Pediatric Physical Therapy Interventions PHT 5140C Faculty Anna Edwards, PT, MA, MBA, ACCE aedwards@usa.edu or Extension 2402 Cornelia Lieb-Lundell, PT, DPT, MA, PCS lieblundpt@sbcglobal.net Additional Pediatric POINT LAB Instructors: Jan Spain, PT Cathy Courtney, PT Luci Schmeiser, PT, DPT Required Texts Effgen, Susan K. (2013).Meeting the physical therapy needs of children. Philadelphia: F.A. Davis. Shumway-Cook A, Woollacott, M.H.Motor Control Translating Research into Clinical Practice, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2011. Child Development, Neuromuscular I and Neuromuscular III required textbooks and course note packets and references. Section on Pediatrics fact sheets as assigned Pediatric Clinical Practice Guidelines Additional References in the syllabus and course notes Course Introduction Objectives APTA Section on Pediatrics Physical Therapy Across the Life Course Development from Pediatrics to Geriatrics Pediatric Diagnosis, Interventions & Settings Conceptual Framework for Clinical Practice applied to Pediatric Physical Therapy Models of team interaction and models of service delivery Issues Influencing Pediatric Physical Therapy Practice 1
Section on Pediatrics Vision: The Section on Pediatrics American Physical Therapy Assoc. 1111 North Fairfax Street Alexandria, VA 22314 - www.pediatricapta.org Transforming society by optimizing movement to improve the human experience for all children, adults with developmental disabilities, and their families A Vision to Transform Society http://www.apta.org/ptinmotion/ 2014/3/Feature/APTAVision/ Objectives to support SOP vision: Pediatric physical therapists will engage in diagnosis, intervention, prevention, and advocacy. Pediatric physical therapists will participate in the advancement of evidence-based practice by identifying critical needs, utilizing currently available evidence, and producing and directing future data. Pediatric physical therapists will provide expertise regarding movement dysfunction in individuals with developmental disabilities and other pediatric disorders. Pediatric physical therapists and physical therapist assistants will participate in community-based activities that enhance comprehensive and accessible services. Pediatric physical therapists and physical therapist assistants will promote health and fitness. Pediatric physical therapists and physical therapist assistants will engage in life-long learning. 2
Physical Therapy across the Life Course A Life Course Approach to Development Katherine Sullivan, PT, PhD, FAHA and Reggie Harbourne, PT, PhD, PCS Development is a life long process related to the development, peak growth, and decline of the muscular skeletal, neuromuscular, cardiovascular/pulmonary, and integumentary systems. Development across the life stages (transitions) Childhood, adolescence, young adult, middle adulthood, older adult, senior adult Our focus in this course will be development in utero, infant, toddler, preschool, school age, adolescence/ teenage Functional capacity changes over the life course Early life is linked to later life Early motor experiences are linked to cognitive development Sitting initiates a period of exploration and change in infant vocalization. http://transitions.canchild.ca/en/ourresearch/bestpractices.asp Diagnosis and Prognosis Medical and Physical Therapy DX Epilepsy Cerebral Palsy Metabolic Disorders/Infant Diabetic Developmental delay Syndrome Down syndrome Chromosomal Disorders Prader Willi Torticollis Angleman syndrome Spina bifida Duchenne s Muscular Dystrophy Autism Club foot surgery Aspberger s syndrome Congenital Hip Dysplasia Rett syndrome Burns Hypotonia Tetralogy of Fallot Down syndrome Global Developmental Delay Traumatic Brain Injuries Aging with Developmental Disabilities Life Transitions in Childhood In Utero Birth to home Being away from parents Preschool Age 2-3 Elementary School Middle School High school Infant Toddler Children 5-6 Children 10-12 Adolescence 13-18 http://health.discovery.com/tv/nicu/ Pediatric Clinical Settings NICU and Inpatient Rehabilitation Home Health Pediatric Hospice Early Intervention Regular Education Public Schools Special Education Private Schools Outpatient Clinics Pediatric Private Practice Independent Consultants Early Intervention Schools (Ch 11) Schools (Ch 12) Sports Setting for the School Aged Child (Ch 13) Pediatric Acute Care Hospital (Ch 14) Neonatal ICU (Ch 15) Rehabilitation Setting (Ch 16) Chapters 11-16 in Effgen Pediatric Development Evaluation Includes: Social Emotional Development Gross Motor Development Fine motor Development Language Development Resources: Pathways Checklists (www.pathways.org) Assure Baby s Physical Development (class handout) Pathways Sensory Motor Checklists by age Play and Social Skills (Social Emotional Development) Coordination (Gross Motor Development) Daily Activities (Fine Motor Development) Self Expression (Language Development) 3
