Case Study of a Cerebral Palsy service user at Green lane community physiotherapy.

1. Case Study of a Cerebral Palsy service user at Green lane community physiotherapy. Sarah Hart u0604985

2. Learning outcomes • Introduction to the service user • Outline cerebral palsy with associated conditions • Assessment and findings • Goal setting • Tone management with positioning • Wheelchair management • Hydrotherapy • ICF summary

3. Introduction • The service user (SU) is a 20year old female. • Her previous medical history is:- • Cerebral palsy • Microcephaly • Epilepsy (no seizures for 6-7yrs) • Dislocation of left hip • Kyphoscoliosis- convex to the left • She has been referred by a senior physiotherapist of paediatrics for continuing physiotherapy in the community with intermittent reviews.

4. Description of Cerebral Palsy • Umbrella term used to describe a wide range of different causative factors and describing an evolving disorder of motor function secondary to a non progressive pathology of an immature brain. • Defined as • “a persistent but not unchanging disorder of posture and movement, caused by damage to the developing nervous system, before, during or after birth or in the early months of infancy” Griffith and Clegg 1988 • Higher prevalence in low birth weight children. • Survival rate is at it’s best particularly in preterm births. • Damage to the brain can occur before, during or after delivery. • Causes are:- • REDUCED OXYGEN TO THE BRAIN • REDUCED GLUCOSE IN THE BLOOD • INFECTIONS

5. Associated conditions • Visual impairments • Reduced visual field, squint and refractive errors • Auditory impairments • Children who have neurological problems due to intrauterine (in uterus) infection or meningitis have increased risk of auditory problems. • Reduced balance mechanism • Epilepsy • Disorder of the brains function characterised by recurrent seizures that have a sudden onset. • Brain is unable to regulate its electrical discharge. • Seizures are split into 2 categories • Partial- affects part of the brain i.e. one lobe, person doesn’t lose consciousness • Generalised- affects the whole brain and person will lose consciousness • Tonic- spasm/ Clonic- convulsions • Dysphasia- expressive

6. Assessment • Physical examination • Posture- “Windswept” hip and knee flexor contractures to the right. Posteriorly tilted hips and the SU rotates to right in supine and sitting. • ROM- voluntary movements in cervical vertebrae and upper limbs. Reduced cognition prevents AROM from being tested. Able to reach and grasp a toy placed in front of her only momentarily. Left hip adductor contractures are present due to her sustained posture. • Balance- Sitting balance is held momentarily.

7. Assessment cont’d • Transfer- hoisted • Muscle strength-unable to assess • Problems identified • Contractures in both lower limbs with particular reference to the left leg adductors • A reduced range of motion in both the lower and upper limbs • Poor static sitting balance.

8. Physiotherapy management • Reduce sustained postures • Maximise function • Prevent pressure sores • Maintain soft tissue length • Reduce discomfort and noxious stimuli • Seating systems-Important to assess each client for a seat if it needs to be, a specific matrix chairs can be custom built for clients to support their posture. • Management of muscle tone- correct handling, positioning, passive stretching • Splinting • Hydrotherapy

9. Goal setting

10. Medical treatments • Drug treatments- • Medications are used to attenuate the motor disorder, baclofen- spascity, benzhexol, benztropine and levadopa derivatives for other tonal problems. • Botox can be used as well to target specific muscles. • Neurosurgery- • Dorsal rhizotomy- partial sectioning of the lumbrosacral dorsal rootlets of the spinal cord is a treatment for spasticity, used more in US than UK. • Orthopaedic management- • Scoliosis correction. • Muscle releases to prevent contractures can be used.

11. Tone management • Tone is defines as the state of readiness within the muscle Bernstein (1967). Tone is made up of non-neural and neural components • Non-neural components • Slow/fast twitch fibres and the changing balance between them • Muscle atrophy • Stiffness/length, tension relationship/predominance of connective tissue • Sarcomeres length and contractures • Neural components • Descending tracts- Control of muscle tone via the balance of pathways: Excitory and inhibitory producing reciprocal inhibition. • Motor neuron pool- translates information from afferent and interneuron's into efferent's to produce movement. If efferent's receive poor information, the neural drive to the muscles will be altered. • Non-neural components can be managed by a splinting and stretching programme • Neural component needs to be medically managed i.e. Botox jobs directly into the muscle.

12. Physiology of spasticity. • Spasticityis a disorder of the central nervous system (CNS) in which certain muscles continually receive a message via descending spinal tracts, to tighten and contract. • The nerves leading to those muscles, are unable to regulate themselves (which would provide for normal muscle tone), permanently and continually "over-fire" these commands to tighten and contract

13. Positioning- Bobath principle • The 'Bobath Concept' is an important approach to rehabilitation in the care of patients with injuries to the brain. • It strives to appropriately and adequately stress the central nervous and muscular systems such that an individual creates, maintains, and reinforces the sensorimotor pathways to enable efficient motor control in their desired environment. • The main aim of treatment is to encourage and increase the service users ability to move and function in as normal a way as possible. More normal movements cannot be obtained if the service user stays in a few positions and moves in a limited or disordered way.

14. Wheelchair and Hydrotherapy referral • The service users mother stated that that she looked uncomfortable in the chair at times. • A wedge is needed to be placed between the service users legs as she had a left adductor release 2 years ago, but the contractures have returned due to her continued positioning in the chair and in bed. • With hydrotherapy the service user will be able to relax in the water and achieve a range of movement within her joint she may not be able to achieve on land

15. WHO I.C.F.

16. References • Stokes, M, (2004) Physical Management in neurological Rehabilitation, Elsevier, London • DoH 05 National Service Frameworks for Long term Conditions. • http://www.yoga.com/filestorage/ArticleImage/139-174_.Wainapel_06_01_0001.jpg