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4th Case Presentation

August 3rd, 2018

HABILITATION OF
CEREBRAL PALSY SPASTIC QUADRIPLEGIC
WITH MOBILIZATION, ADL, COMMUNICATION DISTURBANCE
AND VISUAL IMPAIRMENT

Meinar Ferryani, MD

Supervised by:
Ellyana Sungkar, MD, Physiatrist
Arnengsih, MD, Physiatrist

DEPARTMENT OF PHYSICAL MEDICINE AND REHABILITATION

FACULTY OF MEDICINE PADJAJARAN UNIVERSITY
HASAN SADIKIN HOSPITAL
BANDUNG
2018
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CASE REPORT

IDENTITY
Examination date : April 29nd 2017, 10.00 am
Name : TS
Sex : Female
Age : 11 months old
Religion : Moslem
Referral diagnosis : Cerebral Palsy Spastic Type + Microcephaly ec
Disgenesis Cerebri

ANAMNESIS (April 29nd 2018) (hetero anamnesis: patient’s mother)

Chief Complaint
Unable to roll from supine to prone by herself
History of Present Illness
The child is unable to roll from supine to prone position by herself . If her mother
puts her in prone position she can lift her head only for a few second but not in
straight position. She also can’t rest on her elbow in prone position. If her mother
pulled her to sit from supine position, she can’t held her head in plane with the body.
The child can’t reach and hold things (toys) that her mother gaved although her
hands are mostly open. She can’t hold bottle and differentiates between her family
and new person. She will respond to direct sound that is given to her. She can only
say “aaaa” or “daaa” and she will cry whenever she wanted something. Sometimes
she gives respond to visual stimuli by following or seeking the bright color toys
near her eyes for a few second.

Prenatal History:
TS is the 1st children, from 19 year old mother and 20 year old father. The
pregnancy was expected. During pregnancy, her mother had antenatal care
regularly to the midwife and regularly took the vitamin given. At the age of 3
month of pregnancy, the mother had fever for three days without hospitalization.
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At the age of 6 month of pregnancy, she had USG (Ultrasonography) examination

and the doctor said that the baby had hydrocephalus abnormalities and referred to
Hasan Sadikin hospital. History of consuming herbal or drug is denied. History of
bleeding, seizures, trauma, smoking cigarette, drinking alcohol were denied. No pet
was in or near the house.

Perinatal History:
Patient was born prematurely on 34 weeks of pregnancy, delivered per
vaginam at Hasan Sadikin Hospital, and she cried right after birth without bluish.
Birth weight was 2800 grams and birth length 46 cm but her mother forgot about
the head circumference. Patient could done the breast feeding to her mother without
difficulties.

Postnatal History:
After patient was born, she was consulted to Neurologic Surgeon Department
for the hydrocephalus. She had CT scan examination and since there was no
increasing in hydrocephalus size, the patient asked to continue the treatment in
Pediatric Department. Patient got seizure without fever at 7 months of age and was
given Sodium Valproate medicine. Before the seizure, until age of 6 months, she
still unable to roll from supine to prone position by herself. Since she got
medication, the seizure has resolved.
Patient was consulted to PMR department for the first time by Pediatric
Department on October 2017 with the diagnoses were Cerebral Palsy Spastic Type
+ Microcephaly ec Disgenesis Cerebri, and she had physiotherapy once a week
since then.
Patient got BERA examination for her hearing evaluation and both of hearing
function was normal. Patient also got eye examination at Cicendo Hospital, and
asked to continue the examination after the age of 15 months.

Developmental History
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Side lying : 8 months

Nutritional History:
Breast Milk : birth— now
Rice Porridge : 7 months – now. She is given 3x/day
She eats meal 3x/day. She finishes her food around 15 minutes. Snacks of ± 100 g
of papaya. She finish her snack within 10 minutes. Feeding is in supported sitting
position. No history of choking. There is no problem with bowel function.

Immunization History:
Complete

Behavioral History
Time Activities
06.00 am Wake up
06.00 - 06.15 am Breast feeding
06.45 - 07.30 am Lying in bed
07.30 – 08.30 am Flexibility Exercise
08.30 - 09.00 am Takes a bath
09.00 - 09.30 am Breakfast : rice porridge one small bowl and take medication
09.30 – 11.00 am Playing with her mother and eat snack : fruits/biscuits
11.00 - 12.00 pm Takes a nap
12.00 - 13.00 pm Playing with her mother
13.00 – 13.30 pm Lunch : rice porridge one small bowl
13.30 - 15.30 pm Playing with her mother and eat snack : fruits/biscuits
15.30 - 16.00 pm Takes a bath
16.00 - 17.00 pm Flexibility Exercise and strengthening head-neck control
17.00 - 17.30 pm Dinner : rice porridge one small bowl
17.30 - 18.30 pm Playing with her mother
18.30 – 19.00 pm Breast feeding
19.00 – 06.00 pm Sleep

