Gait Training to Improve Functional Mobility in A

Home , Gait training

GAIT TRAINING TO IMPROVE FUNCTIONAL MOBILITY IN

A CHILD WITH CEREBRAL PALSY

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

Bhumisha Patel

11 GAIT TRAINING TO IMPROVE FUNCTIONAL MOBILITY IN

A CHILD WITH CEREBRAL PALSY

A Doctoral Project

Bhumisha Patel

_____, Second Reader Katrin Mattern-Baxter, PT, DPT, PCS

------, Third Reader Clare Lewis, PT, PsyD, MPH, MTC i ?2-/ulv Date

Ill Student: Bhumisha Patel

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 PT, EdD

Department of Physical Therapy

lV Abstract

GAIT TRAINING TO IMPROVE FUNCTIONAL MOBILITY IN

A CHILD WITH CEREBRAL PALSY

Bhumisha Patel

A patient with c~rebral palsy was seen for physical therapy treatment for 12 sessions from 3110/15 to 5/08/15. Treatment was provided by a student physical therapist under the supervision of a licensed physical therapist.

The patient was evaluated at the initial encounter with the Peabody

Developmental Motor Scales to measure gross and fine motor delays, the Six Minute

Walk Test to measure gait endurance, the Gross Motor Function Measure-66 to measure and predict the gross motor development, and the 10 Meter Walk Test to measure the gait velocity. Following the evaluation a plan of care was established. The main goals for the patient were to improve gait endurance, standing balance, gait speed, and functional mobility. Main interventions used were over-ground gait training including ascending and descending stairs, and treadmill training.

v The patient presented with improved gait endurance, had moderate improvement in his gait speed and functional mobility, but no improvement was noted in his standing balance. The patient was discharged to home with a home exercise program and recommendation to continue with the different therapies provided by the patient' s school.

Date

VI ACKNOWLEDGEMENTS

I acknowledge Dr. Katrin Mattern-Baxter for providing the opportunity for me to learn about cerebral palsy and treat children with cerebral palsy during clinic. I also wanted to thank my husband for the hours of proofreading and support during this project.

Vll TABLE OF CONTENTS Page

Acknowledgements ...... vii

List of Tables ...... ix

Chapter

1. GENERAL BACKGROUND ...... 1

2. CASE BACKGROUND DATA ...... 3

3. EXAMINATION- TESTS AND MEASURES ...... 5

4. EVALUATION ...... 10

5. PLAN OF CARE- GOALS AND INTERVENTIONS ...... 12

6. OUTCOMES ...... 17

7. DISCUSSION ...... 19

References ...... 21

Vlll LIST OF TABLES Tables Page

1. Medications ...... 4

2. Examination Data ...... 9

3. Evaluation and Plan ofCare ...... 12

4. Outcomes ...... 17

lX 1

Chapter 1

General Background

Cerebral palsy (CP) is a non-progressive disorder caused by disruptions during fetal or infant brain development resulting in movement and postural control disorders. 1 A prevalence study published in 2014 found CP in childhood has stayed constant at approximately 3.1-3.6 per 1000 since 1996. Autism spectrum disorders co-occurred with CP in 6.9% of all cases, and these disorders were higher (18.4%) among children with non-spastic CP, particularly hypotonic CP.2 Caring for a child with CP costs approximately an additional $800,000 over the patient's lifetime for the healthcare system, the family, and caregivers.3 A recent study found that the risk of CP declined with increased socio-economic status, primarily reflected by maternal education.4 Cerebral palsy is slightly more common in males than in females.2 The clinical presentation of CP is varied with spastic CP being the most common, affecting approximately 50% of individuals with CP. Athetoid CP affects approximately 20%; ataxic CP accounts for approximately 10%, and the remaining

20% are considered to have mixed presentations. 5

The motor problems of CP primarily arise from the central nervous system

(CNS) dysfunction. This dysfunction interferes with the development of normal postural control, delays normal motor growth, and can lead to secondary musculoskeletal problems.6 The CNS. damage can also lead to disturbances of sensation, perception, cognition, communication, and behavior. Cerebral palsy is also commonly associated with seizure disorders.3 2

