Essay: Patient review and outcome

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  • Patient review and outcome
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The patient was a six-month-old girl who was referred to First Steps Early Intervention for a comprehensive developmental assessment and for physical therapy treatment due to a birth injury to the right arm resulting from a complicated vaginal delivery. The patient was initially diagnosed with a ‘mild stretching’ of the nerves by her pediatrician, and the family was told that the patient would fully recover with no intervention needed.
A comprehensive developmental evaluation was performed, which indicated significant problems with the right arm leading to referrals to a pediatric neurologist and pediatric orthopedist. The patient was referred back to First Steps and physical therapy for treatment following evaluation by these specialists who performed nerve conduction studies and electromyography to rule out the need for surgical intervention. The patient was given Botox injections by the pediatric neurologist into the triceps brachii to decrease muscle imbalance and to allow for strengthening of the elbow flexors with physical therapy.
The patient was chosen due to the involvement of this therapist with First Steps and the local school district with the ability to follow her course of treatment from birth through 21 years of age if necessary. The patient was referred to physical therapy for treatment, which is secondary care; however, the physical therapist was also involved in primary care during the First Steps developmental screening process and referral to specialists.1
The patient’s mother was induced at 41 weeks gestation and delivered an 11 pound 2 ounce baby who had a right shoulder dystocia and traction to the right arm to help pull her head out quickly due to signs of fetal distress. Radiographs were obtained at birth and ruled out clavicular and humeral fractures. The pediatrician diagnosed the patient with a ‘mild stretching’ of the nerves and told the family that the patient would fully recover with no intervention needed, but no improvements were made. The incidence of obstetrical brachial plexus injuries varies in different prospective and retrospective studies and has been reported ranging from 1.3-5.1 per 1,000 live, full term births with Erb’s Palsy injury to C5, C6 occurring in 50% of cases.2
The patient’s mother sought out physical therapy treatment due to decreased movement in her daughter’s right arm with the primary goal to increase her functional use and normalize movement as much as possible. The patient had family support for home care with two attentive parents and an older sister to help with her rehabilitation.
Regional Anatomy and Mechanism of Injury
A review of the anatomy of the right brachial plexus includes the involved C5 and C6 nerves, joints, and musculature. The brachial plexus is a multifaceted intertwining of somatosensory afferent with somatomotor efferent nerves from C5 through T1 spinal nerves. The brachial plexus begins as the C5’T1 spinal nerve roots depart the posterior triangle anterior to the middle scalene muscle, creating the lower, middle, and upper trunks. As the plexus continues its path, the three anterior and three posterior sections of the plexus begin to develop and merge distal to the clavicle to create the posterior, medial, and lateral cords of the brachial plexus.3 In the distal section of the axilla, the posterior cord divides into axillary and radial nerves; the lateral cord then develops into the musculocutaneous nerve; and the medial cord becomes the ulnar nerve. As the cords continue distally and create terminal branches, the median nerve derives as the lateral and medial cords join with the lateral cord transporting somatoafferent fibers and the medial cord transporting somatomotor fibers.4
Action potential is produced by each nerve root in specific muscles of the upper extremity. The C5 nerve innervates the deltoid as shoulder external rotation, abduction, extension. The C6 nerve produces elbow flexion, shoulder flexion and adduction, and forearm supination. Internal rotation of the shoulder is innervated by C6 and C7, with C7 also contributing to wrist, elbow, and finger extension. Lastly, C8 and T1 produce finger and wrist flexion as well as essential muscle function.5
The mechanism of injury in this patient’s case was a birth injury that included right shoulder dystocia and traction to the right arm during the delivery process that led to an injury to the brachial plexus, specifically C5 and C6. The physical location and intricacy of the brachial plexus make it vulnerable to compression in utero and to traction forces during labor contractions and the delivery process. Injury type in this case was from neurapraxia and related to the amount of force and compression transferred to the brachial plexus. Obstetrical brachial plexus injuries are usually unilateral and affect the commonly presenting anterior right arm.6
In this case, right shoulder obstruction occurred due to a discrepancy between the size and orientation of the patient’s shoulder and the mother’s pelvic inlet. This discrepancy prevented proper shoulder rotation for delivery and resulted in impaction behind the symphysis pubis. Different obstetric maneuvers were used to deliver this infant promptly due to fetal distress. One such maneuver included lateral traction applied to the patient’s head to release the shoulder. More forceful traction widened the angle between her head and shoulder and transferred a mechanical force that further stretched her right brachial plexus.
