Applying developmental coordination disorder …27281...Applying developmental coordination disorder...

Applying DCD Treatment Theories to Physical Therapy Practice

Applying developmental coordination disorder treatment theories to physical therapy practice:

a case report

___________________________________________________________

A Case Report

Presented to

The Faculty of the College of Health Professions and Social Work

Florida Gulf Coast University

In Partial Fulfillment

of the Requirement for the Degree of

Doctor Science in Physical Therapy

_____________________________________________________________________

By

Mary Lynn Hodges

2014


APPROVAL SHEET

This case report is submitted in partial fulfillment of

the requirements for the degree of

Doctor of Physical Therapy

__________________________

Mary Lynn Hodges

Approved: May 2014

______________________

Ellen Donald, MS, PT

Committee Chair

_______________________

Sharon Irish Bevins, PhD, PT

The final copy of this case report has been examined by the signatories, and we find that both the content and the form meet acceptable presentation standards of scholarly work in the above mentioned discipline.


Acknowledgments

I would like to begin in thanking those who were influential in my completion of my case

report and final scholarly paper. I begin in thanking my committee, Professor Ellen Donald and

Dr. Sharon Bevins for their knowledgeable insight, patience, advice, and encouragement

throughout my independent study. I also want to especially thank Professor Donald and those at

SPOT Therapy Associates for allowing me develop and increase my therapy skills and work with

their patients. I always looked forward to each day I spent there in developing skills in pediatric

rehabilitation.


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TABLE OF CONTENTS

Abstract ------------------------------------------------------------------------------------------------- 5

Introduction -------------------------------------------------------------------------------------------- 6

Treatment Approaches ------------------------------------------------------------------------------ 9

Top down approach ------------------------------------------------------------------------- 11

Bottom up approach ------------------------------------------------------------------------ 13

Case Report ------------------------------------------------------------------------------------------ 14

Patient History -------------------------------------------------------------------------------- 14

Examination -----------------------------------------------------------------------------------15

Interventions -------------------------------------------------------------------------------- 16

Outcomes ------------------------------------------------------------------------------------ 18

Discussion -------------------------------------------------------------------------------------------- 22

References -------------------------------------------------------------------------------------------- 25

Appendix A Summary of Patient Treatment Sessions ------------------------------------------ 27

Appendix B Total Body Patterns------------------------------------------------------------------- 28


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Abstract

This case report describes the application of two treatment intervention theories for

Developmental Coordination Disorder (DCD) to physical therapy practice. The patient was an 8-

year-old girl with hypotonicity, generalized weakness, balance, coordination deficits, and poor

cardiovascular endurance. Parent concerns related to frequent episodes of tripping and falling.

DCD treatment intervention theories of the bottom up (process or deficit oriented) and top down

(functional skill approach) methods were used to guide and direct the physical therapy treatment.

After 8 months of treatment, the child improved in balance, coordination, gross motor

development, cardiovascular endurance, and self-esteem. The case report demonstrates a method

to apply the current knowledge of DCD treatment theory in a way can be integrated into clinical

practice. Applying a strategic combination of each theory in this case has led to the development

of clinical questions for future research.


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Introduction

Developmental Coordination Disorder (DCD) affects nearly 6% of children in the United

States, aged 5 to11 (Kaufman & Schilling, 2007), with 5% of those born at full term diagnosed

with the disorder as compared to 16% of those born prematurely (Roberts, Anderson, & Davis,

2011). According to the Diagnostic and Statistical Manual of Mental Disorders, DCD presents

with developmental coordination impairment, which can significantly restrict activities of daily

living and academics of a child. The impairments cannot be related to any other medical

condition or another developmental disorder in order to be diagnosed as DCD (Kaufman &

Schilling, 2007). Prematurity has been linked to those who are diagnosed with Developmental

Coordination Disorder by three years of age (Goyen & Lui, 2009). The child must not display

involuntary movements or sensory loss (Barnhart, Davenport, Epps, & Nordquist, 2003). Mental

retardation is one condition that may be diagnosed along with DCD; however, only when the

coordination deficits are in abundance over the mental age of the child (Kaufman & Schilling,

2007). Other terminologies associated with DCD include: clumsy child (Orton, 1930 & Gubbay,

1965), developmental dyspraxia (Walton, 1962), and minor neurologic dysfunction (Hadders-

Algra & Touwen, 1992).

