Pamela A. Mullens

When using the Neuro-Developmental Treatment (NDT) Practice Model in the formation of a care plan for a young child with hemiparesis, practitioners should consider the child holistically, within the context of his or her world. The world for many infants includes their parents and family, as well as care providers. As the child ages and develops cognitive, communication, manual-bimanual, and mobility skills, the boundaries of the child’s world expand. The confidence and sense of self needed to venture away from the security and safety of a trusted caregiver evolve over time, with small successes laying the foundation for larger achievements. This case report explores the possible relationships among the body structures and functions, activities, and participation for a young child with hemiparesis, with a focus on the context of his psycho-social-emotional development.

The term hemiplegia is commonly used to describe the manifestation of a neurological insult to the brain resulting in sensorimotor deficits where one side of the body is more affected than the other. Hemiplegia may refer to a complete paralysis of the involved limbs and hemiparesis to a weakness. For the purposes of this case report, we will refer to hemiparesis, or weakness.

This case report documents the diagnosis, the presenting problems, and the integrities of Perry, a young child with hemiparesis. It also documents the development and application of a plan of intervention specifically designed for Perry.

This case report follows Perry during a 2-year period of physical therapy beginning at the age of 9 months. His initial examination findings revealed delays in fine, gross, and oral motor function, as well as the emergence of impairments in the neuromuscular, musculoskeletal, and sensory-perceptual systems.

Perry was first observed both in his home and at the infant/mother program at the University of Washington. The intent of the observation was to become acquainted with him and with his family, to determine his level of function, and to form initial hypotheses regarding impairments underlying observed activity limitations. These observations were made without handling by the therapist to obtain information regarding spontaneous behavior.

Participation and Participation Restrictions

Perry participated in the life of his family in the role of the youngest child. He also attended and participated in the infant/mother class at the EEU. Perry was unable to participate in the life of his family at the level expected of a 9-month-old child, primarily due to activity limitations preventing him from performing at an expected age level. He preferred not to leave his mother’s lap, and he was carried by his mother, since he had no independent means of locomotion and could not actively explore his room and house independently.

Activities and Activity Limitations

Play

Perry played in a sitting position on the floor, supported in his high chair, or sitting on an adult’s lap. His preference was to be on his mother’s lap or to be carried by his mother. He liked to play with toy cars, noise-making toys (toys that made sound when shaken or banged or pressed), balls, and household items, such as pots and pans. He also enjoyed books and pictures. Perry used only his right hand to engage in play; no two-handed play was observed during the initial examination. When seated on the floor, Perry played with toys that were brought to him and presented either in front of him or on the right side. He ignored objects presented on the left. If toys went out of reach in front of him, he reached for them by bringing his trunk forward with hip flexion. Attempts to retrieve toys out of his reach on his right side were not noted.

Feeding/Nursing

Breast-feeding appeared to be a factor in self-regulation as well as in nutrition. When Perry became anxious, he gestured and indicated that he wanted to breast-feed. When Perry lay on his right side for breast-feeding, he brought his left arm and hand forward to touch his mother’s body. He opened his left hand and held it against her; this appeared to be a purposeful movement and was the only voluntary movement of the left arm that was observed during the initial examination.

Communication

As expected for his age, Perry did not communicate verbally during the observation period. However, he demonstrated a well-developed gestural system of communication. He used facial expression, body movement, and vocalizations to indicate his emotional state and his likes, dislikes, and wants. He pointed with his right hand at objects he wanted and made sounds that drew attention to his gestures.

Locomotion

Balance in Sitting and Supported Standing (Demonstrating Integration of Postural Control and Limb Movement)

Perry exhibited protective and supporting behaviors in his right upper extremity (UE) in the sagittal and frontal planes but not in the transverse plane. Protective and supporting reactions were not observed to the left or in the left UE.

Fine Motor Control

Perry used his right hand for play, demonstrating a radial-palmar or scissors grasp pattern for small objects when positioned in sitting on the floor or in his high chair.

Control and Coordination of Left Upper Extremity (Integration of Posture and Movement)

Spontaneous movement of Perry’s left UE was very limited and noted primarily during breast-feeding. At other times when sitting or held, Perry predominantly maintained his left arm and hand at his side with a slightly fisted hand. At times, he showed some degree of volitional movement in his left arm and hand. When his right arm was manually constrained, he opened the left hand and reached for objects with the left hand. The reach was grossly accurate, but he had no grasp or release with the hand. He became anxious and frustrated because the hand would not grasp. His behavior (crying and beating his head) was interpreted to indicate frustration and a desire that he wished his left arm to remain undisturbed. Additionally, Perry refused to look directly at his left hand and arm. When attention was drawn to his hand, he would not look in that direction.

The initial observations of activities/activity limitations and multisystem integrities and impairments led the therapist to hypothesize as to which single systems needed specific examination. The following systems were targeted for examination.

