Cerebral palsy (CP) is characterized by sensorimotor dysfunctions that lead to atypical muscle tone, posture, and movement.1 Constraint-induced movement therapy (CIMT) shows promise as an approach in treating neurologic injuries. This therapy evolved from the theory of “learned nonuse” described by Taub,2 in which following neurologic injury, individuals compensate by using the less-involved extremity due to depressed neural functioning of the more affected extremity.3 Although variations exist, CIMT consists of 2 fundamental principles: constraint of the less-affected limb and mass practice of activities with the affected limb.3
Constraint-induced movement therapy typically includes intense practice. Most studies use a combination of “shaping,” which involves performing movements in small, discrete steps with increasing difficulty,3 and “repetitive task practice.” Repetitive task practice involves performing a target movement in functional play or in relation to other movements.3–6 Through these types of intense practice, increased use of the more affected limb is argued to “induce expansion of the contralateral cortical area controlling movement of the more affected limb” and recruit new ipsilateral areas.3
The results of randomized controlled trials on CIMT in adults with mild to severe chronic strokes reveal significantly reduced motor deficits, with retention of therapeutic gains reported 2 years postintervention.7 Research now focuses on the use of CIMT in treating children with CP5,6,8,9; however, few randomized controlled trials exist.8,9
The majority of research concentrates on children with hemiplegic CP with primarily upper extremity (UE) involvement5,6,8,9 and rarely document how CIMT of the UE affects lower extremity (LE) function in children with CP.10 This article assesses the assumption that any changes in functional use of the UE will affect total body function, particularly if CIMT using a cast is implemented when the patient is working toward improvements in gross motor function. Since most studies concentrate on the results of fine motor and UE interventions during CIMT, physical therapists implementing CIMT for the UE while doing gross motor interventions for patients with LE involvement may have difficulty choosing the most beneficial gross motor interventions based on current research. Therefore, the purpose of this case report was to describe physical therapy (PT) interventions and gross motor outcomes resulting from a 3-week course of CIMT for a 10-year-old boy with spastic triplegia.
DESCRIPTION OF THE CASE
Patient History and Review of Systems
The patient (T.K.) was a 10-year-old boy, who was right-handed. He was born preterm at 23 weeks' gestation and sustained a grade III intraventricular hemorrhage (>50% involvement of ventricles or ventricle distention) at birth resulting in triplegic CP, involving the left UE and both LEs. T.K.'s extensive surgical history included multiple shunt revisions due to infection, laser surgery for retinopathy of prematurity, surgery for esotropia, dorsal rhizotomy, and Botox injections.
His physician referred him to PT and occupational therapy (OT) to evaluate the appropriateness of beginning a CIMT program (Table 1). Seven months prior to this evaluation, T.K. received Botox injections and then had 7 months of outpatient therapy. One month prior to the evaluation, T.K. received another set of injections in specific muscles of the left UE (biceps and pronator teres) and muscles of both LEs (rectus femoris, hamstrings, gastrocnemius, and tibialis posterior). Botox injections for spastic muscles were customary prior to the start of this particular CIMT program, to try and achieve results more efficiently. At the time of evaluation, T.K. did not take any medications. Functionally, he walked short distances with supervision, using a reverse walker and bilateral hinged ankle foot orthoses with plantar flexion stops. He transferred sit to stand with UE support on walker with close contact guard assist but required minimal assist to stabilize walker (refer to footnote a in Appendix 1 for operational definitions).
The therapists performed a quick review of systems based on criteria in The Guide to Physical Therapist Practice.11 T.K. was alert and oriented to person, place, and time. He attended elementary school where he received school-based OT services weekly for educational-related concerns. Recent medical reports noted no cardiopulmonary or integumentary impairments. His main neuromuscular impairments included increased tone and spasticity throughout the left extremities and the right LE, impaired motor control, and impaired sitting and standing balance. According to the medical record, T.K.'s height, weight, and body mass index were 121.0 cm, 27.1 kg, and 18.2 kg/m2, respectively. The musculoskeletal assessment revealed decreased range of motion (ROM) of involved extremities, and he exhibited functional strength on a gross assessment. T.K.'s function was limited by these impairments and they affected his safety during transfers, activities of daily living (ADL), and gait. Refer to Tables 2 and 3 and Appendix 1 for more details about T.K.'s baseline functional abilities and impairments.
