Comprehensive Pediatric PT

Infant reflexes, motor milestones, diagnosis criteria/classic presentation, treatment considerations, outcome measures

ATNR Integration

4-5 Months

Palmar Grasp Integration

4-7 Months

Plantar Grasp Integration

9 Months

Moro Reflex Integration

3-5 Months

Stepping Reflex Integration

3-4 Months

STNR Integration

8-12 Months

STNR Development

4-6 Months after Birth

Landau Integration

12 Months

Landau Development

4-5 Months after Birth

Forward Protective Reaction Development

6 Months

Sideways Protective Reaction Development

6-8 Months

Backwards Protective Reaction Development

10 Months

Rolling supine to sidelying, non-segmentally

3 Months

Prone on elbows, cervical extension to 90

4 Months

Hands to midline in supine

4 months

Unilateral reaching, prone on forearms

5 Months

Pivot in prone

5 Months

Rolling prone to supine, segmentally

5 Months

Supine, hands to feet

5 Months

Prop Sitting

5 Months

Rolling supine to prone, segmentally

6 months

Ring sitting, full trunk extension and high guard

6 Months

Independent Sitting

8 Months

Quadruped

8 Months

Crawling

8 Months

Pull to Stand

9 Months

Creeping

10 Months

Cruising

10 Months

Standing Independently

11 Months

Walking independently, high guard, wide BOS

12 Months

Running with flight phase present

2 years

Jumping

2-3 years

Kicking a ball

2-3 years

Mature running pattern

3 years

Stairs, ascending with reciprocal pattern

3 years

Tricycle

3.5 years

Stairs, descending with reciprocal pattern

4 years

Single Leg Hop

4 years

Skip

6 years

Bicycle

6-7 years

Mature Walking Pattern

7 years

TIMP Outcome Measure is used for? What score requires monitoring?

• Premature infants, 34 weeks post conception to 4 months old

• Norm Referenced

• -0.5 SD Below Mean requires monitoring

AIMS Outcome Measure is used for? What score requires monitoring?

• 0-18 Months Old

• TIMP is better for 0-4 months old, they score down with AIMS

• Norm Referenced

• <10th Percentile requires monitoring

PDMS (Peabody) is used for what ages?

• 0-5 years 11 months

• Norm Referenced

• Best for once they’re sitting, standing, walking (not a sensitive to quality of movement deviations in infants)

BOT is used for what ages?

• 4 years to 21 years 11 months

• Used for higher level gross and fine motor

• Not useful if there is significant motor delays and impairments

PEDI is used for what ages?

• 6 months to 7 years (norm referenced up to 7 years old, after that can be used as criterion referenced)

School Function Assessment is used for what ages?

• 6 years to 12 years

• Criterion referenced

GMFM is validated for what diagnosis? What ages?

• 88- Cerebral Palsy and Down Syndrome

• 66- Cerebral Palsy

• 5 months to 16 years

Classic Presentation of Torticollis

• Ipsilateral Sidebending, contralateral rotation (named for SCM involved)

• Will have preference for side of rotation (encourage use of other side, place toys on other side for them to rotate head towards)

Biggest Torticollis Treatment Considerations?

• Strengthen lengthened side, stretch short side

• PARENT EDUCATION to switch sides that they lay/diaper change/play to encourage looking to other side

• Can cause plagiocephaly, parent education is HUGE

What conditions can co-occur with Torticollis due to similar risk factors?

• Metatarsus Adductus

• Developmental Dysplasia of the Hip

• Brachial Plexus Injury

What is plagiocephaly?

• Flattening on one side of the head commonly caused by torticollis

• Bossing (forehead bulging) will occur ipsilaterally to the side that is flat (L Plagio caused by L Torticollis, will have forehead bossing on L side)

What is Synostosis, what do you need to differentially diagnose with?

• REFER OUT CONDITION— can lead to increased ICP and seizures

• Need to differentially diagnose with plagiocephaly

• Premature fusing of skull causing contralateral occipital and frontal regions are bossed, ipsilateral side is flat and ear is posteriorly displaced

How much rotation and lateral flexion is normal in infants?

• Rotation 110

• Lateral Flexion 65-70

GMFCS is used for what?

• Classifying Cerebral Palsy— their level does not change, is a good predictor for future function

• Level 1 completely independent

• Level 2 Uses railing for stairs,

• Level 3 Uses assistive device for short distances, wheelchair for long distances

• Level 4 Uses power WC to ambulate

• Level 5 dependent, uses manual chair for ambulation

What are predictors of ambulation for children diagnosed with cerebral palsy?

If they are not sitting by 2 years old it is a good predictor for the ability to ambulate more than 15 meters by 8 years old with or without assistive device

What are theorized causes of cerebral palsy based on gestational week the “insult” occured?

• 20-22 weeks- potentially due to brain malformation due to decreased migration of cells

• 24-32 weeks- PVL damage

• >32 weeks- Insult to basal ganglia

Proposed Etiology of Cerebral Palsy

• PVL damage is most common but it’s known to be multifactorial not due to a single event

• NON PROGRESSIVE

What outcome measures are used for early detection for cerebral palsy?

• GMA is used for infants 20 weeks adjusted and younger

• HINE

• TIMP and AIMS

What happens to Selective Voluntary Control with children diagnosed with Cerebral Palsy?