Psychological, Social, and Economic History:

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She lives with her parents and her grandparents in two level house of ± 110
m2 with 4 bedrooms, a kitchen, 2 bathrooms and 1 living room. Both of her parents
are graduated from senior high school. Her father works in garment business, with
income approximately 1.500.000 rupiah per month. Her mother is a housewife. Her
grandparents always give support for taking care of her. She mostly stays at home
playing with her mother. Her family uses BPJS non PBI for medical insurance.

Parents’ Expectation:
Her parents desires her to be healthy, can sit and walk and develop like other
children.

PHYSICAL EXAMINATION (April 29nd 2017, 10.00 am)

She was put in a supine position. Her hands mostly opened although sometime still
hold in fist. She is unable to hold thing that her mother given to her. In prone
position, she can lift her head for few second. She turned her head towards the
sound. She give slow respon when we give bright color of toys in front of her eyes.
She only makes sound “aaaa” and “daaa”.

Consciousness : compos mentis, eye contact (-), auditory response (+),

visual respon (+) minimal
Vital signs : HR 100 x/min, RR 20x/min, temp 36.8°C
Posture : ATNR
Nutritional status : NCHS
Body weight : 10 kgs BW/age: Normal
Body length : 74 cms BL/age: Normal
Head circumference : 40 cms HC/age: <-3 SD
BW/BL: Normal
Communication : Expressive: cry, smile
Receptive: responded to voice or sound
Mobilization :
Transfer : Lying to sidelying : partially dependent
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Ambulatory : Non ambulatory

Head & Neck Region
Small head size (microcephaly)
Eyes : visual response (+) slow and minimal, eye contact (-),
anemic conjunctiva -/-, icteric sklera -/-, pupil round
equal, light reflexes +/+, strabismus (-), nystagmus (+)
Ears : auditory response (+)
Oromotor :
Lips deformity (-), lip seal (+)
Tongue position: normal
movement: thrust (-), anterior-posterior (+), lateral (-)
Teeth 3 insicivus, 2 in upper side, and 1 in lower side, caries (-)
Palate normal arch
Drooling -
Jaw position: normal
movement (+) superior-inferior (+), rotary (-)
Feeding Feeding skills of 4-6 months
milestone
 Feed in semi-reclined position
 Recognizes the bottle or breast
 Begins to eat puree/smooth creamy foods by sucking food
from a spoon

Neck : lymph node enlargement (-/-)

Head and neck control : poor
Head lag (+) when pull to sit
Head lift (+) in prone position ± 5 seconds
Counterpoising of the head (-)
Shoulder stability (-)
Range of Motion : full
Trunk region
Deformity : (-)
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Trunk control : poor

Thorax region
Symmetrical shape and movement
Retraction (-)
Lung : Vesicular breath sounds right = left, crackles (-), rhonchi (-),
wheezing (-),
Heart : regular heart sounds, murmur (-)
Abdomen region
Flat, soeple, bowel sound (+) normal
Liver and spleen not palpable
Anal, urogenital region
Congenital anomaly (-)
Upper extremities region
Deformity : (-)
Flexor synergic pattern : (-)
Palmar grasp reflex : (-)
Thumb in palm : -/-
ROM : full
Spasticity (Modified Ashworth Scale)
- Elbow flexor : 2/1+
- Elbow extensor : 1/1
Physiologic reflexes : +++/+++ (biceps tendon reflex)
Pathological reflex : -/- (Hoffman Trommer sign)
Hand skills : reach: poor, crude palmar grasp: poor
voluntary release: poor, bilateral hand use:
poor
Lower extremities region
Deformity : (-)
Extensor synergic pattern : (-)
Plantar grasp reflex : (+)
ROM : full
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Spasticity (Modified Ashworth Scale)

- Hip flexor : 1/1
- Hip adductor : 1/1
- Knee extensor : 1+/1+
- Ankle plantarflexor : 1+/1+
Physiologic reflexes : +++/+++ (knee & ankle tendon reflexes)
Pathological reflex : +/+ (Babinski)
Clonus : -/-
Thomas test :-/-
Ely test : -/-
Silfverskiöld test : -/-

Manual Muscle Test:

Swimming: Weak Function
- Concentric contraction of head and neck extensors : WF
- Concentric contraction of rhomboids : WF
- Concentric contraction of back extensors : WF
- Concentric contraction of gluteal : NF
- Concentric contraction of hamstrings : NF

