Unit 2

Developmental Coordination Disorder (PEGS) Perceived Efficacy & Goal Setting

< 8 years - pictures so child can view and reflect on if they are struggling w/ those skills

Developmental Coordination Disorder Canadian Occupational Performance Measure (COPM)

> 8 years - goal oriented - family centered - interview part - environmentally referenced to problem related to participation of real life situation

Myelomeningocele Kim is a 14 year old with L4 MM with lofstrands who has been ambulating in her home and community with Patellar-tendon bearing AFOs. She has been complaining of fatigue from trying to get to classes on time and is feeling left out by her peers due to a slow gait. You recommend: A. A wheelchair B. A reciprocating gait orthosis (RGO) C. Practicing gait to stop reliance on lofstrands D. Practicing gait since her anterior tib is weak

A. A wheelchair

Myelomeningocele Katie is a 3 year old girl you treat today at a new daycare. She is usually a happy, eager child who is diving into your toy bag the minute you walk in the door. Today the daycare provider has had to change her diaper twice already and states she is extremely clumsy. You consider which of the following possibilities: A. Tethering of spinal cord B. Chiari II C. Shunt Infection D. Latex exposure

A. Tethering of spinal cord

4 Specific Tests for Hypotonia

A: pull to sit: open mouth, head lag B: scarf sign: elbow should go to midline of body C: shoulder suspension D: ventral suspension: unable to extend against gravity

Prematurity Fetal Alcohol Spectrum Disorder (FAS-D)

Alcohol RAPIDLY crosses the BBB and the placenta of the fetus. Syndrome: #1 cause of cognitive deficits in the world - Growth deficiency - Cardiac defects - Microcephaly - Dysmorphology: wide eyes, flat nasal area, thin lips

Myelomeningocele Equipment: Levels S1-S2 & S3-S4

- S1/S2 = gastroc soleus - S3/S4 = no loss lesion - S2 = DEC pushoff & stride length

Myelomeningocele What does each layer of cells differentiate into?

- endoderm: inner most layer of neurulation, forms lining of GI tract, lungs, & airways - ectoderm: differentiates into nervous system (spina bifida) - mesoderm: differentiates into musculoskeletal system

Hypotonia / DS Test of Basic Motor Skills

- evaluate motor changes in DS in ages 0-3 years

Prematurity Summary of Brain Lesions

- excitotocicity of glutamate = impair synapse = depolarize = severe hypoxemia occurs

Autism Parents Report

- " Mikey is just not that interested in moving... he likes to sit on my lap" - "Sam is such an easy baby!" - "Georgie is such an independent baby, he doesn't like hugs..." -"I'm concerned that Henry is deaf, he needs his hearing tested..." - " Bobby falls a lot, he's so clumsy!" - "David likes to shake his toys, or hit them on the ground..." - "Liam likes to watch his hands and when he's excited he flaps his hands..." - Matthew doesn't play with his train, he just spins the wheels for hours

Myelomeningocele Complications

- (Arnold) Chiari II Malformation - Hydrocephalus - Tethering - LATEX Allergic reaction - Motor Paralysis - Club Feet

Chart of sensitive times of baby's development to defects throughout 38 weeks of pregnancy

- 1st 2 weeks = period of ovum - all vital organs formed during Embryo - Premature = < 37 weeks - most disorders in 2nd trimesters - heart & neural tube forms week 4 - by week 12 organs formed (not complete) trimesters - 1: 0-14 weeks - 2: 14-26 weeks - 3: 27-40 weeks

Developmental Coordination Disorder Bruininks-Oseretsky Test of Motor Proficiency (BOT-2)

- 4 years to 21 years, 11 months - norm-referenced - 30 mins to 1 hour - 2 trials 8 subtests: ◦ FM precision (cutting) ◦ FM integration (copying) ◦ Manual dexterity (transferring pennies) ◦ Bilateral Coordination (jump jacks) ◦ Balance◦ Running speed ◦ UE coordination ◦ Strength

Developmental Coordination Disorder CPG

- 5-18 year olds - Under-estimated prevalence --> underdiagnosed - Males > Females DSM-V/Research 2016-present ◦ Motor coordination DEC ◦ Motor quality DEC ◦ Motor Imagery DEC ◦ Motor automatization DEC ◦ Motor prediction DEC ◦ Poor dual-tasking ◦ Signs/symptoms begin < 5 years ◦ S/S cannot be explained by another disorder --> NOT have to do w/ cognitive delay, autism, etc

Prematurity Patent Ductus Arteriosus (PDA)

- 5th week fetus heart can pump blood throughout body - lungs not fx until birth mother must supply fetus w/ oxygen rich blood blood must bypass lungs --> via floramen ovale: hole b/w Left & Right atria --> via ductus arteriousus: blood vessel that connects aorta to pulmonary artery - PDA should close 15 hrs after birth - Ovale should close 2-3 months after birth --> due to pressure differential as oxygen blood rises PaO2 at 1st breath, lungs expand w/ air, lungs pr falls, blood enters lungs then R atrium, creating higher..

Premature Infant vitals

- <37 weeks gestation - Axillary temp 98.6-99.8 - HR 120-160 bpm - RR 60+ bpm - 2-5 pounds - Poor physiological flexion (*not as much DF*) - Infant reflexes disorganized (not complete, week, asymmetrical) - Sensory systems underdeveloped (only able to tolerate 1 sensory input at a time) - Transient Tachypnea of the Newborn (TTN - respiratory distress: nasal flaring, grunting, intercostal/subcostal retractions, cyanotic, hypothermia, hypoglycemia) --> resolution: 1-3 days in incubation/ventilation - Apnea & Bradycardia (A's and B's): A = shallow breathing; B = slowing of HR --> d/t immature brainstem & spinal cord - lungs likely require mechanical ventilation before 34 weeks (surfactant begins at 28-30 weeks --> not fully complete until 34 weeks)

Typical Infant Vitals

- >37 weeks gestation - Axillary temp 98.6-99.8 - HR 80-140 bpm - RR 40-60 bpm - 6-9 pounds - Physiological flexion—dorsiflexion* - Moro, tonic neck, galant, gag, suck, swallow, plantar grasp, palmar grasp - Sensory systems intact (vision is 8in) --> prefer faces, black, white, red - NEWBORN Heartbeat *INC HR & RR* breath before umbilical is cut

PT Interventions in the NICU Sitting (sort of...)

- Active head control - Trunk control - WB through spine, UE, LE - Frees hands for exploration - Disassociation of trunk with UE and LE - Gentle WS with elongation - Visual regard changes --> tracking - cognition --> can explore the world

Summary of conception

- An egg within the follicle = oocyte - An egg traveling down the fallopian tube = ovum - Conception = ZYGOTE (sperm meets egg) - Implantation in Uterus = Blastocyte (day 6) - Week 2-8 = EMBRYO - Week 9-birth = FETUS - Placenta: protect & feed baby Oocyte --> zygote --> Blastocyte --> Embryo --> fetus

Hypotonia / DS Associated Medical Conditions

- Cerebellar Hypoplasia: tone, balance, coordination, speech - Cerebral Hypoplasia --> Corpus Callosum: size/thinning - Congenital heart disease (60%) - Obstructive sleep apnea (50-79%) & other respiratory issues - Thyroid disease: hypothyroid (4-18%) - GI disturbances (12%) - Eye diseases (50-70%) - Otitis media (50-75%) - Hearing problems (75%) - Seizures (1-13%) - Leukemia (1%) - Intellectual impairments (100%): widely variable - Inflammatory arthritis - Autism Spectrum Disorder*

Hypotonia / DS Body Structures & Function

- DEC joint stability / ligamentous laxity - joint hypermobility - Weakness - DEC endurance - Delayed milestones - Difficulty with functional activities Associated concerns: it's systemic! - Sleeping - Reflux - Constipation - Feeding problems (e.g. chewing or swallowing) --> concern for aspirations

PT Interventions in the NICU Supine

- Early WB through the LEs --> place feet in hooklying - Towel rolls to DEC the effects of reflexes - Facilitate use of UEs for object exploration, visual regard

Prematurity Surfactant

- Fetuses begin to produce surfactant between weeks 24 & 28. - By about 34 weeks, most babies have enough naturally produced surfactant to keep the alveoli from collapsing. - ground glass appearance d/t low surface tension of lungs

Gait - Clinical Decision Making Stacy Pic

- Hydrocephalus - extra upper trap - straight spine - W sitting - fisted hand - barrel chest - ankle stiffness - can't conform to support surface - atypical alignment distribution of WB - sacral sits d/t tight HS d/t spasticity

Gait - Clinical Decision Making Intervention (PT) Goals - Stacy

- Improve alignment and postural control in sitting - Provide opportunities for age-appropriate self-care and play - INC movement & strength in LEs - Develop ROTATION around the longitudinal axis of the body with weight shift during transitions - Initiate movement with appropriate body part for the task - INC variety of movement patterns in the right UE / hand

