PTA 1011- Pediatric Neurologic and Muscular Disorders PDF

PT Through the Lifecycle (PTA 1011) Power Point #6 Pediatric Neurological and Muscular Disorders Image from iStock ©Stanbridge University 2022 1 NEUROLOGIC AND MUSCULAR DISORDERS Cerebral Palsy...

PT Through the Lifecycle (PTA 1011) Power Point #6 Pediatric Neurological and Muscular Disorders Image from iStock ©Stanbridge University 2022 1 NEUROLOGIC AND MUSCULAR DISORDERS Cerebral Palsy Pediatric TBI Shaken Baby Syndrome Rheumatic Disorders Erb’s Palsy (Brachial Plexus Birth Palsy) https://online.vitalsource.com/#/books/978-1-4160-4750-6/cfi/6/44!/4/18/4@0:99.3 2 ©Stanbridge University 2022 CEREBRAL PALSY PT Guide Pattern 5C- Impaired motor function and sensory integrity associated CHAPTER 5 with non-progressive disorders of CNS ©Stanbridge University 2022 3  Learning Objectives After reading this chapter and other materials presented, student will be able to: Understand the etiology and CEREBRAL causes of cerebral palsy (CP). PALSY Identify the various types of CP and their characteristics. Understand the various sensory, medical, and cognitive problems that are associated w/ CP. ©Stanbridge University 2022  4. Understand the role of evaluation and ongoing assessment in the treatment of a child w/ CP. 5. Identify appropriate treatment Learning strategies for the entire age span of a child w/ CP. objectives 6. Understand the roles of other cont… healthcare professionals in the management of CP. 7. Be familiar with the various assistive technologies that may be used for intervention. What is Cerebral Palsy? A broad term used to describe a group of chronic conditions impairing control of posture and movement. A permanent, non-progressive, neurological disorder A result of faulty development, injury, or damage to motor areas in the brain. Early signs of CP usually appear before the age of 3 ©Stanbridge University 2022 6  Pathology Congenital cerebral palsy is a medical condition caused by a permanent brain insult: - Prenatal (during pregnancy) - Perinatal (during delivery) - Postnatal (shortly after delivery) Premature births and low birth weights are associated with an increased risk of CP Figure 5-1 Children with cerebral palsy often have affected joint motion, muscle strength, balance, and coordination. (From Zitelli BJ, Davis HW: Atlas of pediatric physical diagnosis, ed 5, Philadelphia, 2007, Mosby.) ©Stanbridge University 2022 7  Pathology- Congenital CP Can be caused by a variety of conditions: ▪ Infection during pregnancy (CMV, rubella) can damage CNS of developing fetus ▪ Neonatal hyperbilirubinemia- severe, untreated jaundice can result in brain damage and athetoid CP ▪ Rh incompatibility- a blood condition that causes the mother’s immune cells to attack the fetus resulting in jaundice ▪ not as common in US any longer due to an immunization ©Stanbridge University 2022 8 Pathology- Congenital CP Can be caused by a variety of conditions, continued: ▪ Lack of oxygen to brain- hypoxic ischemic encephalopathy ▪ Stroke or bleeding (hemorrhage) of fetus ▪ Premature infants at high risk ▪ Toxicity ▪ Drug or alcohol abuse during pregnancy ▪ Kidney infections and UTI’s in the mother can lead to brain damage in infant ▪ Multiple pregnancy (twins, triplets, or more) at higher risk ©Stanbridge University 2022 9  Pathology- Acquired Cerebral Palsy Results from brain damage in the first few months or years of life Possible causes: – Brain infections- encephalitis or meningitis – Head trauma or injury from: - falls - auto accidents - child abuse ©Stanbridge University 2022 10  Image from Teaching Keyboard skills Using Motor Learning Principles Classification of Cerebral Palsy There are 3 different classification systems ©Stanbridge University 2022 11  1. Quality/ severity of muscle tone and movement Three Major 2. Pattern of motor Classifications impairment or of CP involvement 3. Gross Motor Functional Classification System (Table 5-2) ©Stanbridge University 2022 12  Classification of CP- Muscle Tone 1.) Classified by quality/severity of muscle tone and movement: – Muscle tone is the amount of resistance to movement in a muscle; the underlying tension example of a rubber band https://www.youtube.com/watch?v=YNnwf_XbRac&t=2s – Muscle tone keeps the body in a certain posture or position e.g., sitting upright – Typical changes in muscle tone allow movement ©Stanbridge University 2022 13  Classification of CP- Muscle Tone – Tone in different muscle groups must be balanced for you to move smoothly Example- to bring your hand to your face, the tone in your biceps muscle must increase, while the tone in the triceps muscle must decrease – Do not confuse muscle spasms with muscle tone – CP has been classified further into different types of muscle tone: Spastic CP Hypotonic CP Athetoid CP Ataxic CP ©Stanbridge University 2022 14 Classification of Cerebral Palsy Location of lesion or damage determines the type of CP Image from KZN Cerebral Palsy Association ©Stanbridge University 2022 15  Types of Muscle Tone Spastic CP- hypertonia, increased resistance to passive stretch (velocity-dependent); abnormal neurologic reflexes, clonus (involuntary muscle contractions), hyperactive DTR; can lead to contractures and abnormal posturing Hypotonic CP- poorly defined muscles, decreased responses to DTR, and hypermobile joints; floppy; head lag; fatigues easily Athetoid CP- (dyskinetic) fluctuating tone, writhing movements; stiffening and abnormal postures; dystonia Ataxic CP- poor balance and coordination; jerky movements; gait pattern with wide base of support (may mimic a drunken gait) ©Stanbridge University 2022 16 Grade Description 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 of the ROM when Modified the affected part(s) is moved in flexion or extension Ashworth Slight increase in muscle tone, manifested by a catch, followed Scale 1+ by minimal resistance throughout the remainder (less than half) of the ROM Standard method 2 More marked increase in muscle tone through most of the ROM, but affected parts move easily used to quantitatively describe tone 3 Considerable increase in muscle tone; passive movement Table 5-1, pg. 52 difficult 4 Affected part(s) rigid in flexion or extension ©Stanbridge University 2022 Types of Muscle Tone Spastic Cerebral Palsy is the most common form under this classification – The involved muscles of the Image from the Journal of Rehabilitation Medicine, Vol. 44, Issue 2 body are stiff and tight an do not allow for normal movement – There is increased resistance to passive stretch which may be velocity dependent This is known as “spasticity” – Spasticity is a hallmark of CP Image from Slideshare ©Stanbridge University 2022 18  Types of Muscle Tone Hypotonic CP- Have decreased ability to generate enough force for a sustained muscle contraction This diagnosis may be made in infancy or when child is a toddler Difficulty with anti-gravity muscle control Landau response will be absent or delayed Infant “floppy” Head lags behind trunk ©Stanbridge University 2022 19  Classification of CP 2.) The second type indicates the pattern of motor involvement; The term plegia is used along with a prefix to designate whether four limbs, two limbs, one limb, or half the body is affected by paralysis or weakness.: Hemiparesis/ hemiplegia- one arm and one leg on same side involved Tetraparesis (quadriplegia)- all four extremities involved Diplegia- both LE’s w/ little or no UE involvement Triplegia- both LE’s w/ one UE involved or both UEs with one LE Monoplegia- only one limb involved, usually an arm ©Stanbridge University 2022 20 FIGURE 6-2 A–C, Distribution of involvement in cerebral palsy, Marin/Kessler ©Stanbridge University 2022 21  Classification of CP 3.) The Third type of classification is a Gross Motor Functional Classification system (See table 5-2 in O’ Shea, pg. 53 and