Coordination, Communication, and Documentation: Baby W's team included neonatologists and neonatal nurse practitioners, nurses, physical therapists, nutritionists, respiratory therapists, and lactation consultants. To assist with the coordination of care and communication across Baby W's NICU team, written bedside recommendations were hung on his isolette. Regarding compensatory strategies during Baby W's stay in the NICU, a sign was posted at the bedside recommending a developmental diaper change16,17 (eg, in side-lying position or supported-supine position with his arms swaddled and hands in midline and avoiding excessive leg lifting), a swaddle bath18 (ie, maintaining flexed, midline position with a blanket), and a decreased stimulation19–21 (eg, reducing light with an eye cover and speaking softly) when performing care to avoid loss of self-regulation. In addition, the protocol for “passive resistive” range of motion and joint compression22,23 was also posted, with the recommendation to complete these activities once daily during Baby W's care. Finally, PT recommendations for Baby W's oral motor development (eg, pacifier dips and syringe feedings)24 were posted when appropriate.
To facilitate communication among team members, the physical therapist updated bedside recommendations as Baby W's PT treatments progressed (see Tables 1 and 2). In addition, the physical therapist participated in biweekly discharge and feeding rounds to discuss Baby W's progress and to update his plan of care with other members of his team.
Parent education and involvement in therapy sessions occurred throughout Baby W's stay, and they were a part of the PT plan of care. Parental involvement included activities such as promoting kangaroo care, holding Baby W at the bedside, partnering with parents for Baby W's sensory activities, and continuous parent education regarding strategies to promote Baby W's development and the role of PT in Baby W's NICU care. At 36 weeks gestation, the physical therapist initiated a discharge plan that included parental education about developmental milestones and newborn neurobehavior related to crying and sleeping,25 a home program to promote age-appropriate sensory, self-regulatory, social interaction and feeding skills.26,27
Positioning: To compensate for decreased flexor tone, the physical therapist recommended flexion positions using boundaries to keep hands in midline, head near midline, legs flexed, and trunk flexed.7,18,28,29 Also, the physical therapist implemented additional positioning aids (eg, gel cushions) to promote more optimal cranial molding7 and prevent plagiocephaly and torticollis. The positional boundaries were also used to assist with age-appropriate responses to sensory stimuli (ie, the boundaries provide proprioceptive input).
Joint Range of Motion: “Passive resistive” range-of-motion exercises and joint compression were performed for 5 to 10 minutes daily to encourage muscle development and bone strength to prevent fractures, contractures, and to encourage movement.22,23,30
Therapeutic Neuromotor Handling: The physical therapist incorporated several therapeutic neuromotor activities into Baby W's PT plan of care, including “passive resistive” range of motion,22,23 massage,31,32 and activities to promote active flexion movements of the upper and lower extremities and trunk.
The physical therapist introduced “passive resistive” range of motion and joint compression, beginning at 28 weeks GA (Tables 1 and 2). In addition, PT treatment sessions promoted active flexion movement patterns26 and later included a massage protocol31 (30 weeks GA; see Tables 1 and 2) to reduce stress behaviors, increase relaxation, and encourage flexion activities. Specifically, as per previously published protocol,31 Baby W's mother or a member of his primary care team, guided by the physical therapist, performed massage for 15 minutes, 3 times daily for 5 consecutive days. At the end of the 5 days, consistent with previously published results, Baby W demonstrated less stress neurobehavior and, therefore, the massage protocol continued until Baby W's discharge.
