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Slide Deck 3.10: Developmental Coordination Disorder (DCD): PT Management Examination: DCD: Common Standardized Assessments Developmental Coordination Disorder Questionnaire (DCDQ), ages 5–15 screening tool, 15 questions...

Slide Deck 3.10: Developmental Coordination Disorder (DCD): PT Management Examination: DCD: Common Standardized Assessments Developmental Coordination Disorder Questionnaire (DCDQ), ages 5–15 screening tool, 15 questions parent or caregiver Modified control during mvmt Preschool version: Little DCDQ 17-42 y/p fine motor organization general coordination Adults: Adult DCD/Dyspraxia Checklist social skills - Movement Assessment Battery for Children, second edition; MABC-2 most widely used (3-16 y/o) involve OT activities/participation Movement ABC-2 Checklist parents/teacher can fill out about general motor fxn, coordination, self care, school Bruininks-Oseretsky Test of Motor Proficiency, second edition; BOT-2 (4-21, fine & gross & other conditions) Other Assessments in Current Research and Recommended Bayley Scales of Infant and Toddler Development, 3rd edition (0-3, comprehensive) Dynamics Gait Index Functional Gait Assessment Peabody Developmental Motor Scales, 2nd edition (0-5, gross motor) Test of Gross Motor Development, 2nd edition (quality of movement) Interventions with Strong Evidence: DCD Task-Oriented Training: task-oriented intervention focused directly on specific functional skills are the most effective way to improve motor performance in children with DCD 4 types: -child practices components of games, e.g. soccer, tag, etc., in workstations under Neuromotor guidance of PT who manipulates different aspects of environment and task as Task Training needed to make task successful can tell you what they struggle -child is able to pick out their own age-appropriate functional goals with Cognitive- -child is encouraged to form a mental model of how to complete a movement task, Orientation to they are led to generate a movement goal, a plan is implemented, and they reflect Daily on how their performance was or was not successful Occupational -PT helps to select and organize environmental factors to fit child’s level of Performance competency, give verbal prompts to encourage reflection & planning during tasks Motor Imagery -child observes skilled models on videos, then creates an action replay by imagining Training of Motor they are doing the activity Task -After mental practice, they physically attempt to complete task -PT constrains environment to minimize amount of practice errors and enables child to experience a sense of mastery and success during task Errorless Motor -Effective and sustained for as long as 12 months Learning Model -Decreases need for use of visual-spatial working memory which is commonly impaired in children with DCD closed environment vs open environment Interventions Overall: DCD Importance of Frequency  more practice the better they get, NEED A LOT One study found: regardless of treatment intervention, training programs with more frequent practice schedules, ex. 4-5x/week instead of just 1x/week, significantly increase training effects on motor performance Important facilitators: Support from parents, school, teachers Barriers: Negative comments from peers and teachers’ lack of understanding of DCD educate all caregivers! Ineffective Interventions with Strong Evidence: DCD Chemical supplements; e.g. fatty acids Core stability training Wii Training Tae Kwan Do group training Potentially Ineffective Intervention Strategies: Aquatic therapy Summary DCD: Exam: use appropriate standardized assessments Most effective interventions: Task-Oriented Training = fxnal skills -> modify environment -> sense of mastery Frequency is KEY: more frequent practice, 4-5x/wk  significantly increases motor performance Slide Deck 3.11: Down Syndrome: PT Management Examination Considerations: Activity Tests and Measures  Peabody Developmental Motor Scales (Norm-referenced): Detect delay  Pediatric evaluation of disability inventory (PEDI) & Gross Motor Function Measure (GMFM): Criterion Referenced: Functional skills scale: Identify current performance & track change over time; criterion-referenced Goals, Outcome, POC  Test of Infant Motor Performance (TIMP) (criterion-referenced): Predictive of future motor Tx performance Participation Test and Measures: Helpful to perform ecological assessments in natural environment Children’s Assessment of Participation and Enjoyment, CAPE—diversity, intensity, enjoyment and context of activities, and Preferences for Activities of Children, PAC-preference for involvement in activities, ages 6 to 21 Caregiver Assistance scale of PEDI participation related to mobility, self-care, social function in home School Function Assessment participation, activities and needed task support in school environment K- 6th grade Body Functions and Structures Test and Measures Endurance: Treadmill can be reliable way to measure endurance following practice Vital signs of HR, RR Strength through ability to move against gravity or through functional skills Prognosis: Achieve all same basic motor skills needed for everyday life and personal independence Later age achieved, May be less refined  Interventions  Purpose: achieve measurable goals identified