Cerebral Palsy - Case study.pptx

A 1-year old case of infantile spastic cerbral palsy.

1. CASE PRESENTATION HETSHREE BHAVSAR MPT IN NEUROLOGICAL CONDITIONS

2. DEMOGRAPHIC DETAILS Name: Master. Ved Rathod Age: 1 year Gender: Male Date of Delivery: 7/01/2020 Birth weight: 3.2 kg Birth Head circumference: Small (figure not mentioned) Birth Height: Not mentioned and not known Present height: 77cm Present weight: 7.7 kg Present Head circumference: 47cm Date of examination: 6/1/2021 to 30/1/2021

3. CHIEF COMPLAINTS FOR CHILD: NOT RELEVANT FOR MOTHER: The mother is having complaints that her child is not able to stand and walk independently even after being 1 year old. He is not talking. Child is unable to crawl and not using his left hand and arm for bimanual tasks in terms of playing.

4. HISTORY – ANTENATAL HISTORY Mother underwent regular antenatal checkups at an interval of 3 months. She was on regular iron, calcium and folic acid supplementation in terms of tablets. Her diet was proper and healthy as told by her. Fetal movements were experienced from approximately five months and were progressively increased. Negative history of fever, rash, TORCH infections, gestational diabetes and HTN. No other complications experienced during gestation and was physically active.

5. NATAL HISTORY Even after 40 weeks of gestation, labor pain was not experienced so was taken to Asarva civil Hospital, Ahmedabad for check-up and where labor was induced by giving oxytoxin injection. Even after giving oxytoxin full term normal vaginal delivery was not possible as the mother was extremely tired and unable to push even after doing episiotomy. So l ower segment cesarean section was done. The presentation of fetus is not known or mentioned. LSCS resulted into obstructed delivery with meconium stained liquor. He did not cried immediately after birth. He encountered birth asphyxia and was immediately shifted to NICU for post resuscitative care. APGAR score is not mentioned.

6. NATAL HISTORY He was put on oxygen but was not maintaining saturation(how much is not mentioned) so he was put on ventilator care for 30 hours (mode and route not mentioned in file and not known) and 2 doses of anti-epileptic drugs were given( name not mentioned) due to convulsive episodes after 6 hours in NICU. The child was diagnosed with hypoxic ischemic encephalopathy grade 2 with meconium aspiration syndrome with metabolic disorder(?) , macrophage activation syndrome(?) And periventricular leucomalacia (?). After 30 hours of venticare , he was found stable and shifted to oxygen support and was able to maintain saturation. He was in NICU for 10 days, where on 7 th day he developed signs of meningeal irritation and so lumbar puncture was done.?????? (may be because of increased ventricular pressure)

7. NATAL HISTORY He was simultaneously treated with antibiotics and steroids. He was found clinically better, seizure free for 50 hours so gradually AED were tapered. After that was shifted to general ward for 15 days and was stable vitally and clinically, so discharge was given. Positive history of fever, seizure and congenital deformity in left foot. Negative history of jaundice or any other infection. Mother was explained breast feeding positions (avoid excessive head down), burping, vaccination and eye care. Drugs that were given at discharge includes Syp . Gardenal (anti- convulsant ), Syp . Hemesi (iron and zinc), vit b12, vit d3 and Syp . Calcium. On examination at discharge, patient was awake, vitally stable, BLAE clear, no murmur, hypertonia in left lower limb and left upper limb and small head. Parents were advised for screening of CP and regular physiotherapy.

8. POST-NATAL HISTORY Since discharge the child’s PT w as started at mahipatram roopram ashram. At 1 month of follow up, child has gained 120 gram of weight and was having fever, difficulty in breathing, refusal to feed, lethargy, abdominal distention and was medically treated. At the end of 3 months brainstem evoked response audiometry and CT brain was done and NAD. Since then he is coming for regular physiotherapy after the covid unlock. At present on no medication. All reflexes have been integrated except Babinski and is able to roll and sit independently, supported standing is achieved with mild support, he recognizes mother and family members and social smile is present.

9. POST-NATAL HISTORY Modified shoes were made as instructed by dr. nikunj of MRA at 7 months, but now they are not fitting and new shoes are not made yet. He encounters regular acute bronchitis which is treated by giving nebulizer with budecort (anti- asthamatic steroid) drops when actually needed.????

10. PROVISIONAL DIAGNOSIS ACUTE MENINGITIS ( complications causes motor and developmental deficits) BRACHIAL PLEXSUS INJURY : OBSTRUCTED LABOUR, SHOULDER DYSTOCIA; BUT HYPERTONICITY PRESENT IN UL. FOOT DEFORMITY: ABNORMAL POSITIONING IN WOMB.

