Child Testing and Data Types

Reasons for Child Testing

• To determine the need for formal evaluation, use a screening tool
• To determine eligibility for services, use discriminative norm-referenced outcome measures
• To determine change over time and progress toward goals, use baseline measures and measurements over time
• Use evaluative, criterion-referenced outcome measures
• To predict future performance
• To gather data for program evaluation and research

Types of Data

• Norm-Referenced: Compares a child to their same-aged peers
• Determines if a child performs above, at, or below expectations for their age
• Used to determine eligibility for therapy services
• Scores can be diagnostic, predictive, or evaluative
• Scores are referenced to the normal curve
• Standard scores include T-scores, z-scores, and percentile ranks
• Examples include Timed Floor to Stand, Timed Up and Down Stairs, and Pediatric Balance Scale.
• Criterion-Referenced: Compares a child to a set of standards or criteria
• Can identify change in a child’s performance over time
• Scores can be used diagnostically, predictively, or evaluatively
• Scores are not referenced to the normal curve
• An individual’s score is not influenced by the performance of others
• Examples include TUG, DGI, and 6MWT

Age Calculations

• Chronological Age: Calculated using the child’s full date of birth and today’s date
• Corrected Age: Corrected age = chronological age - # of weeks premature
• Where # of weeks premature = 40 weeks - # of weeks in utero

Scoring

• Raw Score: The total score on a test based on the number of items passed
• Scaled Score: A raw score converted to a consistent and standardized scale
• Standard Score: Deviation from the mean, expressed as a standard deviation from the mean
• Percentile: The percentage of children expected to score lower than the child being tested

Scoring Summary

• >1.0 SD above the mean: >84 percentile, Above age appropriate skills, No qualification
• -0.99 to +1.0 SD from the mean: >16-84 percentile, Age-appropriate skills, No qualification
• -1.49 to -1 SD below the mean: >6.5-16 percentile, Mild Delay, No qualification
• -1.5 to -1.99 SD below the mean: >2-6.5 percentile, Moderate Delay
• Qualify if the child shows a moderate delay in another domain of development
• Do not qualify if there is a moderate delay in only one domain
• < -2 SD below the mean: <2 percentile, Severe Delay, Yes qualification

School Function Assessment (SFA)

• Assesses function and guides program planning for students with disabilities in educational settings
• Domains: - Participation - Task Support - Activity Performance (physical and cognitive/behavioral tasks)
• Age: Kindergarten through 6th grade
• Data: Criterion-based

Pain Perception

• Nociceptors are present at the 20th prenatal week (23 weeks gestation)
• Peripheral pain pathways are present at birth
• Newborns feel pain
• Permanent structural and functional brain and spinal cord changes occur with repeated painful experiences in infants and children

Infant Pain Experience

• Full-Term, Healthy Infants
• Experience pain from Vitamin K injections, heel sticks for blood draws, immunizations, and circumcision
• Preterm Infants
• Experience an average of 14 painful procedures every day while hospitalized

Effects of Repetitive Neonatal Pain Experiences

• Behavioral: ADD/ADHD, depression, anxiety, and pain catastrophization
• Altered Sensory Perception
• Decreased sensitivity to touch
• Early life: hyposensitivity to pain
• Adolescence/adulthood: hypersensitivity to pain
• Nervous System Changes: Reorganization of the PNS & CNS, decreased volume of the amygdala, hippocampus, thalamus, & basal ganglia
• Poor Health Outcomes: Diabetes & HTN in adulthood
• Cognitive: Lower IQ, language delays, attention deficits, and poor visual-motor skills

Pain Assessments in Children

• Physiological Responses: Observe how the child’s body is responding
• Self-Report: Ask the child what they are feeling
• Behavior: Observe the child's behavior

Physiological Responses to Pain

• Increased Respiratory Rate (RR)
• Increased Heart Rate (HR)
• Increased Blood Pressure (BP)
• Decreased Oxygen Saturation (O2 Sat)

Self-Report Measures

• The Gold Standard is for children over 6 years of age
• Can be used in children as young as 3 years of age
• Should be used when the child is old enough to understand the scale, not cognitively impaired, and not overly distressed
• NRS (Numeric Rating Scale): For children 8 years or older who understand number rank and order
• VAS (Visual Analogue Scale): Can be used with younger children
• Face Pain Scale and Faces Pain Scale
• Wong-Baker FACES Pain Rating Scale
• OUCHER: For 4 races

