PEDIATRIC

REHABILITATION
PEDIATRIC
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 approach

Congenital and child-hood onset physical
impairment
Rehabilitation of children requires
– Identification
– Selection
– Understanding
 INTERDISCIPLINARY TEAM
REHAB
SPECIALIST

PHYSICAL
THERAPIST PATIENT

PSYCHOLOGIST OCCUPATIONAL
THERAPIST

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 conditions

TRANSIENT STATIC PROGRESSIVE
CONGENITAL
Brachial plexus Cerebral palsy Muscular dystrophy
injury Spina bifida Spinal muscular atrophy
Retardation Cystic fibrosis

AQUIRED Spinal cord injury Juvenile rheumatoid

Guillain-Barre Traumatic brain injury arthritis
syndrome Traumatic limb Collagen vascular
amputation disease
polio
 CERBRAL PALSY

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

Classification
By tone abnormalities By body parts involved

Spastic Diplegia
Dyskinetic Quadriplegia
Athetoid Triplegia
Choreiform Hemiplegia
Ballistic
Ataxic
Hypotonic
Mixed
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

 NEUROMOTOR THERAPY APPROACHES

Neurodevelopmental Sensorimotor Sensory Integration

technique (Bobaths) Approach to Approach ( Ayres)
Treatment (Rood)
CNS model Hierarchical Hierarchical Hierarchical

Goals of treatment 1. To normalize tone 1. To activate 1. To improve

2. To inhibit primitive postural efficacy of neural
reflexes responses processing
3. To facilitate 2. To activate 2. To better organize
automatic reactions movement adaptive responses
and normal once atability
movement pattern is achieved

Primary sensory 1. Kinesthetic 1. tactile 1. Vestibular

systems utilized to 2. Proprioceptive 2. Proprioceptive 2. Tactile
effect a motor 3. tactile 3. Kinesthetic 3. kinesthetic
response
 NEUROMOTOR THERAPY APPROACHES
Neurodevelopmental Sensorimotor Sensory Integration
technique (Bobaths Approach to Approach ( Ayres
Treatment (Rood)

Emphasis of treatment 1. Positioning and 1. Sensory 1. Therapists

activities handling stimulation to guides but child
2. Facilitation of activate motor controls sensory
active movement response input to get
adaptive
purposeful
response
Intended clinical CP children Children with CP Children with learning
population Adult post CVA Adults post CVA disabilities
autism
Emphasis on treating yes no No
infants
Emphasis on family yes no no
involvement
HANDLING TECHNIQUES
Lifting and carrying
 POSITIONING

Lying
SUPINE

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

SOFT TOUCH SPRING

ZIP GRIPS
ACTION SCISSORS
 WHEEL CHAIR

Head rest

Strap for trunk

support

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 sitting
 Persistence 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
THANK YOU