OUTPATIENT PHYSICAL THERAPY FOR A TODDLER WITH CEREBRAL PALSY PRESENTING WITH DEVELOPMENTAL DELAYS. A Doctoral Project A Comprehensive Case Analysis

Transcription

1 OUTPATIENT PHYSICAL THERAPY FOR A TODDLER WITH CEREBRAL PALSY PRESENTING WITH DEVELOPMENTAL DELAYS A Doctoral Project A Comprehensive Case Analysis Presented to the faculty of the Department of Physical Therapy California State University, Sacramento Submitted in partial satisfaction of the requirements for the degree of DOCTOR OF PHYSICAL THERAPY by Amy K. Holthaus SUMMER 2015

2 2015 Amy K. Holthaus ALL RIGHTS RESERVED ii

3 OUTPATIENT PHYSICAL THERAPY FOR A TODDLER WITH CEREBRAL PALSY PRESENTING WITH DEVELOPMENTAL DELAYS A Doctoral Project by Amy K. Holthaus Approved by:, Committee Chair Katrin Mattern-Baxter, PT, DPT, PCS, First Reader Brad Stockert, PT, PhD, Second Reader Edward Barakatt, PT, PhD Date iii

4 Student: Amy K. Holthaus I certify that this student has met the requirements for format contained in the University format manual, and that this project is suitable for shelving in the Library and credit is to be awarded for the project., Department Chair Edward Barakatt, PT, PhD Date Department of Physical Therapy iv

5 Abstract of OUTPATIENT PHYSICAL THERAPY FOR A TODDLER WITH CEREBRAL PALSY PRESENTING WITH DEVELOPMENTAL DELAYS by Amy K. Holthaus A pediatric patient with cerebral palsy was seen for physical therapy treatment provided by a student for ten sessions from February 2014 to May 2014 at a university setting under the supervision of a licensed physical therapist. The patient was evaluated at the initial encounter with Gross Motor Function Measurement-66, Peabody Developmental Motor Scale-2 and Pediatric Evaluation of Disability Inventory, and a plan of care was established. Main goals for the patient were to improve development motor functions through increasing independent ambulation, functional balance and strength. Main interventions used were family-centered and task-specific with utilization of the overload principle. The patient achieved the following goals of increased functional strength, independent steps and functional balance. The patient was discharged home to prior living environment with parents, along with continued participation in ongoing physical therapy setting., Committee Chair Katrin Mattern-Baxter, PT, DPT, PCS Date v

6 ACKNOWLEDGEMENTS I wish to thank various people for their contribution to this project; Katrin Mattern- Baxter, PT, DPT, PCS, my committee chair for her guidance and sharing of her immense knowledge in pediatrics. The faculty and staff of Sacramento State s Doctoral of Physical Therapy Program who have guided me throughout my time in the program and their contribution to my education. A deep gratitude to the patient and his family for their commitment to this project, I am grateful to have their friendship. Finally, I wish heartfelt thanks to my loving family and close friends who have shown continued support and encouragement throughout my education, as well as their ability to maintain my sanity through love and laughter. vi

7 TABLE OF CONTENTS Page Acknowledgements... vi List of Tables... viii Chapter 1. GENERAL BACKGROUND CASE BACKGROUND DATA EXAMINATION TESTS AND MEASURES EVALUATION PLAN OF CARE GOALS AND INTERVENTIONS OUTCOMES DISCUSSION References vii

8 Tables LIST OF TABLES Page 1. Examination Data Plan of Care Goals and Interventions Outcomes.. 23 viii

9 1 Chapter 1 General Background Cerebral palsy (CP) is the most common motor disability in children. 1 Cerebral palsy is an umbrella term to identify a group of non-progressive brain lesions or abnormalities of the immature brain, resulting in motor impairments. 1 Development of secondary musculoskeletal problems occur throughout life. 2 Problems can include muscle and tendon contractures, bony torsion, hip displacement and spinal deformity, all of which can be associated with functional limitations. 2 Children with CP experience abnormal ordering of motor control. 3 This lack of coordination can lead to increased balance deficits. 3 The cause of CP is not clearly understood, however there are associations with prenatal, perinatal and postnatal events. 4 Magnetic resonance imaging (MRI) studies have been used to determine the incidence of these events to be 34% for prenatal, 43% for perinatal, and 6% for postnatal causes with 18% being undefined. Events leading to CP include ischemia, hypoxia, and traumatic events affecting the brain. The most prevalent risk factors for CP include low birthweight, multiple gestation, uterine infection, periventricular leukomalacia and encephalopathy when combined with other birth defects. 4 There are three commonly used classification systems used. Cerebral palsy can be classified based on topographical distribution of impairments. 5 These include, but are not limited to monoplegia, diplegia, triplegia, hemiplegia, and quadriplegia. Cerebral

