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Down Syndrome Case Study Presentation

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Melissa Wong

on 26 April 2013

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Transcript of Down Syndrome Case Study Presentation

Examination Evaluation and
Goals Interventions Dylan Age: 4 y/o
Medical Dx: Down Syndrome (Trisomy 21)
& Developmental Delay
PT Dx: Developmental Delay Interventions Worksheet Case Study:
Functional Activities & Stair
Mobility to Improve Developmental Delay & Increase Confidence Levels in a Patient with Down Syndrome By: Melissa Wong PDMS-2 Results / Interpretation of Scores Case Overview Past Medical History Systems Review Outcome Measures Goals/Concerns Lower Extremity Strength Lower Extremity Range of Motion Functional Mobility Assessment Short Term Goals Long Term Goals Intervention Outcomes CMC Discharge Policy Dylan's Discharge Plan Reflection Duration/Frequency 5C - Impaired motor function and sensory integrity assoc. with non-progressive disorders of the CNS - Congenital origin or acquired in infancy or childhood Practice Pattern: Down Syndrome
(Trisomy 21) Genetic disorder caused by the presence of all or part of a 3rd copy of chromosome 21

In the US alone, CDC estimates 1/691 babies born with DS Typical Clinical Presentation Hypotonicty (decreased mm tone)
Excessive joint laxity
Cognitive delay
Decreased muscle bulk
Facial abnormalities
Heart abnormalities (occasionally) Myeloproliferative disease (12/9/08)
Esophageal Reflux
Heart abnormality: Tetrology of Fallot Repair (10/17/09) Current Medications Zyrtec, Nystatin cream, Albuteral, Ibuprofen Therapy History Currently receiving PT, OT, & Speech for 60 min/session; 1x/wk Cardiovascular : Abnormal (heart abnormality, asthma)

Musculoskeletal: Abnormal (see examination)

Neuromuscular: Abnormal (hypotonicity)

Cognition/Communication: Abnormal PDMS-2
to measure developmental delay and compare pt to other children his age

FLACC Pain Scale
selected 2/2 impaired cognition Concerns:
Difficulty keeping up with his peers during recess and often trips on feet
Doesn't go up/down stairs without help
Doesn't get into bathtub or car without help
Doesn't dress IND
Can't Jump
Mother believes Dylan may lack strength and/or may lack confidence in performing activities IND

Goals for Physical Therapy
Increase IND with activities such as getting in/out of bathtub/car, dressing, and stairs
Keep up with peers during recess safely
Increase ability to jump Per Mother Per mother's report / PT observation Dylan has short attn. span, occasional behavioral problems, difficulty sitting still, easily distracted but is easy to engage/motivate. Head and Trunk Strength PROM
Grossly Increased Bilaterally (2/2 hypotonicity) Tone Lower Extremities
Grossly Hypotonic Bilaterally
Hypotonic ** Very important in pediatric setting!

Findings will play major role in Goal Making Process.

All Goals MUST be functional! In all 3 categories, Dylan's gross motor skills compared to other children his age are well below average.
Dylan's age equivalency scores reflect pt's developmental delay. (Appropriate age equivalency = 48 months) Impairments
Functional Limitations
Disabilities Impairments Functional Limitations Disabilities Primary
Grossly Hypotonic throughout entire body - Especially in B ankles & feet
Cognitive Delay
Increased joint laxity of B LE's

Decreased B LE mm strength
Decreased trunk strength Decreased Balance
Impaired Stair Mobility
Decreased ability to dress IND
Inability to jump or hop IND
Impaired floor to stand transfers
Impaired coordination/object manipulation per PDMS-2 Unable to perform age appropriate gross motor milestones

Unable to play safely with classmates and siblings Orthotic Specialist Referral Reasons to refer:
Improve B ankle stability
Improve foot/arch stability
Improve foot position while ambulating, running, playing, squatting, transitioning from floor to stand, ascending/descending stairs
Decrease risk of falling/tripping
Prevent structural damage of joints 2/2 hypotonicity

AFO's for ankle stability
Custom inserts for flat feet/ excessive pronation Prognosis
Goals Re-Evaluation 1. In 3 mo, Pt will maintain modified SLS x 20 sec on each LE with SBA to demonstrate increased LE and core strength / stability to assist during dressing.

