Exam 3 (Peds and Geriatrics) Flashcards
4 Motor Control Factors
1) Neural: structures, pathways, processes participating in movement
2) Physiological: various body systems contributing to movement (ex: thermoregulate, integumentary, etc)
3) Biomechanical: structures/properties of muscles, joints, and soft tissues and physical laws governing them (ex: short vs. long lever arm, COM to BOS when trying to stand, etc.)
4) Behavioral: cognitive, emotional, motivational, perception (of task, environment, and condition), movement outcome in terms of satisfying a goal
Stages of Movement in the Motor Control Framework
1) Initial Conditions: state of individual
- posture
- environment/ability to interact with environment
2) Preparation: organized in CNS (cant see it)
- stimulus identification
- response selection/programming (normal synergy, weight shifting, etc.)
3) Initiation: moment movement BEGINS
- timing (hesitation, delay)
- direction
-smoothness
4) Execution
- amplitude
- direction
-speed
-smoothness
5) Termination: moment movement STOPS
- timing
- stability (keep COM w BOS)
- accuracy
6) Outcome: success? possible improvements to be made?
Motor Control Framework
1) Movement Examination
- where movement does problem occur
2) Movement Analysis
- hypothesize determinants for problem
3) Plan of Care to Address Movement Dysfunction
4) Outcomes
Movement Analysis and PT
· Initial/ongoing assessment
· Helps prioritize and focus intervention
· Match patients progress by developing strategies rather than technique for treatment
· Justifies why patient needs your services
· What is mvmnt problem?/ Why is it occurring?
· Qualitative/Quantitative identification
Medical Diagnosis vs PT Diagnosis (Movement Dysfunction)
· Medical Diagnosis: Pathology that causes impairments
· PT Diagnosis: Impairments that cause Functional Limitations
Levels of PT Diagnosis
· Bodily Structure and Function/Impairment Level (MSK)
· Multi-system-impairment (NMR)
· Activity/Functional Limitation level and skill (motor control)
· Participation (societal roles)
Skill
Ability to achieve meaningful goals with consistency, flexibility, and efficiency
Pathoanatomical Limitation
Does not always explain the full story
Child Find Program/Infants and Toddlers/Early Intervention Program
· Surveillance and prevention program
· For children at risk of developmental delays (up to 3 years old)
· Anyone can call to recommended
· Insurance not required
· Services offered: in home OR center based (at a facility)
What could interference during embryonic stage cause?
· Hamper development of organs, systems, and structures which will persist throughout life
·Spina Bifida due to neural tube (which becomes brain and sc) not fully closing
Critical Periods of Pre-natal development
1) Germinal Stage (conception-2 weeks)
- cells begin to differentiate
2) Embryonic Stage/ CRITICAL STAGE (3-8 wks)
- rapid cell division and differentiation
- vital organs FORMED (ex: neural tube closes)
3) Fetal Stage (9-40wks)
- movement BEGINS
- growth of major organs and body parts
3 Factors causing atypical development
1) Teratogens: an agent that produces malformations (ex: infections, medications/substances)
2) Genetics: genetic alterations passed vis genes (ex: Down Syndrome/Trisomy 21)
3) Internal Environment: “packaging problem”/ confined position in uterus resulting in deformities (ex: club foot, congenital hip dislocation, contractures, metatarsus adductus)
Atypical Pre-natal Development Motor Ability Outcomes
· Lower scores on tests for motor ability
· Uncoordinated movements
· Motor learning issues
APGAR Test (at birth)
· Appearance: skin
· Pulse: HR
· Grimace: reflex response
· Activity: muscle tone
· Respiration: breathing
· Assesses general wellbeing, performed at 1/5/10 minutes
· 10 pts total= perfect, 0-2 pts total= problematic
Age Abbreviations and equations
· Chronological Age (CA): birth to present
· Gestational Age (GA): conception to birth
· Adjusted Age (AA): birth to present - Time missed
*for premature babies, calculated until baby is 2 YEARS OLD, expect performance based on this age
2 Equations:
· Full Term (FT) - GA = time missed
· CA- time missed = AA
Birth Time Frame
· Premature (< 36 weeks)
· On time (40 weeks)
· Early but not premature (35-39 weeks)
Role of Primary (Primitive) and Postural (Attitudinal) Reflexes and difference between them
