A Contemporary NDT treatment approach for a toddler with ataxia post near drowning: A case report Emily Hellmuth, MS/DPTc UCSF/SFSU Graduate Program in Physical Therapy May 7, 2011 Introduction: Near Drowning • In the U.S. in 2006, ~ 4,400 people under the age of 20 hospitalized for near drowning (WHO, 2009)  Highest risk: children <4 yrs  20% suffer neurologic impairment  The total annual cost of near drownings among children ages 4 and under is approximately $3.8 billion (Foundation for Aquatic Injury Prevention, 1999) Near Drowning → Acquired Brain Injury (ABI) Moment of panic Reflex inspiration Altered breathing Fluid aspiration Breath holding Air hunger HYPOXEMIA ISCHEMIC ENCEPHALOPATHY (Wagner, 2009) ABI Presentation Impairments •Strength •ROM •Ataxia •Motor control & planning •Balance •Gait •Cognition Functional Limitations Participation Limitations •Self-help skills •Functional mobility •Social isolation •Delayed gross motor skills •Limited play with peers (Kerkering, 2006) Introduction: Ataxia • Prevalence/Incidence: ▫ Ataxia affects ~150,000 Americans (University of Chicago Department of Neurology, 2010) • Types: ▫ Inherited vs. Acquired ▫ Progressive vs. Non-Progressive • Near-drowning/ABI → acquired, nonprogressive ataxia • Presentation: ▫ Disordered balance, speech and coordination Near Drowning + Ataxia • Less typical presentation ▫ Near-drowning usually dominated by spasticity • Complicates functional mobility and limits participation • No literature describing treatment interventions for this diagnosis PT Treatment Interventions ABI Ataxia • • • • • • • • • • • • • • CIMT Casting Splinting Spasticity management Exercise PBWSTT Task-specific training (Marshall et al, 2006) Strength & endurance training Balance training Gait training Proximal stability training Coordination exercises Compensatory approaches Frenkel’s exercises (Martin et al, 2009; Kerkering, 2006) Theoretical Assumptions of Contemporary NDT (cNDT) Taskoriented approach Motor learning principles Motor Control cNDT Neuromuscular plasticity Biomechanics Nature of movement dysfunction (Howle, 2002) Introduction: cNDT Approach Facilitation • Afferent feedback • ↑ activation & stabilization • ↓ inappropriate muscle activation • Active learning → motor learning • Gradually withdrawn Taskoriented practice cNDT • Individual + Task + • Complementary Environment • Goal-oriented • Active problem-solving • Structured → varied modalities • Orthotics • Assistive devices • Weighting (Howle, 2002) Supporting Literature for cNDT Principles • Task-oriented practice ▫ Improved global function (French et al, 2008) ▫ Neuroplasticity (Gjelsvik et al, 2008; Graham et al, 2009) ▫ Relevance for TBI (Canning et al, 2003) • Motor Learning ▫ Random task-specific practice → improved motor skills in TBI (Giuffrida et al, 2009) ▫ ↑ retention with extrinsic feedback (Herbert et al, 1998; Thorpe et al, 2002; Van Vliet et at, 2006) Gaps in the Literature Diagnosis-related treatments cNDT principles • Near Drowning • Task-oriented practice • Primarily • • Acute medical management Pharmacological management of spasticity (Marshall et al, 2006) ▫ No single set of appropriate activities  Complexity of developing brain  Wide range of injury severity and recovery (Kerkering, 2006) • Ataxia ▫ Little on acquired, non-progressive ataxia in children ▫ Insufficient evidence (Martin et al, 2009) ▫ Primarily applied to children with atypical development • Motor Learning ▫ No guidelines on how to apply et al, 2009) • Contemporary NDT ▫ Little research on application ▫ No protocols for use (Levac Clinical Problem • Children need to meet motor milestones ▫ Near drowning & Ataxia → multiple impairments & functional limitations ≠ motor milestones • Lack of physical therapy standard treatment guidelines for near drowning/ABI ▫ In the absence of guidelines, function is most important • Guidelines are needed to justify treatment and help children return to play Solution The Contemporary NDT approach may provide a framework for children with ABI and