2/16/2024
DEPARTMENT OF REHABILITATION SCIENCES
CLINICAL REASONING IN PEDIATRIC
PHYSICAL THERAPY
Lynn Bar-On
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CONTENT OF THEORETICAL LESSON 1
1. Introduction
2. Learning paths on Ufora: to prepare for the practical
sessions
3. Theory of pediatric clinical reasoning
4. Case Evert
5. Case Samuel
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INTRODUCTION
Clinical Reasoning in Pediatric Physical Therapy
Why should I know this?
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Children can be referred to a physiotherapist, regardless of specialisation
Specialisations are not common in most countries
Patients in treatment may seek physiotherapy for their children
Every adult was once a child – development has life-long effect
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FINAL COMPETENCES
1.
The student is able to formulate relevant short- and long-term SMART treatment goals, based on patient request/problem
statement, relevant information from history taking and clinical examination (what are the goals of the clinical exam?).
2.
The student is able to design an adequate rehabilitation program (goals and expected outcomes, frequency, duration, reevaluation, outcome measures, discharge) based on the treatment goals.
3.
The student is able to adequately select the treatment techniques (specific interventions, information transfer) and is able
to adapt the treatment strategy to patient progression how to evaluate progress?
4.
The student (within a group) is able to search for scientific literature in a systematic way (related to the pathology and the
treatment of the patient case), and is able to critically evaluate these articles, to summarise the information and to integrate it in
the treatment of the patient.
5.
The student is able to communicate with colleagues with respect to issues relevant for the patient case within a
multidisciplinary context (think of all involved in the care taking of a child).
6.
The student listens to the vision and expertise of the other and also accepts the relativity of his / her own vision and ideas.
7.
The student deals constructively with the positive experiences, and/or difficulties that can accompany intercultural
encounters.
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Introduction + EPB –
Prof. Dr. A. M aenhout
Direct Access – F. Lanszweert
Clinical reasoning –
Prof. Dr. T. M atheve
M SS
1. UpperLimb
Upper limb theory – Dr. V. Spanhove
Upper limb case – Dr. K. Berckmans /
Dr. D. Borms
Upper limb response – Prof. Dr. A. Cools
2. LowerLimb
Lower limb theory – B. Sticker
Lower limb case – B. Sticker
Prof. Dr. R. De Ridder
NEUROGERIATRICS
PEDIATRICS
INTERNAL
DISORDERS
Neurogeriatrics theory –
Dr. A. Van Bladel
Pediatrics theory –
Prof. Dr. L. Bar-On
Internal disorders theory –
Prof. Dr. H. Demeyer
Neurogeriatrics case –
J. D ewaele /
W . D e W ilde
Pediatrics case –
N. Vens / B. De Mey /
Dr. N. De Bruyn
Internal disorders case –
Dr. H. Da Silva /
B. Zwaenepoel
Neurogeriatrics response
–
Dr. A. Van Bladel
Pediatrics response – Prof.
Dr. L. Bar-On
Internal disorders response –
Prof. Dr. H. Demeyer
Lower limb response – B. Sticker
3. Spine
Spine theory – Prof. Dr. T. Matheve
Spine case – B. Vanthillo /
Prof. Dr. V. De Witte
Spine response – Prof. Dr. T. Matheve
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— What can I expect
based on the information
I have?
— What should be included
in my clinical
assessment?
Referral to other
Communication,
health care
providers. Who?
