By: Nia M. Torres Doctoral Candidate University of New Mexico School of Medicine Division of Physical Therapy Class of 2015

Transcription

1 Effect of Gait Training With Overground Gait Trainer Support Versus Partial Body Weight Supported Treadmill Training in Children with Spastic Diplegic Cerebral Palsy By: Nia M. Torres Doctoral Candidate University of New Mexico School of Medicine Division of Physical Therapy Class of 2015 Advisor: Marybeth Barkocy, P.T., DPT Printed Name of Advisor: Signature: Date: Approved by the Division of Physical Therapy, School of Medicine, University of New Mexico in partial fulfillment of the requirements for the degree of Doctor of Physical Therapy. 1

2 Table of Contents: Abstract...3 Section 1 Background and purpose PICO...6 Section 2 Case description Introduction Examination Evaluation Interventions Outcomes Section 3 Evidence based analysis Search methodologies Article summaries Table of articles Discussion Conclusion/bottom line...38 References Appendices Article analysis worksheets

3 Abstract: Background/Purpose: Cerebral palsy is a group of neurological disorders that affect movement and motor control. Increased tone and spasticity due to central nervous system damage to the cerebellum and corticospinal tracts contribute to gross motor delay and limit mobility in many cases for children with a medical diagnosis of spastic diplegic cerebral palsy. Physical therapy intervention is often part of the medical management for these children with CP due to the delay and impairment in gross motor acquisition and functional mobility. Case Description: A two year old male patient was born prematurely and received a subsequent medical diagnosis of spastic diplegic cerebral palsy. He had increased tone and spasticity in his bilateral lower extremities and minimal involvement of his right upper extremity. Increased tone in his hip adductors and gastrocnemius muscles were contributing to the gross motor delay apparent upon evaluation. The personal goals voiced by the parents of this patient were to work toward independent or modified independent gait. Outcomes: This patient was seen for the first 8 weeks during a plan of care estimated to continue for a duration of 6 months after initial evaluation. During these 8 weeks, this patient was observed to increase his ability to dissociate his lower extremities in crawling, stair ascension, and overground ambulation with manual assistance. Gait training was provided for this patient via various types of gait trainers during the duration of his physical therapy sessions. \Discussion: A literary review of current research suggests that overground gait training is superior to treadmill gait training in terms of gait kinematics and velocity. There is some evidence to support the use of a gait trainer for improved overall gait quality. Recent literature indicates partial body weight supported gait training appears to be less supported in children with cerebral palsy. Available research is limited by lack of high quality randomized controlled trails. 3

4 Section 1: Background & Purpose Cerebral palsy (CP) is a neurological disorder that affects the developing brain of children and infants prenatally, postnatal, or prior to 2 years of age. CP is characterized by damage to the brain that is nonprogressive throughout the individual's life. With CP, the physical damage to the central nervous system does not worsen with time although the presentation of symptoms can change over the individual's lifespan ( Cerebral Palsy Types and Causes, 2015). Cerebral palsy is the most common motor disability in children. Each year there is an incidence of about 10,000 new diagnosis of CP in the US. Countrywide there are about 764,000 individuals with a medical diagnosis of cerebral palsy. While there are multiple sub-types of cerebral palsy the most common type is spastic CP, which accounts for 80% of all CP cases. In the majority (85-90%) of CP cases the neurological damage occurs during or before birth and is identified as congenital CP ( Facts about Cerebral Palsy, 2015). Cerebral palsy is characterized by impaired motor control secondary to damage to the developing central nervous system. It can be caused by a multitude of types of insults to the brain including, but not limited to, infection, physical trauma, impaired oxygen supply to the brain, or severe illness ( Cerebral Palsy Types and Causes, 2015). In addition CP can be complicated by other concurrent ailments such as osteoporosis, injuries from falls, joint contractures, pneumonia, scoliosis, seizures, cognitive delays, and impaired communication. Spastic diplegia is a type of cerebral palsy that generally affects the lower extremities greater then the upper extremities. If the upper extremities do exhibit spasticity, they tend to be less involved than the lower extremities. This lower extremity involvement can cause individuals to have difficulty acquiring gait and may affect their potential to be functionally ambulate. Gait is altered in individuals with spastic diplegia CP due to the increase in muscle tone causing legs to adduct, internally rotate, and causes a scissor gait 4