With DCD affecting nearly 6% of children aged 5-11 in the United States (Kaufman &

Schilling, 2007), it is important to find treatment strategies for this large population. Physical

therapy has been found to be the most effective treatment for this diagnosis. Within physical

therapy treatment, there are two main types of treatment approaches that have been researched

although no consensus has been reached on which type of approach is the most effective. It is

important to find the most successful approach to treat this population.


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The impairments in DCD are found in gross motor skills, fine motor skills, and

psychosocial skills. Many children with gross motor dysfunctions are hypotonic, present with

primitive reflexes, and have immature balance. Participation in sports is difficult for these

children because they often fall, drop items easily, have awkward running styles, and have slow

reaction times. Dysfunctions involving fine motor skills are identified when children find

difficulty with gripping items, dressing themselves, and handwriting. Indicators of dysfunctional

psychosocial skills in children with DCD are low self-esteem, high anxiety, and fewer friends

than those without DCD (Barnhart, Davenport, Epps, & Nordquist, 2003). Research by Engle-

Yeger & Hanna Kasis found a relationship between children with DCD, their perceived self-

efficacy, and their willingness to participate in activities. With lower self-efficacy, they found

that children also have lower motor performance scores and lower preference to participate

(Engle-Yeger & Hanna Kasis, 2009).

It is still unclear whether the etiology of DCD is due to a physiological impairment or a

type of developmental delay. It is also uncertain as to which sensory system is to blame

(Branhart et al., 2003). The symptoms could stem from a vestibular, visual, or proprioceptive

system complications (Kaufman & Schilling, 2007). Common DCD characteristics are

described in Table 1. This disorder limits children from participating in many activities that are

essential to healthy development. The earlier an effective treatment for children with DCD is

found, the faster they are able to join their peers (Mandich & Polatajko, 2003). There are two

styles of treatment that are currently being researched for their effectiveness in treating DCD.


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Table 1. Common DCD Characteristics

Common DCD Characteristics

No increase or decrease of deep tendon reflexes

Completing tasks inefficiently

Emotionally sensitive

Low muscle tone Appear to be messy or accident prone

Believes their lack of control is due to the environment or someone else

Abnormal Posture • Forward head • Winging of scapula • Increased lordotic curve • Hyperextension of elbows • Genu recurvatum

Decreased reaction times (protective reactions, postural reactions, visual, and auditory)

Gait • Toe walkers • High stepping • Stomping • Slapping foot down • Shuffling

Problems not associated with physical strength, vision, hearing, or deformity

Appear to be messy or accident prone

Low self esteem and at risk for psychosocial problems

Poor motor planning Poor self image Presence of developmental reflexes (ATNR and STNR)

Difficulty with ADLs Vestibular impairment

Oculomotor deficits

Delayed hand dominance Simultanagnosia (inability to perceive more than a single object)

Dysdiadochokinesis (impaired ability to perform rapid, alternating movements)

Somatoagnosia (impairment of body awareness)

Inability to sequence thumb to finger then finger to nose

Delayed auditory processing

Poor proprioception Decreased fine motor control (handwriting)

Very rough with toys and doesn’t explore different ways to play with them

Needs full attention to complete task

Decreased rotation Difficulty weight shifting


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Treatment Approaches

The top-down method of treatment (or Functional Skill Approach) is just one of the two

categories of treatment interventions for Developmental Coordination Disorder. The other

category is the “bottom-up” (or deficit-oriented) treatment, which involves treating the

underlying dysfunction of motor control. Treatment examples include perceptual motor training,

process-oriented treatment, and sensory integration intervention (Hillier, McIntyre, & Plummer,

2010). The “top-down” method (or task oriented) involves gaining new skills and cognitive

problem solving (Branhart et al., 2003). Treatment examples include task-specific intervention

and cognitive approaches (Hillier et al., 2010). Table 2 presents common activities for top down

and bottom up theories. Kaufman and Schilling observed the top down approach in treating

children with DCD to be more effective than the bottom up approach (Kaufman & Schilling,

2007).


