Pediatrics Test 1: Lecture 2 Flashcards
things to keep in mind when performing a neuromuscular peds exam
be diligent with following new tests/measures
need a detailed knowledge of typical motor development
exam/interventions should be based on developmental model
things to keep in mind when considering a peds neuromuscular intervention
intervention should focus on age appropriate functional motor behaviors; don’t necessarily have to stick to strict developmental sequence (i.e. don’t have to crawl before they walk)
assess impairments in body structure to determine reasons for activity restrictions
major intervention goal = improve motor ability and participation in home, school, and community
when testing a kid’s motor behaviors when they have a neuromuscular condition they can be variable. This can be attributed to what factors
fluctuating/abnormal mm tone
poor motor coordination
medications
factors related to fatigue, age, behavior, pain, attention, etc
testing considerations with neuromuscular exam in kids
test items may need to be repeated in a single session and again in later sessions to determine the most common behavior
kid may have concomitant deficits and/or emotion/behavior problems - may be hard to determine if these things are also affecting motor behavior
kids with neuromuscular disabilities are organized by testing categories; these include what
age range for tests and recommended use based on 3 major testing purposes (discriminative, predictive, and evaluative)
impairement of body structures and functions within diagnoses varies greatly and depends on
location
severity
age at time of injury
motor behaviors kid learns to use
practice
available support
what is mm tone and how does it relate to kids with NM disabilities
active mm contraction
readiness to move
kids with NM disabilities can be hyper or hypo
can fluctuate resulting in involuntary movements like athetosis and ataxia
what intrinsic changes are related to hypertonia
contracture of collagen tissues
decrease in viscoelastic properties of mm tissue
collagen accumulation in mm
changes in mm fibers (atrophy; especially of type II)
decreased force production in mm cells
what happens when there is a decreased facilitation of polysynaptic reflexes and what might a kid do to compensate
may result in weakness and pareis during movement in individuals with hypertonia
kid may compensate by using co-contraction to create sufficient tension for postural control and movement
sx/drug interventions to help with hypertonia
goal = lower excitation in motor neuron pools
selective dorsal rhizotomy
intracathecal or oral baclofen
botox
what happens once spasticity is reduced via sx or meds
normal movement does NOT automatically emerge
underlying secondary MSK changes ,weakness, and contractures can still impede movement in addition to learned motor patterns
learned motor patterns also do not disappear once the spasticity is removed; it’s important to understand under what conditions sx/meds are best and will be most effective
examples of standardized assessments in infants
Harris Infant Neuomotor Test (HINT)
Test of Infant Motor Performance (TIMP)
Alberta Infant Motor Scale (AIMS)
infant standardized tests that help predict the likelihood of CP
TIMP
General Movement Assessment (GMA)
Hammersmith Infant Neurological Examination (HINE)
developmental tests for older children typically look at what types of factors
complex balacnce/coordination
SLS
hopping
gallop
jump patterns
skipping
fine and gross motor
examples of assessment for young kids
Bayley Scales of Infant Development
Gross Motor Function Measure
Peabody Developmental Motor Scales, 2nd edition
moderate to good reliability - might be used for discriminative, evaluative, and predictive purposes
what is one of the few tests of motor performance that is for older kids ages 4-21
Bruininks-Oseretsky Test of Motor Proficiency
functional tests that examine child’s activity and participation levels
pediatric evaluation of disability inventory (PEDI)
PEDI computer adaptive test (PEDI-CAT)
childhood health assessment questionnaire (CHAQ)
clinical observation of motor and postural skills (COMPS)
goal attainment scaling (GAS)
school function assessment (SFA)
what is the timed obstacle ambulation test
TOAT
obstacle course tha requires the child to move across different floor surfaces; step up, down, over; duck under obstacles; negotiate through turns and narrow path
testing conditions for the pediatric clinical test of sensory interaction on balance (P-CTSIB)
- eyes open normal surface - vision, vestibular, somatosensory available
- eyes closed normal surface - no vision
- dome normal surface - compromised vision
- eyes open foam surface - somatosensory compromised
- eyes closed on foam - no vision; compromised somatosensory
- dome, foam surface - vision and somatosensory compromised
youngest survivable gestational age
22-25 weeks
when in gestation are major brain structures present
24 weeks
lack of O2 to brain can result from minor stress to infants system
hypoxemia
decrease in amount of oxygen in blood
often occurs with ischemia
ischemia
decreased vascular perfusion to a tissue bed such as the brain
often occurs simultaneously with hypoxemia
asphyxia
most severe lack of O2
“without pulse”
prolonged = results in hypotension and ischemia causing cellular death - usually leads to permanent disability
major brain areas involved in movement generation and control
subcortical nuclei
cerebellum
cortex
basal ganglia
things that can cause CP
unknown genetic alterations causing neurological malformations