5 pattern when ambulating (American Physical Therapy Association, 2001), ( Facts about Cerebral Palsy, 2015). In individuals with spastic diplegia, spasticity is contributory to gait and functional mobility impairments. Spasticity is caused by an upper motor neuron lesion. This damage in the CNS causes an increase in muscle tone that is velocity dependent and elicited with a quick stretch. The quick stretch causes an increase in muscle tone due to a hyperexcitable stretch reflex in which there is an imbalance between excitatory and inhibitory signals to the spinal cord (Trompetto et al., 2014). Conventional physical therapy for individuals with spastic cerebral palsy takes a multi-segmental approach to address functional and developmental limitations. Physical therapy (PT) aims to strengthen weak musculature and provide ROM and flexibility to joints and soft tissue. Physical therapy can additionally include soft tissue and joint mobilization, stretching, strengthening exercise, and endurance type exercise. Conventional PT includes assessment of and intervention for alterations in gait and posture through repetitive practice and child/parent education ( Treatment of Cerebral Palsy, 2015). Physical therapy also addresses adaptive equipment needs and adaptive techniques to allow individuals with CP to compensate and function in a modified fashion with the most independence they physically can achieve. Orthotic and brace recommendations can be included as part of physical therapy interventions, and in some facilities, even casted for AFOs or other bracing options at the same facility ( Treatment of Cerebral Palsy, 2015). Therapeutic exercise for individuals with CP focus on increasing functional mobility, decreasing degree of functional limitations and impairments and positively impacting health, wellness, and fitness. This is achieved through a multitude of interventions during therapy and implemented through home program prescription. Physical therapy works to achieve this through aerobic and endurance conditioning, addressing balance, coordination and agility deficits, flexibility, gait training, neuromotor development, and strength, power and endurance training. Physical therapy implications can vary from aquatic programs, 5

6 general aerobic training via gait or other mobility, strengthening exercises for specific muscle groups, stretching and ROM for flexibility, and body mechanics or postural stabilization for optimal set up and carry through of movement and mobility. Physical therapy can help to reduce the risk and serve as proactive prevention for development of secondary impairments and improved safety for the individual. An episode of care typically lasts 6-90 visits to achieve goals and discharge from therapy (American Physical Therapy Association, 2001). Individuals with CP are often seen for multiple episodes of care throughout their lifetimes. At evaluation, this individual was a 2 year 7 month old male toddler presenting with a medical diagnosis of spastic diplegic cerebral palsy. He was born prematurely at weeks gestational age. He was observed to have increased muscle tone in his bilateral lower extremities with some right side upper extremity involvement. At evaluation, this individual was non-ambulatory and his only form of mobility was hop crawling on the floor with simultaneous alternating movement of his lower and upper extremities without reciprocation. PICO: Does the use of an overground gait trainer improve independent or modified independent upright mobility compared to partial body weight supported treadmill gait training in children with spastic diplegic cerebral palsy? 6

7 Section 2: Case Description Introduction: This case patient was a 2 year 7 month old male of Caucasian descent seen for evaluation and treatment at the Children's Clinics, a pediatric outpatient physical therapy clinic, in Tucson, AZ. He had two very supportive and involved parents caring for him. He was an only child. His father was employed by the Air Force and mother was a stay-at-home mom who cared for this patient's daily needs. The patient was born prematurely at week gestational age. He had a medical diagnosis of spastic diplegic cerebral palsy involving his bilateral lower extremities and his right upper extremity. This patient and his family were familiar to this clinic as he has undergone previous episodes of care for gross motor delay. Chief complaint per family report for this episode of care was delay in acquisition of motor skills including independent ambulation. Patient was evaluated and plan of care developed post botulinum toxin injections to isolated spastic bilateral lower extremity muscles. Evaluation for this episode of care took place on October 24, Patient was referred for evaluation and treatment post botulinum toxin by his neurologist. The neurologist noted increased tone at evaluation on August, 29, 2014 in bilateral lower extremities indicated botulinum toxin injections to bilateral hip adductors and gastrocnemius. It was agreed by the neurologist and physical therapist that this patient was a good candidate for botulinum toxin injection to increase functional mobility by decreasing lower extremity tone. Increased tone was reported to be negatively impacting his mobility and potential for ambulation and other functional mobility. Botulinum toxin injections occurred on October 21, 2014, 3 days prior to initial evaluation. The effects of botox injections typically begin to demonstrate their effect a few days to 2 weeks after the muscles have been injected (Treating spasticity with botox, 2015). Physical therapy was initiated during this time frame of initial effect of the injections and the plan of care continued during the two month time frame following botox injection. Botox 7

8 injections typically have a lasting effect for 2 to 6 months after initial injection (Treating spasticity with botox, 2015). Examination: History: Patient was born at weeks of gestational age via cesarean section. He weighed 2lbs 12oz at birth and was subsequently hospitalized in the NICU for about 2 months. Magnetic resonance imaging (MRI) was found to be positive for periventricular leukomalacia, and the patient was given a medical diagnosis of cerebral palsy. Mother reported that the patient has not had any significant medical involvement aside from routine follow up and physical therapy for gross motor delay since his discharge from the NICU. He has been followed by neurology for ongoing management of increased muscle tone, spasticity, and general neurological involvement associated with cerebral palsy. The patient's history is negative for any surgical procedures. Mother reports that her son s health is good. This patient had a medical diagnosis of spastic diplegic cerebral palsy. Cerebral palsy can be caused either during the prenatal period, perinatal period, or within the first two years of life. Close to half of all children with a cerebral palsy diagnosis were born premature (Marret, Vanhulle, & Laquerriere, 2013, p. 169). Cerebral palsy is most often caused by disruption of oxygen supply to the brain with subsequent cerebral anoxia and damage (Marret et al., 2013, p. 169). Maternal and placental factors have an effect on the brain that when babies are born prematurely they are no longer exposed to these factors that effect appropriate development in a fetus prior to birth (Marret et al., 2013, p. 170). This is what is believed to put premature infants at increased risk for cerebral damage and a resultant cerebral palsy diagnosis. In the brains of children with spastic diplegia there is diffuse white matter injury present on imaging (Marret et al., 2013, p. 172). Like this patient, there is also generally intraparenchymal hemorrhage present in the central 8

