Treatment Planning and Approaches PDF

TREATMENT PLANNING AND TREATMENT APPROACHE S LONG ISLAND UNIVERSITY DPT PROGRAM ORIGINAL: NIA MENSAH PT, DPT, PHD, PCS REVISIONS: MELANIE O’CONNELL, PT, PHD, PCS  WE WORK TO ENHANCE DEVELOPMENT Pediatric Physical Therapists assist the family with enhancing the child’s development through:  Posi...

TREATMENT PLANNING AND TREATMENT APPROACHE S LONG ISLAND UNIVERSITY DPT PROGRAM ORIGINAL: NIA MENSAH PT, DPT, PHD, PCS REVISIONS: MELANIE O’CONNELL, PT, PHD, PCS  WE WORK TO ENHANCE DEVELOPMENT Pediatric Physical Therapists assist the family with enhancing the child’s development through:  Positioning during daily routines & activities  Adapting toys for play  Expanding mobility options  Using equipment effectively PEDIATRIC THERAPY EVALUATION AND TREATMENT FOCUSES ON  Mobility  Muscle & joint function  Strength & endurance  Cardiopulmonary function  Posture & balance  Oral motor skills & feeding  Sensory & neuromotor development  Use of assistive technology PEDIATRIC TREATMENT INCLUDES MANY OF THE TRADITIONAL COMPONENTS OF ADULT REHABILITATION  ROM  Strengthening  Stretching  Gait Training  Postural Training  Wheelchair training / management  Pain management  Fitness AND SOME DIFFERENCES…………  Pediatric PT does not use a high level of modalities  Treatment is mostly 1:1  Tends to be more long term; May have episodes of care HOWEVER, IT IS ALL IN THE FORM OF PLAY!!!! TREATMENT PLANNING  Like the Boy Scout motto:  ALWAYS BE PREPARED  Treatment sessions: Dynamic and change and vary based on the response of the child  With younger children most treatment sessions are play based, and the style of play will vary based on age  Babies: Sensory motor play and exploration  Toddlers: Movement-based play  Pre-schoolers: Imaginative play and creating scenarios  School age children: Focused on function and functional skills with less play  Adolescents: Focus on sporting activities, function and real exercise TREATMENT PLANNING Think about and chart out what you need to work on and how you plan to address that area Motor Problem Functional Goal Treatment limitation Activity Tight Hamstrings  TREATMENT SEQUENCE Ways to sequence activities to get the best and most from the child:  Go from Easy to Hard activities  Use the developmental sequence as a guide  Work – Play – Work – Play  Set up environment for child driven activities  Preparation, Muscle Activation, Movement Responses, Functional Activity (i.e. NDT)  What the child needs based upon when they are coming to you and from where  i.e. a child who has been sitting in a wheelchair all in school will need to get out of the chair and get mobilized (stretched) before working on other skills, particularly walking or standing TREATING AT HOME  Schedule visits to accommodate the family & the CHILD’S schedule  Utilize materials and toys from the home  Have caregiver participate in activities  Leave caregiver with strategies to incorporate into daily activities  Play with siblings during therapy TREATMENT APPROACHES  Neurodevelopmental Therapy  Strengthening  Motor Learning  Electrical Stimulation  Sensory Integration  Conductive Education  Move Curriculum  Body Weight Support Gait Training  Constraint Induced Therapy NEURODEVELOPMENTAL THERAPY  Developed by the Bobath’s in response to lack of neurobased treatment for children with CP and Adult Hemiplegia.  Goal of NDT: Enhance function  Treatment: Active participation of the individual and direct handling to optimize function with gradual withdrawal of direct input by the therapist NDT  Knowledge of normal development of movement and skill are used as a background to define the problem areas or missing components in an individual that are limiting function.  Problem areas/ Missing componenets are then addressed in treatment to gain function that is age appropriate.  Efficient motor function: Ability to combine a variety of movements into functional activities under a wide variety of environmental conditions NDT  Treatment focused on increasing function. Build on the patient’s strengths while addressing specific impairments through therapeutic handling.  Clinicians teach the movement with handling, then gradually withdraw guidance, making the client responsible for the movement.  