Unit 2 - Pediatric Examination, Perinatal Diagnoses, Cardiopulmonary Conditions and Fitness

International Classification of Functioning, Disability, and Health

Health Condition Ex

Down Syndrome

International Classification of Functioning, Disability, and Health

Impairments Ex

• Hypotonia

• Ligamentous laxity

• Muscle weakness

• Poor endurance

International Classification of Functioning, Disability, and Health

Activity Limitations Ex

• Pulling to stand

• Cruising

• Walking

International Classification of Functioning, Disability, and Health

Participation Restrictions Ex

• Interacting with siblings

• Playing with toys on sofa

International Classification of Functioning, Disability, and Health

Environmental Factors Ex

• Home environment

• Access to siblings for play

International Classification of Functioning, Disability, and Health

Personal Factors Ex

• Family support

• Other medical comorbidities

Examination: History

• Obtained via interview with child and family and review of medical records

• The child’s past and current health status

• PT to identify:

  • Child and family strengths

  • Resources

  • Expectations

  • Desired outcomes of PT

• Review of systems

Examination: Systems Review

• Cardiovascular and pulmonary

• Integumentary

• Musculoskeletal

• Neuromuscular

• Communication ability, affect, cognition, language, ability to read, and learning style

• Movement

Movement Analysis of Tasks

Examination: Tests and Measures

• Aerobic Capacity/Endurance

• Anthropometric Characteristics

• Adaptive and Assistive Technology

• Balance

• Circulation (Arterial, Venous, Lymphatic)

• Cognitive and Mental Function

• Community, Social, and Civic Life

• Cranial and Peripheral Nerve Integrity

• Education Life

• Environmental Factors

• Gait

• Integumentary Integrity

• Joint Integrity and Mobility

• Mobility (e.g., Locomotion)

• Motor Function

• Muscle Performance (Strength, Power, Endurance, and Length)

• Neuromotor Development and Sensory Processing

• Pain

• Posture

• Range of Motion

• Reflex Integrity

• Self-Care and Domestic Life

• Sensory Integrity

• Skeletal Integrity

• Ventilation and Respiration

• Work/Community Integration

Pediatric Pain Scale

The FLACC Scale

Face, legs, activity, cry, and consolability

• For children who are pre-verbal or non-verbal

Pediatric Pain Scale

The Wong-Baker Faces Rating Scale or Visual Analog Scale (VAS)

For children who can verbalize type and/or level of pain

Evaluation Leads to Diagnosis/Prognosis/ Plan of Care

Diagnosis

• Identify the impact of a condition on function at the level of the movement system and the whole person

• Example: Force Production Deficit and Movement Pattern Coordination Deficit

Evaluation Leads to Diagnosis/Prognosis/ Plan of Care

Prognosis

• In the likelihood that a child or youth will achieve the desired goals of intervention

• Optimal level of improvement in function

• Amount of time needed to reach that level

SMART Goals

• Short Term Goals (4 weeks)

• Long Term Goals (8 weeks)

Patient Client Management

Evaluation process identifies:

• Body function and structure impairments

• Activity limitations

• Participation restrictions

Physical Therapy Goals

ICF model

• Activity

• Participation

Physical Therapy Goals

SMART-F Goals

• Specific

• Measurable

• Achievable

• Relevant

• Time-bound

  • Short term goals (3 months)

  • Long term goals (6 months)

• Function

Chronological Age

• The age of a child from actual birth

• what a parent will answer when you ask "How old is your child?"

Gestational Age

• Age of a pregnancy started at the woman's last menstrual period

• Also described as the amount of time that a baby has been in mom's belly ("The child was born at 32 weeks GA")

Adjusted or Corrected Age

• The chronological age reduced by the number of weeks the child was born before 40 weeks gestation

• For example, a 3-month-old baby who was born 1 month early would have an "adjusted" aged of 2-months-old.

• allow adjustment up tp 2 years old

What are single task outcome measures?

