An Intensive Model of Therapy for a Child with Spastic Diplegia Cerebral Palsy: A Case Study
By: Neurological and Physical Abilitation Center (NAPA)
Reprinted with the express permission of Lynette LaScala of NAPA Center.
Background and Purpose: Intensive therapy (IT) programs for children with neurological disorders have changed pediatric rehabilitation; although, currently there is no conclusive evidence in support of appropriate protocols, outcome measures, frequency, duration, or intensity of sessions.
Pediatric clinicians agree that children with cerebral palsy (CP) need physical therapy (PT) in infancy and throughout childhood; however, there is often very slow progress in achieving strength, coordination, balance, ambulation with or without assistive devices, or independence in functional activities. Consequently, pediatric physical therapists have spent over fifteen years researching methods to “jump start” the neuromuscular system in children with CP. The purpose of this case study is to describe the management of a child with CP during fifteen days of an intensive model of therapy (IMOT).
Case Description: The subject was an ambulatory three and a half year old female diagnosed at birth with spastic diplegia CP; although she presented with impairments typically seen in hemiplegia.
Outcome: Gross Motor Function Measure (GMFM) scores, gait deviations, functional activities and bimanual skills improved.
Discussion: Intensive therapy incorporates treatment methods that encourage proper alignment, dynamic proprioceptive input, and repetition of functional activities. Follow-up is recommended to evaluate long-term carry-over of IT, and research is warranted to standardize IT protocols and outcome measures.
Key Words: Spider cage, Adeli Suit, Dynamic Proprioceptive Input
Cerebral palsy (CP) represents a group of chronic non-progressive disorders that affect the development of movement.1,2,3 Typically CP results from neurological damage that occurs during the prenatal period, at birth, or within the first five years. In addition to sensory and motor deficits, children with CP often have some degree of retardation, seizure disorder, cognitive deficits, and spasticity. Children with CP demonstrate difficulty moving against gravity, and primitive reflexes fail to integrate, leading to contractures and severe musculoskeletal deformities. Consequently, physical therapy (PT) should be initiated during infancy to decrease the development of pathological movement patterns and sensory defensiveness.4
A child with CP spends years in therapy trying to overcome abnormal movement patterns, spasticity, and communication deficits, while also learning to cope with psychosocial issues. It is common for a child with CP to spend six to ten hours per week in therapy with very slow progress in achieving strength, coordination, balance, ambulation with or without assistive devices, or independence in functional activities. Consequently, pediatric physical therapists from all over the world have spent years researching intensive therapy (IT) to “jump start” the neuromuscular system in children with CP.
Intensive therapy is described inconsistently throughout the research. Some therapists describe IT as sixteen weeks, five days per week for 50-minute sessions; others describe four weeks, four days per week for 45-minute sessions.3,5 Some researchers suggest that increasing the frequency and duration of therapy sessions, then allowing a rest break before resuming traditional therapy, may produce significant and long lasting changes in strength, tone, posture, and gross motor performance; however, the success of any IT depends on the commitment of the parents, caregivers, child, and therapists.3
Few research articles about IT describe specific tests, goals and treatment interventions; although, most researchers report success and improved scores with the Gross Motor Function Measure (GMFM). The American Association of Intensive Pediatric Physical Therapy (AAIPPT) was created three years after IT began in the United States (US) and has the mission “to advance the quality of life and make a difference in the outcome of children with CP and other neuromuscular disorders by promoting the highest ethical and professional standards, and increasing awareness in the healthcare community of the effectiveness of the intensive physical therapy treatment method.”6
The intensive model of therapy (IMOT) for this case study is similar to other programs available in the US and refers to four hours of physical therapy for fifteen days, wherein the subject receives massage to prepare the body for functional activities. Prolonged static stretching is achieved using universal exercise units (UEU) or “cages.” The “monkey cage,” is a rigid metal cage with three walls and a top panel upon which pulley systems may be arranged to stretch and strengthen muscles. Following stretching, each joint is ranged through diagonal patterns similar to proprioceptive neuromuscular facilitation (PNF) patterns.
