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Pediatrics Study guide
Lecture #1 intro
Parents and families have the primary (central) role in their child’s development
 Supported through coordination of services, advocacy, and assistance to enhance the development
of their child through
o Positioning during daily routines and activities
o Adapting toys for play
o Expanding mobility options
o Easing transitions from early childhood to school and into adult life
o Adapting to families choice of settings: home, child care centers, preschools, schools and
job sites
Constructs and concepts that inform physical therapist practice
 Four major constructs and concepts inform current PT practice
o The ICF and biopsychosocial model
o EBP
o Profession values
o Quality assessment
 Principles of PT patient and client management
o Co management
o Consultation
o Direction and supervision
o Referral
 Model of function and disability ICF-enablement perspective
o Part 1: functioning and disability
 Body structure and function-impairments
 Activity
 GMFM 5 Dimensions
o Lying and rolling
o Sitting
o Crawling and kneeling
o Standing
o Walking, running and jumping
 Participation
 Family routines, caregiving routines, outdoor activities, learning, play,
in school activities, for life situations (restaurants, shopping)
o Part 2: contextual factors
 Environmental factors
 Personal factors
o ICF-CY (children and youth)
 confirms the importance of precise descriptions of childrens health status
 greater detail to encompass the body functions and structures, activities,
participation
 ICF-CY is from birth to 18 years of age-infants, toddlers, children and
adolescents
 ICF-CY was developed in a manner sensitive to changes associated with growth
and development
 Activities and participation for mobility
 Changing basic body positions
 Maintaining a body position
 Transferring oneself
 Lifting and carrying objects
 Moving objects with lower extremities
 Fine hand use
 Hand and arm use
 Walking
o
 Moving around and in different locations
 Using transportation
 Driving
Evidence based clinical practice
 Establishes the steps for intervention
 Examines the constituents of health and the effects of disease on the individual
 Provides a process for testing assumptions regarding the nature and cause of
motor control problems
 Suggests essential elements to examine and treat
 Emphasized the integration of research evidence, clinical expertise and patient
characteristics in clinical practice
 Evidence to practice
 Algorithms- written guidelines to stepwise evaluation and management
strategies
 Clinical practice guidelines- systematically developed plans to assist
in health care decision making for specific clinical circumstances
 Clinical, critical, or care pathways- predetermined protocols that
define the critical steps in exam eval and providing interventions
 Clinical prediction rules (CPR)- clinical findings are groups to help
with screening, diagnosing, or prognostications
 Clinical practice guidelines (CPG’s)
 Evidence based recommendations intended to optimize patient care
o Informed by a systematic review of the literature
o Include assessments of the benefits and harms of alternative
care options
o When coupled with clinical judgment and consideration for
patient’s preferences
 CPG’s reduce practice in variation
 Improve diagnostic accuracy promote effective
interventions
 Discourage ineffective or potentially harmful
practices
 Improve patient centered health outcomes
 Clinical reasoning in pediatric PT practice-is complex and critical
o Numerous patient specific variables that influence care
o Innate variability in the growth and development of children
o Identifying and considering contextual variables
o Directs a clinicians actions and decisions
 What is clinical reasoning
o The thinking and decision making of a health care provider in
clinical practice
o The thinking or judgment behind ones action
o Clinical decision making is the action on this process
o Complex and critical
o Numerous patient specific variables that influence care
o Innate variability in the growth and development of children
o Identifying and considering contextual variables
o Includes:
 Critical aspects of reflection
 Mutual decision
 Mutual decision making
 Patient context
 Though processes vital in clinical reasoning
 Discipline specific knowledge
 Metacognition
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 Reflective self awareness patient centered focus
 Development of expertise
o Clinical reasoning as developmental process
 Hypothetico-deductive (deductive reasoning)
 Hypothesis based upon results of test and measures
followed by testing this hypothesis
 Pattern recognition (inductive reasoning)
 Retrieval of information from well structured
knowledge based upon previous clinical experience
o Application of clinical reasoning skills in the classroom
and in the clinic
 Reflection on action
 Reflection in action
 Reflection for action
Issues influencing practice pediatric PT
o Advocacy
o changing health care delivery system
o family centered
o child abuse and neglect
o behavior management
o cultural practice
o natural environment
o early intervention
o defining educationally vs. medically based
Development: A study in contrasts
Why intervene early?