ataxia to meet motor milestones and return to play with their peers Purpose • To describe a multimodal treatment approach using Contemporary NDT for a pediatric patient with ataxia post near drowning • To describe the observed changes in: ▫ ▫ ▫ ▫ Bed/floor mobility Transfers Balance Ambulation Patient Description • 2 year 7 month old boy ▫ Normally developing until this age • Happy, active, energetic • Independent for all age-appropriate mobility, ADLs and communication • Parents are separated; 2 brothers Facility and HIPPA were followed and written informed consent was obtained from the patient’s mother to use his information for this case report Current Medical History • Found floating and unresponsive in a pool with GCS of 4-5 • Lab/imaging findings consistent with anoxia • CT, MRI, EEG • Varying mental status, agitated • Transferred to rehab unit ~3 weeks after initial injury without protocol Examination: Bed/Floor Mobility • Level of Assistance ▫ Modified FIM, motor domain ▫ Scale: 1 – 7  1 = Total Assistance, 7 = Complete Independence  Psychometrics: ICC 0.96 motor domain (Hamilton, 1994) TASK SCORE Rolling Level 3: Mod A Supine <-> Sit Level 3: Mod A Quadruped Level 1: Total A Crawling Level 3: Mod A at 3 weeks Examination: Transfers • Level of Assistance ▫ Modified FIM, motor domain ▫ Scale: 1 – 7  1 = Total Assistance, 7 = Complete Independence  Psychometrics: ICC 0.96 motor domain (Hamilton, 1994) TASK SCORE Transfer in/out of stroller Level 1: Total A Sit <-> Stand Level 2: Max A Squat Recovery Level 2: Max A at week 4 Floor <-> Stand Level 2: Max A Examination: Balance • Functional classification per O’Sullivan, Schmitz ▫ Normal, good, fair, poor • Assessed with level of assistance ▫ Modified FIM, motor domain ▫ Scale: 1 – 7  1 = Total Assistance, 7 = Complete Independence  Psychometrics: ICC 0.96 motor domain (Hamilton, 1994) Balance Level of Assist Static sitting Poor, Max A (Level 2) Static standing Poor, Max A (Level 2 at week 2) Examination: Gait/Ambulation Level of Assist • Level 2: Max A Endurance • Able to ambulate 5 steps Observational Gait Analysis • Wide base of support • Abducted upper extremities • Reduced knee flexion • Ataxic gait • Psychometrics: ICC 0.63 intra‐rater reliability (Perry, 1992) Normal gait (age 2): reciprocal arm motion, increased knee flexion in early stance (POSNA, 2010) Evaluation PT Diagnosis PT Prognosis • Decreased… ▫ Functional mobility ▫ Functional strength ▫ Motor control ▫ Balance ▫ Gait • Associated with… ▫ Ataxia post near-drowning ▫ Fair-good  Young  Family support  Motivation to play and move  Submersion <10 minutes  Low initial GCS score  Lack of literature on how to reliably predict outcome Plan of Care: Treatment Delivery • Physical Therapy ▫ Two 45 minute sessions/day, M-F ▫ One 45 minute session on Saturday ▫ ~8 weeks, totaling 83 sessions • Other therapy services ▫ Occupational Therapy ▫ Speech Therapy Long-term Goals IMPAIRMENT INITIAL EXAM DISCHARGE GOAL Bed/floor mobility Total – Max A (Level 1/2) Supervision Transfers Total – Max A (Level 2) Supervision Balance Poor, Max A (Level 2) x 5 seconds Good, Supervision x 30 seconds, no UE support Ambulation Max A (Level 2) x 5 steps; ataxic with wide BOS Supervision 4x30 ft with good foot placement 95% of the time cNDT Interventions & Progressions COMPONENT INITIAL PROGRESSION Facilitation More facilitation Less facilitation Task-oriented practice Structured task & enviro Varied task & enviro Motor learning strategies Blocked practice Random practice More feedback Less feedback Splinting/Orthoses AFOs SMOs Axial weighting Torso weighting NO weighting Outcomes: Bed/Floor Mobility Outcomes: Transfers Outcomes: Balance 35 7 30 6 25 5 20 4 15 3 10 2 5 1 0 0 Initial Intermediate Terminal Rehab Length of Stay FIM/Level of Assist Time (Seconds) Standing Balance vs. Level of Assist Number of seconds Level of assist Outcomes: Ambulation 120 7 100 6 5 80 4 60 3 40 2 20 1 0 0 Initial Intermediate Terminal Rehab Length of Stay FIM/Level of Assist Distance (feet) Distance