Pediatric Rehabilitation, Afirm

PEDIATRIC REHABILITATION PEDIATRIC REHABILITATION, AFIRM

REHABILITATION

Definition – Process of helping a person – Fullest potential – Consistent with person’s impairment and desires

PEDIATRIC REHABILITATION

A subspecialty Different from adult rehabilitation Everything is changing

PEDIATRIC REHABILITATION

Utilizes interdisciplinary approach Congenital and child-hood onset physical

impairment Rehabilitation of children requires – Identification – Selection – Understanding

INTERDISCIPLINARY TEAM REHAB SPECIALIST PHYSICAL THERAPIST

PATIENT

PSYCHOLOGIST

OCCUPATIONAL THERAPIST SPEECH THERAPIST

PEDIATRIC REHABILITATION  Team members include – – – – – – – – – – –

Pediatric physiatrist Occupational therapist Physical therapist Rehabilitation nurse Prosthetist-orthotist Psychologist Speech-language pathologist Case manager Dietician Therapeutic recreation specialist Spiritual care

TEAM MEMBERS Pediatric Rehab Specialist – – – –

Oversee medical care team Prescribe treatments Coordinate with other specialists Educate patient

OCCUPATIONAL THERAPIST

TEAM MEMBERS Occupational therapist – Provide training • Activities of daily living • To compensate • Upper extremity prosthesis

– – – – –

Recommend equipment Fabricate splint Suggest home modifications Educate patient’s family Manage dysphagia

TEAM MEMBERS  Physical therapist – Evaluate • Muscle length • Muscle strength • Muscle tone

– – – – – – – –

Therapeutic exercises Normalize muscle tone Joint handling techniques Improve balance Training adaptive devices and lower limb prosthesis Perform auscultation to lung fields Physical therapy modalities Assess body posture

FOR BALANCE AND STRETCHING

GAIT TRAINING

TEAM MEMBERS  Rehabilitation nurse – Direct personal care – Determine goal – Assesses and addresses • • • • • • •

Hygienic factors Bowel and bladder programs Intervention related to skin integrity Use of equipment Minimize effects of inactivity Medication management Help manage time

TEAM MEMBERS Psychologist – Neurophysiological testing • Personality style • Psychological status • Testing of intelligence, memory

– Ways to deal with stress – Counseling • Adjustment to body changes • Problem solving skills • Death and dying

TEAM MEMBERS Speech-language pathologist – – – – –

Detailed assessment Evaluation of swallowing Pragmatic and cognitive based disorders Motor speech Augmentative and alternative approaches • Talking tracheostomy tubes • Electro larynx

TEAM MEMBERS

Prosthetist-orthotist – Evaluation, design and fabrication – Instructions in care and use – Follow up maintenance and repair

PEDIATRIC REHABILITATION  Common disabling conditions TRANSIENT CONGENITAL Brachial plexus injury

AQUIRED Guillain-Barre syndrome

STATIC

PROGRESSIVE

Cerebral palsy Spina bifida Retardation

Muscular dystrophy Spinal muscular atrophy Cystic fibrosis

Spinal cord injury Traumatic brain injury Traumatic limb amputation polio

Juvenile rheumatoid arthritis Collagen vascular disease

CERBRAL PALSY

Definition – Disorder of movement and posture – Injury to immature brain – Ages involved

CERBRAL PALSY Classification By tone abnormalities

By body parts involved

Spastic Dyskinetic Athetoid Choreiform Ballistic Ataxic Hypotonic Mixed

Diplegia Quadriplegia Triplegia Hemiplegia

CERBRAL PALSY

Goals of rehabilitation – Decrease complications – Enhance or improve new skills

EVALUATION

Objectives – Type and etiology of disability – Child’s potential for rehabilitation

EVALUATION Screening test for development – Bailey scale of infant development – Denver developmental screening test

Quantitative analysis of motor performance – Physical parameters – Physiological parameters

Jebson Taylor Hand Function Test

EVALUATION Functional assessment – Wee FIM scale – Gross Motor Functional Measure – The Pediatric Evaluation of Disability Inventory

EARLY INTERVENTION Decreases the impact of brain injury on the

development of CP For infants and toddlers ( 0 to 3 years old)

The rationale of early intervention

NEUROMOTOR THERAPY APPROACHES Neurodevelopmental technique (Bobaths)

Sensorimotor Approach to Treatment (Rood)

Sensory Integration Approach ( Ayres)

CNS model

Hierarchical

Hierarchical

Hierarchical

Goals of treatment

1. 2. 3.

Primary sensory systems utilized to effect a motor response

1.

2. 3.

To normalize tone To inhibit primitive reflexes To facilitate automatic reactions and normal movement pattern

1.