refer to next slide) – Categorizes by degree of severity or functional capability – Provides a qualitative, objective measure of prognosis for gross motor skills – Classified at one of five levels, depending on child’s skills, not age ©Stanbridge University 2022 22 TABLE 5-2 Gross Motor Functional Classification System INFANCY CHILDHOOD ADOLESCENCE Level 1 Independent head Independent ambulation, Independent ambulation, control, moves in and rises from floor runs and jumps, reduced out of sitting independently, manages speed, balance, and agility independently steps independently Level 2 Uses upper extremity Continues to use UE for (UE) support to support in sitting, maintain sitting independently rises from floor, reciprocal crawling, ambulates with assistive technology Level 3 Maintains floor sitting “W” sits, may require Community ambulators when low back is adult assistance to with an assistive device, supported, can roll assume sitting, creeps climbs steps using a railing, and creep forward on on stomach or crawls on uses wheeled mobility for stomach hands and knees, may longer distances pull to stand on a stable surface and cruise short distances, walks short distances indoors using an assistive mobility device, sits independently Level 4 Ambulates short Uses wheeled mobility distances, wheeled mobility in community Level 5 Limited voluntary Extensive use of adaptive control equipment ©Stanbridge University 2022 23 ©Stanbridge University 2019  Martin/Kessler 24 ©Stanbridge University 2022  Martin/Kessler 25 ©Stanbridge University 2022  Clinical manifestations may change as child grows Many children have normal intelligence even though they have difficulty with motor control and movement A child with CP may be as mild as being Clinical clumsy or awkward or may not be able to walk Signs of Main common clinical signs- – – Difficulty maintaining normal posture Decreased coordination CP – – – Affected muscle tone Affected speech/drooling Difficulty with fine motor tasks – Involuntary movements – Gross motor delays – Decreased balance skills – Influence of tonic reflexes hamper development and affect tone (ATNR, STNR, and TLR)  Influence of tonic reflexes: – ATNR: predisposes child to scoliosis and in extreme cases hip dislocation on the flexed side; prevents child from rolling and crossing midline Clinical – STNR: when it persists child may bunny hop on hands and knees because it limits their ability to get into Signs of quadruped and creep on all fours – TLR: when child in prone there is CP increased flexor tone, and when child in supine there is increased extensor tone Impairs the infant's ability to develop anti-gravity motion (to flex against gravity in supine and extend against gravity in prone)  FIGURE 6-9 Tonic reflexes, Martin/Kessler ©Stanbridge University 2022 28  Common Warning Signs of Cerebral Palsy Table 5-3 Age of Infant Signs Over 2 months Head lags with pull to sit Muscles or joint movement feels stiff Generally feels floppy, hypotonic, or joints are hypermobile Extensor tendencies: the child seems to overextend the back and neck, constantly acts as if he or she is pushing away from you when held in a cradled position Legs may get stiff and they cross or “scissor” when the child is picked up Over 6 months Continues to have the asymmetric tonic neck reflex Reaches out with only one hand while keeping the other fisted Over 10 months Crawls in a lopsided manner, pushing off with one hand and leg while dragging the opposite hand and leg Scoots around on buttocks or hops on knees, but does not crawl on all fours ©Stanbridge University 2022 29  30 Seizures- 1 out of every 3 develop seizures or have a seizure disorder – Classification of seizures in Neuro Interventions textbook, pg.140 Table 6-4 Secondary Cognitive/intellectual impairment- estimated 30% of children with CP have Conditions issues with this. It can range from mental retardation to mild learning disorders of CP Vision impairments- decrease coordination of eye muscles; strabismus; visual perceptual problems Orthopedic issues- contractures, scoliosis, equinovarus, hip subluxation ©Stanbridge University 2022  31 Dental problems- enamel defects; more cavities Secondary Hearing loss- complete or partial Oral motor dysfunction- tongue control, Conditions eating, swallowing, babbling, talking, difficulty handling secretions (drooling) of CP Spatial awareness impairment- kinesthesia and proprioception issues; neglect of involved limb ©Stanbridge University 2022  Management of CP Medical Management- multidisciplinary approach; child sees an array of medical professionals (e.g., Optometrist, PT, OT, speech therapist, orthopedic surgeon, etc…) Pharmaceutical Intervention- Meds used to decrease tone, control seizures and manage reflux Surgical Intervention- Gastric tube placement, Baclofen pump insertion, Selective Dorsal Rhizotomy, correction or prevention of orthopedic deformities such as: – Contractures: i.e., tenotomy (tendon completely severed) or tendon lengthening surgery – Hip dislocation or subluxation – Scoliosis ©Stanbridge University 2022 32  Common Medications Used For reduction of hypertonia/spasticity: Baclofen, diazepam, dantrolene Botulinum toxin injections (Botox)- blocks nerve transmission to spastic muscle Phenol injections (strips myelin) For seizure disorders: Phenobarbital, phenytoin (Dilantin) Tegretol, Depakote, or Zarontin ©Stanbridge University 2022 33  Baclofen for Reduction of Spasticity Produces systemic side effects- dizziness, Taken weakness, confusion, drowsiness and/or upset stomach orally Does not cross blood-brain barrier therefore requires larger doses Intrathecal Preferred method due to no side affects Delivered directly to cerebrospinal canal Baclofen Smaller doses can produce same effect Administers a constant flow of medicine Pump Implanted under subcutaneous fat in abdomen ©Stanbridge University 2022 34 Baclofen Pump ©Stanbridge University 2022 35  Peacock et al. (1987) began advocating the use of this procedure in which dorsal roots in the spinal cord are identified by electromyographic response. Dorsal roots are selectively cut to decrease synaptic, afferent activity within Selective the spinal cord which decreases spasticity. Through careful selection, touch and Dorsal proprioception remain intact Following rhizotomy, a child requires Rhizotomy intense physical therapy for several months postoperatively to maximize (SDR) strength, range of motion, and functional skills (Gormley, 2001). Physical therapy can be decreased to 1 to 2 times a week within a year. Once the spasticity is gone, weakness and incoordination are prevalent. Martin/Kessler  Selective Dorsal Rhizotomy Surgical Intervention: Selective posterior or dorsal rhizotomy (SDR) has become an accepted treatment for spasticity in certain children with CP. Ideal candidates for this procedure are children with spastic diplegia or hemiplegia with moderate motor control and an IQ of 70 or above (Cole et al., 2007; Gormley, 2001). FIGURE 6-20 in Martin/ Kessler- Selective dorsal rhizotomy (SDR). (From Batshaw ML: Children with developmental disabilities, ed 4. Baltimore, 1997, Paul H. Brookes.) ©Stanbridge University 2022 37 Surgical Intervention Martin/Kessler FIGURE 6-19 Heel cord lengthening. 