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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