pediatric case files - exam 2

cases 4, 6, 7, 8, 10, 11, 12, 13, 18, 19

dynamic ankle-foot orthosis

Category of ankle-foot

brace that allows for anterior-posterior movement at the ankle (includes hinged and posterior leaf spring)

equinus deformity

limited ankle dorsiflexion

SMO

low-profile brace that limits ankle inv and ev, but generally allows DF and PF

POC/goals for young child with hemiparesis

maintain ROM and activity in hemiparetic side to obtain typical or near-typical dev milestones

address mvmt patterns to ensure that the child is using the most energy-efficient methods possible

prevent MSK complications

PT interventions for young child w hemiparesis

WBing and activation of antagonist mms to reduce tone; movement through typical progression and activation of hemiparetic side w activities that encourage participation in typical childhood activities;

constraint-induced therapy;

e-stim;

functional movement;

dynamic bracing to allow functional mvmt without allowing movements into tonal patterns such as excessive PF

precautions for young children with hemiparesis

significantly increased tone often requires pharmacologic management (botox, baclofen) to allow functional movement. Adverse drug reactions (ADRs) of these meds, such as decreased alertness and excessive weakness, must be monitored. Forcing movements against significantly increased tone can cause structural problems (midfoot break from forced DF)

complications interfering with PT for young children with hemiparesis

increased speed or activity can cause increased tone in hemiparetic side

long-term use of constraint-induced therapy could interfere w B limb use

tone reduction could negatively affect mvmt, if tone was used for stability

polymicorgyria

condition related to the formation of gyri before birth; too many gyro and the gyri are smaller than normal

no known cause

Winters Group I

foot drop

flat foot or great toe strike at IC

excessive hip and knee flexion during swing

ADEQUATE DF during stance

Winters Group II

constant PF throughout gait cycle

Winters group III

knee hyperextension and increased lumbar lordosis

Winters Group IV

limited hip mvmt and increased lordosis

Modified Ashworth scale (mas)

0: no increase in mm tone

1: slight increase in mm tone, manifested by a catch and release or min resistance at end of the ROM where the affected part(s) is moved in flexion or extension

1+: slight increase in mm tone, catch and release followed by min resistance throughout the remainder (less than half) of the ROM

2: more marked increase in mm tone through most of the ROM, but affected part(s) easily moved

3: considerable increase in mm tone, passive movement difficult

4: affected part(s) rigid in flexion or extension

polymicrogyria case, early CP

Tardieu

VELOCITIES

1: as slow as possible

2: limb falling against gravity

3: as fast as possible and includes 2 range calculations.

R1= first ROM at feel of a catch. R2= full ROM

-polymicrogyria case, early CP

Gait deviation index (GDI)

provides a way to score multidimensional gait analysis and compare it to typical gait. score >/= 100: absence of pathology

-hemipolymicrogyria

winters classification

may have a floor effect

provides parameters for physical therapists to use when evaluating gait, such as foot position during swing and IC, knee position in stance, and hip position throughout the cycle

in hemipolymicrogyria case

salford gait tool (SF-GT) and visual gait assessment scale

in hemipolymicrogyria case

visually assess hip, knee, and ankle during different points of gait

not great in the clinic

Gross Motor Function Measure (GMFM)

used to show functional progress with use of bracing

A: lying and rolling

B: sitting

C: crawling and kneeling

D: standing

E: walking, running, jumping

-criterion-referenced test

-birth to 5 years, but also used with some adults

-hemipolymicrogyria, CP, cerebral hemispherectomy, down syndrome

Gross Motor Functional Classification System (GMFCS)

5-level classification system based on self-initiated mobility of children with CP; sitting, walking, and wheeled mobility are the primary forms of mobility used. based on age

Level I: highly functional

Level V: dependent

-hemipolymicrogyria, CP early intervention

All of the following are true regarding children with hemiplegia, except:

A. They have an asymmetrical gait pattern.

B. They sometimes present with equinus deformity.

C. They always need bracing to normalize gait.

D. They have involvement of the arm and leg on the same side.

C. Bracing may not always be needed, depending on the amount of tone present. Generally, some amount of asymmetry in gait is present, even if it is mild (option A).