38 ©Stanbridge University 2022  Physical Therapy Management PT examination, evaluation, diagnosis, prognosis, and intervention - Examination and Evaluation should include: …history, chart review, social history, prenatal and postnatal history, developmental milestones, standardized testing, clinical observations, assessment of primitive reflexes and postural reactions - Diagnosis and prognosis: limitations, and impairments aid in establishing a therapy (clinical) diagnosis and determine the prognosis ©Stanbridge University 2022 39  40 Address identified impairments or functional limitations Team effort Embed therapy into family’s routine Interventions – example: stretching/ROM performed during a diaper for CP change Limit or minimize disability in the community ©Stanbridge University 2022  41 Tone reduction techniques Positioning and handling Increase ROM and strength Improve functional motor skills and mobility Interventions Educate caregivers/parents for CP Identify barriers and recommend modifications to make environment more accessible Wheelchair prescription and mobility training ©Stanbridge University 2022  Review the written PT Evaluation including goals established Review other pertinent and applicable The information in patient’s file/chart PTA’s Clinical interventions, such as ROM, ther- ex, SI, gait training, positions to reduce Role tone, caregiver/parent education or training Identify barriers at home or if home modifications are needed. Verbal feedback to PT and documentation ©Stanbridge University 2022 42  1) According to the Gross Motor Classification System, Level I is the highest functioning level of the infant/child. True or False? Learning Assessment 2) Which of the following can be a cause of CP? a) oxygen shortage/anoxia b) toxicity c) Rh incompatibility d) all of the above  3) Athetoid CP is characterized by what type of tone? a) decreased responses to DTR b) writhing movements fluctuating tone c) low muscle tone d) hemiparesis Learning 4) Which one of the following is a common Assessment secondary condition seen in children with CP? a) asthma b) jaundice c) seizures d) tetraplegia  PEDIATRIC Chapter 6 TRAUMATIC BRAIN PT Guide Pattern 5C INJURY ©Stanbridge University 2022 4 5  Learning Objectives After reading this chapter and other materials presented the student will be able to: Pediatric Identify causes of TBI Characterize the brain injury by Traumatic severity Describe the importance of the Brain Glasgow Coma Scale and the Rancho Los Amigos Levels of Injury Cognitive Functioning Identify treatment plan components Learn updates from the CDC on pediatric concussions ©Stanbridge University 2022  Pediatric Traumatic Brain Injury MECHANISMS OF INJURY- CLASSIFIED AS A PATHOLOGY- IN US, IT’S THE MVA- WITH CHILD IN CAR “TRAUMATICALLY INDUCED LEADING CAUSE OF DEATH SEAT OR NOT, MVA-VERSUS- PHYSIOLOGIC DISRUPTION OF AND INJURY-RELATED PEDESTRIAN, SPORTS BRAIN FUNCTIONING, DISABILITIES AMONG INJURIES, ANOXIA, SEIZURE RESULTING IN PARTIAL OR CHILDREN AND YOUNG DISORDERS, SBS, CVA, TOTAL IMPAIRMENTS OF ONE ADULTS TUMORS/NEOPLASMS, NEAR OR MORE AREAS OF DROWNING, INFECTIONS, FUNCTIONING.” HYDROCEPHALUS ©Stanbridge University 2022 47  Clinical Signs Primary injuries: are related to the forces that occur at the time of the initial impact; they can be grouped by the acceleration factors: Acceleration-dependent injury When a force is applied to a movable head It may be translational or rotational in nature Image from Slideplayer.com Translational injury causes lateral movement of both skull and the brain in response to a force applied to side of skull Rotational injury-when the brain remains stationary on a moving, rotating skull Coup injury Occurs at point of impact and when the brain strikes the skull Contrecoup injury When the brain strikes the skull opposite to the area of direct impact Image from Neuropsych Consulting ©Stanbridge University 2022 48  Clinical Signs Secondary injuries: – scalp injuries Image from Harvard Health – skull fractures – cerebral edema – epidural hematomas – acute subdural hematomas – increased ICP – subarachnoid hemorrhages Image from Brainmind.com ©Stanbridge University 2022 49  TBI Classifications MILD TBI: – Defined by: Any period of a loss of consciousness 30 mins or less Image from Pediatric Guidelines- Concussions Ontario Any loss of memory for events immediately before or after the accident Altered mental status at time of the accident Any focal neurological deficit 30 mins or less GCS score of 13-15 after 30 mins or posttraumatic amnesia of no more than 24 hours Concussions are mild TBIs Image from gocomics.com ©Stanbridge University 2022 50  TBI Classifications MILD TBI: common symptoms are divided into- – Early-appearing signs and symptoms (present at time of injury): Headaches, nausea and vomiting, blurred vision, tinnitus, dizziness, stiff neck, fatigue, and light and noise sensitivity Do not typically have associated or visible physical injuries – Late-appearing signs and symptoms (days after): Slowed or impaired information processing, disorganization, reduced frustration tolerance, rapid mood changes and increased irritability, difficulties retrieving previous information, increased sensitivity to noise, and reports of being overloaded or overwhelmed – Can have adverse affect on child’s academic performance and interpersonal skills (negative attitude, poor motivation, difficulty with attention) ©Stanbridge University 2022 51  TBI Classifications MODERATE TBI: – Loss of consciousness and/or posttraumatic amnesia of greater than 30 minutes but less than 24 hours and/or the presence of a skull fracture – GCS score of 8 or 9 to 12 SEVERE TBI – Loss of consciousness or posttraumatic amnesia lasting greater than 24 hours, a GCS score of less than 8, extensive physical impairments with possible respiratory compromise, and a slowed overall recovery With both moderate and severe brain injuries, common impairments are noted in the physical, cognitive, sensory, speech and language, personality, and behavioral domains ©Stanbridge University 2022 52  CDC update on Mild TBI (Concussions) Information found on APTA website – http://www.apta.org/FederalIssues/ConcussionManagement/ – APTA continues to educate policymakers on how PTs are qualified to detect and manage concussions Pediatric mTBI on the rise – CDC estimates nearly 3.8 million incidences Image from Clipart Library of sports-related concussions occur every year. – The SAFE PLAY Act would call for school districts to have concussion management action plans that teach students, parents, and school personnel how to prevent, recognize, and respond to concussions ©Stanbridge University 2022 53  CDC update on Mild TBI (Concussions) If a concussion is suspected for the pediatric athlete: 1. Remove child/adolescent from play immediately (coach/parent need to know the signs) 2. Assess the child- pocket tools have been created a. Child SCAT3 (sports assessment tool for children ages 5-12) b. SCAT3 for ages 13 + Image from Clipart PNG c. Don’t leave child alone and watch for possible changes in status and/or evolving of symptoms 3. Take child to health care professional or doctor ©Stanbridge University 2022 54  CDC update on Mild TBI (Concussions) Presentation/Red Flags- child sent to ER or doctor – Assess and treat any physical, cognitive and neurological deficits Various tools used (i.e., ACE- acute concussion evaluation) – The need for CT scan determined – Possible admission to hospital for Image from Clipart PNG monitoring – Recommend child/adolescent to rest Physical and cognitive for a 24-48 hour period – Discharge from ER or hospital – Education to parents/ caregiver for home care ©Stanbridge University 2022 55  CDC update on Mild TBI (Concussions) Important for PT/PTA to educate family and child around what to look for during recovery including: – Warning signs and management of physical and cognitive activity – Expected course of recovery and return to learn/ play Image from Clipart Library – Guidelines for headache management and treatment – Significant difficulties should not persist past 1-3 months – Advice on the risks and complications of re-injury ©Stanbridge University 2022 56  CDC update on Mild TBI (Concussions) Recommendations of returning back to school / play – Within 72 hours of injury if child symptom free he/she may return to academic related activities gradually – Within 72 hours of injury if child not