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

The benefits of physical therapy (PT) on gross motor function and general strength in children with spastic quadriplegia cerebral palsy (CP) are well documented.1, 2, 3, 4

There have been no firm conclusions that have determined the optimal duration and intensity of PT interventions for patients with spastic quadriplegia CP.5

The purpose of this case report was to investigate an intensive course of PT for 3 hours a day, 5 days a week, for 3 weeks in a pediatric patient with spastic quadriplegia CP.

CP occurs as a result of a brain injury associated with birth. Worldwide the prevalence of CP was 1.5 to 3.0 per 1,000 live births in

2009.6

Previous research demonstrated that PT intervention in children with CP improved gross motor function and strength, decreased the assistance required for mobility, and decreased step length differences.3,7

Current research supports a high frequency schedule of PT, however, the optimal intensity and duration of PT has not been determined.5

2 year old female with infantile spastic quadriplegia CP, Gross Motor Function Classification System (GMFCS) level V.

The patient had a history of seizures and gastroesophageal disease. The patient received Botox injections to bilateral pectoral and

hamstring musculature a month prior to treatment. Her primary impairments were decreased muscle strength and

endurance and abnormal muscle tone leading to a lack of independent age appropriate ambulation and gross motor skills.

PBWSTT: Partial Body Weight Supported Treadmill Training

Modified Ashworth Scale: 2 for all major joints in all extremities Full passive range of motion at all extremities

UEs: upper extremities; LEs: Lower extremities

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 quadriplegia CP.

The dynamic systems theory provides a rationale for use of task-specific, highly repetitious activities for the patient to be an active participant in motor learning.

Future research should continue to investigate the ideal treatment interval and intensity necessary for optimal PT outcomes.

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.

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.

None

Kirsten Buchanan, PhD, PT, ATC Danielle Guerin, DPT

Interventions Week One – Three

Manual Therapy

PROM to all major joints at all extremities into flexion and extension.

• PROM for torso rotation.

Motor Function Training

Rolling Prone press up onto

forearms Prone to quadruped

transitions Quadruped holds Taylor sitting Anterior propped sitting Straddle sit over peanut

90/90 sitting on bench with reaching Sit to stand from low bench Supported standing Lateral protective extension Ambulation and supported standing in

LiteGait (Figure A) Ambulation and supported standing in

Mustang gait trainer (Figure B)

Therapeutic Activities

Prone rocking on therapy ball

Prone on therapy ball with weight shift reaching

(Figure D) Quadruped holds in

Universal Exercise Unit Pull to sit on incline wedge

Rhythmic input on therapy ball Straddle sit on bolster swing Taylor sitting over platform swing Sitting over platform swing (Figure C) Sitting on therapy ball with upper extremity

reaching Amtryke riding Squats in Universal Exercise Unit

Goal (in 3 weeks) Initial Evaluation Discharge

Maintain quadruped with minimal assistance for 10 seconds

Required maximum assistance from therapist at torso and UEs to maintain position

Required moderate support at torso and minimal support at UEs to maintain position

Maintain neutral head alignment during pull to sit in 5/5 attempts

Head lag on pull to sit on all attempts

Goal Exceeded; able to maintain neutral head position for 10 attempts

Maintain anterior and/or lateral propped sitting for 10 seconds with minimal assistance at trunk

Required maximum assistance from therapist at torso and UEs to maintain position

Goal Exceeded; able to maintain propped sitting independently for 10 seconds

Ambulate in the LiteGait for greater than 20 minutes without assist for lower extremity advancement

Ambulated in LiteGait for 12 minutes with therapist assist to advance LEs

Goal Met

Tests & Measures

Initial Evaluation Results Discharge Evaluation Results

GMFM-66 Total score: 5.35% Total score: 7.36%

Gait Assessment Completed in LiteGait PBWSTT No arm swing Poor head control into excessive

flexion Knee flexion throughout gait cycle Left ankle inversion on initial contact

and through stance phase Required therapist assist for forward

progression

Completed in LiteGait – PBWSTT No arm swing Improved head control with minimal

fluctuations into excessive flexion/extension

Knee flexion throughout gait cycle Left ankle inversion on initial contact

and through stance phase Independent forward progression

Physical Therapy Interventions

Cardiovascular/Pulmonary

Impaired Decreased endurance due to limited independent mobility

Musculoskeletal

Impaired Decreased active range of motion at all extremities due to spasticity and decreased muscle strength

Neuromuscular

Impaired Spasticity noted in all major joints of all extremities

Integumentary

At risk Supramalleolar orthotic use in weight bearing

Communication

Impaired Nonverbal; utilized facial expressions and body language

Affect, Cognition, Language, and Learning Style

Impaired Good affect, good cognition, comprehends English, and learned through demonstration and verbal instruction

Systems Review Data

Tests and Measures

Pictured Interventions

Patient Goals

Unique

Purpose

Foundation

Description

Observations

Discussion

References

Funding Sources

Acknowledgements

A D B C