OTA 103 Physical Function & Dysfunction Lecture Class

What are the types of balance reactions?

RIghting Reactions & Protective/Equilibrium Reactions.

Developing Systems are?

Inter-related

Development is a

dynamic process

Why is it important for OT practitioners to understand normal development in children?

Developing treatment plans that are effective, understanding the sequence of normal development to facilitate change. and remembering normal development occur within a varied range of time.

What is postural control?

Ability to maintain body alignment in an upright position

Dynamics Systems Theory

Motor control is contributed by muscle strength, body mass, sensory processing, behavior, cognition & environmental constraints.

Dynamic Systems Theory: Variability?

Allows the child to adjust movement according to environmental or internal changes.

When do balance reactions emerge from birth?

approx. 21 months.

Where do righting reactions maintain alignment?

Between head & body, upper & lower body, & forward flexion of the trunk & prone suspension.

What are protective reactions?

Do not correct a displacement but provide protection from a fall

What are equilibrium reactions?

Returns the child to a vertical position after being displaced

Interaction for Development of Postural Control of Nature

Maturation of the CNS is needed in the development of these skills.

Interaction for Development of Postural Control of Nuture

Motor Skills also develop based on experience that child has in given postures.

Anticipatory Responses?

Are used to program muscle activation in anticipation of movement. Allows for postural adjustments prior to movement & it is dependent on experience.

Mass to Specific

Children start with more mass patterns of movement and then move to more refined skills.

Voluntary Release?

Intentional letting go at a specific time & place

Lateral Pinch

Thumb against radial side of the index finger near DIP joint

Pad to Pad/Two-pinch or pincer

Opposition of the thumb to index finger only

Three-point pinch or three jaw chuck

Opposition of the thumb simultaneously to index & middle fingers

What is the sequence of development for bilateral hand use?

Asymmetry until 3 months, Symmetry b/w 3-10 months, Differentiated asymmetric start around 10 months, & Hand Preference (dominance) around 2-3 years old & continues development til 8 yrs old.

Tool use?

Purposeful, goal directed form of complex object manipulation that involves the manipulation of the tool to change the position, condition, or action of another object.

What are motor problems that affect hand skills?

Inadequate isolation of movement throughout the UE, Tactile problems, Insufficent force due to weakness, abnormal tone, poor timing of movement, poor postural stability & mobility, and disorders of bilateral integration.

Treatment Considerations for Motor Probelms that Affect Hand Skills

Improve postural control, improve muscle strength, inhibit or facilitate tone (weight bearing activities), use activities that emphasize isolated arm & hand movement, positioning to facilitate desired result, & when seated at the table the child should sit with both feet on the floor & table at a level where elbows lie flat on it when they are at a 90 degree angle.

Saccadic Eye Movements/Scanning

Rapid change of fixation from one point to another

Accomodation in Visual-Receptive Functions

Process of being able to focus on objects at varying distances

Stereopsis

Binocular depth perception

Treatment Strategies for Visual Perceptual Problems

Multi-sensory approach of pairing tactile input when learning shapes, letters, & numbers. Organizing the environment by reducing visual clutter & using color coded systems. Grading activities to facilitate visual performance. Tactile discrimination tasks to enchance visualization skills. Use of scan & search pictures/activities. Contrasting colors to emphasize an object from it background. Signage & landmarks to improve topographical orientation. Puzzles, Games.

Eating & Self-Feeding Skills- Newborns to 2 Months

Position with Supine head slightly elevated or reclining at an angle of less than 45 degrees. Eating liquid from breast or bottle. Oral reflexed dominate for the newborn (including rooting, suck/swallow, gag). Sequences two or more sucks before pausing to breathe or swallow.

Eating & Self-Feeding Skills- 3 to 4 Month Old Infant

Position of neck and head control improved. Baby fed in supported semi-sitting position, reclining at an angle of 45-90 degrees. Eating soft cereals depending on reccomendation from pediatrician and having liquid from bottle or breast. Is able to swallow without a discernible pause, sequences twenty or more sucks.

Eating & Self-Feeding Skills- 4 to 6 Months

Positioning of an upright posture with external support in a highchair or feeder seat. Eating cereals & pureed foods between 4 to 6 months. Has difficulty with coordinating swallow from a cup. Able to use long sequences of suck, swallow, and breathing with breast or bottle. Suckles in anticipation of spoon coming near. Present is gag reflex.Brings hands to mouth with toy or object. Pats and/or both hands on bottle or breast when drinking. “Munching” chew pattern. Attempts to secure tiny object (piece of food) with a few fingers or whole hand, makes contact but often unsuccessful.

