Cerebral Palsy

General Information
Case no.	4.A Cerebral Palsy
Authors	Suzanne F. Migliore, PT, DPT, MS, Board Certified Specialist in Pediatric Physical Therapy Karen Warenius, PT, DPT, C/NDT
Diagnosis	Spastic diplegic cerebral palsy, impaired functional mobility, balance gait, and endurance
Setting	Acute care hospital
Learner expectations	☑ Initial evaluation ☐ Re-evaluation ☐ Treatment session
Learner objectives	Explain the pathophysiology of cerebral palsy. Recognize the different surgical interventions utilized for patients with muscle imbalance/shortening due to spasticity. Select, implement, and interpret physical therapy interventions based on initial examination findings.

Medical
Chief complaint	Worsening of gait pattern
History of present illness	Patient is a 16-year-old male with a history of spastic diplegic cerebral palsy Gross Motor Function Classification System (GMFCS) level II who presented to orthopaedics with complaints of worsening in-toeing and scissoring with his gait pattern in addition to hammertoes on both feet. He and his family had considered surgical intervention in the past 2 years, but now, with his worsening gait pattern, the decision was made to move forward with surgery.
Past medical history	Attention-deficit hyperactivity disorder (ADHD); bladder incontinence; global developmental delay; learning disability; platelet dense granule deficiency; mild persistent asthma; Botox injections at ages 9, 10, and 11; serial casting for bilateral gastrocnemius/soleus.
Past surgical history	Adenoidectomy
Allergies	Ibuprofen (due to platelet dense granule deficiency)
Medications	Acetaminophen, Albuterol, Baclofen, Fexofenadine, Fluticasone HFA, Miralax
Precautions/Orders	Non–weight-bearing (NWB) bilateral lower extremities (LEs) Hip abduction pillow in place at all times

Social history
Home setup	Lives with his mom, stepdad, and three siblings in a two-story home with three steps to enter. Mom has lifting restrictions and is unable to assist. Bedroom is on the second floor. Shower/tub combination as well as a shower stall with a small lip to step over/into the shower are on the second floor.
Occupation	High school student
Prior level of function	Independent with bed mobility Modified independent for transfers, community ambulation, and activities of daily living with bilateral Lofstrand /forearm crutches and bilateral Molded ankle-foot orthosis (MAFOs) Occasional use of a wheelchair for extended community distances GMFCS level III
Recreational activities	Participates in modified track and field events

Imaging/Diagnostic test	Hospital day 1: pediatric ward
Hip X-ray	Fig. 4.1

Fig. 4.1 Hip X-ray showing post-operative internal fixation

Medical management	Hospital day 2, post-op day 1: pediatric ward
Surgical intervention	Status post bilateral femoral derotational osteotomies, bilateral adductor tenotomies, bilateral gastrocnemius recessions, left split tibialis anterior tendon transfer (SPLATT), bilateral hammertoe corrections Intraoperative bilateral femoral nerve blocks for postoperative pain management. Placed in bilateral short leg casts (SLCs) and a hip abduction wedge postoperatively
Pain management	1. Patient-controlled analgesia (PCA) pump hydromorphone (Dilaudid) 2. Tylenol/oxycodone
Medications	1. Lactated ringers’ infusion 2. Morphine 3. Albuterol 4. Dextrose 5. Ondansetron 6. Baclofen 7. Docusate 8. Diazepam

Lab	Reference range	Hospital day 2, post-op day 1: pediatric ward
White blood cells	5.0–10.0 × 10⁹/L	14.7
Hemoglobin	14–17.4 g/dL	10.8
Hematocrit	42–52%	32.3
Red blood cells	4.1–5.3 million/mm³	3.61
Platelets	140–400 k/μL	261
Mean corpuscular volume	78.0–98.0 fL	89.5
Mean platelet volume	9.6–11.8 fL	9.1

Pause points
Based on the above information, what are the priority: Diagnostic tests and measures? Outcome measures? Treatment interventions?

