Download Case: Children with Disability

Case: Children with Disability
Case
• J.R. 3 y/o boy
• Stiffness when crying
• Tiptoe walking
Maternal and Birth History
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NSD, full term
APGAR score: 5
BW: 2.5kg
35y/o G1P1 (1-0-0-1)
Regular pre-natal check-up with O.B.
Mother (+) hx of UTI during last trimester, no
bleeding
• Upon delivery, cord was coiled on the neck 3x
Developmental History
6 mos
12 mos
18 mos
At
Present
• Rolled over
• Sat with support
• Pulled himself up to stand
• Walks but needs assistance
• Continues to drool
- Can make simple sounds
Pertinent PE Findings
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Ambulatory with scissoring gait
Poor balance
Maintains high guard of upper extremity
(+) cortical thumb
With good head control
(+) drooling
Good sitting balance
(+) tightness of both Achilles tendons
(+) clonus
Diagnosis: Cerebral Palsy secondary
to perinatal brain injury
What are the pertinent facts in the
history that may point or contribute
to your working diagnosis?
Salient Features
• 3y/o boy – stiffness
when crying and tiptoe
walking
• Delay in achieving
developmental
milestones
• Birth weight: 2.5 kg
(LBW)
• Cord coiled on the neck
3x
• Ambulatory with
scissoring gait
• Poor balance
• Maintains high guard of
extremities
• (+) cortical thumb
• (+) drooling
• (+) tightness of both
achilles tendons
• (+) clonus
Developmental Milestones
Gross Motor Function
Normal
(months)
J.R.
(months)
Rolls Over
2-4.5
6
Sits without support
5-8
12
Stands Alone
10-14
18
At present (3y/o)
•walks but needs assistance
•Can make simple sounds
•Continues to drool
Cerebral Palsy
• collection of diverse syndromes characterized
by disorders of movement and posture
• non-progressive
• static movement disorder (weakness
possible)
• delayed developmental milestones
• persistence of primitive reflexes
• increased motor tone/floppy
Cerebral Palsy
Etiology
• brain injury that occurs prenatal, perinatal or
postnatal
• brain dysfunction
Incidence
• 2 per 1000 live births (industrialized countries)
• M>F 1.33 : 1.00
Cerebral Palsy
Factors that Increases Incidence of CP
• low birth weight <25OO g
• gestational age <32 wk – most common antecedent of
CP
• maternal factors
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mental retardation
seizure disorder
hypothyroidism
2 or more prior fetal deaths
sibling with motor deficit
3rd trimester bleeding
Cerebral Palsy
Manifestations
• floppy infant
• persistent obligatory reflexes
Cerebral Palsy
Diagnosis
• High Risk History
• Posture - FSP, ESP(flexor, extensor synergy patterns),
opisthotonus, scissoring gait = d/t spasticity of hip
adductors; straphanger UE
• Oral Motor - tongue thrust, tonic bite
• Strabismus
• Tone (while awake and not struggling)
• Evolution of Postural Reactions
• Reflexes - MSRs, clonus, Babinski
• confirmed by: MRI
• Other tests: metabolic, biochemical, developmental
Cerebral Palsy
Classification by limb
affectation:
• Quadriplegia – all 4
extremities + trunk
• Diplegia – LE > UE, most
common
• Monoplegia – only 1
limb, either an arm or
leg
• Hemiplegia –
involvement on one side
of body, including arm
and leg
Cerebral Palsy
by muscle tone:
Spastic (70-80%)
• most common
•signs of UMN
involvement
•Hypertonic
•NM condition stemming
from damage to
corticospinal tract, motor
cortex or pyramidal tract/
velocity dependent inc in
muscle tone
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1
2
3
4
Modified Ashworth
scale->
5
No increase in muscle tone
Slight increase in muscle tone,
manifested by a catch and release
or by minimal resistance at the
end of the range of motion when
the affected part(s) is moved in
flexion or extension.
Slight increase in muscle tone,
manifested by a catch, followed
by minimal resistance throughout
the reminder (less than half) of
the ROM (range of movement).
More marked increase in muscle
tone through most of the ROM,
but affected part(s) easily moved.
Considerable increase in muscle
tone passive, movement difficult.
Affected part(s) rigid in flexion or
extension.