Gross motor dysfunction is the primary neuromuscular problem for those

6 7 with CP and the severity of limitation is highly variable. • The movement disorders in CP are clinically characterized as an upper motor neuron syndrome with associated positive and negative signs. The positive signs being pre-dominant and include spasticity, dyskinesia, hyper-reflexia, retained developmental reactions, and secondary musculoskeletal malformations. The negative signs include the loss or absent development of proper sensorimotor control mechanisms and may include weakness, poor coordination of movements, poor balance, and impaired walking ability.3 There are problems with neuronal activation, motor unit recruitment and coordination. 8 Davids et el (20 15), stated that previous studies hypothesized that the deterioration in motor functions and the ability to ambulate could be due to disrupted balance function, progressive joint contractures, impaired motor control, pain, diminished strength, increased spasticity, increased weight, over use (chronic fatigue), and under use (chronic immobility).9

The most common impairment parents want therapists to address is independent ambulation. One of the predictors for independent walking is the demonstration of independent sitting by 24 months. 10 Another study found that children who could pull to stand by age 2 years had a higher chance to ambulate with or without support by age 6 years. Children who can sit independently and pull to stand by age 2 (GMFCS level II) were found to have a 40% likelihood of ambulating by age 14. Those who could roll but could not attain independent sitting (GMFCS level IV) were unlikely to walk at any age. 11 3

Chapter 2

Case Background Data

Examination - History:

The patient was a 4-year-old male who presented developmental delays in all areas of growth when compared with his identical twin brother who did not have CP.

The parents first noticed this delay when the patient turned one year old. The patient had since been evaluated by a pediatrician and a pediatric neurologist to confirm his diagnosis. At that time, the patient was diagnosed with CP and a mild form of autism. When the patient was 3 months old he experienced bouts of vomiting which persisted for a few months. He was found to have a duodenal stenosis in his small intestine, which was repaired by a bypass surgery in November 2011. The patient's parents reported he was able to get around the home without much assistance by either crawling on all fours or using a wall for support while walking. He used the walls at times to ambulate from his bedroom to the kitchen and living area where most of his toys were located. He required assistance in bathing and grooming. The patient did have a walker, which he used inconsistently to ambulate in the community. The main goal for physical therapy was to improve his functional mobility which would increase his ability to engage in social interactions with his twin and other children. At the time of the initial visit, the patient received physical therapy, occupational therapy, speech therapy and aquatic therapy once a week at the school he attended. 4

Systems Review:

The patient showed impaired musculoskeletal and neuromuscular systems as demonstrated by the outcome measures used during the evaluation. The cardiopulmonary systems were not assessed during the evaluation but the patient's father reported it to be within functional limits from the last doctor's visit. The integumentary system was intact per observation.

Examination - Medications:

Table 1

Medications

"'- --- ' o· ·c.-: :·Mwt'iJ:I£;;A,11flj1rt~ -; -~U \<·'J· .. : :- i'" -.:~-;; ·' --.,/ ;'~~:C:t,£;~~~~--:'( Albuterol 5milligrams as Asthma Nervousness, shakiness, dizziness, needed exacerbation. headache, uncontrollable shaking of a part of the body, muscle cramps, excessive motion or activity, sudden changes in mood, nosebleed, nausea, increased or decreased appetite, difficulty falling asleep or staying asleep, pale skin, fast pounding, or irregular heartbeat, chest pain, fever, blisters or rash, hives, itching, swelling of face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs, increased difficulty breathing, difficulty swallowing and hoarseness. 12 5

Chapter 3

Examination- Tests and Measures

The patient's impairments were categorized using the International

Classification of Functioning, Disability and Health (ICF) model. 13 The stationary subscale of the Peabody Developmental Motor Scales 2nd edition (PDMS-2) and the

Six-Minute Walk Test (6MWT) were used to detect limitations at the body, structure and function level ofthe ICF. The 10-meter walk test (10mWT) and the Gross Motor ' Function Measure-66 (GMFM-66) were administered to identify limitations at the activity level of the ICF. The Cerebral Palsy Quality of Life (CPQOL) scale was utilized to assess limitations at the participation level of the ICF.

