Peds Exam 2

Signs of Infection

("sepsis") -Temperature instability (feel cool instead of warm) -Poor Feeding -Respiratory distress -Apnea

What are the options?

(*Don't usually require a LMN) -From extremely (BWS) to minimally (straight cane) supportive -Gait trainers -Reverse, or postural control walkers -Forward walkers -Forearm (Loftstrand) crutches* (low cost enough, families usually just go to the vende) -Axillary crutches* -Quad canes (sometimes bilateral)* -Straight canes*

Bone structure

(1) Cancellous bone (AKA trabecular bone or spongy bone) ---Loose woven strands of bone ---Located at the ends of the long bone and surrounds the inner marrow cavity ---less dense, softer, weaker (2) Compact bone ---Hard, dense bone ---Makes up the shaft of the long bone and provides a covering for cancellous bone

Process of endochondral ossification

(1) Chondrocytes at center of growing cartilage model enlarge and then die as the matrix calcifies (2) Newly derived osteoblasts cover the shaft of the cartilage in a thin layer of bone (3) Blood vessels penetrate the cartilage, new osteoblasts form a primary ossification center (usually in shaft) (4) Bone of the shaft thickens, cartilage near each epiphysis is replaced by shafts of bone (5) Blood vessels invade the epiphyses and osteoblasts form secondary centers of ossification (usually at ends)

Measurement of Anteversion vs. Retroversion

(1) Measure with IR and ER - measure in prone (2) Craig's Test: - Finds neutral position of the femoral head between IR/ER

Reasons to brace/get orthotics

(1) PAIN (2) KINETIC CHAIN CHANGES (3) RIGID FOOT

Definition by Gestational Age

(40 weeks = term) -23-26 Weeks: Very preterm infant -27-33 Weeks: Moderately preterm infant -34-36 Weeks: Late preterm infant ---These infants have received the most attention lately, used to think they were almost term and therefore ok, we know now that they end up with some developmental issues...

Anteversion

(AKA antetorsion) (femoral head more forward) (toes inward) -The angle of the head and neck of the femur is rotated anteriorly, beyond that of the normal torsion with respect to the shaft -The result is a range of medial hip rotation that appears to be excessive, whereas the lateral rotation range appears to be limited

Osgood-Schlatters Disease Definition

(AKA tibial tubercle apophyseal traction) -Inflammation of the patellar tendon at the insertion on the tibial tubercle which is an ossification site -This can progress to a strain on the tubercle (resulting in an abnormal growth outward of the tubercle) or can result in an avulsion fx -Typically self-limiting, but painful (esp with eccentric quad contraction)

Osteogenesis

(Bone development) **Occurs via 2 mechanisms** (1) Intramembranous ossification ---Forms directly from mesenchyme ---Bone forms inside a membranous sheath made of MESENCHYME ---DIRECTLY forms primary ossification site (2) Endochondral Ossification ---Occurs from cartilaginous models ---How all bones except the clavicles and parts of the skull are formed ---Begins with formation of cartilage formation at WEEK 6 ---Developed from Mesenchymal cells condensing (called Chondrification) ---Becomes HYALINE CARTILAGE bone models

Neurofibromatosis: NF-1 Tumors

(Dermal and/or Plexiform Neurofibromas) -Non-myelinating Schwann cells → hyperplasia -Single peripheral n vs multiple nerve bundles -Early vs later in life ---Often softer, larger (Plexiform Neurofibromas) occur earlier than dermal -Malignancy? Plexiform Neurofibromas can become malignant

Late Preterm Infant

(Lots of work to eliminate elective deliveries before 39 weeks) -Infant born at 34-36 weeks gestation -Account for majority of premature births -Known short-term increase respiratory distress, feeding difficulties, hyperbilirubenemia, sepsis, hypothermia, re-hospitalization -Increasing focus on higher incidence of difficulties at school age.

SDR Behavior Assessment

(PT sees the kid the most, likely to wave the red flag, still... this wouldn't keep a kid from getting the procedure) -General impression of behavior -Cognition - could child understand commands? -Cooperation - did child have much difficulty completing evaluation tasks? -Motivation - does child seem motivated to move, walk, and participate in play?

"Frog- legged"

(a little easier to work with) -Hips abducted and ER -Knees flexed -Clubfeet -Shoulder IR and extension -Elbow extension -Wrist flexion and ulnar deviation (waiters tip deformity)

Medications for JRA

(always start with the less damaging drugs) -NSAIDS- Iburofen, Naprosyn, Tolectin -Cox2 inhibitors - Vioxx, Celebrex (older kids) -Disease Modifiying Drugs - Methorexate, Luflunomide -Biologics- -Chemotheraputics - Cytoxan -Cortiocosteriods- joint injections, Predisone, for systemic

Osteonecrosis

(basically, these kids get arthritis (blood vessels get blocked, bone dies)) -Affects up to 1/3 of patients with ALL and Non-Hodgkin's lymphoma (another study said 7%) -Likely caused by gluticosteroid therapy -Happens in weight-bearing bones -Often multi-articular and bilateral -Higher in children >10 and white > African Americans (Sala et al. 2007) -Often asymptomatic (intermittent, vague pain... pts usually don't tell their doctors) -Sx. can include pain, restricted mobility and ROM (most common in knees, then hips, shoulders, ankles) ---Knees: pain in walking and waking, maybe cant get up the floor, knee gives out on them but no weakness in the calf ---Hips: pain with end range hip flexion or IR (in the joint, not a stretch) -We should be asking: are you in pain? any pain in the last mo? -Musculoskeletal deficits that are not explained by weakness, peripheral neuropathy or injury could be a red flag -Tell the physician: may add a med that would increase bone density, consider MRI (want them to do the whole LEs, even if they are only seeing sx in one joint) -If they progress and if the joint line is effected the joint may collapse and they may need jt replacement -Have them see an ortho, who may want them NWB, but oncologists want them WB, do WBT (pool PT!!!) -Surgical options ---Total joint replacements ---Fibular graft ---Core decompression

Acetabular Torsion

(best measured with MRI) -This angle, representing the anterior direction of the acetabulum, is normally 20° to 40° of anteversion (facing forward) (retroversion = more toward the back)

Intraventricular Hemorrhage

(bleeding into the ventricles) (most associated with the sickest, smallest, earliest babies) -Grade 1: Isolated germinal matrix bleed -Grade 2: Blood in the lateral ventricles -Grade 3: IVH with acute ventricular dilation -Grade 4: Hemorrhage into the periventricular white matter

Process-Oriented approach

(bottom up) Treatment addresses components/body functions needed to perform activities -Improvement of body functions leads to better skills performance -Propiroception -Strength -Balance -Sensory Integration -Visual-motor perception

Radiation Side Effects

(consider all systems!) -Fatigue -HA, nausea, vomiting -Loss of taste -Dental problems -Pneumonitis (dyspnea, tachypnea) -Heart disease -Nephritis -Reproductive issues -Slow bone growth (effects epiphyseal plate) -Hypoplastic changes to muscles (could cause scoliosis if asymmetrical) -Skin erythema -Endocrine changes (decreased growth hormone) -Younger ages more at risk *Note: irradiation on one side will lead to asymmetric growth (creating ortho issues), LBP and HA are common in post CA pts*

Slipped Capital Femoral Epiphysis (SCFE) Classification

(depends on age, amount of slippage, ability to amb, sx) -Preslip < 3 weeks (pain) -Acute < 3 weeks with more pain, unable to walk -Chronic > 3 weeks, antalgic gait, decreased ROM (hasn't been caught- this is where its super problematic/bad) (will keep slipping, wont fuse) -Acute‑on Chronic: ongoing, keeps slipping

Dermatomyositis Prognosis

(depends...) -When rash is severe and vasculitis is present, recurrence is very likely -When rash is mild and vasculitis absent, resolution is common within 6 months -Far better for childhood v. adult onset

Developmental Dysplasia of the Hip (DDH) Treatment: Under 6 mo

(do NOTHING-Just ROM and watch (first 2 mo), OR...) -Pavlik Harness: held out in abd and flx with concentric force on hip to reduce the subluxation/dislocation and help with formation of good acetabulum ---Monitored via xray or ultrasound -Potential complications from Pavlik: avascular necrosis of the hip, transient femoral nerve palsy -Not used for completely dislocated hips that cannot be reduced manually, only out of it for 1 hr per day

Lightweight wheelchairs

(don't think "weight", think about "options") -Many more options for commercial or custom seating to meet postural support needs -Pediatric lightweight chairs have growth capability (huge!!) (self-propellers can be getting something that they will grow into- they need to be in neutral alignment, even as they grow) -Adjustability in axle placement -Weight often between 9 and 11 kg (22-25 pounds)

Osteosarcoma

(end up with crazy surgeries) (rotationplasty) -Malignancy of the bone -400 children in US per yr -Peak incidence between 10-25 -80% in the femur -Treatment includes surgery (limb salvage or amputation) and chemotherapy -Cisplatin and carboplatin part of chemo regimen

Retroversion

(femoral head more back) (toes out) -Opposite of anteversion, a posterior rotation of the femoral head and neck would constitute a retroverted hip

Sensation impairments from brain tumors

(from the tumor and from the neuropathy) -Damage to cerebral cortex -Peripheral neuropathy -Point/dull testing, light touch, joint position sense -Can change rapidly or slowly after surgery

Arthrogryposis: Childhood & Adolescence

(goals: interaction with family and at school) -Stretching and Range of motion -Functional home program -Adaptive equipment -Aquatic and Hippo therapy (lots of great options for treatment) ---Hippo: great socialization and proprioception components

Pelvis - Risser Sign

(important for planning for kids with scoliosis- what type of procedure to do) -Often used for Bone age and to determine medical procedures -Indication of the growth plate closer due to calcification of the iliac crest -Risser 0: no bone lay, pre-pubescent -Risser 1: 25% Anterior Superior iliac spine (anterolateral) -Risser 2: 50% extends halfway across iliac wing Seen immediately before or during growth spurt -Risser 3: 75% Indicates slowing of growth -Risser 4: 100% ossification, no fusion to iliac crest, indicates slowing of growth -Risser 5: Iliac apophysis fuses to iliac crest. Indicates cessation of growth (16-25 yo) (avg F: 16, M: 17-18) (certain dx are earlier or later)

Neuroblastoma

(in and outpatient therapy) -Malignancy of the sympathetic nervous system -Wide range of prognostic outcomes -8% of all childhood cancer -Most common between 2-5 yrs -Treatment may include surgery, chemotherapy, radiation, bone marrow transplant, or immunotherapy -Chemo may include vincristine or cisplatin

Congenital scoliosis

(incorrect formation of bones, born with it) -Caused by abnormal development of vertebrae -Fetal factors at 45-60 days -May be associated with diastematomyelia ---Complete or partial separation of the spinal cord into 2 separate "hemicords" (very rare) ---Separation generally occurs in the middle of the spinal cord and then reunite below ---Hair patch, unequal LE size, hearing loss (depending on where it is in the spinal cord), UT anomalies, facial asymmetry, and unilateral undescended scapula

ITW Standardized testing

(less emphasis on standardized testing for ITW) -Assess if toe walking is limiting functional performance and/or milestone achievement -BOT-2 or PDMS-2 (they may actually score really well) -Pediatric Balance Scale (MORE HELPFUL!) -Toe Walking Tool (12) (MORE HELPFUL!)

Incidence and Prevalence of DCD

(literature says about ~14%, 12-18%) -< 5% of children have severe difficulties associated with DCD -Additional 9% have mild to moderate difficulties -Diagnosed more often in boys -Higher incidence among children with a hx of prenatal or perinatal difficulties

Aspiration risk

(more noxious stimulus; like CPAP: pressure keeps epigoltis open, have a hard time learning to close that) (trouble coordinating the swallow) -Common for infants with history of IVH, oral motor anatomical anomalies -Video Fluoroscopy Swallow Study (VFSS) with radiologist to confirm swallow safety (done by OT) ---Thicken with rice cereal (no way to do it with breast milk) ---Can usually get back onto bm in 4-8 wk -Alter liquid consistency for safe swallow or may need G-tube for home feeding

Muscle Weakness and CA

(most severe in induction phase and delayed intensification phase) -Etiology multifactorial -Deconditioning -Steroid myopathy ---Khaleel et al found proximal LE weakness in patients on chronic steroids -Peripheral neuropathy ---Hartmen et al. found muscle weakness in pts. with ALL, NHL and Wilm's 3 years post chemotherapy -Most severe in induction and delayed intensification -Can be asymmetrical

Peripheral Neuropathy in Children with Cancer

(neurons are not rapidly dividing, but that doesn't mean that they cant be damaged, neurons are like divas- need a lot of help from their survival cells to keep their environment pristine) -Injury, inflammation, or degeneration of the peripheral nerve fibers -Distort normal motor, sensory and autonomic functions causing a variety of symptoms -Incidence of neuropathies in cancer patients is relatively unknown -Estimate that 3 - 70 % of adults treated with single agents develop neuropathies related to treatment -Up to 38% treated with multiple chemotherapy agents develop neuropathies -Little data in pediatric oncology -MANY of those with CA have peripheral neuropathy, doesn't mean that its severe in everyone

Common Impairments of kids with osteosarcoma

(note that the physician is likely to say you can only do ROM, but then all the sudden say there are no restrictions → we should ask about specific interventions we want to do) -Decreased ROM -Decreased gait velocity -Decreased muscle strength -Decreased grip strength -Functional Loss -Gerber et al (2006) found these deficits in survivors 20 years post treatment

Vision/hearing/vestibular impairments from brain tumors

(often missed) (cranial nerve 6, 8, 7 get effected) -Often damaged by tumor location -Ototoxicity from chemotherapy can cause hearing and vestibular impairments -Awareness of impairments may assist intervention direction -Vestibular rehab focuses on compensation of the oculomotor and neuromuscular system to overcome balance deficits

ITW Subjective

(really trying to get at ruling out associated disorders) -Pre and peri-natal history -Family History -How long child as been toe-walking? -Motor Milestone attainment ---Speech/Language: May be an increase in incidence of language delays in children who toe walk -Frequent tripping or falling -Difficulty keeping up with peers -Pain -Sensory preferences

Clubfoot Nonsurgical Ponseti Method

(serial casting and often a percutaneus incision if bad enough) -Emphasizes external rotation of the midfoot while keeping the foot in supination and then slowly correcting the forefoot and hindfoot. (will end up looking over corrected) -Following casting, child begins wearing a Dennis Browne Bar for several months to maintain the corrected position achieved during the casting (decreased use of the bar at 3 mo)

Two chemotherapy agents that cause peripheral neuropathy

(these 2 drugs are thought to be the culprits) -Vincristine -Cisplatin

Hematopoietic Stem-Cell Transplantation

(this is like chemo on steroids, but also replacing the bone marrow) -Replace diseased, damaged, or absent stem cells -Treat children with aggressive cancers or recurrent disease -Allogeneic - Stem cells from a donor -Autologous - Stem cells from recipient -Provide rescue after high dose chemotherapy or radiation

Developmental Dysplasia of the Hip (DDH) Treatment: Older kids

(this is where it gets really tough) (tons of pain) -Pelvic Osteotomies -Decreased likely hood of good coverage -The later the treatment, the poorer the outcome (worse prognosis- bone has already formed in a non-ideal way) -High risk for need for hip replacement earlier in adulthood

Research Findings on gait in ITW

(toe walking compared to crouch gait of CP) -Computer aided gait analysis: patients with CP have no terminal knee extension in late swing and early stance phase, land with flat foot due to this knee flexion ---ITW land on toes with knee extension -EMG: found premature onset of gastrocnemius compared to typical walkers and abnormal timing of the tibialis anterior -Gastrocnemius histology found that children who toe walk have more Type I muscle fibers than Type II ---Adapted from prolonged periods of long use (hypertrophy)

Pediatric ROM and mm length tests

(too much or not enough ROM is concerning) -Thomas hip flexor test -90/90 (popliteal angle) vs knee extension -Gastroc vs Soleus length -Hip abduction with and without hips extended -Quad length (Ely's) -IT-Band length

Task-Oriented approach

(top down) -A specific task is broken up into steps to be practiced -Teaching meaningful skills (skipping, soccer, jump rope) -Task analysis ---Planning ---Execution ---Evaluation ---Variable training -A 2012 systematic review recommends task-oriented interventions over process-oriented interventions

Clubfoot French Functional Taping

(typically performed by a physical therapist) -The method consists of DAILY stretching, mobilization (exercise and massage) and taping to slowly move the foot to the correct position. (family has to be DEDICATED!) -Very involved process and requires a lot of dedication on the part of the parents. -Can achieve the most effective change in the first 3 months of life (after that, big changes are prevented by ossification)

SDR and the GMFM

(used when time allows) -Standardized test for children with CP -Looks at function in 5 dimensions (those who do well with SDR do well with the first 3 dimensions, worse on last 2) ---Lying and Rolling ---Sitting ---Crawling and Kneeling ---Standing ---Walking, Running, and Jumping

Serial Casting for ITW

(very gentle positioning, not a stretch!) -6-8 weeks -Brouwer study of 8 ITW with serial casting 3-6 weeks ---All could achieve heel strike after, 1 reverted back ---Conclusion: improved gait as found in previous studies -Causes elongation of sarcomeres! PLUS, teaches them to heel strike!

Surgical tx for ITW

(very rare) -Types ---Open: Achilles z-plasty; Gastrocnemius recession ---Percutaneous -Usually after failed conservative treatment (worst cases) and age 6-10 -Parental satisfaction is high (kids don't go on toes! BUT, they are so weak they cant!) -Stricker found better restoration of ankle dorsiflexion with surgery as compared to casts or stretching (he was a surgeon)

Posterior Fossa Syndrome

(wake up from surgery ok, but then within 24 hours end up with decreased ability to speak or move, irritability) (kids recover at a high rate) (remind parents that it's the brain, not their behavior) -Occurs 24-100 hrs after surgery -Mutism or speech disturbances -Dysphagia -Decreased motor function -Cranial nerve palsies -Emotional lability -Recovery can take weeks to months

Hemophilia: Precautions

(we want these kids to be active, but worry about them getting a bleed) -Decreased ROM -Pain -Swelling/edema -Heat/erythema -Ecchymosis -Muscle guarding of affected joint -Muscle spasm -Disuse of affected joint -Gait deviations: decreased weight bearing, antalgic -Decreased functional mobility/activities of daily living -Pediatrics: decline in developmental milestones

Curves of the spine

(why is this? WOLFF'S LAW) -(Two) convex curves during fetal period and present at birth -Concave cervical curve develops first (cervical ext) (when they start lifting their head against gravity) -Lumbar curve comes with stance

ALL vs AML

**ALL** -Peak age of onset 2-6 yrs -Increased risk in children with trisomy 21 -75-85% cured of disease (standard risk: 93%) -2-3 years of treatment (2 for girls, 3 for boys (potential of CA cells being in testicles) -Outpatient treatment common after dx (in school, playing sports as able) **AML** -Peak age in infants, then steady with slight increase in adolescence -Increased risk in children with trisomy 21 -45-50% cured of the disease -6-7 months intense treatment -Often inpatient treatment

Classification of metatarsus adductus

**Classified by Flexibility of foot** -Actively correctable -Passively correctable -Rigid (also consider often have very rigid, high arch)

Team Approach to Care

**Clustering Care** -Structuring the infant schedule to allow for minimal interruptions. -NICU infant requires 20-22 hours of sleep per day compared to term infant requiring 17-20 hours of sleep per day -Monitoring signs of stress and overstimulation for the infant -For those who are old enough to do feeding (bottle, breast, or tubes) 8-11-2-5-8-11-2-5 there is no schedule, but the baby needs to get everything it needs in the 20 minutes before food

Congenital vs acquired Prosthetic Introduction

**Congenital** -Development considerations -When cruising around furniture -When achieving sitting balance or two-handed motor activities (view prosthesis as a "helper") **Acquired** -ASAP - Immediate Post- op Prosthesis if possible -As soon as wound is stable (view prosthesis as a "replacement")

Congenital vs acquired family response

**Congenital** -Guilt -Lost expectations -Grieving process (this is at birth, get over it pretty quickly) **Acquired** -Guilt -Lost expectations -Grieving process - period of adjustment -Success is usually direct correlation with coping

Congenital vs acquired Patient Response

**Congenital** -No sense of loss -Prosthesis seen as aid or substitute, not replacement -If not functional, it's rejected **Acquired** -Profound sense of loss -Prosthesis is a replacement, but cannot actually replace the original -Success relative to acceptance of prosthesis

Congenital vs acquired motivation

**Congenital** -Try to do what other kids are doing -Limitations often placed on them by adults -Very adaptable **Acquired** -Want to be as they were prior to amputation -Mourn the loss, angry and resentful -Motivation influenced by their ability to resolve this inner turmoil

Congenital vs acquired Residual Limb Characteristics

**Congenital** -Unique **Acquired** -Potential for more complications ---bony overgrowth (common in kids because they are still growing...) (penciling) ---undesirable length ---skin problems

Historical interventions for neuropathy

**Daily heelcord stretching** (did not work!) -Loss of ankle ROM -Midfoot collapse -Hindfoot valgus **Off-the-shelf dorsiflexion stretching splints, night and sedentary time** -Maintains or slight increase in DF ROM -Midfoot collapse -Hindfoot valgus **Hinged AFOs worn daytime and/or nighttime** -Varied results in ankle DF ROM -Collapsed midfoot (allows ROM into a range that they don't have, coming from midfoot -Hindfoot valgus

Assessment of EDS

**Hypermobility (this is likely past age 4-5 yr)** -Beighton Scale (total score = 9, any thing >4 is worth worrying about) -Brighton Criteria ((Major and Minor Criteria) -Skin assessment (often a skin biopsy can tell you about this -History -Pain -Genetic testing

Characteristics of PFFD

**Localized absence of the proximal end of the femur involving the hip joint** -Shortened involved limb -Hip held in flexion, abduction, and ext rotation (usually keep the knee bent, but could straighten it if they wanted) -Knee carried in flexion, but usually has extension ROM available -Soft tissues of upper thigh taper toward knee (funnel) -Fibula and foot deformities common (but could be very normal) -~15% of cases have bilateral involvement -Often the hip joint is problematic as well

Pediatric vs. Adult Cancer: Ethnic predisposition, Most common types, Presentation, Treatment protocols, Prognosis (5-year survival)

**Peds** Higher in White Americans Leukemias, Brain tumors, Solid tumors Often metastatic Widely available (trials are disseminated across the US), all the data is being pooled, similar tx across the whole country 70-90% **Adult** Higher in African Americans Prostate, Lung, Breast, Colon Local Not generally available <60%

