OUTPATIENT PHYSICAL THERAPY for a TODDLER with CEREBRAL PALSY PRESENTING with DEVELOPMENTAL DELAYS a Doctoral Project a Comprehe

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

Amy K. Holthaus

SUMMER 2015

Amy K. Holthaus

OUTPATIENT PHYSICAL THERAPY FOR A TODDLER WITH CEREBRAL PALSY

PRESENTING WITH DEVELOPMENTAL DELAYS

A Doctoral Project

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

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

Abstract

OUTPATIENT PHYSICAL THERAPY FOR A TODDLER WITH CEREBRAL PALSY

PRESENTING WITH DEVELOPMENTAL DELAYS

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

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.

TABLE OF CONTENTS Page

Acknowledgements ...... vi

List of Tables ...... viii

Chapter

1. GENERAL BACKGROUND …….……….…………………………………………….. 1

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

3. EXAMINATION – TESTS AND MEASURES ...... 6

4. EVALUATION...... 13

5. PLAN OF CARE – GOALS AND INTERVENTIONS ...... 14

6. OUTCOMES ...... 23

7. DISCUSSION ...... 28

References ...... 31

vii

LIST OF TABLES Tables Page

1. Examination Data………………………………………………….……………………. 11

2. Plan of Care – Goals and Interventions.…………….……………………………….…. 14

3. Outcomes………………………………….……………………………………………. 23

viii

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

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

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.

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

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.

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 testing11 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

from 18-108 months of age, interrater reliability was shown to be between intraclass

correlation (ICC) values of 0.61-0.87. The test-retest reliability also had a wide range

with the ICC values ranging 0.36-0.83.13

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 > 0.80.14 However, goniometer measurements have low inter-examiner reliability, as reflected with ICC values of 0.38 and 0.48.14

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 0.93. 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

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 (MDC95) 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-88.17 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

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 points18 with a calculated minimal

detectable change at the 95% confidence level (MDC95) 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 (MCID95) 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

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 MDC95 of 12.2 seconds and test-retest reliability with

an ICC range between 0.65 and 0.90.23 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 MCID95 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

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 -6° -10° Decreased ROM following Dorsiflexion 10° 5° Decreased ROM SLR 80° 75° Decreased ROM Clinical observation Base of support and B LE scissor gait; jump gait; narrow base of support; of gait mechanics joint posture 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: Modified independent 1.03 m/s ambulation Walking sticks (mod A to 2 trail average: Moderate assistance given progress sticks and maintain 0.10 m/s to progress walking sticks balance) and to maintain child’s balance 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% Total 53.86% 70th percentile for GMFCS level II PDMS-2 subscales: raw scores: age equivalence; percentile rank Stationary 38/60 points 18 months; 16th percentile rank Locomotion 71/178 points 13 months; <1 percentile rank PEDI Functional mobility domain 39/65 points 60.0%

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

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.

Chapter 5

Plan of Care – Goals and Interventions

Table 2

Evaluation and Plan of Care

PROBLEM PLAN OF CARE Short Term Long Term Goals Planned Interventions Subcategory Goals (8 weeks) Interventions are Direct or Procedural (4 weeks) unless they are marked: (C) = Coordination of care intervention (E) = Educational intervention BODY FUNCTION OR STRUCTURE IMPAIRMENTS Decreased Able to stand 2 Able to stand 3 sec Single leg standing was promoted through balance through sec on single leg, on single leg, kicking a ball and stepping on bubbles. bilateral single bilaterally, bilaterally, without Each activity required pelvic stabilization leg stance without UE UE support to maintain balance and to perform a (measured by support controlled movement. The patient PDMS-2 progressed to no needed stabilization and stationary # 20, was able to perform both activities with 21) good functional balance. (E) Mother was instructed to promote goal with kicking a ball at home, at least 1 time daily for 10 minutes. ACTIVITY LIMITATIONS Increased Decrease level of Decrease level of During all gait intervention (treadmill and assistance needed assistance assistance needed over-ground) red theraband was used on for ambulation needed during during ambulation the patient’s B LEs to promote hip (measured by ambulation with with quad canes to external rotation and abduction during FMS and 10 quad canes to modified gait. Task-specific activity training was mFWT) standby independent utilized for this goal. The patient was assistance encouraged to use canes during all over- ground 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

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 1st 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 Goals Increase ability Able to stand 1 Able to stand 2 sec During the standing reaching activity with to stand on sec on tiptoes on tiptoes with UE magnets (explained above) included the tiptoes (measured with UE over over head child obtaining tiptoe standing to reach the by PDMS-2 head board. Each session averaged about 10 stationary # 22) repetitions of tiptoe standing and maintaining position between 1 and 2 seconds. Patient progressed from needing assistance to maintain balance through

pelvic stabilization to independent stance. Increase ability Able walk to toy, Able walk to toy, Sit-to-stands were performed to increase to return to pick it up and pick it up and walk LE strength as needed to perform walking after return to 2 steps before squat/bend down to obtain toy and return picking up toy standing before losing balance to standing position from a 27 cm bench. (measured by losing balance To encourage standing without stepping 2 PDMS-2 lb ankle weights were used on each ankle. locomotion # 36) 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. Decreased Able to take 5 Able to take 10 This goal was addressed via treadmill independent independent independent steps training, over-ground training, and a steps (measured steps weight shifting exercise. The over-ground by GMFM-66 training was addressed in table above. walking domain: The treadmill intervention was utilized 2 #69) 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

