Spastic Diplegia at Two Years Eight Months: Independent Walking, Botulinum Toxin and Choosing Support
A 2-year-8-month-old girl with spastic diplegic cerebral palsy attends the paediatric physiotherapy clinic of a MOH hospital with her mother. She was born at 28 weeks and had a grade II intraventricular haemorrhage. She walks indoors holding one hand with a wide base, scissoring and toe contact, and falls two to three times a day. Popliteal angle is 50° bilaterally, Thomas test 15°, ankle dorsiflexion 0° with the knee extended and 10° with the knee flexed, and clonus is sustained for four beats. She pulls to stand and cruises along furniture. GMFCS level II. She has never had botulinum toxin or orthoses and is on a waiting list for orthotic assessment. The mother asks whether she will walk alone before nursery starts in 12 weeks, whether she should have 'the injections', and whether a walking frame is better than holding hands. The family drives 45 minutes each way and can attend twice weekly.
1. Set collaborative goals with the mother and specify how you would measure them.
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Negotiate one activity goal, one participation goal and one impairment goal - and be explicit about what 12 weeks can deliver.
Activity: 'walk 10 metres indoors without holding a hand or using a frame, with no more than one fall per week, by 12 weeks'. Measurable, meaningful, and plausible for GMFCS II with twice-weekly input plus a home programme. Participation: 'take part in nursery drop-off and floor play without being carried'. Impairment (supporting): 'increase ankle dorsiflexion with the knee extended from 0° to 5° and popliteal angle from 50° to 40°'.
Measurement:
- GMFM-88, dimensions D (standing) and E (walking, running, jumping): report percentage and raw scores, same assessor, same time of day.
- 10-metre walk test with and without support (time and steps); Timed Up and Go if achievable.
- PEDI or a participation measure for the nursery goal; a maternal falls diary for the safety criterion.
Reasoning: the GMFM is criterion-referenced and responsive in this population, and measuring only range would miss the change the family cares about. Be honest that most children at GMFCS II do achieve independent walking, but not necessarily within 12 weeks; set a review date and renegotiate rather than promise. Share the baseline scores with the mother so progress is visible to her, not only to you.
2. How do you answer the question about botulinum toxin and orthoses, including who decides?
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Both are reasonable adjuncts to intensive practice - not alternatives to it - and their timing must be coordinated.
- Botulinum toxin A: indicated for focal, dynamic spasticity that interferes with function. Her dynamic equinus, scissoring and clonus fit, especially if gait is deteriorating or an orthosis cannot be tolerated. Evidence supports short-term tone reduction and improved gait when combined with physiotherapy, casting or orthoses; the effect peaks at 4–6 weeks and fades. Without a rehabilitation programme afterwards, the benefit is largely lost.
- Orthoses: an ankle–foot orthosis controls equinus, improves stance stability and often walking speed; a hinged design preserves dorsiflexion in swing, which matters with 0° ankle dorsiflexion at the knee extended. Solid versus hinged depends on tone and control. The usual sequence is tone management first, then casting or an orthosis while tone is reduced - an orthosis fitted before injection may not fit afterwards.
- Who decides: this is a multidisciplinary decision with the paediatrician or rehabilitation physician and the orthotist, not a physiotherapy prescription. Your role is to give the family accurate information about benefits, burdens (injections, possible sedation, cost, follow-up visits) and the uncertainty, and to support consent with the child's assent.
- Practical: ask the mother to raise it at the next neurology appointment and request that botulinum and orthotic assessment be coordinated, so she is not making two 45-minute journeys for conflicting plans.
3. The mother asks whether a walking frame is better than holding hands. How do you reason this through, and what home programme fits a family 45 minutes away?
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Support should be a graded, time-limited decision tied to her goal, not a permanent prescription.
- Hand-held support gives assistance at the trunk or arm and is easily faded: two hands, then one hand, then a fingertip, then none. That graded withdrawal is exactly what an independent-walking goal requires.
- A frame gives stability but changes the postural set. Anterior frames encourage a flexed trunk and upper-limb weight-bearing; posterior frames give support behind the child and are usually preferred in diplegia, but both reduce the practice of balance reactions she needs.
- Reasoning: she is GMFCS II and already cruises, so her limiting factors are ankle position, trunk control and confidence, not a need for maximal support. Reserve the frame for long distances or fatigue (nursery outings, the school corridor) and keep short indoor distances as practice.
Home programme given the travel burden: twice-weekly clinic plus 15 minutes daily with the mother - sit-to-stand from a low stool, step-ups, reaching games in half-kneeling, heel-toe walking to a target on the wall, and carrying a small object to encourage trunk rotation. Provide photographs or a short video on her phone, review by phone at 4 weeks, and measure the 10-metre walk monthly so the mother can see that fading support is working. Agree in advance what would trigger a return to the frame.