The PDMS-2 is a norm-referenced, standardized test designed to measure motor abilities that develop in early life (birth through 71 months). The test consists of249 items, which is split into two divisions: (1) the Gross Motor Developmental

Scale consisting of four subsections - reflexes (for children from birth to 11 months), stationary (assesses ability to sustain control of body within its center of gravity), locomotion (assesses ability to move from one place to another) and object manipulation (assesses ability to manipulate balls for children aged~ 12 months); and (2) the Fine Motor Developmental Scale which consists of two subsections - grasping and visuomotor integration. Patients' PDMS-2 test scores can be compared with age-related peers, and test scores also allow comparisons of gross and fine motor skill levels (referred to as composites) within a child. 14 The PDMS-2 serves ~ --· ..

6 best as a diagnostic/discriminative measure15 and is used as an outcome measure in intervention studies. 16

The test-retest reliability of the PDMS-2 was established for the gross motor subsection of the PDMS-2 with an intra-class correlation (ICC) of0.996 (95% confidence interval= 0.991- 0.998), and for the fine motor subsection with an ICC of0.993 (95%CI = 0.985-0.996). The inter-rater reliability ofthis measurement tool was established at ICC of0.99-l.OO for the raw scores and developmental quotients. 17 Developmental quotients are standardized scores based on average performance of children without developmental delays. 18 The standard error of the measure (SEM) for each composite within the gross motor scale has been found to

14 be 1 • The minimal detectable change at the 95% CI (MDC9s) was computed to be

2.77 for each composite. For the total gross motor composite the SEM was 314, therefore the MDC9s was calculated to be 8.32. A change in gross motor and fine motor composites of 3 points should occur for the patient to have a measurable change in his skills. Internal consistency was excellent for subtest and composite scores, with Cronbach's alpha between 0.92 and 0.99. 14 The PDMS-2 was employed as a diagnostic measure to determine the degree of developmental delay, and the stationary subscale was used to assess the static standing balance.

The Gross Motor Functional Classification System (GMFCS) describes the mobility of children with CP in one of the five ordinal levels across five age bands.

Level I is assigned to children who can perform the same activities as their age- matched peers but with some difficulty in speed, balance and coordination. Children 7 rated at level V have a difficult time controlling their head and trunk posture in most positions, and have difficulty achieving any voluntary control of movement. 19 This patient was classified at level II in the 4 to 6 age band for the GMFCS.20

The 6MWT was utilized as an outcome measure to measure the patient's walking endurance. For children with CP ages between 4 and 18 years of age the

SEM ranged from 17.1-23.1 meters (m) and the MDC9sranged from 47.4 m to 64.0 m. The GMFCS levels of these children ranged from level I to level III. The test retest reliability was found to be excellent with ICCs ranging across GMFCS levels from 0.91 to 0.98.21 A change of 64.0 m will indicate a measurable change in the patient's walking endurance.

The Gross Motor Function Measure (GMFM)-66 is a standardized criterion referenced instrument designed to quantify changes over time in the gross motor abilities of children with CP. 3 It consists of 5 dimensions that measure motor capabilities including lie/roll, sit, crawl, stand, and walk/run/jump. The test can be administered across the five levels ofGMFCS and for children~ 5 months.22 The

GMFM-66 is able to capture changes in children in GMFCS levels I to V. 3 After the

GMFM-66 is scored, a computer software program called the Gross Motor Ability

Estimator (GMAE) is utilized to provide a GMFM-66 summary score, a 95% CI associated with the child's score, a SEM and the predictive gross motor developmental curves for the child. The gross motor development curves were created by plotting the GMFM-66 scores for children in each of the GMFCS levels and age band, ultimately creating percentiles for each GMFCS level and age group. 8

These five curves of gross motor development represent the average pattern of development for each classification level and provide evidence of the patient's expected change in gross motor function over time. 3 The test-retest reliability for the

GMFM-66 is excellent with an ICC of 0.99 for patients in all the GMFCS levels. 22

The MDC9s of the total GMFM-66 score was calculated to be 1.2.23 The minimally clinically important difference (MCID) for the total GMFM-66 score for GMFCS level I-III was 1.05.24 The GMFM-66 in combination with the GMFCS level can be administered as a prognostic measure for the patient's anticipated mobility level.