Systems Review
Following a screening decision model (Table 1-Appendix), all First Steps early intervention families complete a general family medical history form and general health form that provide a basic review of the body systems and family medical history for each patient referred. (Figures 1&2-Appendix) The physical therapist reviewed this form and then performed an initial interview to obtain subjective information and pertinent history from the patient’s caregivers. Additional screening is performed during this process if triggered by red flags on the history forms and/or interview. Based on these results, the patient’s treatment process is either continued, modified, or a referral is made back to the referring physician or specialist as needed.
Following completion of the medical history forms and interview, the therapist decided to perform a neuromuscular examination of the right arm. The history of trauma to the right shoulder and arm during the delivery process along with decreased movement focused the examination to the right arm with emphasis on testing range of motion, strength, sensation, and function. These tests were positive for a brachial plexus injury, and the patient was referred to a pediatric orthopedist and pediatric neurologist.
Physical Therapy Examination Procedure
The patient’s history and presentation guided this therapist towards a specific right arm examination that included the Mallet Scale12 and the Active Movement Scale (AMS) to determine arm function. The AMS was chosen because it provides more detail about the integrity of individual muscle and joint function to provide a more complete description. The AMS is described as a tool to grade or quantify movement, motor function, and strength in the upper extremities of infants and children with brachial plexus injuries.7 According to the Nagi system of classification, the AMS is considered to be a test for impairment of an anatomical structure. 8,9,10 The AMS is performed with the upper body and arms of the infant exposed with the patient placed on a flat, firm surface with room to move or roll. All joint movements are scored in gravity-eliminated and against-gravity positions by observing the patient at play in three positions: supine, side-lying, and sitting. Movement is assessed within the age-appropriate range of motion with the involved arm used as a control to estimate the extent of available normal range.7 A study by Akel et al also demonstrated that the AMS can be used as an indicator of functioning in addition to testing range of motion.11
The results of a reliability study suggest that the AMS is a reliable scale for the evaluation of infants with OBPI with an overall quadratic weighted kappa coefficient of 0.89 for interrater reliability and .81 for intrarater reliability.7 A study of 80 children with OBPI by Bae et al again demonstrated interrater reliability of the AMS with kappa coefficient of 0.86 and intrarater reliability of 0.85.12 Bialocerkowski et al performed a systematic review of tests used for children with OBPI with results confirming reliability of the AMS.13 A systematic review by Chang et al demonstrated face and content validity of the AMS by correctly specifying the underlying sources of patterns of injury in OBPI.14
Standardized Measure Test
The patient received comprehensive developmental testing with a team consisting of a physical therapist, speech language pathologist, and special instructor. The patient was tested using the Infant Developmental Assessment15 to test all areas of development with the physical therapist also performing the Alberta Infant Motor Scale (AIMS) to assess motor function in all postures and positions. The AIMS test is an observational scale in which movement ability is documented in all positions. Item scoring criteria specify aspects of quality of movement.16 It is considered by Nagi to be a test for functional limitation.8,9,10
A referenced systematic literature review described sensitivity and specificity of the AIMS at 77.3% and 81.7% at 4 months and 86.4% and 93.0% at 8 months.17 Positive predictive value for the AIMS was 39.5% at 4 months and 65.5% at 8 months.17 Snyder et al identified interrater reliability with ICC = .98-.99 with trained and untrained raters with different cultural backgrounds18 while Piper et al assessed interrater reliability with a Pearson Moment Correlation Coefficient with a range of 0.96-0.99.19 Another study by Piper et al determined test-retest reliability of the AIMS by administering the test twice with seven days between assessments to 233 infants with the results demonstrating Pearson Product Moment Correlation Coefficient with a range of 0.86 to 0.99.20 Blanchard et al also conducted a reliability study of the AIMS with interrater reliability determined to range from 0.98-0.99.21 Discriminative validity for identifying infants with atypical movement was found to be 89%.17
Piper et al also conducted a concurrent validity study to compare the AIMS to the Peabody Developmental Motor Scales22 and to the Bayley Scales of Infant Development,23 which have been considered ‘gold standards’ in developmental testing. Correlation coefficients were found to be r = 0.97 for the Peabody and r = 0.98 for the Bayley.20 Snyder et al repeated this testing with another study comparing the AIMS to the Peabody with results indicating r = .90-.97.18 A ceiling effect with low precision of measurement after approximately nine months of age was determined by Liao et al.24 Kolobe and colleagues found that the AIMS misclassified a high percentage of three month old infants as typical that later were diagnosed with atypical motor issues with six months recommended as an ideal testing age for the AIMS.25
Botox injections of 20 Mouse units/ml were injected into this patient into each of the three heads of the triceps brachii muscle on the right arm. Botox includes ingredients botulinum toxin type A, human albumin, and sodium chloride. Botolinum toxin type A is considered a neuromuscular blocker produced by the bacterium Clostridium botulinum.26 Mechanism of action is by creating a presynaptic neuromuscular blockade by inhibiting the release of acetylcholine from nerve endings. The subsequent chemical denervation of muscle creates local paresis of the injected muscles.27
