Introduction

Cerebral palsy refers to a group of disorders in the development of posture and motor
control, occurring as a result of non-progressive lesion of the developing central nervous
system (Bax. 1964). Cerebral palsy is an umbrella term used to describe a collection of
non-progressive disorders that manifest as abnormalities of motion and posture and result
from a central nervous system injury sustained in the early period of brain development
(Eicher & Batshaw, 1993).

Cerebral palsy is caused by an injury to the brain before, during, or shortly after birth. In
many cases, no one knows for sure what caused the brain injury or what may have been
done to prevent the injury. Sometimes injuries to a baby's brain happen while the baby is
still in the mother's womb (before birth). The injury might be caused by an infection or
by an accident in which the mother is hurt. If a mother has a medical problem such as
high blood pressure or diabetes, this can also cause problems in the baby. There may be
problems during birth such as the baby not getting enough oxygen, or a difficult delivery
in which the baby's brain is injured. Problems after birth may happen when a baby is
born too soon (premature delivery) and his body is not ready to live outside his mother's
womb. Even babies born at the right time can have infections, or bleeding in their brain
which causes a brain injury because the brain is still developing even after birth.

Background Information

List the key information you gained from the subjective assessment and explain why is
this important / relevant

A 3 year-old girl with spastic quadriplegia with less upper limb involvement compared
with lower limbs. She has born at 32 weeks gestation and is one of twins. She had
apnoea at birth for 2 minutes. Her twin has normal development. She is diagnosed
Cerebral palsy with the type moderate spastic quadriplegic flexor pattern. Upper limbs
are better than lower part.

She has undergone tendon lengthening of both hip adductors and hamstrings at Royal
Children Hospital on September . 2001. After operation she is on c.. splint for
correcting and maintaining the position after the operation. She also got Botox injection
in both hip adductor on September . 2001.

She lives with her mother. At the moment her mother is pregnant. Therefore she stays
with her grandparent for half week and another half week stay with her parent. She
follows three days at early school at Yarabah and follows one day at kinder with her
twins.
The functional activities, which she could do before the operation is: She currently
crawls and pulls herself up onto her knees at the couch. She can take some weight
bearing in standing but has marked scissoring.

She was seen an AP view of the pelvis was taken showing that the right hip migration
was 25% and left 27%. The acetabular index (AI) was 20 degree on the right and 23
degree on the left with 5 degree of adduction at both hips. There is significant dysplasia
of the acetabulum with bilateral gothic arches.

Clinical exam showed that she had bilateral tightness of the hip adductors with 50 degree
of abduction on the right in flexion and 35 degree on the left reducing to 25 degree on the
right in extension, 15 degree on the left and 5 degree bilaterally on dynamic testing. She
has moderate tightness of both hamstrings and calf muscle length is adequate but there is
a dynamic component to calf muscle tightness.

GMFM test on the 13th August 2001, the result were: Item A : Lying and Rolling: 40, item
B : Sitting : 29, item C : Crawling and kneeling: 17, item D : Standing: 0 and item E:
walking, running and jumping: 0. Total score of GMFM was; 33% (no aid during the test)

Hypotheses

List the initial hypotheses regarding the source / possible caused of the patients
presenting problem (s) -> Use table to summarize differentiating features of these
possible caused of the patients presenting problems. -> Describe the mechanism by
which the most likely hypotheses could cause the patients presenting problems. (Flow
chart for this purpose).

Flow Chart: Attached.

Selection of test (laboratory, clinical, other)

Which objective clinical tests did you choose and why?

4.1. Ashwort Spasticity Measurement Scale

This test is used for measuring the quality of spasticity. The studies show that
this test is widely used and has reliable and valid (Susan and Pierson, 1997).

The study conducted by Ibrahim at.al. (2001) conclude that the Ashworth and
the Modified Ashworth were found to be reliable measures for assessing
muscle tone regardless of the raters' experience with the scale. The results
support the use of either scale to assess muscle tone in patients with
hemiplegia, with preference for the Ashworth Scale for assessing the upper
extremity and the Modified Ashworth Scale for the lower extremity. Physical
 therapists may use this information to make a more informed choice when
selecting tools for muscle tone assessments.

4.2. Gross Motor Function Classification System

This (Palisano et.al, 1997)
a. Level I: walk without restrictions, limitations in more advanced gross
motor scale.
b. Level II: walk without assistive devices; limitation walking outdoors
and in the community
c. Level III: walks with assistive devices; limitations walking outdoors
and in the community
d. Level IV: Self-mobility with limitation; children are transported or use
power mobility outdoors and in the community
e. Level V: Self mobility in severely limited even with the use of
assistive technology.

