CD test 4

BURNS: THERAPEUTIC INTERVENTION

• May be involved in wound care • ROM!!!! • Functional activities/mobility • Splinting to maintain and gain ROM • Respiratory exercises if inhalation injury present • Your treatment will depend on what stage of healing they are in and where the wound it • Always be aware of graft donor sites and precautions after

burns

• Ages 1-9 second cause of death • Mechanism of injury is most commonly scalding; most deaths from fires which include inhalation injuries • Pulling items from microwave • Knocking down items from stove or touching stove • Bath water • Electrical burns • Playing with matches/fire • Explosives/chemical burns

Spina Bifida Occulta

Spina Bifida Occulta is the most common form of spina bifida and most individuals who have it are not aware that they do because it is asymptomatic. It usually occurs in the lumbosacral region. Some individuals with spina bifida occulta will have a small patch of hair or skin dimpling over the area of the defect. Even though there is a vertebral defect, the spinal cord, nerves and meninges are intact within the spinal canal which is why there are typically no associated symptoms.

CP classifications of CP.. ataxic

results in decreased muscle tone which may have very mild fluctuations towards normal muscle tone. Ataxic CP is also an extrapyramidal problem and typically results from damage to the cerebellum. : This is the third most common type of CP and it typically results in a quadriplegicpresentation with full body involvement. We know it is due to damage to the basal cerebellum and results in general hypotonia with very mild fluctuations from hypotonia to normal. There is often a spastic or athetoid component associated with ataxic CP. ROM: Ataxic CP results in poor coordination and balance so that the individuals appear clumsy. This makes sense considering the damage is to the cerebellum. They tend to have difficulty with postural control and stabilizing proximal joints. They may demonstrate intention tremors and dysmetria. right reactions : These higher level reactions typically develop but they may be abnormally executed due to the decreased coordination and balance problems. These children are generally pretty functional and can walk independently. However, they have a clumsiness and uncoordinated quality to their movements. They tend to not do well in sports and gross motor activities and are the last kids picked to be on the team in school. oral motor: People with ataxic CP tend to have a slow, monotone speech pattern with decreased articulation. While they do not have specific feeding problems they may need to use the teeth to help stabilize the tongue or to hold the cup while drinking. deformtiies : Individuals with ataxic CP are at low risk for developing deformities such as joint contractures. The hypotonia tends to be mild and does not seem to put them at risk for joint instability. other signs : Individuals with ataxic CP usually have decreased deep tendon reflexes. personality: There are no specific personality characteristics associated with ataxic CP.

CP classifications of CP.. dyskinetic

results in extreme fluctuations of muscle tone from low to high. The individual cannot control these fluctuations.Athetoid CP is an extrapyramidal problem and usually results from damage to the basal ganglia. Children tend to demonstrate slow, writhing movements. - Dystonic CP often includes sustained or intermittent muscle contractions that result in abnormal postures or repetitive movements. Dystonic movements may increase when child attempts to complete voluntary movements.

CP classifications of CP.. spastic

results in increased muscle tone which has a velocity dependent component. Muscles will have a resistance to passive elongation. The resistance increases as the speed of the elongation increases. Spastic CP is a pyramidal problem and usually results from a lesion in the motor cortex or damage to the corticospinal pathways. This is the most common of the different types of CP and it can occur in any of the body distributions. We know it is due to damage to the primary motor cortex or to the corticospinal pathways. Spastic CP is characterized by increased muscle tone and this tone may further increase with increased effort or emotional excitement. The muscle groups typically impacted with increased tone are similar to the muscles impacted with increased tone in an adult who has had a stroke. ROM: The increased tone associated with spastic CP typically causes the individuals to have limited mobility. Instead of being able to move the joints through the entire range, they are typically limited to movement in the midranges of the joints. Movement is often difficult and frequently occurs in synergistic patterns with decreased ability to isolate movements at individual joints. Cerebral Palsy SA 2016 CAndrea, PT, NCS, CBIS 169 Righting, Equilibrium and Protective Reactions: Due to the increased tone and the limited movement the righting, equilibrium and protective extension reactions are usually delayed or absent. For example, protective extension usually requires a good bit of elbow extension which these individuals may not be able to achieve due to the limited movement. Also, they tend to pull into their center of gravity due to their fear of falling and to increase their postural security. resp probs : The joint contractures and limited mobility may also impact the rib articulations and decrease the thoracic mobility which will decrease the effectiveness of respiration. The trunk muscles and muscles of inspiration may also have increased tone and decreased extensibility further limiting respiration. There might not be sufficient respiration to support phonation. speech : If the muscles of the tongue and mouth are involved then the individual may not be able to dissociate the lip, jaw and tongue movements. This can impact the ability to articulate, close the lips and control the saliva. feeding : Aside from the above issues that would impact feeding, persistent reflexes can further affect the ability to eat. Common reflexes that could interfere with eating are the bite reflex and rooting reflex. Also, they can have an abnormally strong gag reflex which can be triggered by food and they may thrust the tongue out of the mouth which can make it difficult to keep food in the mouth. deformities: There is great risk for deformities due to the increased tone and the development of contractures. Joint limitations frequently occur in the hip and knee flexors, hip adductors and internal rotators, and ankle plantarflexors. In the upper extremity the joint limitations may involve the shoulder extensors, adductors and internal rotators, elbow flexors and wrist and finger flexors. Hip subluxation or dislocation and scoliosis may occur due to abnormal muscle pull. Surgery may be required to correct joint deformities and increase ROM. : Ankle clonus and increased deep tendon reflexes are common with spasticity. They may also have associated reactions in the upper extremities. : There are some personality characteristics which are often associated with spasticity. They are often posturally insecure and have a fear of falling. This is not difficult to understand since they do not have normal righting, equilibrium and protective extension reactions. They frequently fall and cannot protect themselves when they do so they quickly become afraid of falling or movements that could result in a fall. They tend to pull into their center of gravity to get their center of mass closer to the support surface so they will not have so far to fall. Due to the persistent startle reflex which is associated with the Moro reflex, they may be afraid of loud noises. Severely involved children may remain dependent, withdrawn and passive. While these are common personality characteristics associated with spastic CP it should be remembered that each child is an individual and may certainly deviate from these characteristics.

CP classifications of CP.. hypotonic

results in severely decreased muscle tone. This usually results from severe and diffuse injury throughout the brain. Now, aside from these four classifications you can also have mixed CP in which more than one type of CP can be found in the same individual. This may be found when more than one type of lesion occurs. For instance, an individual may have athetoid CP with a spastic component or ataxic CP with an athetoid or spastic component. Initially, one presentation may be expressed more than the other and then as the child grows and develops the other presentation may become more apparent. For example, a child a friend of mine worked with a child with severe spastic quadriplegic CP. When she first began working with him the spasticity was so severe that he could hardly move at all. Later, as she helped him gain more ability to move he started to demonstrate some athetoid movements in his hands and feet. Early on the spastic component was so strong that it masked or overrode the athetoid component which could not be expressed. You can also have an individual with decreased tone in the trunk but increased tone in the extremities. This is the least common type of CP and it typically results in a quadriplegic presentation with full body involvement. It is due to a large and diffuse area of damage to the motor cortex and brainstem. Individuals with hypotonic CP may experience mild to severe decreased muscle tone. Children who remain severely hypotonic usually have the most physical limitations and cognitive deficits. ROM : Due to the severity of the hypotonicity it may be very difficult for the individual to initiate movement particularly against gravity the movement tends to be very minimal. It may be difficult to develop co-contraction for stability of the trunk or extremities. right reactions : These higher level reactions are usually absent since the individual has such difficulty with initiating movement. resp probs : Breathing tends to be very shallow due to the hypotonicity. Choking and aspiration are problems since the individual cannot generate an efficient cough to help clear secretions or obstructions. speech : Speech tends to be very soft and quiet due to the decreased respirations and shallow breathing and the difficulty in sustaining respiration to support phonation. Speech and language may be delayed due to the hypotonia and cognitive deficits, if present. feeding : The hypotonicity results in a weak gag reflex which increases the risk of choking. Hypotonic CP tends to result in poor coordination of swallowing and breathing which will further increase the risk of choking and aspiration. Individuals with hypotonic CP tend to have an open mouth posture with a protruding tongue. This is common with hypotonicity. oral motor : The hypotonicity, along with the open mouth and protruding tongue, can increase drooling. Individuals are often described as having an expressionless face due to the severity of the hypotonicity. deformtiies : The decreased tone can cause hypermobility and joint instability so there is an increased risk of subluxations and dislocations. Hypotonic infants tend to rest in hip flexion, abduction and external rotation (known as the frog leg position) which can increase the risk of hip subluxation. Due to the severity of the hypotonicity and the joint instability, the children should be moved and handled using the pelvic and shoulder girdles as the key points of control. These children should not be lifted by the arms or legs. other signs : Individuals with flaccid CP usually have decreased deep tendon reflexes. personality : Individuals with flaccid CP seem to have a high threshold to pain and other sensations. They seldom cry and seem to be comfortable in any position. For example, when you assist a child to roll and the child's arm gets trapped or falls over the face, the child will make little attempt to move it or demonstrate signs of discomfort.

CP classifications of CP.. diplegia

results when both upper extremities, both lower extremities and the trunk are involved. The upper extremities are involved to a lesser extent than the lower extremities. So in diplegia the legs are more functionally limited than the arms. Sometimes, it may even appear as though the arms were not involved because they have so much functional ability as compared to the legs. However, in diplegia the arms are involved but significantly less than the legs. Diplegia results from lesions in the motor cortex of both hemispheres with the lesions more centrally located.

CONGENITAL DIAGNOSES DDH first born , breech, mul deliverys, family hx , pos. first yr of life

his is due to mechanical stresses. The uterine cavity and abdominal wall typically do not expand as much in the first pregnancy as they will in subsequent pregnancies. This will cause increased mechanical forces to be applied to the fetus during a first pregnancy. This increased mechanical force can impact the hip joint in the developing fetus. : A breech delivery is when the fetus passes down the birth canal in a bottom first position rather than a head first position. This causes the fetus to be folded over somewhat like a jackknife and places the hips in extreme flexion and adduction as the fetus passes through the narrow birth canal. This will cause abnormal mechanical forces on the hip joint and can result in hip subluxation or dislocation. Also, breech deliveries are more common in female fetuses and the relaxin can impact the ligaments of the female fetus. : Multiple births (twins, triplets, etc.) result in more fetuses taking up space in the uterus which can only expand so far. This can also cause abnormal mechanical forces acting on the fetuses. : DDH is not a genetic disorder. However, there may be certain genetic predispositions running in families that can make the fetus more susceptible to DDH. For Congenital SA2016 CAndrea, PT, NCS, CBIS 130 Positioning in first year of life Predisposing Factors low tone increased tone Signs and Symptoms of a Hip Dislocation or dislocatable hip is dislocated example, some families may have mild hypotonia, increased susceptibility to relaxin, a more shallow acetabulum, etc. Any of these could increase the risk of having DDH. : Cultures which traditionally carry or positioned infants on cradle boards with the legs being positioned and held in more hip extension and adduction than would be found in other cultural practices. This position places abnormal mechanical forces on the hips and can result in a hip subluxation or dislocation. Also at risk, are children in a culture which maintain a wide straddling position when being carried.

peds public laws role of therapist

1. Assessment a. Check for parental permission b. Use multiple methods, including direct observation in the student's natural 2. Program planning a. If therapy is indicated, the therapist participates in development of the IEP 1. Goals are not therapy specific 2. Many professionals may be listed as the person that is responsible for a goal 3. All goals are educationally relevant, not rehabilitative 3. Intervention: includes all activities done to implement the IEP goals a. All decisions on intervention levels/method are made by the team, not the individual therapist! b. Direct "hands-on" services to student - provide individual therapy setting 1. May be done individually or in a small group 2. May be done in a separate therapy room or other space utilized by therapy (counselor's office, hallway, janitor's closet, etc. 3. May be within the student's classroom c. Monitoring status 1. Services are planned by a therapist, but carried out by another person * Teacher, student, parent, aide 2. Activities do NOT need to be directed by a trained therapist 3. Need regular, scheduled contact to check-up on activities * May monitor monthly, each semester, etc., usually in the student's classroom * Student is NOT receiving direct, hands on therapy d. Consultant 1. Type of indirect service - includes adapting tasks, materials, environments, altering postural movement, communication requirements, and teaching adults new skills e. Problem solver f. AT team member g. Teacher h. Includes services provided by COTA/LPTA 4. Management issues a. Documentation: write evaluation and discharge reports 2. Monitor progress on goals and objectives 3. Submit documentation to the school for permanent records as needed b. Billing for services c. Balancing the needs of the student with resources that are available d. Maintaining a schedule of all students E. Dischargingstudentsfromtherapy 1. Team decision based on therapist input a. Student does not need therapy to benefit from education b. Student is not making progress Public Laws BDecker, EdD, OTR/L, FAOTA 2/23/2016 126 2. May pick student back-up on caseload if environment/circumstances change

peds public law Factors influencing the role of therapists in the schools

1. Cost 2. Level of experience of classroom teacher and therapist 3. Relationship with the classroom teacher 4. Degree of physical involvement of student 5. Your interpersonal and communication skills

CONGENITAL DIAGNOSES DDH s&s of dislocating hip

1. Infants born with a dislocated hip will not have the typical hip flexion contracture on the involved side. 2. A dislocated hip will have decreased ROM into hip abduction. This is the ROM that is most limited in a child with a dislocated hip. 3. An infant with a dislocated hip generally demonstrates asymmetrical skin folds or creases in the gluteal and adductor regions of the thigh. 4. A dislocated hip will result in the leg being shorter on the involved side. The leg length discrepancy is due to an apparent femoral shortening on the involved side since the femur is not in the acetabulum. The leg length discrepancy will not always be obvious. Leg length can be assessed with the child in supine with each leg measured from the ASIS to the inferior border of the medial malleolus to determine overall leg length. Additionally, the child can be placed in hooklying (supine with the hips and knees flexed so the feet are on the support surface). With the child in this position, look at the knees from a lateral view. If one knee extends farther than the other in a lateral view then the shorter knee may be due to a shorter femur or a dislocated hip. Note: If one knee is found to be higher in an anterior view, the lower knee is due to a shorter tibia and would not be indicative of a dislocated hip. 5. When a downward force is applied to a flexed and adducted hip, the femur may telescope or seem to shorten. This happens when the hip is already dislocated and the downward force causes the femoral head to move posterior to the acetabulum. If the hip is dislocatable, the downward force may cause the femoral head to slip out of the acetabulum and then move posterior to the acetabulum. Either way, the posterior movement of the femoral head would Congenital SA2016 CAndrea, PT, NCS, CBIS 131 Barlow's Test Ortolani's Test Position Diagnosis 6. seem to shorten the femur and result in abnormal skin folds. Likewise, a traction force applied along the length of the femur may move the femoral head anterior to the acetabulum and cause the femur to seem to lengthen. determines if a hip is dislocatable. With the infant in supine, begin with the hip flexed and abducted with the knee flexed and the pelvis stabilized. The fingers of the hand on the test hip should be aligned along the greater trochanter while the thumb is on the medial aspect of the thigh. Use this hand to gradually bring the hip into adduction while applying a downward force. If the hip is dislocatable the femoral head will slide to the posterior aspect of the acetabulum and then the tester will feel and or hear a "click" or "clunk" as the femoral head moves out of the acetabulum. This would be considered a positive Barlow's Test. If the femoral head only slides to the edge of the acetabulum but does not move out of the acetabulum the hip would be considered subluxable. You should only test one hip at a time, not both simultaneously. is used to manually reduce a dislocated hip. This test begins with the infant supine and the dislocated hip in a position of hip flexion and adduction with the knee flexed and the pelvis stabilized. The fingers of the hand on the test hip should be aligned along the greater trochanter while the thumb is on the medial aspect of the thigh. Gently abduct the test hip while also applying a traction force and pressure from the fingers on the greater trochanter. The tester will feel and or hear a "click" or feel a "jerk" as the femoral head slips over the acetabular ridge back into the acetabulum. Using manual force to reduce the dislocation would be considered a positive Ortolani's Test. Remember that a teratologic hip will not reduce with manual force. After 2 months of age, soft tissue contractures may prevent manual reduction and result in a negative Ortolani's Test. An ambulatory child with a dislocated hip will have some gait abnormalities. The involved side will have limited hip extension resulting in a limp. During stance the involved side will have a positive Trendelenburg sign due to the abnormal positioning of the hip abductors and may demonstrate a shortening leg length as the femoral head moves up along the side of the pelvis. A child with bilateral dislocated hips would demonstrate a waddling gait due to the bilateral Trendelenburg, but it may be difficult to determine as their lower extremities may appear symmetrical. Interestingly, ambulatory children with dislocated hips do not typically complain of pain, refuse to walk or bear weight on the dislocated hip. pos: When the hip is dislocated the femoral head will be located laterally and superiorly to the acetabulum when the hip is in neutral with respect to flexion/extension. When the dislocated hip is flexed the femoral head will be located laterally and posteriorly to the acetabulum.

peds public law . Common therapy concerns

1. Lack of medical/developmental history 2. Lack of time 3. Lack of appropriate environment 4. Educational relevance 5. Availability of equipment, resources 6. Cost

peds public laws years

1975: PL 94-142, Education of the Handicapped Act (EHA) 1990: 101-476; Individuals with Disabilities Education Act (IDEA) 2001: No Child Left Behind 2004: IDEA aligned with NCLB

CP med man casting

: Casting may be used to decrease tone or to increase ROM at certain joints in the upper and lower extremities. inhib casting is used for: 1. Tone reduction - The neutral warmth provided by the cast can help to decrease tone. Also, decreasing the plantarflexion at the ankle can help to decrease the overall extensor tone in the leg and so impact the knee and hip position as well. 2. Immobilization - To prevent movement at a specific joint 3. Weight bearing activities - To align the foot and ankle appropriately to allow for weight bearing on the plantar surface of the foot. serial casting : is much more commonly used than inhibitive casting in children with CP. With serial casting you get the same benefits of tone reduction and alignment but you get the added benefit of increasing ROM. A serial cast provides a prolonged stretch to spastic muscle. This prolonged stretch promotes the addition of sarcomeres which will gradually increase the overall Medical Mgmt CP SA 2016 CAndrea, PT, NCS, CBIS 178 length of the muscle and provide for increased ROM and, hopefully, improve function. Serial casting is generally done over a period of several weeks. The cast is applied with the joint near the end of the available ROM and left in place for a period of time, usually a week. The cast is removed and then ROM activities for the involved joint are performed. Then a new cast is applied as before. As a general guideline, only 5 degree increase should be casted each time for the ankles. This is done for a period of several weeks in an attempt to increase the ROM. At each cast change it is important to carefully inspect the skin to make sure there are no signs of skin breakdown or damage. It is also important to teach the parents or caregivers to inspect the skin above and below the cast to look for signs of poor circulation such as color and temperature changes and to ensure capillary refill is <2 seconds. If there is any concern of decreased circulation the cast should be removed immediately. Sometimes, the last serial cast may be cut down the length of the cast on each side. This is referred to as bivalving the cast. This is done to preserve the cast in order to use it as a night splint. The cut edges of the cast will be covered with a material such as moleskin and then Velcro straps will be attached so that the cast can be secured in place. Then the cast/splint can be placed on the child to wear at night while sleeping to assist to maintain the new range.

CONGENITAL DIAGNOSES DDH females

: In the latter stages of pregnancy, women produce a hormone called relaxin that acts to allow the ligaments of the pelvis to relax and elongate a bit in order to increase the size of the pelvic outlet to facilitate the birth process. The relaxin would be found in the maternal serum and will cross the placenta to the fetus. A female fetus would be susceptible to the effects of this hormone which could impact the ligaments surrounding the hip joint and lead to some degree of ligamentous laxity.