· Survival
· Interact with environment
· Foundation for future movements
· Difference: Postural DONT go away
4 Types of Reflexes/Reactions in Pre-Adapted Period (2-4 weeks to 1 year)
1) Survival/primary
· Rooting, sucking (-7 to 2/3 mo)
2) Attitudinal/postural reflexes
· ATNR (birth to 4/6 mo)
· STNR (UNUSUAL attitudinal)
3) Voluntary Movement Preparation
· Positive Support (-8 to 2/3 mo)
· Step (-8 to 2/3 mo)
· LE Placing (-8 to 2/3 mo)
4) Postural reactions (righting, equilibrium, awareness of where we are in space, KEEPS FOREVER)
· Head Righting (optical) (starts at 4mo)
· Head Righting Labyrinth (starts at 4mo)
· Neck on body (starts at 5 mo)
· Body Righting (starts at 5mo)
Neuromaturational Development Theory
Level 1 (Spinal Cord): Primary reflexes
Level 2( Brainstem): Postural reflexes
Level 3(Midbrain): Righting reactions
Level 4 (Cortex): Willful Behavior (equilibrium)
Reflexive Period (Birth through 2-4 weeks) vs. Pre-adapted Period (2-4 weeks to 1 yr)
1) Reflexive Period:
· Posture: flexor synergy
· Movement:primary reflexes
2) Pre-adapted Period:
· voluntary movement
· progression of positions,postures, transitions of functional movement (ex: prone, supine, sitting, standing)
* Helpful in diagnosis of delay
PT assessment of infant development
· Reflexes
· APGAR
· Interaction ability
Major Motor Milestones/ Quarterly goals
(Month:Milestone)
· 1-2: Lift head in prone
· 3-4: Head control
· 5-6: Supine to prone
· 6: Prone to supine
· 5-6: Sitting momentarily
· 6-7: Controlled sitting
· 8-9: Crawling/creeping
· 10: Stands alone
· 11+: Walks alone
(Quarterly Goals)
·1st Q (0-3 months): lifting and aligning head
· 2nd Q (4-6 months): pushing up and sitting up
· 3rd Q (7-9 months): constant motion on various surfaces, scooting, crawling, creeping, cruising
· 4th Q (10-12 months): walking
Alberta Infant Motor Scale (AIMS) assessment tool
· Detects gross motor delay WITHIN POSTURE (supine, prone, sitting, standing)
· Develops simultaneously not sequentially (meaning within each posture theyre developing different things, dont fully master one before testing the other, ex: dont need to get through all of supine or prone before starting supported sitting and standing)
· 0-18 months
· Validity and reliability
· Sensitive (doesnt miss babies who might be at risk) NOT specific (does NOT diagnose)
Infant Gross Motor Development and Environment
· Follows a sequence
· Development of extensors, flexors, rotator muscles for postural control
· Equilibrium control AFTER being in a position (get to a position and then experiment with it)
· Stability before mobility, proximal before distal
Infant Fine Motor Milestones
· Reach and grasp (VOLUNTARY, pre reqs for reaching)
· Grip progresses from Ulnar side to radial side during 4 months - 1year
· Sequence: Ulnar palmar/primitive squeeze (4 months) to palmer (5 months) to radial palmer (6/7 months) to radial digital (8/9 months) to pincer/precision grip (9/10 months for inferior/pads of fingers, 11/12 for superior/tips of fingers)
Cardiopulmonary System
· Ducts/shunts CLOSE at birth, pulmonary still NOT efficient
· Increased HR (120-180 bpm) and RR (30-40 breaths/min)
Skeletal System
· Large Heads
· High center of gravity
· Growth is cephalo-caudal and proximo-distal
Muscular System
· Hypertrophy after birth (Hyperplasia before birth)
Nervous System
· Excess motor neurons at birth is normal
· Natural pruning occurs
· Myelination occurs over time (ex: cerebellum by 1.5 years)
Sensory Systems: Vestibular, Auditory, Visual
1) Vestibular
· First system to develop (6 months after conception)
· Use begins BEFORE birth
2) Auditory
· Acuity is low/poor
· Perception increases around 4 months for Primary caregiver’s voice
3) Visual
· Not fully developed, myelination and synaptic potential continues
· Contrast> color initially
· Good visual acuity by 6 months
· Most change occurs during 1st year
Cognition vs Perception
· Cognition: intention, attention, memory, information processing
· Perception: understanding the meaning of information
Receptive vs Expressive (Language Development)
· Receptive: localize familiar sound (4 months)
· Expressive: babbling sounds (5 months), reinforces sounds (11 months)
ATNR (Asymmetric Tonic Neck Reflex)/ archer
Motor Development Pyramid
1) Prenatal: -9 mo to birth
2) Reflexive: Birth to 2-4 wks