Pause points

Based on the above information, what are the priority:

Diagnostic tests and measures?
Outcome measures?
Treatment interventions?

Hospital Day 2, Post-Op Day 1, Pediatric Ward: Physical Therapy Examination
Subjective
“My legs hurt and I’m scared to get out of bed”
Objective
Vital signs	Pre-treatment		Post-treatment
Vital signs	Supine		Sitting
Blood pressure (mmHg)	120/55		129/60
Heart rate (beats/min)	96		100
Respiratory rate (breaths/min)	20		22
Pulse oximetry (SpO₂)	96		96
Pain	6/10 at bilateral LEs		8/10 at bilateral LEs
General	Young male, sitting up in hospital bed, bilateral SLCs and hip abduction pillow in place. Lines/equipment notable for left upper extremity (UE) peripheral intravenous catheter (PIV), patient-controlled analgesia (PCA).
Integumentary	Hip/thigh incisions under postoperative bandages which are clean/dry/intact. Unable to visualize gastrocnemius/foot incisions due to bilateral SLCs.
Cardiovascular and pulmonary	Normal sinus rhythm No adventitious lung sounds Capillary refill: < 2 seconds bilateral toes
Musculoskeletal	Range of motion	Bilateral upper extremities (BUEs): within normal limit (WNL) B hips/knees/ankles: unable to fully assess due to hip abduction wedge in place at all times, knee immobilizers, and bilateral SLCs
Musculoskeletal	Strength	Bilateral UEs: WNL Bilateral LEs: unable to fully assess due to hip abduction wedge in place at all times, knee immobilizers, and bilateral SLCs B ankles/feet: active toe flexion/extension noted on both sides
Neurological	Balance	Static unsupported sitting: moderate assistance x 2 therapists
	Cognition	Alert and oriented x 4
	Sensation	BLE: limited assessment due to orthopaedic devices Bilateral toes: intact to light touch/deep pressure
	Tone	Unable to assess due to precautions
	Other	N/A
Functional status
Bed mobility	Rolling supine to side lying: maximal assistance x 3 therapists Side lying to sitting: maximal assistance x 3 therapists attempted, unable to sit on the edge of the bed
Transfers	Bed to/from wheelchair: dependent transfer via mechanical lift
Ambulation	Unable to assess due to NWB bilateral LE precautions
Stairs	Unable to assess due to NWB bilateral LE precautions
Other	Wheelchair mobility: propelled forward/backward for 5 feet within room with minimal assistance; oriented to having brakes on while sitting in the wheelchair

Assessment
☑ Physical therapist’s	Assessment left blank for learner to develop.
Goals
Patient’s	“I want to go home.”
Short term	1. Goals left blank for learner to develop. 2.
Long term	1. Goals left blank for learner to develop. 2.

Plan
☐ Physician’s ☑ Physical therapist’s ☐ Other’s	Continue treatment daily for transfer training, patient and caregiver education, and therapeutic activities. Encourage patient to be out of bed (OOB) to chair for all meals. Discharge planning for home equipment and services.

Plan

☐ Physician’s

☑ Physical therapist’s

☐ Other’s

Continue treatment daily for transfer training, patient and caregiver education, and therapeutic activities. Encourage patient to be out of bed (OOB) to chair for all meals. Discharge planning for home equipment and services.

Bloom’s Taxonomy Level	Case 4.A Questions
Create	Synthesizing the medical data and physical examination findings, develop an appropriate physical therapy assessment of the patient. Develop two short-term physical therapy goals, including an appropriate timeframe for acute care. Develop two long-term physical therapy goals, including an appropriate timeframe for post-acute care.
Evaluate	4. Explain the physical therapy examination findings and expected discharge recommendation to the acute care team.
Analyze	5. Compare the baseline mobility of a patient at GMFCS levels I and II and how they differ. 6. Analyze his postoperative CBC. What could be causing the low values listed? 7. How will the patient’s low hemoglobin affect the treatment session?
Apply	8. Design and implement two in bed exercises to improve upper body strength to assist with bed mobility and transfers. 9. Design and implement bed mobility and transfers out of bed to wheelchair. 10. Design a bedside positioning program to protect the integumentary system and promote function.
Understand	11. What is a PCA? What are the physical therapy implications of hydromorphone? 12. What is the purpose of a derotational osteotomy?
Remember	13. What is spastic diplegia? What are the most common causes? 14. What are the patient’s precautions for mobility? How long will they be in place?