The “spider cage,” utilizes bungee straps wherein the subject can be supported while learning to weight-shift, jump, kneel, half-kneel, and step up and over objects. The “spider cage,” has been tested and used in Poland since 1993 and has been available in the US since 2002. The “spider cage” allows for controlled and independent movement and appears to have the effect of decreasing pathological and neurological reactions that affect mobility.6 The “spider cage” is an effective tool for implementing neurodevelopmental treatment (NDT), one of the most wide-spread and clinically accepted methods for “(re)programming” the central nervous and neuromuscular systems and “teaching” the brain more normal motor skills. The NDT approach devised by the Bobaths in the 1940’s encourages children with neuromuscular deficits to 1) learn more normal movement patterns, 2) change positions comfortably in different environments, and 3) improve quality of movement and functional skills.3 Vertical and quadruped standers are utilized in IMOT for additional weight-bearing and proprioception through all extremities.
Another unique intervention utilized in IMOT is a therapeutic suit. The Adeli suit is an adaptation of the Penguin suit used by Russian cosmonauts to counteract the effects of weightlessness in space. The Penguin suit, which provides resistance to movement, decreases muscle atrophy, and reduces development of osteoporosis and apraxic gait in anti-gravity conditions, was created in 1971 by the Russian space program.7,8 The Adeli (“little penguin”) suit consists of a head piece, vest, shorts, knee pads and special shoes upon which elastic cords with bungee-type characteristics are fastened over flexor and extensor muscles while also providing correct limb alignment. The theory behind the Adeli suit is that once the body is in proper alignment with support and pressure through all joints, intense movement therapy can be performed that will (re)educate the brain to recognize correct movement patterns and muscle activity. It is suggested that the Adeli suit can provide 30 to 80 pounds of pressure and approximation through the joints and provide dynamic proprioceptive input to improve the neuromuscular and vestibular systems.8,9
The nervous system of premature and neurologically damaged children does not receive the unique and crucial pressure and input typically experienced from the second week of gestation, depriving the infant of vital tactile and sensory stimulation. Therapeutic suits such as the Adeli and NeuroSuit assist in re-training the central nervous system by allowing the child to overcome increasingly complex pathological movement and to execute and repeat previously unknown movement patterns. The Adeli suit was first successfully used in the treatment of infantile CP in a study by Semenova, who reported changes in nystagmus, increased balance, decreased pathological synergies, and corrections in cortical mechanisms of movement using electroencephalography, electroneuromyograpy, and studies of the vestibular and somatosensory systems.8 Several patients had reduced dysarthria and muscle tone and increased voluntary upper extremity movements, all of which improved self-care abilities and social interactions.
Changes in the activity of vestibular nystagmus indicated the ability to maintain balance and orientation in space. Eighty percent (80%) of the patients in Semenova’s study presented with impaired function of the labyrinths, resulting in increased muscle tone and pathological reflexes. Sixty-two percent (62%) of the patients presented with adequately distributed muscle tone in static and dynamic conditions at the end of the study. In addition, Semenova reports that children with CP have insufficient cortical control, resulting in stimulation of pathological activity of structures within the reticular formation of the brainstem. The anti-gravity system and postural reflexes are under significant control of the reticular formation of the brainstem. When a child with CP is positioned vertically, pathological reflexes affect the child’s ability to maintain balance. Implementing the Adeli suit treatment with dynamic proprioceptive correction daily for several weeks appears to decrease the influence of pathological reflexes and tone, indicating changes in cortical and reticular structures.8
In a study by Bar-haim et al, NDT was compared to the Adeli Suit Treatment (AST) in twenty-four children with CP for four weeks, five days per week for two-hour sessions. The original Russian protocol for using the Adeli suit was used, including 1) massage, 2) passive stretching, 3) application of the suit with the body in proper alignment, and 4) rigorous exercises and functional activities in weight bearing. The results of IT with AST versus NDT revealed significant improvements in GMFM and mechanical efficiency index of stair-climbing scores in one month within the AST group and in nine months within the NDT group, predominantly in children with higher motor function. However, when the retention of motor skills was tested nine months after treatment, there was no significant difference between the AST and NDT groups. Bar-haim et al suggest that children who are tolerant of short bouts of IT may experience rapid and long term changes in the neuromuscular and vestibuloproprioceptive systems, especially children with higher motor function.10,11,12
The NeuroSuit offers similar benefits as the Adeli suit; however the NeuroSuit is currently the only therapeutic suit that offers upper extremity components. The elbow pads and gloves have hooks to which bungee cords can be attached and facilitate positioning out of flexor synergy patterns typically seen in children with CP. Providing resistance across the major muscle groups improves strength, endurance, posture, coordination, gait deviations, and increases function of the most important branch of the anti-gravity system—the vestibular system.13,10
The subject was an ambulatory three and a half year old female diagnosed at birth with spastic diplegia CP; although she presented with impairments typically seen in hemiplegia.