Prematurity Neonatal Seizures

- Most frequent and distinct neurological sign - 90% occur in first 5-15 days of life - Caused by: HIE, IVH, anatomical defects, hypoglycemia and drug withdrawal (change to brain) - cause baby to stiffen, become asymmetric, eyes deviate to 1 side

Myelomeningocele Movement System Diagnoses

- Myelo: of the spinal cord - Meningo: meninges (content of spinal cord) - Cele: swelling or herniation of body part Forced Production Deficit - CNS pathology - trauma to spine d/t birth defect in way vertebral arches were formed - *primary problem = weakness - most complex birth defect in the world - role of folate (vitamin B6) = manage & prevent neural tube defects --> DEC risk of spina bifida by 70%

Developmental Coordination Disorder Prognosis: without intervention

- Poor academic performance - Poor physical performance - Social isolation - Behavioral problems - Poor self-esteem - Victimization - Higher rates of mental health/substance abuse problems - Depression - Anxiety

Prematurity Respiratory Distress Syndrome (RSD)

- Prematurity causes pulmonary immaturity and deficiency of surfactant - low surfactant production results in INC surface tension, alveolar collapse, diffuse atelectasis and DEC lung compliance - cant breathe d/t lack of surfactant Treatment includes - administering surfactant - oxygen supplementation - assisted ventilation - ECMO (extracorporeal membrane oxygenation)

PT Interventions in the NICU Prone

- Promotes WB through the UEs (not all on head) - Stretches the hip and knee/rectus femoris & iliopsoas - Facilitates active extension & head control - Eye-hand awareness & proprioception - breathing may be difficult - Not possible with ventilator babies and Cardio-Pulmonary issues - Improved hip positioning

Myelomeningocele - PT Management PT Exam

- ROM - Strength/MMT - Tone: altered tone d/t descending tracts - Endurance - Sensation / dermatomes - Proprioception and kinesthesia - Posture, mobility, ADLs - Motor development - Equipment needs Which standardized test? - GMFM-88 - pebody developmental motor skills - pediatric evaluation of disability inventory - 3 min walk test - quality of life scale

PT Interventions in the NICU *Side-lying*

- Scapular protraction & trunk elongation, working on subtle weight shifts - Disassociating the upper & lower trunk using a BOB reaction (trunk move separate from pelvis) - Ideal for HR, RR, BP, O2 saturation (good for sleeping) - work on turning/accept weight to roll - dec effect of tonic reflexes bc neutral position of head - allows for cranial molding - INC tolerance for input - improve weight gain

Myelomeningocele - PT Management PT Interventions

- Strengthening - Functional Stretching - Orthotics and Functional Mobility - Teaching/HEP - Treadmill training (a rhythmic activity that requires coupled mvmt for multiple muscle groups - changes how brain perceives muscle function as it relates to walking)

Prematurity Shaken Baby Syndrome: A Triad

- Subdural hematoma - Encephalopathy: swelling/inflammation --> causing hypoxemia, INC intracranial pressure & reduced profusion pressure - Retinal hemorrhage - PT = mandated reporter - forcefuly shacken - contrecoup injury - brain moves forward & backward = bruising, swelling, bleeding - d/t baby not stop crying - associated w/ CP

Myelomeningocele Equipment: Levels T6-L1

- TLSO: for upright posture - swivel walker - **stand 1 hr/day**

Prematurity What do I need to know from this Lecture?

- Tests & Measures, FLACC - Early detection for CP - Embryology Review - Goals of PT in prematurity - Signs of infant stress - Classification of prematurity - Assessment of Muscle Tone - (11) NICU Medical Complications - Positioning for Preemies

Prematurity Hyperbilirubinemia (jaundice)

- The accumulation of excessive amounts of bilirubin in the blood --> found in bile & broken down by liver - premature: liver immature = skin color changes - if not detected --> bilirubin move from bloodstream to brain = kernicterus = athetoid CP GMCS level 5 - phototherapy - fiberoptic blanket - blood transfusion

Hypotonia / DS Research - Walking

- Treadmill training: systematic review for children under 6: only 3 studies: limited evidence - Treadmill Training Intensity for Infants with DS --> RCT high intensity vs low intensity group for infants taking at least 6 supported steps (home program) --> Those in the high intensity group INC stepping & had accelerated rates of some motor milestones - older studies have indicated that treadmilll training added to PT can accelerate onset of walking

Hypotonia / DS Therapeutic Recommendations

- Tummy Time activities - Infant massage - Treadmill training - Orthotics (SMO) supramalleolar - Adaptive equipment - Postural strengthening - Hip surveillance

Prematurity Retinopathy of Prematurity (ROP)

- VLBP - blinding eye disorder - born < 30 weeks - life long visual impairment - lack blood vessel supply to retina

Gait - Clinical Decision Making Stacy Pic

- WB through hands & knees - upright head - left arm straighter than right (right UE triplegia) - both finger tips curled for stability - wide BOS - weight shifted posteriorly - can she advance reciprocally

Myelomeningocele Type 1. Occulta

- asymptomatic - hole/malformation of posterior vertebral arches - dx made accidentally later in life - can be seen on x-ray

Myelomeningocele How can spina bifida be prevented?

- best test is routine prenatal care & high resolution ultrasound in 1st 2 months of life - neural tube closes at day 22-25-30 - have folate in system

Prematurity Necrotizing Enterocolitis (NEC)

- common in premature - more common if feed w/ formula rather than breast milk - An acute inflammatory disease of the bowel - Occurs most frequently in the first 6 weeks of life(BW: <2000g) - symptoms: vomiting, abdominal distension, bloody stools, lethargy - treatment: broad spectrum antibiotics - surgical treatment: ng tube placement for intestinal decompression, g-tube placement, resection and diversion of necrotic bowel

Hypotonia / DS Atrial Septal Defect

- congenital heart defect in > 60% of babies w/ DS - accompanies pulmonary hypertension - hole in wall of septum b/w atria - lower than normal amount of oxygen as pulled into atria - can flow into lungs --> forces heart & lungs to work hard = congestive heart failure - aka atriao septal ventricular defect - AV canal - endocardial cushion defect - difficulty breathing - weak pulse - blue skin (mouth) - poor feeding - poor weight gain - tired easily - edema in legs/belly

Myelomeningocele Type 3. Myelomeningocele

- cystic protrusion of spinal content - delivered by c-sections so birth canal doesn't cause more damage - cause paralysis BELOW level of lesion - cause bowel & bladder disfunction (S2, S3, S4 - allow normal function) - learning disability / cognitive deficit - dx made w/ routine ultrasounds --> looking for alpha fetal protein level w/ an amniocentesis - small amount of AFP is normally found in amniotic fluid but when open neural tube defect is present amniotic fluid contains elevated level of AFP --> alpha fetal proteins leaks into amniotic sac bc skin is gone

Myelomeningocele What causes spina bifida?

- d/t folate deficiency in 70% of cases Primary neurulation: neural tube formation begins in 1st month - starts w/ open neural plate - sides fold up = form neural groove - neural groove fuses to form neural tube

What is Autism?

- diagnosis - complex developmental brain disorder due to atypical brain organization - genetic risk - environmental risk - huge variability in degree of presentation

Hypotonia / DS Can early PT/Intervention help?

- different schedule - don't compare to peers - norms are different

Myelomeningocele MRI of Chiari II to C4

- direct compression to brainstem, cranial nerves - damage to spinal nerves - blockage causing rise of CSF above this level Patient SIGNS - HA - Stridor - Apnea - Cyanosis - DEC HR - Pain in shoulders and neck - Trouble swallowing - Changes in speech-vocal cord paralysis - Weakness/sensory loss

Myelomeningocele Hip Dislocation

- dislocate superior lateral - unstable hip doesn't result in unstable arthritis (like CP) - L1-L2 = more prone to dislocate **an anatomically located hip does not mean improve level of function** --> much more important to stand, walk, and prevent unnessary surgeries

Gait - Clinical Decision Making Stacy Pic

- feet flat - left hand loose - right hand tight - forearm platform - nice alignment

Myelomeningocele - PT Management PT Test & Measures

- functional measure in kids w/ CP & spina bifida = GMFCS Functional Motor Scale - kids w/ CP & myelodisplagia - aged 4-18 years - good for kids that need walking aids, AD, orthotics - 3 scores for 5 m, 50 m, 500 m - change over time in same child

Prematurity Cystic Fibrosis

- genetic disorder - both parents are carriers - live into 40 yo - disorder of mucus - creates blockages & infections - affects lungs, pancreas, small intestine, stomach, small capillaries, lower bronchi of lungs - skin smells & taste salty (newborns have sweat test) - use bronchodilators - lung transplants S/S: - cough, wheezing, multiple lung infections, SOB, slow growth, big appetite, loose stools, painful tummy - slinder kids

Myelomeningocele What is this level - Pic

- good hip flexion - crawling - anterior tib action unopposed without gastroc (S1-S2) - w-sit (to widen BOS to play - strong core

Gait - Clinical Decision Making Stacy Pic

- hinge joint - sliding through first toe & drawing the toe out - post tiping? - lift at toes - immature reflexes continue w/ CP - when try to stand, toe grasp going to stay until around 1 year for balance - instead of this = lift toes to minimze toe grasp

What is Ineroception?