• Assesses one domain

• Features:

  • Standardized

  • Psychometrically sound

  • Predictive, discriminatory, or useful for showing change in motor performance or functional mobility

  • Takes less time to administer than multi-domain measures

Single task outcome measures

TUG

• stands and walks 3 meters, and then turns and walks 3 meters back and sits back in the chair

• or 10 feet

Single task outcome measures

TUDS

• child walks up and down 14 stairs

• The participants are allowed to choose any method of traversing the stairs. This includes using a "step to" or "foot over foot" pattern, running up the stairs, skipping steps, or any other variation

• Handrails can be available

• The participants wear shoes, but no orthotics

Single task outcome measures

30 Second Walk Test

will tell us more about walking speed and when physical disability restricts the time or distance that a child can walk

Single task outcome measures

6 Minute Walk Test (6MWT)

could be used for a child with cystic fibrosis to monitor their endurance and gain insight into how their pulmonary status impacts their functional mobility

Single task outcome measures

5 x Sit-to-Stand (5xSTS)

just like the adult test, but with a chair that allows the child to start at a 90/90 position

Single task outcome measures

Timed Floor to Stand - Natural

• requires the child to stand up from the floor, walk 3 meters, and then come back to sit on the floor again with their legs crossed

• related to skills children may need to do daily at school or home

Single task outcome measures

Pediatric Balance Scale

very reminiscent of the Berg Balance Scale for adults and allows us to examine functional balance in the pediatric population

A PT would like to assess a kindergartener’s physical ability to participate in his school’s circle time (floor) with his peers. Which outcome measure would be most appropriate?

Timed Floor-to-stand — natural

A 12-year-old adolescent who underwent a heart transplant one year ago would like to go on a field trip to a science center with his classmates. Although there will be intermittent rest breaks, the adolescent will be expected to walk substantial distances. The PT is unsure if the child has the endurance. Which outcome measure would be most appropriate?

6 MWT

A school-based physical therapist is completing her beginning of year assessment for a child with mild cerebral palsy. The therapist takes note that the child has two classes on the second floor of the school. Which outcome measure would be most appropriate to determine if the child will need an elevator pass to get to class on time?

TUDS

A physical therapist would like to assess static and dynamic sitting and standing balance for an 8-year-old who sustained a brain injury two weeks ago. Which outcome measure would be the most appropriate?

Pediatric balance scale

A physical therapist would like to assess a 6-year-old child with Down Syndrome’s self-paced walking speed. Which outcome measure would be the most appropriate?

30 second walk test

Why are multi-item standardized outcome measures important in pediatrics?

• Standardized application and scoring

• Provides accurate and reliable data

• Used for decision-making regarding:

  • Justification for services

  • Intervention

  • Goals

  • Plan of Care

  • Monitor progress

• quite involved and can take anywhere from 15 to 60 minutes to administer

Multi-item standardized outcome measures

Selection based on ICF

Segmental Assessment of Trunk Control (SATCO)

• Body Function & Structure

• assesses postural control

Multi-item standardized outcome measures

Selection based on ICF

BOT-2/BOT-3

• Body Function & Structure

• Activity

• measures strength and coordination

• assesses mobility tasks such as running and jumping

Multi-item standardized outcome measures

Selection based on ICF

School function assessment (SFA)

• Participation

• assesses how a child experiences and performs in the school setting

Multi-item standardized outcome measures

Selection based on ICF

Activity

GMFM-66 and –88
PDMS-2/PDMS-3
TIMP
BOT-2/BOT-3

Multi-item standardized outcome measures

Selection based on Scoring and Interpretation

Criterion-referenced

Evaluate a child's performance on a specific set of skills

• You complete the outcome measure with the child, and they get a score

• There is no comparison of that score to any one other than that child you evaluated

Multi-item standardized outcome measures

Selection based on Scoring and Interpretation

Norm-referenced

Compare children to the child's same-aged peers

• can make the determination of the child you are seeing is performing at, above, or below average because researchers have tested hundreds of typically developing children to make that data set

Multi-item standardized outcome measures

Selection based on Age and Diagnosis

• For what age is the outcome measure validated?

• Is there a diagnosis/condition/functional level associated with the measure?

• For example

  • the GMFM is appropriate for children between 5 months old and 16 years old

  • The Alberta Infant Motor Scale is appropriate for children between 0 and 18 months old

Multi-item standardized outcome measures

Selection based on Technology / Equipment / Feasibility / Cost

• Does the outcome measure require

  • a computer program?

  • special equipment?

• How long does the outcome measure take to administer?

• Can the child fully participate during the assessment?