Expand movement to different environments. Handling: Treatment with hands on client. This provides proprioceptive, tactile, kinesthetic and vestibular input. Includes use of key points of control for guidance of movement Facilitation: Sensorimotor input that creates the possibility of new movements. Assists in the activation of muscles or muscle groups to perform Inhibition: Sensorimotor input that reduces the possibility of movement. The act of inhibiting abnormal reflex activity or movement patterns via handling and positioning  TECHNIQUES TO REDUCE STIFFNESS  Relaxation: includes gentle rocking, warmth, talking gently  Pressure at muscle origin or insertion: Inhibits specific muscle activity  Quick alternating movements: Reciprocal movements with large amplitude oscillation  Rotation: Axial rotation breaks up total synergies, limb rotation to decrease stiffness  Vibration: light tremor applied manually TREATMENT TECHNIQUES CONTINUED  Traction: On limbs or through trunk combined with movement to inhibit agonist  Compression: to facilitate co-contraction  Tapping: to facilitate muscle contraction  Use of mobile surfaces  Incorporate movement directions of rotation and diagonals  Treat with the movement  Work proximally to effect distally TREATMENT SESSION  May begin with “prep work” to gain relaxation of stiffness and muscle elongation to prepare for movement or develop adequate activity for movement  Incorporate Muscle Activation to allow integration of muscles or muscle groups into functional activities  Work on Movement Responses, righting, balance, weight shift, protective responses TREATMENT SESSION Mobility: can continue with ideals of key points of control with facilitation techniques to improve gait Use of equipment, ball, bolsters, wedges, blocks Parental involvement  STRENGTHENING  As a result of the work with children post SDR, a rebirth of the need to strengthen children resulted  Works on the negative signs of UMN lesions: loss of motor control, weakness, fatigue, poor motor planning  Can be done best with children with isolated voluntary muscle control  Functional strengthening is key  Can use all modes of resistive exercise  There is evidence for success of Strengthening:  Children with Spastic Diplegia found to have decrease in crouch gait after strengthening program (Damiano) MOTOR LEARNING/MOVEMENT SCIENCE Developed from the body of knowledge of movement sciences Focus on skill acquisition, learning of tasks in a context specific environment Uses ideas of practice, feedback, feedforward, KR, KP Does not rely on facilitation or handling  ELECTRICAL STIMULATION  Neuromuscular Electrical Stimulation (NMES): High intensity stimulation to augment exercise using surface electrodes  Functional Electrical Stimulation (FES): Sequenced stimulation producing functional movement surface  Threshold Electrical Stimulation (TES): Low intensity simulation at sensory threshold. Thought to increase blood flow to muscle for growth and repair KINESIO-TAPING  Kinesio Tape: Used to facilitate movement patterns and muscle use, increase stability, and improve alignment and function. Proper application techniques are key in obtaining optimal results.  Always be sure to use a test patch over the area to be taped for four days prior to taping, to assess for reactions to the tape.  Often the trunk is more sensitive to tape than the extremities. A light coat of Milk of Magnesia can be used under the tape to decrease sensitivity.  May see KT used for: Torticollis, Brachial Plexus Injury, Cerebral Palsy, Down Syndrome etc. This method stabilizes the ribs to “connect” upper and lower trunk and provide a more stable base. Good for low postural tone This application it to decrease cortical thumb posture (thumb in palm) and improve grasp www.kinesiotaping.com CONDUCTIVE EDUCATION  Developed by Peto in Hungary, a system of education and therapy to achieve “orthofunction”  Conductors are teachers/therapists that structure all of the day’s events  Utilizes specialized equipment, plinths, ladder frames, chair, little to no bracing  Uses task series or exercise routines in group with rhythmic initiation  Widely used in U.K, somewhat in U.S. www.petoinstitute.org MOVE: MOBILITY OPPORTUNITIES VIA EDUCATION/ EXPERIENCE  Activity based program to help with sitting, standing, walking, and transitions  Uses specific equipment  Uses specific systematic instruction for functional tasks especially functional movement  6 steps: 1)Testing; 2) Setting goals; 3) Task analysis; 4) Measuring prompts, 5)Reducing prompts and 6)Teaching skills MOVE CURRICULUM  MOVE is a structured program that provides a framework and method to assess and measure gross motor skills;  Uses a top-down approach that looks at the skills the learner already possesses and teaches the skills necessary to become independent in a given activity at their highest functional level;  It is a form of teaching that embeds skilled practice throughout the learners day in functional activities; and  The majority of children and adults with motor disabilities are appropriate for inclusion in the MOVE Program as functional level and cognitive impairment are not considered a barrier. Most individuals who are in a MOVE program or curriculum are full time wheel chair users.  