Client’s Name: Eli
Age: 2 (will be 3 on 4/2/15)
Diagnosis: Cerebral Palsy
Premature birth – 35 weeks gestation
Sustained intrauterine ischemic event with damage to left parietal lobe, right occipital lobe, Macrodactyly left foot
Current Situation: Eli’s primary means of independent mobility is crawling with a non-reciprocating “bunny hop” pattern. He crawls up and down stairs and pulls to standing independently. He has decreased function of his right upper extremity, but consistently uses his right “helper hand”. Spasticity is present through both legs and right arm. Eli demonstrates typical crouch gait alignment in standing, tending toward bilateral ankle plantarflexion, and flexion at both knees and hips. He propels a gait trainer with minimal assist with forearm prompts and does best with ankle prompts to minimize scissoring and anterior rotation of the left side of the body. He requires verbal prompting to step to or step through with his right foot. Eli has bilateral Ankle Foot Orthotics (AFOs) to assist with alignment of his feet and lower legs.
Eli attends a parent/child Early Childhood Family Education class one day per week with Early Intervention support, including 20 minutes of direct Physical Therapy. He receives one home visit per month from the Early Intervention teacher.
Why do they need to stand?
Eli needs to stand to minimize the effects of abnormal tone and his preference for w-sitting for independent play. Standing, and especially standing in abduction, places the head of his femur within his acetabulum during this key period of bone and joint development. Standing also decreases spasticity, allowing for more upright and functional posture when Eli is working on ambulation skills. Over the long term, it is anticipated standing will result in greater efficiency of functional mobility and decreased health complications (osteoporosis, orthopedic issues) frequently associated with spastic cerebral palsy.
What are you trying to achieve with standing program?
Eli’s family would like for him to achieve independent ambulation with crutches if possible. This will require functional anti-gravity strength, minimization of abnormal muscle tone, functional anatomical alignment, and core stability; all of which can be facilitated by participation in a standing program.
How does it relate to IEP goals (if applicable)?
Eli is still developing functional mobility skills. After he turns three, IEP goals will focus on developing independence with upright classroom and hallway mobility with the most appropriate assistive device. Standing decreases the impact of abnormal muscle tone, improving gait patterning and efficiency.
What type of stander did you use, what options did they use? Why was this stander chosen over other types?
Eli primarily uses a supine stander due to size and portability.
He had the opportunity to try a multi-position stander with hip abduction. The hip abduction option is preferable due to spasticity affecting both lower limbs to minimize his muscle tone. Adjustable knee blocks allow him to be placed in standing to accommodate hip and knee flexion as needed when initiating standing with the option to increase hip and knee extension as range of motion increases over the course of the standing session as spasticity is inhibited. Abduction places the femoral head within the acetabulum and decreases spasticity of the hip adductors, leading to less scissoring in gait. Slightly prone positioning has been shown to improve upper extremity function in children with cerebral palsy, so this is an excellent option for him to be able to access as well.
How often do they stand? How long do they stand? What is the standing protocol
Eli stands for 60 minutes 6-7 days per week.
Where do they stand – rehab/school/home?
Due to his limited time at school, he does his standing at home. When he begins attending preschool 3 or more days a week, standing will be incorporated into his school day.
ADLs or other Activities that they do while standing
Eli enjoys playing with cars, balls, and playdough while standing.
Eli has been able to use district-owned standing technology while obtaining assistive technology for gait training through insurance. Due to limited space in the family home and a busy household, parent education has been essential in commitment to a standing program. Being able to show the family the visible difference in gait before and after a session of standing was very helpful.
Stephenie Labandz, PT, DPT is a graduate of St. Catherine University with a passion for neurological rehabilitation and assistive technology. She currently works serving the children and families of Robbinsdale Area Schools through the Early Intervention and Early Childhood Special Education programs.