coaching,
motivation
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PREPARATION LEARNING PATH
DOMAIN
TASK
SPINE
EBP task: summary of literature for peers
F-groups (SPINE)
PRA 2 SPINE
UPPER LIMB
Learning path: Case 1
All students (on Ufora)
PRA 1 UL
Learning path: Case 2
All students (on Ufora)
PRA 2 UL
Learning path: Case 3 and 4
All students (on Ufora)
No deadline, selfstudy
EBP taks: summary of literature for peers
D-groups (UL)
PRA 2 UL
Case preparation
All students (on Ufora)
PRA 1+2 LL
EBP task: summary of literature for peers
E- groups (LL)
PRA 2 LL
Learning path Case 1
All students (on Ufora)
PRA 1 INT DIS
Learning path Case 2
All students (on Ufora)
PRA 2 INT DIS
Case 3
All students
(On Ufora, self-study)
No deadline, selfstudy
EBP task: summary of literature for peers
C-groups (INT DIS)
PRA 2 INT DIS
Learning path Case Evert
All students (on Ufora)
PRA 1 PED
Learning path Case Sam
All students (on Ufora)
PRA 2 PED
EBP task: summary of literature for peers
B-groups (PED)
PRA 1 PED
Learning path preparation
Points 1+2+3
All students (on Ufora)
PRA 1 NG
Learning path preparation point 4
All students (on Ufora)
PRA 2 NG
EBP task: summary of literature for peers
A-groups (NG)
PRA 2 NG
Mid term peer assessment
All students (on Ufora)
1/4/2024
Submission of the task
All students (on Ufora)
20/5/2024
Final peer assessment
All students (on Ufora)
27/5/2024
LOWER LIMB
INTERNAL DISORDERS
PEDIATRICS
NEUROGERIATRICS
EBP assignment
DEADLINE
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EBP ASSIGNMENT B-GROUPS
The dynamical systems theory of motor development emphasizes that movement emerges from the interaction of different
subsystems under specific conditions, rather than from a hierarchy of motor commands in the central nervous system. Thus,
children’s motor development depends upon various factors that are inherent both to the infant and its interaction with its
environment. If the environment in which an infant is placed plays a role in its motor development, varying the positions of the
infant during sleep or wake time should have an impact on their motor development. In particular, it has been shown that
prone positioning from a very young age is important for the development of head control and anti-gravity extension. In turn,
strong neck and core extensor muscles assist the development of stability in weight-bearing positions such as prone-on-hands, on
all fours, and sitting. However, prone position in sleep has also been associated with an increased risk of sudden infant death
syndrome (SIDS) and many caregivers are reluctant to place their child for extended amounts of time on their tummies.
Another way of varying the baby’s position is by the use of different types of equipment such as baby walkers, baby bouncers, or
infant-sitting devices. Caregivers may use these pieces of equipment believing them to be stimulating of their child’s development or
for practical purposes. The effects of infant positioning on motor development is under investigated.
In this assignment, we would like you to:
1. Look into the scientific evidence of infant (<1 year) positioning (with and without the use of equipment) on later motor
development.
2. Conduct field research on the perceptions and attitudes of a) pediatric physiotherapists b) infant caregivers regarding infant
positioning and motor development.
3.
Create an infographic summarizing the most relevant aspects of 1) & 2)
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EBP ASSIGNMENT
— Related to case Evert – motor development
— Will be scored separately (+peer assessment).
— In case of questions:
During practical 1, Group B
prepares 3 scientific articles
that they will include in the
EBP assignment.
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EXAM PREPARATION
— Study material from 2nd bachelor:
— Motor control, motor learning – theories of motor development, typical development
— Study material from 3rd bachelor:
— Patholgie, alarmsignalen en variante ontwikkeling
— Revaki bij kinderen
— Study material from 1st master:
– Exercise is medicine
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Concentrate on CP, DCD, variable and/or delayed development, psychiatric disorders
and childhood obesity (examen)
— Also know: typical development, common assessments of motor development,
inter/multidiciplinary work, diversity aspects in terms of child development, referral, task
versus process focused interventions, guidelines.
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EXAM
Examining your clinical reasoning:
— Assessments based on history, anamnesis, problem statement.
— Using the ICF to write out a physiotherapeutic diagnosis.
— Setting ST and LT intervention goals based on function, activity and
participation goals.
— Planning an intervention related to goals.
— Integrating the internal and external factors in the intervention, think
about other disciplines, coaching and motivation, diversity
aspects….
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CONTENT OF THEORETICAL LESSON 1
1.
2.
3.
4.
5.
Introduction
Theory of pediatric clinical reasoning
Case Evert
Case Samuel
Learning paths on Ufora: to prepare for the practical
sessions
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THEORY OF PEDIATRIC CLINICAL
REASONING
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GUIDELINES  FIND AND USE THEM!