CP med man orthopedic

: Now, let's discuss the Orthopedic Management issues associated with CP. We know that children with spastic CP are at risk for contractures due to the increased tone so this population may benefit from the use of orthotics and splints to help maintain ROM and prevent contractures at specific joints. Orthotics and splints may also be used to provide stability at a joint and to control involuntary movements. For children these devices are typically custom molded using a plastic material and are made specifically for that child. These devices may be worn during the day to assist with positioning and function or at night during sleep. They are usually held in place with Velcro straps. Children with spastic CP will have increased tone in the involved wrist and hand which will pull them into wrist and finger flexion. Over time they could develop contractures so a resting hand splint could be made for them that would keep their wrist positioned in neutral or slight flexion and their fingers more extended. Spastic CP and/or a persistent palmar grasp reflex may cause a child to develop an indwelling thumb. This occurs when the thumb is adducted and flexed across the palm with the fingers flexed over it so that the thumb is tucked inside the fisted hand. Obviously, the child cannot use the thumb for function when the thumb is in this position. Also, over time the soft tissue in the web space will undergo adaptive shortening and decrease the ability to bring the thumb into a functional position. Thumb spica splints may be used to abduct the thumb and to bring the thumb into a more functional position. This will also help to maintain the extensibility of the soft tissues of the web space. The most commonly used orthotic in the lower extremity is the ankle-foot orthosis (AFO) which is used to promote normal foot and ankle alignment and stability. AFOs are also used to maintain extensibility of the plantarflexors and to prevent plantarflexion contractures. Use of AFOs to maintain the ankle in neutral can help to decrease toe walking, where the forefoot makes contact rather than the whole foot. By keeping the ankle in neutral and limiting the plantarflexion, the tone in the lower extremity may be decreased which could improve the position at the knee and hip. Medical Mgmt CP SA 2016 CAndrea, PT, NCS, CBIS 177 Casting Inhibitive casting Serial casting AFOs may be one solid device which would not allow any motion at the ankle or they may have a hinged ankle (called an articulating AFO) which would allow the ankle to move into dorsiflexion. Note the child must already have the range to move into dorsiflexion in order to use an articulating AFO. This type of AFO is not used to increase the stretch on the plantarflexors in an attempt to gain dorsiflexion ROM. When an articulating AFO is used on a child that does not have the necessary dorsiflexion ROM, the calcaneus will be pulled upward out of the correct position and defeat the purpose of the AFO. One problem with AFOs and other orthotics or splints made out of this plastic material is that that they are hot to wear. The plastic does not allow for ventilation and the close fit does not allow body heat to dissipate easily. This will cause the skin next to the plastic to perspire which makes them more uncomfortable to wear. This is particularly a problem during hot, humid summers in the South. Socks should be worn under the AFOs to prevent skin friction and also to provide a layer between the skin and plastic to help limit the perspiration. Knee immobilizers may be worn during the day or at night to maintain the knee in extension and limit knee flexion. These are used to maintain the extensibility of the knee flexors and are often used following cast removal after lower extremity surgeries. Knee immobilizers cover most of the thigh and lower leg and are made out of fabric and Velcro straps to keep them in place. They will contain hard plastic or metal stays along the medial and lateral sides of the immobilizer which act to limit knee flexion. Abduction wedges or pillow may be used to maintain extensibility of hip adductors since these are muscles have increased tone in spastic CP. Maintaining the extensibility of the hip adductors can be very important not only from a functional perspective but also from a caregiver perspective. When the hip adductors get contracted it makes it difficult for the caregivers to tend to bathing and toileting issues and it can make dressing much more challenging. The hip abduction wedges can also be used to help stabilize the hip joint and prevent hip subluxation and they are used after hip spica casts have been removed. These abduction wedges are often used at night while the child is asleep.

CP med man anti-seizure meds

: Remember that seizure disorders can occur along with CP so the child might be taking medications to control the seizure activity. Four of the more commonly used anti-seizure medications are listed in your course notes. Realize that this is not a complete list of all medications that might be prescribed to control seizure activity and we will discuss some additional medications in the section on seizures. General side effects include drowsiness and Introduction PHARMACOLOGICAL MANAGEMENT Anti-seizure medication Medical Mgmt CP SA 2016 CAndrea, PT, NCS, CBIS 174 Anti-cholinergic medication Anti-spasticity medication ataxia or gait disturbances. While there are certainly other side effects we will concentrate on these two. The drowsiness associated with the anti-seizure medications can be very significant and can impact the child's ability to participate in the evaluation or treatment. We should ask the parents or caregivers if the child experiences drowsiness with the medication and when the drowsiness seemed to have the greatest impact. This might mean that we would need to alter the time of the evaluation or treatment so that the child can more fully participate and so we can get a more accurate picture of the child's actual abilities. For example, if the child has the greatest degree of drowsiness 1 hour after taking the medication then we would not want to see the child at that time. Phenytoin or Dilantin has one additional side effect that we need to be aware of. Dilantin can cause gingival hyperplasia or over growth and swelling of the gums. Since we tend to see the child on a weekly basis, we might be the first to notice the swelling. We would need to tell the parents and recommend that the child be seen by the physician to have the medication adjusted or changed.

CP med man motor point block

A involves injecting a motor nerve within a target muscle. The motor point block is more specific than a nerve block and will not affect sensation. Motor point blocks will last for up to 6 months and then can be repeated. Motor point blocks may cause a few days of localized pain at the injection site.

JUVENILE IDIOPATHIC ARTHRITIS Physical & Occupational Therapy Assessment posture

A complete postural assessment should also be performed in both standing and sitting. There are some common postural deviations that occur in association with JIA. These deviations include: a forward head posture; increased thoracic kyphosis and lumbar lordosis; scoliosis and/or a pelvic obliquity that may or may not be due to functional leg length discrepancies; increased hip and knee flexion due to contractures (these may cause a functional leg length discrepancy); genu valgus (deviation of the lower leg away from midline); and a variety of foot deformities including hallux valgus (deviation of the great toe away from the midline of the body), hammertoes (increased flexion of the IP joints of the involved toes), overlapping toes and decreased MTP extension.

CP med man nerve block

A nerve block involves injecting phenol into a motor nerve which will decrease spasticity to all the muscles controlled by that nerve past the point of injection. The nerve block may also cause sensory loss due to damage to the sensory nerves.

JUVENILE IDIOPATHIC ARTHRITIS MSKO problems

A variety of musculoskeletal problems are associated with JIA. As indicated above, the involved joints may develop contractures and joint deformities. These problems can be exacerbated by the boney overgrowth that can occur when the disease is active. The joint deformities and alignment problems can cause joint instability which can increase the risk for additional joint injury and additional joint problems. These joint problems can persist even when the disease is in remission and cause significant pain and disability. All of these issues can result in postural deviations.

peds public laws team edu plan

A. 3-21 years olds must have an individualized education program (IEP) 1. Defines individualized needs and appropriate program with anticipated outcomes 2. Emphasizes participation in general education curriculum 3. Includes program modifications and support 4. Includes how disability affects general education a. Links child's annual goals to general education b. Statement of the child's present level of educational performance c. Annual goals to be achieved by end of school year d. Short term instructional objectives in measurable, intermediate steps 5. Adds "factors" to be considered a. Behavior, communication, language, AT needs b. Needed supplementary aids and services c. Location, frequency, duration of special education and related services d. All decisions on this are made by the team, not the individual therapist! e. May use "benchmarks" instead of short term objectives f. Progress reporting to parents as often as for children without disabilities g. Modifications for participation in district or state assessments * OR explain why child is not-participating 6. Implications: a. Students are more involved in all general education curriculum b. Related services are integrated into the general education environment/curriculum c. More communication with families B. 0-2yearoldsmusthaveanindividualizedfamilyserviceplan(IFSP) C. Educationplacementthechildwillhave 1. Children receiving special education services are to be educated in the least restrictive environment (LRE) a. Regular classroom b. Regular classroom with consulting teacher c. Regular classroom with supplementary instruction & service d. Regular classroom and resource room e. Full time special class f. Special school g. Specialized facility

peds public laws related services

A. Definition: transportation and such developmental, corrective, and other supportive services (including speech pathology and audiology, psychological services, physical and occupational therapy, recreation, including therapeutic recreation, early identification and Public Laws BDecker, EdD, OTR/L, FAOTA 2/23/2016 124 assessment of disabilities in children, counseling services, including rehabilitation counseling, orientation and mobility services, and medical services except that such medical services shall be for diagnostic or evaluation purposes only) as required to assist a child with a disability to benefit from special education. Includes the early identification and assessment of disabling conditions in children. The term also includes school health services, social work services in schools, and parent counseling and training. B. Child MUST qualify for special education services BEFORE they are eligible for related services C. Services are documented in the IEP/IFSP

peds public laws due process safeguards

A. Parent involvement has increased 1. Consent for evaluation and re-evaluation 2. Data gathering role 3. Eligibility and placement determination Public Laws BDecker, EdD, OTR/L, FAOTA 2/23/2016 123 B. Parentshavetherighttoactivelyparticipateinthedecisionsabouttheirchildwith disability's education 1. Parents must be informed & participate in decision to change their child's education program (in native language of parent) C. Hearing before impartial party: Parents and students have the right to challenge or examine the decision before a person not employed by the school district D. Right to present a defense: Parents & school district have the right to present evidence and answer charges & to be represented by advocates or lawyers if they so choose E. Written decision: After the hearing, the school must send a written statement specifying facts considered and conclusions drawn F. Right to appeal: Parent, student or school may appeal the decision to the state departmentofeducation.Court:lowercourt,statesupremecourt,federalsupreme court

peds public laws therapy in schools

A. Therapyservices 1. Student MUST have a disability that affects educational performance 2. Therapy MUST support the student's ability to benefit from an education a. Services must be educationally relevant 1. Services ARE NOT rehabilitative 2. Disease and dysfunction are not as important b. A student may qualify for therapy in the outpatient clinic, but does NOT qualify in the public schools B. Occupationaltherapyincludes: 1. Improving, developing, or restoring functions impaired or lost through illness, injury, or deprivation 2. Improving ability to perform tasks for independent functioning when functions are impaired or lost; and 3. Preventing loss of function C. Physical therapy includes: 1. Students with muscular or neuromuscular conditions, skeletal deformities, trauma andphysicallydebilitatingconditionswhichlimithis/herabilitytoattain functional performance within the educational setting 2. Student is functioning significantly below his/her chronological age in the developmentofgrossmotorskillsandshowsreadinessforthedevelopmentof higher level skills 3. Student is functioning significantly below his/her neuromuscular development such as: a. Abnormal motor control, and/or functional joint mobility b. Delayed bilateral coordination, and/or reflex integration which are necessary for higher level neuromuscular development 4. Student exhibits deficiencies which interfere with educational progress in one or more of the following sensory-motor areas: a. Balance and postural responses b. Bilateral integration c. Motor planning

CONGENITAL DIAGNOSES DDH Dx

All the things we have talked about (leg length discrepancies, asymmetrical skin folds, telescoping thighs, etc) are a part of the diagnostic process. The definitive diagnosis comes from imaging. Ultrasound is the recommended imaging choice for children under 6 months of age. Prior to 6 months, the boney elements of the hips have not ossified enough to show on X- ray. These X-rays do not allow visualization of the femoral head's position in relation to the acetabulum. MRIs will also provide enough detail to diagnose a dislocated hip but the ultrasounds are more commonly done.

CONGENITAL DIAGNOSES Clubfoot def

Another congenital disorder is clubfoot, a deformity of the foot and ankle that results in adduction of the forefoot, a varus position of the hindfoot or calcaneus, and a rigid plantarflexed position of the ankle which is also known as ankle equinus. Clubfoot is found more commonly in males and about half the cases will involve both feet. There are many theories concerning what actually causes clubfoot. Clubfoot can occur as a unique musculoskeletal disorder of the foot without any other associated disorders. It is believed that some cases occur due to an abnormal positioning of the foot in utero. Sometimes, clubfoot will occur as a component of another disorder such as arthrogryposis multiplex congenita, myelomeningocele (spina bifida), or Down syndrome. Lastly, some cases of clubfoot are thought to occur more commonly in members of families that have a genetic predisposition for this disorder although the disorder itself is not considered to be transmitted genetically. Clubfoot is quite a complex disorder involving the malalignment of three major joints: talocalcaneal, talonavicular and calcaneocuboid. In addition to the joint malalignments, there will also be a significant involvement of the soft tissues, including muscles, tendons, and ligaments, on both the medial and lateral aspects of the foot and ankle. While the soft tissues on the posterior medial aspect of the foot and ankle will be shortened, the tissues on the lateral aspect of the foot and ankle will be over-lengthened. Additionally, the foot and calf muscles will be smaller on the involved side. This size difference may persist into adulthood with the involved foot being 1 to 1 1⁄2 shoe sizes smaller than the non- involved foot. This is particularly noticeable when there is unilateral involvement. Since the ankle is fixed in plantarflexion, the gastrocnemius and soleus will be underdeveloped. The involved foot is shorter and has a kidney bean shape when viewed from the plantar surface of the foot. The involved foot may also have a cavus deformity or an abnormally high medial longitudinal arch. The dorsalis pedis artery, located on the dorsum of the foot, is often missing in cases of clubfoot

CP med man Anti-cholinergics

Anti-cholinergics are sometimes used to treat uncontrolled movements like dyskinesias. This group of medications are primarily used to treat symptoms of Parkinson's disease and have not been well studied as treatment for cerebral palsy. Although initially they help improve muscular problems in some people, the gains often are temporary. Over time, the medicine may lose its effectiveness.

ARTHROGRYPOSIS MULTIPLEX CONGENITA

Arthrogryposis Multiplex Congenita (AMC) is a non-progressive neuromuscular disorder characterized by multiple joint contractures and muscle weakness. This disorder will be obvious at birth due to the abnormal extremity positions due to the joint contractures. Mild cases may involve only 2 joints which are typically more distal while more severe cases may involve major joints in all 4 extremities, as well as the spine and the temporomandibular joint. At birth the involved joints may have a few degrees of motion or they may be rigid.

Medical Management of Hydrocephalus

At birth an infant with spina bifida will be screened for hydrocephalus. If the infant is found to have hydrocephalus then a shunt will be surgically implanted to drain the excess CSF. The shunt will generally be placed at the same time as the surgery to close the lesion on the back. There are two types of shunts: ventriculoatrial and ventriculoperitoneal. With either type of shunt, a hole will be drilled into the skull and a tube will be placed into the lateral ventricle. The tube will be attached to a device placed just under the scalp. A drainage tube will be attached to the device under the scalp and this drainage tube will be ventriculoatrial ventriculoperitoneal Signs and Symptoms of Shunt Malfunction Infants may also demonstrate bulging of the fontanelles (or the "soft spot" on the infant's skull) and the head circumference may increase. An infant may also demonstrate something referred to as "sun setting" of the eyes. This is a downward deviation of the eyes. The downward deviation causes the iris to resemble the sun setting on the horizon of the lower eyelid. Toddlers may complain of headaches or may develop nystagmus or strabismus of the eyes. School-aged children may also complain of headaches. Additionally, school-aged children may have a decline in school performance due to problems with handwriting and memory. The shunt may also become infected which could result in edema and redness along the shunt track. In addition to edema and redness along the shunt track, which are also signs of a shunt malfunction, an infection would be accompanied by fever and an elevated white blood count. Anytime a shunt malfunction or infection is suspected, the child should be referred to the physician immediately. passed just under the skin along the posterior edge of the sternocleidomastoid muscle and then under the clavicle. In the shunt the drainage tube will be positioned to end in the right atrium. This allows the excess CSF to drain into the right atrium and then to be resorbed through the circulatory system. In the hunt the drainage tube is passed into the peritoneal cavity with excess tubing to allow for growth. As the child grows the tubing will uncoil and remain in the peritoneal cavity where the excess CSF will drain and be resorbed. Either type of shunt can malfunction and lead to problems. While the ventriculoatrial shunt tends to have fewer malfunctions, the impact can be much more serious since these malfunctions can impact the brain and the heart. Ventriculoperitoneal malfunctions are more common and while the impact can be significant, it is less serious than with a ventriculoatrial malfunction. The ventriculoperitoneal (VP) shunt is the primary type of shunt used in the US. It is not unusual for a child with a shunt to require surgical revision to correct a malfunction sometime during childhood. Some children will require multiple shunt revisions.

ARTHROGRYPOSIS MULTIPLEX CONGENITA clinical features

At birth infants with AMC are easily identified due to the joint deformities in the extremities and/or trunk. Typically more than 2 joints are affected in a symmetrical pattern between the right and left extremities. While the presentation is often symmetrical there can be a wide variety of variations. Distal joint involvement is usually greater than proximal joint involvement. The extremities in children with AMC are described as being cylindrical with no skin creases across the joint surface. Since the joints have little to no movement, skin creases are not developed at birth. The Musculoskeletal SA2016 186 joints may be rigid and, again, the distal joints tend to be more severely involved than the proximal joints. There may be dimples in the skin overlying the joints. The skin is described as being thin with little subcutaneous tissue. The hips may be dislocated or subluxed and the patellae may be subluxed or missing. Muscles are often atrophied since they have not been active and sometimes these children may be missing muscles or muscle groups. Deep tendon reflexes are absent or reduced since they may not be able to cause joint movement. These children have completely intact sensation and have normal intelligence. Speech is also typically normal unless the temporomandibular joint (TMJ) is involved. If the TMJ is involved then the child may have facial abnormalities and feeding problems. When the spine is involved in the more severe cases the child will have some degree of scoliosis and respiratory problems. Some children with AMC will also have congenital heart disease, abdominal hernias and hemangiomas.

generalized seizures

Generalized seizures involve abnormal electrical activity in both hemispheres of the brain and account for 40% of all seizures. There are 7 different types of generalized seizures each of which results in specific motor activity during the seizure.

CP intro

Cerebral palsy is an umbrella term that applies to a group of disorders characterized by a non- progressive disorder of posture and movement due to a static lesion or defect in an immature brain. There are many different lesions that can occur with very different presentations but they are still under the umbrella classification of CP. It is important to note that although the lesion itself is static and will not grow or progress, the child's presentation may change over time. As the child grows and develops it will encounter new challenges such as moving against gravity, changing positions, etc. that require increased effort of the child. This increased effort may appear to make the CP get worse although the lesion has not changed. Also, new components of the CP may be expressed as the child grows. We should also note that we discuss CP in the child development course because individuals with CP will begin physical therapy in infancy or early childhood. However, CP is a life-long disorder and, like most of the disorders we will discuss in this course, the great majority of these children will survive into adulthood. Therefore, even those of you who do not plan to work with the pediatric population may encounter an adult with CP in your clinical practice.

peds public laws ass. tech

Characteristics: 1. Evaluated child's functional needs in his/her customary environment 2. Purchasing, leasing or otherwise providing for the acquisition of AT 3. Selecting, designing, fitting, customizing, adapting, applying, retaining, repairing, or replacing AT 4. Coordinating and using other therapies, interventions, or services with AT 5. Training or technical assistance for a child with a disability or, if appropriate, that child's family 6. Training or technical assistance for professionals (including individuals providing education or rehabilitation services), employers, or other individuals who provide services to, employ or are otherwise substantially involved in the major life functions of children with disabilities

CP med man asst. device

Children with CP may need positioning devices to support them in positions that they are unable to maintain on their own. For example, an adapted chair can be used to support a child without good head or trunk control in sitting while maintaining good alignment of the head, trunk, pelvis and lower extremities. A prone or supine stander can support a child without lower extremity control in standing to get weight bearing through the legs to improve bone density and to decrease contracture formation. There is a wide range of types and styles of positioning devices that are commonly used for children with CP. Please see class presentation for more information.

ARTHROGRYPOSIS MULTIPLEX CONGENITA clinical presenatation

Classical presentations There are two classical presentations of AMC which involve all the joints in the extremities. One presentation is commonly referred to as the "Jack Knife" while the other is known as the "Frog Leg" presentation. The "Frog Leg" presentation is generally described as having extended arms and flexed legs. The legs are in hip flexion, abduction and external rotation with knee flexion. The "Jack Knife" presentation is usually described as having extended legs and flexed arms. It is though the infant could be flexed at the hips and folded over as in closing the blade of a pocket knife. Note that the following joint positions are found in either presentation. Classical presentations Upper Extremities: ● Shoulders o Pronated ● Wrists o Flexed with the thumb flexed across the palm Lower Extremities: ● Hips o Clubfoot deformity The primary differences between the two presentations have to do with the elbow and knee positions. The "Frog Leg" presentation has extended elbows and flexed knees. Additionally, the hips are abducted and externally rotated. The "Jack Knife" presentation has flexed elbows and extended knees. Additionally, the hips are adducted.

