pediatric rehabilitation fi

PEDIATRIC REHABILITATIONPEDIATRIC REHABILITATION, AFIRM

REHABILITATION

Definition– Process of helping a person– Fullest potential– Consistent with person’s impairment and

desires

PEDIATRIC REHABILITATION

A subspecialty

Different from adult rehabilitation

Everything is changing

PEDIATRIC REHABILITATION

Utilizes interdisciplinary approachCongenital and child-hood onset physical

impairmentRehabilitation of children requires

– Identification– Selection– Understanding

INTERDISCIPLINARY TEAM

PATIENT

REHAB SPECIALIST

OCCUPATIONAL THERAPIST

PHYSICAL THERAPIST

PSYCHOLOGIST

SPEECH THERAPIST

PEDIATRIC REHABILITATION

Team members include– Pediatric physiatrist– Occupational therapist– Physical therapist– Rehabilitation nurse– Prosthetist-orthotist – Psychologist– Speech-language pathologist– Case manager– Dietician– Therapeutic recreation specialist– Spiritual care

TEAM MEMBERS

Pediatric Rehab Specialist– Oversee medical care team– Prescribe treatments– Coordinate with other specialists– Educate patient

OCCUPATIONAL THERAPIST

TEAM MEMBERS

Occupational therapist– Provide training

• Activities of daily living• To compensate• Upper extremity prosthesis

– Recommend equipment– Fabricate splint– Suggest home modifications– Educate patient’s family– Manage dysphagia

TEAM MEMBERS

Physical therapist– Evaluate

• Muscle length• Muscle strength• Muscle tone

– Therapeutic exercises– Normalize muscle tone– Joint handling techniques– Improve balance– Training adaptive devices and lower limb prosthesis– Perform auscultation to lung fields– Physical therapy modalities– Assess body posture

FOR BALANCE AND STRETCHING

GAIT TRAINING

TEAM MEMBERS

Rehabilitation nurse– Direct personal care– Determine goal– Assesses and addresses

• Hygienic factors• Bowel and bladder programs• Intervention related to skin integrity• Use of equipment• Minimize effects of inactivity• Medication management• Help manage time

TEAM MEMBERS

Psychologist– Neurophysiological testing

• Personality style• Psychological status• Testing of intelligence, memory

– Ways to deal with stress– Counseling

• Adjustment to body changes• Problem solving skills• Death and dying

TEAM MEMBERS

Speech-language pathologist– Detailed assessment– Evaluation of swallowing– Pragmatic and cognitive based disorders– Motor speech– Augmentative and alternative approaches

• Talking tracheostomy tubes• Electro larynx

TEAM MEMBERS

Prosthetist-orthotist– Evaluation, design and fabrication– Instructions in care and use– Follow up maintenance and repair

PEDIATRIC REHABILITATION

Common disabling conditionsTRANSIENT STATIC PROGRESSIVECONGENITALBrachial plexus injury

AQUIREDGuillain-Barre syndrome

Cerebral palsySpina bifidaRetardation

Spinal cord injuryTraumatic brain injuryTraumatic limb amputationpolio

Muscular dystrophySpinal muscular atrophyCystic fibrosis

Juvenile rheumatoid arthritisCollagen vascular disease

CERBRAL PALSY

Definition– Disorder of movement and posture– Injury to immature brain– Ages involved

CERBRAL PALSY

ClassificationBy tone abnormalities By body parts involved

SpasticDyskinetic Athetoid Choreiform Ballistic AtaxicHypotonicMixed

DiplegiaQuadriplegiaTriplegiaHemiplegia

CERBRAL PALSY

Goals of rehabilitation

– Decrease complications

– Enhance or improve new skills

EVALUATION

Objectives– Type and etiology of disability

– Child’s potential for rehabilitation

EVALUATION

Screening test for development– Bailey scale of infant development– Denver developmental screening test

Quantitative analysis of motor performance– Physical parameters– Physiological parameters

Jebson Taylor Hand Function Test

EVALUATION

Functional assessment– Wee FIM scale

– Gross Motor Functional Measure

– The Pediatric Evaluation of Disability Inventory

EARLY INTERVENTION

Decreases the impact of brain injury on the development of CP

For infants and toddlers ( 0 to 3 years old)

The rationale of early intervention

Neurodevelopmental technique (Bobaths)

Sensorimotor Approach to Treatment (Rood)

Sensory Integration Approach ( Ayres)