Children who present with increased tone may benefit from all of the following, except:

A. Medical management of tone

B. Strengthening programs

C. Bracing during movement

D. Increasing tone for stability

D. Increasing tone in children with spasticity can lead to even more inefficient movements and increased energy expenditure.

A valid and reliable tool for measuring tone is:

A. GMFM

B. Modified Ashworth scale

C. Manual muscle testing

D. Palpation of the muscle

B!

APGAR SCORES

Quick assessment performed on a neonate at 1 min & 5 mins after birth. The 1-minute score indicates how well the baby tolerated the birthing process, while the 5-minute score indicates how well the baby is doing outside the mother’s womb. The examiner looks at: breathing effort, heart rate, muscle tone, reflexes, and skin color.

Each category is scored with 0, 1, or 2, depending on the observed condition, with a maximum score of 10. Scores of ≥ 7 are considered normal; scores <7 indicate that medical attention is needed.

Low Apgar scores at 1 and 5 minutes are significantly associated with CP

-NICU, EARLY CP

early intervention

federally funded program of support and services designed to meet the developmental needs of children w a disability and their families. needs may be related to physical, cognitive, communication, social/emotional, and/or adaptive development

individualized fmaily service plan (IFSP)

For infants and toddlers with disabilities who receive services through IDEA Part C; multidisciplinary assessment of the family resources, priorities and concerns, The strengths and needs of the child with the disability, needed services, and an individualized service plan to meet these needs. This plan is evaluated at least once per year and reviewed at least every 6 months.

IDEA Part B

Federal legislation that establishes school-aged services for students (3-21 years of age) with disabili

IDEA Part C

Federal legislation that establishes early intervention services for infants and toddlers (birth to 3 years of age) with disabilities and their families

knee immobilizer

External support worn on lower extremity that provides support during stance and/or to provide prolonged stretch of the HS

preeclampsia

Pregnancy complication (usually after 20 weeks of gestation) in which the mother experiences hypertension that may lead to significant complications including morbidity or mortality of the mother or unborn child

supine stander

positioning device that enables supported standing in a supine position for individuals that are unable to maintain ind standing

POC/Goals for child w CP in early intervention

initiation of ealy interventions services; maximize ind mobility and physical fxn, activity, and participation; minimize secondary impairments

interventions for child w CP in early intervention

Coordination and communication with parent, IFSP team, and medical team;

patient-related instruction (targeted toward parent and other caregivers) regarding topics such as handling, positioning, caregiving, biomechanical safety for lifting-related tasks, and equipment usage;

procedural interventions including procuring appropriate equipment for positioning, mobility, and caregiving; gait training, strengthening activities, orthoses and bracing, maintenance of range of motion (ROM);

play and child engagement

precautions: early intervention CP

skin integrity w AFO use

close positioning of PT to child during gait training and transfers

safety monitoring due to potential impulsivity

complications: early intervention CP

parental need to learn about diagnosis and implications and how to help daughter learn, play, and gain ind

parent w limited financial means that requires assistance from SW at hospital for obtaining equipment and transportation

three systems classify individuals w CP based on their functional abilities

GMFCS

Manual ability Classification System (MACS)

Communication Function Classification System (CFCS)

Each of the three systems (GMFCS, MACS, CFCS) consists of five levels of ability, with level 1 representing the highest level of ability and level 5 representing the most limited level of ability.

MACS

based on their ability to use their hands to manipulate objects and on their need for assistance in daily activities during play, eating, and dressing. This classification is designed to reflect the child’s typical manual performance, not the child’s maximal capabilities. The MACS was developed for children 4 to 18 years of age.

CFCS

classifies individuals based on their communication abilities.9 The CFCS has been developed for children 2 years of age and older.

types of CP

-hemiplegia, diplegia, triplegia, or quadriplegia

-spastic CP

-Dyskinetic CP (includes athetoid, choreoathetoid, and dystonic). Athetoid CP is characterized by “slow, continuous, writhing movements that prevent maintenance of a stable posture.” Dystonic CP is characterized by “involuntary sustained or intermittent muscle contraction with repetitive movements and abnormal postures.” In ataxic CP, the individual demonstrates movement that is uncoordinated, abnormal, and unstable. This movement pattern is not due to weakness or involuntary muscle activity. Individuals with mixed CP may demonstrate varying types, though the most common type is spastic dyskinetic CP.

