Greta – Cerebral Palsy – spastic, quadriplegic

Brief description of environment of facility/school

Greta is served through  Early Intervention with a trans-disciplinary, family routines-based model and Physical Therapist as primary service provider.

Basic Info about client

  • Greta
  • Age: 30 months
  • Diagnosis: Cerebral Palsy – spastic, quadriplegic
  • Brief history:
    • born after an uncomplicated pregnancy at 39 3/7 weeks
    • at birth, she had a heart rate of 92 but no spontaneous respirations
    • Apgars were 3 at birth; 4 at one minute; and 4 at ten minutes
    • shortly after birth, Greta had Sarnat stage III encephalopathy and on admission to Newborn Intensive Care Unit at 2 ½ hours of age, she had stage II encephalopathy
    • initial EEG showed occasional electrographic seizures. She was cooled for 72 hours and her EEG showed improvement
    • receives regularly scheduled botulinum toxin injections to most affected areas (usually upper extremity)
    • had trial of Sinemet for motor function, but drug was discontinued due to gastrointestinal side effects (vomiting)

  • Current Situation:
    • maximal assistance for transfers
    • obtained manual wheelchair with custom seating at age 29 months
    • ambulates hundreds of feet with her own gait trainer which provides support at pelvis and trunk
    • uses a fully supportive bath chair for support during hygiene activities, obtained at age 25 months
    • she raises her hips off the floor when lying on her back, and can scoot herself short distances (3-5 feet) using this technique
    • she requires moderate support for sitting, and maintains prop sitting for 20-30 seconds when placed in position
    • she bears weight through her legs wearing ankle foot orthotics (AFOs) on both legs, and stands with anterior support at chest level, such as standing facing the couch, with minimal assist for 20-30 seconds
    • she rolls from belly to back and from back to sides
    • then lying on her tummy, she brings one knee forward into a pre-crawling position
    • Greta has strong reflexes intact, including symmetrical tonic neck reflex and asymmetrical tonic neck reflex
    • Greta has impaired head control, and with inadequate support, tends toward a position of right head rotation with left neck tilt and lateral lean with spine convex to the right
    • Greta reaches for and grasps toys briefly
    • she does not engage in midline play with both hands
    • she loves to color with triangular crayons she can insert her fingers through

 Goals

  • Why does Greta need to stand?
    • because of her abnormal muscle tone, Greta has not been able to achieve gross motor milestones at times comparable to same-age peers
    • Greta needed to start standing around one year of age when most children begin standing and walking to help with development of her bones and joints
  • What are you trying to achieve with standing program?
    • Maximum appropriate physiologic and motor development
  • How does standing relate to family goals?
    • Greta’s motor goals on her Individual Family Service Plan (IFSP) are related to trunk strength and control, which are improved with standing.
      • By February 2014, Greta uses back scooting, rolling, or army crawling to move 10-15 feet on the floor toward a desired toy, activity, or interaction on three consecutive days.
      • By April 2014, Greta uses an isolated finger with assistance from a glove to touch a 2″ square target in a book, on the iPad screen, or on a communication device in 8 out of 10 attempts on three consecutive days.
      • By June 2014, Greta grasps a writing utensil and marks paper for 3 periods of at least 10 seconds on three consecutive days.
      • By July 2014, Greta brings a spoon to her mouth and feeds herself a spoonful of food at least three times during each meal over three consecutive days.
      • By August 2014, Greta ring sits on the floor propped on hands for at least 60 seconds in 2 out of 3 attempts on three consecutive days.
    • Greta currently uses eye gaze most effectively for communication and recently tried a head mouse with a communication device, which shows a great deal of promise. Improving trunk strength and head control functionally through standing will increase her breath support for vocalization as well as her ability to effectively use augmentative and assistive communication options.

The Standing Program

  • What type of stander did you use, what options did they use? Why was this stander chosen over other types?
    • Greta used a TherAdapt supine stander because of her size at age 12 months, her limited head control, and availability of lending equipment from her Early Intervention program
  • How often do they stand? How long do they stand? What is the standing protocol?
    • Standing was incorporated into the daily routine for 45-60 minutes.
  • Where do they stand – rehab/school/home?
    • Greta did all of her standing at home
  • ADLs or other Activities that they do while standing
    • The stander tray provided an excellent surface for Greta to do art activities and play with simple cause-and-effect toys

Other points of interest

  • The family and team were faced with the question of whether seeking insurance reimbursement for standing or gait training technology would result in greater long-term benefit for Greta. By initiating standing around 12 months, Greta was able to develop functional strength allowing her to walk up to 80 feet in a gait trainer with trunk and pelvis support and with direction lock on by 18 months. At 30 months, she walks hundreds of feet in the gait trainer with trunk and pelvis support and controls her own steering, making controlled 90 degree turns. The gait trainer was ultimately the best choice for seeking reimbursement from insurance, but the stander was a vitally necessary component in developing gait.

Outcomes

  • How were the (long or short-term) goals of standing met (medical benefits, physiological/emotional benefits, ease in daily living, etc.)
    • By standing, Greta was able to develop skills necessary to develop mobility
    • By standing, Greta has developed improved trunk strength which has helped with her fine motor skills – she now grasps a crayon and holds it to color for over a minute at a time
    • By standing, Greta has improved her core strength and is producing more vocalizations to increase communication
    • By standing, Greta has increased her head control, which will make it possible for her to utilize a head mouse for computer and communication device
  • Advice for others (therapists, parents, consumers)

Remember the natural progression for  developing mobility. I don’t believe a child must necessarily crawl before she walks, but she must stand before she walks. Using standing technology is not giving up on walking. A standing program is an excellent way to develop requisite flexibility, strength, and function for gait.

Background/Bio of therapist/writer

Stephenie Labandz, PT, received her MPT degree in 2002 and her DPT degree in 2009, both from the College of St. Catherine in St. Paul, MN. Her primary professional interests are neurological rehabilitation and assistive technology. She currently serves the children and families of Robbinsdale Area Schools through their Early Intervention and Early Childhood Special Education programs.