Clinical signs of JRA

**Primary** -Joint swelling, pain and stiffness (without trauma) -Morning stiffness -MM atrophy/weakness -Systemic manifestations **Secondary** -Limited joint motion -Fatigue -Decreased Aerobic capacity -Growth AB -Altered mechanics and joint deformities -Osteopenia -Difficulties with ADL's -Activity restrictions (sometimes)

Changes in anteversion with growth

**Progressive decrease of Anteversion** -30‑40 degrees at birth -Decreases progressively throughout growth to ~15 deg at skeletal maturation (5-6 yo) -In adults, anteversion avgs 8 ‑ 14 deg (men typically ~8, women ~14) -Age appropriate to appear excessively anteverted at about two or three (looks pigeon toed) but should start to resolve at 5‑6 -Medial hip rotation is greatest during early childhood, but then declines w/ increasing age, decreasing about 2‑3 deg/year -Often attributing to frequent referrals for in‑toeing at ages 3‑6 which are typically age appropriate mechanics

Legg Calve Perthes Treatment

**Varies‑ but depending on when it is caught, early on treatment is conservative** -Minimal to no wt bearing (prevent flattening of the head) (NWB until x-ray shows re-ossification phase) -May be allowed to walk but no running, jumping, impact -ROM daily into all hip planes -Hip strengthening, especially glut med/ max -In later stages if head is significantly deformed and acetabular coverage becomes an issue, MD may consider surgery -Often perform osteotomies of the femur, and depending on the coverage, osteotomy of the acetabulum to help maintain maximum coverage of the head (usually do a pelvic osteotomy- move bone to allow for better coverage of the head)

APTA lab guidelines

**no exer, light, resistive** -White blood cells: <5,000 with fever, <5,000, >5,000 as tolerated -Platelets (mm3): <20,000, 20,000-50,000, >50,000 -Hemoglobin: <8, 8-10, >10 -Hct: <25%, 25-30%, >30%

Measurement of scoliosis

**scoliometer or the cobb method** Cobb angle... -Measured in the coronal plane -Measured beginning with the apical vertebra (most displaced and rotated, typically upright) -Find the most tilted inferior and superior vertebra to the apical

SDR Week 2: Day 7

*Begin PT & OT in department, progress stretching & strengthening -HOB >30° if KIs are off -Add adductor stretching & hamstring curls

SDR Week 2: Day 9

*Begin PT & OT in department, progress stretching & strengthening -Start bridges, with pelvic support as needed (not arching back, should have a neutral spine) -Start four-point & crawling with abdominal support (want to see reciprocal pattern) -Start sitting in PT using position of 90°at hip/knees -Transfer in/out of sitting via side-lying with assist (takes them time to relax) (maintain 90/90) -Start wheelchair 30 minutes, 3-4 times/day (firm seat and firm back) -Family education for transfer technique -Start high-back commode for toileting

SDR Week 2: Day 10

*Begin PT & OT in department, progress stretching & strengthening -Wheelchair time increased to 30-45 minutes, 3-4 times/day (still use the cart- great for hip flexor stretching) -Add side lying hip abduction exercises -May begin therapeutic pool: chest deep (low impact on spine, but allows walking)

SDR Week 2: Day 11

*Begin PT & OT in department, progress stretching & strengthening -Wheelchair time increased to 45-60 minutes, 3-4 times/day -Start tricycle (needs some back support)

SDR Week 1: Day 4

*Head of bed (HOB) flat for 72 hours (dura needs to heal to avoid CSF leaks, could result in headaches) -Bedside Exercises: add supine hip abduction, TKEs, ankle pumps -Begin rolling with assist (log roll) -Transfer to prone cart. May be on cart as tolerated -Family education for transfer technique (keep braces on) (this is when parents often notice differences in tone)

SDR Week 1: Day 2

*Head of bed (HOB) flat for 72 hours (dura needs to heal to avoid CSF leaks, could result in headaches) -Don AFOs with KIs (maintain ankle position) -Care Conference

SDR Week 1: Day 3

*Head of bed (HOB) flat for 72 hours (dura needs to heal to avoid CSF leaks, could result in headaches) -Raise HOB up to 30° -Bedside Exercise: heelcord & popliteal angle hamstring stretching, heelslides

SDR Week 3: Day 17

*Precautions discontinued, except kids must continue to have lower body support when lifted *Progress stretching and strengthening: add four-point hip extension with abdominal support, add abdominal curls -Begin ambulation with reverse walker (occasionally on day 16) (reverse provides good postural support)

SDR Week 3: Day 16

*Precautions discontinued, except kids must continue to have lower body support when lifted *Progress stretching and strengthening: add four-point hip extension with abdominal support, add abdominal curls -Begin sit to stand in parallel bars, emphasizing graded control (not relying on extensor tone, have to lean forward and then stand) -Begin ambulation in parallel bars

SDR Week 3: Day 18

*Precautions discontinued, except kids must continue to have lower body support when lifted *Progress stretching and strengthening: add four-point hip extension with abdominal support, add abdominal curls -May do exercises in standing -Start tall & half-kneel at a bench -Work on sit to tall kneel with graded control -Begin side-sit (involves trunk rotation), tailor sit, long sit

Carseat

-"Angel Gaurd" (about $90) -Apnea test -Can position in supine or sidelying -Can loan or buy for longer term use

Obesity definition and classification

-#1 problem knee pain (25% of all subjects classified as overweight or obese in a study by Yanovski) -Accelerated bone and puberty development **Classification according to BMI %iles** -Healthy: 55-84 -Overweight: 85-94 -Obese: 95-98 -Severely obese: 99 -BMI > 85% once between 24-54 mo and 5X more likely to be overweight at 12 yr ---60% of overwt preschoolers were overwt at 12 ---80% at elementary school -Studies show 50-80% with mean of 70% of children over weight obese in teens are also overweight or obese in adulthood

What factors affect decision making, regarding an AD?

-(Many payors will not pay for a gait trainer or walker AND a stander) -Cognition -Vision (keep them safe, but get them mobile) -Seizures (how frequent?) -Leg length discrepancy/ bony deformity -Contractures -Endurance -Tone (always scissoring? Gait probably wont work well) (some devices are made for this, but aren't super good- lots of torque) -Behavior -Caregiver situation -Layout of the home -Potential for improvement -School -Outcomes of the home trial!!!

Chemotherapy treatment in ALL (phases)

-(first 6-9 mo is intense, then they go into maintenance therapy 1X per mo, trying to get them back to normal) -Induction: lasts 4 weeks - induce a remission (get rid of as many of the CA as you can) (very intense) -Consolidation: 4 to 6 weeks - kill leukemia cells that may remain after induction, treat central nervous system -Interim maintenance/delayed intensification: 12 to 16 weeks - go back in and "clean house" with intensive treatment when cancer burden is low -Maintenance - 2 to 3 years - IV chemo once a month

As a PT, why would you recommend a stander?

-*Prevent or decrease contractures -*Assist with bone health -Decrease urinary and bowel problems (this is heard from many people!) -Improve skin integrity (weight bear on a different surface) -Improve respiratory function -Decrease pain from spasticity -Increase alertness (Rancho level 2)

Muscle Weakness Intervention for CA: Hip strengthening

---Bridges with cars, side step with t-band, clam shells (alligator mouths, feed koosh balls) Muscle Weakness Intervention for CA: Quads/hams ---Floor to stand transitions, sit to stand 1 min, eccentric control ---(compare sit to stand time to chart (you sit to stand like a 55 yo))

Muscle Weakness Intervention for CA: Peripheral strength

---Heel walking ---Tip toe statues (or every time they want something make them come up for it, try to push them over) ---Jumping high for push off (into and out of hula hoops) (make sure they are doing both feet) ---Jumping down for eccentric control ---Toe grasping (pick up legos, squinkies)) ---Foot "caves" ---Dorsiflexion tug-of-war (long sitting foot to foot with siblings) (loser snaps the winder) ---Toe "claws (hold little things, walk) (have to open

Blout's disease pathology

---If Infantile, may be caused by malformed plate or metabolic condition (not sure exactly...) ---If in adolescence, more likely to be caused by severe obesity that misshapes the tibia (this is the more severe version of the disease) --- More common in hispanic and African American individuals

Rickets Presentation

---Skeletal deformity including femoral and tibial either bowing or valgus ---General muscular hypotonia ---Large foreheads ---Occasionally Pectus carinatum ---Short stature ---Opaque x-rays, cupping and flaring of the metaphyses (ends of bones cup, arc to the bone) ---Beading at the costochondral junctions ("rosary")

Etiology of OI

-1 of every 20,000 live births -Lax joints, weak muscles, diffuse osteoporosis, recurrent fractures -Other characteristics ---Deafness (bones of the ears also effected!) ---Bowing of long bones ---Hernias ---Bruising and sweating (skin is very thin, base temp is higher than typical, need breaks and hydration)

Incidence of Scheurmann's kyphosis

-1-8% -Most common type of structural kyphosis in adolescents (can be seen with scoliosis as well) -M:F ratio between 2:1 and 7:1

Incidence of Prematurity In the US in 2010:

-12% of infants were born premature -2% were very preterm -10% were moderately preterm

Medulloblastoma

-15-20% of pediatric brain tumors -Always located in the cerebellum, but can spread through the CSF at 4th ventricle to spine -Symptoms: behavioral changes, symptoms of intracranial pressure (HA, nausea, vomiting), ataxia -Survival rate 60-70% -(lobes = limb ataxia, central = trunk ataxia) -Can get cranial-spinal radiation → could lead to scoliosis (esp if its half of the spine)

DCD Labels

-1989: Dyspraxia -1994: DSM diagnosis of Clumsy Child Syndrome or Minimal Brain Dysfunction -DSM-IV: Developmental Coordination Disorder (preferred diagnostic label) -ICD-10 in Europe: Specific Developmental Disorder of Motor Function (SDDMF)

Medical Management of JDM

-1st Line: Corticosteriods! (first line is high level corticosteroids) ---Prednisone ---Methyloprednisolone ---May use Methotrexate to increase speed of bringing down inflammation ---Goal is to send it into remission (prevent progression, less likelihood of return inflammation) -2nd Line: IV IG and other antibody prep meds ---ALL DAY INFUSIONS (big deal)

Incidence of JRA

-2-20 per 100,000 -Affects 70,000-100,000 in United States -May be as low as 30,000

DCD gait characteristics study

-20 males, 6-11 yrs with Gait Rite analysis -Results: ---Poor reliability of velocity parameter ---Good reliability of cadence ---Moderate reliability of step and stride lengths, double-limb support -Conclusions: reliable data for only some parameters (this reminds us that kids with DCD are so different, cant come up with specific criteria)

Definition by Birth Weight

-2500 grams: Normal Birth Weight -1500-2500 grams: Low Birth Weight -1000-1500 grams: Very Low Birth Weight -< 1000 grams: Extremely Low Birth Weight

Type IV OI

-2nd most functional (after type I) -Rare -Normal sclera -Hearing loss +/- -Dentinogenesis imperfecta

SDR Follow Up

-3 months post-op: brief PT follow-up -6 months post-op: full evaluation -1 year post-op: full evaluation, GMFM -2 year post-op: full evaluation, GMFM, gait lab

Dx Criteria for JDM

-3 out of 5 ---Skin Rash ---Weakness of proximal mm ---Elevated mm enzymes with labs (labs are essential) ---EMG shows mm inflammation ---Muscle biopsy shows mm inflammation

PT Evaluation-Goals for ITW

-3-year-old: Patient will descend stairs using alternating pattern, 1 railing, with heels down, in order to safely and independently negotiate stairs. -6-year-old: Patient will walk across balance beam with heels down, no stepping off, in order to participate in playground games with peers. -10-year-old: Patient will complete a Presidential Fitness shuttle run in __ in to keep up with peers in PE ---Note: presidential fitness testing is part of "keeping up with peers," makes for good goal writing

Routine NICU Follow-up Visits

-4 months corrected age -12 months corrected age -24 months corrected age -4 years of age

Pauciarticular/Olioarthritis definition (more commonly seen)

-4 or less joints -Chronic arthritis with swelling for 6 mo -If pt develop in MORE than 4 joints after the FIRST 6 mo, then classified as having Extended Olioarthritis (oppsed to persistent) -50-60% of all cases of JRA this classification

Surgical Treatment for scoliosis

-45-50 deg or more -Posterior spinal fusion ---Most common approach ---Uses rods -Anterior spinal fusion ---Used for lower curves ---May be used with PS (bigger curves- can do both)

Polyarticular or Polyarthritis definition

-5 or more joints -Classified as either RF positive or negative (if its negative, it doesn't mean that its ruled out, means that you have more looking to do) -Cervical spine or TMJ may also be involved -RF positive may have more finger limitations -30% of all cases of JIA/JRA -Age of onset bimodale (2 different periods of life) ---early onset - 1 to 4 yrs (tend to be RF neg) ---later onset 6-12 yrs (tend to be RF positive)

Prognosis for systemic JRA

-50% of children with SJIA recover completely -Other 50% show general worsening and chronic disability

Astrocytomas

-50% of pediatric brain tumors -Grade I - Pilocytic (a ball that you can go grab) -Grade II - Pilomyxoid, diffuse, or pleomorphic astrocytoma -Grade III - Anaplastic astrocytoma -Grade IV - Glioblastoma multiforme, giant-cell glioblastoma or gliosarcoma (tenticles reaching out, cant resect) (consider way to approach- what will we effect?)

DCD fMRI study, 2010

-7 children with DCD, 7 age-matched controls -Used a trail tracing task, measured error -Results: ---Underactivation of the cerebellar-parietal and cerebellar-prefrontal networks in DCD group ---Areas of cerebellum associated with working memory, executive function, and spatial processing -Conclusions: DCD = Underactivation of cerebellum -Limitations: small sample size

Ependymoma

-9% of pediatric brain tumors -70% in the posterior fossa in the 4th ventricle -Surgery for total resection -If partial resection, radiation and chemotherapy

Definition of DCD

-A chronic condition found in children characterized by motor impairment that interferes with the child's activities of daily living or academic achievement (playing, getting dressed, etc) -Idiopathic in nature -A unique and separate neurodevelopmental disorder -Motor characteristics ---low muscle tone ---difficulties maintaining ---balance ---awkward running ---falls frequently ---difficulty imitation body positions ---drops items ---difficulty with handwriting or drawing (fine motor, but also fits with this dx)

Club foot definition

-A congenital foot deformity characterized by: ---Hind foot equinus ---Forefoot adduction ---Subtalar joint varus ---Cavus of the foot -Present at birth, occurs in varying degrees of severity -Cause is still undetermined, but is some cases there appears to be a genetic link or increased intrauterine compression

Diagnosis of ITW

-A diagnosis of exclusion ---Considered abnormal past the age of 2 years (would argue 20 mo) ---Exclude neurologic and orthopedic conditions -May be a congenital tendo-calcaneous shortening ---Genetic factor is 30% -Also known as: habitual toe walking, idiosyncratic walking

Sickle Cell Disease PATHOPHYSIOLOGY:

-A disorder in hemoglobin resulting in long, rigid, cresent-shaped cells that lack the oxygen-carrying capacity ---Get caught, causes symptoms of anemia -Autosomal recessive

Apophysis definition

-A growth plate which does not completely ossify until maturity -Cartilaginous structure at the end of long bones -Tendon attachment -In apophysitis, strong, repetitive forces cause a traction injury to the apophysis -Because it is not fully ossified, it is more vulnerable to injury (problem: active or growth spurts) -Avulsion fx: a complete disruption of apophysis, usually the result of a sudden, violent stress

What is Selective Dorsal Rhizotomy? (SDR)

-A neurosurgical approach to spasticity in children with cerebral palsy -Results in a decrease of spasticity

Splinting for ITW

-AFO's assist in changing gait pattern and forcing a heel strike (helps change motor patterning) (used right away or after serial casting) ---Solid: have seen improved dorsiflexion range of motion with consistent daily wear (similar to serial casting) ---Articulated: block plantar- flexion while allowing dorsiflexion ------Assist in normalizing gait (CPG recommendations) (strong toe-walkers still toe walk in these...)

Neurofibromatosis

-Abnormal growth of nerve tissue= tumors (neurofibromas) ---Tumor suppressor gene (Neurofibromin) mutation ---Skin discoloration: melanocytes affected ---Think: social implications in addition to functional implications ---Autosomal Dominant, but high percentage of cases de novo mutation -Numerous sub-types: NF-1 most common -1 in 4,000 births -Males and females equal

Hypoxic Ischemic Encephalopathy

-Abnormal tone, state, posture, reflexes, seizures -Stages of HIE ---Stage 1 (Mild): hyperalertness, hyper-reflexia, dilated pupils, tachycardia, absence of seizures ---Stage 2 (Moderate): lethargy, hyper-reflexia, miosis, bradycardia, seizures, hypotonia with weak suck and Moro ---Stage 3 (Severe): stupor, flaccidity, small to midposition pupils which react poorly to light, decreased stretch reflexes, hypothermia and absent Moro -Body or head cooling for 72 hours (relatively new therapy, helps prevent brain damage)

Why do we care about DCD?

-Academic Outcomes ---Poor handwriting, organizational skills ---Children expend more energy than their peers in simple academic tasks -Functional skills ---Difficulty with hygiene tasks ---Poor performance in physical fitness activities -Children start to compare their abilities with peers by age 5 (this is the age they start pulling themselves out of group activities) -Low Self-esteem (less positive social interaction with peers) -Limited participation in physical activities (do more individual than group activities) -Life-long effects ---Continues through adolescence and adulthood ---50% of kids with DCD have impairments that persist into adulthood (and still negatively impact their lives)

Pediatric Acquired Amputation

-Account for about 40% of pediatric deficiencies -90% involve a single limb -60% involve a lower extremity -Incidence of acquired limb loss 3:2 males to females (think risk taking behaviors) -Most occur during the summer

Expected Outcomes/Discharge Goals for ITW

-Active Ankle dorsiflexion (knee extended) at least 10 degrees (ideally 15-20 degrees) -Heel-toe walking at 100% of the time (ideally without orthotic, but may need that) ---CPG recommendation is 75% of the time -Independence with HEP -Age appropriate gross motor skills -Wean from AFO's but patient still may need an orthotic due to biomechanics

Leukemias

-Acute lymphoblastic leukemia (ALL) 75-80% ---Abnormalities of the lymphoid cell lineage (cells that would have developed into B or T cells) -Acute myelogenous leukemia (AML) 15-20% ---Abnormalities of the myeloid cell lineage (cells that would have developed into granulocytes or monocytes) -Chronic myeloid leukemia (CML) <5% ---Abnormality of the proliferation of myeloid cells

Graft vs. Host Disease

-Acute or Chronic -Donor T-cells recognize the recipient antigens as foreign and mount an attack -Target organs include the skin, liver, and gut. -Chronic CGVHD can cause dry eyes and mouth, hair loss, thin skin, malabsorption of food, obstructive lung disease, contractures, immunosuppression and thrombocytopenia

Clinical picture of spondylolysis/lysthesis

-Adolescent girl with LBP -In severe case (spondyloptosis), may be shortening of torso, abdominal crease, and flattened lumbar spine -In mild cases, lumbar lordosis -Step off is palpable -Hamstring tightness/spasm (stretch them, teach them the right way) -May be neurological signs, such as bowel/bladder control changes, distal weakness

Achondroplasia CLINICAL PICTURE:

-Adult stature of about 4' -Frontal bossing -Lordosis -Significant LE bowing

Advantages and disadvantages for PFFD

-Advantages ---Increased limb length ---Improved prosthetic function ---Improved WB capacity (WB through heel) ---Eliminates problems with bony overgrowth -Disadvantages --Unpleasing cosmesis ---Chance of derotation

Rigid vs folding frame

-Advantages of a rigid frame: ---Better fit! ---lighter ---decreased maintenance ---increased weight on back wheels leads to improved energy usage ---decreased energy lost to flexing of frame with manual propulsion ---can still fold pretty small! (take off back, fold down back, take off wheels) -Advantages of a folding frame: ---may be easier to fold for caregivers ---you can get swing away footrests (but footrests on rigid frames can usually flip up) (this is what the school likes for transferring!)

Systemic JRA

-Affects many systems, arthritis is only one of the manifestations -Defined: presences of arthritis +2 weeks (note: not the 6 weeks!), plus at least one: -typical rash (diffuse), generalized lymphadenopathy -Hepatosplenomegaly -Serositis (inflamation of tissue lining e.i pleura) (like difficulty breathing) -Excludes pts who fit criteria for other forms of arthritis (want to r/o demomyositis or lupus) -ONSET: infancy through adolescence -Both females and males affected equally

Sidelying

-Again, use Snuggle Up -Separate the knees, keep hips in neutral (less tension on ITB) -Arms flexed and strapped -CRANIAL CONTAINMENT!

Supine

-Again, use Snuggle up -Similar to prone -PLUS froggy around head, prevent head from turning

Chemotherapy

-Agents used to prevent proliferation of cancer cells (kill rapidly dividing cells or stop their division) ---Also interfere with proliferation of normal cells -General side effects (cells that are also rapidly dividing) (what in the system needs to be replenished) ---GI: nausea (this has gotten much better), vomiting, diarrhea, constipation ---Skin: mucositis (painful sores), rashes, alopecia (loss of hair) ---Hematalogic: anemia, neutropenia, thrombocytopenia (red blood cells last ~120 days) ---Immunosuppression ---Pulmonary, renal, cardiac, neurologic, reproductive

Foot position

-All infants initially have "flat feet" -Arches start to develop from strengthening and use of ankle/foot mm once walking begins -Typically have a flat foot presentation until 2‑3 years of age -Should correct on heel rise

Ultra-lightweight wheelchairs

-Almost always the choice for patients with SCI capable of self-propulsion -Axle adjustability -Decreases risk of repetitive stress injury to shoulder complex -Weight between 5.5 and 7 kg (12-15 pounds) (some carbon fiber chairs are even lighter- just make sure they aren't tippy) -Rigid v. folding (rigid is almost always better)

CPG Recommendations on standardized tests for DCD

-An appropriated, valid, reliable, and standardized motor test -M-ABC-2 or BOT-2 -15th percentile as a cut-off (insurance likes the 10th percentile better) -"The diagnosis of DCD should not be made only on the basis of a standardized motor test. It requires careful history taking, clinical examination, and confirmation using valid tests and questionnaires."

