Download Multi-disciplinary therapeutic intervention programmes for athetoid

IJTRR 2012, 1: 3
E-ISSN: 2278-0343
International Journal of
Therapies and Rehabilitation
Research
www.ijtrr.com
Multi-disciplinary therapeutic intervention programmes for athetoid
cerebral palsy child in clinical settings: a case report
Pardeep Pahwa
Composite Regional Centre for Persons with Disabilities, Under Ministry of Social Justice &
Empowerment, Sundernagar, Himachal Pradesh, India
Email: [email protected]
ABSTRACT
Cerebral palsy (CP) is a disorder of movement and posture with additional potential to affect cognitive
status. Thus, the goals for management of the child with CP include the following: to promote optimal
function; to maintain general health; to foster acquisition of new skills; to assist and educate parents
and caregivers, and to anticipate, prevent, and treat the complications of this disorder. Single case
study, combined with efforts to develop measures specifically for child with athetoid cerebral palsy may
make more valuable contributions to the scientific justification of therapeutic interventions in clinical
settings. This case report intends to address the importance of multi-disciplinary therapeutic
intervention programmes for children with athetoid cerebral palsy.
Settings: CRC for persons with Disabilities, Sundernagar, Himachal Pradesh, India.
Keywords: Cerebral palsy, Multi-disciplinary approach, case report
INTRODUCTION
Cerebral Palsy (CP) is the most common physical
disability in childhood with prevalence of 2 to
2.6/1000 live births in industrialized countries.
CP can be defined as “a heterogeneous group of
non-progressive, but often changing, motor
impairment syndromes caused by chronic brain
injuries”. It occurs as a result of prior perinatal
events (congenital CP), or a variety of factors in
the first few years of life (acquired CP).
However, many children with such disorder may
have associated disabilities, such as cognitive
deficits, visual, hearing, speech and language
disorders, and epilepsy. The four major subtypes
of motor deficit in CP are the spastic form, the
dystonic type (commonly referred to as athetoid
CP), ataxia, and hypotonia [5]. It has been
estimated that about 10% of children with
cerebral palsy have athetoid cerebral palsy.
Athetoid CP is caused by damage to the
cerebellum or basal ganglia which is responsible
for processing the signals that enable smooth,
coordinated movements as well as for
maintaining body posture. Damage to the
cerebellum or basal ganglia may cause a child to
develop involuntary, purposeless movements.
Such movements can be noticed in the face,
arms, and trunk. It has been observed that
these movements often increase during periods
of emotional stress and totally disappear during
sleep. Children with athetoid CP often have low
muscle tone and experience a lot of difficulty
maintaining posture for sitting and walking.
Children with athetoid cerebral palsy present
with marked involuntary writhing movement.
They also have difficulties with speech as lack of
muscle control makes articulation of words
difficult. Athetoid cerebral palsy is a movement
disorder that affects gross motor skills [1]. The
most recent definition underlines the idea that
the concept of CP needs to be multidimensional
Pardeep Pahwa / International journal of therapies and rehabilitation research 2012, 1: 3
and that management of CP always requires a
multidisciplinary setting.
CASE REPORT
A 14 year old cerebral palsy child presented with
choreo-athetoid movements of both upper and
lower limbs, since birth. The involuntary
movements were basically noticed while doing
any activity. At the time of initial assessment
child had marked hypotonia, great difficulty in
independent walking, and in self-help skills. The
onset of the condition was since birth. History
revealed delayed birth cry and delayed
developmental
milestone.
Neurological
examination of child including motor, sensory
and deep tendon reflexes of lower limb was
performed and deemed with-in normal limits.
But, plantar responses of both lower limbs were
rarely observed. The lower limb muscle strength
was 3/5, except for the dorsiflexors which were
1/5, and that of upper limb was 3-/5. Active and
passive range of motion was within the normal
limits. On observation, the child presented with
buckling of knee in upright standing. The
choreoathetoid movements were combined
with dystonic posturing, and with fair trunk
control. At the early stage the child was wheel
chair bound and his speech was gradually
deteriorating. In the following years, the patient
received multi-agency support in terms of
regular medical care, physiotherapy but not
regularly, and social services.
TREATMENT
The patient was admitted and treated at OPD,
Composite Regional Centre nearly for 7 months.