Common side effects include dry mouth, discomfort or pain at injection site, tiredness, headache, and neck pain. Precaution indicated for patients who have received any other Botox in the last four months, have recently received an antibiotic injection, or currently take muscle relaxants, allergy/cold medicine, sleep medicine, or blood thinners. FDA approved indications include chronic migraine, cervical dystonia, axillary hyperhidrosis, strabismus, and blepharospasm. Treatment for brachial plexus injuries is considered experimental.28 This medication was given to treat the muscular imbalance of the patient’s right elbow due to differential weakness resulting in impaired movement. The purpose of the injections was to help increase active elbow flexion by weakening elbow extensors.29
Systems Review
The purpose of the Clinical Screening Decision Model (Table 1-Appendix) is to identify base factors that lead to secondary screens and/or follow up care of patients. Prior to patients receiving an examination and comprehensive developmental evaluation through First Steps, their parents/caregivers must complete a medical history form and general health form. (Figures 1&2-Appendix) The patient’s mother presented her history forms at the time of the examination with the therapist performing an interview at this time. Following the Clinical Decision Screening Model, this patient had the following base factors obtained from the medical history form, general health form, and the interview: history of birth trauma, subjective reports from the caregiver of decreased movement in the right arm, and signs of muscle atrophy and decreased response to sensory stimuli. The base factors led to a neuromuscular examination focusing on the right arm. The examination of the right arm was then focused on specific brachial plexus testing that included the Mallet Scale and the AMS with results indicating decreased strength and function of right elbow flexors and delayed motor skills. The medical history, vitals assessment, neuromuscular exam, and testing led to a referral to a pediatric neurologist and orthopedist.
Physical Therapy Examination Procedure
The goal of using the AMS was to confirm an obstetrical brachial plexus injury at C5, C6 and to determine which active movements were affected by the injury. The AMS was developed as an 8-point scale to grade movement in infants with brachial plexus injuries. Scores from 0-4 reflect movement with gravity eliminated, while scores 5-7 are movements against gravity. The patient scored 2 in elbow flexion, 7 in elbow extension, 4 in shoulder flexion, and 4 in shoulder abduction for a combined score of 17.7 Ranges of values for reliability were found from two studies that demonstrated overall quadratic weighted mean Kappa coefficient for intrarater reliability at .817 and .8512 with interrater reliability at .897 and .86.12 Interrater reliability is the measure of the consistency of repeated measures performed by one individual while intrarater reliability is the measure of the consistency of scores between different raters.30 Kappa statistical testing is designed for use with nominal level data to assess the association among 3 or more variables. The reliability coefficient indicates the strength of the association from -1 to +1.31 Overall the AMS was considered to be a reliable tool for the evaluation of infants up to one year of age with brachial plexus injuries using trained raters with the Kappa scores falling within the 0.81-1.00 range, which is considered an ‘almost perfect agreement’.31 A systematic review of tests used for children with OBPP by Bialocerkowski et al identified the studies by Bae at al and Curtis et al as confirmation of the reliability of the AMS but exposed the lack of evidence supporting construct validity.13 A systematic review by Chang et al demonstrated content and face validity of the AMS by correctly specifying the underlying sources of patterns of injury in brachial plexus injuries.14 Face validity is the degree to which an instrument measures what it is designed to measure while content validity is the degree to which an instrument represents all of the facets of the variable being measured.30 Although useful in evaluating an instrument, these are subjective and challenging to determine because no statistical criterion was used against it.32
Akel et al performed a concurrent validity study to compare the AMS to the WeeFIM and PEDI in order to determine its effectiveness as a measurement of function in OBPP.11 In the study, it was concluded that the AMS with its detailed classification system can be effective to show the functional status of children with OBPP. The study also described the AMS as an objective measurement that can provide information to estimate the limitations in daily living and hand functions.11 Criterion validity may be evaluated based on the relationship between scores on the instrument of interest and scores on a ‘reference standard’ instrument. A high correlation coefficient suggests that the instrument measures a comparable phenomenon.30 In this study, the AMS was correlated with the PEDI at r = 0.398 and with the WeeFIM at r = .403. Correlations between the continuous variables were given by Pearson product moment correlation. The results demonstrate a ‘fair degree of relationship’.30
The lack of Level I evidence based research studies to measure validity gave this physical therapist somewhat less confidence in using the test alone. However, extensive training on the AMS along with experience using it increased the confidence that this was a reliable measure to determine objective measures of movement in this patient based on evidence based interrater reliability and validity specific to OBPI. The referenced sources included research studies considered to be Level III and Level IV evidence specific to this diagnosis. The patient in this case was also tested with other procedures prior to initiating treatment, including goniometric measurements and the Mallet test.