CP Classification by Function: Gross Motor Functional Classification System Expanded and Revised (GMFCS E&R)

Classifies a child's gross motor function based on his/her typical performance, not their best capability in home, school and community • Communicates use of mobility aids and performance in sitting, standing, wheeled mobility and ambulation activities • 5 point ordinal scale; Level I is most independent and Level V is most severe • Descriptors for 5 age groups: less than 2 years, 2-4 years, 4-6 years, 6-12 years and 12-18 years • Used in the clinic to communicate functional level as well as in research • Stability of GMFCS classification over child's lifespan unless the child undergoes large surgical procedure (Single-event multilevel surgery (SEMLS)). In that case, GMFCS levels II, III, IV have shown improvement in their classification level. • Allows classification for prognosis and categorization - Incidence of hip dislocation increases linearly with GMFCS classification from level I (0% incidence) to level V (>90% incidence)1 - Children who are independent walkers at age 12 (GMFCS I and II) have an 88% change of having a similar functional status as an adult. Children whom use a wheelchair at this same time have a 96% chance they will use a wheelchair in adulthood.2 • Emphasizes the ICF model •

peds public laws transition services

Coordinated set of activities for each student, with outcome-oriented process, promoting movement from school to post-school activities. 1. Transition planning begins at 14 yrs., transition services at 16 yrs 2. Includes postsecondary education, vocational training, integrated employment, continuing and adult education, adult services, independent living or community participation 3. Based on individual student needs, preferences, interests 4. Includes instruction; community experiences, development of employment and other post-school adult living objectives; acquisition of daily living skills and functional vocational evaluation

meningcele SB

Meningocele is the least common form of spina bifida and is a more serious defect than spina bifida occulta but it, too, is asymptomatic. In meningocele the meninges will protrude through the vertebral defect and form a cyst or pouch filled with cerebrospinal fluid outside the vertebral column. However, the spinal cord and nerve roots are still located within the spinal canal and are not damaged.

peds public laws eligibility criteria (9)

Mental Retardation: refers to significantly subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior, and manifested during the developmental period. a. Adaptive behavior: the effectiveness or degree with which the individual meets the standards of personal independence and social responsibility expected of his age and social group 2. Hearing Impaired: No legal determination; not enough hearing to understand speech 3. Physical and Health Impairment a. Orthopedic or neurological impairments: CP, Spina Bifida, Muscular Dystrophy, Osteogenesis Imperfecta, Spinal Cord Injuries, Head Trauma, Amputations Public Laws BDecker, EdD, OTR/L, FAOTA 2/23/2016 121 b. Chronic illness and other health-related conditions: Seizure disorder (Epilepsy), Diabetes, Cystic Fibrosis, Hemophilia, Burns, other 4. Speech-Language Impaired (Communication Disorder) a. Speech Impairments: if speech is unintelligible, abuses the speech mechanism, or is culturally or personally unsatisfactory (Articulation disorder; Voice disorders; Fluency disorders) b. Language Disorder: serious difficulty in understanding language (receptive) or in expressing themselves through language (expressive) 5. Visually Impaired: legally blind (visual acuity is 20/200 or less in the better eye, even after the best possible correction OR visual field is restricted to an area of 20 degrees or less) a. Educational definition looks at how student makes use of whatever vision s/he has 6. Seriously Emotionally Disturbed (SED): exhibits one or more of the following characteristics over a long period of time and to a marked degree, which adversely affects educational performance: a. An inability to learn which cannot be explained by intellectual, sensory, and health factors; b. An inability to build or maintain satisfactory interpersonal relationships with peers and teachers c. Inappropriate types of behavior or feelings under normal circumstances d. A general pervasive mood of unhappiness or depression e. A tendency to develop physical symptoms or fears associated with person or school problems 7. Specific Learning Disabilities: disorder in 1 or more of basic psychological processes involved in understanding or using language, spoken or written, which may manifest itself in an imperfect ability to listen, think, speak, read, write, spell or to do mathematical calculations. 8. Autism: developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age 3, that adversely affects a child's educational performance. 9. Traumatic brain injury: an acquired injury to the brain caused by an external physical force, resulting in total or partial functional disability or psychosocial impairment, or both, that adversely affects a child's educational performance resulting in impairments in one or more areas, such as cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual, and motor abilities; psychosocial behavior; physical functions; information processing; and speech. The term does not apply to brain injuries that are congenital or degenerative, or brain injuries induced by birth trauma.

CP med man local man.

Local management: - Phenol - Botox A child with spastic CP may be taking medication to decrease the degree of spasticity. There are other pharmacological agents that are used to decrease spasticity and increase function. Phenol is an alcohol that can be injected to produce a nerve block or a motor point block. The phenol chemically impacts the nerve to decrease transmission of impulses and so decreases the spasticity.

ARTHROGRYPOSIS MULTIPLEX CONGENITA therapy

Management Management is best accomplished with an interdisciplinary team for the best functional outcome for the child. Therapy The general goals of therapy are to increase the child's functional active and passive ROM. As range is gained the muscles that act across a joint will need to be strengthened to function within the new available range. The hope is that the child will be able to participate as fully as possible at home, at school and in the community. The child will not likely gain normal range of motion of limbs, however small gains may be made. Treatment: The conservative approach to treatment involves a variety of activities to increase functional ROM. Most ROM increases occur prior to the age of 3. Serial casting will be initiated soon after birth and is used to increase the ROM of specific joints including the foot, knee and wrist. A variety of splints and braces will be used to maintain the increased ROM and to prevent the reoccurrence of contractures. Therapy should facilitate normal motor development with an emphasis on righting reactions, postural control and mobility. Functional and therapeutic exercise should also be used to increase the child's strength. The parents need to be taught a home exercise program to include ROM activities as well as positioning activities to increase function and decrease deformity. The goal for the lower extremity is to provide as normal alignment as possible to facilitate standing and ambulation. Each joint in the lower extremity needs to be specifically addressed to decrease the contractures and increase the ROM. The clubfoot deformity needs to be addressed as soon as possible to provide a more normal alignment to promote weight bearing. When the lower extremity alignment is sufficient the child should be supported in standing using a device such as a parapodium or stander. This weight bearing will facilitate normal bone and joint development, particularly deepening the acetabulum for better hip joint congruence. Most children with AMC will be able to walk but some may require lower extremity bracing and an assistive device such as a walker or crutches. The assistive device may need to be adapted with platform attachments to accommodate upper extremity deformities. If the child uses crutches a four point gait pattern will initially be used and may be progressed to a two point gait pattern. The goal for the upper extremity is to increase functional abilities and increase the child's ability to perform activities of daily living (ADLs). Again, a variety of serial casting and splinting will be used to increase joint ROM in the upper extremity joints. Many devices such as eating utensils, hairbrushes, Musculoskeletal SA2016 187 toothbrushes, and writing utensils will need to be adapted to accommodate the upper extremity contractures and the lack of hand function. They may benefit from the use of computers in the classroom if they have limited ability to write. These children may also need to have their clothes adapted with Velcro, elastic, large rings on zippers or large buttons to facilitate dressing due to the upper extremity limitations. There are a number of things that can be done to promote cognitive and social development. Adapting infant carriers will help with positioning and make it easier for parents to transport the child on community outings. The child may benefit from positioning devices such as prone scooter boards, etc. to help facilitate mobility and environmental exploration. The older child may also benefit from adapting the classroom environment to make it easier for the child to participate in academic activities. Again, the child may need to use a computer for writing assignments and note taking. Children with AMC should be integrated into regular classrooms since they have normal intelligence.

JUVENILE IDIOPATHIC ARTHRITIS medical man.

Medical Management Children with JIA are often followed in Rheumatology clinic for comprehensive management of the disease with a multidisciplinary approach. Medications will be used to control the joint inflammation and the pain. The goal is to preserve joint integrity and to minimize the impact on mobility and function so the child will have the greatest degree of independence possible in performing ADLs and participating in recreational activities. Education of the family and child is important to help them understand the disorder and how to best achieve the above goals.

THERAPY AND THE CHILD WITH CANCER

Decreased passive and active ankle ROM • Weakness • Pain • Delayed gross motor development • Limited functional mobility • Decreased participation due to fatigue • Deconditioning • May need AD/orthosis • Psychological, social functioning and cognition may be affected

peds public laws FAPE

Definition: All children with disabilities receive a free appropriate public education that emphasizesspecialeducationandrelatedservicesdesignedto meettheiruniqueneeds and prepare them for employment and independent living

OSTEOGENESIS IMPERFECTA Desired Outcome/Prognosis

Desired Outcome/Prognosis Children with OI should be able to attend school and participate in a normal educational environment since OI is not associated with cognitive deficits. These children should be capable of performing functional activities and ADLs and be able to participate in social and recreational activities within the limitations of their musculoskeletal systems. Children with OI should also be able to learn vocational skills for future employment and skills that will facilitate their ability to live independently as an adult.

cancer consideration for exer

Exercise is feasible and safe* • Indwelling catheter (Broviac, Hickman, Port-a-Cath) • Always check blood count levels if available (i.e. acute care) • Check vitals during aerobic activity • Monitor pain • Communicate with physician, parents, school; schedules may be hectic and intermittent due to treatment protocols • Radiation therapy can lead to contracture of soft tissue - stretch and complete self-mobilization of area • Take into consideration fatigue and infection factors • Exercise is recommended for individuals with bone tumors - avoid high-impact/high-torsion • Supervised exercise interventions should be implemented into acute treatment phase Gotte et al 2014 • Outcome measures: 2 minute walk test; 6 minute walk test for endruance • Improved health-related QOL* • Positive impact on BMI, sleep effieciency, endurance, functional mobility* • Always consult physician if you are unsure of how to proceed

ARTHROGRYPOSIS MULTIPLEX CONGENITA Desired Outcome/Prognosis

Desired Outcome/Prognosis The desired outcome is that the alignment of the child's legs will support weight bearing and ambulation. The upper extremity ROM and function should maximize the child's ability to independently perform ADLs, possibly with adapted devices. The parents will be educated and instructed in a home exercise program to maintain ROM and functional ability. This child was highly motivated and desperately wanted to walk. Note the upper extremity adaptations to the walker. Also, note the overall posture and the flexed hips. The therapist has to assist with the weight shift and movement of the feet. Sorry about the jumpiness of the video - I was not the videographer. Note the ROM limitations and the cylindrical shape of the extremities with no skin creases. The therapist is fitting the infant with a custom made resting hand splint to improve alignment. Also note the natural resting position of the hips with bilateral hip flexion and complete abduction. The hips have some movement into hip adduction which can be seen in the side lying position as well as when the infant is placed in the custom molded foam positioning device to hold the hips in a more adducted position. Also note the decreased active movement of the extremities.

peds public laws non discrim eval

Determines eligibility for SPED 1. Look at existing data (classroom-based assessment and observations from teachers/therapists) 2. Evaluation is completed by knowledgeable and trained personnel Public Laws BDecker, EdD, OTR/L, FAOTA 2/23/2016 122 B. Freefromracial,cultural,languagebias

CONGENITAL DIAGNOSES Developmental Dysplasia of the Hip (DDH)

Developmental dysplasia of the hip is a condition of the hip joint that results from inappropriate alignment of the femoral head to the acetabulum. At birth, the acetabulum is shallow and may have poorly developed lateral borders. This can contribute to the problems at the hip joint. Developmental dysplasia of the hip was previously known as Congenital Hip Dislocation (CHD) and you will see this term in some of the older literature. As you can see in the table in your notes there are 4 types or grades of DDH resulting in various degrees of instability of the hip. The first is a subluxatable hip which is when the femoral head may slide to the border of the acetabulum but it will not move completely outside the boundaries of the acetabulum. If the femoral head moves to this abnormal position and remains there then the hip is subluxed. A dislocatable hip is when the femoral head can be moved with manual pressure from its position within the acetabulum to completely outside the borders of the acetabulum. A dislocatable hip has greater instability than a subluxatable hip since the femoral head can be moved to a position outside the acetabulum. Generally, a dislocatable hip can be corrected with manual pressure to re-place the femoral head within the acetabulum. A dislocated hip is when the femoral head has moved completely outside the acetabulum and remains there. Depending on the cause of the dislocation the femoral head may or may not be moved back into the acetabulum with manual pressure. A teratologic hip is a more serious problem and often occurs in association with another disorder such as arthrogryposis multiplex congenita or myelomeningocele. We will discuss both of these disorders later in the course. In a teratologic hip the femoral head either never aligns within the acetabulum or moves outside the acetabulum early during in utero development. In either situation the femoral head will be outside the acetabulum and cannot be re-placed by manual pressure. Teratologic hips will always require surgical correction with boney reconstruction to correct the joint.

OSTEOGENESIS IMPERFECTA Dx

Diagnosis is made based on the child's medical history with multiple fractures and physical exam that demonstrates abnormalities. As previously stated, the more severe types of OI will result in multiple fractures and deformities at birth and the infant's appearance at birth will be cause for genetic testing. The less severe types will not result in an obvious physical appearance at birth and so diagnosis is delayed. Radiology studies that demonstrate a history of multiple fractures may also help to identify a child with OI. Finally, the diagnosis will be confirmed with a skin biopsy that reveals the abnormal collagen and genetic testing.

multitraumas

Don't forget! Often there are numerous "traumas" that happen at once!! As a competent clinician, you need to be aware of EVERYTHING that is happening with your patient and all precautions • Orthopedic complications • Internal injuries • Metabolic and lab abnormalities • Respiratory complications • Vascular injuries • Abuse • Emotional trauma

Down Syndrome def

Down syndrome is a genetic defect that results from an extra 21st chromosome. Typically there will be 3 complete copies of the 21st chromosome but sometimes there may be only 2 complete copies plus some component of a third. This disorder will result in some degree of cognitive deficits and delayed motor development. Sensory and musculoskeletal abnormalities commonly occur with this disorder. In addition, individuals with Down syndrome may also have congenital cardiac and gastrointestinal defects.

OSTEOGENESIS IMPERFECTA sx

Harrington rods may need to be surgically implanted to correct scoliosis. Deformities of the long bones of the arms and legs may also be surgically corrected by making numerous horizontal cuts along the length of the bone and then inserting intramedullary rods to hold the bone in a normal alignment as the bone heals. Some rods will need to be replaced as the child grows. Other rods are designed to telescope and these rods can lengthen as the child grows so they will not have to be replaced.

GLASCOW COMA SCALE

Head Injury Classification: • Severe Head Injury----GCS score of 8 or less • Moderate Head Injury----GCS score of 9 to 12 • Mild Head Injury----GCS score of 13 to 15

CONGENITAL DIAGNOSES DDH 6-24 mon

If the child has not been diagnosed prior to 6 months of age, the treatment is more complicated since there will typically be some soft tissue adaptation and contractures around the hip joint. Traction may be needed to stretch the soft tissue prior to the reduction which may be closed (non-surgical) or open (surgical). Regardless of the method (closed or open), the child will be placed in a hip spica cast for 3 months or longer to maintain the reduction and stabilize the hip. A hip spica cast will extend from above the waist, down over the pelvis and over each leg. Both legs are commonly enclosed by the hip spica cast to stabilize the pelvis even if only one hip is involved. Once the hip spica cast is removed an abduction brace may be worn during the day or at night to support the hip in abduction until the hip has completely stabilize.

pedatric spinal cord injury

Impairments: Impaired sensory function, impaired muscle function, movement function, gait, transfers, participation • Most common cause of pediatric SCI is MVA - 40% (followed by violence and sports) • SCIWORA has been reported in 10-20% of children with SCI • Adolescence Boys: Girls 4:1 study KEY POINTS • Congenital and acquired pediatric spinal cord injuries (SCI) pose unique management challenges because of the dynamic nature of cognitive and physical development in the growing child and the impact of the SCI on this complex process. • Care for children and adolescents with SCI should be developmentally based, using appropriate strategies to facilitate adjustment and maximize independence across the spectrum of physical and emotional maturity levels. • The goal of SCI rehabilitation for children and adolescents is to maximize function and independence and to prepare them for a successful transition to adulthood. • Depending on age at injury, the acquisition of certain skills (eg, bowel and bladder continence) may not be rehabilitation, but rather habilitation, because they may have never achieved this skill previously.

OSTEOGENESIS IMPERFECTA precatuino and contras

In addition to precautions listed above, it is important to monitor a child with intramedullary rods for sudden loss of ROM. This may indicate that the rod has moved and the end may have broken through the end of the bone and protruded into the joint space causing decreased ROM. Also note that healed fracture or surgical sites can be osteoporotic so extra caution should be used when applying passive ROM to the involved limb

CONGENITAL DIAGNOSES DDH predisposing factors

Infants with or mild hypotonicity will have less muscle support to stabilize the hip joint. Likewise, an infant with some degree of ligamentous laxity will have less stability at the hip joint. When an infant has in the hip adductors and internal rotators, the resulting abnormal muscle pull may cause the femoral head to sublux or dislocate. Infants are born with an increased amount of femoral anteversion as compared to the adult configuration. If this anteversion is further increased the abnormal mechanical forces can result in hip instability. We know that at birth the acetabulum is not much more than a shelf and does not provide for the same hip stability as does the deeper adult acetabulum. A genetic predisposition that results in an even more shallow acetabulum would further decrease the stability of the infant's hip.

MOD - SEVERE TBI THERAPEUTIC INTERVENTIONS

Initially, prevent secondary complications (comatose) • Address mobility • Work within multi-disciplinary team • Family education • Safety • Complicated by cognitive and behavioral control • Managing behavior • Structured environment • Cues for improving memory and orientation • Consistency in responses

JUVENILE IDIOPATHIC ARTHRITIS SUBTYPES

JIA Subtypes There are 3 primary subtypes of JIA: oligoarthritis, polyarticular or systemic. Some of the subtypes can be further divided into subgroups. Pauciarticular JIA has 3 subgroups while polyarticular has 2 subgroups. For our purposes we will discuss only the 3 main subtypes but you should be aware that there are further subdivisions. Oligoarthritis Oligoarthritis, is the most common of the JIA subtypes and affects about half the children with JIA. This subtype affects girls more often than boys. Oligoarthritis is characterized by affecting 4 or fewer joints, generally in an asymmetrical pattern. The knees, ankles and elbows are more commonly involved while the wrists and small joints of the hands and feet are less commonly involved. Children with oligoarthritis JIA are at risk for chronic inflammation of the iris which can lead to visual impairments so their eyes need to be periodically screened for signs of this inflammation. These children do not have systemic affects from JIA so their overall prognosis is good. Polyarticular Polyarticular JIA is the second most common subtype of JIA and, like oligoarthritis, it affects girls more often than boys. Polyarticular JIA is characterized by affecting 5 or more joints, generally in a Musculoskeletal SA2016 194 symmetrical pattern. The small joints of the hands and the wrists are more commonly involved while the hips, knees, ankles and feet are less commonly involved. Additionally, the temporomandibular joint and the cervical spine can also be involved in polyarticular JIA. This subtype of JIA has some moderate systemic involvement with a low grade fever and anemia. Also, pressure nodules may develop just under the skin. The overall prognosis for children with polyarticular JIA is not as good as in oligoarthritis. Systemic Systemic JIA, also known as Still's Disease, is the least common subtype of JIA and it affects girls and boys equally. In addition to joint pain, systemic JIA is characterized by a high fever that persists for weeks or months and that may spike (up to 103 degrees F) once or twice each day. These children will also have a salmon colored rash on the trunk and on the proximal extremities. There may also be some degree of organ involvement such as: an enlarged liver or spleen: inflammation of the pleura, the pericardium, or the myocardium; and swelling of the lymph nodes. The prognosis for children with systemic JIA is the worst of the 3 subtypes since about 25% of them will have severe involvement and unremitting arthritis.

JUVENILE IDIOPATHIC ARTHRITIS Physical & Occupational Therapy Assessment school

JIA does not result in cognitive deficits but these children may have academic difficulty due to frequent absences and problems concentrating due to pain and decreased endurance. The child may need to use a backpack to carry textbooks due to the pain and deformity in the hands. If the child cannot manage the backpack then the child may need to have a friend carry the books or to have textbooks kept in each classroom with an extra set of textbooks kept at home. Encourage the child to participate in appropriate school activities to facilitate socialization and improve self-esteem.

JUVENILE IDIOPATHIC ARTHRITIS def

Juvenile Idiopathis Arthritis (JIA) is a group of chronic inflammatory diseases that affects children and adolescents and may cause joint or connective tissue damage throughout the body. JIA as a whole affects girls twice as much as boys. The majority of cases occur in Caucasian children.

CONGENITAL DIAGNOSES Brachial Plexus Injuries klumkes palsy

Klumpke's palsy (C7-T1) affects the muscles of the hand and the sensation of the medial arm. The hand is held in a claw position of extension of the metacarpal phalangeal joints and flexion of distal, intra, and proximal phalangeal joint. The thumb is an abduction.