She was accompanied by her mother who provided written informed consent and the following birth history: the subject was born at twenty-eight weeks gestation, weighing one pound, fourteen ounces. She spent two months in NICU, where she was treated for a right Grade IV intraventricular bleed. At eight months, the subject was treated for infantile spasms/seizures. She received traditional physical, occupational and speech therapy two to three times per week from the age of five months. She had a left ankle foot orthoses, bilateral supramalleolar orthoses, and a left thumb abduction splint.
The Gross Motor Function Measure (GMFM) was used pre and post IT. The subject’s gait was analyzed and described according to the Rancho Los Amigos Observational Gait Analysis System; see table one for gait analysis.14 Range of motion (ROM) and girth of the lower extremities were also measured. The subject had full active ROM in the right upper and lower extremities and limited active and passive ROM in the left upper and lower extremities. The subject’s left elbow, wrist, knee and hip flexors; hip adductors and ankle plantarflexors received a Grade one (1) on the Modified Ashworth Scale (MAS) for Grading Spasticity; refer to table two.15 In addition, the subject was video-taped while performing multiple components of the GMFM and other functional activities.
The subject’s physicians, PT, and parents agreed that she was a good candidate for IMOT to improve gait deviations, ROM, weight shifts, balance, coordination, bimanual skills and functional activities.
The subject was diagnosed according to The Guide to Physical Therapist Practice in Neuromuscular practice pattern 5C: Impaired Motor Function and Sensory Integrity Associated with Nonprogressive Disorders of the Central Nervous System-Congenital Origin or Acquired in Infancy or Childhood.16
Prognosis and Plan of Care
The subject had committed parental support, good motivation and rehabilitation potential. The plan included intensive physical therapy five days per week, four hours per day for three weeks. The parent’s goals for the subject were to 1) incorporate more automatic bimanual skills, 2) step over objects without side-stepping, 3) transition from stand to squat without turning in her left leg, 4) increase left step length, and 5) improve ambulation up and down steps. The goals established by the PT included items from all five dimensions of the GMFM as well as attending to objects on her left by rotating her head, weight-shifting to the left lower extremity, and maintaining kneeling position more than five seconds.
Intensive therapy included massage of the left upper extremity, neck, back and left lower extremity for 30 to 45 minutes to prepare the body for functional activities. Manual stretching was focused primarily on the left biceps, wrist and finger flexors, hamstrings, adductors, internal rotators and plantarflexors. One to one and a half kilogram weights were used with the pulley system in the “monkey cage” to isolate and strengthen hip abductors, adductors and extensors. The subject performed activities to challenge balance, coordination, weight-shifting, half-kneeling, tall kneeling, single leg stance, stepping, jumping and running in the “spider cage,” using four to eight bungee straps and manual facilitation.
