This 19 y/o young man was seen today for a Physical Therapy consultation. This patient is known to me-I had seen him at Kids in Motion for several years when he was of pre-school age. Jaime presents with spastic diplegia-cerebral palsy, and has just moved back into
the Midwest to continue his studies. He ambulates independently without a device, and has just secured his own apartment. Jaime is concerned over his physical status, especially with the physical effort and exhaustion in walking even short distances.
In 2004, Jaime received adductor and Achilles tendon releases in Chile. He was unclear about hamstring or hip flexor releases as well.
GAIT Very labored. Severe crouch gait. Speed is remarkably functional. even though step lengths are severely limited to 6 inches each side, Advances feet via hip hiking and swiveling at the 1umbar 5pine. To keep up his speed, Jaime is expending an extraordinary amount of energy by using a jogging cadence even while his walking companions are taking a leisurely stroll. Real concern over long term spine integrity.
Feet extremely pronated. Knees in valgus, right more than left. Stands with feet behind the gravity line, knees flexed and adducted. Can barely separate legs to take steps. Can do stairs, but does them with even more exaggerated knee valgus as he descends and ascends. Circumducts legs in both cases.
Little isolated hip flexion in walk or stairs. Endurance a real issue- quite out of breath even after a short 30 foot walk. This may account for Jaime’s account that he really eats huge meals, but has a hard time keeping his energy up. He presents as a thin, but well proportioned, young man in the trunk area, with overdeveloped quads (as he tries to hold himself up against gravity) and lower legs with inadequate bony growth and muscle deve1opment.
STRENGTH
It is very dear that Jaime has put forth massive effort throughout the years in his physical therapy program. Surprisingly, he truly has a grade 4 out of 5 strength in his dorsiflexors, quads, hips flexors, gluteals and abdominals when tested in supine; and throughout his shoulder girdle when tested in sitting. No problems initiating or sustaining muscle contractions. Brisk coordination. He plays guitar and is able to oppose thumb to each finger even in overhead positions. Strengthening should no longer be his main concern, except for his calf muscle groups and feet. I did encourage Jaime to join a gym and begin working with a physical therapist on proper use of weight equipment to continue his strengthening efforts. Beautiful sitting balance, with quick equilibrium responses. Jaime could take my maximal challenges to balance in quarduped in all planes. Very strong, stable trunk, as reflected in his ability to stand truly still without the typical excessive side-to-side weight shifts typically found in individuals with cerebral palsy.
ROM
Herein lies my main concerns. Note that when Jaime was lying at rest in supine, he was truly out of breath, even after resting for 10-15 minutes as I tested his ROM. Upon further exam, it was noted that Jaime’s rib excursion was extremely poor throughout his thorax. He was unable to fully inflate his lungs, and he was over-dependent upon his diaphragm, for breath support. Chest expansion was obviously poor due to the real tightness found throughout his trunk.
Although Jaime used great effort and strength to lift his arms overhead, he presents with 15 to 20 degree elbow flexion contractures, and shoulder abduction and overhead flexion of only 160 bilaterally, again due to tightness throughout the shoulder girdle.
In sitting, cannot do side bends with his trunk at all-lateral flexion range in the thoracic spine almost zero. In sitting, could actively rotate trunk to left to 50-60 degrees, but could not rotate trunk to right more than 10 degrees at most, again due to tightness throughout.
Lumbar spine is hyper mobile as Jaime compensates for complete lack of pelvic femoral dissociation.
With great effort in standing, using upper extremity support on wall, Jaime can raise each knee and flex hip up 55 degrees max upwards when asked. Normally, a young man should easily be able to flex hip in single-leg stance to at least 120 degrees easily. Hamstring tightness really impedes ability to flex hip and take forward steps during gait. In fact, during gait, Jaime could only flex each hip 10- 20 degrees, resulting in the very severely limited step lengths described above.
Note severe contractures throughout lower extremities.
-Hamstrings Length Test – Missing 90-100 degrees of the normal 180 degrees of expected range.
-Thomas test – Missing 30-40 degrees of hip flexor range bilaterally.
-Hip abduction -limited to 10-15 degrees bilaterally.
-Dosiflexors- Contracted. Cannot passively plantarflex feet beyond 15 degrees bilaterally.
-Feet – Severe pronation. Valgus deformity in midfoot. Hallux valgus bilaterally to the point where 2nd toe has been pushed into flexion on left foot.
-Calcaneous – Downwardly tipped.
-Leg Length Discrepancy- Left tibia shorter than right. Appears left femur shortened also, but could be due to pelvic obliquity so could not be sure on this one-time consultation. The fact that the left tibia is shorter is obvious, and Jaime would benefit from a shoe lift. Further dynamic balance evaluation needed to determine amount of lift, but I would start with a 1/4 inch and recheck for changes to stand and gait balance.
Summary. This very strong young man is putting forth massive effort each and every day to walk and move despite his very severe contractures throughout his lower legs, and despite his moderate plus limitations in his trunk and upper extremities. This effort is already taking a strong toll on his respiratory system and his breathing is compromised. Simply speaking, Jaime is working much too hard to make it through the day. Because of his wonderful determination and young age this has not stopped him as yet, but as he ages, he will find that he must limit his activities more and more.
It is essential that all efforts are made to free his body of his many severe range of motion restrictions, and to manage his spasticity medically so that they do not return.
Jaime’s is in need of direct attention to the movement limitations of his ribcage, so that his breathing may become more efficient.
Finally, orthotic management and strengthening of the lower legs must also commence, in a step-by-step manner, so that the ankle, foot and knee pain and early arthritis that is typical for young adults with CP and poor joint alignment can be delayed or averted. Jaime is at extreme risk for early and severe joint pain as he gets older. ,
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Recommendations
1. Jaime must immediately seek out an orthopedist with extensive experience in cerebral palsy in his area.
2. Also, he must immediately connect with a spasticity management clinic, where the options of Baclofen (oral or pump) or Artane or other similar drug management can be explored. Botox is also an option for those muscle groups that are in need of extra attention, but the fact that he presents with real tightness throughout his body necessitates that he also explore systemic spasticity management with his physicians. There are excellent referral sources in the Chicago area, if the family desires.
3. Physical therapy should begin once medical management is in place, so that long-lasting results can occur. Note that only 3 years after his last orthopedic surgery, Jaime again presents with adduction contractures. To avoid repeat procedures, and resultant weakening of vital muscle groups, it is important that Jaime receive physical therapy and medical spasticity management in concert. This young man has worked very hard in the past, and wou1d like to see physical therapy supported by medical management.
4, Therapy should be done witl1 someone well-versed in soft tissue, manual therapy and myofascial release techniques, with the main goal of radically improving all muscle ranges. At this point in his lifespan, an NDT trained therapist is not needed. Rather, a therapist with advanced orthopedic techniques is recommended.
5. Orthotic management should also commence, starting perhaps with simple UCBL’s, and moving on up to SMO’s. Bracing to the AFO level is highly recommended against, as it will cause atrophy of the calf group and even more long-term problems remaining upright throughout Jaime’s life. Rather the crouch gait should be approached by achieving proper hamstring and hip flexor lengths, and following up with much calf strengthening, i.e. stair work and push activities, including toe flexor strengthening.
Please do not hesitate to contact me with any questions. My phone number is 800-555-0000.
Jon H Doe, PT, PCS