OT1028 Medical-Surgical Foundations in Pediatrics PDF

OT1028 MEDICAL-SURGICAL FOUNDATIONS IN PEDIATRICS SHIFT 1 Introduction to Pediatric Rehabilitation...

OT1028 MEDICAL-SURGICAL FOUNDATIONS IN PEDIATRICS SHIFT 1 Introduction to Pediatric Rehabilitation LESSON Dra. Arlene Ledesma| August 16, 2024 01 PEDIATRICS Prepubescent (late school child 10 - 12 years (girls) Pediatrics - medical care of infants, children, up to or early adolescent) 12 - 14 years (boys) adolescence American Academy of Pediatrics - pediatric care up to Pubescent (adolescents 10 - 20 years (girls) age 21 proper) 12 - 14 years (boys) Puberty (average) 12 years (girls) AGE GROUPS 15 years (boys) Perinatal period - from 20th week of gestation to the first six days after birth P (late adolescent or youth) 16 - 20 (boys) Neonatal period - first 28 days after birth Under five 1st trimester ○ Early infancy - under 1 mo. to 1 year very critical for the genetic error of the child ○ Later infancy (toddler) - 2-3 years medications would have a significant impact on the School age - from 6 years quality of life of the child Adolescence - 10-19 years Girls mature earlier than boys due to menarche PERIODS OF GROWTH Early menarche (menstruation) and late menopause pose higher risk for breast cancer PRENATAL (0-280 days) PEDIATRIC REHABILITATION Ovum 0-14 days Children with disabilities need attention in improving function → pediatric rehabilitation Embryo 14 days to 9 weeks focuses on maximizing the function and enhancing Fetus 9 weeks to birth lives Early Fetal life 2nd ○ Mobility, speech, and strength trimester ○ Gadgets can cause delays in children Late Fetal life 3rd trimester congenital disabilities, improvement in quality of life (ped rehab) Premature infant 23 weeks to 37 weeks High risk of cerebral palsy. Not GROWTH all but high risk. Increase in physical size and dimension Most rapid growth rate during infancy and prepubescent BIRTH through adolescence Average of 280 (37-42 weeks) POST NATAL Infancy Birth to 2 years Neonate (newborn/ early First 4 weeks after birth infant) Infancy (middle or nursing) 1 year Infancy (transition, toddler, or 1-2 years run about) Childhood Early childhood 2-6 years FOUR CHARACTERISTIC STAGES OF GROWTH (preschool) FROM BIRTH TO ADULT: Later childhood (school 6-10 years (girls) Rapid growth in infancy and early childhood child) 6-12 years (boys) Slow, steady growth in middle childhood (8-10 y/o) Rapid growth during puberty Adolescents First year ○ Secondary sexual characteristics emerge 10-18 (girls) Gradual slowing down of growth in adolescence until 12-20 (boys) adult height is reached UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 1 OT1026 SHIFT #1 | LESSON #1 | Introduction to Pediatric Rehabilitation Newborn: FACTORS AFFECTING GROWTH AND DEVELOPMENT ○ Head is large Hereditary ○ Abdomen is prominent Environmental factors Due to lordotic curve in newborns ○ Prenatal environment (significant stunting) ○ Trunk and extremities are short (compared with Nutritional adults) Important in-utero, natally, and With changing body proportion, there is a shift in body’s postnatal COG from the xiphoid process to the sacral Diabetic mother (maternal condition) promontory Radiation, infection ○ Change in gait pattern as well ○ Related to fetus Malposition, placental implantation ○ Postnatal Environment Socio-economic status Child’s nutrition Number of siblings Internal environment ○ Child’s intelligence ○ Hormonal influences ○ Emotions Infants with neurologic impairment and oral motor dysfunction require supplemental feeding (NGT) Some endocrine dysfunctions or systemic skeletal diseases may lead to generalized growth retardation ○ Pituitary tumors, dwarfism The typical 2-3 y/o has a mild lumbar lordosis with protuberant abdomen ○ In females, lumbar lordosis is visible during pregnancy ○ In males, lumbar lordosis is visible during middle age NEUROLOGIC LESIONS THAT AFFECT GROWTH By early school age, increased abdominal strength leads Brachial plexus palsy to a more mature pelvic alignment and decreased ○ If the baby is too big due to mother‘s diabetes, lordosis the head and shoulders may be compromised. ○ Abdominal strength increases as we age ○ Shoulder may incur shoulder traction injury ○ Lumbar lordosis disappears Klempke’s or Nerve’s Palsy The rate of growth is a sensitive indicator of health or Congenital varicella syndrome disease. ○ Chickenpox of mother ○ Anthropometric measurements of weight, height, Myelodysplasia (Spina Bifida) head, abdomen indicate health status ○ Folic acid deficiency of mother Ie. increase in head circumference may indicate microcephaly DISORDERS INSIDE THE BRAIN It should be serially measured and recorded on the standard growth chart for comparison Head Circumference Birth 35 cm 4 months 41 cm 12 months (+12cm from birth) 47 cm UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 2 OT1026 SHIFT #1 | LESSON #1 | Introduction to Pediatric Rehabilitation Maturity 57 cm 30 to 60 respirations per min 100 to 160 beats per min Ave. 40 respirations per min 100 while sleeping 160 while crying TEMPERATURE BLOOD PRESSURE (AT BIRTH) Rectal Average: 75/42 90.0° F to 99.5° F (35.6° C to 37.5° C) Systolic: 60 to 80 mmHg Axillary Diastolic: 40 to 50 mmHg 97.6° F to 98.6° F (36.5° C to 37.0° C) APGAR SCORE RATES: APGAR SCORING CHART SIGN 0 1 2 1 min 5 mins ANTERIOR FONTANELLE Heart Rate Absent Less than Over 2 2 100 100 Diamond in shape The junction of the sagittal, coronal and frontal sutures Respiratory Absent Slow, Good 1 2 forms it Effort/Rate Irregular Cry ○ Does not close because it allows growth Muscle Limp Some Active 1 2 Between 2 frontal & 2 parietal bones Tone Flexion Motion 3-4 cm in length and 2-3 cm width Closes at 12-18 months of age Reflex No Grimace Cry 1 2 Irritability Response POSTERIOR FONTANELLE Color Pale Body Pink, All 1 2 Triangular in shape Extr. Blue Pink Located between occipital & 2 parietal bones Closes by the end of the 1st month of age TOTAL SCORE 6 10 An adult patient that incurred a hemorrhagic bleed or ventricular Score Interpretation Status obstruction can have hydrocephalus, but their head does not 7 - 10 Normal enlarge