2. In 3 mo, Pt will maintain B static tiptoe stance for >= 7 sec IND without heels touching floor to demonstrate increased LE strength and aid with progression toward double limb jumping.

3. In 2 mo, Pt will ascend 4 standard stairs with SBA, no handrails, and reciprocal step pattern 3/4 trials for 2 sessions in a row to demonstrate increased IND at home and in school.

4. In 3 mo, Pt will descend 4 standard stairs with CGA, no handrails, and step-to pattern 3/4 trials for 2 sessions in a row to demonstrate increased IND at home and in school. 1. In 6 mo, Pt will sustain half kneeling with R and L LE leading x 5min each with SBA while participating in UE play to demonstrate increased core, hip, and LE strength/stability and to increase ease of functional transitions from floor to stand without LOB.

2. In 6 mo, Pt will ambulate across 3inch balance beam with CGA 2/3 trials throughout session to demonstrate increased balance with narrowed BOS.

3. In 6 mo, Pt will perform single leg stance x 10sec on each LE to demonstrate improved balance and LE stability in order to assist with LE dressing and transfers in/out of tub and car.

4. Family/Caregiver will be compliant and IND with HEP and recommendations provided by PT to optimize therapy gains. Duration = 60min/session

Frequency = 1 session/week for
6 months CMC Re-Evaluations Re-Evals occur:
Every 6 months
Re-Authorization request to insurance for more visits
Interims (CMC policy)
Conducted first of the month every month to evaluate progress towards goals / change POC. Improving Stair Mobility and Confidence Level Strength and Agility Training Progressive Resistance Training Outcomes Discharge SAMPLE Goals of Intervention:
Increase IND with stair mobility
Increase LE strength and dynamic balance
Increase confidence levels and safety

Equipment: 4 standard stairs with handrails, 1 pound ankle weights with .25
increments for progression

Possible Toys: Legos, stickers, craft supplies, bean bags, puzzle pieces, matching game, etc

Toys at top of stairs, collect 1 item after ascending and play with item after descending.
Carry item while ascending, shoot towards bball hoop at top of stairs, descend to retrieve toy

Assistance Level Progression
PT held item, pt held 1 hand 1HR step-to pattern/reciprocal step pattern
No PT assistance 1HR reciprocal step pattern
CGA No HR step-to pattern/reciprocal step pattern Research "A stair-walking intervention strategy for children with down syndrome" Repetition of ascend/descending stairs increases LE muscle strength, stability, muscle control, proper gait mechanics of reciprocal stepping pattern, decreases rotation during descending stairs, and increases confidence levels of stair mobility in children with Down Syndrome. Results support stair mobility intervention Lafferty ME. A stair-walking intervention strategy for children with down syndrome. J Bodywork Movement Ther. 2005; 9(1):65-74. doi: 10.1016/j.jbmt.2004.01.003. Research "Strength and agility training in adolescents with down syndrome: A randomized controlled trial" Lin et al. had postive results of increasing LE strength by using the Wii. There was a significant increase in LE strength esp. knee flexor/extensor muscle groups when using the Wii for short-term(6wks) intervention strategies Results support LE strengthening using Wii in adolescents with DS. Lin H, Wuang Y. Strength and agility training in adolescents with down syndrome: A randomized controlled trial. Res Dev Disabil. 2012; 33(6):2236-2244. doi: 10.1016/j.ridd.2012.06.017. Goals of Intervention:
Increase LE strength (quads and hams)
Improve LE balance
Improve safety during static/dynamic standing activities

Equipment: Nintendo Wii + games

HEP Intervention: Play Wii Sports or Wii Fit for 20min, 3x/week

Assistance Level Progression
Hand held assist x 1

HEP Intervention modifications were made by mother occasionally 2/2 Dylan's mood/behavior, time varied from 15-30min with rest breaks PRN. Research "A student-led progressive resistance training program increases lower limb muscle strength in adolescents with down syndrome: A randomized controlled trial" Shields N, Taylor NF. A student-led progressive resistance training program increases lower limb muscle strength in adolescents with down syndrome: A randomized controlled trial. Journal of Physiotherapy.2010;56(3):187-193. doi:10.1016/SI836-9553(10)70024-2. Impairments and Func. Limitations
1. Decreased B LE strength (quads, hams, gastroc,
tibialis ant)
2. Impaired balance (SLS)
3. Impaired transitions from half kneel -> stand
4. Unable to jump without assistance