3) Pre-adapted: 2-4 wks to 1yr
4) Fundamental Skills: 1 to 7yrs
5) Context-specific: 7 to 11yrs
6) Skillful: 11+yrs
Infant Reflexes begin/end
· Rooting: 7 mo gestation to 2-3 month
· Sucking: ^
· ATNR: birth to 4-6 mo
· Positive support: 8 mo gestation to 2-3 mo
· Step: ^
· LE placing: ^
Postural Reactions (start time)
· Heading righting (optical): 4 mo
· Head righting (labyrinth): 4 mo
· Neck (on body): 5 mo
· Body on body: 5 mo
Equilibrium Reactions (start time)
· Sit: protective extension (FWD): 6 mo
· Sit: protective extension (SIDEWAYS): 8 mo
· Sit: protective extension (BKWD): 10 mo
· Sit Equilibrium: 8 mo
· Quadraped Equilibrium: 10 mo
Importance of Labyrinthe head righting
· Baby has eyes covered (“vision obliterated”)
· Uses vestibular system to perform head righting, determines if vestibular system is in tact
Types Of Fundamental Motor Skills
1) Mobility and locomotor
· Walking, running, jumping
2) Manipulative Skills
· fine motor skills (eating, writing, drawing)
· gross motor skills (throwing, catching, kicking, dressing)
3) Balance
· static or dynamic
Lateralization
· Dominant handed/footed
· Preference by age 4
Cognitive Development
· Birth to 2yr: sensorimotor driven
· Age 2-7 yr: Preoperational (classification, egocentric, avoids punishment)
FLACC Scale (pain scale)
· FLACC: face, legs, activity, cry, consolability
· Children 3& under who can’t self-report pain using faces or analog scale (unless cant verbalize pain)
· 2 pts per category, 10 pts max (high score is high pain)
·
Faces Scale (pain scale)
· Ages 3-7
· Happy face = no pain, sad face = pain
· Scale from 0 (no pain) to 10 (hurts worst), score greater than 3/10 requires action
Major Motor Development Miletstones / Locomotor Sequence (Fundamental Skills, Age 1-7yr)
1) Walking
2) Running
3) Galloping and jumping (vertical bounce)
4) Jumping (broad/standing long/2 feet)
5) Hopping (1 foot)
6) Skipping
Basic Communication with children
· Age 1 & under (pre-verbal)
- use parents
- use infant talk
- expect only 2-3 words (low verbal communication)
· Ages 2-5 (pre-school):
- use play
- 1:1 instructions
* FLACC Scale for ages 3 & under
· Year 5-7 (school-age)
- simple sentences
- can express needs
- game-like activities
- multi-step instructions can begin
-group instructions
* Faces Scale for ages 3-7
Dynamical System and Constraints of motor skill development
· Development emerges from interactions among constraints (environment, organism, task)
Fundamental Skills Development and underlying systems impact
· Cardiopulmonary:
- smaller SV
- HR: 120 to 90 BPM
· Lungs:
-small airways
- RR: 22- 35 breaths/min
· MSK:
- flat/inverted feet, knee varus (age 2)
· Knee VALGUS (3-4 yo)
- excess lumbar lordosis
- plantar arch developed by age 4
· NS myelination
- injury at young age could present w/ deficits later in life
- overinclusive (take in a ton of information but cant process/focus it all, thus cant dual task and hard to grab attention)
· Visual Perception
- know what something is
* PT: simple, grab attention, use bright colors
· Proprioceptive Awareness (still developing):
- clumsy
Overinclusive and PT job
· Overinclusive: taking in a lot of information but unable to process/focus on specifics
* PT Job: get attention for instructions bc kids are easily distracted
Qualitative vs. Quantitative Methods of Movement
· Qualitative (movement PROCESS/ how it’s happening):
- components
- sequences
*coordination
(ex: accuracy and precision of throwing a ball)
· Quantitative (movement PRODUCT/outcome):
- result
- distance/height/speed
- completed vs not completed
*performance
(ex: how far they can throw a ball)
Peabody Developmental Motor Scale (PDMS-2)
· Ages birth/18 mo - 5 yo (but best to use AIMS for 0-18mo)
· BEST for 18mo- 5 yo
· Identifies atypical/delays in development
· Product (amount) > Process (form)
Developmental Expectations of Context Specific Period (Ages 7-11)
· Learning to control skills and combine movements (ex: Control- terminating mvmnt, Combine- throwing a baseball)
· Learning cognitive strategies for movement
· Learning culturally appropriate motor skills
Individual Constraints impact on skillful movement (Context Specific Period)
1) Structural: rate of change
- structure and size of body (physical)
- changes in myelination, synaptic connections, experience driven connections (perceptual-cognitive dev.)