Standardized Measure/Test
This patient received comprehensive developmental testing with the Infant Developmental Assessment and the AIMS to specifically assess motor function. The AIMS was standardized on 2,202 infants in Alberta, Canada, and provides a total score that can be converted to a percentile. The AIMS specifically tests 58 items in each position: 21 in prone; 9 in supine; 12 in sitting; and 16 in standing.16 This patient initially scored 10 in prone and 5 in supine with 0 scores in sitting and standing. This total score of 15 represented the patient at 4 months with a 33% delay in motor skills, corresponding to the 10th percentile when compared to other babies her age.
A systematic literature review described sensitivity of the AIMS at 77.3% and 80% and specificity of 81.7% and 90%.17 Positive predictive value and reliability with ICC >0.90 were demonstrated along with discriminative validity of 89% for identifying infants with atypical movement.17 Sensitivity is the proportion of patients with the condition that test positive or ‘true positives’. A highly sensitive test that is negative for a condition is useful to exclude that condition. Specificity is the proportion of patients without the condition that test negative or ‘true negatives’. A highly specific test that is positive for a condition can be useful in ruling in the condition.30
Test retest reliability is a measure of reliability of an instrument over different points of time. Intraclass Correlation Coefficient (ICC) is used to assess repeated measures and may range from -1 to +1. For reliability, ICC should exceed 0.70.32 In multiple studies, the AIMS was found to be reliable with ICC ranging from 0.96-0.99.18,19,21
An instrument has concurrent validity when it involves administering the test of interest and the reference standard test at the same time.30 A study by Piper et al compared the AIMS to the Peabody Developmental Motor Scales (PDMS) with a correlation coefficient of r=.97 and the Bayley Scales of Infant Development with a correlation coefficient of .98 to establish concurrent validity.20 Another study by Snyder et al also established concurrent validity when compared to the PDMS with a correlation coefficient of 0.98-0.99.18
An instrument has good predictive validity when it reflects the degree to which the results from the test can predict a future outcome, preferably measured by a reference standard. Darrah et al calculated predictive validity of 39.5% at 4 months and 65.5% at 8 months for the AIMS.17 The referenced standards were the PDMS22 and the Movement Assessment of Infants.33 Discriminative validity reflects the degree to which an instrument can distinguish among different characteristics. Darrah et al determined the discriminative validity for identifying infants with atypical movement as atypical was 89% when using the AIMS.17
Pearson’s Product Moment Correlation is a measure of the strength of relationship between two variables and ranges from -1 to + 1. The coefficient of determination (r2) indicates the percentage variation in one variable that can be explained by the other variable.30 Piper et al found Pearson values with a range of 0.86 to 0.99 for test retest reliability of the AIMS.20
A study by Liao et al found a ceiling effect using the AIMS with low precision of measurement after approximately 9 months of age.24 Researchers in a study by Kolobe et al also found that the AIMS is much better at identifying infants with motor disabilities at 6 months old compared to 3 months because a high percentage of infants at 3 months old were misclassified as typical that were later diagnosed as atypical.25 Because the patient in this case study was tested at 6 months old, she falls within these researched standards.