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Table 2. Top Down and Bottom Up Activities

Top Down Bottom Up Uses motor learning principles and emphasizes direct teaching of a task specific activity

Activities that use proprioceptive, vestibular, and tactile input- not mastery of the specific activity

Changes can be made in • Sequence • Size or shape of the tool • Position of the tool • Speed, length, or repetition of the trial • Required strength

Vestibular • Rolling on floor, down inclines • Rolling chairs • Tilt boards • Mini trampolines • Running, fast walking • Bolster swings • Scooter boards

Need to be taught as a specific skill, break down the skill into a number of parts, include problem solving activities to encourage the child to search for solutions

• Galloping • Throwing a ball • Mirroring activities • Strengthening • Rock wall climbing • Ladder activities

Proprioceptive • Shaking out hands and arms • Pressure on top of head/ shoulders • Weighted vest • Chewing

Cognitive Motor • Emphasize the planning and execution of

movement • Child is able to choose goals and be

guided through the learning activity and problem solving

• Comparative Discussion o How can you make this better?

Comparing two ways • Self rating

o What type of grade would you give yourself

• General question and answer o Did that work for you?

• Therapist evaluation o You are throwing the ball well

and hitting the target- reinforcing positivity

Dynamic Systems • Promote participation and change the

environment or task to challenge • Practice

(Connolly, 2013)


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Top Down Approach

Some of the effective top-down approach methods include: strength training, aquatic

therapy, cognitive treatments, and verbal actions. A strength training study was conducted by

Kauffman & Schilling, which involved a young boy diagnosed with Developmental

Coordination Disorder undergoing a twelve-week strength-training program. The child had poor

proprioception and consequently, he became inactive as most children do with DCD. The theory

behind this method is that the child will develop a better awareness of his body with increased

neuromuscular activation through muscle action during his strength training. The body interprets

joint position with the information provided by the muscular system. With increased strength and

neuromuscular changes the child could find an increase in proprioception due to increased

information input from the muscular system. This child was unsafe in his environment. He also

put the other students in his class in danger because of his poor coordination. A program was

developed with the use of the Guide to Physical Therapist Practice (American Physical Therapy

Association, 2003). At the conclusion of the study, the boy increased his muscle strength

(including rectus abdominus and gluteus medius) showed much improvement in functional

movement (including increased ability to jump in place, raise his scapula off of mat to perform

an abdominal crunch, maintain a wheelbarrow position, increased running speed and increased

running agility) and enhanced both static and dynamic limb position awareness (able to replicate

all movements except counterclockwise in hips and shoulders). Other observable changes in

functional movement included the ability to swim underwater, improved awareness in the

classroom with decreased incidence of stepping on other children or objects, and marked

confidence increase in new abilities. This intervention gave the boy positive outcomes for both

impairment level and functional level (Kaufman & Schilling, 2007). Aquatic therapy


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interventions have also been studied along with land-based exercise programs as described

below.

An aquatic therapy randomized control study was conducted by Hillier, McIntryre, &

Plummer (2010) which involved giving a treatment group six weekly aquatic therapy sessions

while the other group the control group remained on a waitlist for those six weeks. The study

group included thirteen children diagnosed with DCD, with a mean age of 7 years old. The

aquatic therapy included task-specific, low intensity training such as standing balance, running,

and ball skills. The children were able to see immediate feedback during their performance.

Those who experienced the aquatic sessions achieved an improved score on the Movement

Assessment Battery posttest (Hillier et al., 2010). This pilot study provides a foundation for

continued investigation for aquatic therapy in the top down approach theory. Another treatment

intervention under the top down approach included cognitive treatment.

A cognitive treatment study was conducted in 2001 by Miller, Polatajko, Missiuna,

Mandich, & Macnab. They narrowed cognitive treatments to two approaches for this study

involving children diagnosed with DCD. One approach, Cognitive Orientation to daily

Occupational Performance (CO-OP), was then evaluated against another approach known as the

Contemporary Treatment Approach (CTA). In the end, the CO-OP approach was found to be

more effective. The CO-OP involves the therapist teaching the child to self-talk during problem-

solving strategies. The children learn the Goal-Plan-Do-Check method and they try to apply it to

their task. The therapist is allowed to only guide the child and connect their knowledge along

with helping them apply it to new situations (Miller, et. al., 2001). With self-talk found to be an

effective strategy, other studies have included using verbal actions as a treatment method.