10 2 palsy can also be classified based on the type of motor impairment, which includes spastic, ataxic, dyskinetic or mixed CP. Children with spastic CP account for 70-80% of CP cases. The last classification system that is commonly used is based on the Gross Motor Function Classification System (GMFCS). The GMFCS levels range from level one to level five. Level one classifies a child who can walk without the need for an assistive mobility device and sit independently. Level five is designated to a child who has all areas of motor function limited and no means of independent mobility. 5 The prevalence of CP in developed countries is 2.0 to 2.5 per 1,000 live births. 6 The prevalence has increased from the 1970s to 1990s, from less than 2.0 to more than 2.0 per 1,000 live births. 6 Over the past couple of decades the prevalence has remained steady, 1 however there has been a shift in the types of CP with an increasing incidence of spastic diplegic CP. 2 Cerebral palsy remains a clinical diagnosis determined when a child does not reach early motor milestones and presents with abnormal muscle tone or movement patterns. 7 The cost of care for individuals with CP in the United States is estimated to be 11.5 billion dollars. 8 Cerebral palsy is more common among boys than girls with African-American children having a higher prevalence than Caucasian or Hispanic children. 9

11 3 Chapter 2 Case Background Data Examination History The patient who participated in this case study was a 33 month old male toddler with a diagnosis of spastic diplegic CP. The patient presented with developmental delay. The patient s mother self referred him to physical therapy with goals to increase trunk control and increase ambulation. The patient was born prematurely at week 32 and weighed 3 pounds 12 ounces as the only child in his family The patient s mother reported a normal pregnancy without any complications. The mother reported that she had been born prematurely herself, and that there were several children born prematurely on her side of the family. The patient was admitted to the Neonatal Intensive Care Unit (NICU) for respiratory distress secondary to the premature birth. He was treated with Continuous Positive Air Pressure on 21% oxygen, lipids, ampicillin intravenous (IV), IV gentamycin and Total Parenternal Nutrition. He was discharged home at 1 month old with stable oxygen saturation levels on room air, stable temperature and feeding by mouth. The patient was diagnosed with spastic diplegic CP at 18 months of age. Per parent report, the child had a radiograph of bilateral hips at time of diagnosis with no positive findings of hip displacement. The mother reported no history of surgery, or other medical problems. The patient was followed by a pediatrician, developmental pediatrician, pediatric ophthalmologist and pediatric audiologist.

12 4 The patient wore eyeglasses throughout the day for hyperopia. He had bilateral solid ankle foot othoses, which he received at 30 months old. His mother reported his expression of discomfort while wearing the orthotics, leading to minimal usage, only while ambulating outdoors. The patient received a reverse wheel walker at 26 months of age which he used during ambulation with minimal assistance from parent for turning. The patient received physical therapy (PT) and occupational therapy (OT) intermittently since his diagnosis. At the time of the study, the patient received PT and OT once weekly, each for 30 minute sessions at an outpatient clinic. He also participated in a treadmill walking program 2 times per week for 30 minute sessions, which he had started at age 28 months. The patient lived in a single story house with five steps into the home. He lived with his biological mother and father, with the mother being the primary caregiver. The patient was able to crawl and scoot up and down steps independently. He was able to maneuver in his home independently by crawling or pushing a push toy. Per parental report, the patient had no pulmonary, urogenital, cognitive, or gastrointestinal pathology. Through observation, he had no integumentary involvement. His cognition was cleared via the child s ability to follow 3-step commands. The patient s neuromuscular and musculoskeletal systems were impaired, as measured by outcome measures and observation. He also presented with a learning barrier through wearing glasses for hyperopia. The patient presented with decreased range of motion (ROM), spasticity of lower extremities (LE), and gross motor function that was not age

13 5 appropriate indicated by impaired balance, gait, and transfers. The cardiovascular and pulmonary system was not objectively measured. The chief complaint from the patient s mother was decreased ambulation. The mother s primary goal for the patient was to increase ambulation and standing balance. Examination Medications The patient was not on any medication, per parent report. There were no medication recommendations at the time.

14 6 Chapter 3 Examination Tests and Measures The tests and measures and outcome measures utilized for this patient were from the International Classification of Functioning (ICF) categories of Body Structure and Function, Activity, and Participation. 10 The Modified Ashworth scale (MAS) and passive range of motion (PROM) were used for to measure Body Structure and Function impairments. Measurement of strength was not specifically measured using manual muscle testing (MMT). Based on the child s limited understanding to maintain specific positions for testing 11 and the presence of an upper motor neuron lesion, traditional MMT was not appropriate. 12 Strength was addressed at a functional level within the Activity ICF category. The Functional Mobility Scale (FMS), Gross Motor Function Measure (GMFM-66), 10 meter walk test (10 MWT), and the Peabody Developmental Motor Scale (PDMS-2) were used as Activity measures. Lastly, the Pediatric Evaluation of Developmental Inventory (PEDI), a parent report of the child s functional level, was utilized in the Participation category of the ICF model. The MAS is a measure to assess muscle tone. The scale is scored as follows: 0 indicates no spasticity; 1 indicates slight increase in tone with a catch and release or minimal resistance at end of range; 2 indicates marked increase tone, catch in the middle ROM, part easily moved; 3 indicates considerable increase in tone, passive movement difficult; and 4 indicates affected part rigid, flexion or extension. Psychometrics of the MAS have ranged from strong to poor. 13 In a study of children with spastic CP ranging