Eating & Self-Feeding Skills- 7 to 9 Months

Upright posture in a highchair with no external support need. Liquids, pureed foods, ground or junior foods, and mashed table foods. Tongue is able to move food to center from side of mouth using tongue for chewing. Can close lips around spoon and cleans it up after bites. Gags slightly less sensitive. Voluntary bite for soft food. Starts to drink or suckle from open cup when given jaw support, difficulty coordinating sucks with swallowing and breathing. Scooping or Raking. Begins to use thumb and index finger (inferior Pincer) for self feeding.

Eating & Self-Feeding Skills- 10 to 12 months old

Eats coarsely chopped table foods. Starts controlled bites. True suck & can drink from staw. Drink from cup starting with more jaw control but lips may open during swallow and spill liquid. Neat pincer grasp. Holds spoon to play, bang, mouth, drop.

Eating & Self-Feeding Skills- 13 to 15 Months

May bite on cup to stablize jaw. Starting to close lips while chewing. Learning to make controlled bite on hard cookie. Dips spoon in food. Brings spoon to mouth, tirns spoon over, but obtains some food.

Eating & Self-Feeding Skills- 16 to 18 months

Usually fed from the family table with tall chair or booster seat. Coarsely chooped table foods including most meals and raw vegetables. Better control food and liquid with minimal loss during feeding. Improved control of liquid within mouth and able to independently drink from a cup. Better control of food and liquid with minimal loss during feeding. Improved control of liquid within mouth and able to independently drink from cup. By 18 months, can hold own cup to pick up, drink, and set down with some spillage and can feed self with fingers or spoon.

Eating & Self-Feeding Skills- 19 to 24 Months

Seated at the family table. Can use tongue to clean lips. Drink from straw with lips. Can chew meat competently. Can transfer food from one side of mouth to other (across midline). Chews food completely with “rotary” jaw movements. Can transfer from one side of mouth to other. Chews food completely with rotary jaw movements. By 24 mouths, feeds self with spoon with some spillage.

Eating & Self-Feeding Skills- 25 to 36 Months

Can independently drink from small cup with one hand. Holds spoon with fingertips, hand in palm up position. Can pour liquid from a small container with control. Can use a fork to piecre soft foods and bring to mouth. Can wipe mouth with napkin when given reminders.

Eating & Self-Feeding Skills- 3 to 4 Years

Swallows food in mouth before taking another bite. Serves self at table. Refills a cup with some spilling using a container with handle and spout. Holds cups with one hand while holding straw with other hand to drink.

Eating & Self-Feeding Skills- 3.5 to 4.5 Years

Can open at least 5 different kinds of food containers without assistance. Can prepare simple foods for eating.

Eating & Self-Feeding Skills- 4 to 5 Years

Puts appropriate amount of food in mouth and can chew with lips closed. Can spread soft substances with plastic/child-safe knife.

Eating & Self-Feeding Skills- 5 to 6 Years

Can cut foods with a knife undersupervision (Dull knife or Slightly Serrated)

Eating & Self-Feeding Skills- 5.5 to 6.5 Years

Can cut with a fork and knife

Low Tone Problems with Eating & Drinking

Reducing strength & skill & may cause poor lip closure & drolling. Treatment includes build tone in trunk and provide proximal stability; play games that incorporate patting, tapping, stroking and proprioceptive input through food selection & discrimination, teach straw drinking; use of blow toys.

High Tone Problems with Eating & Drinking

Can cause lips and/or tongue retraction in downard stroking motion symmetrically to cheeks and around lips; place child in good postural alignment; place bowl of spoon in middle of child’s tongue and apply rhythmic downward pressure.

Sensory Defensiveness Problems with Eating & Drinking and Suggestive Treatment

Slow vestibular stimulation. Find most acceptable touch, like vibration. Therapists facilitates what’s placed on child’s mouth and verbally prepares the child.

What is California Childern’s Service (CCS)?

Statewide program in California that provides treatment for children with certain medical conditions and chronic disabilities.

Medical Therapy Program (MTU)

Outpatient therapy clinic set up in designated schools.

