Two Months of Catching Up Walking Ability in

3-Year-Old Girl with Spastic Diplegic Cerebral Palsy:

Comprehensive Rehabilitation Program Involving the Family

T. Takwarif

, R. K. Wardhani

Department of Physical Medicine and Rehabilitation, Cipto Mangunkusumo Hospital,

University of Indonesia, Jakarta, Indonesia

Keywords: Cerebral Palsy, Diplegic, Rehabilitation, Comprehensive, Family, Home-based, Walking Ability

Abstract: A 3-year-old girl was presented to our clinic with a chief complaint of not being able to stand and walk

unsupported. She was born prematurely on 31 weeks of gestation and was diagnosed with spastic diplegic

cerebral palsy (CP) at the age of two years. During supported standing, she still had noticeable equinus on

both of her feet. We gave comprehensive rehabilitation consisted of a hospital-based and home program.

Hospital-based management was done two times per week included dynamic neuromuscular stabilization

(DNS) technique and conventional exercise such as stretching, strengthening, and postural control exercise.

The home program was done three times per day consisted of DNS, swimming, cycling, standing in an

inclined surface, squat to stand exercise and stretching exercise. After two months of a rehabilitation

program, she was able to stand unaided and walk 2-3 steps independently. We also added botulinum toxin

injection on her gastrocnemius muscle and hinged AFO prescription to improve her walking ability.

Comprehensive rehabilitation program involving healthcare providers and family is an effective approach in

catching up walking ability in a patient with spastic diplegic cerebral palsy.

1 INTRODUCTION

Cerebral Palsy (CP) applies to a non-progressive

neurodevelopmental disorder caused by an insult to

the developing brain, in which the primary clinical

manifestation is a motor deficit. A total of 17 million

people are estimated to have cerebral palsy with

worldwide prevalence is approximately 2.11/1000

live births (Sharan et al., 2016). CP patients have a

nonprogressive brain lesion accompanied by motoric

clinical manifestation that may change over time

during their growth and development. Spastic

diplegia cerebral palsy is a form of CP, with affected

people have increased muscle tone which leads

to spasticity in the muscle (Azar et al., 2015).

In rehabilitation of children with cerebral palsy

(CP), varying approaches and techniques are used,

ranging from very conservative and conventional

techniques, such as muscle strengthening, manual

stretching, and massage, to more complex motor

learning-based theories, such as neurodevelopmental

treatment, conductive education, and several others

(Balci, 2016).

Even though the loss of brain function in CP

cannot be fully recovered, the evolving medical

intervention has been able to reduce secondary

complications and increase patient participation in

activities of daily living. However, the management

of CP is complex and must be tailored to each

specific individual due to the wide variance between

CP cases (Jan, 2006; Kolar et al., 2013). Of the

medical management strategies for CP,

rehabilitation plays a key role in managing

symptoms, preventing secondary complications, and

improving the child’s self-care abilities and

independence (Kolar et al., 2013).

Rehabilitation of CP comes in two forms: home-

based and hospital-based treatment. Several studies

have shown that home-based treatment gives a

beneficial result and a lot more cost-effective than

hospital-based treatment (Azar et al., 2015).

Comprehensive rehabilitation therapy requires a

multidisciplinary approach that includes family and

Takwarif, T. and Wardhani, R.

Two Months of Catching Up Walking Ability in 3-Year-Old Girl with Spastic Diplegic Cerebral Palsy: Comprehensive Rehabilitation Program Involving the Family.

DOI: 10.5220/0009090603470350

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 347-350

ISBN: 978-989-758-409-1

347

healthcare providers. Both parties are needed to

establish a suitable approach to reach a desirable

goal (İçağasıoğlu et al., 2015).

CP rehabilitation treatment is intended to reduce

or prevent secondary musculoskeletal complications

rather than the primary neurological deficit. Most

rehabilitation strategies are based on the principle of

neuroplasticity, postural control, balance, muscle

stretching and strengthening (Azar et al., 2015).

