Physical Therapy Treatment of a 4-year-old Following Tethered Cord Release and Chiari

Malformation Decompression with Sensory Seeking Behaviors

Author: Delaney Harris

Research Advisor: Kristin VanderArk, PT, MS, NCS, CBIS

Doctoral Program in Physical Therapy

Central Michigan University
Mount Pleasant, Michigan

12/18/2023

Submitted to the Faculty of the

Doctoral Program in Physical Therapy at

Central Michigan University

In partial fulfillment of the requirements of the

Doctorate of Physical Therapy

Accepted by the Faculty Research Advisor

Kristin VanderArk, PT, MS, NCS, CBIS

Date of Approval: 1/1/2024

 ABSTRACT

Background and Purpose

One in every 4000 infants are born with tethered cord syndrome. Tethered cord release surgury is

the primary form of treatment to address the symptoms of bowel and bladder dysfunction, back

pain, lower extremity deformities or weakness, sensorimotor deficits, and neuropathic pain.

Tethered cord syndrome has been found to be linked to Chiari malformation. Physical therapy

interventions following these procedures is a vital component of care when complications

continue to persist after. Research has found that improving hamstring length and core

strengthening can decrease back pain and neuropathic pain. Lower extremity strengthening and

balance exercises are shown to increase gross motor function as the pediatric population ages.

The purpose of this case report was to describe the effectiveness of physical therapy

interventions on a 4-year-old female patient following tethered cord release surgery and previous

Chiari malformation decompression who also displays sensory seeking behavior.

Case Description

A 4-year-old female was seen in outpatient physical therapy 2 months following tethered cord

release surgury and a previous history of a Chiari malformation decompression surgury. At the

time of examination, the patient presented with neuropathic low back pain, decreased hamstring

and dorsiflexor range of motion, decreased lower extremity strength, and decreased balance.

Physical therapy interventions include therapeutic exercise focused on lower extremity and core

strengthening. Therapeutic activity was aimed at addressing the deficits that impact daily life,

such as transfers and stairs. The balance deficits were addressed using neuromuscular

reeducation principles.
Outcomes

The patient was seen in physical therapy 1 time a week for 14 weeks. The therapy sessions were

45 minutes long and consisted of neuromuscular reeducation, therapeutic exercise, and

therapeutic activities. The patients reported no pain at the finial assessment. Her strength

improved in all measures of the left lower extremity and increased right extremity knee

extension. The range of motion increased by 5 degrees for the right ankle and 6 degrees for the

left ankle dorsiflexion. She also improved popliteal angle range of motion. It was measured at 16

degrees on the right and 20 degrees on the left. There were slight improvements from the

examination by 5 degrees bilaterally. The patient increased her single leg balance test time from

2 seconds bilaterally to 5 seconds on the right leg and 8 seconds on the left leg. The patient’s 6-

minute walk test improved by 24 meters. There was no significant change in the PEDI-CAT

looking at quality of life.

Discussion

The improvements made by the patient were consistent with the research of improving hamstring

length and core strength which helped decrease back pain. Lower extremity strengthening and

balance exercises have been found to increase gross motor function. The negative factors

impacting this case report include the patient and family not being compliant to the home

exercise program. The patient also demonstrated sensory seeking behavior on the seventh visit

and heavy work was implemented on the eighth visit. The patient did have good family support

in therapy sessions. Future research should include physical therapy interventions that focus on

the specific limitations and impairments that are seen following a tethered cord release and a

Chiari malformation decompression surgury.