MOVE: DESCRIPTION  Nicole is a 4-year-old child with multiple disabilities. She has spasticity in all four limbs. Her functional ability is affected.  She currently uses a Tech Talker as an augmentative communication device.  Nicole is enrolled in an integrated pre-school class. There are 6 preschoolers with disabilities and 6 preschoolers without disabilities in her class. She has a one-on-one aide to assist her throughout the day.  With the assistance of the MOVE Program, we see Nicole walk into school every day and to the classroom. She arrives on the bus, and then she is placed in her gait trainer, and she walks into class with her classmates.  During playtime, Nicole can be seen quite often, pushing her doll carriage while standing and walking in her gait trainer.  MOVE: DESCRIPTION  With the use of an adaptive chair she is able to sit and participate in classroom activities with her classmates. During this past year, her sitting and standing ability have increased tremendously.  Nicole is now able to sit on the Blue Wave potty system in the bathroom that her classmates use. Nicole has also partaken of numerous school activities with a second-grade buddy.  She even recently performed in a school play about "Somewhere over the rainbow". Nicole can always be seen smiling and laughing as she shows everybody what she can do.  “This child believes in herself, and because of the MOVE Program has shown people what she can do independently."  - UCP, The Children's Center, a MOVE Model Site on Long Island, NY. BODY WEIGHT SUPPORTED TREADMILL TRAINING  The rationale for use of BWSTT is supported by current motor learning principles specifying active engagement in task performance over time for neuroplasticity to occur.  BWSTT allows repetition and intensity of training in the task-specific practice of walking.  BODY WEIGHT SUPPORTED TREADMILL TRAINING  Frequency 2-5 days per week  Session length 5-30 minutes per session  Treadmill speed.05 mph-3mph  Percent body-weight support  Load stance limb Use least amount of body weight support to maintain erect postural alignment  Manual assistance: Least amount required for stepping. Assist intra- and inter-limb coordination  Support using arms/hands: Fading use of handrails  Episode of treatment 2-16 weeks  Pre post assessments, walking speed, 6MWT, GMFM dimensions D &E BODY WEIGHT SUPPORTED TREADMILL TRAINING  Cochrane Systematic review finds little but improving evidence for the efficacy of BWST  Best with Children with DS (Improve age of onset of independent walking) DD (walking velocity) and somewhat in CP (motor skills) BODY WEIGHT SUPPORT THERAPY  CONSTRAINT INDUCED THERAPY  Based on the work of Taub, began with adults  Stronger arm is restrained for 6 hours a day for 21 days  Weaker arm is then facilitated and trained in specific age appropriate tasks  Therapy is given to produce changes in motor behavior and theoretically in brain activation www.circ.uab.edu/cit.htm  ALTERNATIVE THERAPIES Hippotherapy https://www.youtube.com/watch?v=RzcUTg-V KsM Craniosacral Therapy : https://www.youtube.com/watch?v=U_c ESXXnRB4 Patterning : https:// www.youtube.com/watch?v=QsAl97RyuX8 HIPPOTHERAPY HIPPOTHERAPY  Completed by professional therapist (OT, PT, or Speech Therapist) in conjunction with a professional horse handler  Direct hands on participation by therapist at all times  The horse's movement is essential to assist in meeting therapy goals  The goal of hippotherapy is professional treatment to improve neurological functioning in cognition, body movement, organization, and attentional levels  Hippotherapy is 1:1 treatment and often involves the use of NDT like handling or movement while on the horse  In hippotherapy the treating therapist continually assesses and modifies therapy based on the client's responses  THERAPEUTIC RIDING  Completed by professional horseback riding instructor in conjunction with volunteers including a therapist who may be involved as a consultant  Occasional hands on assistance by riding instructor and/or volunteer, with instructor primarily teaching from center of arena.  