COMMON TYPES OF CHILDHOOD CANCERS

Leukemia • Acute Lymphoblastic leukemia (ALL) 75% of all childhood leukemia cases • Acute myeloid Leukemia • Lymphoma (Hodgkin and non-Hodgkin) • Brain cancer • Sarcoma (rhabdomyosarcoma, osteosarcoma, Ewing sarcoma) • Wilms tumor (kidney)

ACUTE LYMPHOBLASTIC LEUKEMIA

Most common cancer in children (accounts for 1/3 of all pediatric cancers); White males affected most Overall survival rate is 80% Treated with combination of chemotherapy drugs over years; if relapse, may require stem cell transplant or bone marrow transplant TREATMENT: Induction: 4-6 weeks of high dose chemotherapy Consolidation and Intensification phases: 1-2 months of high does chemotherapy Maintenance therapy: 2-3 years of low dose chemo to prevent relapse BMT or SCT: 1 week of conditioning for strong chemo and possible irradiation and then receive transplant. *** children are at risk for infection, bruising and fatigue during this time

Myelomeningocele SB

Myelomeningocele is the second most common form of spina bifida and is the form that we treat in the clinic. This is the form that is typically referred to when using the term spina bifida. This is similar to meningocele except that in myelomeningocele the spinal cord and nerve roots are disrupted and may protrude through the vertebral defect into the cyst or pouch. This will result in some degree of motor and sensory loss below the level of the lesion. Bowel and bladder control are also typically impacted since the sacral plexus is involved. This is basically a congenital spinal cord injury. Here is a reminder of the innervation levels of the spine:

JUVENILE IDIOPATHIC ARTHRITIS Physical & Occupational Therapy Assessment pain man,

Non-pharmacologic strategies to help manage the child's pain are important to include in therapy and family education. Heat may be used to decrease both pain and morning stiffness. Taking warm baths or showers, application of hot packs or use of paraffin baths for the hands and feet may be helpful. Morning stiffness may also be decreased by utilizing the child's own body heat by having the child sleep in a sleeping bag or in sleeper pajamas. Some children will prefer the use of ice and cold packs to help manage pain. There are many pharmacologic protocols for children with JIA. Please understand you will need to inquire about the medicine a child is taking when completing a history with their caregiver, but it is not necessary to know for this course.

SB diagnosis

Now that we have an idea of how the defect occurs we need to discuss how it is diagnosed. Spina bifida may be diagnosed prenatally. The maternal blood or the amniotic fluid can be tested for alpha- fetoprotein levels. We discussed this in the Prenatal Diagnostics section. Remember that alpha- fetoprotein (AFP) is a substance produced by the developing fetus. When the fetus has myelomeningocele the cerebrospinal fluid, which has a higher concentration of AFP, can leak into the amniotic fluid. From the amniotic fluid the AFP can cross over into the mother's blood. Therefore, higher than normal levels of AFP can be indicative of a fetus with spina bifida. This is a screening tool and is not a definitive diagnostic tool. Spina bifida may also be noted on ultrasound which can detect either the defect in the vertebral column or the sac protruding from the spine. The skull will also be screened for the "banana sign" (an abnormal anterior curvature of the cerebellar hemispheres) and the "lemon sign" (an inward depression of the bilateral frontal bones due to the leaking cerebrospinal fluid). If the spina bifida lesion is detected prenatally then the obstetrician will plan to deliver the baby by Cesarean section in order to prevent further damage. If the infant passes through the birth canal the pressure could cause the external sac to tear open and cause additional stretching and damage to the nerves. This can also increase the risk of infection which is particularly serious since the infection could impact the CNS. Prenatal diagnosis also allows the appropriate medical team to be prepared to deal with the complications that occur with spina bifida. One of those issues is an allergic reaction to latex which can cause anaphylactic shock. Knowing that the fetus has spina bifida allows the medical staff to make sure the delivery room equipment and supplies, such as gloves and tubing, are free of latex. When the diagnosis is made prenatally there may be an opportunity to attempt an in utero surgical repair of the defect. According to a large cohort, 7 year study (Management of Myelomeningocele Study or MOMS- Adzick et al., 2011), in utero surgery decreased the need for shunt placement and improves mental and motor outcomes as opposed to repair surgery after the child is born. At this time, only specialized medical centers complete this surgery. Incidence If the in utero surgery is not completed, the lesion will be surgically closed within 24 to 72 hours after birth to prevent further damage and to minimize the risk of infection.

Seizure Disorders defs

Now what exactly is a seizure? Generally a seizure is triggered by an abnormal electrical discharge in the brain that results in an involuntary alteration in consciousness, motor activity, sensory experiences, behavior or autonomic function. A seizure is typically a brief episode and is often a symptom of some other problem. Just because someone has a seizure does not mean the person has epilepsy. It is not unusual that someone has a single seizure and then never has another one. In these cases the seizure may be caused by an electrolyte imbalance or a metabolic disturbance. Once the electrolyte or metabolic issue is corrected then the seizure activity will no longer occur. Epilepsy is a condition of chronic or recurring seizures that are not related to high fevers. While most seizures are brief in duration, occasionally seizure activity can last for 30 minutes or more without the individual regaining full consciousness. This extended seizure activity is known as status epilepticus and constitutes a medical emergency since during the seizure the individual may experience anoxia resulting in brain damage or death. Status epilepticus can occur in any individual, whether or not that individual actually has epilepsy. SEIZURES/SEIZURE DISORDERS Following this section, required reading and independent study, the learner will be able to: 1. Define a seizure. 2. Distinguish between a seizure and epilepsy. 3. Describe the pathophysiology of seizures. 4. Name the two major classifications of seizures. 5. Differentiate between the characteristics of generalized versus partial seizures. 6. Describe the clinical features of the following Generalized Seizure types: The incidence and prevalence rates are listed in the course notes but you will not be responsible for knowing these. This information is included for general reference. Seizures occur more commonly in males than in females but the reason why is unknown.

CONGENITAL DIAGNOSES Congenital Muscular Torticollis Dx

One in 5 children presenting with a torticollis posture has a non- muscular etiology. Non-muscular causes may include skeletal abnormalities such as Klippel-Feil syndrome or neurologic causes such as brachial plexus injury. Because many lesions can masquerade as congenital muscular torticollis, the initial examination should include a detailed history and a thorough physical examination to determine if the lesion is congenital or acquired. Acquired nontraumatic torticollis may be caused by ocular lesions, Sandifer syndrome, benign paroxysmal torticollis, dystonic syndromes, posterior fossa pathology, postencephalitis syndromes, Arnold-Chiari malformation, and syringomyelia.1

OSTEOGENESIS IMPERFECTA def

Osteogenesis Imperfecta (OI) is a genetic disorder that causes collagen to be produced in a disorganized manner throughout the body. The collagen abnormality results in weak or fragile bones that break easily, often from little or no apparent cause.

SB clinical mani

Other Clinical Manifestations Aside from the motor and sensory loss there are additional problems that can be associated with spina bifida. Impaired Intellectual Function A child with spina bifida may have some degree of cognitive dysfunction which can be related to the hydrocephalus and the increased intracranial pressure that can result from the hydrocephalus. The cognitive dysfunction can range from mild learning disabilities to more severe intellectual disability. Cognition can be impacted by the child's limited ability to explore the environment due to the motor and sensory loss affecting the legs. Even for children with average intellectual abilities, they may still have problems with organization, attention and memory. Speech and Language Impairments Language may be impaired any time that cognition is impaired. Children with spina bifida often have a language impairment known as "cocktail party syndrome." This is a language disorder commonly associated with hydrocephalus but may also occur with other disorders. "Cocktail party syndrome" results in a child who talks a lot and often uses sophisticated words and phrases that would not be expected for a child. However, the child uses these words inappropriately and repetitively. The child has difficulty taking turns during conversation and can dominate the conversation. Bowel and Bladder Dysfunction The nerves that control bowel and bladder function are located in the sacral plexus which is typically disrupted in spina bifida. The child may not have volitional control of the bladder which can result in incontinence or problems with completely emptying the bladder. If the bladder does not empty completely, urine can back up and cause damage to the kidneys or the urine can stagnate and increase the risk for urinary tract infections. The parents can be taught to use clean intermittent catheterization where a sterile catheter is inserted into the urethra, past the sphincter, to allow the bladder to empty and then the catheter is removed and disposed of. Parents can also be taught to apply pressure on the abdomen to help facilitate emptying of the bladder. Older children may also be taught to catheterize themselves. A child with spina bifida will also have problems with bowel control ranging from constipation and difficulty moving the bowels to overflow diarrhea. Medications may be used to assist with bowel and bladder management and there will need to be a regime to regularly empty both. Later, a suprapubic catheter may be surgically implanted to assist with bladder management. Impaired Fine Motor and Perceptual Skills Children with spina bifida often have delays in the development of fine motor skills, bimanual activities, and in the development of hand dominance. This is often related to the delay in gross motor skills. Since these children often have some degree of paralysis of the legs they must rely more on the use of their arms for sitting and for mobility. A typically developing child will be able to sit with forward propping at 5 months of age and then free the hands to sit without forward propping on the arms at 6 months of age. A child with spina bifida will need to rely on forward propping on the arms for much longer due to the lack Lack of Independent Mobility and Self-Care Skills of sensation and motor control in the legs and possibly the lower trunk. This will depend on the level of the lesion. There can also be decreased upper extremity strength in the case of Arnold-Chiari II malformation and with hydromyelia. Additionally, children with spina bifida often have problems with spatial relation issues and with body perception due to the sensory loss. The degree of deficit in mobility and self-care skills will be related to the level of the lesion. Typically, the higher the lesion is the greater the motor and sensory loss will be. Spina Bifida SA 2016 14 Children with spina bifida will be provided alternate means of mobility such as a prone scooter board, a wheelchair or a mobile stander. Children will be encouraged to walk with the necessary leg braces and assistive devices such as walkers and forearm crutches until school aged. When these children start school they may prefer to use a wheelchair for ease of negotiating the school environment and due to the energy demands of walking with the assistive devices and braces. Dependence in self-care issues may also be related to the perceptual and fine motor problems. This can impact their ability to feed themselves. Delays in dressing will be further hampered by the degree of paralysis and any weakness caused by secondary problems. Orthopedic Problems Children with spina bifida are prone to develop contractures due to the unopposed action of muscles at specific joints. For example, a child with an L1 lesion will have active hip flexion but not hip extension. The children will use the muscles they have available so they will pull the hips up into flexion but will not be able to move the hips into extension. The constant use of hip flexors in conjunction with immobility and excessive sitting will increase the risk of developing hip flexion contractures. An L2 lesion will result in active hip flexors and hip adductors so there is an increased risk of hip subluxations or dislocations due to the abnormal muscle pull. In addition, a lower thoracic lesion will result in no muscle activation around the hips and this too could result in hip instability. If the muscles that act at the foot and ankle are not innervated then there is an increased risk of clubfoot. Clubfoot will need to be corrected as soon as possible to align the feet appropriately for standing and weight bearing. The deformity of the involved vertebral segments may result in scoliosis, kyphosis and kyphoscoliosis. Secondary issues such as hydromyelia or tethered cord may also result in scoliosis. These conditions may require surgical placement of rods to correct the spinal column alignment. The lower extremity paralysis will result in decreased muscle pull on the bones of the legs and decreased weight bearing. Both of these issues can contribute to osteoporosis and increase the risk of bone fracture. Associated Problems Children with spina bifida have an unusually high incidence of latex allergies. This latex allergy can result in anaphylactic shock and can be life threatening. Because of this the child should not be exposed to latex. We have already discussed the need to have no latex-containing products in the delivery room. Therapists need to make sure they use latex-free gloves and toys during treatment. Children with spina bifida will have areas of skin that have no sensation and those areas are susceptible to injury. The children may not cry when the parent sits them in too hot bath water. The children will not feel the discomfort of a blister forming from the rubbing of braces or shoes. The children will not cry when commando crawling and pulling their bare legs over rough surfaces and tearing the skin. Therapists play an important role in educating children and their families about skin protection and regular skin checking regimens. Children with spina bifida lesions at L2 or above are at risk for becoming obese due to the decreased energy expenditure. Not only are these children less active due to the degree of lower extremity paralysis but their metabolic needs are lower due to the inactivity of the large muscles of the legs. It is not uncommon for children with spina bifida to have seizure disorders. These seizure disorders can be related to the hydrocephalus or the Arnold-Chiari II malformation and are usually well controlled with anti-seizure medications. Visual impairments may also occur and can be related to the hydrocephalus and Arnold-Chiari II malformation. Spina Bifida SA 2016 15 When children with spina bifida reach adolescence they may become depressed due to lack of social interaction. They may not be invited to the parties and dances due to the limited mobility and their wheelchair use. The lack of sensation and the neurological impairment can result in sexual dysfunction which can add to the poor self-esteem and self-concept.

JUVENILE IDIOPATHIC ARTHRITIS Physical & Occupational Therapy Assessment ROM

PROM should always be measured goniometrically. In the upper extremities the motions that are often limited include shoulder flexion and external rotation, elbow extension, forearm supination and wrist and finger extension. The commonly limited motions in the lower extremities include hip flexion, adduction and both internal and external rotation, knee flexion and extension, and ankle dorsiflexion and plantarflexion. The cervical spine PROM into extension, lateral flexion and rotation should also be measured. If the TMJ is involved then the distance from the top border of the lower teeth to the bottom edge of the upper teeth should be measured with a tape measure. AROM can be assessed by playing a game such as Simon Says. ROM activities should be performed at least twice daily with each joint being moved through the available range for 3-5 repetitions. This will help to improve the extensibility of the muscles and connective tissues to improve joint mobility. Encourage the child to participate in active ROM activities as much as possible. Be cautious when using passive ROM and stretching since using too much force could cause joint damage such as subluxing the tibia posteriorly on the femur. It is recommended that when performing passive ROM slight overpressure should be applied at the end of the available range and then hold the overpressure for 60 seconds. Musculoskeletal SA2016 197 Positioning can also be used to address ROM issues. Encourage the child to lay prone for at least 20 minutes each day with the hips and knees fully extended and with the feet off the end of the support surface. Light weights can be placed on the child's ankles to increase the effects of gravity in increasing the knee extension ROM. When seated the child's feet should be supported with the ankles in neutral to minimize the risk of plantarflexion contractures. Dynamic splints may use springs or rubber bands to provide a maintained stretch on tight tissues. These can be worn at night while the child is asleep or for shorter periods of time when the child is awake. Functional splints may be used to support a joint during functional activities such as AFOs worn to increase stability or decrease pain or a splint used to support the wrist during while doing schoolwork. Serial casts may also be used to increase ROM by maintaining a prolonged stretch on the tight tissue. Compliance may be better than with splints since the child cannot remove the cast as they can the splint. However, the casts may need to be changed every 2-3 days to prevent excessive stiffness caused by lack of mobility. ROM activities would need to be performed on the involved segments before application of the next cast.

traumatic brain injury

Physical, external force to the head • Impairments may include: spasticity, ataxia, muscle weakness, balance dysfunction, *intellectual/cognitive, behavioral, emotional and speech deficits • < 2 years old; most common cause is non-accidental trauma (abuse) • Shaken baby syndrome: retinal hemorrhages, SDH or SAH, little external trauma • 3 y.o. and older: falls, MVA, pedestrian accidents

ARTHROGRYPOSIS MULTIPLEX CONGENITA precutions and contras

Precautions/Contraindications Gains will be made in ROM but progress is slow. Most increases in ROM will occur before the age of 3 and after surgical intervention. Stretching should not be overly aggressive or forceful since this could in fact cause damage to the joint or the soft tissues surrounding the joint. Stretching can be accomplished through the use of serial casts and splints which provide a prolonged stretch. Due to lack of normal weight bearing through the long

seizures etiology

Seizure activity is triggered by an abnormal electrical discharge in the brain. This abnormal electrical activity may originate with a small number of cells and then spread to other cells. Eventually, the abnormal firing of neurons can spread rampantly creating what is referred to as a "storm" of electrical activity which can eventually involve the entire brain. The abnormal firing of neurons may result in the atypical behavior observed during the seizure. The part or parts of the brain that are involved in the abnormal electrical activity will result in different types of seizures and behaviors observed during the seizure. The abnormal electrical activity is typically caused by some functional or structural problem in the brain which lowers the threshold for electrical activity. Causes of this abnormal electrical discharge include metabolic disturbances, electrolyte imbalances, vascular disturbances, fevers, or some insult or injury to the brain. Traumatic brain injuries, closed head injuries, brain tumors or central nervous system infections may also cause seizures. Brain injuries, infections, or tumors are typically the cause of adult onset seizure activity. Some types of seizures may have a genetic link with a lower threshold for the abnormal electrical activity that causes the seizure.

seizures classified (not gen or partial )

Seizures may be classified as idiopathic or symptomatic idiopathic seizures have no obvious cause such as an infection or injury to the brain. Idiopathic seizure activity typically begins between 2 and 14 years of age. Symptomatic seizures can usually be linked to a specific cause such as a birth trauma or a metabolic disorder. The onset of symptomatic seizure activity is earlier than in idiopathic seizures and typically begins prior to the second birthday.

OSTEOGENESIS IMPERFECTA s&s of new Fx

Signs and symptoms of a new fracture include: pain and guarding the area around the fracture; swelling, bruising, redness and warmth in the soft tissues around the fracture; and deformity of the segment due to the fracture. Sometimes a child demonstrates minimal signs indicating they have a fracture. As a clinician, make sure you always ask the caregiver what that specific child's signs/symptoms look like.

SB incidence

Spina Bifida is the most common permanently disabling birth defect in the United States. (spinabifidaassociation.org) and the second leading cause of mobility limitations. Although this is a startling fact, the incidence is decreasing due to the discovery of a maternal nutritional link to spina bifida. Decreased maternal intake of folic acid, one of the B vitamins, prior to conception Spina Bifida SA 2016 11 was found to increase the risk of having a child with spina bifida. Currently the US Public Health Service recommends that women take 0.4 mg of folic acid (folate) daily prior to conception and for the first 12 weeks of pregnancy. There is a genetic link to a type of spina bifida and when the above recommendations are followed the genetic risk is decreased by 70%. Folic acid can be found in foods such as cereals, broccoli, spinach, corn and others, or it can be taken as a vitamin supplement. Many foods are now being enriched with folic acid for this reason. Now, we know the embryological origins of spina bifida but what causes the nonunion of the neural fold or the rupture of the neural tube? This is a complex and multifactorial issue. We have already discussed the folic acid issue. Spina bifida has also been linked to maternal use of the anti-seizure medication valproic acid (Depakote) and the acne medication Accutane after conception; maternal alcoholism and increasing maternal age; and paternal exposure to Agent Orange a defoliant sprayed in the jungle during the Vietnam War. Spina bifida has also been linked to other environmental factors such as pollution and to lower socioeconomic levels. Typically people in the lower socioeconomic levels tend to live in the less desirable areas where they are exposed to negative environmental factors such as pollution. Also the risk is greater in people of Irish descent but lower in people of African or Japanese descent.

CHILDHOOD CANCER TREATMENT IMPLICATIONS

Stage of growth and development of child • Stage of psychosocial, emotional and cognitive development • Immaturity of child's organ system • Late effects of disease and treatment • Treatment of • CNS can cause cognitive, hearing and visual deficits • CNS, head, neck, gonads can cause endocrine abnormalities (short stature, hypothyroidism, delayed secondary sexual development) • Musculoskeletal system can cause scoliosis, spinal shortening • The child who has received radiation or chemotherapy has a 10x greater chance of developing second malignancy (compared to child who never had CA)*

SB standing and ambulation

Standing and Ambulation When typically developing children would typically be standing, children with spina bifida will be supported in a standing position. There are a number of different devices including standing frames, parapodiums and orthoses that can be used to support the child in standing. Regardless of the level of the lesion, supporting the child in standing will allow gravity to assist with bowel and bladder drainage. Weight bearing through the legs will help to prevent osteoporosis, maintain ROM and prevent contracture formation and improve the congruence between the femoral head and the acetabulum and help to deepen the acetabulum. Standing will also help to improve upper extremity strength and function since the arms are not required to stabilize the body and can be used for function. Standing can also improve cardiopulmonary endurance and circulation. Another advantage of standing is improved interaction with the environment. This can also be beneficial for their socialization with other children. Children supported in standing can be at eye level with their peers rather than having their peers stand while the children with spina bifida are seated in the floor or in a wheelchair. Another device that may be used is a mobile stander which is a supportive device with wheels attached so that the child can propel the device in a standing position rather than a seated position as in a wheelchair. With lower level lesions the child may be able to ambulate with leg braces and walkers or forearm crutches.

ARTHROGRYPOSIS MULTIPLEX CONGENITA Sx

Surgery When the conservative approach using stretching, serial casting, and splinting has not been successful in increasing ROM and function, surgery may be required. Surgery is usually performed on the lower extremities before the age of 2 to improve alignment of the legs for standing and ambulation. This may involve stabilizing the hips and increasing mobility of hip ROM. Unilateral hip dislocations will be corrected to level the pelvis and decrease the risk for scoliosis to develop. Interestingly, if both hips are dislocated surgical correction may not be done to prevent the risk for complications of pain and stiffness that might further impair mobility. Sometimes the hips will be surgically fused in a more functional position and to decrease pain. Knee surgery may not be attempted unless the child is already ambulatory and the surgery could further improve alignment and function. Surgery may also be required to correct the clubfoot deformity to provide a normally aligned foot for standing and ambulation. Surgery to improve function and ROM for the upper extremities is usually performed later than surgery for the lower extremities. The primary functional goals for the upper extremity is to improve ROM for Musculoskeletal SA2016 188 functional activities such as getting the hand to the mouth so the child will be able to eat independently or to improve the child's ability to dress and perform toileting skills. Sometimes to increase function, one elbow will be fused in flexion to facilitate getting the hand to the face and mouth while the other elbow is fused in flexion to facilitate dressing and toileting. Tendon transfers, as we discussed in the Medical Management of Cerebral Palsy may be used to improve muscular function for elbow movement. Likewise, the wrists can be fused in either flexion or extension to improve function. Shoulder contractures are usually not surgically corrected. Scoliosis is usually managed with bracing unless the curve progresses to 50 degrees or more and then surgery will be required to prevent further progression and to improve respiratory function. ROM, exercise and functional activities will be needed following surgical procedures to get the best outcome.

