Case Series: Feasibility of an Intensive Physical Therapy Intervention in the Neonatal Intensive Care Unit

Background & Purpose: Physical therapy (PT) in the Neonatal Intensive Care Unit (NICU) is a well-established intervention to support behavioral state regulation, alignment and movement, developmental progression, and address atypical postures and muscle tone. Dosage of PT in the NICU typically averages two visits per week. Unlike many institutions in which infants well past term equivalent age (TEA) may transfer to pediatric intensive care, infants remain in our NICU throughout their stay. Intensive therapy, defined as 3-11 visits per week, is more commonly used in the outpatient setting. This report describes intensive therapy services (ITS) for three infants in the NICU.

Case Description: Three infants with prolonged hospitalization past TEA, tracheostomy and ventilator dependence, abnormal findings on brain MRI, multiple comorbidities, and global developmental delays underwent ITS. Infant 1 is a full-term male with Central Congenital Hypoventilation Syndrome and Neonatal Encephalopathy. Infants 2 and 3 are preterm females with birth weight < 1000 grams. Adjusted ages of the infants ranged from 10 to 15 months when starting ITS. ITS initiation was based on sensitive periods when the infants demonstrated medical stability and readiness to learn new skills. Infants received an average of 218.8 minutes of PT per week over 3-4 weeks, in 14-16 sessions. PT intervention used developmentally appropriate positions and functional activities focused on improving postural control and transitional movements. All infants followed a daily routine that prioritized scheduled therapy sessions and naps. Families and nurses continued pre-existing play and positioning programs recommended by the infants’ therapists.

Outcomes: All infants demonstrated increased scores on the Gross Motor Function Measure-88 (GMFM-88) from pre- to post-test. The mean change in GMFM-88 score was 6.29%. Goal Total Scores for Dimensions A (lying and rolling) and B (sitting) increased by an average of 14.85%. All infants completed the entire bout of intensive therapy without adverse effects.

Discussion: Infants in the NICU experience a starkly different environment from the natural environment of most infants that affords far fewer opportunities for learning through natural exploration. Chronic, severe health conditions often limit their readiness to learn. Despite these challenges, infants experiencing prolonged hospitalization may show readiness for intensive interventions to improve developmental skills. Infants’ GMFM-88 scores indicate improvement in skills related to supine, prone, and sitting positions, rolling, and dynamic postural control. Provision of ITS in a NICU setting is not well documented, and validity of the GMFM-88 for infants with ventilator dependence is not established. Despite these limitations, this case series illustrates that ITS is feasible in a NICU setting, and the GMFM-88 may be useful to document gains in gross motor function. Collecting two pre-ITS GMFM-88 scores to establish a baseline rate of progress would help elucidate the specific effects of ITS intervention.