9 nervous system. This type of injury causes the spastic presentation due to the damage to the corticospinal tracts, cerebellum, and basal ganglia (Marret et al., 2013, pp ). Current medications for this patient were limited to oral baclofen with doses given two times per day. This was an ongoing medication taken by the patient for spasticity management prior to botox injections and physical therapy evaluation and treatment. Baclofen was the current medication this patient was taking for management of spasticity. Each dose of baclofen (5mg per dose) was administered in liquid form. This patient did receive botulinum toxin injection of 50 units in each of his bilateral hip adductors and gastrocnemius muscles for a total of 200 units. This patient received no other current medications. This patient had no significant medical family history, both mother and father reported they were healthy. This patient lived with his mother and father who were, at evaluation his primary caregivers. He did not yet attend school secondary to his young age. Mother was a stay-at-home mom and provided daily care for patient. Father was employed in the Air Force. Both parents were noted to be engaged in this patient s daily care and physical therapy/medical care. They were noted to have had a good history for follow through with home programs and follow up appointments during previous episodes of care and with other medical disciplines. Follow though appointment information provided per case manager report. Mother reported that patient shows some interest in walking and has some limited independent floor mobility with modified crawling. The parents goals for their child included walking and independent mobility with the least restrictive assistive device allowable. They additionally expressed a goal for increased range of motion to allow for better positioning with mobility. Systems Review: Musculoskeletal - Patient was observed to have impaired motor control. He had right sided upper extremity hemiparesis. Lower extremities were both noted to have an increase in tone with spasticity in bilateral lower extremities. Right lower extremity was observed to have more involvement then left. There was resultant impaired motor function and performance in bilateral 9

10 lower extremities. Patient was able to use right upper extremity to manipulate objects, but required verbal cueing to initiate and had some fine motor deficits in the right upper extremity. Neuromuscular - Patient had impaired motor function which was noted non-progressive in nature due to periventricular leukomalacia during the perinatal period. Cardiopulmonary - No significant findings per medical progress note from neurologist. Report states lungs are clear to auscultation, regular heart rate and rhythm with normal first and second heart sound and no murmur. Integumentary - Skin was intact with no significant findings noted. Patient does not have a history of integumentary disruption or injury. Tests & Measures: Anthropometric Height 84cm Weight 11.19kg BMI = (underweight) Cardiovascular Heart rate 90 BPM Respiratory rate 28 respirations/min Communication observations: Patient was able to talk but he exhibited dysarthria. He was interactive with his environment, responded to simple gross motor commands, and did demonstrate an interest in objects. Orientation: Patient was oriented to person. Secondary to young age, other orientation questions were not asked during evaluation or treatment. 10

11 Gait: Patient was unable to stand or take steps with or without an assistive device. He was observed to intermittently take a short step but required maximal assistance for balance. Steps were noted in a scissor-like pattern when performed. Current mobility consisted of a modified crawl/hop in quadruped. Floor mobility was performed with alternating forward movement of simultaneous upper or lower extremities without reciprocation. Motor function: This patient presented with increased tone in hip flexors, adductors, hamstrings, and ankle plantar flexor muscle groups. This increase in tone was impacting his ability to voluntarily control his lower extremities and caused decreased ability to dissociate his lower extremities, negatively impacting his ability for reciprocal crawling and gait. His right side presented with greater tone compared to the left. With his right upper extremity in a flexed position at rest. He was able to use his right upper extremity, but did require frequent verbal cueing to initiate use of right upper extremity. Fine motor control of the right upper extremity was noted to be impaired as well. He was able to use a mass grasp to pick up objects, but fine motor control is not symmetrical on the right. The motor involvement aspect of this child's cerebral palsy is impacting his postural control and dynamic trunk control, contributing to decreased balance and righting reactions in sitting and standing. Orthotic devices: Patient had bilateral Cascade AFOs for his lower extremities. Posture: Patient was unable to long sit due to hamstring tightness pulling him into a posterior pelvic tilt. Patient preference was to w-sit. In sitting, there was observed increased lumbar flexion and a posterior pelvic tilt. In supported standing with AFOs donned, this patient was able to stand with a narrow base of support with lower extremities fixed in extension. He was able to bear weight through his lower extremities, but required maximal assistance for balance. 11