Impaired due to damage to corticospinal tract

• Triple Flexion Synergy is most common (DF, knee and hip flexion)

Muscles most important for ambulation in children with spina bifida

In order: iliopsoas, gluteus medius/maximus, quadriceps, tibialis anterior, hamstrings

Predictors of Loss of Ambulation for Duchenne’s Muscular Dystrophy

• Loss of MMTs by 50%, 3/5 MMT hip extensors, 4/5 DFs

• 4 Stairs- 5-12 seconds means 2.5 years out, >12 seconds means 1.5 years out

• 10MWT- >9 seconds 2 years out, >12 seconds 1 year out

• 20m change in 6MWT

Classic Presentation of Duchenne’s Muscular Dystrophy

• Increased lordosis (weak extensors, lengthened abdominals)

• Weak neck flexors, plantarflexors

• Pseudohypertrophy of calves- fatty deposits- they become tight

• Rely on stacking on passive structures to remain upright

• Waddle/ER gait

• Scapular Winging

• Gower’s Sign

Etiology of Duchenne’s and clinical implication

• Decreased or absent dystrophin (a protein that helps with recovery)

• CANNOT workout to fatigue or do eccentrics

• Will eventually develop respiratory issues/chest expansion issues which will lead to death

• Our goal is to prevent contractures, keep mobile as long as possible, and prolong QOL

How is MSK development affected with preterm birth?

• Decreased strength due to less muscle fibers present

Describe skeletal/articular surface development

• Ossification begins week 6-7 of gestation (from mesoderm)

• Diaphysis is near full ossification at birth (think about implications for premies)

Describe hip development— how does it look at birth, how does it develop?

• Infant hip is unstable and at risk of dislocation due to shallow acetabulum, flat femoral head, high head-neck-shaft angle

• Fully developed around age 10→ forces of movement and compression (STANDING) help the acetabulum and femoral head develop shape

Congenital Diagnosis associated with larger birth weights/lengths, first birth, breech positions (3)

• Developmental Hip Dysplasia

• Congenital Talipes Equinovarus (Clubfoot)

• Metatarsus Adductus

Cause and presentation of Developmental Hip Dysplasia

• Could be due to hip dislocation in utero (first birth, breech, large baby)

• Mild could go undetected leading to degenerative joint disease later in life

• Presentation: Limited hip abduction (<60 with knee flexed 90), Leg length discrepancy (Galeazzi test) Asymmetrical skin folds

Around what month should infants have full hip abduction ROM? What happens if infant is still lacking range?

• 10 months old→ refer out for potential DDH

What tests are used to screen for Developmental Hip Dysplasia?

• 0-3 months: Barlow (pop out) and Ortolani (pop in)

• >3 months: LLD (Galeazzi) asymmetrical folds, decreased hip abduction (<60)

Presentation of Clubfoot (Congenital Talipes Equinovarus)

• Forefoot adductus, hindfoot varus, ankle equinus

• Extrinsic is treated with serial casting, bracing

• Intrinsic is treated with surgery

Good prognosis is family is compliant with treatment plan

Presentation of Metatarsus Adductus

• Deformity caused by intrauterine positioning, typically resolves by a year (if not, send to an orthopedic)

• Increased risk for stress fractures in adulthood

Toe-In during pediatric gait could be indicative of what?

• Decreased hip abduction range/strength, decreased core strength

Children with Cerebral Palsy are at a higher risk for what MSK conditions?

• Dislocation/Subluxation→ dec WB, spasticity, dec ROM→ risk increases with higher GMFCS levels

• Neuromuscular Scoliosis

• Contractures (spasticity)

• Arthritis (atypical alignment)

• Patella alta

• Overuse syndrome

• Fractures

Idiopathic Scoliosis is named for what? How many degrees of curvature are considered scoliosis?

• Named for the convexity

• >10 degrees

What are factors that strongly correlate with curve progression?

• Curve magnitude → Cobb Angle

• Risser Sign (lower grades= increased risk of progression (more malleable)

• Patient’s age at time of diagnosis

Spinal fusions for scoliosis are indicated for what Cobb Angle? Why?

• Greater than 45 degrees

• Increase risk of pulmonary issues

What is Legg-Calve-Perthes?

• Common is ages 4-8, boys more likely to develip

• AVN of femoral head, it begins to flatten and enlarge (bone breakdown and body tries to build on top of it)

Presentation of Legg-Calve-Perthes?

• Limping!!! Investigate

• Decreased strength/ROM

• Pain in hip, groin, thigh, knee worse with activity and improves with rest

What is Slipped Capital Femoral Epiphysis?

• Medical Emergency!! Could cause AVN Femoral neck and shaft move relative to femoral head

• Onset around puberty

How does SCFE present?

• Limping!!! Investigate!!

• LLD, Pain in groin, hip, thigh, knee

• Acute→ severe fracture like pain

• Chronic→ vague pain, prefer ER in hip, limited hip IR, abd, flexion

What is Osgood-Schlatter?

• Anterior knee pain due to repetitive traction of patellar tendon on tibial tuberosity

How does Osgood-Schlatter Present?

• Activity related pain

• Antalgic gait

• Tenderness to palpation to tibial tuberosity

What is Osteochondritis Dissecans?

• Separation of subchondral bone from articular surface due to necrosis

• Typically occurs on lateral aspect of MFC

How does Osteochondritis Dissecans present?

• Vague, poorly localized knee pain

• Effusion, catching in knee if fragment is loose

• Antalgic gait or ER gait pattern

What is Sever Disease?

Overuse syndrome due to repetitive microtrauma at insertion of achilles tendon

• Common around 8-15 years (growth spurts)

• WORSE WITH ACTIVITY