like this anymore because the anterior fontanelle is already closed, which leads to increased intracranial pressure 4-6 Moderately depressed and ataxia 0-3 Severely depressed MICROCEPHALY AND HYDROCEPHALUS MEASUREMENTS IN GROWTH Height / Stature Birth 50 cm 12 months (increase by 50%) 75 cm 4 years 100 cm Early school age 5 cm annually Prepubescent/adolescence 5-8 cm annually Hydrocephalus Microcephaly Recumbent length more precise for children below 5 Hydrocephalus – a lot of fluid or having obstruction in years of age the ventricles. For children with deformity of the spine of LE, height Microcephaly – mother incurred virus like Zika virus prediction can be obtained by measuring arm span Adult height can be estimated by doubling length at 2 RESPIRATION HEART RATE (APICAL) years UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 3 OT1026 SHIFT #1 | LESSON #1 | Introduction to Pediatric Rehabilitation Girls attain maximal growth velocity before menarche and Absent babbling by 5 months Hearing deficits cessation 2 years after Boys grow fastest late in puberty concurrent with the Absent stranger anxiety by 9 May be related to multiple care appearance of facial hair months providers W-sitting and bunny hopping at Evaluate for adductor spasticity Weight 7 months or hypotonia (cerebral palsy) Birth (full term) 3.4 kg Inability to localize sound by 10 Unilateral hearing loss months 5 months Double Persistent mouthing of objects May indicate lack of intellectual 12 months Triple at 12 months curiosity Until adolescent growth spurt 2 kg annually Identify Developmental Delay and (Age-appropriate) Functional Delay Newborns 6 months UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 4 OT1026 SHIFT #1 | LESSON #1 | Introduction to Pediatric Rehabilitation ERICKSON’S PSYCHOSOCIAL STAGE MILESTONES IN CHILD DEVELOPMENT Milestones in Child Development Favorable Unfavorable Stages Crisis Outcome Outcome Childhood Faith in the Trust vs Suspicion, fear of 1 environment and Mistrust future events future events A sense of Feelings of Autonomy vs 2 self-control and shame and Doubt adequacy self-doubt Ability to be a A sense of guilt Initiative vs “self-starter,” to and inadequacy 3-5 Guilt initiate one’s own to be on one’s activities own Ability to learn A sense of Industry vs how things work, inferiority at 6 to puberty Inferiority to understand and understanding organize and organizing Transition years Seeing oneself as Confusion over Identity vs Adolescence a unique and who and what Confusion integrated person one really is Adulthood Ability to make Inability to form Early Intimacy vs commitments to affectionate adulthood Isolation others, to love relationship Concern only for Generativity Concern for self one’s own Middle age vs Self- family and society well-being and absorption in general prosperity A sense of Dissatisfaction integrity and Integrity vs with life; despair Aging years fulfillment; despair over prospect of willingness to death face death Habilitation ○ Application of the principles of rehabilitation to a child who have not had the chance to develop his function from the onset Advantage of pediatric patient is the plasticity of the brain and adaptability of the child to his disability provided he is given the proper milieu to grow and develop At 8–10 years, the school–age child: STAGES OF GROWTH AND DEVELOPMENT ○ Throws balls skillfully Pre-natal stage ○ Used to participate in organized sports Infancy ○ Handles eating utensils skillfully ○ Neonate birth to end of one month At 10–12 years, the school–age child: ○ Infancy one month to end of one year ○ Enjoy all physical activities Early childhood ○ Continues to improve his motor coordination ○ Toddler 1-3 years ○ Pre-school 3-6 years SCHOOL AGE: COGNITIVE DEVELOPMENT Middle childhood At 7-11 years, the child now is in the concrete operational ○ School age stage of cognitive development ○ 6 to 12 years Reading, playing computer and board games. Late childhood ○ Adolescent ○ 13 years to 18 years UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 5 OT1026 SHIFT #1 | LESSON #1 | Introduction to Pediatric Rehabilitation ADOLESCENT AGE INFANTILE REFLEX DEVELOPMENT Physical growth Motor behavior is influenced by primitive reflexes as a Physiological growth result of the immature CNS. Secondary sex characteristics These reflexes generate predictable and stereotypic Cognitive development movements and postures. Emotional development During the first 6-8 months of life as the CNS matures Social development these reflexes are gradually suppressed. At the same time, more sophisticated postural responses emerge between 2-14 months of age that are used and 13 TO 18 YEAR OLD incorporated into volitional motor behavior. PHYSICAL GROWTH: REFLEX DEVELOPMENT Weight: ○ Growth spurt begins earlier in girls (10–14 years, while it is 12–16 in boys) REFLEX RESPONSE AoS ○ Males gain 7-30kg, while females gain 7-25kg Moro or Startle Shoulder abduction; 4-6 months Height: Extension of the elbow and ○ By the age 13, adolescent triples in birth length fingers; Followed by adduction ○ Growth in height ceases at 16 or 17 years in Rooting Moving head towards stimulus 4 months females and 18 to 20 in males Positive Legs extend for partial 3-5 months Supporting support of BW APPEARANCE OF SECONDARY SEX CHARACTERISTICS Secondary sex characteristics in girls: Asymmetrical Extremity extend on the face 6-7 months Tonic Neck side and flex on the occiput ○ Development of the breasts Reflex (ATNR) side ○ Change in the vaginal secretions ○ Growth of pubic and axillary hair Symmetric Tonic Neck flex, arms flex, legs 6-7 months Neck Reflex extend; Neck extend, arms ○ Menstruation (first menstruation is called (STNR) extend, legs flex menarche, occurs between 12 to 13 years) ○ Body image Palmar Grasp/ Flexion of fingers/toes Palmar 5-6 m Plantar Grasp Plantar 12-14 m Secondary sex characteristics in boys: ○ Increase in size of genitalia Automatic Alternating automatic steps 3-4 months ○ Growth of pubic, axillary, facial, and chest hair Walking with support ○ Change in voice Placing Extremity flexion to put foot Before end of first ○ Rapid growth