Kinesthetic Proprioceptive tactile

1.

2.

2. 3.

To activate postural responses To activate movement once atability is achieved

1.

tactile Proprioceptive Kinesthetic

1.

2.

2. 3.

To improve efficacy of neural processing To better organize adaptive responses

Vestibular Tactile kinesthetic

NEUROMOTOR THERAPY APPROACHES Neurodevelopmental technique (Bobaths

Emphasis of treatment activities

1. 2.

Sensorimotor Approach to Treatment (Rood)

Positioning and 1. handling Facilitation of active movement

Sensory stimulation to activate motor response

Sensory Integration Approach ( Ayres

1.

Therapists guides but child controls sensory input to get adaptive purposeful response

Intended clinical population

CP children Adult post CVA

Children with CP Adults post CVA

Children with learning disabilities autism

Emphasis on treating infants

yes

no

No

Emphasis on family involvement

yes

no

no

HANDLING TECHNIQUES Lifting and carrying

POSITIONING Lying SUPINE

PRONE SIDE LYING

POSITIONING

SITTING

Long sitting

W Sitting

Cross legged Sitting

POSITIONING

– Standing

MOVEMENT BETWEEN POSITIONS Movement between positions – Rolling – Lying to sitting

MOVEMENT BETWEEN POSITIONS  Sitting to standing

MOVEMENT BETWEEN POSITIONS Exercises for sitting to standing

MOVEMENT BETWEEN POSITIONS  Walking

TREATMENT TECHNIQUES Mobilization activities

TREATMENT TECHNIQUES Activities to facilitate postural abilities

Activities to challenge postural abilities

Activities to improve the child’s ability to

move

AIDS AND APPLIANCES

STANDER

PRONE MOBILE STANDER

STANDER

SUPINE STANDER

WALKER

PLATFORM WALKER

WALKER STANDING SEATED WALKER

WALKER NON-FOLDING WALKER

AIDS FOR ADLS

WEIGHTED UTENSILS

HAND STRAP

AIDS FOR ADLS

CURVED UTENSILS

SUCTION BOWL

AIDS FOR ADLS

ZIP GRIPS

SOFT TOUCH SPRING ACTION SCISSORS

WHEEL CHAIR Head rest Strap for trunk support Wedge

CP CHAIR

ANKLE FOOT ORTHOSIS

Supramaleolar orthosis

Solid ankle foot orthosis

Hinged ankle foot orthosis

Posterior leaf spring AFO

KNEE ANKLE FOOT ORTHOSIS

•

HIP-KNEE-ANKLE-FOOT ORTHOSIS

MEDICATIONS FOR SPASTICITY  Drugs in use – Baclofen ( lioresal) • 2.5-5 mg twice daily

– Diazepam • 1-2 mg twice daily

– Dantrium • 0.5 mg/kg/day

– Clonidin • 0.05 to0.1 mg twice daily

 Intrathecal Baclofen infusion

INJECTION THERAPY  Botulinum toxin A – 12 to 14 U/kg

 Local injections – Phenol – Alcohol

 Nerve blocks – – – – –

Obturator Sciatic Tibial Femoral Musculocutaneous

SURGICAL PROCEDURES

SURGERY IN CEREBRAL PALSY Foot and ankle – Tendoachilles lengthening for ankle equinus – Split anterior tibialis transfer for inversion and dorsiflexion – Split posterior tibialis transfer for inversion and plantiflexion – Subtalar arthodesis for calcaneovalgus

SURGERY IN CEREBRAL PALSY Knee – Hamstring lengthening for crouch and internal rotated gait – Rectus transfer (to semitendinosis or sartorius) to balance hamstring weakness and prevent recurvatum – Tibial derotation osteotomy for internal rotation

SURGERY IN CEREBRAL PALSY Hip – Psoas lengthening ( intramuscular over the pelvic brim for hip flexion – Adductor tenotomy for scissored gait or early hip subluxation – Varus derotational osteoyomy for hip subluxation – Pelvic shelf procedure for subluxation with severe acetabular dysplasia

SURGERY IN CEREBRAL PALSY

Neurosurgical procedure – Selective posterior rhizotomy

FUNCTIONAL PROGNOSIS  Independent Ambulation – – – – – –

Spastic CP 75% Diplegia 85% Quadriplegia 70% Hemiplegia Ataxic CP Hypotonic CP

 Independent sitting  Persistence of primitive reflexes

PEDIATRIC REHABILITATION  Indoor – – – – – – –

Physical therapy gym Occupational therapy gym One-way mirrored observation room Sound proof one-way mirrored speech therapy room Regular speech therapy room Psychological assessment and therapy room Special education classroom

 Outdoor – Sensory integration playground – Functional activities playground

PHYSICAL THERAPY GYM

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