THE ALFRED I. DUPONT INSTITUTE
This young male was born premature on 10/11/84 and was in the hospital
for 3-1/2 weeks. Because of subluxation of the right hip, he had a varus
derotation femoral osteotomy with dega pelvic osteotomy in January of 1991,pre-operative
, post-operative .
The VIDEO FROM AUGUST 1992 demonstrates his slow gait and very stiff knees
prior to a 1993 bilateral hamstring lengthening with rectus transers and
blade plate removal. Radiographs show normal hips .
The VIDEO FROM JULY 1993 was compiled following the rectus transfers and
shows an increase in knee motion.
He started walking by cruising at 18 months and is now walking using his crutches and a walker. He uses a combination of the bilateral Lofstrand crutches, a K-posture walker and a light-weight wheelchair depending on the distance that he has to ambulate. He is continuing to make some progress in his ambulation but continues to have toe dragging with rolling over of this feet. He does not have seizures and does not experience any pain. He does very well in school which is where he receives his therapy once a week. He has bilateral supramalleolar orthoses, but is not wearing them currently.
Case material is organized below:
Videotape, July '94 Videotape, November '95
Physical Exam, July '94 Physical Exam, November '95
Kinematic Data, July '94 Kinematic Data, November '95
EMG Data, July '94 (N/A) EMG Data, November '95
Oxygen Consumption Data, July '94 (N/A) Oxygen Consumption Data, November '95
Summary and duPont Recommendation, July '94
Summary and duPont Recommendation, November '95
The PT evaluation reveals good knee range of motion with very mild hyperextension of the knees bilaterally. There is mild to moderate spasticity or rectus femoris, left greater than right. There is also mild spasticity in bilateral adductors and iliopsoas. Gross motor functional testing in standing revealed rather poor function. He is able to stand independently for 1 - 2 seconds. He was not able to rise from the floor through a half kneeling position, even with assistance of the upper extremities. He uses hand suport to rise from a chair or lower to the floor. His parents report poor tolerance for orthotics presently; he complains significantly of pain while wearing orthotics.
KNEE PROM/STRENGTH MUSCLE TONE/MOTOR CONTROL R L R L Knee ext 0-4 0-3 Rectus 2 3 Knee flex 0-135 0-135 FLEXIBILITY Pop angle 45 50 Ely test 125 120 TRUNK FLEXIBILITY Sit/Reach 0 cm FUNCTIONAL STRENGTH Independent standing: 1-2 sec. One leg stance: <3 sec. on both legs Short sit to stand: only with both hands Lowers to floor: with hands controlled Standing-picks pen from floor: with hands (turning to side)
Examination of his hips demonstrates adequate flexion. He is really quite weak throughout. His knee extension and flexion is full. He has very little ability for any independent motor control in any of his lower extremities.
HIP PROM/STRENGTH MUSCLE TONE/MOTOR CONTROL R L R L Hip flex 115 120 Iliop - - 3 3 - - Hip abd(ext) 10 15 Glut med - - - - Adductor 2 2 Hip ext 20 20 +/- +/- - - Glut max +/- +/- Int rot 25 25 Ext rot 5 40 FLEXIBILITY Thomas T 15 20 Ober T - - KNEE PROM/STRENGTH MUSCLE TONE/MOTOR CONTROL R L R L Knee ext 0 0 Quads - - 4+ 4+ Rectus T 3 3 Knee flex 130 130 Hamstring 0 0 2- 2- - - Knee jerk 3+ 3+ Ankle jerk 1+ 1+ FLEXIBILITY Pop angle 40 (35) 40(30) Ely test 120 120 ANKLE PROM/STRENGTH MUSCLE TONE/MOTOR CONTROL R L R L Dorsi (flex) 10 11 Ant tib - - 2+ 2+ Gastroc 1 1 (ext) 1 5 - - Plantar 50 45 Soleus - - - - Post tib 0 0 Inv 25 20 - - - - Peroneals - - Ever 25 45 - - Babinski - - TFA 20 ext 25 ext Clonus sustained sustained TRUNK STRENGTH MOTOR CONTROL Abdominals 20 sec. Abdominals +
This nine year old boy with a diagnosis of spastic diplegia, post - orthopaedic surgery, demonstrates obvious progress in gait. Specifically, he has improved knee flexion in swing phase, hip extension in stance phase, and trunk posture and balance. His balance and coordination have also improved, as noted by his improved use of the Lofstrand crutches.
The following recommendations are suggested:
This eleven year old boy with a severe diplegic pattern cerebral palsy is dependent on crutches or a walker for ambulation but appears to demonstrate adequate ability to ambulate in household and some community environments. He does, however, display significant difficulties with balance and motor control, and demonstrates severe muscle weakness as well as some BONY DEFORMITIES RELATED TO HIS FEET. Hip flexion is normal. He has mild circumduction which he uses for clearance. His knee flexion has good contact. Though hamstring length is substantial, they are very weak. Knee flexion and swing phase are somewhat diminished and occur quite late, especially on the right side. Rectus and vastus EMG patterns reveal that he is using these muscles predominantly for stance phase stability in co-contraction with the hamstrings. Ankle dorsiflexion was somewhat low on the right and occurred late. There is constant tibialis anterior activity with good appropriate stance phase gastrocnemius activity. The external foot progression appears mainly due to severe planovalgus deformity. This deformity has not caused an increase in knee flexion in stance phase. It is, however, making brace wear difficult.
The following recommendations are suggested:
A comparison of findings from the first and second visits demonstrates
that there is really no change in any of the hip motions.
Right Hip Flexion/Extension Left Hip Flexion/Extension
Right Hip Ab/Adduction Left Hip Ab/Adduction
Right Hip Internal/External Left Hip Internal/External
When comparing knee motion, it appears that flexion is the same in magnitude
in both gait analyses but occurs later in time in the second analysis than
in the first. There are no other significant findings at the knee as there
are almost all overlapping curves.
Right Knee Flexion/Extension Left Knee Flexion/Extension
Right Knee Varus/Valgus Left Knee Varus/Valgus
Right Knee Torsion Left Knee Torsion
At the ankle, there is no change in tibial torsion or valgus from the
first visit to the second visit. Foot progression angles are almost exactly
the same, indicating again that ankle motion demonstrates essentially no
change in the two gait analyses.
Right Ankle Plantar/Dorsi Left Ankle Plantar/Dorsi
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