The 1Om WT was utilized as an outcome measure to measure the walking speed over 10 m.25 The test-retest reliability for the 10mWT was found to have ICCs ranging from 0.59 to 0. 78. The SEM found for this outcome measure ranged from

0.6-6.4 seconds across GMFCS levels, with the MDC9s ranging from 1.7 seconds for

GMFCS level I, 4.3 seconds for GMFCS level II, and 17.7 seconds for GMFCS level

III.21 There has to be a 4.3 second change between the pre- and post-intervention in the 10mWT time for the change to reflect a measurable difference in the patient's walking speed.

The CPQOL is a condition-specific QOL tool and there are two versions:

CPQOL-Child to assess the quality oflife for children between 4-12 year of age and

CPQOL- Teen for children between 13-18 years of age. The CPQOL- Child has two versions, one for the primary caregiver/parent report for children aged 4-12 and a self-report for children between ages 9-12. The test consists of seven domains: (1)

Social wellbeing and acceptance, (2) Feelings about functioning, (3) Participation 9 and physical health, (4) Emotional wellbeing and self-esteem, (5) Access to services,

(6) Pain and impact of disability, and (7) Family health.

The internal consistency for the CPQOL-Child was found to be good for all domains with a Cronbach's a of0.74-0.91. The Pearson's correlation between the domains of the CPQOL-Child, the Child Health Questionnaire, and KIDSCREEN-10 were found to be moderately correlated reflecting good concurrent validity.26

Table 2

Examination Data

Impaired endurance 6MWT with reverse

Impaired mobility/gross motor function

Impaired velocity

Impaired quality of life 3/9

PDMS -2 =Peabody Developmental Motor Scales edition 2; 6MWT =Six-Minute Walk Test;

GMFM-66 = Gross Motor Function Measure-66; GMFCS = Gross Motor Functional Classification

Scale; IOmWT = 10 meter walk test; CPQOL =Cerebral palsy quality of life. 10

Chapter4

Evaluation

Evaluation Summary:

The patient was a 4-year-old male who was given a diagnosis of ataxic cerebral palsy and impaired gross motor development. The patient was classified at

GMFCS level II in the 4 to 6 age band for the following reasons: he could sit on a chair with both hands free; he could move from the floor or sitting to standing often requiring a stable surface to push or pull up using his upper extremities; he could ambulate without a hand-held mobility device indoors and for short distances on level surfaces outdoors; climb stairs using hand rails; and he cannot run or jump.20

The results from the PDMS-2 show that the patient's standing balance was equivalent to that of an 18-month-old child since he could not maintain independent standing balance for more than 1-2 seconds. His locomotive capabilities were those of a 10-month-old with the percentile at< 1 and raw score of 58, and the patient's ability to play with or manipulate objects was not associated with even the youngest age group in the test, as the raw score was 0 and percentile at < 1. He presented with an ataxic gait, requiring minimal assistance to ambulate with a reverse walker or one hand held and required verbal and tactile cues to follow one-step commands.

Diagnostic Impression:

The patient's signs and symptoms were consistent with the diagnosis of ataxic CP resulting in impairments at the body structure and function, activity, and participation levels of the ICF model. The patient's balance and functional mobility 11 were impaired which decreased his ability to participate in social interactions with other children his age.

G-Codes: G8978 (Mobility: Walking & Moving around) based on the 6MWT.

• Current with modifier: CL reflects at least 60% but less than 80% impaired,

limited, or restricted.

• Goal with modifier: CK-08979 based on the 6MWT.

Prognostic Considerations:

The positive prognostic factors included: going to a special-needs school where he received physical, occupational, speech and aquatic therapy once a week; parents who were very proactive in providing him the necessary assistance; a positive family environment in which he could further develop his motor abilities; the patient's young age; and the patient's motivation to walk in order to keep up with his peers and twin. The negative prognostic factors included: his low level in gross motor abilities, and autism. The patient was expected to improve to independent functional mobility without use of assistive devices.

