Physical therapy comparisons using the Pediatric Evaluation of Disability Inventory (PEDI) Article Summary
Aizawa CY, Morales MP, Lundberg C, et al. Conventional physical therapy and physical therapy based on reflex stimulation showed similar results in children with myelomeningocele. Arq Neuropsiquiatr. 2017;75(3):160-166. doi:10.1590/0004-282X20170009
Purpose: Meningomyelocele, (MMC) is a type of spina bifida which is a birth abnormality that impacts the child’s development due to the damage of the spinal cord and nerves. This causes delays in motor skills such as ambulation, trunk control with independent sitting, bimanual tasks along with other functional tasks. It has been proposed that an early intervention physical therapy program could optimize the function of infants with MMC to enhance their sensory-motor function. Techniques such as proprioceptive neuromuscular facilitation (PNF) techniques such as rhythmic initiation and isotonic combinations have been utilized to facilitate activities like rolling, standing from sitting, and walking. The use of these techniques has been studied previously and has shown improvements in multiple populations with sensory-motor impairments with improved muscle tone, functional performance and gait speed. The purpose of this study was to explore the ability for infants with MMC to better their motor skills and function after a 10-week Physical therapy intervention of either conventional physical therapy (CVT) or a reflex stimulation based approach (RPT) measured using the Gross Motor Function Measure (GMFM) and the Pediatric Evaluation of Disability Inventory (PEDI).
Study population: Twelve children with MMC participated in the study that had hydrocephalus with a ventriculoperitoneal shunt and urinary and fecal incontinence. The mean age was 18.2 +/- 15.6 months in the RPT group and 18.3+/- 12.4 months in the CPT group.
Methods: Twelve children with MMC were randomly assigned into the respective CPT or RPT groups. After random placement, each child attended 45-minute weekly sessions for 10 weeks under the care of the same physical therapists with a blinded child examiner who completed pre and post testing.
Outcome measures: Motor function was measured using the Gross Motor Function Measure (GMFM) which is an 88-item measure with 5 subcategories: lying and rolling; sitting; crawling and kneeling; standing; walking, running and jumping. Each item is scored on a 4-point ordinal scale, a total score for each dimension is produced and a final total percentage is what is used. This measure has not specifically been validated to be used with children with spina bifida, it is the most commonly used scale throughout the literature and has been used with populations of children with cerebral palsy, down syndrome, and spinal cord disease.
The Pediatric Evaluation of Disability Inventory (PEDI) assesses functional status in children aged 6 months to 7.5 years with 3 subcategories of self-care, mobility, and social function. This is utilized via an interview with the parents of each child.
Intervention: CPT interventions were based on enhancing mobility and functional independence. Sessions included muscle strengthening, postural control training and use of orthotics. Muscle strengthening protocol included 10-30 repetitions of isotonic contractions of various muscle groups and in various positions. Postural control was challenged by maintaining sitting, crawling, kneeling, and standing positions with 3-10 repetitions of each.
RPT interventions were based around the initiation and maintenance of postural changes. Myotatic reflexes were collected and utilized for stimulating skin receptors via touching the corresponding muscle to the motion desired. This was done with rhythmic initiation for rolling, sitting and crawling with passive and active assisted phases with at least five repetitions for at least two muscle groups per session. Righting reactions were also utilized in treatment to facilitate the use of extensor muscles when lying prone and sitting upright on a ball. 5-10 repetitions were performed in each direction. Parents were taught home exercise programs for both groups and were encouraged to spend 15-20 minutes daily on the exercises.
Results: When looking at results for the GMFM, many patients scored zero for pre and post testing for standing and walking, and running and jumping. For the CPT group domain A improved 2.5%, domain B improved 16.3%. For the RPT group domain A improved 18% and domain B improved 24.2%. The results from the PEDI were compared using a Wilcoxon test comparing pre and post testing for all treatment groups and both demonstrated significant improvements for all items with the exception of social function. The results indicate that no significant differences were noted between CPT and RPT but it is theorized that CPT could optimize upper limb and trunk control with loss of lower limb control and RPT could optimize better lower limb control. Regardless, significant improvement was found in both groups over the 10 week program.
Strengths/limitations: Strengths of this study include positive and significant improvements in scores over a relatively short treatment course of 10 weeks which could be further examined in a longitudinal study. Additionally, this study did offer vestibular and sensory stimuli to the upper extremities which may have a positive impact on sensory-motor integration between the spine and cortex. A limitation of this study is that there are very few studies that examine exact dosing for physical therapy interventions with the MMC population, although this study did find that ~45 minutes weekly treatment plus supplemental home exercises 20 minutes daily can produce positive results for this population. Another limitation of this study is that there was a small sample size and there were not available participants in order to make a control group to make further comparisons although it is controversial ethically to follow a non-therapeutic group.
Overall conclusion: Based on the results of this study, both physical therapy protocols enhanced motor and functional skills in infants with MMC. The improvements made in motor ability were strongly correlated with an overall better functional status. More research is needed in order to verify interventions and outcomes of physical therapy for this population based on the PNF principles for treatment of neurological dysfunction of pediatrics.
2 responses to “Physical therapy comparisons using the Pediatric Evaluation of Disability Inventory (PEDI) Article Summary”
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Great summary! This is very interesting to read since we recently learned about the spina bifida diagnosis during the Neuro module, and now even better seeing different physical therapy protocols showing significant improvements. I like how this study involved the parents with encouraging a daily home exercise program since the PT sessions were just once a week. Having a specific population of infants, I appreciate the significance of challenging postural control within both physical therapy programs. Reading the limitation of only being a few studies on prescribing the exact dose of PT for this population, it would be awesome for further research to be published. During my undergraduate internship, I had the opportunity to work with a child with spina bifida, and it was amazing to see their progress throughout the plan of care.
Brendal, Thanks for your comment!