Considerations When Bottle Feeding NICU baby

-Anatomical: frenulum length (tongue tie, hard to stick tongue out, necessary for sucking), tone of tongue, hard/soft palate structure ---Extension/protrusion ---Cupping ---Lateral ---Jaw needs to do protraction and retraction -O2 needs -Organization of suck pattern with NNS -Historical considerations

Angle of Inclination

-Angle between the neck and shaft of the femur -Approximately 125 -If the angle is greater than 125 degrees it is termed coxa valga

Van Ness Rotationplasty for PFFD

-Ankle joint functions as the knee -Requires functional ankle joint with good residual foot and minimal alignment difficulties -Done rarely (hard to meet the requirements), but kids do great -Requirements... ---20 ̊ of ankle DF will allow for amb and sitting ---30 ̊ of ankle DF will allow for some squatting and bike riding ---Optimal ankle PF ROM (45-50 ̊) will allow for best extension of leg

Apophyseal avulsion fx

-Apophyseal avulsion fx due to traction forces at the apophysis -Common sites of avulsion fx: ASIS, AIIS, lesser trochanter, ischium -Iliac crest fx is rare

Special concerns of adolescent age group and limb deficiency

-Appearance -Acceptance by peers -Dating relationships -Career decisions -Living and functioning independently

Size for Dates

-Appropriate for gestational age -Large for gestational age: mom has DM (>95%ile, sometimes 97%) -Small for gestational age: could be due to mom's high BP, chromosomal abnormalities, etc ---Intrauterine Growth Restriction

Arthrogryposis Definition

-Arthrogryposis Multiplex congenital (AMC) ---Nonprogressive ---Multiple joint contractures found at birth (thinking that maybe there was not enough movement in the inutero environment) -Non-progressive neuromuscular syndrome -Subtypes based on systems affected or subtype like neurologica or distal -8 official subtypes -Cause unknown ---Fetal akinesia ---Several potential causes: drugs, trauma, infection, fetal abnormalities ---1st trimester in utero? -Present at birth -Severe joint contractures, muscle weakness and fibrosis (cylindrical limbs, little mm) -Can be detected at birth or in utero -The frequency is about 1 in 3,000 live births -About equal males to females -Functional outcomes depend on severity

DCD associated diagnoses

-Associated with ADHD, phonological disorder, expressive language disorder, or mixed receptive-expressive language ---56% of children with DCD have Learning Disorders ---41% of children with DCD have ADHD

Retinopathy of Prematurity

-At risk infants require eye exams at 4-6 weeks of age until retinal mature ---<1500 grams ---<30 weeks gestation -The youngest, smallest, sickest infants at greatest risk -Retinal maturity described as zones as goes out from the optic nerve -Outcomes: ---Need for glasses ---Strabismus ---Blindness -Treatment: initial treatment laser surgery or injection of Avastin, regular eye exams for a couple years

Juvenile Myositis

-Autoimmune disease that involves both skin and muscles -Includes 3 types... ---Juvenile Dermatomyositis (JDM) (most common, but still rare) ---Amyopathic Dermatomyositis (AMD) ---Juvenile Polymyositis (JPM) -Weak muscles and skin rash are the primary symptoms of JDM (will notice plateauing of motor development) -Muscle weakness without a rash is the primary symptom of JPM. -AMD experience the skin rash without the weakened muscles.

Additional Precautions/Contraindications for Hemophilia

-Avoid aggressive exercise and activity -Increasing activity too early -Monitor for nerve compression -Use of heat modalities including ultrasound: (refer to MASAC Guideline #130 at www.hemophilia.org) -No return to sport/activity until pain-free full ROM and strength

Spondyloarthropathies

-Axial Involvement, particularly of the vertebrae -Typically involves less than 5 joints, including: ---Spine, SIJ, UNILATERAL LE ---Enthesitis ---Uvveitis ---Associated Disease Features: Psoiatic rash, dysria, etc -Includes: ---Ankylosing Spondylitis ---Psoriatic Arthritis

Pacing infant in bottle feeding

-Babies want to eat super fast, suck and swallow like on the nook; 5-6 sucks then a breath (holding bottle like a pencil), increase number of sucks, -Bucal pad (fat) helps provide sustained control for sucking (w/o that they need some cheek support- push in and forward)) (chin support- finger under chin) -Moms bf will let down milk slower (sometimes a problem with moms of multiples)

Wheelchair configuration considerations

-Back height (head rest, self propulsion) -Arm rests (desk/ full length, flip back, tray?) -Foot rests (swing away or fixed) -Angles (seat to back, hanger) -Floor to seat height -Position, size of wheels and casters -Push canes -Axle placement -Transport option

Oseiod Osteoma

-Benign boney tumor (causes scoliosis (not idiopathic)) -Frequently manifests in spine -Most common between ages of 4-25 -Number 1 cause of PAINFUL scoliosis -Tend to be less than 1.5 cm in size -Hx: back pain, worse at night (WORRY ABOUT THIS!) -Alleviated with NSAIDs -Non-flexible curve -Paraspinal spasms -Smaller curvature -Tend to resolve if removed within 15-1

CA Surgery

-Biopsies -Complete resection -Debulking (take part of the tumor out) -Debridement -Limb Salvage procedure -Amputation

SDR Interview

-Birth and development history (anecdotally, premature with PVL do better than those who had more anoxic events) (studies argue different points, those with hydrocephalus have poor outcomes) -Current therapies -Adaptive equipment -Parent goals/expectations for SDR (they will never be 100%, CP is multi-faceted (not just tone))

Criteria for NICU Follow-up Clinic

-Birth weight <1500 grams -Gestational age < 32 weeks -Required more than four days on the ventilator or has persistent pulmonary problems (BPD) -Intrauterine growth retardation (> 2 S.D. below the mean in two growth parameters) -ECMO patients -Neonatal seizures, intraventricular hemorrhage (any grade), periventricular leukomalacia, hydrocephalus, perinatal asphyxia, or other neurological abnormality -Elevated bilirubin levels requiring an exchange transfusion -IDM with symptomatic hypoglycemia -Congenital or acquired infection (meningitis or positive blood cultures associated with pulmonary compromise, DIC, or shock)

Development of the musculoskeletal system

-Bone growth before muscle growth -Linear growth comes primarily from the limbs -Children's femurs reach adult length by between 8 and 12 years old -Growth in the spine is about an inch a year until age 5 -From age 10 until the end of the growth spurt, another 6 inches (allows MDs to predict height) -Majority of muscle fibers present before birth -Remainder form in the first year -Growth is entirely through hypertrophy, as well as addition of myofibrils (building blocks of muscle fibers) -Longitudinal growth through addition of sarcomeres

Bone development (age they develop until, rate, "osteogenesis," "ossification," "mesenchyme," "woven bone")

-Bones can continue to develop until about the age of 25 years -Different bones develop at different rates ---Last bones to ossify: pelvis/spine ---Usually use hand to measure growth age -Osteogenesis: bone formation -Ossification: Process of REPLACING pre‑existing tissue with bone -Mesenchyme: embryonic connective tissue arising from the mesoderm - - undifferentiated mesoderm -Woven Bone: immature bone that consists of irregular collagen fibers and is less materialized than mature bone

Rickets definition

-Bony disease which is caused by a failure of osteoid calcification during growth (softening of the bone) -Most commonly caused by a Vitamin D deficiency (possibly other minerals) ---Outside the US, often from dietary deficiency ---In the US, Vit‑D malabsorption disorders (intake of Vit‑D there, but body is unable to absorb) -Inheritable -Typically managed with medications but if does not work on non‑complaint with medications (resistant to meds)

Outcome measures and diagnosis

-Both the BOT and the MABC fulfill criterion A ---Criterion A: Motor Coordination ---Work slower, trade speed for accuracy ---Poor proprioceptive function ---Deficits in timing of actions -But what about criterion B? (how as PTs do we address this? ---Criterion B: Academic Achievement/ADL ------Poor academic performance ------Lack of confidence ---Try the DCDQ

Treatment of Scheurmann's

-Bracing <75 deg -PSF <75 deg (depends on surgeon, some say closer to 90) (BMI also has a big influence on whether or not a doctor will do surgery)

Brain tumor IP vs. OP (in vs out pt)

-Brain tumor patients often have rehabilitation services during hospital admission after surgery -Possible candidates for IP rehabilitation -Outpatient therapy during and after radiation/chemotherapy treatment ---Fatigue with radiation can be a factor

Precautions and Considerations for OI

-Brittle bones! Teeth, too -Hearing impairment -Scoliosis and associated complications -Degree of severity varies on type -May limit participation is certain sports

Outcome measures

-CHAQ (great, used in almost all JRA clinics) (can I brush my hair, teeth, how is it impacting my life?) -Juvenile arthritis functional assesment index and JAFAreport -COPM -Active Joint count (specifically count whats inflamed, used to predict prognosis)

Why treat ITW?

-CPG Recommendations: to prevent adaptive shortening of the gastroc and persistent abnormalities of gait and balance -Biomechanical changes may occur -Muscle Imbalance -Development/Social -Decreased ankle dorsiflexion is correlated with foot pain or pathology in adulthood -Associated developmental problems and learning problems

Physical therapists deal most often with...

-Car seats -Lifts -Standers -Aids for ambulation -Wheelchairs, both power and manual -You may also evaluate for: ---Other positioning devices (sidelyers, classroom/feeding chairs, etc.) ---Bath seats (often OT) ---Adapted trikes, etc.

Legg Calve Perthes Cause

-Cause is unknown, but the blood supply to the capital femoral epiphysis is interrupted. -This is basically pediatric avascular necrosis in the hip -During active Perthes, the head continues to deform due to lack of blood flow and a fracture of the femoral head (will re-vascularize, but the head will not be a nice shape)

Motor Control Impairments and brain tumors

-Caused by tumor location or surgical/ hemorrhagic complication -Motor control training ---Repetitive task specific training -Constraint therapy for hemiplegic upper extremity

Treatment Basics (often getting multi-modal tx)

-Chemotherapy (usually) -Surgical resection (sometimes) -Radiation therapy (sometimes) -Hematopoietic Stem-Cell Transplantation (more experimental) -Immunotherapy (more experimental) -Gene therapy (more experimental) -Cell therapy (more experimental)

Common Impairments in ALL

-Chemotherapy-induced peripheral neuropathy -Loss of ROM -Posture dysfunction -Gait disturbances -Muscle weakness -Balance impairment -Motor skills impairments -Poor endurance

Surgical Preparation

-Child positioned prone -Needle EMG electrodes inserted in major muscle groups of LEs (except hip flexors) and anal sphincter -EMG monitored by neurophysiologist -Physical Therapist will palpate muscles corresponding to spinal level being stimulated -Motor response monitored by PT (this is usually stimulated first- don't want to cut this!!!)

Pediatric vs Adult Acquired Limb Deficiencies

-Children are still growing and have a high level of osteogenic activity -Kids are much more likely to have problems with bony overgrowth on their residual limbs than adults

Potential Candidates for SDR

-Children with CP who have spasticity primarily in the legs (spastic diplegia) -Spasticity interferes with function or daily cares (not really for kids with only mild impairments) -Children who can cooperate with a vigorous post-op therapy program

History of assistive devices

-Choices were limited -Letters of justification were minimal -Equipment often wasn't used -Then... ---Cost containment ---Requirements to justify expensive equipment ---Strengthening of family and patient centered care concepts ---Overview of equipment

EDS Types

-Classic (type I, II): AD, skin hyperextensibility; widened atrophic scars; joint hypermobility -Hypermobile (type III): AD, skin involvement (hyperextensibility &/or smooth, velvety skin); generalized joint hypermobility -Vasular (type IV): AD, thin translucent skin; arterial, intestinal, or uterine fragility or rupture; extensive bruising; charactertistic facial appearance (more associated with shortened lifespan) -Kyphoscoliosis (type VI): AR, generalized joint laxity; severe muscle hypotonia at birth; scoliosis at birth (progressive); scleral fragility & rupture of the ocular globe -Arthrochalasia (type VIIB): AD, severe generalized joint hypermobility with recurrent subluxations; congenital bilateral hip dislocation -Dermatosparaxis (type VIIC): AR, severe skin fragility; sagging, redundant skin

Specialized Infant feeding

-Cleft palate: cant create neg pressure, would go into nose -Haberman bottle: allows squirting to help with milk expression

Syndactyly

-Common congenital malformation resulting in digits failing to separate (soft tissue or bony) (could look fat)

Neuromuscular scoliosis

-Common in children with dystrophies, myelomeningocele (spina bifida), CP -Begins in young childhood and progresses -Is not correctable through bracing (may still brace, but regardless, it gets worse (aggressive)) -Often long C curve -Caused by pelvic obliquity, asymmetric tone, asymmetric strength, athetoid movement patterns -VERY STIFF CURVE! (aggressively pulled by the mm tone)

SDR Week of Discharge

-Complete discharge evaluation -Instruct family in home exercise program of stretching and strengthening -Provide equipment: wheelchair, assistive device, ankle weights (for HEP)

Evaluation Process

-Comprehensive two-day evaluation (PT, OT) ---Gait lab analysis ---Videotape of functional abilities -Social Services assessment -Return to clinic for evaluation by neurosurgeon -Interdisciplinary team discusses the child's suitability for SDR (bring up concerns, talk to family)

Pediatric Oncology: % of CA cases, # cause of death, mortality rates

-Comprise 2% of all cancer cases in the U.S. (the vast majority of CA is in adults) -Leading cause of death from disease of children in the U.S. (2nd in adults) -Mortality rates ---2.4 per 100,000 in children ages 1-4 ---2.5 per 100,000 in children 5-14 ---Rate of cancer in age 15-29 3x higher than below 15

Gait - Outcome Measures for CA

-Computerized gait analysis -Observational gait analysis (OGA) -Water marks on paper -Measure/observe ---Push-off ---Initial contact ---Step length ---Base of support ---Out-toeing/in-toeing ------Out: due to hip or pronation at foot ------In: great toe extension weakness (can even get paralyzed there)

Slipped Capital Femoral Epiphysis (SCFE) Definition

-Condition where there is a displacement between the proximal femoral epiphysis and the metaphysis -Faulty anterior and superior displacement of the femoral neck -Diagnosed by X‑ray

Pediatric muscle testing

-Conflicting literature on whether this is valid in pediatrics -However, in general, gives good relative measure of strength -When unable to test (either due to age or decreased ability to follow instructions) general assessment of motor function is used to grade muscle ability

Congenital Brevicollis: Klippel Fiel sd

-Congenital fusion and shortening of the cervical vertebrae -Limited Rom of the head and neck (appear like they have a short neck) (work a lot with OT for turning in ADLs) -We do more protection/pain in PT

Polydactyl

-Congenital malformation resulting in additional digits (may or may not be functional)

Balance interventions with brain tumors

-Consider vision/vestibular/ neuromuscular impairments -Monitor asymmetry -Progress difficulty by taking away use of one system (unsteady surface, eyes closed) -Challenge balance during gait ---Head turns, perturbations, crowded hall, change in surfaces (do head turns)

PT Exam

-Consider what stage and what type of condition ---ACUTE, SUBACUTE or CHRONIC? -Joints to consider: KNEE, ankles, wrist, elbow, shoulder, clavicle, finger and toe joints, and if more involved, cervical and TMJ ---Hip often is less involved (tends to be a much more serious case if hip is involved -Joint restriction = Position of comfort (problematic- leads to contractures, can do sprinting to prevent contractures) ---Hip flexion and loss of IR and ABD also noted ---Knee - flexion contracture ---Wrist - flexion loss of ext ---Shoulder - loss of flexion, abd, and IR ---Ankle - loss of flexion

Leg inequality definition

-Considered significant when more than 2.5 cm or more -May be congenital or acquired ---Congenital: Several other more commonly seen pediatric conditions contribute to LLD including, MHE, hemihypertrophy, Blount's, club foot, and cerebral palsy -May occur as a result from various acquired disease processes, such as Legg Calve Perthes, SCFE, infection, necrosis of a joint, after a tumor, or post chemotherapy -LLD will probably increase with age as the rate of growth is different (esp when there is significant LLD) -Amount of LLD determines treatment!!! (physicians can use charts to figure that out...); manipulate growth plates

Legg Calve Perthes Goals

-Contain Hip and Protect Head shape, limit pain, prevent ROM loss (recommend a lot of swimming or biking to promote a nice rounded head)

PT treatment guidelines: sub-acute Hemophilia

-Continue RICE as needed for pain and after exertion -Splinting, resting splint for protection at night, weaning splint as able with pain as guide -Wean assistive device and begin progressive weight bearing -Activity modification to avoid pain -Pain-free gentle AROM of affected joint -Pain-free progressive strengthening of affected and unaffected joint

Other symptoms of Neurofibromatosis (other than tumors)

-Convulsions -Freckles in the underarm or groin -Pain (from affected peripheral nerves) -Optic glioma (loss of peripheral vision, blindness) -Lisch nodules: pigmented tumor in iris, non-malignant -Skeletal Abnormalities (scoliosis, Bowing/pseudarthroses of tibia, fibula, femur or clavicle) -"café au lait" spots

wc eval: plan

-Coordination of team members ---Vendor: when/how long trial ---Caregivers: detailed log of use ---Other care providers: feedback ---Be prepared to spend a good deal of time in follow up! (keep an eye on the progress pts are making) ---Be sure each team member understands what is expected -Paperwork ---At least partially dependent on facility's requirements ---Need to have a face to face with physician and needs to be documented (past 60 days before your eval) (needs to be documented that they talked with the pt about a wc) (SO, look at the order and the MD's notes before you have the kid come) ---Particularly power/Medicare ---May write short evaluation immediately ---Draft letter ASAP (time à forgetting!)

PT Implications of Juvenile Ankylosing Spondylitis

-Core stabilization -Treat with extension exercises -Protect the spine, prevent further forward flexion (keep them upright/neutral) -Lots of pec stretching -Icing and aquatic PT are good -Remember: very inflamed (no US) -Also note: on many meds

Postural Interventions for CA

-Core strengthening (closed chain biomechanics!) (jump, squat) ---Prone over ball, Wiifit Yoga, Crab walk, prone extension ---Hip and peripheral LE strengthening

Posture Dysfunction and CA

-Core weakness and deconditioning cause poor spinal posture (forward head, thoracic kyphosis) ---Sometimes also "protect" the port -Knee hyperextension (soleus weakness, ankle contracture) -Altered foot posture (talk to the families about this A LOT!) (document: level of arch, calc val/var, in/out toe) ---Etiology: ROM restriction and weakness ---Lose medial longitudinal arch quickly ---Hindfoot valgus ---Poor foot posture can alter gait pattern, enhance muscle weakness, and further restrict ROM

NICU follow-up clinic

-Corrected gestation age: corrected until 2 years of age, education to parents on developmental expectations -Assess for development "red flags": cranioplagia, torticollis, asymmetry, cerebral palsy, etc -At 12 month CGA completion of Bayley's Pediatric assessment

Manuel Edema management

-Critically ill infants will have fluid imbalance with significant acute/chronic edema. Immature lymphatic system that needs facilitation for maturation -Manuel Edema mobilization, kinesiotaping, clear/flow PROM program, weight bearing with joint compression

Scoliosis definition

-Curvature of the spine in the coronal plane greater than 10 deg associated with variable degree of rotational deformity (rotary component) -Measurable curve LESS than 10 degrees = spinal asymmetry (not clinically concerning, not tracked or tx) -Scoliosis can be C-shaped or S-shaped -Curve named for the convex side 3 types of scoliosis: Infantile, Juvenile, Adolescent

DCD strengthening study

-DCD group produced significantly lower levels of maximum force and are less powerful -Concentric and eccentric contractions through full range of motion -Exercise learned (and demonstrated properly) before weight was added -2x/week; 20-30 minutes; 12 weeks (this is actually not that much!) -Improvements in gross motor function and proprioception (limited, but this tells us that minimal strengthening activity practice can actually help!)

Muscle Weakness with brain tumors

-Deconditioning -Motor control dysfunction -Peripheral neuropathy

Vincristine and functional changes for Non-Hodgkin's lymphoma

-Decrease in Motor Performance in Children with Cancer is Independent of Cumulative Dose of Vincristine ---128 children ages 4-12 measures with Movement Assessment Battery for Children 1 year after completing therapy (57 with ALL) ---M-ABC scores of total group significantly lower than normal population ---No differences in scores between children with ALL, Wilms, NHL

Thrombocytopenia

-Decrease in circulating platelets defined as a platelet count < 100,000/mm -SX: bruising, petechiae, bleeding -Treatment: Platelet transfusion usually if less than 10,000/mm in children

Functional limitations-JRA

-Decrease in gait velocity -Limited endurance for aerobic activities -Decreased power with explosive movements (poor mechanical efficiency) -What about effects on participation? ---Effects on cardiovascular endurance - noted impaired not due to the joint disease but due to hypoactivity

Pes planovalgus definition

-Decrease in the medial longitudinal arch and a valgus hindfoot and forefoot abduction with weightbearing (vs pes planus (flatarch)) -Can be from multiple causes in children, including but not limited to: ---Genetics ---Tarsal collation ---Tight heelcord ---Lack of muscle tone in foot ---Spasticity ---Absence or insufficiency of the posterior tibial tendon ---Obesity (excessive wt along a foot with open plates) ---Ligamentous laxity

Cardiopulmonary endurance and CA

-Decreased during treatment and after treatment -Can test using 6-minute walk test -Encourage activity level of 45-60 minutes/day for pediatric patients -Educate family (make goals like "family will do an exer based activity 1X per week)

ROM impairments and CA

-Decreased passive and active dorsiflexion ---Less ankle dorsiflexion: 7.5 degrees vs 16.1 in survivors approximately 3 years after treatment -Also see loss of hamstring ROM (relation to ankle, sedentary kids) and hip rotation ROM (RED FLAG for osteonec)

Spondylolysis

-Defect or fracture of the pars interarticularis without slippage -Scotty dog sign (important!) (seen on an OBLIQUE view) -Usually seen at L5, sometimes L4 -Not congenital -Acquire through repeated extension, typically in adolescence

Spondylolisthesis

-Defect with forward slippage -Isthmic spondylolisthesis is the most common type ---May also be degenerative, pathologic, dysplastic, or traumatic -Degree of slippage indicated by grade ---Grade 1: less than 25% (conservative tx) ---Grade 2: 25-50% ---Grade 3: 50-57% ---Grade 4: greater than 75% (definitely not conservative tx) -Spondyloptosis: complete translation of L5 body off sacrum

Congenital scoliosis: types of defects

-Defects of Segmentation = block vertebra or unilateral bar -Defects of Formation = hemiverebra or wedge vertebra

Cancer definition

-Definition: diseases in which abnormal cells divide without control and are able to invade other tissues -Spread to the body through blood and lymph -More than 100 different types of cancer

Arthrogryposis - Presentation

-Deformities are usually symmetric, and severity increases distally, with the hands and feet typically the most deformed and will present in either flexion or extension -Joint rigidity -Some have joint dislocation (most commonly at hips, knees) -Muscle atrophy -Deep tendon reflexes diminished -Two common presentations: ---"Jack-knife" ---"Frog- legged" (a little easier to work with) -Associated characteristics

General Pediatric Orthopedic Guidelines

-Deformities often occur more toward the ends of the bone where the growth plates are located -Skeletal deformities WORSEN as abnormal growth continues -In pediatrics, pain is typically an indicator for medical follow up (children in general, should not have pain- if they have pain they should see a doctor for it)

Factors Influencing Long Term Outcome of Premature Infants

-Degree of Prematurity -Size for Dates (SGA) -Intraventricular hemorrhage -(Periventricular) Leukomalacia -Socio-economic Status -Postnatal Nutrition

Clinical Considerations: Neurofibromatosis

-Depend on extent of skeletal and visual involvement -Participation ---Deconditioning resulting in decreased participation in age appropriate activities ---Emotional/ Psychological ---Endurance Impairment 2' pain/decreased activity -Social isolation secondary to facial disfiguration ---Bullying ---Leads to deconditioning -Respiratory/GI issues secondary to scoliosis and/or compression from tumor

Wheelchairs: What are the options (base v. seating)?

