Adapting VT for Special Populations Flashcards
What groups of people are special needs?
infant-preschool, ABI/TBI, developmental delay, elite athletes
Down syndrome historically…
one of the first developmental disabilities recognized as a syndrome (Langdon Down 1866); diagnosed based on physical findings
What two features was Down syndrome historically diagnosed based off of?
upward slanting of temporal palpebral fissure and significant epicanthal folds
What are the genetics of Down syndrome?
congenital, inherited genetic anomaly; trisomy 21 (94%), translocation (5%), mosaicism (1%)
What is Trisomy 21?
three copies of chromosome 21
What is Translocation?
portion of chromosome 21 breaks off and attaches to another chromosome; most common attachment chromosome is 14
What is Mosaicism?
some cells have trisomy and some do not, less effects/manifestations
What is the most common genetic anomaly?
Down Syndrome 1:700 babies in the US, all races and socioeconomic levels
What is the biggest risk factor for Down Syndrome??
maternal age, 1:50 for moms over age 44
Why is maternal age not as big of a deal as it seems for Down Syndrome?
80% of babies with DS are born to moms under 35 (more babies)
What is a geriatric pregnancy?
maternal age 35 or more
What are physical characteristics of Down Syndrome?
hypotonia, palmar crease, dysplastic ears, enlarged tongue, dental anomalies, flat nasal bridge
What medical conditions are associated with Down Syndrome?
congenital heart defects (50%), thyroid dysfunction, respiratory problems, digestive problems, increased susceptibility to infection, increased risk for/earlier onset of Alzheimer’s, increased prevalence of ADHD, autism, seizures and leukemia
How is speech and language affected by Down syndrome?
poor hearing… slow auditory processing, need small instruction sets, wait for comprehension before continuing; poor expressive language but OK receptive
What does poor expressive language mean?
unable to verbalize wants/needs well
What does OK receptive language mean?
able to understand what you are saying/asking
What are the three most common ocular manifestations of Down Syndrome?
epicanthal folds, strabismus, significant refractive error
What are other ocular manifestations of Down Syndrome?
oblique and narrow palpebral fissures, nystagmus, keratoconus, cataracts, accommodative issues, amblyopia, glaucoma, astigmatism, blepharitis
In down syndrome which strabismus is more common?
eso
What does significant refractive error mean in relation to Down Syndrome?
hyperopia and astigmatism>myopia but when myopia is present likely -8D or more
What are iris manifestations of Down Syndrome?
iris hypoplasia and brushfield spots
What are optic nerve manifestations of Down Syndrome?
RPE disturbance at disc and hyperemic optic disc
What are exam tips for Down Syndrome?
children may be sensitive to perceived failure, slow down and build confidence, consider longer/multiple appointments
What are glasses fitting considerations for Down Syndrome?
wide nasal bridge, short canthus-to-ear measurement, narrower PD, wider head than age-matched non-DS patients
T/F you must co-manage Down Syndrome patients with their PCP
true
What is Cerebral Palsy?
1862-motor impairment resulting from brain damage, whether pre-, peri- or postnatal, diagnosed clinically not by lab testing or imaging
What is the genetics of CP?
not hereditary, non-progressive
What are the prenatal causes of CP?
most cases unknown, severe injury to mother, alcohol/drug/cigarette use during pregnancy, severe malnutrition in the mother, intrauterine infections: rubella, toxoplasmosis, CMV, HIV
What are peri/postnatal causes of CP?
intraventricular or other intracranial hemorrhages, birth trauma, choking, poisoning, drowning, head injury including shaken baby syndrome, severe infections
What are three presentations of CP?
spastic, dyskinetic/athetoid, and ataxic
What is spastic CP?
stiff muscles, most common form (70-80%), periventricular white matter damage, hypertonia, muscle pairs contract simultaneously, stiff, jerky movements, difficulty releasing objects
What is dyskinetic/athetoid CP?