The NeuroSuit and components of the Adeli Suit were utilized for one hour each session to provide joint approximation and dynamic proprioceptive input through the entire body. The NeuroSuit was chosen for this subject, because it offers elbow pads and gloves to which bungee straps can be attached to decrease upper extremity flexor synergy patterns. The Adeli knee pads were selected, because they fit the patient more appropriately. It is extremely important that the entire suit fit snug like a “second skin.”
Hippotherapy was utilized with the subject wearing the NeuroSuit as a means to increase weight bearing and proprioception and to facilitate head and trunk control while she performed reaching and grasping activities with the left upper extremity. Many other functional activities such as stair climbing, walking up and down inclines, kicking balls, jumping, squatting, kneeling and running were facilitated and successfully performed while the subject wore the NeuroSuit. Vertical and quadruped standers were also implemented in the plan of care to encourage weight-bearing and increase proprioceptive input through all extremities.
The measured outcomes for this subject were the GMFM, ROM, and girth at the beginning of week one and at the end of week three; although ROM and girth were measured inconsistently by the investigators. The GMFM is a criterion-referenced test used specifically to evaluate change in gross motor function in children with CP and to determine treatment goals.17 The test is validated for children between five months and sixteen years and best suited for children two to five years of age. It is suggested that a typically developing five year old child would be able to complete each item on the test, earning a total score of one-hundred percent (100%). The dimensions of the test are 1) lying and rolling; 2) sitting; 3) crawling; 4) standing; and 5) walking, running and jumping, and each dimension has a different number developmental tasks. Scoring of each item is based on a four-point Likert scale measuring how much of the item the child completes.18 Over the fifteen day treatment period, the subject increased her total GMFM score by eighteen percent (18%) from fifty-four percent (54%) to seventy-two percent (72%). The GMFM is a good measurement of gross motor performance; however, many changes observed in the subject’s movement were qualitative and not measurable by the GMFM. Refer to table three for GMFM dimension and total scores. The subject demonstrated improvements in left hip and knee flexion and decreased left hip abduction and circumduction during gait after three weeks of IMOT. The subject’s ability to step over three to four inch objects without side-stepping improved, and she demonstrated more automatic bimanual skills during functional activities. She also attended to her left side more by rotating her head to find toys. In addition, the subject’s spasticity grade remained a one according to the MAS.
The results of this case study are consistent with other research articles regarding IT for children with CP. Researchers across the world report improvements in the neuromuscular, vestibular, and proprioceptive systems and in speech and communication. While several IT programs rely mostly on the NDT method, the use of the “spider” and “monkey” cages along with the therapeutic suits in IMOT appear to be an effective way to encourage improvement in gross motor skills, functional activities, strength, proprioception and proper alignment while the child participates in playful tasks. Fortunately, this subject had minimal limitations in ROM; however, she had several components affecting her gait, including mild spasticity. While wearing the therapeutic suit, gait deviations improved significantly, and the subject experienced a more normal gait pattern. The success of the subject in IMOT appears to be related to the increased frequency and duration of sessions; unique interventions and goals; repetition of activities with the entire body supported in proper alignment through the use of therapeutic suits; dynamic proprioceptive input to muscles and the brain; and the compliance and commitment of the patient, family, and therapists.
An IMOT program incorporating massage, stretching, strengthening, UEUs, therapeutic suits, vertical and quadruped standers, and hippotherapy, in which the subject receives 1) proper alignment, 2) dynamic proprioceptive input through the entire body, and 3) repetition of tasks, appears to provide unique methods of “jump starting” the neuromuscular system in a child with spastic diplegia CP. Research articles and parental anecdotes report positive and lasting changes in confidence, movement, posture, balance, coordination, ambulation, strength, endurance, and functional activities. Follow-up is recommended to evaluate long-term carry-over of IMOT, and continued research is recommended to identify appropriate outcome measures, interventions, frequency, duration, and intensity of IT for children with neurological and developmental disorders.
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Modified Ashworth Scale for Grading Spasticity
Gross Motor Function Measure Scores
GMFM- Gross Motor Function Measure
IT- Intensive Therapy
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