-Dependent mobility devices (strollers, e.g.) (preferred term) -Manual wheelchairs -Power wheelchairs -TONS of options for seating

Motor skill impairments/ Activity limitations with brain tumors

-Dependent on tumor location and treatment -Survivors of brain cancer were most likely to report performance limitations ( 26.6%) and restrictions in ability to do routine activities (20.9%) and attend work or school (20% and 11.2%). Survivors of brain cancer were most likely to report restricted ability to perform personal care (10.5%). -Weefim, Gross Motor Function Measure, PEDI are additional outcome measurements used in this population

DCD and obesity

-Developmental Coordination Disorder as framework (identification and intervention) -Many contributing factors to pediatric obesity, intervening at the level of coordination and motor skills is just one aspect -Overweight/obese children have been found to be significantly higher in the DCD -DCD children demonstrate significantly lower performance in fitness tests with high demands of coordination (consider the shuttle run- doesn't measure endurance, more coordination!) -Low motor competence is associated with increased body fat and low cardio- respiratory fitness and increased indicators for cardiovascular disease

General Pediatric Orthopedic Exam Components

-Developmental history and current developmental milestones -Family history - many orthopedic conditions are linked to heredity -Current complains: Pain, falls, mobility, other symptoms and onset noticed (why are you coming to see me? most commonly = clumbsiness)

Side effects of cancer treatment

-Diabetes insipidus -Cranial nerve deficits -Cognitive deficits -Behavioral changes (in childhood, kids should be learning how to take responsibilities, take care of themselves; what does 3 yrs of being sick/taken care of do to behavior) (in addition, irritability is increased) (hunger too!) -Posterior fossa syndrome -Ototoxity (loss of hearing) -Endocrine abnormalities -Cardiac and pulmonary abnormalities -GI complications -Renal and bladder complications -Nutritional complications -Musculoskeletal complications

Developmental Dysplasia of the Hip (DDH) Diagnosis

-Diagnosis 3‑12 months (this is when we want to get them in!) ---Limitation in movement ---Leg length discrepancy ---Uneven gluteal folds ---May also use legs unequally (WB) -Diagnosis after 1 year ---Pelvic obliquity ---Trendelenberg ---Toe walking (due to limb length or preference in WB) ---Excessive lumbar lordosis (trying to change position of hip)

Idiopathic scoliosis risk of progression is higher with...

-Diagnosis at a younger age (before menarche) -S-shaped curves -Lower Risser sign -Larger curves -Females (7X greater) -*70% of JIS curves progress and require some form of tx* Importance of the side of the scoliosis -In IIS: almost always L sided thoracic curve -In AIS and JIS... ---Typically R sided thoracic curve ---L sided thoracic curve is associated with spinal cord pathology

Parts of the Bone

-Diaphysis‑shaft, primary center of ossification -Epiphysis‑ends of long bones, formed by secondary centers of ossification (this is where we get growth) -Epiphyseal plate‑ growth plate zone, hyaline cartilage (where the growth happens, growth stops when closed) -Metaphysis‑wide portion of the bone connected to epiphyseal plate

Muscle Weakness Outcome Measurements for CA: Manual muscle tests

-Difficult in children under 5 -Look at all muscle groups ---toe extension/flexion strength (MMT at 3+ years, also try toe wars, etc)

Syme amputation

-Disarticulation at the ankle, but keep the heel pad, take malleoli off -Need a window in the back (bulbous nature of the heel)

Feeding

-Discuss with family their preferred feeding plan for home discharge ---Breastfeeding (need 2-5 days to work on this before we work on bottle) (most premies usually need to do a combo until 40 weeks) (but don't want mom to give up!) ---Bottle feeding (easier, faster) -Coordinated plan to reduce risk of over-fatigue of oral motor musculature -Breastfeeding starts around 32 weeks, bottle feeding at 34 weeks

Pediatric vs. Adult Cancer: response to treatment

-Disease and treatment occur during a critical point of development in pediatric cancer ---Have not yet acquired mature posture, gait, motor skills, cognitive skills, social skills, etc ---The process can alter the course of development -Adults have mature nervous systems, kids are trying to develop at the same time that there will be a major insult (this is also happening in all other systems) -This can alter the course of their development, how do you help with that?

Outcome predictors for JRA

-Disease onset and type (early = worse prognosis) ---Early hand involvement (not a good sign!) -Duration (want short flare ups) -Active Disease

Vincristine and Peripheral Neuropathy

-Disrupts the microtubules (building blocks of axons) -Causes degeneration of the axon cytoskeleton -Disassembly both at the ends and within the axonal microtubules -Inhibits and interferes with axonal transport

wc eval: observation

-Document physiological, anatomical and behavioral reaction to equipment -Compare posture, function, affect with and without equipment (this an be very powerful in LMN) -Document caregivers' independence with assisting

Radiation Therapy

-Done over 2 weeks usually, get doses almost daily (if they need another bout later they will do it) -Uses high-energy particles to destroy cancer cells by breaking strands of DNA (if you irradiate an area, all cells are damaged, but the CA cells don't recover as well as the normal cells) -Not recommended for children under 3 as myelination is not complete and it could cause neurocognitive and functional deficits (time of high myelination, myelin is protective from the damage of radiation) -Acutely can cause fatigue that reportedly resolves after 4-6 wk (BUT, long term fatigue is also a major issue)

SDR History

-Dr. Warwick Peacock is credited with beginning the present day surgical technique in South Africa in the 1960s -Dr. Peacock moved to the United States in the 1980s and began training surgeons here -The technique was refined throughout the 1980s-2000, resulting in the current methods used today -Over the years there has been a lot of controversy, has mostly died down now

SDR Post-Op Rehab duration, frequency, goals

-Duration: 4 week rehab program - Frequency: 2 hours of PT and 1 hour of OT per day -Goals ---Increase ROM/flexibility ---Increase strength and graded motor control ---Develop good postural alignment in sitting ---Develop active movement transitions using normal motor patterns ---Develop reciprocal movements in LEs ---Initiate ambulation, emphasizing normal movement patterns ---Address equipment needs for discharge ---Individualized short-term goals written weekly

Legg Calve Perthes PT treatment

-During Phase 1‑3: ---Instruct family in Active ROM and stretching, esp into IR, and ABD, and check Extension (stretching important: had been doing a lot of protective isometric contractions) ---Encourage no impact activities for ROM and strength (sometimes NWB, sometimes walking OK, but no running/jumping/etc) ---Focus on hip strength ---May need to help with gait training in Petrie Casts -Post surgical: Gait training and ROM (had been walking in ER, so will need to work on this) -After Phase 4: ROM and strengthening, return to prior level of activity

Juvenile Ankylosing Spondylitis

-Dx of AS before age 17 (results in growth changes) -Present with inflammatory Low Back Pain -Typical onset >9 years -Typically Boys -Progressive Radiographic Changes in the Lumbar spine -Reducing ROM -Progresses towards hip involvement and fusion of the spine

Weights

-ELBW <1000 g -VLBW <1500 g -LBW <2500 g

Development of Gait- Refresher

-Early Gait Pattern ---Hip flexion with toe-off/relative drop foot (not necessarily on the toes) ---Hip abduction/wide base of support ---No arm swing/arms at high guard -Mature Pattern ---First rocker: controlled ankle plantarflexion until foot flat ---Second rocker: forward translation of tibia over foot ---Third rocker: push off

Achondroplasia: Treatment Strategies

-Early childhood ---Stress careful positioning ---Bracing? -Lifelong ---Promotion of physical fitness ---Strength training to maintain or achieve muscle balance

Sickle Cell Disease: Treatment Strategies

-Education exercise and hydration -Palliative care (find techniques to reduce pain crisis) -Airway clearance education and breathing exercises

Treatment for EDS

-Education: Proper Footwear -Orthotic use for casual shoes -Postural education -Strengthening = Stability = PROXIMAL ----Safe yoga positions -Principles of joint protection, including bracing -OT/ Adaptive devices

Knee arthrodesis for PFFD

-Eliminates knee instability -Increases lever arm -Typically done between the ages of 2.5-4 year of age -Foot ablation often done with knee arthrodesis -Goal would be for limb length on the prosthetic side to be about 5 cm shorter than contralateral femur -This allows prosthetic knee joint to be approximately at the same level as the sound leg -Femoral and/or tibial epiphysiodesis of sound leg may to done to achieve optimal limb length difference

Achondroplasia PATHOPHYSIOLOGY:

-Endochondral ossification at epiphyseal plate is disturbed -Proximal limb segments more shortened than distal -Limbs shortened relative to trunk -Macrocephaly (head is bigger)

Osgood-Schlatters presentation

-Enlarged and/or swollen tibial tubercle (possible redness) -Painful with palpation to the distal patellar tendon -Pain reproduced with eccentric quad contraction (initial recommendation: limit activity) -Hx of repetitive activity - often seen in young athletes who do a lot of jumping/kicking -Radiograph shows enlarged tibial tubercle

Site of Bone Growth

-Epiphyseal plate‑ cartilage between epiphysis and diaphysis = longitudinal bone growth -Appositional growth‑ growth in width occurs when bone is absorbed from the inner surface and via accumulation of new bone on the surface of the bone. (develops with weight bearing) -Traction epiphyses‑cartilaginous growth plates found at the muscular attachments (not well defined at birth, more developed with movement/growth) ---Tubercles of humerus, femoral trochanter (these all had their own growth plates- over-stretching these places could increase growth or cause stress fx)

Clinical Presentation OI

-Equal numbers girls and boys -May be misdiagnosed initially as abuse (family issues may come up, parents may want to keep kids safe/not let them play with others) -Short stature -Low tone -Blue sclera -Fragile teeth -Bowed long bones -Ligmentous Laxity -SECONDARY IMPAIRMENTS (overall endurance and deconditioning) -FUNCTIONAL LIMITATIONS? Hard to keep up with family and friends

Common Orthopedic Terms of the Foot

-Equinus‑ plantar flexion positioning -Equinovalgus - PF and EV, often with midfoot breakdown -Planovalgus - flat foot and in PF -Cavo varus -Pes Cavus -Pes Planus - flat foot -Metatarus adductus - midfoot adducts in -Metatarus Abductus

Stander home trial goals

-Esp important for standers -Need a log from 1 week with the stander for MA! ---Goals (improvement in respiration, pain behaviors) (HARD to write!) ---Think: what is the long term goal (less pain, prevent contracture, possibly improved mobility); what are little pieces of that? (sleeping better, less meds for BM) ---7 day log with many observations of pt

JDM Etiology

-Etiology largely unknown, autoimmune -Muscle inflammation ---Symmetrical, proximal muscle weakness/inflammation ---Possible pain ---Smooth and striated muscles can be affected (typically striated noticed first, later notice smooth) -Skin involvement ---75% of cases have a distinctive rash ---Atrophic changes over extensor surface of knees and elbows (fingers) (hallmark sign) ---Calcinosis (see picture) (calcium deposits on skin and in joints, facial rash) ---On face in malar region, erythematous ---+/- vasculitis

PT Considerations for limb deficiency

-Every child is unique and develops at different rates -Initial amputations and revisions may take place at any developmental age -Treatment should focus on the development functions that are age-appropriate to that child -For children with acquired amputations, activities may have to backtrack in development to smooth out the movements needed for prosthetic control and optimal function -For children with congenital limb deficiencies orthopedic deformities, muscle atrophy and weakness, and asymmetry may effect outcome and quality of function -Be open-minded -Listen to the child and the parents -Think and play at the level of the child -Have fun!

Conservative treatment strategies

-Exercise ---Literature does not support exer alone as effective prevention progression (won't change curve) ---Schroth method (very intense method (8 hours per day), claim to be able to change scoliosis) ------Strengthening, motor control, pole use for lateral shifts (no manips) -NMES ---Stimulation on the convex side ---Rarely used ---No support for actual changes -Orthotics (TLSOs) ---Used on curves of greater than 20-25 deg, less than 45 ---Curves progressing more than 5 deg with clinic visits ---About 20% will require surgical correction ---May be used in conjunction with PT ---Note that braces are to be worn 22-23 hours per day, but that results in MAJOR decreases in core strength

Infant and Toddler Age - Prosthetic Ambulation

-Expect to see gait deviations typical for child of this age ---Wide base of support ---Increased ER of hips ---Arms in high guard position -Have child use assistive device (most likely a reverse walker) if needed for child to achieve erect trunk or for balance (often kids don't need this!) -Some children may not need assistive devices (especially children with transtibial limb deficiencies) -Children with transfemoral limb deficiencies that are younger than 2 years of age usually receive prosthesis without a knee component -Prosthetic knee is typically added when the child is 3-4 years old ---Prosthetic Ambulation; why age three for knee? ---Stiff pylon prosthesis provides increased stability when beginning to stand ---Knee components are often too large to fit in the space of a small prosthesis

Expected and abnormal responses to sensory root stimulation

-Expected ---Single motor twitch response in up to 3 muscle groups (usually it can be seen before the PT can feel it) ---No motor response (due to low level of stimulation) -Abnormal Responses to Sensory Root Stimulation ---Sustained motor contraction ---Crescendoing motor contraction ---Motor responses in greater than 3 muscles groups ---Contralateral motor response

Hemophilia sx

-Extensive bruising -Bleeding: Common Sites ---Muscles: calve, thigh, forearm, upper arm ---Joints: ankles, knees, elbows

Risk Factors

-Extreme prematurity -Intraventricular hemorrhage -Periventricular Leukomalacia -Severe bronchopulmonary dysplasia -Intrauterine Growth Restriction

Important variables for bottle feeding

-FLOW: how much comes out, Gerber or Dr. Browns (which reduces reflux); kids with downs need the wider based nipple (orthodontic) which allows them to suck with less cupping -RATE: how fast it comes out (help with pacing)

Overall Goals of PT for limb deficiency

-Facilitate as normal sequence of development as possible -Prevent or minimize joint contracture, weakness, and skin problems -Develop independence with mobility and self care skills

Medical management of Hemophilia

-Factor replacement (as soon as you notice a joint bleed you can do this (on demand), OR you can do it profilactively (when they have lots of activity coming up)) -Rest -Immobilization -Aspiration of joints -Potential surgical interventions

PT treatment guidelines: Acute Hemophilia

-Factor replacement per medical team orders (consider prophylaxis prior to PT) -RICE -Immobilize/Splint (people like this) -NWB with appropriate assistive device (some physicians recommend this, but we want them moving!) -No passive range (injury may still be occurring, we shouldn't be going to end range)

Tarsal coalition definition

-Failure of segmentation between tarsal bones -Can be fibrous, carilaginous, or bony connection -Mostly either Calcneonavicular OR Talocalcaneal

Spondylolysthesis presentation

-Focal LBP -Radicular sx -Posture ---Short torso (body) ---Flat buttocks/glut atrophy ---Rib cage appears low ---Iliac crests (hip bones) are high ---Altered gait bc of tight hamstrings ---Vertical sacrum/posterior pelvic tilt ---Hips don't fully extend back ---Lumbar hyperlordosis

Preschool and School Age PT Intervention: Prosthetic Ambulation

-Focus on normal characteristics of gait ---Stride length ---Stance time on prosthetic limb -Velocity -Emphasize symmetry -Kids with newly acquired amputations will use an assistive device initially -Discontinue assistive device when balance is safe and ambulation speed is functional enough to keep up with peers

Gait Impairments in CA

-Foot slap (early sign, weak DFs) -Flat foot (decreased DF strength, great toe ext, push off... less initial contact at the heel) (results in short step) -Decreased step length -Wide base of support -Toe walking (2-6 will go full up when they get weak) (more commonly a bouncy walker) -Steppage pattern (seen occasionally) -Lateral lurch (CHECK for osteonecrosis of the hip!)

Standing alignment

-Forefoot (splayed?) -Hindfoot (everted?) -Knees -Hips/Pelvis -Compensations ---Anterior weight-shift ---Anterior pelvic tilt ---Lumbar lordosis

Sickle Cell Disease EPIDEMIOLOGY:

-Found in persons of African, Mediterranean, Indian and Middle Eastern descent -Difficult to track, but perhaps 100,000 with SCD in US -About 8% of people of African descent in US -Life expectancy to the mid-40s (probably gone up in the last several years)

Leg inequality measurement

-Frequently with measure with at least 2 methods. ---1. Tape measure: ASIS to Medial Malelioli:Least accurate- especially difficult to use with children with contractures. ---2. Blocks: will have pt stand with shorter limb on blocks and measure at PSIS for when level; more accurate but still not the best ---3. X-ray: More accurate as able to measure boney land marks but MD must do

Wheelchairs (power)

-Front-, mid-, or rear-wheel drive -Placement/configuration of control -Power recline or tilt -Elevating leg rests -Lower to floor -Seat elevators -Transition to stand

Gait interventions for CA

-Gait -"Quiet walking" (control the foot slap, watch how they are doing it) -"Squish the bugs walk" -Lengthen stride length (big steps!) -Heel walking (strengthening technique) ("heel walking hallway") -Treadmill training (used for lengthening stride, DF component) -Inversion - look at toe extensors, circumduction -Out-toeing - foot compensation or WBOS (decide if it's a hip issue) -ORTHOTICS

Gait Analysis in ITW

-Gait Analysis looking at all phases of gait- may see any of the following: ---Toe contact/lack of first rocker (short step) ---Absent second rocker/Limited anterior translation of tibia over foot ---Early heel rise (bouncers) ---Hip/trunk flexion throughout cycle ---Over-pronation during stance ---Increased external tibial torsion (if they have been toe walking for a long time) -70% of children with ITW could normalize some part of their gait (they know that its not normal, so they can fix it) (note that this could still relate to the sensory defensiveness)

SDR Sensation Testing

-Generalized testing -Test for light touch -Note whether sensation is intact, impaired, or absent over broad areas of LEs -Test proprioception sense of great toe flexion and extension (this will not be a determining factor on if they get the surgery, but gives you a baseline for thinking about it later)

ROM interventions with brain tumors

-Gentle prolonged stretching/positioning -Knee immobilizers for hamstrings -Serial casting/orthotics for ankle contractures -Wrist/hand splinting -Work closely with physiatrist for medical interventions and feedback on function

Oral Motor development and Feeding

-Goal is for each infant to have a positive feeding experience and avoid oral aversion development ---Oral aversion: sensory perception can be altered by too much oral stimulation (tubes, thrush, big tongue), changes the sensory perspective, feel pain when they try to eat, VERY hard to turn it around until they start different textures ---By far, this is the most problematic issue for parents -Feeding a NICU baby is complex, challenging, and risky as the infant is learning to coordinate SSB and high probability for aspiration -Requires advanced training: AOTA recommends minimal of 2 years pediatric experience before NICU placement

Slipped Capital Femoral Epiphysis (SCFE) Grades

-Grade I < 33% slipped -Grade II 33‑50% -Grade III > 50% -More severe slips → ORIF

metatrasus adductus grades

-Grade I will correct itself by the age of 4‑6 months -Grade II‑ corrective shoes and stretching exercises -Grade III‑ manipulation and serial casting

Supportive Environment

-Graded sensory input following the hierarchy of neurosensory development of the brain -Hierarchy ---Tactile (begins development at conception, 27-28 weeks they can handle imposed touch) ------The equipment helps with this ------Tactile defensiveness is the potential resulting issue (make goals about this- 4 minutes with no moro and no changes in vitals) ---Vestibular (21 weeks gestation) ---Gustatory and Olfactory (begins 11-15 weeks, developed at 26) (benefits of breastmilk- paint their lips with it so they accommodate to the taste and smell if it) ---Auditory (23-28 weeks gestation) (hypersensitivity can develop from being by the ventilator) ---Visual (30 weeks papillary response begins) (slowest of all developmental categories)

Achondroplasia FUNCTIONAL LIMITATIONS

-Gross motor delay in early childhood -Pain -Spinal stenosis

Ehlers-Danlos Syndrome

-Group of inherited connective tissue disorders -Deficiency of collagen -Several different forms/subtypes -Most are autosomal dominant disorders -1 in 5,000 births -**Vascular EDS (Type IV, Ecchymotic) is the only type that is associated with a shortened life span** -Note: this is different than flexibility built from sport (we still have tissue stability

Craniopharyngiomas

-Grow in the suprasellar area of brain including hypothalamus, pituitary (hormonal issue, leading to increased calorie intake) and optic chiasm -5% of pediatric brain tumors -Treated by surgery, but sometimes partial resection with radiation to decrease side effects -Memory, visual, behavioral, and hormonal problems as late effects -High risk of obesity (could end up unable to ambulate)

Infant and Toddler Age - Prosthetic Training

-Have child work on other movement transitions once they are comfortable with walking ---Squatting (initially holding onto support surface, progressing to hands free) ---Kneeling and Half Kneeling ---Floor to/from Stand

What factors affect decision making regarding standers?

-Head and trunk control (supine is better for low head control) -Seizures (need to be able to get them down FAST) -Existing contractures (make sure it can fit AND allow for weight bearing on both sides- can have separate foot plates or noodles and duct tape) (sit to stand models are good for this) -Current bone health (no torqueing of long bones if they have had pathological fx) (some kids cannot stand without fracturing) -Feeding tube/tracheostomy/colostomy (need adjustability to accommodate) -Scoliosis (asymmetrical support required) -Transfers to and from (becomes more of an issue as they get bigger) -Layout of the home (supine standers are HUGE!) -School (10 hours a week in a stander is required for bone health- they usually don't get that at school) -Growth potential (5 years worth of growth is the goal) -Caregiver situation -Many payers will not pay for a gait trainer or walker AND a stander (if both are needed, do your stander first) (children are expected to change and improve) -Outcomes of the home trial!!!

