Week 4 Lecture: Assessment in Paediatric Physiotherapy PDF

ASSESSMENT IN PAEDIATRIC PHYSIOTHERAPY PHTY5201 Physiotherapy Across the Lifespan Presented by Mohammad Fauzan Bin Maideen Discipline of Physiotherapy Sydney School of Health Sciences Faculty of Medicine and Health The University of Sydney Page 1  LEARNING OBJECTIVES Understand how...

ASSESSMENT IN PAEDIATRIC PHYSIOTHERAPY PHTY5201 Physiotherapy Across the Lifespan Presented by Mohammad Fauzan Bin Maideen Discipline of Physiotherapy Sydney School of Health Sciences Faculty of Medicine and Health The University of Sydney Page 1  LEARNING OBJECTIVES Understand how paediatric assessments are different from adult assessments Understand what to assess in paeds Understand the difference between formal (standardised) and informal assessments A general knowledge of paediatric formal assessment tools The University of Sydney Page 2 3 ASSESSMENT VS MEASUREMENT a qualitative and/or quantitative description of a patient’s status Assessment: e.g. age related motor activities (Movement ABC, Motor Assessment Scale, AIMS) a number or score which reflects a patient’s status at the time it is Measurement: assigned e.g. joint ROM, muscle strength, muscle length The University of Sydney Page 3  ASSESSING & MEASURING MOTOR PERFORMANCE Why assess? What are we assessing or measuring? What type of assessment tool? What affects results? The University of Sydney Page 4  WHY ASSESS? Early identification → early intervention Baseline of motor behaviour Developmental red flags Comparison of motor behaviour Change in performance Evaluate intervention Evaluate outcomes of known events Screening The University of Sydney Page 5 5 WHAT ARE WE ASSESSING? ICF – CY (2001) The University of Sydney Page 6 WHAT ARE WE ASSESSING? Loss or abnormality of physiological, psychological or anatomical structure Impairment or function E.g. p/f contracture Activity Restriction or lack of ability to perform an activity Limitation E.g. ↓walking capacity Disadvantage experienced by individuals with Participation ill-health due to inability to fulfil a role which is typical for someone of that age, sex and Restriction culture E.g. difficulty getting around school compound The University of Sydney Page 7 WHAT ARE WE ASSESSING? Movement gross/fine motor quality co-ordination of movement postural adjustments everyday functions milestone/age related activities new skill acquisition how children problem solve with their movement The University of Sydney Page 8 8 WHAT ARE WE MEASURING? Growth & development Height & weight Lower limb alignment The University of Sydney Page 9 9 WHAT ARE WE MEASURING? Growth percentile charts The University of Sydney Page 10 10 WHAT ARE WE MEASURING? Physical constraints on movement Joint range of motion reliability and validity of measurements in children Muscle strength ? similar to adults, at what age? Correlation with everyday function? Muscle Tone Active vs resting Variability even within normal limits The University of Sydney Page 11 11 WHAT AFFECTS ASSESSMENT RESULTS? Growth and development Parental expectations & emotions Context eg clinic vs home, background noise, distractions, familiarity to the tester, validity of testing environment Behaviour state e.g. in infancy - Prechtl (1964) – 6 states The University of Sydney Page 12 12  Prechtl’s 6 states – why is it useful? State Description What Your Baby Does State 1 Deep Sleep Lies quietly without moving State 2 Light Sleep Moves while sleeping; startles at noises State 3 Drowsiness Eyes start to close; may doze State 4 Quiet Alert Eyes open wide, face is bright; body is quiet State 5 Active Alert Face and body move actively State 6 Crying Cries, perhaps screams; body moves in very Caring for Your Baby and Young Child: Birth to Age 5 (Copyright © 2009 American Academy of Pediatrics) https://www.healthychildren.org/ disorganized ways https://www.youtube.com/watch?v=49zvTaqzkws The University of Sydney Page 13 The University of Sydney Page 14 TYPES OF PAEDIATRIC MOTOR ASSESSMENTS Informal / non-standardised descriptive analysis of movement (does include objective measures e.g. spatial / temporal measures Formal / standardised Discriminate i.e presence/absence of the diagnosis or clinical impairment; extent/severity Predict e.g. high risk subgroup; who will/will not benefit from intervention Evaluate - change of function over time or with intervention The University of Sydney Page 15 15 INFORMAL (NON-STANDARDISED) ASSESSMENT To complete first where possible Subjective Communication between PT and parent/caregiver/child Assessment Attempt to be comprehensive for the initial assessment Child’s Observed vs Elicited performance Objective Be cautious when interpreting findings especially if the child is especially Assessment fretful, unwell and /or atypical behaviour reported by parent/caregiver on assessment day The University of Sydney Page 16  Subjective Assessment ▪ Reason/s for referral ▪ Infant’s/Child’s routine ▪ Birth history ▪ Natural environment ▪ Maternal history ▪ Primary Caregiver ▪ Past medical history ▪ Family structure ▪ Past surgical history ▪ Past interventions ▪ General Health ▪ Current ability of ▪ Developmental history infant/child ▪ Goals (Parent/ Caregiver/ Child) The University of Sydney Page 17  The concept of age in paediatrics Committee on Fetus and Newborn et al, Pediatrics 2004; 114:1362 - 1364 Developmental Age The University of Sydney Page 18  Objective Assessment Observation General health/ well being of child. Temperament. Attachments. Incisional sites. Resting postures Milestone development Gross Motor (Postural Fixations/Transitions). Fine Motor. Speech/Communication. Social/Behaviour Primitive Reflexes Aka Stereotypical Patterns of Movement, Infant Patterns of Movement Asymmetrical Tonic Neck Reflex, Stepping, Moro etc. Neurological Function Tone. Deep tendon reflexes. Clonus. Spasticity. Babinski The University of Sydney Page 19  Objective Assessment (continued) Postural Reactions Righting reactions. Equilibrium reactions. Placing reactions. Parachute reactions. Landau Sensory Motor Function Tactile. Oculomotor. Proprioception. Auditory. Vestibular. Musculoskeletal Function ROM, Ms strength, Ms length, Limb length discrepancy, etc. Cardiopulmonary Function Auscultation, Breathing patterns, Endurance, etc. The University of Sydney Page 20  PRIMITIVE (INFANTILE) REFLEXES Also known as ‘infant patterns of movement’ or ‘stereotypical patterns of movement’ integral part of movement for the first months of life non-obligatory In paediatric assessment, such reflexes are important indicators if they are absent in the early stages of life, or if the baby is still demonstrating them when they should no longer be a reflex but should be a controlled movement. All should be integrated in the first year of life The University of Sydney Page 21 Commonly identified primitive reflexes a. Rooting reflex Assists with feeding Primitive tactile response Activated by stroking the baby’s side of mouth – head will turn towards the ipsilateral side and baby will open mouth Test contralateral side for symmetry ▪ Emerges at birth ▪ Integrates by 2 -3 months Other feeding-related reflexes are sucking, swallowing and gag The University of Sydney Page 22 Commonly identified primitive reflexes b. Moro Reflex Primitive vestibular response ▪ Emerges at 0-4 weeks ▪ Integrates by 3-4 months The University of Sydney Page 23 Commonly identified primitive reflexes c. Stepping Reflex Emerges at birth Primitive tactile response integrated by 2 - 4 months d. Palmar grasp reflex Fingers automatically flex when a tactile stimulus is placed in baby’s palm (ulnar side) Test both hands for symmetry Emerges at birth Integrates by 3-4 months The University of Sydney Page 24 Commonly identified primitive reflexes e. Galant Reflex Tested for at birth to rule out spinal cord damage or brain damage. Primitive tactile response Test both sides for symmetry. ▪ Emerges from 0-4 weeks ▪ Integrates by 9-12 weeks The University of Sydney Page 25 Commonly identified primitive reflexes f. Asymmetrical Tonic Neck Reflex (ATNR) Primitive proprioceptive response Fencing posture Facial side – extend Occipital side – flex Emerges from 0-6 weeks Integrated by 3-4 months Test both sides for symmetry. The University of Sydney Page 26 POSTURAL REACTIONS Righting reactions responsible for maintaining head & body alignment in relation to space & maintaining relationship of body-to-body segments Equilibrium reactions body’s response to tilting of support surface Protective (parachute) reactions Body’s protective response to loss of balance The University of Sydney Page 27 Righting Reactions (RR) (Shumway-Cook & Woollacott, 2012) The University of Sydney Page 28  Lateral Head Righting The University of Sydney Page 29 Righting Reactions (RR) (Shumway-Cook & Woollacott, 2012) The University of Sydney Page 30  Equilibrium Reactions (ER) The University of Sydney (Shumway-Cook & Woollacott, 2012) Page 31  Equilibrium Reactions (ER) The University of Sydney (Shumway-Cook & Woollacott, 2012) Page 32  Protective (Parachute) Reactions (Shumway-Cook & Woollacott, 2012) The University of Sydney Page 33  Forward Protective (Parachute) Reaction The University of Sydney Page 34  Downward Protective (Parachute) Reaction – Lower Limbs The University of Sydney Page 35  Putting it all together Sitting Balance The University of Sydney Page 36  Auditory Vestibular Sensory Tactile Motor Systems Proprio- Visual/ ception Oculomotor The University of Sydney Page 37  Maturation of the Sensory-Motor Systems Largely mature by 4-6 Tactile years of age Mature by about 9 years Vestibular of age Body parts mature at Proprioception different rates The University of Sydney Page 38  Orients body to Tactile stimulus Central reference for other systems Linear movement Vestibular →otolith cells Angular acceleration/ deceleration/rotatory → semi-circular canals The University of Sydney Page 39  Relative position for body parts Proprioception Orient to support surface Joint position sense Motivation to move Vision Orientation to visual surroundings by 6 months The University of Sydney Page 40 TYPES OF FORMAL (Standardised) ASSESSMENTS Norm referenced use normative values as