Rehabilitation is aimed to reach optimal physical,

sensory, intellectual, psychological, and social

function (Balci, 2016). There is no scientific

evidence to compare the benefit of one strategy to

another. The duration and frequency of each therapy

have not yet been established. This study aims to

investigate the result of comprehensive rehabilitation

therapy consisted of home-based and hospital-based

rehabilitation, combined with orthotic use and

botulinum toxin injection to improve walking ability

in children with cerebral palsy.

2 CASE PRESENTATION

A 3-year-old female child was presented to pediatric

rehabilitation outpatient in November 2018 with a

chief complaint of walking difficulty. She was

already able to stand up on her toes, with her hand

grasping the surroundings to stabilize her body.

However, she could not yet walk independently and

still needed aid or support to transfer herself from

sitting to standing position.

She was born at 31 weeks gestation and later

diagnosed with spastic diplegic CP since birth due to

preterm delivery. From history-taking, we found that

the patient had delayed motor development as

summarized in Table 1. She had undergone

physiotherapy at her previous hospital since she was

1,5 years old. Nevertheless, by the age of 3 years,

she still required assistance in standing up from a

seated position and was unable to ambulate unaided.

Thus, her parents wanted to seek a second opinion

and for re-evaluation from our department. She had

a previous history of congenital talipes equinovarus

(CTEV), which was successfully treated by casting.

Spina bifida was not found in this patient. Currently,

she uses bilateral solid ankle-foot orthoses (AFO) to

walk.

Table 1. Patient’s initial gross motor development

milestones

Milestone Age

Rolling 6 months

Sitting unaided 10 months

Standing up by holding the hand 1 year

Standing up unaided Unable

Walking Unable

On physical examination, her general status was

found to be normal. She had full ROM in all the

lower extremity muscle groups. Motor strength

examination revealed apparent Manual Muscle

Testing (MMT) of 4 on her bilateral hip extensors,

hip flexors, knee extensors, and knee flexors; MMT

of 1 on her bilateral ankle dorsoflexors. Spasticity

was found in both gastrocnemius muscles

(Australian Spasticity Assessment Scale / ASAS 3

for her right gastrocnemius and ASAS 2 for her left

gastrocnemius) with positive Silfverskiöld test.

There was no spasticity on her upper extremities.

Both Thomas and Ely’s test results were negative,

indicating no tightness or spasticity in the hip

flexors. She required assistance in standing up.

While standing up, ankle valgus and slight pronated

foot were observed along with pes equinus posture

and a forward shift of the trunk. She had poor hip

control and was unable to ambulate independently.

The patient scored 0 on the standing dimension and

3 on walking dimensions of the Gross Motor

Function Measure (GMFM) at the initial

examination.

A comprehensive medical rehabilitation program

consisted of hospital-based and home-based

rehabilitation was given to the patient. The hospital-

based rehabilitation program was done twice weekly

involved Dynamic Neuromuscular Stabilisation

(DNS) technique and also a conventional exercise

included stretching exercise, strengthening exercise,

and postural control exercise. DNS technique for

this patient included trigger zone activation started

with trigger zone stimulation in the 5th-6th

intercostal space and the anterior superior iliac

spine. As a part of this technique, we also gave the

developmental position in 5 months old child

position (patient in the supine position, raising and

flexing both hips and knees). DNS lasted for 20

minutes each session. Home-based rehabilitation

program including bicycle training, swimming, squat

to stand exercise, manual stretching, standing with

backslab. DNS was also prescribed as a home

program, which was done by her mother for 20

minutes, three times daily. The patient went

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

348

swimming twice weekly for 30 minutes since the

start of the program. Her mother also manually

stretched her muscles especially gastrocnemius

muscle twice daily with 30 repetitions per session.

Two months in the program, she could move

from sit to stand independently. She could stand

unsupported for 5 minutes without backslab, and

more than 15 minutes when using backslab. She was

able to walk independently for 2–3 steps unaided

using solid AFO she got from the previous hospital.

At that time, she scored 10 in standing and 9 in

walking dimensions of GMFM.

We continue all of the programs. For the DNS

technique, we added stimulation on her lateral

calcaneus. We also added walking exercise

unsupported or supported with the chair as a home

program exercise.