with parents and child  PT Goals o Enhance rate of acquisition of motor skills o Prevent occurrence of secondary problems resulting from compensatory strategies to overcome o Hypotonia and joint instability o Improve participation in life activities  Interventions: direct and more intensive for infants and toddlers  then more consultation as child attends progresses through school Interventions: Overview Tummy time Treadmill Training (start at ~10 months old) Developmental milestones Therapeutic Horseback Riding (Hippotherapy) Two-wheeled bicycle training Perceptual-motor therapy Balance: Yoga, Stability Exercise, Corrective positioning, Stair climbing Physical activity Interventions: Infants and Toddlers; Age Birth to 3 Years Educate parents on development of motor skills and functional skills Arrange access to parent-to-parent support Attempt to prevent compensatory movements Treadmill training start at ~10 months, reduces delay in walking When child starts to stand, flexible supramalleolar orthoses to improve postural stability Provide adaptive seating or other positioning devices to compensate for lack of postural control to facilitate reaching and hand function to participate in learning activities Facilitate parent–child interactions Promote perceptual-motor competencies; eye gaze & joint attention to people, objects, environ. Coordinate and communicate with any day care or preschool providers Interventions: Preschool Encourage preschool teachers: include child in PA to promote motor development Educate parents re: active play (trike riding, swimming, etc)  Consider orthoses: improve stability to develop higher-level motor skills Promote communication: ASL, visuals, augmented assistive technology for communication Interventions: School Age  Coordinate and consult physical educator and parents to do activities that promote fitness  Promote regular PA including cardiovascular, flexibility, strengthening, balance, and agility o Minimize risk of injury: greater frequency, less intensity compared to typical peers o Vary the PA: enjoyable and motivating for child o Teach typical motor activities; i.e. bicycle riding o PA Bouts: short-term exercise training program to improve strength and agility  Refer to physician if myelopathy symptoms; neck pain, head tilt, gait changes, weakness, due to increased risk of atlanto-axial subluxation  Community involvement: adaptive and inclusive sports; Special Olympics, Unified Sports  Atlantoaxial Instability (AAI): warning o Between C1-C2 vertebrae Normal is < 5mm o Occurs in 10% of individuals with Down Syndrome o If large separation/impingement on spine. If not surgically corrected, can lead to paralysis or death o Asymptomatic AAI: 10–30% of children with DS o Symptomatic AAI: 1–2% of children with DS o Symptomatic AAI  easy fatiguability  difficulties in walking  abnormal gait  neck pain  limited neck mobility  torticollis  incoordination and clumsiness  sensory deficits  spasticity  Hyperreflexia; signs and symptoms Interventions: Summary  Postural control: to meet motor milestones and decrease secondary impairments  Foot orthoses: improve stability & alignment for stance & gait, reduce risk of orthopedic issues  Aerobic exercise: increase cardiopulmonary fitness and endurance  Strength training: improves functional mobility and muscular endurance  Positioning equipment & caregiver education on promoting alignment: minimize pressure and skin breakdown  Interventions: Better outcomes when provided in natural environments within context of functional tasks Slide Deck 3.12: Torticollis: PT Management Intervention: Overall Prevention of limitations and deformities by repositioning to facilitate symmetrical movement and head shaping Prevention education to caregivers, professional staff, community PT intervention: highly effective when initiated early in infancy Historically, this is the torticollis referral process: 1. Begin parent reports or pediatrician notices persistent positional preference of tilting or turning to one side, or resistance to passive cervical rotation a. Parents report challenges with cleaning under infant’s chin breastfeeding on one side 44% have preferred feeding side positioning infant symmetrically in car seats asymmetry noted in pictures 2. PT referral a. Begin PT Exam with taking parent report Feeding Sleeping Tummy Time Time in Equipment and Positioning Devices Exam: Body structure and function Posture and Positioning Supine, side, prone, supported sitting Bilateral Passive Range of Motion (PROM) into cervical rotation and lateral flexion Bilateral Active Range of Motion (AROM) into cervical rotation and lateral flexion PROM and AROM of Upper and Lower Extremities AROM of Upper and Lower Extremities Pain Skin Integrity Craniofacial Asymmetries Limitation PT Measurement Cervical PROM Arthrodial protractor measurement of PROM Cervical AROM Arthrodial protractor or seated swivel test Prone tolerance Time per episode and episodes per day in prone Gross motor function TIMP for < 4 months old; AIMS for > 4 months to 1 year Pain FLACC Cervical strength Muscle Function Scale Exam: Activities Symmetrical movements in their immediate environment Visual tracking Full & active range of neck, spine, and extremities Activity limitations Changing tolerances to positions Acquisition of or