Since T.K. had most difficulty maintaining positions such as sitting, crawling, kneeling, standing, and walking while playing, transferring, and performing self-care activities, the Gross Motor Function Measure (GMFM-88)12 and the Functional Independence Measure for Children (WeeFIM)13 were selected as functional outcome measures to evaluate his functional abilities pretreatment and posttreatment.
The GMFM-88 is a criterion-referenced and validated measure that assesses gross motor function of children with CP in 5 different positions or “dimensions.”12 The GMFM-88 was chosen instead of the GMFM-66, because the GMFM-66 has not been validated in children using assistive or orthotic devices, which the patient used on allowed items for safety.12
The WeeFIM was selected because it assesses not only mobility but also self-care abilities, as well as communication, and social cognition. The WeeFIM is used by multiple disciplines to determine functional independence of children with disabilities based on the amount of assistance needed to perform basic daily activities.13
Goniometric measurements, based on the American Academy of Orthopedic Surgeons normative ranges,14 were selected to measure T.K.'s active and passive ROM. Mutlu et al15 revealed moderate to high intra- and interrater reliability when measuring LE passive ROM in children with spastic diplegia, with more experienced raters demonstrating higher reliability. Generally, coefficients ranging from 0.50 to 0.75 represent moderate reliability and coefficients greater than 0.75 indicate good reliability.16
The patient's muscle tone and spasticity throughout the involved extremities were rated according to the widely used Modified Ashworth Scale.9,17
A physical therapist and an occupational therapist, with 3 and 21 years of experience, respectively, performed impairment-based tests and measures (Table 2) and a third-year physical therapist student completed the functional outcome measures (Table 3). At the clinic where the CIMT program took place, customarily the physical therapist assessed LE strength, ROM, and baseline function with transfers and gait, and the occupational therapist assessed UE strength, ROM, and baseline function with ADL and self-care. A physical therapist student implemented the functional outcome measures not only for educational purposes but also to objectively measure functional improvements as a result of CIMT.
T.K. demonstrated most difficulty with the last 3 dimensions of the GMFM-88 (crawling/kneeling, standing, walking/running/jumping), primarily attributed to his strength and motor control and resultant poor static and dynamic balance and his inability to perform higher-level tasks, such as running (Table 3). According to WeeFIM norms,18 he demonstrated self-care abilities representative of children aged 57 to 59 months, mobility of children younger than 36 months, and cognitive abilities of children aged 54 to 56 months. His WeeFIM total of 94/126 indicated that he displayed the functional abilities of children aged 42 to 44 months.18 Table 3 lists the results of the functional outcome measures, and Appendix 1 describes his functional abilities at initial examination in greater detail.
In terms of posture, T.K. preferred to keep his body weight on the right side in sitting and standing positions with his walker. He sat with a rounded back and posterior pelvic tilt and held his left arm in typical flexor posturing, with elbow flexion, pronation, and left thumb adducted into palm. Table 2 lists the joints displaying limited ROM, with all other joints within functional limits. The left supinator, bilateral gastrocnemius, and quadriceps muscles had the greatest spasticity, with Modified Ashworth Scale scores of 3 (Table 2).
Because of T.K.'s difficulty isolating specific muscle groups, gross UE and LE strength was assessed functionally rather than through formal manual muscle testing. He required moderate to maximal assist to scoot on a mat and total assist to stand without UE support and demonstrated no weight bearing (WB) through his left UE in side sitting or quadruped. In general, T.K. could take only minimal resistance applied to his UE and LEs and did not have full ROM; therefore, his affected extremities would be rated poor 2/5, according to testing guidelines.19
T.K.'s classification using The Guide to Physical Therapist Practice11 was Practice Pattern 5C: impaired motor function and sensory integrity associated with nonprogressive disorders of the central nervous system-–congenital origin or acquired in infancy or childhood. T.K.'s prognosis was estimated to be good based on the positive outcomes of previous research on UE CIMT.3–9 A pilot study by Zipp and Winning10 lent some support to the prediction that T.K.'s LE function would also improve. Those authors reported positive secondary effects of a 3-week course of CIMT on gait parameters, balance, and functional locomotor mobility in children with CP aged 4 to 12 years. T.K. and his mother shared functional goals of improving his ability to use his involved extremities during self-care activities, such as dressing and bathing, and improving his ability to participate in leisure activities, such as adaptive baseball.