 Early brain development is primed for early learning
 Early experience through early intervention can shape the developmental trajectory
 Early intervention is the law
Development
 Motor control- control and organization of processes underlying movement
o Takes milliseconds
 Motor learning- acquistion of skill through practice and experience
o Hours, days, weeks
 Motor development- age related process of change in motor development
o Months, years, decades
o Key concepts
 Children develop cephalocaudal
 Proximal stability develops before distal stability
 Gross motor skills develop before fine motor skills
 Undifferentiated to specific= DISSOCIATION
 Kinesiological concepts
o Physiological flexion
o Antigravity extension-tummy time to develop extension and break “contractures”
o Antigravity flexion-time the child is supine to decrease the amount of force
 Mobility and stability
o Postural control
o Mobility precedes stability
o Proximal stability requires co contraction
o Controlled mobility
 Accurate reach
 Open chain activity
 Asymmetry to symmetry to controlled asymmetry
 Relationship between weight bearing and weight shifting
 Rotation and disassociation
Variables affecting outcomes
 Age, cultural beliefs, hx and environment, medications, anthropometric measurements, MS
impairments, neurologic status
Development: What do we expect
 Traditionally, neurological evaluations have shown good predictive validity for detecting major
developmental disorders however when the assessment of the quality of movement is added, the
predictive value for major and additionally minor developmental disorders increases
 A current perspective
o In normal development, the children develop the capacity to adapt motor performance to
environmental constraints
o When children have lesions of the motor cortex, they are noted to have problems of
 Reduced numbers of motor strategies
 Decreased ability to select the most efficient strategy for the environmental
situation
 Evaluation skills and an evaluation/assessment tool that combines the achievement of
developmental milestones with the assessment of the quality of the child’s motor behavior
 Tools that use a combine approach
o Test of infant motor performance (TIMP)
o Prechtl’s qualitative assessment method
o Infant motor profile (IMP)
 Quality in motor development includes:
o Symmetry
o Variability of size of repertoire
o Variability or ability to select adaptation(s)
o Fluency of movements
o Performing the developmental task
o Influenced by muscle tone
Four to Six Months
 Reaches for nearby toy while on the tummy
 Reaches with both hands for both feet
 Touched and bangs objects
 Sits by self for short periods
 Sidelying/prone reaching
 Feet to mouth with pelvic mobility
 Reaching in sitting with trunk stability
 Sitting with upright pelvis and back extension
Six to eight months
 Sits and reaches without falling
 Grasps small object by pinching
 Moves on hands and knees
 Decreases need for LE positional stability
 Reaching in sitting
 Visual reaching and grasp
 Trunk stability
 Trunk mobility
Nine to twelve months
 Cruises
 Stands but unsteady (12 months)
 Stoops and recovers
 Climbs onto
 Towers two items
 Stands supported
 Stands unsupported
Thirteen to fifteen months
 Climbs
 Walks independently, seldom falls (15 months)
 Drinks from cup
 Immature stair climbing (but safe)
 Upright stability
 Bilateral hand use in cup drinking
Sixteen to eighteen months
 Runs stiffly
 Walks up steps holding rail/hand
 Uses spoon for entire meal
 Takes off simple clothes
 Walks no upper extremity support for balance
***concentric and eccentric contraction-which comes first???
***Limited supination in self feeding
How might pathology influence development of posture and movement?