15 7 from months of age, interrater reliability was shown to be between intraclass correlation (ICC) values of The test-retest reliability also had a wide range with the ICC values ranging Passive range of motion measured with a goniometer has excellent intra-examiner reliability, as concluded in a study of children with CP, ranging from 7-15 years of age, with an ICC of > However, goniometer measurements have low inter-examiner reliability, as reflected with ICC values of 0.38 and The PDMS-2 is a diagnostic measure used to assess children s motor skill from birth to 5 years of age to diagnose developmental delay. 15 It can also be uses as an outcome measure assess change post intervention. The PDMS-2 has 6 subtests: Reflexes, Object Manipulation, Stationary, Grasping, Locomotion and Visual-Motor Integration. In this case study, the Stationary and Locomotion subtests were used. The Stationary subscale consists of 30 items including assessment of the child s ability of postural control and static balance. The 89-item Locomotion subscale includes assessment of the child s ability to mobilize over varying surfaces. Each subscale raw score can be converted to a percentile rank and age equivalence. The Stationary and Locomotion subtests have strong test-retest reliability with ICC values of 0.89 and 0.96, respectively. These subcategories have a high construct validity as measured through correlation with age; Stationary subscale of 0.87 and Locomotion subscale of The SEM varies depending upon specific age categories. The child progressed from one age category to the next during the study; therefore two standard error of the measures (SEM) was utilized. Between 24

16 8 and 35 months of age, the SEM for Stationary and Locomotion subtests are 1 point. For children in the age range of 36 and 47 months, the SEM is 2 points for the Stationary subtest and 1 point for the Locomotion subtests. 15 Based on the child s age at initial evaluation, the SEM was used to calculate the minimal detectable change with a 95% confidence interval (MDC 95 ) for the Stationary and Locomotion subscales, which were determined to be 5.54 and 2.77 points, respectively. The GMFM-66, which can be used as a prognostic measure and an outcome measure, is a criterion-referenced tool to measure motor function. There are two versions of the GMFM, the GMFM-88, which is used for children with Down syndrome, acquired brain injury and CP. The abbreviated version of the original, GMFM-66, is primarily used for children with CP. 16 The GMFM-66 has been reported to have a greater responsiveness when compared to the GMFM The GMFM-66 has 5 dimensions with a total of 66 tested items. 16 Dimension A, (Lying and Rolling), is comprised of various items in prone and supine position. Dimension B, (Sitting), ranges from the ability to obtain sitting from supine to obtaining a seated position on a large bench from the floor. Dimension C, (Crawling and Kneeling), includes creeping on one s stomach and walking forward in the high kneeling position. Dimension D, (Standing), includes pulling to stand from the floor, single leg stance and attaining a squat from standing position. Lastly, Dimension E, (Walking, running, and jumping) examines cruising (side stepping with upper extremity support on a bench/surface), jumping, kicking a ball and stair mobility. Each dimension is calculated as a percentage of the maximal score. 16 This

17 9 test has been shown to have high test-retest reliability and validity (ICC > 0.99 and 0.99, respectively). 18 The GMFM has an SEM of 1.3 points 18 with a calculated minimal detectable change at the 95% confidence level (MDC 95 ) of 3.41, using the following equation: calculated MDC = 1.96 x SEM x 2. The minimum clinically important difference with a 95% confidence interval (MCID 95 ) has been determined for dimensions D and E to be 5.3 and 4.5, respectively. 19 Motor development curves were developed for the GMFM-66, which describe patterns of gross motor development over time based on GMFCS levels. 20 These curves also determine prognosis of children with CP, within their GMFCS level. 20 To obtain GMFM-66 scores the Gross Motor Ability Estimator (GMAE) version 1.0 program was utilized in this case study. The GMAE provided 95% confidence intervals (CI) along with a total percent score, which was then converted to a percentile score. 21 The GMFM-66, along with the GMFCS levels have been validated as a prognostic tool. 20 Please see prognosis section below for further detail. The FMS is a reliable and valid outcome measure to assess a child s support needed for mobility giving a rating of the assistance required for home, school, and community distances (5 meters, 50 meters and 500 meters respectively). 22 This measure has a numerical scale from 1-6 as well as a crawling rating and a rating for distances that the child cannot ambulate. Each rating designates the level of assistive device needed for the child to ambulate the walking distances, with 1 indicating a wheelchair and 6 indicating independent ambulation on all surfaces. The reliability ranges from ICC s of 0.86 to 0.92

18 10 between the three distances, with a range of 96% to 98% agreement between parent and clinician reports. 22 The 10 MWT is an outcome tool which measures the child s gait speed. There are no psychometrics established for the pediatric population. Research on the 10 meter fast walk test (10 mfwt) indicates an MDC 95 of 12.2 seconds and test-retest reliability with an ICC range between 0.65 and Regardless of the wide range of ICC values, the 10 mfwt has been deemed a better test of functional ambulation for children between 4 and 18 years of age versus the 10 MWT. 23 The PEDI, which is an outcome measure, is completed by parent report and is used to evaluate the child s current functional status. 24 It consists of a Mobility Domain with three subcategories of Functional Mobility, Caregiver Assistance, and Mobility Modifications. The MCID 95 has been determined for the functional skill scale and the caregiver assistance to be 10.9% and 11.6% respectively for children and adolescence between 1 and 22 years of age in a hospital setting. This test has responsiveness (effect size) of > 0.8. The construct validity has been determined to be able to discriminate between children with disability and those without disability. 24

