Case Study Report
Population: Pediatric
Colleen Peyton, PT, DPT, PCS, Pediatric Physical Therapist, University of Chicago, Comer Children’s Hospital colleen.peyton@uchospitals.edu
Michael Msall, MD, Professor of Pediatrics, University of Chicago, Comer Children’s Hospital mmsall@peds.bsd.uchicago.edu
Keywords: Plasticity, Prediction, CIMT, Infants
Background & Purpose: The corticospinal tract undergoes the most structural change and has the largest window for plasticity in the first 3-12 months of life. Animal models suggest that constraint induced movement therapy (CIMT) initiated immediately after injury can lead to improved motor function, when initiated during critical periods of motor learning. However there are few studies of CIMT treatment in very young infants. The purpose of this case study was to describe the use of CIMT in an infant and follow his early motor trajectory during the first two years of life.
Case Description: A term male infant with history of meningitis and neonatal seizures was referred to neonatal follow-up clinic at 12 weeks post-term age. During the general movement assessment (GMA) he was found to have absent fidgety movements, a biomarker for cerebral palsy. He returned for treatment at 16 weeks of age and was noted to have asymmetrical hand preference and preferential reaching with his right hand. He lacked active supination in the left upper extremity and was unable to bring both hands to the midline. A modified CIMT approach with maternal consent was undertaken as described in the baby CIMT protocol (Eliassian AC, et al). A soft restraint was used for 30 minutes/day, 6 days/week, x 6 weeks; reach training was provided at home by his mother. The physical therapist coached his mother 1x/week during outpatient visits. Kinesiotape to the left forearm to facilitate supination was used x 2 weeks.
Outcomes: After 6 weeks of treatment, the child was able to reach for objects presented in midline symmetrically with active supination of left forearm. At one year of age, he was able to creep reciprocally without upper or lower extremity asymmetry, and pull-to-stand. At 2 years , he demonstrated a pincer grip with the left hand, used his hands for bimanual tasks without range of motion or tone abnormalities, and cruised laterally equally. He walked independently at 27 months. His 2 year composite scores on the Bayley Scales of Infant Development were >2SD below the mean in cognitive (65), language (68), and motor (52) subscales. He does better with manipulative skills with his right hand compared to left.
Discussion: The GMA was a useful clinical tool that helped guide targeted intervention during the critical period of motor plasticity. This child’s enhanced upper extremity and lower extremity functioning was optimized by avoiding activity dependent withdrawal that is often undetected. Early CIMT may play an important role in maximizing function of children presenting with early asymmetry. The Hand Assessment for Infants is currently being developed to meaningfully measure change in similar cases.
Citation:
Peyton, Colleen , PT, DPT, PCS; Msall, Michael E, MD. Constraint Induced Movement Therapy in a 4 month old infant: 2 year developmental outcomes.. Poster Presentation. IV STEP Conference, American Physical Therapy Association, Columbus, OH, July 17, 2016. Online. https://u.osu.edu/ivstep/poster/abstracts/069_peyton-msall/