Maturation:
Brainstem level:
ATNR (+)
Milestone:
Gross motor : 4 month
Fine motor : 4 month
Personal social : 4 month
Speech & language : 4 month
Cognition : 4 month

Bleck’s Walking Prognosis :

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1. ATNR (+) :1
2. Neck Righting reflex (-) :0
3. Moro Reflex (-) :0
4. STNR (+) :1
5. Extensor Thrust (-) :0
6. Parachute Reaction (-) :1
7. Foot Placement Reaction (-) : 1
Total Points :4

Functional Examination:
Prone : Prone with head-neck extention : poor

Functional Assessment:
Gross Motor Function Classification System (GMFCS): Level V (between 0
and 2nd birthday)
(Infant has physical impairments that limit voluntary movement. Unable to
maintain head or trunk control in prone or supine postures. Needs assistance to roll.)
Communication Function Classification System (CFCS) : Level V
(A person is seldom able to communicate effectively even with familiar people)
Manual Ability Classification System for Children with Cerebral Palsy
(MACS) : level V
(Does not handle objects and has severely limited ability to perform even simple
actions. Requires total assistance)
Hypertonia Assessment Tool (HAT) : Spasticity Tone
WeeFIM : 18 (total assistance : selfcare, mobility, communication, cognition)

SUPPORTING EXAMINATION :
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1. Brainstem Evoked Response Audiometry (BERA) examination (April 4th 2018)

: normal in both ears
2. CT Scan Examination :
Arachnoid cyst di daerah konkavitas temporo parieto occipitalis kanan dan
parietalis kiri.

Hydrocephalus Non Communicans

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Hip Migration
Right side : 18 degree
Left side : 8,3 degree
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ASSESSMENT
Medical diagnosis
Clinical diagnosis : Spastic quadriplegic of cerebral palsy (G80.8),
Microcephaly (Q02), Visual Impairment (H54.7)
Location Diagnosis : Brain (cortical and subcortical)
Etiological Diagnosis : Prenatal (hydrocephalus, prematurity) and
postnatal (seizure) risk factor
Functional diagnosis : GMFCS Level V (between 0 and 2nd birthday)
CFCS Level V
MACS Level V
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Functional Diagnosis
Health condition
spastic quadriplegic type of cerebral palsy + Microcephaly

Activities:
Body function: Acquiring language (d113),
Intellectual functions (b117) , Acquiring skills (d155),
Seeing function (b210), Maintaining a body position
Muscle tone functions (b735), (d415),
Control of voluntary Fine hand use (d440), Participation:
movement functions (b760), Moving around (d455), Engagement in play (d880)
Walking (d450),
Body structure: Eating (550)
Structure of brain (s110), Toileting (d530),
Basic interpersonal
interactions (d710)

Environmental factor: Personal factor:

Products and technology for personal use in daily girl, 11 month y.o,
living (e115), Products and technology for personal low socioeconomic condition
indoor and outdoor mobility and transportation
(e120), Products and technology for communication
(e125), Health professional (e355), Health services,
systems and policies (e580)
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PROBLEM LIST

Medical Problem Rehabilitation Problem

- Cerebral palsy spastic type Mobilization
quadriplegia Activity daily living
- Microcephaly Communication
- Suspek Visual Impairment

GOAL
Short term: - Parents understand patient’s condition, set reasonable
expectation and give motivation to do the habilitation program
- Determine the diagnosis for patients visual impairment from
Cicendo Hospital
- Head-Neck-Trunk control increased
- Rolls to prone
- Hand midline play
- Prevent contracture
Long term: - Good Head-Neck-Trunk control
- Can Propped sitting
- Reach and hold objects
- Transfers cube from hand to hand
- Drop and throw objects
- Fingers feeding
- Uses single word (family members) and imitates speech sounds
- Prevent dislocation, scoliosis
- Mobilization with wheelchair
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PROGRAM
Problem Mobilization
Cause Brain lesion non progressive, Microcephaly, weakness of head,
neck, and trunk muscles
Limitation - Spasticity
- Visual impairment
Potency Good compliance of caregiver, visual and audio response (+)
Prognosis Propped sitting
Target - Good head, neck, trunk control
- Maintain sitting position with support
Program - Facilitate head, neck control and strengthening head, neck,
back extensor by :
1. Position the child in prone on mother’s lap or soft cushion
or physioball, then elevate her arms and gently stretch the
arms, stroking her back, stimulate with audio above eye
level
2. Pull to sit the child from half sitting position with
supported back
3. Sitting on activity chair
- Facilitate rolling by stimulate with audio and rotate the
child’s
head with lower extremity counteract
- Supported Sitting :
a. On mother’s lap: keep head and trunk in midline position,
hip flexion 90°, knee extension or slight flexion, mother’s
thigh as adductor separator
b. With chair: head and trunk in midline, hip and knee
flexion 90°, hip abduction ,and ankle plantigrade.
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- Chair modification for ADL (eating and playing) with back

and head support, chest harness, arm rest, pelvic strap, and
table or tray.
- 24 hours postural management

