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A Three-Week Intensive Pediatric Physical Therapy Plan Of A Three-Week Intensive Pediatric Physical Therapy Plan of Care for a Child with Spastic Quadriplegia Cerebral Palsy: A Case Report Brandie Schmierer, DPT student; Kirsten Buchanan, PhD, PT, ATC University of New England, Department of Physical Therapy, Portland, Maine Unique Physical Therapy Interventions Observations Tests and Measures The benefits of physical therapy (PT) on gross motor function and Interventions Week One – Three general strength in children with spastic quadriplegia cerebral palsy Tests & Initial Evaluation Results Discharge Evaluation Results (CP) are well documented.1, 2, 3, 4 Measures There have been no firm conclusions that have determined the optimal PROM to all major joints at • PROM for torso rotation. GMFM-66 Total score: 5.35% Total score: 7.36% duration and intensity of PT interventions for patients with spastic Manual all extremities into flexion quadriplegia CP.5 Therapy Gait Assessment Completed in LiteGait PBWSTT Completed in LiteGait – PBWSTT and extension. No arm swing No arm swing Poor head control into excessive Improved head control with minimal Purpose flexion fluctuations into excessive Knee flexion throughout gait cycle flexion/extension Left ankle inversion on initial contact Knee flexion throughout gait cycle The purpose of this case report was to investigate an intensive course Rolling 90/90 sitting on bench with reaching and through stance phase Left ankle inversion on initial contact of PT for 3 hours a day, 5 days a week, for 3 weeks in a pediatric patient Prone press up onto Sit to stand from low bench Required therapist assist for forward and through stance phase with spastic quadriplegia CP. progression Independent forward progression forearms Supported standing Motor PBWSTT: Partial Body Weight Supported Treadmill Training Prone to quadruped Lateral protective extension Foundation Function transitions Ambulation and supported standing in Modified Ashworth Scale: 2 for all major joints in all extremities CP occurs as a result of a brain injury associated with birth. Training Quadruped holds LiteGait (Figure A) Full passive range of motion at all extremities Worldwide the prevalence of CP was 1.5 to 3.0 per 1,000 live births in Taylor sitting Ambulation and supported standing in Patient Goals 6 Anterior propped sitting Mustang gait trainer (Figure B) 2009. Goal (in 3 weeks) Initial Evaluation Discharge Previous research demonstrated that PT intervention in children with Straddle sit over peanut CP improved gross motor function and strength, decreased the Maintain quadruped with Required maximum assistance Required moderate support at minimal assistance for 10 from therapist at torso and UEs torso and minimal support at assistance required for mobility, and decreased step length seconds to maintain position UEs to maintain position differences.3,7 Maintain neutral head Head lag on pull to sit on all Goal Exceeded; able to Current research supports a high frequency schedule of PT, however, alignment during pull to sit in attempts maintain neutral head position 5 the optimal intensity and duration of PT has not been determined. 5/5 attempts for 10 attempts Prone rocking on therapy Rhythmic input on therapy ball ball Straddle sit on bolster swing Maintain anterior and/or Required maximum assistance Goal Exceeded; able to lateral propped sitting for 10 from therapist at torso and UEs maintain propped sitting Description Prone on therapy ball with Taylor sitting over platform swing seconds with minimal to maintain position independently for 10 seconds Therapeutic weight shift reaching Sitting over platform swing (Figure C) assistance at trunk 2 year old female with infantile spastic quadriplegia CP, Gross Motor Activities (Figure D) Sitting on therapy ball with upper extremity Ambulate in the LiteGait for Ambulated in LiteGait for 12 Goal Met Function Classification System (GMFCS) level V. Quadruped holds in reaching greater than 20 minutes minutes with therapist assist to The patient had a history of seizures and gastroesophageal disease. Universal Exercise Unit Amtryke riding without assist for lower advance LEs extremity advancement The patient received Botox injections to bilateral pectoral and Pull to sit on incline wedge Squats in Universal Exercise Unit UEs: upper extremities; LEs: Lower extremities hamstring musculature a month prior to treatment. Her primary impairments were decreased muscle strength and Discussion endurance and abnormal muscle tone leading to a lack of independent age appropriate ambulation and gross motor skills. As a result of a 3 week intensive PT session, improvements were noted in gross motor function and strength in a 2 year old with spastic Systems Review Data quadriplegia CP. The dynamic systems theory provides a rationale for use of task- Cardiovascular/Pulmonary Pictured Interventions specific, highly repetitious activities for the patient to be an active Impaired Decreased endurance due to limited independent mobility participant in motor learning. Musculoskeletal Future research should continue to investigate the ideal treatment interval and intensity necessary for optimal PT outcomes. Impaired Decreased active range of motion at all extremities due to spasticity and decreased muscle strength Neuromuscular References 1. Damiano DL, Abel MF. Functional outcomes of strength training in spastic cerebral palsy. Arch Phys Med Rehabil. 1998;79(2):119-25. PubMed PMID: 9473991. 2. Blundell SW, Shepherd RB, Dean CM, Adams RD, Cahill BM. Functional strength training in cerebral palsy: a pilot study of a group circuit training class for children aged 4-8 years. Clin Rehabil. 2003;17(1):48-57. PubMed PMID: 12617379. 3. Begnoche DM, Pitetti KH. Effects of traditional treatment and partial body weight treadmill training on the motor skills of children with spastic cerebral palsy. A pilot study. Pediatr Phys Ther. 2007;19(1):11-9. PubMed PMID: 17304093. Impaired Spasticity noted in all major joints of all extremities 4. Curtis DJ, Butler P, Saavedra S, Bencke J, Kallemose T, Sonne-Holm S, Woollacott M. The central role of trunk control in the gross motor function of children with cerebral palsy: a retrospective cross-sectional study. Dev Med Child Neurol. 2015;57(4):351-7. doi: 10.1111/dmcn.12641. 5. Størvold GV, Jahnsen R. Intensive motor skills training program combining group and individual sessions for children with cerebral palsy. Pediatr Phys Ther. 2010;22(2):150-9. doi: 10.1097/PEP.0b013e3181dbe379. 6. Arneson CL, Durkin MS, Benedict RE, Kirby RS, Yeargin-Allsopp M, Van Naarden Braun K, Doernberg NS. Prevalence of cerebral palsy: Autism and Developmental Disabilities Monitoring Network, three sites, United States, 2004. Disabil Health J. 2009;2(1):45-8. doi: 10.1016/j.dhjo.2008.08.001. 7. Sorsdahl AB, Moe-Nilssen R, Kaale HK, Rieber J, Strand LI. Change in basic motor abilities, quality of movement and everyday activities following intensive, goal-directed, activity-focused physiotherapy in a group setting for children with cerebral palsy. BMC Pediatr. 2010;10:26. doi: 10.1186/1471-2431-10-26. Integumentary Funding Sources At risk Supramalleolar orthotic use in weight bearing Communication None Impaired Nonverbal; utilized facial expressions and body language Acknowledgements Affect, Cognition, Language, and Learning Style A B C D Kirsten Buchanan, PhD, PT, ATC Impaired Good affect, good cognition, comprehends English, and learned Danielle Guerin, DPT through demonstration and verbal instruction .
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