Nonsurgical treatment/PT implicationsof pes planovalgus

-Heelcord stretching but with emphasis on protecting the midfoot/ arch of the foot from further disruption -Ankle inversion/ post tib strengthening (ABC's, bury toys in the sand or rice, finger paints, mouse holes, pick up toys with both feet) -Intrinsic toe flexor strengthening (toe crunches, picking up toys with toes, finger painting with toes...) -Arch supports (only if needed)

wc eval follow-up

-Help with appropriate use? -How did the trial go? (via vendor or possibly family) -What's happening in the process? ---Not all DME vendors automatically contact you with denials or no actions -Check when equipment is delivered

Gait disturbances for brain tumors

-Hemiparetic gait pattern -Steppage gait -Flat foot shuffling gait -Foot slap gait -Ataxic gait pattern (wide-based, variable, sways) (looks different in every kid)

Legg Calve Perthes: Active Phase classification

-Herring Lateral Pillar Classification -Normal, A (normal pillar height), B (>50%), and C (<50%) -Assists with determining treatment

Slipped Capital Femoral Epiphysis (SCFE) Long Term Outcome

-High incidence of early hip arthritis in affected peds so needs to be followed after surgery at least annually -Expected to return to prior level of function

Epidemiology of ITW

-Higher incidence in boys -Estimated 7-24% of childhood population (when it is not due to CP) -May see a family history

Strengthening for ITW

-Hip extensors -Dorsiflexors (start seated, progress to standing and dynamic) -Ankle stability -Toe-intrinsics: sensory bin, cotton ball carry

Notable Pediatric ROM Norms

-Hip flexion: 0-140 at 1 mo, 0-125 at 6-12 yr -Hip IR: 0-40 at 1 mo, 0-50 at 6-12 yr -Hip ER: 0-65 at 1 mo, 0-50 at 6-12 yr -DF: 55 at 1 mo, 10-20 at 6-12 yr

Legg Calve Perthes Clinical Presentation

-Hip, knee or groin pain, which may be referred to the thigh -Limp -Usually no history of trauma, but usually really active kids (WB restrictions are hard!) -Decreased range of motion (ROM), particularly with internal rotation and abduction -typically painful into these ranges (usually present with adduction/flexion) -Atrophy of thigh/ glut muscles secondary to disuse -Leg length inequality due to collapse -Trendelenburg gait

"Jack-knife"

-Hips (extreme) flexed and dislocated, knees extended -Clubfeet -IR of shoulders -Elbow and wrist flexion -Ulnar deviation of wrists -Arthrogryposis

At Each Follow-up Clinic Visit

-History and Physical Exam -Growth and Nutrition Assessment -Health Status -Development and muscle tone -Referrals if needed -Summary of visit to primary care provider -Anticipatory guidance

Components of a wc eval

-History: risk factors, primary diagnosis, recent illness, seizures (also do a chart review) (not super throrough) -Observation: watch while you are talking (potential for independence, positioning) -Explanation of options -Targeted physical exam (mat evaluation- get more info from Janey- sitting balance, how much support do they need?) -Mutually agreed-upon plan: you need to coordinate with the vendors, have MD sign off, send to insurance company (6 weeks to say yes, no, or ask questions (usually ask questions))

EDS Symptoms

-Hyperextensible skin (can pull out far) (velvet texture, little tone, thin) -Skin is velvet-like -Bone and soft tissues are fragile -Easy bruising -Joint hypermobility -Slow wound healing -Osteopenia -Myopia -Chronic pain

Muscle Tone Abnormalities from brain tunors

-Hypertonia caused by damage to the CNS by tumor location or hemorrhagic incident during/after surgery -Cerebeller tumors can cause appearance of "low tone" secondary to poor regulation of muscle tone

Periventricular Leukomalicia

-Hypoxic-ischemic etiology -Periventricular echodensities are common on early ultrasound and are not prognostic ->2mm cysts at 1 month are 95% predictive of CP if lesions extend from anterior to posterior -Most common CP is spastic diplegia

Non-medical pain relieve for JRA

-ICE (active inflammation) -Aquatics -Kids yoga (non - painful, non-funky poses) (be creative, don't do anything potentially joint damaging, don't push knee flexion or wrist extension) (play games) (restful breathing) -May do warm heat with chronic or very stiff joint but with precaution* (shower, bath, etc - no direct high heats= inflammation)

Goals of NICU Follow-up Clinic

-Identification of concerns related to health, growth and development -Early identification of problems related to development -Responding to parent concerns, remaining questions from NICU course -Recommendations for care -Appropriate referrals -Reassurance

Goals of NICU Follow-up Clinic

-Identification of concerns related to health, growth and development -Early identification of problems related to development -Responding to parent concerns, remaining questions from NICU course -Recommendations for care -Appropriate referrals -Reassurance that the baby is doing well (parents often worry excessively after discharge)

Legg Calve Perthes Definition

-Idiopathic osteonecrosis of the capital femoral epiphysis of the femoral head -Self-limited disease if not treated (will re-vascularize)

Slipped Capital Femoral Epiphysis (SCFE) PT Implications

-If a child < 15 yo who has not had an X-ray and is neurotypical presents in your clinic with: hip pain, limp, and loss of ROM → REFER OUT -Also may want to give them crutches until seen MD to decrease WB through fem head to limit possibility of further slip -POST SURGERY‑ pain typically resolves, WBAT ROM and HIP STRENGTHENING (especially glut med/max)

Congenital band syndrome

-If a fetal arm or leg is pushed though the amnion, the amnion can pinch off the blood supply to the developing limb, causing it to either grow in a withered fashion or be lost so that it appears to have been amputated -A spectrum of congenial birth defects caused by entrapment of fetal parts in the amniotic band in utero -Varies vastly in presentation -Most commonly presents as a congenital amputation followed by constriction bands -Can be fatal

Additional considerations for Clubfoot

-If residual, ROM loss, decreased jt mvmt, abnormal wt bearing surface -Pain -Balance deficits (get kids into activities that emphasize balance) -Delayed higher level GM skills -Often orthotics (life-long)

Fracture PT implications

-If the fracture is in the lower extremity, PT is often following for gait training -WB status and equipment used is dependent on type of fracture, location, pt age, and type of fixation -Often in Pediatrics, PT is limited except in significant trauma recovery as children are very active and tend to do well with simple return to activity -Occasionally follow if needed for ROM and strengthening after precautions removed

Legg Calve Perthes Long term implications

-If well treated, ROM should return to almost full, though may have some residual loss (most likely not to return is IR) -LLD so may need small lift in shoe -Return to prior level of function -Can lead to early hip OA -Grade B and C typically have limb length differences- need a shoe lift

Other treatments for CA

-Immunotherapy ---Agents that stimulate the body's immune system to eliminate tumor cells -Gene therapy ---Replacing, removing, or introducing genetic material into cells ---Mostly experimental

ROM deficits with brain tumors

-Impairments depend on etiology ---Hypertonia ---Hip abduction/rotation/extension, knee extension, ankle dorsiflexion ---Shoulder abduction/flexion, elbow extension, wrist supination/extension and finger extension/abduction -Peripheral neuropathy ---Ankle dorisflexion, knee extension

Authorization for lifts

-In Minnesota (MA August 2010), can order without prior authorization if: ---Assistance of another person is needed to transfer between surfaces in the home ---Transfers are unsafe without a lift because of the person's medical condition, or caregiver health ---The lift is documented as fitting in all necessary areas of the home -While there are provisos for use of electric lifts, these are often reimbursed at a rate lower than the actual cost of the equipment

Where on the bone does growth come from? Bone growth continued...

-In long bones, the growth and elongation occurs in the epiphyseal plates -Found in the hyaline cartilage plate in the metaphysis at each end of long bones -Bone ossifies outward, therefore, growing from both ends (NOT FROM THE CENTER)

Brain Tumors

-Incidence rate of 4.5 per 100,000 in 2007 -Frontal, temporal, parietal, occipital most common sites (18.5%) ---Cerebellum - 17% ---Brain stem - 12% ---Ventricle - 6% -Most common: ---Age 0-4: embryonal/primitive neuroectodermal(PNET)/medulloblastomas ---Ages 5-19: Pilocytic astrocytomas -5-year survival rate is 66%

Biomechanical changes that may occur with ITW

-Increase external rotation of the tibia ---Due to prolonged hind-foot valgus -Risk of structural abnormalities ---Widened feet ---Bunions

School Age

-Increase in special education services -Higher incidence on ADHD, increase in attention problems -Lower IQ scores, generally in normal range, but lower than term infants -Learning disabilities -Visual-motor problems -Impaired executive function -Increase autism spectrum disorder

Preschool and School Age Overall PT Goals

-Independence in self-care skills -Independence in mobility -Acquisition of skills needed for school with overall goal of child entering school with minimal or no activity limitations

Halo traction (only seen in peds)

-Indications ---Very stiff, unflexible ---Greater than 90-95 (can get down to 30 degrees) ---Neuromuscular -May do ASF prior, halo 3 wk, then PSF -May start with halo 3-4 wk, depending on correction, then PSF

PT interventions for DCD

-Individualized approach -2 orientations of intervention... ---Process oriented (bottom-up) ---Task oriented (top-down)

Muscle Weakness Intervention for CA

-Induction/delayed intensification ---hoping to maintain strength -Consolidation/Maintenance ---Increase strength -Functional tasks ---encourage independence ---Standing while playing, kneeling while playing ---Up/down pieces games to encourage floor to stand transitions ---Stairs/step stool -Core strengthening ---Yoga, pilates, theraball, push-ups

Infant ROM

-Infant starts in phyisological flexion -Newborns should have some limitations of hip extension, knee extension and excessive DF -Also restrictions in elbow extension

When is pes planus problematic?

-Infants have a minimal arch; toddlers present with flattening of the long arch, forefoot pronation, & heel valgus on wt bearing -In children, a flexible flatfoot that is not painful and not associated with a tight heelcord/ neuromuscular condition is typically left untreated -A child that has a rigid flatfoot is followed closely; may warrant surgery later (fixed deformity, can lead problems later)

Additional Clinic Visits

-Infants with Chronic Lung Disease ---Management of oxygen and medications -Infants with Feeding Problems -Infants with Growth Concerns ---Assessment of growth ---Changes in feeding regimen -Infants with Developmental Concerns -Children return for interim assessment ---8 months ---18 months ---3 years

Juvenile Dermatmyositis

-Inflammatory vasculopathy that affects primarily the skin and skeletal mm -20% of all myositis -Onset 4-10 years; Median age 7 yrs -Higher incidence in Hispanics and African-American -Female>Male

Osteogenesis Imperfecta (OI)

-Inherited disorder of connective tissue (autosomal dominant) -Defect in collagen synthesis ---Results in very brittle bones ---(often people think that this is child abuse) -Varies depending on severity -8 types (Type 2 is typically fatal)

Oral Motor development

-Initial sucking and swallowing of amniotic fluid at 9 weeks gestation -Coordination of SSB (suck, swallow, breath) at 28 weeks gestation -Fully maturation to allow for fluid introduction at 32-34 weeks -Protective cough at 36 weeks (if you are choking you need to be able to cough!)

Limb lengthening process

-Insert pins into shaft of bone, wires go all the way through -Cut through the cortex, slowly increase the size of the gap, typically a mm per day (fast enough that new bone doesn't calcify or harden) -At increased risk for fx -While lengthening, usually WB ok, also working to retain strength and flexibility at surrounding joints (gastroc tends to tighten (knee flexion and DF) (can be quite painful)

CPG Recommendations on intervention for DCD

-Intervention is better than no intervention -The highest effect size is for task-oriented approaches -Limited/Poor/No Evidence for: ---Sensory Integration, Motor imagery, Strength, Parent and teacher guided approaches ---Fatty-acids, vitamin E supplementation -Not enough studies with high levels of quality -Minimal studies comparing 2 or more treatment approaches

Physical Therapy SDR Evaluation Components

-Interview (spend a lot of time talking to the family) -Tone testing -Strength testing -Isolated motor control -ROM -Sensation -Balance -Gait analysis -Functional ability -GMFM -Behavior

Evaluate foot in Standing

-Is it flat? Does it have an arch? -Do the toes point inward or outward? -What is the alignment of the forefoot to the hindfoot? -Do they achieve an arch with rise to their toes? -Can they even stand in foot flat? -In those with flat feet, when they raise up on their toes, does their arch correct? (worry if they have a rigid foot)

PT for OGS

-Isometric quad and hamstring strengthening -Glute med strengthening -Hamstring and GENTLE quad stretching -Start with open chain and concentric closed chain ONLY -Progress to eccentric in controlled manner AS TOLERATED -Ice massage -(no ultrasound!)

Physical Therapy Assessment of JRA

-Joint appearance, PROM, AROM and measure both sides -Look for red, warm, swollen -PAIN! -Pain reporting in children -Gait (decreased stance time, decreased DF, toe walking, everting?) -Gross motor skills -Movement patterns and substitutions -Functional strength (MMT probably wont tell you as much)

Caregiver Education

-Joint compression, PROM -Tummy Time -Back to sleep -Flexion swaddling -Feeding techniques: including use of home bottles while in NICU -Abdominal development -Visual development -Referral to Early Intervention -KT/splinting education as needed -Expected development

Developmental/social issues if ITW

-Keeping up with peers ---At risk for falling/tripping ---Limitations in mobility ---Inefficient pattern with excessive energy use and deficit in power generation -Attaining appropriate milestones (esp jumping or running)

PFFD non-surgical treatment

-Kids are often most functional without surgical treatment -May be treated with non-standard prosthesis (doesn't look like a standard adult one) -If you removed part of the limb, you would loose a lot of function -Bilateral cases are uncommon, but when they happen they are usually pretty symmetrical (prosthese bring them to typical height)

Sensory tx for ITW

-Kids who toe walk are getting altered proprioception through the ankle (you can put a lot of weight on, up to 10% of the body weight) -13/17 children had improved gait (heel contact) after vestibular activity/stimulation (think about first fulfilling the sensory needs) ---Ankle Weights (sensory input!) ---Weighted Vests (sensory input!) ---Spinnerboards (vestibular input) ---Deep pressure activities (crawling through a tunnel or under a blanket) -Likely to see this become an issue with ITW + autism (sensory issues common)

Preschool and School Age PT Intervention: Stairs

-Kids without limb deficiencies typically ascend stairs hands free and alternating feet ~3 years old, and descend stairs in this manner at ~3.5-4.5 years old -Kids using prosthesis will likely use UE support, and may go back to two feet on step -School bus sized step

Genu Valgum/Varum

-Knee alignment within the frontal plane -Typical Genu valgum: 170‑175° -Excess genu valgum: ≤165° -Genu Varum: ≥180° -Measured by assessing the intermalleolar distance in supine or standing with the medial aspect of the -Best measured with X ray and measuring differences in angles between joint surfaces -Norm is 84 for distal fem and 87 for prox tib in adolescents

Physical Therapist Muscle Palpation

-L1 (Hip Flexors): Hip Flexors -L2 (Hip Flexors, Adductors): Hip Flexors, Adductors -L3 (Adductors, Quads): Adductors, Quads, Hamstrings -L4 (Adductors, Quads, Anterior Tibialis): Adductors, Quads, Hamstrings -L5 (Hamstrings): Adductors, Quads, Hamstrings -S1 (Gastrocs): Gastrocs -S2 (Toe Flexors): Toes

Surgical Procedure

-L1-L5 laminoplasty -Stimulation of motor root to identify spinal level -Stimulation of sensory root to identify threshold -Microdissection into sensory nerve rootlets -Stimulation of individual rootlets -Rootlets showing abnormal response cut (usually~30%, typically will not cut more than 50%) -L1-S2 spinal levels tested

Infant and Toddler Age - Prosthetic Fitting Considerations

-LE: when child is beginning to pull to stand -UE: typically when child is able to sit independently (about 5-7 months); can be as early as 3 months to assist with weight bearing in prone -Instruct parents in donn/doff of prosthesis (usually on with a neoprene sleeve) -Instruct parents in checking child's skin -Instruct parents in wearing schedule ---Usually 30-60 minutes initially ---Increase time as skin tolerance allows ---Eventually wear prosthesis all day, but off for naps and at night -With prosthesis on, have child work in different positions ---Prone ---Rolling ---4-point progressing to crawling ---Floor sitting -Work with child in supported stand ---Begin at support play surface such as bench, coffee table, sofa ---Weight shifting ---Cruising

Wilm's Tumor

-Large, rapidly growing tumor of the kidney -6% of childhood cancer -Diagnoses peaks at age 2-3 -92% 5-year survival rate -Treatment - surgical resection and chemotherapy ---Radiation for advanced stages -Vincristine in frequent doses -Peripheral neuropathy and impairments clinically seen as in ALL.

Rear wheel drive power wheelchairs

-Largest turning radius—76-84 cm (30-33 inches) -Foot plates will add significantly to turning radius because front casters are close together -Smooth ride -Worst at handling obstacles -Least stable on inclines (must have anti-tip bars) -Best at driving fast and straight -May be a good option if patient's reaction speed is decreased -(usually only recommended for pts who have always had this...)

Movement disorders-JRA

-Learned patterns of disuse -Substitutions

Pediatric Oncology Categories

-Leukemias - malignant disorder of the blood and blood-forming organs including the bone marrow, lymph nodes, and spleen (most common CA in children) (by definition, this is a disseminated cancer, not localized, already systemic) -Lymphomas - malignancy that begins in the cells of the immune system (the lymph nodes) (sign: large, matted lymph nodes) -Solid tumors - cancers of the bone, tissues, or other organs of the body (tumors of organs, localized) (ex: kidney, liver, brain)

Levels in Newborn Intensive Care Unit

-Level 1: Normal Newborn Nursery -Level 2: Special Care Nursery -Level 3: Newborn Intensive Care ---Respiratory ---Neonatal surgery ---Special diagnostics ---Very preterm infants -Level 4: Newborn Intensive Care ---Cardiac Surgery

Treatment strategies: Neurofibromatosis

-Likely directed more toward secondary impairments ---Pain ---Deconditioning ---Motor delay ---Assistive devices and technology if needed ---Adapting school/IEP ---Position education/ Core strength ---Community education - education to school, family, etc ---Hemophilia

Causative Factors of congenital limb deficiency

-Limb development is complex, involving precise timing of events often signaled by genes -Sporatic mutations and vascular interruptions -Amniotic Band Syndrome -Teratogenic (eg. medications, irradiation) -32% of cases are of unknown causes

Wheelchairs: Who needs them?

-Limited or no independent ambulation

Tarsal coalition signs

-Limited to no subtalar motion -No correction of heel valgus or longitudinal arch on tiptoe -Pes Planus -Hindfoot valgus -Flat Medial long arch -Antalgic gait -mm spasms of peroneals -midfoot prontation

Tarsal coalition treatment

-Limited to no subtalar motion -No correction of heel valgus or longitudinal arch on tiptoe -Pes Planus -Hindfoot valgus -Flat Medial long arch -Antalgic gait -mm spasms of peroneals -midfoot prontation

PT considerations for scoliosis

-Literature -Posture impairments -Respiration -Positioning -Endurance impairments -Pain due to mm imbalance

Standers: Who needs them?

-Little to no potential for functional ambulation -Cannot stand alone for "appreciable amounts of time" (we have to determine what that means) -Children at serious risk of contracture from positioning, abnormal tone, or both -Children at serious risk for osteopenia (standers have some benefits for bone health) (not great research...)

Vincristine and Peripheral Neuropathy

-Longer axons more susceptible -Drug effects tend to accumulate ---Distally predominant CIPN "stocking glove" distribution (distal) ---Often begins in lower extremities and later appears in upper extremities -Affects motor, sensory, and autonomic nerve fibers: ---Distal paresthesia (numbness, tingling, pain) ---Loss of deep tendon reflexes (100% of the kids in their initial study) ---Muscle weakness and cramps common and may develop rapidly (98% mm weakness) (40% sensory) (40% vibration) (50% light touch, pin sensation) -Relation to function: IMPAIRED

SDR Testing Functional Ability

-Look at child attempting a variety of developmental activities -Rolling, various sitting positions, quadruped, crawling, tall and half-kneeling, sit to stand -Look at child's transitional ability, how much assist needed to maintain position, and postural control (This is a good way to tease out- is spasticity being used for function?)

Foot Alignment

-Look at foot position in standing and in non weight bearing -Is it in equinus, cavo varus, and does it change with weight bearing -Midfoot alignment: evaluate for Metatarsus Adductus

Congenital Limb Deficiencies

-Loss of a limb segment before birth -Failure of formation of a limb -Account for about 60% of pediatric limb deficiencies

Referrals for DCD

-Lots of kids are referred at kindergarten screening age -9-10 no bike = red flag

Presentation of Spondylolysis

-Low back pain L5-S1 -10% present with sx -Not typically neurology -Pain with hyperextension -Physical findings that may also be present include antalgic or normal gait, tight lumbar musculature, hamstrings, hyperlordosis, and buttock or thigh pain

Epidemiology of spondylolysis/lysthesis

-Lysis: present in 5-11.5% of the population -Listhesis: about 2.5% -Girls more likely to have a slip (activities they participate in, more lax...) -Individuals with lig lax are at higher risk Functional limitations to spondylolysis/lysthesis -Fairly limited in daily activities -Sport-related activities likely have limitations (may go on a permanent restriction) ---Gymnastics, diving, dance ---Contact sports

Type II OI

-MOST SEVERE -Incompatible with life -Minimal mineralization of bones -Long bones crumbled

Treatment strategies—JRA, Goals of physical therapy treatment...

-Maintain ROM and strength—or minimize their loss -Optimize joint alignment -Improve function and participation -Improve gait -Pain control -Posture control -Improve strength, power, endurance for play -Teach home program for flare ups and prevention (important!!!) -Communication with School Team/Coaches -Strengthening, fitness, development, aerobic ---NON-IMPACT encouraged ---Depends on acuity and involvement -Overall improved function with increased activity!

Slipped Capital Femoral Epiphysis (SCFE) Epidemiology

-Males 2‑3x more frequently -Occurs from about age 6 up to the point of growth plate closure -High incidence is found in children with clinical obesity -Bilateral SCFE incidence is currently reported at about 60% but not typically of equal degree of slippage -Risk factors for Bilateral: African Am, younger age at dx (6-7 yo), obesity

Retinoblastoma

-Malignancy of the eye often originating in the posterior retina -200 cases in US per yr -96% 5-year survival -Treatment can include surgery, chemotherapy or radiation -Chemo can include carboplatin and vincristine

Hodgkin's lymphoma

-Malignancy of the spleen and lymphatic system -Only <10% of tumor is malignant cells, otherwise inflammatory cells and fibrosis -Cure rate 90-95% -Vincristine also used in treatment -Treatment lasts ~4 mos. -Research in survivors reveals a high rate of fatigue

Lifts: What are the options?

