Targeted Physical Therapy Combined with Spasticity Management Changes Motor Development Trajectory for a 2-Year-Old with Cerebral Palsy

Abstract

Therapies for children with cerebral palsy (CP) often fail to address essential components of early rehabilitation: intensity, child initiation, and an embodied approach. Sitting Together And Reaching To Play (START-Play) addresses these issues while incorporating intensive family involvement to maximize therapeutic dosage. While START-Play was developed and tested on children aged 7-16 months with motor delays, the theoretical construct can be applied to intervention in children of broader ages and skills levels. This study quantifies the impact of a broader START-Play intervention combined with Botulinum toxin-A (BoNT-A) and phenol on the developmental trajectory of a 24 month-old child with bilateral spastic CP. In this AB +1 study, A consisted of multiple baseline assessments with the Gross Motor Function Measure-66 and the Assessment of Problem Solving in Play. The research participant demonstrated a stable baseline during A and changes in response to the combination of BoNT-A/phenol and 12 START-Play sessions during B, surpassing the minimal clinically important difference on the Gross Motor Function Measure-66. The follow-up data point (+1) was completed after a second round of BoNT-A/phenol injections. While the findings suggest the participant improved his gross motor skills with BoNT-A/phenol and START-Play, further research is needed to generalize these findings.

Keywords: Botulinum toxin-A; cerebral palsy; early intervention; phenol; physical therapy.

Figure 1

Bayley Scales of Infant Development-Third Edition Changes from 14 to 24 months Chronological Age. Changes in Bayley Scales of Infant Development, 3rd Edition, scores over 10 months as assessed at 14 and 24 months chronological age in NICU follow up clinic prior to study enrollment. mo = months, d = days. The scaled score population mean is 10 with a standard deviation equal to +/−3 [38].

Figure 2

Sitting Together And Reaching To Play (START-Play) Intervention. When S played with a toy house, he needed to problem solve the best solution for play with the smaller toy house pieces. He could decide if (A) he wanted to transition from an upright posture to a lower one to look under the bench for hand-held toys, (B) he wanted to cruise around the bench to access a different affordance of the toy, or (C) he wanted to make a postural adjustment, such as transitioning from heel sitting to tall kneeling, to better visually engage with the toy house to manipulate and role play a story with the smaller toy pieces (affordance). S chose the toy house to play with which provided a variety of combined motor and problem-solving opportunities. He self-selected the best motor solution for the play task with his parent or therapist simultaneously supporting the “just right” level of challenge via environment and task modifications.

Figure 3

Gross Motor Function Measure Across the AB +1 Phases. Scores of the Gross Motor Function Measure (GMFM-66) across the AB +1 phases as plotted in reference to the +/− 2 standard deviation band (shaded in grey). A = baseline data collection with no intervention, B = Botulinum toxin A/phenol and START-Play physical therapy intervention provided for 12 sessions, Post AB = one data point collected via telemedicine (+1) due to Covid-19 restrictions. Points 1–11 denote GMFM-66 testing points. Bolded, black, vertical lines denote Botulinum toxin-A/phenol injections. The bolded, red vertical line denotes treatment ending due to the Covid-19 pandemic.

Figure 4

Assessment of Problem Solving in Play Across the AB +1 Phases. Scores of Assessment of Problem Solving in Play (APSP) (reported in frequency APSP/minute) across the AB +1 phases as plotted in reference to the grey shaded +/− 2 standard deviation band. A = baseline data collection with no intervention, B = Botulinum toxin A/phenol and START-Play physical therapy intervention provided during data collection, Post AB = data point 11 collected via telemedicine (+1). Points 2–9 and point 11 represent administered APSP data points. Points 1, 7, 8, and 10 were omitted from the figure as these data collection days did not include APSP testing due to testing site or child-related limitations. Bolded, black, vertical lines denote Botulinum toxin-A/phenol injections. The bolded, red vertical line denotes treatment ending due to the Covid-19 pandemic.