Child With Disability Case

JR is a 3 year old boy, who was brought to the clinic by the mother because of stiffness when crying and tip toe walking. History revealed that patient was born via NSD, full term, to a 35 year old mother G1P1 (1001), with regular pre natal check-up with obstetrician. She had history of UTI during her last trimester but no bleeding. During the actual delivery, it was noted that the cord was coiled on the neck 3 times. APGAR score was 5 and birth weight was 2.5kg

On patients developmental history, mother noted:  Baby started to roll over at 6 months  Sat with support at 12 months  Pulls himself up to stand by 18 months Currently, he can walk without assistance. He can make simple sounds and continues to drool

• • • • • • • • •

Ambulatory with scissoring gait Poor balance Maintains high guard of upper extremities (+) Cortical thumb With good health control (+) drooling Good sitting balance (+) Tightness of both Achilles (+) Clonus

Cerebral Palsy

 Maternal

history of urinary tract infection (UTI) during the last trimester - Intrauterine exposure to maternal infection such as UTI is associated with a significant increase in the risk of cerebral palsy in normal birth weight infants  Cord coil and apgar score of 5  The

baby may have experienced hypoxia due to the cord coiled on the neck which may have been severe to enough to exceed the adaptive capacity of the fetus which in turn may have caused neurologic damage.

 Tip

toe walking - An affected child often walks on tip toes because of the increased tone  Ambulatory with scissoring gait - Scissoring gait is due to spasticity of hip adductors  (+) Clonus - Clonus may be demonstrated in the lower extremity by sudden dorsiflexion of the foot with knee partially flexed - Five to ten beats in a newborn is normal unless it is asymmetric - Spasticity results from lesion involving the upper motor neuron tracts and may be unilateral or bilateral

Delay in Developmental milestones - patients with cerebral palsy often are not at par with normal children their age and often retains their primitive reflexes  Gross motor function - J.R. started to roll over at 6 months (Normal: 2 – 4.5 months)



- Sat with support at 12 months (Normal: 7 months) - Pulls himself up to stand by 18 months (Normal: 10 – 14 months) - Can walk but needs assistance at 3 years old (Normal: 1 year old) Speech and Language - Can make simple sounds at 3 years old (Normal: 1.5 – 3 months)

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•

is a disorder of posture and movement that occurs secondary to damage to the immature brain before, during , or after birth. it is called a static encephalopathy because it represents a problem with brain structure or function.

 Once

an area of the brain is damaged, the damage does not spread to other areas of the brain, as occurs in a progressive neurologic disorder such as a brain tumor.  However, because the brain is connected to many different areas of the nervous system, the lack of function of the originally damaged areas may interfere with the ability of these other areas to function properly.

 CP

is characterized by decreased functional abilities, delayed motor development, and impaired muscle tone and movement patterns.  When damage occurs before birth or during the birth process, it is considered congenital cerebral palsy.  If the brain is damaged after birth, up to 3 years of age, it is considered to be acquired.

 Due

to cortex/pyramidal tract lesion  Characterized by  Spasciticity  hyperreflexia  Clonus  Babinski

reflex

Topographical Classification: Diplegia

Characteristics:  Bilateral spasticity of legs greater than in arms  First indication: infant drags legs upon crawling rather than using four limbed movement  Physical exams reveals spasticity in legs with brisk reflex, bilateral Babinski sign.

 Scissoring

posture of lower extremities when suspended by axillae  Scissoring gait (hips flexed and adducted, knees flexed with valgus, and ankles in equinus)  Delayed walking  Feet in equinovarus position and walks on tiptoes

 Scissoring

gait  Poor balance  Maintains high guard of upper extremities  (+) Tightness of both Achilles tendon  Ankle clonus

 All

fingers flexed with thumb under second to fifth fingers  Infants with corticospinal tract damage caused by hypoxic-ischemic insult

 Defined

as velocity dependent resistance to passive range of motion experienced by the examiner as increased muscle tone, caused by an increase in stretch reflex activity  Arises from injury to pyramidal tracts secondary to loss of inhibitory control on lower motor neurons

Grade

Description

0

No increase in muscle tone

1

Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of ROM when part is moved in flex or ext

1+

Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than ½ ) of ROM

2

More marked increase in muscle tone though most of the ROM, but affected part is easily moved

3

Considerable increase in muscle tone, passive movement difficult

4

Affected part rigid in flexion or extension

 Oral

Medications

 Benzodiazepenes

(GABA-A receptors)  Baclofen (GABA-B receptors)  Tizanidine (alpha-adrenergic receptors)  Dantrolene (calcium influx)

Side effects: drowsiness, dizziness, and weakness

Medication

Starting Dose

Maximum Dose

Common Effects

Relative Contraindications

Baclofen

5–10 mg tid

20 mg qid

Sedation, rare hepatotoxicity

Cognitive impairment

10 mg qid

Sedation

History of benzodiazepine or other substance abuse

12 mg tid

Sedation, hypotension, hepatotoxicity

Cognitive impairment

10 mg qid

Weakness, hepatotoxicity, occasional sedation

Liver disease

Diazepam

Tizanidine

Dantrolene

2 mg bid

2 mg Tid

25 mg daily

FDA approved only up to 80 mg/day, but many clinicians exceed this in patients who tolerate this medication well but do not respond to lower doses.