(BUT STAY CRITICAL)
Nederlandse richtlijnen: https://richtlijnendatabase.nl
DCD op basis van de EACD richtlijnen
op initiatief van Nederlandse Vereniging van Revalidatie artsen
ondersteund door het Kennisinstituut van de Federatie van Medisch Specialisten
https://richtlijnendatabase.nl/richtlijn/developmental_coordination_disorder_dcd/startpagina__developmental_coordination_disorder_dcd.html
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1. THEORY OF CLINICAL REASONING
 Clinical reasoning by an expert clinician
— pattern recognition (inductive reasoning) and forward reasoning
— collaborative patient-centered model
— reflection in action
 Clinical reasoning by a novice clinician (wij)
— therapist centered approach
— hypothetico-deductive (deductive reasoning) from initial cues from patient 
to initiate assessment
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1. THEORY OF CLINICAL REASONING
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HYPOTHESIS-ORIENTED PEDIATRIC
FOCUSED ALGORITHM
— Framework for novice clinicians in the clinical reasoning process in
pediatric physical therapy
— Child and family-centered approach
— Reflection to learn and to become an expert
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STEP 1: INITIAL HYPOTHESES IN ICF
Prior to examination
— Building mental image of the child (youngster)
A. Chronological age: expected (motor) functions – activities – participation
B. Primary and secondary dysfunctions and (motor) impairments related to
medical diagnosis
 Plan foundations of the examination
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STEP 2: INITIAL DATA COLLECTION (anamnesis)
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Based on initial mental image
Past medical diagnosis and history
Observation of child and family
Develop impression of functional capacties and status
Getting insight in patient's and family's desired goals and expected
outcomes
 Hypothesise which areas to investigate during the hands-on physical
examination.
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STEP 3: PROBLEM STATEMENT (HULPVRAAG)
— “This family/child is seeking physical therapy to be able to…,”
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STEP 4: HYPOTHESIZE GOALS FOR ASSESSMENT
— Short and long-term goals to prioritize during the examination
process.
— Ensures that family’s concerns, goals and expected outcomes
are addressed during the examination process.
— Encourage family involvement in the decision-making process.
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STEP 5: EXAMINATION PLANNING
Based on:
— Steps 1-4
— Knowledge of available valid, reliable, and feasible measurements
— Within ICF framework
— Aligned with the family’s desired goals and expected outcomes
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STEP 6: EXAMINATION
— Carry out examinations as planned in step 5
— Develop rapport with the child and family by explaining
the procedures used and briefly reporting on findings.
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STEP 7: EVALUATION OF THE EXAMINATION
— Evaluate and interpret examination results by answering:
— Use mental image developed in Step 1 – what are the expected
activities and social roles? Consider age, gender, societal
expectations, and environmental barriers.
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STEP 8: PT DIAGNOSIS AND PROGNOSIS
ICF!!!
— What are the movement dysfunctions
— Which 1 or 2 physical therapy problem areas are most limiting
to the child’s functional execution of motor skills?
— Are referrals to other disciplines indicated?
— Are the hypothesized goals reasonable and attainable?
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STEP 9: GENERAL INTERVENTION PLANNING
Answer these questions:
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STEP 9: GENERAL INTERVENTION PLANNING
— If the therapist determines that physical therapy interventions are indicated
related to the child's capacity to achieve gains in function, a plan of care is
developed.
— The plan of care includes the goals and expected outcomes, the specific
physical therapy interventions to be used, the proposed frequency and
duration of physical therapy services, anticipated dates for re-examination
and readministration of outcome measures, and predicted plans for
discharge.
— Determine the specific strategies, such as a home program, that will help
achieve therapeutic carryover for the child.
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STEP 10: INTERVENTION SESSION PLANNING
— Session goal based on functional goal
— Motivational or play component and feedback?
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STEP 11: REFLECTION
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Assess the effectiveness of the intervention
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Consider the child’s overall progress within the plan of care.
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STEP 12: FORMAL RE-EXAMINATION
— Re-administration of selected tests and outcome measures to
evaluate progress and to modify or redirect intervention.
— Revisit steps 1-8
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CONTENT OF THEORETICAL LESSON 1
1.
2.
3.
4.
5.