19 11 Table 1 Examination Data BODY FUNCTION OR STRUCTURE IMPAIRMENTS Test Action Right Left Interpretation MAS Triceps 1/4 1/4 Slight increase Biceps 1/4 1/4 Slight increase Quadriceps 2/4 2/4 Marked increase Hamstring 1/4 1/4 Slight increase Gastrocnemius 3/4 3/4 Considerable increase PROM: extremities Hip ext (knee flexed) 8 5 Decreased ROM WNL except the Knee extension Decreased ROM following Dorsiflexion 10 5 Decreased ROM SLR Decreased ROM Clinical observation of gait mechanics Base of support and B LE joint posture scissor gait; jump gait; narrow base of support; equinovalgus ACTIVITY LIMITATIONS Test Action Results Interpretation FMS 5 meters 2/6 Reverse walker used 50 meters 2 /6 Reverse walker used 500 meters N (does not Unable to ambulate distance apply) 10 mfwt Reverse walker (mod Ind) 2 trial average: 1.03 m/s Walking sticks (mod A to progress sticks and maintain balance) 2 trail average: 0.10 m/s GMFM - 66 Lying & Rolling 12/12 points 100% Sitting 45/45 points 100% Crawling & Kneeling 28/30 points 95.2% Standing 15/39 points 38.5% Walking 14/72 points 19.4% Modified independent ambulation Moderate assistance given to progress walking sticks and to maintain child s balance Total 53.86% 70 th percentile for GMFCS level II PDMS-2 subscales: raw scores: age equivalence; percentile rank Stationary 38/60 points 18 months; 16 th percentile rank Locomotion 71/178 points 13 months; <1 percentile rank PEDI Functional mobility domain 39/65 points 60.0%

20 12 Mobility modifications 6/21 points 28.6%; use of car seat, crib and reverse walker PARTICIPATION RESTRICTIONS Test Subscales Results Interpretation PEDI Caregiver mobility domain 14/35 points 40.0% MAS = Modified Ashworth Scale; PROM = Passive Range of Motion; ROM = Range of Motion; SLR = Straight Leg Raise; FMS = Functional Mobility Scale; 10 mfwt = 10 Meter Fast Walk Test; m/s = meters per second; GMFM-66 = Gross Motor Function Mobility; GMFCS = Gross Motor Functional Classification Scale; PDMS-2 = Peabody Developmental Motor Scale; PEDI = Pediatric Evaluation of Disability Index; Mod Ind = modified independent; mod A = modified assistance; WNL = within normal limits

21 13 Chapter 4 Evaluation Evaluation Summary The patient was a 33 month old male toddler with spastic CP. He presented with developmental delay as measured by PDMS-2, GMFM-66, decreased ambulation, functional strength, impaired balance and LE spasticity. Diagnostic Impression Patient presented with developmental delay consistent with spastic diplegic CP leading to impaired motor function. Physical Therapy Guide Practice Pattern 5C: Impaired Motor Function and Sensory Integrity associated with Nonprogressive Disorders of the Central Nervous System Congenital Origin or Acquired in Infancy or Childhood 5B: Impaired Neuromotor Development G-Code G8978 CK: modification based on 53% impairment calculated from averaged age equivalence from PDMS-2.

22 14 Chapter 5 Plan of Care Goals and Interventions Table 2 Evaluation and Plan of Care PROBLEM Subcategory Decreased balance through bilateral single leg stance (measured by PDMS-2 stationary # 20, 21) Increased assistance needed for ambulation (measured by FMS and 10 mfwt) Short Term Goals (4 weeks) Able to stand 2 sec on single leg, bilaterally, without UE support Long Term Goals (8 weeks) PLAN OF CARE BODY FUNCTION OR STRUCTURE IMPAIRMENTS Able to stand 3 sec on single leg, bilaterally, without UE support Decrease level of assistance needed during ambulation with quad canes to standby assistance ACTIVITY LIMITATIONS Decrease level of assistance needed during ambulation with quad canes to modified independent Planned Interventions Interventions are Direct or Procedural unless they are marked: (C) = Coordination of care intervention (E) = Educational intervention Single leg standing was promoted through kicking a ball and stepping on bubbles. Each activity required pelvic stabilization to maintain balance and to perform a controlled movement. The patient progressed to no needed stabilization and was able to perform both activities with good functional balance. (E) Mother was instructed to promote goal with kicking a ball at home, at least 1 time daily for 10 minutes. During all gait intervention (treadmill and over-ground) red theraband was used on the patient s B LEs to promote hip external rotation and abduction during gait. Task-specific activity training was utilized for this goal. The patient was encouraged to use canes during all overground training. The child was encouraged with various toys and activities. Assistance was given as needed to maintain balance/minimize falls and to progress canes forward when the child s motivation to continue decreased. Distances varied from session to session based on child s motivation, but ranged from 1 bout of 20 feet to 3 bouts of 20 feet. The following posture exercises were completed to improve posture during gait, to rely less on UE support through assistive device: To promote increased trunk and hip extension, reaching exercises were performed in standing and sitting. The standing exercise was