symptom free, should not return back to school – If child still symptomatic after 7 days, accommodations may need to be set for child Develop a return to learn program ©Stanbridge University 2022 57 Image from shutterstock  TBI Classifications Glasgow Coma Scale (GCS) – Table 6-1 pg. 71 – An observational scale utilized in ER’s and intensive care units – Rates the injury on a newly injured infant or child – Used to project a future prognosis for the child’s possible outcome – The items rated include eye opening, motor response, and verbal response – Scores 3-8 are severe injury, 9-12 are moderate injury, and 13-15 are mild injury ©Stanbridge University 2022 58 Modified Pediatric Glasgow Coma Scale ©Stanbridge University 2022 Image from Slideshare 59  Clinical Signs of Moderate to Severe TBI Partial or total impairments of one or more of the following: ▪ Cognition and reasoning ▪ Memory and attention ▪ Abstract thinking ▪ Judgment ▪ Problem solving ▪ Information processing ▪ Receptive and expressive language ▪ Psychosocial behavior ▪ Sensory and perceptual abilities ▪ Motor and physical functioning ©Stanbridge University 2022 60  Clinical Signs of TBI- Physical Impairments Impairments vary Limitations in Impaired motor depending on age Impaired strength independence with planning and of child, location of and ROM mobility coordination injury, and severity Impaired Decreased safety Vision deficits and proprioceptive and Impaired balance awareness and / or hearing deficits kinesthetic impulsivity awareness Risk of developing Possibility of heterotopic seizure activity ossification (HO) ©Stanbridge University 2022 61  Assessment of TBI Once child is medically stable, inpatient rehabilitation begins. Typically PT, OT, and speech therapy is ordered in the acute setting. Neurologic signs, reflexes, sensory functioning, proprioception, skull integrity, stereognosis, quality of movement, vestibular, pain, posture, motor planning, muscle tone… Assessment- Refer to Table 6-2 pg. 73 for (see next slide): – The Rancho Los Amigos Levels of Cognitive Functioning A multi-level scale of cognitive recovery ©Stanbridge University 2022 62 Rancho Los Amigos Levels of Cognitive Functioning This scale is used for Developed by the assessment of recovery, professional staff of the communication between Rancho Los Amigos medical professionals and Hospital in Downey, facilities, and to measure California. change and progress during the rehabilitation course. ©Stanbridge University 2022 63 ©Stanbridge University 2022 64 ©Stanbridge University 2022 65  66 Intervention Based upon the Rancho Los Amigos Levels of Cognitive Functioning score, if appropriate: – coma stimulation interventions can be initiated to promote increased arousal with modulation – increased attention and following of simple one-step commands – increased eye contact upon request – activation of trunk and extremity musculature with purpose and intention of movement – Need to avoid overstimulation; modify treatment area Stimulation controlled, dim lighting, limiting outside noise ©Stanbridge University 2022  Physical Therapy Treatment Plan & Interventions Kinesthetic and proprioceptive awareness (i.e., compression) Positioning Splinting, orthotics, immobilizers & adaptive equipment – involve family and Image from Methodist Rehabilitation Center caregivers Sensory integration (SI) Incorporate strategies for inappropriate behavior and emotional responses W/C mobility training Functional mobility training- bed mobility, transfers and gait training Image from rightathome.net ©Stanbridge University 2022 67  Physical Therapy Treatment 68 Plan & Interventions Maximize independence in functional mobility, self-care, and reintegration into the family and community Address postural issues, malalignment and asymmetries Identify compensatory patterns and abnormal tone (tone reduction techniques) Re-education of developmental motor skills (appropriate for infant/child’s age) Dynamic sitting and standing balance activities ©Stanbridge University 2022  Physical Therapy Treatment Plan & Interventions As the child's functional and cognitive skills improve, The child will learn to process providing more challenging various, possibly conflicting, cognitive tasks while performing information while improving more challenging motor tasks will motor planning and sequencing test the ability to multi-task a and executive functioning skills variety of sensory inputs. ©Stanbridge University 2022 69  Physical Therapy Treatment Plan & Interventions May have to incorporate strategies for modifying inappropriate behavior and emotional responses. Adaptations for cognitive delays and memory loss may also be an integral part of physical therapy. Schedules, routines, and expectations should be consistent. Rewards and consequences must be carefully and repeatedly explained and reinforced with the child. Clear, simple expectations explained in a cognitively appropriate manner will benefit children after TBI. ©Stanbridge University 2022 70 SHAKEN BABY Chapter 7 SYNDROME Guide pattern 5A ©Stanbridge University 2022 71  Learning Objectives After reading this chapter and the materials presented the student will be able to: Shaken 1. Identify 5 traits and of classic Shaken Baby Syndrome (SBS) Baby 2. Identify 5 warning signs of possible SBS Syndrome 3. Discuss steps used to diagnose SBS 4. Identify 4 potential health-related (SBS) problems associated with SBS 5. Identify parent education strategies that would help prevent it 6. Describe the conditions under which the event is likely to occur  Learning Objectives cont… 7. Discuss a child’s predisposition to injury in the shaken baby syndrome spectrum 8. Describe hallmark signs of SBS and ways Image from American SPCC.org they are diagnosed 9. Identify short- and long-term health- related issues associated with the diagnosis of SBS 10. Describe three potential long-term problems that a PT/PTA may encounter 11. Know how to report suspected child abuse ©Stanbridge University 2022 73  Pathology of SBS When baby is shaken, the brain is jolted back and forth inside the skull: - acceleration then deceleration of movements are created A form of child abuse Circulatory structures in and around brain are damaged and bleed – Can lead to death or severe injury Considered a non-accidental TBI ©Stanbridge University 2022 74  Spread Awareness Babies' necks are weak, and cervical facet joints are shallow and horizontally oriented, making this area more susceptible to injury  Clinical Signs of SBS Hallmark signs- subdural and retinal hemorrhages, accompanied by the absence of signs of external abuse Often diagnosed with MRI or CT scan Pale or bluish skin Trouble breathing Convulsions or seizures Irritability Sleepiness or lethargy Vomiting Image from Medlineplus Poor feeding ©Stanbridge University 2022 76  Medical Treatment for SBS Initial/Emergency care: – Assessing airway, breathing and circulation – Stop the hemorrhaging and stabilize BP – ICP (intercranial pressure) monitored closely Once stabilized: – Physician performs in depth evaluation and neurological assessment – Then child monitored closely – Also assess if there are fractures present ©Stanbridge University 2022 77  Physical Therapy Assessment of SBS PT/PTA’s may encounter these patients in the acute phase for post traumatic intervention followed by rehabilitation and continued services throughout their lifespan. Assessments in the following areas may be indicated: - aerobic capacity and endurance - posture - arousal, attention, and cognition - skin integrity - assistive and adaptive devices - joint integrity/ROM - cranial nerve integrity - muscle performance - gait locomotion and balance - pain - neuromotor development - sensory integrity - ventilation/respiration - self-care ©Stanbridge University 2022 78  Physical Therapy Intervention ROM