2. Gross Motor Functional Measurement.

GMFM is designed to assess status and change in status of motor profiency

due to therapeutic interventions in children with cerebral palsy. (Boyce at.al.
1991, Rusell et.al. 1989, Rusell et.al. 1993).

GMFM is a responsive tool for measurement of change in young children with

cerebral palsy (Russell, et.al. 1993)

GMFM is able to show the functional limitation of the cerebral palsy children.
This test is developed more likely for assessing and monitoring the functional
limitation of cerebral palsy and development delay in children.

3. Hip Surveillance (Scrutton and Baird, 1997)

This test can measure the migration of the hips and also show the acetabulum
index (AI). And also some study show that this test is reliable and valid to be
used to judge the need of the operation, such tendon lengthening, tendon
transfer or hip reconstruction in CP children.

Under ideal circumstances what tests would you have chosen and why?

GMFM and Asworth measure Scale

Select one of this clinical test and use a table to show the results of research
investigating the reliability and validity thus test (Maximum 6)
 Gross Motor Functional Measure (GMFM) manual

STUDY TITLE AUTHORS RESULT

(Year) Reliability
Improved Scaling of the Dianne J Russell; Lisa Reliability
Gross Motor Function M Avery; Peter L Test-retest reliability data
Measure for Children Rosenbaum; Parminder using the new GMAE scoring
With Cerebral Palsy: S Raina; Stephen D method showed that the
Evidence of Reliability Walter; Robert J GMFM-66 has a high level of
and Validity (2000) Palisano stability over time
(ICC=.9932) and is only
slightly different from that of
the original scoring system
using the 88-item GMFM
(ICC=.9944, mean
difference=.0013 [95%
confidence interval of -.082
to .0109]).
Validity
The authors believe the results
support the construct validity
of the GMFM-66 scores, the
measure detected less change
in the older children regardless
of severity of CP.
Inventory[29] may be more
appropriate for evaluating
change in older children with
CP.

Gross Motor Function Russell, D., GMFM Dimension: Some studies support the use
Measure Manual Rosebaum, P., - Intra rater: 0.99 of GMFM.
(GMFM) (1993) Gowland, C., - Inter rater: 0.99 The GMFM demonstrated
Hardy,S., non-significant variation under
Lane, M., Repeated Judgment: stable condition (p>0.05) and
Lane, M., - Therapists: 0.96 significant change when
Plew, N., - Parents : 0.92 change was believed to have
McGavin, H., taken place (p<0.0001)
Cadman, D. The GMFM is a criterion
Jarvis, S. referenced observational Validity was established by
measure. There is intra-rater correlating change on the
reliability (ICC = 0.99), and GMFM with parent judgement
inter-rater reliability (ICC = of change (r = 0.54), therapist
0.99) for repeat administration judgement of change (r =
of the GMFM. There is 0.65), and change judged from
reliability of scoring from masked evaluation of
revised guidelines (ICC = videotapes (r = 0.82).
0.90).
Development and Robert Palisano
Reliability of a System Peter Rosenbaum
to Classify Gross Motor Stephen Walter
Function in Children Dianne Russell
with Cerebral Palsy Ellen Wood
(1997) Barbara Galuppi
Early Childhood JMP Anderson
Sensory Motor M.J. Hawke
 Developmental Screen.
Gross Motor Carolyn Gowland Total score ICC: 0.92 to 0.96.
Performance Measure William F Boyce Intrarater 0.90 to 0.97
Virginia Wright Interrater: 0.84 to 0.94
Diane J Russell Test-retest: 0.89 to 0.96.
Charles H Goldsmith

Training Users in the Dianne J Russell

Gross Motor Function Peter L. Rosenbaum
Measure: Mary Lane
Methodological and Carolyn Gowland
Practical and Practical Charles H. Goldsmith
Issues (1994) William F. Boyce
Nancy Plews

Discuss possible source of error explain how could you get a false result?

In this it is very difficult the find out the source of error. Positive error .. Negative
error

What laboratory or other tests are appropriate and why?

As noted above, in making a diagnosis of cerebral palsy the most meaningful aspect of
the examination is the physical evidence of abnormal motor function. A diagnosis of
cerebral palsy cannot be made on the basis of an x-ray or blood test, though the physician
may order such tests to exclude other neurologic diseases (such as those mentioned
above). Blood tests and chromosome analysis are helpful in diagnosing hereditary
conditions that may influence the parents' future child-bearing decisions. When the tests
indicate that a child's condition is something other than cerebral palsy and that the
condition is inherited, family members will benefit from genetic counselling. Cerebral
palsy is not a hereditary condition, however, and these tests will neither establish nor rule
out a diagnosis of CP.