Background and Purpose

One in every 4000 infants are born with tethered cord syndrome.1 Tethered cord

syndrome is a group of pathologies that causes the spinal cord to be taught. The most common

form of tethered cord syndrome puts the distal aspect of the spinal cord on tension and puts

pressure on the conus medullaris. There can be a benign tumor of tissue that is enveloped within

spinal cord that causes tension. The conus medullaris innervates the lower extremities as well as

the bladder and bowels.2 When put under stress, it can lead to bowel and bladder dysfunction,

back pain, lower extremity deformities or weakness, sensorimotor deficits, neuropathic pain, and

could lead to scoliosis.1,2 Tethered cord syndrome that is moderate to severe is typically

diagnosed with magnetic resonance imaging (MRI) as an infant or young child. In mild cases, it

may not be diagnosed until adulthood.1

The primary treatment of tethered cord syndrome is tethered cord release surgury. This

surgical procedure is typically done with a laminectomy of the lumbar vertebrae where the tumor

or greatest tension is.2,3 The tumor is removed, and the tension is released during the surgury.

Recovery consists of a week or so in the hospital and a multidisciplinary approach to

management following the release.2 This team can be comprised of a neurologist, urologist,

pediatrician, orthotist, and physical therapists. The health care professionals work together using

a patient centered approach to create the best treatment for the patient. 2 Following the surgury,

bowel and bladder dysfunction is usually resolved almost immediately. The neuropathic pain and

weakness might take time to resolve once the swelling is decreased and the muscles are

strengthened post surgury.3 In a study of patients who also had Ehlers Danlos syndrome, around

66% of all patients who had this surgury report they are highly satisfied with no residual

1
symptoms within a year of the tethered cord release surgury.4 21% of the patients were satisfied

with minimal symptoms reported.4

It has been found to be a correlation between having tethered cord syndrome and Chiari

malformation type I.5 Hans Chiari described the malformation as an “elongation of the tonsils

and the medial parts of the inferior lobes of the cerebellum into cone-shaped projections which

accompany the medulla oblongata into the spinal canal.”6 The inferior portion of the cerebellar

tonsils descend through the foramen magnum which can lead to symptoms such as headaches,

pain, scoliosis, balance difficulties, syncopal episodes, and dizziness.7 Though some patients may

be completely asymptomatic. Pediatric patients may present with brainstem dysfunction, sleep

apnea, and difficulty feeding.8 These symptoms are most often relieved with Chiari

decompression surgery.8 After decompression surgery, 75% of patients have a decrease or

resolved symptoms.9

A link has been found between a Chiari malformation type I and sensory disturbances.10,11

Around 50% of pediatric patients with Chiari malformations report having sensory disturbances

such as sensory regulation disorders, decreased sensation, or numbness and tingling.10 Some

researchers believe that there is a link between a Chiari type I malformation and autism spectrum

disorder.11,12 Many of the symptoms present with the Chiari malformation are similar symptoms

that could be present with autism spectrum disorder.11,12 A Chiari malformation might not be

noticed if a person has autism spectrum disorder if they believe the symptoms are caused by it. A

person who has autism spectrum disorder can have sensory regulation difficulties that can lead to

sensory seeking.11 Sensory seeking behaviors can be described as looking for sensory outlets that

help regulate the sensory system. Sensory seeking can be found in other conditions such as

2
attention deficit hyperactivity disorder.13 attention deficit hyperactivity disorder has also been

seen in children who have Chiari type I malformation.14

A study called Effectiveness of sensory integration program in motor skills in children

with autism, looks at using heavy work to help increase motor skills in children ages 40 to 65

months who have been diagnosed with autism.15 Heavy work can be defined as activities that are

used to help regulate children with sensory processing difficulties. Heavy work can help increase

attention for a task, decrease defensiveness, and increase arousal. In this study, these activities

include pushing, lifting, and pulling heavy objects, walking and running in sand, and carrying

heavy objects. The Peabody Developmental Motor Scale was performed before and after heavy

work. It was found that when performing heavy work activities before participating in stationary,

locomotive, object manipulation, grasping, and visual motor integration tasks there was an

increase in performance in all tasks. There was a greater increase in performance for gross motor

tasks than fine motor tasks. In conclusion, this study found that performing heavy work tasks is

beneficial for children with sensory processing difficulties before performing motor skills. 15

While researching, it was found that there were limited articles that addressed the

physical therapy interventions following tethered cord release and Chiari malformation

decompression surgury. Therefore, the treatments were individualized based on the impairments

present for the individual. These impairments include neuropathic low back pain, lower

extremity weakness, balance deficits, and decreased range of motion. These impairments are

seen in many adolescent conditions. The evidence used in this case report that was found to treat

these impairments, can be presented to be beneficial to treating similar impairments found

following tethered cord release and Chiari malformation decompression surgury.

