A Team Approach to Care for We have nothing to disclose Children - - PowerPoint PPT Presentation

3/9/2018 1

A Team Approach to Care for Children with Cerebral Palsy

Christina Buysse, MD Helen Phung, PT Supervisor Patty Walsh, OT Chief Therapist We have nothing to disclose

California Children’s Services Medical Therapy Program

CCS

• CCS was established in 1927 by the State of

California to provide medical case coordination for children ages birth to 21

• Eligibility
• Medical
• Residential
• Consists of CCS Administration and CCS

Medical Therapy Program

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CCS Administration

• Statewide program administered by each

county

• It arranges, directs and pays for medical care,

equipment & rehabilitation for children and young adults under 21, historically for eligible conditions only

• Clients must be medically and financially

eligible

• Senate Bill (SB) 586: Department of Health Care

Services (DHCS) to establish the Whole-Child Model (WCM) program

• Incorporates California Children’s Services (CCS)

into Medi-Cal managed care plan (MCP)

• Health Plan San Mateo (HPSM) has operated

the first pilot program since 2014

• HPSM contracts with CCS San Mateo

CCS Pilot Project

• Improves care coordination for CCS children

for both CCS and non-CCS conditions

• Maintains CCS program standards including

services provided by CCS paneled providers

• Comprehensive treatment focuses on the

whole-child, addressing the full range of needs, not just the CCS health condition

• Minimal impact on services at the Medical

Therapy Program to date

CCS Pilot Project Medical Therapy Program (MTP)

• Established in 1945
• Funded 50% by the state and 50% by the

counties

• Physical & Occupational

Therapy

• Eligibility
• No financial eligibility
• Residential
• Medical

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Children served: birth to 21 years

Location where services are provided

• Medical Therapy

Unit (MTU)

• Housed in public

schools

• 2 MTUs
• 1 Satellite
• 2

Referral process

• Anyone can refer
• Parents, teachers, nurses,

social workers, doctors

• Requirements
• CCS application
• Current medical report
• Doctor’s prescription for

OT & PT evaluation

• http://www.dhcs.ca.gov/services/ccs/Pages/

apply.aspx

Eligible diagnoses

• Neurologic

Cerebral palsy, Spina bifida, Spinal cord injuries, Traumatic brain injuries, At risk for cerebral palsy under age 3

• Orthopedic

Arthrogryposis, Osteogenesis imperfecta, Arthritis, Amputations

• Neuromuscular

Muscular dystrophy, Spinal muscular atrophy, Myopathy

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Eligible diagnosis – at risk for CP

• CCS applicants under three years of age shall be eligible

when two or more of the following neurological findings are present:

• Exaggerations of or persistence of primitive reflexes

beyond the normal age (corrected for prematurity)

• Increased Deep Tendon Reflexes (DTR) that are 3+ or

greater

• Abnormal posturing as characterized by the arms, legs,

head, or trunk turned or twisted into an abnormal position

• Hypotonicity, with normal or increased DTRs in infants

below one year of age.

• Asymmetry of motor findings of trunk or extremities

Meet Ava

Ava

• Born at 36

weeks gestation

• Small for

gestational age

• Hospitalized for

2 weeks in the NICU working

• n feeding

issues

Enrollment in CCS-MTP

• First seen in CCS-

MTU at 11 months

• ld
• Not yet sitting

independently

• Using right hand

more than left

• Hypertonia
• Accepted into the

program with diagnosis of “At- risk for CP”

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Medical Course

• She continued to

grow very slowly

• Head MRI

normal

• Facial differences

were noted

• Initial round of

genetic testing was normal

• Second tier of

genetic testing revealed a diagnosis

Developmental Progress Over Time

• Feeding was a challenge;

syringe fed. Oral motor therapy was initiated.

• Nice pincer grasp
• She began to sit

unsupported, then crawl, then stand independently

• Still not walking

independently

• Using all of her limbs

symmetrically

• No braces or equipment
• Limited language

Determination of Medical Eligibility – Age 3

• Taking one or two steps;

nice movement patterns that suggest she is capable of walking without assistance

• Normal muscle tone and

reflexes

• Symmetrical use of arms

and legs

Determination of Medical Eligibility – Age 3

• No qualifying diagnosis of

CP

• Services will be

transitioned to the school district and private therapists for ongoing OT and PT services when she turns 3

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How are therapy services determined?