Body Structure and Function Integrities and Impairments

Muscle Tone and Activity

Perry’s left arm displayed variable muscle tone ranging from low to high tone (measured by resistance to passive movement). At rest, tone in the trunk and arm musculature appeared low, although the left hand was frequently fisted with the thumb adducted. With strenuous use of the right hand, involuntary muscle activity in the left arm increased. The left arm assumed a high guard position—arm abducted at the shoulder and elbow flexed, forearm in pronation, wrist flexed, and hand fisted. Vigorous activity of the right arm also caused the left leg to exhibit increased hip flexion, abduction, and external rotation, knee flexion, ankle plantar flexion, and clawing of the toes. Additionally, in a supported standing position, strong excitement (annoyance or pleasure) or vigorous activity in the right arm resulted in clawing of the toes of the left foot.

Differences in muscle activity between the right and left sides of Perry’s trunk were difficult to assess due to minimal differences between his right and left sides. Muscle activity in response to lateral weight shifting was present bilaterally but was slower on the left. This difference in response time between the two sides may be an indication that muscle activity was slightly lower on the left side when compared with his right.

Musculoskeletal System—Range of Motion

Perry showed full range of motion bilaterally in his shoulders, elbows, forearm, wrist, and fingers. Full range of motion was present in his hips, knees, and ankles.

Musculoskeletal System—Strength

There was weakness of the left elbow extensors. Strength was difficult to assess due to infrequent volitional movements of the left extremities.

Tactile System

Perry’s perception of light touch, deep pressure, and sharp and blunt sensation in his left arm was examined when his visual attention was diverted. Perry did not respond to sensory input to his left arm if his attention was diverted. When he saw that his left arm was being touched, he objected, used the right arm to move the left arm to the right, and covered it with his right arm so that it could no longer be touched. Similar behaviors were not noted relative to touch of his left lower extremity (LE). Perry localized to touch of his legs and did not become upset. He also was observed to touch his left leg with his right arm. Perry responded to touch on both sides of his trunk.

Proprioception—Kinesthesia

Kinesthesia also appeared to be impaired on the left side with the upper limb more involved when compared with his lower limb. If Perry’s arm was moved when he was looking away from the left side (when he could not see the arm), he did not react at all, giving the impression that he was unaware of the movement or touch. He reacted to passive movement or position change in the left leg when vision was diverted from the limb, by moving his leg and looking toward that limb.

Visual Tracking

Perry visually tracked objects in the vertical and horizontal directions. Visual fields also appeared to be intact.

Perry’s vestibular system was not formally examined, although it appeared to be functioning at an age-appropriate level, based on observations of the orientation of his head and body in space and the presence of righting responses.

Neuromuscular System

Perry’s movements in the left arm and leg were slow, demonstrating limited control and coordination of muscle activity on his left more so than his right side and greater difficulty with control in his arm when compared with his leg. He had more difficulty in recruiting motor units in the left arm. Perry also had difficulty isolating motor activity on the left side and in the arm more so than the leg. The muscle synergies observed were more massed synergies, with less refined movement, particularly distally. Perry’s left arm tended to pull into patterns of flexion, rather than extension, with stiffness varying from slightly low at rest, to increased with effort and emotion. There were no signs of clonus or tremor.

Perry demonstrated the greatest number of impairments of neuromuscular control and coordination in his left UE with some difficulties in the left LE and remarkably few expressions of the impairments in his trunk. In the left arm, the most obvious impairment was decreased isolated control (that was hypothesized to be due to involuntary muscle overflow and loss of selective motor control) within and between the arms, and to a lesser degree within the distal aspect of his left leg. At times, Perry’s left foot assumed a position of plantar flexion at the ankle and clawing of the toes. He demonstrated slightly limited recruitment of postural motor units with his arm presenting with lower tone at rest but with the hand fisting, suggesting the ongoing recruitment of phasic motor units. In addition, Perry demonstrated decreased integration of postural functions and movement functions within his left arm with decreased use of the limb for support during transitions, and decreased use of the limb to move rapidly and then support as in protective reactions. Other signs of poor timing and sequencing of muscle activation were slow and imprecise movements in the left arm. The left arm was typically held in flexion, distally greater than proximally. Movements into extension were infrequent, demonstrating limited synergy or muscle group selection. The stiffness in his left arm varied from being lower at rest but increasing with effort and emotion. The hyperstiffness was greatest in the hand.

The following list exemplifies the body system impairments as they were hypothesized to relate to activity and activity limitations.

Activity Limitations

• Absence of transitional movements from prone to supine, supine to prone, sitting to lying, or lying to sitting.

Perry received physical therapy at his home once a week. The physical therapy program at home was coordinated with the infant program at the EEU. The physical therapist attended the meeting where the IFSP was created, and the occupational therapist visited Perry at his home and observed the physical therapy. This interaction promoted collaboration with the staff of the infant program. The infant program placed strong emphasis on promoting independent mobility, drawing attention to the left arm and hand, providing sensory input, and promoting use of the left arm and hand in play and other activities. The teacher, the occupational therapist, and the physical therapist collaborated on this goal, thus providing consistent and regular practice in a variety of settings.

