Report B4 Achieving Sitting with Hands Free for Play in a 23-Month-Old Girl with Hypertonic Cerebral Palsy

Case Report B4 Achieving Sitting with Hands Free for Play in a 23-Month-Old Girl with Hypertonic Cerebral Palsy

Marjorie Prim Haynes

B4.1 Introduction

Neuro-Developmental Treatment (NDT) is a recognized therap eutic intervention for children and adults with cerebral palsy (CP) with a focus on active practice to guide the individual to his or her highest functional level.1,2 Parents of children with special needs often seek out the services of an NDT-educated occupational therapist (OT), physical therapist (PT), and speech-language pathologist (SLP) to assist in attaining specific age-appropriate goals.

Goals/outcomes may need to be modified and updated as the child develops and as the family and child’s expectations and goals change. Intervention requires frequent modifications based on the child’s changes in all domains of function (participation, activity, and body structure/function). An NDT-educated therapist uses a problem-solving approach to determine where to start an intervention session based on a specific activity (function), age of the child, and the repertoire of effective and ineffective postures and movements that the child uses. Critical impairments are highlighted to allow for maximal changes in function that is performed within a single session, in the next six sessions, or in an episode of care to help the child expand participation and activities. This case highlights the process to achieve a specific age-appropriate function based on parental request and the child’s present functional level while making plans for the future.

The literature addresses key areas that influence a child’s overall function. Within the NDT context, posture and movement are viewed as multisystem integrities and impairments that are addressed in relationship to a specific functional task (either participation or activity) and in the contexts of both the individual and the environment.^{3,4,5,6,7,8,9,10} Postural control ensures task-specific stability and efficient orientation for motor performance of functional skills.^3,11,12,13 Over time, practice of posture and movements within functional tasks influences neuronal networks and maps for functional changes.^11,14,15 In addition, time-dependent motor learning takes place with appropriate levels of feedback and practice over the course of days, weeks, months, and years, reinforcing effective and/or ineffective postures and movements to complete functions.^11,14,16,17 Theoretical constructs of motor control, motor learning, plasticity and recovery, and their applications to the practice of NDT are discussed in Chapters 12, 13, 14, and 15.

Postural control impairments and movement dyscoordination are key problems in clients with CP.^{3,11,14,18,19,20} Research that focuses on addressing the postural system as a component of a specific task is limited. Two relevant randomized, controlled trials using NDT as intervention specifically focused on postural control/trunk protocol to influence overall motor skills with positive outcomes related specifically to function were identified in a PubMed database search.^21,22 Both studies highlighted the use of direct handling to facilitate postural control and movement synergies to enhance the child’s ability to achieve successful motor outcomes.^21,22 Harbourne et al²³ addressed postural control specific to the motor task of sitting as a way to maximize function. Their intervention strategy included use of touch as a basis for change. Cope et al²⁴ combined an NDT trunk protocol that included handling with emphasis on symmetry to augment a modified constraint-induced movement therapy (mCIMT) program. The results demonstrated changes in functional use of the hemiplegic hand/arm with brain reorganization. These findings have recently been corroborated by Haynes and Phillips²⁵ in their study in which two children showed changes in the use of the more involved hand as well as specific gross motor functions. NDT strategies (direct intervention handling with emphases on postural symmetry, activating from a dynamic base of support, weight shifts with trunk elongation, and rotation) were incorporated by the team.

Children with bilateral spastic CP have difficulty fine tuning the degree of postural muscle contraction that is needed for a specific task.^3,11,13,26 Therefore, the child may activate muscle contractions in an improper sequence. This improper sequence influences the postural system when performing a specific task, such as sitting and reaching^{4,5,26,27,28,29} or standing.^{13,27,30,31,32,33} As a result, children with CP often use a top-down recruitment of muscles (cranial–caudal) to assist with sitting balance^4,5,7,31 and standing balance.^{12,27,30,31,33}

Excessive antagonistic muscle coactivation emerges as a strategy to provide postural stability as an attempt to stabilize and protect balance.^4,13,26 Movement muscles (fast twitch/type II) often take over the functioning of the inefficient postural muscles (slow twitch/type I).^3,11 This change in muscle function further compromises postural control because functioning muscles are unable to maintain stability. Therefore, children with CP often use a force-control strategy in which the arms are used to generate force to transition between positions and remain upright (sitting or standing).^3,13,20 In NDT intervention, therapeutic direct handling provides specific three-dimensional directional input to facilitate postural muscles to generate a dynamic base of support.^11,21,22,23 This active base of support encourages the bottom-up (caudal–cranial) recruitment and activation of muscles supporting reactive and proactive postural control and movement coordination.^{4,5,7,13,26,30}