Introduction
Theory of pediatric clinical reasoning
Case Evert
Case Samuel
Learning paths on Ufora: to prepare for the practical
sessions
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3. CASE EVERT
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UFORA
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REFERRAL
Evert X
Stimulation of milestones, does not walk yet
General
9X
Delay of motor development
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ADMINISTRATIVE INFORMATION
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1,5 years old
First and only child
Does not yet walk
Bottom shuffler
Cognitive and fine motor skills age-appropriate
Single mother
Support from family and friends, overprotective
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HISTORY
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Pregnancy uncomplicated
Preterm birth at 32 weeks, 6 days. 1650g, 40cm
Apgar score 4/7/8
First 7 weeks in neonatology
No major infections, brain scans remained normal
Did not like being placed pronegastro-oesophagel reflux.
First 6 months: no motor developmental issues noticed, except head
lag.
— 8-9 months: rolling from supine to prone not possible
— Sitting at 10months, posture hypotonic and kyphotic
— Use of sitting aid and trotter (kan in interactie gaan maar is passief)
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PROBLEM STATEMENT
— Gross motor development to encourage walking
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ASSESSMENTS
Qualitative evaluation
Quantitative evaluation
Tone
— Hyperlaxity and low base tone
Alberta Infant Movement Scale (AIMS)
Mobility
— Cannot roll from supine to prone
— Cannot come to sit
— No crawling
— Bottom shuffler
— Pulls to stand through half-kneeling
— Cruises with support of table – no rotation
— Cannot stand or walk independently
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4. ASSIGNMENTS
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UFORA: PREPARE LEARNING PATH EVERT
1.
2.
3.
4.
5.
Calculate corrected age
Watch videos, score and calculate AIMS and interpret
Fill in pediatric medical history form
Formulate physiotherpeutic diagnosis in ICF framework
Set treatment goals:
— ST: (2 weeks)
— LT: (12 weeks)
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UFORA: PREPARE LEARNING PATH EVERT
6. Work out an intervention plan
— Plan intervention sessions
— Exercise examples – 1 for ST and 1 for LT goal
7. Motivation and communciation
— How will you deal with her fear of moving?
— How will you work with the family and the other people involved in
her care?
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UFORA: PREPARE LEARNING PATH EVERT
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3. CASE SAMUEL
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REFERRAL
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ADMINISTRATIVE INFORMATION
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9y 5m old (na 1st referral)
Regular education: 3rd grade (at time of assessment)
One 13y old sister
First referral to psychologist due to psychosocial problems at
school.
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Suspicion of autism spectrum disorder (ASD) from age 7.
High IQ.
No executive functioning problems.
Motor skill deficits.
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HISTORY
— Normal pregnancy.
— Quiet baby
— Delayed motor milestones; first steps at 22m.
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STATUS
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Cycling and swimming performance affected.
Hobbies: aikido, puzzels,
Fine motor skills (+writing) affected.
ADLs affected.
Psychosocial wellbeing at school affected.
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ASSESSMENT
— Movement ABC-II
— Readability of Handwriting
— Systematic detection of writing problems –SOS-2-NL
— DCD-Q
— Groninger Motor Observation Scale (GMO)
— School questionnaire for teachers (SQT)
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FOLLOW UP 5/9/2023 – CURRENT
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Now in 5th grade
Has been following PT for 1 year for handwriting problems
Mom has been diagnosed with DCD (kan ook op volwassen leeftijd)
Mom has concerns about Sams’ increasing weight
Samuel complains of difficulties participating in gym class and low
fittness levels.
— Psychosocial issues remain.
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4. ASSIGNMENTS
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UFORA: PREPARE LEARNING PATH ROB
1. Formulate physiotherapeutic diagnosis in the ICF framework (ICF
form on UFORA)
2. Study the assessment results and interpret. EACD guidelines
3. Which additional assessments would you carry out?
4. Fill in the pediatric medical history form (anamnesis) (history
form on UFORA)
5. Set the treatment goals
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UFORA: PREPARE LEARNING PATH ROB
6. Work out intervention plan
— Plan intervention sessions
— Include a coaching plan: motivation and communciation
— How will you motivate Samuel?
— How will you cooperate with the other health workers?
— How will you work with his family?
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UFORA: PREPARE LEARNING PATH ROB
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Prof. Dr. Lynn Bar-On
Department of Rehabilitation Sciences
lynn.baron@ugent.be
Universiteit Gent
@ugent
www.ugent.be
@ugent
Ghent University
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