 Spasticity-velocity-dependent increase of muscle response to phasic stretch, routinely tested by
tendon taps or passive mobilization
o Limits degrees of freedom
o Limits range of adaptations and accommodations
 Low Tone
o Hypotonia-decreased normal muscle tension with increase muscle extensibility and at
times delayed response to stimulus, but does not equal weakness
o Increased degrees of freedom
o Leads to limited mobility options
Variation and variability in human motor development
Human motor development variability and variation
 Variability within and between individuals is an essential element in the developmental process
 Motor development is viewed as an innate maturational process that is largely affected by
experience
 Theoretical frameworks
o Dynamic systems theory
o Neuronal group selection theory
o Share opinion motor development is a nonlinear process with phases of transition that is
affected by many factors
 Features of the child
 Housing conditions
 Presence of stimulating caregivers
 Presence of toys
o Acknowledge the importance of experience and the relevance of context
o Differ in role of genetics
 DST genetics play a limited role
 NGST genetic endowment and experience play equal roles
 Typical Human Motor development Intra-individual variability
o Difference in motor development or performance within individuals and between
repeated measurements
o Essentials for exploration and selection
o Is omnipresent in motor behavior providing flexibility in motor performance and motor
strategies
 Atypical human motor development Intra-individual variability
o Variability within and between individuals is an essential element in the developmental
process
o Atypical motor development is characterized by a limited variation (a limited repertoire
of motor strategies)
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o Limited ability to vary motor behavior according to the specifics of the situations
Neuro mechanisms underlying motor development
o Innate maturational process
o Cerebral connectivity is the neural basis of human behavioral variability
o Motor development characterized by abundant variation
o Exploration reflects the continuous dynamic interaction between genes and experience
Primary and secondary variability
o Primary
 Characterized by abundant variation in motor behavior
 The absence of the ability to adapt the various movement possibilities to the
specifics of the situation
o Secondary or adaptive-function
 Information produced by behavior and experience allows for the selection of the
motor behavior that fits the situation best
 Based on active trial and error experiences that are unique to the individual
 Sensorimotor development plays a pivotal role in motor development
o The transition from primary variability to secondary variability occurs at function
specific ages
 Sucking in utero, secondary prior to term porstural adjustment at 3 months
 Foot placement in walking 12-18 months, postural behavior in sitting at 4
months. Adaptive sitting behavior at 6 months
 Around 18 months basic motor functions, sucking, reaching, grasping, postural
control and locomotion have reached the first stages of secondary variability
 In late adolescence the secondary neural repertoire has obtained its adult
configuration
Less variability in atypical development
o More stereotyped motor behavior
o Delay in achievement of milestones (impaired selection)
 Limited variation and limited complexity
o Mild or major deviation in muscle tone
o Persistence of infantile reactions
o Repertoire of motor strategies is reduced
 Limited repertoire of specific motor strategy
 Best solution may not be available due to prolonged periods of trail and error
needed to explore
 Impaired ability to vary motor behavior
Typical Motor development
o Non-goal directed motility
 General movement begins in utero usually by 7 months
 Once gravity affects infant after birth general movements continue but are now
against gravity
o Goal directed motility
 Variation in the emergence of function, variation in the performance of function
 Gross motor activity the emergence of function happens within specific age
ranges
Experience and sensory motor input
o Supine exploration
 Hands to mouth, hands to close, kicking, foot to foot, looking, head position,
eventually rolling, eventually reaching
o Sitting exploration
 Weight shifting, hands on surface, different leg positions, reaching for toys,
banging, manipulating objects, looking
Presentation on variability in postural control during infancy
o Five key tenets proposed
 Variability is part of normal development
 Variability in postural control is needed for functional skill acquisition
 Variable and adaptive postural control facilitates exploration
 A lack of complexity in postural control may be an earlier marker of disability
 Enhancing complexity may lead to functional change
 Assessment: planning and outcomes
o Look at global development, not only postural control or motor development
o Observe spontaneous play and parent child interaction
o Readiness for change precursors interest in toys, stable gaze, and active movement
o Development is non-linear in all domains
o Small and varied exploratory movements are essential building blocks
o Errors are part of the learning process, ample opportunities to explore diverse movements
are necessary
 Focus of intervention
o Increase amount of variability of experiences
o There is not one correct postural control strategy
o Design activities that are based on the requirement for the action you are trying to
advance
o Readiness for new skills
o Expand activities for the just right challenge
o Variable practice
o The process of learning to select the more appropriate motor solution in a specific
situation is based on implicit motor learning and does not involve conscious decision
making.
