Crouch gait after botulinum toxin in cerebral palsy
Layla, an 8-year-old girl with spastic diplegic cerebral palsy (GMFCS level II), had botulinum toxin injections to both hamstrings and gastrocnemius muscles 3 weeks ago. She walks independently but with a crouch gait. Popliteal angle is 55° on the right and 60° on the left; ankle dorsiflexion with the knee extended is 0° bilaterally. She has no fixed contractures. Her parents want her to 'walk straight' and ask for daily prolonged stretching. She attends physiotherapy twice weekly and is motivated. She complains of calf tightness after school. Her school day includes 30 minutes of PE. She has no seizures and no orthopaedic surgery. Her mother reports that she trips when walking on uneven ground. She is in grade 3 and carries a backpack of 4 kg.
1. Explain the physiological rationale for botulinum toxin and the expected time course. How should this alter your physiotherapy priorities at 3 weeks post-injection?
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Botulinum toxin reduces spasticity by blocking acetylcholine release at the neuromuscular junction. Its effect begins within days, peaks at about 2–6 weeks, and wears off over 3–4 months. At 3 weeks, she is in the window for strengthening and motor learning, not just stretching. The aim is to use the reduced spasticity to strengthen antagonist muscles, improve joint alignment, and practise gait. Priorities: task-specific gait training, strengthening hip extensors/abductors, quadriceps, and ankle dorsiflexors, and only moderate stretching to maintain range. Prolonged daily stretching alone is unlikely to change fixed contracture and may reduce the opportunity for active practice.
2. Design a 6-week programme that addresses crouch gait, including strength, stretching, and gait training. Give specific dosages and justify why you would not prescribe daily prolonged stretching alone.
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Supervised twice weekly plus home programme for 6 weeks. Strengthening: sit-to-stand 3 × 8–10; step-ups 3 × 8 each leg; hip abduction with band 3 × 10; ankle dorsiflexion with band 3 × 10. Gait training: 20 minutes per session, including uneven surfaces, stairs, and turning; use visual feedback and a mirror. Stretching: hamstrings and gastrocnemius, 30 seconds × 3, once daily, gentle; not prolonged. Review footwear and orthotics. Home: carry a lighter backpack (4 kg is heavy for an 8-year-old) and pace PE. I would not prescribe daily prolonged stretching alone because evidence for contracture prevention is weak, it can be painful, and it displaces active training.
3. How would you set collaborative goals with Layla and her parents and measure progress? Include at least one patient-reported and one performance-based measure.
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Use collaborative goal setting: ask Layla what she wants to do (e.g., keep up with friends at break) and ask parents about priorities. Write SMART goals, such as 'walk 100 m on uneven ground without tripping in 6 weeks'. Use Goal Attainment Scaling for individualized goals and the Canadian Occupational Performance Measure (COPM) for parent/child-reported performance and satisfaction. Performance-based: 6-minute walk test, Timed Up and Go, and Edinburgh Visual Gait Score. Measure at baseline, 3 weeks, and 6 weeks. Review goals with the family and adjust.