of shoulder breadth over an obstacle year ○ Production of spermatozoa Neck Righting Sequential body rotation from 4 months shoulder to pelvis (toward COGNITIVE DEVELOPMENT direction of face) Through formal operational thinking, adolescents can deal with a problem PHYSIOLOGIC POSTURAL REFLEX RESPONSE Reflexes that should emerge EMOTIONAL DEVELOPMENT This period is accompanied usually by changes in emotional control REFLEX RESPONSE AoE Adolescents exhibit alternating and recurrent episodes of Head and Body Align face and head Prone: 2 m disturbed behavior with periods of quite one Righting vertical, mouth horizontal Supine: 3-4 m He may become hostile or ready to fight, complain, or Parachute Extension of extremity to Sitting anterior: 5-7 m resist everything Reaction or prevent falling Lateral: 6-8 m Protective Posterior: 7-8 m Extension Standing: 12-14 m SOCIAL DEVELOPMENT He needs to know "who he is" in relation to family and Age of Suppression (AoS); Age of Emergence (AoE) society, i.e., he develops a sense of identity If the adolescent is unable to formulate a satisfactory SETTING THE TONE identity from the multi-identifications, sense of Child-friendly self-confusion will be developed Small table and chair According to Erikson: Toys for different ages, pictures of cartoon characters or ○ Adolescents show interest in other sex. animals on the wall ○ He looks for close friendships Examiner’s attire (bright colors) UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 6 OT1026 SHIFT #1 | LESSON #1 | Introduction to Pediatric Rehabilitation Valuable skills: observant, flexible and spontaneous, outweigh the risk creative with play and other activities that foster intrinsic motivation in children X Studies showed evident risk to the foetus and use of the drug is contraindicated in pregnant women HISTORY Based on age and developmental level Reason for referral, evaluation process, and management NEURAL TUBE DEFECTS BIRTH HISTORY Maternal complications during pregnancy: seizures, febrile illnesses, hypertension, or hyperglycemia Medications, supplements, alcohol, tobacco or other substances Duration of gestation, presence of multiple fetuses, fetal presentation Folate intake Decrease in fetal movement Complications with previous pregnancies–stillbirth, miscarriages, or fetal anomalies Child’s birth weight, length, and Apgar scores Postnatal complications: Hyperbilirubinemia, retinopathy Defect Description of prematurity, respiratory difficulties, feeding difficulties, Craniorachischisis Completely open brain and spinal cord and duration of respiratory support Anencephaly Open brain and lack of skull vault Encephalocele Herniation of the meninges (and the brain) Iniencephaly Occipital skull and spine defects with extreme retroflexion of the head Spina Bifida Closed asymptomatic NTD in which some of the Occulta vertebrae are not completely closed Closed Spinal Deficiency of at least two vertebral arches, here Dysraphism covered with a lipoma Meningocele Protrusion of the meninges (filled with CSF) through a defect in the skull or spine Myelomeningocele Open spinal cord (with a meningeal cyst) HISTORY OF PRESENTING PROBLEM Onset Associated factors Fetal alcohol syndrome Progression of symptoms ○ Short intercanthal space ○ Static? Worsening? Improving? ○ Fascies Diagnostic tests and treatment ○ Therapeutic modalities? SUBSTANCES AND ABNORMALITIES Temperament and personality ○ Have an idea of child’s readiness to participate in therapy Categories Description ○ Whether it’s not not normal if child is restless, no A Adequate studies on pregnant women indicated crying, excessive crying, hyperactive no foetal risk Significant illnesses, hospitalizations, surgeries, previous trauma, injuries, burns, fractures, allergies, feeding B Animal studies have showed no evidence of intolerance, respiratory complications harm to the foetus, but lack of studies in Medications pregnant women Immunization C Animal studies have shown adverse effect or no ○ Risk for disorders like polio and tetanus animal studies are conducted and no adequate studies in pregnant women APGAR SCORES D Studies showed risk to foetus, but benefit may SIGN 0 1 2 UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 7 OT1026 SHIFT #1 | LESSON #1 | Introduction to Pediatric Rehabilitation Appearance Pale Body Pink, Extr. All Pink Visual impairment Blue Pulse Absent Less than 100 Over 100 FAMILY HISTORY Early stroke, early myocardial infarction, peripheral Reflex No Response Grimace Cry neuropathy, joint or tissue abnormalities, myopathies, or Irritability bony abnormalities, gait abnormalities, or developmental Muscle Tone Limp Some Flexion Active Motion delays Respiratory Absent Slow, Irregular Good Cry ○ Pattern of inheritance of diseases Rate Genetic testing if warranted Recorded at 2 minutes, 5 minutes, and 10 minutes Score of 7-10 is considered normal SOCIAL AND EDUCATIONAL HISTORY Child’s environment g ○ Who lives with the child at home? Siblings? Own room? Accessibility Peer group ○ Influence on the child Extracurricular activities ○ Hobbies, interests, sports Educational history ○ Delays in schooling? Regular school or SPED? PHYSICAL EXAMINATION OBSERVATION Reaction to separation from the parents (in young children) Apparent visual and auditory awareness Temperament (calm or hyperactive, compliant or difficult) DEVELOPMENTAL HISTORY Spontaneous exploration and interest in toys, games, or books in the room Style, concentration, attention span or distractibility during play Level and manner of motor activities Attempts to engage the parents and examiner in conversation, vocabulary, complexity of language, and quality of speech Interaction with parents or examiner (appropriate, shy, or demanding) EXAMINATION BY AGE INFANTS AND YOUNG CHILDREN Develop rapport ○ Popular cartoon character to gain interest while testing Delay motoric in nature → neuromuscular disorder Easy tools to engage a child and test visual fixation, ○ First report → Lack of spontaneous movement reach, grasp, and release when a child is put on the crib (hypotonic or Hearing, vision, cranial nerves and postural abnormalities spastic) also