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A verbal actions study was conducted in 2003 by Neimeijer, Smits-Engelsman, Reynders,

& Schoemaker. They used teaching principles to help improve motor learning. The principles

were put into three categories: giving instruction, providing and asking for feedback, and sharing

knowledge. This was a way to supplement instruction on motor skills. Children without DCD

informally learn and perform without paying close attention to their actions; children with DCD

have to pay close attention to all of their actions in order to learn effectively. The therapist

becomes the way the child learns motor skills through their instruction verbally (Niemeijer, et.

al., 2003).

These studies incorporated top-down methods to treat DCD. The children all acquired a

new skill, which helped to treat their overall coordination. In all of the studies’ discussions and

conclusions, they found that there needed to be more research as well as larger testing groups for

the findings to be more widely accepted. In order for research to continue, it is important to

identify which type of treatment approach is being utilized by practicing physical therapists for

the best treatment outcomes for their patients. The other treatment category, bottom-up, activates

higher levels of neuronal function in order to address the motor dysfunction (Branhart et al.,

2003). The bottom-up treatments include initiating normal movement strategies through the

sensory system with research explained below.

Bottom-up Approach

A bottom-up approach includes sensory integration therapy, kinesthetic training, and

perceptual motor training. Through research these strategies have found success with positive

feedback and motivation. The kinesthetic training uses positive reinforcement for acquiring a

motor skill through memorizing the kinesthetic information. (Laszlo & Bairstow, 1983)

Perceptual motor training has the child use a wide range of experiences with motor and sensory


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tasks with improvement through practice of the sensory to enhance motor capability (Miller, et.

al., 2001). Both approaches have found to be successful in the literature: however, there is

limited research investigating the most commonly used approaches by practicing physical

therapists.

Case Report

The following case report is included to provide an example of an 8-year-old girl

receiving physical therapy. The child described in this case report demonstrated motor behaviors

consistent with a diagnosis of DCD. The purpose of this case report is to demonstrate how the

strategic use of both bottom up and top down theories were used to develop an intervention

approach to be utilized in clinical physical therapy practice.

Patient History

The case patient was an 8-year-old girl who was referred to physical therapy by her

pediatrician. She was born prematurely at 24 weeks gestation with a birth weight of 1 lb 7oz. She

had a medical diagnosis of hypotonia (781.3), a treatment diagnosis of lack of coordination

(781.3), and strength and balance deficits (781.99). Parents expressed concerns of clumsiness,

falling frequently at school, not enjoying gym class, and the patient was often picked on at

school. With this information, it was determined that the patient was appropriate for participation

in a bottom up and top down theory rehabilitation program due to coordination deficits and

history of prematurity. Physical examination would have been needed to support the parental

reports to determine if top down and bottom up theories of rehabilitation should be included in

the patient’s plan of care.


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Examination

At the time of evaluation, the patient demonstrated hypotonicity, poor cardiovascular

endurance, significant generalized weakness, poor body composition (significant weight

distribution around the waist), delayed gross motor skills, as well as delayed balance and

coordination deficits. She also displayed shortening of her hamstrings, gastrocnemius, and soleus

muscles bilaterally, leading to toe walking and running on her toes without trunk rotation. She

demonstrated delayed equilibrium reactions in standing and sitting with single limb balance of 2-

3 seconds with poor control. Poor control in hopping was observed and it was noted that she

always lead with the left lower extremity and unable to land symmetrically. She displayed poor

body awareness requiring verbal and visual cuing for activities and decreased strength with

inability to perform modified push up, able to complete one sit up, and unable to crab walk or

wheelbarrow walk. She was unable to consistently mirror upper extremity and lower extremity

movements given by the therapist. It was noted the patient could not tie her shoes and preferred

to wear footwear that did not require the fine motor task. This patient was appropriate for DCD

treatment theories of top down and bottom up due to decreased coordination, delayed motor

skills, toe walking, delayed equilibrium reactions, and poor motor planning. It was observed that

the patient was emotionally sensitive. She was quick to come up with a story to explain why she

wasn’t able to complete a task or tell a story about an activity in which she excelled. With a

combination of theories approach, it seemed appropriate that the patient have found gains in

motor planning and coordination by completing and mastering basic tasks before attempting

coordination challenging tasks. Below is the patient’s problem list with deficits consistent with

DCD in bold consistent with Table 1.


