Journey of a child with spastic diplegic cerebral palsy from doldrums to hope

Abstract

This case study describes the physical therapy of a 9-year-old male child with spastic diplegic cerebral palsy with the aim to improve his gross motor function and social skills. The child had severe impairments across the full spectrum of developmental functions, especially affecting the gross motor and self-care functions at Stage V of gross motor function classification system (GMFCS) in spastic diplegic cerebral palsy. His body was completely stiff with marked asymmetrical spasticity in lower limbs, truncal dystonia, and chest deformity with cardio respiratory complications. The physical therapy was performed by giving sessions of Roods approach, sensory integration, and static weight-bearing exercise for a period of 9 months. Pre- and post-therapy evaluation of child was done using GMFCS. There was an improvement in the child with his social skills, transitional activities, activities of daily living, and gross motor skills, reaching to Stage IV with the 9 months physiotherapy intervention given by a neurological physical therapist.

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© 2015 Indian Journal of Cerebral Palsy | Published by Wolters Kluwer - Medknow
INTRODUCTION
Spastic diplegia is one of the most common clinical
subtypes of cerebral palsy.[1] Gross motor function
classification system (GMFCS) is a standardized
method to classify gross motor function in children
with cerebral palsy.[2] The system has five levels that are
based on differences in self‑initiated movements, with
particular emphasis on sitting, standing, and walking.[3]
Bartlett and Palisano (2000) emphasized to identify
factors contributing to change in basic motor
abilities of children with cerebral palsy, which can
be optimized to improve the long‑term outcomes
of intervention.
[4]
The aim of the present study
was to evaluate changes in the full spectrum of
developmental functions including gross motor
development and social skills.
CASE REPORT
The present case is presented to show the effect
of physical therapy on severely affected child
using GMFCS as measurement scale pre‑ and
post‑therapy. The patient was a 9‑year‑old boy with
spastic diplegia functioning at GMFCS Level V. As
per medical records provided by family members,
patient was born as full term baby with a birth
weight of 1500 g and hospitalized in the Neonatal
Intensive Care Unit (NICU) for 1 month as he was
diagnosed with meconium aspiration syndrome.
He required mechanical ventilation and was later
referred to the NICU follow‑up clinic. Child was
This case study describes the physical therapy of a 9‑year‑old male child with spasc diplegic cerebral palsy with the aim to improve his
gross motor funcon and social skills. The child had severe impairments across the full spectrum of developmental funcons, especially
aecng the gross motor and self‑care funcons at Stage V of gross motor funcon classicaon system (GMFCS) in spasc diplegic
cerebral palsy. His body was completely s with marked asymmetrical spascity in lower limbs, truncal dystonia, and chest deformity
with cardio respiratory complicaons. The physical therapy was performed by giving sessions of Roods approach, sensory integraon,
and stac weight‑bearing exercise for a period of 9 months. Pre‑ and post‑therapy evaluaon of child was done using GMFCS. There was
an improvement in the child with his social skills, transional acvies, acvies of daily living, and gross motor skills, reaching to Stage
IV with the 9 months physiotherapy intervenon given by a neurological physical therapist.
Key words: Cerebral palsy, diplegia, spascity
Journey of a child with spastic diplegic cerebral palsy from
doldrums to hope
ijcp_14_15R6
Divya Midha, Manisha Uttam, Megha Neb
Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar University, Mullana, Ambala,
Haryana, India
Access this article online
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Website:
www.ijcpjournal.org
DOI:
***
Address for correspondence: Dr. Divya Midha,
Maharishi Markandeshwar Institute of Physiotherapy and
Rehabilitation, Maharishi Markandeshwar University, Mullana,
Haryana, India.
E-mail: divyamidha.pt@gmail.com
ABSTRACT
Case RepoRt
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Midha, et al.: A spastic diplegic cerebral palsy child journey
Indian Journal of Cerebral Palsy | Jul-Dec 2015 | Vol 1 | Issue 2
diagnosed as having spastic diplegic cerebral palsy at
the age of 2 years and physical therapy was started
only after 9 years of age.
Child’s assessment
The child in this study had impairments across the
full spectrum of developmental functions, especially
in gross motor and self‑care functions. He was
malnourished, had malaligned teeth with frequent
drooling of saliva. He used to attain hyperextension
posture at the level of neck and whole spine use
to go in to complete arching position with any
external touch on his body and with any loud noise
in the surroundings. He had marked asymmetrical
spasticity, in all the extremities (left arm least
affected), truncal dystonia at rest that increased
with action. His chest had pigeon shaped deformity,
due to which many cardio respiratory complications
developed. Social skills did not develop in proportion
to his age. He lacked ability to recognize his mother.
Pretreatment and post treatment child’s evaluation
was done using GMFCS at baseline and after
9 months of therapy.
Physiotherapy intervention
The child received PT 3 days a week for 40 min for
the period of 9 months in physiotherapy OPD by
a skilled physiotherapist specialized in the field of
neurological physiotherapy. Therapeutic sessions
were started with the aim to develop his head and
neck control. Rood’s approach was given to facilitate
neck extensors using various aids such as brush
and ice followed by Swiss ball to and fro exercises,
and thumping activities were also done on him. To
inhibit hyperextension posture sensory integration
therapy was given to the child by keeping him
in prone position on different platforms such as
Wobble board, Bolster, and Swiss ball as shown in
Figure 1. The patient’s PT sessions were structured
to challenge his dynamic balance by encouraging
movement transitions to develop his automatic
righting reactions and equilibrium reactions in
different positions.
Static weight bearing (SWB) was performed by
placing the child in standing frame for 5 min daily
initially which was increased gradually with the
practice of the child. Task‑specific gentle loading
was given to child’s body to alter force distribution
in different directions to guide the patient to adapt
himself to a new situation. The child’s parents were
active participants and they consistently followed
him with his home program activities. These
included working on the movement transitions,
trunk dissociation exercises, SWB exercises, etc.,
as shown in Figure 2, with appropriate guarding
for safety. The child was made to perform different
activities on different days that helped them to
maintain the child’s interest in home therapy.
RESULTS
There was improvement in Gross motor functions
and social skills of spastic diplegic CP child after
the intervention in various outcomes such as head
and neck control, posture, static weight bearing and
social skills which are discussed in Table 1. Child
also became less irritable on tactile stimulation to
his body. Social Smile got develops in the child and
he got acclimatized with people in the surroundings
following the physical therapeutic measures.
DISCUSSION
The primary goal of treatment for the present case
was to prepare the child for his greatest possible
independence in the various activities involving gross
motor functions.[5] Neuro‑rehabilitation approaches
are important for treatment of a cerebral palsy child
to prevent postural abnormalities, sensory deficits,
gross motor dysfunction, and to increase functional
capacity.[6,7]
In the present case, the child’s treatment was
based on therapeutic techniques of Roods
approach, sensory integration therapy, and SWB.
Figure 1: Prone position - Swiss ball training