Magnetic resonance imaging (MRI) and Computed Tomography (CT) scans are often
ordered when the physician suspects that the child has cerebral palsy. These tests may
provide evidence of hydrocephalus (an abnormal accumulation of fluid in the cerebral
ventricles), and they may be used to exclude other causes of motor problems. These scans
do not prove whether a child has a cerebral palsy; nor do they predict how a specific child
will function as she grows. Thus, children with normal scans may have severe cerebral
palsy, and children with clearly abnormal scans occasionally appear totally normal or
have only mild physical evidence of cerebral palsy. As a group, though, children with
cerebral palsy do have brain scars, cysts, and other changes which show up on scans
more frequently than in normal children. Therefore, when a scar is seen on a CT scan of
the brain of a child whose physical examination suggests he may have cerebral palsy, the
scar is one more piece of evidence indicating that the child is likely to have motor
problems in the future.
What key information did you gain from the objective assessment?

How did you use the information from the subjective and objective assessment to reach a
decision regarding the main causes of the patients problem?

Subjective assessment:

Before operation:

The author have never met the parent of the grand-parents. All the information are from
teachers and physiotherapists from Yarrabah School where the author did clinical posting.

She is 3 years old girl and twin. Her sibling is normal and she is at the normal
kindergarthen. She is cooperative and able to follow simple commands. She can

Objective assessment:

1. The GMSM before the operation

 2. Ashworth before the operation: She has moderate tightness of both hamstrings
and calf muscle length is adequate but there is a dynamic component to calf
muscle tightness.

3. Hip Surveillance:

4. ROM:

Outline the short and long term treatment aims for this patient.
Present the rationale behind your choice of the treatment techniques / preferred
management of the condition.

Injectable Medications (Botox[R])

Botox is the trade name for the endotoxin of Clostridium Botulinum. It is a

chemoneurolysis that blocks the nerve from sending a message to the muscle for a limited
time period. Botulinum toxin A is a protein polypeptide chain that irreversibly binds to
the cholinergic terminal at the neuromuscular junction. It inhibits the release of
acetylcholine, which prevents the nerve from stimulating the muscle to move. Recovery
of the nerve is slow, over 3 to 6 months, as new terminal axon sprouts form and restore
transmission (Flett, 1999).
The primary objectives of Botox are to maintain or regain range of motion, to prevent or
reduce contracture, and to maximize functional mobility (Flett et al., 1999). Nonsurgicai
approaches to calf tightness before the age of 6 years old can avoid the potential risks
associated with surgery, such as overlengthening the muscle, infection, scarring, and/or
anesthesia (Flett et al., 1999).
The ideal candidate for Botulinum toxin A is the young child whose spasticity is localized
in the lower extremities. This is used commonly for the children with spastic calf muscles
who walk on their toes, unable to dorsiflex the ankle. The goal is that the Botox will
weaken the muscle so that the muscle can be stretched and the child can walk plantigrade
or fit comfortably into an ankle foot orthosis. The child will probably need surgery to
lengthen or release the heel cord when older.
It is hoped that this deforming factor can be corrected in one surgical procedure and not
multiple ones as growth occurs. The confounding factor is growth of the bone. A spastic
or tight muscle cannot stretch to match the new length of the bone. This can set the stage
for bony malalignment with further surgical procedures warranted.
At our facility, the Botox protocol for spastic calf muscles is done in the following
manner. A baseline assessment is completed, which includes range-of-motion
measurements of the targeted muscles, radiographs of the foot and ankle, and an
observational gait analysis with video documentation. EMLA (topical anesthetic) cream
is applied to the calf muscles with a protective Tegaderm bandage an hour before the
procedure.
The family will be asked if they are interested in oral conscious sedation for their child.
Midazolam is used. Botox is injected into the vicinity of the neuromuscular junction of
both the gastrocnemius and soleus muscles. The medication is massaged into the muscle
complex. A cast will be applied to slowly stretch the calf muscles. Serial stretch casting
will continue until maximum muscle length is obtained.
Physical therapy and braces are adjunct therapies used to reap the maximum benefit of
the Botox. Stretch casting is not applied if there is malalignment of the midfoot bones.
Putting excess stretch on the muscles can cause further bony displacement.
Advantages of the Botox therapy are a decrease in hypertonicity of the muscle and an
increase stretch of the relaxed muscle, which decreases the incidence of fixed
contractures (Cosgrove, 1994). Patients have described a "cold sensation" when the
Botox is administered. Complaints of soreness at the injection site lasting for 1 to 2 days,
generalized fatigue, and transient weakness of the injected muscle have been sited by
Koman (1993) postinjection. No generalized or clinically significant systemic
complications resulted from a study series of 87 injections done by Koman (1993).
One of the disadvantages of Botox is that it is temporary and the long-term effects of
repeated doses are still under investigation. The potential problem is that the child could
develop antibodies toward the drug and become immune with prolonged use.
At this time another serotype of Botox is being developed in response to this issue. The
cost also needs to be considered. A vial of Botox is approximately $360.00, which
contains 100 units. Graham et al. (2000) recommends 3-6 units per kilogram for each
muscle injected of the lower extremity. It is not uncommon for the medication alone to
cost over $700.00 when both calf muscles are treated for dynamic equinus.