Expected Discharge destination/status:

The patient would be discharged from physical therapy to continue living with his family and receiving physical, occupation, speech, and aquatic therapy through the school he attended. The father stated that the family planned to increase the amount of speech therapy the patient received with the goal of improving the patient's communication. Table 3

Evaluation and Plan of Care

.RRQBLEM. ~ PLAN OF CARE ~- - ...- . . Short Term Goals Long Term Goals Planned Interventions (STG) (4 visits) (LTG) (8 visits) Interventions are Direct or Procedural unless they are marked: (C)= Coordination of care intervention

(E) = Educational intervention .; .. . .• ...... ~ i -~ . . ··.'·.':'' . ·i "· /-.~·.. :· ~ ~'~~. ;· '' BODY;FUN'GnON~l$~ueTJtJK,_ .· - Impaired Improve score on Improve the score on For both STG and LTG, the following interventions were provided =0 ...... , standing balance the PDMS-2 item the PDMS-2 item 20 2x week for 4 weeks: C'".:l 20 by 1 point as by another 1 point, as • Ascend and descend 1-2 flights of stairs each step 6 inches in ..,~ measured by: measured by: height. Verbal, visual and tactile feedback will be given where til I . ·' Patient able Patient able to appropriate and to progress the intervention. '-l (J • • 0 stand on one foot i:J"' ... to stand on • Decreasing the assistance required for standing and ambulating ~ Ill one foot with with hands on his such as from using a reverse walker progress to one hand held to rll ,. - ...... ~ ~ hands on his hips for 3 independent walking. '"t hips for 1-2 seconds. =Q. VI ~ seconds. .... Impaired Increase the Increase the distance Pediatric treadmill training (IT) with variable speed for 30 minutes til= .. ~ endurance distance to 32 m to more than 64 m or or longer starting at 0.3m/s. The speed was set at patient tolerance til on the 6MWT more on the 6MWT for each treatment session and increased as tolerated...... = using a reverse using a reverse Ambulating over-ground (OGT) with the use of a reverse walker or 0 walker. walker. one hand held assistance for 20-30 minutes. rll=

·: .:; ·-~r~.~~r~:~;~>"''~~~·';;)g :r,':;;f:f.~!i!':f':~> }'t;~·~1t:.::fF.; '~?~ .• ' .:: ·'ft'f;;:· ; • ':i ' 1;:m;· ' .:bf~L:a:t.> ,.; . :' :. ' . ; :. . .:' ··:.; :'\:-I : .' '. :.. { \··r<· Impaired Improving the Improving the overall OGT and IT as described above. mobility overall GMFM-66 score of the GMFM- Repetitive sit-to-stand from a bench 7.5 inches in height to fatigue. score to 49.7%. 66 to or over 50.2%. Patient was given approximation on anterior superior spine to increase proprioceptive feedback.

...... N Impaired velocity Increase speed on Increase the speed on OGT and IT as described above. the treadmill by the treadmill by Ascending and descending stairs starting by having pt. use the hand 0.2rnls, therefore O.Srnls, therefore rails with one hand and moderate assistance from SPT with the LEs. completing the completing the Progress by decreasing the assistance from the SPT to minimal or no 10mWT in 18.76 10mWT in 12.00 sec. assistance. sec._ All activities re eed.

! • :~;~::.J.;:;g Impaired social Increase the score Increase the score by Patient's parents were advised to encourage the patient to interact with participation as by 2 points on the another 2 points on the other children in smaller groups and social settings to get the patient measured using CPQOL. CPQOL. comfortable initially. Progress by increasing the time spent and theCPQOL. Increase the time Increase the time spent interacting with the children or twin. The patient's participation in spent playing and playing and interacting social situations can be enhanced by improving the pt.'s ability to interacting with with other children ambulate with less assistance. other children including his twin by 2 including his twin hours daily by by 1 hour daily by increasing the duration increasing the of ambulation by 2-3 duration of hours w/ a reverse ambulation w/ walker or one hand reverse walker or held. one hand held by 1 hour. PDMS -2 =Peabody Developmental Motor Scales edition 2; 6MWT =Six-Minute Walk Test; GMFM-66 =Gross Motor Function

Measure--66; GMFCS =Gross Motor Functional Classification Scale; 10mWT = 10 meter walk test; CPQOL =Cerebral palsy quality of

life; Over-ground training= OGT; Treadmill training (IT).

...... w 14

Plan of Care- Interventions:

Refer to Table 3.

Overall Approach:

The interventions addressed the different aspects of the patient's functional mobility such as speed, endurance, and balance. The guiding treatment philosophy implemented in the duration of physical therapy interventions was task specific training.

