A 5-year-old male child, who was the firstborn of a non-consanguineous marriage, was diagnosed with a seizure disorder and neuroregression as a post encephalitis sequel. He presented at the physiotherapy department with an inability to stand and walk. He was able to hold neck, roll, and maintain sitting with support. The patient was delivered by cesarean section, cried immediately after birth, and weighed 2 kilograms. He achieved age-appropriate developmental milestones in the first year of life. On his first birthday, he performed unsupported standing, took a few steps without the support and spoke 2-3 meaningful words. At 13 months of age, he had an episode of fever. After 24 hours, he experienced convulsions and was referred to a tertiary care centre by a local practitioner. He was admitted to PICU for 15 days with a high-grade fever of 106 degrees F and refractory status epilepticus. He was afebrile after day 3 of admission, and seizures continued till day 6. At the time of discharge, he had a frequency of 10 seizure episodes per day. He had neuroregression in all domains of development. He was unable to hold neck or roll, unable to speak, and unresponsive to any visual stimulus. He was discharged with anti-epileptic medications and a home exercise program.
On evaluation, his Gross Motor Function Classification System (GMFCS) was at level IV, and Pediatric Balance Scale (PBS) score was 5. He had generalized hypotonia, preferred W-sitting, had tightness of bilateral hamstrings and calf muscles, displayed body rocking and chewed the clothes. Child neither made eye contact nor, was there visual fixation and tracking. His light perception was equivocal. Figure 1 and Table 1 shows the Magnetic Resonance Imaging (MRI) findings of the brain and the timeline of the events, respectively.
Diagnostic assessment: GMFCS and PBS were used to measure gross motor function and balance, respectively.
Diagnostic challenges: visual and cognitive impairment posed challenges. Furthermore, the child continued to have seizures 3-4 times per day.
Physiotherapy intervention: the patient received regular physiotherapy based on the principles of neurodevelopmental treatment (NDT) and sensory integration (SI). The initial phase of 3 months included sustained stretching of the bilateral calf and hamstring muscles in functional positions, using unstable surfaces (equilibrium board and swiss ball) to challenge his sitting balance, using swing system to impart vestibular input, using visual stimulus to initiate a response, facilitating transitions like supine to sit and sit to stand by appropriate therapist s hand placement, providing proprioceptive stimulus by bouncing on a trampoline with support, weight-bearing exercises, joint compressions and use of a chewy tube. As the child regained the ability to sit and stand without support, walker (rollator) was used as a walking aid. The parents were educated about the home exercise program. During the follow-up visits interspersed over 2 years, the patient was reassessed and the exercise plan was modified accordingly. The child started taking a few steps without support. In the second phase of regular physiotherapy for 6 months by a physiotherapist, the goal was to achieve unsupported walking under supervision in the view of visual impairment. Sessions included standing on equilibrium board and stability disc with just as much support as required. Walking on compliant surfaces, ramp, uneven terrain and across obstacle course was practiced. Negotiating stairs holding onto the railing with moderate assistance was included. Proprioceptive, vestibular and visual inputs were continued to be given.
Outcomes: after the course of physiotherapy, the child was able to sit and stand without support. He was able to walk without support on uneven surfaces under standby supervision. He started responding to light. He seemed to be avoiding bumping into objects or persons by apparently improved visual ability. Body rocking and chewing on clothes were seldom observed. Improvement in functional activities led to an increase in the participation of the child in social gatherings. Figure 2 shows the functional abilities of the child at the age of 5 years and 8 years, respectively.