• What is the cost associated with the outcome measure?

• Does the setting have requirements for certain outcome measures?
  *Is the test reliable and valid?

Multi-item standardized outcome measures

• Test of Infant Motor Performance (TIMP)

• Alberta Infant Motor Scale (AIMS)

• Peabody Developmental Motor Scales (PDMS)

• Bruininks-Oseretsky Test of Motor Performance (BOT)

• Gross Motor Function Measure (GMFM)

• Pediatric Evaluation of Disability Inventory (PEDI)

• School Function Assessment (SFA)

• Segmental Assessment of Trunk Control (SATCO)

Multi-item standardized outcome measures

Important Information to Know

• Age Range

• Construct(s)

• ICF domain

• Norm or Criterion Referenced

• Special populations or general?

• Other unique factors

Multi-item standardized outcome measures

Norm-referenced

BOT

AIMS

PDMS

PEDI

Multi-item standardized outcome measures

Criterion referenced

TIMP

Multi-item standardized outcome measures

Both norm-referenced and criterion referenced

SFA

GMFM

SATCO

AIMS age range

0-18 months

PDMS age range

0-60 months

BOT age range

4-21 years

PEDI age range

6 months - 7.5 years

GMFM age range

5 months - 16 years

SFA age range

kindergarten - 6th grade

TIMP age range

34 weeks GA - 4 months

Brachial Plexus Injury (BPI)

Etiology and Incidence

• Injury to the brachial plexus complex during a difficult vaginal delivery

  • Most frequent cause is shoulder dystocia or a unilateral traction injury to the brachial plexus

• Incidence ranges from 0.38 to 4.6 per 1000 based on regional obstetrical care and mean birth weight

Brachial Plexus Injury (BPI)

Risk Factors

• Shoulder dystocia

• birth weight >90th percentile (4500–5000 g)

• Maternal gestational diabetes

• Prolonged maternal labor

• Labor induction

• Mechanical assistance (forceps, vacuum)

• Breech delivery

• Previous delivery of an infant with BPI

Brachial Plexus Injury (BPI)

Pathophysiology

• Injury can occur anywhere between the spinal nerves to the peripheral nerves

• Type of injury can vary from complete rupture to partial rupture

• May require surgical repair

• Regrowth 1 mm/day so up to 4-9 months depending on location

• Recovery can continue up to 2-4 years depending on location

• Approx. 65% of infants recover

Brachial Plexus Injury (BPI)

Injury Classification and Motor Impairments

Erb’s Palsy

• Most common classification at 52%

• Injury to C5 and C6 nerve roots (sometimes C7)

• Shoulder held in extension, IR and ADD, elbow extension, forearm pronation, hand and finger flexion

• Referred to as a “waiter’s tip position”

Brachial Plexus Injury (BPI)

Injury Classification and Motor Impairments

Klumpke’s Palsy

• Rare

• Involvement of the lower roots or spinal nerves of C8-T1

• Forearm in supination and elbow flexion, paralysis of wrist flexors and extensors, and intrinsic muscles of the hand

• Horner’s Syndrome

  • results from a T1 root abortion or an injury to the sympathetic ganglion, which can cause deficient sweating, the recession of the eyeball, abnormal pupillary response, miosis ptosis, and the irises of different colors

Brachial Plexus Injury (BPI)

Injury Classification and Motor Impairments

Global Palsy

• Combination of injury to the upper and lower plexus C5 –T1

• Total arm paralysis and loss of sensation

• Approximately 13% of children

• Can present with a milder form of Horner’s syndrome

Brachial Plexus Injury (BPI)

Clinical Presentation

Impairments

• Torticollis and/or plagiocephaly

• Muscle substitutions based on strength of available innervated muscles

• Presents unilaterally

• Neglect of upper extremity

• Soft tissue contractures

• Abnormal bone growth

• Sensation changes can cause injuries

Brachial Plexus Injury (BPI)

Clinical Presentation

Activity and Participation

• Varies based on injury, recover, and residual impairments

• Asymmetrical developmental milestones

• Creeping

• Reach and grasp skills

• Bilateral UE tasks: catching a large ball or lifting objects, and ADLs

Brachial Plexus Injury (BPI)

