Cerebral palsy case presentation

spastic diplegia type of cerebral palsy (CP)

1. CASE PRESENTATION ON CEREBRAL PALSY Presented by- Dr. Jaishree(PT)

2. DEMOGRAPHIC DATA NAME- Master Yash AGE- 2 year and 6 month SEX- Male D.O.B-18.08.2019 D.O.A- 16.02.2021 INFORMANT-Mother

3. Growth Parameter Head circumference- 43cm Neck circumference- 41cm Limb length –True Lt. 36cm Rt. 36.4cm Apparent Lt. 37.9cm Rt. 37.2cm Chief complaint- Unable to sit without support , Unable to walk and stand since 1.5 years

4. PARENTAL HISTORY Details of marriage-18 year Age of mother during first delivery-22 year Family tree- DEATH AFTER BIRTH

5. Continued 1.History of illness in the family- No similar history 2.Any addictions- No history 3.H/o previous abortions- 2 nd child death after birth 4.H/o multiple pregnancies- No history present 5.Any other relevant details –no similar history

6. 2.PRENATAL HISTORY Pregnancy- Pregnancy confirmed at hospital by gynaecologist Antenatal check-up- 5 USG done during the gestational period Quickening- Felt at 4 month of gestation Malnutrition- No Hypoglycaemia- No Maternal infection-No

7. CONTINUED Maternal hypertension/diabetes/cardiovascular abnormality- No history E xposure to x-ray- No history Epilepsy jaundice/any infection- No relevant history A ny drugs taken pregnancy- Iron and folic acid intake started in 3 rd month of gestation

8. POSTNATAL HISTORY POSTNATAL HISTORY OF MOTHER ANY INFECTION - No history BREAST FED- Start after 2 days ,initially mother was not lactating ANY OTHER COMPLICATION- No history

9. POSTNATAL HISTORY OF CHILD Whether the infant was floppy /spastic- Spastic Head injury /trauma- No history Epilepsy- No history Fever/hydrocephalus- No history Neonatal jaundice - No history Hypoglycaemia- No history Age of child when disability was notice -Around 6 month

10. 3.PERINATAL HISTORY Nature of delivery- Lower segment caesarean section Prolonged labour/asphyxia- Birth asphyxia present Birth cry (p/a loudness) - Cried after 5 minutes of birth Birth weight- Around 2 kg Any complications during birth- No history Child presentation (breech/vertex)- Breech APGAR score- Not known

11. DEVELOPMENT MILESTONE GROSS MOTOR Neck holding –Not achieved Rolls over-Segmental rolling present, supine to prone Sits with support-Only with moderate support Sits without support-Not achieved Stand with support-Not achieved Not able to stand without support-Not achieved

12. FINE MOTOR Bidexterous reach present since 1 and 3 month Unidexterous reach –Not achieved Pincer grasp –Not achieved

13. SOCIAL MILESTONE Recognise mother- Since 1 year Stranger anxiety - Not observed Waves bye bye - Not achieved Social smile - Achieved since Handle spoon well- Not achieved

14. LANGUAGE COOS- After 1.5 years MONOSYLLABLES- Not achieved BISYLLABLES- Not achieved 2-3 WORD SENTENCE- Not achieved STORY TELLING- Not achieved

15. CRANIAL NERVE EXAMINATION First cranial nerve Normal Second cranial nerve Normal Third cranial nerve Abnormal Fourth cranial nerve Abnormal Fifth cranial nerve Abnormal Sixth cranial nerve Abnormal Seventh cranial nerve Normal Eighth cranial nerve Normal Ninth cranial nerve Normal Tenth cranial nerve Normal Eleventh cranial nerve Normal Twelfth cranial nerve Normal

16. SENSORY EXAMINATION SUPERFICIAL SENSATION- Not assessed DEEP SENSATION – Not assessed CORTICAL – Not assessed

17. REFLEXES Biceps Triceps Brachioradialis Patella Ankle Plantar reflex – Present Left Right 2+ 2+ 2+ 2+ 2+ 2+ 3+ 3+ 1+ 1+

