Case of the Week:
16th July 1999
from The Hong Kong Polytechnic University & Tuen Mun Hospital,
Hong Kong
5 year old girl with a diagnosis of hemiplegia, and referred prior to
Botox injection. 
Birth details: 34/40 gestation, 1.8 kg, delivered by Caesarean section,
required resusitation at birth and incubator for 1 month. A CT scan at
1 y (PR of China) showed cerebral atrophy and cerebral palsy. Received
acupuncture and massage before coming to Hong Kong.
Clinical Examination
| Joint |
Test |
Right |
Left |
| Hip |
Abduction |
70 |
60 |
|
Abd. with hip@90 |
85 |
80 |
|
Rotn. prone |
70-0-70 |
70-0-60 |
|
Trendelenberg |
-ve |
+ve |
|
Thomas |
0 |
10 |
| Knee |
Ext |
5 |
5 |
|
Duncan Ely |
-ve |
-ve |
|
Hamstring deficit |
20 (10 post) |
35 (15 post) |
| Ankle |
Dorsiflexion |
25 (30 post) |
10 (20 post) |
Muscle Tone (Ashworth-Bohannon)
| Group |
Right |
Left |
| Adductors |
1 |
1 |
| Hip Flexors |
0 |
0 |
| Quads |
0 |
1 |
| Hamstrings |
1 |
2 (1 post-Botox) |
| Plantarflexors |
1 |
2 (1 post-Botox) |
| Clonus |
4 beats |
4 beats |
Manual Muscle Test (Oxford-MRC)
|
|
Right |
Left |
| Hip |
Flexors |
5- |
5- |
|
Extensors |
4+ |
4- |
|
Abductors |
4+ |
4- |
|
Adductors |
4- |
4- |
| Knee |
Flexors |
4- |
4- |
|
Extensors |
4- |
4- |
|
Quads girth |
33 |
32 cm |
| Ankle |
Dorsiflexors |
4- |
3- |
|
Plantars |
4- |
3- |
|
Calf girth |
23 |
22 cm |
Selective control in high-sitting
Gross Motor Function Measure
| Lying & rolling |
100 % |
| Sitting |
100 |
| Crawling |
100 |
| Standing |
84 |
| Walk, run & jump |
67 |
| Total |
90 |
Anthropometry
Weight 20 kg
Lower-limb length 52 cm.
Temporal-spatial Parameters
| Velocity |
Cadence |
Stride Length |
Stance Duration |
| 0.29 m/s (28% predicted) |
82 steps/min |
0.43 m
(53 % pred) |
R = 73 %
L = 68 % |
QuickTime Movies 
Centre of Gravity from above
3D Gait Analysis results
(Vicon 370 Version 2.6, full-body marker set, VCM kinematics
& kinetics, Noraxon EMG)
... points for discussion:
-
Do you think the diagnosis is hemiplegia or diplegia?
-
What is the main problem?
-
Is weakness or spasticity predominant?
-
Do you think she can be helped by Botox injection?
Post-Botox Analysis
A second study was performed 6 Weeks post-injection of 40 IU Botox into
the left and 20 IU to the right gastrocnemius. 
Temporal-spatial parameters
|
Velocity |
Cadence |
Stride Length |
| Pre |
0.29 |
82 |
0.43 |
| Post |
0.52 |
108 |
0.58 |
QuickTime movies
3D Gait Analysis
results
(Vicon 370 Version 2.6, VCM kinematics & kinetics)
Pre/Post comparison
... points for discussion:
-
How do you account for the improvement?
-
Does this change your opinion about the diagnosis?
-
Do you have any further treatment options to suggest?
What people said...
Case prepared by Dr.
Chris Kirtley & referred by Nerita
Chan
Email your comments to [n/a]
Maintained by DDr.
Chris Kirtley, Andreas
Kranzl
Last modified on 16th July. 1999.
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