Pediatrics

Sensory Modulation

Our ability to respond appropriately to sensory information

Hyporeactivity

Under responding; delayed responses to sensory stimuli → child misses info

Hyperreactivity

Overrespond or overreact to stimuli

Tactile Defensiveness

Avoidance of texture, clothing, food

Auditory Defensiveness

Distress or covering ears to certain sounds

Gravitational Insecurity

Excessive fear of feet living ground during activity

Sensory Discrimination / Perception Issues

Can’t tell the difference between things

Proprioceptive example of Sensory Discrimination

Using too much force in activities, like breaking pencil lead when writing

Visual example of Sensory Discrimination

Confusing “b” and “d” during writing activities

What does the Vestibular System help with?

Maintaining posture

Praxis

Motor planning

Challenges with Dyspraxia

• Clumsy

• Knocking down things

• Difficulty imitating actions of other

Proprioceptive Signs of Sensory Seeking Behaviors

Stomping, jumping, bumping into people

Vestibular Signs of Sensory Seeking Behaviors

Intense swinging and swinging without getting dizzy

Signs of Hyposensitivity

• Oblivious

• Unresponsive

• Delayed response

Arousal Techniques for Hyposensitivity

Tactile and Vestibular

• Light Touch

• Fast, unpredictable swinging

Hypersensitivity

• Defensive

• Anxious

• Unwilling to perform

Calming Techniques for Hypersensitivity

• Proprioception / Deep Touch

• Weighted Vest/ Blanket

• Dim Lights

• Ear Muffs

What type of techniques do you use to address hypersensitivyt?

Calming and Organizing techniques, such as Proprioception → Proprio & Chill

What type of techniques do you use to address hyposensitivity?

Arousal Techniques, especially Tactile and Vestibular

Swinging used to address hypersensitivity

Slow, consistent, and linear

Swinging used to address hyposensitivity

Fast and unpredictable

Signs of Autonomic Activation of Vestibular System

Blanching, nausea, severe dizziness

What should you do when your patient shows signs of autonomic activation during vestibular input?

Switch to slow, linear swinging or increase proprioception

Wilbarger Protocol

• Brushing

• Remember: “Wilbarger will brush her with pressure”

T/F: Passive Tactile Stimulation leads to less defensiveness

False; Passive tactile stimulation leads to more defensiveness

4 Month Developmental Milestones

Lifts head

6 Month Developmental Milestones

• Raises trunk in prone

• Reaches for objects

• Rolls

• Raking grasp

• Brings object to mouth

• Sits with propping

12 Month Developmental Milestones

• Lyings → Sitting

• Sits without propping

• Crawling

• Stands, holding for support

• Walks with hand hold

• Doffs socks, threads sleeves

18 Month Developmental Milestones

• Squats to pick up items

• Walks well (begins to run)

• Uses cup/spoon

2 Year Developmental Milestones

• Remember 2 Sets of 2: High/Low and Fast/Slow

  • Climbs up/down furnituve

  • Up/Down stairs holding on

  • Jumps with both feet

  • Builds block towers

  • Runs

  • Kicks/throws ball

3 Year Developmental Milestones

• Pedals tricycle (TRI-cycle)

• Catches large ball (3 Strikes You’re Out)

• Dresses with min A (3/4 dressed)

4 Year Developmental Milestones

Remember: “Four-dinated”

• Stands on 1 foot

• Begins to skip/hop

• Alternate feet up stairs

• Colors in line

5 Year Developmental Milestones

Remember: High FIVE for Independence

• Uses toilet independently

• Dresses independently

Moro Reflex

Startle reflex

Remember: “You surprised me. I didn’t expect you until tomoro”

What deficits would you expect if the moro or rooting reflex didn’t integrated?

Issues with head control

Rooting Reflex

Turning head in response to touch → breastfeeding

What would you expect to happen to trigger palmar grasp?

Touching palm → grasping

ATNR

• Remember: “Fencer’s Reflex”

• turning head to side → arm/leg extension on same side; arm/leg flexion on opposite side

Technique for an ATRN reflex that is late to integrate

Interact @ midline

What deficits would you expect for a child with an unintegrated ATNR reflex?