Description of Interventions
The interventions chosen were based on T.K.'s examination findings, previous CIMT research, and the individual goals and motivational interests of the patient. The Figure illustrates a broad timeline of the plan of care. T.K. participated in 2 OT and PT sessions per week for 2 weeks at an outpatient pediatric clinic to prepare him for the CIMT program. The interventions used during this initial phase of treatment consisted of the same interventions used during CIMT; however, no restraint was worn at this time. At the start of the third week, the occupational therapist fabricated a lightweight, fiberglass cast, which extended below the right elbow to the fingers, with a thumbhole. Three days later, the occupational therapist bivalved the cast and the dorsal aspect was secured with Velcro straps, to allow for easy removal to check T.K.'s skin condition and perform ROM. He wore the cast restraint during treatment sessions and 90% of waking hours. He participated in OT 3 days per week but continued with PT 2 days per week, and he started therapeutic recreation (TR) 2 days per week.
Although the 3 disciplines (OT, PT, and TR) focused on different areas of treatment, they shared a common goal of increasing the patient's overall function through play and functional activities. The 9 OT sessions focused on fine motor activities and function of the left UE, consisting of UE stretches, WB exercises, grasping, pinching and releasing objects, scooping, ADL, and board games. Occupational therapy focused on fine motor movements with self-care activities to work toward T.K.'s goals. The 6 TR sessions incorporated games using the left hand, small group therapy activities, crafts, cooking, and self-feeding. The 6 PT sessions focused on gross motor activities (eg, weight shifting games in side-sitting, quadruped, tailor sitting, and standing) and improving function of the lower extremities, with the goal of improving his balance and gait to increase his participation in adaptive baseball.
Appendix 2 lists the PT interventions implemented with examples of activities and the rationale for each intervention. The therapists rarely used formal shaping techniques.3 While difficult tasks were broken down into smaller steps, the refinement of each step was not necessarily reinforced, to encourage T.K, to “problem-solve” his own movement strategies. Motor learning models emphasize that self-generated, voluntary actions should be used and repeated in motivational settings and difficulty of the task kept at an appropriate level for successful learning.5 T.K. mainly performed repetitive-task practice,6 in which particular movements were continuously repeated and incorporated in functional or play activities, allowing T.K. to discover new movement strategies. The therapists used verbal encouragement, praise, occasional snacks, and games as positive reinforcement and incentives to continue activities but allowed short rest breaks as needed if the quality of movement declined. All disciplines emphasized compliance with the home exercise program (HEP), consisting of functional play activities and stretches, to encourage carryover of gains made during treatment sessions. T.K. and his parents reported compliance with the HEP throughout treatment. After completion of the 3-week CIMT program, T.K. and his parents were instructed to perform the HEP at least 2 hours, 2 days per week, and wear the restraint 90% of waking hours, 1 day per week.
Description of Outcomes
Appendix 1, Table 2, and Table 3 list the patient's posttreatment outcomes following CIMT. Although T.K. showed some improvements in fine motor function of the left hand, after initiating CIMT he made remarkable progress in his ability to maintain grip on his walker and stability in sitting and quadruped positions. He transferred with less assist, which appeared to be associated with his increased ability to maintain left UE and LE WB and shift weight to his left side (Appendix 1,; Table 3). T.K.'s mean GMFM-88 score changed from 44.55% to 62.35%, with an increased gross score of 8.6 points, displaying greatest improvements in the lying, sitting, and crawling/kneeling categories. T.K. improved on 1 WeeFIM item (Transfers: Chair/Wheelchair), which resulted in no change in self-care, mobility, or cognitive age norms from the initial evaluation. His WeeFIM total of 95/126 indicated that his functional abilities improved from a 42- to 44-month level to about a 45-month level.18 T.K.'s functional goals were partially met. Although there was no change in WeeFIM self-care abilities, T.K.'s mother reported that he was more actively participating in self-care activities (dressing and bathing). T.K. was also actively participating in adaptive baseball by the end of this therapy with assistance to bat.
T.K. demonstrated improved active ROM in left shoulder flexion, shoulder abduction, supination, and thumb extension, and improved passive ROM in left supination, bilateral knee extension, and ankle dorsiflexion. He exhibited no change in muscle tone postintervention. While he did not achieve complete independence with all self-care and leisure activities, both T.K. and his parents expressed satisfaction with the functional gains and goals achieved.
