The child and family’s desires and articulated needs as well as the results of the examination are considered to formulate the evaluation report. The physical therapy evaluation reflects the examiner’s hypotheses for the basis of the child and family’s needs related to the child’s current movement problems. The physical therapy diagnosis is the primary movement problem that has brought the child/family to seek physical therapy services and is the focus of the planned episode of care. In the PTCMR-SD), the physical therapy diagnosis is difficulty with functional mobility.
Developing a plan of care is a complex problem solving activity, which requires integration of examination and evaluation findings and child and family goals. The physical therapist should incorporate components of the ICF enablement model when developing a plan of care. Primary outcomes should include functional activities and participation in life’s roles.
Limited research findings are available to determine the optimal amount of intervention required for the best/most effective functional outcomes for infants, children and adolescents with cerebral palsy.54,55 Bower and colleagues56–58 have shown that short term (two to three weeks) intensive intervention does create short-term benefits in motor function, however the differences across a six month period between a higher (five times/week, 60 minute sessions) and a lower intensity of therapy were not significantly different. Recently, Trahan and Malouin59 reported on the use of intermittent intensive intervention: four times per week for four weeks, followed by eight weeks of no therapy. That frequency of therapy was shown to be feasible and led to improvements in motor function in children with cerebral palsy in Gross Motor Function Classification Systems Levels IV and V.59 Although results from their study cannot be generalized to children with spastic diplegia, they do provide some support for a variety of service delivery models. More research is needed in the area of intensity of services. The frequency and duration of physical therapy services noted below are based on current common practice in the USA.
Functional outcomes for children will vary greatly depending on the severity of spastic diplegia. Severity may be influenced by the child’s muscle strength, sensory systems compromise, spasticity, cognitive abilities, and medical status. Several researchers have studied the prediction of functional outcomes for children with cerebral palsy. All of the studies included some children with spastic diplegia. Montgomery65 reviewed several of these studies66–71 and reported that persistence of primitive reflexes, ability to maintain sitting, type of cerebral palsy, age/maturation and level of cognition influenced ambulation potential. Based on outcomes from three studies,67,70,72 Montgomery65 reported that 86-90% children with spastic diplegia achieved some form of ambulation. More recently, Wu and colleagues73 have retrospectively studied 5366 subjects with CP, 12.8% who could walk independently, and 18.4% who could walk with support. Independent predictors of walking were early motor milestones such as obtaining the ability to sit and pull to stand.
Motor Development Curves have been developed to provide prognostic information about functional ability in children with cerebral palsy.74 Although these curves are not specific for children with spastic diplegia, they still provide useful information. Longitudinal observations of motor ability included the ability to hold the head upright, maintain unsupported sitting, walk 10 steps unsupported and walk down four steps. The Gross Motor Functional Classification System (GMFCS)75 was used to create the motor development curves. The GMFCS has five levels. Most children with spastic diplegia would be classified as Level I, II or III. Children classified in Level I walk without restrictions and have limitations in advanced gross motor skills. Level II is defined as walking without assistive devices and having limitations walking outdoors and in the community. Level III is defined as walking with assistive mobility devices and having limitations walking outdoors and in the community. Children classified in Level IV have self-mobility limitations and are transported or use power mobility in the community. Level V includes children who are dependent for mobility. The GMFCS has also been shown to correlate well with the Gross Motor Function Measure (GMFM), the Pediatric Orthopedic Data Collection Instrument, temporal-spatial gait parameters, and oxygen cost assessments.76
These are processes intended to ensure high quality of care. They include working and communicating with all parties involved with the child and family and documenting services and care provided.8
This involves informing, educating and training children, youth, families and caregivers for the purpose of promoting optimal care.8 Instruction may include providing information about the diagnosis of spastic diplegia, plan of care, transition from one service delivery system to another, need for a health and fitness program, and strategies to practice functional mobility during daily routines.
This involves the use of physical therapy procedures and techniques to produce an improvement in the life and function of a child or youth with spastic diplegia. Procedural interventions address a child’s limitations in body and/or environmental systems and are focused on improving functional mobility outcomes.8
Encourage youth to develop a movement practice schedule involving movement through difficult terrains, on bleachers, escalators, bus steps, in moving vehicles such as public transportation, stores and other community environments.
• Consider martial arts, adapted sports programs, bicycle riding, track exercise, swimming and aquatic gait exercise, hippotherapy or recreational horseback riding.
Children with cerebral palsy may have compromised cardiopulmonary systems. Intervention strategies should include techniques to improve cardio respiratory endurance. For typically developing children, 30 to 60 minutes of moderate to vigorous intensity physical activity, three to six times per week is recommended for overall health benefits.61,153,154 Children with cerebral palsy (CP) are considerably less active than their peers without disability and do not exercise at high enough intensity to increase fitness.155–157 Inactivity may be due to difficulty accessing appropriate programs or availability of programs or accessible equipment. Several randomized control trials are currently underway to assist in better determining outcomes from fitness training for children with cerebral palsy (personal communication: Fowler, EG, 2005).
For young adults with special health care needs, a primary goal of transitions in health care is to maximize function and lifelong potential by providing appropriate, uninterrupted health services.191 Physical therapists often provide health services to young adults with spastic diplegia in their transition from related services under IDEA to adult services. Physical therapists may take the role as a consultant and provide community-based interventions to facilitate a student’s transition to successful participation in the community as an adult.
Essential elements of physical therapy services during this transition process include:192
After an episode of care, a child and family should undergo a reexamination to determine if outcomes/goals have been achieved. If goals are achieved, then the child is discharged from service and may be referred to community agency/resources for recreation or other physical activity services. If goals are only partially achieved or not achieved, then the plan of care for the child and family is revised and services may be continued if appropriate.
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