PURPOSE: The purpose of this case series was to report the impact of a home-based dynamic standing program on postural control and gross motor activity in two children with truncal hypotonia.
BACKGROUNDS/SIGNIFICANCE: Poor postural control associated with central hypotonia limits a child’s ability to interact with the environment, delaying attainment of developmental milestones such as sitting, crawling, standing and walking. Participation in social interactions with peers and caregivers may be restricted resulting in a decreased quality of life. Supported standing programs are commonly used to ameliorate impairments and optimize function in children with poor postural control. Increased social interactions, as well as reduced burden of care have all been associated with supported standing programs. The Upsee is an orthotic standing and walking device which is worn by the child and parent. As the adult stands, moves, and walks the child is encouraged to stand, move, and step. Functional tasks and participation activities are encouraged while the child is in the Upsee. There are no reports of the effectiveness of the Upsee as a dynamic standing program. Because of its simple design and ease of use, the Upsee can be readily added to a home program to increase standing and weight shifting in children.
SUBJECTS: Child 1 was a 24-month-old boy born at 37 weeks gestation and diagnosed at birth with a rare form of chromosome 3 deletion and agenesis of the corpus callosum. His Gross Motor Function Classification System (GMFCS) classification was Level IV. Child 2 was a 21-month-old boy born at 39 weeks gestation. Prior to birth, his mother experienced decreased fetal movement. A cesarean section was performed and the baby was found to have a true umbilical cord knot, causing hypoxic ischemic encephalopathy. He was diagnosed with Cerebral Palsy (CP) at 12 months of age. His GMFCS classification was Level V. Both children displayed truncal hypotonicity with significant gross motor delays for their ages. They both had cognitive ability to follow simple commands, but no verbal communication skills. The children had excellent family support and parents of both children expressed an overall goal for improvement with functional independence.
METHODS AND MATERIALS: Each child participated in 12 weeks of a home-based program that included upright dynamic weight bearing using the Upsee device. The harness system was adjusted by a physical therapist during the first assessment period to provide appropriate anatomical alignment and positioning for the children to bear weight through their lower extremities. The families were educated in the correct use of the device, and followed a protocol that included up to 30 minutes of weight bearing per day, 3 to 5 days a week. The parents were educated on dynamic weight bearing to facilitate muscle activation in the trunk and legs while using the Upsee. Families were asked to keep a journal of the amount of time spent in the device and activities performed by their child.
ANALYSES: The Segmental Assessment of Trunk Control (SATCo) and the Gross Motor Function Measure (GMFM- 66) identified changes in gross motor function and trunk control. Pre- and post-intervention scores were compared.
RESULTS: Final scores revealed that both children improved gross motor function, and Child 1 demonstrated improved trunk control in sitting. Child 1 improved his SATCo score from 11/20 to 20/20 and GMFM-66 score from 35 to 42. Child 2 initially scored 0/20 on the SATCo outcome measure, which did not change. His GMFM-66 score improved from 16 to 21. By the end of the study period, both children were able to take steps independently with a gait trainer. This new ability expanded opportunities for physical therapy goals and interventions for both children.
CONCLUSIONS: Children with truncal hypotonia can participate in, and benefit from, a dynamic standing program using the Upsee. We speculate that this program may be effective in improving the gross motor abilities of children with severely impaired postural control. Of the two children, Child 1 demonstrated more improvement in gross motor function and trunk control. One possible reason for this is that Child 2 presented with increased extensor tone of his four extremities, which increased when he became excited or when attempting to focus on an activity at hand and constrained his movement activity. Also, Child 2 spent less time overall in the Upsee, never progressing beyond 15 minutes of weight bearing per session.
Future research is needed to further explore the necessary dosage of an upright dynamic weight bearing program for children with impaired postural control. Studies with a more homogenous and larger sample are needed to conduct a randomized controlled trial design comparing the use of the Upsee to a traditional standing frame. Future studies should also aim to capture changes across the full ICF-CY model, including activities and participation. The findings from this case series support the use of the Upsee as a new home-based upright dynamic weight bearing program for children with impaired postural control.
Flores M, Manella K, Ardolino E. Upsee Daisy! Gross Motor Outcomes after Dynamic Weight Bearing in Two Children with Truncal Hypotonia: A Case Series. 2017.