3
 A study looking at the efficacy of an 8-week exercise program to decrease back pain in

adolescents concluded that a specific exercise program consisting of core strengthening, hip

range of motion, hamstring flexibility, was beneficial to decrease nonspecific back pain. A group

of 54 adolescents ranging from 13- to 15-year-old were split randomly into 2 groups. The first

group was the control group who did not receive any treatment and the second group who

received a specific exercise program. The exercises aimed to improve core strength, hip range of

motion and hamstring flexibility. After the 8-week program, the patients who participated in the

specific exercise program had a decrease in pain and an increase in strength and hamstring

length.16 They looked at the severity of pain on a 1-10 scale, sit and reach performance, and

number of sit ups in 60 seconds and there were improvements in all categories.16

Children with Down’s syndrome also experience decreased strength and balance deficits.

A group of 23 children were randomly selected to be placed into a control group and an

intervention group. The intervention group was given progressive resistive training exercises for

lower extremities and balance exercises. Handheld dynamometry was used to measure lower

extremity strength and the Bruininks Oseretsky Test of Motor Proficiency (BOTMP) was used to

test balance and gross motor skills.17 The BOTMP has 9 balance tests that include standing on

one foot, eyes open and eyes closed balance.17 This program lasted 6 weeks and following it

showed improvements in both strength and balance. The control group recorded about 12.12

pounds for knee extension and the intervention group recorded 18.4 pounds. Hip flexion strength

also was greater in the intervention group with 16.66 pounds and the control group with 12.23

pounds. For the BOTMP, the intervention group scored 10.5 points higher.17

Overall, there is minimal research on physical therapy treatment following tethered cord

release surgery and Chiari malformation type I decompression. However, the research reviewed
4
shows that physical therapy would benefit patients following these surgeries. The purpose of this

case report was to describe the effectiveness of physical therapy treatment on a pediatric patient

following tethered cord release surgery and previous Chiari malformation decompression with

sensory seeking needs.

Prior to preparing this report, assent was obtained from the patient and consent was

obtained from the patient’s mother to proceed. All information contained in this case report

meets the Health Insurance Portability Accountability Act (HIPAA) requirements of the clinical

agency for disclosure of protected health information. This case report was completed under the

direction of the Department of Physical Therapy and with the oversight of the College of

Graduate Studies at Central Michigan University.

Case Description

Patient History and Review of Systems

The patient was a 4-year-old female who presented to outpatient physical therapy with

neuropathic pain following a tethered cord release procedure. The tethered cord release was

successful and occurred 2 months before being seen in the clinic. The patient regained functions,

such as bowel and bladder control, and reports a decrease in migraines that were constant before

the release. The referral from the neurologist stated to focus on hamstring tightness and

neuropathic pain following the tethered cord release. During the initial examination, the

information received was given by the patient and her mother. The patient/family’s chief

complaint was of back pain in the morning after she wakes up and that her legs give out and will

have difficulty walking about 3 times per week. She was seen previously at another outpatient

physical therapy clinic, but the parents were not satisfied with the treatment that only focused on

5
hamstring stretches. At the time of the referral, she was being seen by a speech language

pathologist at her school as well.

The patient was a twin and was born at 28 weeks gestation. She reached all the

developmental milestones with her corrected age. The patient was also diagnosed with Chiari I

Malformation and underwent decompression surgery 3 months prior to the tethered cord release.