lack of O2 at or around birth or during early development
insults/trauma to head
what is selective neuronal necrosis
in full term infant = neuronal injury with characteristic pattern in CNS
early neuronal changes occur within 24-36 hours of injury
signs of cell necrosis within several days
over next several weeks - macrophages will consume necrotic cells
with severe lesions, a cavity may form in cerebral cortex that becomes a fluid filled cyst
what is CP
most common peds disability
general term for CNS insult
gross motor classification system (5 levels)
characteristics of CP
primary CNS disorder; motor disabilities due to early damage of brain in areas controlling motor behaviors
characteristic ortho impairments associated with a GMFCS level such as scoliosis or hip dysplasia
kids with CP often have more variability in the size of mm fibers, type of mm fibers/composition, atrophy, decreased vascularization, increased extracellular space, and increase in fatty and connective tissue deposit in mm
do CP lesions progress
no
sequelaw may vary as child ages as a result of the development of atypical motor habits used by the child to compensate for poor motor/posture control and motor learning deficits
how are kids with CP classified
- distribution of motor disability
-quadraplegia = all limbs involved
-hemi = one side
-diplegia = primarily LEs - type of mm tone or motor control disorder
- spastic = exaggerated reflexes with abnormal patterns posture/mvmt
- dyskinetic = atypical patterns of posture and involuntary uncontrolled reoccuring stereotyped mvmt
-dystonic = involuntary, sustained, intermittent mm contraction with repetitive mvmt and abnormal posture
- athetosis = slow continuous writhing movements
- ataxic = inability to generate normal or expected voluntary mvmt trajectories not due to weakness or involuntary mm activity
- mixed = spasticity and dyskinesia
secondary to the brain insult, what other S&S are typical with CP kids
hearing impairments
sensory impairments
seizures
functionally = problems with sustaining postural control in prone, sitting, and standing; trouble with complex movements
wide range of limits/restrictions
what are hyperkinetic movements
unwanted excess movements
dystonia
in reference to hypertonia… increased tone not always present in dystonia
movement disorder in which involuntary sustained or intermittent mm contractions cause a twisting and repetitive movements and/or abnormal postures
chorea
on going random appearing sequence of one or more discrete movements or movement fragments
vary in timing, duration, direction, and body location
distinguish from dystonia by unpredictable and continuous nature of movement
distinguish from atheosis by presence of discrete movements within the continuing sequence of movement
tremor definition
rhythmic back and forth or oscillating involuntary movement about joint axis
relative symmetry in speed
can be resting, postural, or action tremor
intention tremor = cerebellar dysfunction; worsening when reach target; can resemble dysmetria
dysmetria
inaccurate movements leading to repeated over corrective attempts
ataxia
gross lack of coordinated movements that generally originates from damage to cerebellum
child with ataxia generally has normal strength and no hypertonia, but movements are jerky and inaccurate
can be limb, trunk, or gait ataxia depending on where the cerebellar lesion is
how to look at coordination of voluntary movements in kids
often difficult; requires complex computer equipment (measures kinematics, kinetics, and EMG during movements like gait and reach)
video based tech can measure duration, accceleration, and types of leg movement in infants; can see subtle differences in movement in kids to determine if movements are typical or atypical
clinical testing of the neuromuscular system to look at coordination of voluntary movements in kids with CP usually involves what
methods of observational analysis of motor coordination during balancing
i.e. therapist can place child on a movable surface, move the surface under the child, and subjectively grade the motor response caused by the perturbation
tests like this are informative but reliability is questionable
spine related problems in kids with CP
15% incidence of scoliosis
lack of stability and decreased amount of movement places child’s spine in atypical postures for prolonged periods resulting in flexible or fixed deformities
pelvis/hip related problems in kids with CP
result from bony abnormalities, alignment, and shape and mm abnormalities
hypertonicity around hip (common with spastic CP) of hip flexion, adduction, IR can lead to atypical posture, bony alignment, ROM limits, and hip dislocations
PPT often occurs with tight HS and results in trunk flexion
foot/ankle problems common with kids with CP
reduced DF = most common impairment (bc shortened gastroc)
inability to generate sufficient stability at ankle
child assumes PF position
interventions for kids with CP
provide WBing opportunities - promotes bone modeling and increased ROM
deficits in ROM change normal skeletal alignment and decrease fluidity and efficiency of movement (want to help ROM as best you can)
decisions to use AFO should be carefully considered and individualized to each child
tendon lengthening or transfers if ROM and splinting are unsuccessful
strength training; positive benefits in gait characteristics, endurance, and functional activities
describe the neurodevelopmental treatment
1940s; Karl and Berta Bobath
focus shift from ortho to neuro
sensory and motor impairments like abnormal tone interpreted as release phenomena controlled by lower centers of the hierarchical nervous system