11. FAMILY HISTORY Father’s age: 34 years Mother’s age: 29 years No. of children: 2 Ved : 1 year Diya: 5 years ( she is normal and undergoing normal schooling) No history of abortions and live birth deaths No history of similar complaints in family. Consanguinity (cousin marriage) – No Socio-economic status: Low to middle class family according to kuppuswamy scale (score: 13).

12. DEVELOPMENT HISTORY- GROSS MOTOR Head control (6 months) Rolling supine to side lying (7.5 months) Rolling supine to prone and prone to supine (not achieved) Sitting with support (8 months) Sitting without support (9 months) Pull self to stand (not achieved) Standing with support (11 months) Standing without support ( not achieved) Walking with support (not achieved) Walking without support (not achieved) Climb stairs ( not relevant)(occurs at 2-3 years)

13. FINE MOTOR RIGHT LEFT VOLUNTARY GRASP (6 MONTHS) ACHIEVED REACH ( 8 MONTHS) ACHIEVED PINCER GRASP (1 YEAR) ACHIEVED ACHIEVED

14. PERSONAL SOCIAL Social smile – 5 months Recognizes mother – 2 to 3 months Stranger anxiety – 5 to 6 months COMMUNICATION Cooing Crying ( monosyllables and disyllables use not present yet)

15. ON OBSERVATION GENERAL: Child is alert, playful and non-irritable Built : Mesomorphic 7.7 kg weight Facial appearance: Red cheeks and symmetrical Skin color: Light brown

16. POSTURE SUPINE: Head in midline and turning to both sides Visual tracking present Upper limbs: able to bring to midline only right not left Manipulation skills only with right hands Movement of lower limbs present, minimal for left foot

17. POSTURE PRONE: Able to turn head to side in prone Able to sustain head lift posture in prone and play Not able to achieve prone on forearms because of left limb hyper tonicity Able to reach for toys with right hand only

18. POSTURE SITTING: Sit on floor independently Sit on stool independently with center of mass within base of support

19. POSTURE TRANSITIONS: Supine to side lying (only from right side) Side lying to prone(only from right side) Supine to sit (with assistance) Sit to stand and walking (with assistance) Crawling – not able to do

20. ON EXAMINATION HIGHER CORTICAL FUNCTIONS: Child is fully alert and conscious Recognizes family members Give response to play activities Follow simple commands like dancing, giving and taking things , side flexing head and neck in terms of saying hi-hello Can express needs through gestures mostly understandable by mother Is aware of surrounding that are familiar (home and clinic)

21. ON EXAMINATION CRANIAL NERVE EXAMINATION: 2: blink reflex ( b/l positive) 3,4,6 : able to follow eyes with moving object, either toy or phone 5: rooting, sucking reflex (integrated), clenching of teeth when irritated 7: b/l facial symmetry present while laughing or crying, nasolabial fold, wrinkling forehead 8: eyes follow direct of sound in terms of someone calling , music, moving toy and moving phone. Startle response: present 9,10: gag reflex- present, swallowing present, coordinates sucking present 12: symmetry and tone of tongue NAD ,b/l same

22. ON EXAMINATION SENSORY EXAMINATION: Awareness or response by doing eyeball movements, turns head towards side of touch, sound, phone, pain, moving object, etc.

23. NEUROMUSCULAR EXAMINATION : MUSCLE TONE (MAS): RIGHT SIDE AND TRUNK MUSCLES TONE : ALL NORMAL Left shoulder flexors 2 extensors IR ER 1+ Abductors 2 Left elbow flexors 2 extensors Wrist flexors 1 extensors Finger flexors extensors 1

24. NEUROMUSCULAR EXAMINATION : MUSCLE TONE (MAS): Left Hip flexors 2 extensors IR ER 1+ Abductors 2 Left knee flexors 2 extensors Foot D. flexors P. extensors can’t comment Invertors Evertors

25. NEUROMUSCULAR REFLEXES SUPERFICIAL REFLEXES: Babinski b/l positive: not integrated (2 years)(crawling, standing and reciprocal gait patterns) Abdominal: no reflex, in all four quadrants ( umn lesion) Corneal : b/l normal and symmetrical Ankle clonus : b/l not present Plantar grasp: b/l present(left weak) Palmar grasp: b/l present (left weak) DTR: KNEE R & L : 3+ BICEPS R & L : 3+