Pediatric Interventions Frequency, Intensity, and Duration of Interventions Tone management Balance & Coordination Stretching & Strengthening Joint mobilization Movement and mobility Kinesiotaping Splinting and Serial Casting Transfer training Gait training Standing Wheelchairs Treadmill/Gait Lite Body weight support training NDT (Adele) Suit Therapy Theratogs Hip Huggers NMES TENS FES Botox Hippo therapy Conductive Education Facilitation can take many forms, remember to document what worked and the resultant outcome in terms of motor and muscle activity What Role Does the Family Play? Parents and families have the primary (central) role in their child s development. The pediatric physical therapist collaborates with the family to implement an individualized program for the child. Families are supported through coordination of services, advocacy, and assistance to enhance the development of their child through: Positioning during daily routines and activities, Adapting toys for play, Expanding mobility options, Easing transitions from early childhood to school and into adult life. Adapting to families choice of settings: home, child care centers, preschools, schools and job sites. Child and Family Centered Practice While I have worked many hours with professionals, my parents were the key people. David, age 22 with cerebral palsy Child and Family Centered Practice Patient and Family Centered Practice Applying principles of Dignity and respect Transparent access to information Active participation Collaboration between the patient, their family and the therapist Take into account personal context and environmental context Team-based Service Delivery Models of Team Interaction Conceptual Framework for Clinical Practice Unidisciplinary Multidisciplinary Interdisciplinary Transdisciplinary Collaborative PT Models of PT service delivery Direct Integrated Consultative Monitoring Collaborative 1. Model of practice 2. Model of function and disability 3. Hypothesis-oriented clinical practice 4. Principles of motor control and motor learning 5. Evidence-based clinical practice Resources: SOP Fact Sheet Effgen pp. 23-28 Motor Control 4 th edition 4
Constructs and Concepts That Inform Physical Therapist Practice Four major constructs and concepts inform current physical therapist practice: The International Classification of Functioning, Disability and Health (ICF) and the biopsychosocial model Evidence-based practice Professional values Quality assessment Model of Practice Using APTA s Guide to Physical Therapist Practice in Pediatric Settings Practice Patterns Child may have a PT diagnosis of one or more practice patterns 5B (impaired neuromotor development) 5C (non progressive CNS disorders-child) 4C (impaired muscle performance) 6B (deconditioning) Model of Practice Using APTA s Guide to Physical Therapist Practice in Pediatric Settings Structure of the International Classification of Functioning, Disability and Health (ICF) model of functioning and disability.5. Practice Patterns Child may have a PT diagnosis of one or more practice patterns 5B (impaired neuromotor development) 5C (non progressive CNS disorders-child) 4C (impaired muscle performance) 6B (deconditioning) 2014 by American Physical Therapy Association Interaction among the components of the International Classification of Functioning, Disability and Health (ICF) model of functioning and disability.5. Components of evidence-based practice.13. 2014 by American Physical Therapy Association 2014 by American Physical Therapy Association 5
Principles of Physical Therapist Patient and Client Management Co-management Consultation Direction & Supervision Referral 2014 by American Physical Therapy Association Model of function and disability ICF ICF framework enablement perspective Part 1: Functioning and disability Body structure and function-impairments Activity Activity limitations are difficulties an individual may have in executing activities Participation Participation restrictions are problems an individual may experience in involvement in life situations Part 2: Contextual Factors Environmental Factors Personal Factors Table 1.1 p 6 Effgen Activities Prone: Supine: Side lying: Sitting: Quadruped: Kneeling half kneeling Standing: Single leg stance: Cruising: Walking Walking, stairs, varied surfaces GMFM 5 Dimensions Lying and Rolling Sitting Crawling and Kneeling Standing Walking, Running and Jumping Participation Participation Young Child Family routines (household chores and errands) Care giving routines (bathing, dressing, eating, grooming, bedtime) Family rituals and celebrations (holidays, birthdays, religious events) Outdoor activities (gardening, visits to park/zoo) Play activities (physical play and play with toys) Learning activities (listening to stories, looking at books/pictures) CAPE Children's Assessment of Participation and Enjoyment In school activities Lunchtime activity among peers Use boy s bathroom in Elementary school Age appropriate art activities in school classroom Play on playground ad interact with peers in neighborhood For Life situations Go with family in restaurant to celebrate an occasion Participate in shopping Walk in part to spend time with friend's. 6
ICF-CY (WHO, 2007) www.who.int/classifications/terminology Confirms the importance of precise descriptions of children's health status Greater detail to encompass the body functions and structures, activities, participation ICF-CY is from birth to 18 years of age - infants, toddlers, children and adolescents ICF-CY was developed in a manner sensitive to changes associated with growth and development http://apps.who.int/iris/bitstream/10665/43737/1/9789241547321_eng.pdf ICF-CY International Classification of Functioning, Disability and Health Children and Youth Version Activities and Participation for Mobility Changing basic body position Maintaining a body position Transferring oneself Lifting and carrying objects Moving objects with lower extremities Fine hand use Hand and arm use Walking Moving around Moving around in different locations Using Transportation Driving Effgen, Chapter 3 Table 3.5 Differences: Codes for Manual and lateral dominance Learning through actions and playing Following routines Managing one s own behavior Qualifiers for Performance