Observable Pain Behaviors

• Facial Expression: Grimace, clenched teeth, wince, frown, furrowed brow, tongue thrust
• Vocalization: Moan, cry, whimper
• Body Movement: Squirming, tensing body, writhing, flailing
• Tone Changes: Increase or decrease
• Sleep: Change
• Affect: Change

Pain Scales (0-7 years)

• FLACC Scale:
• Age: 0-7 years - Scoring: 5 categories scored 0-2 - 0: no sign of pain - 1: some or occasional pain - 2: frequent or constant pain - Important: -Five categories: face, legs, activity, cry, consolability -0 indicates the lowest level of pain, while 2 indicates the highest -For nonverbal and preverbal populations
• Revised FLACC Scale - Age: 0-7 years Scoring: 5 categories scored 0-2 - 0: no sign of pain - 1: some or occasional pain - 2: frequent or constant pain - Important: Used with children with Cognitive disabilities
  • Face, legs, activity, cry, consolability, Simplified compared to FLACC
  • Individualized to child and how they perceive pain (atypical pain responses)
• Evendol Pain Scale - Age: 0-7 years - Scoring: 5 categories scored 0-3 - 0 - absent - 1 - weak - 2 - moderate, present half the time - 3 - strong, present almost all the time - Important: Emergency departments, Vocal/ verbal expression, Facial Expression, Movements, Postures, and Interaction
• CRIES Scale - Age: Infants - Scoring: 5 categories scored 0-2 for a total out of 10 - Important: Looks at vital signs, expressions, and sleeplessness

Gait Characteristics 18-24 Months

• Hip Alignment: ↓
• Femoral Anteversion: ↓
• Tibiofemoral Joint Alignment: Straight
• Tibial Torsion: ER (External Rotation)
• Talotibial Joint Alignment (frontal): Eversion
• Center of Mass: Lowering
• Base of Support: ↓
• Step Length: ↑
• Cadence: ↓
• Hip & Knee Position: ↓ flex
• Initial Contact: Inconsistent heel first
• Swing Foot Position: ↓ PF
• UEs: By side
• Walking pattern changes are related to maturation of the neurological system, body structure changes secondary to growth, increased strength and experience w/ walking
• Consistent heel strike is present by 24 months of age
• Requirements of heel strike: improved motor control (allowing ↓ BOS), improved strength, and improved dynamic balance to maintain stability on the heel (smaller contact area)
• EMG activity: Decreasing co-contraction in antagonist muscle group implies increased control and stability with most changes seen in stance phase

Gait Characteristics 3-3.5 years

• Hip Alignment: neutral
• Femoral Anteversion: ↓
• Tibiofemoral Joint Alignment: Valgus
• Tibial Torsion: ER (External Rotation)
• Talotibial Joint Alignment (frontal): Eversion
• Center of Mass: Lowering
• Joint torques and propulsion patterns remain immature
• Child is working on refining balance
• Postural development is not complete
• Visual & vestibular systems are immature
• Walking velocity (when normalized for height)=adult values

Gait Characteristics 6-7 Years

• Hip Alignment: neutral
• Femoral Anteversion: Higher than adult values
• Tibiofemoral Joint Alignment: Straight
• Tibial Torsion: ER (External Rotation)
• Talotibial Joint Alignment (frontal): neutral
• Center of Mass: L3(Lumbar 3)
• Joint torque & propulsion patterns= similar to adult patterns
• Ankle joint is an exception, with less values compared w/ adult values
• Movement (Mvmt) speed in children under 10 is limited by muscular coordination
• Postural control is not fully developed until 10-12 years

Crouch Gait

• Potential causes of crouch gait

Muscle Tone

• Valgum: positional indicates weak hip abduction and external rotation
• Lack of knee extension leads to knee and/or hip flexion contracture, increased hamstring tone, quad weakness, hip extensor weakness, ankle plantarflexion weakness
• Difficulty with motor control
• Muscle Tone described as the resistance of muscle to passive elongation or stretch - Represents a state of slight residual contraction in normally innervated, resting muscle, or steady-state contraction

Normal Muscle Tone

• Normal variability between individuals
• Muscle tone is variable within an individual -Influenced by mood/emotions, illness/health and arousal level

Continuum of Muscle Tone

• Hypotonia -Decreased resistance to passive motion -Flaccid without muscle fibers firing, with low tone appearing floppy
• Normal Tone -Slight resistance to stretch
• Hypertonia -Increased resistance to stretch -Rigidity with a high level of the muscle fibers firing

Hypotonia

• Decreased resistance to passive motion
• No specific objective measure
• Controversy exists between terminology and differentiation of symptoms -hypotonia, hypermobility, and ↑ muscle flexibility