Due to the test retest reliability, high sensitivity, high specificity, concurrent validity, high discriminative validity, and high predictive validity of the instrument and good Pearson’s Product Moment Correlation when comparing this test to gold standard instruments, this physical therapist felt confident in using the AIMS to assess motor function in the patient. This test also provided a measurable way to track the patient’s progress of motor function over time.
The patient was given Botox injections of 4 units per kilogram into the 3 heads of the triceps brachii muscle on the right arm. The physical therapist had to be aware of muscle soreness at the injection sites when performing exercises and activities with the right arm. Potential for headaches and neck soreness may require the therapist to provide gentle exercises initially and decrease treatment time until side effects resolve. Potential for slowed or weakened right elbow function required the therapist to be aware of slowed reactions when performing balance, neuromuscular, and dynamic exercise challenges.29
Evidence Based Treatment
One of the interventions utilized for this patient was Constraint Induced Movement Therapy (CIMT), which inhibits use of the non-affected upper extremity to encourage use of the affected upper extremity in order to improve strength, range of motion, and functional use.34 This therapist has experience with documented benefits in utilizing this method in pediatric patients with multiple diagnoses. A Critically Appraised Topic was performed with the clinical question of ‘What is the effectiveness of CIMT to improve upper extremity function in children with obstetrical brachial plexus injuries when compared to therapeutic management without CIMT’?
The search strategy included key search terms for Patient Population of Erb’s Palsy, obstetrical brachial plexus, OBPP, brachial plexus palsy, brachial plexus birth injury, brachial plexus birth injuries, brachial plexus neuropathies, congenital quadriparesis, neonatal brachial plexus, and perinatal brachial plexus. Search terms for the Intervention included Constraint induced movement therapy, CIMT, induced movement therapy, pediatric constraint therapy, PCT, constraint therapy, modified constraint induced movement therapy, and forced use. Search terms for the Comparison included conservative management, rehabilitation, conservative treatment, therapy activities, motor learning, and stretching exercises. Search terms for the Outcomes included improved upper extremity function and improved arm function.
External validity examined included inclusion criteria of 1) published from 1998-2015 2) Research participants were patients with obstetrical brachial plexus injuries 3) Included therapy interventions 4) Levels I-IV studies 5) Related to improved upper extremity function 6) included patients who had received Botox injections and those who did not. Exclusion criteria were 1) Published prior to 1998 2) did not include a CIMT or MCIMT intervention 3) did not include patients with obstetrical brachial plexus injuries 4) did not examine changes in upper extremity function 5) Level V studies 6) studies that did not analyze statistical data. External validity examination also included ability to generalize results to other patients with obstetrical brachial plexus injuries and to the current case study. Internal validity examined included sample size, selection process, participant ages, instrumentality, and confounding variables.
The results of the CAT found three articles that fit the criteria. One of the articles was analyzed as Level 1 evidence that included a randomized controlled trial; one of the articles was Level IIIb evidence that included a case control study; and the remaining one was considered Level IV evidence involving case series without a control group for comparison. Results of the Level I study demonstrated significant improvement in upper extremity function observed in children following modified constraint induced movement therapy in addition to an upper extremity exercise program when compared to children following an upper extremity exercise program only.35 Results of the Level IIIb study demonstrated improvements in quality of movement, amount of use, and willingness to use the involved extremity.36 Results of the Level IV study revealed improved arm function between two pre-intervention and follow-up tests.37
Limitations of the studies appraised that threatened internal validity included the following for the Level I study: a small sample size, co-occurring exercise program that may have impacted the results, motivational targets that may have impacted resultant data, and no control implemented for motivation and self intention.35 The Level IIIb study had limitations of no control group or comparison36 while the Level IV study had limitations of small sample size, all male subjects, all subjects the same age, and intervention administrated by patients without supervision with adherence to protocol compromised by this.37
Results indicated that more Level I research with a larger sample size, including a wide age range of male and female participants from various locations, along with more standardized intervention applications, should be conducted. Although the Clinical Appraisal Topic revealed limited evidence supporting the use of CIMT in patients with OBPI, the results of the appraised studies imply that CIMT provides positive benefits that can be utilized at the case-by-case level.
This therapist feels that even a small benefit to increase active functional movement of the involved upper extremity would be important, especially in achieving developmental milestones. If the evidence based research studies had all shown no potential benefit from this intervention, then this therapist would not utilize it. However, this intervention was included as a part of the total rehabilitation and did not take the place of other exercises. The patient performed various forms of stretching, range of motion, strengthening, developmental activities, and motor training through the course of her physical therapy treatment.
