PEDIATRIC REHABILITATION

Dr ELLY TRITURAWATI SpRM

I. History

A.

Patients name.

B. Reason for

referral and source of referral C. Birth history : Where born, complications, term, birth weight, Apgar scores, feeding history, age at discharge, intensive care admissions, ventilator,dependence, hospitalizations
D. Maternal

history : prenatal care, unusual weight gain or loss, hypertension, infection (e.g., rubella), induction, mode and duration of delivery, use of anesthesia, intrapartum complications, expected and actual date of birth, alcoholism, diabetes, use of anticonvulsants, history of spontaneous abortion and other births, complications with other pregnancies, use of street drugs
E. Developmental

history

(developmental milestones)

Gross motor : rolling, sitting, crawling, walking Fine motor : pincer, drawing, stacking Social : play, dressing, helping Speech : words, sentences

I. History
F. Medical history : especially surgeries, interventions related to presenting problem, medications (especially related to seizures), bowel, bladder, behavior G. Therapy history : where, what kind, how much H. School history : school district, type of classroom (see Appendix D for different educational settings and referral plan for special education), plans for future, knowledge of system, level of education, success in school

I. History
I.

Functional history Eating : Orally? with utensils? what kind of treatment? weight gain? gastrostomy tube problems? choking while eating? Dressing : upper limbs, lower limbs, button and snaps, braces, ability to tie shoes Bathing : safety and accessibility in tub, tub seat Hygiene : who does it? What kinds of problems Mobility : how does child get around the house? school? mall? How does child travel in car? Adaptive equipment : braces, wheelchair, walker, cane, adaptive car seat (ask type, when and where obtained, reason for use) Communication : age-appropriated? Augmentative communication device?

I. History
J. Social history : family, vocation if out of school, source of income, type of home and accessibility K. Allergies L. Family history : history of diagnosis or problem ame as or related to patients M. Review of system : focus on swallowing difficulties, appetite, how long it takes to eat a meal, breathing difficulty, constitutional symptoms (weight gain or loss, fever, chills), nausea or vomiting, sleeping habits, seizures, pain, bowel and bladder control, constipation or loose stool, change in range of motion, change in strenght or sensation N. Vital signs

II. Physical Examination

A. For younger children, do as much as you can by watching, playing, and having parents do things. B. Observe mobility, hand funtion, language, cognition, funcional strength, and range of motion. C. Have toys available, and avoid wearing the while coat. D. Assess weight, height, head circumference (see Appendix D for recording charts and normal values).

II. Physical Examination

E. Head, ears, eyes, nose, throat : assess gum care, thrush in more severely impaired and immunocompromised patients, oral hygiene. F. Cardiopulmonary assessment is specially important with patients with swallowing or pulmonary concerns and patients at risk for aspiration. G. Abdominal assessment is aspecially important with patients with bowel programs, gastronomy tubes, or other abdominal concern. H. Rectal assessment is reraly necessary exept for suspected impaction or questions about spinal cord function

II. Physical Examination

I. Skin : look for erythema under braces, decubitus ulcers. J. Assess extremities for active and passive range of motion, including test for hip dysplasia in infants and children with impaired mobility (see Section IX, Congenital Disorders), Document tone, condition of skin, edema, and fit of braces. K. Assess neurologic function, including mental status, head and trunk control, cranial nerves, strength, sensation, balance, gait, cerebellar, tone, reflexes (see Appendix D fo r reflex development).

III. Approch to Prediatric Patients

A.

Communication with parent

Treat the patient as a person, not a disgnosis. Recognize that parents are experts on their child. Explain what you are looking for and what you find. Be sensitive to the parents need for information. If you dont know, say so. Acknowledge their sense of urgency, and call back promptly. Be sensitive to how and what you write in the progress notes. Parents often read them, and they should match the tone and information that you conveyed at the visit. Be knowledgeable about free service and resources, such as early intervention and school program (authorized by federal law with funds passed from federal to state and local education agencies).

III. Approch to Prediatric Patients

B. Functions of physical therapist (PT) To position child for functions : alignment, skin protection, cardiovascular status, nutrition, assessment of developmental level by caregiving and play. To prevent deformity : influence muscle length, manage tone, preserve joint integrity, prevent/reduce pain. To make sugsestions about mobility and adaptive devices based on level of function. To design task and manage environment : give choices, incorporate repetition, change as necessary.

III. Approch to Prediatric Patients

C. Functions of occupational therapist (OT) To position child for function : aligment, skin protection, nutrition, assessment of developmental level by caregiving and play. To make suggestion for self-care, life roles/relationships, developmental and adaptive devices. To teach manipulative and perceptual skills D. Task design and environmental Design task and manage environment by giving choices; incorporate repetition, and change as needed.