Medical Management

Diagnostic Testing

• MRI

• EMG

• CT

• CT-myelogram

• Diagnostic ultrasound

Brachial Plexus Injury (BPI)

Medical Management

Surgical Intervention

• Infants without full recovery by 1 month should be referred to specialty clinic

• Neurosurgery

  • Primary nerve repair or reconstruction

  • Age 3 to 9 months typically recommended

  • <3 months if complete paralysis and/or with Horner’s syndrome

  • Post-op: immobilization for 3 weeks and then PROM/AROM

• Orthopedic Surgery may also be warranted

• Botox of antagonists

Brachial Plexus Injury (BPI)

PT Examination

History/Interview

• History of birth and complications

• Results of MRI and/or EMG

• Parent understanding/perception of diagnosis

Brachial Plexus Injury (BPI)

PT Examination

Physical Examination

• PROM & Strength/Motor Function – cervical and UE

• Posture

• Pain – FLACC scale

• Sensation

• Tone

• Developmental positions

• Gross motor skills – symmetry, age-appropriate

Brachial Plexus Injury (BPI)

Outcome Measures

• Active Movement Scale: infants <1 yo

• Modified Mallet Scale: 3-4+ yo

• Test of Infant Motor Performance (TIMP): <4 months old

• Alberta Infant Motor Scale (AIMS): 0-18 months

• Brachial Plexus Outcome Measure: 4-19 yo

• Brachial Plexus Outcome Measure Activity Scale: 4-19 yo

• Assisting Hand Assessment: 18 mo-12 yo

• Mini-Assisting Hand Assessment: 8-18 months

Brachial Plexus Injury (BPI)

PT Intervention

• Instruct family on ROM

  • Gentle stretching

  • Stabilize scapula manually during ROM and reaching

• Positioning guidelines to prevent contracture and to emphasize function

• Facilitate normal movement patterns

• Immobilize unaffected arm – CIMT

• Kinesiotaping

• Electrical Stimulation and Biofeedback – older children

• Utilize tactile stimulation

• Joint compression

• Splinting

• Gross motor skills and transitions

Brachial Plexus Injury (BPI)

Rehab Goals

• Increase PROM

• Increase strength

• Increase sensation

• Decrease pain

• Prevent contractures

• Facilitate symmetrical gross motor development

• Decreased activity limitations or participation restrictions

What is Developmental Delay?

When a child does not achieve their developmental milestones compared to their age-matched peers

• Mild

• Moderate

• Severe

What is Developmental Delay?

Significant delay

performance is two or more standard deviations below the mean on standardized norm-referenced testing

Common Etiologies of Developmental Delay

Prenatal

• Genetic disorders: Down syndrome, Fragile X syndrome, chromosomal microdeletion or duplication

• Cerebral dysgenesis: microcephaly, absent corpus callosum, hydrocephalus, neuronal migration disorder

• Vascular: occlusion, hemorrhage

• Drugs: cytotoxic, anti-epileptic

• Toxins: alcohol, smoking

• Early maternal infections: rubella, cytomegalovirus, toxoplasmosis

• Late maternal infection: varicella, malaria, HIV

Common Etiologies of Developmental Delay

Perinatal

• Prematurity, intrauterine growth retardation, intraventricular hemorrhage, periventricular leukomalacia

• Perinatal asphyxia: hypoxic-ischemic encephalopathy

• Metabolic: symptomatic hypoglycemia, bilirubin- induced neurological dysfunction

Common Etiologies of Developmental Delay

Postnatal

• Infections: meningitis, encephalitis

• Metabolic: hypernatremia, hyponatremia, hypoglycemia, dehydration

• Anoxia: suffocation, near-drowning, seizure

• Trauma: head injury, either accidental or non-accidental

• Vascular: strok

Common Etiologies of Developmental Delay

Others

• Social: severe understimulation, maltreatment, malnutrition

• Maternal mental health disorder

• Unknown

Domains of Development

• Physical

• Social-Emotional

• Language

• Cognitive

Domains of Development

Physical

gross motor and fine motor

Types of Developmental Delay

• Isolated

• Global

Types of Developmental Delay

Isolated

a single domain

Types of Developmental Delay

Global

two or more developmental domains affecting children under the age of five years old

Where does physical therapy come in?

• Early Identification!

• Early Intervention!