Following the decompression surgery, the patient developed an infection, was put on antibiotics,

and had an extended stay in the hospital. The Chiari Malformation led to cervical scoliosis with

hemivertebrae. The patient was at high risk for Ehlers-Danlos Syndrome because her mother had

been diagnosed. The patient was taking rizatriptan, diazepam, and hydrocodone as needed.

Rizatriptan was used to treat headaches. Diazepam was used to treat muscle spasms.

Hydrocodone was being used to treat back pain. These drugs were only taken as needed and they

were administered by the patient’s mother. She was allergic to penicillin, and milk protein, and

had environmental allergies.

The patient lived with her mother, twin brother, and her older brother. The father was in

and out of the house due to being in school in a different state. The family lived in a one-story

ranch-style home with 3 steps leading into the house. The patient was a student and enjoyed

playing with her brothers and going to the park. The patient and family’s goals were to have the

patient be more confident in walking and balancing and to have decreased back pain.

Clinical Impression #1

Based on the information received by the patient and family, the patient was expected to

present with pain, weakness, and balance deficits. These factors likely led to participation

limitations when it came to keeping up with peers her age at school and her siblings. It was

important to do a full in-depth examination to further determine the deficits. It was important to

6
examine lower extremity strength, range of motion, gait assessment, and balance. Examining

lower extremity strength and range of motion can show deficits that lead to pain and decreased

functional mobility. Depending on the patient’s ability to follow instructions, manual muscle

tests may be performed or more functional muscle tests for pediatrics may be indicated. The 6-

minute walk test (6MWT) would be conducted as a formal gait assessment and to test endurance.

This would gain insight into the patient’s ambulation in the community and activity participation

with her peers. The single-leg stance test would be used to test the ability to perform gross motor

functions appropriate for her age such as kicking a ball and walking up the stairs. The patient

was a good case report candidate due to the limited research on physical therapy following

tethered cord release surgery and her past medical history making the patient more complex.

Examination

Pain. When asking a pediatric patient about pain, the Wong-Baker Faces Pain Scale had 6

different faces that show an expression that correlates to the numbers. It was created to help

children better communicate the pain they are feeling.18 The validity of the Faces Pain Scale is

excellent 0.90 and the reliability is good to excellent at 0.86 to 0.93.19 Overall, in the study by

Wong and Baker, they found that the FACES pain scale is the preferred method of collecting pain

scores from patients from the ages 3 to 18.18 When asked, the patient scored her pain a 3 to 4

when she is having back pain.

Strength. The proper manual muscle tests that were outlined using Muscle and Sensory Testing

by Nancy Berryman Reese were used for this patient.20 The interrater reliability for these tests

was excellent at 0.98 and the validity was 0.87.20 These tests were able to be performed because

the patient could follow directions to be able to follow the proper techniques. The patient had

7
decreased lower extremity strength bilaterally. The results of the manual muscle tests are

outlined in Table 1.

Range of motion. Norkin and White developed the range of motion tests and positions that were

used with this patient.21 The interrater reliability and the intra-examiner reliability were both

excellent, at 0.99. The patient’s range of motion was within normal limits for all measures except

dorsiflexion and the popliteal angle. Dorsiflexion was measured in the position developed by

Norkin and White.21 The patient displayed 10 degrees of passive dorsiflexion with the patient’s

knee fully extended. This indicated tightness in bilateral tightness of the gastrocnemius.

The 90/90 method was used to measure the popliteal angle which was created by

Reurink.22 There is an interclass correlation coefficient of 0.77 and the standard error of

measurement is 7.6.22 The patient measured 25 degrees on the left lower extremity and 21

degrees on the right lower extremity. She reported pain in both legs while the popliteal angle was

measured. The patient displayed bilateral hamstring tightness.