• Range of motion
• Strength
• Neurologic status
• Balance and

Equilibrium

• Postural alignment
• Hip surveillance
• Fine Motor Skills
• Gross Motor Skills
• Activities of Daily Living
• Oral Motor Skills
• Perception
• Mobility
• Gait

OT and PT Evaluation

• Assessments commonly used

Strength Activities of daily living Fine motor skills

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Gross motor skills Gait Balance Posture & alignment

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How are therapy services determined?

OT and PT Evaluation

• Standardized Assessments
• Gross Motor Function Measure (GMFM)
• Peabody Developmental Motor Scales (PDMS)
• Beery-Buktenica Developmental Test of Visual

Motor Integration (VMI)

• Bruininks-Oseretsky Test (BOT) of Motor

Proficiency

• Canadian Occupational Proficiency Measure

(COPM)

• Functional Improvement Scale (FISC)

Classification of Cerebral Palsy

• Gross Motor Function Classification System

(GMFCS)

• Manual Ability Classification System (MACS)
• Communication Function Classification System

(CFCS)

How are therapy services determined?

OT and PT Evaluation

• Goals
• Child and Parent
• Functional
• Canadian Occupational Performance

Measure (COPM)

Individualized therapy plans

• Hands on treatment

activities

• Co-Treatment
• Consultation
• Monitoring
• Intensive Treatment
• Home activity

program

• Home and School

visit

• Durable Medical

Equipment

• Orthoses
• Frequency

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Determining Therapy Frequency

• Motivation
• Cognition
• Parent Involvement
• Progress/Regression
• Complexity/Multiple

needs

• Age
• Recent

procedure/surgery

• Participation
• Diagnosis
• Emerging skill
• Change in status: growth

spurt, hospitalization, seizures

• Shift in age expected

skills

• Equipment needs
• Home Program training
• Specific Goal
• Rate of change
• Maturity

Medical therapy conference

Developmental Pediatrics Physiatry Orthopedics

Medical therapy conference

• Developmental pediatrician (birth to 6

years)

• Physiatrist (ages 7 to 11 years)
• Physiatrist (ages 12 to 21 years)
• Orthopedist (as appropriate)
• Kaiser (birth to 21 years)

Medical therapy conference

• Every 6 months for active therapy
• Every 12 months for monitoring
• Determine medical eligibility at age 3
• Supervise therapy program
• Recommend durable medical equipment
• Referrals to specialists
• Hip surveillance
• Transition planning

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Social Worker Parent liaison

Durable medical equipment (DME) clinics

Orthotics clinics

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Dental clinics ADL groups Exercise groups Prom

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Prom

Meet Taylor

Taylor

• 39 weeks gestation via C-section

due to decreased fetal movement

• Low APGARs
• Fetal maternal hemorrhage
• Very low hematocrit
• Global brain injury
• Respiratory failure
• Seizures, pulmonary

hypertension, thrombocytopenia, sepsis

• NICU 12 days

Picture of Taylor as a newborn

Taylor

• By 11 months: increased tone and reflexes in

all extremities; asymmetrical use of hands

• Diagnosed with cerebral palsy at 24 months
• Services through Early Start by 11 months
• Developmental specialist
• Occupational therapist (OT)
• Physical therapist (PT)
• CCS at 2 years 11 months
• OT
• PT

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Neurologic status

• 8 year old with spastic quadriparesis
• Increased tone in all four extremities
• Lower extremities > Upper

extremities

• Left > Right
• Impaired balance reactions
• Impaired protective reactions
• Impaired sensation: vestibular, tactile
• Impaired visual motor skills
• Possible seizures

Range of Motion and Strength

• Tightness into shoulder flexion and

abduction, supination, elbow extension, hip abduction, hip extension, knee extension, dorsiflexion

• Weakness in all four extremities and

trunk

• Difficulty dissociating:
• Eyes from head
• Right and Left lower extremities
• Trunk and extremities

Current picture of Taylor in therapy

Posture

• Sits independently with erect

posture for 2 minutes

• Sits and rotates to either side

(to right better than to left

• Postures with rounded spine;

elbow, wrist, finger, hip, and knee flexion; hip adduction and internal rotation; plantar flexion

Fine Motor Skills

• Reaches over head without loss of

balance

• Difficulty with elbow extension,

supination, precise use of fingers and hands

• Hypermobility of some joints with

hypomobility of others in her hands

• Recommended use of hand splints

to improve fine motor function

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Activities of Daily Living (ADLs)