18. Passive range of motion(In degree) Shoulder flexion 120-168 133-172 Hip flexion 0-87 0- 76 Shoulder extension 0-89 0-78 Hip extension 0- 15 0-18 Shoulder abduction 0-159 0-159 Hip abduction 0-42 0-42 Shoulder adduction 159-0 159-0 Hip adduction 0-15 0-23 Elbow flexion 0-120 0-135 Knee flexor 0-138 0-146 Elbow extension 124-0 135-0 Knee extensor 0- 30 0-34 Wrist flexion 0-60 0-81 Ankle plantarflexion 0-15 0-10 Wrist extension 0-60 0-77 Ankle dorsiflexion 0-31 0-25 LEFT RIGHT LEFT RIGHT

19. MUSCLE TONE (MAS GRADING) Hip flexors LEFT 1+ RIGHT 1 Hip extensor 1 1 Hip abductor 1+ 1 Hip adductor 1+ 1+ Knee flexor 1+ 1 Knee extensor 1 Ankle dorsiflexion 1 1 Ankle plantarflexion 1+ 1 Shoulder flexor Shoulder extensor 1 Elbow flexor Elbow extensor Wrist flexor Wrist extensor

20. OUTCOME MEASURE

21. SCORING GMFM-88 96 out of 264 GMFCS LEVEL V

22. PROBLEM LIST Development milestone delay Uncoordinated movement of upper limb and eye Tonic labyrinthine reflex (TLR) persist Hip abductors, Achilles tendon ,knee flexor and extensor tightness Unable to do functional activity – Independent walking , sitting, standing ,eating ,grooming ,personal hygiene

23. SHORT TERM GOALS Improve neck and body coordination Reduce spasticity Teach correct handling and sleeping strategies

24. Short term goals Prevent and improve range of motion by releasing tight muscles (Achilles tendon, calf muscle ,hamstring ,Tensor fasciae latae ,gluteus Medius and gluteus minimus ) Reduce the caregiver assistance( moderate to minimal assistance) Comprehension of word with meaning Improve grasping

25. LONG TERM GOALS Improve strength and range of lower limb Improve functional limitation of ambulation Independent self care activities ( eating, grooming , dressing, hygiene)

26. INTERVENTION Hydrocollator pack for 20 min Prolonged stretching of calf ,hamstring ,hip adductors ,hip abductors(10reps x 60 sec. hold x 1 set ) Soft tissue release -Achilles tendon release -5 reps,  5 days/week for 6 weeks. Functional reach activity at wall corner with pillow support for 20 min Effect of combining passive muscle stretching on spasticity and physical performance of children and adolescents with cerebral palsy. J Phys Ther Sci.  2016 Jan; 28(1): 7–13.Published online 2018 Jan 30.  doi :  10.1589/jpts.28.7

27. CONTINUED Vestibular stimulation exercises using Swiss ball:To and fro : 10 mins and spinning for 10 mins. Head lifting activity over the swiss ball in prone lying with auditory , tactile stimulus (10 mins . upward And side ways) Standing over the CP chair with neck ,trunk and lower limb support for 45 min Standing Programs to Promote Hip Flexibility in Children With Spastic Diplegic Cerebral Palsy. Pediatric Physical Therapy:  Fall 2015 - Volume 27 - Issue 3 - p 243-249 Effect of Swiss Ball on Balance in Children with Spastic Diplegia: A Case Study. ARC Journal of Pediatrics Volume 1, Issue 1, April-June 2020, PP 8-11

28. PROPOSED FOLLOW-UP Straddle roll activity with support for 10 min Throwing basketball with support for trunk and upper limb mobility -10 rep. Unidexterous functional activity for 10 min. Management of musculoskeletal condition –physical therapy for children ,Campbell's 5 th edition page no.236

29. HOME ADVICE Corner wall sitting with support ,in long sitting including functional activity - 20 min ,3 time a day Prone lying - Stimulate to rolling in supine Stretching of all the major muscle of lower limb as taught

30. THANK YOU