Types of Hypotonia

• Central Hypotonia - 60-80% population - Caused by atypical damage: brain or brainstem - Results from developmental delay with o known cause - DTRs: Increased, normal or decreased - Weakness: Mild to moderate -Down Syndrome, CP, Prader-Willi syndrome, fragile x, idiopathic. Associated muscle weakness, limited activity tolerance, delayed motor skills, joint hypermobility and increased flexibility.
• Peripheral Hypotonia - 15-30% - Caused by atypical damage: anterior horn cells of SC, muscle or peripheral nerve & neuromuscular junction(NMJ) -DTRs: Absent or decreased -Weakness: Severe to profound -Spinal muscular atrophy, myotonic dystrophy.
• Caused by delays in the muscles ability to respond to outside forces/ stretches
• Decreased ability of the muscle to maintain a prolonged contraction, affecting: postural reactions, righting reactions and protective reactions

Hypotonia-PT examination

• Use PROM, MMT, assess the patients sitting endurance and test general mobility & tone
• Assess for Muscle Length and conduct DTR/Primitive testing
• Evaluate the patients Prone, supine posture while rolling, scooting or sitting
• During participation asses school and play activity
• Account for personal/ environmental factors- home setup, SES and support

Hypotonia- Interventions

• Therapy service with PT, OT and SLP
• Build strength, aligning the body in proper alignment and avoiding joint end ranges
• Utilize braces, supports or compression garments to assist with postural alignment
• Decrease external support over time and be patient

Hypertonia

• Resistance to passive movement
• Not dependent on velocity
• Can occur with or without spasticity
• Increases the risk of contracture secondary to decreased ROM
• Ranges from mild to severe
• Spasticity
• Type of hypertonia dependent on velocity
• Hyperexcitability of the stretch reflex
• Upper motor neuron signs are often present: clonus, Babinski, hyperreflexia
• Increased muscle tone with resistance to passive motion
• Agonists and antagonists affected

Upper Motor Neuron Sings

• Clonus
• Babinski
• Hyperreflexia

Spasticity interventions

• Function: Spasticity & Strength in Children with Spastic Diplegic Cerebral Palsy -Minimal relationship between spasticity and gait pattern or gross motor function -Strong Relationship with strength and gross motor function -Moderate relationship between strength and gait

Dystonia: Intervention

• Movement disorder consisting of abnormal or variable muscle tone -Contractions in muscles are involuntary with repetitive or twisting movements -Abnormal postures are sustained or intermittent -May occur in one body part/several body parts/OR throughout the entire body - Multiple theories for its cause including damage to basal ganglia and issues neurotransmitters

Modified Ashworth Scale

• 0: No increase in muscle tone
• 1: Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end range of motion when the part is moved in flexion or extension/abduction or adduction, etc.
• 1+: Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM
• 2: Marked increase in muscle tone through most of the ROM, but the affected part is easily moved
• 3 :Considerable increase in muscle tone, passive movement is difficult
• 4: Affected part is rigid in flexion or extension (abduction or adduction, etc.)

Modified Tardieu Scale

• Measures the point in the ROM where spasticity occurs by -use of a goniometer and measuring joint angles
• R1: point in the ROM where a “catch” in the muscle is felt with a rapid stretch
• R2: maximum joint ROM measured after slow stretch
• R2-R1 indicates dynamic component of spasticity - Small difference indicates an orthopedic issue - Large difference indicate spasticity issue

Intramuscular Injection Interventions

Neurolytic block focally decreases spasticity: botox or phenol and Blocks release of acetylcholine at neuromuscular junction with use in 3-4 muscle groups maximum at one time with a repeat frequency of every 8 weeks while lasting 3 months with decreasing effectiveness over time

• Allows temporary in spasticity to allow for strengthening/ development of new movement patterns

Oral medication interventions

• Baclofen, Diazepam, Dantrolene and Tizanidine -An effective oral route for reducing spasticity throughout the body or can be administer through a g-tube)
• Oral CNS depressants are often prescribed while watching for side effects: sedation, decreased attention, depression, decreased coordination, confusion, muscle weakness and difficulty swallowing

Intrathecal Baclofen Intervention

• Pump Surgically inserted subcutaneously into abdomen with catheter into intrathecal space of spinal canal to localize effects of baclofen
• Needs to be refilled every 1-3 months and replaced when battery fails (5-7 years)
• Recommended for children 6 years or older (or 20kg or heavier) -Complications with infection and catheter problems

Selective Dorsal Rhizotomy Intervention

• A surgical procedure utilized to ID dorsal nerve roots via EMG
• Cut dorsal/sensory rootlets that are overactive
• This surgery is recommend Indications for spastic diplegia/quadriplegia with some independent ambulation and and over 2 years old