12 Pain: This patient did complain of pain in his lower extremities with AFOs donned. He stated it hurts. Mother stated that he does not like to wear the AFOs and says they hurt, so that they will be taken off. She reported she does not believe pain is present. Patient did not appear to be in any pain when distracted with toys with AFOs donned. Passive Range of Motion Hip flexion within normal limits bilaterally Knee flexion within normal limits bilaterally Knee extension -5 o bilaterally o abduction bilaterally Dorsiflexion with knee extended (right) +5 o (R2 measurement) Dorsiflexion with knee extended (left) 0 o (R2 measurement) Reflex integrity: Clonus was observed in bilateral ankles. Hyperreflexive bilaterally for patellar tendon reflex. Evaluation: Medical diagnosis: Spastic dipelegic cerebral palsy Medical ICD-9 codes: (congenital diplegia), (periventricular leukomalacia) PT diagnosis: Gross motor delay in reaching milestones secondary to congenital diplegia PT ICD-9 codes: (Coordination disorder), (unspecified delay in development), (delayed milestones), (abnormality of gait) Narrative Assessment: This patient was a 2 year 7 month old young boy who presents with a medical diagnosis of spastic diplegia cerebral palsy. He demonstrated increased muscle tone in his lower extremities with an associated decreased ROM and motor control in his bilateral lower extremities. He was unable to dissociate his lower extremities and had impaired balance reactions, which were both negatively 12

13 impacting his independent mobility including ambulation. This patient had a very supportive family and support system, and parents were eager to participate and encouraged participation from the patient in physical therapy both in clinic and at home. Mother did report that patient had shown some interest in walking at home. This patient is a good candidate for making functional gains during physical therapy because of his supportive family and his reported interest in ambulation, active participation in his current modified independent mobility, and ability to support weight through his lower extremities in standing. Prior to evaluation this patient had received botulinum toxin injections and is on oral baclofen, which will provide a supportive environment for decreasing muscle tone to allow for more functional mobility with use of lower extremities. This patient will benefit from physical therapy to address these impairments and functional limitations to increase ROM, motor control, and increase independent mobility. Problem list: Impairments: Increased spasticity and muscle tone bilateral lower extremities Increased spasticity and muscle tone right upper extremity Decreased knee bilateral knee extension Decreased bilateral hip abduction Decreased dorsiflexion with knee extended Decreased balance in standing Scissoring step pattern Decreased protective responses Inattention to right upper extremity Decreased endurance Functional limitations: 13

14 Unable to dissociate lower extremities to crawl reciprocally Unable to pull to stand at support surface Unable to consistently take steps even with with maximal assistance for balance Unable to cruise at a support surface Crossover of lower extremities during gait resulting in fall risk Unable to ascend or descend stairs Prognosis: Plan of Care & Goals The parents of this patient were highly motivated and involved in actively participating and working with their child to increase his self-mobility and address functional limitations. The patient himself appears less interested in ambulation and preferred to bunny hop crawl as his main form of mobility. He was interactive with his environment and was cooperative with participating in standing and assisted ambulatory activities. In clinic, therapy will focus on repetitive practice for developing motor skills. It will address ROM limitations, family training, home exercise prescription, assistive device prescription and education, and general strengthening. Home program interventions will address repetitive practice with an appropriate assistive device for ambulation. Home program will also include stretching exercises and positions to address long duration, low load stretching. Posture and positioning will be addressed and parents educated to correct w-sitting and increased trunk flexion. This patient was seen on average for one session per week during the first 8 week following evaluation. Frequency was expected at 1-2 visits per week for 3 months tapering down to 1 visit every other week for months 4-6 months. Plan of care anticipated for 6 months to achieve goals. Patient was being seen under the Children's Rehabilitative Services program (CRS), which was part of the Arizona Medicaid program. This patient had no copay for physical therapy visits at the Children s Clinic s for Rehabilitation. 14

15 Anticipated discharge will occur at time when patient is able to accomplish feet minimum of modified independent mobility in the least restrictive assistive device with only verbal cues. This patient was not expected to be a functional community ambulator due to the involvement of his cerebral palsy and increased tone in his lower extremities. He was expected to be able to ambulate short distances with an assistive device such as a trunk and pelvic supported gait trainer. This plan of care was designed to facilitate increased independence with in home mobility and interaction with his environment through gait training and functional training for upright balance, postural control, and anti-gravity movement with modified independence. He demonstrated a fair to good prognosis to be able to participate in modified independent upright mobility in the home. This patient was classified as a GMFCS level IV for gross motor function. Long Term Goals: Patient will stand at support surface, to manipulate a toy, with unilateral upper extremity support to play with an object for 2 minutes with stand by assistance for safety within 3 months. Patient will cruise 2 steps to the right and left, to access toys in his environment, with minimal assistance at pelvis for balance, limb cueing, and verbal cueing for motor planning within 5 months. Patient will take 10 consecutive alternating steps with verbal cueing and encouragement in the least restrictive assistive device (likely gait trainer) to provide modified locomotion within 6 months. Short Term Goals: Patient will stand at support surface with bilateral upper extremity support, to play with a toy on the support surface, for 10 seconds with no loss of balance with stand by assistance for safety within 4 weeks. Patient will cruise 1 step R and L, to reach for a toy, with facilitation at the hips for weight shifting and to initiate side stepping with 50-75% assistance within 8 weeks. 15

