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

Chapter 1

General Background

1

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

with CP and the severity of limitation is highly variable.6•7 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

:·Mwt'iJ:I£;;A,11flj1rt~ -; -~U \<·'J· .. o· ·c.-: "'- --- : :- 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

--· . ~ .

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

be 114• 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

6

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

Impaired mobility/gross motor function

Impaired velocity

Impaired quality of life

6MWT with reverse

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.

Evaluation Summary:

Chapter4

Evaluation

10

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 1 0-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

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:

11

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 "· ;· BODY;FUN'GnON~l$ ~ueTJtJK,_ .· i -~ ...

/-.~· .. :· '' ~'~~.

. Impaired Improve score on Improve the score on For both STG and LTG, the following interventions were provided standing balance the PDMS-2 item the PDMS-2 item 20 2x week for 4 weeks:

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

• Patient able • Patient able to appropriate and to progress the intervention. to stand on stand on one foot • Decreasing the assistance required for standing and ambulating one foot with with hands on his such as from using a reverse walker progress to one hand held to hands on his hips for 3 independent walking. hips for 1-2 seconds. seconds.

Impaired Increase the Increase the distance Pediatric treadmill training (IT) with variable speed for 30 minutes 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

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 walker. walker. one hand held assistance for 20-30 minutes.

' . :: ·'ft'f;;: · ; ·: .:; • ·-~r~ .~~r~: ':i ~;~>"''~~~·';;)g :r,': ;;f:f.~!i!':f':~> ' 1;:m;· ' .:bf~ L:a:t.> }'t;~ ·~1t:.::fF.; . '~?~ ' ; :'\:-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.

~ -~ = 0 ......, C'".:l ~ .., til I

'-l (J 0 i:J"' ~ Ill - ~ rll

~ '"t = Q. VI

~

= .... til

~ til

= .... ... 0

= rll

........ N

. ·' ... ,. .. ..........

..

Impaired velocity

Impaired social participation as measured using theCPQOL.

Increase speed on the treadmill by 0.2rnls, therefore completing the 10mWT in 18.76 sec._

Increase the score by 2 points on the CPQOL. Increase the time spent playing and interacting with other children including his twin by 1 hour daily by increasing the duration of ambulation w/ reverse walker or one hand held by 1 hour.

Increase the speed on the treadmill by O.Srnls, therefore completing the 10mWT in 12.00 sec.

Increase the score by another 2 points on the CPQOL. Increase the time spent playing and interacting with other children including his twin by 2 hours daily by increasing the duration of ambulation by 2-3 hours w/ a reverse walker or one hand held.

OGT and IT as described above. Ascending and descending stairs starting by having pt. use the hand rails with one hand and moderate assistance from SPT with the LEs. Progress by decreasing the assistance from the SPT to minimal or no assistance. All activities re eed.

! • :~;~::.J.;:;g

Patient's parents were advised to encourage the patient to interact with other children in smaller groups and social settings to get the patient comfortable initially. Progress by increasing the time spent and interacting with the children or twin. The patient's participation in social situations can be enhanced by improving the pt.'s ability to ambulate with less assistance.

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.