standards for interpreting individual test scores describe a child’s test score relative to a large body of scores that have already been collected on a defined population Criterion referenced interpreted on basis of absolute criteria e.g. number of items answered correctly rather than how a group performed Used to measure mastery on a set of objectives/criteria – looks into the quality of performance The University of Sydney Page 41 FORMAL ASSESSMENTS Examples of Norm Referenced Assessments Alberta Infant Motor Scales (AIMS) Bayley Scales of Infant Development (BSID) Bruininks-Oseretsky Test of Motor Proficiency - 2nd ed (BOTMP-2) Movement Assessment Battery for Children (MABC) Paediatric Balance Scale (PBS) Peabody Developmental Motor Scales (PDMS) The University of Sydney Page 42 FORMAL ASSESSMENTS Examples of Criterion Referenced Assessments Gross Motor Function Measure (GMFM) HiMAT Motor Assessment of Infants (MAI) Neuro-Sensory Motor Development Assessment for Infants and Young Children (NSMDA) Prectl’s General Movement Assessment WeeFIM The University of Sydney Page 43 43 WHICH ASSESSMENT TYPE TO CHOOSE? Clinical usefulness perspective - Appropriateness Conditions, domains tested, age of child Acceptability Child, parent and profession Timing, comprehension, administration, Simplicity scoring, availability Cost Standardised vs non standardised Degree of consistency and stability of Reliability results a measure of how well a test predicts Validity abilities The University of Sydney (Palisano et al, 2004) Page 44 WHICH ASSESSMENT TYPE TO CHOOSE? Paediatric physios commonly use observation and task analysis approach (informal) during regular visits Clinical sites - may have developed their own observational assessment templates/forms will use a norm or criterion referenced (formal) tests less often Every 6 -12 months depending on the child’s progression The University of Sydney Page 45 ADVICE for your INITIAL ASSESSMENT It may be challenging as child/infant & parent do not know you – it can be stressful to child, parent/carer and you May end up being an observation only Try initially to just to identify whether child’s motor performance/abilities are: typical (within “normal” variation), delayed – immature, or are suspect or abnormal This will also help with choice of tool for further assessment The University of Sydney Page 46 46 Developmental red flags Atypical clinical history Prenatal Perinatal Postnatal Significant developmental delay (DD) Parental concern / family report Abnormal neurological examination e.g. Abnormal muscle tone Persistent primitive reflexes Asymmetry Abnormal postural reactions Holistic concerns in other areas, e.g. sensory dysfunction /loss The University of Sydney Page 47  Clinical Reasoning Process (What do you ask yourself when assessing?) Is the movement quality Emerging, mature or atypical? Is the milestone age appropriate? What is the ‘standard deviation’ for that particular milestone? What is contributing to a particular delay? Is it the environment, personal attributes, sensory motor dysfunction, pathology, body system dysfunction? Will it contribute to potential activity limitations and/or participation restrictions? Consider all types of environments that the infant/child will be exposed to The University of Sydney Page 48 Communicating and Interacting with Young Children Give the pre-schooler your full attention. Get the pre-schooler's attention before speaking Remember that you’re bigger than a pre-schooler – so get on their level The University of Sydney Page 49  Other tips when communicating with young children Make Requests Simple - Offer limited choices – limit to 2 Don’t over-explain your instructions – Speak as simply as possible. Be aware of your tone throughout The University of Sydney Page 50  More tips when communicating with young children Avoid ending your unless you are ready for sentence with ‘OK’ your child to say ‘No’! e.g. don’t run that way versus run this way/follow me! Positive instructions will help your pre- Use more dos than don’ts schoolers succeed in tasks because it indicates exactly what you want them to do rather than focusing on what you don’t want them to do Use kind and/or positive lots of non-verbal skill sets words too The University of Sydney Page 51  Final tips… They don’t really understand Preschoolers take things sarcasm or hidden meanings. So it’s a good idea to be very literally, and interpret careful about how you say things. things based on the words This can avoid upsetting pre- they hear. schoolers who think the joke is on them! It can be hard for the Use language and ideas pre-schooler to keep that the pre-schooler will paying attention if he understand. doesn’t understand what you’re talking about. The University of Sydney Page 52  …RECAP… ❑ Understand how paediatric assessments are different from adult assessments ❑ Understand what to assess in paeds ❑ Understand the difference between formal (standardised) and informal assessments ❑ A general knowledge of paediatric formal assessment tools The University of Sydney Page 53 The University of Sydney Page 54