can be observed Delay in speech ○ Vision: Follows pen light ○ Hearing loss (infants start to fall behind after 6-8 ○ Hearing: Name calling months) A very young child is typically most comfortable on the ○ True language dysfunction parent’s lap during the examination Affects reception and expression The actual hands-on examination is the last stage; ○ Oral motor dysfunction anxiety-provoking or painful tests are preferred to the end History of recurrent ear infections and antibiotic use Giving choices involves preschool child in examination ○ Aminoglycocites and cochlear toxicity UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 8 OT1026 SHIFT #1 | LESSON #1 | Introduction to Pediatric Rehabilitation SCHOOL-AGED AND ADOLESCENTS Children with cognitive deficits need to be approached INSPECTION according to their mental rather than chronologic age Facial anomalies, epicanthal folds, increased intercanthal Older children and adolescents can easily be evaluated distance, external ear anomalies, palmar simian crease, on the examination table malformations of toes and fingers Adolescents’ concerns may be different from those of the Skin examination: port wine stains (Sturge-Weber family and should be addressed with respect and privacy syndrome), café-au-lait spots, axillary freckling, scalded Take note of the increasing functional needs in IADLs and skin appearance, purpura, ash-leaf spots, telangiectasia, other areas of competence – educational achievements, malar rash writing, reading, arithmetic (3Rs) GROWTH HEIGHT Measuring Height: ○ Average full-term newborn — 50 cm in length ○ Increases 50% by age 1 ○ Doubles by 4 years of age ○ Adult height can be estimated by doubling its height at age 2 years Turner and Down syndrome – short stature ○ Turner – XO chromosome instead of XX ○ Down’s – Trisomy 21 Precocious puberty – growth Arrest ○ Onset of puberty in girls younger than 8 years and boys younger than 9 years of age (early) Spina bifida and other disabilities that require full time wheelchair use, arm span measurement is recommended Sacral dimple, skin lesions over the spine, and/or a hairy instead of height. tuft Extremity length and girth are recorded in children with Cranial deformities, facial dysmorphisms, and neurogenic weakness, epiphyseal fracture, or arthritis. asymmetries Joint abnormalities or asymmetry of stature or sides WEIGHT ○ Varus or valgus deformity or claw toes ○ Calluses, bruises and abrasions Normal for the infant to initially lose weight ○ Anterior axillary and upper chest muscle atrophy By 5 months of age, the weight should have doubled ○ Congenital clubfeet or multiple joint deformities By a year, the child should have tripled its birth weight ○ Hypertrophy of the calf (Duchenne muscular Decreases in height velocity or weight loss dystrophy) Poor nutrition or malabsorption ○ Scoliosis Significant increase in weight ○ Pituitary tumor, metabolic disorder, or poor diet HEAD CIRCUMFERENCE Average head circumference at birth is 35 cm ○ Increases to 47 cm by 1 year of ageA Macrocephaly ○ HC greater than 2 SDs above the mean ○ Quick inspection of the parents’ head sizes may help to differentiate between a familial trait and hydrocephalus or some type of mass Microcephaly ○ HC greater than 2 SDs below the mean ○ Brain has not fully formed or growth has been arrested PALPATION In infants and young children, the fontanelles and cranial sutures should be palpated for patency, tension, and size UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 9 OT1026 SHIFT #1 | LESSON #1 | Introduction to Pediatric Rehabilitation The skin should be felt for texture, temperature, and MUSCULOSKELETAL ASSESSMENT absent or excessive perspiration Inspection and palpation of the bones, joints, and Subcutaneous abnormalities may be palpable muscles When arthritis is suspected, each joint should be felt for Lymphedema, congenital amputations, calf hypertrophy cardinal signs of inflammation Brachydactyly (lack finger/s), polydactyly (extra finger/s), ○ Warmth, discomfort, swelling syndactyly (webbed finger/s) Palpation of muscle tone and bulk Tenderness, swelling, warmth, and synovial thickening Passive and active range of motion of all joints NEUROMUSCULAR SYSTEM ○ A full-term infant may lack as much as 25° of Testing reflexes, tone, active motion, strength, and elbow extension and 30° of hip extension coordination ○ A preterm infant has increased range of motion After 4-5 years of age the standard examination is as a result of lower muscle tone (scarf sign) generally applicable ○ Differences between bilateral hip abduction, Infancy reflex testing apparent shortening of one leg and asymmetric In the first few months of life, flexor tone predominates gluteal and upper thigh skin folds are highly Hypo or hypertonia signals neurologic abnormalities suggestive of congenital or acquired hip Child should be examined in supine, prone, and vertical dysplasia positions to elicit typical postures ○ An early varus configuration of the tibia ○ Increased scissoring, extension, and contribute to the physiologic bowleg appearance plantarflexion when child is suddenly lifted into in infancy and corrects itself by 2-3 years of age vertical suspension (cerebral palsy) A 4-month old infant elevates the head and trunk on extended arms in the prone position ○ Scapular winging → weak serratus anterior mm Lifting up under the axilla elicits spontaneous active shoulder depression ○ Shoulders slide upward, virtually touching the ears → suggest myopathy with proximal weakness Walking on tiptoes, squatting and rising without using the arms for assistance, and straight sitting up from supine position or to the side – 3 years Testing for Trendelenburg sign and grading the triceps surae – 4 years The standard technique of manual muscle testing – after school age, except in children who have serious behavioral problems or mental retardation Detection of coordination deficit is based mostly on observation of gross and fine motor function – less than 2-3 years Around 3 years of age, the child can walk along a straight line, unsteadily placing one foot in front of the other Clumsiness of handwriting