23 15 performed after each sit-to-stand, by the child reaching with alternating UEs to place a magnet on a whiteboard. The sitting exercise was performed on a Swiss ball, with support from student therapist on the patient s pelvis. While seated the patient played catch with mother to encourage reaching to catch the ball. Reaching was also performed during treadmill ambulation with ball tethered to a stick. All reaching exercises were alternated to maintain child s interest, with an average of 15 minutes per session. The patient s LE base of support was address through trialed sitting with pelvic support for balance on yellow peanut ball (92 cm in circumference) to promote increased hip abduction. The patient tolerated the sitting position well during 1 st session for 3 minutes and was issued ball for home use. (E) Mother was educated on proper donning/doffing of red theraband while the patient ambulated at home. Parent was instructed to have the child use the canes during all over-ground training with decreasing assistance as the patient progressed. The patient progressed from minimal assistance to maintain balance to mod Ind. Mother was given the peanut ball for the duration of the case study to utilize at home; patient progressed from 5 minutes with support at pelvis from mother to independent sitting for 30 minutes daily. Patient progressed from independent sitting to dynamic sitting via lateral rocking on ball with LE eccentric contraction. Increased developmental delay as measured by PDMS and GMFM (Point increase for reaching the following long term goals within the appropriate measure: GMFM-66 by +3 points, PDMS-2 by +2 points) Measurement Short Term Long Term Goals Planned Interventions Item Increase ability to stand on tiptoes (measured by PDMS-2 stationary # 22) Goals Able to stand 1 sec on tiptoes with UE over head Able to stand 2 sec on tiptoes with UE over head During the standing reaching activity with magnets (explained above) included the child obtaining tiptoe standing to reach the board. Each session averaged about 10 repetitions of tiptoe standing and maintaining position between 1 and 2 seconds. Patient progressed from needing assistance to maintain balance through

24 16 Increase ability to return to walking after picking up toy (measured by PDMS-2 locomotion # 36) Decreased independent steps (measured by GMFM-66 walking domain: #69) Able walk to toy, pick it up and return to standing before losing balance Able to take 5 independent steps Able walk to toy, pick it up and walk 2 steps before losing balance Able to take 10 independent steps pelvic stabilization to independent stance. Sit-to-stands were performed to increase LE strength as needed to perform squat/bend down to obtain toy and return to standing position from a 27 cm bench. To encourage standing without stepping 2 lb ankle weights were used on each ankle. The patient progressed from needing assistance via 1 hand held to obtain standing to independent standing. Patient performed 10 reps per session, on average. During over-ground training, intermittent breaks were taken to pick up a toy from the floor and return to standing. This activity was encouraged to be performed without the child sitting down. Patient progressed from needing pelvic support to maintain balance to independent toy grab and return to standing. This goal was addressed via treadmill training, over-ground training, and a weight shifting exercise. The over-ground training was addressed in table above. The treadmill intervention was utilized 2 times per week for 30 minute sessions. The assistance level decreased from metal frame to removal of frame with a table placed to decrease UE support (further explanation in intervention modification). The overload principle was applied with increases in speed (2.5 m/s), incline (4 inches), ankle weights (2 lbs bilaterally), and incorporation of reaching activities (explained in table above). The child averaged 25 minutes of treadmill training each session. Weight shifting exercise was performed to promote functional balance. This exercise was performed on a Bosu ball with pelvic stabilization. Reaching and further balance was encouraged with throwing and catching a ball with a Velcro mitt. Facilitation of a lateral shift force was applied through at the pelvis to encourage weight shift from one LE to another. This was performed 10 minutes per session on average. (E) Mother was instructed to perform weight shifting exercise on a pillow/cushion while providing pelvic support. This exercise was encouraged to be performed often with a minimum of 2

25 17 Problems Increased caregiver assistance needed (measured by PEDI caregiver mobility domain) Lack of implementation of HEP by parent Short Term Goals No expected change Caregiver independent in completing HEP bouts of 5 minutes per day. PARTICIPATION RESTRICTIONS Long Term Goals Planned Interventions Increase independence with ambulation and transfer activities by 11.6% as measured by PEDI HOME EXERCISE PROGRAM (HEP) Caregiver understands importance of continuing HEP and how to progress exercises This goal was address through all interventions listed above. (E) Parent instructed on how to perform exercises below with encouragement to perform activities multiple times per day. Stretching: 1. LE PROM stretching (ankle dorsiflexion, knee extension) 2. Sitting on peanut ball (progress to 30 minutes daily) with reaching activities and bouncing Functional balance: 1. On pillow/cushion perform weight shifting exercise with pelvic support while performing reaching exercise (2 bouts of 5 minutes daily) 2. Repeated kicking of ball to promote single leg standing (10 minutes daily) Ambulation: 1. Use quad canes maximally during over-ground ambulation (at least 50 ft daily) giving assistance as needed. 2. Use red theraband during assisted and independent ambulation at most times during outdoor ambulation (at least 100 ft daily) FMS = Functional Mobility Scale; 10 mfwt = 10 Meter Fast Walk Test; m/s = meters per second; GMFM-66 = Gross Motor Function Mobility; PDMS-2 = Peabody Developmental Motor Scale; PEDI = Pediatric Evaluation of Disability Index; LE = lower extremity; UE = upper extremity; B = bilateral; ft = feet; cm = centimeters; mod Ind = modified independent