- is a sense - helps us feel what is going on inside of our body - ex: feel hungry bc of interception - unclear body signals make it hard to identify exactly how you feel - "my son is incredibly sensitive to pain. the smallest bump or scrape can send hip into a full meltdown" - "i feel so many things going on inside my body at once it is hard to make sense of it all" - " I do not feel that I am getting upset until I am really, really upset. By then it is too late. I can't control it" - "my son walked around on a broken leg for 2 days w/o a single sign of pain. It wasn't until I noticed the swelling & bruising that I realized he had a serious injury" - "do not feel full"

Gait - Clinical Decision Making Stacy Pic

- kneeling - Weight shift to left side - neglect of right UE - nice alignment - compensation - wide BOS - internal rotation at both hips - hip flexion - winging of scapula - to become stable & have mobility --> has to widen BOS & crouch to keep COG low

Myelomeningocele Type 2. Meningocele

- least common - protrusion, needs to be fixed - doesn't cause damage - spinal nerves remain protected

Central Hypotonia

- little to no resistance to passive mvmt - softy muscles - difficulty grading mid range control - moving through quick sand - gama motor neuron system sets baseline so alpha motor neuron can regulate how muscles move - gama motor neuron stays on

Developmental Coordination Disorder DCD & Academic Skills

- looks at impact of academic achievement - reading difficulties - social communication difficulties - attention difficulties - generalized immaturity of motor system - DEC academic achievement

Hypotonia / DS Down Syndrome: Physical Characteristics

- low muscle tone (hypotonia) - short round skull w/ flat occiput (brachycephaly) - short neck - small posteriorly rotated ears - flat face - small nose - flat nasal fold - epicanthal folds at eyes - brushfields spots in iritis - single transverse palmar crease - wide space b/w first & second toes - small stature - low bone mineral density

Prematurity Periventricular Leukomalacia

- main ischemic lesion of premature infant caused by necrosis of white matter surrounding the ventricle - prognostic of CP Grades: - 1: persisting > 7 days w/o cyst - 2: echogenicity resolved into small periventricular cyst - 3: extensive periventricular cysts, occipital & fronto-parietal - 4: in deep white matter developing into extensive subcortical cyst (multicystic encephalopathy)

Gait - Clinical Decision Making Stacy Pic

- move from kneel to stand - can use right UE (for stability) - standing on toes - maintins IR - wide BOS - shoulder elevation - shoulder block to remain upright - pushing with UE (strong left arm) - shifting weight to right

Myelomeningocele Shank & Foot

- muscle imbalance favors ankle DF, inversion d/t L5 lesion bc anterior tib in unposed - Lack of PF (gastroc = S1/S2) vertical talus - talus shifts vertical d/w muscle imbalance - rocker bottom foot (not fit in orthosis or AFO) Cavus Deformity - S1 level excessively strong - posterior tib, peroneus longus causing PF, eversion - forefoot valgus w/ rearfoot varus - pulling up of foot = shortening from front to back - Treatment: surgically transfer anterior tib tendon to heel so can have pushoff via anterior tib

Myelomeningocele Spinal Deformity

- must be treated if larger than 50 deg - imped lung function - VEPTR: vertical expandable prosthetic titanium rib

Gait - Clinical Decision Making Stacy Pic

- neck hyperextension - balance an enlarged head - shift weight back to manage weight of head - hanging on w/ feet - wide BOS - hip flexion - tight right UE - IR - barrel chest (ventilator at birth - respiratory distress syndrome) - no rotation of trunk --> so weight shift is going to be difficult

Infant test & measures - Prematurity FLACC

- pain rating scale - infants to 7 years old - clear score system - how infant is tolerating sessions & specific activity - can vary each treatment session - new one can include parent input Lower the score = the better

Developmental Coordination Disorder Movement systems diagnoses

- poor coordination - weakness - difficulty sequencing - difficulty recruiting muscle segments in relation to one another

Prematurity PT Intervention for brachial plexus injury

- positioning to elongate shortened soft tissue - carry child w/ affect arm elevated - normalizing scapulohumeral & scapulothoracic rhythm during play - rhythmic use of arm - closed chain reaching activity - body position used to INC WB through arm - taping - strengthen weak muscles - stretch shortened muscles

Prematurity Neonatal Abstinence Syndrome

- pregnant female takes alternate addictive medication/drug

Prematurity Hypoxic Ischemic Encephalopathy (HIE)

- reduced umbilical cord blood supply - lack of glucose to brain resulting in energy failure & oxidative stress - attempt of resuscitation at birth - hypothermia can protected by inhibiting events - puts brain on hold (depends on age & weight of infant)

Developmental Coordination Disorder Standardized walking obstacle course (SWOC)

- reliability & validity of a new functional measurement tool for children - determine ambulation capacity by measuring stability & speed during gait under different circumstances - time - number of steps b/w obstacles - look at stability

Prematurity Finnegan Neonatal Abstinence Syndrome

- score infant at birth & throughout stay at hospital - test associated w/ maternal addiction term score > 8 need for intervention & follow up

Myelomeningocele Equipment: Levels L4-L5

- strong quads

Gait - Clinical Decision Making Stacy Pic

- triplegia - right UE stiff - can't conform to support surface - long sitting - only bearing weight in hand, heal, Left ischial tuberosity

Prematurity 24 weeks - viable birth

- ultrasound: make sure placenta is healthy - proper growth - EKG leads - intubated & ventilated - disorganized nature - ABD & ER - splaying of arms & hands - cramped irregular mvmt of legs - retractions at rib cage - sidlying = calming --> regulate HR & RR

Myelomeningocele Orthoses & Adaptive Equipment

- want to brace above the highest functioning level - pattern by age 10 = continue into adulthood - THKAFO - HKAFO - RGO: reciprocating gait - KAFO - AFO - SMO: supramalor

Examples of Sensory Processing Interventions

- weight ball - linear acceleration - obstacle course - core stability - rotatory mvmt - spin - rock wall / climb - vertical surfaces = easier to write on - tire swings

Prematurity Signs of stress

- yawning - crying - tremours activity (jaw, hands, legs) - cycling mvmt (cramped synchronous mvmt --> responding poorly to touch, pressure, or position) - hand placement - stiffening: rule out seizure - sneeze - cough

Developmental Coordination Disorder Movement Assessment Battery for Children, 2nd Ed (M-ABC)

3 - 16 years 11 months - score of 9 = < 5th percentile: "significant movement difficulty" - 0 = desired score

Hypotonia / DS Karyotype for Down Syndrome

3 copies of chromosome 21

Hypotonia / DS Presentation Variability

3 different groups - strong UE & weak LE - strong LE & weak UE - weak UE & LE --> more weakness longer the delay of walking

Autism Incidence & Characteristics

1 in 44 children in the USA Boys have 4x more risk than girls Age of dx is between 2-4 years - Mild delay in gross motor skills (2-3 months behind; walk after 14 months) - Loss of skills in the 5 domains within the first 2 years of life - any regression of skill = RED FLAG Marked impairment in Socio-communicative abilities...and Motor Skills - Delayed or Absent language - Not pointing or seeking attention - Difficulty transitioning (play to leaving play, going to bed) - Self-injury, tantrums, emotion-regulation Marked repetitive and stereotypic behaviors - Ex: tension, hand flapping, hitting, pinching, biting - Inflexible - No spontaneous or imaginative play - Playing with parts of objects rather than the object itself

4 Diagnostic Paths to Hypotonia

1. Damage to the immature brain ("supraspinal"- postural mvmt) - Low APGAR Score - ANTERIOR CSTx 2. Genetic Disorder - DS and thousands of other genetic syndromes - Dysmorphic features - Weakness - Ligamentous laxity 3. Central Developmental Hypotonia - no UMN lesion - no dysmorphic features - no LMN lesion - cultural, familiular - not meeting milestones 4. Delays in Development after 1st 6 months --> LMN sign - damage to muscle via alpha motor neuron - weakness & atrophy - fasciculations - intact sensory system - Concern for peripheral injury = brachial plexus injury - Concern for spinal muscular atrophy (SMA) if anterior horn cell - Concern for duchenne muscular dystrophy (DMD) if is muscle itself 1 & 2 = damage to brain 3 = resolves 4 = damage to muscle

Developmental Coordination Disorder Intervention: Top Down --> task oriented

1. Motor Skill Training (ML/MC) - kick ball, figure out where to stand --> progress by adding degrees of freedom (running to ball) 2. Neuro-motor Task Training (NTT) - based on dynamic systems theory (TIE) - sensory input can enhance strategies to INC attention 3. Cognitive Orientation to Occupation Performance (Co-Op) - "Goal, Plan, Do It, Check" - knowledge of results - contextual based - socially safe - teach child methods to minimize errors - EX: set up the ball, keep eye on ball, is there a black dot on the ball, hit it - how did that feel? --> have child figure out the results 4. Motor Imagery - compare predictive mvmt to actual mvmt - lack ability to predict/control mvmt = internal modeling deficit - focus on observing my actions - EX: kick ball, ask where did the ball go? didn't go where i wanted it to go. okay lets adjust our body --> you model it first 5. Video Gaming? Wii? Xbox? - NO

Myelomeningocele 3 Types

1. Occulta: - Hidden - most common - defect in formation of spinal canal - hair, dimples, red marks on lumbar spine 2. Meningocele - spinal cord protrudes but meninges not exposed - least common form 3. Myelomeningocele - poor formation of spinal cord - lack of vertebral arches - meninges exposed = infection - damage to area BELOW lesion - spinal cord & neurological injury - most severe form

Gait - Clinical Decision Making Intervention Strategies

1. What do I want to accomplish today-on behalf of the child and family? (PT goal:___________) 2. How do I plan to accomplish this? (design an intervention plan) 3. How will I get repetitions for ML?. 4. How will I integrate play to provide motivation and direct movement using ACTIVE strategies?