and drawing, difficulties in physical education or sports, and other subtle signs may Passive and active range of motion of all joints be suggestive of apraxia, visuomotor perceptual deficit, or ○ Loss of range of motion - joint contracture from learning deficit arthrogryposis, orthopedic conditions such as Klippel-Feil syndrome, spasticity, pain, inflammatory disorders such as juvenile inflammatory arthritis, or trauma. ○ Hypermobility of joints and skin elasticity – Marfan syndrome Gait abnormalities evident on clinical observation ASSESSMENTS UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 10 OT1026 SHIFT #1 | LESSON #1 | Introduction to Pediatric Rehabilitation Hip or knee contractures Hemiparetic Posturing of upper limb Cerebral palsy Circumduction of hip Cerebral vascular Inversion of foot accident (CVA) Waddling / Weakness of hip girdle Neuromuscular Trendelenburg Wide-based gait disease Ataxic Coordination problems Cerebellar ataxia Poor tandem walking Friedreich ataxia Gait Abnormalities Description Talipes Congenital deformity in which the foot is twisted from its normal position Tail Ankle Pes Foot Talipes Cavus High arched foot Talipes equinus Plantar Flexion Back and Spine Examination Talipes calcaneus Dorsiflexion ○ Examined in both sitting and standing positions Talipes Valgus Abduction and eversion Any leg length discrepancy may affect the spine and pelvis examination Talipes Varus Adduction and inversion Shoulder height, the position of the scapulae, the space between the trunk and the upper limbs, and the height of the pelvis should be evaluated Idiopathic scoliosis in adolescent girls is the most common type of scoliosis ○ The spine curve should be evaluated by serial radiographs to determine the severity, flexibility, and progression of the curve over time ○ The rib hump can be further accentuated by having the child bend forward Tibial Torsion — In-toeing in toddler GAIT ABNORMALITIES Femoral Anteversion — In-toeing in older child Hip or leg length discrepancy – hip may be subluxed or Gait Characteristic(s) Clinical Association dislocated Spastic Adducted hips Cerebral palsy Child’s knee should be evaluated for stability, mobility, Internal rotation of hips and positioning Toe walking Child’s foot can be normal at (pes planus) until 3-5 years Crouched Weak quadriceps Neuromuscular Charcot-Marie-Tooth disease Weak hip extensors disease ○ Pes cavus with sensory loss, weakness in ankle Excessive dorsiflexion Cerebral palsy dorsiflexors and clawing of toes UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 11 OT1026 SHIFT #1 | LESSON #1 | Introduction to Pediatric Rehabilitation NEUROLOGIC ASSESSMENT Cranial nerve function, sensory function, strength, movement, reflexes, coordination, balance, gait, and cognitive function Sensory function - light touch, proprioception, vibratory, pain, and temperature sensation ○ Objective evaluation is generally feasible after 5-6 years ○ Nonverbal cues – looking at a light touch stimulus or pulling the limb away when touched Visual stimulus – bright light or interesting object ○ Track an object to midline at 1 month ○ Track an object from side to side at 3 months ○ Perception of color at 8 weeks ○ Depth perception at 3-5 months Visual evaluation ○ Stycar test and the illiterate E chart are used for screening preschool children at risk for visual deficit. Auditory evaluation ○ In the infant, hearing can be evaluated by clapping or making a loud noise and watching for a startle (Moro) or blink response ○ Older children should respond to rubbing one’s fingers close to their ears or using toys that make sounds Primitive and postural responses ○ Primitive reflexes are suppressed between 3-6 months UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 12 OT1026 SHIFT #1 | LESSON #1 | Introduction to Pediatric Rehabilitation Manual muscle examination FUNCTIONAL ASSESSMENT ○ Not very accurate before the age of 5 years, but Functional independence wee the child should show at least antigravity ○ Functional Independence Measure (weeFIM) strength Developmental skills Tone ○ Denver Developmental Screening Test (DDST-II) ○ Hypotonia – neuromuscular abnormality - birth to 6 years of age ○ Hypertonia – spasticity (catch), dystonia ○ Bayley Scales of Infant Development - from birth (co-contraction), and rigidity (all throughout) to 30 months of age Gait ○ Gesell Developmental Schedule - from 4 weeks ○ Pattern changes and progresses from 1-7 years to 6 years Intellectual evaluation PRIMITIVE REFLEXES ○ Stanford-Binet Intelligence Scale ○ Wechsler Preschool and Primary Scale of Resolves by Reflex Stimulus Response Intelligence-Revised (WPPSI-R) (Months) ○ Wechsler Intelligence Scale for Moro Sudden neck Shoulder abduction, 3-4 Children-Revised (WISC-R) extension elbow and finger extension followed by ○ Kaufman Assessment Battery for Children shoulder adduction Academic achievements and elbow flexion, ○ Wide Range Achievement Test—Revised infant may cry (WRAT) Rooting Stroking area Head and mouth 4 ○ Woodcock-Johnson Psychoeducational Battery: around the mouth move toward Test of Achievement stimulus ○ Peabody Individual Achievement Test Galant Stroke skin along Trunk flexes to the 2-6 Visual motor abilities the side of the side that is stroked ○ Beery-Buktenica Developmental Test of Visual spine with the child in prone Motor Integration and the Bender Visual Motor Gestalt Test Palmar Touch palm Flexion of all fingers 5-6 ○ Rey-Osterrieth Complex Figure Test Grasp Social and adaptive skills and perceived quality of life ATNR Head turned to Arm and leg on face 6-7 ○ Vineland Adaptive Behavioral Scale side side and flex on ○ Pediatric Quality of Life Inventory (PedsQL) occipital side Disability-specific assessment STNR Neck flexion and Arm flex, legs 9 - 11 ○ Gross Motor Function Measure (GMFM-66) neck extension extends, arm extend, ○ 32 the Manual Abilities Classification Scale legs flex (MACS) ○ Quality of Upper Extremity Skills Test (QUEST) POSTURAL REACTIONS SUMMARY Reflex Stimulus Response Age of Emergence Pediatric history and examination should be Head Vestibular or Head and face Prone: 2 months