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
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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
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 ... .; .. . . •
. 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
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= .... ... 0
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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.