 Intramuscular  onset

botulinum toxin type A

at 24–72 hours after the injection  provides local relief of spasticity for 3 to 4 months  larger muscles require higher doses

 Intrathecal

baclofen pump

 for

intractable bilateral lower extremity spasticity  delivers the medication directly into the spinal fluid via a catheter  Orthopedic  after

surgery

failure of more conservative measures  e.g. tendon lengthening, tenotomy, or joint fusion

 To

prevent contracture  To temporarily reduce increased muscle tone  stretching exercises  passive range of motion

movements

 To

reduce the impact of spasticity on function

 Splinting

a spastic limb

 pre-fabricated  low temperature thermoplastic  plaster or fiberglass casts

 Physiotherapy  Occupational

therapy

 Bracing  Assistive

devices  Adaptive technology  Sports and recreation

http://www.global-help.org/publications/books/help_cphelp32management.pdf http://www.cerebral-palsy-help.com/injuries/ninds.html

 Help

child grow up to be a productive, independent individual  Provide education  Achieve independent mobility  Encourage

use of standers  Bring child to an erect position regardless of prognosis for walking

http://www.global-help.org/publications/books/help_cphelp32management.pdf http://www.cerebral-palsy-help.com/injuries/ninds.html

 Improve

mobility

 Teach

child to use his remaining potential  Teach child functional movement  Gain muscle strength  Prevent

deformity

 Decrease

spasticity  Improve joint alignment  Position

for sitting, transfers

http://www.global-help.org/publications/books/help_cphelp32management.pdf http://www.cerebral-palsy-help.com/injuries/ninds.html

 Educate

the parents

 To

set reasonable expectations  Do the exercises at home  Teach

daily living skills

 Have

the child participate in daily living activities

 Social

integration

 Provide

community and social support

http://www.global-help.org/publications/books/help_cphelp32management.pdf http://www.cerebral-palsy-help.com/injuries/ninds.html

 Nearly

all children with CP develop an abnormality of physical form or function  The need for assistive technology in this patient should be according to all the therapists involved with the child e.g., physiatrists, surgeon (if applicable), etc.

Braddom, Randall. Physical Medicine & Rehabilitation

 In

this 3 y/o kid, who would have been jumping, pedaling a tricycle & learning nursery rhymes, an assistive device aims to help him develop social and cognitive well-being by making him more interactive with his environment

Braddom, Randall. Physical Medicine & Rehabilitation

 Frequent

reevaluation of orthoses because children quickly outgrow them & can undergo skin breakdown if used improperly

Braddom, Randall. Physical Medicine & Rehabilitation

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–

Since this patient already developed the ability to walk but with assistance, a walker will help him move about his immediate environment To improve gait, decrease contracture & increase endurance

Baker, K.M. Rehabilitation Analysis of WalkerAssisted Gait in Spastic Diplegic Cerebral Palsy

– –

–

Patient has a (+) cortical thumbing WHO use leads to excellent positioning of small hands & even larger hands that do not have significant tone or malpositioning This can help with improving function so that a child can hold pencils, crayons and utensils better

Nelson, Maureen, M.D. Cerebral Palsy Equipments. http://www.disaboom.com/Health/CerebralPalsy/Core-Knowledge/Cerebral-Palsy-

References:  Behrman, R E et al. Nelson Textbook of Pediatrics 17th Edition. Elsevier Science. Copyright 2004. pp. 1978, 2024 – 2025.  http://www.originsofcerebralpalsy.com/09-asphyxia.html  Frontera: Essentials of Physical Medicine and Rehabilitation, 1st ed. 2002 Hanley and Belfus  Baker, K.M. Rehabilitation Analysis of Walker-Assisted Gait in Spastic Diplegic Cerebral Palsy Children. http://www.orec.org/resna2003.pdf  Nelson, Maureen, M.D. Cerebral Palsy Equipments. h ttp://www.disaboom.com/Health/Cerebral-Palsy/Core-Knowledge/Cere  Braddom, Randall. Physical Medicine & Rehabilitation  http://www.global-help.org/publications/books/help_cphelp32manage  http://www.cerebral-palsy-help.com/injuries/ninds.html