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Problem List

• Low tone • Decreased coordination • Toe walking/ running • Difficulty weight shifting • Decreased rotation • Poor proprioception • Emotionally sensitive • Poor self image and self-esteem • Decreased reaction time • Difficulty with fine motor tasks (tying her shoes) • Requires full attention to complete a task • Anxiety disorder • Decreased strength • Poor body composition • Decreased cardiovascular endurance • Delayed equilibrium reactions

Interventions

Over the course of 8 months with, 60-minute sessions once per week, the patient was

treated using a strategic combination of the DCD treatment theories of bottom up and top down

methods. The bottom up method (deficit oriented) involves treating an underlying dysfunction or

motor control (Hillier, McIntyre, & Plummer, 2010) and top down involves gaining new skills

and cognitive problem solving (Branhart et al., 2003). Each session began with a bottom up

theory activity then progressed to a top down activity. In early sessions, the patient was trained in

a normalized gait pattern with the added benefit of increasing cardiovascular endurance in

treadmill walking. This type of practice was used to increase proprioceptive input in a safe

environment consistent with the bottom up theory. The safe environment was an important

consideration because to begin with the patient was hesitant on walking on the treadmill. She

was trained on safe habits when using the treadmill and she gained confidence in that she was in


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control of the speed. After instruction and verbal cues, the patient was able to self-correct to a

normalized gait pattern. With practice, the patient was able to progress to treadmill running with

improved gait pattern and reduced anxiety. With every new activity, the patient displayed

anxiety and expressed that she was unable to complete the activity. After attempting the activity

and practicing, the patient was able to gain confidence in her motor skills and understanding that

she was able to complete the activities.

Other bottom up activities which focused on proprioceptive, vestibular, and tactile input

without mastering an activity included: jumping on the mini trampoline focusing on symmetrical

jumping, tilt board, and swing progressing, to quadruped position, scooter board supine and

prone, lower extremity stretching, modified push ups and sit ups. By beginning with a bottom up

activity, the patient was able to become more aware of her body and increase confidence in her

motor skill abilities to prepare for top down activities. The patient found increased difficulty in

completing top down activities if the bottom up activities were not performed first.

Top down activities require motor planning integration along with gross motor skills,

coordination, balance, and strength. When using the top down theory, changes can be made to an

activity in order to help increase the learning of the task or activity to increase or decrease

difficulty. Those changes include sequence, size, speed, length, position, number of trails, and

the required strength to complete the activity (Connolly, 2013). The patient was able to progress

in galloping and backward walking with increased speed and proficiency in starting with either

foot. Bear walking with decreased knee extension and increased endurance in the activity. She

improved balance beam walking with ability to complete three feet of tandem walking without a

fall. In the beginning of treatment, the patient was unable to complete the rock-climbing wall.

She required verbal and tactile cues for foot and hand placement. By the end, of treatment she


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was able to self-talk herself through the activity for hand and foot placement to be able to reach

the top of the wall using the cognitive theory of this top down activity as well as her gains in

motor skills.

Cognitive motor theory was also used in top down swing activities. The patient was

instructed in prone swinging with the objective to weight shift and plan movement to be able to

return an object. The activity was broken down and each part was emphasized so the patient

would be able to complete each movement well. The patient was asked to problem solve to

determine which type of movement was necessary to complete the task. The patient was asked if

one way was better than another while each attempt was made. The patient learned to self-correct

and to be able to tell when a movement would achieve the desired result. The therapist reinforced

positivity throughout the attempts consistent with cognitive motor theory. The patient learned to

be able to push herself in a way that she would be able to reach the object, then planned to move

to get it to the desired target. The activity was successfully progressed to a quadruped position

with increased targets. In the top down theory, dynamic systems was also used on the swing and

rock climbing wall through promoting participation in the activity, changing the environment to

challenge the patient, and practicing the task.