skilled handling to reduce tone and facilitate normal movement
integrate current motor learning principles and emphasizes the goal of gradual reducing the reliance on passive handling techniques
little formal evidence on effectiveness
describe the sensory integration theory
Jean Ayres in 1960s
addresses the sensory processing and motor/perceptual deficits of kids with learning disabilities
states that motor learning is dependent on the ability to take in sensory info derived from the environment and from movement of the body, process and integrate these inputs in the CNS, and use this info to plan and produce organized behavior
describe the cognitive education theory
not considered a PT intervention but peds therapists may be involved
Andras Peto (Hungarian neurologist) developed in 1940s
holistic approach to development and edu of children with neuro dysfunction
not a therapy system but a system of edu that aims to teach kids to be active and self reliant participants in the world
evidence based treatment for CP kids
bimanual training
constraint induced movement therapy
context focused therapy
fittness training
strength training
goal directed training
home exercise programs
improve motor activity performance and cardiovascular endurance
kids with CP often use assistive devices
what is autism spectrum disorder
complex developmental condition
limits in social interaction, communication, and restricted or repetitive behaviors that interfere with a child’s ability to function
describe sensory abnormalities with ASD
between 40-90% of kids with ASD have them
95% have processing impairments
may be over-responsive to typical sensory input (hypersensitivity) or under responsive (hypo)
some kids have hypo and hyper at the same time
responses may fluctuate so interventions can be complicated
describe the rate of fine/gross motor defiicts in kids with ASD and how PT can help
63% of kids had decreased fine and gross motor skills (measured by peabody)
this qualifies kids for early intervention
PTs should be involved with screening kids in schools; often PT is underutilized
other S&S of ASD in kids aside from social skills
hypotonia
gait dysfunction
toe walking
decreased posture control
dyspraxia
what does evidence suggest could be an early predictor of ASD before specific dx signs occur
early motor delay
ways to help increase participation in kids with ASD
sensory integration
sensory based interventions
relationship based interventions
what is developmental coordination disorder
overall deficit in motor control and motor learning
specifically, lack of predicted control of movements described as internal modeling deficits
interventions for developmental coordination disorder
task specific interventions based on motor learning principles
neuromuscular task training which accentuate the use of augmented feedback for learning, memory cues, and practice in varied environments
fitness activities and karate have good research
what is cognitive orientation to daily performance and what is this intervention often used for
often used to improve motor performance in kids with DCD
focuses on increasing performance of child using a problem solving approach with task specific strategies
explain what factors are important when collaborating with the child, family, and other team members of kids who have a DCD dx
- explain the nature of the disorder
- provide strategies for controlling sensory input to make learning more successful
- devise appropriate consistent behavioral consequences to support the child in trying activities
what do longitudinal studies on kids with DCD suggest
some problems may decrease with age but they usually do not disappear
describe the pathophysiology of down syndrome
most common chromosomal abnormality in kids; 90% have extra chromosome on chromosome pair 21
neuropathological differences:
- small/smooth brain (76% of normal) especially in frontal lobe
- small cerebellum and brainstem (66% of normal)
intellectual deficits can affect motor abilities
visual/vestibular deficits can affect postural control
common comorbidities with down syndrome
respiratory issues
GI issues
cardiovascular issues
endocrine issues
immune health problems
MSK issues
neurological issues
hearing loss
visual deficits
ortho limits
GU issues
sensory limits
describe the physiological structure difference of neurons in those with down syndrome
structural difference in spines of pyramidal neurons
lack of myelination of neurons in cortex and cerebellum
decrease neurons in hippocampus
increase in alzheimer’s neurofibrillary tangles with age
what are common reasons you may see a down syndrome pt in PT
short stature
pes planus
hip dysplasia
ligamentous laxity
patellar dislocation
low mm tone (hypotonus)
alantoaxial instability
ligamentous laxity
common problems that develop with adults with down syndrome (usually due to excessive wear and tear on joints)
patellofemoral instability
genu valgus
pes planus
hip instability
hypoextensibility of connective tissues in those with down syndrome results in what
decreased rebound of tissue
low mm tone in those with down syndrome usually has what affect
decreased effectiveness of stretch reflex because the proprioceptors are not at a hight state of readiness to respond
examples or recommended interventions for down syndrome pts may include
strengthening using resistive training
balance training
treadmill gait training
orthotic management
associated BMI issues = ongoing aerobic conditioning and promotion of wellness
orthotics that may be used with down syndrome