Juvenile Idiopathic Arthritis/ Juvenile Rheumatoid Arthritis (JRA)

Autoimmune disease that cause chronic imflammation of the joints, tissues around the joints and other organs of the body. Systemic disease because it can affect organs other than just joints. No blood tests to positively identify JIA.

Oligoarticular JIA (Pauciarticular)

Initially affects 4 or < smaller joints (usually in wrists or knees) Children < 7 yrs may go into remission. Children > 7 yrs have higher chance of the disease spreading to other joints.

Polyarticular JIA

Can begin at any age & affects 5 or > joints of any size in the legs, arm, jaw or neck. In a phsyical exam, children might also have swollen livers, spleens, and lymph nodes.

Systemic Onset JIA (Still’s Disease)

Least common type of JIA affecting 10% of people with arthritis. Begins with spiking fevers up to 103 degrees and persistent red rash. Joints swelling and damage may not appear for months or years. Anemia and elevated WBC can be an indicator of JIA and looked for in blood tests.

Malaise

General feeling of discomfort, illness, or uneasiness.

Iridocyclitis

Occurs when both the iris and ciliary body become inflamed.

Managing JIA

Medical Management- Proper diet, Low impact exercise, Medications.

OT Intervention- Respecting pain. Decreasing pain and inflammation: heat or cold. Joint protection. Maintain/increase ROM: active assistive exercise with gentle passive stretch, activities to involve movement. Maintain/increase strength and endurance: Exercise (no resistance in acute stage) and activities like biking, swimming, or biking. Self-help training with adaptive equipment as needed. Patient/parent education.

Cerebral Palsy

Non-progressive syndrome that affects muscle control and posture. Results from abnormal brain development or damage to developing brain. Caused by stroke, trauma, tumors, infections, anoxia (lack of oxygen to the brain)

Spastic Cerebral Palsy

Most common. Caused by damage to cerebral cortex. Characterized by increased muscle tone (hypertonia) resulting in stiff limbs and resistant to flexing or relaxing.

Athetoid/Dyskinesia Cerebral Palsy

Caused by damage to the basal ganglia. Characterized by involuntary & uncontrolled fluctuations in muscle tone alternating between floopy and tense. Involuntary movements can affect walking, sitting, talking, and postural control and are activiated by excitement and disappear during sleep.

Ataxic Cerebral Palsy

Caused by damage to cerebellum. Characterized by weakness and impaired balance, posture, and cooridination of movement. May present with problems with eye movement control and depth perception. Often affects fine motor control in activities that require eye-hand coordination.

Other Problems Involving CP

Intellectual disability, Seziures, Failure to thrive, Impaired vision, Impaired Hearing, Impaired Sensation

OT Treatment of CP

ROM, Muscle tone, Oral motor skills, Fine Motor Skills, VIsual motor skills, Postural control, Strength, Occupational Activity, & NDT.

Muscular Dystrophy (MD)

Inherited disorder characterized by progressive degeneration & weakness of skeletal muscle. Most common of Duchenne Muscular. Progressively weaker throughout life. Death results from respiratory failure, congestive heart failure, pneumonia, or aspiration.

OT Treatment for MD

Goal not to strengthen muscles or improve function, but to maintain strength and function if possible. Avoid excessive exercise. Family training. Classroom programs. Adaptive equipment.

Spina Bifida (Myelomenigocele)

Neural tube defect where there is a protrusion of the meningeal sac and spinal cord through defect in closure of vertebral arches.

Complications that can occur from Spina Bifida

Hydrocephalus, Seizures, Contractures, Hip dislocation, Scoliosis, Bowel & Bladder incontinence, Skin Breakdown, Precocious Puberty, Obesity, & Low Intelligence.

Ventriculo-peritoneal (VP) shunt

fluid goes to the peritoneal cavity

Ventriculo-atrial (VP) shunt

fluid goes to right atrium of the heart

Ventriculo-pleural (VPL) shunt

fluid goes to the pleural cavity

Lumbo-peritoneal (LP) shunt

fluid goes from the lumbar area to the peritoneal cavity

OT Treatment for Spina Bifida

NDT approach, Functional Skill Training, Adaptive equipment training, Patient/family education

Osteogenesis Imperfecta (Brittle Bones)

Congential disorder where the bones are brittle and easily fractured. Short stature, scoliosis, and progressive deformities are usually seen with this disorder.