26. PRIMITIVE REFLEX GRADINGS –O’SULLIVAN : Absent 1 +: Tone changes: slight, transient with no movement of the extremities 2 +: Visible movement of the extremities 3 +: Exaggerated full movement of extremities 4 +: Pathologic. Obligatory and sustained movement, lasting for more than 30 seconds

27. AUTOMATIC REFLEXES MORO LANDAU’S GALLANT INTEGRATED WITH GRADE 2+ PARACHUTE STARTLE

28. SPINAL REFLEXES FLEXOR WITHDRAWAL EXTENSOR WITHDRAWAL CROSS EXTENSOR PALMAR GRASP PLANTAR GRASP INTEGRATED WITH SUCKING REFLEX GRADE 2+ ROOTING PRIMITIVE WALKING( STEPPING REFLEX)

29. BRAINSTEM LEVEL REFLEXES STNR ATNR TONIC LABYRINTHINE INTEGRATED WITH GRADE 2+ POSITIVE SUPORTING NEGAVTIVE SUPPORTING

30. MIDBRAIN REFLEXES OPTICAL RIGHTING NECK RIGHTING INTEGRATED WITH GRADE 2+ CORTICAL LEVEL EQUILIBRIUM REACTIONS: NOT INTEGRATED YET GRADE 3+

31. MUSCULOSKELETAL EXAMINATION REFERENCE ( O’SULLIVAN EDITION 6) ROM: ALL PROM OF RIGHT UL AND LL IS WITHIN NORMAL LIMITS AND ENDFEELS ARE ALSO NORMAL ALL AROM OF RIGHT UL AND LL WITHIN FUNCTIONAL LIMITS ALL PROM OF LEFT UL AND LL ARE NOT WITHIN NORMAL LIMITS AND ENDFEELS ARE NOT NORMAL ( A SOFT CAPSULAR END FEEL FELT AT SHOULDER, ELBOW, HIP AND KNEE, WRIST IS NORMAL, ANKLE IS HARD) ALL AROM OF LEFT UL AND LL ARE NOT WITHIN FUNCTIONAL LIMITS (WE CANNOT COMMENT ON MMT IN 1 YEAR CHILD: DEVELOPMENTAL MILESTONES AND REFLEXES ARE CONSIDERED)

32. MUSCULOSKELETAL EXAMINATION DEFORMITY AND CONTRACTURE: LEFT FOOT TALIPOEQUINOVALGUS (CONTRACTURE/CHRONIC TIGHTNESS) OF LEFT FOOT PLANTARFLEXORS (GASTROSOLEUS) AND EVERTORS (PERONEUS LONGUS AND BREVIS) Talocrural joint in plantarflexion (HINDFOOT) Subtalar and midtarsal joint in pronation and calcaneal abduction, DF and eversion; talus adduction and plantarflexion (MIDFOOT) FOREFOOT: Protective toes flexion

33. MUSCULOSKELETAL EXAMINATION LIMB LENGTH: TRUE: (ASIS TO MM) R(26CM) AND L(23CM) SEGMENTAL: ASIS TO LATERAL KNEE JOINT LINE MM R 13 CM 13CM L 13 CM 10CM 3 CM SHORTENING IN LEG DUE TO FOOT DEFORMITY REQUIRES SHOE MODIFICATION.

34. MUSCULOSKELTAL EXAMINATION LIMB GIRTH: NOT OBJECTIVELY MEASURED, APPROX. DIFFERENCE OF 0.5 TO 1CM NOT MORE. BUT BY OBERVATION; ARM: R>L FOREARM:R>L LEG:R>L THIGH:R>L

35. CARDIORESPIRATORY ASSESSMENT BREATHING PATTERN: MAINLY ABDOMINAL, ADBOMINAL EXAPANSION > THORACIC (THERE BY NOT SIGNIFICANT) CHEST SHAPE: PES EXCAVATUM ( FUNNEL SHAPE CHEST) BREATHING RATE: 30 BREATHS/MIN CHEST SYMMETRY: BY HAND METHOD UPPER, MIDDLE AND LOWER– B/L SYMMETRICAL FLARING OF RIBS : PRESENT (ON AUSCULTATION) B/L AIR ENTRY PRESENT AND EQUAL AT UPPER, MIDDLE AND LOWER LOBES. BREATHE SOUNDS: B/L LOWER LOBES : FINE CREPETITIONS (R>L)