Gait assessment. The 6-minute walk test (6MWT) was used to evaluate ambulation and

endurance of the patient. This test is used with many different populations to assess gait, fall risk,

and endurance. The 6MWT is used in patients 3 years of age up to 65 plus.23 The interclass

correlation coefficient is .98 with the minimal detectable difference of 13.1 meters. 24 The

parameters for this test were walking in the flat, even hallway of the hospital with the therapist

walking behind the patient reminding the patient to keep walking. The patient also told how

many minutes left each minute of the test. The patient was able to ambulate 374 meters. This was

1.42 standard deviations below the mean for the patient’s age. The patient walked with a normal

gait pattern while performing this test and did not report any pain afterward.

8
Balance. The single-leg balance test was used to test the ability to perform single-leg static

balance that could affect gross motor development like kicking a ball and climbing up stairs.

This test has excellent reliability with an intraclass correlation coefficient of 0.84-0.98. 25 The

validity of the single leg balance test is 0.73-0.92.26 The patient was able to stand on each lower

extremity for 2 seconds. Pediatric patients should be able to stand on one leg for as many

seconds as their age. The patient is 4 years old; she should be able to stand on one leg for 4

seconds.27

Quality of life. The Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-

CAT) was completed by the patient’s mother to assess the quality of life. The PEDI-CAT has 4

domains that look at daily activities, mobility, social/cognitive, and responsibility. 28 This test has

excellent test/retest reliability at 0.96-0.99 for all four domains.28 The validity of this PEDI-CAT

is 0.82.28 Table 2 displays the results from the patient. She scored in the 5-25th percentile for daily

activities and mobility, the 25-50th percentile for social/cognitive, and the 50-75th percentile for

responsibility.

Evaluation/Clinical Impression # 2

The patient experienced back pain, which was a 3-4 out of 10 on the Faces pain scale

when she was having pain. She also had decreased lower extremity strength bilaterally in her

hips, knees, and ankles. There was also a decreased range of motion in bilateral hamstrings and

gastrocnemius. This could be impacting the movement of the patient when performing functional

tasks. The patient also had balance deficits when standing on one leg. This can affect the

patient’s gross motor development.

9
 The deficits found were consistent with the diagnosis of post-tethered cord release, lower

extremity weakness, muscle tightness, balance deficits, and neuropathic pain. The patient had

excellent rehabilitation potential as long as the patient was consistently seen in the clinic as well

as following their home exercise program. The barriers to progress could be external family

factors such as the patient’s brother also having surgery during her episode of care that could

potentially impact the patient’s ability to get to therapy and complete the home exercises.

The goals for physical therapy were to have decreased pain, improved lower extremity

strength, increased single-leg balance, and improved distance during the 6MWT. The patient was

a good case report candidate due to the tethered cord release surgery and her past medical history

making the patient complex. There is also limited research on the symptoms of post-tethered

cord release surgery and the effectiveness of physical therapy to address the deficits.

Interventions

It was recommended that the patient be seen in outpatient physical therapy 1 time per

week for 14 weeks. The sessions would be 45 minutes long, consisting of therapeutic exercise,

therapeutic activity, and neuromuscular reeducation. Therapeutic exercise would be focused on

lower extremity and core strengthening. Therapeutic activity would be aimed at addressing the

deficits that impact daily life, such as transfers and stairs. The balance deficits would be

addressed using neuromuscular reeducation principles.

Therapeutic exercise. Therapeutic exercise focused on strengthening the lower extremities and

the core. To strengthen the lower extremities, the patient performed exercises that consisted of

squats, step ups, and eccentric step downs. These exercises were performed with various tasks

and repetitions depending on the patient’s tolerance to activity. Research shows that performing

10
functional strengthening exercises such as squats and step ups are most beneficial to pediatric

patients.29 Step ups and eccentric step downs varied on step height of the step depending on

tolerance session to session. This ranged from a 3-inch step to 8 inches depending on the week.