-·._ ! .. --, :~ ·' ' ' '•, :_.· .. ,·':·· -~:-•<,,: '"-".:~~-~-~~-Y~ll~1 _,

~~~f· ~·o•;'f'!""' '::::·:-~""' •":: -._ ,. :\"l!C:'-l~>'ll'h

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

I measure/te 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.

Chapter 7

Discussion

19

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.

References

1. Vaz DV, Cotta Mancini M, Fonseca ST, Vieira DS, Pertence AEM. Muscle

stiffness and strength and their relation to hand function in children with

hemiplegic cerebral palsy. Dev Med Child Neural. 2006;48(9):728-733.

21

2. Christensen D, Van Naarden Braun K, Doemberg NS, et al. Prevalence of

cerebral palsy, co-occurring autism spectrum disorders, and motor functioning­

Autism and Developmental Disabilities Monitoring Network, USA, 2008. Dev

Med Child Neural. 2014;56(1):59-65.

3. Richards CL, Malouin F. Cerebral palsy: definition, assessment and

rehabilitation. Handb Clin Neural. 2013;111 :183-195.

4. Durkin MS, Maenner MJ, Benedict RE, et al. The role of socio-economic status

and perinatal factors in racial disparities in the risk of cerebral palsy. Dev Med

Child Neural. 2015;57(9):835-843.

5. Professional guide to diseases. 8th ed .. ed. Ambler, PA: Ambler, PA:

Lippincott Williams & Wilkins; 2005.

6. Labaf S, Shamsoddini A, Hollisaz MT, Sobhani V, Shakibaee A. Effects of

Neurodevelopmental Therapy on Gross Motor Function in Children with

Cerebral Palsy. Iran J Child Neural. 2015;9(2):36-41.

7. Butler C, Darrah J. Effects ofneurodevelopmental treatment (NDT) for cerebral

palsy: an AACPDM evidence report. Dev Med Child Neural. 2001;43(11):778-

790.

8. Eek MN, Beckung E. Walking ability is related to muscle strength in children

with cerebral palsy. Gait Posture. 2008;28(3):366-371.

9. Davids JR, Oeffinger DJ, Bagley AM, Sison-Williamson M, Gorton G.

Relationship of Strength, Weight, Age, and Function in Ambulatory Children

With Cerebral Palsy. J Pediatr Orthop. 2015;35(5):523-529.

22

10. da Paz Junior AC, Burnett SM, Braga LW. Walking prognosis in cerebral palsy:

a 22-year retrospective analysis. Dev Med Child Neurol. 1994;36(2):130-134.

11. Wu YW, Day SM, Strauss DJ, Shavelle RM. Prognosis for ambulation in

cerebral palsy: a population-based study. Pediatrics. 2004;114(5):1264-1271.

12. Information ACM. Albuterol. 2008;

https://www.nlm.nih.gov/medlineplus/druginfo/meds/a604025.html. Accessed

Oct 2, 2015.

13. Atkinson HL, Nixon-Cave K. A tool for clinical reasoning and reflection using

the international classification of functioning, disability and health (ICF)

framework and patient management model. Phys Ther. 2011 ;91 (3):416-430.

14. Folio MR. Peabody developmental motor scales. In: Fewell RR, Pro E, eds.

PDMS-2. 2nd ed .. ed. Austin: Austin: Pro-Ed; 2000.

15. Goyen TA, Lui K. Longitudinal motor development of"apparently normal"

high-risk infants at 18 months, 3 and 5 years. Early Hum Dev. 2002;70(1-

2):103-115.

16. Tieman BL, Palisano RJ, Sutlive AC. Assessment of motor development and

function in preschool children. Ment Retard Dev Disabil Res Rev.

2005;11(3):189-196.

17. Wang HH, Liao HF, Hsieh CL. Reliability, sensitivity to change, and

responsiveness of the peabody developmental motor scales-second edition for

children with cerebral palsy. Phys Ther. 2006;86(10):1351-1359.

18. Kolobe TH, Palisano RJ, Stratford PW. Comparison of two outcome measures

for infants with cerebral palsy and infants with motor delays. Phys Ther.

1998;78(1 0): 1062-1072.

19. Reid SM, Carlin JB, Reddihough DS. Using the Gross Motor Function

Classification System to describe patterns of motor severity in cerebral palsy.

Dev Med Child Neural. 2011;53(11):1007-1012.

23

20. Palisano RR, P.; Bartlett, D.; Livingston, M. Gross Motor Function

Classification System- Expanded and Reviewed. 2007;

https://www.canchild.ca/system/tenon/assets/attachments/000/000/058/original/

GMFCS-ER English.pdf. Accessed January 27th, 2015.

21. Thompson P, Beath T, Bell J, et al. Test-retest reliability of the 10-metre fast

walk test and 6-minute walk test in ambulatory school-aged children with

cerebral palsy. Dev Med Child Neural. 2008;50(5):370-376.

22. Russell DJ, Avery LM, Rosenbaum PL, Raina PS, Walter SD, Palisano RJ.

Improved scaling of the gross motor function measure for children with cerebral

palsy: evidence of reliability and validity. Phys Ther. 2000;80(9):873-885.

23. Debuse D, Brace H. Outcome measures of activity for children with cerebral

palsy: a systematic review. Pediatr Phys Ther. 2011 ;23(3):221-231.

24

24. Oeffinger D, Bagley A, Rogers S, et al. Outcome tools used for ambulatory

children with cerebral palsy: responsiveness and minimum clinically important

differences. Dev Med Child Neurol. 2008;50(12):918-925.

25. Watson MJ. Refining the Ten-metre Walking Test for Use with Neurologically

Impaired People. Physiotherapy. 2002;88(7):386-397.

26. Davis E, Shelly A, Waters E, Davern M. Measuring the quality of life of

children with cerebral palsy: comparing the conceptual differences and

psychometric properties of three instruments. Dev Med Child Neurol.

2010;52(2): 174-180.

27. Salem Y, Godwin EM. Effects of task-oriented training on mobility function in

children with cerebral palsy. NeuroRehabilitation. 2009;24(4):307-313.

28. Rosenbaum PK, S.; Law, M. et al. Family-Centered services: a conceptual

framework and research review. Phys Occup Ther Pediatr. 1998;18:1-20.

29. Willoughby KL, Dodd KJ, Shields N. A systematic review of the effectiveness

of treadmill training for children with cerebral palsy. Disability and

rehabilitation. 2009;31 (24): 1971-1979.

30. Cemak K, Stevens V, PriceR, Shumway-Cook A. Locomotor training using

body-weight support on a treadmill in conjunction with ongoing physical

therapy in a child with severe cerebellar ataxia. Phys Ther. 2008;88(1):88-97.

25

31. Swe NN, Sendhilnnathan S, van Den Berg M, Barr C. Over ground walking and

body weight supported walking improve mobility equally in cerebral palsy: A

randomised controlled trial. C/in Rehabil. 2015.