delays in milestones Presence, absence, or asymmetry in reflex postures or protective reaction patterns Asymmetry of volitional movements and positions Developmental milestones: assessed with an age-appropriate, standardized valid, reliable tool Test of Infant Motor Performance: 34 weeks post-conception to 4 months old Harris Infant Neuromotor Test: 2.5–12.5 months old Alberta Infant Motor Scale: 0–18 months old Exam: Participation Ability to pose for pictures Symmetrically explore their immediate surroundings both visually and physically Alternate sides easily during breast or bottle feeding Tolerate playing while prone for increasingly longer periods of time Time spent in supine-positioning devices; car seats, strollers, bouncers or infant swings: Symmetrical positioning *Parent interview *Observation of infant during these activities Intervention: Five Components as the First Choice Intervention Neck PROM Manual stretching: most commonly reported intervention for CMT Improves head tilt and cervical rotation 10x/day Low intensity, sustained, pain-free stretches recommended to avoid muscle tissue micro trauma Stretch should not be painful, stop if infant resists or parent sees changes in breathing or circulation Neck and Active ROM: *standard of care in combination with other interventions* Trunk AROM Practical, routines-based strengthening to achieve AROM Strengthening neck & trunk muscles during: Positioning, handling, carrying infant, feeding Exercises to isolate weaker muscles Affected side of CMT Encourage activity of weaker, nonaffected side Development  Developmental exercises of symmetrical  When: In PT interventions and HEPs movement  Promote symmetrical movement in weight bearing postures  Prevent impaired movement patterns in prone, sit, crawl, walk Environmental Adaptations to the infant’s environment can be incorporated by adaptation -Alternating position in crib & changing table promotes head turn in desired direction -Adapting car seat to promote symmetry & minimize time in car seat and infant carrier -Placing toys on affected side for infant to turn head toward tighter side Parent and -Integrated into infant’s daily routines caregiver Tummy time at least one cumulative hour daily education Positioning and handling for symmetry Minimize time in equipment Alternate feeding side to side -Adherence to HEP monitored through verbal report and parent demo -Frequency can be adjusted based on compliance Intervention: Key Interventions for CMT Limitation PT Intervention Decreased cervical Manual stretching of tight musculature, active cervical rotation toward rotation nonpreferred side, strengthening of cervical musculature, passive positioning to stretch tight tissues Head tilt Manual stretching of tight musculature, active cervical lateral flexion away from head tilt, strengthening of cervical musculature, passive positioning to stretch tight tissues Positional preference Active movement & strengthening opposite of preferred side or asymmetry and/or trunk asymmetry Prone position Increase use of prone positioning to strengthen capital muscles and facilitate intolerance symmetrical trunk and head alignment Asymmetrical postures Active movement and strengthening opposite of the asymmetry Developmental delay Facilitate equal use of all extremities and head turning to both directions during daily activities and play Intervention: Key Interventions for CD Limitation PT Intervention Brachycephaly -Increase prone positioning to relieve pressure on occiput to allow for reshaping. -Refer severe cases for cranial orthotic assessment at 4 months of age and moderate cases for cranial orthotic assessment at 6 months of age Plagiocephaly -Head turning and positioning opposite of preferred position, increased time in prone, facilitation of development to encourage overall movement away from flattened side. -Refer severe cases for cranial orthotic assessment at 4 months of age and moderate cases for cranial orthotic assessment at 6 months of age. Slide Deck 3.13: Cerebral Palsy: PT Management PT Management: Overall considerations PT intervention for CP is very individualized, team approach; family, health professionals, school staff Practice Activities: more one practices a skill/task, the more one learns, thus activities should be repeated many times in each treatment session and throughout each day Goal for families: educate about CP, assist parents with decisions about managing their child's lives From infancy to adulthood, PT goals: focus on promotion of participation by maximizing gross motor activity and helping child compensate for activity limitations when necessary Be aware of environmental and personal factors that could enhance or restrict activity/participation Habilitation interventions: tasks that are purposeful, relevant, developmentally appropriate, active, voluntarily regulated, goal directed, and meaningful to child PT Management: Infancy Educate family, facilitate caregiving, promoting optimal motor experiences and skills Use variety of movement and postures to motor skills such as reaching, rolling, sitting, crawling, transitional movements, standing, pre-walking skills Using positions that promote functional voluntary movement of the limbs Positioning of all playing with upper extremities free: allows infant to see their