5/10/2016
Disclosure
Interventions for Children With
Developmental and Movement
Challenges, Part I
Venita Lovelace-Chandler, PT, PhD, PCS
Consultant, Adjunct Faculty UNTHSC & RMUHP
• Venita Lovelace-Chandler, PT, PhD, PCS has no
relevant financial relationship to disclose.
• Margaret McGee, PT, PhD, PCS has no relevant
financial relationship to disclose.
Margaret McGee, PT, PhD, BSN, PCS
Associate Professor, University of Central Arkansas
Course Description
Session Learning Objectives
• PTs and PTAs intervening with children must meet the
developmental, postural, and movement needs of young
children with a variety of diagnoses. This session provides EB
interventions to foster head, trunk, and extremity control;
transitional movements; gait; and participation activities. All
interventions utilize concepts of child motivation and
interaction within the environment for cognitive growth and
communication/participation with family members and peers.
Examples of interventions include constraint-induced
movement therapy, upright mobility, treadmill walking,
hippotherapy, and powered mobility. Participants will utilize
patient cases and the current guidelines to determine plans of
care and support families.
After completing this session, you will be able to:
1. Practice and demonstrate interventions to promote movement
control and strengthening.
2. Identify and prioritize the best treatment options for specific
pediatric clients.
3. Utilize recent articles and best practice guidelines to inform
practice, including concepts of child motivation.
4. Plan intervention programs to meet developmental challenges,
to foster cognitive and communication growth and participation,
and to support families.
Real Objectives
Course Outline
• To inspire people to think
and/or act differently.
8:00
8:10
8:40
9:10
• To engage in on-going
evidence-based practice
9:20
9:30
Introduction to the course
Review the variety of diagnoses seen in pediatric practice
and discuss current outcomes regarding early intervention.
Practice and demonstrate interventions to promote motor
control and strengthening based on current literature and
practice guidelines.
Gain consensus on the best practices to support families
and enhance participation by young children.
Questions and Answers
Close session
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Variety and Complexity of
Diagnoses in Pediatrics
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•
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Cerebral Palsy – incidence and types
Down Syndrome – incidence
Babies born prematurely – incidence/outcomes
Torticollis – incidence/related complications
Autism Spectrum Disorder – incidence and
new classification
• Development Coordination Disorder
• Spina Bifida
Variety and Complexity of
Diagnoses in Pediatrics
• Genetic syndromes – large variety
– SMA, q deletion syndromes, dystrophies
•
•
•
•
•
•
Effectiveness of Early Intervention
Obesity – Exercise-Deficit Disorder
ADHD/Learning differences
Seizure disorders;
Congenital anomalies – musculoskeletal; cardiac;
Fractures, injuries, burns, amputations
Your Practice???
Effectiveness of Early Intervention
1. Enhances parent bonding and social interaction
within families
4. No specific philosophy has been shown to be
efficacious for all children
2. Fosters cognitive development
5. Stretching not usually effective; static positions not
usually effective;
3. Specific motor skills do not necessarily improve;
more neuromuscular involvement = less
improvement unless interventions are intense
6. Exploration/participation most beneficial
Concepts Which Have Some
Theoretical and Research Support
Effectiveness of Early Intervention
1. Perceptual-motor experience within cultural and
social contexts forms cognition;
2. Exploration through early behaviors broadly
facilitates development;
3. Exploration that is limited = risk for global
development impairments;
4. Early intervention targeting exploratory behaviors
may advance abilities across developmental domains
and times.
Lobo, Harbourne, Dusing, McCoy 2013. Grounding Early Intervention: PT
Cannot Just Be About Motor Skills Anymore
•
•
•
•
Early Intervention and Healthy Activities
Avoid painful experiences in interventions
Practice family-centered care
Accept that families (and third party payers)
want mobility (upright) and participation
• Strengthening & motor control/motor learning
to gain, keep and advance motor skills
• Consider Dosing Information (when known)
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The problem of pain
• Young neonates feel pain and possibly feel the pain
intensely
• Neonates experience a greater intensity of pain than
older children because of the inability to modulate
and inhibit pain.
