developmental coordination disorder, muscular dystrophies, juvenile idopathic arthritis (10/29)

developmental coordination disorder (DCD) pathophysiology

chronic condition w/ impairment in: gross motor, postural and/or fine motor performance

affects performance of academic & self care tasks

not attributable to known neuro or medical disorder

higher risk: born prior to 32 wks gestation, or less than 1500g at birth

strong associations with ADHD, ASD, speech/articulation difficulties, language based learning disabilities (esp reading)

dx of DCD

must meet all 4 criteria

motor coord below what would be expected when considering chronological age & exposure to motor activities

mvmt qualities incl. clumsiness, slowness, inaccuracy which impact daily living skills, school, leisure, play

s/s beginning in developmental period

s/s can’t be explained by other conditions (intellectual disability or other neuro cond w/ motor impairments)

formal dx not typically made before 5 y/o

not in PT scope to dx: recognize motor & behavior characteristics, can provide info on criteria 1 & 2 for phsycians

dx can help initiate edu, interventions, accommodations

DCD subjective

birth: prematurity, birth weight, onset of s/s, coexisting conditions

development: gross/fine motor, language, social/adaptive, other areas of concern

edu hx: previous interventions & services, areas of difficulty

participation hx: home ADLs, social activities

DCD body fx & structure

sensory, perceptual deficits

motor control deficits

motor learning deficits

fatigue

decr strength

DCD activity limitations

self care, academic skills

gross motor coordination (motor + ballistic skills)

DCD sensory/perceptual deficits

decr kinesthetic processing

poor proprioceptive fx

impaired visual-spatial processing

reliance on visual info

DCD motor control & learning deficits

awkward, slow mvmts with rigid/jerky quality

freq bump into people or objects

tendency to trip and fall

decr balance, postural control

ineffective strategies in mm activation and sequencing

“fix” jts for stabilization

lack adaptability and flexibility in motor behavior

hypotonia, jt laxity common

DCD pry impairment examination

posture

observational mvmt analysis!!!

• common findings: incr time to complete task, asymmetry, poor coord, poor motor planning

gait

balance, postural control

coord

ballistic skills

DCD physical impairments

decr energy/fatigue

decr strength, power, endurance

DCD social/emotional/behavioral impairments

may be quiet/withdrawn at school

avoid schoolwork, frequent “off task” beahviors

often give up on tasks easily, occasional angry, aggressive classroom behavior

DCD secondary impairment examination

strength: MMT, fxl mvmts

endurance: 6MWT and compare to typically dev peers; TUD

DCD self care limitations

snaps/zippers/buttons

tying shoes

managing forks/spoons

dressing & undressing

DCD academic limitations

printing

handwriting

large discrepancy btwn oral and written work

difficulty w/ coloring/cutting/pasting

DCD gross motor limitations

may show delays w/ each novel skill

poorly coord higher-level skills

hand-eye coord—ballistic skills

coord of both sides of body (jumping jacks, swinging a bat)

DCD activity limitation & participation restriction examination

ballistic skills

school setting: observe in school

outcome measures: developmental coord disorder questionnaire (DCDQ, MABC-2, BOT-2 (3))

developmental coordination disorder questionnaire

parent report screening for children 5-15 y/o

scores per age group for “suspected DCD” or “probably not DCD”

lower score=more likely DCD

DCD task-oriented intervention strategies

neuromotor task training: emphasized verbal feedback, variable practice

cognitive orientation to daily occupational performance: verbal strategies to help problem solve through new motor tasks

motor imagery: imagine doing movement w/o physical movement

DCD body fx & structures intervention

core stability training

cardiorespiratory training

fxl movement-power training program

combo of all strategies tends to be most effective

overall concepts: freq practice, variable settings, consistent feedback

DCD intervention dosing

2-5 practice sessions/week

incl practice at home and/or school, does not all have to be w/ PT

DCD edu and HEP

written recs for home & school

learning in multiple environments over time

help parents understand child’s strengths & limitations

DC & adulthood PT recs for DCD

encourage fun, effort, and participation in PE rather than proficiency

teach use of playground equipment in 1-on-1 setting

repetitive sports allow for success w/ constant monitoring of feedback—swimming, cycling, skating, skiing

individuals do not outgrow their impairments

consider career choices that may require fewer quick adaptations in motor performance

duchenne muscular dystrophy (DMD) pathophysiology

X-linked disorder

abnormal or missing protein (dystrophin)→progressive muscle cell destruction

initial dx without family hx ~5 y/o

longevity: variable from late teens to 3rd-4th decade

DMD pharm mgmt

creatine: improved strength & endurance, decr jt stiffness

steroids: prolong walking, improved strength & pulm fx

DMD clinical presentation

insidious muscle weakness

joint contractures

impaired posture

progressive respiratory fx impairments

progressive loss of gross motor skills, amb, standing

gower’s sign (requires hand push up from legs to stand from sitting)

DMD insidious muscle weakness

initial: neck flexors, abdominal, interscapular, hip extensors

becomes generalized w/ progression

pseudohypertrophy of calf muscles

DMD joint contractures

PF, TFL tightness occurs first

DMD impaired posture

incr lumbar lordosis, scapular winging, scoliosis just before or during adolescence

DMD examination prioritization bdy fx & structures

LE ROM: PFs, IT band, hip/knee flexors to guide stretching & positioning

UE ROM: prioritize forearm pro, wrist/elbow flex/ext, shoulder elevation to guide stretching & positioning

posture: sitting, standing to guide stretching, brace, equipmet, positioning recs

pain: monitor for signs of overexertion, guide positioning recs

RPE: guide activity pacing, exercise rx recs

DMD amb measures

north star ambulatory assessment (amb boys >3 y/o)

6MWT or 2MWT

DMD UE use measures

performance of upper limb module (PUL)

brooke upper extremity scale

other DMD standardized assessments

pediatric quality of life inventory (peds QL)

pediatric evaluation of disability inventory (PEDI)

DMD stretching at time of dx

PF, hamstrings, hip flexors, IT band

DMD exercise at time of dx

facilitate gross motor milestones, low impact play, cycling (low or no resistance), swimming

DMD interventions equipment at time of dx

resting AFOs, stroller for community if needed or manual WC/motor scooter

avoid eccentric excs

avoid fall/collision risk activities

DMD education at time of dx

family edu & resources on DMD

coord care w/ other teams

DMD early amb presentation

frequent tripping/falling

gower’s maneuver

difficulty jumping/hopping

gait deviations: incr lumbar lordosis, wide BOS, toe walking

difficulty keeping up w/ peers, require rest breaks

DMD early amb (childhood) exercise

sub-max aerobic activity (low impact)

cycling w low or no resist

swimming

respiratory m training

fxl ADL training

DMD early amb (childhood) equipment

resting AFOs

manual WC/stroller/motor scooter for community

DMD early amb (childhood) edu

avoid eccentric excs

avoid fall/collision risk activities

energy conservation

self recognition for rest breaks

coord care w/ otehr teams

DMD early amb (childhood) stretching

PF, hamstrings, hip flexors, IT band

DMD late amb presentation

progressive lumbar lordosis, wide BOS

progressive LE contractures

toe walking

limited endurance, fatigue

more freq falls

loss of stair climbing

marked incr in timed tests

DMD late amb (late childhood/adolescence/YA) stretching

ITB, TFL, hip flex, hamstrings, gastrocsoleus, post tib, plantar fascia