The intervention program (plan of care) was created based on information from observation of spontaneous behavior, from examination and evaluation, from literature related to the development of children with hemiplegia and hemiparesis, and from an understanding of Perry’s interests, preferences, and emotional reactions to his hemiparesis.

The reports from other team members, including the occupational therapist (OT), speech-language pathologist (SLP), and teacher at the EEU, were used to guide the intervention plan. Perry received a concentrated period of play therapy from a child psychoanalyst. The report of the psychoanalyst was another factor used to guide the intervention plan. The physical therapist did not address oral motor therapy because this was provided by the SLP at the EEU. The intervention program included a review of the targeted outcomes and provided specific examples of home program recommendations made for the parents, as well as specific examples of the therapeutic activities performed by the therapist with Perry.

General Aims of Intervention and Global Plan of Care

To assist Perry in developing transitional movements and an independent mode of locomotion

Desired Goals for Physical Therapy

Desired goals 1 and 2 are subservient or preparatory to goal 3.

1. To promote awareness of the left UE by encouraging visual attention to the arm and hand (getting Perry to look at his arm and hand) and by providing tactile, proprioceptive, and kinesthetic input to the arm and hand.

2. To allow muscle length to keep pace with limb growth during development, to prevent secondary impairments such as muscle shortening and joint capsule and ligament tightness leading to joint contracture.

3. To move independently from supine to prone lying, from prone lying to sitting, and sitting to either prone or supine lying, to creep on all fours, and to begin pulling to a standing position. As far as possible, weight bearing over the left arm and leg will be incorporated into the movements.

Desired Short-Term Physical Therapy Outcomes

• Perry will look at his left hand at least twice during a weekly physical therapy intervention session for 4 weeks in succession. This could include looking at the hand spontaneously while performing an activity with the arm and hand independently or with assistance, or when tactile, proprioceptive, or tactile stimulation is applied to the left arm or hand.

• Perry will incorporate the left arm in a simple two-handed activity, such as clapping hands, holding onto a handle bar with two hands, or holding a ball with both hands without assistance.

• Perry will transition from lying to sitting independently, incorporating weight bearing over the left arm during the transition.

Specific Examples of Direct Intervention

The home program was the initial focus of intervention. Later, other activities were included in therapy sessions. Since the intervention began with the home program, this program will be described first.

Family Instruction and Home Programs

Initially, Perry showed anxiety and was reluctant to separate from his mother. Although the aim was to help him to accept age-appropriate separation, it was important to provide effective intervention immediately to encourage the development of efficient posture and movement, to prevent secondary impairments, and to stem his present tendency to perform all activities without using the left arm and hand. In view of the urgency for initiating intervention parent instruction was integral to the intervention plan.

Initially, much of the intervention was given with Perry held by his mother or sitting on her lap. Having the parent carry out parts of the therapy program at home increased the intensity of the therapy. Perry’s mother was advised of the need to maintain appropriate range of motion and muscle length, particularly in the left hamstrings, left heel cord, and left shoulder, elbow, wrist, fingers, and thumb.

Perry’s mother needed handling skills that would fit into her daily routine of bathing, feeding, diapering, lifting, carrying, and so on. At each home visit, intervention focused on an activity of daily living and worked on making this a time to optimize use of and attention to the left arm and hand and on other therapy goals. Perry’s mother was creative in incorporating the goals of therapy into many play activities and activities of daily living. She was able to incorporate therapy in to a variety of settings, thus providing repetition and variability of practice.

Specific Suggestions for Activities during Diapering

During diaper changing, the mother and caregivers were encouraged to include the following:

• Encouraging activities to provide elongation of hamstrings, knee extensors, and heel cords.

• Bringing both arms into elevation above Perry’s head and playing the game “So big.”

• Flexing hips and knees toward the chest and then bringing both arms forward with hands on knees.

• Drawing visual attention to the hands and knees.

Bath Time Suggestions

At bath time, the mother worked on encouraging Perry to attend to the soap being rubbed on the left arm and in putting soap or lotion on the left hand and having him apply it to the right arm. He also rubbed soap and lotion on the left arm with his right hand. He played such games as splashing in the bath with hands and both feet and hiding the left arm under soap bubbles in the water and having his mother ask Perry where it was. He would then bring the arm out and show it.

Dressing

The left arm was incorporated into dressing to draw visual attention to the arm as in bathing and diapering. For much of the time, the movement was largely assisted movement, as in bringing the arms forward for pulling off socks.

Other Activities Outside of Therapy Sessions

Based on her understanding of the therapy goals, the mother invented and adapted games. She played pata-cake with Perry and facilitated use of both hands, and when he was on a hobbyhorse at home, she assisted him in holding on with two hands.

Perry’s family enrolled him in a music class for pre-school children. The activities of this class encouraged bimanual activity. For example, Perry held hands with children on his left and right sides when they formed circles for various activities. They also had a variety of bells and percussion instruments that needed bimanual activity. The class was also an opportunity for social interaction since Perry enjoyed being with the other children.

Physical Therapy Intervention Sessions

In addition to the home program and the school program, Perry received individual physical therapy sessions. These sessions included intervention strategies designed to achieve the established desired outcomes.