• They are unable to communicate their pain and
provide self-report
• Children lose motivation to participate if experience
is painful
Painful Experiences Cause Structural
& Physiological Changes
•
•
•
•
•
•
•
Use calories needed for growth to control the pain
Decreases oxygen saturations
Increased heart rate & respiratory demands
Increased intracranial pressure
Release of stress hormones
Altered pain threshold
Decreased sensitivity & Increased somatization of
unspecific origin
• Structural changes in the brain and spinal cord
Mitchell & Boss, 2002
Examples of Physiologic &
Behavioral Responses to Pain
Examples of Physiologic &
Behavioral Responses to Pain
• Muscle tone – increase
• Sleep disturbances
• Oxygen saturation decreases – fatigue
• Loss of appetite
• Facial changes – grimacing, nasal flaring, eye
bulging, quivering of chin (jaw clonus), gaze aversion
• Sweating, mottling of skin, skin pallor or flushing
• Increased release of stressful hormones – changes in
insulin production
Principles of pain intervention
• Physical therapists cannot cause pain AND
achieve developmental advancement
• Have to manage with environmental and
behavioral interventions
• Pharmacological interventions may be additive
• Pain is not conducive to health
• Head banding, fingers and hand flexion, self-biting,
back arching, pulling out hair, other self-injurious
behaviors
Venita’s view of strengthening and
movement
• Type of contractions must be considered when
planning interventions
• Apply that concept to total body movements
• Use concepts of motor control/motor learning
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Venita’s view of strengthening and
movement
• Type of contractions – easiest to hardest; isometric
(submaximal - maximal, joint angle specificity; short
arc; eccentric + concentric = increase in
strengthening
• Apply that concept to total body movements
• Use concepts of motor control/motor learning
– Repetition, repetition, repetition (practice) to learn
the skill
– Vary the environment (complexity) to use the skill
functionally or for participation
Karen Adolph
• Twelve- to 19-month-olds averaged 2,368 steps
and 17 falls per hour. Novice walkers traveled
farther faster than expert crawlers, but had
comparable fall rates, which suggests that
increased efficiency without increased cost
motivates expert crawlers to transition to walking.
• Immense amounts of time-distributed, variable
practice constitute the natural practice regimen for
learning to walk.
Venita’s view of importance of
being upright
• Reticular activating system - The part of the
reticular formation in the brainstem that plays
a central role in bodily and behavioral
alertness; its ascending connections affect the
function of the cerebral cortex and its
descending connections affect bodily posture
and reflex mechanisms. Thought to influence
motivation.
• Most active when the head is vertical.
Infants: Handling/Interventions
Turn to the person next to you and suggest 2
important techniques to foster head and upper
trunk control
Share with group
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Venita’s view
• What are the MOST
IMPORTANT
ACTIVITIES to Foster
in Infancy and
Childhood?
•
•
•
•
•
•
Sitting
Reaching
Looking
Standing
Upright mobility
Participation and
exploration
What Families Want
Family Centered Care
• Collaborative partnership with families and
practitioners by:
– Adapting care
– Teaching family priorities
– Taking into account learning styles
– Addressing emotional stresses
– Respecting cultural variability
• Understanding that this is not what families
“imagined” or “wished for”
International Classification of
Functioning, Disability and Health
• Interactive, complex
interactions between individual
and the environment
• Health
– 1. Functional and structural
integrity of body parts/systems
– 2. Promotion of age appropriate
postural and movement
activities
– 3. Appropriate interaction
among the neonate, family and
professionals
• Upright mobility
• Participation
• Allows for consideration of
impairments, activity
limitations and participation
restrictions.
Principles of Best Practice:
Young Children
• Avoid causing pain in
infants/children
• Provide family-centered
care
• Provide Early
Intervention and
Transition
• Look for opportunities for
participatory activities
• Promote Health
• Use Standardized testing
• Use Clinical guidelines
• Use research to inform all
aspects of patient
management
• Be able to respond to
accountability of families,
institutions, third party
payers
Infants: Handling/Interventions
Turn to the person next to you and suggest 2
important techniques to foster sitting, looking
and reaching.
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Older Infants and Toddlers
• Turn to the person next to you and suggest 2
important techniques/interventions to foster
trunk and extremity control, transitional
movements, and gait activities in upright
positions.
• Please share some examples and let’s practice
together.
Dosing
Why is Dosing Important?
