Case Study: Spastic Cerebral Palsy

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Managed in Clinical Setting: Rehabilitation in Physiotherapy Department

During my practice, I worked with a 13-year-old girl diagnosed with spastic cerebral palsy (CP), presenting with bilateral spasticity affecting both the upper and lower limbs. This was an ongoing case, with the patient attending regular physiotherapy sessions for several months. Although the case details were limited, the focus was on improving mobility, managing spasticity, and enhancing the girl’s overall functional abilities.

Presentation and Common Complaints:

The child presented with the following clinical features:

• Spasticity: Most evident in the lower limbs (particularly in the calf muscles and hamstrings), limiting her ability to walk with proper gait mechanics.

• Limited range of motion (ROM) in both upper and lower limbs, particularly in the ankle and knee joints.

• Functional Impairments: Difficulty with independent ambulation, walking with an abnormal gait pattern, and challenges in performing daily activities such as climbing stairs or sitting/standing from the floor.

• Muscle Weakness: Weakness in the upper limb (especially in the shoulder and hand muscles), affecting fine motor tasks.

• Postural Control Issues: Difficulty maintaining an upright posture due to trunk weakness and spasticity in the lower limbs.

• Psychosocial Factors: The child appeared motivated to participate in therapy, though there were occasional frustrations related to limitations in movement and strength.

Assessment:

On initial assessment, I observed the following:

• Tone: Hypertonia (spasticity) was present in both the upper and lower limbs, with significant tightness in the hip adductors, hamstrings, and calf muscles.

• Range of Motion: Limited dorsiflexion, knee flexion, and hip abduction. Passive range of motion (PROM) showed resistance due to muscle tightness.

• Strength: Reduced strength in the hip extensors, quadriceps, and ankle dorsiflexors.

• Posture and Gait: Abnormal gait with scissoring in the lower limbs and difficulty with heel strike and toe clearance during walking. The patient was able to walk with the assistance of a walker, but walking was slow and effortful.

• Balance: Impaired dynamic balance, especially when transitioning from sitting to standing.

Treatment Approach:

The primary goal of the physiotherapy sessions was to improve mobility, reduce spasticity, and increase functional independence. I used a combination of stretching, strengthening, and functional exercises in each session. Key treatment strategies included:

1. Stretching for Spasticity Management:

  • Focused on lower limb stretches (calf, hamstring, hip flexors) to reduce tightness and improve flexibility.
  • Hip adductor stretches and knee extension stretches were essential in addressing the spasticity that limited her gait and standing posture.
  • Gentle ankle dorsiflexion stretches to improve range of motion, especially for better gait mechanics and ankle control.

2. Strengthening Exercises:

  • Hip abductor and extensor strengthening to improve pelvis and trunk control, which would enhance posture and balance.
  • Quadriceps strengthening through closed-chain exercises like squats and step-ups to improve stability during standing and walking.
  • Upper limb strengthening, focusing on shoulder and forearm muscles, to improve fine motor tasks like grasping and reaching.
  • Core strengthening to improve trunk stability, using exercises like pelvic tilts, bridging, and seated trunk rotations.

3. Functional Gait and Balance Training:

  • Walking with support: The patient practiced walking with a walker, focusing on improving step length, heel strike, and toe clearance. We worked on proper weight shift and control of the lower limbs.
  • Balance exercises using balance boards and standing with support to help improve static and dynamic balance. This work was gradually progressed to weight-shifting activities to enhance trunk control.
  • Gait training: I incorporated walking drills where she was encouraged to take small steps, maintain a steady rhythm, and work on hip and knee coordination. Additionally, we used visual and verbal cues to guide her during walking tasks.

4. Adaptive Equipment and Postural Training:

  • Occasionally used assistive devices, such as knee orthoses to maintain knee extension and AFOs (ankle-foot orthoses) to provide ankle stability during weight-bearing activities.
  • Postural training to encourage upright sitting and standing posture, using verbal cues and physical guidance as needed to maintain a neutral spine.

5. Parent Involvement and Education:

  • Educated the parents on home stretching routines and positioning techniques to manage spasticity outside the clinic.
  • Provided strategies to promote functional independence in daily activities like self-care, dressing, and sitting-to-stand transitions.

Outcome:

Over the course of treatment, gradual but notable progress was observed. Although the child’s progress was slow, consistent efforts led to improvements in various areas:

• Functional Gait: With continued therapy, the child’s gait became more coordinated. While she still used a walker, her walking speed increased, and she was able to walk with more confidence.

• Spasticity Reduction: Through regular stretching, there was a noticeable reduction in muscle tightness, particularly in the hamstrings and calf muscles, allowing for better knee and ankle control.

• Strength Improvements: Significant improvements in muscle strength, particularly in the hip abductors, quadriceps, and core muscles, led to better postural control and an increased ability to perform daily activities with minimal assistance.

• Balance: Dynamic balance improved, and the patient was able to transition from sitting to standing more easily with less support.

• Emotional and Psychological Progress: The patient became more motivated, enjoying the sessions and showing increasing confidence in her ability to perform functional tasks.

While the rehabilitation process was ongoing and progress was gradual, both the child and her family were satisfied with the improvement in her functional independence and mobility.


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