At the initial stage, the main aim was to improve
the strength of the weak muscles. PRE training
was initiated with therabands, weighted vests
were wrapped initially with low resistance and
gradually progressed to moderate and high
resistance. To strengthen the arm and leg
muscles and to prevent involuntary movements,
weight cuffs of ½ kg were wrapped around wrist
and ankle. Close kinetic chain exercises such as
rolling on the swiss ball were introduced to gain
stability of upper limb movements. Child
completed various mat activities including
Rhythmic Stabilization on Swiss ball. Balancing
exercise on swiss ball, and bouncing on
trampoline in sitting position were performed
by the child. We used various sensory inputs to
maintain balance: visual inputs, vestibular
inputs and proprioception. After gaining
strength and control over shaking movements,
activities were carried out in standing frame.
Following this, gait training was initiated in
parallel bars with hinged AFO. During
locomotion training in parallel bars, a wide
range of sensory inputs with potential feedback
including visual, proprioceptive, vestibular and
tactile inputs were given. Child was shifted to
bilateral elbow crutches from parallel bars. With
help of proper Rehabilitation programme, the
child started to walk independently with Tripod.
Child gained good grip strength became
independent in his ADL. The child also received
speech therapy from the same rehabilitation
centre. The choreioform movements noted
earlier had almost ceased. The child’s father
reported considerable improvement in fine
motor, gross motor, coordination and speech
abilities, which matched with the observations
made by the physician, physiotherapist. He is an
active, cheerful young lad and now likes to sit
cross-legged. He occasionally sings during the
clinic. His ability to ambulate has consistently
increased.
STUDY DESIGN
This is a single test retest case report. The
outcome was measured using GMFM -88(Gross
motor function measure – 88). Baseline
measurement was taken twice with GMFM -88:
once without AFO’s and assistive devices and a
second time with AFO’s and assistive devices.
The GMFM-88 consists of 88 items grouped into
5 dimensions: 1. Lying and rolling (17 items), 2.
Sitting (20 items), 3. Crawling and kneeling (14
items), 4. Standing (13 items), 5. Walking,
running, and jumping (24 items). The GMFM
Pardeep Pahwa / International journal of therapies and rehabilitation research 2012, 1: 3
takes approximately 45 minutes to administer [7]. GMFM is designed to evaluate gross motor function
in children with cerebral palsy from birth to twelve years of age. The GMFM has shown to be reliable,
valid, and responsive to change in gross motor function for children with CP [9, 10].
In this case study the intervention following the baseline measurement included the intensive physical
therapy two hours/day for four weeks. Post-test was taken both with and without braces and assistive
devices using the GMFM-88. The patient was also retested six months post-intervention.
RESULTS
Table1: Base line Measurement
Category
Lying and Rolling
Sitting
Crawling and Kneeling
Standing
Walking, Running and Jumping
Table 2: Post Test
Category
Lying and Rolling
Sitting
Crawling and Kneeling
Standing
Walking, Running and Jumping
Total
Without AFO’s and Assistive With AFO’s and AD
devices
76.47%
76.47%
60.00%
60.00%
14.29%
14.29%
33.33%
33.33%
5.56%
22.22%
Total 37.93%
Without
and AD
84.31%
71.67%
19.05%
38.46%
19.44%
46.59%
AFO’s Change
+7.84
+11.76
+4.76
+5.13
+13.88
+8.66
With AFO’s and Change
AD
84.31%
+7.84
71.67%
+11.76
23.81%
+9.52
43.59%
+10.26
30.56%
+8.34
50.79%
+9.53
Table 3: 6 months follow-up
Category
Without
AFO’s and
AD
Lying and Rolling
86.27%
Sitting
68.33%
Crawling and Kneeling
30.95%
Standing
25.64%
Walking, Running and 25.00%
Jumping
Total
47.24%
Change
Change
(Base Line) (Post test)
+9.8
+8.33
+16.66
-7.69
+19.44
+1.99
-3.34
+11.9
-12.82
+5.56
With
AFO’s and
AD
86.27%
68.33%
30.95%
41.05%
36.11%
+9.31
+0.65
52.54%
Change
Change
(Base Line) (Post test)
+9.8
+8.33
+16.66
+7.22
+13.89
+1.99
-3.34
+7.14
-2.54
+5.55
+11.28
+1.75
Table 1 shows the GMFM-88 scores for each category recorded at the initial evaluation. The subject
participated in the multidisciplinary therapeutic programme at CRC therapy unit. During the four weeks
of intervention, the subject received sixty hours of therapy.