III. Approch to Prediatric Patients

E. Function of speech and language pathologist To aid in recognition of speech and language disorders To aid in developing or restoring communication and oral motor function. To make suggestions about adaptive communication devices. To assess dysphagia, to improve swallowing in children with dysphagia, and to make suggestions about adaptive feeding devices (also may be done by OT).

F. Function of neuropsychologist To recognized and aid in confronting maladaptive issues relating to disability. To perform and analyze psychological assessment through testing, including tests for cognitive and intellectual function, adaptive behavior, psychosocial function, and neuropsychological testing (often used in brain injury).

III. Approch to Prediatric Patients

G. Functional measurement : WeeFIM is used most commonly . Domains : self-care, mobility, cognition (18 items total) Scores based on childs ability : documentation on a circular graph at 7 levels of performance.

IV. Cerebral Palsy (CP)

A. Description CP is a symptom complex (not a disease) that has multiple etiologies; diagnosis usually is made (at earliest) at 9-12 months of age. CP is the leading cause of childhood disability. CP is a disordre of tone, posture, or movement due to a lesion in the developing brain. CP is static, but symptoms may change with maturation. Lesions result in paralysis, weakness, incoordination, or abnormal movement.

IV. Cerebral Palsy (CP)

There is no cure, but CP is not contagious. Motor development is slowed. Some children may outgrow the diagnosis. The two major types of CP are determined by location of lesion : pyramidal and extrapyramidal. Pyramidal type is more common (about 75% of cases). Symptoms and anatomic lesions may overlap .

IV. Cerebral Palsy (CP)

B. Epidemiology Constant prevalence is likely due to increased survival of premature infants with low birth weight. Prevalence of one subtype (choreoathetoid CP, which is due to kernicterus related to hyperbilirubinemia) has decreased. Overall incidence : 2.0-3.0/1000 live births. Etiology CP has multiple etiologies, many still unknown; often no specific cause is found. 70-80% of causes are prenatal;prematurity is most common to CP.

IV. Cerebral Palsy (CP)

Comparison of Symptoms of

Pyramidal

Extrapyramidal

Involuntary movements: Tone Type of tone Deep tendon reflexes : Clonus Contractures Primitive reflexes

(Spastic) (Dyskinetic) Rare Often Increased Alternating Spastic (clasped knife) Rigid(lead pipe) Increased Present Early Delayed Normal to increased Present occasionally Late Persisten

IV. Cerebral Palsy (CP)

Risk Factors
Prenatal Congenital malformations Socioeconomic factors Intrauterine infections Teratogenic agents Maternal mental retardation Maternal seizures Maternal hyperthyroidism Placental complications Additional trauma Multiple gestation Perinatal Prematurity (< 32 weeks) Birth weight < 2500 gm Growth retardation Abnormal presentations Intracranial hemorrhage Trauma Infection Bradycardia and hypoxia Seizures Hyperbilirubinemia Postnatal Trauma Infection Intracranial hemorhage Coagulopathies

From Molnar GE, Alexander MA : Pediatric Rehabilitation. Philadelphia, Hanley & Belfus, 1999

IV. Cerebral Palsy (CP)

Classification/syndromes 1. Pyramidal (spastic) lesions : motor cortex, internal capsule, and/or corticospinal tract; most common (75% of cases) Spastic quadriplegia Involves all four extremities Can be associated with diffuse HIE Often affects cognitive region as well as motor areas of brain. Swallowing/feeding often a problem. About 50% have seizures. Visual impairment common. Children with moderate to severe quadriplegia have poor walking prognosis. Highest incidence of mental retardation, proportional to severity. Significant oromotor dysfunction.

Spastic triplegia Involves three extremities, classically bilateral lower and one upper extremity. Features similar to those of spastic quadriplegia.

IV. Cerebral Palsy (CP)

Spastic hemiplegia Involves one side of the body; usually arm is more affected than leg. Most cases are congenital (70-90%). Usually due to unilateral vascular lesion of middle cerebral artery. Associated with porencephaly and visual, sensory, and perceptual deficits. Seizures are common (about 50% of cases). Growth retardation of affected limbs is common. Spastic diplegia Involves legs more than arms. Motor cortex primarily affected. Affects 80% of patients with CP who were preterm. Associated with intraventricular hemorrhages in 28-32-week infant and with periventricular leukomalacia or porencephaly. Associated with seizures (20-25%), visual deficits (63%), strabismus (50%), and cognitive impairment (30%).