For children with cerebral palsy who are non-ambulatory, supported standing programs reduce spasticity and improve bone density, hip stability, social interaction, and alertness.

osteoporosis and low BMD is a worry for children with CP

The Child Engagement in Daily Life (CEDL)

valid and reliable tools to assess participation for young children with CP

17-59 months of age

Ease of Caregiving for Children measure

18-60 months of age

difficulty of caregiving for young children w CP

a 26-month-old child diagnosed with CP at age 20 months. The child is able to sit independently, but does not pull to stand independently. She plays with toys and blocks like her 2-year-old cousin, but she log rolls on the floor to get to different toys.

When held in standing, she tends to keep her legs very stiff and crosses them like a pair of scissors with her hips adducted and internally rotated. Her legs are more involved than her arms.

Based on extent and location of limb involvement, what type of CP does this child most likely demonstrate?

Based on the child’s lower extremity posture and motor skills, what intervention is most important to initiate first?

diplegia

Body-weight-supported treadmill training

evaluative report (ER)

Multidisciplinary report containing at least two student evaluations completed by the school district; if a student is found to qualify for special education, the educational team has 30 calendar days to complete an IEP.

Individualized Education Program (IEP)

Legally binding document developed annually for students who require specially designed instruction; identifies the special education and related services the student will receive for one calendar year

notice of recommended educational placement (NOREP)

document that classifies type of classroom and programming that a child will receive for the duration fo the IEP

permission to evaluate (PTE)

document that parents/guardians are required to sign before a school system may evaluate a student for special education services

SECTION 504 OF THE REHABILITATION ACT OF 1973

Federal legislation that makes discrimination against individuals with disabilities illegal; Section 504 provides that students who do not require specially designed instruction may receive accommodations and services including physical therapy if they are considered to have a disability that impacts a major life function.

ensures access and accommodations for students in public primary and secondary schools who do not require special education, for students in colleges and universities, for adults employed by governmental agencies or other employers that receive federal financial assistance, and for individuals seeking the services of governmental agencies or other agencies that receive federal financial

elementary CP POC/goals

coordinate transition to kindergarten

provide efficient means to access the school environment including classroom, general school building, cafeteria, and playground

create meaningful adaptations to promote participation in school activites

elementary CP interventions

Coordination and communication with all members of the educational team; education to school staff including strategies to promote increased student self-efficacy and safe strategies for

assistance with transfers and mobility; p

rocedural interventions forspecific goals (e.g., mobility, balance, and strength related to participation in the school environment and school activities);

development of an emergency evacuation plan;

varied positioning during school day to meet the child’s needs; accommodation of school activities (e.g., physical education class, extracurricular activities) and environments (e.g., student areas of the classroom, playground) to enhance participation

elementary CP: precautions

fatigue, esp throughout school day

elementary CP complications

increased time required for educational activities and related services

increased energy/time demands of activity throughout school day

increased energy/time demands of mobility w ADs

School Function Assessment (SFA)

a criterion-referenced tool that measures participation in the school setting and activity in physical and cognitive/behavioral tasks for students in K - 6.

Any educational professional familiar with the child’s function in the school environment may complete the SFA. Raw scores can be converted to criterion scores for each individual section of the SFA.

The SFA includes two separate criterion cut-off score scales, one for kindergarten through 3rd grade and one for 4th through 6th grade.

CP and spina bifida

A school PT is working with a kindergarten student diagnosed with CP, GMFCS level III. The student is able to ambulate with use of a rolling walker. She enjoys being with her classmates, but becomes frustrated during PE class or while outside on the playground and school sports fields. The student is on grade level for all academic areas.

Which of the following tools would be most appropriate to measure this student’s participation in the school setting and activity in school-related tasks?

A. Children’s Assessment of Participation and Enjoyment (CAPE)

B. Gross Motor Function Measure (GMFM)

C. Quality Function Measure (QFM)

D. School Function Assessment (SFA)

D. The SFA is a criterion-referenced tool for children in kindergarten through 6th grade. The SFA measures participation in the school setting and activity in physical and cognitive/behavioral tasks.