36. CARDIORESPIRATORY ASSESSMENT OBSERVATION : COLOR: NORMAL EDEMA: NOT PRESENT CLUBBING OF DIGITS: NOT PRESENT ACCESSORY MUSCLE USE : NOT SIGNIFICANT ACCEPT MORE USE OF ABDOMINALS RATIO OF I:E: 1:1.5

37. CARDIORESPIRATORY ASSESSMENT PALPATION: SYMMETRY OF CHEST MOVEMENT: B/L SYMMETRICAL AT U,M AND L LOBES. TVF: NORMAL MUFFLES VIBRATIONS HEARD WHEN COOING AND CRYING IN ALL IC SPACES. CHEST WALL PAIN/TENDERNESS: NOT PRESENT TRACHEAL DEVIATION: NOT PRESENT(TRAIL SIGN) PERCUSSION: RESONANT AT B/L ALL IC SPACES PARADOXICAL BREATHING : NOT PRESENT

38. CARDIORESPIRATORY ASSESSMENT EXAMINATION: CHEST EXPANSION: INCH TAPE: AXILLA LEVEL: 0.5 CM NIPPLE LEVEL: 1 CM XIPHISTERNUM LEVEL: 0.5 CM VOICE SOUNDS: EGOPHANY- WHEN COOING NORMAL MUFFLES VOICE CAN BE HEARD AT ALL IC SPACES BRONCHOPHANY: SAME AS ABOVE WHISPERED PECTORILOQUY: NOT RELEVANT APEX BEAT: LOCATED AT 5 TH INTERCOSTAL SPACE AT MID-CLAVICULAR LINE

39. VITAL SIGNS BLOOD PRESSURE: NOT MEASURED TEMPRATURE: AFEBRILE HEART RATE: 145 BEATS /MIN RESPIRATORY RATE: 32 BREATHS/MIN

40. OROMOTOR ASSESSMENT TONGUE MUSCLE TONE: B/L NORMAL (BY OBSERVATION) PALATE: NORMAL NO ARCHING TONGUE: SHAPE, TONE AND POSITION (NORMAL) MOUTH CLOSURE : PRESENT DROOLING OF SALIVA: OCCASIOANLLY CHEWING OF FOOD AND SWALLOWING PRESENT: ROTI, DAAL, RICE ( Can’t comment on cognitive and intellectual abilities )

41. SCALES GMFCS SCORE: BEFORE 2 ND BIRTHDAY LEVEL 2 INFANT MAINTAIN FLOOR SITTING WHEN THE LOW BACK IS SUPPORTED, INFANTS ROLL AND CREEP FORWARD ON THEIR STOMACH. INFANT NEUROLOGICAL INTERNATIONAL BATTERY( INFANIB): SPASTICITY-10 VESTIBULAR FUNCTION-12 HEAD AND TRUNK-8 FRENCH ANGLES- 12 TOTAL- 48/100

42. INVESTIGATIONS BEFORE 1 YEAR AT BIRTH: CHEST XRAY: NAD, FLARING OF RIBS USG ABDOMEN: NAD MRI BRAIN: B/L PERIVENTRICULAR AND SUBCORTICAL CEREBRAL WHITE MATTER PROMINENT. B/L PROMINENT CORTICAL SULCI. AREAS OF RESTRICTED DIFFUSION IN B/L DEEP PERIEVNTRICULR WHITE MATTER, INTERNAL CAPSULE AND CORPUS CALLOSUM. PERIVENTRICULAR LEUCOMALACIA CT BRAIN (BEFORE 2 MONTHS); NAD AS TOLD BY CONCERNED DOCTOR AND MRA THERAPIST

43. INFANTILE LEFT HEMIPARETIC SPASTIC CEREBRAL PALSY DIAGNOSIS

44. PROBLEM LIST ( AS INFORMED BY MOTHER) CHILD UNABLE TO USE LEFT UPPER LIMB UNALBE TO CRAWL, STAND AND WALK INDEPENDENTLY DEFORMITY OF LEFT FOOT OCCASIONAL COUGH

45. GOALS SHORT TERM TO MAKE HIM USE HIS LEFT UL TO ITS MAXIMUM FUNCTION CORRECT LEFT FOOT DEFORMITY TO THE MAXIMUM POSSIBLE TO MAKE HIM ACHIEVE CRAWLING, STANDING AND WALKING INDEPENDENTLY TO REDUCE CHEST SECRETIONS AND IMPROVE CHEST MOBILITY; TO IMPROVE LUNG FUNCTIONS

46. GOALS LONG TERM IF FOOT DEFORMITY NOT GET COMPLETELY CORECTED, NEW MODIFIED SHOES TO BE MADE. TO IMPROVE HIS MAXIMUM FUNCTIONAL MOBILITY.

