Exam and Eval of Atypical Development Flashcards
Describe the posture in a 4-month-old infant with severe L Torticollis.
Which muscles are shortened?
L SB / R rotation
SCM / Scalenes / Upper Trap / Levator Scapulae / shortened
SCM is main contributor!
T or F: Atypical development may start out just as typical development does.
T
Many typical components are missing
What do babies do as a result of the missing components associated with atypical development?
They compensate
These compensations soon become pathological and cause abnormal / atypical movement postures and patterns
What should you think if a child only recently began walking on their toes?
RED FLAG
What questions can you ask when obtaining a Developmental History?
Achievement of Specific Milstones - When did the child start sitting / walking?
How long have they been walking on their toes?
Chronological / Adjusted Age
Observed Level of Function (fine and gross motor, ADLs)
Does info make sense with established dx or referral concerns? - Clinical Picture
The quality of ___ may provide an indicator of the chronic neurological condition of the fetus.
fetal movement (“Did you feel baby move?”)
Overall quality of pregnancy - high BP (preeclampsia) / placenta avulsion
What aspects of a child’s chart should you consider beforehand?
Age (select appropriate toys / testing items ahead of time)
Diagnosis
Primary Concern (what do you expect to see - Clinical Picture)
Essential Elements of History (Overall)
General Demographics - age (chrono and corrected) / gender / diagnosis
Social History and Living Environment - pt lives with who and where? / does what?
Employment - job / school / play
Developmental History
Important Aspects of PMH
Reason for referral
Primary dx / comorbidities
Functional Status and Activity Level
Medications
Prior clinical tests / surgeries
Maternal pregnancy / birth history
Family hx
General health status
Health habits
Systems Review (Examination)
Cardiopulm / Integumentary / MSK / Neuromuscular / Vision, Hearing, Cognition
Communication Skills / Affect / Cognition / Language Abilities / Learning Style
Systems Review Findings
May affect patient management process / narrow focus of tests and measures
May identify need to refer patient to other providers
Tests and Measures:
Skeletal Exam
Muscle Function
Skeletal Exam: Anthropometric Characteristics / Joint Integrity and Mobility / Posture / ROM
Muscle Function: Muscle Performance (Strength / Power / Endurance)
Tests and Measures:
Reflexes
Movement: Frequency / Pattern / Control
Reflexes: Presence or absence of Primitive Reflexes
Movement: Gait / Locomotion / Balance / Motor Function (Motor Control / Learning)
Tests and Measures:
GM / FM Functional Skills
Skin and Sensation
GM / FM: Motor Function / Neuro-Motor Development / Self- Care and ADLs / Work (job / school / play)
Skin: Integrity / sensory / pain
Tests and Measures:
Equipment
General Observations
Equipment: ADs / Orthotic, Protective Devices (how old is the equipment?)
General Observation: Aerobic Capacity, Endurance / Arousal, Attention, Cognition / Circulation / Environmental Barriers / Ventilation, Respiration
Methods of Examination
ALL are important
Interview: Taking history from client / parents / caregiver
Observation: Naturalistic observation
Direct Handling
Essential Components of an Examination
Functional Skills
PROM (key for ITW) / AROM
Muscle Tone
Skeletal Alignment (Posture)
Balance / Postural Control
Muscle Strength
Quality of Movement
Primitive Reflexes
Pain
Functional Skills (Examples)
Developmental Milestones
Methods of Play
ADLs
AROM: Assess through play
Gait
Perseveration (Definition)
The inability to stop activity when appropriate
e.g., Red Light, Green Light
Eye Dominance
3-4 years
Typically established by age 6
Ask child to look through kaleidoscope / camera window / toilet paper roll - will often hold up to dominant eye
Hand Dominance
3-4 years
Usually established by age 4-6
May change hands during early years as child is learning how to perform differing tasks / activities
Leg Dominance
~3 years
Typically established by age 6
Modified Ashworth Scale (MAS) Grading
0 - Normal tone (no increase)
1 - Slight increase in tone / catch and release or minimal resistance at end range flexion, extension
1+ - Slight increase in tone / catch followed by minimal resistance at end range
2 - Increase in muscle tone throughout most of the range / affected parts easily moved
3 - Considerable increase in tone / passive movements difficult
4 - Affected part rigid in flexion or extension
Ankle Clonus Grading
0 - Absent
1 - Un-sustained (a few beats at a time)
2 - Sustained (continuous beating)
3 - Spontaneous / light touch provoked and sustained
DTR Grading
0 - No reflex jerk
1 - Lower than normal reflex
2 - Normal reflex
3 - Higher than normal reflex
4 - Exaggerated reflex + clonus
At what age can you start MMT?