Goals of interventions
1. Improve LE strength to
improve safety during ambulation and running increase IND with stair mobility
increase IND with daily activities like dressing and bathtime
decrease tripping
2. Improve balance (SLS) to
improve safety during stair mobility
increase IND with putting pants on
increase IND and safety with getting in and
out of bath and car
increase confidence levels in age appropriate
tasks and daily activities
3. Improve LE, hip, and core strength/stability to increase safety and IND with transitioning
4. Increase LE strength and stability to allow pt to jump/hop and increase confidence level during tiptoe activities

List of possible toys/equipment and uses for each
Bubbles - pop with toes to improve DF strength, pop while performing rotational sit ups on therapy ball
Legos - legos at top of stair to collect 1 at a time to build building
Bolsters, ramps, step - create obstacle course for "The Hulk" to knock over with feet (SLS practice and LE strength)
Ankle weights - during any activity to promote LE strengthening and progressive resistance Intervention Worksheet Pt Name: Dylan (AKA The Hulk) Progressive resistance exercises using weight machines resulted with increased LE strength. Concluded that progressive resistance exercise programs are beneficial, feasible, and safe for adolescents with DS. Results support progressive resistance exercise interventions Goal of Intervention:
Increase LE strength
Increase joint stability

Equipment: 1 pound velcro ankle weight x2 with .25 increments for progression PRN

Wrap ankle weight on each LE in PT session during stair mobility, heel-walking, static double limb tiptoe, floor to stand transitions etc.

Intervention Modification:
Modified by PT.
Pt to use more age appropriate weights (ankle weights with .25 increments) instead of weight machine with 1 pound increments in research article.

Ankle weights should be incorporated into games, activities and other interventions to increase motivation and compliance with intervention.
Improved B ankle stability via B AFO's
Decreased severity of Developmental Delay in gross motor skills (certain items of PDMS-2 retested during interims to note progress)
Increased B LE and core strength
Increased IND with stair mobility
Improved single leg balance
Increased confidence in performing daily activities
Improved safety during ambulation and play during recess
Pt will be discharged when:
Pt has met or is on track to meeting all goals
Pt reaches a plateau in progress towards goals
Pt /family is not compliant with HEP or recommendations given by PT
Pt does not have any remaining authorized visits / is not approved for more visits via insurance provider
Pt /family is non-compliant with CMC's attendance policy. Dylan discharged 2/2:
Met or was close to meeting all short and long term goals
End of authorization period
Not a lot of progression to current interventions could be made 2/2 pt's rapid progress.

Preparation for Discharge:
Progress towards unmet goals were closely monitored and was primary focus of remaining sessions.
Mother was informed of Discharge Plan 3 sessions prior to D/C.
Mother educated on new HEP and ways to modify/progress each exercise.
Mother educated on signs of outgrowth and/or irritation of AFO's.
PDMS-2 Age Appropriate Gross Motor Skills Chart was provided for future reference.
Mother encouraged to contact PT if any questions arise after D/C. Surprised there was a large amount of research regarding PT and medical interventions for DS.
Didn't get to try treadmill training with Dylan.

Learned a lot about managing children with behavioral issues.

Flexibility with course of treatment session is key!

Be prepared! Know your toys and what you can do with them so you can modify interventions quickly and as needed.

Try to make interventions and goals as functional as possible in peds setting!
Prognosis Good Prognosis with referral to Orthotic specialist, compliance with HEP, and compliance with CMC attendance policy Posture Sitting: Forward head, rounded shoulders, increased kyphosis, prefers to "W" sit.

Standing: Forward head, rounded shoulders, excessive pronation of B feet (flat feet) QUESTIONS ?? THE END References
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