The CAPE measures children’s engagement and participation in recreation and leisure activities while not in the school environment. The GMFM and the QFM are two common standardized tests that measure gross motor performance in students with CP.

A school PT is working with a kindergarten student diagnosed with CP, GMFCS level III. The student is able to ambulate with use of a rolling walker. She enjoys being with her classmates, but becomes frustrated during PE class or while outside on the playground and school sports fields. The student is on grade level for all academic areas.

Which of the following objective measures would be most appropriate to measure this student’s mobility and endurance?

A. 6-minute walk test (6MWT)

B. 30-second walk test

C. Early Activity Scale for Endurance

D. MobQues28

A. The 6MWT is an objective measure used to assess both mobility and endurance. While the 30-second walk test (option B) and MobQues28 (option D) both measure mobility, they do not measure endurance. The Early Activity Scale for Endurance (option C) measures endurance, but does not specifically measure mobility in children.

Rehabilitation act of 1973

rights and protections as individual w a disability

ADA of 1990

fed civil rights legislation that prohibits discrimination against individuals w disabilities in employment, transportation, public accommodations, communications, and governmental activities

adults w CP POC/Goals

Coordinate transition and support into the work environment; assistance to facilitate workplace acceptance and accommodations for employment; provide adaptations needed to support participation in a full-time working environment; successful transition into adult-oriented healthcare systems

adults w CP interventions

Coordination and communication with the high school educational team, University Accommodations office, orientation and mobility specialist, public transportation accessibility office, and adult-oriented healthcare providers (e.g., physicians, PTs, OTs); instruction on health promotion and energy conservation; assistance in transitioning to adult-oriented healthcare providers who are familiar with adults with CP and its long-term sequelae

adults w CP: precautions

fatigue, pain, postural asymmetries, decreased balance

complications interfering w PT, adults w CP

medical insurance plan restrictions; increased time and energy demands for daily tasks, employment, and exercise; decline of mobility and increases in secondary impairments from CP; transition to adult-oriented healthcare providers; lack of public transportation accessibility

associated MSK disorders that may progress during adulthood for those with CP

OA, patella alta, hip dysplasia, spondylolysis, and cervical stenosis

PPAS Posture and Postural Ability Scale

7 point ordinal scale to assess mobility into and out of prone, supine, sitting,and standing postures, and assesses the quality of posture in these static positions in the frontal and sagittal planes

for young adults with CP, what programs significantly increase strength of targeted mm groups and aerobic exercise programs improve cardiorespiratoty fitness and body composition?

progressive resistance exercise (PRE)

Initial studies on adults with spastic diplegic CP who have undergone selective dorsal rhizotomy in adulthood demonstrate significant improvement in what?

in hamstring and gastrocnemius passive ROM, improved gross motor function for crawling and kneeling, and decreased lower extremity spasticity, along with subjective reports of improvement in function.

An outpatient physical therapist is working with a 22-year-old young adult diagnosed with diplegic CP, GMFCS level III. She reports that she has been experiencing increased pain with ambulation, anterior knee pain, and decreased endurance, all of which have become more pronounced over the past year.

Which of the following tools would be most appropriate to measure this young woman’s cardiorespiratory fitness?

A. Gross Motor Function Measure (GMFM)

B. Progressive protocol test with a cycle ergometer

C. Short Form 36 Version 2.0 (SF-36v2)

D. Tinetti Performance Oriented Mobility Assessment

B. A progressive protocol test using a cycle ergometer has been found to be an appropriate means to test cardiorespiratory fitness in adults with CP. The GMFM (option A) assesses typical developmental milestones.

The SF-36v2 (option C) assesses physical functioning, pain, general health perceptions, vitality, social functioning, performance in emotional roles, and mental health. The Tinetti Performance Oriented Mobility Assessment (option D) is a balance assessment.

Anterior knee pain in an adult with spastic diplegic CP is most likely to

be the result of which of the following?

A. Hip dysplasia

B. Osgood-Schlatter disease

C. Patella alta

D. Spondylolysis

Patella alta

An outpatient physical therapist is working with a 22-year-old young adult diagnosed with diplegic CP, GMFCS level III. She reports that she has been experiencing increased pain with ambulation, anterior knee pain, and decreased endurance, all of which have become more pronounced over the past year.