Deficits with rolling and R/L coordination

Tonic Labyrinthine Reflex

Lying on the floor

• Neck flexion → extremity/trunk flexion

• Neck extension → extremity/trunk extension

Functionally, what is the importance of the TLR reflex?

Develops postural strength and muscles for head/neck and trunk control

What deficits would you expect with an unintegrated TLR reflex?

• Decreased trunk control

• Decreased ability to transition

• Decreased tone

• (Rolling over, lying to sit, crawling)

STNR

Remember: STNRsault

• Look down → Bottom goes up (Next flex → BUE flex, BLE ext)

• Look up → Bottom goes dwn (Next ext → BUE ext, BLE flex)

What deficits would you expect to see with an unintegrated STNR reflex?

• Decrease core strength

• Decreased gross motor coordination

Landau

Superman → suspended in prone

• Neck flexion → legs flex

• Neck extension → legs extend

Interventions for unintegrated reflexes

• Encouraged motor patterns that break reflex pattern

  • Cat/Cows for STNR

What deficits would you expect for an unintegrated landau reflex?

Difficulties with sitting and standing upright

Purpose of protective and equilibrium reactions

• Prevent us from falling/hurting ourselves

• Never integrate

Mnemonic for Reflexes

MR. PATS Land → Hey Hey Real Roll Right PCS

• Moro → Head

• Rooting → Head

• Palmar → Release

• ATNR → Roll/ RL Discrimination

• TNR → Posture / Transitions

• STNR → Core / Coordination

• Landau → Sitting / Standing

Main issues faced with ASD

• Sensory (hypo/hyperreactivity)

• Rigidity

• Motor

Heads Up for Autism!

Kids with ASD like familiar routines and struggle with transitions and changes, especially when they don’t see it coming → provide advance notice of upcoming change (ex: visual schedule, modeling)

Outside the Box -Rigidity

Inside the box → Rigidity

Intervention → outside the box

• Think of child with ASD playing inside a box with toy

Rigidity Mnemonic for ASD

Child with ASD is inside the box playing with a toy car → Spinning the wheel FAST

F- Focused

A- Alone

S - Same

T - Transition

Intervention for Rigidity (FAST)

ENGAGE HIM

FAST → ENGAGE HIM (Engage, Model Socialization, Ideation/creativity, Heads Up)

DIR/ Floortime

Parent/child approach using child’s preference to increase engagement with playful blocking

CO-OP

Learn new skills and generalize skills into everyday life

• Goal-Plan-Do-Check

Ayer’s

Sensory Integration

Child is hyperfocused on own task and uninterested in social play, what interventions should you consider?

Strategies to capture attention or involve child → use preferred objects and create fun problems to solve

Child insists on sameness, difficult with transitions. What interventions should you consider?

• Give child a heads up of change

  • Visual schedule

  • Written instructions

• Build tolerance to unexpected changes

  • Prompting

  • Provide choices

Child is distressed about demands of daily tasks. What interventions should you consider?

• Sensory strategies to decrease discomfort

  • Attend to sensory environment and child’s response

  • Provide deep pressure and proprioception through active play

• Grading Task to find Just Right Challenge

  • Introduce novelty into session carefully

  • Decrease eye contract and alter proximity

Child fixates/perseverates on object with repetitive behaviors. What interventions should you consider?

Prompting and helping them create new ideas

• Use realistic props to promote imagination

• Take turns imitating each other

Child has difficulty planning and executing unfamiliar tasks. What interventions should you do?

Increase attention to movement/body awareness

• Obstacle courses challenging motor ability, alternate sensory activities with challenging motor tasks

• Building blocks

Child doesn’t engage socially with peers, what interventions should you consider?

• Video modeling, imitation

• Peer-mediated intervention (play groups)

• Provide choices, preferred toys

Child has difficulty falling and staying asleep, what interventions should you consider?

Provide calming sensory techniques (proprioception and decreased tactile/sounds/visuals)

Child seeks attention from parents during bedtime, what interventions should you consider?

Once in bed, ignore child until morning

• Monitor for safety

Child has difficulty with self-soothing, what interventions should you consider?

Parents alternate between ignoring behaviors and checking on child

When is the side-lying position useful?

Useful for weakness due to gravity eliminated position as it’s better for limb movement without gravity

What is the significance of the Prone Extension/Prone on Elbow, and Quadruped positions?