Lecture #2 Neuromuscular System: structures, functions, diagnosis, and evaluation 5/19/15
Neuroscience related to pediatric neuro/MS disorders
 Knowledge of the type of motor disability that may develop from CNS injury may assist with
outcome prediction but:
o Take into account Genetics and environment
o Imaging techniques are still unclear
o Plasticity cannot be predicted
 Developmental maturation of bone is the same process as bone healing (i.e. cartilage becomes
bone in the developing healing bone)
 Deviant bone maturation can be either:
o Too much: heterotopic ossification
o Too little: non-union
 Recent studies have demonstrated that developmental and pathological bone growth is at least in
part regulated by beta-catenin
 Beta-catenin can be chemically regulated by administering of nefopam (lithium)
o Why developmentally relevant?
 Pharmacological management of scoliosis overgrowth
 Chondroplastic syndromes
 Osteoarthritis
Neuroscience of the CNS development and maturation
 Beyond imaging, developmental neurology can clarify the result of a prenatal insult when we
understand NS development
o Neurulation
o Ventral induction
o Neuronal proliferation
o Neuronal migration
o Neuronal organization
o Myelination
 Prenatal/postnatal neuronal organization
o One neuron may make as many as tens of thousands of synaptic contacts with other
neurons
o There is a theory that Autism could be due to over responding neuronal organization
Moving towards Evaluation
 Present function and history, General observations, developmental level
 Systems review
 Reflexes, righting, equilibrium reactions
 Muscle tone, ROM, strength
 Sensory systems
o Vision and hearing are mandated for 0-3 years old
 Need to look at APGAR score
o 5 min= needs to be >7-10
o 5 additional min if <7; send to NICU
 Gather head circumference information
o Head circumference is an indicator of brain size and growth
o Microcephaly vs. macrocephaly
o Brain grows to 80% of adult volume in first two years of life
o Charted in the Pediatricians office
o Diagnosis specific to head growth charts (i.e. Down’s Syndrome)
 How old is the infant/child?
o Developmental age- is determined by outcome measure (developmental
assessment/evaluation)
o Gestational age- # weeks in utero
o Chronological age (CA)- age in weeks or months since birth
o Adjusted gestational age (AA)- number of weeks premature
 Reflexes terminology
o Deep tendon reflexes-also called tendon or mystatic reflex
o Neonatal reflexes- often referred to as primitive reflexes
o Primitive reflexes- also called neonatal reflexes, automatic responses, reflex responses,
attitudinal reflexes
 Moro-disappears by 4 months
 Asymmetrical tonic neck reflex- appears at 2-4 weeks; disappears by 6 months
o Righting or postural reflexes/responses-function to align head with trunk, may become
integrated or remain for life
o Equilibrium reflexes/responses- function to gain or maintain COG
Neuromuscular including: impaired neuromotor development
 Large group of clinical presentations associated with a variety of movement disorders
 Can include:
o Impaired motor function and sensory integrity
o Non-progressive CNS disorders
o Progressive CNS disorders
Down Syndrome
 Hypotonicity
 Weakness
 Hyper-flexible joints (atlantoaxial, C1-2 subluxation)
 40% have congenital heart defect
 greater use of co-contraction
 longer to develop antigravity musculature
 as adults greater number of knee (patella), hip and foot problems
 potential interventions
o disciplinary team collaboration-promote play and development
o education
o treadmill- early before walking before peers
o regular exercise programs
o APE- adaptive physical education
o Special Olympics
Developmental Coordination Disorders
 Interferes with academics and ADL’s
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soft signs
o associated movements
o mild hypotonia and weakness
o poor postural control
o problems with coordination
o delayed milestones
o why?