47. ICF HEALTH CONDITION: CEREBRAL PALSY ( 1 YEAR) BODY STRUCTURE AND FUNCTION: HYPERTONICITY IN LEFT UL AND LL TALIPOEQUINOVALGUS IN LEFT FOOT DELAYED MILESTONES UNABLE TO STAND AND WALK INDEPENDENTLY

48. ICF ACTIVITY LIMITATIONS: STANDING WITHOUT ASSISTANCE WALKING WITHOUT ASSISTANCE MOBILITY CRAWLING DIFFICULTY IN OBJECT GRASPING, MANIPULATION WITH LEFT HAND AND UL

49. ICF PARTICIPATION RESTRICTIONS: COMMUNICATION CANNOT PLAY WITH PEERS SOCIAL COMMUNICATION INVOLVEMENT IN HOME LIFE EDUCATION ENVIRONMENTAL FACTORS: PHYSICAL SUPPORT NEEDED ALWAYS IN MOBILITY AND EATING MIGHT NEED USE OF ASSISTIVE DEVICE IN FUTURE OR A MODIFIED SHOE PERSONAL FACTORS: NOT EXPLORED (AGE, COGNITIVE FUNCTION, CONFIDENCE, MOTIVATION, PERSONALITY)

50. PHYSCIAL AND FUNCTIONAL DIAGNOSIS STRUCTURAL IMPAIRMENT FUNCTIONAL IMPAIRMENT HYPERTONICITY OF LEFT UL OBJECT MANIPULATION, GRASPING AND BIMANUAL TASK,CRAWLING HYPERTONICITY IN LEFT LL CRAWLING STANDING WALKING PLAYING CONRACTURE IN LEFT FOOT STANDING WALKING DELAYED MILESTONES COMMUNICATION EDUCATION EATING

51. PHYSIOTHERAPY MANAGEMENT 1 ST WEEK (6/1/21 TO 9/1/21) SUPINE : KNEE FLEX/EXT AND CYCLING (PASSIVE) (*10) HIP FLEX/EXT (PASSIVE)(*10) STATIC STRETCHING OF LEFT PFs (3* 20 SEC HOLD) ACTIVE ASSISTED HIP BRIDGING (*10) LEFT UL SHOULDER FLX,EXT,ABD, ELBOW FLEX,EXT PROM (*10) ACTIVE ASSITED SIT TO STAND (*10) SUPPORTED STANDING, WEIGHT BEARING ON LEFT KNEE AND LEFT FOOT (*5 MINS) PRONE – QUADRAPUD AND CRAWLING (ACTIVE-ASSISTED)

52. PHYSIOTHERAPY MANAGEMENT 2 ND WEEK ( 13/1/21) SAME AS ABOVE ASSISTED WALKING SUPPORTED STANDING WITH MILD SUPPORT AND INTERMITTENT RELEASE CIMT FOR 10-15 MINUTES , EACH SESSION DIVIDED INTO PARTS OF 2-3 MINUTES , INSTRUCTED MOTHER TO DO IT AT HOME.

53. PHYSIOTHERAPY MANAGEMENT 3 RD WEEK (20/1/21 TO 23/1/21) SAME AS ABOVE SENSORY INTEGRATION INTERMS OF SLOW BRUSHING IN LEFT UL AND FOOT FOR 10-15 MINUTES. WAS OPENING LEFT WRIST AND INITIATING GRASPING BUT UNABLE TO HOLD BECAUSE OF WEAKNESS. ( INSTRUCTED MOTHER TO DO IT AT HOME.) WALKING ON TREADMILL AND WAS INITIATING STEPS BY SELF.(THERAPIST SUPPORTED AND ASSISTED)

54. PHYSIOTHERAPY MANAGEMENT 4 TH WEEK (27/1/21 TO 30/1/21) SAME AS ABOVE MOTHER TAUGHT ABOUT GIVING POSTURAL DRAINAGE POSITION AFTER NEBULIZER GIVEN. (LOWER LOBES PD POSITIONS) BREATHING EXERCISES TAUGHT IN TERMS OF BLOWING AIR OUT WITH PURSED LIPS, MAKING BUBBLES WITH WATER VIA STRAW, INFLATING BALLOON AND MAKING FOG ON MIRROR. ( MAKE HIM DO WHEN IN FUTURE POSSIBLE) LUNGES WITH BOLSTER, B/W TWO LEGS (*10)

55. THANK YOU