hands, practice midline play, reach for his or her feet, or suck on fingers PT Management: Preschool, School Age, Adolescent Postural alignment & active movement to promote motor development, fitness, function; equip Age-appropriate play, adaptive toys/games based on desired exercises: KEY to child's full cooperation PTs: encourage performance at a level of success to maintain child's interest and cooperation Activities: treadmill, mobility training, strength training, task specific training; ascend/descend stairs Address impairments that may hinder function, or lead to further secondary impairment, ie. Scoliosis Maintain muscle strength, joint integrity, & fitness: important to prevent secondary impairments Casting may be needed to increase ROM of joint by lengthening muscles or tendons or both Maintain, improve level of functional activity and participation while considering increasing demand in life skills and participation in community activities Encourage involvement in adapted or integrated sports activities; swimming, skiing, fishing, yoga, etc Involving patient in setting goals and determining programming Examination and Evaluation: Body Structure and Function DOB – calculate adjusted age if necessary  PMH: Surgeries, Hospitalizations, Meds Current concerns and goals for therapy Pain: FLAAC, Faces, 0-10 Neurological: Muscle tone, spasticity: modified Ashworth, Tardieu Balance and postural control; Pediatric Balance Scale, Movement Assessment in Infants, Early Clinical Assessment of Balance Reflexes Cardiopulm: vitals Endurance: Early Expenditure Index, 2 or 6 minute walk, Early Activity Scale for Endurance Musculoskeletal: posture alignment, strength, ROM (active and passive) Tardieu Scale R1 – first resistance to passive stretch, functional position for tasks R2 – actual length of muscle Spine – assess trunk rotation, spinal flexion UE and chest—esp. scapular mobility LE – pelvis; tilt, rotation, obliquity, hips subluxation, femoral anteversion, HS tightness, DF with subtalar neutral, leg length Examination and Evaluation: Activity Limitations Movement patterns and mobility; can be observed in play while you are taking history Positions Transitional skills If pt. does not move much, assess posture when being held or positioned in mobility device Motor Skill: Gross Motor Function Measure, Peabody, Alberta Infant Motor Scale, BruninksOseretsky Gait: Timed up and go, Dynamics Gait Index Functional Mobility: Pediatric Evaluation of Disability Inventory (PEDI), School Function Assessment (SFA), Gillette Functional Assessment Questionnaire Self-care skills Pediatric Evaluation of Disability Inventory (PEDI), Wee FIM Play skills: Preschool Play Scale Determine GMFCS level Gross Motor Function Classification System GMFCS Very important to know!!!! 5 level classification system for children with cerebral palsy (CP) Describes gross motor function based on self-initiated movements, emphasis on sitting walking wheeled mobility Different descriptions for 5 different ages less than 2 years  2 to 4 years 4 to 6 years 6 to 12 years 12 to 18 years During their life it is expected that children will stay at the same level GMFCS Use Enhance communication amongst families and medical professionals Encourage efficient use of healthcare services Allow comparisons and generalizations between homogenous groups of children Assist with clinical decisions making Help establish treatment goals; fostering collaborative goal setting 5 Levels of GMFCS Level 1: Walks without limitations Walks without limitations indoors or outdoors and climbs stairs without limitations. Speed, balance and co-ordination are reduced Level 2: Walks with limitations Walks with limitations indoors or outdoors, climbs stairs holding on to a rail. Limitations walking on uneven surfaces & inclines, in crowds or confined spaces Level 3: Walks with hand-held mobility device Walks indoors or outdoors using a hand held mobility device and climbs stairs holding onto a railing. May require a self-propelled wheelchair when travelling longer distances, outdoors or on uneven terrain Level 4: Self-mobility with limitations: May use power mobility Self-mobility with great limitations and may use powered mobility Level 5: Transported in Manual Wheelchair Physical impairments restrict voluntary control of movement and have no means of independent mobility. Transported in a manual wheel chair Distinctions between levels are based on functional abilities, the need for assistive technology (including wheeled mobility versus hand-held mobility devices such as walkers, crutches, or canes) and, to a much lesser extent, quality of movement Intervention Planning: Intervention for levels IV and V: focus: health promotion, prevention of secondary impairments, and use of technology and adapted equipment Intervention for levels I, II, and III: focused more on achievement of gross motor abilities Levels: very stable after 2 years old, children not likely to change levels even with intervention GMFCS can be used to give prognosis of gross motor function later in life Examination and Evaluation: Participation Children’s Assessment of Participation and Enjoyment (CAPE) Assessment of Preschool Children’s Participation (Preschool CAPE) Pediatric Evaluation of Disability Inventory (PEDI) Canadian Occupational Performance Measure