26 18 Prognostic Considerations Five motor development curves have been developed based on the GMFM-66 and the GMFCS levels. 20 The patient in this case study who had a GMFCS level of II. The age at which he will reach 90% of his motor development potential could be predicted. When this patient reached the age of 4 years and 5 months, he was predicted to reach 90% of his motor development potential. 20 Research shows average prediction percentages of mobility for children with CP across multiple GMFCS levels as: 54% walking independently by 5 years of age, 16% walking with aids, and 30% unable to walk. 25 Based on the child s GMFCS level of II, the family s motivation level and the child high cognitive status, the patient had a good potential to meet the set goals. Plan of Care- Intervention See table 2 Overall Approach There is increasing evidence that task-specific training is beneficial for children with CP. Task-specific training is necessary for the occurrence of motor learning as well as functional organization. 8 This is especially true when tasks are meaningful. 8 Sit-tostand training is an effective task-specific exercise for children with CP. 26 This activity can increase functional balance, functional motor strength, walking efficiency and basic gross motor function as measured by GMFM-66 Dimensions D and E. 26 When compared to children with CP who receive treatment following the neurophysiologicial treatment method, children with CP who received task-specific physical therapy had greater improvements in daily functional motor skills. 27 There was evidence of the overload

27 19 principle being effective with two children with hemiplegic CP. 28 Functional MRI data showed measurable neuroplastic changes after repetitive intensive strengthening training of 10 weeks of 60 minute sessions 3 times per week. These changes were associated with increases in muscle strength, size and motor function after. 28 The parent involvement was a major component of the interventions. Research demonstrates that involvement of parents in the interventions is an effective approach to treat children with CP. 29 The concept of family-centered services has emerged in therapy and is supported by professionals. In a study of treatment programs, early interventions tended to initially be child-focused with a gradual transition to family-centered care. 30 This concept was utilized during treatment, particularly with integration of the home exercise program (HEP). Treadmill training allows opportunity for intensive training with repetitive movements to facilitate the overload principle as well as being task-specific to increase ambulation. Treadmill training was shown to increase gait speed, functional balance, static balance and gross motor function in children with CP between 3 and 12 years of age. 31 This type of training is believed to improve control between agonist and antagonist muscles. 31 Over-ground walking speed can be increased with treadmill training as well as over-ground ambulation training, 32,33 however treadmill training was shown to lead to greater improvement of gait speed. 33 A systematic review reported statistically significant change in Dimensions D and E of the GMFM-66 with treadmill training in children with spastic diplegic CP ages 3 to 6 years and GMFCS levels I and III. 32 These improvements had a carryover effect lasting up to 12 weeks after completion

28 20 of the intervention. 32 Statistically significant improvements in the PEDI mobility scale were shown to have a carryover effect lasting up to 16 weeks post intervention for young children with CP after an intensive treadmill program 6 times per week for 6 weeks. 34 PICO question For a child, 33 months of age, with developmental delay secondary to CP (P) is treadmill training (I) an effective intervention to increase balance (O) compared to conventional physical therapy (C)? Assessment of balance pre- and post-treadmill intervention was measured in 2 articles. Both articles reported that children with CP had significant improvement in balance post treadmill intervention. 31,35 The first was a randomized control trial (Level of evidence: 1b; PEDro score 7/10). 31 This particular study compared the effects of treadmill training versus over-ground training on functional balance on children with CP between the ages of 3-12 years, with GMFCS levels I, II and III. The protocol was two 30 minute sessions per week over 7 weeks. Both groups increased functional balance, but the treadmill group demonstrated statistically higher balance scores. 31 The second study was a case series (Level of evidence:4). 35 In a study with 6 children with CP, ranging in ages between 2.5 and 3.9 years and GMFCS levels I to IV, treadmill training was reported to improve balance. This study utilized a one month protocol, with 1 hour sessions, 3 times per week. The standing dimension in the GMFM-66 and a timed balance measure of static standing were performed. The balance measure was only used when the children were able to stand independently and able to understand the directions. Two children completed the balance measure and approximately doubled their balance