individualized. righting visual aligned vertical and Rehabilitation approaches and goals should be tailored to mouth aligned Supine: 3-4 months horizontal the child’s developmental level. Assessment tools will assist in determining the child’s Protective COG Abduction of upper Sitting anterior: 5-7 strengths and weaknesses in all domains. extension displaced limb toward months outside base displacement to Inform the family about the findings of the examination of support in prevent falling Lateral: 6-8 months and the rehabilitation plan. sitting The client should be treated holistically. Posterior: 7-8 Future needs in care and functional rehabilitation should months be provided. Parachute COG Extension of upper Standing: 12-14 reaction displaced limbs outside base months toward of support in displacement to CASE standing prevent falling B.C is a 10-year old right-handed child born at 36 weeks of gestation whose brain imaging shows a prenatal stroke on the left. He has right spastic hemiplegia, treated with botulinum injections every 4 months. He is on ankle-foot orthosis to help in walking, running and playing soccer with his friends. He is in regular classes at school and has no problem seeing, hearing, eating, talking, or socializing. UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 13 OT1026 SHIFT #1 | LESSON #1 | Introduction to Pediatric Rehabilitation CEREBRAL PALSY 70-80% are prenatal in origin. Prematurity remains the most A group of permanent disorders of the development of common antecedent of cerebral palsy movement and posture, causing activity limitation, that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain. PATHOPHYSIOLOGY The motor disorders of cerebral palsy are often Immaturity, fragile brain vasculature and physical accompanied by disturbances of sensation, stresses of prematurity → compromise of cerebral blood perception, cognition, communication and behavior, flow → Intraventricular hemorrhage (IVH) by epilepsy, and by secondary musculoskeletal Outcome of infant with IVH depends on the degree of problems associated parenchymal injury A higher proportion of children had growth retardation, dental enamel abnormalities, and abnormal PRENATAL HYPOXIC-ISCHEMIC CEREBRAL INJURY dermatoglyphic patterns and other congenital anomalies Associated with multiple pregnancy, maternal bleeding, or dysmorphic features maternal drug use, or most frequently idiopathic Dr. William John Little: First person to study CP (1853) Lack of blood supply (ischemic) and oxygen (hypoxic) on Sir William Osler: Coined the term “cerebral palsy” the cerebrum Dr. Sigmund Freud: First to state that CP might be caused by abnormal development before birth and is VOLPE’S SUBTYPES OF HYPOXIC-ISCHEMIC NEUROPATHOLOGY associated with other disorders PARASAGITTAL CEREBRAL INJURY EPIDEMIOLOGY Involves bilateral cortical and adjacent subcortical white Leading cause of childhood disability matter necrosis of the superior medial and posterior Overall prevalence rate: 2.11 per 1000 live births aspects of the cerebral convexities Dramatic increases in prevalence are seen in children Most Frequent Long Term Consequence: spastic with very low birth weight (59.6 per 1000 live births) and quadriplegia (because it is bilateral) very early gestation (111.8 per 1000 live births) ETIOLOGY/RISK FACTORS PRECONCEPTION (MOTHER) Mother alone Maternal seizures, intellectual disability, thyroid disease (hyper and hypo), history of stillbirth or neonatal death, maternal age older than 40 years, and low socioeconomic status ANTENATAL (DURING PREGNANCY) PERIVENTRICULAR LEUKOMALACIA Birth defects, small for gestational age, low birth weight, Occurs in the preterm infant involving bilateral white placental abnormalities, maternal disease during matter necrosis adjacent to the external angles of the pregnancy (respiratory, heart, seizures, and incompetent lateral ventricles affecting the centrum semiovale and cervix), abnormalities in fluid volume, maternal bleeding optic and acoustic radiations in the second and third trimesters, hypertension, Long term Manifestations: spastic diplegia and spastic preeclampsia, and chorioamnionitis quadriplegia, with visual and cognitive deficits in more severe injury INTRAPARTUM (DURING LABOR) ○ Effects in optic and acoustic gradations Birth hypoxia (lack of oxygen to the brain), meconium staining, meconium aspiration, abnormal duration of labor, and fetal presentation NEONATAL (BIRTH TO 28 DAYS OF AGE) Prematurity, low birth weight, growth retardation, seizures, respiratory distress, hypoglycemia, infections, and jaundice POSTNATAL (PAST NEONATAL STAGE) Stroke, abusive head trauma, bacterial meningitis, and motor vehicle crashes UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 14 OT1026 SHIFT #1 | LESSON #1 | Introduction to Pediatric Rehabilitation Negative – lack of muscle activity or control FOCAL AND MULTIFOCAL ISCHEMIC BRAIN NECROSIS ○ Weakness Injury to all cellular elements caused by an infarction ○ Reduced selective motor control within a vascular distribution ○ Ataxia ○ MCA most commonly affected ○ Apraxia or Incoordination Long term neurologic manifestations: spastic hemiplegia, spastic quadriplegia, and seizures Movement patterns typically increase with stress or purposeful activity Deep tendon reflexes are usually normal to slightly STATUS MARMORATUS increased and some spasticity can be present Rarest lesion Pseudobulbar symptoms such as dysarthria, swallowing Neuronal injury within the basal ganglia difficulty, drooling, and oromotor dyskinesias might be Associated with one of the neuropathologic subtypes present Long Term Neurologic Manifestation: choreoathetosis Involuntary movements cease during sleep ○ Dance-like with slow writhing movement CLINICAL PATTERNS SELECTIVE NEURONAL NECROSIS Most Common variety of injury Coexists with one or more of other lesions NEONATAL PATTERN Specific Neurons Vulnerable: hippocampus, lateral After a severe brain injury, neonates tend to be hypotonic geniculate body, thalamus, caudate, putamen and globus and develop spasticity over time pallidus, CN 5 and 7 motor nuclei It can be difficult to elicit muscle stretch