-Manual (pumps) (this is pretty much all that MA pays for) -Power -Ceiling -Sling type (solid or split leg)

ITW Strength

-Manual Muscle Testing (if old enough) -Functional ---Squat ---Heel Walking

Muscle weakness measurement for brain tumors

-Manual muscle testing -Functional strength skills -BOT-2 Strength subtest -Look for asymmetry!

Neonatal Seizures

-Many causes ---Metabolic ---Infection ---Bleeding ---HIE -Signs ---Abnormal movements ------Need to differentiate seizures from jitteriness ------If jitters, touch will make them stop moving (opposed to seizures) ---Apnea ---Staring ---Sucking, chewing -Treatment ---Determine and treat underlying cause ---Anticonvulsants -Outcome ---Often dependent on cause of seizures

Adapted strollers

-May be more attractive to parents ("less medical") -Given expectation to use mobility device 5 years or more, may not be the ideal solution -What is appropriate for a 3 year old may not be appropriate for an 8 year old -In most cases, permanently tilted back, decreasing face to face interaction with peers -Always dependent -May be useful for patients who are able to walk in most situations ---Fatigue over long distances, unable to self-propel (target, malls, etc) (back up chairs) ---Seizures (can rest there until postictal phase is over)

Definition of idiopathic scoliosis

-May be structural (fixed) or no-structural (flexible) -No known cause -May appear at any age (infantile, juvenile, or adolescent) with adolescent being the most common (80%) -Appears to have a familial link Idiopathic scoliosis incidence -Infantile, juvenile (3-10 yo), and adolescent ---Adolescent is the most common ---AIS is less aggressive -Progressive curve: defined as 5 deg progression in 2 consecutive exams less than 6 mo apart -Treatment angles ---Annual follow up at 10 deg ---Bracing at 25-45 deg, skeletally immature (if Riser sign still open) ---Surgery at 40 deg

Power assist

-May be useful for client who is able to propel MWC, but has difficulty up hills or over long distances -Fits on most MWCs -Goes about 25 km (15 miles) per charge -Assists propelling to about 6 kph (4 mph) -Each wheel weighs about 11 kg (24 pounds) -Each battery weighs about 2 kg (4-5 pounds) -Cost almost as much as a power chair, don't need an adaptive vehicle

Aids for ambulation: Who needs them?

-May or may not walk without assistance in the future -Demonstrates potential for ambulation -Lacks one or more of the necessary components of gait--balance, coordination, strength...

Tibial Torsion

-Measured as the angular difference between the tibial plataue and mallaloi -Typically slightly external -Typically measured clinically with the Thigh‑ Foot Angle -Normal TFA: 0‑30 degrees - in adults, typically 15‑30 and in infants TFA is about ‑5 to 15 degrees with average being 5 degrees -Anything at into IR is considered abnormal alignment, particularly after 7 yrs old

wc eval: physical exam

-Measurements (most recent height and weight) -Document alignment and constraints on range of motion in different positions ---Standers: start with ankles (how much ROM, contractures? symmetry? ---Wheelchairs: start with pelvis (neutral alignment? Movable or fixed? How to I compensate? From there move up and down) ---Involuntary movements and triggers (note: opening up the seat to back angle can feed into extension and other movements, try closing it up!) -Skin integrity (from history also) -Very methodical -What's causing the malalignment? -What can be done to correct or compensate? -Always do a "mat evaluation" ---Check alignment, head to toe, in supine ---Recheck in sitting, beginning with pelvis

Posture Outcome Measurement for CA

-Medial arch measurements ---50% foot length dorsum height/truncated foot length ---Angle between medial malleolus/navicular/ first met head -Hindfoot measurements (can use an inclinometer, draw lines) ---Bisect calcaneus with ankle dorsiflexed to O in prone and draw line ---In standing, measure the angle between vertical and calcaneal line

Metatarsus Adductus Definition

-Medial subluxation of tarsometatarsal joints, adduction of metaphysis of the 2nd to 5th metatarsals, and medial deviation of the articular surface of the medial cuneiform -Lateral Border of Foot is C shaped and curved rather than straight -Forefoot is deviated inward compared to the hindfoot -ANKLE IS MOBILE -Increased association with DDH -Thought to be due to "Packaging"

Treatment of OI

-Medical treatment ---Bisphosphonates ---Rodding Long bones -EDUCATION ---Handling (parents are terrified of touching them) (teach how to feed and diaper properly) ---Fracture prevention -Positioning -Problem solving for safe and independent mobility -Orthoses -Ambulation aids -Joint hypermobility support

Major Morbidity of Prematurity

-Mental Retardation -Cerebral Palsy -Blindness -Severe hearing loss

Infant and Toddler Age Overall PT Goals

-Monitor developmental progress and facilitate as normal development as possible -Achieve/maintain ROM and strength needed for future prosthetic use -Develop independence with mobility and movement transitions -Achieve symmetry of posture and movement during developmental activities -Achieve correct alignment, weight shifting, and balance with prosthetic ambulation

Dynamic Balance for ITW

-Moon-shoes (requires them to really coordinate motion through the ankle) -Balance beam (forward and backwards) -Incorporate throwing and catching

Type I OI

-Most common (50% of cases) -Most functional -Blue sclera -Osteoporosis -Conductive hearing loss -Hypermobility of joints -Normal stature at birth -+/-dentinogenesis imperfect -Normal cognition -Vary in presentation -May be shorter than peers but not as pronounced as other OI types -Fractures may or may not be present at birth -May or may not have significant skeletal deformity ---Often have a triangular shaped face, more barrel shaped chest

Fibular Hemimelia: the partial or complete absence of the fibula

-Most common cause of congenital limb length discrepancy -Associated foot deformity often present -May be fit with non conventional prosthesis -Limb lengthening with external fixator considered if length discrepancy small (<10 cm) and ankle/foot in good condition -Foot ablation may be done for better prosthetic fit

Achondroplasia EPIDEMIOLOGY:

-Most common cause of dwarfism -2-4.7 in 10,000 individuals -Autosomal dominant, but as many as 75-90% represent spontaneous mutation -Achondroplasia

Rheumatic Disease in Children

-Most common condition is JRA -Conditions have inflammatory etiology which increases risk for damage and disability -Non-articular signs: ---fevers, wt loss, chills, night sweats, signs of organ disfuncion, rashes, dsyspnea ---(families may see, but not realize these issues) ---(these are RED FLAGS in your eval) -Often have periods of activity and inactivity, "flare ups" -Almost all pediatric rheum conditions are chronic -Need to rule out Acute conditions (injury, acute organ dysfunction)

Pediatric Acquired Amputation Causes

-Most commonly caused by trauma ---Farm machinery and household power tools (eg lawnmowers) are leading causes ---Motor vehicle accidents ---Gunshot wounds ---Railroad accidents -Malignant tumors are most common disease related cause -Primary bone tumors are rare in children, accounting for only about 6% of childhood cancers -Infection can also be a cause (a growing cause, infections not treatable by antibiotics)

Pediatric Physiological Genu Varum

-Most commonly presents at 10 to 24‑months -Developmental knee alignment: ---Progresses from 10‑15 ° of VARUS at birth to 10‑15 ° of VALGUS at about 3y/o ---neutral femoral‑tibial alignment occurs at ~18‑24 mo months old.

Epidemiology of apophysis

-Most commonly seen in adolescence ---Girls: 8-13 ---Boys: 10-15 -Boys : girls = 3-7 : 1

Joint compression

-Most important thing: look at lab values, looking for Alk phos -Premies went from getting close chain in mom to not- this is weight bearing that facilitates mineralization of the long bones! Risk of osteopenia (can get a fx just from a diaper change) -Alk phos is taken frequently, norm: 140-300, >400: automatic referral to OT for compression and ROM, help the growth plate mineralize (alk phos is related to calcium and therefore bone integrity); has been seen as high as 1200 (higher fx risk) -NO TORQUE, hard and smooth (5 compressions, 5 ROM) -Get an x-ray if necessary, fx usually heal in 2 weeks

Neuropathy in Children with Cancer: motor vs sensory nerves

-Motor Neurons (Efferent) ---Send messages from CNS to PNS (muscle/glands) ------Conduct impulses at a higher rate of speed ------Responsible for muscle tone, voluntary movement, and coordination -Sensory Neurons (Afferent) ---Send messages from PNS to CNS ------Slower transmission than motor fibers ------Responsible for relaying pain, vibration, position, touch, and temperature signals

DSM-IV definition of DCD

-Motor coordination is substantially below what would be expected given the child's chronological age and measured intelligence -Poor motor performance significantly interferes with academic achievement or ADL's -Not due to a general medical condition such as cerebral palsy, hemiplegia, or muscular dystrophy -DSM-IV criterion A-D (need to fulfill all 4) ---Criterion A: Motor Coordination (inclusion) ------Work slower, trade speed for accuracy ------Poor proprioceptive function ------Deficits in timing of actions ------Heterogenous (all present differently) ---Criterion B: Academic Achievement/ADL ------Poor academic performance (inclusion) ------Lack of confidence ---Criterion C: Medical Conditions (exclusion) ------Excludes identifiable neurological disorder ---Criterion D: Cognitive Level (exclusion) ------If mental retardation is present, motor difficulties must be in excess of those associated with it

Motor Skills Deficits in CA

-Motor skills affected by "all of the above" -Patients completing treatment for ALL scored significantly lower on the Bruininks-Oseretsky Test of Motor Performance compared to controls -Children post treatment of ALL scored significantly lower in Movement ABC test than normal -Patients have difficulty in higher level tasks such as hopping side to side, running speed, skipping.

Dx of Infants admitted to Intensive Care

-Multiple diagnosis -Prematurity -Respiratory Distress -Surgical (GI, cardiac, renal) -Neurological problems -Congenital anomalies -Infection -Metabolic

ITW Neurologic Exam

-Muscle Tone (could be hyper or hypo) -Clonus (up until 1 yo, kids will have a couple beats of clonus) -Deep Tendon Reflexes

Oral Motor Progression

-NNS (non-nutritive sucking) program at 28 weeks gestation -Pacifier options ---Thumbie: smallest pacifier, soft and flexible, fits even with an ET tube (without this, they can cause a ridge, cant generate enough power to suck from a bottle later ---Premie soothie (smell like vanilla, trying to have a positive experience) ---Oral trials (bf with mom, transition to a full size nook); can have cut outs by nose to allow for tubes ---Non-nutritive: doing compression instead of sucking, 2X as fast, masseter pattern (not buccinators, orbicularis oris) -Handling techniques facilitate transition to nutritive sucking

Pauci/Oligo Management

-NSAIDS -PT/OT (strengthening, pain management, AQUATIC therapy, biking, developmental screens) -May require corticosteriod joint injection or if severe placed on Methotrexate -Orthotics (shock, LLD, alignment) (trying to protect the joints from impact)

Poly-JRA Management

-NSAIDS (rarely alone) -DMARD's (disease modifing anti-rheum drugs) ---Methotrexate- Mild Chemotherapy drug -Systemic Steriods (used sparingly- osteoporosis, weight gain, immunosuppression, lack of growth!) -Anti-tumor necrosis factor medications -Intra-articular injections -PT/OT -Orthotics

Periacetabular Osteotomy (realign femoral head)

-NWB x 6 weeks, may have hip precautions (active hip flexion) -PWB or progressive WBAT over 2 more weeks -High risk for non union of pubic symphysis (AVOID resistive ADD) -These kids also often have PT dx anterior glide syndrome (discernment/precaution if considering PA glides)

PROM to all extremities

-Neck ROM and speed of lateral neck flexion to stimulate vestibular sx -Increase handling tolerance -Facilitate vestibular development -Monitor potential movement disorders: are their movements seizures? Dystonia? -Oral motor development and feeding -Cranial molding -Musculoskeletal development support: could put a cloth under the neck, circular pad under occiput

Orthotics in gait for CA

-Need to address foot position to encourage push-off and increase step length -Solid AFOs ---Good foot position ---Increase step length (rigid lever) ---"Gait training" not support

Reclining wheelchairs

-Need to be cautious about shear -Dependent patients who need catheterization and are too large to easily transfer -Will also need elevating leg rests

Kinesiotaping in the NICU

-Need to pass skin test 2 days in a row, then only leave on for 24 days -Mostly for position inversion at the ankle (get them more eversion) (occurs with multiples) -Neuro-motor facilitation -Functional correction -Edema management (fan technique) -Orthopedic correction

Epidemiology of scoliosis

-Neuromuscular: nearly all with dystrophinopathy or high SCI in early childhood (DMD), about 60% of persons with myelomeningocele, about 25% of persons with CP -Congenital -Idiopathic: in the US, .5-3% of kids have a curve >10%, 10% of them require tx (70% of JIS though)

Surgical Team

-Neurosurgeon -Neurophysiologist -Physical Therapist or Physiatrist -Surgical Nurses -Anesthesiologist

SDR Team

-Neurosurgeon -Physical Therapist -Occupational Therapist -Nurse Coordinator -Social Worker (get them services, deal with family circumstances)

Developmental Dysplasia of the Hip (DDH) Associated Dx

-Neurotypical child with environmental factors -Congenital Torticollis -Neuromuscular disorders (CP, others) -Club foot/ metatarsus adductus (shows the importance of checking hips)

Extrauterine Environment

-New Exposure to: ---Light ---Smells ---Touch ---Sounds -It can be TOO much for an immature CNS, so developmental intervention is critical for long-term outcomes

Sickle Cell Disease: Clinical Picture

-Newborns do not typically show signs (detected when they start moving a bit usually) -Anemia can be detected by ~4 months -Dactylitis (hand-foot syndrome) is often the first sign ---Painful, symmetric swelling of hands and feet ---Ischemic necrosis of small bones -Vaso-occlusive (pain) crises requiring hospitalization average one per year -Stroke (10%) -Cardiomegaly -Maxillary hyperplasia -Underweight -Delayed puberty -Chronic leg ulcers in adolescence -Acute Chest Syndrome

Outcome measures for DCD

-No Gold Standard (different assessments of impairments may define problems differently) -MABC and BOTMP (first addition) are both used in the literature ---Both measures have a high standard of reliability and validity ---BOT allows much more verbal cues, helps if someone has never been exposed to these activities -Recent Systematic Review: MABC and Test for Gross Motor Development-2 were recommended based on reliability and validity -Limitations: adolescents and ceiling effect

SDR Post-op Movement Precautions

-No hip flexion > 90° -No straight leg raise > 30° -No passive trunk rotation -Use prone dependent lift for transfers until sitting. Once sitting, child can be lifted maintaining 90°at hip/knees -Always support lower body during transfers (don't want to pick up from under the arms (traction on spinal column)

Craniotomy Precautions

-No increase in physical exertion for 4 weeks. -No contact sports or jumping/running for 3 months. -Can work on passive/active cervical ROM (super important, could lead to tension headaches) -Can work on gait, gentle strengthening, walking, controlled balance training

Prevention

-No reliable data on intervention for prevention of DCD has been found in the literature

Hemophilia Treatment Ideas

-Non impact -Swimming -Biking -Pilates or non-stressful kids yoga poses -Walking -Exercise Ball -Sports: Other - golf, Tai- Chi, archery, hiking -Be aware of Secondary Impairments: ---mm contractures ---Deconditioning ---Decreased joint range ---Risks associated with factor replacement (AIDS, hepititus)

Juvenile Pilocytic Astrocytoma

-Non-infiltrating tumors -Slow-growing ---Considered benign -Usually cured by surgery alone -Most common glioma in children

Primitive Reflexes Testing for SDR

-Note presence/absence of primitive reflexes (some kids use their reflexes to MOVE- take note!) (outcomes not expected to be as good) ---ATNR ---STNR ---TLP/TLS ---Moro reflex ---Extensor thrust -These reflexes should be integrated by 8-12 mo in a typically developing child, but may persist in children w/ CP

Moderating Factors

-Nutrition and Adequate Postnatal Growth ---Use of breastmilk (raises cognitive scores for years after discharge) -Home Environment -Early Intervention

Potential secondary impairments-JRA

-Obesity (!) -Cardiopulmonary impairment -Joint instability (!) -Weakness -ROM decrease/contracture -Amplified pain -Growth restrictions ---on Prolonged steroids -Joint changes, LLD, premature closure of growth plate

Foot Progression Angle

-Observe child walk -Evaluate foot long axis relative to line of walking ---Imagine line from heel to second to third toe ---Estimate angle of foot deviating from this line

Developmental Dysplasia of the Hip (DDH) X Ray Findings

-Obvious hip malformation -Hip subluxation or dislocation -Disruption of Shenton's Line: line drawn along the superior border of the obturator foramen and along the inferomedial border of the neck of the femur

Incidence of Congenital Limb Deficiencies

-Occurs in 2-7 per 10,000 live births -58% of cases involve upper limbs -20% of cases have more than one limb involvement

Treatment of scoliosis

-Often require early fusion with hx of progression -Typically seen every 4-6 mo for close monitoring (often go to PT for pain and strengthening)

Achondroplasia PRECAUTIONS/CONSIDERATIONS:

-Often seen in clinic for developmental delay, pain (lig lax, lordosis), obesity -Ligamentous laxity -In infants larger head coupled with low tone -Potential for stenosis in foramen magnum

Medical Team

-Oncologist -Nurse Practitioner -Nurse case manager -Neurosurgeon -Radiologist -Neurologist -Pharmacist -Endocrinologist -Social worker -Child Life Specialist -Physical Therapist -Occupational Therapist -Speech-Language Pathologist -Dietician -Integrative Medicine -Psychologist -Neuropsychologist

Testing of Isolated Motor Control for SDR

-One of the most critical aspects of evaluation -Done in conjunction with strength testing -Note if child can isolate a particular motion -Note if child can only use patterned movements, such as overall extension or flexion (most kids with CP- if you ask them to do a movement, they pull in additional muscles; struggle to pull out pure motor movements)

SDR Tone Testing

-One of the most critical aspects of evaluation -Spasticity of major muscle groups in LEs graded using Modified Ashworth Scale (do they have spasticity, what degree (wont improve if they don't have spasticity) -Note presence of clonus in gastrocs (another sign of spasticity) -Note presence of active tone (an observed increase in spasticity with activities) ---Kids usually look more spastic with movement, less able to modulate spasticity when doing other things ---Important, but cant put a number on it ---Not necessarily a sign for or against; just note that SDR seems to help more with passive tone -Note presence of athetosis, ataxia, or rigidity (Adductors and gastroc are more commonly more spastic than glutes, hip flexors, quads)

SDR Strength Testing

-One of the most critical aspects of evaluation -Use manual muscle testing to evaluate strength of major muscle groups in LEs -Graded, using standard 5 point rating scale -Note if child has one side of body stronger than the other (usually SDR is not done on those with hemiplegia) (if they are using their spasticity, they are not a candidate) (this is something you tease out over the process)

Scheurmann's Manifestations

-One side (the back) of the vertebral body grows normally, and front grows slowly or abnormally → leads to vertebra with wedge shape -Autosomal dominant inheritance pattern associated conditions (often hear that uncle or someone had it) -Orthopaedic manifestations ---Hyperlordosis (overuse of paraspinals) ---Spondylolysis (30-50%) ---Scoliosis (33%) ---Abducted scapulae (no rhomboid stabilization) ---Headaches (levators) -Non-orthopaedic manifestations ---Possible pulmonary issues in curves exceeding 100 deg

Pauciarticular/Olioarthritis epidemiology

-Onset is early in childhood (typically around 2-4 years) -Female > Male 3:1 -Rarely Familial -Uveitis - need to be followed by Opthamalogist -Often regression after 1-2 flares -Better prognosis- serious functional disability long term rare

Criteria for Dx of JRA

-Onset less than 16 yr old -1 or more joints involved -Present LONGER than 6 weeks* (chronic condition) (this varies: some physicians require 3 mo) -Rule out other Dx

Non-Hodgkin's lymphoma

-Originates in cells and organs of immune system -70-95% survival rate -T-cell lymphoblastic lymphoma, Burkitt's lymphoma, Diffuse Large B-cell lymphoma, -Anaplastic large cell lymphoma -T- cell lymphoblastic lymphoma similar to ALL -Treatment includes vincristine and steroids

Differential Diagnosis for DCD

-Orthopedic causes ---Unresolved club foot (equinovarus) -Neurologic causes ---Cerebral Palsy: most difficult to differentiate from mild spastic CP (esp in little kids) ---Tethered Cord ---Other possible causes: spinal tumors, myopathy, neuropathic disorders -Sensory ---Associated with Autism ---Associated with learning problems

Precautions-JRA

-Osteopenia -Stretching of the joint capsule secondary to inflammation → joint instability -Pain

Differential Dx of Pauci/Poly JRA

-Other causes of: ---Reactive arthritis ---Lyme arthritis ---Septic arthritis ---Trauma Neoplastic disease -In older children ---Spondyloarthropathy ---Leg Calve Perthes disease ---Osteoid osteoma ---Slipped capital femoral epiphysis ---Exclude structural abnormalities ---Discoid meniscus ---Hemophilia

ROM measurement (measured at every visit) for CA

-Outcome measurement ---Goniometric measurement (poor reliability for measuring, esp DF) ---Technique extremely important ---Two-person measurement optimal to hold subtalar neutral position and avoid measuring a pronated foot

Lifts: Who needs them and why would a PT recommend one?

-Over 30 pounds (OSHA recommendation) -Completely dependent for transfers -Caregiver health

Pediatric CA survival rate

-Overall 5-year survival rate of 80% (IMPORTANT!) (5 years from the time they are diagnosed) (always scary for parents, BUT compared to adults (~60% survival rate) these kids are expected to have long productive lives) -However, those who have cancer are more likely to have recurrence of their cancer, a new cancer, or other diseases (CV disease, joint replacements, HTN) -Going through CA tx ups the risk of further health problems in the future

PT Considerations with EDS and Hypermobility syndromes

-PAIN -Hypotonia -Proprioception -Postural Orthostatic Tachycardia Syndrome (changes in position) -Orthopaedic concerns (joint instability) ---Hip and shoulder subluatxions ---Hip and shoulder labral tears ---Patellofemoral pain (consider kinesiotape) ---ITB snapping hip (strengthen adb and EE) -Spinal Abnormalities - Spondyls, DD, disc herniation, scoliosis (30-50%)

SDR Outcomes

-PT programs for all children included stretching, strengthening, and training in functional movements to enhance mobility (pretty consistent, minor differences) -Follow-up was at 9 or 12 months -SDR did result in a clinically important change in spasticity levels -Children who had SDR+PT had a small but statistically significant improvement in GMFM scores ---Positive change of additional 4 percentage points over children who had PT only -No significant problems with adverse events were noted

Sickle Cell Disease: Precautions

-Pain crisis: tissues aren't getting the necessary O2, becomes painful -Must get vaccinations (influenza, Hepatitis B) -Prophylactic penicillin until age 6 (infection control) -Medical attention for fever -Dehydration -Sickle Cell Disease

Slipped Capital Femoral Epiphysis (SCFE) PT presentation

-Pain in hip, knee or groin -Limp, Stiff gait, walking in ER or unable to bear wt (trying to keep it in open packed position) -ROM limitations especially into IR and FLEXION* -Typically presents with no trauma, etiology is unknown

Tarsal coalition sx

-Pain with activity -Repeated sprains -Age of onset -More sx during teen years (sx typicall start at 8-‐‑12) -Location at anterolatearl or lateral or Peroneal mm (spasms)

What are the stander options?

