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 by Bhumisha Patel SUMMER 2016 ©2016 Bhumisha Patel ALL RIGHTS RESERVED 11 GAIT TRAINING TO IMPROVE FUNCTIONAL MOBILITY IN A CHILD WITH CEREBRAL PALSY A Doctoral Project by 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 of GAIT TRAINING TO IMPROVE FUNCTIONAL MOBILITY IN A CHILD WITH CEREBRAL PALSY by 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