Pediatric Physical Therapy Evaluation and Plan of Care Study Guide

Purposes and Scope of Pediatric Initial Physical Therapy Examination

  • Initial Practice Determination: One of the foundational purposes of the initial examination is to determine if the child's specific needs fall within the scope of physical therapy practice.
  • Benefit Assessment: Once clinical appropriateness is established, the therapist must decide if the child will specifically benefit from physical therapy interventions.
  • Interprofessional Collaboration: The examination serves to identify if the child requires referrals to other specialists or different types of therapists (e.g., Occupational Therapy or Speech-Language Pathology).
  • Data Collection and Baselines:
    • Therapists use tests and measures to collect objective data.
    • Establishing a baseline is critical for measuring future progress.
    • Initial data helps determine when a patient has reached their goals and is ready for discharge.
  • Clinical Decision Making: The initial exam enables the physical therapist to determine the physical therapy prognosis and diagnosis, which directly drives the formulation of goals and the plan of care (POC).
  • Process Schema from the Guide to Physical Therapist Practice:
    • The examination leads to the evaluation.
    • The evaluation determines if additional referrals or consultations are necessary.
    • The evaluation process defines the diagnosis and prognosis.
    • These components decide the appropriate interventions.
    • Interventions lead to outcomes.
    • Outcomes necessitate re-examination and further evaluation to determine if the needs of the child were met.

Subjective History and Patient Background

  • Methodology for Observation: In pediatrics, especially with younger children, it is beneficial to observe the child's movement while simultaneously taking the history from the caregiver. It is crucial to inform parents of this observation so they understand the therapist is working while talking. Observation reveals:
    • What the child is able to do or struggles with.
    • The child's likes and dislikes.
    • A "warm-up" period that allows the child to become comfortable with the therapist.
  • Age Classifications:
    • Date of Birth (DOB): Used to determine chronological age.
    • Gestational Age (GA): The age of the fetus between conception and birth.
    • Chronological Age (CA): Time elapsed since birth.
    • Adjusted Age (AA): Used for premature babies to account for the weeks they were born early.
  • Chief Complaint: Inquiring "How can I help you?" reveals the parents' level of understanding. If the parent only knows the doctor sent them, the therapist must approach with more care to educate them on the purpose of the visit.
  • Pregnancy and Birth History:
    • Prematurity: Length of stay in the Neonatal Intensive Care Unit (NICU).
    • NICU Interventions: Use of a ventilator or oxygen support.
    • Mode of Delivery: Vaginal versus Cesarean section (C-section). C-sections often indicate complications in pregnancy or delivery.
    • Extraction Methods: Use of forceps or vacuum extraction, which implies delivery difficulty and potential injuries.
    • Position: Breech position (foot-down instead of head-down) informs specific musculoskeletal issues to check for.
    • Multiple Births: Twins, triplets, etc. Higher counts increase the risk of neurological impairment or damage.
    • Maternal Health: History of eclampsia or Rh incompatibility (blood type mismatch between mother and baby).
  • Social and Developmental History:
    • Living Situation: Home life with parents, grandparents, or foster care.
    • Siblings: Numbers and ages. Siblings can motivate the child; their presence also indicates the parents' experience with child development.
    • Schooling: Attendance and whether the child receives therapy services in the school setting.
    • Developmental Milestones: History of when the child sat, walked, or talked.
    • Feeding History: Breastfed, bottle-fed, and stages of baby food (Stage 1, 2, or 3). Issues with textures or transiting to table food.
  • Sensitive Medical Records: Information often found in the medical record rather than through direct questioning includes birth weight, Apgar scores, maternal drug/alcohol abuse, maternal illness/medications during pregnancy, and history of previous abortions or miscarriages (which can correlate with higher likelihood of special needs).