Prematurity & Physical Therapy PT Goals

1. maintain steady vitals with positioning, calming, self-soothing, non-nutritive sucking - sidelying = best position (stops influence of tonic labyrinthine --> remove stimulus to arch) - soothing = put on mother's chest, skin-to-skin contact - pacifier 2. developmental positioning to minimize alterations in tone, prevent contracture, minimize reflexes - ideal position for that newborn 3. provide optimal positioning for visual, social, fine, gross, and cognitive development

Prematurity Levels of NICU care

1: basic, recitation, no specialization 2: specialty, turn away if < 32 weeks 3: comprehensive care to high risk infants, ECMO

Developmental Coordination Disorder (PDMS-2) Peabody Developmental Motor Scales

< 8 years - fine & gross motor skills

Developmental Coordination Disorder Pediatric Balance Scale

5-15 years - assess functional balance skills in school aged children - max score = 56 points - 0 = lowest - risk for falls

Prematurity using cannabis during pregnancy

70% of women in the U.S. believe that there is "slight or no risk of harm" in using cannabis during pregnancy - THC crosses plaenta and stays 10 days at a time Infant - DEC HR, RR, BP Child: - INC impulsivity - Hyperactivity - Destructive behaviors - Memory dysfunction - DEC IQ Scores up to 10-15 points Adolescents: - Higher rates of drug use - DEC concentration - DEC memory - Depression - Schizophrenia - Anxiety disorders

Myelomeningocele 5 month old baby with intact trunk function, gravity minimized hip flexion; no active knee, ankle, or toe movement is observed. You consider which level of MM lesion: A. T10-T12 B. L1 C. L2 D. L3

B. L1

Myelomeningocele 8 year old with strength WFL in hips and knees, active anti-gravity df, knee flexion and gravity minimized hip abduction bilaterally. Ankles are pronated with calcaneal valgus. You consider the following level of lesion: A. L3-4 B. L4-5 C. L5-S1 D. S2

B. L4-5

Myelomeningocele An 8 month old is diagnosed by the pediatric neurologist with a level L4 myelomeningocele. Which muscles are functioning: A. Iliopsoas, quadratus lumborum, posterior tibialis B. Quadriceps-strong C. Quadriceps; anterior tibialis D. Glut Max strong

B. Quadriceps-strong C. Quadriceps; anterior tibialis

Autism Component 1: Motor Domain Intervention

Behavior Management Strategies Infants/Toddlers - Postural Control - Milestones - Sensory exploration - Tolerance of vestibular input (tolerate changes in head positions) - Functional and graded sensory input - 5 domains Preschoolers / Young Child - Structure! - Floor play - Set up a plan - Use pictures - Set timers, see meltdowns before they happen - Take Turns - Strength - Endurance - Movement/Vestibular - Trampoline! - INC proprioceptive feedback - Obstacle Courses Adolescents - Vigorous exercise (jog, run 15-20 mins) - Aerobic + resistance training - Water aerobic conditioning - Yoga - Therapeutic Horseback Riding

Developmental Coordination Disorder Case study

Bill is an 7 year old boy in 1st grade. His mother has recently noticed that he is much more clumsy than his older sibling was at his age, especially with simple tasks around the house. Bill is constantly falling and tripping while playing and climbing stairs. Bill is still unable to tie his shoes and continues to have difficulty with buttons and zippers. His teachers have expressed concern over his unmotivated attitude towards school. According to his mother, the word "lazy" has been used in reference to Bill's slow progress in copying words from the blackboard. Bill wants to learn to ride a 2-wheeled bike. History & Review of Systems - Reason for referral (usu. Participation!) - DOB, DOE, Gender, Parent/caregiver concerns, cultural/religious considerations - Medical Hx: Birth Hx, BW, Prematurity, Labor & Delivery, Medications, Diagnoses - Developmental Hx: 5 domains - Family Hx: "does anyone in your family have a hx of these concerns?" - Educational Hx: prior Testing? Services? - Environmental Hx: Home, School, Activities, Fitness, Behavioral regulation, Communication, sleep Review of Systems: ◦ MSK: Height, Weight, Symmetry/ROM, Ms mass and strength, h/o weakness (acute?), Scoliosis ◦ NEURO: ms. Tone, coordination, # falls, toe walking, DTRs, gowers?, CN screen, HA, pain, vision ◦ INTEG: bruises, trauma, atypical pigmentation, skin integrity ◦ Cardio-Pulm: endurance/fatigue Examination - Bill was observed during his gym class and then in a private therapy room at his school. He was friendly but shy when greeting the examiner. He was able to "high five" and was eager to complete the tasks asked of him. - Parent Interview: # falls/day? Milestones? Illnesses? Fractures? (PMHx,PSHx) - Developmental Assessment: Bill was asked to lie down on the floor and stand up quickly. He did so by initiating movement from his head, turning to quadruped, and using plantigrade to stand. He used a stagger response upon standing. When walking on a taped line on the floor, he could use a heel-toe pattern in one direction but was easily distracted, which caused him to step off in the other direction. He was able to stand on his R LE for 3 seconds and his L LE for 5 second with maximal body sway used to remain upright. He was able to jump in place and hop on 1 foot 2x in succession bilaterally before falling. - Tone: low-normal with ligamentous laxity DTRs: 2+ - Strength: overall 4/5, adequate at end range but lacking mid-range, graded control in floor <-> stand. Influence of ATNR was noted when turning his head in quadruped.

Developmental Coordination Disorder Summary - ICF

Body Structure and Function All = Dyspraxia - DEC strength - DEC coordination - fine & gross motor deficits - joint laxity (mild hypotonia) - poor visual perception/spatial organization - DEC muscle memory & motor feedback Activity Limitations - Awkward gait - Delayed oral-motor skills - Immature movement patterns - Poor quality of fine and gross motor skills --> Hand writing, jumping, hopping, etc. Participation Restrictions - "Recess" - Physical Education - Team sports - DEC social participation Environmental Factors - Difficulty completing work on time - Difficulty with academic subjects that require handwriting - Difficulty dressing, using a fork, brushing teeth, doing zippers, organizing a backpack - Slow with activities Personal Factors - Depression - Anxiety - DEC self-confidence - Lack of motivation --> "Lazy" "Clumsy" "Clown" - Difficulties coping with change/transitions - Avoids socializing with peers (especially on the playground) - Associates with younger children or seeks adults as playmates - Frustration with seemingly easy tasks - May seem dissatisfied with his/her performance

Developmental Coordination Disorder Intervention: Body Structures & Function

Bottom Up Option Core Stability /Postural training Cardio-Training Functional Movement Power Training (FMTP): - Static exercises --> progress to dynamic exercises - deep squats Education and Community Integration Home Program - Modify environment - Alter expectations (just plates) - Teach strategies - Self-discovery Participation - Taekwondo - Soccer - Modified Swim Team - Tennis - Therapeutic Horseback Riding

Myelomeningocele Katie is a 3 year old girl you treat today at a new daycare. She is usually a happy, eager child who is diving into your toy bag the minute you walk in the door. Today the daycare provider has had to change her diaper twice already and states she is extremely clumsy. You consider which of the following possibilities: A. Tethering of spinal cord B. Chiari II C. Shunt Infection D. Latex exposure

C. Shunt Infection

Prematurity Bronchopulmonary Dysplasia (BPD)

Chronic Lung Disease: - persistent areas of increased densities on chest radiographs - 25-50% of infants weighing less than 1500g and requiring ventilation - VLBW & ELBW = ventilatio - INC airway resistance --> LOTS of WORK to BREATHE - if RDS unchecked or severe = BPD * if infant still needs ventilator by 36 weeks have BPD * pathophysiology: - interstitial fibrosis resulting from alveolar collapse (absorption of intra-alveolar exudate by the alveolar wall) during resolution of RSD