Observation of the posture and movement systems and understanding how the systems work efficiently together is important in the NDT Practice Model for task analysis and for assisting a client to achieve skill mastery. For children with CP, targeted body system impairments that affect postural control and movement coordination are identified in the neuromuscular, musculoskeletal, and sensory systems.3,11,14,21,22 Body systems work together to adjust posture prior to a destabilizing voluntary movement made by specific arm or specific leg movements.^3,5,30,31,33 The inability to activate postural control in anticipation of voluntary arm movement or leg movement is a clinical observation described in children with cerebral palsy.^{4,28,29,31,33}

The NDT clinician analyzes the impairments that affect postural control related to a specific task, such as sitting with arms free to play. Musculoskeletal problems of shortened muscles in ankles, knees, and hip can be a limiting factor influencing atypical and ineffective postures and movements in sitting.^3,11 Neuromuscular impairments that affect sitting with arms free for play include insufficient force generation, increased tone (stiffness), and impaired muscle synergies.^3,6,14

Ineffective muscle synergies are resistant to change or adaption and interfere with a flexible movement repertoire that is needed to meet specific task requirements that may change based on environmental demands.^3,11,14,21 Shumway-Cook et al,³ Van der Heide et al,⁵ and Westcott and Burtner¹² have concluded that patients with spastic hypertonia are unable to recruit and regulate the firing frequency of motor neurons. The sensory systems may also be compromised, affecting function.^6,10,34,35

A therapist using the NDT Practice Model provides sufficient time to practice the posture and movement requirements of a specific task, such as sitting with hands free for play in a variety of ways and conditions. Motor learning and improving performance require practice and experimentation of specific components of the task^11,14,36 and practice of the entire task.^{11,14,16,30,31,36,37} The therapist uses hands-on facilitation to guide practice.^12,13,24 As the child indicates readiness, handling is gradually removed with opportunities to practice the task independently.^11,14,25 Therefore, NDT strives to improve motor function, and judicious use of handling helps the child perform the function as energy efficiently as possible.^11,21,25

Feedback is another important component for motor learning.^11,33 Wittenberg¹⁵ suggests that therapies designed to restore the most normal type of motor system may prove to be the best for assisting with neuronal development (neuroplasticity). The clinician using the NDT Practice Model selects individualized feedback strategies based on the client’s postural and movement responses as they relate to the specific task (functional outcome).^11,37 Physical feedback for children with CP is provided and gradually decreased as the skill is mastered.^11,37

This case report describes problem solving using the NDT Practice Model to address the activity of sitting with Makayla, a 23-month-old girl. Makayla’s mother would like her to sit safely to play with her twin sister at a child-size table. When Makayla’s ability to sit safely with her hands free for play is achieved, she would like Makayla to move on her own from the floor to sitting on a chair at a small table. This is a place where the girls enjoy playing together.

This case report analyzes the postures and movements required to sit safely on a bench and free the hands for play. This skill is crucial for peer play, playing with toys, and later success in academic skills. Sitting safely with arms free is a skill used throughout life in home, work, play/leisure, and community participation. The case report then highlights Makayla’s body system impairments that will be crucial to address for successful sitting. This analysis leads directly to strategies for intervention.

B4.2 Case Description

B4.2.1 Patient History—Information Gathering

Makayla was discharged home from the hospital at 4 months of age (adjusted age 23 days) with a primary diagnosis of prematurity. Birth records indicated her mother’s pregnancy was complicated by maternal age and fibrotic cysts. Makayla and her twin sister were delivered by C-section. Spontaneous rupture of membranes occurred at delivery with moderate amounts of clear fluid. The delivery required no assistance. The Apgar score was 8 at 1 minute and 9 at 5 minutes. Her birth weight was 650 g (1 lb 6 oz), which is small for gestational age (SGA). During her 90-day stay in the neonatal intensive care unit, Makayla was on and off the ventilator for 30 days to support her respiratory needs. Full feeds began after the first 30 days.

A cranial ultrasound was completed for intraventricular hemorrhage (IVH) screening with no evidence of a bleed. A mild increase in periventricular white matter echogenicity was noted and could indicate ischemic changes, with the left greater than the right side of the brain. A later examination revealed no evidence for IVH or periventricular leukomalacia.

Makayla was eligible to participate in the Infant Toddler Program (ITP) by the Sandhills Children Developmental Service Agency (CDSA) due to a medical diagnosis of prematurity (gestation age of < 27 weeks) and being SGA (birth weight of less than 1000 g) at the time of discharge from the hospital. Makayla was evaluated by the ITP intake team at 4 months 14 days chronological age with an adjusted age of 37 days. Makayla was found to be developing age appropriately based on her adjusted age using the results from the Test of Infant Motor Performance (TIMP).