CNS model Hierarchical Hierarchical Hierarchical

Goals of treatment 1. To normalize tone2. To inhibit primitive

reflexes3. To facilitate

automatic reactions and normal movement pattern

1. To activate postural responses

2. To activate movement once atability is achieved

1. To improve efficacy of neural processing

2. To better organize adaptive responses

Primary sensory systems utilized to effect a motor response

1. Kinesthetic2. Proprioceptive3. tactile

1. tactile2. Proprioceptive3. Kinesthetic

1. Vestibular 2. Tactile3. kinesthetic

NEUROMOTOR THERAPY APPROACHES

Neurodevelopmental technique (Bobaths

Sensorimotor Approach to Treatment (Rood)

Sensory Integration Approach ( Ayres

Emphasis of treatment activities

1. Positioning and handling

2. Facilitation of active movement

1. Sensory stimulation to activate motor response

1. Therapists guides but child controls sensory input to get adaptive purposeful response

Intended clinical population

CP childrenAdult post CVA

Children with CPAdults post CVA

Children with learning disabilitiesautism

Emphasis on treating infants

yes no No

Emphasis on family involvement

yes no no

NEUROMOTOR THERAPY APPROACHES

HANDLING TECHNIQUES

Lifting and carrying

POSITIONING

SUPINE

Lying

PRONE

SIDE LYING

POSITIONING

SITTING

Long sitting W Sitting Cross legged Sitting

POSITIONING

– Standing

MOVEMENT BETWEEN POSITIONS

Movement between positions– Rolling– Lying to sitting

MOVEMENT BETWEEN POSITIONS

Sitting to standing

MOVEMENT BETWEEN POSITIONS

Exercises for sitting to standing

MOVEMENT BETWEEN POSITIONS

Walking

TREATMENT TECHNIQUES

Mobilization activities

TREATMENT TECHNIQUES

Activities to facilitate postural abilities

Activities to challenge postural abilities

Activities to improve the child’s ability to move

AIDS AND APPLIANCES

STANDER

PRONE MOBILE STANDER

STANDER

SUPINE STANDER

WALKER

PLATFORM WALKER

WALKER

STANDING SEATED WALKER

WALKER

NON-FOLDING WALKER

AIDS FOR ADLS

WEIGHTED UTENSILS HAND STRAP

AIDS FOR ADLS

CURVED UTENSILS SUCTION BOWL

AIDS FOR ADLS

ZIP GRIPS SOFT TOUCH SPRING ACTION SCISSORS

WHEEL CHAIR

Strap for trunk support

Head rest

Wedge

CP CHAIR

ANKLE FOOT ORTHOSIS

Supramaleolar orthosis Hinged ankle foot orthosis

Solid ankle foot orthosis

Posterior leaf spring AFO

KNEE ANKLE FOOT ORTHOSIS

•

HIP-KNEE-ANKLE-FOOT ORTHOSIS

MEDICATIONS FOR SPASTICITY

Drugs in use– Baclofen ( lioresal)

• 2.5-5 mg twice daily– Diazepam

• 1-2 mg twice daily– Dantrium

• 0.5 mg/kg/day– Clonidin

• 0.05 to0.1 mg twice daily Intrathecal Baclofen infusion

INJECTION THERAPY

Botulinum toxin A– 12 to 14 U/kg

Local injections– Phenol– Alcohol

Nerve blocks– Obturator– Sciatic– Tibial– Femoral– Musculocutaneous

SURGICAL PROCEDURES

SURGERY IN CEREBRAL PALSY

Foot and ankle– Tendoachilles lengthening for ankle equinus– Split anterior tibialis transfer for inversion and

dorsiflexion– Split posterior tibialis transfer for inversion

and plantiflexion– Subtalar arthodesis for calcaneovalgus

SURGERY IN CEREBRAL PALSY

Knee– Hamstring lengthening for crouch and internal

rotated gait– Rectus transfer (to semitendinosis or sartorius)

to balance hamstring weakness and prevent recurvatum

– Tibial derotation osteotomy for internal rotation

SURGERY IN CEREBRAL PALSY

Hip– Psoas lengthening ( intramuscular over the

pelvic brim for hip flexion– Adductor tenotomy for scissored gait or early

hip subluxation– Varus derotational osteoyomy for hip

subluxation– Pelvic shelf procedure for subluxation with

severe acetabular dysplasia

SURGERY IN CEREBRAL PALSY

Neurosurgical procedure– Selective posterior rhizotomy

FUNCTIONAL PROGNOSIS

Independent Ambulation– Spastic CP 75%– Diplegia 85%– Quadriplegia 70%– Hemiplegia– Ataxic CP– Hypotonic CP

Independent sittingPersistence of primitive reflexes

PEDIATRIC REHABILITATION

Indoor – Physical therapy gym– Occupational therapy gym– One-way mirrored observation room– Sound proof one-way mirrored speech therapy room– Regular speech therapy room– Psychological assessment and therapy room– Special education classroom

Outdoor– Sensory integration playground– Functional activities playground

PHYSICAL THERAPY GYM

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