Myelomeningocele Arnold Chiari Malformation

Complication: A caudally displaced rhombencephalon with 2 main subtypes: Chiaari 1 Malformation: - downward displacement of cerebellar tonsils as they descend into foramen magnum - 4th ventricle does remain in posterior fossa - may need decompression - Syringomyelia: collection of fluid, press on spinal nerves Chiari 2 Malformation: - urgent surgical procedure, decompression & laminectomy - cerebellar vermis, brainstem, 4th ventricle, pons medulla descend w/ cerebellar tonsils into foramen magnum into cervical spine - resultant buildup of intracranial pressure - blockage = INC ICP = cranial nerves compressed - risk for Hydrocephalus (accumulation of fluid on outside of cranial valt) Patient SIGNS - HA - Stridor - Apnea - Cyanosis - DEC HR - Pain in shoulders and neck - Trouble swallowing - Changes in speech-vocal cord paralysis - sWeakness/sensory loss

Myelomeningocele Motor Paralysis & Ortho Conditions

Complication: Complete: normal function to the level of lesion, flaccid paralysis, loss of sensation, absent reflexes DTR below level of lesion Incomplete: Skipped: 1 or more functional segments interposed b/w functional segements *motor level is determined by the lowest intact (3/5 MMT) muscle group - Ex quads can move up against gravity full range = lowest intact level - Sensory level may not correlate with motor level

Myelomeningocele Latex Allergy

Complication: SIGNS of LATEX reaction: - Swelling of eyes & mouth - Chest tightness-difficulty breathing - Hives/Rash - Nausea - Cramping - Vomiting - Dizziness

Myelomeningocele Hydrocephalus

Complication: - enlarged head - brain swells = presses on skull = pressure on brain tissue Ventriculperitoneal Shunt - Normal Shunt: cathater in ventrile w/ valve to release to stomach - Shunt Malfunction/Infection: red, swell, bulge, lethargy, DEC reflex, vomit, sunset sign S/S of Ventricular Shunt Failure - shunts fail frequently or become infected, leading to life threatening INC in cranial pressure - spina bifida is non-progressive, so if neurological deterioration is noted the cause must be evaluated Typical Signs - headache, irritability, lethargy - vomiting, anorexia - INC head circumference, bulging anterior fontanelle - estropia, diplopia, paralysis of upward gaze (changes in vision) Subtle/Confusing Signs - cognitive change (decline in school performance) - moodiness, change in personality - signs of chiari malformation - signs of tethered cord

Myelomeningocele Clubfoot & Repair

Complication: - occurs almost exclusively in mid-lumbar myelomeningocele - prevents any form of plantar grade or ambulation or shoewear - risk for pressure ulcers - if too stiff = posterior medial surgical release casting using ponseti method - weekly serial casting followed by bracing - to prevent subtalar deformities/stiffness

Myelomeningocele Tethered Cord

Complication: - treatable - Normally spinal cord hangs loose in the canal - can happen w/ growth spurts in 1st year, year 2-4, years 6,7, 8 up to 12-14 years - where lesion repaired --> cause scar tissue = tethering - New onset hip dislocation - Changing foot deformity - Bowel & Bladder changes (UTIs) - Worsening Scoliosis - Pain - Sensory changes - Motor changes - Be Vigilant and Re-assess every month to 3 months, depending on age: PTs can prevent loss of function - Get them to a Neuro-Surgeon

Autism Typology I, II, III, IV Consequences for toe walking:

Consequences for toe walking: - heart shaped gastroc - forefoot widening/pad formation at metatarsals - hypertrophy of medial gastroc (bc of varus inclination) - v shape of Achilles tendon (= gatroc/soleous stiffness & dec ROM) - wrinkles of achilles tendon

Developmental Coordination Disorder Differential Diagnosis

Coordination difficulties are likely not DCD when a history of any of the following is reported: - recent head injury or trauma - deterioration in previously learned or acquired skills - headaches, eye pain, blurred vision - global developmental delays - INC muscle tone, fluctuating tone, or significant hypotonia - asymmetrical tone or strength - musculoskeletal abnormality - neurocutaneous lesion - avoidance of eye contact, unwillingness to engage socially (autism) - gower's sign (difficulty rising to a standing position) - ataxia, dysarthria - absence of deep tendon reflexes - dysmorphic features - visual impairment (untreated)

Myelomeningocele Joe is a 10 month old infant with a dx of L1-2 MM. He lives with his parents and 4 siblings. He has: A. Grade 4 quadriceps strength B. Grade 5 abduction & external rotation C. Grade 3 quadriceps strength D. Grade 2 quadriceps strength

D. Grade 2 quadriceps strength

Myelomeningocele Katie is a 3 year old girl you treat today at a new daycare. She is usually a happy, eager child who is diving into your toy bag the minute you walk in the door. Today she is irritable has a rash on her face. You consider which of the following possibilities: A. Tethering of spinal cord due to growth spurt B. Chiari II due to irritability, likely a headache C. Shunt Infection due to incoordination D. Latex exposure

D. Latex exposure

Myelomeningocele 3 year old with normal strength in hip and knee musculature. Can plantarflex ankles and abduct hips against gravity. You consider the follow MM lesion level: A. L3 B. L4 C. L5 D. S1

D. S1

Prematurity Obstetric Brachial Plexus Injury (BPI)

Difficult Labor - injury to brahial plexus during birth d/t stretch injury from forceful vaginal birth - injurys nerve roots - Erb's Palsy - Klumpke's Palsy Risk Factors - large for gestational age baby (macrosomia) - multiples - forceps - breach - prolong labor

Myelomeningocele - PT Management PT Impairments

Disruption of nerve conduction below the level of lesion with motor/sensory loss - Reduced movement, and delayed milestones - Social isolation and DEC peer interaction - affect all 5 domains Joint contractures due to agonist/antag imbalance - Limited standing/bracing options - Pressure sores due to bracing/extensive siting - Back pain DEC Bone Density - DEC standing & WB pathological fracture, kyphosis, scoliosis Loss of Sensation - Reduced light touch, pain & temperature DEC proprioception for balance, frost bite, pressure sores, burns DEC Bowl & Bladder function (S2-4) - UTIs, flaccid bladder, incontinence CNS Changes - Shunt malfunction, tethering, Chiari II

Autism Toe Walking - Typical/Atypical

Do 12-18-month-olds typically toe walk? - Yes, for several seconds...a brief phase. Typical! Do children with ASD toe walk? - Yes, > 80% walk on their toes. Atypical! Do children without ASD toe walk? - Yes, this is called ITW if there is NO OTHER explanation. Do children with CP toe walk? - Yes, d/t spasticity lack of descending inhibition Do children with CP have autistic features? - Yes, 2-30% Do children with DMD toe walk? - Yes, d/t proximal weakness ***See toe walking of all types --> additional info you need to know**** - tone - self-correct - stereotypical affective socio communication type behaviors - underlying degenerative condition - damage to imature brain

Infant test & measures - Prematurity GMA + HINE

Early Detection in Cerebral Palsy - < 5 months: HINE, GMA - > 5 months: HINE

Gait and Orthotic Management Ankle Rocker

Foot flat to heel rise Function: control the rate of forward progression of the body as the tibia rotates at the ankle joint over the fixed foot under the eccentric control of the triceps surae.

Prematurity Prematurity & Neuro developmental Outcomes

Function of Gyri & Sulci - INC surface area of brain for growth & development of neuronal selections

Infant test & measures - Prematurity GMA

General Movements Assessment - early detection in CP - 1: general movements intro - 2: fidgety movements - 3: cramped synchronized mvmts

Autism Case of George

George is a 3-year-old with ASD. His mother is concerned that he prefers spinning until he falls rather than sitting at circle time. He "crashes" into his friends and ends up in "time out". He refuses to eat anything except soft rice and oatmeal. During art class he gets covered in paint and glue because he leans his head and chest on the table. What sensory systems are affected ? - Vestibular: spinning - Proprioception: "crashing" - Oral-Tactile: food aversions - Body Position/fatigue: art class What is/are the sensory problem(s)/diagnoses? why? - Vestibular:• MODULATION d/ --> CRAVING - Proprioception:• HIGH THRESHOLD --> CRAVING - Oral:• DISCRIMINATION d/0 --> Over Responsive/ sensitive/avoiding - Leaning:• POSTURAL d/o --> poor endurance, strength, position sense, core stability Construct 2 sensory intervention activities for PT - Vestibular: rotary movement --> orbital - Tactile-Oral: introduce "fun foods" gummy worms; ice pops; lolly pops; applesauce - Leaning: Motor stability/core activities on Ball - Proprio: climb a rock wall and jump down onto a large pillow; trampoline! - acitve timeout (run, jump) Suggest 2 sensory intervention activities for parent/home - get input ot feet & UE = feed childs CNS that is organizing - swinging prior to seated activity - sandwich w/ couch cusion - weighted blanket