2) Functional: how they can use their environment
- strength (physical)
- cardiovascular efficiency
- Aerobic vs anaerobic power
- Norms vs consequences (perceptual-cognitive dev.)
* Experience driven
Over-exclusive Attention
· Begins to dominate during context specific stage
· Hyper-focus on one thing
Bruininks-Oseretsky Test of Motor Proficiency -2 (BOT-2)
· Ages 4- 21
· Discriminative and evaluative (can discriminate between different levels/concepts and can evaluate if someone is delayed/behind in development)
· 7 items
Memory (declarative/explicit vs procedural/implicit) and Implications for teaching patient (7-11 yo)
· To build verbal (declarative/explicit):
- teach back strategy
- positive feedback
· To build motor (procedural/implicit):
- increasing reps
- pt explain as performing
How to work with children ages 7-11 (fundamental skills level)
· Be authority figure
· Interact directly
· Explain why
· Challenge them but allow success
· Understand what motivates them, use that to offer rewards
High Tone Vs Low Tone in Children
· High Tone appears more rigid/stiff
· Low tone appears more flaccid
Supine to Standing Movement Differences between beginner vs advanced
· Beginner:
- UE: push and reach to bilateral push
- Trunk: FULL Rotation
- LE: jump to squat
· Advanced:
- UE: symmetrical reach
- Trunk: NO rotation
- LE: symmetrical narrow based squat with balance step
Initial conditions of newborn vs 5mo old
Newborns have greater flexor tone (initial conditions) and use head and arms to initiate, momentum carries to other side
Gross Motor Subtests of PDMS vs BOT-2
1) PDMS
· Reflexes
· Stationary (push ups)
· Locomotion (walking down stairs)
· Object Manipulation (throw ball at target)
2) BOT-2
·Bi-lateral coordination (jumping jacks w same sides synchronized, tapping feet and fingers w same sides synchronized)
·Balance
·Running speed and agility (stationary/side hop, shuttle run)
· Upper Limb Coordination (dribbling a ball, throwing at target)
· Strength (wall sit, push up, sit up)
Fine Motor Subtests of PDMS vs BOT-2
1) PDMS
· Grasping
· Visual-motor integration (building tower)
2) BOT-2
· Fine Motor Precision (filling in shapes)
· Fine Motor Integration (copying shape)
· Manual dexterity (placing pegs into pegboard, sorting cards, etc)
PDMS Scoring
· 0-2 pts per subtest (0= did not perform correct, 2= performed correctly)
· Score of 3 “0’s” in a row = ceiling (bc not going to do any better on following tests)
· Score of 3 “2’s” in a row = basement
Expectations of Context-Specific vs Skillful Period
· Context-Specific: COMBINE mvmnts and control skills
· Skillful: COORDINATE and control
Motor Tests
1) APGAR (birth)
2) AIMS (0-18mo)
3) FLACC ( 3 and under)
4) FACES (3-7 yo)
5) PDMS-2 (birth/18mo - 5 yo) (best to use AIMS for 0-18 mo)
6) BOT-2 (4-21yo)
Developmental Expectations for Skillful Period (11+)
· Biomechanically efficient coordination (energy conservation)
· Control of coordination
· Variety of contexts (kicking ball in multiple planes and lengths, penalty kick vs corner kick)
· Automation, do 2 things at once
Developmental Differences between sexes regarding skills requiring Power (force/time) vs Balance