16 Patient will take 4 consecutive alternating steps with tactile cueing at lower extremities to advance lower extremity in least restrictive assistive device to progress toward upright modified independent mobility though space. Potential Barriers: This patient had a very supportive family, but does lack motivation for upright ambulatory mobility during evaluation. His mother reported he does demonstrate increased interest in walking in his home environment, but this client s motivation may have impacted his ability to meet goals and participate during sessions. Another barrier included his bilateral lower extremity involvement with increased tone. This aspect of this patient's medical involvement may have negatively impacted this patient's ability to meet his goals. This patient had functional activity limitations impacted his ability to participate in independent mobility. At evaluation he was unable to reciprocally crawl, ascend/descend stairs, stand without assistance, and demonstrated decreased balance in upright postures. His participation restrictions were influenced greatly by his lower extremity spasticity and decreased motivation for standing mobility. This patient was a fall risk due to his lack of postural control in standing and sitting with mobility. He was noted to live with his mother and father with a supportive extended family in the area. Therapeutic interventions: During the course of 7 visits for outpatient physical therapy this child progressed in his independence for certain areas of functional mobility. Initially at evaluation, this patient's only form of independent locomotion was bunny hopping. All standing therapeutic interventions were performed with AFOs and shoes donned. See table 1 for details regarding specific interventions, progression, and assistance required to complete therapeutic interventions. This patient was generally agreeable to participate during therapeutic interventions. He did not enjoy participating in gait training with the gait trainer assistive devices and preferred to participate in gait with manual assistance for balance. Motivation was a 16

17 challenging factor for this child due to his young age and increased energy requirement to participate in standing activities. Set up with stimulating activities and encouragement were an important component of therapeutic intervention sessions. During the 6 th visit, the use of the Star Kart was trialed to allow this patient to manually propel a wheelchair-like device to trial a more independent form of mobility. This decision was made due to the lack of progress and disinterest this patient had in gait with the gait trainer assistive devices during the plan of care thus far. Patient related instruction was provided via manual techniques for movement facilitation and verbal instruction. Therapeutic interventions were implemented with one-on-one instruction with the patient. Interventions were structured by arranging play area to emphasize strengthening, lower extremity dissociation, and massed locomotor practice. Intervention plan initially included manual techniques and facilitation for balance, cruising, ambulating with and without a gait trainer, stair training, endurance, ROM, and home exercise prescription. This plan of care was decided on to focus on increasing upright locomotion and balance. Use of a gait trainer for ambulation training was implemented based on clinical experience and testimony of the physical therapy team at the outpatient clinic this patient was seen at. Physical therapy evaluation and treatment was coordinated with this patient's neurologist for optimal timing of physical therapy interventions after botox injections were administered. Timing of initiating PT intervention was important to optimize the functional benefits of the botox injections. (Physical therapy is an integral part of treatment in children with cerebral palsy who have received botox injections.) Patient care also included coordinating with orthotist for AFO brace management and adjustments as indicated. Adjustments were made to the plan of care based on the disinterest this patient demonstrated with ambulation. These adjustments included a secondary focus on alternative forms of mobility, through coordination with NuMotion for a referral for a manual wheel chair evaluation. Plan of care did continue to address impairments and functional limitations and encouraged ambulation with manual facilitation and use of gait trainers for pelvic and trunk support. 17

18 Table 1: Interventions and Outcomes for plan of care 10/24/14 to 12/8/14 Date Visit # Treatment Duration 10/24/ mins Mother reports improved range since botox injections 10/31/ mins Mother reports improved standing and lower extremity ROM 11/11/ mins Mother reports pushing baby walker at home in kneeling and tries to climb into chair in standing 11/20/ mins Mother reports taking steps at Subjective Objective Interventions Outcomes HEP -Lower extremity crossover with gait -Dorsiflexion past neutral -Increased knee flexion on right in standing -Mod A reciprocal crawling with facilitation at lower extremities -Min A standing with anterior lean against support surface -Max A cruising at support surface with weight shift and facilitation -Max A and tactile cues for reciprocal gait -Max A sit to stand from floor -Mod A to Max A cruising R/L -Min A static stand -Intermittent stepping 2-4 steps self initiated -Mod A stairs with assist for lower extremity advancement -Hip & ankle ROM -Short sitting on peanut ball -Standing balance at support surface -Gait training (reverse walker) -Reciprocal crawling up stairs -Reciprocal crawling up soft steps -Standing activity with upper extremity reaching -Gait training (pony gait trainer) -Hip & ankle ROM -Cruising at support surface -Sit to stand -Cruising at support surface -Static standing -Gait training (pony gait trainer) -Reciprocal stair crawling -Observational analysis of gait and standing/sitting balance -ROM Dorsiflexion with knee extended: L+2 o, R+4 o Hip abduction: L +30 o, R+35 o -Observational analysis -Observational analysis -Standing balance activities -Side stepping at support surface Pony gait trainer loaned for home use. Mother was provided with instruction on use 18