Objective Examination Categories

  • General Physical Therapy Categories: Many pediatric exam categories are identical to adult exams, including posture, muscle tone, Range of Motion (ROM), muscle performance/strength, motor learning, sensation, integumentary system, cardiopulmonary system, and pain.
  • Unique Pediatric Elements:
    • Fine Motor Screening: Reach, grasp, playing with toys at midline, crossing the midline, and transferring toys between hands.
    • Hand Preference: A preference should not be noted until preschool or kindergarten age.
    • Sensory Processing: Screening for sensory defensiveness (e.g., refusal to walk on grass, or wearing shoes/socks), overstimulation (crying or withdrawing in crowded rooms), and eye contact.
  • Oral Motor Screening:
    • Drooling: Normal in infants, but significant drooling in children aged 22, 33, or 44 years is abnormal.
    • Feeding Fluid Loss: Losing fluid from the mouth during feeding is an indicator for referral to Occupational Therapy (OT) or Speech Therapy.
    • Safety Signs: Coughing or gagging may indicate a poorly coordinated suck-swallow reflex.
    • Tone Indicators: Mouth hanging open may suggest low muscle tone.
    • Tongue Thrust: Sticking the tongue out while eating, which pushes food out of the mouth.
    • Vocalization: Presence of sounds or words during the session.

Musculoskeletal and Tone Assessment

  • Musculoskeletal Screening:
    • Signs of scoliosis.
    • Hip subluxation or dislocation (indicated by leg position or asymmetrical skin folds).
    • Genu Valgus vs. Varus: Knock-kneed versus bow-legged presentation.
    • Genu Recurvatum: Hyperextension of the knees in standing.
    • Tibial Rotation: Assessed with the child sitting; internal or external rotation should be equal and bilateral.
    • Foot/Ankle Position: Pronation or supination in standing.
    • Frog Leg Posture: Legs in hip flexion, abduction, and external rotation while supine or prone.
    • Leg Length Discrepancy: Apparent or true discrepancy requiring orthopedic evaluation.
  • Muscle Tone: Defined as resistance to passive movement.
    • Velocity Dependency: The speed of movement affects the assessment; faster speeds are more likely to stimulate spasticity.
    • Quality Variations:
      • Hypotonic: Decreased tone.
      • Hypertonic: Increased tone or spasticity.
      • Dyskinesia: Athetosis (large-scale uncontrolled movements) or Dystonia (less rhythmic predictive patterns).
      • Ataxia: Characterized by an inability to walk in a straight line, similar to an intoxicated gait.
    • Distribution: Evaluation should note if tone is in the neck/trunk vs. extremities, proximal vs. distal, or asymmetrical (side-to-side/upper vs. lower body).
  • Range of Motion and Flexibility:
    • Assessment of active and passive ROM.
    • Physiological Flexion: Normal in neonates.
    • Cortical Thumb Posture: The thumb is tucked inside the fist under the fingers.
    • Joint Hypermobility: Often seen at the junction of the thoracic and lumbar spine.
    • Targeted Muscles for Tightness: Hip flexors, rotators, abductors, adductors, hamstrings, quadriceps (common in spina bifida), sartorius, and heelcords (plantarflexors).
    • Popliteal Angle: A specific pediatric measure for hamstrings. The hip is placed at a 90∘90^{\circ} angle, and the lower leg is extended. The resulting angle is subtracted from 180∘180^{\circ} to determine the popliteal angle.

Strength and Motor Performance

  • Objective Measures: Manual Muscle Testing (MMT) or Dynamometry for older children (55 years and up).
  • Functional Strength Assessment: For younger children, strength is estimated via function.
    • Head Lag: Observed when pulling a child to a sitting position.
    • Abdominal/Oblique Weakness: Indicated by rib flaring.
    • Scapular Adductors: Weakness is indicated by scapular winging in prone.
    • Quadriceps: Observed during the transition from sitting to standing or eccentric control when descending stairs.
  • Reflexes and Reactions:
    • Asymmetric Tonic Neck Reflex (ATNR): Normal up to 99 months; characterized by the "fencing" posture (head turned, arm on that side extended, opposite arm flexed). It should never dominate the child's movement.
    • Moro Reflex (Startle Reaction): Elicited by a perceived drop (vestibular). The arms abduct and then adduct.
    • Protection and Balance: Righting reactions, equilibrium reactions, and protective extension (putting an arm or foot out to prevent a fall).
    • CNS Indicators: Clonus is normal in infants up to 22 years of age. The Babinski reflex is also normal in infants and does not necessarily indicate a CNS lesion as it does in adults.