· Power: hormonal (estrogen/testosterone affects FORCE) and cultural influences (nutrition) attribute to males having greater power than females
· NO difference in balance between sexes
Constraints affecting movement (skillful period, ages 11+)
1) cognitive and moral (conventional/external ethics to post-conventional/personal ethics) development
2) Body Parameters
3) Problems of adolescence and puberty
4) Task and environmental constraints
Cognitive Development for motor periods (fundamental, context specific, and skillful)
1) Fundamental: pre-operational (classification NOT conservation/logical thinking)
2) Context-specific: concrete operational (ex: kick ball hard on playground but soft inside house)
3) Skillful: formal operational/abstract thinking
Physical Inactivity and Sedentary Death Syndrome (SeDs)
· Physical inactivity is a leading cause of disease and death
· Half of adults over 18 meet guidelines for aerobic physical activity
· 1/4 of adults over 18 meet guidelines for aerobic and muscle strengthening activities
Senescence
Damage, harm, loss, fragility, or failure associated with aging systems (slow, progressive decline)
Theories of Aging
1) Primary (Genetic Theory): internal causes, genetically determined
· Hayflick Limit theory- limited number of times a cell can divide
2) Secondary: external causes and damage systems
· Weak and Tear Theory
· Cellular Garbage/Mutation theories
· Immune Systems Theory: body loses ability to fight infections
· Hormonal Theory: loss of hormones
Models of Aging
1) Linear Decline: inevitable decline
2) Catastrophe: neuronal function remains optimal w/ aging unless disease occurs and causes a decline in function
Physical Stress Theory (Successful vs Non-successful aging)
· Successful Aging: higher stress tolerance
· Non-Successful: lower stress tolerance
MSK System Changes with Age
· Age 30: 1% strength loss/ year or 10%/decade, 40% decline in force generation follows
· Type I and II fibers decrease, protein synthesis decreases, harder to build muscle
* TYPE II DECREASE FASTER THAN TYPE I
· Strength and Power are important for function
Type I vs Type II (A and B) Muscle Fibers
· Type I:
- slow twitch
- endurance
*ex: distance runners
· Type II A:
- fast twitch
- strength/power
*ex: sprinters
· Type II B:
- FASTEST twitch (fatigues quickest)
- power
*ex: sprinters
* Type A can be converted to Type B
Sarcopenia and Diagnosis Requirements
· Age-related muscle mass loss
· Diagnosis Requirement: low muscle mass AND low strength OR low physical performance
What age do strength and force begin to decline
Age 30, accelerates around age 50
Normal vs Pathological Skeletal system changes with Aging
· Normal: collagen fibers and synovial membranes degrade, synovial fluid decreases
· Pathological: degenerative joint diseases (osteoarthritis)
Normal vs Pathological Nervous System changes with Aging
· Normal:
- M1 and S1 lose neurons
- reduction in nerve conduction velocity resulting in DECREASED MVMNT FLUIDITY AND INCREASED PROCESSING TIME
* BG AND BRAINSTEM REMAIN STABLE
How do nervous system changes with age affect cognition?