19 home in gait trainer with AFOs donned 11/25/ mins Mother reports the patient is now sitting in the pony gait trainer and does not want to move. Inquired about age appropriate toys for pt. 12/01/ min Mother reports standing at a support surface independently and patient verbalizes when he is going to fall. Enjoys standing against and placement -Max A kneeling to stand via half kneel -Min A stand at support surface for balance -Upper extremity reaching with min A for sitting balance and verbal cues for left upper extremity -Mod A and tactile cueing for lowers to complete standing stair mobility -Min A for balance standing without support surface -Mod A squatting -Mod A gait with trunk/pelvic support -Min A sit to stand from cube chair -Min A left lower extremity positioning stair crawling, noted increased dissociation of lower extremities -Mod A standing stair mobility -Min A static stand and verbal cues to use bilateral upper extremities to manipulate object -Min A sit to stand from short sitting -Min A for Star Kart -Tall kneeling to stand -Standing at support surface -Righting responses on physioball -Short seated reaching with upper extremities -Standing without support surface -Up/down stairs in standing -Short sitting -Gait with manual assistance -Squatting from stand -Reciprocal crawling up steps -Standing at support surface -Sit to stand from short sitting -Up/down stairs in standing with AFOs -Assisted standing without support surface -Standing bimanual manipulation of object with support -Sit to stand at support -Observational analysis -Observational analysis Discussed age appropriate toys. Handout given for standing at support surface and cruising at support surface. Instruction given for standing against wall for support during play. Discussed wheel chair clinic referral, mother agreeable. 19

20 wall or couch at home. 12/08/ min Mother reports taking side steps at mall in the play area. Pushing self backward in pony gait trainer at home propulsion with bilateral upper extremities -Stand by assist for short seated tailor sit -Able to self-correct minimal perturbation anterior/posterior and lateral weight shifts with trunk righting -Semi-reciprocal crawling with Min A (small amplitude of dissociation) -Min A to squat and return to standing -Sits in the Mini-walk and does not attempt to participate -Min A to propel tricycle surface -Star Kart -Postural control in tailor sit -Sit to stand from short seated -Tall kneeling at support surface -Static standing without support surface -Semi-reciprocal crawling -Mini-walk gait trainer -Tricycle -Observational analysis Instructed mother in fit of pony gait trainer for appropriate adjustments at home. 20

21 Outcomes: This patient did continue to receive treatment for this episode of care. He had not met his goals at the time of the 7 th visit in clinic. Referral was made for wheelchair clinic for joint evaluation by occupational therapy, physical therapy, and ATP from NuMotion for recommendation for adaptive seating. Focus of this plan of care was changing to provide this child with modified independent mobility and not solely focusing on independent ambulation. This child at the time of the 7 th visit showed little interest in independent gait with the gait trainer interventions and did not participate in home gait training or gait training with the gait trainers in clinic. He did participate in gait activities overground with manual assistance, but did require maximal encouragement and stimulating activities to have the motivation to participate in gait during physical therapy sessions in clinic. Long-term goals were ongoing and plan of care was not completed at the time of completion of the 7 th visit in December Long-term goals had not been achieved as of the last visit in clinic with this patient. Short-term goals had all been partially met as follows; 1. Patient will stand at support surface with bilateral upper extremity support, to play with a toy on the support surface, for 10 seconds with no loss of balance with stand by assistance for safety within 4 weeks. This patient was able to stand at a support surface with stand by assist, however he did tend to lean his pelvis forward for support in standing. 2. Patient will cruise 1 step to the right and left, to reach for a toy, with facilitation at the hips for weight shifting and to initiate side stepping with 50-75% assistance within 8 weeks. This cruising goal had been met, however this patient was difficult to motivate for any upright mobility and required maximal encouraging to achieve this goal consistently. 3. Patient will take 4 consecutive alternating steps with tactile cueing at lower extremities to advance lower extremity in least restrictive assistive device to progress toward upright modified independent mobility 21

22 though space. This gait goal had been met but also requires maximal encouragement. This patient was able to take 4 consecutive steps with maximal encouragement and cueing with manual assistance. He showed little interest in gait in a gait trainer device and verbalized his dislike for this form of ambulation during therapy sessions. 22

23 Section 3: Evidence Based Analysis Methodologies of Search: PICO: Does the use of an overground gait trainer improve independent or modified independent upright mobility compared to partial body weight supported treadmill gait training in children with spastic diplegic cerebral palsy? Databases: Databases used to identify articles and studies for this Capstone included Pubmed, Cochrane, and PEDRO. Search terms/key words: 1) Gait trainer cerebral palsy, 2) gait trainer, 3) body weight supported gait training children, 4) partial body weight supported treadmill training 5) overground partial body weight support and 6) body weight support gait training cerebral palsy. Excluded articles: Articles were excluded based on relevance to the PICO question. Articles were excluded if published greater than 5 years ago. Articles were excluded for all articles with subjects >18 years of age. All duplicate articles and studies were excluded. Articles were excluded based on subject population and limited to children with cerebral palsy. See figure 1 for flow chart of search results from the included data bases and excluded articles. Included articles: Articles included in analysis for this Capstone addressed children with cerebral palsy <18 years of age. Articles published within the last 5 years were included in this analysis. Inclusion criteria addressed body weight supported gait training on the treadmill and overground. When able, systematic reviews and randomized controlled trials were chosen for review as the preferred types of studies. Current research is limited and other types of studies were also included as part of this analysis for additional evidence. See figure 1 for flow chart of search results from the included data bases and included articles. See table 2 for a summary of the eight analyzed articles for this review. 23