10-15% of pt, basal ganglia damage, mixed or fluctuating muscle tone, difficulty maintaining positions, many random involuntary movements (usually large), rarely affects intelligence
What is ataxic CP?
poor balance, least common 5%, cerebellar damage, hypotonia, poor coordination, very unsteady movements, poor balance, wide-based gait, shakiness and/or intention tremor, poor depth perception
What is quadriplegia?
all four limbs affected 10-15% of CP
What is hemiplegia?
one side of the body 20-30% of CP
What is diplegia?
lower limbs only 60-70% of CP
What are highest risk for CP?
premature infant, low birth weight (3 lbs, 1500 g has 25x greater risk than >2500g), low APGAR score (less than 3 at 20 minutes is 250x greater risk), ventilator for over 4 weeks
What conditions are associated with CP?
epilepsy or other seizure activity, learning disabilities, ADD/ADHD, hip subluxation/scoliosis, gait problems, dysarthria (speech muscles), swallowing problems
What are ocular manifestations of CP?
cicatricial ROP, cortical visual impairment, strabismus, refractive error, oculomotor dysfunction/accommodative dysfunction
Which oculomotor direction is worse in CP?
vertical worse than horizontal
What are CP exam tips?
room/equipment accessibility, slow down, VT can be very effective, bring activities to chair height
Are surgical outcomes for strabismus good or poor with CP?
poor
What are adaptive devices for CP?
wheelchair, walker, braces, pencil grips, custom shoes, crutches, seats/cushions, lap desks
What are the autism spectrum disorders?
ADD, ADHD, Dyslexia, Asperger’s, hyperlexia, PDD, autism
What is the autism spectrum?
complex group of disorders of brain function affecting the way the brain uses or transmits information
How common is autism?
1:60, boys 4x more likely than girls
What are the genetics of autism?
strong genetic link
What are risk factors of ASD?
rubella, ethanol, valproic acid, thalidomide, PKU, tuberous sclerosis
What are physical characteristics of ASD?
essentially normal appearance, corners of mouth low, tops of ears turn over, ears lower than normal, square shape
What are behavioral characteristics of ASD?
inability to interpret emotions of others, limited language skills, difficulty initiating or maintaining conversations, intense preoccupations with a single subject, activity or gesture, profound social interaction problems, hypersensitivity to senses
What are ocular manifestations of ASD?
oculomotor dysfunction
Why do you have to watch out with ASD and binocular vision difficulties?
CI, accommodative dysfunction and binocular instability have symptoms similar to those of ADD/ADHD conditions
What are ASD exam tips?
many meds have ocular side effects, objective testing is key, eye contact is difficulty so observe at all times, minimize external sensory distractions, slow down therapies, be patient, be flexible and creative
What challenges arise when patients are too young (or have a developmental delay) for traditional VT activities?
sufficient gross or fine motor control, cognitive understanding of certain tasks, letter/number knowledge, attention span
How can you address the challenge of patient being too young or having developmental delay?
get child moving, incorporate active games, ball/beanbag toss, hopscotch, myer’s flying rings, simon says, angels in the snow
How can you address fine motor control problems?
large crayons/pencils, large print or other targets, bead stringing, allow additional time for fine motor tasks
What is the Delly decoder activity?
accommodation, fine motor, oculomotor, and perceptual coloring activity
How can you address cognitive understanding difficulties?
break directions down into single steps, move slowly, simple tasks ex: basic puzzles, tangrams, parquetry blocks, memory games
How can you address a limited amount of letter/number knowledge?
picture charts, stickers, toys, videos, colors
How can you address a limited attention span?
have a selection of targets ready, be able to change quickly from one activity to another, if something isn’t working abandon it
What should you do in each exam?
put yourself on the patient’s level emotionally, cognitively, and physically; the more engaged the patient the better the response
What does research show about ASD engagement?
developmental, individual differences, relationship based techniques in addition to floor time is most engaging
ABI/TBI patients may have new physical limitations like….
limited ambulation, restrictions of upper limbs, difficulty turning neck/head; frustration is high because they understand what they have lost