Current CIMT research reports improved UE motor function of children with hemiplegic CP.5,6,8,9 However, the paucity of studies exploring how UE CIMT affects LE function and reporting the details of gross motor interventions points to the need for further research. This case report described PT interventions used and gross motor outcomes achieved during a 3-week course of CIMT for a 10-year-old boy with spastic triplegia.
The functional outcome measures yielded differing results in terms of functional improvements after treatment. While T.K. improved 17.8% and 8.6 total points on the GMFM-88, he improved only 1 point on the WeeFIM. One possible explanation for this discrepancy may be that the GMFM-88 is more responsive to change over a shorter amount of time than the WeeFIM. A study assessing the responsiveness to change of the GMFM-88 found a group of children with CP changed 6.2 points over 6 months,12 whereas T.K. changed 8.6 points over 5 weeks.
T.K. did not demonstrate as significant functional improvements on the WeeFIM. Although the WeeFIM is designed to objectively score items using an ordinal scale, scoring is actually quite subjective since scores depend on the caregiver's perception of the amount of assistance provided. The WeeFIM also takes into account communication and social cognition, which would likely not be affected by CIMT.
One of T.K.'s most noteworthy functional gains included his ability to demonstrate equal WB through both the upper and lower extremities and his ability to shift weight to his involved side in various developmental positions. Since these improvements were not observed until after the initiation of CIMT, the cast worn on his right UE may have forced him to shift and bear weight on the left UE and LE due to his inability to grip the walker with his right hand. The increased “forced use” and proprioceptive input to the left side may have enhanced T.K.'s perceptual awareness of his involved side in other developmental positions.
Another possible explanation for this improvement in function may be that during “repetitive task practice,” T.K. was forced to “problem-solve” and perform different movement strategies to achieve successful outcomes.5 For example, while repetitively popping bags of air with his feet to facilitate weight shifts, T.K. had to determine how to keep his constrained right UE on the walker and this forced him to put weight through the left UE to help balance in standing.
T.K. showed minimal to no changes in joint flexibility and muscle tone. Although he demonstrated some improvements in joint ROM (Table 2), the changes may be due to measurement error. McDowell et al20 reported same-day and different-day measurement error of ±10° to 14° for hip abduction, internal rotation, and foot/thigh angles, and different-day error ranged from ±18° to 28° for biarticular muscles of children with CP. Their study found that the main sources of error were systematic differences between days, child-assessor variability, changes in patient status, and residual error.20 While the passive ROM of his LEs improved, it remains unknown whether the improvements were due to stretching alone or his improved ability to bear weight through his LEs.
T.K. also received Botox injections about 1 month prior to treatment to help increase ROM and decrease tone; therefore, the ROM measurements should be interpreted with caution. Neither Botox nor the treatment interventions implemented improved muscle tone for this patient.
Because of the nature of case reports, a cause-and-effect relationship cannot be established between CIMT and the patient's functional gains. Although effort was employed to provide the intervention plan in detail, variations among therapists and patients may result in different outcomes. Since the occupational therapist assessed ROM and strength of the UE and the physical therapist assessed the LE, this may have affected interrater reliability of ROM and strength measurements. In addition, T.K. did not receive an equal number of therapy sessions among the 3 disciplines; therefore, one cannot distinguish if the one therapy discipline produced a greater influence on the results. Finally, we allowed the patient to use his walker and ankle foot orthoses during administration of the GMFM-88. Although GMFM-88 authors recommend testing with and without assistive devices,12 the therapists determined that testing without the patient's assistive devices compromised his safety. As a result, GMFM-88 scores may represent an overestimation of T.K.'s actual abilities in the standing and walking/running/jogging categories.
The need for more rigorous, comprehensive research of CIMT for children remains. Since few randomized control trials of CIMT with children as subjects have been reported,8,9 future research should focus on conducting controlled clinical trials using larger samples of children. Future research may also include children with more LE involvement and further study the secondary effects of CIMT on LE gross motor function.
The author thanks the child who participated in this study and his family; Janet Santos, OTR, Kirsten Hallstrom, PT, and Kristen Klompstra, PT, for completing assessments and treatments; John Hollman, PT, PhD, and Kendra VanWasshenova, PT, DPT, for their advice and review of the manuscript.
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activities of daily living; cerebral palsy/triplegia; child; exercise therapy/methods; human; male; motor skills; outcome measures; physical therapy
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