Bloom’s Taxonomy Level	Case 4.A Answers
Create	1. The patient is a 16-year-old male with a history of spastic diplegia who presents with worsening gait pattern. He was having difficulty ambulating at home, in the community and at school. His loss of quality of gait was interfering with his participation in adaptive sports. He underwent major orthopaedic surgery to correct the alignment of both lower extremities and improve flexibility at his ankles and hips. He presents with pain, limited strength, decreased balance, requiring significant assistance for transfers and will be NWB bilateral LEs for 6 weeks. He will benefit from continued skilled physical therapy to address these impairments, provide patient and caregiver education, and minimal assistance x 1 caregiver with discharge planning. Patient would be appropriate for intensive inpatient rehabilitation once cleared for weight-bearing. 2. Short-term goals: Patient will perform rolling either direction in bed with minimal assistance x 1 to reposition self and assist in pressure relief within 5 days. Patient will independently perform incentive spirometer and deep breathing exercises twice per hour to aid in the prevention of atelectasis within 5 days. 3. Long-term goals: Patient will mobilize bed to/from wheelchair via slide board transfer, NWB bilateral LEs, with minimal assistance once to improve independence within 10 days. Patient’s caregiver will perform a wheelchair transfer up/down one threshold step independently in order to safely get the patient into/out of home within 10 days.
Evaluate	4. During the physical therapy examination, the patient demonstrates pain despite being on a PCA. He also had slightly elevated systolic blood pressure and heart rate at rest. He had significant difficulty with bed mobility due to pain, restriction of his LE bracing/casting, and his baseline cardiovascular endurance. He needed maximal assistance with three caregivers to roll in bed and was unable to assist much with bed-to-wheelchair transfers. Due to his size and inability to effectively assist with transfers, a mechanical lift was implemented. He had overall a low tolerance to mobility activities, becoming easily fatigue. Due to his anticipated length of time in non–weight-bearing, and needing increased level of support for transfers, a brief inpatient rehabilitation stay was recommended so that he could improve his bed mobility, his caregivers could learn to assist him with transfers (slide board or mechanical lift), and that his pain could be managed without intravenous medication.
Analyze	5. GMFCS level I: between the 12th and 18th birthday, those classified as level I are able to walk at home, school, outdoors, and in the community. The child is able to walk up/down stairs without using a railing. He can run and jump, but speed and coordination are limited. Participating in sports and physical activities is possible, depending on environmental factors and patient choice. GMFCS level II: The child is able to walk in most settings. Uneven surfaces (terrain/inclines/long distances) may influence whether or not he uses an assistive device or wheelchair. In school, he is able to use a handheld mobility device. In the community, he may choose to use wheel mobility. When ascending/descending stairs, he will use a railing or need physical assistance if there is no railing. Participation in physical activities and sports may need adaptations/accommodations. 6. The patient’s hemoglobin and hematocrit levels are lower than the reference ranges for his gender and age. The total number of procedures included in this surgery are the likely causes of these levels due to blood loss. These levels will be monitored for the first few days postoperatively to ensure there is no active bleeding and that he can recover these counts on his own versus needing a blood transfusion. 7. Implications for physical therapy sessions with low hemoglobin include the potential for lightheadedness and fatigue with even minimal exertion. He may present with pallor and may have tachycardia. Monitoring his vitals during the session would be important, especially with mobility. Monitoring his hemoglobin if it were to trend further downwards (< 8 g/dL) may indicate the need for transfusion.
Apply	8. In-bed exercises: Due to his recent surgery and limited in-bed mobility, maintaining active range of motion (ROM) of those joints not affected by surgery is important. He is fearful of moving, having LE pain, and will need his arms and core to help him start mobilizing. Start with UE active range of motion (AROM) via shoulder flexion and abduction. Keep it simple, selecting repetitions or even challenging him to keep moving for a set amount of time. The physical therapist can add in a functional component by having him reach for the bed rails to assist with rolling (pulling self to the side), or if he has an overhead trapeze, pulling himself up (modified biceps curls) to relieve pressure and assist with repositioning. He will also benefit from deep breathing exercises to assist after anesthesia, and to improve aeration while spending most of his time in bed. He is at risk for atelectasis or pneumonia if allowed to just rest supine in bed while recovering. Use of a bedside incentive spirometer may be beneficial. In addition to the incentive spirometer, consider putting the head of the bed up, work with him on diaphragmatic breathing with a 1:2 ratio. If he is able to combine the exercise, consider an UE D2 PNF pattern incorporated with deep breathing. 