bouts of 5 minutes per day. PARTICIPATION RESTRICTIONS Problems Short Term Long Term Goals Planned Interventions Goals Increased No expected Increase This goal was address through all caregiver change independence with interventions listed above. assistance needed ambulation and (measured by transfer activities PEDI caregiver by 11.6% as mobility domain) measured by PEDI HOME EXERCISE PROGRAM (HEP) Lack of Caregiver Caregiver (E) Parent instructed on how to perform implementation independent in understands exercises below with encouragement to of HEP by parent completing HEP importance of perform activities multiple times per day. continuing HEP Stretching: and how to 1. LE PROM stretching (ankle progress exercises 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

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-to- stand 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

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

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

time from pre- and post-intervention with continued improvement at the 1 month follow-

up.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 over-

ground 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

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.

Chapter 6

Outcomes

Table 3

Outcomes

OUTCOMES

BODY FUNCTION OR STRUCTURE IMPAIRMENTS Outcome Initial Follow-up Change Goal Met (Y/N) Increase # 20: 0/2 points # 20: 1/2 points +2 points on N balance #21: 0/2 points #21: 1/2 points PDMS through (unable to stand on (able to stand on single leg 2 (+ 2 seconds on bilateral single leg) seconds) single leg) single leg stance (PDMS-2 stationary # 20, 21) ACTIVITY LIMITATIONS Outcome Subcategories Initial Follow-up Change Goal Met (Y/N) FMS 5 meters: 2/6 (walker) 3/6 (canes) 1 Y (MCID95 1) 50 meters: 2/6 (walker) 2/6 (walker) No change N (MCID95 1) 500 meters N (N/A): N (N/A): No change N unable to unable to (MCID95 1) ambulate ambulate distance distance 10 mFWT Walker: 1.25 m/s 0.92 m/s -0.33 m/s N 9.75s 11.35s +1.6s (MDC9512.2s) Walking sticks: 0.10 m/s 0.14 m/s -0.04 m/s N 99s 113s +14s (MDC9512.2s) GMFM-66 Lying/Rolling: 12/12 points 12/12 points 0 points N/A (100%) (100%) Sitting: 45/45 points 45/45 points 0 points N/A (100%) (100%) Crawling/kneeling: 28/30 points 29/30 points 1 points N (95.2%) (96.7%) Standing: 15/39 points 18/39 points 3 points N (38.5%) (46.2%) (MCID95: 5.3 points)

Walking: 14/72 points 14/72 points 0 points N (19.4%) (19.4%) (MCID95: 4.5 points) Total score: 53.86% 55.62% +1.76% N (95% CI: (95% CI: (MDC95: 51.45-56.27); 53.33-57.91); 3.24%) 70th percentile 75th percentile GMFCS level GMFCS level II II PDMS-2 Stationary: 38 points; age 41 points; age +3 points; age N equivalence: equivalence: equivalence: 18 months; 33 months; +15 months th th 16 percentile 37 percentile (MDC95: 5.54 rank rank points) Locomotion: 71 points (13 80 points (15 +9 points Y mo); mo); (2 mo) <1 Percentile 1 Percentile (MDC95: 2.77 rank rank points) Specific tasks Increase ability to 0/2 points 1/2 points +1 point on Y from GMFM- stand on tiptoes (unable to (stands of PDMS 66 and (PDMS stationary # stand on tiptoes for 2 (+2 seconds on PDMS-2 to 22) tiptoes) seconds) tiptoes) improve gross motor Increase bilateral # 20: 0/2 # 20: 1/2 +2 points on N development single leg stance points points PDMS (+ 2 (PDMS-2 stationary # #21: 0/2 #21: 1/2 seconds on 20, 21) points points single leg) (unable to (able to stand stand on single on single leg 2 leg) seconds) Increase ability to 0/2 points 1/2 points +1 point on Y return to walking after (loses balance (picks up toy, PDMS picking up toy when picking returns to (maintains (PDMS-2 locomotion up toy) standing, takes balance, + 2 # 36) 2 steps) steps) Increase Independent 2/3 on GMFM 2/3 on GMFM no change in N steps (GMFM-66 E: (4 steps) (7 steps) GMFM score #69) (+3 steps)

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 N (9.2%) (MCID95 10.9) PARTICIPATION RESTRICTIONS Outcome Subcategories Initial Follow-up Change Goal Met (Y/N) PEDI Caregiver: 14/35 (40.0%) 26/35 (74.3%) +22 points Y (34.3%) (MCID95 11.6)

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; MDC95 = the minimal detectable change with a 95% confidence interval; MCID95 = The minimum clinically important difference with a 95% confidence interval

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.

Discharge G-code

G8980 CJ: modification based on 33% impairment calculated from averaged age equivalence from PDMS-2

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%

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.

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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