The horse's temperament is essential to learn riding skills  Therapeutic riding aims to provide social, educational, and sport opportunities in recreational horseback riding lessons adapted to individuals with disabilities  In therapeutic riding, the individual is often taught riding lessons in a group format, which runs in "sessions". The instructor must respond to the group as a whole, in addition to fostering individual success  In therapeutic riding, focus on the group lesson is encouraged, along with emphasizing proper riding position and rein skills HIPPOTHERAPY  DOLMAN DELACATO / PATTERNING  Based on the theories of Temple Fay who believed that motor development or sequences paralleled evolution and movement like amphibians and reptiles could help children with brain damage  Use of systematic reciprocal movements and sensory inputs would stimulate brain cells and restore normal movement. Requires hours of parental and volunteer work on the child (passive movement)  American Academy of Pediatrics and AACPDM have position statements against this form of intervention.  CRANIOSACRAL THERAPY  Craniosacral Therapy (CST) is a gentle, hands-on method of evaluating and enhancing the functioning of a physiological body system called the craniosacral system - comprised of the membranes and cerebrospinal fluid that surround and protect the brain and spinal cord.  Using a soft touch generally no greater than 5 grams, or about the weight of a nickel, practitioners release restrictions in the craniosacral system to improve the functioning of the central nervous system. From: Health Foundations Naturopathic Medicine & Midwifery Website CRANIOSACRAL THERAPY Why would a child need craniosacral therapy? One of the most common causes of pediatric problems arises from a difficult labor. Although the body is designed to withstand most forces during birth, prolonged or difficult labors can cause restrictions in the craniosacral system. Restrictions in the craniosacral system can cause the following symptoms:  CRANIOSACRAL THERAPY In an infant:  Excessive crying, irritability, and/or wakefulness  Startles easy  Difficulty with suckling or wants to suck constantly  Severe neurological impairments such as cerebral palsy or autism  Vomiting or spitting up after feeding  Arched back or throwing head back when held on should or side In the older infant or child:  Recurrent ear infections  Head banging  Thumb sucking  Constant rocking  Hear and/or ear pulling  Sensitivity around the head - does not like head touched or hair combed CRANIOSACRAL THERAPY  Insufficient evidence to support therapeutic effects from craniosacral therapy. ADELI SUIT, EUROMED, THERASUIT www.suittherapy.com Suit Therapy Euro-peds Adeli Suit Penguin Suit www.europeds.org  ADELI SUIT  Developed (1971) in Russia Modeled after the suit worn by cosmonauts  Suit was to provide resistance to counteract the effects of zero gravity (hypokinesis) to prevent muscle wasting and bone loss  1992 adapted to be used by those with neuromuscular problems particularly CP  Its major goal is to improve and change: proprioception (pressure from the joints, ligaments, muscles), reduce patient's pathological reflexes, restore physiological muscle synergies (proper patterns of movement) load the entire body with weight All of the above normalizes afferent vestibulo- proprioceptive input (information arriving to the vestibular system) influencing muscle tone, balance and the position of the body in space. The more correct proprioception from the joints, ligaments, muscles, tendons, joint's capsule etc., the more correct alignment.  SUIT THERAPY RESEARCH  1 published report 1 unpublished  1. Frank and associates in Israel  24 subjects GMFCS level II, III, IV, age matched randomized  Treatment 5 days a week 2 hours  Control group regular PT  Experimental Group Adeli Suit under Russian Protocol  Both groups improved, no difference between groups  2. Dabrowski Children's Hospital of Michigan  57 subjects  All had PT, OT and Speech 3 x a week for 8-10 weeks with 4-week home program  Experimental group wore Adeli suit for last 4 weeks of therapy  All improved no difference between groups SUIT THERAPY RESEARCH AACPDM and UCP cannot at this time support the use of the Adeli suit or suit therapy as there is no suggestion that the suit itself has any advantage over intensive therapy itself