This young woman is interested in starting an exercise program for health promotion and wellness. Which of the following is the most appropriate recommendation for her?

A. Progressive resistance exercise and aerobic exercise using a stationary bike or recumbent cross-trainer

B. Exercise for health promotion is not recommended for this young woman, as secondary impairments will continue to progress with age.

C. Passive stretching 20 minutes per day

D. Walking 20 minutes per day in the community

A. Progressive resistance exercise and aerobic exercise programs have

been found to create significant improvements in strength and

cardiorespiratory fitness in young adults with CP. Passive stretching

(option C) will not improve health and wellness. Walking 20 minutes per

day (option D) is not ideal for increasing or maintaining her aerobic

fitness, given her ambulation status.

Ranitidine

histamine H2-receptor antagonist that inhibits stomach acid production and is commonly used to treat gastroesophageal reflux

ventricular septal defect

hole in the wall (septum) that separates the lower chambers of the heart (the ventricles)

down syndrome POC/goals

improve quality of motor control for achievement of motor milestones; initial focus on pulling to stand, sitting, standing, and ind amb; caregiver ed regarding how to facilitate motor development at home; monitor LE alignment and need for orthoses

interventions Down Syndrome

caregiver ed regarding how to create an environment conducive to ind exploration and gross motor play

strengthening in the form of play activities to encourage pull to stand, standing, and core control/balance such as reaching outside BOS; assisted ambulation; evaluation for orthoses

precautions: down syndrome

protect joints from extreme ROM secondary to hypotonia and ligamentous laxity; observe for signs and symptoms of AA instability; observe for signs of inadequate management of thyroid and CP comorbidities

complications: Downs

Behavioral challenges secondary to young age and intellectual disability; atlanto-occipital instability, though uncommon, is potentially devastating if not identified and treated; rare medical complications

gross motor delays related to down syndrome are due to what

hypotonia, ligamentous laxity, and reduced brain volume, esp in cerebellum

congenital heart defects such as septal defects are present in 44% to 58% of persons with?

DS

Surgery to correct anatomical heart defects is often performed via a median sternotomy approach at 2 to 4 months of age.

heart conditions are treated by diuretics, ACE inhibitors, and digoxin

Diuretics are used to decrease blood pressure by increasing the kidneys’ ability to excrete water, thus decreasing the fluid load on the heart. The most serious adverse effects of diuretics include dehydration and electrolyte imbalances. Orthostatic hypotension, weakness, and fatigue may also occur and be problematic for physical therapy interventions.

ACE inhibitors also decrease blood pressure and are generally

tolerated well. Adverse reactions may include gastrointestinal discomfort, dizziness, chest pain, or a persistent dry cough.

Digoxin is used to increase the force of the heart muscle contractions, thus improving the heart’s effectiveness. Adverse effects include cardiac arrhythmias, gastrointestinal distress, drowsiness, fatigue, confusion, and visual disturbances

Although relatively uncommon, persons with DS are at risk for atlanto-occipital, or atlanto-axial, instability (AAI) due to ligamentous laxity. Up to 15% of persons with DS have this problem, but only 2% are symptomatic.

The signs and symptoms include easy fatigability; difficulty walking; abnormal gait or a change in gait; neck pain or torticollis; limited neck mobility; change in hand function; new onset of urinary retention or incontinence; increase in incoordination or clumsiness; sensory impairments; and spasticity, hyperreflexia, or a Babinski’s sign.

between what ages may you use a hand-held dynamometer to measure strength

7-15 yo

Even though the Bayley Scales of Infant Development in infants (1-42 months) with DS has been the gold standard in research, what was relatively more responsive?

GMFM

Bayley OM: This tool evaluates global development, including cognitive, language, motor, adaptive behavior, and social-emotional areas.

peabody developmental motor scales

a norm-referenced test for children from birth to 72 months that provides age-equivalent scores, percentile ranks, and scaled scores for GM and FM skills

DS

DCD

relapsed clubfoot

OBPP

Test of Basic Motor Skills of Children with Down Syndrome

15 items developed within a postural control framework, and reportedly has similar sensitivity to change as the GMFM.