· decreased processing speed
· decreased accuracy
· shortened attention span
Normal CV system changes with aging
· decline in HR and aerobic capacity
· Increased stiffness of heart and vascular tissues
Presbyopia (“aging eye condition”)
· Visual System normal aging
· hardening of lens and flattening or cornea, hard to focus on close objects
Presbycusis
·Auditory system normal aging
· sensorineural hearing loss
· Difficulty hearing high pitch
Presbyastasis (“disequilibrium of aging”)
· Vestibular System normal aging
· Inability to use vestibular cues fo postural control (ex: standing w eyes closed on foam pad)
Somatosensory Pathological Change with Aging
· Diabetic Peripheral Neuropathy: sensory changes in distal extremities due to nerve damage by high blood sugar
Hyposmia vs Hypogeusia
1) Hyposmia: diminished sensitivity to SMELLS
2) Hypogeusia: diminished sensitivity to TASTE
Main Motor Control and Functional Changes in Aging Adults
1) Balance
2) Gait
3) Transfers
4) Reaction Time
5) Eye-Hand Coordination
6) Bilateral Activities
7) ADL’s
Mobility Skills Loss with Aging
1) Postural Control (balance): increased sway, decreased anticipatory
- results in INCREASED FALL RISK
2) Gait: shorter step, increased cadence, increased ankle eversion, decreased ankle ROM
3) Reaction Time: increased, LE > UE
4) EYe-Hand Coordination: increased manipulation time, decreased hand dexterity
Basic Activities of Daily Living (BADL) vs Instrumental Activities of Daily Living (IADL)
1) BADL: bathing, dressing, feeding, toileting
2) IADL: transportation, meal prep, housework, phone usage/basic communication
- Most functional bi-lateral movements require NON-SYMMETRIC actions of each hand
Frailty Criteria to be a Clinical Syndrome
- Frail: Must meet at least 3 of the criteria
- Prefrail: 1-2 criteria
1) Unintentional weight loss
2) Low grip strength
3) Self-reported exhaustion
4) Slow Gait
5) Physical inactivity
Routine Exam Questions for Patients 65+
1) Have you fallen in the last year?
· Amount?
· Injured?
2) Do you feel unsteady when standing or walking?
3) Do you worry about falling?
- If yes to any questions then pt is considered to be at increased fall risk
Cognitive Changes of Normal Aging
1) IQ: remains steady through adulthood
2) Crystallized Intelligence: gradually increase through adulthood (acquired knowledge)
3) Fluid Intelligence: peaks during adolescence, declines rapidly during adulthood (ability to think on feet/mental speed, problem solving, spatial manipulation)
Dementia and Criteria (Cognitive Pathological Changes of Aging)
· Memory and language affected
· Criteria: multiple memory deficits and AT LEAST ONE of the following
- Aphasia: loss of expressing or understanding speech
- Apraxia: loss of ability to perform purposeful actions
- Agnosia: loss of sensory processing, such as recognizing sound/faces/objects
- Executive Functioning disturbances
3 Types of Dementia and Parts of Brain Affected
1) Alzheimer’s Disease (most common)
· Memory loss followed by language
· Atrophy and shrinkage of brain tissue
2) Vascular Dementia: multiple small/large strokes
3) Lewy Body Dementia: mimics PD symptoms
· Parts of Brain Impacted:
1) Frontal Lobe: executive/impulse control
2) Temporal Lobe (L>R): language
3) Hippocampus: memory
4) Occipital Lobe: vision (peripheral vision impacted, approach pt from FRONT)
7 Stages of Dementia: Global Deterioration Scale (GDS)
1) No memory deficit
2) Begin masking cognitive issues
3) Denial, begin getting lost in unfamiliar locations
4) Poor safety awareness, poor historians
* LAST STAGE TO TEACH WALKING W DEVICE, INCREASED FALL RISK
* PT should use VISUAL CUES
5) No safety awareness, tunnel vision
* PT should frame sessions similar to activities pt enjoyed in past
6) Increased fall risk due to shuffled gait and decreased step length, dont recognize objects, no fine motor
7) Dependent with ADL/s and all functional activities
* PT should consider positioning, skin integrity, weight, and preventing contractures
Functional Mobility Tests
1) Functional Reach
· balance
· stability in fwd direction
2)TUG (standard, cognitive, manual)
· Mobility and balance
3) Chair Stand (30 second and 5x STS)
· 30 Sec: strength and endurance
· 5x STS: strength and function (and power{force/time})
4) Romberg (Standard, Sharpened, Challenged)
· STATIC balance
· proprioception, balance, and NMR pathologies
· Standard: feet together (EO, EC)
· Sharpened: tandem/heel-toe (EO, EC)
· Challenged: tandem with cervical rotation
5) 10 Meter Walk Test
· Gait speed
6) Four Square Step Test (FSST)
· DYNAMIC balance
7) Grip Strength
· hand strength
8) Box and Blocks Test
· UE function (gross and fine motor)
· Good for stroke pts
9) 9 Hole Peg
· Visual-motor coordination (UE speed, intrinsic hand muscle control, visual perception)
10) Sequential Finger-Thumb Test (EO and EC)
· Coordination (all ages)
Communication with older adults
1) Allow extra time for processing
2) Sit face to face
3) Speak slowly