• Feeds self using fingers,

utensils, cup with lid

• Takes off socks
• Pulls shirt off overhead
• Takes off open front sweater

with minimal assistance

• Pushes large buttons through

button holes using thumb splints

Functional Mobility and Gait

• Rolls, commando crawls, transitions

side-lying to sitting

• Transitions
• Sit to stand with Contact Guard
• Floor to kneel with Contact

Guard

• Floor and standing with Minimal

Assistance

• Transfers
• Bed and wheelchair with

Moderate Assistance

• Toilet and tub: Dependent

Functional Mobility and Gait

• Walks
• Level surfaces and up stairs with

Moderate Assistance

• Gait trainer independent in open

space once positioned

• Manual wheelchair
• Independent in home and

classroom

• Power mobility
• Supervision
• Working with orientation and

mobility specialists

Strengths

• Communication and social skills
• Age appropriate play skills and

interests

• Willing to try anything
• Loves coming to therapy

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PT

• Stand with one arm support

for 30 seconds

• From sitting on edge of bed,

lower self to side-lying to either side in the correct

• rientation

Goals

OT

• Put on open front shirt or sweater
• Hike pants up while standing with one hand

support

Individualized therapy plans

• Active treatment
• Between 1x/week and 4x/week
• Increased frequency after
• Bilateral soft tissue

surgery

• Bilateral femoral

derotation osteotomies

• Botox injections
• Selective dorsal rhizotomy
• Consultation
• Home visits
• Home exercise program
• Functional transfers
• Equipment
• School visits
• Equipment
• Positioning
• Collaborate with school

based therapists

Individualized therapy plans

• Consultation
• Private specialists
• Orthopedists
• Equipment
• Orthoses
• Surgeries
• Neurologists
• Spasticity management
• Physiatrist
• Botox injections

Individualized therapy plans

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• Consultation
• Private specialists
• Spasticity Management

Clinic

• Selective Dorsal

Rhizotomy

• Children’s Hospital Oakland
• Inpatient Pediatric

Rehabilitation

Individualized therapy plans

• Home Activity Program
• Standing in a stander
• Hand splint
• Positioning
• Stretches
• Balance
• Posture

Individualized therapy plans Medical therapy conference

• Developmental pediatrician (age 3 – 5)
• Physiatrist (age 5 to present)
• Every 6 months

Durable medical equipment (DME)

• Manual wheelchair
• Power wheelchair
• Gait trainer
• Adaptive tricycle
• Stander
• Toilet seat

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Orthoses

• Ankle foot
• rthoses (AFO)
• Sitting Walking

and Standing Hip orthosis (SWASH)

Meet Rebecca

Rebecca

• 32 year old woman
• Spastic quadriparesis
• Bay Area native
• Oldest of two girls
• Sister is a physical

therapist

• Graduated with BA and

MA from Notre Dame de Namur

• Marriage and Family

Therapist (MFT)

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Birth History

• Pregnancy uneventful until 28

weeks

• Hospitalized and administered

steroids for lung development

• Delivered at 29 weeks
• 2 pounds 3.7 ounces

Birth History

• Ventilated for 24

hours

• NG tube for less than
• ne month
• Diagnosed with

Tetralogy of Fallot

• NICU 2 months

Tetralogy of Fallot

• At 6 months,

Tetralogy of Fallot repair

Rebecca and Mom

Spastic quadriparesis

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Services

• Regional Center
• OT
• PT
• Speech

CCS Services

• Parent goals
• Mobility
• Social
• Education
• Maximize her
• pportunities

Services

• Attended Early Childhood Education preschool
• In a class with other children with orthopedic

and neurologic conditions

• Special education teacher and classroom aides

CCS Services

• OT and PT services at the Medical Therapy Unit
• Located on the Early Childhood Education

campus

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Physical Therapy

• Increased tone in

extremities

• Decreased range
• f motion
• Postural

alignment

• Balance
• Mobility
• Gait

Occupational Therapy

• Range of motion
• Increased tone
• Weakness
• Postural

alignment

• Fine motor skills
• Self care
• Perception

Durable medical equipment

• Manual wheelchair
• Walker
• Ankle Foot Orthoses
• Power wheelchair

Surgery

• Age 6, soft tissue

lengthenings

• Hip adductors
• Hip flexors
• Hamstrings

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Opportunities Adult Life

• Lives in San

Francisco

• Works full time as

MFT

Adult Life

• Exercise
• Recreation
• Travel
• Restaurants
• Movies
• Sporting

events

Adult Life

• Self care
• Independent with upper

dressing

• Manages clothes for toileting
• Maximal assistance to don

lower extremity garments

• Independent with basic

grooming

• Benefits from assistance for

bathing, cooking and household chores

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Adult Life

• On the go
• Drives adapted van
• Transfers independently

between power wheelchair and seat of the car

Adult Life

• Challenges
• Travel
• Weather
• Medical care
• Equipment

failure

Questions?