Outcomes

The patient demonstrated increased ability to complete more difficult motor planning

intensive top down activities after beginning each session with a bottom up activity. At the

beginning of each treatment session the patient started with a proprioceptive, vestibular, or tactile

input intensive activity. Occasionally, the patient would come in attempting a top down activity

first such as galloping or balance beam walking. The patient would usually struggle to maintain

proper form or complete the activity. Those observations demonstrated the need to complete


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bottom up activities at the beginning of the session. The patient also demonstrated increased

ability to begin sessions with more intensive bottom up activities as cardiovascular endurance,

strength, and self-efficacy improved. Appendix A demonstrates the patient’s ability to complete

more difficult tasks as time progressed.

Bottom Up

From the baseline, the patient was anxious about starting a walking program on the

treadmill. Her anxiety was noticeable in her reluctance to increase the speed of the treadmill or

stay on for longer durations of time. She expressed that she was afraid she would not be able to

keep up with the treadmill or become tired. The patient found comfort in ability to know how to

safely use the treadmill with safety clip attached and that the therapist was close. The patient was

able to learn how her feet should sound when walking with a normalized gait pattern and enjoyed

it when she knew she was doing a good job helping to reduce her anxiety. The patient had full

control over the treadmill speed and was positively encouraged to increase speed when the

therapist knew the patient was ready. In the first 4 sessions of treatment, the patient completed

walking on the treadmill with a progression to running in the last 4 sessions of treatment with

increased duration to 5 minutes of running with 2 minutes of a warm up and cool down.

Cardiovascular endurance training became an added benefit to the bottom up theory and gait

training. After 8 training sessions, the patient was able to complete the sessions with a decrease

in rest breaks, decreased visible signs of fatigue, and less reports of fatigue. After the treadmill,

the patient was instructed in stretching the bilateral gastrocnemius, soleus, and hamstrings.

Improvements were noted in cognitive awareness of the stretch, ability to complete the stretch,

and increased bilateral lower extremity flexibility. The patient improved in mini trampoline

jumping with increased ability to sequence jumps with poor carryover to over ground jumping.


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The patient was able to attempt modified push-ups and sit-ups in the last three weeks of

treatment. She completed one set of ten sit-ups with proper form and one modified push up with

good form. This demonstrated an increase in strength due to her inability to complete those

activities from the beginning of treatment.

Other bottom up activities included the tilt board with increased apprehension for forward

and backward tilting more than right to left. In the, beginning the patient’s self-doubting talk was

most prevalent in this activity. The patient was adamant she was not able to complete the

activity; however, within a few minutes she was able to deliberately rock the tilt board

comfortably. Within two weeks the tilt board became a smooth motion and an activity she

enjoyed. After completing these bottom up activities, the patient was able to move to more

advanced top down activities during the treatment sessions.

Top Down

Many of the top down activities were practiced throughout the 8 sessions. Those

activities included galloping, backwards walking, bear walking, and balance beam. The patient

found improvements in galloping though ability to gallop bilaterally increased speed of

backward walking, increased speed and duration in bear walking stance, and ability to complete

tandem balance beam walking for three feet without a loss of balance. The bear stance and

modified bear stance is an example of a flexion total body pattern (found in Appendix B). The

total body patterns can be used to move the body into one pattern to encourage normalized

movement patterns. Crab walking was attempted in the last 4 sessions. The patient found

improvement in strength to maintain crab-walking stance but continued to need development in

ability to coordinate hands and feet to walk. In reference to the strength training study conducted

by Kauffman & Schilling, this patient found increased strength through improved ability to


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complete sit-ups and maintaining crab-walking position. The patient also found improvement

with mirroring activities due to enhanced static and dynamic limb position awareness. The

patient also demonstrated improved limb awareness and coordination through ladder activities.

Each session of the ladder activity started out with a slow demonstration of the activity broken

down to each step. The patient usually found difficulty in the first few attempts and through each

session she was able to integrate the movement more quickly than the session before. If the steps

were too difficult, the patient would run through it quickly and not stop to listen to instruction. It

was very important to bring it back to basic movements before moving on in order for the patient

to feel comfortable with the movement for the to perform it properly. In order to break down

jumping with two feet, the patient was instructed in hoop jumping in the last few sessions of

treatment. The patient was able to progress to being able to complete the jumps within the hoops

with increased speed. Fatigue limited this activity in the beginning with 5 jumps; however, the

patient was able to progress this activity to include 4 sets of 5 jumps. The patient was able to

improve to more advanced top down activities in the last sessions of treatment.

