Spastic diplegia in a patient with Cerebral Palsy

Author: Alessio Liberati

 

Cerebral Palsy (CP) in infancy includes a group of permanent developmental movement and posture disorders resulting from brain damage.
Brain injury can occur before, during, or shortly after birth (1,2,3). The adjective "permanent" excludes transient disorders but includes variable clinical manifestations that can improve or worsen the condition.

ANAMNESIS AND OBSERVATIONAL ASSESSMENT

Patient with CP, 22 years old.
The following characteristics emerge from a first observation:

Walking

  • without the use of aids
  • with skimming load on the left 
  • foot support with poor fragmentation 
  • slight flexion of the knees 
  • slight difficulty in controlling the gait pattern 
  • sometimes staggering step 
  • tendency not to raise the foot completely during the forward progression phase 
  • greater difficulty in dealing with downhill stretches and stairs
  • gait influenced by frequent pain of varying intensity, which is why the patient prefers to have a person close by when walking in case of need.

Posture and postural steps 

  • moderate safety during performance.

Manipulation

  • good upper limb mobility 
  • good fine motor skills of the fingers, because of his/her guitar passion.

Daily life

She can carry out most of the activities independently. As for those that require greater physical effort (such as maintaining an erect position for prolonged time) he prefers to be assisted. Probably also due to some difficulties in maintaining balance for a prolonged time because of frequent small imbalances on the right and left.

PRE-TREATMENT INSTRUMENTAL EVALUATION

Moreover, during the first evaluation, some objective analysis tests are carried out with the baiobit system.

Cervical test: movement evaluation on the three planes.

Results

  • limited extension
  • limited lateral flexion below the normal values • bending to the limit of the reference values.

Walk test: analysis of spatio-temporal parameters, gait phases and pelvis angles.

Results

  • extremely low walking speed
  • reduced cadence
  • quite low Harmonic Ratio (HR) index, which shows a not very fluid walk.

By analyzing the pelvis movements, a marked attitude in front tilt and a high walking rotation also emerged.

Trunk test: movements assessment on the three planes.

Results: acceptable range of motion compared to reference normal values.


REHABILITATION PROGRAM

A rehabilitation process is undertaken with a frequency of 2 sessions per week for a total of 5 weeks.

Two main types of treatment are planned within the rehabilitation process:

  • fascial manipulation treatment with the aim of improving the range of joint mobility where there are limitations 
  • neuromotor exercises and application of neuromuscular taping to support the patient in improving her adaptive strategies during walking to increase functionality and safety.

RESULTS

At the end of the rehabilitation process, a re-evaluation was carried out through the tests performed with baiobit system, to assess the effectiveness of the undertaken path and to show the patient the progress.

Post Treatment Instrumental Evaluation

Cervical test

Comparing the initial evaluation (TO) with the final one (T1) it can be noted:

  • improved extension
  • improved head flexion
  • improved angular velocity in left and right head bending which, even if it didn't improve the ROM, could indicate an increase in confidence with this movement.
INITIAL EVALUATIONFINAL EVALUATION


Walk test

Comparing the pre- and post-rehabilitation walk tests, it emerges:

  • improved walking speed
  • increased gait cycle cadence
  • improved HR, highlighting an improved walking fluency
  • improved WR index, highlighting an improved stride length and cadence ratio
  • increased stride length.


IMPROVED SPEED (RED) AND CADENCE (BLUE) PERCENTAGEIMPROVED SYMMETRY (RED) AND HARMONIC RATIO (BLUE) PERCENTAGEIMPROVED WALKING RATIO INDEX (BLUE) PERCENTAGE

The gait cycle phases assessment also shows the following progress:

  • the left and right support phases decrease compared to T0 thus returning to the normal range (norm.55,57-65.01)
  • the first left and right Double Support phases decrease compared to the initial evaluation, returning to the normal range (norm.6,24-12,67)
  • the 2nd right and left double support phases decrease after the treatment tending to normalize (34.99-44.43)
  • the single left and right support phases tend to increase compared to T0 returning to the normal range (norm 34.03-44.33)
  • the left and right swing phases increase compared to T0 returning to the normal range (34.99-44.43).
IMPROVED LEFT (RED) AND RIGHT (BLUE) SUPPORT PHASE PERCENTAGEIMPROVED LEFT (RED) AND RIGHT (BLUE) SWING PHASE PERCENTAGE


Finally, the analysis of pelvic movements also shows an improvement: 

  • reduction of oscillations in the sagittal plane
  • reduction of oscillations in the horizontal plane.
INITIAL EVALUATIONFINAL EVALUATION




Trunk Test

Comparing the initial evaluation (TO) with the final one (T1) it can be noted:

  • improved left rotation
  • improved trunk flexion 
  • improved lateral inclination of the trunk to the left.
INITIAL EVALUATIONFINAL EVALUATION


BIBLIOGRAPHY

  1. Bax, M., Goldstein, M., Rosenbaum, P., Leviton, A., Paneth, N., Dan, B., ... & Damiano, D. (2005). Proposed definition and classification of cerebral palsy, April 2005. Developmental medicine and child neurology, 47(8), 571-576. 

  1. Mutch, L., Alberman, E., Hagberg, B., Kodama, K., & Perat, M. V. (1992). Cerebral palsy epidemiology: where are we now and where are we going?. Developmental Medicine & Child Neurology, 34(6), 547-551.

  1. Bax, M. C. (1964). Terminology and classification of cerebral palsy. Developmental Medicine & Child Neurology, 6(3), 295-297.

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