Use supporting literature (where available) to demonstrate the effective of the chosen
interventions

1. Conventional surgery
2. Multilevel surgery
3. Botulinum toxin
4. Selective dorsal rhizotomy
5. Intrathecal baclofen
6. Sophisticated orthoses
7. Targeted training
8. Less orthodox treatments

Explain how you would evaluate treatment effectiveness / patient progression.

The goal of the treatment focused on the effects of a functional approach to physical
therapy for children with cerebral palsy. Functional physical therapy, as defined in this
report, emphasizes the learning of motor abilities that are meaningful in the child's
environment and perceived as problematic by either the child or the parents (Katelaar,
et.el. 2001). Children practice these motor abilities in functional situations, with the child
having an active role in finding solutions for motor problems rather than having the
physical therapist's handling result in a solution. Functional goals, in terms of skills, are
established with parents and children based on their priorities. Functional activities are
assumed to be learned by repetitive practice of goal-related tasks in functional situations.
Evaluation of treatment for cerebral palsy is complicated by the fact that therapists often
do not use therapeutic approaches uniformly. Therefore, we first performed a pilot study
in which we examined the intervention of all children who were referred to us to
participate in the study. We asked their therapists to describe the methods of therapy they
used with the children and their treatment goals. We concluded that all participating
therapists based their therapy mainly on the principle of normalization of the quality of
movement.27 After this baseline study, half of the therapists were trained to
systematically apply the principles of functional physical therapy. The purpose of the
study was to examine whether the motor abilities of children with cerebral palsy who
were receiving functional physical therapy improved more than the motor abilities of
children in a reference group whose therapy was based on the principle of normalization
of the quality of movement. We hypothesized that the children in the functional physical
therapy group would improve more over time than the children in the reference group.

The Goal of the treatment

When it comes to expectations and questions of what the future holds for the child with
CP, it is important to maintain a combination of optimism and realism, just as one would
with any child. Suppose, for example, that the parent of a non-disabled three-year old has
hopes and expectations that the child will go to college and law school, enter politics, and
eventually become President of the United States. Some of these expectations are realistic
and are likely to be met, while others are extremely unlikely to occur to the point of being
clearly unrealistic. Regardless of these realistic and not realistic expectations, however,
the parent needs to care for the child as a three year old and not as a college student or as
a politician. It is equally important for the parent of a child with cerebral palsy to
understand the child's present and future abilities. That parent's expectations are also
probably a combination of realistic and unrealistic goals for the child, but in time, with
professional help, the parent will develop a set of mostly realistic goals and it is to these
goals that the parent, child, and professional will dedicate their effort. Occasionally,
difficulties in communication arise when the parents, educators, and medical care
providers discuss present abilities. As stated in the Preface, a significant goal of this book
is to., improve this communication so that parents, educators, and medical care providers
can communicate their impressions to each other regarding a specific child and in this
way help the child function at his or her maximum ability. An attempt to define future
expectations is usually most important in the teenage years and beyond, when function is
better defined and the future looks more clear to everyone involved.

Medical Problems which associated with Cerebral Palsy

Children with cerebral palsy have many problems, not all of them related to the brain
injury. Most of these complications are nevertheless neurological. They include epilepsy,
mental retardation, learning disabilities, and attention deficit-hyperactivity disorder.
These problems are discussed in chapter 3, as are problems that occur less commonly,
such as swallowing problems in children with spastic quadriplegia. In the next chapter,
we look at normal pediatric development, to establish a basis with which to compare the
development and behavior of a child with cerebral palsy.

Reference:

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