In addition, Baby W's physical therapist incorporated activities to promote active flexion of the extremities (32 weeks GA; see Tables 1 and 2), in particular the lower extremities. Also, the physical therapist discontinued passive flexion activities (described earlier in this section). This decision was made to correspond to the neurodevelopmental progression of active flexion emerging in the lower extremities at around 32 weeks GA.33 Following the introduction of active lower extremity flexion activities, the physical therapist added activities to promote more active flexion of the upper extremities and emergence of active flexion of the head, neck and trunk (34 weeks GA; see Tables 1 and 2). Similar to the progression described for the lower extremities, this decision was made to follow the neurodevelopmental progression of active flexion emerging in the trunk at about 34 to 35 weeks GA.33
Multimodal Sensory Stimulation: The primary goals of the sensory activities were to (1) mitigate stressful environmental stimuli and (2) promote age-appropriate sensory responses. The former goal was achieved through this NICU's lighting policies (see Appendix 2) and PT recommendations placed at Baby W's bedside (described earlier). To promote age-appropriate sensory skills, specific sensory exercises (eg, facilitating hands to midline and mouth,26,34 tactile exploration of face as tolerated, opportunities for nonnutritive sucking,35 and facilitation of tucking movements16 [29 weeks GA; see Tables 1 and 2]) were used in all of the weekly treatments in an effort to assist with self-calming and reorganization.
Support of Oral Feeding: To address Baby W's immature oral feeding skills and offer him opportunities for successful, pleasant oral feeding experiences, the physical therapist introduced several oral motor activities (29-31 weeks GA; see Tables 1 and 2), such as hands to mouth and nonnutritive sucking35 during gavage feedings. As Baby W's oral motor skills improved, the physical therapist encouraged Baby W to engage in nutritive sucking with either a pacifier dipped in breast milk or small boluses (ie, 2 mL) of breast milk introduced into the front of the mouth using a syringe (31-32 weeks GA; see Tables 1 and 2). Because of Baby W's oral feeding immaturity, his primary care team decided to wait to begin bottle-feeding with Baby W until breastfeeding was established and Baby W was deemed by the physical therapist to be developmentally ready to bottle-feed (32-34 weeks GA).36 When bottle-feeding commenced, the physical therapist initiated pacing techniques37 in combination with the use of a slow-flow nipple to reduce the fluid rate from the bottle into Baby W's mouth to assist with development of age–appropriate suck-swallow-breathe coordination.
Summary of the Progression of Physical Therapy Interventions: Baby W's PT sessions progressed from 15 to 20 minutes per session 3 to 4 times per week to 5 times per week (Tables 1 and 2). The initial frequency and intensity were based on his neurobehavioral immaturity and poor tolerance for handling. To this end, during the initial PT sessions, Baby W was seen by physical therapist inside his isolette to minimize environmental stimulation and maximize his success at self-regulation. Physical therapy intervention focused on parent and staff education, positioning, and gentle encouragement of flexion patterns to promote self-regulation during routine care. As Baby W's repertoire of self-regulatory skills improved, PT treatment frequency and intensity increased to match his developmental maturity and address new activities and social participation.
During this time (around 34-35 weeks GA), the majority of the PT sessions were conducted outside the isolette as tolerated. On days when Baby W was demonstrating more fragility and difficulty with self-regulation, PT sessions occurred inside the isolette to mitigate environmental stimulation and task requirements to promote Baby W's self-regulatory capacities. The PT plan of care between 32 and 36 weeks GA focused on flexion movement activities in the supine position, introduction of the supported-upright position, and oral motor activities to support the development of bottle-feeding. Physical therapy sessions at the “bedside” also allowed for greater social interaction activities, including visual and auditory fixation and tracking with decreasing positional supports and environmental modifications. Thus, within and across PT treatments, the physical therapist constantly monitored Baby W's neurobehavioral cues and neurodevelopmental level to guide progression of postural and movement demands, oral feeding, and social interaction.
Environmental Modifications: The NICU where Baby W was receiving care has policies for positioning and lighting, which were used with Baby W. A detailed explanation of this NIUC's lighting and positioning policies are given in the Appendices.
