|Year : 2015 | Volume
| Issue : 2 | Page : 127-130
Journey of a child with spastic diplegic cerebral palsy from doldrums to hope
Divya Midha, Manisha Uttam, Megha Neb
Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar University, Mullana, Ambala, Haryana, India
|Date of Web Publication||7-Jan-2016|
Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar University, Mullana, Haryana
Source of Support: None, Conflict of Interest: None
This case study describes the physical therapy of a 9-year-old male child with spastic diplegic cerebral palsy with the aim to improve his gross motor function and social skills. The child had severe impairments across the full spectrum of developmental functions, especially affecting the gross motor and self-care functions at Stage V of gross motor function classification system (GMFCS) in spastic diplegic cerebral palsy. His body was completely stiff with marked asymmetrical spasticity in lower limbs, truncal dystonia, and chest deformity with cardio respiratory complications. The physical therapy was performed by giving sessions of Roods approach, sensory integration, and static weight-bearing exercise for a period of 9 months. Pre- and post-therapy evaluation of child was done using GMFCS. There was an improvement in the child with his social skills, transitional activities, activities of daily living, and gross motor skills, reaching to Stage IV with the 9 months physiotherapy intervention given by a neurological physical therapist.
Keywords: Cerebral palsy, diplegia, spasticity
|How to cite this article:|
Midha D, Uttam M, Neb M. Journey of a child with spastic diplegic cerebral palsy from doldrums to hope
. Indian J Cereb Palsy 2015;1:127-30
| Introduction|| |
Spastic diplegia is one of the most common clinical subtypes of cerebral palsy.  Gross motor function classification system (GMFCS) is a standardized method to classify gross motor function in children with cerebral palsy.  The system has five levels that are based on differences in self-initiated movements, with particular emphasis on sitting, standing, and walking. 
Bartlett and Palisano (2000) emphasized to identify factors contributing to change in basic motor abilities of children with cerebral palsy, which can be optimized to improve the long-term outcomes of intervention.  The aim of the present study was to evaluate changes in the full spectrum of developmental functions including gross motor development and social skills.
0The present case is presented to show the effect of physical therapy on severely affected child using GMFCS as measurement scale pre- and post-therapy. The patient was a 9-year-old boy with spastic diplegia functioning at GMFCS Level V. As per medical records provided by family members, patient was born as full term baby with a birth weight of 1500 g and hospitalized in the Neonatal Intensive Care Unit (NICU) for 1 month as he was diagnosed with meconium aspiration syndrome. He required mechanical ventilation and was later referred to the NICU follow-up clinic. Child was diagnosed as having spastic diplegic cerebral palsy at the age of 2 years and physical therapy was started only after 9 years of age.
The child in this study had impairments across the full spectrum of developmental functions, especially in gross motor and self-care functions. He was malnourished, had malaligned teeth with frequent drooling of saliva. He used to attain hyperextension posture at the level of neck and whole spine use to go in to complete arching position with any external touch on his body and with any loud noise in the surroundings. He had marked asymmetrical spasticity, in all the extremities (left arm least affected), truncal dystonia at rest that increased with action. His chest had pigeon shaped deformity, due to which many cardio respiratory complications developed. Social skills did not develop in proportion to his age. He lacked ability to recognize his mother. Pretreatment and post treatment child's evaluation was done using GMFCS at baseline and after 9 months of therapy.
The child received PT 3 days a week for 40 min for the period of 9 months in physiotherapy OPD by a skilled physiotherapist specialized in the field of neurological physiotherapy. Therapeutic sessions were started with the aim to develop his head and neck control. Rood's approach was given to facilitate neck extensors using various aids such as brush and ice followed by Swiss ball to and fro exercises, and thumping activities were also done on him. To inhibit hyperextension posture sensory integration therapy was given to the child by keeping him in prone position on different platforms such as Wobble board, Bolster, and Swiss ball as shown in [Figure 1]. The patient's PT sessions were structured to challenge his dynamic balance by encouraging movement transitions to develop his automatic righting reactions and equilibrium reactions in different positions.
Static weight bearing (SWB) was performed by placing the child in standing frame for 5 min daily initially which was increased gradually with the practice of the child. Task-specific gentle loading was given to child's body to alter force distribution in different directions to guide the patient to adapt himself to a new situation. The child's parents were active participants and they consistently followed him with his home program activities. These included working on the movement transitions, trunk dissociation exercises, SWB exercises, etc., as shown in [Figure 2], with appropriate guarding for safety. The child was made to perform different activities on different days that helped them to maintain the child's interest in home therapy.
| Results|| |
There was improvement in Gross motor functions and social skills of spastic diplegic CP child after the intervention in various outcomes such as head and neck control, posture, static weight bearing and social skills which are discussed in [Table 1]. Child also became less irritable on tactile stimulation to his body. Social Smile got develops in the child and he got acclimatized with people in the surroundings following the physical therapeutic measures.
|Table 1: Improvement in gross motor functions and social skills of spastic diplegic cerebral palsy child after the intervention in the following outcomes |
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| Discussion|| |
The primary goal of treatment for the present case was to prepare the child for his greatest possible independence in the various activities involving gross motor functions.  Neuro-rehabilitation approaches are important for treatment of a cerebral palsy child to prevent postural abnormalities, sensory deficits, gross motor dysfunction, and to increase functional capacity. ,
In the present case, the child's treatment was based on therapeutic techniques of Roods approach, sensory integration therapy, and SWB. Lack of head and neck control is the most common complication in CP. Since such children lack language abilities to respond to direct commands. Sensory feedback techniques are appropriate techniques for them to provide immediate and consistent information related to specific motor skills.  In 1950, Margaret S. Rood, a physical therapist used sensory stimuli like stroking or brushing at a given speed and for a given duration for activation of a phasic muscle response. In the present case, brushing and stroking was given for facilitation of head and neck extensors for gaining head and neck control in the child. 
Sensory integration therapy is an active therapy involving activities with use of equipment such as big rolls and Swiss balls, swinging hammocks, which provide intense proprioceptive, vestibular, and tactile inputs to the patient. It is a process occurring in the brain that enables the child to make sense of their world by receiving, modulating, organizing, and interpreting the information that comes to their brains from their senses. 
SWB exercises are widely used for children with cerebral palsy. For the lower extremities SWB is achieved by positioning child in a standing frame. It prevents tightness or contracture of soft tissue, restores length of the muscles by prolonged stretching, reduces spasticity by inhibiting motor neuron excitability through prolonged stretch and compression on the muscle spindles, Golgi tendon organs, and joint receptors.  Severe consequences in a cerebral palsy child can be prevented with early diagnosis and comprehensive physiotherapy intervention.
In the course of 9 months of physiotherapy treatment, child developed his head and neck control and there was no more head lag present. Voluntary control of the trunk muscles was developed by providing sensory inputs to his body in the form of tactile, proprioceptive, and vestibular stimuli that helped him to attain sitting position on his own, SWB helped in reducing stiffness in the back and also there was significant reduction in the overall muscle tone.
| Conclusion|| |
With the application of various therapeutic techniques such as Roods approach, sensory integration, and static weight bearing therapies, an improvement was brought (GMFCS Level V-IV) in the gross motor functions as well as the child's social skills. Child may also become less irritable on tactile stimulation to his body. Social Smile may also develop in the child and he may get acclimatized with people in the surroundings following the physical therapeutic measures.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]