-Parapodiums or upright standers (used to be commonly used) (rarely used now) -Prone -Supine -Tristanders (prone or supine) -Dynamic standers (legs move) (vibration is a growing trend) -Sit to stand models (Belt standers are not used in the peds population)

Criteria for Discharge

-Parental Education -Completion of appropriate elements of primary care in the hospital -Development of a management plan for unresolved medical problems -Development of a comprehensive home care plan -Identification and involvement of support services -Determination and designation of follow-up care

DCD Questionnaire (DCDQ)

-Parents answer 15 questions, comparing their child to other children the same age -Identified children with motor coordination problems who had not been identified by parents or professionals (Wang) -Looks at both fine motor and gross motor skills: ---Running, jumping, throwing, catching, hitting, planning ---Writing speed, legibility, writing effort, cutting ---Interest in sports/activities, learning new motor tasks -This can be a nice way to bring up some school/academic issues

Gait Interventions for brain tumors

-Partial weight bearing treadmill training -Gait training in the aquatic environment -Functional electrical stimulation -Focus on symmetry, stride length, weight shift, etc -Consider vision/vestibular changes -Orthotic considerations

Beighton Scale

-Passive DF of MCP >90 deg (1 pt per side) -Passive opposition of the thumb to flexor aspect of forearm (1 pt per side) -Hyperextension of elbows beyond 10 deg (1 pt per side) -Hyperextension of knees beyond 10 deg (1 pt per side) -Forward flexion of trunk with knees extended, palms rest flat on floor (1 pt)

ITW ROM

-Passive dorsiflexion ---Knee extended, sub-talar neutral ---(don't be surprised if they have normal DF- may be hypermobile and may be coming onto toes to get some stability) -Passive plantarflexion -Active range of motion -Functional range of motion ---Squat ---Stairs

Stretching for ITW

-Passive stretching: consider patient's age and strength of their muscles/tendons (you probably aren't strong enough to stretch them manually, better to do in WB) -Active stretching: squatting, standing on inclines (incline wedge) -Evidence is mixed regarding the effectiveness of botox for ITW ---2013 study showed no difference in serial casting outcomes when botox was added (totally different physiology than CP)

Blout's disease definition and sx

-Pathological Tibia Vara (bowing), infantile or adolescent -Malformation of medial proximal epiphysis of the tibia (lateral intact) -Symptoms: lots of pain

Thigh foot angle

-Patient lies prone (infants in crawl position) -Knees flexed 90 degrees off table -Assess angle between femur axis and foot axis ---Femur axis: Line along length of femur ---Foot axis: Line from heel through bisector of the heel or 2nd toe space ---Used to measure tibial torsion -Degrees of in‑toeing: ---Mild is ‑5 to ‑10° ---Moderate is ‑10 to ‑15° ---Severe is more than ‑15° -Children's torsion typically is fixed (unless there is some other underlying orthopedic condition, i.e. CP) by age 4 or 5

Cardiopulmonary endurance and brain tumors

-Patients can be at risk for obesity secondary to radiation late effects or tumor location -Craniopharyngioma patients at high risk for obesity -Encourage appropriate exercise activities fitting cognition, social setting (support network), and motor abilities -45-60 min/day

JRA Prognosis

-Pauciarticular: ~50% in remission 10y after diagnosis; appears to be minimal adult functional limitation -Polyarticular: 6-23% in remission 10y after dx -Systemic: varies widely, but much worse if arthritis persists after systemic symptoms subside ---Severe hip joint degeneration primary cause of long term functional limitation (total hip procedure)

Wheelchairs: What factors affect decision making?

-Payer -Prognosis (what is going to work for most of their life, even if there are other things they may want) -Head control -Need for catheterization (as kids get bigger it may not always be possible to transfer) -Need for other durable medical equipment -Endurance -Skin integrity -Visual impairment (does not preclude the use of indep mobility, just harder) (some fancy stuff on power wheelchairs, but many more simple options too!) -How transfers will occur—floor to seat height -Cognition -Ability to follow directions? -Age of child? -Layout of home (note: medicare only cares if you can use it INSIDE OF THE HOME! Watch out for that creeping into peds) -Caregiver situation -School -Where and how it will be used -Stages of grief -Wheelchairs (Manual)

Team members for JRA

-Peds Rheumatologist -PT/OT -Pediatrician -Nursing -Social Worker -Family -Arthritis Foundation! (great org, meets 1X per mo at Shriners pool) -May also need endocrine, ortho and opthomalogist

DCD Subjective

-Perinatal history: term, hospitalization -Motor milestones achievement -Current level of physical activity and activity preferences (likely, tried some sports, didn't like any of them, feel like they cant keep up, prefer individual activities, have trouble keeping up with others) (families tend to know that there is a problem before its picked up on by the pediatrician)

Balance impairments and CA

-Peripheral neuropathy -Decreased ROM -? Vestibular impairment -Children s/p treatment for ALL scored significantly lower on the balance subtest of the BOTMP than control group. ---Wright, Halton, Martin, & Barr (1998) -Using sway measurements on force plate, 32% of ALL survivors unable to complete eyes closed task compared to 2% of controls

Fine motor skills and CA

-Peripheral neuropathy can cause deficits in fine motor skills -Reinders-Messelink et al (1999) found 33% of children had fine motor deficits after last vincristine dose during ALL treatment -Often seen later in treatment compared to lower extremities -Referral to occupational therapy -Ask: have they stopped coloring?

Clinical Trial Phases

-Phase I: determines the maximal dose that is tolerated -Phase II: determine the efficacy of the drug in specific types of cancer -Phase III: determine whether the treatment is superior to standard or current treatment -Phase IV: investigate long-term safety after treatment is standard with goal to decrease side effects of treatment

History of premie care

-Pioneer of Developmental Care: Dr. Heidelise Als -Research based discovery that the premature infants extrauterine sensory experience was damaging to the neurological structure of the immature brain. -Created a new approach to care in the NICU called "Developmental Care" -Newborn Individualized Developmental Care and Assessment Program (NIDCAP): developmental specialists can get specialized in this, monitor movement patterns and sensory input to develop a positioning program to reduce stress on that environment -Can we be better in the NICU and potentially decrease the negative effects on development that show up later

Concerns of Premature Infants

-Poor growth -Motor Delays -Cognitive Problems -Hearing loss (esp w/ greater than 5 days NICU) -Vision Problems ---Retinopathy of prematurity -Higher incidence of re-hospitalization -Increased health care costs the first year

Principles of bottle feeding

-Positioning -Pacing -Oral motor control -Musculoskeletal support

Developmental Dysplasia of the Hip (DDH) Clinical Presentation

-Positive Barlow (putting it back) or Orolani (subluxing or dislocating) -Limitation of Abduction -Leg length discrepancy (Galleazi test) -Asymmetry of thigh folds -Limp in a walking child -Galleazi test: (+) if uneven, (-) if even

Motor Control Changes for ITW

-Posterior Weight-Shift ---Rockerboard ---Reaching backwards ---Standing on wedge ---Walking and stepping backwards -Step-forward and return (keep back heel down to increase DF) -Heel walking

Common impairments of obesity

-Posture: Genu valgus, knee hyperextension, lumbar lordosis, abd and depressed scapula, flat mid-foot arch, decreased active DF, increased forward head with cervical extension (overuse of the levator scapulae) -Headache -General fatigue -Upper back pain -Endurance deficits -Balance -LQ strength -Gross motor delays: locomotion, coordination

PT after PSF

-Precautions ---No BLTs (bend, lift, twist) ---Teach log rolling ---Start POD 2 ---May start with walker (progress to w/o) ---No lifting >5 lb (milk) ---No driving for 6 wk -Abdominal bracing → exhalation w/ mvmt -Lung clearance and incentive spirometry

SDR Selection Criteria

-Presence of spasticity that is not significantly asymmetrical -No significant athetosis or ataxia noted (if subtle, its ok) (watch their hands when they are walking...) -Good isolated motor control and strength (should have at least grade 3 strength, preferably grade 4+) (be concerned if they are struggling with testing of the spastic mms) -Gait characteristics congruent with spasticity per gait lab analysis -Good cooperation with therapy activities -Family commitment to extensive outpatient therapy needed after selective dorsal rhizotomy (recognize what a commitment this is) -Appropriate family expectations (probably not going to keep them from having the surgery if they have the wrong expectations, but something to consider)

Slipped Capital Femoral Epiphysis (SCFE) Physical Exam Findings

-Presents in ER and slightly flexed hip (open packed position) -Pain with Hip tests (Faber, Scores, flexion, Joint stress tests) (unlikely that you will even be able to do these) -Pain with SLR -Loss of IR and Flexion -Decreased Abduction, flexion, IR -LLD -Trendelenburg Lurch

SDR 4th Week

-Progress stretching & strengthening -Begin stairs -Work on barefoot ambulation -Child allowed to play on the floor independently (down on inpatient floor)

SDR Additional Weeks

-Progress stretching and strengthening -Progress ambulation; continue to emphasize normal patterns of movement -Increase ambulation independence and endurance -Continue with transitions in/out of various developmental positions, emphasizing normal movement patterns and graded control -Add other activities, such as Pedalo and treadmill (with auditory feedback for heel strike)

As a PT, why recommend an assistive device?

-Promotion of independent mobility (independent movement is super important (imposed to dependence)) (exploration, spatial relations, pathfinding) -May work well for weight bearing (may work nicely as a stander)

Interventions for DCD

-Proprioception and balance (rely more on visual than proprioceptive information) ---Static: weighted vest, ankle weights, weighted blankets ---Dynamic: child to do heavy muscle work (carry heavy bags, weighted blanket, etc) ---Balance and Body Awareness -Strengthening -Core strength: children lack anticipatory control and compensate with strong contractions at distal joints instead of proximal (over recruit other muscles) -Team approach ---Involvement and collaborations with families ---Referral to OT's (sensory integration and self care functions) ---Psychological and social components of a child's life (self-esteem!!!)

Preschool and School Age PT Intervention

-Prosthetic Ambulation (see other card) -Stairs (see other card) -Have child ambulate on a variety of outdoor surfaces -Practice negotiating playground equipment -Work on other school skills ---Walking while carrying lunch tray ---Donn/doff/carrying backpack -When child is transitioning to school for the first time, meeting with or sending information to the child's teacher could be helpful -A referral to School PT for evaluation of how child is able to function in school setting will allow child to get PT help at school if needed -Bikes may need adaptation of toe clip to help keep prosthetic foot on pedal (if child is a transfemoral amputee) -If child is interested in sports play, instruct in running techniques -Work on other sport skills per child's interest

Common Congenital Limb Deficiencies

-Proximal Femoral Focal Defi -Fibular Hemimelia (AKA: longitudinal (total or partal) fibular deficiency)

Secondary impairments of scoliosis

-Pulmonary compromise -Skin breakdown -Pain (some people argue that idiopathic scoliosis shouldn't cause pain (only ones with tumors cause pain), but note that overuse of mms is super common, which causes a lot of discomfort) (neuromuscular sees increased pain with aging -GI dysfunction -Decreased attn./socialization

Preschool and School Age - PT Evaluation

-ROM and Strength -Skin Integrity -Gait and Balance -Aerobic Capacity and Endurance -Self Care Skills -Gross Motor Skills -Stairs -Ambulation while carrying objects -Playground equipment, outdoor surfaces -Sports skills, trike/bike riding

Infant and Toddler Age - PT Evaluation

-ROM: remember physiologic flexion -Skin Integrity -Gross motor development -Self Care: age appropriate -Weight Bearing Ability: check in various positions with support as needed; does child take more weight through involved vs. noninvolved side? (first just watch them play, then facilitate positions) -Gait and Balance -Activity Tolerance and Endurance

ITW Objective

-Range of motion -Strength -Neurologic Exam -Mobility/Transitions: floor to stand, squatting -Balance -Standing alignment -Joint Integrity -Standardized testing (less emphasis on standardized testing for ITW)

Brainstem Glioma

-Rapid onset of symptoms, very sad (these are the ones that we try to keep functional for as long as possible) -Usually surgically inoperable -Less than 10% survival after 18 months s/p diagnosis

Type III OI

-Rare -Very severe, but less so than type II -Extremely short stature -Death in childhood—less common now -Lots of fractures -Most severe that survive -With severe deformities -Often non-ambulatory

Management of systemic JRA

-Rarely respond to NSAIDS only -Methotrexate (nasty drug) -other drugs (chemo drugs)

Neutropenia (low white blood cells, particularly neutrophils)

-Reduction in circulating neutrophils of less than 1000 absolute neutrophil count (ANC) < 1 yr of age and 1500 ANC > 1 yr -Bacterial infection risk increased if ANC <500 -Calculated by White Blood Cell Count X % neutrophils -Often asymptomatic - Sx: signs of infection (no symptoms other than being susceptible to infection) (can become septic) (infection control is crucial)

Muscle Imbalance that may occur with ITW

-Relative short/stiff posterior musculature compared to weak anterior musculature

Clinical Trials in Peds Oncology

-Research designed to evaluate the therapeutic effect of a specific treatment ---Protocol guides treatment management ---Allows systematic treatment of patients across sites ---Investigate which treatments offer best cure rate with least side effects ---New trials are formed based on results of previous trials

Discharge Planning

-Resolution of medical and surgical problems that required hospitalization -Adequate weight gain on oral feedings -Thermal stability -Education and comfort of parents -Predischarge health maintenance ---Appropriate screening (metabolic screening, hearing test, eye exams, head ultrasounds at one week and 36 weeks corrected age) ---Immunizations ---Medications and equipment -Post discharge environment -Support and follow-up ----Primary care provider ---NICU Follow-up Clinic ---Other Specialty Clinic appointments ---Community Resources (Early Intervention, Home Health Care)

Respiratory Distress

-Respiratory Distress Syndrome ---Oxygen ---Assisted Ventilation ---Exogenous Surfactant ---On x-ray lungs have more of a blown glass appearance (should be clear) -Transient Tachypena of the Newborn (TTN) ---Supplemental Oxygen ---Retain fluid, need O2 for a few hours or days -Meconium Aspiration (stool in utero, gets into the lungs) ---Oxygen ---Assisted ventilation ---ECMO

Common Diagnosis of the Preterm Infant

-Respiratory Distress Syndrome: deficiency in surfactant, require ventilators, dc with O2 and meds -Chronic Lung Disease or Bronchopulmonary Dysplasia -Sepsis -Necrotizing enterocolitis: babies that were relatively stable, then have a distended abdomen -Retinopathy of Prematurity: eye disease -Intraventricular hemorrhage: bleeding into the brain

Spondylolysis/lysthesis Treatment strategies

-Rest -Core strengthening -Hamstring stretch with meticulous alignment -Orthotic management -Surgery

Balance Testing for SDR

-Righting reactions of trunk and head in sitting -Protective reactions of UEs in sitting -Function in sitting (taking off shirt or sock while sitting on edge of bench) -Protective reactions in standing (stepping and UE) -Function in standing (able to stand independently, able to pick up toy from floor)

Scheurmann's kyphosis

-Rigid thoracic hyperkyphosis defined by >45 degrees -Caused by anterior wedging of >5 degrees across 3 consecutive vertebrae (x-ray) -Differentiated from postural kyphosis by rigidity of the curve -Form of juvenile osteochondritis of the spine -(80-100 deg is common)

Orthopedic implications of obesity

-SCFE (85% of current dx are overwt/obese) -Blount's -Forearm fx -LE fx -Back pain -Knee pain -Pes planus -Posture impairments

Physical Exam

-START WITH WHAT YOU SEE: (withdrawn from pain, limp) (children likely wont know where it hurts) (watch in lobby, playing with mom, walking in) -Sitting or standing alignment - posture, sitting position (can they sit independently, W sitting) -General appearance: any boney abnormalities noted, general tone, level of interaction in environment, BOS -General development: Can they roll, sit to stand, walk, scoot, hop, jump, stand on one leg (depending on age)

Anemia: reduction of circulating hemoglobin

-SX: fatigue, shortness of breath, headache, fast heart rate, paleness of the skin or gums, dizziness -Measured by Hemoglobin ---Usually transfused if Hgb between 6-7 gm/dL if symptomatic (doesn't mean that we stop working with them) ---Normal Hgb is 12-16 gm/dL -Also measured by hematocrit or % of RBCs in the blood ---Normal 36-50%

Lifts: What factors affect decision making?

-Safety (dan the caregiver understand how to use it without hurting himself of the child) -Caregiver situation -Head control -Seizures or athetosis -The home trial!!!

Gottron Papules

-Scaley, rash on hands (look like pimples, itchy)

The evaluation

-Scheduling -Components -Follow-up

Associated characteristics of Arthrogryposis

-Scoliosis -Dimpling over joints (look for abnormal skin folding) -Hemangiomas (common form of tumor, growth of endothelial cells, usually resolve by age 10) -Absent/decreased finger creases -Heart disease -Facial dysmorphism -Respiratory impairment

Other apophyseal conditions

-Severe's disease: traction apophysitis at the posterior calcaneus; often seen with aggressive running -Iselin's disease: traction apophysitis at the base of the 5th met -Sinding-Larsen-Johansson: inferior pole of the patella (similar to OGS) -Apop of the medial epicondyle -Apop of the pelvis (iliac crest, ASIS, PSIS, SIIS, ischial tub, greater troch, lesser troch) (seen with kickers and kids with osteogenesis imperfect)

Legg Calve Perthes Epidemiology

-Sex: males are affected 4‑5 times more often than females -Age: LCPD most commonly is seen in persons aged 3‑12 years, with a median age of 7 years -Bilateral 20% of time ‑ rarer, so need to rule out skeletal dysplasia (full body growth plate dysplasia)

Positioning infant for bottle feeding

-Sidelying: sitting, tilted to R or L (good bc this is how mom will feed baby with bf; also bc gravity pulls milk into the check, more sensory receptors there, good coordination for swallow (allows them to anticipate the swallow) -Supported upright: sitting up helps them stay awake

SECONDARY IMPAIRMENTS with Sickle Cell Disease

-Significant deconditioning/endurance impairments -ROM limitations

ITW Balance

-Single leg balance, eyes open/closed ---3 yo SLS: 3 seconds... idiopathic toe walkers wont be able to -Tandem stance -Walking on balance beam

Balance Outcome Measures for CA

-Single leg stance ---eyes open or closed, hands on hips -BOT-2 balance scale

Balance interventions for CA

-Single leg stance work ---Step stance, kicking ball, soccer ball stop, Yoga, Wiifit, popping bubbles with feet, etc ---watch foot position and hip lean -Unstable surface ---standing, tandem stance, single leg stance -Eyes closed -Balance beam ---forward, backward, tandem -Play on a partially inflated air matress -"Balance hallway" -Digging in beans for objects

Achondroplasia SECONDARY IMPAIRMENTS:

-Skeletal malalignment ↔ muscle weakness -Obesity -Decreased participation in fitness activities -Back pain

Clinical Presentation of JDM

-Skin rash initial sx: eyelids, knuckles, elbows, knees and ankles -shortly after, complaints of falling, difficulty with stairs, weakness ---May complain of GI issues or difficulty swallowing (progression to smooth mm) -Fever - low grade, frequently at night (persistent = big red flag) -Fatigue

Kangaroo Care

-Skin to skin time for baby and mom or dad -Helps with bonding, GI motility, may root/latch -Done as soon as possible, as much as possible

Seating considerations

-Sling -Firm seat pan with standard cushion -Custom seat and back -Molded seat and back -Pressure relied

Mid-wheel drive power wheelchairs

-Smallest turning radius—51-66 cm (20-25 inches) (can do a 360 in place) -Footplates have little, if any impact -360 in place -"Hardest" ride of the three types (bumpier bc of where the power is) -May get stuck in soft ground (hard to move 250 lb chair) -Most stable on slopes

Splinting

-Soft splint: wrist/finger anomalies ---Hold thumb out -Thermoplastic splinting: clubfoot deformity, wrist flexion contracture ---Clubfoot splinting and casting, get ponseti when they leave the NICU -Amniotic banding of extremities

Rhabdomyosarcoma

-Soft tissue tumor of the muscle -4% of childhood cancers -Can be linked with Li-Fraumeni syndrome, neurofibromatosis or Beckwith-Weidemann syndrome -Surgery, chemo, and radiation treatment -High, frequent doses of vincristine used in chemo treatment -Peripheral neuropathy clinically observed -Some patients may have symptoms of peripheral neuropathy

Current ROM/Posture/Gait Intervention for CA

-Solid ankle AFO worn 23/24 hours until full DF ROM and normal gait pattern -Wean out slowly to SMO/FO/ no orthotic with AFO worn at night **Results...** -Increased ankle DF ROM to normal -Absent or minimal collapse in midfoot -Neutral to minimal hindfoot valgus. -Normalized gait pattern in AFO and after intervention barefoot

Stages of ROP

-Stage 1 is a faint demarcation line. -Stage 2 is an elevated ridge. -Stage 3 is extraretinal fibrovascular tissue. -Stage 4 is sub-total retinal detachment. -Stage 5 is total retinal detachment.

Motor skills interventions for CA

-Stairs -Floor to stand ---Squats - especially for young children - ?femoral anteversion risk ---1/2 kneel to stand - able to lead with either leg -Jumping ---2 foot take off and landing ---Distance and height for strength/power ---Hopping - look at both legs ---Plyometrics for older kids ---Jumping jacks: star man-stick man -Running ---Look at speed, symmetry -Skipping (great for teaching hopping, asymmetries often seen), Galloping

Muscle Weakness Outcome Measurements for CA: Functional movement

-Stairs - kids over 4 should alternate up/down ---with and without verbal cues -Floor to stand through squatting or 1/2 kneel (2 yrs) ---Use any kid game: squat down, get a piece, walk, come back -Supine to sit (core weakness) -Hopping (using plantarflexion or quads/hams) (look for push-off and catch) (do freeze jump games) ---Also do jump down from a bench, up on a bench -Heel walking -Strength subtest of Bruininks-Oseretsky Test - Second Edition

Types of wheelchairs

-Standard v. lightweight v. ultra lightweight -Rigid v. folding -Tilt in space or recline v upright -Adapted strollers (dependent mobility devices) -Power assist (E-motion or Magic Wheels) -(also many subcategories!)