PT Interventions:

Interventions for spasticity focus to: Prevention of joint contractures, Strengthening and with NMES intervention, focusing on Function

Definition of sensory Integration

Neurophysiological process of receiving and responding to input received from environment through all various senses which is then integrated for the bodys ability to organ and sensory input received from the CNS

Sensory Systems

Body allows for the:

• discrimination of the sensory information received from the environment which allows for the participation in daily functional tasks
  • Tactile- Skin, light and deep
  • Auditory- ear
  • Gustatory- tongue
  • Olfactory- nose
  • Vision- eyes
  • Vestibular- Inner ear or balance and body position
  • Proprioceptive-Muscles and joints
  • Interoception-Inner organs

Sensory Integration (SI) A. Jean Ayres

• Sensory integration is the neurological process that organizes sensations from one’s body and from the environment and makes it possible to use the body effectively in the environment for Observed children with learning disabilities

• SI combines concepts from human development, neuroscience, psychology, and occupational therapy into a framework for looking at behavior and learning

• Brain as the organizer and interpreter of sensory information when dysfunction occurs causes brain not to is interpret or organ properly and this interfered of functional performance- impacts -behavior, motor skill development, learning, participation in activities

Interventions for dysregulation:

Use neuro biological and developmental science to improves adaptive responses of neuroplasticity for these errors with this information which impacts behavior and creates and an inability to effectively organize contributing to difficulties with developing motor skills and tasks

Core Interventions of Ayres Sensory Integration

• Sensory information provides foundation for learning and behavior with sensory integration to promotes neuroplasticity
• Brain is an integrated whole with sensory information for adaptive responses or appropriate action in successfully environmental demand with an Inner drive to seek meaningful experiences in their environment through Winne Dunn’s Threshold

Neurological thresholds -Defined as the amount of stimulation required for a neuron to respond and varies for all and includes neuronal excitation/reaction to sensation while being balanced with neural inhibition or the ability to decrease/ block response

Sensory Threshold

Winnie Dunn Threshold includes:

1. High threshold with sensory seeking for low registration individuals)
2. A Low threshold (with sensory avoiding with sensory sensitivity individual)

Under Reporting Sensory Information:

Sensory Under Reporting is when has an increased sensory threshold the bodies requires MORE physical input with those who have diminished motor skills

Over reporting of Sensations:

Sensory Over Reporting is when as sensory threshold is too diminished it requires LESS input with the child is averse to and may want to minimize contact to textures

SCM (Sternocleidomastoid muscle) origin and insertion:

SCM originates at the Temporal Bone (mastoid process) to the Sternal sternum (manubrium ) and Clavicle

Unilateral and bilateral actions of the SCM

Action for SCM is Cervical flexion and capital extension, while ipsilateral side-bending/lat. Flex neck with contralateral rotation; Spina Access Spinal accessory nerve (motor C2,C3 for (motor) proprioception

SCM unilateral contractions:

With R SCM we would see R side-bending wit L rotation while the contraction of the L SCM will create L sidbending and R rotation which will create for torticollis where We would involve the Right or Left SCM with associated Resting Posture will limit the R or L Lateral Flexion with the R or L Rotation

Types of Torticollis interventions and levels:

• Postural Torticollis with -Postural preference of cervical lateral flexion &/or rotation to improve normal Muscle flexibility the goal for improving ROM

• Muscular intervention is for -Cervical lateral flexion &/or rotation AND SCM tightness is treated to improve with increasing ROM. with in more severe

• CMT is -Cervical Lateral Flexion/rotation with fibrotic thickening of the SCM (with resistance) for improved Range of Motions

• Large Babies, Multiple Babies, Position in which they were breech or there was Birth trauma all leads to Vacuum or forceps delivery which puts them at higher risk

If untreated, Torticollis can cause:

• Plagiocephaly Asymmetrical ears or Uneven eyes

Other causes for the posture in unbalance weightbearing which leads to

• Cervical & or thoracic scoliosis -Uneven shoulders and weight bearing

Importance of Screen for Torticollis patients:

• Be on Loolout for * Patients who have other Underlying Conditions where we see the Klippel syndrome or a Neuro Cause and patients who have - -Brachial plexus injury

What to check for while on this assessment

• Brachial plexus injury -Check motor coordination of the UEs which May also have Retained primal reflexes which limits the BPI

• The 1st assess ment is the Chronological age corrected and and note their head tilting as well there Head preference or facial assymetry to not for head and/or facial asymmetry