JUVENILE IDIOPATHIC ARTHRITIS Physical & Occupational Therapy Assessment Sx man.

Surgery may be necessary to address severe contractures that have not responded to conservative techniques. Tendon lengthenings are commonly performed on the hip flexors and adductors, knee flexors and ankle plantarflexors to increase range of motion for improvement of functional activities, for ease of positioning and care-giving, and for pain reduction. Immobilization after surgery should be avoided since that may contribute to additional stiffness and further loss of ROM. A continuous passive motion (CPM) device may be used post-surgery to prevent immobilization complications. A splinting and positioning program incorporating several position changes throughout the day and night may also help prevent losing ROM. When the physician clears the patient for active movement and therapy, an active exercise program should be implemented to increase ROM and strength but without increasing the child's symptoms. Some children will need to have the joints fused into a functional position to decrease pain or they may need to have the joint surgically replaced. Most surgeons prefer to wait until the child is an adolescent before performing a joint replacement. If the replacement surgery is done when the child is younger, the joint components may have to be replaced again later due to growth of the child. The course notes contain a suggested postoperative program for a total hip replacement and

CP med man Anti-spasticity medication

Systemic management: - Baclofen- oral vs intrathecal (see below) - Diazepam (Lioresal) - Dantrolene sodium (Dantrium) Oral baclofen has a systemic effect and since it is taken by mouth, it will not reach the concentration of intrathecal baclofen. Baclofen is thought to be a GABA agonist (binds at GABA receptor) and works at the level of the spinal cord to inhibit the release of excitatory neurotransmitters. Overall, it depresses the CNS. It is important as a therapist to communicate with the physician when a child you are working with is going through the titration phase with his/her medication. You may need to communicate with the parents or doctor if you notice the patient is more lethargic or is demonstrating signs of hypotonia (drooling, increased weakness etc.). Oftentimes the therapist is the person who sees the child most often and has a skilled eye to notice changes that might indicate high or low dosages of medicine. Another used to decrease spasticity is to implant a baclofen pump. Remember that Baclofen (Lioresal) is one of the oral medications that are used to decrease spasticity. Like the other oral anti-spasticity medications, oral baclofen has side effects which may have a significant impact on the child's function. The baclofen pump allows the baclofen to be delivered intrathecally or directly into the spinal canal. The baclofen pump is a disk-shaped device about the size of a hockey puck that is implanted under the skin of the abdomen. Tubing is connected to the pump and then the other end of the tubing is inserted into the intrathecal space of the lumbar spine. The pump has a reservoir that contains the liquid baclofen and a neurosurgical procedure Medical Mgmt CP SA 2016 CAndrea, PT, NCS, CBIS 175 computer which controls the release of the baclofen into the intrathecal space. The amount of baclofen released can be adjusted by changing the computer settings. Delivering the baclofen directly into the intrathecal space into the cerebrospinal fluid increases the effectiveness so smaller doses are required to reach a therapeutic level. The risks of systemic side effects are decreased since smaller doses are required as compared to orally administered baclofen. Unfortunately, refilling the reservoir can be uncomfortable or painful to the child. A needle must be inserted through the skin and into a rubber bladder in the center of the pump to inject more baclofen into the reservoir. It is important to keep baclofen in the pump. There have been a few cases where the pump ran completely out of baclofen and the sudden lack of baclofen triggered a series of events that had fatal outcomes. This requires close medical supervision to assure the correct dosage of administration and to maintain appropriate levels of baclofen in the pump. There can also be serious consequences if there is a mechanical failure of the pump. MedTronic is a manufacturer of the baclofen pump and one of their representatives once told me they have about a 10% failure rate. Failure generally requires replacement of the pump. Also, there is a risk for infection since a foreign object is being surgically implanted in the body. Another advantage of the baclofen pump is that since the baclofen is delivered directly into the intrathecal space, there is an opportunity to decrease spasticity to muscles other than just those in the lower extremities. By working the tubing up the spinal canal toward the thoracic region there can be a greater impact on reducing spasticity in the muscle of the upper extremities. Diazepam (Lioresal) is the oldest anti-spasticity medicine should be only a short-term treatment in children. Like Baclofen, it has an increased affinity for GABA resulting in presynaptic inhibition. It is best given as a nighttime dose, as it causes a lot of sleepiness; other side effects: ataxia, constipation, urinary retention, weakness, sedation, hypersalivation; prolonged use can cause physical dependence and cannot be discontinued abruptly. Dantrium- works at the level of the muscle and should not be used in children under the age of 5. It inhibits the calcium release from the sarcoplasm reticulum and thus limits overactivity or spasticity of the muscle

JUVENILE IDIOPATHIC ARTHRITIS Physical & Occupational Therapy Assessment observstion and inspection

The assessment should also include an observation and inspection of the children's joints to see which joints have signs of active inflammation. A joint is considered to be active if the joint has effusion, tenderness or joint pain. Joint effusion is assessed by applying pressure over the joint to see if there is Musculoskeletal SA2016 195 movement of synovial fluid. Joint tenderness is present when firm pressure directly over the joint line causes greater pain or discomfort than the same pressure applied to the bone adjacent to the joint. Stress pain is present when gentle overpressure applied at the end of the available passive ROM of a joint results in pain. The course notes contain an example of a diagram used to record and track the active joint count. The appearance of each involved joint should be recorded including girth measurements which are used to note edema. Note that the girth measurements can also increase due to the boney overgrowth that can occur at the humeral head, radial head, femoral head, medial femoral condyle and the proximal tibia. The girth measurements can decrease as the edema decreases but not if the increase is due to boney overgrowth. The joints should also be assessed for signs of redness, heat and synovial thickening.

CONGENITAL DIAGNOSES Brachial Plexus Injuries def

The brachial plexus is made up of spinal nerve roots C5, C6, C7 C8, and T1. An obstetric brachial plexus injury (OBPI) usually occurs during a difficult vaginal delivery. Traction on the newborn's shoulder during delivery of the head in a breech delivery can injure the cervical roots, fracture the clavicle or humerus or sublux the shoulder. Forceful traction and rotation of the head during a vertex presentation to deliver the shoulder tends to injure the C5 and C6 roots. Associated damage to the phrenic nerve at C4 is less common, yet will cause ipsilateral hemiparesis of the diaphragm. Congenital anomalies such as cervical rib, abnormal thoracic vertebrae, or shortened scalenus anticus muscle can also cause pressure on the lower plexus.1 BPI can be caused in older children as a result of a sports injury or other trauma. Several factors can increase a neonate's risk of OBPI. Gestational weight over 8 pounds, breech presentation (transverse orientation rather than head down in pelvis) during delivery, and the use of a forceps or evacuation pump to deliver the baby all increase the risk of OBPI. The dysfunction seen in the infant depends upon which nerves are stretched. Pathophysiology: Damage can occur at the level of the nerve rootlet attached to the spinal cord, the anterior or posterior rootlets, or distal to where the rootlets coalesce to form the mixed nerve root that exits the vertebral canal. Roots, trunks, divisions, neurotmesis(complete rupture), axonotmesis (disruption of axons while neural sheath remain intact), or neuropraxia (temporary nerve conduction block with intact axons). Partial or complete rupture may evolve into a neuroma and a mass of fibrous tissue is disorganized neurons on the proximal end attempt to reach their distal end. Hemorrhage into the subarachnoid space leads to presence of blood in the cerebrospinal fluid, which can be diagnostic of this more serious injury.1 Recovery is usually very limited after ruptures. Prognosis after axonotmesis is better as the neurons reconnect more successfully through the intact neural sheath. As axon regrowth proceeds at approximately 1 mm per day, the majority of recovery usually takes 4 to 6 months in the upper arm and 7 to 9 months in the lower arm. Continued recovery can occur for up to 2 years in the upper arm and 4 years in the lower arm. Early recovery after neurapraxia occurs as edema resolves and is usually quick and complete, sometimes within days or weeks. In children with OBPI, a combination of these types of lesions is common, which may explain the variability of return of motor function in individual muscles.1

JUVENILE IDIOPATHIC ARTHRITIS Physical & Occupational Therapy Assessment gait

The children's gait should be observed both with and without shoes on level surfaces. Their gait on uneven surfaces such as an incline or ramp and stairs should also be assessed as should their ability to run, Musculoskeletal SA2016 196 if possible. Note the use of assistive devices, if any, required for ambulation and whether or not the child can ambulate without the device. Also note if the devices have been adapted to accommodate upper extremity pain and limitations. Document any gait deviations which are typically due to either weakness and/or ROM limitations. Some of the commonly observed gait abnormalities associated with JIA include: decreased velocity due to pain and stiffness; decreased step and stride length due to weakness and ROM limitations; decreased hip extension due to hip flexion contractures; decreased plantarflexion at toe-off or preswing; and an increased anterior pelvic tilt due to the hip flexion contractures and the increased lumbar lordosis.

JUVENILE IDIOPATHIC ARTHRITIS Physical & Occupational Therapy Assessment strength

The children's strength should also be assessed. If the child is at least 5 or 6 years old and can follow the verbal commands then manual muscle testing can be used to assess strength. Note that the manual muscle testing may need to be modified somewhat to use shorter lever arms and to consider the children's pain tolerance when applying the resistance. Younger children's strength can be assessed by noting the functional positions the children can assume and how they transition into various positions. The lower extremity antigravity muscles including the hip extensors and adductors, the knee extensors and the ankle plantarflexors should be assessed. In the upper extremities the strength of the deltoids, biceps, triceps, wrist extensors and finger flexors and extensors should be assessed. Girth measurements of the thighs and the lower legs can be used to help track disuse atrophy, including the quadriceps and gastrocnemius muscles. Another option for assessing strength is to have the child push against a partially inflated blood pressure cuff and record the highest "pressure" achieved. Strengthening activities should focus on the antigravity muscles as previously noted. Isometric exercises may be used during active joint disease or when movement of the segment against gravity is painful. Isometric holds for 6 seconds or less should be performed at several points throughout the range. Submaximal contractions should be used to prevent compression of the joint surfaces which could be painful. Active-resistive exercises can be used once the child can move the joint against gravity for 8-10 repetitions without pain. These exercises should be performed only in the pain-free range. The child should eventually be able to perform 8-10 repetitions of 8-10 different exercises 2-3 times per week. These exercises should not be performed on consecutive days to prevent exacerbation of symptoms. The exercise program should be closely monitored and adjusted, as necessary, to prevent an increase in symptoms. A gentle warm-up and cool-down period should be incorporated into the exercise program. Endurance The child's endurance to the exercise should be monitored and increased if possible. Aerobic activities that cause minimal stress to the joints should be used to increase functional strength and endurance. These activities include such things as walking, riding a stationary bike, low impact aerobic dancing or swimming. Swimming or exercising in a heated pool may help with pain management while also increasing movement.

seizure diagnosis

The diagnosis of seizure disorders can be complex. Since many things can trigger a seizure, part of the diagnostic process is to investigate and rule out possible causes. Blood can be analyzed for electrolyte or metabolic imbalances and screened for toxins. CNS infections may be detected through a lumbar puncture and analysis of the cerebrospinal fluid. Magnetic Resonance Imaging (MRI) and Computerized Topography (CT) scans may be able to identify CNS tumors, vascular disorders such as an AV malformation or brain abnormalities. If one of the above is identified, correcting the problem may eliminate the source of the seizure activity so the individual may not have any more seizures. If none of the above is found then an Electroencephalogram (EEG) may be performed to measure the electrical activity of the brain through surface electrodes placed on the head. During the EEG the individual may be exposed to different stimuli such as strobe lights flashing at different intervals to determine how the brain responds. The stimuli may trigger a seizure and then the abnormal electrical activity during the seizure can be recorded. The electrical activity recorded during the EEG can help to identify the type of seizure the individual has since different types of seizures can produce different patterns of electrical activity. It is estimated that approximately 80% of children with seizure disorder will have abnormal patterns of EEG Seizures may be classified as idiopathic or symptomatic Idiopathic activity in between seizures. The time when the seizure activity occurs is referred to as the ictal period while the time immediately following the seizure is known as the postictal period. On the next page are some of the different EEG patterns recorded during different types of seizures. It is important to identify the type of seizure the child has because different seizure types require different treatments.

JUVENILE IDIOPATHIC ARTHRITIS etiology

The exact cause of JIA is not well understood but it is thought to be multifactorial. JIA is considered to be an autoimmune disease. It is thought that an infectious agent or some type of trauma can result in an autoimmune response in a child who is genetically predisposed. There is generally no family history of JIA and it is rare to find multiple cases in one family.

OSTEOGENESIS IMPERFECTA etiology

The exact cause of OI is complex and not well understood other than the genetic defect interferes with normal collagen synthesis. Currently there are 3 different genetic defects on 3 different chromosomes that have been identified as leading to OI. Mutations in the COL1A1 (collagen, type I, alpha 1) gene located on chromosome 17, the COL1A2 (collagen, type I, alpha 2) gene located on chromosome 7, and the CRTAP (cartilage associated protein) gene located on chromosome 3 can all cause OI. Most cases of OI are inherited through an autosomal dominant pattern but there is at least one form that is inherited through an autosomal recessive

DS types

The first of these is something called nondisjuntion which accounts for the majority of cases. This results in the failure to separate of one of the 21st chromosome pairs during either the first or second meiotic division during the production of ovum or sperm. The figure below demonstrates this occurring in the production of the ovum but it can also occur during the production of sperm. The dark cells in the diagram that have only 1 copy or less of the 21st chromosome will not be viable. The second mechanism is Translocation which occurs when a part of the 21st chromosome gets transferred or "stuck" onto another chromosome during meiosis. The other chromosome is typically the 14th, 21st or 22nd. While this is not a complete copy of the 21st chromosome, there may be enough extra 21st chromosomal material to result in Down syndrome. An example of this can be seen in the figure below. The last mechanism is which is the least common cause of Down syndrome. Mosaicism results due to faulty cell division which occurs after fertilization, often during the 2nd or 3rd cell division. This faulty cell division will result in an individual with some cells having 46 chromosomes (with only 2 copies of the 21st) and some having 47 chromosomes (with 3 copies of the 21st). This is demonstrated in the diagram below.

CONGENITAL DIAGNOSES Congenital Muscular Torticollis incidence

The incidence of plagiocephaly has increased significantly since it was recommended that infants be placed on their backs to sleep to prevent sudden infant death syndrome (SIDS) in the 1992 "Back to sleep" campaign. More recently, the incidence of plagiocephaly has been reported to have increased to as high as 1 in 60 live births, which may be partially explained by infants sleeping on their backs. In 2008, Stellwagon3 reported that one in six or 16%, of healthy newborns have torticollis, most newborns exhibit mild or moderate craniofacial asymmetries, and it is possible to detect torticollis early in life. In the study cohort, infants were identified by measuring neck rotation and neck lateral flexion (how far the ear tilted toward the ipsilateral shoulder), and by comparing left and right side neck mobility. Torticollis was defined as >15% difference when comparing the two sides. The study found that the newborn with torticollis generally can rotate the head to the shoulder but demonstrated restriction in lateral flexion when measured in supine. Habal and colleagues 4 have suggested that a new syndrome, the 'flathead' syndrome is being introduced and may identify neurocognitive difference or delay disorders among patients who may have appeared normal before the change in sleep position. It is hypothesized that infants born with torticollis are at risk for developing deformational plagiocephaly, and this risk may be reduced by early intervention. Plagiocephaly is reported as a coexisting impairment in 80% to 90.1% of children with congenital muscular torticollis.1If cranial deformation begins in-utero, the deformational forces on the occiput may continue after birth if the infant sleeps supine and also spends time in supine or semi-supine during waking hours. In this case, the cranial deformation may worsen after birth because the infant cannot yet move the head away from the supporting surface.

CONGENITAL DIAGNOSES Congenital Muscular Torticollis activity limtations

The infant with CMT is unable to have purposeful symmetric movement of the head because of the neck muscle contracture and neck muscle strength imbalances. Impaired mobility may lead to persistent asymmetry of early reflexes and reinforcement of an asymmetric postural preference. Secondary impairment would include neglect of the ipsilateral hand; decreased visual awareness of the ipsilateral visual field; Congenital SA2016 CAndrea, PT, NCS, CBIS 140 interference of symmetric development of head and neck righting reactions; delayed propping and rolling over to the side; and limited vestibular, proprioceptive and sensorimotor development. These early activity limitations can lead to asymmetrical weight bearing in sitting, crawling, walking, and transitional movement skills and incomplete development of automatic postural reactions. If the limitations are not addressed, the postural asymmetries may persist causing structural deformities such as pelvic obliquity and scoliosis. Inability to rotate the head and neck will result in the child rotating the body to compensate. The inability to recruit lateral neck flexion with automatic reactions will cause the child to compensate with overuse of the trunk muscles. Often the child with CMT may clinically present as a child with hemiplegic cerebral palsy. Other activity limitations may include inability to sustain midline head posture in an upright position; regaining head midline posture in vertical, prone, or supine with weight shifts; and maintaining midline head posture during movement Both the infant and child will exhibit impaired abilities to weight bear on the upper extremity on the involved side, reaching toward midline with forearm supination, shoulder external rotation and flexion, and full expression of upper extremity protective and equilibrium reactions. The infant will use compensatory maneuvers to perform a task such as hand clapping by crossing midline to bring the uninvolved side upper extremity toward the involved arm. The systems contributing to these activities limitations include the musculoskeletal system (limited cervical range of motion and muscle strength) and the sensory systems of vision, vestibular function, and somato-sensation needed to regulate posture. These systems also influence adaptive and anticipatory responses to help control head position and anticipate postural adjustments by adapting head positions during weight shifts and active exploration. The infant with CMT responds to these imposed restrictions with self-initiated movements that include a pattern of head tilting to the ipsilateral side and rotation to the contralateral side of the SCM muscle involvement. The infant with CMT is then unable to adapt appropriately to the supporting surface and has limited kinesthetic feedback, which affects the development of the sensorimotor systems, postural organization, orientation, and body schema. The infant may demonstrate difficulty participating in activities toward the involved SCM muscle side while developing appropriate postural, motor, and visual control of the uninvolved side. The infant may not exhibit organized midline behavior as a result of the foregoing asymmetries. Motor milestones may develop atypically because the various subsystems (visual, vestibular, somatosensory, and musculoskeletal) are developing asymmetrically and the infant is not experiencing normal interactions of each system as growth and development occur.

JUVENILE IDIOPATHIC ARTHRITIS pathology

The inflammation will affect the tissues around synovial joints. There will be an increased production of synovial fluid with swelling and distension of the joint capsule. An overgrowth of synovial cells, called a pannus, spreads over the articular cartilage causing the cartilage to soften and weaken. The joint surfaces will become irregular due to erosions in the articular cartilage and subchondral bone. These erosions in the joint surfaces will affect joint congruency as well as the alignment and stability of the joint. Adhesions and osteophytes can form within the joints which can further affect joint alignment and congruency. The tendons and ligaments around the joint can become fibrotic resulting in joint contractures. Muscles that act across the joint can atrophy due to reflex inhibition and disuse. Subluxations may occur in the wrists and hands and the tibia may posteriorly sublux on the femur. Increased blood flow to the joint during periods of active disease often results in overgrowth of the bones of the involved joints. This often occurs in the humeral head, radial head, femoral head, medial femoral condyle and the proximal tibia. While JIA can cause increased growth of some bones it can also cause premature epiphyseal closure in the bones of the hands and feet so that these bones do not grow to their genetically programmed length.

CONGENITAL DIAGNOSESClubfoot wheaton brace

The is a type of AFO used to treat clubfoot. The lower part of the brace helps to correct the foot position while the upper part of the brace helps to protect the knee and prevents the torsional forces from being transmitted to the knee. Up to one-half the cases of clubfoot will achieve a complete correction with only a conservative approach. When the conservative approach is not successful in providing a well aligned, mobile foot for weight-bearing and ambulation, surgical correction will be necessary. Some pediatric orthopedic surgeons prefer to perform surgery around 3 months of age while others prefer to wait until the child is about 1 year old. At 3 months of age the structures involved are very small, making a complicated surgery even more challenging. At 1 year of age the structures are larger but the risk for boney deformity is greater. Either way the surgery will involve elongating structures on the medial aspect of the foot and ankle and tightening structures on the lateral border of the foot and ankle. Osteotomies may also be required to achieve good alignment of the foot. After the surgery, a series of serial casts will be applied to help hold the correction. Then an AFO will be used to maintain the alignment. Unfortunately, clubfoot can re-occur even when there was a good correction achieved either with a surgical or conservative approach. This re-occurrence is often associated with a growth spurt. Surgery is the preferred treatment for a re-occurrence of clubfoot.