29 21 time from pre- and post-intervention with continued improvement at the 1 month followup. 35 The main gait intervention was weight supported treadmill training with handlebars, however, the child unloaded too much of his body weight through his UEs on the frame. To maximize treatment, other interventions were attempted such as overground ambulation with the patient in a harness supported overhead by a student therapist. This gave the child too much support and allowed him to fall into the support. The other treatment attempted was removal of the treadmill handlebars and positioning the belt of the treadmill under a stable table. This modification allowed the child to use the table for needed support while allowing the student therapist the opportunity to minimize the child s UE support via encouragement to play with toys. The table and treadmill intervention was adopted into the treatment plan on the second session. As the subject s ambulation progressed, the child was introduced to small quad canes which allowed him to independently ambulate without therapist/parent support. The surface on which balance exercises and weight support were performed was modified. Due to the child s low body weight, the trampoline and foam gave too much support, however, the Bosu ball was observed to elicit more trunk activation. A tricycle was attempted to incorporate reciprocal motion, however, this intervention was not effective because the tricycle was too big. The last intervention that was added to the initial plan of care was high repetitions of sit-to-stands with weights on the child s ankles to minimize stepping upon standing. Repeated sit-to-stands were supported by research to increase functional balance and over-ground ambulation. 26 This intervention was added

30 22 after a trial of prone extensions on a Swiss ball which the patient was unable to be complete effectively. The effectiveness of the sit-to-stand exercise was supported by research, 26 was a functional activity, and activated the same muscle group as the prone extension exercises. The indirect interventions utilized during this case study included parent education of the HEP and the use of various equipment. The parent was educated on the HEP (Table 2) including correct technique and incorporation of task specific exercises into daily activities. At the start of the case study the patient used a reverse walker as needed for ambulation, however, from observation the reverse walker was giving too much assistance during ambulation. This led to the designing of custom quad canes to provide less assistance to maintain the overload principle and to challenge the patient s balance.

31 23 Chapter 6 Outcomes Table 3 Outcomes OUTCOMES BODY FUNCTION OR STRUCTURE IMPAIRMENTS Outcome Initial Follow-up Change Goal Met (Y/N) Increase balance through bilateral single leg stance (PDMS-2 stationary # 20, 21) # 20: 0/2 points #21: 0/2 points (unable to stand on single leg) # 20: 1/2 points #21: 1/2 points (able to stand on single leg 2 seconds) +2 points on PDMS (+ 2 seconds on single leg) ACTIVITY LIMITATIONS Outcome Subcategories Initial Follow-up Change Goal Met (Y/N) FMS 5 meters: 2/6 (walker) 3/6 (canes) 1 (MCID 95 1) 50 meters: 2/6 (walker) 2/6 (walker) No change (MCID 95 1) 500 meters N (N/A): N (N/A): No change unable to unable to (MCID 95 1) ambulate ambulate distance distance 10 mfwt Walker: 1.25 m/s 9.75s Walking sticks: 0.10 m/s 99s GMFM-66 Lying/Rolling: 12/12 points (100%) Sitting: 45/45 points (100%) Crawling/kneeling: 28/30 points (95.2%) Standing: 15/39 points (38.5%) 0.92 m/s 11.35s 0.14 m/s 113s 12/12 points (100%) 45/45 points (100%) 29/30 points (96.7%) 18/39 points (46.2%) m/s +1.6s (MDC s) m/s +14s (MDC s) N Y N N N N 0 points N/A 0 points N/A 1 points N 3 points (MCID 95 : 5.3 points) N

32 24 Walking: 14/72 points (19.4%) Total score: 53.86% (95% CI: ); 70 th percentile GMFCS level II PDMS-2 Stationary: 38 points; age equivalence: 18 months; 16 th percentile rank Locomotion: 71 points (13 mo); <1 Percentile rank Specific tasks from GMFM- 66 and PDMS-2 to improve gross motor development Increase ability to stand on tiptoes (PDMS stationary # 22) Increase bilateral single leg stance (PDMS-2 stationary # 20, 21) Increase ability to return to walking after picking up toy (PDMS-2 locomotion # 36) Increase Independent steps (GMFM-66 E: #69) 0/2 points (unable to stand on tiptoes) # 20: 0/2 points #21: 0/2 points (unable to stand on single leg) 0/2 points (loses balance when picking up toy) 2/3 on GMFM (4 steps) 14/72 points (19.4%) 55.62% (95% CI: ); 75 th percentile GMFCS level II 41 points; age equivalence: 33 months; 37 th percentile rank 80 points (15 mo); 1 Percentile rank 1/2 points (stands of tiptoes for 2 seconds) # 20: 1/2 points #21: 1/2 points (able to stand on single leg 2 seconds) 1/2 points (picks up toy, returns to standing, takes 2 steps) 2/3 on GMFM (7 steps) 0 points (MCID 95 : 4.5 points) +1.76% (MDC 95 : 3.24%) +3 points; age equivalence: +15 months (MDC 95 : 5.54 points) +9 points (2 mo) (MDC 95 : 2.77 points) +1 point on PDMS (+2 seconds on tiptoes) +2 points on PDMS (+ 2 seconds on single leg) +1 point on PDMS (maintains balance, + 2 steps) no change in GMFM score (+3 steps) N N N Y Y N Y N PEDI Mobility modification: 6/21 (28.4%) 6/21 (28.4%) 0 points N Functional: 39/65 (60.0%) 45/65 (69.2%) +6 points (9.2%) (MCID ) N PARTICIPATION RESTRICTIONS Outcome Subcategories Initial Follow-up Change Goal Met PEDI Caregiver: 14/35 (40.0%) 26/35 (74.3%) +22 points (34.3%) (MCID ) (Y/N) Y

