE [] Facial Asymmetry [] Assistive Device [] Chest Deformity [] Eye Deformity [] Drooling [] Surgical Scars [] Attachments [] Orthotic Device [] Trophic Skin Changes [] LLD [] Atrophy [] Swelling Palpation> Normothermic on all 4s Normotonic on (B) UE Hypertonic on (B) LE [+] Contracture of (L) foot invertors [+] Tightness of (L) ankle PF [] Subluxation/ Dislocation on all 4s Behavior> cooperative [+] Meaningful eye contact >10secs (+) dual play behavior

(N) age 4 mos. 5-6 mos. 6 mos. 6-7 mos. 10-11 mos. 15 mos.

Age achievement 3 yrs. 1 yr. 7 mos. 2 yrs. Not yet achieved Not yet achieved

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CP Spastic Diplegia [+] Separation Anxiety G attention span G frustration tolerance G concentration span

PA> standing> anterior view> shoulder level > Pelvis level (B) hips IR & adducted > lateral view> (L) hips & knees flexed, (L) ankle in varus, foot Sensorimotor skills>

arch

ROM> All major jts of (B) UE/LE are WNL, actively & passively done, c N endfeels except: Joint Movement (L) ankle DF (L) hindfoot eversion PROM 0-5 0 (N) 0-20 0-15 Difference 25 15 Endfeel firm firm

FMT> can reach for ball placed in all directions overhead c 1.5 lbs AW in sitting position > can walk c min +1 assist on (B) hands for 36 steps Tone assessment> [+] Grade 1 spasticity on (B) LE

Sensory Perceptual Motor Skills> STD Vision: Threat Tracking Localization Tactile: Light touch Pain Pressure Audition: Localization Voice of mother Head turns towards mother Using PTs fingers PT pinches pt. PTs thumb Looks @ stimulus Withdraws Withdraws PTs hands ~ 1in away from pts face Orange ball Orange ball Blinks Head & eyes follows toy Head & eyes turns to toy Response

Reflexes> Pathologic Reflexes> [+] Babinski (B) feet > [+] Clonus (B) feet DTRs> (L)

++ ++ ++

++

Legend: 0: areflexia +: hyporeflexia ++: normoreflexia +++: hyperreflexia ++++: clonus

+++ ++++

+++ ++++

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GMS> N head control in sitting, pull-to-sit & sitting > N trunk control in roll-over, prone & sitting > N pelvic control in quadruped and kneeling > N sitting tolerance > N static/dynamic sitting balance > F pelvic control in standing > P static/dynamic standing balance > P standing tolerance ~10mins FMS> (+) RGCR on (B) hands > hand dominance ADLs>Feeding> hand-to-mouth pattern > able to drink from cup indep Dressing> indep in donning & doffing UE/LE garments s difficulty Mobility& transfers>Bunny hops from one place to another when no support is available indep in STS c (B) hands holding onto stable object GA> walks c min+1 assist on (B) hands & c scissoring gait c (L) ankle inversion on level surfaces ~ 15m > step length Stance Phase (R) (L) HS (-) (-) FF N N MS N N HO N TO N (-) Swing Phase PS (-) (-) MS N N TS

Guide Questions for the Written Report:

What findings point to the medical diagnosis? diagnosis?

Do all findings consistently support the

Differential Diagnosis:
Give other medical conditions that you may want to rule out in this case. Give at least one specific finding that will support the presence of each of these conditions.

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Continuation of Guide Questions for the Written Report:

Are there additional examination procedures that should have been done to confirm the diagnosis? What is your physical therapy diagnosis for this case? What is the prognosis of this patient? Which of these abnormal findings could be addressed by physical therapy intervention? Classify these findings as impairments, limitations of activity and participation restriction. Develop a diagram indicating the relationships (using arrows) of the different impairments, activity limitations and participation restrictions that you will address in the case. Which among the problems listed should take priority over the others? intervention scenario for the case. Explain your

Prioritization in Other Case Situations:

Enumerate the different classifications of Cerebral Palsy. Explain and/or cite examples on how problems and their prioritization will differ across these classifications.

Continuation of Guide Questions for the Written Report:

What functional outcomes do you expect from this patient? Translate these expected outcomes to long term goals. Remember to formulate rehabilitative and/or preventive goals. What skills or activities will be pre-requisites to achieving your functional outcomes? Formulate short-term goals for the top five problems in your list.

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Progressing Your Goals:

In diagram format, show how you will progress your STG from the first day of treatment up to discharge.

Continuation of Guide Questions for the Written Report:

Give five most important treatment procedures (aside from HEP and Patient Education activities) that you will use for this patient. Remember to include one treatment modality that will be most useful for this case. What will be the specific parameters you will use for each of the treatment procedure? How will you sequence the treatment procedures so that they are carried out in a logical and efficient manner?

Incorporating Evidence into Your Practice:

Find a journal article that discusses the effectiveness of any PT intervention that you can use for any of the problems related to CP Spastic Diplegia. Briefly describe the following: Objectives Methods Results Conclusions Relevance to CP Spastic Diplegia

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