PEDIATRIC CONTENT Flashcards
Pediatric Assessment Considerations
Wholistic Approach essential
interdependence of musculoskeletal and nervous system necessitate assessment of status of both systems to accurately identify primary problems of the MS system
Comfortable, non-threatening environment
social and physical context will significantly influence the child’s performance
Physiologic status will influence muscle tone
state of arousal
sympathetic/parasympathetic balance
History-taking/subjective info gathering
comprehensive history important
parent usual reporter/ child input may vary but pertinent questions should be referred to child
when managing both acute and chronic musculoskeletal concerns understanding child’s and or parents goals is essential
Hypotheses oriented pediatric-focused algorithm (hop-FA)
History or gathering cont
- onset or history of presenting complaint
- if pain is present, what aggravates or alleviates it
- If acute onset, ask how postyre or activity level has changed since onset of the problem
- Evaluate quality of movement, not just the ability to perform the task
- Review related pertinent medical history
- It may be helpful to have the parents describe a typical day for their child
- during history, begin observations of child’s typical motor behaviors such as postural alignment, asymmetries, spontaneous movements, types of play behaviors, interaction with parents
- Question parents/child about challenges with performance of age appropriate functions abilities
- Inquire about participation in sports, physical education, recreatioal activities, hobbies
There is a decision making protocol.
We are habitual with patients in the pediatric population. You have to think about how your treatment will affect them as they continue to develop..not rehabilitation…habituation.
What do we focus on with children?
We focus on what they can do, not what they can not due…then we use what they can do to treat and overcome their difficulties.
As anomalies/abnormalities are identified…
every effort should be made to identify strengths/highlight abilities
Always try to obtain best performance!
Observation skills are critical
Pediatric PT’s must rely equally on what they hear, see, and feel
Children have limited attention span
Must gain multiple pieces of info from single task
Inspection/Palpation/Measurement
You have to look/feel and listen at the same time! You have to remember how the child presents to document and also to know how to preogress/regress.
- to obtain the attention of the child turn the exam into a game whenever possible
- Exam should be a positive experience
- often remove clothing to permit visual inspection of alignment, measure ROM, assess strength and endurance, identify atrophy and joint effusion
Postural
Screen
Should assess skeletal alignment in a variety of positions
Skeletal alignment should include
spinal alignment
saggital plane & posterior view
examine kyphotic/ lordotic curves
assess for lateral curvature/ rotational deformity of the spine
Play?
As you are engaging the child in activity you are noticing the development and skeletal behavior of the child.
Postural Screen Continues
•Symmetry of shoulder, scapulae and pelvic height alignment of hip, knee, and ankle
- asymmetries in rib position, such as rib hump, would indicate a rotational deformity of the spine
- Limb length should be assessed in both a weight-bearing and non-weight-bearing position
What ways can you assess postural alignment
Foward Bend
Plumb Line
Wall Grid
How do we evaluate postural alignment and movement patterns?
WIth and without adaptive equipment
Learn to distinguish between normal maturational physiologic changes and pathology
- progressive decrease in mefial femoral torsion throughout childhood to 8-16’
- shift from medial tibial torsion at birth to apprx 25’ of lateral external tibial torsion by maturity
- genu varum to genu valgus (3-4 yrs) to neutral (6’)
- calcaneal varus to calcaneal valgus to relative neutral
Assessing Range of Motion on a child
• Must appreciate physiologic / ethnic variations in joint laxity
—degree of joint laxity diminishes with age
——-mean popliteal angle with hip flexed to 90’
——-external rotation of hip decrease
Asian more lax than European than blacks
Range of Motion
Goniometric techniques for AROM & PROM same as adults
Age related differences in rotational and angular measures must be take into account
physiologic neonatal hip flexion contractures
genu varus/valgus; tibial torsion; femoral antiversion; coxa varus
Muscle length tests should also be included in the overall joint motion assessment
For accurate ROM
ensure that the child is relaxed and calm
move slowly to avoid
eliciting stretch reflex in children with increased muscle tone
avoid pain response
risk of injuring brittle bones
Assessing strength in children
assessment strategy varies with age
children younger than 3 years of age
—accomplished through observation of movement anf function
Muscle grades assigned when testing infants, toddlers and preschool aged children
Functional(F) --Normal for age or only slight impairment or delay Weak Functional (WF) Non-Functional (NF) No function(0) --cannot do activity
How to use observational method
…
MMT
may be used as soon as child can follow directions-usually by age 5
- -child must be able to understand instructions
- -may choose to test functional muscle groups
MMT
has some inherent weaknesses with children as well as with adults
—may not accurately identify strength deficits<50%
Dynamometer
Dynamometer or isokinetic testing equipment may be used as soon as the child's size permits accurate placement of equipment Handheld dynamometry (HDD) has proved reliable and sensitive in a variety of pediatric populations
Lower Extremity Alignment
Rotational and angular values important
rotational profile
—foot progression angle
——angle between the longitudinal axis of the foot and the line of progression of the child’s gait
–Hip Rotation to determine femoral torsion
——check medial and lateral
Thigh-Foot angle
assessed in prone, knee flexed 90’
- measure bisection of axis of thigh & axis of foot
- determine rotational variation of the tibia and indfoot
- —–positive—foot is out toeing
- —–negative:foot is intoeing
Transmalleolar Axis
mmm
Staheli’s Totational Profile…
…
Bla bla bla I got behind she started going off on a fast tract because of time…like she can cover 7 more pages in 20 minutes
lol…
Physiologic Indications of Acute Pain
Autonomic Nervous System–overdrive
Dilated Pupils Increased Perspiration Increased rate /force of heart rate Increased rate/depth of respirations Increased blood pressure Decreased Urine output Decreased peristalsis of GI tract Increased basal metabolic rate
Possible Behavioral Manifestations of Pain in young Infants
Vocalizations:
crying (often with apneic spells)
whimpering, groaning, moaning
State Changes:
Changes in sleep/wake cycles
Changes in activity levels
agitation of listlessness
Gross body movements: limb withdrawal, swiping, or thrashing rigidity flaccidity clenching of fists
Facial Expression (most reliable behavioral sign): eyes tightly closed or opened mouth opened, squarish furrowling or bulging of brow qulverving of chin deepened nasolabial fold
Observe for Specific Behaviors that Indicate Local Body Pain
Pulling Ears Rolling head from side to side Lying on side with legs flexed on abdomen Limping Refusing to move a body part
Pain Indicator for communicatively Impaired Children (PICIC)
Most common cues identified by 67 parents screwed up or distressed looking face crying with or without tears screaming, yelling, groaning, moaning stiff or tense body difficult to comfort or console Flinches or moves away if touched