Ambulated vs. Level of Assist Distance in feet Level of assist Outcomes: Patient Agitation Rehab Length of Stay Agitation level Initial •Agitated, uncooperative behavior •Unable to participate in >50% of session Intermediate •Decreased agitation in quiet room •Calm and engaged ~75% of session Terminal •No agitation in noisy gym •Calm and engaged ~95% of session Outcomes: Family Involvement Rehab Length of Stay Participation Level Initial No family participation in therapy Intermediate Participation except mother Terminal Each family member with sufficient training and good return demo of patient’s HEP Outcomes: Patient Improvements MEASURE INITIAL EXAM FINAL EXAM GOAL MET Bed/floor mobility Total – Max A (Level 1/2) Supervision √ Transfers Total – Max A (Level 2) Supervision √ Balance Poor, Max A (Level 2) x 5 seconds Good, Supervision x 30 seconds √ Ambulation Max A (Level 2) x 5 steps; ataxic with wide BOS Supervision x >100 ft; mild ataxia and wide BOS <15% of the time √ Discussion • Elements of the cNDT approach that may have influenced outcomes ▫ Facilitation ▫ Task-oriented practice ▫ Orthotics ▫ Torso weighting ▫ Family involvement ▫ Agitation level • Mechanisms independent of therapy ▫ Natural motor recovery ▫ Developmental plasticity Discussion: Facilitation Contemporary NDT component Physiological mechanisms Outcomes Sensory changes Motor learning Facilitation Muscle strengthening Postural stability Improved functional mobility, balance & gait Mechanisms for facilitation Sensory changes Motor Learning Strengthening Postural Stability ↑ Afferent info → accurate feed forward commands Facilitation = extrinsic feedback → motor acquisition ↑ Excitation to amotor neuron pools → ↑# active MUs & firing rate ↑ excitation to amotor neuron pools Remove once ↑intrinsic feedback → motor retention → ↑ muscle force & strengthening of muscles for action Sensory input influences postural control & internal representation of postural body schema Re-educates internal reference system → ↑ movement choices & efficiency Improved problem-solving → generalization and transfer of learning •Repetitive deep squats without rest breaks for prolonged periods •Accommodation to different surfaces •Independent task performance without facilitation Graham et al, 2009; Gjelsvik, 2008; Raine et al, 2007) Howle , 2002; Levac et al, 2009) Howle, 2002; Ghez, 1991) •Dynamic reaching while standing on balance board without LOB Gjelsvik, 2008; Graham, 2009) Discussion: Task-oriented practice Contemporary NDT component Physiological mechanisms Outcomes Neuroplasticity/ Motor recovery Motor control Task-oriented practice Muscle strengthening & endurance Postural stability Improved functional mobility, balance & gait Mechanisms for task practice Motor Recovery Motor Control Attempted action → adaptive plasticity Repetition & practice = best & most common way to ↑ coordinated movement Task-specific training + sensorimotor learning/experience Practice, timing and feedback strategies •Supine <-> sit with SBA after repetitive training with props Forsyth, 2010; Johnston, 2009; Hubbard et al, 2009; Yeleswarapu et al, 2010 → ↑ global motor function •Ambulation closer to age-appropriate pattern, no LOB, navigate obstacles, ↓ ataxia Shumway-Cook & Woollacott, 2007; French et al, 2008; Hubbard et al, 2009 Strengthening Postural Stability Repetition → strengthening Balance is a motor skill Cortico-motor neuron pools organized to specific tasks NOT muscles Challenging dynamic task practice → improved stability with carryover •Repeated sit<-> stand on compliant surfaces •↑ stability in functional activities and gait after dynamic balance tasks Katz-Leurer et al, 2009; Hubbard et al, 2009 Cassidy et al, 2009; Katz-Leurer et al, 2009 Discussion: Orthotics Compression & consistent proprioceptive feedback Improved: - midline positioning - joint receptor functioning - ↓ postural sway - control of movement ↑ LE stability in functional mobility, balance, & gait Contradictory Evidence: • Limited efficacy • ↓ ankle strategy • Little