The more advanced activities included prone activities on the swing and the rock-

climbing wall. The patient started uncomfortable sitting prone on the swing but she was able to

advance to maintain a quadruped position, hold a pelvic tilt, and then lift up to two limbs for up

to a 30 second hold. She was also able to advance prone swinging with weight shifting and motor

planning to be able to reach an object then change direction and trajectory to place the object. In

the beginning, the patient was frustrated with the activity and would move out of position to be

able to complete the activity. As the patient practiced and talked to the therapist about the next

step, the patient began to enjoy the activity and was successful in completing it. The therapist

instructed the patient to pay close attention to the activity to increase the patient’s knowledge as


22

the Neimeijer, Smits-Engelsman, Reynders, & Schoemaker study finds is the most beneficial

way to instruct a child with DCD. The study found giving instruction, asking and providing

feedback, and sharing knowledge are beneficial in instructing motor skills.

Another use of the verbal actions study was in the instruction of the rock-climbing wall.

The patient was eager to try the wall for the first time but after stepping up and onto the wall, the

patient stated that she did not know where to put her hand next. She also stated that she was

unsure if she could pull up with her arms, unaware that she would also be pushing up with her

legs. The patient was given instruction and both the patient and therapist talked through each

hand and foot placement along with tactile assistance and support from the therapist. The patient

was encouraged to try again after reaching the top and each time with less verbal instruction.

Each time back at the wall, the patient made progress first with less tactile assistance and support

then to less verbal instruction. The patient learned how to talk herself through the motor activity

as well as to plan her next move. By the end of the sessions, the patient successfully climbed the

rock wall without tactile or verbal assistance. Functional improvements were also observed with

decreased toe walking, decreased running on toes, and increased confidence in motor abilities.

Those achievement displays and increase in strength, coordination, and motor planning with the

application of both top down and bottom up motor learning principles.

Discussion

This case report provided an example of an 8-year-old girl with low tone, decreased

strength, poor coordination, toe walker, and poor body awareness. The patient received treatment

consistent with the two DCD treatment theories of bottom up and top down. Through the use of

both treatment theories, the patient demonstrated gains in strength, balance, coordination, gross

motor development, cardiovascular endurance, and self-esteem. One of the most significant gains


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was in self-efficacy and the belief that she was able to complete many of the activities her peers

were completing. She was able to decrease the amount of self-doubt throughout the sessions and

became more open to trying new activities.

Engel-Yeger & Hanna Kasis identified the correlation between children with DCD, low

self-efficacy, and willingness to participate in activities. They emphasized the importance to

identifying DCD early in order to avoid low self-efficacy for children (Engel-Yeger & Hanna

Kasis, 2009). Before physical therapy treatment, this patient fit Barnhart, Davenport, Epps, &

Nordquist’s assessment of children with DCD with low self- esteem, high anxiety, and fewer

friends than those without DCD. Towards the end of the treatment sessions, there was a decrease

in her excuses and stories because she learned the tools necessary to overcome her motor

deficits. She learned how to complete increasingly difficult tasks by integrating the steps of the

less difficult tasks such as prone swinging to reach for objects. By the end of the session, she was

able to think through the steps to be able to swing far enough to reach for the objects the

complete the task.

The patient’s increase in coordination and proprioception can be linked to increases in

strength due to neural adaptation (due to a structured program) and neuromuscular learning (due

to repetitions of the activity). Kauffman & Schilling found increased information provided from

the muscles on joint position for improved proprioception (Kauffman & Schilling, 2007).

Increases in willingness to participate due to decreased fatigue can be linked to increased

cardiovascular endurance. Continued monitoring of this patient’s weight and obesity risk is

important. A consultation to assess cardiovascular fitness would be beneficial for this patient.

Setting goals with the patient to become more involved in activities would also help improve her


24

deficits. With improvements in motor skills and self-efficacy this patient will see improvements

in the school and home environments.