Capacity Evidence Based Clinical Practice SOP initiatives aimed at supporting the translation of evidence based knowledge and information into clinical practice 1. Establishes the steps for intervention 2. Examines the constituents of health and the effects of disease on the individual 3. Provides a process for testing assumptions regarding the nature and cause of motor control problems 4. Suggests essential elements to examine and treat 5. Emphasized the integration of research evidence, clinical expertise and patient characteristics in clinical practice Evidence Based Clinical Practice Translation from research to clinical application Increased emphasis on EBP Reimbursement issue Development of the Guide Practice guidelines APTA Clinical Research Agenda Legislative affairs Access to Evidence APTA.org Google Scholar PT research Development of Residencies and Fellowships PhD programs in rehabilitation sciences Research preformed by clinician in clinical setting Revised APTA Clin Research Agenda 7
Evidence Based Clinical Practice in Pediatric Physical Therapy Developing Evidence Based Practice through research Translation How to implement EBP translation into the clinic: 1: Ask a clinical question 2: Find the best evidence 3: Critically appraise the evidence 4: Integrate evidence with practice 5: Evaluate effectiveness www.pediatricapta.org EBP is the integration of research findings, clinical expertise, individual professional opinion & values. 4 elements of good evidence (Law and McDermid (2008): 1. Awareness 2. Consultation 3. Judgment 4. Creativity It s about integrating individual clinical expertise and the best external evidence (David L. Sackett) Use of current best evidence in making decisions about the care of individual patients Physical therapists are positive and indicate they are interested in learning or improving skills necessary to implement EBP Jette Phys Ther 2003 83:786-805 Knowing which test to choose to use to diagnose and which intervention to deliver in order to limit or eliminate disability (or prevent disability) PT s note that they need to increase the use of evidence in their daily practice Evidence to Practice Algorithms Written guidelines to stepwise evaluation and management strategies Clinical practice guidelines Systematically developed plans to assist in health care decision making for specific clinical circumstances Clinical, critical, or care pathways Predetermined protocols that define the critical steps in exam eval and providing interventions Clinical prediction rules (CPR) Clinical findings are groups to help with screening, diagnosing, or prognostications Clinical Practice Guidelines (CPG s) What are CPGs? Evidence based recommendations intended to optimize patient care. Informed by a systematic review of the literature Include assessments of the benefits and harms of alternative care options When coupled with clinical judgment and consideration for patient s preferences CPG s reduce practice in variation Improve diagnostic accuracy Promote effective interventions Discourage ineffective or potentially harmful practicies Improve patient centered health outcomes Clinical Reasoning in Pediatric Physical Therapy Practice Complex and Critical Numerous patient specific variables that influence care Innate variability in the growth and development of children Identifying and considering contextual variables Directs a clinicians actions and decisions What is Clinical Reasoning The thinking and decisionmaking of a health care provider in clinical practice Clinical reasoning the thinking or judgment behind one s action Clinical decision making is the action on this process Complex and Critical Numerous patient specific variables that influence care Innate variability in the growth and development of children Identifying and considering contextual variables Directs a clinicians actions and decisions 8
Clinical Reasoning Clinical Reasoning as a Developmental Process Critical aspects of reflection Mutual Decision Mutual decisionmaking Patient context Thought processes vital in clinical reasoning Discipline specific knowledge Metacognition Reflective self awareness Patient centered focus Development of expertise Hypothetico-deductive (deductive reasoning) Hypothesis based upon results of test and measures, followed by testing this hypothesis Pattern recognition (inductive reasoning) Retrieval of information from well structured knowledge based upon previous clinical experience Application of clinical reasoning skills in the classroom and in the clinic Reflection-on-Action Reflection-in-Action Reflection-for-Action Issues Influencing Practice Pediatric Physical Therapy Advocacy and Public Policy Changing Health-Care Delivery System Family Centered Care Child Abuse and Neglect Behavior Management Cultural Practices Pediatric & Adult POINT Labs Natural Environment - What is it? Early Intervention Defining Educationally vs Medically based Interventions Essential Key Components for Successful Teams (Reflection Paper) A shared framework of trust Clearly defined roles and responsibilities Respectful and empathetic open communication Appreciation of diversity Equal participation among all team members Established common goals Consensus decision making Solution focused problem solving Ongoing evaluation Strong Leadership 9
THANK YOU Thank you to the parents and children and educational website sources who participated in the development of this information and graciously allowed the use of their pictures for educational purposes. Picture material is copyrighted and may not be used without the author s permission. 10