Movement Assessment Battery for Children and DCD

-Standardized norm-related scores at 4 age intervals -Each interval contains 8 items ---3 manual dexterity ---2 ball skills ---3 balance -5th percentile is considered obvious motor problems -Well-researched, high reliability and validity -More used in research settings

Motor skills outcome measurements

-Standardized testing (pick a good day for them, don't want to get a super bad score because they are in chemo) ---Peabody Developmental Motor Scales, Second Edition ---Bayley Scales of Infant Development - Third Edition ---BOT-2: Bruininks-Oseretsky Test of Motor Proficiency, Second Edition

Night Splinting for ITW

-Static splints -Off the shelf -Custom fit ---Solid AFO ---Articulated with added stop -Dynamic stretching splints ("Dyna-Splint")

Normal Values for a few parameters: (5 yo)

-Step length: 47.6(5.4) -Base of Support: 8.5(2.3) -Velocity: 123.5(23.5)

DCD Objective

-Strength/ROM (up stairs with a smooth pattern? tripping?) -Posture/Alignment -Proprioception- Static and Dynamic position sense (limb matching test) -Balance -Coordination ---Quality of movement: stairs, skipping, jump rope, hop-scotch (hop scotch and skipping are hard, but seem to be less common for pts to have even tried) ---Standardized Testing -Gait

Muscle Weakness Intervention for brain tumors

-Strengthening -Strengthen using synergy and out of synergy if decreased motor control -Strengthen gravity assisted, gravity eliminated, anti-gravity -Repetition in functional activities with assistance for quality of movement

How does SDR work?

-Stretch reflex overactive due to damaged brain's poor ability to modulate reflex arc (theory of spasticity!) -SDR interrupts reflex arc at sensory nerve level -Sensory nerve rootlets electrically stimulated -If abnormal motor response noted, sensory rootlet is cut -This reduces excitatory input from the LEs

Current Research on Obesity and DCD

-Study that followed 2,083 children for 3 years ---VO2max: Lager 20m shuttle run (doesn't seem like a great assessment (DCD = likely to struggle) ---BOT-2 Short Form ---Results: ------Children with probable DCD are more likely to fall into the low fitness range at a faster rate ------Differences increase over time ---DCD= decreased physical activity = decreased CRF = increased CVD -Other studies... ---Children with poor motor proficiency had poorer performance than peers ---Children with DCD are less physically activity than peers ---Elevated body fat → overwhelming evidence ---CV Fitness: measures rely on motivation of child to perform to exhaustion (often these kids don't want to) ---Mixed results for flexibility ---Strength and Endurance: withdraw from activities → less practice ---Aerobic capacity: poor motor proficiency → lower anaerobic performance ---Physical Activity: lower participation in free and organized play

Intrauterine environment

-Supportive ---1. 3D and flexible ---2. Consistent containment (close chain imput) ---3. Active movement, but always brought back to midline position -Controlled (control this in NICU) ---1. Sound (needs to be very quiet, babies cant handle high decibles) ---2. Light (isolettes are covered with a blanket) ---3. Smell (fragrance free environment)

Medulloblastoma Treatment

-Surgery -Radiation and chemotherapy over 3 years of age -High-dose chemo with autologous stem-cell rescue for age <3. -Chemotherapy often includes neurotoxic drugs

wc eval: history

-THE most important part of the evaluation!!! -Listening skills are paramount -Asking the right questions -Include the whole team -Don't rush (if you don't finish, have them come back)

ITW and Sensory Processing Disorder (an OT disorder)

-Tactile defensiveness is a common complaint in children with ITW (avoiding the ground) -Toe walking may be a form of sensory input for children with sensory seeking behaviors (proprioceptive input from gastroc) -A sensory screen is recommended using the Short Sensory Profile and/or refer to Occupational Therapy if you suspect Sensory Processing Disorder -2012 Case Series found all 5 children with ITW had at least probable differences on the Sensory Profile. This study also recommended the Sensory Integration and Praxis Test (supports that we are seeing some sensory abnormalities)

Infant and Toddler Age - PT Intervention

-Teach parents appropriate positioning and ROM exercises (you will get better compliance if you explain purpose) ---PFFD - tend to have hip flexion and abduction contractures ---Fibular Hemimelia - tend to have ankle plantarflexion and eversion contractures -Teach age appropriate developmental activities -Encourage symmetrical weight shifting in various positions ---This will help to develop balance reactions and erect trunk, strength ---Weight shifting onto limb deficient side is an important pre-prosthetic activity needed for future standing and ambulation

Adolescence to Young Adulthood PT Intervention

-Teens with congenital deficiencies have been adjusting functionally and emotionally since birth, but will still have increased concerns with social acceptance, dating, and participation in school athletics -Teens with acquired deficiencies have to accept that their lost limb will not be replaced functionally or cosmetically by their prosthesis -Teenagers should be involved in the selection of prosthesis ---Socket design ---Component options

Intrauterine Growth Restriction

-Term Infants: National Collaborative ---Perinatal Data Base -6.9 point IQ deficit at 7 years of age -Preterm Infants: with and without postnatal nutrition -8 point deficit on one year MDI if > 2weeks postnatal malnutrition

Popliteal Angle Test

-Test by starting supine with hip at 90, knee at 90; straighten the knee and measure from full extension -In children (>1-2 yr), this should be 0 -In teens, 0-15 within normal limits depending on functional needs (some site up to 30 in active boys (muscular!)) -Need for length may very on dx, activity, etc (ex: high kick = need length for function!) -SLR: more measuring the origin, popliteal: more measuring the insertion -No way to document hyperextension, just note it (pop angle of 0, also moves into hyperext) -For this measure, the pelvis should be level, opposite knee should be held down straight

PT Considerations for limb deficiency

-The child with multi-limb deficiencies has special needs -Requires prioritization of function -Adapt the environment to allow the child to function, don't just adapt the child to function in the environment

Interventions for ITW

-There is variable results within the research regarding conservative treatments -Even if you lengthen the muscle, and don't look at the child as a whole (motor patterns or sensory needs) the child will likely return to their preferred pattern. -CPG recommendation to initiate therapy as young as possible as older children have significant contractures and do not respond as well to conservative treatment -Multidisciplinary approach with OT -Interventions: stretching, splinting, night splinting, surgical, serial casting, sensory tx, static balance, dynamic balance, strengthening, motor control

Developmental Dysplasia of the Hip (DDH) Definition

-This is a spectrum of disorders resulting from malformation of the femur head and socket at birth that typically results in less coverage of the femoral head (could be head, neck, or acetabulum) -Can be dysplasia w/o subluxation, sublux-ation of the hip, or full dislocation of the hip -Can be one side or both sides

Angle of Torsion

-This is the angle in the horizontal plane -Typically defined as the angular difference between axis of femoral neck -Normal = 10-15 deg, anteverted = 25-30 deg

Most fractured site in kids

-Tibia is the most commonly fractured bone in kids (ALSO: most common ortho problem in kids)

Why use adapted car seats?

-Too big for standard seat ---Placement of straps ---Weight limit (important!) -Deformities (scoli, pectus, etc) -Very poor head control or hypotonia -Spica cast (usually temporary) -Behavioral issues -May need to consider alternate solutions: ---EZ-on vest (allows for laying down) ---Car beds

Additional considerations for power wheelchairs

-Tracking technology (can make a huge difference when working with a switch, prevents fatigue) (really nice for the kids with poor motor control) -Adding seat functions to control ---Tilt in space ---Recline/elevating leg rests ---Seat elevation ---Standing -Attendant control/remote stop (added safety feature)

Congenital Deficiencies can be described as...

-Transverse ---Limb developed normally to particular level ---No skeletal elements beyond that level, but digital buds may be present ---Named by the segment at which the limb terminates -Longitudinal ---Reduction/absence of elements within long axis of bone ---May be normal skeletal elements distal to affected bone ---Named by stating affected bones and whether each is total or partial absence

Treatment

-Treatment includes carefully timed surgical procedures ---+/- success rates secondary to ↓ muscle function ---(sitting by 10 mo is a good indicator of walking eventually)

Developmental Education to parents of children with special needs

-Trisomy 21 -Cardiac complications -Genetic syndromes -Orthopedic anomalies -Referral to appropriates outpatient services ---Rehabilitation ---Specialized physician ---VFSS ---NICU follow-up clinic

Pediatric Postural Assessment

-Trunk: ---Check for kyphosis ---Scoliosis ---Pectus Carinatum ---Pectus Excavatum ---Rib flaring -Esp. look at hips, knees and feet positioning (BIG POINT!) ---Things like thigh-foot angle, genuvalgus or varus, intoeing, retroversion

Balance impairments with brain tumors

-Tumor in motor cortex, cerebellum, disturbing ascending/descending tracts (thalamus) or vestibular system (cranial nerve VIII or vestibular nuclei) -Peripheral neuropathy -Combination of central balance and peripheral balance deficits

Front wheel drive power wheelchairs

-Turning radius of 63-71 cm (25-28 inches) larger than mid wheel, smaller than rear wheel -Foot rests add little, if any to turning radius -Able to maneuver with ease over obstacles like curbs (wont get stuck when off-roading) -Smoother ride than mid wheel -Fairly to very stable on slopes

Salter Harris Classification System for Growth Plate Fractures of Tibia

-Type I: complete physeal fx with or without displacement (above GP, not worried about deformity) -Type II: physeal fx that extends through metaphysis with a chip (above GP, not worried about deformity) -Type III: physeal fx that extends through epiphysis (death/disruption of GP, needs close following, may lead to deformity (limb length, varus/valgus)) -Type IV: physeal fx, plus epiphyseal and metaphyseal fx (death/disruption of GP, needs close following, may lead to deformity (limb length, varus/valgus)) -Type V: compression fx of growth plate (death/disruption of GP, needs close following, may lead to deformity (limb length, varus/valgus)) **If a fracture crosses into the growth plate, can lead to limb length difference and angular deformities → may require follow up surgeries to limit deformity or change angulation, growth plate manipulation on same or opposing side**

Costal angle

-Typically 90 degrees or less -Is much more OBTUSE in infants and newborns (makes breathing harder, more respiratory vulnerability)

Systemic Clinical picture and exam:

-Typically ill with sx of systemic inflammation (wt loss, anemia, elevated sed rates) -High fever present for 2 weeks -Often have salmon pink rash that is migratory -Involves swelling of both small and large joints -Radiographs - joint destruction -No uveitis (eyes are spared) -RF factor/ ANA typically negative, BUT WBC, platelets, ESR and CRP high (those all indicate infection)

Osgood Schlatters Treatment

-Typically non-surgical unless full avulsion -PT and home program (gentle strengthening, ice massage, glute strengthening, taping) ---Note: no ultrasound (growth plate) -Modification of activity: limit jumping and quick eccentric quad contraction for 4-6 wk

Developmental Dysplasia of the Hip (DDH) Treatment: 18 - 36 mo

-Typically require femoral and/ or acetabular osteotomy -May require Femoral shortening or varus osteotomy -Place in hip Spica in hip flexion and abduction -Recommend a belly cart or a big bean bag chair

Developmental Dysplasia of the Hip (DDH) Epidemiology

-Typically seen in the first 3 years of life -More girls than boys (L > R) -Has a familial pattern -Often associated with breach deliveries -Dysplasias 1:100 births, dislocations 1:1000

Tilt in space wheelchairs

-Typically used as dependent mobility device (so heavy!) (chairs have decreased in size- bottom comes forward as they go back) -Reasons for use? ---Frequent seizures (need to be able to get them into a position that works despite loss of postural control) ---Decreased anti-gravity head and trunk control ---Need for pressure relief

Standard wheelchairs

-Typically used for rehabilitation after acute orthopedic injury/surgery v long term use (in pediatrics) -Fixed axle precludes self propulsion with efficiency (where axel attaches to chair is fixed- too much shoulder extension) (where should it be for self propulsion? Right where your middle finger falls) -Axle plates... ---Axle height: can effect floor to seat height (effects transfers, knee height, head height, sight line) ---Axle front to back: want to be stroking 10-3 -Convenient and inexpensive -Features may include reclining back and/or elevating leg rests -Limited ability for custom seating (almost none) -Up to 23 kg (50 pounds) -LOW COST!

Arthrogryposis: Infancy

-UE/ LE bracing -Serial Casting -Therapy for development and mobility -Adaptive equipment -Ambulation if able -Surgeon may address dislocated hips

Treatment of Slipped Capital Femoral Epiphysis (SCFE)

-URGENT‑ needs to have surgical intervention as soon as possible and limit WB until then (send them with crutches) -Typically treated with a pin through fem neck through head (unless needed, typically do not re‑align fem head) -(we don't do anything, non-WB until they get it fixed) -Surgical tx: pin it where it is (don't put it back where it belongs) ---At risk for more problems later on, need strengthening, watch for impingement

CPG DCD Diagnosis Recommendations

-Use DSM-IV criteria -Multidisciplinary approach (pediatritian, psych, OT, etc) -A dual diagnosis of DCD and other developmental or behavioral diagnosis should be given ---Learning disability or autism spectrum dx (make sure that the other issues are also addressed) -Co-morbidities should be addressed -Not typically diagnosed before 5 or after 16 years old -Diagnosis made from at least 2 assessments performed at least 3 months apart (but note, you can start treating)

Ewing's Sarcoma

-Usually a type of bone cancer, but can be within soft tissues (peripheral primitive neuroectodermal tumor PPNT) -A bone cancer that is sensitive to radiation -150 children in US per yr -Treated by surgery (limb-salvage procedure or amputation), radiation, and chemotherapy -Chemo includes vincristine

Visceral Manipulation and Abdominal strengthening

-Utilized with infants with significant reflux -Rectus abdominus home program to increase GI motility, reduce constipation, and increase gastric emptying -Visceral Manipulation: mobilization of abdominal viscera to support GI motility

Static Balance tx for ITW

-Various surfaces for proprioception with foot flat -Single-leg stance; one foot on ball (getting some assistance -BOSU ball -Rockerboard ---Balance in a dorsiflexed position (on a wedge) ---Helps with posterior weight shift (posterior weight shift helps them squat with their heels down)

Ossification of the axial skeleton

-Vertebral Column ossification spans the embryonic period to 25 years of age -Ossification starts at the vertebral arches at 8 weeks -Noted fusion of the vertebra by 6 years of age, ---lumbar to cranially ---(taken into account when planning surgical procedures) -5 secondary ossification centers develop and later fuse after puberty -Primary curves of the spine (THORACIC and SACRAL) formed during fetal period

VEPTR

-Vertical expandable prosthetic titanium rib to treat thoracic insufficiency syndrome -Expanded twice per year to accommodate growth -Usually followed by fusion -Used in small kids, esp if there is a thoracic insufficiency

Osgood-Schlatters incidence

-Very common overuse injury -Affects 15% of teen boys and 10% of teen girls -Typical onset: 10-15 yo

Common Impairments with brain tumors

-Vision/hearing/vestibularimpairments -Muscle tone abnormalities -Sensation changes -ROM deficits -Postural dysfunction -Muscle weakness -Gait disturbances -Balance impairments -Motor control deficits -Motor skill impairments -Decreased endurance

Goals of seating system

-Vital functions -Interaction with environment (where are their eyes, what can they look at?) -Skin protection (continence?) -Prevention of deformity? (use common sense, position them to prevent secondary deformity, promote breathing) -Maximal independence given limitations

Fetal development as it relates to pediatric musculoskeletal issues

-Week 4: ---Neural Tube forms and closes by day 28 ---Limb buds form near end of 4th week Gestation ---Limbs form prox to distal -End of week 8: ---Gross limb development complete ---Critical period during this time for bone development -Week 6: cartilage formation starts in the limb buds -Week 12: primary ossification centers are present in the LONG BONES -Term: diaphysis is ossified, with epiphysis cartilage

Scheduling

-What (the more you can do before hand, the better- try to get school PT to come): personal communication, if possible -Who: the team (bigger teams take longer, but work better) -Where: home v. clinic v. school -When ---Partially dictated by answers to the above ---May need as long as 90 minutes, especially at first

Car seats

-Whenever possible, use off the shelf ---Weight limits and size increasing (getting bigger as requirements change) ---Much more cost effective ($100s vs $1000s for adaptive) ---Often easier to install

Developmental Dysplasia of the Hip (DDH) Treatment: 6‑18 mo

-Will first attempt percutaneous adductor tendonotomy (lengthening) with arthrogram (place in ideal position) and a closed reduction with spica -If closed reduction (under anesthesia, but no cutting skin) cannot be achieved or is unstable, open reduction is indicated (open up for surgery)

FUNCTIONAL LIMITATIONS with Sickle Cell Disease

-Will range from very mild to significant, depending on timing/severity of last crisis, and +/- stroke (fairly common), acute chest syndrome (not enough blood/O2 to lungs, constricting sensation), infection

Solid Tumors

-Wilm's tumor (kidney tumor) -Rhabdomyosarcoma -Ewing's sarcoma (bone tumor, responsive to radiation) -Osteosarcoma (bone tumor, NOT responsive to radiation) -Neuroblastoma -Retinoblastoma -CNS tumors

Hemophilia

-X-linked recessive coagulopathy -Impaired blood clotting -Type A and B ---Different clotting factors involved (protein that is mutated) ---Type A more common -Hemarthrosis is the most significant problem (bleeding joints) ---Occurs in knees, ankles, elbows ---When recurrent, can lead to chronic synovitis and degeneration of the joint -Pannus formation degrades the quality of the cartilage and bone à joint instability -(precautions are similar to those who have JRA)

PT after hip osteotomy

-after 4‑6 weeks can progress to against gravity exercises -at 3 months with X ray clearance, slow return to running and jumping -ROM essential (no substituting) (BUT, if they don't have the range don't force it! Will do damage!) -Typically struggle with disassociation of hip and pelvis (everything moves as a block) -Movement faults and mm imbalances: FAI association

Pauciarticular/Olioarthritis Clinical Hx and Exam

-again, 4 or less joints ---Knee arthritis most common (usually knee, followed by ankle, maybe wrist) ---rarely hip and small joints involved -Low grade fever -More often ANA positive -Complaints of Morning stiffness -Limp in AM and after long play -Chronic involvement may have LLD or joint contractures

Prone

-good position for premies- pulls the tongue forward to facilitate easy breathing -Prone positioner pack ---Size depends on weight ---Helps them get their arms under them to prevent overworking the rhomboids (and the long term consequence of high guard positioning in walking) ---Baby lays on the prone positioner with the chin just above the rounded piece ---Arms are flexed with the hands by the face (calming, helps facilitate sucking) ---Legs are tucked into physiological flexion ---Supports the diaphragm (infants are obligatory diaphragm users) -Snuggle Up ---Lays flat on crib ---Bottom supports LE in flexion ---Memory foam baby bendy allows baby to extend, but then be pushed back into phys flexion ---Strap tucked under to prevent ER of legs (prevent circumducted gait pattern) ---Other strap supports UE in phys flexion -Zackies: looks like hands, absorbs mom's scent; beans inside hold baby into phys flexion -Frederick T frog: filled with beans, provide proprioception (can change the number of beans in the arms), helps with bone development

Rickets Common Compaints...

-mm weakness -Family complaints of leg bowing -Increased dental issues

JRA/JIA classifications

-with JRA nomenclature, 3 types: ---Pauciarticular - less than 5 joints involved ---Polyarticular - 5 or more joints involved ---Systemic - (lots involved) -JIA (jeuvenile idiopathic arthritis) (international Leauge of Associations for Rheumatology)- (trying to make this the definition) ---Oligarthritis- less than 5 joints, two sub types ------Persistent ------Extendent ---Polyarticular RF negative (RF is the blood type) (RF = rheumatoid factor) (note, blood tests are not always helpful) ---Polyarticular RF postitive ---Systemic ---Other categories

Legg Calve Perthes: Four Stages course of LCPD

1. Condensation‑ Necrosis (6-12 mo) 2. Fragmentation and reabsorption of bone‑ fractures and deformation; flattening of the acetabulum (1+ years) 3. Reossification‑ revascularization; when new bone has regrown (will not end up being a nice pretty head again) (many years) 4. Remodeling: when new bone reshapes (the shape of head during this phase determines long term outcome) (many years)

PT IMPLICATIONS of Arthrogryposis

1. Stretch what you can as early as you can 2. Strengthen what you can in available ROM 3. Pool therapy is wonderful for this population 4. Focus is on MAXIMUM FUNction

Clubfoot Nonsurgical Stretching Treatment

1.Dorsiflex the first ray and stretch plantar fascia 2.Supination 3.Abduction of the forefoot around the talus 4.Dorsiflexion of the hindfoot

Incidence of Major Handicap for infants

< 1500 grams -No Hemorrhage: <10% -Grade I or II IVH: 12% -Grade III IVH: 36% -Grade IV IVH: 75%

Weight or weeks to automatically qualify for early intervention services

<1500 grams, <32 weeks, or if they have a medical dx---will automatically qualify for early intervention services

Rickets and long term follow up

In long term follow up studies: ---Chronic knee pain ---Arthritis ---Menisectomy (not trauma, old looking)

Club foot incidence

Incidence -Occurs in about 1 in every 1,000 births -Ratio of 2:1 boys to girls -50% of the time it is bilateral

Premie status

Micro Preemie=23-26 wks Preemie=27-33 wks Late Preterm=34-36 wks Term ~ 37 wks (and up?)

Heelcord and Pes Planus

Note the pull of the heelcord on the calcaneus. This is a primary cause of rigid flatfoot deformity in children with CP (teach stretches with calcaneus locked!)

PT considerations for rickets

Other PT considerations ---Back pain ---Joint pain ---Chronic Obesity ---Poor exercise tolerance ---Developmental delays associated with obesity or decreased general activity ---Depression and self esteem issues (more in females)

Why are children with blout's disease seen by PT?

Seen by PT for associated impairments (knee, back, foot pain; glute/eccentric quad weakness) and post-op rehab

Treatment for

Treatment -90% are flexible and actively correctable (no intervention)

Angular deformities may be due to:..

abnormal cellular proliferation, abnormal mechanical loads, trauma or injury to the growth plate