• Key component of clinical effectiveness
• Dosing of therapy for children with
development disabilities identified as a
national priority and will impact health policy
• Critical for informed clinical decision-making
• Used to establish guidelines for reimbursement
Strengthening and Skill
• How do you incorporate strengthening into
your interventions?
• Motor learning principles for skill
development?
– Practice, practice, practice
– Increase complexity through variation
What are the components of
dosing?
• Frequency
– # of sessions/week and # of weeks
• Intensity
– How strenuous is the exercise each session
• Time
– Length of each session
• Type
– Mode of exercise
Current Topics/Trends
• Participation – including
tests and measures
• Sitting and reaching and
looking
• Child motivation
• Health Promotion and
Physical Activity
• Strengthening/Motor
Learning/Endurance
• Complexity or variance
of tasks
• Treadmill Walking
• Upright Mobility
• Constraint Induced
Movement Therapy
• Dosing
• Clinical Practice
Guidelines
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Review of Lit from 2015 Article
• Research has indicated that, compared with typically
developing peers, children with autism (Wiggs &
Stores, 2004), Down syndrome, Prader-Willi
syndrome, intellectual disability (Cotton & Richdale,
2010), and cerebral palsy (Newman, O’Regan, &
Hensey, 2006) may experience diminished quantity
and quality of sleep. This sleep debt may have
negative consequences for health & performance of
childhood occupations. Impaired sleep can exacerbate
behavioral, anxiety, and mood disorders.
Variety of Guidelines
Great Site for pediatric clinical guidelines
• Cincinnati Children’s Hospital Medical Center
• Best Evidence Statement (BESt)
• http://www.cincinnatichildrens.org/service/j/an
derson-center/evidence-basedcare/recommendations/default/
Clinical Guidelines/Summaries
• APTA
• Section on Pediatrics
• Cincinnati Children’s
Hospital
APTA
• NICU
• Torticollis
• Down Syndrome
• Muscular Dystrophy
• AOTA and ASHA have
guidelines too
Suggested Journals for Therapists
Treating Infants and Young
Children
• Pediatric Physical Therapy (journal of the Section on
Pediatrics, APTA)
• Physical Therapy (journal of the APTA)
• The American Journal of Occupational Therapy
(journal of the AOTA)
• Physical & Occupational Therapy in Pediatrics
• Pediatrics (American Academy of Pediatrics)
• Developmental Medicine and Child Neurology
• Others in your specific area of interest
Findings
• The findings of the current study are consistent
with the emerging shift in disability research
from a disablement framework to a framework
with a greater emphasis on health and wellbeing (Larson, 2006) and participation in life
roles and expectations.
• AJOT, Sept/Oct 2015
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Purpose
• Therefore, the purpose of this systematic
review was to examine the broader literature
on the effectiveness of occupational therapy
interventions for people with ASD that
improve parental self-efficacy, (decrease)
stress, family coping and resiliency, and family
participation in daily life and routines.
Exercise Programs for
Children with Disabilities
• Focus of intervention for school-aged children
• Important to avoid potential health issues
related to decreased activity level
• Avoidance of Sedentary Behavior
• Cardiorespiratory Training
– Aerobic Capacity
– Endurance
Participation (ICF-CY)
• Defines participation as “involvement in a
life situation”
• New tests and measures being developed to
measure just participation
• “Participation is the context in which
children develop skills”
• Successful participation is critical in
achievement of successful outcomes
• Muscle Strengthening
Participation
• Positive relationship between overall
functional level and participation
• Important because low participation in
physical activities has impact on health and
overall fitness level
Participation Measures for SchoolAged Children
• Children’s Assessment of Participation and
Enjoyment (CAPE)
• Preferences for Activities for Children (PAC)
• Child and Adolescent Scale of Participation
(CASP)
• Participation and Environment Measure for
Children and Youth (PEM-CY)
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Questions???
• Vlc.phd.pt.pcs@gmail.com
• Thank you so much
References
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Predictors of Independent Walking in young Children with Cerebral Palsy. Phys Ther.
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Boss RD; Kinsman HI; Donohue PK. Health-related quality of life for infants in
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Case-Smith J. Systematic Review of Interventions to Promote Social-Emotional
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References
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