Case Study Pediatric Neurology
I Preamble information
This case was prepared by Marie Brien, physiotherapist in the Early Childhood Program
at the Ottawa Children’s Treatment Centre.
Both the parent (consenting for the child) and therapist agreed to have the case released.
The client’s name has been changed but none of the facts.
II. Opening paragraph
1. The client’s name is Anne Leclair. She is 2½ year old.
2. The client was assessed in physiotherapy in August 2005 at the Ottawa Children’s
Treatment Centre where she was followed till July 2006 in the preschool program.
3. She has a diagnosis of cerebral palsy, spastic diplegia, with involvement greater
on right side than left, caused by a hypoxic ischemic encephalopathy which
occurred at birth.
4. The role of the reader is to consider the diagnosis, the child’s age, the results of
the assessment and the parent’s priorities to determine the treatment goals. This
case also requires the use of the Gross Motor Function Classification System for
Cerebral Palsy (GMFCS).
III. Outline of the case by subtitle
1) Client’s background
Medical History
The client was born, outside of Canada, following a 40 weeks gestation. The
delivery was done by emergency C-section due to fetal heart rate decelerations.
She remained in Neonatal Intensive Care unit for 10 days and required
mechanical ventilation for 7 days.
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Previous physiotherapy intervention:
The client received very little previous physiotherapy intervention starting at one
year of age. Her family needed to travel to another country to receive services and
these were quite costly to them.
He doesn’t have any specialized aids or orthoses.
Social History:
During the summer of 2005, Anne, then 2½ years old, immigrates to Canada with
her family. She is then referred to the Ottawa Children’s Treatment Center for
assessment and treatment.
Anne is an only child and she is motivated to be mobile and to interact with her
peers. She has parents who are quite involved and who want to learn how to
promote their child’s development. They have registered her in the preschool
program of the Children’s Treatment Center.
Parent’s priority for their child:
The parents would like Anne to become independent in her mobility at home, at
the preschool and in the community so that she may be able to participate in
activities that she enjoys with her peers.
Objective Assessment :
Muscle tone: Presents with a moderate hypertonia in the right lower extremity, a
mild hypertonia in the left lower extremity and mild hypertonia in the right upper
extremity.
Gross Motor Function Measure-GMFM
Dimension A-Lying and rolling: 94%
Dimension B-Sitting:87%
Dimension C-Crawling and Kneeling : 82%
Dimension D-Standing: 21%
Dimension E: Walking, running, jumping: 4%
Total score: 57%
Description of gross motor function
-Assumes sitting independently and maintains sitting in « W-sit » (sitting with
legs flexed and in internal rotation) for play at floor level.
-She uses 4-point crawl as primary means of floor level mobility. She crawls up
and down stairs.
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-She pulls up to stand at a stable support with dissociation of her lower
extremities.
-She maintains a standing position briefly while holding onto a support and with
hips in flexion, adduction, internal rotation and equinus feet.
-If held at 2 hands by an adult, she will take up to 10 steps with lower extremities
in a dynamic extensor pattern.
Range of motion: (initial/maximal)
Hips- Abduction: 20º/35º
Popliteal angle: on left: -30º/-10º
on right : -55º/-20º
Ankle dorsiflexion: on left: -10 º/10º
(knees extended) on right: -20 º/0º
2) Specific Area of Interest
Using the above data from the assessment and the parent’s priorities, the reader must:
Identify 3 technical aids (including orthoses) which will be essential.
Determine 3 functional short term goals (to be achieved in the next 6 months).
Determine 3 functional long term goals (to be achieved in the next year).
Determine one long term goal aimed at preventing secondary impairment.
3) Specific Problem or Decision
Before proceeding with the determination of the goals, it is essential to identify
the client’s level on the Gross Motor Function Classification System for Cerebral
Palsy (GMFCS).