Patient/Family Education
The APTA’s Credentialed Instructor’s Manual lists three stages of learning: 1) exposure, 2) acquisition/practice, and 3) integration/mastery.38 In this case, the parents of the patient were the target audience, so the focus was on adult learners. Discussion with the parents revealed that they preferred to have the therapist demonstrate the treatment followed by feedback from the therapist while they performed the treatment. The parents also wanted to be provided with a handout that included pictures and instructions along with a video demonstrating the exercises.
Malcolm Knowles defined the characteristics of adult learners to be self-directed, possessing a foundation of life experiences and knowledge, goal-oriented, relevancy oriented, practical, and respectful.39 Bodner-Johnson further describes early intervention practices as experiencing a needed paradigm shift towards a partnership model in which professionals collaborate with and support parents as adult learners.40 A research study by Jennings et al provided evidence for the effectiveness of the use of handouts in educating parents of infants with torticollis, which supported the therapist’s use of handouts as a tool for education in this case.41 Rasmussen et al performed a prospective cohort study with 76 adult caregivers of pediatric patients with OBPI and provided significant evidence that a home exercise DVD may specifically benefit these patients and caregivers and may provide an adjunct to formal therapy sessions.42
Injury Prevention/Wellness and Emerging Roles of PT Practitioners
Risk factors for OBPI can usually be classified before birth. O’Leary identified maternal birth weight, prior shoulder dystocia, abnormal pelvis, maternal obesity, multiparity, and advanced maternal age as risk factors for delivering a child with OBPI. Cesarean section should be taken into consideration as a preventive measure when a mother has multiple risk factors for a child being born with shoulder dystocia.43
The APTA’s Vision 2020 statement has challenged all physical therapists to expand their practices to a doctoring role that includes wellness and prevention strategies.44 Working in early intervention allows the therapist to be involved in prevention and wellness through developmental community playshops, developmental screenings of at risk infants, and community health fairs to explain the benefits of pursuing early intervention services.
A SWOT analysis was performed for the local early intervention community health fair with OBPI as the focus of one of the displays. (Table 2-Appendix) The SWOT analysis looks at the strengths, weaknesses, opportunities, and threats of a program.45 The Strengths include multiple sponsors, including a well established parenting center; held at a centralized community park and indoor pavilion for easy access to the entire community; no cost to families for all activities and services; free immunizations and medical/dental check-ups that attract families and increase attendance; and local school district providing numerous qualified early interventionist, teachers, physical therapists, occupational therapists, and speech language pathologists to help with the fair. The Weaknesses include primary focus of only general prevention and wellness needs; limited space for early intervention educational handouts and materials specific to obstetrical brachial plexus injuries; and shortage of physical therapists experienced in treating infants with brachial plexus injuries. The Opportunities include a way to reach a large audience; provide parents with available resources to assist them; and educate parents on the benefits of early intervention to improve outcomes of obstetrical brachial plexus injuries. The Threats include lack of funding with need for additional grants and donations; being held in the summer when families tend to go on vacation; and competing community activities that decrease attendance.
The purpose of this health fair was to collaborate with other community partners to provide access to free screenings and services and to promote health-focused awareness and detection among diverse populations, empowering families to take charge of their health. The specific booth for Early Intervention provided education and materials explaining the importance of pursuing early treatment for multiple diagnoses, including birth injuries.
Management, Legal, and Ethical Considerations
The care of this patient involved specific ethical issues. Based on evaluation and examination results, the physical therapist recommended direct services twice a week for one hour per session in order to achieve the best possible outcome. Because the patient did not have Medicaid or private insurance that covers physical therapy, payer of last resort funding was requested through the early intervention program. The district coordinator denied the frequency recommended, stating that he only approves monthly therapy sessions for 30 minutes in order to save money. He also stated that services could not begin until 30 days after the evaluation.