DESCRIPTION OF OUTCOMES
Reexamination of Challenges
A reexamination occurred 5 days before discharge. In addition to the physical therapist reexamination of Baby W's movement and self-regulation, the physical therapist also used the Morgan Neonatal Neurobehavioral Examination (MNNE)38 to evaluate Baby W's neurodevelopmental level. The MNNE is a routinely used impairment-level examination used to identify asymmetries, abnormal tone, and atypical behavioral patterns and reflexes.
This patient was discharged from the NICU to home at 36 weeks 5 days' GA, which was considered an early discharge.34 He was given a referral to early intervention PT on the basis of his eligibility for early intervention services due to his history of preterm birth.39 His main goals in the NICU were met at discharge, with the exception of asymmetry in his neck and left leg extension.
Baby W began PT through the part C early intervention program15 at 38 weeks GA in his home 1 time weekly for 6 weeks, during which time he met all milestones expected of him (on the basis of the early intervention provider notes shared by his family). At 6 weeks following the start of early intervention, he was reexamined and his PT session frequency was decreased to every other week for an additional 6 weeks since he was no longer 25% or more developmentally delayed. At 12 weeks post-NICU discharge, he was placed on hold or temporarily discharged from early intervention home care, having obtained age-appropriate milestones for his adjusted age.
This case report describes the retrospective application of the neonatal PT clinical decision-making algorithm6 to the PT treatment in an urban level III NICU of a little boy born at 26 weeks GA. Several lessons were learned.
In terms of the specific processes of the decision-making algorithm, some steps were more readily implemented than others. For example, neonatal physical therapists in this NICU typically take a patient history, perform an initial observation, and conduct a PT examination. However, when comparing the treatment of this baby in the case report, along with the current PT practice in the NICU, with the recommendations for implementing additional diagnostic procedures, areas for care improvement were revealed. For example, reflecting on the MNNE, there is minimal research on the benefits of using this examination as compared with other examinations. In the literature, popular developmental tests include the Assessment of Preterm Infants' Behavior (APIB),40 and the Test of Infant Motor Performance (TIMP).41 However, compared with the MNNE, the APIB and the TIMP are designed for experienced clinicians. Moreover, these tools require specialized training, and for the APIB specifically, clinicians must be trained to become reliable in administration. Therefore, in accordance with the clinical decision-making algorithm,6 further investigation would be beneficial to determine whether one of these tools would be more useful for understanding the infant's limitations and the need for PT.
In the direct intervention step of the decision-making algorithm,6 most of the PT interventions implemented in this NICU, both generally and specifically for Baby W, were supported by evidence. For example, the benefits of developmentally supportive positioning and oral motor or feeding techniques, kangaroo care, infant massage, and parent education have a strong evidence base.3,34,35,42 Other PT direct interventions implemented in Baby W's PT plan of care were less well supported by the clinical decision-making algorithm. For example, the efficacy of “passive resistive” exercise and joint compression to support bone and muscle development is unclear.22,23,42 There are several articles that support the use of this exercise technique in the NICU, secondary to the bone and muscular benefits derived.22,23 However, recently, a Cochrane review30 concluded that the evidence supporting “passive resistive” range of motion for increasing bone density and weight gain was insufficient because most studies contained small sample and effect sizes, suggesting no difference in bone density at 12 months of age. Following this case report, the practice of “passive resistive” range of motion and joint compression has been reevaluated, and the PT team has decided to discontinue the general use of the “passive resistive” range of motion and joint compression for all infants born preterm and instead use it only on a subset of infants cared for in the NICU on a short-term basis.
Reflecting on the extent to which the NICU policies facilitated implementing the clinical decision-making algorithm, several lessons were learned. This NICU has policies considered developmentally supportive for cycled lighting, promotion of kangaroo care, and developmentally supportive feeding (eg, promoting breastfeeding and waiting to initiate bottle-feeding until the infant is developmentally ready).