IV. Cerebral Palsy (CP)

2. Extrapyramidal (dyskinetic) lesions Involves basal ganglia, thalamus, subthalamic nucleus, and cerebellum. Infants generally are hypotonic at birth. Associated with oromotor difficulties, including dysarthria, swallowing difficulties, drooling. Associated with hyperbilirubinemia and Rh incompatibility; therefore, incidence reduced because of adequate treatment. May also be due to incomplete resusciation (rare in U.S). Normal intelligence in approximately 78% of cases. Athetosis Slow, writhing movements and involuntary movements, especially in distal extremities. Antagonist and agonist muscles are active.

IV. Cerebral Palsy (CP)

Chorea : quick, jerky-like movements, irregular. Choreoathetoid : both athetosis and choreiform movements. Ataxia Large-amplitude, involuntary movements. Generally athetoid movements dominates. Pure ataxic CP is rare. Dystonia Tremor and wide-based, drunken-like gait with uncoordinated movements. Associated with nystagmus and dysmetria. May be associated with cerebellar lesion. Slow, rhythmic movements with tone changes, generally in trunk and extremities. Abnormal postures. 3. Mixed types : features from both classifications (e.g., spastic-athetoid type, in which child may have predominantly dyskinetic movements with underlying component of spaticity).

IV. Cerebral Palsy (CP)

Associated problems 1. Orthopedic Scoliosis Hip dislocation Contractures 2. Spasticity (See Chapter 19, Spasticity). 3. Mental retardation 4. Communication disorders

IV. Cerebral Palsy (CP)

5. Neurobehavioral problems Entire spectrum from attentional problems to autism may be seen. Prevalence rates may reach 50%. 6. Seizures Seen in 50% of children with CP. Associated with spastic (pyramida) CP, most frequently in spastic hemiplegia and quadriplegia. All types of seizures are seen, but incidence of generalized focal and multifocal seizures is increased. Child needs appropriate antiseizures medications, 7. Cortical sensory deficit Spastic hemiplegia Child needs to be aware of risks related to lack of sensation (e.g., burns). Adaptation to deficit, such as visual input, should be stressed. 8. Visual deficits 50-92% of children with CP have refractive errors and/or strabismus. Homonymous hemianopsia is associated with spastic hemiplegia. Cortical vision impairment is associated with spastic diplegia, hemiplegia.

IV. Cerebral Palsy (CP)

9. Sensorineural hearing loss Affects 10% of children with CP. Associated with hyperbilirubinemia. May require hearing aids. 10. Nutrition problems Affect 50-70% of children with CP. Due to oral motor problems related to swallowing. Most common in spastic quadriplegia and extrapyramidal (dyskinetic) types. May require tube feeding or special diet. Referral to speech language phatologist is recommended. May require video-fluoroscopically guided swallowing study. 11. Drooling Due to oral motor problems. Treatment includes oral medications (cetirizine, glycopyrrolate) or scopolamine patch as well as surgery to excise salivary glands, redirect parotid ducts, and/or sever chorda tympani nerves. 12. Dentition

IV. Cerebral Palsy (CP)

13. Neurogenic bladder : may be due incoordination and lack of voluntary control over hypertonic pelvic floor (also see Chapter 15, Neurogenic Bladder Managements). 14. Vasomotor problems : in pyramidal (spastic) types, with coolness/edema of affected limbs. 15. Temperature instability : especially in severely affected child with spastic quadriplegia CP; environment should be regulated. 16. Gastrointestinal problems : reflux (H2 blockers or proton pump inhibitors), constipation (See Chapter 16, Neurogenic Bowel Management). 17. Pulmonary problems Deficient ventilation. Bronchopulmonary dysplasia in premature infants. precautions. Some may require tracheostomy, mechanical ventilation. Sleep apneanmay be central or obstructive.

IV. Cerebral Palsy (CP)

Prognasis in CP 1. Best prognosis with ataxic CP and diplegia in terms of mobility, communication, and cognition. 2. Extrapyramidal group has lowest rate of mental retardation. Overall mental retardation rate is 30-50%, with the highest rate in children with rigid, atonic, and severe spastic quadriplegic CP. 3. Walking prognosis Almost all children with hemiplegia walk. Upper limb weakness and deformity are usually the chief concerns. Most children with diplegia walk (at least with aids). Sitting independently before age 2 is a good sign for independent walking; most children who do not sit by 4 years will not walk. Most children with moderate to severe quadriplegia do not walk. Persistence of primitive reflexes and absence of protective reflexes by 1 year of age poor prognostic signs.