33 FMS = Functional Mobility Scale; 10 mfwt = 10 Meter Fast Walk Test; m/s = meters per second; GMFM-66 = Gross Motor Function Mobility; PDMS-2 = Peabody Developmental Motor Scale; PEDI = Pediatric Evaluation of Disability Index; MDC 95 = the minimal detectable change with a 95% confidence interval; MCID 95 = The minimum clinically important difference with a 95% confidence interval 25

34 26 Discharge Statement The patient of this case study was diagnosed with spastic diplegic CP at 18 months of age and had developmental delay as measured by PDMS-2 and GMFM-66 during initial evaluation. He was seen in a university setting for a total of 11 visits beginning with the patient being 33 months of age and ending at 36 months of age. The patient received task-specific training to address the parent s goals of increased ambulation and functional balance. The parent, who is the primary caregiver, was educated in expected outcomes and a HEP. The patient progressed ambulation as measured by the level of assistance needed from assistive devices. Prior to treatment, the patient utilized a reverse walker as his primary assistive device and progressed to the ability to use two quad canes. The number of independent steps increased from 4 to 7 steps over the course of treatment. Functional balance was measured with improvement in specific sub-items within the GMFM-66 and PDMS-2 with single leg stance time. The patient and his parent were highly motivated and compliant with participation in the HEP. Not all goals were met during the course of this case study. Unmet goals of increased independent steps and increased single leg stance time would be expected to be met over a longer course of treatment and motor development. The patient was discharged home with instruction to the parent to continue with prescribed HEP and to ongoing PT and OT treatments.

35 27 Discharge G-code G8980 CJ: modification based on 33% impairment calculated from averaged age equivalence from PDMS-2

36 28 Chapter 7 Discussion The patient of this case study showed improvements in developmental function as demonstrated from outcome measures as well as parent report of increased functional mobility. The patient met the parent s goals of increased independent ambulation and increased functional balance. The patient increased independent steps and improved in the Stationary subscale of the PDMS-2. The subject showed progress within the short time frame of this case study. The child had good potential to continue to improve functional mobility beyond the time course of this study. The patient had a classic presentation of spastic diplegic CP. His participation in therapy as well as the progress he made will influence my future treatment of children with CP. The interventions included in this study will apply to many children with CP, particularly children in the GMFCS level II. The measurements used can be applicable to other children with CP, however many outcome measures are age specific. There was limited evidence available for this age group. Treadmill training has strong evidence reporting improved ambulation. However, there is limited research on dosage in which to perform treadmill training to obtain maximal improvements in the pediatric setting; further research would have improved my ability to treat this patient. There is limited evidence pertaining to the pediatric setting in regards to outcome measures, such as ROM. The patient in this study had increased muscle tone leading to abnormal ROM. The initial ROM was measured using a goniometer, however research states that a change of more than 20 is needed to be 95%

37 29 confident that a true change has occurred with LE ROM in children with CP. 36 This amount of change in ROM, with increased muscle tone, is unlikely in an 8 week course of care. 37 Based on this research, as well as observational assessment of ROM during functional assessment, I did not see the significance of measuring ROM post the 8 week intervention to assess ROM improvement. However, if the opportunity arose for treatment of a similar patient I would include ROM testing post intervention to ensure that ROM was not becoming more impaired. With future patients in the pediatric setting I will be more likely to use an inclinometer which is a highly reliable instrument for measuring ROM on children with CP. 14 This instrument will allow the measurement to be taken more quickly, requiring the child to be in the fixed position for less time. Lastly, to better treat patients, I would complete a thorough systems review and include objective measurements for all systems. A limitation of this case study involved the short duration of the course of care. The child had a better prognosis of making functional improvement with a longer duration of treatment. 20 However, the child was expected to continue with functional improvements with adherence to the HEP and continued PT. Another limitation was the inclusion of canes half way through the intervention timeline. This late inclusion did not allow for canes to have initial testing to note progress pre- and post-intervention. The canes did allow the patient to ambulate independently with less stable assistive devices when compared to the reverse walker. The FMS was used to report a decreased level of assistance needed, however, gait speed pre-and post-intervention was unable to be measured under all conditions.

38 30 The patient responded well to the treatment and achieved many goals. The mother s high motivation to improve her son s functional mobility and great compliance to the HEP was a key factor. The child presented with age-appropriate cognition and communication skill. There was more progress when the child had limited environmental stimuli to decrease distraction. He was moderately content with repeated interventions. To increase application of the overload principle, reflecting back, I would increase the integration of multiple interventions to one activity to use treatment time more efficiently. This concept would also be reflected in the HEP with integration of more task-specific activities to be conducted multiple times a day.

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