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 by Amy K. Holthaus SUMMER 2015 © 2015 Amy K. Holthaus ALL RIGHTS RESERVED ii OUTPATIENT PHYSICAL THERAPY FOR A TODDLER WITH CEREBRAL PALSY PRESENTING WITH DEVELOPMENTAL DELAYS A Doctoral Project by 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 iv Abstract of OUTPATIENT PHYSICAL THERAPY FOR A TODDLER WITH CEREBRAL PALSY PRESENTING WITH DEVELOPMENTAL DELAYS by 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 v 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. vi 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 1 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 2 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 3 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. 4 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