Osteogenesis Imperfecta Type II Fetal

Most severe, high mortality rate. Fractures occur in utero and during birth. Shortened extermities from multiple fractures, soft skull bones and blue sclera.

Osteogenesis Imperfecta Type III Infantile

Moderately Severe. Fractures occur in early childhood. Limb deformities & growth disturbances.

Osteogenesis Imperfecta Type I Juvenile

Least severe. Fractures begin in late childhood. Musculoskeletal pain from hypermobile joints.

Osteogenesis Imperfecta OT Treatment

Handling & positioning techniques to reduce fractures, assessment for adaptive equipment, movement activiity to increase muscle strength, assessment for developmental delay due to environmental restrictions, and caregiver training.

Arthrogryposis

Different rare conditions that are multiple joint contractures throughout the body at birth. Muscles often around these joints are thin, weak, stiff or missing.

OT Treatment of Arthrogyposis

Management of symptoms, stretching, splinting, adaptive equipment, and functional skill development.

Brachial Plexus Injury

Injury of nerve complex that originates between C4 and T1 and innervates the upper extremity.

Erb’s Palsy

Damage to the C5-6 roots. Can result in full or partial paralysis to the upper arm and elbow or it can result in lack of movement of the entire arm. Waiter-tip arm.

Klumpke’s Palsy

Damage to C8-T1. Affects the distal part of the upper extremity. Claw-like hand.

OT Treatment by Brachial Plexus Injury

Splinting and positioning to prevent contractures. Passive and active-assistive exercises. Resistive exercise and activities to facilitate optimal movement & strength a

Cystic Fibrosis (CF)

Pulmonary & gastrointestinal disease. With complications like wheezing, respiratory infections, recurrent pneumothorax, chronic cough hemoptysis (coughing up blood), Problems with sodium absorption, diabetes, malabsorption with vitamin deficiencies, and gastrointestinal obstruction.

OT Treatment for CF

Work Simplification & Energy Conservation

Amniotic Band Syndrome

Believed to be caused by entrapment of fetal parts in fibrous amniotic bands while in utero.

Syndactyly

Webbing of fingers or toes

Brachydactyly

Short fingers or thumb

Macrodactyly

Overly large fingers or thumb

Amelia

Absence of limb or distal segments of limb

Phocomella

Missing one or more segments of proximal segments of limb

OT Treatment for Limb Deformities

Splinting, Functional skill training, Prosthetic, Training, Bimanual activities for play, school, self-care

Causes of Dysphagia

Neurological problems, head or neck cancer, neck or chest injuries, aging in the older adult population

Phasing of Swallowing

Oral preparatory phase, oral transit phase, pharyngeal phase, esophageal phase

Oral Preparatory Phase

Preps food to be swallowed. Chewed food becomes bolus

Oral transit phase

tongue move bolus to back of mouth

Pharyngeal phase

Bolus passes pharynx & swallow reflex is triggered, epiglottis covers top of larynx

Esophageal phase

Food enters esophagus & transported to stomach

Importance of Coughing

Removes objects from entering airway, protective reflex of body to expel foregin particles, Clears lungs and airways (lower respiratory system)

Signs for Difficultly with Eating and/or Swallowing

Drooling, weight loss, recurrent respiratory infections, spitting out lumps of food, pocketing of food in the mouth, choking and coughing, gurgly or wet voice quality, complaints of food being stuck in not going down or throat, regurgitation of the food

Evaluating Dysphagia

Bedside Swallow Examination (BSSE) & Videofluroscopic Swallowing Study (VFSS) or Modified Barium Swallow Study (MBSS)

Bedside Swallow Examination (BSSE)

Oral Examination, Cognitive Status, Oral sensation, Touch Function, Vocal Quality, Gag reflex, Ability to cough/clear throat, Vocal Quality, Ability to cough/clear throat, trial food consistencies if appropriate

Videofluroscopic Swallowing Study (VFSS) or Modified Barium Swallow Study (MBSS)

Evaluate cause of dysphagia & Look for silent aspiration

Dysphagia Treatment

Positioning during eating, Frequent swallows, Small amounts of food or liquid in mouth at a time. Alternating food and drink with swallows after each. Consistencies of the food/liquid provided. Adaptive Equipment. Oral motor exercises for lips, tongue, cheeks, and mouth.