Some weeks the patient was able to perform eccentric step downs on an 8-inch step and other

weeks she was only able to perform it from a 3-inch step. It varied throughout the course of

treatment. Core strengthening exercises were performed such as supine bridges focusing on

transverses abdominus activation, prone walkouts over a bolster, sit to prone and prone to sit

over a bolster, and activities in the bird dog position. Dynamic and static core strengthening such

as curl ups, prone extension holds, and the plank position can improve or prevent low back pain

in adolescents.30 Throughout the 10 weeks there was limited progression of exercises depending

on the tolerance to activity and how the patient reacted to the exercises.

Therapeutic activity. Therapeutic activities focused on stair training and half kneel to stand

transfers. These everyday tasks are important to help increase the strength and the confidence of

the patient while performing them.29 The patient was able to perform the stairs with 1 rail using a

step to pattern at the start of therapy and the goal was to use a reciprocal pattern and no upper

extremity support. Throughout the session the patient was able to use a reciprocal pattern and

one rail and then was asked to use a reciprocal pattern with no rail. Once the patient was able to

perform reciprocal pattern with no rail the patient was asked to carry an object in one hand and to

walk up the stairs. Half kneel to stand transfers are important because it increases the lower

extremity muscle activation and improves the proper posture of the patient.31 Half-kneel-to-stand

transfers also progressed by performing them by themselves and then adding in an UE task such

has holding a toy or standing up to step up.

11
Neuromuscular reeducation. Neuromuscular reeducation exercises were focusing on improving

balance on both lower extremities and on a single lower extremity. Standing balance on a rocker

board was used with different tasks to work on double leg balance. Step standing with one foot

up on a step used to help increase single leg balance with dynamic upper extremity activities.

The upper extremity activities ranged from playing a game on a table to throwing a ball back and

forth. To continue working on single leg balance the patient would stand on one leg while

kicking a ball or using a stomp rocket holding her foot up in the air before stomping down. The

exercises for single leg balance were progressed by standing on a hard surface then moved on to

a soft blue mat. The difficulty of the upper extremity task also changed while performing step

standing and single leg balance. It started with playing a game in front of the patient, turning and

grabbing objects on either side, to throwing and catching a ball. Improving balance can help

improve gross motor function overall. Being able to stand on one foot while stepping over

objects, on stairs, or kicking a ball are all important for gross motor function and development as

the patient continues to grow.32

During week 3, while performing balance exercises the patient seemed to have trouble

with head turns while balancing. Oculomotor techniques were examined such as smooth pursuit,

horizontal and vertical saccades, and rotational chair test for prolonged nystagmus. With the

smooth pursuit test, the patient presented with 3 saccadic eye movements and had difficulty

crossing midline. The patient had difficulty with continuous motion and slow eye movements

were noted with horizontal and vertical saccades. The rotation on the chair test was within

normal limits and presented only a few seconds of nystagmus. It was determined that the patient

would benefit from a referral to occupational therapy.

12
 On the 7th visit of treatment. It was noted that the patient was experiencing sensory

seeking behaviors. The patient kept falling on soft surfaces when performing different balance

activities but when we went to hard floors and perform the same activities she would not fall.

Heavy work was added into the therapy session to determine if it was sensory seeking and if that

would help her focus on tasks. After adding heavy work of lifting weighted balls, pushing heavy

objects and core work, the patient was able to focus better on the tasks performed in the sessions.

Heavy work was added to the beginning and spaced out in the sessions going forward. During

weeks 8 through 10, heavy work was added at the beginning of the session to help the patient

focus and throughout the session when the patient seemed like she wasn’t focusing as good.

Research shows that adding heavy work to decrease the sensory seeking input will help the

patient stay focused and will perform better with gross motor tasks.15

Home exercise program. A home exercise program was given to the patient at the second visit.