exercises Positioning and splinting Managing abnormal tone and posturing Improving movement quality and functional mobility Other common interventions: Vision therapy, assistive technology, speech, OT for self care and feeding issues ©Stanbridge University 2022 79  Suspected Child Abuse The California Child Abuse and Neglect Reporting Law (CANRA) – https://www.mandatedreporterca.com/images/P ub132.pdf – Was passed in 1980 – Over the years, numerous amendments have expanded the definition of child abuse and the persons required to report it – Procedures for reporting have also been clarified – In California, certain professionals are required to report known or suspected child abuse ©Stanbridge University 2022 80  Standards for Reporting in California Citation: Penal Code § 11166 – A mandatory reporter shall make a report whenever he or she, in his or her professional capacity or within the scope of his or her employment, has knowledge of or observes a child whom the mandated reporter knows or reasonably suspects has been the victim of child abuse or neglect. – The term 'reasonable suspicion' means that it is objectively reasonable for a person to entertain a suspicion, based upon facts that could cause a reasonable person in a like position, drawing, when appropriate, on his or her training and experience, to suspect child abuse or neglect. – https://www.childwelfare.gov/topics/systemwi de/laws-policies/statutes/manda/ ©Stanbridge University 2022 81  Who is Required to Report? California Professionals Required to Report: Penal Code § 11165.7 Mandated reporters include the following: – Firefighters and police officers – Teachers and school district administrators – All healthcare professionals including nurses, physicians, PT/PTAs (including PTA students), social workers, psychologists, clergy, athletic coaches, foster parents, etc… SPTAs who suspect or know for certain of an incidence of child abuse should report the information to their clinical instructor ©Stanbridge University 2022 82  Institutional Responsibility to Report Penal Code § 11166(h)-(i) The term “institutional reporting” refers to those situations in which the mandated reporter is working (or volunteering) as a staff member of an institution, such as a school or hospital, at the time he or she gains the knowledge that leads him or her to suspect that abuse or neglect has occurred. Many institutions have internal policies and procedures for handling reports of abuse, and these usually require the person who suspects abuse to notify the head of the institution that abuse has been discovered or is suspected and needs to be reported to child protective services or other appropriate authorities. https://www.childwelfare.gov/topics/systemwide/laws- policies/statutes/manda/ ©Stanbridge University 2022 83 Critical to Report Child Abuse If you suspect that a child is undergoing abuse, it’s critical to report it—and to continue reporting each separate incidence if it continues to recur. Each report you make is a snapshot of what’s going on in the family. The more information you can provide, the better the chance of the child getting the help they deserve. Of course, it’s normal to have some reservations or worries about reporting child abuse. Call Childhelp at 1-800-422-4453 or visit Child Welfare Information Gateway When Child Protective Services (CPS) staff receive reports from professionals and concerned citizens alerting them to concerns about a child's welfare, they may initiate an investigation to determine if a child has been or is at risk of being harmed. ©Stanbridge University 2022 84  1) According to the Rancho Los Amigos Levels of Cognitive Functioning, level II recovery for Learning TBI describes: a) no response Assessment b) purposeful and responsive c) generalized response to pain d) confused and agitated  2) An acceleration-dependent injury occurs: a) when a force is applied to a movable head Learning b) at the point of impact and when the brain strikes the skull on the Assessment opposite side c) when there is lateral movement of both the brain and skull in response d) all of the above  3) The hallmark signs of SBS are which of the following? a) Convulsions or seizures b) Sleepiness and noticeable skull Learning fractures Assessment c) Subdural and retinal hemorrhages seen on CT scan with no signs of external abuse d) Vomiting or loss of appetite  4) Who is mandated to reported child abuse in California? Learning a) Doctors b) Elementary school teachers Assessment c) Student PTAs d) All of the above Rheumatic Chapter 8 Guide pattern 4H Disorders ©Stanbridge University 2022  Learning Objectives After reading this chapter and other materials presented the student will be able to: Rheumatic 1. Identify the types of juvenile arthritis Disorders 2. Identify intervention techniques 3. Identify short- and long-term treatment objectives  Juvenile Rheumatoid Arthritis (JRA) defined as: – A disorder causing joint inflammation and stiffness for more than six weeks in children less than 16 years of age Rheumatic Disorders (From Zitelli BJ, Davis HW: Atlas of pediatric physical diagnosis, ed 5, Philadelphia, 2007, Mosby.) Fig. 8-1 A 2-year-old girl with arthritis of the left knee. 91 ©Stanbridge University 2022  An autoimmune disease- the body mistakes its own cells and tissues as foreign and attacks them – Results in inflammation marked by redness, heat, pain, and JRA swelling The cause of JRA varies in different Pathology children – The immune system malfunctions – Genetic factors and viruses have been suggested as playing a role  1. Pauciarticular- (has 3 sub types) 1) Test positive for antinuclear antibodies- ANA Three 2) Affects spine in late teens and may test positive for the gene identified with adult ankylosing Types of 3) spondylitis Only joints involved, not organs JRA 2. Polyarticular (2 subtypes) 3. Systemic (Still’s disease) The determination of diagnoses between types is made within the first 6 months of onset  Affects 4 or fewer joints Affects large joints, most Pauciarticular commonly the knees JRA: Clinical Signs Risk for iridocyclitis in subtype 1 (inflammation of the eyes) Affects 5 times as many girls as boys ©Stanbridge University 2022 94 Fig. 8-2 Pauciarticular juvenile rheumatoid arthritis. A, A close look at this child's knees reveals left knee swelling. B, The left knee can only be extended to 35 degrees (secondary to a flexion contracture). (From Zitelli BJ, Davis HW: Atlas of pediatric physical diagnosis, ed 5, Philadelphia, 2007, Mosby.) 95 ©Stanbridge University 2022  Affects both Affects 5 or more large joints and joints smaller joints Polyarticular Often affects the Rheumatoid same joint on factor (RF) JRA: both sides of the antibodies in body subtype 1 Clinical Signs Affects 3 times as many girls as boys ©Stanbridge University 2022 96  High-spiking fevers Rash on chest and thighs Systemic JRA: Joint involvement Clinical Signs Internal organs can be affected Affects girls and boys in equal numbers ©Stanbridge University 2022 97  Skeletal Abnormalities: – Seen in extremities, spine or jaw – Chronic hyperemia (excess blood flow) in an inflamed joint Secondary can stimulate accelerated maturation of epiphyseal Factors of plates leading to skeletal overgrowth JRA Can result in leg length discrepancy Limitations in hip mobility Can lead to valgus deformity in knee and foot  Skeletal Deformities Skeletal deformity in both LE’s- valgus at knees, resulting in leg length discrepancy Image from rxonline.Epocrates Fig. 8-3 The hands of a patient with polyarticular Image from US Pharmacist JRA. Note the inability to Image from Webmed, Inc. fully extend the fingers. Joint Structure Changes ©Stanbridge University 2022 100  Skeletal abnormalities cont.. Mandibular underdeveloped or Secondary small called micrognathia – May cause oralmotor problems factors of