4) Conclusion
The client will be followed in physiotherapy on a weekly basis. In addition to direct
treatment with the client, the physiotherapist will play a consultative role with the staff in
the preschool that the child attends two afternoons a week. As well, a home program will
be provided and reviewed with parents on a regular basis.
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IV. The Data Requirements List (choice of answers)
Gross Motor Function Classification System for Cerebral Palsy
(GMFCS) level: level III
Identify 3 technical aids (including orthoses) which will be essential:
-Ankle-foot orthoses –A.F.O.
-Rear-style walker
-Adapted tricycle (adapted pedals, possibly an adapted seat)
-Standing frame (may be required to allow freeing of hands for play in standing)
-Manual wheelchair (for long-term goal)
Determine 3 functional short-term goals (to be achieved in the next 6 months):
-Anne will pull to stand at various supports in her environment while initiating with
lower extremity dissociation.
-Anne will maintain a standing position at a support, with a stable base, allowing her
to play with her peers at the preschool for periods of 5-10 minutes.
-Anne will cruise short distances along furniture and at various supports in her
environment (i.e. tables, sofa…) at home and at the preschool.
-Anne will walk short distances with a rear-style walker within the preschool room
and at home from one room to another with assistance from an adult for steering.
Determine 3 functional long-term goals (to be achieved in the next year):
-Anne will walk short distances outdoors within her neighbourhood with a
a rear-style walker.
-Anne will walk up and down stairs while holding onto a railing and adult’s hand at
home.
-Anne will pedal and steer a tricycle (with adapted pedals) for short distances in her
neighbourhood.
-Anne will obtain a manual wheelchair for her long distance mobility in the
community.
Determine one long term goal aimed at preventing secondary impairment:
-To maintain and/or improve muscle length in hip adductors, hamstrings, and
gastrosolei.
-To improve muscle strength in hip extensors and abductors and knee extensors in
gait.
-To improve cardiovascular endurance while moving in the preschool, at home and
in the community.
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V. Teaching Notes
A) Teaching Objectives
1) This case is written for the neurology course- pediatrics section.
2) Basic knowledge of cerebral palsy is essential.
3) This case requires the integration of notions of normal motor development,
neurology and orthopedics.
4) The student must have concepts of family-centered care and have the ability
to determine functional goals based on the context, the age of the child and
their GMFCS level.
B) Alternatives None provided
C) Actual Outcome
Anne obtained a rear-style walker and ankle-foot orthoses (A.F.O.) in the first few
months of her follow-up. During the course of the year, she received BOTOX injections
in the gastrosolei, hamstrings and hip adductors to allow for improved muscle length.
Her ability to wear the orthoses and to dissociate her lower extremities in transitions and
during gait was improved. She presents with greater hip and knee extensor control in
standing and in ambulation. Anne plays in standing at furniture with her friends at the
preschool for periods of up to 10 minutes, cruises along furniture and uses her rear-style
walker indoors after 6 months.
By the end of the year of follow-up, she uses her rear-style walker for short distances
outdoors and a manual wheelchair has been ordered for her long distance mobility. She
pedals a tricycle with adapted pedals (with velcro) to get to the park near her home.
D) References
The Gross Motor Function Measure (GMFM-66 & GMFM-88) User's Manual
(Russell, D., Rosenbaum, P., Avery, L. & Lane, M.) Clinics in Developmental
Medicine No. 159, 2002. Published through Mac Keith Press in the U.K. and
distributed through Blackwell Publishing.
http://www.canchild.ca/Portals/0/outcomes/pdf/GMFMscoresheet.pdf
THE GROSS MOTOR FUNCTION CLASSIFICATION SYSTEM FOR
CEREBRAL PALSY, Robert Palisano, Peter Rosenbaum, Stephen Walter, Dianne
Russell, Ellen Wood, Barbara Galuppi
Référence : Dev Med Child Neurol 1997; 39 :214-223
http://www.canchild.ca/Portals/0/outcomes/pdf/GMFCS.pdf