Not attempted before the age of 5
Typical 8-year-old should be able to follow basic MMT’ing direction
FLACC Observation Scale
Used w/ infants, preschoolers, and non-verbal children (to assess pain)
Face / Legs / Activity / Cry / Consolability - each category scored 0 to 2
Higher overall score = increased severity of pain
Wong-Baker Faces Pain Rating Scale
Ages 3+
Verbal Analog Scale
Ages 10+
Asked to describe pain on a scale of 0 to 10
0 - None / 2 - Annoying / 4 - Uncomfortable / 6 - Dreadful / 8 - Horrible / 10 - Agonizing
What are the two general types of diagnoses?
MSK Diagnoses
Neuromuscular Diagnoses
Prior to initiating PT for CMT, what MUST be done?
We would need to rule out Non-Muscular Torticollis (can be related to serious conditions - Cervical Rib / Cataracts)
Which SCM is tight in the case of Right Torticollis? How would the infant’s posture look in this case?
R SCM is tight
R Lateral Flexion (SB) / L Rotation
Comprehensive treatment of CMT includes a screening for ___ due to the association between CMT and ___.
hip instability, DDH
What value of asymmetry related to hip abduction ROM may be indicative of hip dysplasia?
5-10 degrees
Tumors (thickening or lump) in the SCM area due to CMT usually resolve by when?
12 months of age
In the case of CMT treatment, the prognosis is better if the infant is treated at what age?
BEFORE 1 year
What is key in the process of providing conservative treatment for CMT?
A comprehensive home program - exercises / ROM that are comfy for children and caregivers
In the case of conservative CMT treatment, when are WS activities on a ball / lap effective?
After / around 3-4 months
Plagiocephaly (Definition)
Misshapen head
Brachycephaly (Definition)
Flat head
Type of Plagiocephaly
Scaphocephaly (Definition)
Elongated head
When does the Posterior Fontanelle usually close?
1-2 months
When does the Anterior Fontanelle usually close?
7-18 months
Why is it better to provide an infant with a cranial orthosis earlier in life?
Once fontanelles close, the orthosis can no longer help mold the skull
Is Developmental Dysplasia of the Hip (DDH) always visible at birth?
No!
Hip may have been / appear to have been typical at birth before dysplasia was found later
What mechanical factors are thought to predispose infants to DDH?
Small intrauterine space
Breech position
Fetal hip against mother’s sacrum
What physiologic factors are thought to predispose infants to DDH?
Maternal hormonal influence of estrogen and relaxin
What environmental / cultural factors are thought to predispose infants to DDH?
Strapping of children’s LEs in extension - Cradle Board (Eskimo / Native American cultures)
What is the gold standard for confirming hip dislocation?
Ultrasound
What is the most consistent clinical sign of Hip Dysplasia in neonates?
Hip abduction limitation / asymmetry
5-10 degrees difference in ROM of hip abduction can be a sign
In addition to CMT, what other bony abnormality is associated with DDH?
Metatarsus Adductus / Calcaneovalgus
Types of DDH (Newborn)
Typical and Stable
Subluxable
Dislocatable
Dislocated and Reducible
Dislocated and Not Reducible (most severe)
Pavlik Harness
DDH treatment in infants less than 3 months old
Puts hip into position of flexion / abduction and restricts hip extension / adduction
Closed Reduction and Spica Cast
DDH treatment in infants aged 3-6 months
Considered if ~3 week trial of Pavlik Harness not successful in reducing a dislocated hip
Pavlik Harness (Complications)
Avascular Necrosis
Femoral Nerve Palsy
Inferior dislocation
Surgical treatment is usually required for dislocated hips between ___ and ___ months of age.
6, 18
Diagnosis of hip dislocation in children aged 2 or older is generally considered to mandate what type of surgery?
Open Reduction
Older children with continuing Acetabular Dysplasia may benefit from what procedure?
Pelvic Osteotomy
Remodeling potential of Acetabulum decreases with age