Therapists need to consider that each child with DCD might have common characteristics

but each presents differently and might need several strategies to make improvements. With a

combination of motor and psychosocial deficits this population is unique and requires attention

because many children go too long before a diagnosis is made. These children miss years of

potential help and possible avoidance of related disorders.

The patient’s family was very reliable and brought her to every treatment session

scheduled once per week. There could have possibly been more gains made within this time

frame if treatment sessions were increased to two times per week. The use of more total body

patterns such as the rotation patterns could help to improve rotation in gait. There are limitations

in generalizing recommendations from this case report to the larger population of children with

DCD. With this case patient, outside activities were not controlled; her obesity could have

affected her progress in significant ways and a lack of reliable and variable standardized tests

covering her deficits.

The gains found in applying this strategic combination of theories has led to more clinical

questions and the need for future research. Future multi-subject research studies that utilize this

combination of approaches would help substantiate this application of theory to practice.

Research comparing the combination approach to traditional use of either top down or bottom up

approach for children with coordination deficits is needed.


25

References

American Physical Therapy Association. (2003). Guide to Physical Therapist Practice 2nd ed. Alexandria, VA: American Physical Therapy Association. Barnhart, R. C., Davenport, M. J., Epps, S. B., & Nordquist, V. M. (2003). Developmental coordination disorder. Physical Therapy , 83 (8), 722-731. Connolly (2013) Praxis: Evaluation and Treatment of the Clumsy Child Davis NM, Ford GW, Anderson PJ, Doyle LW. Developmental coordination disorder at 8 years of age in a regional cohort of extremely low birthweight or very preterm infants, Developmental Medicine and Child Neurology 2007; 49: 325-330 Engle-Yeger, B., & Hanna Kasis, A. (2009). The relationship between Developmental Coordination Disorders, child's perceived self-efficacy and preference to participate in daily activities. Child: Care and Health Development, 36(5): 670-7 Goyen, T., & Lui, K. (2009). Developmental Coordination Disorder in "apparently normal" school children born extremely preterm. Archives of Disease in Childhood , 94 (4), 298- 302. Hadders-Algra, M. (2003). Developmental coordination disorder: Is clumsy motor behavior caused by a lesion of the brain at early age? Neural Plasticity. , 10, 39-50. Kaufman, L., & Schilling, D. (2007). Implementation of a strength training program for a 5 year old child with poor body awareness and developmental coordination disorder. Physical Therapy , 87 (4), 455-467. Laszlo, J., & Bairstow, P. (1983). Kinaesthesis: its measurement, training, and relationship with motor control. Experimental Psychology , 35, 411-421. Mandich, A., & Polatajko, H. (2003). Developmental coordination disorder: Mechanisms, measurement and management. Human Movement Science , 22 (4-5), 407-411. Miller, L., Polatajko, H., Missiuna, C., Mandich, A., & Macnab, J. (2001). A pilot trail of a cognitive treatment for children with developmental coordination disorder. Human Movement Science , 20 (1-2), 183-210. Niemeijer, A., Smiths-Engelsman, B., Reynders, K., & Shoemaker, M. (2003). Verbal actions of physiotherapists to enhance motor learning children with DCD. Human Movement , 22 (4-5), 567-581.


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Roberts, G., Anderson, P. J., & Davis, N. (2011). Developmental coordination disorder in geographic cohorts of 8 year old children born extremely preterm or extremely low birthweight in the 1990s. Dev Med Child Neuro , 53, 55-60.


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Appendix A

Summary of Patient Treatment Sessions


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Appendix B

Total Body Patterns

Total Body Patterns

Flexion

• Curling up • Scooter board • Sitting and holding against

resistance • Modified bear stance • Supine flexion • Marching on ball • Sitting and pulling with legs or

arms

Extension

• Wheel barrels • Scooter board • Prone on elbows • Kneeling activities- isolate hip

extension • Half kneeling

Rotation

• Rolling up inclines • Sitting on ball and rotating to floor • Kneeling side to side • Quadruped to sitting

Weight Shifting

• Uneven surfaces • Kneeling to half kneeling • Stand/ hop on one foot • Crab walk • Wheelbarrow walk • Walking up an incline (anterior/

posterior weight shift)

Grading Movement

• Squat to stand from different heights

(Connolly, 2013)

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