This program consisted of a supine hamstring stretch and supine bridges to increase core

strength. At the 4th visit half kneeling to stand transfers and step standing with 1 foot on an

elevated surface to improve balance were added to the program. Due to the patient and family

not being compliant to the home program no further exercises were given but the importance of

doing the exercises was expressed to the family.

Outcomes

Outcomes were measured at the tenth visit of the recommended 14 visits. The patient will

continue to come to therapy for the remainder of the plan of care and goals will be reassessed

then and determine if the patient needs to extend the plan of care.

13
Pain. The patient did not complain of pain in any therapy sessions and when asked on the Wong-

Baker Faces Pain Scale she reports 0 out 10. When reassessed at the tenth visit the patient

continued to report 0 out of 10. The patient’s mother stated that she complains of some pain at

home but does not experience it as often. She reports that the pain normally occurs in the

morning before getting out of bed.

Strength. By discharge, the patient increased strength in all items of the left lower extremity and

increased right lower extremity knee extension. The results of the manual muscle tests can be

found in Table 1. It became evident that the patient favors her left lower when performing tasks

such as stairs and half kneel to stand. The patient was able to perform the activities bilaterally but

prefers to put the load on the left lower extremity.

Rand of motion. The patient’s passive dorsiflexion range of motion was measured at 16 degrees

for the right ankle and 15 degrees in the left ankle. This was an improvement from the

examination by 6 degrees for the right and 5 degrees for the left. The minimal detectable change

for ankle dorsiflexion range of motion was 5 degrees. 33 There was a significant change in

bilateral lower extremity dorsiflexion.

Popliteal angle was measured at 16 degrees on the right and 20 degrees on the left. There

were slight improvements from the examination by 5 degrees bilaterally. Even though there were

slight improvements was not a significant improvement due to the minimal detectable change

being 21 degrees.22

Gait Assessment. The patient improved their 6MWT from 374 meters to 398 meters. The patient

continues to be below the standard deviation for her age by 1.15 standard deviations below. The

minimal detectable change is 13.1 meters, so the patient has a significant increase by 24 meters.

14
The patient continued to walk with a typical gait pattern for her age and did not complain of any

pain.

Balance. The patient improved her single leg balance test from 2 seconds on each lower

extremity to 5 seconds on the right leg, and 8 seconds on the left leg. This puts the patient in a

normal range for her age of 4 seconds. It was noted that the patient has increased difficulty on the

right lower extremity compared to the left.

Quality of life. There were no significant changes or improvements on the PEDI-CAT. The

patient’s scores stayed the same or slightly decreased from the examination. The final scores can

be seen in Table 2. This could be because the mother was more aware of the patient’s deficits

after being pointed out in therapy.

At the time, the patient continued to be seen in outpatient therapy to further address the deficits

of lower extremity strength, core strength, and hamstring length. The patient was to continue to

finish the current plan of care to 14 visits and then a reassessment would be performed then to

determine if further therapy was needed.

Discussion

The purpose of this case report was to describe the effectiveness of physical therapy

interventions on a 4-year-old female patient following tethered cord release surgery and previous

Chiari malformation decompression who also displays sensory seeking behavior. The treatment

was patient specific to address their specific impairments and goals. The interventions focused

on the use of therapeutic exercise, neuromuscular reeducation, and therapeutic activity.

15
 The improvements made by the patient were consistent with the research found.

Improving hamstring length and core strength helped decrease back pain.16 The patient reported

no back pain at the end of the tenth visit. The patient had increasing hamstring length and core

strength throughout the 10 weeks that led to a decrease in back pain. Core strengthening

exercises were performed during every session. Hamstring stretches were given in the home

exercise program and improved slightly but could have improved more with an increase in

compliance.

The patient also improved with single leg balance. She increased bilateral balance to

normal range for a 4-year-old. Balance exercises have been found to increase gross motor

function.17 The balance exercises performed varied from single leg balance, step stance, and

double leg balance. All tasks were challenging and progressed when needed. Upper extremity

exercises were performed with the balance activity to help increase the difficulty. It became

easier for the patient to step over objects, kick a ball, and ambulating stairs with improvements of

balance.