Preparatory for crawling and builds proximal stability and strength

Which positions are preparatory for standing?

Tall Knell and Half Kneel

Which position should we NOT promote?

W Sitting

• Puts stress on joints and decreases postural strength

• Normal until 12 months

Common issues with positioning

Extensor tone → straight as a board (hypertonic)

Flexor tone → slouched forward (hypotonic)

Mnemonic for Positioning

“Proximal Stability Before Distal Mobility”

• Especially true with hypotonicity; address proximal stability first (positioning devices)

Supportive / Adaptive Positioning for Dressing

Promote flexion → Quadruped

Side-Lying → easier to move limbs and dress (d/t gravity elimination)

Supportive / Adaptive Positioning for Toileting

Reducer ring to improve balance

Supportive / Adaptive Positioning for Bathing

Hammock- full support

Trunk support ring

Inflatable bath color

NDT / Handling Techniques

Uses sensory input (deep pressure / UE weightbearing) in order to:

• Decrease spasticity and primitive reflexes

• Facilitate normal movement patterns

Mnemonic: “Normal (movement pattern) Do Touch)

NDT Mnemonic

Normal (movement pattern), Do Touch

Positioning Devices

Promote weightbearing and weight shifting in prone to increase promximal stability, UE strength and trunk stability

• Firm foam wedges

• Side lyers

• Play over a bolster or exercise ball

• Towels propped under trunk

Corner / Bolster Chair

Promotes upright sitting

Supine/Prone Standers

Promote Standing

You are assisting a BLE amputee with fitting for W/C. Where would the COG be for this patient?

COG Forward, with weight on the casters, making it harder to move but more stable

Benefits of a wheelchair wht the COG backward?

Popping wheelines onto curbs due to the easy maneuverable with tipping back. Less stable

Rear Wheel Drive Powerchair

• Easy to steer

• Good over rough terrain

Rear → Rough Terrain

Mid-Wheel Drive

• Increase maneuverability d/t small turning radius

• Good in small spaces

Mid → Maneuverable

Front-Wheel Drive

• Various terrain due to power in front

• Disadvantage: fishtails

Front → Fishtail

Benefits of a Reclining W/C

• Back of chair leans back, avoids hip flexion

• Good for: hip precautions

Benefits of a Tilt In Space W/C

• Tilts forward/backward

• No affect on hip angle

• Good for: extensor tone or hip contracture as the hip angle stays the same

Explain the 1 inch rule for Wheelchairs

Leave an extra inch for the:

• seat to back of knee

• hips to side of chair

Seat Height Wheelchair Measurement

Usually ends at scapula

• Poor postural stability → higher seat height

A patient experiences postural weakness and decreased tone, what interventions/AE would you consider?

• Recline/Tilt In Space

• Raised back rest

• Custom contour seat cushion

• Lateral trunk supports

• Lap tray (UE WB)

• Harness (dynamic use of UE)

A patient experience UE weakness, what interventions/AE would you consider?

• Lightweight/ultraweight wheelchair

• Walker with forearm trough

• Lap tray

Child can’t keep up with peers while self-propelling wheelchair, what interventions/AE would you consider?

Powerchair / power assist unit or one-arm drive

A child demonstrates difficulty with manipulating controls, what interventions/AE would you consider?

U-shaped joy stick that supports the palm

A pt demonstrates increase tone (Hypertonicity), what interventions/AE would you consider?

• Tilt in space

• Lower seat-to-back angle ( < 90 deg of hip flexion)

• Seatbelt at 90 deg angle to thighs

• Hip guides

• Wedge downward slope point back

A pt demonstrates motor control deficits (tremors, ataxia), what interventions/AE would you consider?

• Tremor dampening joystick

• Joystick @ midline or rotated toward body → decrease reach

• Powered elevating seat

A pt demonstrates significant motor deficits, what kind of approach should be used at this point?

Compensation

• Alternative control/head switch

• Eye gaze

• Pneumatic sip n puff

Foam Cushion

Benefits: Cheap, light weight, good contour

Disadvantage: traps heat → has to be replaced often

Memory Foam

Benefits: stable base, moves heat away from body

Disadvantage: sliding d/t material