Cerebral Palsy - spastic diplegia...help!!!

[arifa]

hi all
need help with a 13year old girl with cp spastic diplegia. I have not had much experience with cp, neuro etc.
My patient has had great access to healthcare. She has had P.T, O.T etc most of her life, so functionally she is doing pretty well. Her HFL is walking independently.
She walks with a rollator at school. During gait cycle she tends to scissor with her left lower limb. Poor dissociation with trunk and lower extremities. Most of her weight bearing is through her Right lower limb. Unable to actively dorsiflex left foot.
She walks on her toes with left lower limb.
I have been working on trunk control with ball activities. Tons of stretches (increase tone-left hamstrings), activities in standing to promote weightbearing through the left L.L.
I have run out of treatment ideas. She has had therapy all her life and gets quite bored.
I know treatment would have to address her problems. I have tried but am running out of ideas.. please help.
Thanks

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[estherderu]

dear Arifa,

in my country ( Holland) people have access to all kinds of treatment. But that does not mean that everybody is always being treated.
We, paediatric physiotherapists first ask our patient his/her problems and possible goals for treatment.
Ex. I want to play footbal,
I want to be able to hold a pack of cards etc etc.
If the patient is too young, you ask the parents and goals could be....
I want my child to help me when I pick him/her up to spare my back,
I want him to learn how to brush his teeth and hold the toothbrush......

By then assessing the possibilities and steps you have to take to reach these goals, you get completely new and functional goals to work for. It can make you discover that you can "make up" new functional "games" to keep your therapy varied and fun.

On the other hand, is treatment always necessary?
I doubt it....... You could arrange to assess the child properly (ROM etc) give him/her a therapy break and look what happens......

Hope this helps a little.

Keep reading on the matter.
Motor Control 3rd edition Shumway Cook and Woollaccott Lippincott Williams & Wilkins Home Page is a definite must to keep up with the newest science about motor control.

kind regards
Esther de Ru

[arifa]

Thanks Esther for your help

As I mentioned my patient has been walking with a rollator at school, at home she walks independently. Her goal would be to walk independently for longer distances.
I have tried improving her gait with activities encouraging more weight through her left leg. When I started with her, her hamstrings on the left were very tight. I was unable to get full extension but with continous stretching that has made a huge difference. Thanks for your advice.
I will try and get a hold of this book.

Kind Regards.

[equiphys]

are you able to refer her to a hospital that has a gait lab? she may be too old for botox but if she is scissoring & walking on her toe(s) she would be better having a full medical review with a 3D gait analysis to see if botox of hamstrings/calves &/or serial casting (or possibly tendon release) may improve her gait.

[Thiri Nwe]

hi all
need help with a 13year old girl with cp spastic diplegia. I have not had much experience with cp, neuro etc.
My patient has had great access to healthcare. She has had P.T, O.T etc most of her life, so functionally she is doing pretty well. Her HFL is walking independently.
She walks with a rollator at school. During gait cycle she tends to scissor with her left lower limb. Poor dissociation with trunk and lower extremities. Most of her weight bearing is through her Right lower limb. Unable to actively dorsiflex left foot.
She walks on her toes with left lower limb.
I have been working on trunk control with ball activities. Tons of stretches (increase tone-left hamstrings), activities in standing to promote weightbearing through the left L.L.
I have run out of treatment ideas. She has had therapy all her life and gets quite bored.
I know treatment would have to address her problems. I have tried but am running out of ideas.. please help.
Thanks

I 'm also a junior physiotherapist. I'm very interested in it.I think you should use splints for foot. To promote weightbearing you should train her in parallel bar with applying strong splints to lower limbs. Standing chair can be used.For scissors gait , You should use physio ball to reduce that position.

[leamcq]

Hi guys,
the scissoring implies overactivity of the anterior adductors, this is commonly because of poor lumbosacral and posterior hips stability.This is often present with overactivity of the superficial back extensors. The toe walking could also be caused by insufficient hip extension and proximal control. If the client is 'hanging on' with these muscles, you cannot succedd with lengthening strategies as this will destabilise further. Rather than consider stretching & Bot. toxin you probably need to look at getting better pelvic alignment & stability, possibly in supine initially, to get firing of the rear adductors/ extensors/ & external rotators which act like the rotator cuff of the hip. Practising a walking motion against manually applied resistance in supine can be good, as you can control the alignment, joint proprioception and put emphasis of resistance or assistance where needed in the cycle. This can then be translated to other postures. The most important factor is what muscles is the client activiating to stand up from rest, as this will dictate how they are pulling themselves together and how they will act againbst gravity. The movement pattern they produce is only a continuance of this.

Lea

[siva_ji]

what he told is correct. simply stretching, botox inj doesn't give good result. facilitating the muscles in the posterolateral aspect of hip(abductor+hip extensor and ext rotator), bringing the muscles around knee joint to coactivate in order to keep the joint in neutral and plantar flexors of foot to act properly to anchor the foot on floor instead of raising the heel paid good result for all children with diplegic cp disorder. check the lower extremity alignment tilting the pelvis posteriorly in standing position with proper AFO support.