9. He will require assistance to roll for hygiene, repositioning to relieve pressure, and to start with bed mobility for transfers. Start with raising the head of the bed and monitoring his vital signs for orthostatic hypotension. Utilize the bed environment as an advantage, using the side rails or overhead trapeze to have him participate as much as possible. He needs assistance with rolling his lower body, especially since he must keep the hip abduction wedge on due to the pelvic surgery and is non–weight-bearing bilateral LEs, so he can’t do a traditional bridge. Due to the amount of assistance he needs, he would be most appropriate for a mechanical lift OOB to reclining wheelchair. Many hospitals have specific policies and procedures regarding the amount a practitioner may lift, and when a patient needs to utilize a mechanical lift. These policies may be classified as “no lift” or “safe patient handling” and have the patient and caregivers’ safety in the forefront. Incorporate a pressure reducing surface in the wheelchair to aid in pressure relief. Once up in the wheelchair, teach him pressure relief via lateral weight shifts and wheelchair/triceps pushups. Limit his time out of bed to less than an hour for the first trial, monitoring vitals, pain tolerance, and fatigue level. If he tolerates this well, have him up and OOB for all meals. 10. Considerations for in-bed positioning include his level of mobility, his NWB status, the need for the ABD wedge to be in place at all times, and that he is in bilateral short leg casts. To determine the patient’s overall risk for developing pressure injuries, a pressure injury risk assessment tool such as the Braden Q Scale may be appropriate to implement. Positioning programs could include raising the heels of his casts slightly off the bed surface so that he is not lying supine, with his heels bottoming out in the casts all day. He will be able to be in supine position, modified semi-side lying, and semi-Fowler and Fowler positions throughout the day. The physical therapist may want to consider using the clock method for position changes, for example, 8 a.m.: supine; 10 a.m.: semi-Fowler, 12 p.m.: modified side lying, 2 p.m.: Fowler, and continue to change his position every 2 hours. He should also be on a pressure reducing mattress (Fig. 4.2).
Understand	11. A patient-controlled analgesia device is a machine that will deliver specific dosages of pain medicine, through an IV, accessed via a button which is controlled by the patient. The patient is able to self-dose with a PCA at specific locked-out intervals (to avoid overdosing) when they are having pain, rather than waiting for oral or IV pain medicine to be brought to them by nursing. The hydromorphone this patient is getting is an opioid used for pain management. This medication has side effects including nausea, vomiting, constipation, dry mouth, lightheadedness, dizziness, drowsiness, and sweating. While on this medication, the physical therapist would want to monitor his vitals, his pain levels, and his complaint of dizziness/lightheadedness while coming up to sitting. It would be appropriate to have the patient self-administer the PCA prior to starting LE ROM exercises or bed mobility to improve his comfort level during therapy sessions. Patients who are able to self-administer should continue to do so, and not have their parent/caregiver administer for them. 12. The derotational osteotomy is a common reconstructive, orthopaedic surgery for a patient with spastic diplegic cerebral palsy. In this patient’s case, it was utilized to correct his severe in-toeing, with the aim of surgery to correct excessive femoral neck anteversion. The surgical site is typically intertrochanteric, with the bone cut, rotated to the new position and held in place with screws or a blade/plate. Adverse effects of this surgery include infection, hardware failure, penetration of the hardware into the femoral neck, and delayed union (if NWB status is not maintained) for at least 6 weeks postoperatively.
Remember	13. Cerebral palsy occurs when there is abnormal development of the brain or damage to the developing brain. The damage can occur in utero, during the birthing process, or during the first month of birth (often following meningitis or a stroke). Triggers in utero may be bacterial or viral infections, or events that cause hypoxic events including placental abruption or a tight nuchal cord. Spastic diplegic CP is a diagnosis in patients whose lower extremities are affected, while their trunk and upper extremities are not. The most common cause of spastic diplegic CP is periventricular leukomalacia (PVL). PVL affects premature infants and presents with brain tissue death in the areas surrounding the ventricles. This area contains the long descending motor tracts as they travel from the motor cortex to the spinal cord. The motor tracts that control the lower extremities are closest to the ventricles and are more likely to be damaged and present as spastic diplegia. Patients with spastic diplegic cerebral palsy may have typical cognition, or a range of learning and cognitive deficits. 14. The patient has NWB orders for bilateral LEs. This is due to the extensive orthopaedic surgery they had. While the osteotomies are healing, the patient will remain NWB for at least 6 weeks or until radiographic signs of acceptable union of the bones have occurred.

