A Physical Therapy Protocol to Enhance Anticipatory Postural Control and Standing Balance in an Adult with CP: A Case Report

Gay L. Girolami, PT, PhD

Introduction
Individuals with cerebral palsy have impaired balance and anticipatory postural adjustments (APAs), which interfere with their ability to prepare for postural perturbations and sustain independent sitting and standing balance [1]. There are studies which report on compensatory postural adjustments (CPAs) and standing balance training in individuals with cerebral palsy [2, 3]. There is seminal research on APAs in children with typical development, hemiplegia and diplegia [4,5], but no research describing how to train APAs in individuals with cerebral palsy. The purpose of this case report was to examine the effectiveness of an intensive physical therapy program to improve balance and APAs in an adult with cerebral palsy.

Methods
PARTICIPANT A 31 year old male with spastic quadriplegia (GMFCS III), who participates in multiple weekly physical, occupational and speech therapy sessions, consented to participate in the intervention as part of an intensive PT treatment program. Goal: transition to forearm crutches in the home. Reverse walker for community ambulation Wears AFOs Prior surgical lengthenings: bilateral hip flexor, hamstring and gastrocnemius Works outside the home/active in the community Participates in sports (swimming/horseback riding) INTERVENTION 60 minute physical therapy sessions were provided four days per week in two 8 week phases for a total of 39 sessions (Tables 1 and 2)
Total

Results
Table 3. GAS Scores - Phase I
Phase I: February 22 April 8, 2010 Baseline Goal 1. Standing Balance: Support from Ball 2. Standing Balance: Trapeze Support GAS 2 seconds 3 seconds -2 -2 40 sec 20 sec 21 sessions April 8 GAS 0 -1

Results
Goal Attainment Scaling (Tables 3 and 4) Timed Standing (2 sec to 90 sec ); Standing Balance/Unstable Support (3 sec to 38 sec) Standing Reaching (2 reaches to 7 reaches). Pediatric Reach Test 4.4 inch improvement - Left sideways reach (the more involved side) No change - sitting forward reach No change - right sideways reach. EMG: (Figs 3 and 4) Pre-test EMGs - no APAs in the trunk or upper leg prior to perturbations in sitting and standing, Post-test EMGs - APAs documented in trunk and upper leg Video Documentation/Photos Improved alignment Improved ability to sustain sitting posture during upper extremity abduction movements Fig 3 Stand: Pre-test (L) and Post-test (R): RA and ES

Conclusion
Positive functional and EMG changes were found following this intensive physical therapy program using these outcome measures Goal Attainment Scaling Pediatric Reach Test EMG Video Documentation This intensive physical therapy protocol appears to be an effective intervention to improve sitting and standing balance as well as anticipatory postural adjustments. This protocol merits further investigation. Enrolling a larger group of participants would create more robust data to determine whether this protocol can be effectively applied as a therapy intervention. A larger data set would also be beneficial to determine the efficacy of the Goal Attainment Scale to assess changes in balance and APAs. EMG and force platform data can be effectively used as objective measure of change in anticipatory postural control.

Table 4. GAS Scores - Phase II

Phase II: April 12 May 19, 2010 April 12 Goals 1. Standing Balance: Support from Ball 2. Standing Balance: Trapeze Support 3. Standing Reach: 4. Independent Sitting 5. Bench Sit: Throw Ball GAS 40 sec 14 sec Right = 0 Left = 1 2 seconds 3 catch/ throw 0 -1 -2 -2 -2 90 sec 38 sec Right = 2 Left = 9 58 seconds 23 catch/ throw 18 sessions May 19 GAS +2 0 -2 -1 +1 +2

Intervention/Testing
Table 1. Therapy Sessions
Phase I February March April Total Sessions 2 15 4 21/28 April May Total 8 10 18/23 39 Phase II Sessions

Perturbations and mobile supports were used to effect changes in trunk posture, balance and APAs in sitting and standing. (Figs 1 and 2) External perturbations Mobile support Verbal and sensory cues Guided facilitation PRE, MID AND POST TESTING Goal Attainment Scale (GAS) measures individualized goal achievement of functional tasks based on a 5 point scale Pediatric Reach Test (PRT) - a measure of sitting and standing balance (administered in sitting) Electromyography (EMG) - documents timing, sequencing and magnitude of muscle activity Video documentation/Photos - an objective tool to assess changes in performance and alignment

Table 2. Testing Schedule Baseline

Video Documentation February 2, 2010 Goal Attainment Scale February 22, 2010 X EMG February 15, 2010

Fig 1. Externally initiated perturbations in sitting designed to train APAs

References
1. Bax, M., et al., Proposed definition and classification of cerebral palsy. Dev Med Child Neurol. 2005; 47(8): 571-6. 2. Shumway-Cook, A., et al., Effect of balance training on recovery of stability in children with cerebral palsy. Dev Med Child Neurol. 2003; 45(9): 591-602.

Test Session 1
Video Documentation April 12, 2010 Goal Attainment Scale April 12, 2010 Pediatric Reach Test April 12, 2010 X

Test Session 2
Video Documentation May 17, 2010 Goal Attainment Scale May 19, 2010 Pediatric Reach Test May 19, 2010 EMG May 7, 2010

Fig 4 Stand: Pre-test (L) and Post-test (R): RF and BF

3. Woollacott, M., et al., Effect of balance training on muscle activity used in recovery of stability in children with cerebral palsy: a pilot study. Dev Med Child Neurol. 2005; 47(7): 455-61. 4. Girolami GL, Shiratori T, Aruin AS. Anticipatory postural adjustments in children with typical motor development. Exp Brain Research. 2010; 205(2):153-165. 5. Girolami GL, Shiratori T, Aruin AS. Anticipatory postural adjustments in children with hemiplegia and diplegia. J Electromyogr Kinesiol. 2011. in press.

Fig 2 Standing balance practice using a mobile surface

This study was supported in part by Pathways Foundation and the Knecht Movement Science Laboratory, UIC.