24 Figure 1: Methodologies of Search Exclusion Criteria: Published >5 years ago Subjects >18 years of age Duplicates Subject population other than CP 24

25 Articles Critically Appraised: 25

26 Reference: Celestino, M. L., Gama, G. L., & Barela, A. M. F. (2014). Gait characteristics of children with cerebral palsy as they walk with body weight unloading on a treadmill and over the ground. Research in Developmental Disabilities, 35(12), doi: /j.ridd Level of Evidence: 4 Purpose: "This study was designed to investigate gait kinematic parameters of children with CP by manipulating BWS and two different types of ground surfaces (treadmill and overground)" (Celestino, Gama, & Barela, 2014, p. 3625). Methods: This study consisted of 6 children with spastic CP. Each child participated in five experimental conditions and gait was analyzed via videotaped gait analysis. Each subject completed each experimental condition 4 times. The experimental conditions were overground gait or treadmill gait with 0% body weight support and 30% body weight support, and overground walking without body weight support. The Ariel Performance Analysis System was used to analyze the gait videos of each experimental condition. Results: This study found that overground gait with and without body weight support was significantly associated with faster walking speed and cadence compared to treadmill gait with and without body weight support. An improvement in stride length was also observed in the overground without BWS and 0% BWS compared to treadmill with 0% and 30% BWS. Single leg stance phase of gait was noted to be significantly longer in duration when walking overground. Hip ROM was observed to be significantly greater in the overground walking intervention. Critique/Bottom Line: This study examining the effect of treadmill versus overground walking and body weight support versus no body weight support found that gait kinematics are more positively influenced with overground walking with and without body weight support. The improved kinematics suggest that with overground ambulation has positive immediate effects on gait as seen with greater hip ROM, increased stride length, increased single leg stance, and faster speed. 26

27 Reference: Kurz, M. J., Stuberg, W., DeJong, S., & Arpin, D. J. (2013). Overground body-weight-supported gait training for children and youth with neuromuscular impairments. Physical & Occupational Therapy in Pediatrics, 33(3), doi: / Level of Evidence: 4 Purpose: The purpose of this study was whether overhead BWS (body weight support) during overground gait training improve the walking abilities of children and youth with motor impairments (Kurz, Stuberg, DeJong, & Arpin, 2013, p. 355). Methods: Eight subjects participated in an overground gait training program in a school physical therapy setting two days per week for a period of 12 weeks. During the 12 weeks of intervention, the body weight support provided was systematically decreased allowing for greater body weight every other week of the training program. Each session was performed for a period of 20 minutes with 2 rest breaks during the intervention period. Results: The results of this study found a significantly faster average walking speed in the subjects during the second half of the intervention period. Along with this positive effect on walking speed there was an observed increase in cadence with ambulation. This improvement in cadence was observed at a greater effect in older children ages with less of an effect in children 9-10 years old. Critique/Bottom Line: This article provides evidence suggesting that gait training with a body weight supported overground system is an effective intervention for increasing gait speed and cadence. The article suggests that the influence on gait speed may be due to the effect of massed practice. There did not appear to be a significant observable change in gait pattern. 27

28 Reference: Matsuno, V. M., Camargo, M. R., Palma, G. C., Alveno, D., & Barela, A. M. F. (2010). Analysis of partial body weight support during treadmill and overground walking of children with cerebral palsy. Revista Brasileira De Fisioterapia (São Carlos (São Paulo, Brazil)), 14(5), Level of Evidence: 4 Purpose: The purpose of this study was to analyze the spatial-temporal characteristics and joint angles during overground walking without BWS and with 0% and 30% BWS, and during treadmill walking with the same BWS in children with cerebral palsy (Matsuno, Camargo, Palma, Alveno, & Barela, 2010, p. 405). Methods: This study recruited 10 children with spastic CP to assess overground walking versus treadmill walking with and without body weight support. Each subject participated in treadmill and overground walking with 0% BWS, 15% BWS, and 30% BWS. Each subject completed a minimum of 3 trials for each of the intervention combinations. Data was analyzed and recorded using a computerized gait analysis system. Results: The only difference seen with body weight support was a slower stride speed. Overground ambulation did demonstrate shorter double limb stance and shorter single limb stance. Overground walking was noted to significantly affect pelvic tilt, knee extension, hip flexion, and ankle plantar flexion. Critique/Bottom Line: According to this study the type of surface ambulation is performed on is more important than the amount of body weight support provided. This study suggests that gait cycle kinematics are positively impacted with overground walking compared to walking on a treadmill surface. Noted in this study was the observation that children who could not ambulate independently were able to ambulate with 30% body weight support on both the treadmill and overground surface. Ambulation overground surface may improve kinematics to promote a more normal gait pattern in children with cerebral palsy. 28