biomechanical effect on ankle during dynamic gait analysis Martin, 2004; Hylton, 1989; Shumway-Cook & Woollacott, 2007; Bjornson et al, 2006 Discussion: Torso Weighting Change perception of moment of inertia Joint compression ↑ afferent input + sensory changes ↓ Ataxia ↑ coordination ↑ stability ↑ awareness of a body segment Evidence: • Improved cortical plasticity, functioning, and upright mobility in stroke and MS Contradictory Evidence: • Unknown if joint compression or awareness plays a role in its effectiveness • Detrimental to balance and mobility? ↓ Ataxic • Inconsistent effects on gait movement, ↑ Stability, ↑ Coordination Shumway-Cook & Woollacott, 2007; Widener et al, 2009; Clopton et al, 2003; Gibson-Horn, 2008 Discussion: Agitation Level • Healing process • Environmental modification ▫ Quiet, calm environment - least amount of “brain distractions” ▫ Therapy focused, short and with regular therapists to avoid over-stimulation (Yen & Wong, 2007) Discussion: Family Involvement • Improved family dynamics • Motivated with realistic expectations • Early family education and involvement (Yen & Wong, 2007) ▫ ↓ reliance on hospital-based systems → ↓ cost of caring for child (Ylvisaker et al, 1998; Yen & Wong, 2007) • Extensive family training ▫ Nature & severity of injury, rehab goals, short & long term needs → ↑ understanding, motivation, and participation ▫ Therapeutic activities family can incorporate into daily care → motor learning (Howle, 2002) Discussion: Neuronal & Developmental Plasticity Natural motor recovery Age-related neuroplasticity • Capacity in both the healthy and injured brain ▫ ALWAYS ACTIVE! • Biological + environmental factors • Age at time of injury effects recovery of function Impairments worsen “grow into” deficits Age at time of injury skill acquisition impeded Hubbard et al, 2009; Forsyth, 2010 new deficits emerge Chapman & McKinnon, 2000; Shumway-Cook & Woollacott, 2007; Bate et al, 1992 Discussion: Value of cNDT • Flexible guidelines, applicable in many situations • Patient-specific interventions ▫ Emphasizes individuality of developmental paths (Levac et al, 2009) (Levac et al, 2009) ▫ Allows for other treatment modalities ▫ Provides framework of possible influences on recovery in children post TBI (Canning et al, 2003) • Facilitation, not just assistance • Active rehabilitation → functional experiences → self-organization + may influence neuroplasticity and recovery in the CNS (Levac et al, 2009) Discussion: Potential disadvantages of cNDT • Very little research on its application in children ▫ Approach still evolving; variability in practice worldwide • No standard protocols exist ▫ Difficult to communicate treatment application or re-create treatments • Research on traditional NDT has limited itself to adults with stroke and children with CP ▫ Limited applicability to other diagnoses? • Requires some formal training and clinical experience • Inclusive approach = which aspects are most effective? Limitations • Multiple intervention techniques • PT intern with limited training in the pediatric rehab setting • No formal motor function or developmental assessments Directions for Future Research • Additional pediatric literature on… ▫ Ataxia post near drowning ▫ Application of cNDT and its underlying principles to children with ABI ▫ Use of weighting and orthoses ▫ Short and long-term effects of physical therapy • Describe operational definitions and guidelines using the cNDT approach for this population with treatment parameters Conclusions Structuring therapy sessions using the Contemporary NDT approach to change motor behavior through facilitation and task-oriented practice may contribute to improvements in functional mobility, balance and gait in children with ataxia post near drowning Acknowledgements • Faculty Readers ▫ Carla-Krystin Andrade, PT, PhD ▫ Linda Wanek, PT, PhD ▫ Monica Rivera, PT • Peer Editors ▫ ▫ ▫ ▫ Allison Legakis, MS/DPTc Ryan Johnson, MS/DPTc Natazha Bernie, MS/DPTc Elizabeth Carter, MS/DPTc • UCSF/SFSU DPT Class of 2011