Apophyseal joint disease associated with poor development JRA of vertebrae in spine (eventually fuse) Scoliosis  Ophthalmic Considerations- Secondary - uveitis (iridocytclitis)- inflammation of the iris and ciliary factors of body (whites of the eye looks red) Anemia JRA Poor caloric intake  JRA Intervention Multidisciplinary team approach: ophthalmologist, pediatric rheumatologist, nutritionist, PT, OT,… Primary goals are pain relief, reducing swelling, maintaining movement and joint mobility and slowing the progression of the disease Pharmaceutical interventions- – Anti-inflammatory drugs: (NSAIDs), Ibuprofen, Naproxen – Disease-modifying antirheumatic drugs: (DMARDs), Methotrexate – Corticosteroids: Prednisone (can interfere with child’s normal growth and cause weakened bones) – Biologic response modifiers: Enbrel (helps block an inflammation promoting substance in the body) ©Stanbridge University 2022 103 Physical Therapy Intervention – Improving child’s strength – A/PROM (gaining and maintaining) – Functional mobility – Improving independence – Endurance and energy conservation – Educating the child and family on the musculoskeletal effects of the pathology process and secondary damage from medications – Joint protection strategies – Examples: aquatic therapy, cryotherapy, positioning, thermotherapy, low-impact ther-ex program ©Stanbridge University 2022 104  Scleroderma- “Hard-skin”- a connective tissue disease involving skin, blood vessels, and the immune system as well as internal organs. Other – Two types: Localized and Systemic Rheumatic – Localized scleroderma is more common in children Diseases Typically does not affect internal organs – Believed to be thousands of cases of juvenile scleroderma worldwide and many go undiagnosed  Scorebuilders ERB’S PALSY PTA Exam The Complete Study Guide Scott M. Giles ©Stanbridge University 2022 106  Erb’s Palsy- Brachial Plexus Birth Injury Also called Erb-Duchenne Palsy It is an obstetric brachial plexus disorder (dystocia of the shoulder) Physical injury occurs during birthing process Can be due to a difficult delivery such as, prolonged labor, big Image from erpspalsyonline.com baby, breech positioning, or use of forceps ©Stanbridge University 2022 107 Giles 2018  Erb’s Palsy- Brachial Plexus Birth Injury Pathology: Seen in1-2 babies born in every 1,000 according to AAOS Caused when infants neck is stretched to the side, too much traction on the neck, or when the infant’s shoulder gets stuck A lower motor neuron disease Lesion at C-5 and C-6 with loss of function of the: – Rotator cuff – Deltoid – Brachialis – Coracobrachialis – Biceps brachii ©Stanbridge University 2022 Giles 2018 108  Erb’s Palsy- Brachial Plexus Birth Injury Signs and Symptoms: Loss of shoulder function, loss of elbow flexion, loss of forearm supination; may be able to move fingers Loss of feeling/sensation in involved arm Partial or total paralysis (flaccidity) of involved arm – Changes in position of upper extremity – Arm rotated toward body (internal rotation) with flexed wrist nicknamed “waiter’s tip deformity” 109 ©Stanbridge University 2022 Giles 2018  Erb’s Palsy- Brachial Plexus Birth Injury Physical Therapy Intervention – PT and OT indicated immediately – Develop program that focuses on increasing A/PROM and promoting use of weak UE for functional activities – Adaptation of developmental milestones – Weight bearing activities (on weak UE and bilateral UE’s) – Sensory techniques – Home program instruction to caregivers including: Positioning Integration of weak UE into all functional activities A/PROM Strengthening Caregiver must be competent and perform HEP consistently ©Stanbridge University 2022 Giles 2018 110  Erb’s Palsy- Brachial Plexus Birth Injury Prognosis: Most infants will recover movement and feeling within 3-4 months with conservative management If it is more severe, length of treatment will be longer and surgery may be indicated – Nerve graft or nerve transfer – Followed with wearing a splint for 3-4 weeks It can take up to 2 years for nerves to re-grow completely – Nerves grow at a rate of one inch per month Daily ROM taught to the parents by physical therapy is very important for a positive outcome Giles 2018 ©Stanbridge University 2022 111  1) Polyarticular JRA affects a) 4 or fewer joints b) 5 or more joints c) 3x’s as many girls as boys Learning d) b and c Assessment 2) Micrognathia is a skeletal abnormality in the jaw often related to JRA, True or False?  PT Through The Lifecycle Lab Week 6- Interventions NDT (Neurodevelopmental treatment), Head Control, and Joint approximation/Compression techniques 1. Intro to Neurodevelopmental Treatment (NDT) on an Infant/small child: Demonstration of NDT techniques on Mon Ami doll and on student volunteer by instructor; students will return demo in partners and with doll Activity 1- Everyone lie on the floor in supine and follow instructor’s directions with head lifting Elongate spinal extensors to promote head flexion and downward visual gaze in supine without compensating and in preparation for ant-gravity flexor control Infant in supine: place one hand under sacral area and other hand under cervical area o providing gentle light sustained traction Elongate lower spine and promote posterior pelvic tilt (facilitated bottom lifting) o Also activates abdominals o Infant in supine: place hands on LE’s, thumbs under on posterior side of thighs and fingers on anterior side and bring their LE’s to their chest, lifting the bottom up slightly from surface. This brings feet toward their face and helps to promote grabbing the feet with hands  PT Through The Lifecycle Lab Week 6- Interventions *can use bolster to prop up the kid if kiddo cannot sit up *can put beads/toys on the ankle to get kid’s attention *parent education in order to do the intervention at home during mundane activities like changing diaper *goal is for kid to start activating abdominals and for it to reach the end range m o Different method as infant progresses- place one to two fingers under bottom and facilitating posterior pelvic tilt and bottom-lifting, hold it there so infant see’s feet (not pictured) Activate abdominals with chin tuck and head lifting off surface in supine o May need to place infant on wedge bolster o May need to place hand on posterior head to help lift up o May need to use toy or object to encourage infant to lift head  PT Through The Lifecycle Lab Week 6- Interventions *have kid engage their obliques by having them reach across their body towards their opposite leg *can use bolster if kiddo need more support for the back Activate abdominals with UE flexion and adduction across body and can facilitate rolling toward that same direction o Gently grab one UE on forearm area and pull up on a diagonal toward the opposite UE (repeat x 3-5 reps); find where the patient responds the best with this facilitation o May continue to follow through where infant rolls in the same direction Facilitation of weight bear on forearms over therapy ball o Place infant on therapy ball in prone with weight bearing on elbows and forearms. Manually facilitate forearms in place and provide gentle bouncing o May add joint compression down through shoulder joints to forearms *can use yoga ball to facilitate neck lifting *position is prone on elbows *can put toys or ipad infront of the baby to look at *joint approximation by having hands on the scapula and shoulders (c-grip) Activate the core in sitting- Facilitation on lower back and/or trunk to promote sitting upright and decrease posterior pelvic tilt (as learned when went through sitting postures) o Child seated on floor, low bench, or edge of mat  PT Through The Lifecycle Lab Week 6- Interventions o Use light manual cues to move trunk to more upright position and promote more of an anterior pelvic tilt. Hands can be placed on low back and/or