Gait - Clinical Decision Making Goals Examples - Stacy

Goal 1: Improve postural control in sitting --> Ball-mobile surface provides WS and rotation over the R UE --> serial task (combine play w/ function) --> feedback = high frequency --> knowledge of results & performance Goal 2: Improve R UE function & awareness Goal 3: LE anti-gravity activation & weight shifting (climbing into bathtub) --> skill: massed task --> attention: focused --> feedback: KR --> practice: variety, solve motor problem Goal 4: LE disassociation and isolate hip extension; flat foot; weight shift; tibia! (step stance posture) --> skill: discrete task/complex --> attention: focused & shifting --> feedback: duel task, KP --> practice: random for L UE, closed practice Goal 5: - INC isolated muscle activation on the WB side - Symmetry - Flat foot posture - Longer step length --> skill: continious task --> attention: --> feedback: immediate results --> practice: blocked Last Pic --> skill: discrete (sit & stand) --> attention: focused --> feedback: KR --> practice: closed (requires 1 thing - fwd weight shift & extensor side of body working glutes/HS/soleus)

PT Interventions in the NICU 4 Main Intervention:

Goal is Competence: self-regulate, assume & maintain positions, gain weight, strong vitals - interventions implemented in form of systems 4 main interventions: - Encasement/Swaddling: - Graded Sensory-Motor Input: 1 stimulus at a time - Non-nutritive Sucking - Positioning: Prone, Supine, Sidelying, Sitting

Developmental Coordination Disorder Goal Attainment Scaling

Goal: Teacher would like Bill to sit quietly at circle time +2 = much greater than expected outcome +1 = greater than expected outcome 0 = expected outcome -1 = less than expected outcome -2 = much less than expected outcome

Hypotonia / DS Goal Attainment Scaling (GAS)

Goal: mother would like Sally to walk up stairs without a railing +2: Sally will walk up stairs reciprocally w/o rail in same time as her peers +1: Sally will walk up stairs in a step-to fashion w/o rail 0: Sally will walk up stairs without use of rail -1: In a step-to fashion, with the use of the rail -2: Sally will walk up stairs sideways with 2 hands on rail

Gait - Clinical Decision Making Motor Learning Intervention

Gold Standard Intervention Motor Control: How movement Is produced Motor Learning: How movements are saved/stored to be re-produced later Skills are the "Tasks" that can be: - discrete, serial, continuous Attention is: - Focused, shifting, sustained/alert - Encoding/processing Feedback is: - Extrinsic (about the task) --> KP or KR - Intrinsic (about the performance) Practice: - massed, distributed, blocked, random, variable, part or whole, massed, open task, closed task

Prematurity Intraventricular Hemorrhage (P/IVH)

Grades: - 1: isolated germinal matrix hemorrhage - 2: IVH w/ normal sized ventricles - 3: IVH w/ acute ventricular dilation - 4: IVH w/ hemorrhage into PV-white - germinal matrix fragile b/w 26-32 weeks

Infant test & measures - Prematurity HINE

Hammersmith - 2 months to 24 months - 26 items - cranial nerve function - posture - quality & quantity of mvmt - muscle tone - reflexes - reactions - each item scored individually - easily performed & relatively brief standardized & scorable clinical neurological examination for infants - optimality score & cut-off scores provides prognostic information on the severity of motor outcome - Good inter-observer reliability

Gait - Clinical Decision Making CASE STUDY Stacy is a 6 year old girl, born 10 weeks prematurely after her mother was injured in a car accident. She has a history of a grade III periventricular hemorrhage, RDS, neonatal seizures and hydrocephalus. She has a shunt and is currently on Tegretol for seizures, which recurred when she was 2 years old. She is GMFCS III spastic triplegic CP.

Health Condition: Cerebral Palsy - Mental Picture: GMFCS III - Force Production Deficit Recall: - Weakness due to changes in muscle itself - Shortened muscle-tendon unit - Exaggerated DTRs - LACK of descending inhibition of motor fibers --> spasticity, clonus, babinski - Compensatory patterns (blocks at neck, shoulder girdle, pelvis) - DEC ROM: 2-joint muscles - Impaired selective motor control - Impaired force production Activity Limitations & Participation Restrictions - sitting - walking - running - jumping - skipping - playground - kick ball - hop scotch - jump rope - bicycle riding Neuromuscular Impairments - Abnormal alignment and distribution in weight bearing - Muscle stiffness MAS = 2 - Impaired strength (AROM & PROM) - Impaired force production - Impaired selective motor control - Impaired balance and postural reactions

Gait and Orthotic Management Forefoot Rocker

Heel rise until the end of stance Function: to extend the period of ground contact via the gastrocnemius to exploit the GRF vector's helpful influence on swing initiation. preparing for swing

Autism Component 1: Motor Domain History, Exam, Evaluation

History - Milestones - Coordination (ball skills, bilateral mvmts, speed tasks, crossing midline, FM deficits) - Endurance - Gait - Motor planning/dyspraxia - Nursing (prefer the bottle?) - Routines - Self-regulation --> Sleeping --> Food preferences --> Toys/imaginative play? --> Tolerance to touch, movement, etc. --> Manage emotions/interoception Tests & Measures - Review of Systems based on Patient History Sensory Profile 2 (birth to 14 years, 11 months) --> Tactile, oral, visual, vestibular, kinesthetic, proprio ____My infant toddler has trouble falling asleep or staying asleep ____My infant/toddler has difficulty shifting focus from one activity to another ___My infant/toddler resists cuddling or arches away from me when holding him ___My infant/toddler is constantly active and moving ___My infant/toddler has a floopy body and is delayed in walking.

Case of Grace

History - born 26 weeks weighing 960 grams. - mother = 24 yo - pregnancy uncomplicated until she presented to the hospital in labor - emergency cesarean section was performed d/t fetal distress & PROM - limp at birth with no respiratory effort - Apgar scores: 3 at 1 min, 5 at 5 min, 8 at 10 - intubated in delivery room & remained on ventilator for 6 weeks. - Multiple attempts were made to wean her from the ventilator - remained on supplemental oxygen for 5 weeks after she was extubated - head ultrasound revealed a right grade III IVH - referred to PT at 21 days of life (29 weeks' postconceptional age) Observation - Grace was asleep in the prone position in an isolette and was extubated that morning - HR at rest: 147 bmp, RR of 42 bpm, oxygen saturation 93%. - pink and appeared comfortable - no visible edema or signs of fluid overload - central line in her right forearm & a nasogastric tube for feeding - Non-nutritive sucking was helpful to maintain state organization - During diaper changes, Grace displayed some signs of stress, but maintained her vitals within acceptable ranges. - The repositioning caused her to exhibit stiffness in her LEs and extensor posturing in her UEs. - With the change in position, Grace's oxygen decreased to the low 70s and she displayed hiccupping and coughing. Her nurse responded by bringing her hands and legs in close to her body. - She slowly increased her oxygen saturation, but continued to have episodes of apnea & bradycardia (A's & B's). - The PT waited until Grace was calm and had maintained her oxygen saturation at an acceptable level of greater than 85% for several minutes before checking ROM, tone, and primitive reflexes. - She had full ROM in her extremities with tightness at end range of shoulder flexion and hip flexion bilaterally. Her tone was increased in all 4 extremities and she preferred to arch her back into the isolette as her primary mean of movement. - Movements were jerky and global with little variability. Summary of Exam/Evaluation - Limitations in body structure: Tightness at end range of hip flexion and shoulder flexion. Increased tone in all extremities. Posturing; limited variety of movement - Limitations to activities: Poor tolerance to handling and stimulation with signs of stress. Unable to self-calm without facilitation. - Strengths: Full ROM in all extremities. Sustained transition to awake & alert state without irritability; tolerated pacifier with good oral motor control and coordinated suck-swallow- breathe. Diagnosis - Impaired Motor Function and Sensory Integrity Associated with Non-progressive Disorders of the Central Nervous System— Congenital Origin or Acquired in Infancy or Childhood (American Physical Therapy Association) - Force production deficit (FPD); Movements Systems - Cerebral Palsy

Myelomeningocele Sunset Sign

Hydrocephalus causing upward gaze paralyzed d/t obstruction of CN 3, 4, 6

Hypotonia / DS Atlantoaxial instability (AAI)

Hypoplastic Odontoid Process - Measure: look at atlantoaxial interval b/w atlas C1 & axis C2 - when odontoid is smaller = more play/movement of entire vertebral system - AAI interval > 4.5 mm = concerning Signs and Symptoms of myelopathy : - neck pain, limited neck mobility, torticollis (neck held in rotation & contralateral flexion) - difficulties in walking, altered gait - In-coordination, clumsiness - sensory deficits, spasticity, hyperreflexia ("hemiplegia") - Reports of recent incontinence

Autism Etiology - Neuroanatomical Correlates of ASD

INC brain volume: GM & WM - Frontal: responsible for higher cognitive functioning (emotion, impulse control, problem solving, social interaction) - Temporal: place of language & memory - More CSF: related to INC brain volume INC head circumference at birth - born w/ autism - on overload --> lights too bright, sounds too loud - early hyper-connectivity - DEC synaptic pruning - too many synapses firing & not a fine tune response DEC head circumference by adolescence - hypoconnectivity by adolescence - under pruning Strong connection b/w Immune system <--> nervous system: - brain recognizes a pro-inflammatory condition mTOR - inflammatation marker - mTOR = protein park of creatine kinase - large amounts of overactive mTOR found in the brain of autism - excessive production of synapses (supposed to regulate activity) --> protein dec --> chaotic synapes - MRI --> changes in brain tissue, connectivity, & growth patterns - Cerebral Cortex - Amygdala: fight or flight - Hippocampus: memory - Brain stem: primitive fx of body - Basal Ganglia: fluid movement - corpus callosum: connections b/w left & right hemisphere (critical for shared connectivity & processing) - cerebellum: center of balance, fluid body mvmt, memory