A 6-month follow-up evaluation was recommended due to questionable items on the TIMP and general consensus of the team. A follow-up physical therapy visit took place at age 16 months 14 days, adjusted age of 13 months 6 days. Scores on the Bayley Scales of Infant Development Motor Scale Second Edition (BSID II) placed Makayla at 10 months on fine motor skills and 7 months on gross motor skills. The PT observed an increase in extremity stiffness (tone) that was greater in the lower extremities than the upper extremities. Physical therapy services were initiated with a recommendation to seek occupational therapy services. Makayla was monitored routinely by the Special Care Clinic at Duke Medical Center.

At the age of 15 months, the medical team determined that oral baclofen administered daily would help control the lower extremity spasticity that interfered with Makayla’s overall function. Makayla’s mother reported that the medicine was recommended due to the “excessive stiffness” in the lower extremities. Makayla stood on her toes with mild scissoring of the feet at age 15 months with the medical team. Toe standing was a routine behavior that Makayla used at home. Her main means of locomotion was commando-crawling. On the Modified Ashworth Scale, Makayla scored a grade of 4 bilaterally.

B4.2.2 Makayla’s Diagnosis

When Makayla was age 23 months, the medical team confirmed a diagnosis of spasticity (CP) affecting the lower extremities significantly greater than the upper extremities. The medical team expressed the importance of continuing with physical therapy services and occupational therapy services and initiating speech-language pathology services.

B4.2.3 Data Collection during Examination: Current Level of Function

Participation and Participation Restrictions

Makayla is a happy and energetic soon-to-be 2-year-old. She enjoys interactions with her peers and therapist. She plays routinely with her sister but is also content to play alone. Her mother states that Makayla becomes easily frustrated when she is unable to keep pace with her sister or accomplish a task. Makayla models her sister and attempts to perform the same activities. Even though Makayla strives to be independent, caregivers are needed to assist with mobility and self-care.

Makayla attends all social activities with her family, who are able to carry her or use a stroller in the community. Makayla cannot interact with playmates outside (home or community) unless she is placed where it is appropriate to creep on her hands and knees. Makayla cannot keep up with her peers during outdoor play because she is unable to walk; therefore, she spends time alone when outside.

Makayla creeps on her hands and knees to move across the floor in her environment both at home and at day care. She reverts to commando-crawling when stressed and when increase in speed is necessary to complete a task. The floor is the only place where Makayla safely plays with her sister. The W-sit position is a preferred pattern since her arms are free for play. In other sitting positions, her hands are not free for play. Instead, Makayla’s arms are used for balance and support. To move safely from place to place and keep up with her peers, the family intervenes and carries Makayla when creeping on her hands and knees is not appropriate.

Activity and Activity Limitations

Makayla creeps on hands and knees to move, sits on the floor (W-sit position) independently, finger feeds, and drinks from a sippy cup when in her high chair or a chair with a safety strap. When sitting in a chair, Makayla slumps in her chair and constantly needs to reposition herself, frequently with the help of caregivers. To move to stand, she pulls up and holds with her hands. She is unable to free her hands for play in a supported standing position. Makayla enjoys standing with her sister and will remain standing on her toes supporting at furniture for ~30 seconds before collapsing to the floor. She takes one or two cruising steps leaning on the furniture and then collapses to the floor. Makayla’s mother is concerned about her safety when she is upright because she frequently falls.

Standardized Testing—Outcome Measures

Results on the BSID II placed Makayla at 12 months on fine motor skills and 8 months on gross motor skills. Testing was completed by the PT from the Infant Toddler Program prior to this therapist initiating services. Occupational therapy services were not in place because her mother’s primary concern was gross motor skills. On the Gross Motor Function Classification System (GMFCS), Makayla functioned at level II.

Observations of Posture and Movement

In all positions and during movement, weight is asymmetrically positioned to the right. Makayla’s head is slightly flexed (capital extension with cervical flexion) with shoulder elevation. The trunk maintains a flexed pattern with the hips and knees relatively flexed. Her feet remain in plantar flexion during activities. Excessive stiffness with her lower extremities positioned into relative extension is used to maintain an upright position. See Fig. B4.1, Fig. B4.2, Fig. B4.3 and additional photos and videos of Makayla on Thieme MediaCenter.

Body Structure and Function Integrities and Impairments

Neuromuscular System

Excessive Coactivation

Lower extremity stiffness is a result of excessive coactivation of the agonist and antagonist muscles (gastrocnemius/tibialis anterior, iliopsoas/gluteus maximus).