Cerebral Palsy
Atonic (10%)
• Hypotonia and tremors
• Motor skills like writing,
typing, using scissors,
balance while walking are
affected
• Visual and/or auditory
processing of objects
Athetoid (25%)
• Alternating hyper and
hypotonia
• Trouble holding themselves
upright, steady position of
sitting or walking
• Involuntary motions
• Difficulty getting their hand
to a certain spot (e.g.
scratching nose, reaching
for a cup)
• May not be able to hold on
to objects
Cerebral Palsy
Comorbidities
• Mental retardation (IQ<50) – 31%
• Active seizures- 21%
• Mental retardation (IQ <50)+ and not walking20%
• Blindness- 11%
Topographical Classification of
Cerebral palsy in our patient
• Spastic
– (+) cortical thub, (+) drooling, (+) clonus
• Diplegia
– ambulatory with scissoring gait, poor balance and
maintains high guard of UE, good head control
5. How will you grade the spasticity of the
patient?
(Modified Ashworth)
Clinical Scale For Spastic Hypertonia
MODIFIED ASHWORTH SCALE
0
No increase in tone
1
Slight increase in muscle tone manifested by a catch and
release or minimal resistance at the end of the ROM when
the affected part(s) is moved in flexion or extension
2
Slight increase in muscle tone, manifested by a catch
followed by minimal resistance throughout the remainder
(less than half) of the ROM
3
More marked increase in muscle tone through most of the
ROM, but affected part(s) easily moved
4
Considerable increase in muscle tone, passive movement
difficult
5
Affected parts rigid in flexion or extension
6. How will you manage the spasticity?
Management
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Rehabilitation
Daily stretching
Oral Medications
Local Injectables
Surgical treatments
– Tendon release, Selective dorsal rhizotomy
Management
• Rehabilitation
– individualized stretching and exercise program
that can be used at home on a regular basis
– Improve ROM and function
– Useful component to all other modalities
– Braces, walking aids (help reduce impact of
spasticity)
Management
• Oral Medications
– Baclofen (Lioresal)
– Tizanidine (Zanaflex)
– Diazepam (Valium)
– Clonazepam (Klonopin)
– Dantrolene sodium (Dantrium)
Management
• Advantages of Oral Medications:
– Relax a large number of muscles
– Dose is easily adjusted
– May be stopped anytime
• Disadvantages:
– Modest effect
– Drowsiness, dizziness, weakness
– Liver inflammation
Management
• Local Injections
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Phenol black
Intrathecal Baclofen pump
Botox injection
Management
• Botilinum toxin
• Protein made by bacteria causing botulinism
• BTX-A (Botox), BTX-B (Myobloc)
• Can relax spastic muscle when injected in small
quantities
• Affects only injected muscle
• 2-3wks to take effect last 3-6mo.
• Safe and can be injected w/o use of sedatives, however
injections maybe uncomfortable
Management
• Intrathecal Baclofen Therapy (ITB)
– Baclofen pump
– Surgically implanted
– More effective than oral Baclofen
– Delivers medication directly to the spinal fluid via
catheter
– Well tolerated, reversible
– Test injection (to determine if patient is good
candidate for the Baclofen pump)
7. What will be your immediate rehab
goal for this patient?
Goals
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Obtain optimal function despite residual disability
Prevent secondary impairement or complications
Prevent or delay contractures
Maintain mobility
Improve function
– Promote motor and developmental skills
– Activities necessary to help the child reach his/her full
potential
Physical Therapy: Daily ROM Exercises
• Stretching exercises
– Increase motion
• Progressive resistance exercises
– Increase muscle strength
Daily ROM Exercises
• Strengthening knee extensor muscles helps to
improve crouching and stride
• Postural and motor control training
– Should follow the dev’t sequence of noraml
children (head and neck  trunk control)
• Use of age appropriate play and of adaptive
toys and games based on the desired exercises
Daily ROM Exercises
• Hippotherapy
– Horse back riding therapy
– Improve child’s tone, ROM, strength, coordination,
balance
– Offers many potential cognitive, physical and
emotional benefits
Occupational Therapy
• Activities of Daily Living
– Feeding, dressing, toileting, grooming
– Goal: to function as independently as possible w/
w/o use of adaptive equipment
Speech Therapy
• Cerebral Palsy
– Involvement of the face and oropharynx, causing
dysphagia, drooling and dysarthria
– Speech therapy can be implemented to help
control the muscles of the mouth and jaw and
improve communication
• Encourage se of age appropriate play and of
adaptive toys and games based on the desired
exercises to achieve child’s cooperation
8. Will he need assistive device?
Assistive Devices
• Ankle foot orthoses (AFO)
– Help improve balance and walking
– Hinge AFO more effective and helpful
– Reduction in foot pronation and prevent
contracture by stretching spastic muscles
• Splints
– Correct spasticity in the hand muscles
Assistive Devices
– Devices that help individuals move about more
easily and communicate successfully at home at
school, or in workplace
– Help child with CP to overcome physical and
communication limitations
Assistive Devices
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Postural support or seating systems
Open front walkers
Quadrapedal canes (lighweight or metal)
Gait poles