Because of this, several bioethical principles were at risk.46 First of all, autonomy was at risk because the patient’s parents had expressed their desire for her to begin receiving physical therapy immediately based on the results of the evaluation and the problems that could occur from delaying treatment. Maleficence was at risk because this principle requires an intention to avoid needless harm that can arise through acts of commission or omission. This case was clearly an act of intentionally omitting physical therapy services that the patient needed and could have resulted in a worsening of her condition with possible need for surgery. Beneficence was at risk because failure to remove these conditions could cause harm to the patient. Distributive justice was also at risk because this patient was being denied the benefits of the recommended services that other patients were being given simply because she did not have a third party payer that covered physical therapy services. Distributive justice demands that health care providers should try to be as fair as possible when offering treatments to patients and allocating medical resources.47
The therapist decided to initiate services immediately by providing pro bono physical therapy treatments. This was based upon the desire to honor the Code of Ethics for Principle 8a that states, ‘Physical therapists shall provide pro bono physical therapy services or support organizations that meet the health needs of people who are economically disadvantaged, uninsured, and underinsured.’48
The therapist worked through Greenfield’s phenomenological model to realize that an ethically sound resolution would be to try to affect change throughout the district by discussing with district and state directors how this patient and other patients’ needs were not being met and how they were not being valued as individuals.49 The therapist contacted the district coordinator and state administrator to discuss the harm that could come to this patient if the recommended frequency was not provided. Research was provided to them demonstrating the urgency for appropriate and immediate intervention in patients with OBPI.
The therapist also helped to coordinate a meeting between the district coordinator and providers within the district in order to discuss how to manage budgetary concerns without violating ethical principles that put patients at risk for harm and that allow some patients to receive better services than others. The ethical issues were resolved with the state administrator issuing policy that allowed approval for the patient to receive the recommended frequency.
Patient Outcome (Conclusion)
The patient was originally seen during a comprehensive developmental screening. The systems review followed a clinical decision model involving medical history forms, an interview process, and vitals assessment, which streamlined the examination process. Due to the information obtained, the patient was referred to a pediatric neurologist and orthopedist who performed nerve conduction studies and electromyography to rule out the need for surgery. The patient also began receiving Botox injections at this time.
The patient received specific right arm examination that included the AMS. A search of the literature for the AMS testing statistical measurement properties found it to have high interrrater reliability and content validity. This information provided confidence that the results of the testing were accurate.
The AIMS was used as the standardized measurement tool for this patient. A systematic literature review described high sensitivity and specificity for this tool along with high reliability and discriminative validity. These high values made the therapist confident in the use of this scale to determine the patient’s functional progress throughout the rehabilitation process. The patient’s improvement in scores at two different intervals led to the therapist progressing her towards functional motor milestones.
The Critical Appraisal Topic performed for CIMT found three studies at Level I, IIIb, and IV that concluded that this type of intervention can provide a benefit but should not be used in the place of other exercises and activities but as an adjunct to them. The results of the CAT influenced the decision to include this intervention with stretching and strengthening exercises, developmental activities, and motor training.
The AMS, along with goniometric measurements, birth history, and mechanism of injury were positive for a diagnosis of obstetrical brachial plexus injury of C5, C6. This was confirmed by the orthopedist and neurologist as a result of their radiological testing. The initial involvement and testing by the physical therapist led to complete care for the patient who falls under the neuromuscular practice pattern of 5f.50
The Critical Appraisal of CIMT concluded that this intervention can provide benefits to the patient. This therapist feels that this intervention should only be one part of a complete rehabilitation program. The use of the AIMS was validated through the statistical data found in the research. It was found by the therapist to be a useful tool to measure the patient’s functional progress from the starting point of the rehabilitation process to the point of starting functional rehabilitation in order to meet developmental milestones.
This patient’s education process was targeted to her parents and included demonstration, handout with pictures and written instructions, video of exercises, and feedback. The physical therapist found that these various forms of instruction and practice met the adult learner preferences as evidenced by their ability to demonstrate the exercises independently.
The physical therapist discovered several areas of benefit to clinical practice. The clinical decision model with systems review provides a structured system of examining and evaluating the patient for further care and/or referral. The AMS was found to be a reliable test to use with patients who have OBPI in order to determine deficits. The AIMS was found to be a statistically sound and useful outcome tool when rehabilitating patients with injuries that affect motor function. The therapist also discovered that CIMT can provide positive benefits when combined with other therapeutic interventions. The analysis of the patient education provided found that a multifaceted approach is best to meet different levels of learning and that parents are a unique category of adult learners specifically motivated by wanting the best outcome for their child.
The overall benefit to the therapist was the realization that evidence based testing and intervention can lead to better patient outcomes, as demonstrated by this patient’s remarkable progress that resulted in full functional movement and motor milestones achieved. The therapist also discovered that research studies are limited in pediatric physical therapy and that it is the responsibility of all therapists to contribute meaningful information to advance this process.

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