OM for participation for those w DS and DMD

DS very young children: social function section of PEDI

DS 6-21 years: CAPE and PAC

DMD CAPE and PedsQL

DS: Early intervention birth to 3 years

intensity of intervention and parent investment are likely keys to progress

parents prefer home-based programs that empower them to provide low-tech strengthening programs for their child

parental involvement and ability to promote development are likely more impt than # of therapy visits/week

DS: treadmill training is appropriate when infant can sit alone for 30 second or take 6 steps on treadmill in 1 min (~10 months) or can take 3-6 ind steps

teach parents to suspend child over a motorized treadmill to stimulate stepping → earlier onset of ind walking (3 months earlier)

kinematics and maturity/stability of gait pattern improved

achievement of other motor milestones positively affected

best when stepping is variable, inconsistent, and unstable

8 min/day, 5 days/week

DS: Postural control

15-31 months and 4-6 years

focus on dev and refinement of postural synergies

include specific practice and changing task conditions to improve motor coordination

DS: orthoses

hsoe inserts/foot orthoses and SMOs improve gait, balance, and GM skills for those who are pulling to stand or willing to stand when placed on their feet, possibly leading to earlier onset of ind amb

Poor activity tolerance, as evidenced by the child’s refusal to participate in active play for more than a few minutes, could be a symptom of inadequate management of:

hypothyroidism

creatine kinase

enzyme that catalyzes conversion of ADP and phosphocreatine into ATP and creatine; expressed in many tissues, but in higher concentrations in the brain, striated muscle, and other tissues that rapidly regenerate ATP

Gower’s sign

When an individual rises from the floor using a 4-point stance placing hands on the knees and then hyperextending the knees while pushing on the thighs to compensate for hip extension weakness

hypercapnia

excess CO2 in the blood; results from lung disease, hypoventilation, or impaired consciusness

pseudohypertrophy

Increase in the size of a muscle that is not due to an increase in the size of individual skeletal muscle fibers; in DMD, muscles are replaced by fibrous tissue and fat.

transaminase

enzyme that catalyzes the transfer of an amino group from one molecular group to another, which is an important process in forming amino acids in the metabolism of proteins; elevated transaminase levels in the blood may indicate liver dysfunction

preteen with DMD POC/goals

Maximize safe participation and function at home and in the community;

optimize positioning throughout the day and night to minimize contractures;

improve/maintain LE strength, ROM, and endurance;

maintain respiratory status;

optimize transfers to and from WC, bathing area, and toilet;

progress standing tolerance and ambw and without an AD;

maximize safe and functional independence;

promote self-advocacy

preteen DMD: interventions

practice negotiating WC through tight spaces, over ramps, into and out of home, van, and bus

practice safe and effective transfers into and out of family pool

review strengthening, ROM, and resp program taught during therapy and integrate into a home program

weight-shifting in WC and sitting balance at the EOB

promote self-advocacy in daily tasks and activities such as ROM, transfers, and proper transportation techniques

walk if possible!

glosso-pharyngeal breathing

preteen w DMD: precautions

no resisted or forceful ROM to extremities or trunk due to high fx risk and damage to mms

p! , weakness, fatigue

assistance w WBing activities required during transfers to decrease risk of fall or injury

close monitoring of skin when wearing orthoses

PT complications preteen DMD

pt discomfort w AFOs and prolonged positioning

pt and parent anxiety regarding potential fxs

gait characteristics of someone w DMD

ant pelvic tilt w increased lumbar lordosis, a waddling gait pattern, ad foot pronation and eversion

DMD: more than 40-50% of mm power is lost by what age? when is amb lost?

6 years old. ambulation ceases at 10-12 years old

DMD: glucocorticoid use

the earlier the glucocorticoid was initiated, the more sustained the neuromuscular function

Participants were able to ambulate two to five years longer than those not taking glucocorticoids.

better QoL

Other benefits of long-term use: decreased need for spinal stabilization, decreased rate of pulmonary dysfunction, and postponement of the need for nasal intermittent positive pressure ventilation. In two of the trials, left ventricular ejection fraction was maintained when compared to those not on the medication regimen

side effects of long-term systemic glucocorticoids

cataracts; decreased longitudinal growth; an increased mean weight

long bone fxs were same between groups