Age Specific Exam and PT Intervention

Question 1

Infancy

Answer 1

Typical Participation Restrictions: Causes/Implications

• • Edu for parents- parents often anxious to handle child which decreases stimulation
• • children may also have decreased opportunities through early environmental stimulation, observation, and exploration d/t sensory/motor deficits, hypotonia and visual deficits
• • delayed fine and gross motor development common d/t multiple impairments

Exam of Impairments

• • be aware or normal physiologic flexion of the hips/knees- may have limitations up to 35d in normal newborns, contractures may be more pronounced in a child with MM, does not spontaneously reduce in children with MM due to decreased limb activity d/t mm weakness
• • 2 primary orthopedic concerns: dislocated hips and foot deformities, want to achieve plantigrade alignment regardless of amb prognosis, provides optimal shoe fit, positioning and equal weight distribution
• • MM tone: use HINT or the Movement Assessment of Infants– hypotonia is typical in MM even if sacral function is present, poor head control, delayed head/trunk righting, etc.– can have a mixture of hypotonic, hypertonia, and spastic movements in limb– important to differentiate between voluntary and reflexive movement
• • must establish reliable baseline of mm function before and after back closure– helps to predict future function
• • mm function established before and after closure to determine extent of mm paralysis– SIDELYING = position of choice to avoid injury to expose neural tissue, consider state of alertness, may need to do repeated exams, mm activity is best observed when infant is alert, hungry, or crying. If leg movements in myotomes caudal to MM occur concurrently with performance of general movements in infants, functional neural conduction through MM is implicated– classify mm function as normal, weak, or absent (this 3 point scale lacks sensitivity, may want to use grade 0-5)
• -sensation- difficult to assess d/t cognition, testing with pin or sharp object should begin at lowest level of sacral innervation and progress more proximally
• Step responses- infants with MM step less than typical infants, high lesion = very low step response over time

Ongoing monitoring: joint alignment, mm imbalance, and development of contractures

• • frog leg contractures are common
• • changes in mm tone are observed with progressive neuro dysfunction
• • look for behavioral changes and signs of shunt malfunction
• • monitor motor development

Typical PT Goals and Strategies: be sensitive to parents and feelings, education regarding ROM program, handling techniques for those with hypotonia, positioning

Prevention of Secondary Impairments and activity limitations: positioning, ROM, and handling of lower limbs in neutral alignment and contracture prevention, education if hips are dislocation (positioning, double diapering), surgery for hip dislocations usually performed after 6m, inspection of insensate areas

Question 2

Toddler and Preschool Years

Answer 2

Typical Participation Restrictions: Causes/Implications

• • continued delay in development of fine and GM milestones, mobility is impaired = decreased exploration/socialization/independence in ADL’s, if do not have effective independent mobility at 1 year may need mobility device
• • due to limited mobility may develop passive dependent behavior
• • educate teachers, parent, and child care personnel on delayed hand eye coordination = difficulty with acquisition of hand writing and ADL skills

Exam of Impairments

• • ROM should be WNL by end of 1st year, distinguish btwn fixed and flexible deformities
• • Function mm strength testing is advocated for children 2-5 y/o bc may have difficulty following instruction for graded MMT
• • by 2 y/o child light touch and position sense can be assessed with tickling responses, sensory modalities used in 5-7 y/o
• • FM and GM development should be testing using standardized assessments, exam of ADL’s , Functional Activities Assessment

Ongoing monitoring: joint alignment, mm imbalance, contractures, posture and s/s of progressive neuro dysfunction

Typical PT Goals and Strategies

• • continue to treatment impairments in ongoing monitoring, proper positioning for sleep and sitting, stretch/strengthen as indicated
• • use of therapy ball, biofeedback, mm re edu through FES, E-stim
• • preschool years- improve independence, efficiency, and effectiveness of ADL’s and mobility
• • kindergarten able to dress and toilet themselves
• • Instruct parents in importance of positive reinforcement
• • skin inspection and pressure relief techniques
• • explore mobility options if not able to maneuver through environment by age 1– w/c assessment
• • preparatory activities for mobility indicated in 1-2 y/o: balance, trunk control, facilitate upright posture
• • once child is able to pull to stand– need to consider orthotics to improve wb alignment
• • high level lesion emphasize w/c mobility, can use orthotics for household amb
• • w/c used for community ambulation in children with thoracic to L3 lesions
• -L4 and below = biped ambulation
• • children will all lumbar lesions will need ue AD for walking- reverse walker, forearm crutches, etc.