Problem Increased muscle tone

Cause Brain lesion non progressive
Limitation -
Potency Good compliance of caregiver
Prognosis No musculoskeletal complication
Target Prevent deformity and joint malalignment
Program - Passive range of motion exercises: everyday, 2
sessions/day, 1 set/session, 10 repetition/set
- Position when carried by parents, supported sitting on
parents’ lap, with chair : as in program for head-neck
control
- Chair modification : as in program for head-neck-trunk
control
- The managements are part of 24 hours postural
management

Problem Delayed speech and language

CFCS Level V
Cause Brain lesion non progressive, poor cognition
Limitation Visual impairment
Potency Good compliance of caregiver, visual and audio response (+)
Prognosis Able to communicate with verbal (using simple words and
understand simple vocabularies)
Target - using single word (family member)
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- imitates speech sounds

Program - Increase stimuli audio by repeating simple words by her
parents (family members)
- Cardiopulmonary fitness: rolling exercise, sitting position

Problem Activity daily living disturbance: unable to hold object with

her hands
MACS level V
Cause Brain lesion non progressive
Limitation - Poor shoulder stability
- Poor cognition
- Visual impairment
Potency Good compliance of caregiver, audio response (+)
Prognosis Fingers feeding and able to hold bottle or toy given to her hand
Target Able to intermediate grasping and pincer grasping
Program - Stimulating of hand grasping by tactile stimulation in
supine and sitting position
- Placing the object in hand, introduced of toys, food of
varied textures, sizes, and shapes to encourage grasp
- Position her in chair while eating.

Follow Up
July 21rd 2018
S: Improvement (+)
The patient able to hold toys that is given with her right hand and play it for few
minute but she can’t reach the toys by herself. Sometimes she can bring the toys
into her mouth but she can’t transfer the toys to the other hand. She still can’t
rolls from supine to prone by herself and when her mother puts her in prone
position, she can lift her head only for + 5 second. Her mother routinely trained
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her child at home at least twice a day using wedges, physioball and also
facilitated her to rolls to prone. Since 2 weeks ago, sometimes the patient
appetite decrease and her mother tried to modify her foods. Chooking (-).
O:
Vital sign: HR: 110 x/m, RR: 22 x/m, S: 36.7°C, SaO2: 97%
BW 8,5 kg, BW/age : 0 – (-2) SD
BL 74 cm.; BW/BL : 0 – (-1) SD
HC 40 cm; HC/age : <-3 SD (microcephaly)
Posture: symmetrical position
Head & neck control : poor
Head lag (+) when pull to sit
Head lift (+) in prone position ± 5 seconds
Counterpoising of the head (-)
Shoulder stability (poor)
Manual Muscle Test:
Swimming: Weak Function
- Concentric contraction of head and neck extensors : WF
- Concentric contraction of rhomboids : WF
- Concentric contraction of back extensors : WF
- Concentric contraction of gluteal : WF
- Concentric contraction of hamstrings : WF
Maturation:
Brainstem level:
ATNR
Milestone:
Gross motor : 4 month
Fine motor : 4 month
Personal social : 4 month
Speech & language : 4 month
Oromotor :
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Lip seal (+)

Drooling (-)
Tongue movement : anterior-posterior (+), lateral (+)
Jaw movement : superior-inferior (+), rotary (-)

Spasticity :
- Elbow flexor : 1+/1+
- Elbow extensor : 1/1
- Hip flexor : 1/1
- Hip adductor : 1/1
- Knee extensor : 1+/1+
- Ankle plantarflexor : 1+/1+
A :Feeding disturbance
Global delay development
Spastic type quadriplegia of cerebral palsy
Visual Impairment

P:
For feeding disturbance :
- Feeding in sitting supported position with chair
- Positioning when feeding : head in midline and firmly held in the
upright and forward.
- Give and introduce another variation of food
- Planning to consult to nutrisionist considering the increase of exercise
frequency at home
Education :
- to increase exercise frequency at home
- Stimulating of hand grasping by tactile stimulation in supine and sitting
position
- Placing the object in hand, introduced of toys, food of varied textures,
sizes, and shapes to encourage grasp
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