Task specific training has been shown to improve muscle strength and functional abilities through repetition essential for motor learning. One study found that task specific training was used to improve functional mobility including standing and walking performance in children with CP. The children involved in the study were aged between 4 and 6. 27 With this approach of rehabilitation the focus was on improvement of functional task performance through repetition and feedback.

The tasks were challenging; it was difficult to motivate and maintain the focus of a 4-year-old child to carry through with all the planned interventions. An electronic tablet was utilized to play the patient's favorite shows or music while he ambulated on the treadmill or over-ground. Tactile an~ verbal cues were used to give the patient feedback during the interventions to improve the patient's focus on his task.

Improving the patient's functional mobility was addressed through the utilization of the overload principle where by the patient's family was recommended to increase the dose of the home exercises given. This would assist in improving the patient's muscular and cardiorespiratory endurance. 15

Family centered service recognizes that all families are distinct and exclusive, and that the best child performance takes place in an accommodating family and community framework. The therapists are seen as teammates with the parents since the parents know their children the best. The goals are based on collaborative input from the family, child, and therapist. There is evidence to indicate that this approach leads to positive outcomes for the children and family and, therefore, was used in this case study.28

PICO question:

For a child with CP (P), is treadmill training (I) more beneficial than conventional physical therapy (C) to improve functional mobility (0)?

A systematic review (level of evidence la, PeDro scores ranging from 3-6/10) assessed whether treadmill training with or without body weight support was effective in improving the gross motor function and societal participation in children with CP.

Inclusion criteria for an article were: (1) subjects had to be 18 years old or less; (2) 80% or greater had a diagnosis ofCP; and (3) treadmill training was greater than 80% ofthe total interventions used. The age of the children ranged from 3.5 years to 14.33 years with a higher ratio of boys to girls in each study and the GMFCS levels ranged from I to

IV. The training protocols administered across the studies varied in intensity ranging from twice a day to 2-4 per week for 20-45 minutes and duration ranging from 2 weeks to 3 months. Each session consisted of gait facilitation including assistance with initiation of swing, facilitation of heel contact, attention to knee extension, prevention of hyperextension during stance and prolonging stance phase. All studies employed 16 some form of partial body weight support as part of their protocol. Each study progressed patients' training by increasing the intensity by either: 1) decreasing the amount of body weight support provided; or 2) by increasing the treadmill speed or the time spent walking; 3) or through a combination of both. Two of the studies out of four showed large effect sizes for increased self-selected walking speed over the 1Om WT reflecting increased speed of over ground walking. The authors of the review concluded that treadmill training was safe and practical for children with CP. It was also indicated to have positive gains in walking speed over small distance and in general gross motor skills.29

The patient of this case study fit into most of the population sample requirements except for the need of partial body weight support used in the studies.

While treating the patient, treadmill training without partial body-weight support and over-ground training (OGT) were used to give the patient a variety of surfaces to ambulate on with the goals of improving his balance, walking speed, and endurance.

The treadmill had handrails on both sides of the walking platform which were utilized by the patient, therefore, the patient did not require body weight support to ambulate on the treadmill. Varying walking surfaces allowed varied conditions to be introduced such as adding obstacles during OGT or changing walking speed on the treadmill when appropriate. The walking was progressed by increasing the intensity of treadmill speed and decreasing the support from the handrails by removing one or both. 17

Chapter 6

Outcomes

Table 4

Outcomes

OUTCOMES

,. BODY·:~. .. ~~ ~RS'tlttJCl' ;':"''' ,·.~<''i:"· ;, :~~,_~;;.:-~-- Outcome Initial Follow-up Change Goal measure/te Met st used (YIN) Stationary Raw Score 38 Raw Score 38 Raw Score 0 N sub scale Percentile 2 Percentile 2 Percentile 0 inPDMS- Standard 4 Standard 4 Standard 0 2 Score Score Score Age 18 months Age 18 months Age 0 equivalent equivalent equivalent 6MWT 62.18 meters (m) with a 114.08m 51.90m N reverse walker.