DS etiology

The mechanism which results in the extra genetic material from the 21st chromosome being found in these individuals is known but the exact cause which triggers this mechanism is not well understood. For many years it has been known that the risk for having a child with Down syndrome increases as the age of the pregnant woman increases. However, newer research has linked increasing paternal age as well. Keep in mind, younger women also have babies with Down Syndrome.

SB clinical manifestation

The neural defect will result in some degree of motor and sensory loss at and below the level of the defect. The defect may cause a complete lesion which would result in flaccid paralysis, loss of sensation and loss of reflexes at and below the lesion. The defect may also cause an incomplete lesion which would result in some areas of spasticity and hyperactive reflexes as well as some areas with volitional movement. An incomplete lesion can also result in areas with and without sensation below the level of the lesion. With either a complete or an incomplete lesion there can be asymmetry in the level of the lesion from anterior to posterior and from left to right as seen in the picture below. This asymmetry can occur in both motor and sensory function. Also, the motor and sensory function may be different from anterior to posterior and from left to right. The motor and sensory loss can be due to the original spinal defect itself and this is considered a primary cause of motor and sensory loss. The lesion is classified according to the last intact nerve root that is found. For example, an L3 lesion would indicate that L3 is intact but not L4. There can also be motor and sensory loss due to secondary causes or issues other than the primary lesion itself. Secondary loss can result from further damage or trauma to the exposed neural elements during the delivery process if the infant is delivered naturally and passes through the birth canal. An infection involving the neural elements can result in additional loss. There are two other causes of secondary loss described in the course notes, hydromyelia and tethered spinal cord. Both have similar symptoms but hydromyelia impacts the upper extremity function first and may impact the lower extremity function if left untreated. Tethered spinal cord tends to impact the lower extremities resulting in weakness that may present in an asymmetric pattern. The last cause of secondary loss we will discuss is hydrocephalus or an abnormal accumulation of cerebrospinal fluid (CSF) in the brain. Hydrocephalus occurs in about 90% of children with spina bifida and results in increased intracranial pressure. Another brain abnormality that often occurs with hydrocephalus is the Arnold-Chiari Type II malformation in which part of the posterior cerebellum, the medulla and the cervical spinal cord herniate down through the foramen magnum. Now the question is: Which came first, the chicken or the egg? It is not known if the increased pressure from the hydrocephalus causes the herniation of the brain structures down through the foramen magnum or if the herniation of the brain structures causes constriction of the areas that provide for drainage of the CSF and Spina Bifida SA 2016 12 results in the hydrocephalus. Arnold-Chiari II malformation can result in several problems which are listed in the course notes. Signs and symptoms of Arnold-Chiari II include stridor or a high pitched vibratory noise that occurs during inspiration. The infant may stop breathing while asleep or while crying. The infant may sound hoarse due to the paralysis of the vocal cords. There may be gastroesophageal reflux, bronchial aspiration and difficulty swallowing. More severe cases can result in extreme extensor posturing and upper extremity weakness. If we note any of these symptoms in an infant or child with spina bifida the child should be immediately referred to the physician for evaluation of Arnold-Chiari II.

CP prenatal period

The perinatal period is the time around the birth process and would include anytime from the onset of labor to the 7th day after birth. Problems during the perinatal period that can result in CP include: 1. : brain injury An injury to the brain that occurs during the birth process such as from a traumatic delivery or a breech presentation may cause CP. 2. : asphxia A lack of oxygen to the fetus caused by prolonged labor, a prolapsed umbilical cord or sedation from drugs administered to the mother. A prolapsed umbilical cord is when a loop of the umbilical cord passes through the birth canal along with the fetus and the umbilical cord will become compressed which blocks its function. The umbilical cord may also get wrapped around the neck of the fetus which would inhibit its function. 3. : preclampsia This is a medical condition of the mother that results in increased blood pressure and protein in the urine. This can also impact the fetus and may become a medical emergency requiring immediate delivery. 4: preemie: This is believed to be one of the most common causes of CP especially when combined with a low birth weight. Some resources would place prematurity in the prenatal period rather than the perinatal period.

CP postnatal period

The postnatal period is considered to begin on the 7th day after birth and continue until 2-5 years of age. Some facilities and resources consider the postnatal cutoff time to be 2 years while others consider it to be 5 years of age. Either way, anything that causes a static, non-progressive lesion to the brain prior to the cutoff age will be considered as CP. After the cutoff age, the lesion may be classified as a traumatic brain injury (TBI), closed head injury (CHI) or a diagnosis other than CP. Problems during the postnatal period that can result in CP include: 1. Head injuries: An injury to the brain from a fall, motor vehicle accident or child abuse could result in a TBI or CHI. 2. Infections: These would be infections that the child contracts rather than the TORCH-S infections that the mother contracts. The most common infections include meningitis and encephalitis. 3. Brain hemorrhage: The cerebral blood vessels are very fragile and can bleed easily. Anything that increases blood pressure may cause cerebral bleeding. The bleeding can result in an intraventricular hemorrhage which we discussed in the section on High Risk Infants. 4. Asphyxia: A number of things can cause a child to stop breathing including cardiac arrest from an electrical shock or a near drowning event. The lack of oxygen can result in hypoxic ischemic encephalopathy (HIE) and cause a lesion in the brain and a diagnosis of CP. The presentation or type of CP will depend on where in the brain the lesion occurs. Your course notes where some of these lesions occur and the type of CP that they will cause.

CONGENITAL DIAGNOSES Clubfoot med man

The primary goal for the management of clubfoot is to correct the alignment of the foot to provide for normal weight-bearing and to have as much mobility as possible to facilitate the development of ambulation. Conservative management is typically the first treatment option and is most successful when begun as soon after birth as possible. The conservative approach often includes treatments such as stretching, taping, splinting and serial casting. The recommended order of correction is to first decrease the forefoot adduction by bringing the forefoot toward as much abduction as possible. Then bring the calcaneus as close to normal alignment as possible by decreasing the hindfoot varus. Lastly, apply a dorsiflexion force to decrease the plantarflexion as much as possible. Correcting in this order (forefoot, hindfoot, and then ankle) seems to provide the best outcome. When the foot has been manually moved into as close to the normal alignment as possible, a serial cast can be applied to hold the correction and allow elongation of the shortened soft tissues and adaptive shortening of the over-lengthened soft tissues. Each time the serial cast is removed, the foot can be stretched, mobilized with PROM and then a new serial cast can be applied. Once the last serial cast is removed a custom molded ankle-foot-orthotic (AFO) can be made for the infant to wear to maintain the new alignment achieved. Initially, the AFO may be worn 24 hours a day. Later, the AFO may only be worn at night.

CONGENITAL DIAGNOSES Congenital Muscular Torticollis risk factor and Hx

The risk factors for muscular torticollis and plagiocephaly are similar and include large birth weight, male gender, breech position, multiple birth, primiparous mother, difficult labor and delivery, use of vacuum or forceps assist, nuchal cord (cord wrapped around the neck see figure below), and maternal uterine abnormalities.1 The typical history of congenital muscular torticollis includes the appearance of a fibrous tumor (usually 1 to 3 cm in diameter and spindle shaped) in the sternocleidomastoid muscle (SCM) between 14-21 days after birth. Although the first appearance can be as late as 3 months. The tumor disappears by the time the patient is 4 to 8 months of age. If the diagnosis is made within 2 to 6 weeks after birth, the term 'pseudotumor of infancy' may be used.1 Biopsy of the tumor reveals the histologic appearance of a fibroma. The tumor is characterized by a deposition of collagen and fibroblasts around the individual muscle fibers, with an absence of normal striated muscle. The severity and distribution of the fibrosis, its location within the muscle, individual growth patterns, and the amount of atrophy of normal muscle tissue varies among patients. The nature of the fibrous tissue in the neonate suggests the disease may begin before birth and be related to in utero fetal positioning. One may observe an associated head tilt because (1) the healthy myoblasts degenerate; (2) the remaining fibroblasts produce excess collagen, which results in a scar like band and muscle contracture; or (3) the infant is unable to maintain a vertical head against gravity in static posture or during transitional movement.1

CONGENITAL DIAGNOSES Brachial Plexus Injuries erbs palsy

The two most common types of BPI are Erb's palsy (C5 and C6) and Klumpke's palsy (C7 - T1). A child with Erb's palsy has a characteristic appearance that has been named the 'waiter's tip.' The shoulder is positioned in internal rotation and adduction, the wrist is flexed, and the fingers extended as it the child is waiting for someone to put something into their hand from behind.

CONGENITAL DIAGNOSES Clubfoot PT

Therapists may be involved in management of the scar tissue to maintain pliability of the surgical scars to prevent adhesions and tightening of the soft tissues. Therapists must monitor and teach the child's caregivers to monitor for potential problems with the serial casting. The toes should be assessed to make sure they are still pink and warm to the touch. If they are not, there may be too much pressure resulting in decreased circulation and the cast should be immediately removed. Therapists should also monitor and teach the parents to monitor for signs of skin breakdown or increased pressure from the AFOs. Therapists will engage the child in sensorimotor experiences to facilitate gross motor development and gait training.

ARTHROGRYPOSIS MULTIPLEX CONGENITA Therapy for the older child and adolescent:

Therapy for the older child and adolescent: Secondary problems may develop in the older child and adolescent due to overuse of functional muscles and joints to compensate for weakness and decreased range in other joints. This can lead to the development of carpal tunnel syndrome and tendonitis. Arthritis is also fairly common due to joint problems and irregularities. Pain management becomes important at this point. Emphasis should also be placed on decreasing stiffness which could further impair functional abilities. Older children and adults who are ambulatory may choose to use a power wheelchair or scooter for ease of mobility particularly for community outings. They would not be able to independently propel a manual wheelchair due to the upper extremity ROM and strength limitations. Also, a power wheelchair will be more efficient and decrease the energy demands of ambulation.

ARTHROGRYPOSIS MULTIPLEX CONGENITA etiolgoy

There appear to be several causes of AMC and the exact etiology is not well understood. Some theories focus on a neurological origin which others focus on muscular or skeletal problems. There are also theories related to restricted intrauterine spaces or decreased intrauterine movement. Cases with a neurogenic origin are thought to be due to a degeneration of the anterior horn cells of the spinal cord. This degeneration will lead to muscle weakness and result in decreased fetal movement in utero. With decreased fetal movement the joints in the extremities might get "stuck" in an abnormal position, leading to contractures. Cases with a myogenic origin have some sort of abnormality within the fetal muscles which can again lead to muscle weakness and decreased fetal movement. Other cases are related to decreased intra uterine space for the developing fetus which will again lead to decreased fetal movement. This can result when there is an abnormal septum in the uterus which blocks off part of the uterine cavity, leaving a smaller than typical uterine cavity in which the fetus will develop. Also, if there is not enough amniotic fluid in the amniotic cavity, the uterine cavity will not expand as much and the fetus will have less room in which to develop. Musculoskeletal SA2016 185 Pregnant women who contract viral infections and/or fevers of greater than 100 degrees in the first trimester have an increased risk of having a child with AMC. The infection or fever may lead to the myogenic or neurogenic conditions that cause decreased fetal movement. There is at least one type of AMC which is inherited through an autosomal dominant genetic defect. The genetic form seems to primarily affect the distal extremities. AMC may also be associated with other diagnoses such as spina bifida.

CP Dx

There are no specific diagnostic tests, blood work or imaging studies which can be used to definitely diagnose CP. A diagnosis of CP involves ruling out other disorders and then observing the child's presentation and noting the tonal alterations and the abnormal posture and movement patterns. When these things are noted, possibly in conjunction with imaging studies indicating signs of brain involvement, and the other potential diagnoses have been ruled out, the child can be diagnosed with CP. "Developmental delay, abnormal growth charts, impaired muscle tone, and abnormal reflexes are early indications of cerebral palsy".5 Prematurity and low birth weight have also been found to be significant predictors of an eventual diagnosis of CP.

CP etiology

There are quite a number of things that can result in a diagnosis of CP and these things can be classified as occurring during the prenatal, perinatal or postnatal periods. The prenatal period is anytime during the pregnancy up until the onset of labor. It is believed that the majority of cases of CP are due to events that occur during the prenatal period. Problems during the prenatal period that can result in CP include: infections : Some of the TORCH-S infections that we discussed in the High Risk Infant section can cause CP. These specific infections are Toxoplasmosis, Rubella, Cytomegalovirus and Herpes. fetal anoxia : Anything that causes a lack of oxygen to the fetus including problems with the Rh incompat: This results when the mother and fetus have different Rh factors in their blood. This is usually not a problem for the first pregnancy but can be a significant problem for subsequent pregnancies with different Rh factors. The mother's system will "attack" the fetus and cause an excessive breakdown of red blood cells. This can result in hyperbilirubinemia (neonatal jaundice) which can lead to Kernicterus (yellow staining of the brain) and an eventual diagnosis of CP. Medical treatment has advanced so that this is less of a concern now. Following a first pregnancy where there is a difference in Rh factors, the mother is given a dose of gamma globulin which protects future pregnancies. Although there are not many new cases of CP resulting from hyperbilirubinemia in the US, you may encounter adults who have a history of this. dev def: Any sort of abnormality of the developing brain such as a cyst or vascular malformation may cause a lesion and a diagnosis of CP. toxix substances : Anything that the mother is exposed to or ingests that could act as a teratogen including prescription medication, recreational drugs and alcohol may cause CP.

DS diagnosis

There are some prenatal diagnostic tests that would indicate whether or not the developing fetus had Down syndrome. We have already discussed some of these in the Prenatal Diagnostics section. The first of these is to take a sample of the pregnant woman's blood and screen it for levels of alpha-fetoprotein. Remember that low levels of this substance would be a "red flag" for Down syndrome. This would warrant further testing. Ultrasound may also be used to screen the fetus for some signs or characteristic defects associated with Down syndrome. The ultrasound may detect the cardiac or gastrointestinal defects that commonly occur with Down syndrome. Ultrasound can also be used to measure the thickness of the skin at the back of the fetal neck and the length of the fifth finger. Thesemeasurements are then compared to normative data. A fetus with Down syndrome will typically have thicker skin at the back of the neck and a shorter fifth finger than found in a fetus without Down syndrome. Abnormal ultrasound findings will not be specifically diagnostic of Down syndrome but will provide another "red flag" that warrants further investigation. With "red flags" on alpha-fetoprotein levels or ultrasound findings or if the pregnancy is considered "high risk" for Down syndrome then a more invasive procedure may be used for diagnosis. Again, we have already discussed the issues associated with amniocentesis and chorionic villus sampling in the section on Prenatal Diagnostics. The course notes provide a quick review of this information. Both of these tests can provide fetal cells for chromosomal analysis. If the pregnant woman does not seek prenatal care or elects not to have further testing to evaluate any "red flags" for Down syndrome, then diagnosis may be made at birth due to the characteristic facial dysmorphology and global hypotonia that occurs with this disorder. Even if the baby has the typical facial features of Down syndrome, chromosomal analysis will still be used to confirm the diagnosis. Sometimes, even good prenatal care and appropriate testing will not identify a fetus with Down syndrome.

JUVENILE IDIOPATHIC ARTHRITIS Dx

There is no definitive diagnostic test to identify JIA. To assist in the diagnosis of JIA the American College of Rheumatology has developed a set of diagnostic criteria. The symptoms must begin before the child reaches the age of 16 and must persist for at least 6 weeks. During the first 6 months the symptoms should be consistent with one of the 3 subtypes of JIA: pauciarticular, polyarticular or systemic. Additionally, the physician should rule out other types of rheumatic diseases, joint trauma or infections, and malignancies.

ARTHROGRYPOSIS MULTIPLEX CONGENITA Dx

There is no specific prenatal diagnostic test that can identify a fetus with AMC. However, abnormal positioning may be detected prenatally by ultrasound.

Gen seizure myoclonic

These seizures involve brief but powerful contractions in individual muscles or in groups of muscles. When large groups of muscles are involved the child may fall to the ground. These seizures usually last less than 5 seconds but they may occur in clusters. Because these seizures are of such short duration, consciousness may only be briefly altered or not be altered at all.

JUVENILE IDIOPATHIC ARTHRITIS Physical & Occupational Therapy Assessment pt history

This area should include an assessment of the child's pain. There are a number of ways this can be accomplished in children. One method is to use a visual analog scale (VAS) which has been shown to be a valid and reliable method of measuring pain in children as young as 5 years old. One example of a VAS for children is shown below. Another method of assessing children's pain is to use a Quality of Pain assessment. The children are given a list of words that all describe pain (burning, throbbing, aching, stabbing, etc) and the children circle the words that describes their pain. Another method is to give the child a body diagram as shown in the course notes and colored pens, pencils or crayons. The child will indicate which color will be used for the worst pain, the constant pain, etc. The child can then color in the areas on the body diagram according to the type of pain felt. The assessment should include whether or not the child complains of "morning stiffness." If so, how long does it last and what does the child do to relieve the "morning stiffness"? The children and parents should also be asked about fatigue, the children's ability to perform ADLs including mobility and whether or not the children use any sort of splint or adaptive equipment to assist in the performance of ADLs.

CP med man Sx

This brings us to Orthopedic Surgery. While we would obviously not be involved in performing the surgery, we are involved in post-surgical treatment. Again, it is helpful to have a basic understanding of some of the most common surgical procedures so we know what occurred and so we can be better prepared to work with the child after the surgery. Orthopedic surgery is typically performed to: • Prevent deformity and pain • Correct deformity • Improve comfort • Improve function Orthopedic surgery may be indicated to increase ROM when conservative attempts to do so, such as serial casting, have not been successful. Surgeries to increase ROM involve either a lengthening, release or transfer of the affected muscles and tendons. There are several common orthopedic surgeries listed in the course notes. You are not required to know specific details about these different surgeries. You will need to know the difference between a lengthening, a release and a transfer. Orthopedic surgery to correct contractures is very common in the lower extremities of children with CP. Children with spastic CP are susceptible to hip flexion, knee flexion and ankle plantarflexion contractures. Surgery may be required to improve ambulation when these contractures interfere with lower extremity alignment for standing and walking. Rather than subject the child to three different surgical procedures it is common to address all three joints during one surgery with a Single-event Multi-level surgery (SEMLS). Correcting all three joints at the same time will also provide a better overall outcome with appropriate alignment of all three joints. After the surgery a cast will be used to immobilize the involved body segments for 6-8 weeks or longer to allow the corrected areas to heal in the new position. After the casts are removed a resting splint may be used for a period of time to assist with maintaining the ROM. Then the splints may only be used at night while the child is sleeping. Knee immobilizers and hip abduction wedges may be used as previously discussed. Children will require intensive therapy after SEMLS to regain function lost and work toward new function with their new alignment. We may treat the child while in the cast, depending on the area of the body that is casted and the functional abilities of the child. In other cases, the child may not attend therapy until the cast is removed. Once the casts are removed the child will need therapy to stretch and strengthen the affected muscles. Strengthening can particularly be an issue with respect to a lengthening procedure. In the case of spasticity, the increased tone would have contributed to the decreased ROM. The tendon of the tight, spastic muscle is lengthened which improves the ROM. Now the tight, spastic muscle has a longer lever arm that the muscle must use to move the joint. Functionally, this makes the tight, spastic muscle even weaker so therapy is very important to help strengthen the muscle in its new length. The child may also have lost skills due to the immobility of the cast and therapy would help the child to regain those skills as well as to learn to use the new ROM for function. A lengthening procedure involves making a series of small incisions in the tendon without actually severing the tendon. The incisions allow the tendon to elongate while maintaining the function of the tendon and muscle. A release involves cutting completely through the tendon or muscle and leaving the cut ends free. This will eliminate the function of the muscle since the two attachments are no longer connected but it will increase the ROM that was limited by the tight muscle. Hip adductor releases may be performed on a non-ambulatory child with adduction contractures that interfere with dressing and perineal hygiene. The release will make these tasks easier for the parents or caregivers by increasing the range into hip abduction. This may also assist with positioning the child more appropriately. Note that this release is done on a child who is non-ambulatory and is not expected to ever be ambulatory. This release may also be done to prevent hip dislocation due to the abnormal muscle pull of the hip adductors and flexors. A tendon transfer also involves cutting completely through the tendon or muscle but then the cut end of the muscle is sutured to another muscle. This preserves the function of the cut muscle but the muscle's function may be different. The cut muscle is used to reinforce the function of another muscle. For example, transferring rectus femoris to the sartorius. Now rectus femoris will assist sartorius with hip abduction and external rotation. Another common procedure involves transferring the flexor carpi ulnaris to the extensor carpi radialis brevis. This will decrease the pull of the wrist into flexion and assist with active wrist extension to improve function. hip dyplsia or dislovcation : Note that correction of a dislocated hip may require extensive reconstruction to the pelvis and or the femur. Femoral Osteotomy fmeoral osteotomy: To correct a bony rotational deformity such as excessive femoral anteversion or excessive medial torsion of the femur, the femur itself may be cut horizontally through the shaft so the distal end can be rotated into a better alignment. To correct the angle between the femoral neck and the shaft, a wedge of bone may need to be removed. In either of these situations, the femur will be stabilized in the corrected position with plates and screws.