Pardeep Pahwa / International journal of therapies and rehabilitation research 2012, 1: 3
When comparing the Time 1 score to the Time 2
score it shows an increase in the subject’s
GMFM scores in each category, as well as an
increase in the overall total score. At the
completion of the four week intense therapy
program,
significant
improvement
of
performance was found in all the GMFM
categories as well as the overall score. Six
months
post-intervention
the
patient
maintained the progress made at the time of
completion of the therapy program. This is
shown by the total score changing slightly. The
total score increased slightly when compared to
the previous scores. The subject demonstrated
slight improvements in lying and rolling,
crawling and kneeling, and walking, running,
and jumping categories as compared to the
baseline and retest at four weeks
measurements. There was a minor decline of
scores at the six month re-test in the categories
of sitting and standing.
DISCUSSION
The results demonstrated that functional
physical therapy improves motor abilities of
children with CP. All dimensions of gross motor
function including lying and rolling, sitting,
crawling and kneeling, standing, and walking,
running, and jumping, measured by the GMFM
were significantly improved following functional
physical therapy. The results also indicated that
differences in GMFMS levels between pre- and
post-treatment are clinically meaningful.
Because CP is a handicapping condition with
known CNS aetiology, it is essential to assess,
monitor, and provide interventions to promote
development and acquisition of skills, thus
optimizing potential. Therapies are most
effective when started early. This Case Report
intends to enhance and facilitate the
appropriate use of proper and valid methods of
clinical trials and systematic reviews to fully
address the information needs of professionals
and patients in the field of CP rehabilitation.
Along with medications prescribed by the
physician, physical therapists can help treat
symptoms of athetosis [4]. The functional
physical therapy was effective in improving
gross motor skills in children with athetoid
cerebral palsy.
The following improvements were noted in the
child on follow up:
1. Child no longer required a crutch, but used a
Tripod during walking in up and downhill
area for support and safety.
2. The Coordination and balance has improved
in sitting and able to control his involuntary
movements even in classroom
3. The child performs dorsi-flexion, which was
not present, in a limited range.
Notably, this case report suggests, the child
who participated in the four week intensive
therapy was able to maintain the progress for at
least six months post-intervention.
Conclusion
Because athetoid cerebral palsy is a chronic
lifelong
disability,
a
comprehensive
management program is essential. It can be
seen that, there is a marked improvement in
child gross motor function. This can be
attributed to an initial strengthening and also to
constant muscle re-education and various
rehabilitation techniques.
Acknowledgements
I would like to thank my whole Physiotherapy
Staff, Orthotic and Prosthetic dept.and Speech
Therapist for their valuable contribution in
treating child with regards to preparation of this
manuscript.
Conflict of Interest
There are no conflicts of interest to declare.
References
1. Bacharach S, Miller F.Cerebral Palsy; A
complete guide for care giving. Baltimore, MD:
John Hopkins University Press; 2006.
2. Miller F. Physical therapy of cerebral palsy.
New York, NY: Springer Science and Business
Media; 2007.
3. Jones MW, Morgan & Jean E Shelton. Primary
care of child with cerebral palsy; a review of
systems (Part 2), Journal of Paediatric Care, 21,
226-237.
Pardeep Pahwa / International journal of therapies and rehabilitation research 2012, 1: 3
4. Hou M, Zhao JH and Yu R. Recent advances in
dyskinetic cerebral palsy. World J Pediatr 2006;
2 (15):23-28.
5. Siebes RC, Wijnroks L, Vermeer A , Qualitative
analysis of therapeutic motor intervention
programmes for children with cerebral palsy: an
update. Dev Med Child Neurol 2002; 44 (9):
593-603.
6. Russel DJ, Rosenbaun PL, Avery LM, et al.
Gross Motor Function Measure (GMFM-66 &
GMFM-88) User’s Manual. London, England:
Mac Keith Press: 2002.
7. Palisano RJ, Hanna SE, Rosenbaum PL, et al.
Validation of a Model of Gross Motor Function
for Children With Cerebral Palsy. Phys Ther
2000; 80: 974-983.
Pardeep Pahwa / International journal of therapies and rehabilitation research 2012, 1: 3