 Poor processing, integration and modulation
 Motor control less precise and timing problems
 Typically reach all milestones but delayed
o Fine motor sequencing-hand writing and tying shoes
o Complex coordination-skipping, dribbling
o Learning new task-high and low playground equipment
o Low academics, few hobbies, poor self esteem, poor athletic competence, less
participation and low aspiration
 Associated issues
o ADHD
o Medications- Ritalin and concerta
 Potential interventions
o Memory cues
o Practice in varied environments
o Education and collaboration of team
o Using the ball for coactivation of abdominal and gluteal muscles and facilitation of
weight shit
o NDT: activation of core postural muscles through facilitated rolling, then modified to
increase stability for a very active child
 Sustained co activation of gluteals and shoulder girdle progressing to tall
kneeling and transition to stand
Acquired Non-progressive Disorders of the CNS
 Insults to the fetus
 Prematurity
o Hypoxemia
o Ischemia
o Asphyxia
 Full term infant
o Selective neuronal necrosis
 Cerebellum
 BG
 cortex
Prematurity and low birth weight
 full term- 40 weeks
 late preterm- <37 weeks
 very preterm- <32 weeks
 extremely preterm- <25 weeks
 low birth weight- <2500 g
 very low birth weight- <1500g
 extremely low birth weight- <1000g
 micropremie- <700-800g
Cerebral Palsy
 developmental disorders of movement and posture related to disturbance occurring in fetal or
infant brain
 classification
o distribution of motor disability
o type of muscle tone
o gross motor function classification for CP
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interventions for CP-diversity in limitations requires diversity in treatment
o coordinate and communicate with team
o ROM
o Strength
o Sensory feedback
o Flexibility and functional movement patterns
o Orthopedics concerns
o Assistive devices
o Treadmill training
Traumatic brain injury
 Focal vs. diffuse
 Inactivity during coma=hypertension
 Cognitive, emotional and behavioral
o Personality changes
o Frustration
o Memory
 Interventions for TBI
o ROM
o Stimulation of senses
o Team approach to behavioral management
o Motor learning concepts
o Reflexive
o Developments
Myelodysplasia
 Spina bifida
o Spina bifida occulta
o Meningocele
o myelomeningocele
 Mixed lower motor neuron and brain dysfunction- motor control, learning, functional ability
 Orthopedic issues
 Bowel and bladders
 Interventions for MM
o Early surgical interventions
 Collaboration
 Strengthening
 prevention
o mobility-based on level of lesion
 ambulation
 wheelchair
o changes with body size
Typical pediatric intervention example approaches
 maturational based theories
 NDT
 Ayres sensory integration
 Motor control theories
 Neuronal group selection theories
Developing a plan of care
 Determine the family’s concerns and priorities
 Determine the infant or child’s developmental and functional status and identity limitations
 Arrive at a diagnosis
 Arrive at a prognosis
 Develop a plan of intervention strategies
Principles related to POC
 Intervention plan should
o Increase participation in life roles
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o Meet the developmental needs
o Have measurable goals and objectives
Link goal to child
o Function (motor-sit stand walk), communicate, participate in social interactions
o Measurable outcome written as behavioral objectives (distance, time, %, number)
o Use of physical prompts (with orthoses)
o Functional activity (step up a one inch step)
Behavioral objectives- SMART
o To retrieve a toy in sitting, jon will maintain sitting when placed for one minute with no
upper extremity support, three out of five trials
o Who- jon
o What- sitting
o How- no UE support
o How much- 3/5 trails
o When/where- when placed on floor
o How long- 1 min
Intervention strategies
o Optimally you should have evidence to drive evidence to drive your strategies
o Therapeutic practice-task oriented interventions
 Increase readiness
 Modify the task to promote success
 Provide physical guidance
 Give verbally mediated support
Integrating intervention strategies
o Current motor control theory focuses on identification of controlling variables which are
defined as
 Development and motor systems maturation
 Sensorimotor includes CPGs and other neural mechanisms
 Mechanical including body mass and distribution that respond to gravity
 Cognitive: arousal, motivation, development of special maps
 Task requirements (can shape motor strategies)