CP Athetoid (part of dyskitetic)

This is the second most common type of CP and it typically results in a quadriplegic presentation with full body involvement. We know it is due to damage to the basal Cerebral Palsy SA 2016 CAndrea, PT, NCS, CBIS 170 Range and Quality of Movement Righting, Equilibrium and Protective Reactions Respiratory Problems Speech Problems Feeding Problems Deformities Other signs Personality Characteristics ganglia and results in large, dramatic tonal fluctuations from hypotonia to hypertonia. Interestingly, these infants are usually hypotonic at birth. The athetoid movements do not develop until around the first birthday. It is unusual to find an individual with pure athetoid CP. There is often a spastic component as well. This is actually beneficial since the spastic component might help to dampen the tonal fluctuations and involuntary movements. This can facilitate stability and function for these individuals. ROM : Athetoid CP results in movements through the extremes of range with no limitations. The tonal fluctuations make it difficult to stabilize the body and develop postural control. The fluctuations also make it difficult to grade movement and develop midrange control. Movements lack coordination and it is difficult to isolate movement at a specific joint. A hallmark characteristic of athetoid CP is the involuntary movement that occurs. These involuntary movements can be abrupt and jerky or slow and writhing. Either way, the individual is not able to stop these movements from occurring. However, the involuntary movements do not occur during sleep. righting reactions : Due to the tonal fluctuations the righting, equilibrium and protective extension reactions are usually delayed or absent. If they do develop, they may be unreliable due to the fluctuations in tone and the problems with grading movement and stability. resp probs : There can be decreased thoracic mobility and shallow breathing due to poor control of the muscles of respiration which are also subject to tonal fluctuations. speech : Since athetoid CP typically has a quadriplegic distribution the muscles of the trunk, neck, face and mouth will be involved. This will again cause problems with articulation and control or the lips and tongue. Also, the fluctuations of the trunk muscles and the respiratory muscles make it difficult to maintain a steady volume during speech so the volume may fluctuate along with the tonal fluctuations. feeding : The involuntary movement and the lack of stability will make feeding a challenge. It is difficult to coordinate the oral muscles for moving the food in the mouth, chewing and swallowing. As in spastic CP there can be an abnormally strong gag reflex and tongue thrusting which will contribute to the problems with feeding. deformities : Individuals with athetoid CP are at low risk for developing deformities such as joint contractures. This risk will certainly increase if there is also a spastic component to the CP. There can also be a risk of joint instability if the individual tends to remain more hypotonic. other : Individuals with athetoid CP usually have normal deep tendon reflexes. personaility : Individuals with athetoid CP are often described as being emotionally unstable and immature. They tend to be easily frustrated and have mood fluctuations which can range from happy to extreme anger and temper tantrums. They seem to be less fearful of movement than in individuals with spastic CP but this may increase if they also have spasticity. Again, remember that each child is an individual and may not demonstrate these characteristics.

Gen seizure Tonic-Clonic

Tonic-Clonic The most common type of generalized seizure is the tonic-clonic seizure. This is the seizure type that is most often found in children with developmental disabilities. You may be more familiar with the older term for this type of seizure - grand mal seizure. Today, the preferred term is tonic-clonic seizure. Tonic- clonic seizures have two phases: tonic and clonic. The tonic phase occurs first and results in a brief stiffening of the trunk and extremities followed by a loss of consciousness and a fall to the floor. The stiffening may force air through the vocal cords causing some vocalization or grunt from the child. After this the child may not breathe during the rest of the tonic phase which usually lasts a total of 30-60 seconds. The tonic phase is followed by the clonic phase which is characterized by alternating muscle contractions that result in repetitive jerking throughout the body for 1-3 minutes or longer. During the clonic stage the child may bite the inside of the cheeks or the tongue. In the past it was common practice to put something in the child's mouth to prevent biting the inside of the mouth or "swallowing the tongue". Now, this is no longer the accepted practice and you should not attempt to put anything in the mouth of a person during a tonic-clonic seizure. The object may obstruct the person's airway and become a choking hazard or you may be bitten while attempting to put the object in the person's mouth. It is not uncommon that the child will be incontinent at the end of the clonic phase. When the child regains consciousness during the postictal period, the child may be agitated or confused and may not remember the seizure or know what happened. The child may also fall into a deep sleep for several hours following a tonic-clonic seizure. Tonic This type of seizure involves only the tonic or stiffening phase of the tonic-clonic seizure. The entire body may become stiff and the child will fall. However, these seizures often occur while the child is sleeping. These seizures are of short duration and generally last less than 20 seconds. Clonic This type of seizure involves only the clonic or rhythmical jerking phase of the tonic-clonic seizure. The muscle contractions may begin in one area of the body and then progress to other areas until the whole body is involved.

JUVENILE IDIOPATHIC ARTHRITIS Physical & Occupational Therapy Assessment acute phase treatment

Treatment during the acute phase should be carefully monitored to make sure the treatment does not increase the child's symptoms. Gentle active ROM or active-assisted ROM should be used to prevent the loss of ROM and disuse atrophy at involved joints. Encourage the child to participate in the performance of ADLs and to maintain mobility. Resting splints may be used to support and inflamed joint in a more functional position such as supporting the wrist in 20 degrees of wrist extension or holding the knee in knee extension.

OSTEOGENESIS IMPERFECTA treatment

Treatment/Management One thing we need to help the parents understand is that fractures can occur even with the most careful handling and treatment. We can help the parents learn to protect the child and minimize the risk for fractures. An important aspect of treatment is teaching the parents how to handle and position the child to minimize the risk of fractures. The parents should be taught to lift the infant carefully while supporting the head and trunk. The extremities need to be supported and not left dangling in a position where they could be bumped against a hard surface. Sometimes these infants may need to be carried on a pillow, in a padded carrier or in a custom molded device to minimize the risk for damage and fractures. Infants with OI should never be lifted by the arms or legs. Also, when changing diapers parents typically grasp the infant's ankles to lift the pelvis off the diaper. Infants with OI should not be lifted by the legs. Instead, the pelvis should be gently rolled off the diaper by placing the hands directly on the gluteal region. Parents should select loose fitting clothing and clothing with Velcro fasteners so that they will not have to pull or tug on the extremities while dressing the child. Infants with OI should be positioned to promote midline orientation and symmetry of the head and trunk and proper alignment of the extremities. Towel rolls can be used to facilitate infant positioning. A variety of positions should be used to help facilitate normal development. Changing positions should be done carefully by using the trunk, pelvic girdle and shoulder girdle as key points of control. When rolling the infant between prone and supine make sure the extremities do not get caught under the body. Do not use the arms to pull the child into sitting. Encourage the infant to reach for toys in a variety of positions to develop upper extremity strength. Musculoskeletal SA2016 191 When positioning the child in sitting, make sure the trunk is supported in symmetry with extension. The child can also be supported in sitting astride an adult's leg or a bolster to work on weight bearing through the legs, pelvis and arms. It is not recommended that infants with OI be placed in baby walkers or jumping seats sometimes known as Johnny Jump Ups since these devices do not provide sufficient support for the infants and can increase the risk of fractures. When performing ROM activities use short lever arms and be very gentle to decrease the risk for fractures. Passive ROM activities should be used following treatment for a fracture or after surgery. It is recommended to facilitate strengthening through active movement. Aquatic exercise is an excellent way to promote strengthening and ROM activities by using the resistance of the water. However, monitor the temperature of the water to make sure the child's body temperature is not raised. For older children isometric exercises might be helpful for strengthening. School-aged children may be able to use resistance with theraband or weights for strengthening. The resistance or weight should be increased in small increments and placed near the joints to decrease the lever arm. The emphasis should be on increasing repetitions rather than the weight. Splints can be made for the upper extremities to help prevent fractures and the bowing deformities that can occur with weight bearing. The same concept can be applied to the lower extremities with custom made braces that have splinting material attached to support the long bones of the legs and to facilitate ambulation. A variety of devices including parapodiums, tilt tables, and standers, can be used to support these children in standing. The stress from weight bearing not only helps to decrease osteoporosis but also promotes the formation of osteoblasts which can facilitate the healing of fractures. Children may be fit for custom long-leg braces between the ages of 2 and 3 years old. The braces should totally support the long bones of the legs to prevent bowing deformities from standing and ambulation. Gait training may begin in parallel bars and then progress to the appropriate assistive device, typically a walker or crutches. The 4 point gait pattern is preferred for stability while using axillary or lofstrand crutches. The upper extremities may need splinting support to prevent bowing deformities while weight bearing through the arms on the assistive devices. Generally, children with Type III OI should not be allowed to walk without lower extremity bracing to minimize the risk for fractures and severe limb deformities. Children with more severe OI may benefit from the use of a wheelchair for ease of mobility and to minimize the risk for fractures and leg deformities. A power wheelchair may be the best choice to prevent the risk for fractures and deformities to the upper extremities. The wheelchair should have custom molded seating to help support the trunk and minimize the risk for scoliosis. When a fracture does occur the child should be taken to the physician as soon as possible. Generally, once the fracture is stabilized the physician may encourage weight bearing and mobilization to prevent osteoporosis and increasing the risk of future fractures and to prevent complications from immobility. Custom molded splints providing total support as in the long-leg braces may be used rather than traditional casts to stabilize the fracture. Heat and/or cold may be used to decrease the pain and edema associated with a fracture.

OSTEOGENESIS IMPERFECTA types

Type I Type I is the most common form of OI and is the least severe. It is inherited in an autosomal dominant pattern. Children with Type I will have an average of 20-40 fractures before puberty. At birth these children will be an average height (length) but they will not achieve an average height as adults. There can be some weakness and ligamentous laxity. Aside from the fragile bones children with Type I OI will have other anomalies due to the abnormal collagen. One interesting component is that the sclera of the eyes (the white part of the eye) will have a bluish tint. Additionally, the teeth will also have abnormalities. They are described as having thin skin which contributes to heat intolerance with an increased body temperature and excessive sweating. They also bruise easily. As adults, in their 20s or 30s, they may have some hearing loss due to fractures of the bones of the middle ear. They may develop scoliosis due to fractures and abnormalities of the vertebra. Additionally, children with Type I are described as having a small, triangular-shaped face. Most of these children will be ambulatory and they will not have misshaped bones as seen in Types II and III. They also have normal intelligence. Type II Type II is the 3rd most common form of OI and can be inherited in an autosomal recessive pattern but can frequently result from a new genetic mutation. This is the most severe form of OI and many of the children will not survive infancy. Type II results in many fractures in utero and during the birth process. Infants are born with gross deformities of the limbs due to the in utero fractures. These infants do not have an average height (length) at birth. Their chests are usually very small and their lungs are underdeveloped which can lead to fatal respiratory complications. Musculoskeletal SA2016 190 Type III Type III is the second most common form of OI and the second most severe. Type III can be inherited in an autosomal recessive pattern but can also frequently result from a new genetic mutation so there is no family history of this disorder. Children with Type III may have up to 20 fractures by the time they are 3 years old and more than 100 fractures by the time they reach puberty. They may also have some fractures at birth. This form of OI results in very soft bones that can not only break easily but can also bend and become misshapen resulting in limb deformities. Sometimes just weight bearing through the long bones of the legs and arms is enough to cause the bones to bend. The vertebrae may also be compressed and misshaped resulting in kyphoscoliosis. Due to this and the limb deformities, adults with Type III OI may only be 3 feet tall. As in Type I, people with Type III may also have hearing loss and abnormalities of the teeth. While some resources indicate the sclera would have a bluish tint as in Type I other resources indicate the sclera would be normal. Children with Type III usually cannot walk and have difficulty performing self care activities. Type III may be fatal in childhood due to respiratory problems. Type IV Type IV is the rarest form and is considered to be more severe than Type I but less severe than Type III. It is thought to be inherited as an autosomal dominant disorder. These individuals will have mild to moderate bone deformity with scoliosis and a shorter stature as adults. They may have hearing loss and teeth abnormalities but the sclera are normal. Most of these individuals will be ambulatory

CONGENITAL DIAGNOSES DDH med. man

When an infant is found to have a dislocated hip the goal is to reduce the dislocation so that the femoral head is re-located within the acetabulum. Then the treatment is Congenital SA2016 CAndrea, PT, NCS, CBIS 132 directed toward stabilizing the hip joint. This stabilization typically involves holding the hip joint in flexion and abduction since this position provides the greatest congruence between the femoral head and acetabulum. The age of the child at diagnosis will determine which treatment method will be used to maintain the hip flexion and abduction.

CONGENITAL DIAGNOSES DDH 2+

When the diagnosis occurs after 2 years of age correction generally requires open reduction. Following the surgery the child will be placed in a hip spica cast to maintain the reduction. Again, an abduction brace may be used for further stabilization of the hip once the spica cast is removed.

CONGENITAL DIAGNOSES DDH 0-6 mon

When the infant is less than 6 months old at the time of diagnosis, the treatment of choice is the Pavlik harness. The Pavlik harness is a cloth device with a series of straps and stirrups which are used to hold both hips in flexion and abduction. The front straps to the legs are used to hold the hips in 100-110 degrees of flexion while the back straps to the legs are used to hold the hips in 50-70 degrees of abduction. The hips are not held in a rigid position and the infant can move the hips and knees somewhat but the hips are held within the "safe zone" of flexion and abduction. The Pavlik harness allows the infant to be placed in both supine and prone. Prone is particularly important since this provides lower extremity weight bearing and helps to push the femoral head into and deepen the acetabulum. The infant usually wears the Pavlik harness 24 hours per day for the first 3 months and then the wearing time is reduced under the physician's guidance for the next 3 months. Use of the Pavlik harness is successful in stabilizing the hips in about 90% of cases diagnosed before 3 months of age.

Signs and Symptoms of Shunt Malfunction

When the shunt malfunctions the CSF can build up within the skull and result in increased intracranial pressure. There are some signs and symptoms that are common to all age ranges and include redness and edema along the shunt track, irritability, lethargy, seizures and vomiting. The vomiting is usually forceful and may be described as projectile. Infants may also demonstrate bulging of the fontanelles (or the "soft spot" on the infant's skull) and the head circumference may increase. An infant may also demonstrate something referred to as "sun setting" of the eyes. This is a downward deviation of the eyes. The downward deviation causes the iris to resemble the sun setting on the horizon of the lower eyelid. Toddlers may complain of headaches or may develop nystagmus or strabismus of the eyes. School-aged children may also complain of headaches. Additionally, school-aged children may have a decline in school performance due to problems with handwriting and memory. The shunt may also become infected which could result in edema and redness along the shunt track. In addition to edema and redness along the shunt track, which are also signs of a shunt malfunction, an infection would be accompanied by fever and an elevated white blood count. Anytime a shunt malfunction or infection is suspected, the child should be referred to the physician immediately. passed just under the skin along the posterior edge of the sternocleidomastoid muscle and then under the clavicle. In the shunt the drainage tube will be positioned to end in the right atrium. This allows the excess CSF to drain into the right atrium and then to be resorbed through the circulatory system. In the hunt the drainage tube is passed into the peritoneal cavity with excess tubing to allow for growth. As the child grows the tubing will uncoil and remain in the peritoneal cavity where the excess CSF will drain and be resorbed. Either type of shunt can malfunction and lead to problems. While the ventriculoatrial shunt tends to have fewer malfunctions, the impact can be much more serious since these malfunctions can impact the brain and the heart. Ventriculoperitoneal malfunctions are more common and while the impact can be significant, it is less serious than with a ventriculoatrial malfunction. The ventriculoperitoneal (VP) shunt is the primary type of shunt used in the US. It is not unusual for a child with a shunt to require surgical revision to correct a malfunction sometime during childhood. Some children will require multiple shunt revisions.

JUVENILE IDIOPATHIC ARTHRITIS Physical & Occupational Therapy Assessment chronic phase treatment

Whereas the emphasis of treatment during the acute phase emphases maintaining the child's functional abilities, ROM and strength, treatment during the chronic phase will emphasize increasing those same areas.

CONGENITAL DIAGNOSES DDH physcial therapy

While the child is in the hip spica cast we will be involved in teaching the caregivers how to position and transport the child. A beanbag chair works well for positioning. Other children may be larger and the cast may be configured differently so they may need other types of positioning. An adult reclining wheelchair may be modified to transport the child as seen in the picture below. Once the physician has cleared the child to be upright and bear weight through the feet then the child may be positioned in a standing device or should be encouraged to stand with assistance. Prolonged standing can assist with hip alignment and prevent future dislocations by allowing time/forces for the hip joint to form. Sometimes the cast will be cut back to above the knee on the non-involved side to give the child more freedom of movement and to minimize the soft tissue adaptation that will occur due to the immobilization. The child may also be positioned in prone on a prone scooter board or built up surface. Once the cast is removed the child will require a strengthening program to address the muscle atrophy and ROM activities to address the contractures due to the immobilization caused by the cast. The child may also have experienced some developmental delay due to the cast since they would have only been able to move their arms, head and upper trunk with the cast in place. The physical therapist would help the child to regain any skills that were lost such as the ability to roll over and to change positions and to develop age-appropriate gross motor skills. This would include ambulation activities and the necessary assistive devices until the child gains independent ambulation skills.

RANCHOS LEVELS OF COGNITIVE FUNCTIONING

____ (1) Level I - No Response. Patient does not respond to external stimuli and appears asleep. ____ (2) Level II - Generalized Response. Patient reacts to external stimuli in nonspecific, inconsistent, and nonpurposeful manner with stereotypic and limited responses. ____ (3) Level III - Localized Response. Patient responds specifically and inconsistently with delays to stimuli, but may follow simple commands for motor action. ____ (4) Level IV - Confused, Agitated Response. Patient exhibits bizarre, nonpurposeful, incoherent or inappropriate behaviors, has no shortterm recall, attention is short and nonselective. ____ (5) Level V - Confused, Inappropriate, Nonagitated Response. Patient gives random, fragmented, and nonpurposeful responses to complex or unstructured stimuli - Simple commands are followed consistently, memory and selective attention are impaired, and new information is not retained. ____ (6) Level VI - Confused, Appropriate Response. Patient gives context appropriate, goal-directed responses, dependent upon external input for direction. There is carry-over for relearned, but not for new tasks, and recent memory problems persist. ____ (7) Level VII - Automatic, Appropriate Response. Patient behaves appropriately in familiar settings, performs daily routines automatically, and shows carry-over for new learning at lower than normal rates. Patient initiates social interactions, but judgment remains impaired. ____ (8) Level VIII - Purposeful, Appropriate Response. Patient oriented and responds to the environment but abstract reasoning abilities are decreased relative to premorbid levels.

CP med man botox injjections

are another method of decreasing spasticity. Botulinum toxin is produced by the bacterium Clostridium botulinum and is the same toxin that causes botulism, a type of food poisoning. Botox is injected into spastic muscles where it will irreversibly block the nerve- muscle junction. This will temporarily decrease spasticity but the spasticity will return due to collateral sprouting which will form new nerve-muscle junctions. The decrease in spasticity will last for 3-6 months. This provides a window of opportunity to increase the functional strength of muscles before the spasticity returns. Botox injections may be used in conjunction with serial casting to increase ROM of the plantarflexors. Botox injections are easier to administer than motor point blocks and are not as painful. However, Botox is more expensive than motor point blocks. Also, the long term effects of repeated Botox injections are not yet known.