Autism Idiopathic Toe Walking

ITW: Sensory Processing Problem - May or may not have ankle equinus (PF inverted) --> WB on met heads w/ varus or valgus inclination - forefoot WB ONLY - May have a genetic/family connection with same - Not related to gender - Diagnosed after age 3 - NOT unilateral --> CP - Able to self-correct (at first) - Respond to Botox, serial casting (1 leg or both), orthotics, load sensors Birth history - Prematurity - Post-natal complications - SPD - Speech delay - L Handedness - tell child to walk on heels or flat-footed & they do --> just perfer not to - heel strike: 2 years --> need 10 deg of DF

Prematurity Small for Gestational Age - SGA

Implies Non-pathology - birth weight below 10th %-ile - most will catch up by 2 years of life - can be d/t maternal malnutrition or prenatal care, smoking, alcohol etc. - also can be LGA (like an infant of a diabetic mother > 90th %-ile)

Prematurity Intra-uterine growth restriction - IUGR

Implies Pathology - not defined by low birth weight - reflects fetal distress - develop diagnosis

Gait and Orthotic Management Heel Rocker

Initial contact to foot flat. Function: translate the vertical component of the ground reaction force into forward progression of the tibia through the link provided by the eccentric action of tibialis anterior

Autism Sensory Interventions Pic

Intervention Summary Child under 10 - feed a craver - dampen an avoider - structure the sensitive - activate for low registration

Autism ICF

Know - what is autism - DSM definition - outcome measures (add sensory profile) - body structures & function

Myelomeningocele *Ambulation Take Away*

L2 and/or 3 = household ambulation (iliopsoas) because it connects the spine to the pelvis/leg L4 = household "+" L5 = community ambulation

Myelomeningocele What is this level - Pic

Left - L2 - high pelvic band - brace down leg - support to patellar tendon/quad mechanism Right - L3/L4 - IR - AFO - trip over toe w/ speed

Gait and Orthotic Management Orthotic Examples

Left = patella tendon baring / floor reaction - gives extensor moment - HS can't be tight - if > 15 deg popliteal angle contracture NOT good choice Middle = hinged/articulating ankle Right = posterior leaf spring - freedom in midfoot/forefoot

PT Interventions in the NICU Carrying, rocking, holding

Left: infant that dislikes prone Middle: can't tolerate sidelying or needs stretch Right: struggling w/ excessive extensor tone = INC tolerance to flexion

Autism Clinical Practice Pattern for ITW - R1 & R2

Look at initial PROM - R1: palpate subtalar neutral --> DF --> first resistance = R1 - R2: how much can you push them beyond neutral to DF PROM: R2 < neutral - serial casting: change cast weekly over the course of 2-6 weeks depending on severity. Child will sleep in knee immobilizer if able - no change refer for surgical consult PROM: R2 = Neutral +5 deg - night splinting w/ or w/o knee immobilzers - weekly PT focusing on stretching, functional/gait training, gross LE strengthening, HEP - no change refer for serial casting PROM: R2 = 5 deg-10 deg, 10+ deg - daytime articulating AFO with possible night splinting - weekly PT focusing on stretching, functional/gait training, gross LE strengthening, HEP - no change consider outside referrals

Hypotonia Classification

Mild - mvmt patterns similar to children w/o DS at similar stage of development - sufficient muscle tone, strength, & voluntary control to initiate, adapt, & sustain mvmt during play Moderate - able to initiate & sustain mvmt during play but mvmt patterns are less efficient compared to children w/o DS - excessive motion in some WB joints, wide BOS, reduced balance, compensatory mvmt when strength & tone are insufficient to meet task demands Severe - difficulty initiating, adapting, and sustaining mvmt during play; frequency of mvmt may be limited - mvmt inefficient & characterized by compensations; may have limited voluntary of mvmt

Autism Screen: M-CHAT

Modified checklist for autism - 20 items - yes/no - parent report

Autism ASD: 2 Components

Motor ◦ Mild low tone ◦ Dyspraxia / postural control deficits ◦ Delayed milestones "DD" Sensory ◦ Hyper-reactive ◦ Hypo-reactive ◦ Variable / unpredictable ◦ Interoception ◦ Idiopathic toe walking

Developmental Coordination Disorder The Big 5 Skills*

Motor Skills Checklist ◦ Rhythmic galloping (attained by age 4) ◦ Single Limb Balance (8-10 sec by age 5 & >10s by age 6) ◦ Hopping (8-10x on one foot by age 5) ◦ Skipping (by age 5) ◦ Riding a 2-wheeled bike (by age 6) * if you do not have a standardized test

Developmental Coordination Disorder Must exclude....

Must exclude ANY other medial & neurological disorders associated w/ motor incoordination before a formal diagnosis of DCD is made. Including the following: - Genetic disorders (down syndrome) - neurologic disorders (CP) - degenerative conditions (duchenne muscular dystrophy, brain tumor) - musculoskeletal disorder (legg calve perthes disease) - physical impairments (impaired visual acuity) - cognitive impairments (developmental delay) - pervasive developmental disorder (autism) - injuries (traumatic brain injury) - environmental contaminants (lead, pesticides)

Developmental Coordination Disorder Etiology

No specific neuropathology, but... - In some cases, may be related to anoxia at birth, grade I or II IVH - Many children w/ DCD also have speech or learning problems or attention deficit disorder suggesting a common underlying mechanism - less frequent anticipatory activation of tib anterior, TrA, & oblique muscles in children w/ DCD - used preparatory muscle contractions 1/2 to 1/4 as often as typically developing child --> consider this when making interventions --> motor control/learning = BEST intervention for DCD

Hypotonia / DS Etiology

Non-disjunction - failure of pair of chromosomes to disjoin properly - embryo gets 3 copies of chromosome 21 - in every cell of the body Translocation - long arm of chromosome 21 attached to another chromosome (14) - when parent is a carrier Mosaicism - extra chromosome 21 present in some but not all cells of body

Prematurity Erb's Palsy

Obstetric Brachial Plexus Injury (BPI) C5-6 - ADDuction - IR - elbow extension - pronation - wrist flexion

Prematurity Klumpke's Palsy

Obstetric Brachial Plexus Injury (BPI) C8-T1 - ADDuction - elbow flexion - claw hand (interossei of hand = tight fingers + wrist flexion)

Gait - Clinical Decision Making Intervention Functional/School-Based Goals - Stacy

PT Goal: Improve popliteal angle by 20 degrees in step-stance activity to increase stride length at least 2" x 10 steps. School Goal: Improve gait speed to get to classroom on time from bus (<10 min). Parent Goal: Improve ability to transfer in/out of the bathtub at home.

Gait - Clinical Decision Making Gait --> Practice is Everything...

Per day, average infant spends practicing ~ If crawling, 41% time on the floor, crawls 2 football fields/day If walking , 50% of day on floor, 500 steps in 16 min of play, >1500 Novice Walkers: 12- to 19 month-olds - averaged 2368 steps/hr - travels 7.7 American football fields - falls 17 times/hour

Prematurity Premature Infants have

Poor flexion/poor repertoire of movement and poor antigravity movement - extremes of flex/ext - arms over head - not know where he is in space - Dorsiflexion to <40 degrees - No physiologic "contractures" (hypotonicity) - Varying Vitals: body temperature, HR, RR, BP, O2 sat - Reflexes either hyper-active or under- active - Muscle tone develops in a CAUDAL--> CEPHALO pattern (from extremities out) - Sensation: touch develops first --> desensitize them

Developmental Coordination Disorder (DCD)

Poor motor coordination & quality of movement that interferes with: - Academic performance - Self-care - Participation in leisure activities - can't be diagnosed by PT - movement ABC = gold standard for measuring baselines of DCD - AKA: Dyspraxia - identified < 5 yo (preschool) - movement difficulties unrelated to specific neurological conditions or cognitive impairments - previously dx as clumsy child w/o DS or CP - struggle w/ ADL's (dress, catch, write, ride bike) - clumsiness - coordinated motor skills substantially below age - onset of symptoms in early developmental period - mild hypotonia

Prematurity Rick Factors related to BW

Prematurity - 8-10% of all live births in the US - 75-80% of all neonatal complications and death due to prematurity - More than 50% in the VLBW Birth weight categories - LBW: 3-5 pounds (typical for multiples) - VLBW: 2-3 pounds - ELBW: 1-2 pounds

Autism DSM-5 (2013)