Re-evaluation at six months after the

rehabilitation started showed improvement in

postural control and walking function. She could

stand unaided for 30 minutes. She was able to walk

for 100 meters unaided and able to cycle her tricycle

unaided. To optimize her gait, we changed her

previous solid AFO to hinged AFO. We gave her

botulinum toxin injection on her bilateral

gastrocnemius muscles to reduce her spasticity. Her

scores on the GMFM standing and walking

dimensions also improved to 27 and 20,

respectively.

This case report showed walking ability

improvement that was achieved two months after the

rehabilitation program started. The better function

was remarkable after 6 months of rehabilitation.

3 DISCUSSION

Spastic diplegic CP in our patient was confirmed

with existing movement and postural control

disturbance that caused gross motor development

delay since her early life. Prematurity was suspected

as a risk factor of cerebral palsy in this patient.

The patient came to our clinic in non-ambulatory

conditions despite having already received

rehabilitation treatment from another hospital since

the age of 1,5 years old. She could only stand up

aided at the time of the first presentation. After she

came to our clinic, comprehensive rehabilitation

treatment consisted of a hospital-based and home-

based program that was given to the patient. We

choose to collaborate with family members to

establish family-centered models to improve her

walking ability. A successful collaboration between

health care professionals and family members has

been reported to give a good result in pediatric

rehabilitation settings. This method needs good

communication between both parties which include

effective information exchange, competency of

health care professionals in identifying both the

patient and family's needs and potentials, and the

determination of family members to be involved in

the program. This approach allows us to deliver an

effective rehabilitation service that suits each family

because every family is different (Balci, 2016).

For the hospital-based program, we prescribed

two times weekly DNS treatment lasted for 20

minutes each session. Her DNS program mainly

involved stimulation by activating specific trigger

zones. Trigger zone stimulation involves the

activation of various muscle groups that contributes

to postural control. It stimulates the brain to learn to

use the appropriate muscles in a specific postural

task and strengthen the muscles involved, which can

potentially improve postural control. A study

investigating the effect of DNS in CP patients

showed significant improvement in activation of the

transverse abdominal muscle and the internal

oblique muscle, both of which play a central role as

core stabilizers, thus contributed to improved

postural control in our patient (Kolar et al., 2013).

We also gave the conventional exercise to reduce

equinus, strengthen the muscles, and reach good

postural control.

The home program consisted of DNS,

swimming, cycling, standing in an inclined surface,

squat to stand exercise and stretching exercise.

These exercises increased her overall

cardiorespiratory endurance, coordination, sensory

input, and strength. Research on home-based

physical exercises for muscle strengthening had

shown improvement in gait pattern for children with

cerebral palsy when was done daily for 6 weeks in

young CP patients between eight and eighteen years

old (Patrícia et al., 2012). Swimming is a type of

aerobic exercise also contributed to ameliorating

overall walking ability, accounted for the

improvement in cardiorespiratory endurance. Even

though limited evidence was found on how manual

stretching could improve walking ability, research

has shown that stretching could reduce spasticity.

For this reason, we still prescribed stretching

exercises to the patient (Pin, Dyke, and Chan, 2006;

Novak et al., 2013).

She demonstrated type 3 gait deviation according

to Amsterdam Gait Classification (Becher, 2002),

shown by knee hyperextension and heel rise during

the midstance phase. We chose to change his

orthotic treatment using hinged AFO. Hinged AFO

Two Months of Catching Up Walking Ability in 3-Year-Old Girl with Spastic Diplegic Cerebral Palsy: Comprehensive Rehabilitation

Program Involving the Family

349

is indicated for ambulatory, active children which

we hope to be able to walk up the stairs. This type of

orthosis increases stance stability, normalize the first

contact, and control knee stability. It increases

dorsoflexion which in turn decreases genu

recurvatum and increases toe clearance. Hinged

AFO corrects equinus and provides energy-efficient

gait (Miller, 2005; Ofluo, 2009).

We gave a botulinum toxin injection to decrease

her spasticity in bilateral gastrocnemius muscles.