Plan of Care

• Services delivered by a pediatric PT in an outpatient clinic unless the child has developmental delay and qualifies for El.
• There is no optimal PT frequency and duration documented, literature suggests often 1x/wk
• Most important aspect of PT is caregiver education

First Choice Interventions for CMT

    - Neck PROM when PROM is limited
    - Neck & trunk AROM
    - Developmental of symmetrical movements
    - Environmental adaptations
    - Caregiver education

Neck PROM Interventions when PROM is limited

• Should be performed frequently throughout the day
• Use slow, gentle, pain-free stretches
• Stabilize head & shoulders to prevent compensations
• Can be performed in a variety of positions
• Contraindications to PROM: c-spine bony abnormalities, clavicle fracture, tumors, Arnold-Chiari malformation

Neck and Trunk AROM Goal

• Goal: strengthen neck and trunk muscles through positioning, carrying, eating & play
• Cervical Rotation: Practice visual tracking to non-preferred side and feeding from non-preferred side
• Cervical lateral flexion: practice righting reactions to non-preferred side
• Minimize time in positioning devices & encourage prone play

Symmetrical Movements Goals

• Facilities symmetrical age-appropriate motor skills
• Prevent asymmetry with prone, sitting, crawling & walking
• Transition to the right and left between all developmental positions

Environmental Modifications

• Alternate infant’s position in crib & changing tables
• Minimize time in positioning devices
• Use positioning devices with attention to infant symmetry & encourage cervical rotation to the non-preferred side
• Maximize awake time in prone; the goal is at least 1 cumulative hour of tummy time per day

Caregiver Education

• Educate about:
• CMT
• Tummy time when awake
• Minimize time in infant positioning equipment
• Alternate sides when feeding
• Create individualized home program with family structure & schedule in mind

Outcomes & Criteria for PT Discontinuation

• Direct PT can be discontinued when:
• Cervical PROM is within 5° of the unaffected side
• Symmetrical movement patterns are present
• Age-appropriate gross motor skills are present
• No visible head tilt
• Caregivers demonstrate understanding of how to monitor their child as they grow

Reassessment Recommendations

• Child must be re-assessed 3-12 months after discontinuation of services or when the child starts walking to assess for:
• Postural symmetry
• Functional abilities
• Caregiver understanding of home exercises/monitoring
• Caregiver satisfaction with outcomes
• If all 5 criteria continue to be met, the child can be discharged from PT services, if not, restart ongoing direct PT services. Intermittent Head Tilt May Return With illness, when fatigued, and when learning a new motor skill

Cranial Deformation

• Distortion of head shape secondary to mechanical forces on the skull that occurs prenatally or postnatally Associated with:
• CMT
• Prematurity
• Multiple births
• Firstborn children
• Increased incidence after the Back to Sleep campaign began in 1994 to decrease the incidence of SIDS
• Decreased time in prone and increased time in supine
• 80% of brain/skull growth occurs before 12 months of age, the skull is most malleable prior to 3 months of age, and brain growth begins to slow at 5-6 months

Types of Cranial Deformation

• Plagiocephaly: Ipsilateral occipital flattening & contralateral occipital bossing
• Brachycephaly: Central occipital flattening
• Dolichocephaly: Long & narrow skull - Positional/Deformational Plagiocephaly - Asymmetrical head shape & associated facial asymmetry-parallelogram shape - Jaw, ears & eye mal-alignment (ear on posterior flat side moves anterior) - Associated with CMT, prematurity, multiple births

Craniosynostosis Consideration

Premature closure of one or more cranial sutures that causes cranial asymmetry Sx:

• Slow or no head growth
• Raised ridge on skull along suture
• Abnormal skull shape
• Positional Molding: frontal protuberance, ear displaced anteriorly, flattened occiput, all sutures open, posterior protuberance
• Lambdoid Synostosis: frontal protuberance, ear displaced posteriorly, mastoid protuberance, closed lambdoid suture, posterior protuberance

Craniofacial assessment

• Palpation of anterior and posterior fontanelles (size, shape, position, fullness)
• Palpation of cranial sutures (look for ridging)
• Visual assessment of craniofacial symmetry (take photos of 6 views) or use standardized assessment
• Reassess monthly

Evidence-Based Recommendations for Intervention

• Decrease pressure on flat spots by using more tummy time, less time in positioning equipment, and treatment for CMT and if needed:

Cranial Molding Helmets

• Initiated when the skull is rapidly growing (4-6 months) for worn 20-23 hours per day and note that poorer outcomes are often associated with older age, greater severity, and poor adherence