Fig. 4.2 In bed positioning with hip abduction brace and bilateral LE short leg casts

Key points
1. Patients with spastic diplegic cerebral palsy may have varied medical and surgical interventions to affect the quality of their gait.
2. Working with a patient postoperatively poses challenges including monitoring lab values, monitoring pain and vital signs, and selecting appropriate and safe mobility options.
3. Interventions for acute care patients must incorporate all the body systems. Being mindful of the patient’s cardiovascular and pulmonary, integumentary, neuromuscular, and musculoskeletal needs will guide physical therapy interventions.

General Information
Case no.	4.B
Authors	Suzanne F. Migliore, PT, DPT, MS, Board-Certified Specialist in Pediatric Physical Therapy Karen Warenius, PT, DPT, C/NDT
Diagnosis	Spastic diplegic cerebral palsy, impaired functional mobility, balance gait, and endurance
Setting	Acute inpatient rehabilitation
Learner expectations	☑ Initial evaluation ☐ Re-evaluation ☐ Treatment session
Learner objectives	Interpret initial examination findings from the inpatient rehabilitation setting. Select appropriate physical therapy interventions based on initial examination findings. Create a discharge plan for the next phase in the continuum of care.

Medical
Chief complaint	“I need to get stronger and start walking.”
History of present illness	Patient is now 6 weeks status post orthopaedic surgery and bilateral SLC placement. Patient was discharged home from the acute care hospital 10 days after surgery and received 16 hours a day of home health aide and home care nursing while NWB on bilateral LEs. He had his SLC removed, had follow-up X-rays with orthopaedics, and referred to acute inpatient rehabilitation to start weight-bearing, gait training, and LE strengthening.
Past medical history	Attention-deficit hyperactivity disorder (ADHD); bladder incontinence; global developmental delay; learning disability; platelet dense granule deficiency; mild persistent asthma; Botox injections at ages 9, 10, and 11; and serial casting for bilateral gastrocnemius/soleus.
Past surgical history	Patient underwent bilateral femoral derotational osteotomies, bilateral adductor tenotomies, bilateral gastrocnemius recessions, left split tibialis anterior tendon transfer (SPLATT), and bilateral hammertoe corrections. Intraoperative bilateral femoral nerve blocks for postoperative pain management. He was placed on bilateral short leg casts (SLC) and a hip abduction wedge postoperatively.
Allergies	Ibuprofen (due to platelet dense granule deficiency)
Medications	Oxycodone, Acetaminophen, Diazepam, Baclofen, Fluticasone, Miralax, Dexmethylphenidate HCI
Precautions/Orders	Activity as tolerated WBAT BLEs