'•, _, -·._ ! .. --, :~ ·' ' ' :\"l!C:'-l~>'ll'h :_.· .. ,·':·· -~:-•<,,: '"-".:~~-~-~~-Y~ll~1 ~~~f· ~·o•;'f'!""' '::::·:-~""' •":: -._ ,. Outcome measure/te st used IOmWT Average of2 trials= 30 Average of 2 trials = 21.4s 8.6s y seconds (s) GMFM-66 Lying/roll 100% Lying/roll 100% Lying/roll 0% ing ing ing Sitting 93.3% Sitting_ 93.3% Sitting 0% y Crawling/ 40% Crawling/ 66.7% Crawling/ 26.7% kneeling kneeling kneeling Standing 61.5% Standing 66.7% Standing 5.2% Walking/ 16.7% Walking/ 16.7% Walking/ 0% Running Running Running Overall 49.2% Overall 50.6% Overall 1.4% Score Score Score GMFCS 25th GMFCS 25th GMFCS 0 Percentile Percentile Percentile GMFCS 25th GMFCS 25th GMFCS 0 Percentile Percentile Percentile

-_. --.- ,, .. !~ "·,' ~-. '>-' c "U'I; ,.~:x'l.~f~ftlU~l·.;...... ,, ""f'/ .~Yt ·~r,.y;-!!'J :AI·-' Outcome measure/te I st used CPQOL 3/9 7/9 4 y : 18

PDMS -2 =Peabody Developmental Motor Scales edition 2; 6MWT =Six-Minute Walk Test; GMFM-66

=Gross Motor Function Measure-66; GMFCS =Gross Motor Functional Classification Scale; IOmWT =

I 0 meter walk test; CPQOL = Cerebral palsy quality of life.

Discharge Statement:

The patient was seen for 12 visits over an 8-week period including the initial evaluation, 10 visits for the interventions, and the discharge re-assessment. The goal of the interventions was to improve the patient's functional mobility with or without a reverse walket so that he could keep up with his twin brother and other children while playing. The patient improved his gait speed as reflected by the 1Om WT and had improved his functional mobility. There was an improvement in the distance he could ambulate but not by a clinically significant amount. The patient's parents were given a home exercise program of 30 minutes or more of ambulation with the patient, progressively decreasing the amount of assistance given during the ambulation. The discharge destination for the patient was to remain at home with his family.

DC G-Code with modifier:

• Mobility: Walking & Moving Around current: 08980

o Modifier: CL 60-79% impaired

o Patient walked 114.08m with a reverse walker in the 6MWT on the last

visit. 19

Chapter 7

Discussion

Overall, the patient achieved both goals at the activity level and one goal at the participation level of the ICF model. The improvements can be credited to the physical therapy interventions provided, the parents support, and the patient's motivation to play and keep up with his twin and other children. The patient's balance and endurance did not change as reflected by the stationary subscale on the PDMS-2 and the 6MWT. This could be due to the patient's young age, the short period of treatment and the ataxia.

Cernak et el (2008) stated that patients with ataxia may have better functional gains in walking and balance after longer duration or intensity of the interventions.30 The parents were given recommendations on how to address the ataxia to improve the patient's functional ambulation. The approximation technique on the anterior superior iliac spine was used to provide more proprioceptive feedback from the lower extremities while ambulating.

The patient's improvement in gait velocity was clinically.significant as reflected by the lOmWT. This improvement could be due to the treadmill training for 30 minutes or more per session.31 There was some improvement in the patient's endurance but not enough to be clinically significant. The lack of focus, strength, and coordination of the lower extremities may explain why the patient did not increase the distance he ambulated during the 6MWT.

There was a clinically significant improvement in the overall score of the

GMFM-66, representing an improvement in functional mobility. The improvements 20 were mainly in dimensions C & D (kneeling & crawling and standing). Dimensions D

& E are commonly used to predict whether a child will be a functional ambulator as the dimensions reflect standing and walking, and running and jumping, respectively.

The participation goal was to improve the patient's social involvement with his peers and twin. The parent's report on the CPQOL indicated that the patient had increased his social interaction duration on a daily basis as reflected by his playtime with his twin and other children.

When treating patients with similar diagnoses and impairments in the future, I will employ a comparable approach but increase the frequency, duration, and intensity of the interventions. I will also change the intervention environment to improve the patient's focus by working in a quiet room with fewer distractions. I will try to include more balance activities, which are fun and engaging for younger patients. In addition, I will request the parents to be more involved in home activities with their children on a daily basis. In the future, treadmill and over-ground training interventions will be applied when working to improve functional mobility in children with CP. 21

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