Previously Part of "Umbrella" - Autistic Disorder - Asperger syndrome - Childhood disintegrative Disorder - Pervasive Developmental Disorder (PDD-NOS) - Rhett Syndrome All 3 Areas Involved: - Social Impairment - Language/Communication Impairment - Repetitive/Restricted Behaviors Today: Autism Spectrum Disorder - Level 3: Requiring very substantial support - Level 2: Requiring substantial support - Level 1: Requiring support All 4 Areas Involved: - Social Impairment - Language/Communication Impairment - Repetitive/Restricted Behaviors - And...SENSORY PROCESSING (new)

Prematurity Examination

Priorities - Observation - Tone - Heel to ear: symmetry, closer to early = less muscle tone (term = heel to chest) - Scarf sign: reach acros to opp. shld (term = goes to chest) - Popliteal angle*: >90 = concern for low muscle toe - Ventral suspension: hold baby up in palm of hand - react to gravity - Pull to sit: full head lag first 2 months = norm - Slipping through the axilla: - Positioning - Reflexes - Behavioral Assessment - Habituation: sound - Orientation: visual & auditory input - Activity - Regulation: console self - Autonomic: skin color (touch baby = immediately become cyanotic = RED FLAG) - Reflexes Outcome Measures - GMA - TIMP-2 - HINE - HINT - Finnegan - Pain (FLACC, CRIES, etc) Infant "State" 1. Deep sleep 2. Light sleep 3. Drowsy 4. Quiet Alert 5. Active Alert 6. Crying

Hypotonia / DS Movement Systems Diagnoses

Problem with: - intersegmental mvmt - timing - sequencing

Gait - Clinical Decision Making The Determinants of Gait

Purpose: minimize energy expenditure by containing center of mass in correct plane - Pelvic tilt - pelvic rotation - knee flexion in stance - ankle PF/DF - foot mechanism - WS/lateral displacement of body

Autism Component 2: Sensory Processing Sensory Processing Disorder (SPD)

Sensory Modulation Disorder (SMD) - difficulty w/ different levels of input & appreciate the response - SOR: threshold for sensation is ver LOW, hypersensitive, feel things too intensely, rigid - SUR: hypersensitive, LOW registration of incoming sensory data, HIGH threshold for incoming sensory data (passive, clueless, uninterested) --> treat by INC sensory input to meet the threshold - SC: risk takers, easily bored, no satisfaction - always drive for more, constantly moving, ADHD Sensory-Based Motor Disorder (SBMD) - dyspraxis: difficulty thinking/planing/execute skilled mvmt, accident-prone, avoid sports, lack of muscle memory - postural disorder: poor body perception in space based on poor proprioceptive feedback, poor muscular endurance, poor core stability Sensory Discrimination Disorder (SDD) --> difficulty interpreting subtly of objects, people, foods - visual: - auditory: listening hear "P" or "q" - tactile: feel rock or button - taste/smell: smell flower or dirt - position/mvmt: fall to side or bwk - interoception:

Autism Component 2: Sensory Processing - Loop

Sensory Processing Disorder - body doesn't provide reliable feedback - neurophysiological condition sensory input poor detected, modulated, or interpreted = atypical response

Hypotonia / DS Motor skills - DP - standardization of motor growth curves

Sitting: 12-18 months Creeping: 26-36 months Walking: 36 months Running: 72 months Stairs: 72 months Jumping: 72 months

Infant test & measures - Prematurity TIMP-2

Test of Infant Motor Performance - 34 weeks to 3.5 months - < 30 mins - posture & selective motor control - functional preformace & how it impacts baby's life going home Anti-gravity hip flexion response - look for ability of hips to ext & come back to antigravity hip flexion Orientation to sound - shack rattle baby becomes still Roll from leg Response - BOB - supine --> move leg across hip to opposite side --> look for log roll

Autism Component 2: Sensory Processing The Power Sensations

Touch - parietal lobe - make connections from thalamus to spinal cord - over or under response to touch Proprioception: pressure - Conscious (cerebrum ) - posterior column/medial lemniscal pathway - Unconscious (cerebellum) - dorsal spinocerebellar tract Vestibular/Balance: - Rotary Movement (spin) --> info sent back/forth by three semi-circular canals --> horizontal: vertical input (spin, ice skate) --> anterior: frontal plane motion (cartwheel) --> Posterior: anterior/posterior mvmt (nod head, ride in car) - Linear Movement --> otoliths (accleration & deceleration) Interoception - hunger, HR, thirst - autonomic regulation during sensory stimulation occurs 100% w/ ASD --> found differences in sins rhythm (measure of SNS)

Gait and Orthotic Management Common Gait Problems

True Equinus - hip & knee extended (lock knee) - sometimes knee recurvatum - noted in stance phase of gait in spastic hemiplegia - d/t contracture spastic gastroc soleus Jump Gait - anterior pelvic tilt & lumbar lordosis - hip & knee flexed - kids w/ myelodysplagia & CP diplegia - motor sensory loss of L4/5 - rectus femoris kicks in during swing phase causing knee to be stiffer Apparent Equinus - defined by foot position in relation to tibia - no Heel strike (d/t proximal deviations) - toe makes contact w/ ground first - INC hip & knee flexion - DEC equinus Crouch Gait - excessive hip & knee flexion - scissoring - excessive DF (d/t downward weight) - have equinus but not real

Developmental Coordination Disorder Plan of Care

Top-Down Approach: - Child centered plan of care, task specific, cognitive strategies, problem solving to address dyspraxia - motor learning, Bottom-Up Approach: - emphasis on addressing underlying deficits: Strengthening, balance training, etc. Team Approach: - Parents, teachers, and therapist involvement Patient Education: - Address implications of DCD on social interactions, and stress how treatment can significantly improve symptoms. CPG Frequency & Duration - 3-5 x/week x 9 weeks - specific skills & underlying skill component alone (top dwon & bottom up)

Myelomeningocele Sign of INC intracranial pressure

anterior fontanelle - junction of sagittal, coronial, & frontal suture - 2-4 cm AP length - 2-3 cm transverse length - closes around 9-18 months palpate area & it bulges, strong pulse, tense fontanelle = SWELLING

Autism Sensory Profile 2

birth to 14 years, 11 months --> Tactile, oral, visual, vestibular, kinesthetic, proprio ____My infant toddler has trouble falling asleep or staying asleep ____My infant/toddler has difficulty shifting focus from one activity to another ___My infant/toddler resists cuddling or arches away from me when holding him ___My infant/toddler is constantly active and moving ___My infant/toddler has a floopy body and is delayed in walking.

Myelomeningocele UMNL or LMNL?

both

Myelomeningocele Flow of CSF

choroid plexus: place in lateral ventricle to secret & form CSF --> to 3rd ventricle through foramen of monro --> cerebral aqueduct of sylvius --> 4th ventricle (gets most damage causing blockage)

Gait and Orthotic Management Observational Gait Scale - Example

yes

Prematurity Typical Diagnoses in the NICU

• RDS • BPD • PVL • IVH • HIE • NAS • NEC • ROP • Jaundice • FAS-D • PDA • BPI • CF • SBS

Autism Component 1: Motor Domain 2-5 Years

◦ Does not use imaginative play ◦ Avoids eye contact, stares ◦ Dislikes tactile "input" ◦ Does not speak / stops speaking ◦ Speaks in monotone voice ◦ Echolalic (mirror/repeating what they hear) ◦ Hyper-arousal or hypo-arousal ◦ Fixated/perseverative play ◦ INC falls (dont know where body is in space - cerebellum) ◦ DEC endurance ◦ Compensatory motor strategies --ITW (toe walking - first sign) - Scale to evaluate sensory & psychomotor signs

Autism Component 1: Motor Domain Infant to Age 2

◦ No smile/eye contact ◦ Does not respond to name ◦ Not affectionate ◦ Low tone (mild) (wide BOS, no rollover, truncal hypotonia & want to W sit) ◦ No babbling ◦ No words by 16 months ◦ No pointing or gestures by age 1 ◦ No imaginative play ◦ Regression of typical skills ◦ Gross motor delay - motor milestones at 6 months are predictive of concern for autism & language - lack of graded muscle control - ligamentous laxity - poor posture (don't like to sit at a table & play) - poor endurance & easily fatigue

Developmental Coordination Disorder Test & Measures

◦ Observational Movement Assessment ◦ Movement ABC * -- questionnaire used by a teacher/parent/PT + motor test used by a PT ◦ Bruininks Oseretsky Test of Motor Proficiency (BOT-2) ◦ 6 MWT ◦ Functional Strength Measure (8 domains) ◦ Peabody Developmental Motor Scales (PDMS-2) ◦ Perceived Efficacy & Goal Setting System ◦ Standing-Walking-Obstacle-Course (SWOC) ◦ Goal Attainment Scaling (GAS) --> tracks change in performance child's perception of performance in activities, recreation, play ◦ CAPE ◦ COPM * first choice, although does NOT address participation, it identifies a movement disorder - shows change over time

Developmental Coordination Disorder Observational Movement Assessment (OMA)

◦ Symmetry ◦ Balance ◦ Speed, initiation, execution ◦ ROM & quality Control ◦ Smoothness ◦ Timing ◦ Sequencing ◦ Mobility upon Stability ◦ Clumsiness