Gross Motor Development and Mobility

  • Standard Positions: Evaluation in supine, prone, sitting (supported/unsupported), and standing.
  • Milestones: Rolling (prone to supine and supine to prone, left vs. right), commando crawling (on belly), getting into quadruped, creeping (hands and knees), and kneeling.
  • Transitions: Moving from one position to another. Difficulties here are common in neurological issues like Cerebral Palsy.
  • Balance: Static (staying in position) vs. Dynamic (reaching outside the base of support).
  • Gait and Stairs:
    • Visual gait analysis.
    • Stair Patterns: Step-to-step (both feet on one step) vs. step-over-step (alternating feet).
    • Advanced Skills: Tandem gait (heel-to-toe), skipping (highest coordination complexity), hopping, jumping, and ball skills (throwing, catching, kicking, targeting).
  • Adaptive Equipment:
    • Wheelchairs or medical strollers.
    • Standers and gait trainers.
    • Adaptive tricycles.
    • Examination must confirm if equipment still fits the child properly or needs repair/adjustment.

Assessment and Documentation

  • The SOAP Note Thinking Process:
    • Subjective (S): History gathered from parents, caregivers, nurses, or medical records.
    • Objective (O): Tests, measurements, and outcome measure results.
    • Assessment (A): The integration of S and O. It should begin with a summary statement including age, medical diagnosis, and major findings (e.g., "16-month old female diagnosed with Down syndrome with associated gross motor developmental delay").
    • Plan (P): The goals and roadmap for future treatment.
  • Component of the Assessment Section:
    • PT Diagnosis: Clinical identification of impairments (e.g., gross motor developmental delay).
    • Prognosis: The maximal level of improvement anticipated and the projected timeframe for achievement.
    • Atypical Movement Patterns: Identifying bunny hopping, arm flapping (stereotypical movements), or self-abusive behaviors (biting, head-banging).
    • Functional Component: Goals must be functional for insurance coverage (e.g., "standing for one minute to progress to cruising").
    • Data Specificity: Levels of success should be noted (e.g., 3/53/5 trials or 75%75\% of the time).
  • Evaluation Complexity Levels (Effective Jan 2017):
    • Low Complexity (97161): No personal factors/comorbidities; 1−21-2 body structure/activity elements; stable/uncomplicated presentation.
    • Moderate Complexity (97162): 1−21-2 personal factors; 33 exam elements; evolving presentation.
    • High Complexity (97163): 3−43-4 personal factors; ≥4\geq 4 exam elements; unstable or unpredictable presentation.
  • Mandatory Reporting: Physical therapists have a legal responsibility to report suspected child abuse or neglect to the Department of Children and Families. These reports are anonymous.

Plan of Care (POC) and Interventions

  • Communication: Includes plans to contact the MD or other specialists.
  • School vs. Outpatient: Therapists must clarify if a child receiving school-based PT also requires outpatient PT, ensuring the specific goals for outpatient care are distinct.
  • Frequency and Duration: Documentation must specify how often (e.g., once a week) and for how long (e.g., six months) therapy will occur.
  • Intervention Types: General categories to include are Home Exercise Programs (HEP), developmental activities, strengthening, stretching, and gait training.
  • Rehab Potential: The therapist's professional judgment on the child's potential for progress.

Questions & Discussion

  • Task for Students: The speaker asks students to pause the presentation and list what they would ask a parent regarding history and what categories they would include in a PT exam (e.g., ROM). The goal is to prove that students already know the basics of evaluation even before specializing in pediatrics.
  • Parental Communication: The speaker emphasizes that if a parent says "the doctor sent me," it necessitates different communication than a parent who says "my child is not able to do [specific task]."
  • Handling Response: How the child responds to being handled (facilitation or inhibition) is a critical piece of the evaluation that informs future treatment strategy.