reflexes, and Pathogenesis related to oxygen deprivation and there are minimal milestones to evaluate excitotoxic amino acids Milestones may be delayed in premature children until 2 Long term sequelae: mental retardation and seizures years GENESIS OF HYPOXIC-ISCHEMIC EVENT DIPLEGIC PATTERN Usually prenatal Hypertonic deficits are noted mainly in bilateral lower Cerebral ischemia before the 20th week of gestation → limbs neuronal migration deficit Scissoring of bilateral lower limbs and talipes ○ In a developing brain, the nerve cells fail to equinovarus deformities predominate migrate to where they should be located ○ Equinovarus — inverted/papasok foot 28-34 weeks → periventricular leukomalacia If ambulatory, toe walking with crouching tends to be 34-40 weeks → focal or multifactorial cerebral injury present Loss of range of motion and hyperreflexia is present in the lower limbs CLASSIFICATION Topography or distribution of affected extremities A total of 38% of children with CP will have this pattern Hemiplegic – unilateral upper and lower limb distribution ○ Focal damage HEMIPLEGIC PATTERN Quadriplegic or tetraplegia – bilateral upper and lower Hypertonic focal deficits, early hand lateralization, loss of limb distribution ROM in affected limbs, and asymmetric limb use are ○ Diffused damage evident Diplegic – bilateral lower limb distribution Persistent primitive reflexes may be present A total of 39% of children with CP will have this pattern Motor sign Positive – involuntary increases in frequency or QUADRIPLEGIC PATTERN magnitude of muscle activity Diffuse spastic hypertonicity with truncal dystonia, ○ Hypertonia persistent primitive reflexes, intellectual disability, Spasticity hyperreflexia, and loss of ROM in all affected limbs Dystonia A total of 23% of children with CP will have this pattern Rigidity ○ Hyperkinesia ASSOCIATED PROBLEMS IN CEREBRAL PALSY Dystonia Mental retardation Chorea — dance-like and ○ 50% incidence, most common in rigid, atonic, uncontrollable movement and severely spastic quadriplegia Athetosis — slow writhing movement in Seizures distal extremities ○ 50% incidence; most frequent in hemiplegia and Myoclonus — sudden jerk or spastic quadriplegia involuntary movement of muscles Oromotor Tremor (rhythmic shaking), tics, and ○ Difficulty sucking, swallowing, and chewing stereotypes UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 15 OT1026 SHIFT #1 | LESSON #1 | Introduction to Pediatric Rehabilitation ○ Poor lip closure, tongue thrust, drooling, with limited selection sends and/or dysarthria limitations; of easily receives ○ Most common in spastic quadriplegia and may use managed information even dyskinetic powered objects in with familiar Gastrointestinal mobility adapted partners ○ Reflux, constipation situations Dental V Transported in Does not handle Seldon effectively ○ Enamel dysgenesis, malocclusion, caries, a manual objects with sends and gingival hyperplasia wheelchair severely limited receives Visual ability to perform information even ○ Strabismus, refractive errors even simple with familiar ○ Hemianopsia in hemiplegia actions partners Hearing impairment ○ Infection (TORCH), medications, bilirubin CLASSIFICATION encephalopathy Multifaceted classification system proposed in 2006: Cortical Sensory Deficit motor abnormalities, accompanying impairments, ○ Hemiplegia anatomic and neuroimaging findings, and causation and Pulmonary timing ○ Deficit ventilation World Health Organization (WHO), in collaboration with ○ Bronchopulmonary dysplasia in premature many organizations (2007) : International Classification of infants Functioning, Disability and Health for Children and Youth ○ Micro-aspirations with oromotor dysfunction (ICF-CY) ○ Internationally accepted terminology and FUNCTIONAL classifications that focus on the relationship Gross Motor Function Classification System (GMFCS) between structure and function and moves from ○ Sitting, standing, using stairs medical model of disability to a biopsychosocial ○ 5 levels in 5 age groups model of care Manual Ability Classification System (MACS) ○ UE use INT’L CLASSIFICATION OF FUNCTIONING, DISABILITY, & HEALTH Communication Function Classification System (CFCS) Broken down into 5 categories: body function (b), body Eating & Drinking Ability Classification System (EDACS) structure (s), activity and participation (d), environmental Moderate: Definitive difficulties in ADLs; need AD and factors (e), and personal factors bracing Each domain has multiple levels associated with it: chapter number (first digit), second-level categories (two CLASSIFICATION SYSTEM digits), third- level categories (one digit), fourth-level categories (one digit), and qualifiers (one digit) Level GMFCS MACS CFCS I Walks without Hands objects Sends and Level Example Coding limitations easily and receives successfully information with Category Body function b familiar and unfamiliar partners Chapter Chapter 2: Sensory b2 effectively and functions and pain efficiently Second level Seeing functions b 2 10 II Walks with Handles most Sends and limitations objects but with receives Third level Quality of vision b 2 10 2 somewhat information with reduced quality familiar and Fourth level Color vision b 2 10 2 1 and/or speed of unfamiliar partners achievement but may need extra time HISTORY Medical history, birth history, family history of blood clots III Walks using a Handles objects Sends and or stroke, and any possible risk factors for CP hand-held with difficulty receives Developmental history should include when and how a mobility device needs help to information with milestone was achieved as well as if there is regression prepare and/or familiar partners modify activities effectively, but not of milestones after attainment with unfamiliar Functional history partners ○ Discussing the individual’s mobility in the home and community setting, education, participation IV Self-mobility Handles a Inconsistently in ADLs and participation in community activities UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 16 OT1026 SHIFT #1 | LESSON #1 | Introduction to Pediatric Rehabilitation ○ Equipment CLINICAL