The patient had increased left lower extremity strength. The patient had improved

strength for all items tested in Table 1. She has increased right lower extremity extension.

Performing functional exercises helped improve lower extremity strength.28 Step ups, eccentric

step downs, and squats are all exercises that are used while performing everyday tasks. These

exercises were done bilaterally, and it is unknown why there was a greater increase in left lower

extremity strength.

The patient and family were not compliant with their home exercise program. They

started out performing the exercises but due to becoming busy with the patient’s sibling having

16
surgury, or other factors, they stopped. The family was educated on the importance of performing

the home exercises regularly, but it did not seem to change their compliance. If the patient and

family were more compliant with the home exercises given there could have been a greater

increase in the results seen.

It was found that the patient demonstrated sensory seeking behaviors on visit 7. Adding

heavy work increased the focus and attention to tasks for the rest of the visits. If heavy work was

added in at the beginning of the treatments, there could have been greater outcomes. The patient

began working with occupational therapy about 5 weeks into the physical therapy treatment to

address the visual motor and vestibular components noted and to also help with sensory seeking

behavior.

A limitation to this case report includes the therapist being out on sick leave one week

and another week the patient was sick. Both times the patient was not seen for therapy. The

patient went 2 weeks without having a therapy session on both occasions and they were not

compliant with their home exercise program limiting improvements during those weeks.

A positive factor to support the outcomes of the case report could include that the patient

started seeing occupational therapy outside of our sessions that could have helped with some of

the visual components of her impairments and sensory seeking behaviors. Occupational therapy

treatments for visual motor and vestibular impairments included oculomotor components, hand

eye coordination movements, and balance with different head positions. They also focused on

treatments that provided techniques to help with sensory integration that is used to help decrease

sensory seeking behaviors. All these techniques could help alongside physical therapy because it

17
will overall improve her balance and focus for gross motor tasks. Another positive factor was

that her mother was very active and positive while we were in treatment sessions.

Future research should include physical therapy interventions that focus on the specific

limitations and impairments that are seen following a tethered cord release and a Chiari

malformation decompression surgury. There is very limited research out there about the how

physical therapy can impact and improve the impairments following a tethered cord release and a

Chiari malformation decompression surgury. Upcoming research should also cover the benefits

of heavy work on children in physical therapy who are sensory seeking. For patients who are

sensory seeking while performing physical therapy interventions, adding heavy work could

increase outcomes overall. Overall, understanding the benefits of physical therapy with this

population could help improve the overall outcomes of patients following these surgeries.

18
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78522012000300003
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22
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7852201200030

23
Table 1.

Manual Muscle Tests (Berryman 2020)a,b

Muscle Examination Discharge

Hip Flexion R: 4/5 L: 4/5 R: 4/5 L:5/5

Hip Extension R: 4-/5 L: 3+/5 R: 4-/5 L:4/5

Hip Abduction R: 4/5 L: 4/5 R: 4/5 L:4/5

Knee Extension R: 4-/5 L: 4-/5 R: 4/5 L: 5/5

Ankle Dorsiflexion R: 5/5 L: 4/5 R: 5/5 L:5/5

a
The patient had decreased muscle strength in all areas measured except right lower extremity
ankle dorsiflexion. 5/5 is full strength at the examination. By discharge, the patient increased
strength in all items of the left lower extremity and increased right lower extremity knee
extension.
b
R: Right, L: Left
Table 2.

PEDI-CAT (Dumas 2012)

Domain Examination Examination Discharge Scaled Discharge

Scaled Score Percentile Score Percentile

Daily activities 54 5-25 53 5-25

Mobility 63 5-25 63 5-25

Social/Cognitive 64 25-50 64 25-50

Responsibility 46 50-75 44 25-50