anterior chest area *half kneeling w/ posterior leg supporting pt’s back *J-grip on the PSIS will help facilitate anterior pelvic tilt & guide shoulder to an upright position with the other hand clinician-view.com Promotion of sitting upright and maintaining position on bolster o Many manual cues for NDT can be utilized o Therapist sitting behind child o Example- hands on anterior trunk across shoulders- see image below:  PT Through The Lifecycle Lab Week 6- Interventions 2. Positioning to Encourage Head control: Instructor to demo and students to return demo the following techniques: Supine positioning- can be used to encourage symmetry of the child’s head position and reaching forward in space and head lifting off surface o Antigravity flexion of the neck is necessary for balanced control of the head and can be difficult for children with pathologies o Preparatory positioning in a supine position on a wedge or half-roll puts the child in a less difficult position against gravity to attempt head lifting o A midline position can be encouraged by using a rolled towel arch or by providing a visual focus such as a toy o If a child cannot demonstrate any forward head movement, increasing the degree of incline so the child is closer to upright than to supine may help Intervention 5-15 (Marin/Kessler pg. 112) Modified pull to sit maneuver (i.e., therapist’s hands on shoulder girdle instead of hands/arms) add wedge or raised supported surface so infant not starting from flat surface A. Position the child on an inclined surface supine in preparation for anterior head lifting.  PT Through The Lifecycle Lab Week 6- Interventions B. Provide support at the child’s shoulder, rotate the child toward yourself, and begin to move the child toward sitting on a diagonal. Prone positioning- is used to encourage head lifting and weight bearing on forearms and extended arms o Prone is usually the first position the newborn experiences head lifting o When an infant is placed over a small roll or bolster, the child’s chest is lifted off the support surface, and this maneuver takes some weight off the head o The infant’s forearms can be positioned in front of the roll, to add further biomechanical advantage to lifting the head o The elbows should be positioned under the shoulders to provide weight- bearing input for a support response from the shoulder girdle muscles o A visual and auditory stimulus, such as a mirror, brightly colored toy, or noisemaker, can be used to encourage the child to lift the head o A wedge may also be used to support the infant’s entire body and to keep the arms forward for an activity or weight bearing  PT Through The Lifecycle Lab Week 6- Interventions A. Positioning the child prone over a half-roll encourages head lifting and weight bearing on elbows and forearms. B. Positioning the child prone over a bolster encourages head lifting and shoulder control. C. Positioning the child prone over a wedge promotes upper-extremity weight bearing and function. B, Courtesy of Kaye Products, Inc., Hillsborough, NC Prone over therapy ball is another technique Upright or supported sitting position- in relation to gravity, this position is easier to maintain head control compared to prone and supine o A balance of neck flexors and extensors is needed to maintain the head position o Proprioceptive input by approximation provided by spine and pelvis o Manual contacts under or around the shoulders are used to support the head o Establishing eye contact with infant/child also assists head stability because it provides a stable visual input to orient them FIGURE 5-10 Early head control in supported sitting. Placing child in a supported sitting position on the floor can help promote head control. Seated on therapy ball with gentle bouncing and mild tilting are beneficial techniques  PT Through The Lifecycle Lab Week 6- Interventions Fig C. A feeder seat/floor sitter that allows for different degrees of inclination. It has a Velcro base and the upper seat position can be moved so the angle of incline changes to more reclined. Other activities that promote head control Weight shifting while seated on caregiver’s lap with support Holding/carrying positions (e.g., football hold) Prone suspended in a hammock swing ____________________________________________________________________________  PT Through The Lifecycle Lab Week 6- Interventions 3. Manual Approximation Techniques (pg. 103, Martin/Kessler) Approximation- a technique where compression is provided through joints in weight bearing or prior to weight bearing (non-weight bearing positions) o Manually apply firm pressure thru the long axis of aligned body parts, graded to the child’s tolerance and pathology Can be intermittent or constant compression (should be slow and rhythmical with hypertonicity, and can be quicker for hypotonia) Provides proprioceptive cues to alert postural muscles to support the body Body parts in area of approximation must be aligned Typically about 5 reps Can also prepare a limb or trunk to accept weight prior to loading the limb Rocking on hands and knees, pushups, knee walking or bouncing a ball in sitting are examples of activities that provide joint approximation. Preparation for upper extremity weight bearing (i.e., sitting with arm propped, quadruped, prone on forearms) Application of pressure through the heel of the hand to approximate the joints of the upper extremity helps to prepare the UE for weight bearing as seen in propped sitting or quadruped Best done with arm in 45 degrees of external rotation and elbows extended (not locked) Joint approximation (proprioceptive input) also helps a child to focus, organize their thoughts, and has calming effects; often used with children on the spectrum or who have sensory processing dysfunction. Can also help to reduce spasticity or clonus. PT Through The Lifecycle Lab Week 6- Interventions PT Through The Lifecycle Lab Week 6- Interventions  PTA 1011- Lecture Handout Week 6- APTA CMT Guidelines CMT: Congenital Muscular Torticollis 2018 APTA Evidence-based Clinical Practice Guideline Torticollis Physical Therapy Intervention Plan: 1.Neck PROM: Manual stretching most commonly reported intervention for CMT Increased frequency of stretching is more beneficial, with greater improvement in head tilt and cervical rotation for 10 stretches x 10 sessions/day (versus 10 stretches x 5 sessions/day) No consensus on best stretching technique, number of repetitions, the duration of stretches and rest periods, and number of persons required for stretches Stretching should not be painful to baby and stopped if infant resists or parent perceives changes in breathing or circulation Low intensity, sustained, pain-free stretches recommended avoiding microtrauma of muscle tissue Follow supervisor PT guidelines and take into account family dynamics 2. ACTIVE ROM for neck and trunk: The affected side of CMT is placed downward, elongating the tighter muscles and encouraging the activity & strength of the weaker, non- affected side 3. SYMMETRICAL Movement Activities: Weight-bearing positions- prone, sitting, crawling, walking Developmental exercises should be incorporated into PT interventions and home programs to promote symmetrical movement in weight-bearing postures and to prevent the development of impaired movement patterns in prone, sitting, crawling, and walking 4. Environmental Adaptions: Change position in the crib, top of the changing table, car seat, toys Adjust positioning both when awake and asleep. Infant time needs to be spent in the prone & side-lying position.  