CP med man aug/ alt. comm. devices

are another type of assistive device that can be used by children with CP. We discussed a variety of ways that speech and language could be negatively impacted by CP in the previous section. If the muscles of the face and mouth are impacted the child may have difficulty articulating so it may be difficult or impossible for people outside the family to understand what the child is saying. Family members often can understand some if not most of what the child says so they can interpret for the child. However, the family generally is not with the child at day care or school or on the bus, etc. Also, a cognitive deficit may further impact the development of language. Not being able to communicate wants and needs as simple as asking for a drink of water or to be taken to the bathroom can be very frustrating for children. There are quite a few devices from very low tech picture books to very high tech computers that a child can use to help people understand what the child is trying to communicate. Some of these are pictured in the course notes. The child may need to just point to a picture to indicate she wants some milk or wants to go to bed. Some of the computers allow the child to push certain buttons or to type in phrases and then the computer will "speak" for them. There are computers that can speak in a child's voice and others that will allow a specific voice to be recorded to say the words for the child. You do not need to know any specific detail about these devices but I wanted you to be aware that they exist in case you see a child who is using one or in case you work with a child that could benefit from one. The same problems that can cause a child to have difficulty speaking can also lead to fedding issues . If the child is not able to take in enough nutrition to support growth and development or if the child is at risk for choking or aspirating, then the child may need to be tube fed. There are two primary methods of tube feeding, a nasogastric (NG) tube or a gastrostomy. This is usually only used for a short time since the tube and the tape used to secure the tube to the face can be very irritating. Also, having a tube coming out of your nose is not very appealing to other children who may not want to talk to or play with the kid with the tube hanging out of his nose. For long term feeding assistance, a gastrostomy is preferred. This involves making an incision through the abdominal wall into the stomach and inserting a device with either a tube attached or one that can have a tube inserted into it. The device that is inserted into the stomach usually has some sort of inflatable balloon on the stomach side that will help secure the device in place. Fluids can be poured into the tube and then gravity will assist draining the fluid into the stomach. The tubing can be tucked under the clothes and remain out of sight when not being used. Care should be taken to protect the tube and not pull the device out of the stomach. Another type of device is gastrostomy button which looks like a little plastic flip top on the child's abdomen. The flip top is opened and the tube is inserted for the feeding. Once the feeding is complete, the tube is removed and the tab is closed. This way the tube does not get in the way or get pulled or damaged when not in use

TD and BU learning

bottom-up models of the reading process say that the reading puzzle is solved by beginning with an examination of each piece of the puzzle and then putting pieces together to make a picture. TD Example Asking learners to predict what a newspaper article might be about from the headline or first sentence will encourage them to use top-down processing on the article. BU Example Asking learners to read aloud may encourage bottom-up processing because they focus on word forms, not meaning. in a reading comprehension learners use their knowledge of the genre to predict what will be in the text (top-down), and their understanding of affixation to guess meaning (bottom-up).

Pediatric Trauma

def

CONGENITAL DIAGNOSES Brachial Plexus Injuries erbs-klum palsy

is a combination of the injury to the upper and lowe roots (C5-T1) resulting in total arm paralysis and loss of sensation. Involvement is usually unilateral but has been reported to be bilateral in 4% of cases. In Erb-Klumpke palsy, the extent of the initial paralysis frequently recedes, with a total paralysis becoming limited to muscles innervated by the upper roots. The pattern of motor loss does not always fit the classic definitions, indicating incomplete or missed upper and lower types. Horner's syndrome, usually a result of avulsion of T1 roots, can cause deficient sweating, recession of the eyeball, abnormal pupillary contraction, myosis, ptosis, and irises of different colors. Considered rare, Eng and colleagues reported 8 of 15 infants w/ BPI had Horner's syndrome.

CONGENITAL DIAGNOSES Congenital Muscular Torticollis intervention LOOK AT PICS pg. 142

is directed toward resolving each impairment or activity limitation identified during the therapy assessment. Currently, most authors advocate conservative, nonoperative treatment for CMT. Conservative intervention typically consists of passive neck ROM exercises Equally important to include is active assistive ROM, strengthening, and postural control exercises. Caregivers are instructed in how to carry and position the infant to promote elongation of the involved SCM as well as how to promote active contraction of the contralateral SCM. Caregivers are also instructed in developmental exercises and how to reposition the child to prevent progression of deformational plagiocephaly. (see below)

CP classifications of CP.. hemipelgia

is just what we think about with an adult who has had a hemiplegic stroke; the leg, trunk and arm on one side of the body are involved. The upper extremity usually has a more severely involved presentation and a worse functional outcome as compared to the lower extremity. Depending on the extent of the lesion there can also be involvement of that side of the neck, face and oral motor mechanism. Hemiplegia results when there is a lesion in the motor cortex on only one side of the brain which will impact the other side of the body. The extent of the lesion in the motor cortex determines how much of the body will be impacted on the involved side.

CP classifications of CP.. monoplegia

is when only one extremity is involved and the other extremities and trunk are not impacted. The involved extremity is more commonly an upper extremity.

CP classifications of CP.. paraplegia

is when only the lower extremities and perhaps the lower trunk are involved and the upper extremities are not involved. This distribution is very similar to a paraplegic spinal cord injury.

CP med man neauro

neuroSx may also be used to address spasticity for children with CP. A Selective Dorsal (SDR), can be used to decrease spasticity in the lower extremities. The spasticity is due to a loss of inhibitory input from the cortical pathways which creates an overactive reflex circuit. Cutting the posterior or dorsal roots can impact the reflex circuit and decrease the overall spasticity. It is important to note that it is the posterior or dorsal roots which are the afferent sensory roots that are cut to decrease spasticity. Cutting the anterior or ventral roots which are the efferent motor roots would cause paralysis. Following surgery the child will need extensive therapy to maximize the benefits of the surgery. Remember that decreasing the spasticity will emphasize the underlying weakness since the child no longer has the spasticity to use for function. The children who have the best overall outcomes from SDR are children with spastic diplegic CP who have a history of prematurity and who are at least 2 years old. The surgery and intensive therapy can have a significant impact on the child's functional ambulation. Remember that SDR will only decrease spasticity in the muscles of the legs. It will not decrease spasticity anywhere else in the body. Another population that is a candidate for SDR are children whom are dependent and their spasticity interferes with positioning, sitting, hygiene or classroom activities or causes major orthopedic or pain issues.

CP classifications of CP.. quadlegia/tetra

occurs when there is total body involvement including both upper extremities, both lower extremities, as well as the trunk, neck, face and oral motor mechanism. In quadriplegia the arms and legs are equally impacted. Quadriplegia results from lesions in the motor cortex of both hemispheres with the lesions extending out more laterally than seen in diplegia

CONGENITAL DIAGNOSES Brachial Plexus Injuries prognosis

or full recovery varies on the type of injury. Infants with injury to the complete brachial plexus (C1-C6 and C7-T1) have a poor prognosis with traditional therapy and should be referred to a neurosurgeon for possible surgical reconstruction. Infants with Erb's palsy have a very good prognosis, if therapy is initiated at birth. The majority of infants have recovered tricep, bicep, deltoid, and wrist extensor by 6 months of age. If significant improvement is not see by 6 months of age, long-term disability is likely.2 Successful outcome is dependent on treatment beginning at birth. The family will need information about positioning the arm so that it is not left hanging when the child is being held. They will also need to remember that the perception of pain is not present in the involved arm, so injury can occur without the child crying. Incorporating frequent ROM into the daily routine will help prevent potential contractures due to the static positioning caused by muscle imbalances. Strengthening of the involved muscles through play activities and weight bearing will improve function. In the initial period, activities that minimize the effects of gravity on the movement will be helpful. For example, to reach a toy may be too difficult. However, if the child is held on the caregiver's lap with the arm supported on a table, this movement is simplified by eliminating the need for shoulder flexion and reduces the effects of gravity.1

CP Primary Motor Abnormalities involved with Cerebral Palsy (5)

persistance primry reflexes : We discussed these in the first part of the course. Some of the more commonly persistent reflexes in CP are listed in your course notes. If you do not remember these reflexes you should go back and review them, including the functional consequences that can result when the reflexes persist. For example, a persistent ATNR will interfere with midline orientation and rolling from supine to prone. A persistent STNR will interfere with dissociation of the left extremities from the right extremities. A child with a persistent STNR will not be able to creep reciprocally so but it may be able to "bunny hop." A persistent positive support reflex can contribute to toe walking due to the over activity of the extensor muscles of the legs while a persistent crossed extension reflex can contribute to a scissoring gait. Remember that in a typically developing child these primitive reflexes will be gradually inhibited or integrated (meaning they are no longer expressed) which allows the development of normal motor skills and the expression of automatic movement reactions such as the righting reactions. If the primitive or developmental reflexes do not become integrated or inhibited and continue to be expressed, this will negatively impact the development of normal motor skills and automatic movement reactions. Abnormal muscle tone: We know that a child with CP can have increased tone as in spastic CP or decreased tone as in flaccid CP. Athetoid CP results in tone that demonstrates extreme fluctuations from hypotonic to hypertonic while ataxic CP tends to have very mild fluctuations from hypotonic towards normal muscle tone. And again, there can be mixed presentations of tone where the trunk is hypotonic and the extremities are hypertonic or mixed presentations due to more than one lesion. Also, each of the tonal abnormalities can have a wide range of deviation from the norm usually indicated as mild, moderate or severe. So you can have a child with mild spastic diplegia or severe spastic quadriplegia. Abnormal balance and righting reactions: Remember that the righting reactions are those innate drives to keep the face vertical and the eyes and mouth aligned on the horizon. When the muscle tone is either increased or decreased that can interfere with the expression of the righting reactions. This would certainly also impact the expression of balance reactions including the equilibrium and protective extension reactions. Abnormal voluntary movements: The tonal abnormalities would also impact the voluntary movements. With the increased tone associated with spasticity the child tends to move in synergistic patterns and in the midranges of movement rather than through the entire range of motion. The tone may be so increased that the child may have great difficulty moving at all. With the decreased tone associated with hypotonic CP the child may have difficulty moving against gravity or generating enough tone to move at all. In athetoid CP the child will have difficulty stabilizing and grading movements due to the tonal fluctuations. This often results in a jerky component to the movement and dysmetria or over shooting targets. Ataxic CP often results in clumsiness to the movement and the child may demonstrate mild intention tremors while reaching for targets. Involuntary movements: This is very characteristic of athetoid CP where the child may be demonstrating constantly moving parts of the body due to the constant tonal fluctuations.

CP classifications of CP..triplegia

results when there is involvement of three extremities and the trunk while one extremity is not involved. Typically it is an upper extremity that is not involved. This can result from two different lesions, for example, one resulting in hemiplegia and one resulting in diplegia but with a less extensive lesion on one side so that the arm on that side is spared. Again, depending on the overall extent of the lesions there may be involvement of the neck, face and oral motor mechanism. While it is possible to have all the above described distributions, hemiplegia, diplegia and quadriplegia are the most common.

issues asso. with CP

seizure: can occur with CP. It is not hard to imagine this association since there has been some insult to or abnormality in the brain that caused the CP. This may cause the brain to be more susceptible to abnormal electrical discharges that would cause seizure activity. Seizures are most commonly seen in the children with spastic CP. cog. disfuction : Again, since there is some abnormality or impact to the brain cognition may be negatively impacted. Some degree of cognitive deficit is fairly common in the population with CP. This cognitive deficit can range from learning disabilities to severe intellectual disability. However, this does not mean that all individuals with CP will have a cognitive deficit and the degree of motor impact is not always indicative of the degree of cognitive deficit. We live in a very appearance conscious society and it is not unusual for people to make assumptions about cognitive ability based on the way someone looks, moves or talks. Many people would look at someone with physical limitations and automatically assume that person would have a cognitive deficit. When they see that the person looks and moves differently they lower their cognitive expectations for that person. That cognitive stereotyping tends to increase if the individual has difficulty speaking due to the tonal abnormalities in the muscles of the face and mouth. However, we need to realize that there can be an incredibly bright individual trapped inside a crummy body. Imagine how it must feel to have people constantly speak to you and treat you as though you had a cognitive deficit just because you have motor control problems. Instead, assume normal cognition and speak to the individual accordingly. It might be better to start off with high expectations and adjust them accordingly, if necessary. At least that way we won't insult the individual. Remember, we cannot just look at someone and know how smart they are so we should not assume it would work in the opposite direction. So the bottom line is that you should not assume cognitive dysfunction based on physical appearance or physical abilities. But do realize that in CP there may be some cognitive problems or cognitive dysfunction due to the impact or damage to the brain that resulted in the CP. speech and lang. : CP may have a negative impact on speech and language. Speech can be impacted when the tonal abnormalities involve the muscles of the face and mouth which can affect the ability of the person to move the lips and tongue to articulate clearly. The ability to control respiration to support phonation can be impacted if the trunk is involved. Language is closely associated with cognitive ability so cognitive deficits may impact the development of language. oculomotor and feeding: can arise when the tonal abnormalities involve the oral motor mechanism or the muscles of the tongue and mouth. The individuals may have difficulty controlling their saliva, coordinating their suck-swallow or respiration and swallowing, and moving the food around inside the mouth or keeping the food inside the mouth. Also, some children will have oral sensory defensiveness where they may not be able to tolerate different textures of foods in their mouths. The child might not have a problem with one type of texture and will be able to eat foods with that texture but another type of texture may cause the child to gag or vomit and the child would not be able to eat food with that texture because the child's system perceives that texture to be noxious. Cerebral Palsy SA 2016 CAndrea, PT, NCS, CBIS 167 Visual impairments Hearing impairment Somatosensory disorders Perceptual impairments Emotional and behavioral disorders visiual : can range from vision deficits to blindness. Since prematurity is one of the risk factors for developing CP the child may have a history of retinopathy of prematurity (ROP). Additionally, the insult to the brain that caused the CP may be significant enough to cause blindness. Also, the child may have strabismus, where the two eyes are not on the same axis. One eye might be deviated laterally while the other eye is deviated medially or both eyes may be deviated laterally or medially. Nystagmus with repetitive lateral movements of the eyes may also occur with CP. hearing : may be associated with CP and can be related to the issue that resulted in CP. For instance, when the mother contracts Rubella while pregnant, the impact of the Rubella on the fetus may result in hearing impairments and CP. somatosensroy: are also fairly common in children with CP. Some children will have difficulty sensing where their body is in space. These children often have to use vision to help guide them in positioning the hand in space to reach for something or to place the foot appropriately during ambulation. When we walk up or down steps we do not have to look at each step in order to be able to place our feet appropriately. We have enough awareness of where our body is in space to be able to safely negotiate stairs without having to watch our feet. Children with CP who are ambulatory may have to rely on vision and must watch their feet in order to place them appropriately on the stairs. Without relying on vision they may miss a step or trip on a step. Other children may develop gravitational insecurity and they will not like movements such as being on a swing or sitting on a therapy ball. Also, just as we discussed oral motor sensory defensiveness, children can have sensory defensiveness to tactile stimulation to their bodies. These children's sensory system may perceive certain tactile stimulation as a noxious stimulus. These children can be very bothered by clothing tags or labels, or when the seam of the sock is not in the exact right place. Some children may find different textures such as carpet, grass or sand on their hands or feet to be very uncomfortable and they will become fussy or cry when exposed to these textures. In more extreme cases the child may perceive weight bearing on the hands or feet to be a noxious stimulus and so they will avoid weight bearing which can delay motor development. perceptional : are related to the somatosensory disorders discussed above. emotional : are also fairly common in this population as they are in other pediatric diagnoses. This can be related to the global developmental delay that these children can experience so that their social emotional development is not age appropriate. This can be exasperated by parenting styles. It is not unusual for the parents of children with special needs to be overly protective of their children. These parents often feel guilty because life will be hard for their children so they do what they can to make things easier for the child. When the child wants something, the parents tend to immediately provide it to the child. If the child wants a toy in the room, rather than letting the child work hard to go get the toy the parents bring the toy to the child. This well-meaning behavior of the parents often results in a child who is used to getting everything it wants when it wants it. These children often do not know how to deal with frustration or the word "no" because they have not experienced it before. This can be particularly challenging in the clinic when we need to assist the child to develop motor skills by using toys to encourage the child to move and to do the things that are hard for the child. The child wants us to Cerebral Palsy SA 2016 CAndrea, PT, NCS, CBIS 168 bring the toy to the child rather than help the child go to the toy. When the toy is not immediately provided to the child or when we make the child work harder than they want to, the child often responds with frustration and crying. This is certainly not always the case and some parents use different parenting styles which are more beneficial to emotional development and learning to deal with frustration. However, it is not unusual for infants and young children to sometimes cry during treatment. After all, we are pushing the kids and making them work harder than they want to in order to help them develop motor skills. Kids, like many adults, prefer to take the path of least resistance so they may get fussy and cry when they are pushed to work harder than they want to. As adults we usually just whine a bit when we have to work harder than we want to. Learning disabilities: can also be associated with CP. We touched on these when we discussed cognitive dysfunction. These can range from very mild issues to more severe learning problems and may be related to the brain insult. Orthopedic disorders: are also quite common in children with CP. Children with spastic CP are prone to develop contractures and ROM limitations at involved joints. The abnormal muscle pull associated with spasticity can also cause hip subluxations and dislocations. Persistent primitive reflexes such as the ATNR and postural muscle weakness can contribute to scoliosis. Children with hypotonia are also susceptible to hip and shoulder subluxations and dislocations as well as to scoliosis.

CONGENITAL DIAGNOSES Congenital Muscular Torticollis etiology

unkonwn head position in utero can selectively injure the SCM muscle, leading to th Position of the head and neck in utero or during labor and delivery of forward flexion, lateral Muscular torticollis is the third most common congenital musculoskeletal anomaly after dislocated hip and clubfoot, with reports of incidence varying from 0.3% to 1.9% of newborns.1 Associated with muscular torticollis at birth are ipsilateral mandibular symmetry, ear displacement, plagiocephaly, scoliosis, pelvic asymmetry, congenital dislocated hip, and foot deformity.1

POST-CONCUSSIVE SYNDROME

• "Biomechanically induced clinical syndrome related to alterations in brain function that can affect memory and orientation" AAN • GCS 13-15 • May or may not include a LOC (only in 8-19% - Not a defining factor) • Often do not show up on imaging (CT scan) • Clinical diagnosis • Post-concussive syndrome • Headache • Memory loss • Behavior disturbances (irritability) • Impaired concentration • Fatigue • Dizziness • Light/noise sensitivity • Tinnitus • Nausea/vomiting • Slow reaction time • Decreased balance • Increased legislature and awareness; increased health care utilization • Pre and post season testing • Most symptoms should clear within 7-10 days, but some can last months or years • Less data available for younger athletes • drop stick • Neuro exam + clinical history + assessment tools • Standardized Assessment of Concussion • The Sport Concussion Assessment Took 3rd ed • The Balance Error Scoring System • The Sensory Organization Test (expensive equipment) • The King-Devick test (visual spatial) • The Drop-stick test (reaction time)• Rest, but unclear how much • Vestibular • Balance • Treatment of Headaches • Cognitive and sensory issues to be addressed • Activity tolerance - gradual increase of exercise leads to improved symptoms • Goal: return to learning - multidisciplinary team to recommend school accommodations • Medical and neuropsychology treatment • Biofeedback may be helpful • Return to play guidelines

PEDIATRIC BRAIN TUMORS

• Most common 0-6 years old • Most common are astrocytoma, medulloblastoma, ependymoma and brainstem glioma • Typically located infratentorially (primarily in brainstem and cerebellum): • Posterior fossa syndrome: ataxia, cranial nerve involvement, decreased cervical AROM, *cerebellar mutism, headaches, drowsiness, irritability, hypotonia, hemiparesis, cognitive changes

SECONDARY COMPLICATIONS OF CHEMOTHERAPY

• Myelosuppression • Peripheral neuropathy • Vincristine • Myopathy/Osteonecrosis • Dexamethasone/prednisone • Impedes skeletal growth and causes osteoporosis/fractures • Methotrexate

PREDICTORS OF OUTCOME AFTER MOD-SEVER TBI positive and neg

• Positive predictors • Age • Family support • WeeFIM or FIM scores discharging from rehab • Length of LOC <11 days • GCS >5 • Length of acute and rehabilitation stay • Negative predictors • Vegetative state entering into rehab • Associated anoxic brain injury

Ped SCI therapy

• Spasticity • Possible injury related LMN involvement may mask spasticity • Not always negative - can be used for function • FES bike, prolonged positioning, hydrotherapy • Medical management • Autonomic dysreflexia • Impaired temperature regulation • Respiratory issues • Continence (IC should be initiated at 3 years old and mastered by 5-7 years old to match peers; Bowel program should be started at 2-4 years old) • Skin integrity • Orthopedic concerns • Scoliosis: almost every child whom suffers SCI prior to skeletal maturity develops scoliosis and 2/3 require surgery Dearolf WW 3rd, Betz RR, Vogel LC, et al. 1990 • Hip dislocation/subluxation: More than 90% of children with SCI before age 10 years develop hip subluxation or dislocation. McCarthy JJ, Chavetz RS, Betz RR, et al. 2004 • Equipment management • Wheelchair, stander, orthotics, splints • Strengthening innervated muscles • Teaching compensatory patterns for functional movement • Preventing secondary complications • Patient and family education

categorzing burns

• Superficial (3-7 days) • Partial-thickness • Superficial (heal within 7-21 days) • Deep (21-35 days) • May need surgical intervention • Full-thickness • Little or no pain • Surgical excision and grafting