One challenge to initiating the clinical decision-making algorithm was determining the frequency and intensity of PT treatment. There is a debate on the frequency of therapy in the NICU,6,34 although given the successful outcomes in this patient, the frequency will most likely need to be determined by a skilled clinician and adapted to each patient. There is conflicting evidence on when to begin therapy in the NICU for those supporters of hands-on treatment. The ranges include postnatal day 5 to 7 for “passive resistive” range of motion23 to obtain maximal benefit, 28 to 33 weeks GA for a Newborn Individualized Developmental Care and Assessment Program (NIDCAP) assessment,34,43 33 weeks GA to begin flexion exercises,26 and 35 weeks GA for those infants with asymmetrical or atypical development with a high-risk birth history.26 More evidence needs to be collected through a blinded, randomized study with key outcomes such as length of stay or long-term disability to determine the most effective course of treatment. This patient began therapy when he was stable, was monitored throughout the course of the treatment to ensure safety, and progressed through an exercise program as tolerated. He also demonstrated good progression of his milestones up through 6 months chronological age, considering his high-risk birth.
Physical therapy frequency and intensity includes consideration of when PT should be initiated for which groups of infants. Reflection on Baby W's reason for referral to PT (ie, intraventricular hemorrhage and tone abnormalities) and when PT was initiated (ie, day 18 of life) brings to light a need for further neonatal PT program development. For example, the NICU multidisciplinary care team (eg, medicine, nursing, rehabilitation, nutrition, respiratory therapy, and lactation consultation) would benefit from clearly defined PT referral criteria. For example, some NICUs have a “blanket” referral for PT for all infants born younger than 32 or 28 weeks GA (ie, to coincide with state part C eligibility criteria and local policy), whereas other NICUs have stricter protocols for determining appropriateness of an NICU PT referral. The application of the clinical decision-making algorithm highlighted the need for a matrix justifying frequency and intensity of PT treatment on the basis of the available evidence.
An additional challenge to implementing the clinical decision-making algorithm was writing PT goals that most appropriately capture the family's strengths, priorities, and concerns while still meeting rehabilitation departmental guidelines for goal-writing in an acute care clinical setting.
Finally, this case study was conducted in an academic hospital where a neonatal PT program exists. Despite the strengths of this program, this case study outlined several areas for improvement. Indeed, previous research suggests that only 2 of 3 NICUs in this country have similar neonatal developmental and/or therapeutic programs, and of those, fewer than 1 of 3 have a sufficient operating budget.44 Moreover, recent evidence suggests that more frequent, higher-quality developmental and therapeutic care practices are associated with improved neurobehavioral outcomes of infants born preterm.45 Thus, the lessons learned in the application of the neonatal PT clinical decision-making algorithm in this case study, combined with recent evidence suggesting both the variability and importance of developmental and therapeutic programming in the NICU, underscores the utility and clinical relevance of this case study. Physical therapists who work in an NICU where the neonatal PT clinical decision-making algorithm is not being used should pay special attention to this case study and conduct similar endeavors to improve the quality of patient care.
As the field of neonatal PT grows, evidenced by the presence and growth of neonatal PT fellowship programs, along with growth in developmental science and outcomes research for infants at high risk, it will be imperative for physical therapists who treat in the NICU to participate in NICU quality improvement activities (eg, creating evidence-based protocols for initiating and progressing infants in the NICU, developing evidence-based clinical pathways or care plans, and documenting outcomes of infants who receive PT). This case report highlights the utility of the NICU clinical decision-making algorithm for not only assisting with developing an evidence-based PT plan of care for one infant at high-risk but also highlighting NICU programmatic and policy strengths and areas for improvement. The NICU developmental and therapeutic teams should conduct similar endeavors to ensure that they are providing the highest-quality therapeutic interventions for this vulnerable population.
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case study; infant/premature; male; neonatal intensive care unit; physical therapy modalities; practice guidelines as topic; quality of health care© 2013 Lippincott Williams & Wilkins, Inc.