Congenital Heart Defects (CHD)

• The most common birth defect

• Occurring in ~1% of births each year

• Often require physical therapy

• Understanding the difference between acyanotic and cyanotic heart defects

Acyanotic Congenital Heart Defects

Definition

Impact the normal flow of blood through the body, including left-to-right shunting of blood through the heart and outflow obstructions.

Acyanotic Congenital Heart Defects

Types

• Atrioventricular Septal Defect

• Pulmonary Stenosis

  

Key Considerations for Children with Acyanotic Congenital Heart Defects

• Tummy time may be limited and sternal precautions may vary

• Promote safety with physical activity

• At risk for executive functioning impairments

• Follow up with cardiologist for exercise prescription

• Pre-operative PT: optimize neuromotor development and endurance

• Post-operative PT: upright positioning to maximize pulmonary function, airway clearance, and developmental handling with sternal precautions

• Caregiver education and family-centered care

Cyanotic Congenital Heart Defects

Definition

Defects that allow the mixing of oxygenated and non-oxygenated blood

Cyanotic Congenital Heart Defects

Types

• Pulmonary Atresia

• Hypoplastic Left Heart Syndrome

  

Key Considerations for Children with Cyanotic Congenital Heart Defects

• Critical CHDs result in cyanotic presentations

• Tummy time may be limited and sternal precautions may vary

• At risk for executive functioning impairments

• More physical activity limitations compared to acyanotic peers

• Activity considerations for patients with single ventricles

• Inspiratory muscle training after Fontan procedure

• Cardiac rehab is shown to be safe and beneficial

• Pre-operative PT

• Post-operative PT

• Caregiver education and family-centered care

Physical Fitness Is…

Multidimensional

Health related fitness

includes daily function and health maintenance

• Components include:

  • Cardiorespiratory endurance

  • Muscular strength and endurance

  • Flexibility

  • Body composition

Motor fitness

includes physical abilities related to:

• Athletic performance

• Agility

• Coordination

Fitness Components

Cardiorespiratory endurance

• improves their physical working capacity

• reduces fatigue

• reduces their risk of coronary heart disease

• optimizes their growth and development

Fitness Components

Muscular strength and endurance

• improves their functional capacity for lifting and carrying

• reduces the risk of low back pain

• optimizes their posture

• optimizes their growth and development

Fitness Components

Flexibility

• enhances their functional capacity for bending and twisting

• reducing the risk of low back pain

• optimizing their growth and development

Fitness Components

Body composition

• reduces the risk of hypertension

• reduces the risk of coronary heart disease

• reduces the risk of diabetes

• optimizes their growth and development

Fitness Testing

FITNESSGRAM

• Is a National youth fitness test used throughout the United States

• Uses criterion-referenced standards that reflect levels of fitness important for good health

Fitness Testing

Brockport Physical Fitness Test

• Health related criterion referenced test for youth with disabilities

• Offers options that can be individualized based on health-related needs

• Targets the following populations

  • Visually impaired

  • Intellectual disability

  • Cerebral Palsy

  • Spinal Cord Injury

  • Amputation

Cardiorespiratory Endurance

Measured using Maximum Oxygen Uptake (VO2max)

• VO2max increases throughout childhood

• Slightly higher in boys than in girls

• Estimated peak O2 consumption is measured in the field through distance run tests commonly a 1-mile run/walk

• Studies report improved aerobic power with training suggesting the principles of training (frequency, intensity and duration) of children before puberty are similar to those for adults

• Boxing, running, rowing, swimming, cross-country skiing and bicycling are highly correlated to improving cardiorespiratory endurance

Muscular Strength and Endurance

• Strength is required for movement and effective performance

• Important for optimal posture & reduced risk of low back pain

• Lack of reliable, valid laboratory, and field standards for musculoskeletal fitness

• Isokinetic and isometric dynamometry have been used in laboratories

• Field tests such as the flexed arm hang, push up, curl up and trunk lift from the FITNESSGRAM are common but lack data

• Muscular strength increases linearly with chronological age to ~age 13-14 years in both sexes (boys have greater strength than girls at all ages)

• Strength and muscle mass can be achieved with training in children

• Increases in strength, relate to increases in muscle mass during growth

• Controversy exists as to the efficacy of strength training for children and adolescents