PTA 1011- Lecture Handout Week 6- APTA CMT Guidelines 5. Parent education: Tummy time- Minimum of 1 cumulative hour daily Alternate feeding sides Minimize time in equipment Handling to promote symmetry and head position changes Discontinue direct PT services to monitoring when: PROM within 5 degrees of the non-affected side Symmetrical active motor patterns Age appropriate motor development No visible head tilt Caregiver understands what to monitor as the child grows. Discharge 3-12 months following decreased direct services or when walking Consult with physician/PT when asymmetries are not resolving after 4-6 weeks of comprehensive treatment or after 6 months of treatment there is a plateau PLAGIOCEPHALY/FLAT HEAD/CRANIAL DEFORMITY The prevalence of craniofacial asymmetry has been reported as 90.1% in children with CMT at initial evaluation Plagiocephaly, brachycephaly, scaphocephaly Craniofacial asymmetries on the side of the torticollis may include a smaller and elevated eye with changes in the orbit, the recession of the ipsilateral ear, a reduced jaw height with malocclusion, and possible gum line asymmetry Early position changes for the head that start at 2 days old are the best prevention for cranial deformity. 90% of parents typically receive education on back to sleep position, but only 27% receive education on best positions for awake time play and carrying positions. 2018 APTA Evidence-based Clinical Practice Guideline: Kaplan SL, Coulter C, Sargent B. Physical therapy management of congenital muscular torticollis: a 2018 evidence-based clinical practice guideline from the APTA academy of pediatric physical therapy. Pediatric Physical Therapy. 2018;30:240-290. Provides a graded classification system for CMT: Level 1 - 3: Early Mild, Mod, Severe à Level 4 - 8 Later Mild, Mod, Severe, Extreme; Very Late PTA 1011- Lecture Handout Week 6- APTA CMT Guidelines  PTA 1011- PT Thru the Lifecycle Updates on Pediatric Mild TBI- from APTA and CDC Pediatric mTBI on the rise Health care providers/PTs should help the family/patient to understand that 70-80% of children/adolescents with mTBI that have significant difficulties will typically not have the symptoms 1-3 months after the injury. And that recovery is unique to every injury and every person. The family/patient should be educated on what to look for during recovery including warning signs and management of physical and cognitive activity, guidelines for management and treatment of headaches, sleep, etc.. Guidelines- Recommended by Timeline (for pediatric athletes) 1. Learn to recognize the symptoms of concussion (coaches, teachers, parents, athletic trainers, etc..) a. There are formal tools/guides developed to help, i.e., pocket guide 2. Adopt a formal policy that prevents a child/adolescent who may have sustained a concussion from returning to play on the same day as the injury (school boards, community sports organizations) 3. Ensure policies are in place to accommodate the child/adolescent who may have sustained a concussion (use of tools) 4. Consider setting up base-line testing for young athletes If a concussion is suspected- 1. What to do initially: a. Remove child/adolescent from paly immediately (need to be aware of what the signs are) b. Assess the child/adolescent- can use pocket tools, childSCAT3 (sports assessment tool for children aged 5-12), or SCAT3 (aged 13 +) c. Do not leave child alone d. Watch for possible changes in status or symptoms evolving e. Take to hospital ER, urgent care or doctor 2. Presentation and “red flags”: a. Assess and treat any physical, cognitive and neurological deficits (various tools, i.e., ACE (acute concussion evaluation)) b. Need for CT scan determined c. Admission to hospital? (child needs overnight monitoring or more intensive care?)  PTA 1011- PT Thru the Lifecycle d. REST- from physical and cognitive- at the minimum for a 24-48-hour period e. Discharge from ER or hospital to home 3. Education to parents: a. What to do at home; what to be aware of b. Expected course of recovery and return to learn/play c. Advice on the risks and complications of re-injury d. Advice on managing sleep issues, headaches, coping with fatigue, social networks/interactions, avoiding drugs and alcohol, and driving 4. Recommendations of returning to school/play a. Within 72 hours of injury- if child symptom free, they can return to academics gradually; if still have symptoms- not to return to school b. After 7 days of injury- if symptoms persist, accommodations may need to be set up for child. i. Develop a return to learn program  5 Tips for Positioning and Play to Help Your Newborn Baby's Posture and Movement Development Follow these tips from the time your baby is born unless otherwise directed by your doctor or other medical professional. Correct head and body position Your baby should always sleep so neither are off to one side for on his/her back. Turn your extended periods of time. baby's head to the opposite side For example, put your each night to prevent a flat spot baby in your lap facing from developing on one side. No. 1 CENTER BABY'S you. No. 2 ENCOURAGE BABY No. 3 BACK TO HEAD AND BODY TO LOOK BOTH SLEEP WAYS Alternate holding baby on your left and right arm while feeding. Also, center head and You may also alternate which side is the body while in the car Put interesting infant toys "head of the bed" when placing baby in crib seat. on both sides of your baby. each night. This helps baby turn to each side to see out of the crib. 3 At least times each day, place your baby on his/her tummy to play. No. 4 WHILE AWAKE AND SUPERVISED During the first 6 months, supervised tummy time while awake helps your baby's motor development. TUMMY TO PLAY All above photographs used with permission from Children's Healthcare of Atlanta "Tummy Time Tools" available at: https://www.choa.org/medical-services/orthopaedics/orthotics-and-prosthetics/tummy-time-tools Limit baby's time in infant positioning equipment (such as car seats and strollers) to only the time your baby is being transported. No. 5 #1 Minimize the time your infant spends in other infant positioning equipment (such as infant swings, bouncy seats, and infant/toddler rockers). 1. Hold your baby in your arms or using a sling instead of a container. DO: MINIMIZE TIME IN "CONTAINERS" 2. Allow baby to play freely in a playpen or on a blanket on the floor with adult supervision. 3. Remember tummy time to play! American Physical Therapy Association Move Forward "Container Baby Syndrome". Available at: https://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=53d90264-1846-4b86-891f-0facc63db3e8 SIGNS OF CONGENITAL MUSCULAR TORTICOLLIS (CMT) 5 TO WATCH FOR: Monitor for these early signs of CMT (neck muscle tightness and movement preference). Talk to your physician/medical provider about seeing a physical therapist if you notice: 1. Baby holds head tilted or turned to one side. 2. Baby struggles more with nursing or feeding on one side. 3. Baby's head is flat on one side on the front or back. 4. Baby avoids turning head to one side. 5. Baby prefers to use one hand more when reaching or putting hand to mouth. If you notice signs of congenital muscular torticollis: Start physical Starting physical therapy sooner is better. therapy. Starting physical therapy care as soon as possible gives your baby the best chance for the best outcome. Users of this resource are strongly encouraged to read the full clinical practice guideline: Kaplan SL, Coulter C, Sargent B. Physical therapy management of congenital muscular torticollis: a 2018 evidence-based clinical practice guideline from the APTA academy of pediatric physical therapy. Pediatr Phys Ther. 2018;30:240–290. Available at: https://journals.lww.com/pedpt/Fulltext/2018/10000/Physical_Therapy_Management_of_Congenital_Muscular.2.aspx This document along with other 2018 CMT CPG implementation resources are available at: https://pediatricapta.org/clinical-practice-guidelines/ ©2018 Academy of Pediatric Physical Therapy. Knowledge Broker Network (KBNet) contributors M McKinney, PT, DPT, PCS, S Kent, PT, DPT, PCS, C Daly, PT, DPT, PCS