29 Reference: Paleg, G., & Livingstone, R. (2015). Outcomes of gait trainer use in home and school settings for children with motor impairments: A systematic review. Clinical Rehabilitation. doi: / Level of Evidence: 3a Purpose: Focus of the review was for children with motor impairments, which outcomes are positively influenced by a gait trainer intervention? Secondary questions address which populations benefit from gait trainer interventions and at what age should they be introduced? (Paleg & Livingstone, 2015, p. 2). Methods: Preferred reporting items for systematic reviews and meta-analyses (PRISMA) was use to guide this systematic review. Studies were gathered from a search of electronic data bases and hand searching of bibliographies of included studies. Inclusion criteria required assessment of outcomes based on use of a gait trainer in children less then 18 years of age with a delay in motor impairment. Data was obtained from the selected articles using the McMaster Critical Review forms for quantitative and qualitative designs. Outcomes were grouped according to ICF groupings. 17 articles were chosen to include in this review. Results: Results lean toward a positive impact with use of gait trainers the results from current research is not able to provide a definitive conclusion regarding the efficacy of gait trainers as a gait intervention in children with motor delays. Results from current studies included in this systematic review suggest that gait trainers as an intervention may support increased overground ambulation distance and independence with walking. Other benefits may include a positive influence on bowel function and bone mineral density. From this review the population most apt to benefit from this intervention is cerebral palsy and complex developmental delays. Age of most effective impact appears to be 2-3 years or older. Critique/Bottom Line: The evidence for supporting the use of gait trainers as an intervention in children with motor delay is weak due at least in part to the lack of high quality research available for inclusion in this review. In the current research that use of gait trainers in children 2-3 years and older may be an effective way for providing support to influence ambulation in children with CP and developmental delay. 29

30 Reference: Smania, N., Bonetti, P., Gandolfi, M., Cosentino, A., Waldner, A., Hesse, S., Munari, D. (2011). Improved gait after repetitive locomotor training in children with cerebral palsy: American Journal of Physical Medicine & Rehabilitation, 90(2), Level of Evidence: 1c Purpose: The purpose of this study was to evaluate whether repetitive locomotor training with the Gait Trainer GT 1 can improve walking speed and endurance in tetraplegic or diplegic ambulatory children with CP. The second aim was to assess whether training can also have a positive impact on kinematic and spatiotemporal gait parameters and on disability (Smania et al., 2011, p. 138). Methods: This was a randomized controlled trail of 18 children with diplegic or tetraplegic CP. Randomly allocated into the experimental or control groups. Programs for the two groups consisted of 40 minutes a day five days per week for a period of two weeks. The experimental groups participated In 30 minutes of gait training on the gate trainer GT I and 10 minutes of passive joint mobilization and stretching. The control group participated in passive joint mobilization and stretching for the lower extremities, strengthening exercises for the lower extremities, and balance and overground gait exercises. Results: The experimental group demonstrated a significant improvement gait velocity and endurance. Improvement was still noted at one month follow-up. The experimental group also showed noted improvement in gait speed and step length. There was a noted improvement in hip kinematics with observed increased hip extension during the middle stance and the initial swing phase of gait. Critique/Bottom Line: This article suggests that use of the gait trainer GT I may improve gait quality in children with cerebral palsy. It suggests that this improvement may have a retained benefit for at least one month following daily interventions. Although this study involves a small sample size it does provide evidence for improvement in primary outcomes including 10-meter walk test and 6-minute walk test. Improvements were seen in secondary outcomes in joint angles during gait. Kinematic changes were seen with improved hip angle during initial contact, middle stance, and initial swing. 30

31 Reference: Su, I. Y., Chung, K. K., & Chow, D. H. (2013). Treadmill training with partial body weight support compared with conventional gait training for low-functioning children and adolescents with nonspastic cerebral palsy: A two-period crossover study. Prosthetics and Orthotics International, 37(6), doi: / Level of Evidence: 3b Purpose: The purpose of this study was to evaluate the effectiveness of PBWSTT for improving gross motor skills among children and adolescents with severe mental retardation and non-spastic type of CP (Su, Chung, & Chow, 2013, p. 446). Methods: 10 subjects were randomly allocated into two treatment groups. This study was designed as a randomized two-period crossover study in which each subject acted as his/her own control. Each group underwent a 12 week program of PBWSTT and a 12 week program of conventional gait training. These two training periods were separated by a 10 week period between. The group participating in the PBWSTT intervention underwent 25 mins of the treadmill intervention two times per week. The conventional gait training group underwent 30 minutes of intervention 3 times per week. Results: No carryover effects were noted in regards to the potential threat to carryover associated with a two period cross over design. There was an improvement in gross motor skills that was seen in the PBWSTT group. Gains were seen in speed of gait and gross motor function as demonstrated by the CMFM outcomes. Critique/Bottom Line: Partial body weight supported treadmill training is a safe means of gait training in children with cerebral palsy. This study suggests that PBWSTT is an effective intervention for improving gait quality and gross motor functioning. 31