Botulinum toxin has been proved to be an effective

drug to relieve spasticity by multiple trials (Kaushik

et al., 2018). A systematic review involving several

good quality Randomized Controlled Trials have

investigated the outcome of injection of botulinum

toxin for equinus with positive results utilizing

objective outcome measures (Love et al., 2010).

Improvement in walking and postural control

was shown after two months of rehabilitation. A

remarkable improvement was noticed after six

months of rehabilitation; she could stand for 30

minutes unaided, cycle her tricycle independently,

and able to walk for 100 meters unaided. These

improvements were achieved from a comprehensive

hospital rehabilitation program and support from the

family to comply with the home program.

There was no adverse effect identified during the

study.

4 CONCLUSIONS

A hospital-based and home-based rehabilitation

program is an effective approach for patients with

CP. We gave DNS technique, hinged AFO,

botulinum toxin injection, and conventional

exercise. We also encouraged the family to do the

home program. DNS is a new method that can be

applied as hospital-based and home-based treatment.

Family support is an important aspect of a successful

rehabilitation program. This case report shows the

result of comprehensive rehabilitation treatment

involving both healthcare providers in hospital-

based setting and family as a caregiver in a home

setting.

REFERENCES

Azar, E. S. et al. 2015. ‘Home-based versus center-based

care in children with cerebral palsy: a cost-

effectiveness analysis', Journal of medicine and life,

8(4), pp. 245–251.

Balci, N. C. 2016. ‘Current Rehabilitation Methods for

Cerebral Palsy’, in Gunel, M. K. (ed.) Cerebral Palsy -

Current Steps. Croatia: Intech, pp. 51–78.

Becher, J. G. 2002. ‘Pediatric Rehabilitation in Children

with Cerebral Palsy ’:, JPO Journal of Prosthetics and

Orthotics, 14(4), pp. 143–149.

İçağasıoğlu, A. et al. 2015. ‘Rehabilitation outcomes in

children with cerebral palsy during 2 years', J. Phys.

Ther. Sci., 27(10), pp. 3211–4.

Jan, M. M. . 2006. ‘Cerebral palsy: Comprehensive review

and update’, Annals of Saudi Medicine, 26, pp. 123–

32.

Kaushik, P. S. et al. 2018. ‘A randomized control trial of

botulinum toxin A administration under ultrasound

guidance against manual palpation in spastic cerebral

palsy', Journal of Pediatric Neurosciences, 13(4), pp.

443–447. DOI: 10.4103/JPN.JPN_60_18.

Kolar, P. et al. 2013. Clinical Rehabilitation. Edited by P.

Kolar. Prague: Alena Kobesova.

Love, S. et al. 2010. ‘Botulinum toxin assessment,

intervention, and after-care for lower limb spasticity in

children with cerebral palsy: international consensus

statement', Eur J Neurol, 17(Suppl. 2), pp. 9–37.

Miller, F. 2005. Cerebral Palsy. New York, US: Springer-

Verlag. DOI: 10.1007/b138647.

Novak, I. et al. 2013. ‘A systematic review of

interventions for children with cerebral palsy : state of

the evidence Study design', Developmental Medicine

& Child Neurology. DOI: 10.1111/dmcn.12246.

Ofluo, D. 2009. ‘Orthotic management in cerebral palsy',

Acta Orthop Traumatol Ture, 43(2), pp. 165–172.

DOI: 10.3944/AOTT.2009.165.

Patrícia, P. et al. 2012. ‘Cerebral palsy - lower limbs :

rehabilitation’, Acta Fisiatr, 19(2), pp. 114–122. doi:

10.5935/0104-7795.20120018.

Pin, T., Dyke, P. and Chan, M. 2006. ‘The effectiveness of

passive stretching in children with cerebral palsy’,

Dev Med Child Neurol, 48, pp. 855–62.

Sharan, D. et al. 2016. ‘Neuromusculoskeletal

Rehabilitation of Severe Cerebral Palsy’, in Gunel, M.

K. (ed.) Cerebral Palsy - Current Steps. Croatia:

Intech, pp. 141–172.

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

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