Prevention of Secondary Impairments and activity limitations: joint contractures, skin inspection and pressure relief, habitual posture positions that contribute to deforming forces should be discouraged, encourage upright posture when learning to walk

Question 3

School Age

Answer 3

Typical Participation Restrictions: Causes/Implications

• • continued impairment in independence with ADL’s
• • mobility limitations become magnified at this age– need to work on advanced mobility skills to navigate environmental barriers
• • negative effects of limited mobility and physical limitations on socialization become apparent at this age
• • Edu parents and teachers on deficits of perceptumotor, visuoperceptual, and sensory deficits

Exam of Impairments: joint alignment, strength, mm imbalance, contractures, mm extensibility and posture continue to be monitored

• • also look at sensation, gait, coordination, FM skills, body awareness and functional skills
• • can do MMT with this group- graded or dynamometer
• • assess independence with ADL’s Functional Activities Assessment, BB function

Ongoing monitoring: joint alignment, mm imbalance, contractures, posture and s/s of progressive neuro dysfunction

• • at this age children should become more responsible for skin inspection
• • monitor specifically in times of rapid growth bc can have a decline in function due to tethered cord

Typical PT Goals and Strategies

• • Stretch/strengthen
• • improve flexibility to low back extensors, hip flexors, hams, shoulder girdle
• • Incorporated activities into PE program
• • continued exam of positioning when sleeping, sitting in class and selection of proper seating– modifications in classroom to ensure full participation
• • If child has no achieved independence with a given ADL by age at which 50% of normative group achieve independence on in Functional Activities Assessment–should assess child’s performance to determine need for adaptive equipment
• • ADL goals should be for independence and efficiency
• • important to ensure that child has independent and efficient mobility at home and at school and in community
• • encourage recreation and physical fitness– physical and psychological benefits
• • incorporation of regular aerobic activity– weight mgmt, endurance, strength, etc.– low impact aerobics are preferred

Prevention of Secondary Impairments and activity limitations:

• • joint protection important early in childhood b/c deficit often become magnified as child ages and transitions to adulthood
• • involve parents and children in decisions regarding AD

Question 4

Adolescence and Transition to Adulthood

Answer 4

Typical Participation Restrictions: Causes/Implications

• • IF normal stages for early childhood development have not been accomplished = crisis in adolescence
• • increased travel and need for indep and efficient mobility
• • changes in mobility often occur concurrently with rapid changes in adolescence–those who were previously ambulatory often become more dependent on w/c
• • if orthotic stabilization is required of hip, knee or both it is unlike that adolescents will maintain community ambulation
• • changes in body proportions and body composition– increased difficulty with upright balance and increased energy expenditure– changes in msk forces
• -progression of neuro deficit– another cause of decline in mobility
• • immobilization used for intervention = decreased mobility
• • prolonged periods of bed rest = decreased mobility = increased risk of pressure ulcers
• • progression of spinal deformities during growth spurt = changes in sitting and standing balance, limited trunk and hip ROM, osteoporosis leading to fx
• • begin to develop degenerative changes as result of wb and overuse syndromes– joint pain, lig instability, tendonitis

Exam of Impairments:

• • joint ROM and mm extensibility of two joint mm, esp hip/knee flexors and trunk mm– neck and low back ROM often restricted
• • joint swelling/instability, crepitus, pain with and without movement
• • mm strength should continue to be monitored
• • if suspect declined neuro fxn check coordination, grip strength, balance, etc.
• • bed mobility, floor mobility, transfers, appropriate equipment

Ongoing monitoring: comprehensive exam should occur on a yearly basis
** early detection of progressive mm strength loss, scoliosis, progression of spasticity, contractures— allows for timely referral and intervention

Typical PT Goals and Strategies

• • achieve independent basic and community mobility skills
• • PT should be aware of all environments that individual is required to negotiate
• • PT/OT for driver’s ed
• • Expanded Functional Activities Assessment looks at adolescent skills needed for independent living
• • Assessment of Motor and Process Skills (AMPS)– valid assessment for ADL performance– looks at motor and process skills in terms of efficiency, safety, and level of independence
• • Kohlman Evaluation of Living Skills- also used in determine independence with adult living skills
• • if limited in ADL’s need to modify or make adaptations
• • may need social worker to assist with vocational counseling, indep living transitions, etc.

Prevention of Secondary Impairments and activity limitations:

• • PT plays an important role in anticipating functional loss
• • PT should advocate for pt
• • want to prevent permanent decline in function