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Midha, et al.: A spastic diplegic cerebral palsy child journey
Indian Journal of Cerebral Palsy | Jul-Dec 2015 | Vol 1 | Issue 2
Lack of head and neck control is the most common
complication in CP. Since such children lack
language abilities to respond to direct commands.
Sensory feedback techniques are appropriate
techniques for them to provide immediate and
consistent information related to specific motor
skills.[8] In 1950, Margaret S. Rood, a physical
therapist used sensory stimuli like stroking or
brushing at a given speed and for a given duration
for activation of a phasic muscle response. In the
present case, brushing and stroking was given for
facilitation of head and neck extensors for gaining
head and neck control in the child.[9]
Sensory integration therapy is an active therapy
involving activities with use of equipment such
as big rolls and Swiss balls, swinging hammocks,
which provide intense proprioceptive, vestibular, and
tactile inputs to the patient. It is a process occurring
in the brain that enables the child to make sense of
their world by receiving, modulating, organizing,
and interpreting the information that comes to their
brains from their senses.[10]
SWB exercises are widely used for children with
cerebral palsy. For the lower extremities SWB is
achieved by positioning child in a standing frame. It
prevents tightness or contracture of soft tissue, restores
length of the muscles by prolonged stretching, reduces
spasticity by inhibiting motor neuron excitability
through prolonged stretch and compression on the
muscle spindles, Golgi tendon organs, and joint
receptors.[11] Severe consequences in a cerebral palsy
child can be prevented with early diagnosis and
comprehensive physiotherapy intervention.
In the course of 9 months of physiotherapy treatment,
child developed his head and neck control and there
was no more head lag present. Voluntary control of
the trunk muscles was developed by providing sensory
inputs to his body in the form of tactile, proprioceptive,
and vestibular stimuli that helped him to attain sitting
position on his own, SWB helped in reducing stiffness
in the back and also there was significant reduction in
the overall muscle tone.
CONCLUSION
With the application of various therapeutic
techniques such as Roods approach, sensory
integration, and static weight bearing therapies,
an improvement was brought (GMFCS Level V–IV)
in the gross motor functions as well as the child’s
social skills. Child may also become less irritable on
tactile stimulation to his body. Social Smile may also
develop in the child and he may get acclimatized
with people in the surroundings following the
physical therapeutic measures.
Financial support and sponsorship
Nil.
Conicts of interest
There are no conflicts of interest.
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Table 1: Improvement in gross motor functions
and social skills of spastic diplegic cerebral
palsy child after the intervention in the
following outcomes
Outcomes At beginning
(before intervention)
After 9 months
(after intervention)
GMFCS level Level V Level IV
Head and
neck control
Lack of head and neck
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Head and neck control was
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Posture Hyperextension posture
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Hyperextension posture
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integration therapy
Static weight
bearing
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Social skills Social skills was not
developed
Social skills was developed
GMFCS: Gross motor function classication system, CP: Cerebral palsy
Figure 2: Standing frame

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