supramalleolar orthotics
used to improve postural stability and lower extremity alignment
prevent secondary deformities that can result from malalignment and overuse
** do not want to give orthotics before they are able to ambulate independently; may negatively impact child’s motor skill development
rates of TBI in kids
kids 0-4 have highest risk (due to fall)
children under 17 were among those most likely to sustain a TBI due to blunt force trauma by an object
what is a closed head TBI and what are the implications of this
occurs focally at point of impact and diffusely
reverberations occur to the brain within the cranium or shearing forces cause by initial blow
ischemic damage can occur after initial trauma if child stops breathing
what is cerebral edema (associated with TBI) and what are ways to manage it
occurs due to bilogical products leaking from dead cells
immune system products sent by body to combat damage and can destroy the remaining unharmed brain tissue if left uncontrolled
shunting and medication to releave ICP can improve outcomes
S&S associated with kids with TBI
show some cognitive, emotional, behavioral control problems
attributed to frontal and temporal lobes to shearing force damage
can include hyperactivity, distractibility, involving poor ability to filter out unimportant sensory stimuli in the environment
difficulty with visual perception
factors that glascow coma scale measures
eye opening
verbal response
motor response
interventions for kids as they are coming out of a coma following TBI
want active movement in response to passive ROM and sensory stimuli
sensory stimulation - cutaneous (brushing/tapping), auditory (talking/music), visual (use of lights and bright colored objects), gustatory (tastes), and olfactory (diff odors)
all of the above may trigger child to come out of coma
common impairments seen with kids post TBI
decreased balance and gait speed
increased step length variety
what is spina bifida
split spine
indicates that bony structures of the spinal vertebrae fail to close over the posterior aspect of the spinal cord at some level or levels during neurulation (around week 3-4 of gestation)
what is myelodysplasia
displacement of some tissue in a sac that protrudes through this posterior opening of the spinal vertebra
degree to which neural elements are involved in this protrusion and the level of the spinal cord affected define the severity of the loss of motor and sensory function around and below that level
what is spina bifida occulta (closed)
malformation of one or more vertebrae is malformed
most cases, this one does not cause impairments
what is a meningocele
a sac protrudes at spinal opening containing spinal fluid and meninges but no neural tissue
LMN damage is likely
what is a myelomeningocele
protruding sac contains spinal fluid, meninges, and neural tissue
treatment of a myelomeningocele and the pros/cons
in utero or post birth, protruding tissue is excised and spinal opening is surgically closed
at 26 weeks in utero:
pros = decreases need for postnatal ventriculoperitoneal shunting, hindbrain herniation, and improved motor function
cons = risk of ruptured membrane during pregnancy, preterm delivery, and unknown urologic function
etiology of myelomeningocele
unknown
thought to be a combo of genetics and environment
relationship between inadequate vitamins and folic acid intake in neural tube defects
how can open lesions of MM be detected
before birth
mother’s erum alpha fetoprotein levels
ultrasound
amniocentesis (more invasive)
S&S of spina bifida kids
mix of LMN and brain dysfunction
affects motor control learning and functional motor ability
51-65% of kids with myelodysplasia develop hydrocephalus
bowel/bladder problems common
visual deficits (especially if kid has hydrocephalus)
what is arnold chiari or chiari II malformation
brainstem is displaced inferiorly beyond foramen magnum
partial blockage of passage of CSF from brain to SC
likelihood of walking in kids with spina bifida based on location of lesion
thoracic and high lumbar lesions - kids may start walking; less than 20% still walking by 9 years
midlumbar level lesions = more likely to walk; 40-70% still walking by 9
sacral lesions = reach and maintain functional ambulaiton with ADs and/or orthotics
overall goals for intervention with kids with spina bifida
- strengthen innervated mm and teach compensatory movement patterns and posture control necessary for kid to achieve functional movement
- prevention of further MSK problems, LE contractures, OA, scoliosis, or pain
- prevent skin breakdown due to loss of sensation
interventions for spina bifida that do not have adverse effects
E-stim, exercise training, and motor skill training lead to improvements in strength with no adverse effects
how to determine the type of mobility that should be encouraged with kids with spina bifida
must be individualized to pt according to
- child/family desires
- social issues
- energy consumption for different types of mobility
-cognitive development
encourage assistance with early mobility; mobility development linked to some cognitive abilities (depth perception, cause and effect links, and object permanence)
describe brachial plexus injuries in kids and the general outcomes expected
at birth or in older kids after trauma
2 most common types: Erb’s palsy (C5 and C6) and Klumpke Palsy (C8 and T1)
good prognosis with early therapy for Erb
most kids recover triceps, biceps, deltoid, and wrist ext function by 6 moths
long term difficulty is likely if there is not significant recovery by 6 months