EXAMINATION MUSCULOSKELETAL EXAMINATION Static ○ Isolating joint movements and passive ROM Dynamic ○ Movement and function GAIT ASSESSMENT Hip — observe for excessive hip flexion, hip adduction and femoral anteversion Knee — note flexion and extension along with varus and valgus stress Foot — look for equinus or toe walking along with dynamic varus or valgus of hindfoot HIP ASSESSMENT Tests for hip contracture Thomas test LEG LENGTH EVALUATION ○ Bringing both legs up to the chest to stabilize the Should be taken from anterior-superior iliac spine to the lumbar spine medial malleolus ○ One leg at a time is extended until there is Knee contractures: 2 segments – medial joint space in resistance in hip extension or movement in the the knee as an additional anatomic point pelvis Pelvifemoral angles are asymmetric – measurements ○ Measurement taken by angle of the femur and are from the greater trochanter to the medial malleolus the table Ely test KNEE ASSESSMENT ○ Done in a prone position with examiner’s hand Test for Hamstring contracture on the buttock ○ Popliteal angle is measured by stabilizing the ○ Lower leg is quickly flexed, and if buttock rises contralateral leg on the table, then flexing the off the table à spastic or tight quadriceps ipsilateral hip to 90 degrees Staheli test ○ Lower leg is extended until resistance is felt ○ Done with the patient in a prone position with the ○ Angle is measured from either the tibia and the legs dangling over the edge of the table line of full extension or the 90 degree position to ○ Pelvis is stabilized, then one leg at a time is full extension extended until there is anterior movement of the Evaluation of Position of Patella pelvis Test for Posterior Capsular Tightness ○ Angle is measured by the femur and a horizontal ○ Done with the legs extended on the examination line table Test for Adductor Contracture ○ Knees extended until there is resistance Test for Internal and External Rotation Popliteal Angle Test UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 17 OT1026 SHIFT #1 | LESSON #1 | Introduction to Pediatric Rehabilitation ○ Most beneficial after the child is 2-3 weeks FOOT AND ANKLE ASSESSMENT PET Test for Gastrocnemius/Soleus Contracture ○ Define blood flow and glucose metabolism ○ Silfverskiold test of ankle dorsiflexion SPECT ○ Document cerebral perfusion MR spectroscopy ○ Compares MR signal ratios of phosphocreatine to inorganic phosphorus to find indications of cerebral asphyxia Evoked potentials ○ Useful in assessing anatomic pathways of auditory and visual pathways EEG ○ For comorbid seizures EVALUATION OF THE POSTERIOR TIBIALIS AND PERONEAL MM Spastic posterior tibialis can cause varus of the heel along the plantar flexion Spastic peroneus can cause valgus deformity. TEST FOR TIBIAL TORSION Prone: Thigh-foot angle Sitting: Femoral condyles lined up, line is drawn through the malleoli BACK ASSESSMENT UPPER EXTREMITY ASSESSMENT NEUROLOGIC EXAMINATION Tone Postural and reflex assessment DIAGNOSIS The term CP does not reflect a specific etiology but is a description of clinical findings and a diagnosis of exclusion The initial evaluation of a child with suspected CP should determine the diagnosis, decide which tests are needed to make the diagnosis; determine the etiology of the symptoms; determine comorbidities; and develop treatment options LABORATORY TESTS AND DIAGNOSTIC IMAGING MANAGEMENT Metabolic and genetic diseases: Thyroid functioning, lactate and pyruvate, organic and amino acids, and THERAPEUTIC MANAGEMENT chromosomes Early intervention Perinatal asphyxia Therapeutic exercise ○ Blood pH Phelps ○ CSF protein ○ Extensive bracing, withdrawing support as ○ Lactate-to-pyruvate ratio motion is performed with a minimum of tension, Cranial ultrasound overflow, and substitution ○ Premature infant ○ Emphasis on self-help skills and development of ○ To check for intraventricular hemorrhage balance and position sense Cranial CT Deaver Cranial MRI UST OT 2026 | MEDICAL-SURGICAL FOUNDATIONS FOR ADULT PHYSICAL DYSFUNCTION 18 OT1026 SHIFT #1 | LESSON #1 | Introduction to Pediatric Rehabilitation ○ Extensive bracing, limiting all but two motions of Once basic control has been established, therapy can be an extremity directed toward coordination ○ Voluntary motion was emphasized for ADL Gross motor abilities and hand dexterity are physical performance determinants for planning a program in ADLs Temple, Fay, Doman and Delacato ○ Series of set patterns repeated many times THERAPY INTERVENTIONS during the day, attempting to train cerebral Main goal of all therapies is to promote and facilitate dominance and normalization of function development in all domains of function Rood Therapies are commonly provided at school, home, and ○ Activating muscles through sensory receptors in out-patient clinics with a frequency of one to two times Bobath and Bobath a week per discipline ○ Normalize tone, inhibit abnormal primitive reflex Regardless of the setting, it is imperative that the family patterns, and facilitate automatic reactions and and child are included in the therapy plan to promote subsequent normal movement carryover and reinforcement in the home setting ○ Providing key points of control throughout the body STRETCHING Vojta ○ Activation of postural development & equilibrium Goal is to reduce the risk of contracture development as reactions to guide normal development a result of muscular imbalance and hypertonicity Conductive education Sustained stretching can be achieved through the use of ○ To function independently in the world w/o aids positioning devices, orthoses, and serial casting A 2017 Cochrane systematic review found high-quality evidence that “stretch did not have clinically important effects on joint mobility” in individuals with neurologic conditions. However, no study followed patients longer than 7 months, and there was no conclusive evidence if stretching affects quality of life or pain STRENGTHENING AND AEROBIC EXERCISE A systematic review of the effectiveness of strength training programs in CP reported increased strength without any negative effects of increased spasticity or reduced ROM Indi